cvs examination edited

Examination of Cardiovascular

System

First impression

Inherited syndromes

•Down's syndrome (PDA, ASD & VSD)

•Marfan's syndrome (aortic dissection, valve disease)

•Turner's syndrome (aortic coarctation & aortic stenosis)

Ankylosing spondylitis (aortic regurgitation)

Acromegaly (hypertension & cardiomegaly)

Other syndromes

Down’s syndrome

Marfan ’s syndrome

Turner ’ s syndrome

Acromegaly

General Examination

BreathlessnessIn pain

Febrile

Pallor

Xanthelesma

Cleft ear lobes

Central cyanosis

Dental care

Thyroid enlargement

Central cyanosis

Clubbing of the fingers

Splinter heamorrhages

Splinter haemorrhages

Osler’s nodes

Janeway’s lesions

Ankle oedema

Sacral oedema

PulsePresence or absenceRate Rhythm Character

Presence of bruits

Jugular venous pulse

Jugular venous pressure

The internal jugular vein provides information about right atrial and right ventricular function

The jvp can be discriminated from the carotid pulse because:

It cannot be palpated

It has a complex wave form; it is usually seen to flicker twice within each cardiac cycle

It moves on respiration, normally decreasing on inspiration and rising on expiration

Mild pressure applied to the base of the neck obliterate its pulsations

Mild pressure applied over the liver will expel more blood into the right side of the heart and elevate the jvp, a positive hepato-jugular reflex

Jugular venous wave pattern

The jvp is described in terms of:

• Height

• character

The height of the jvp is expressed as the vertical distance from the manubriosternal angle to the maximum height of pulsations in the internal jugular vein with the patient semi-recumbent at an angle of 45 degrees

It is normally less than 3 cm.

This equates to a right atrial pressure of 8 cm of water as in this position, the manubriosternal angle is about 5 cm above the centre of the right atrium

Causes of a raised jvp

• increased right ventricular filling pressure

• obstruction of blood flow from the right atrium to the right ventricle

• superior vena caval obstruction

• positive intrathoracic pressure

Abnormal waves

Abnormally large a waves indicate increased resistance to right atrial emptying from right ventricular hypertrophy, as in severe pulmonary stenosis, or tricuspid stenosis.

Abnormal waves

A waves are absent in atrial fibrillation, since coordinated atrial contraction is necessary to produce them,

Abnormal wavesCannon waves are very large a waves that occur when the right atrium contracts against a closed tricuspid valve.

They occur irregularly in complete heart block and ventricular tachycardia, conditions that are characterised by atrioventricular dissociation with random occasional simultaneous atrial and ventricular contractions.

An exaggerated x descent indicates that blood is being ejected from a restricted pericardial cavity, for example, because of cardiac tamponade or constrictive pericarditis without calcification.

A slow y descent may be seen in tricuspid stenosis and right atrial myxoma.

Examination of the precordium

Scars, The midline scar of a sternotomy The left lateral scar of a mitral valvotomy

Deformity

Pacemaker

Visible apex beat or other pulsation

Inspection

Pectus excavatum

PalpationApex beat

Parasternal haeve

Palpable heart sounds Plapable murmurs

Apex beats different types

Sustained or heaving apex beat is caused by pressure overload

• aortic stenosis,

• severe hypertension.


Tapping apex beat seen in

Mitral stenosis


Thrusting displaced apex beat is caused by volume overload: an active large stroke volume ventricle

•Aortic regurgitation•Mitral regurgitation •Left to right shunts.


Double or triple impulse occur in

Hypertrophic obstructive cardiomyopathy


An impalpable apex beat •Obesity •Overinflated chest •Pericardial effusion •Dextrocardia

Apex beat

Parasternal heave is detected by placing the heel of the hand

over the left parasternal region. In the presence of a

heave the heel of the hand is lifted off the chest wall with

each systole.

Parasternal haeve

Parasternal heave is caused by:

Right ventricular enlargement

Severe left atrial enlargement which pushes the right ventricle forwards

Thrill

These are palpable murmurs

They always indicate an organic defect

The area where the thrill is felt strongest gives clues as to the aetiology of the thrill

Thrills may be Systolic or diastolic:

Best felt site suggest the oetiology

Systolic:

• Apex mitral incompetence • at 3rd or 4th interspace vsd• At base on right aortic stenosis • at base on the left pulmonary stenosis

• Below left clavicle - pda

Diastolic:

Apex mitral stenosis

Accurate and sensitive auscultation

of the praecordium requires experience

Location of heart valves

Auscultation should begin in the mitral region:

Use the bell initially to detect the low frequency sounds of mitral stenosis or a third heart sound

Use the diaphragm to detect the higher frequency sounds of mitral incompetence or a fourth heart sound

Using the bell and diaphragm, listen in the following locations

Tricuspid area Pulmonary area

Aortic area

Never forget toAuscultate over the mitral area in left lateral position in expiration with the bell to find mid diastolic murmur in mitral stenosis

Never forget toAuscultate over the lower left sternal edge in expiration , in seated and bent forward position, with the diaphram to find early diastolic murmur in aortic incompetence

Heart sounds

There are two major groups of heart sounds They are classified according to their mechanism,

Valvular

Ventricular filling

Valve sounds

These include:

• First heart sound• Second heart sound • ejection sounds • opening snaps

The first heart sound is caused by the closing of the mitral valve and the closing of the tricuspid valve

It is heard loudest at the apex.

Possible causes of a soft first heart sound include

• Mitral regurgitation • low blood pressure, • rheumatic carditis • severe heart failure • left bundle branch block

Loud first sounds

A loud first heart sound occurs when the leaflets are wide open at the end of ventricular diastole and shut forcefully at the beginning of ventricular systole.

Causes of loud first heart sound

• Atrial fibrillation

• short diastole – tachycardia

• Atrial premature beat

• Mitral stenosis where high left atrial pressure delays mitral valve closure

If the blood flow from atria to ventricles varies from one beat to the next, then the intensity of the first heart sound will change accordingly

Causes include

Varying duration of diastole

Complete atrioventricular block

A soft, or absent, a2 is heard in:Poorly mobile cusps –

• calcification as occurs in some forms of aortic stenosis

• dilatation of the aortic root - syphilitic aortitis

A soft, or absent, p2 is heard in:

Pulmonary stenosis

Loud second heart sounds can be loud a2 or a loud p2.

Loud a2 occurs in systemic hypertension where there is a dilated proximal aorta

A loud p2 is heard in pulmonary hypertension

Splitting of second heart sound

A2 and p2 separate on inspiration(P2 following a2)

This is because of the increased right ventricular stroke volume that occurs as the result of increased venous return

The second heart sound is widely split if there is an early a2 or if the p2 is delayed.

Early A2 can occur in

• Mitral regurgitation

• Ventricular septal defect

Delayed p2 –

Possible causes include :-

• Right bundle branch block• Pulmonary stenosis • Atrial septal defect

Fixed splitting

Splitting of seond heart sound in both inspiration and expiration

Reversed splitting

In this condition, p2 occurs before a2

On expiration, a2 is delayed such that it occurs after p2

Inspiration causes p2 to be delayed and the split is diminished.

Possible causes of a delayed a2

• Left bundle branch block • systolic hypertension • severe aortic stenosis or hocm • patent ductus arteriosus • left heart failure

Ejection clicks

These are caused by the opening of the aortic and pulmonary valves.

These sounds are high pitched and often described as clicky.

They occur in early systole and are best heard with a rigid diaphragm chest piece.

Opening snaps

In certain pathological states the av valves open more rapidly than normal, this results in an audible opening snap.

A mitral opening snap may be caused by:

Mitral stenosis with a mobile valve

Rapid mitral flow causes a soft snap in left to right shunts such as Vsd or pda.

Severe mitral regurgitation

A tricuspid opening snap is rare and may be caused by:

• Rheumatic stenosis

• Atrial septal defect with increased tricuspid flow

Filling sounds

These sounds are of much lower frequency than the valve sounds and may be difficult to hear.They are best heard with the bell gently applied to the chest and are described as a dull thud becoming palpable when loud.

Ventricular filling sounds include:Rapid filling (third)

Atrial (fourth)

Third heart sound

This heart sound is caused by rapid ventricular filling in early diastole.

The third sound is normally audible in children, with the intensity diminishing with age.

The third heart sound becomes inaudible (but recordable) in normal subjects in middle age with increasing ventricular stiffness.

Fourth heart sound

The fourth heart sound is due to atrial contraction inducing ventricular filling towards the end of diastole.

They are never audible in normal subjects.

A fourth heart sound is the result of powerful atrial contraction filling an abnormally stiff ventricle.

Left atrial heart sound is maximal at the apex, with possible causes including:

• Left ventricular hypertrophy • fibrotic left ventricle • hypertrophic cardiomyopathy

Right atrial heart sound is maximal at the lower left sternal edge and on inspiration.

This may occur in

Right ventricular hypertrophy

MurmursHeart murmurs are caused by turbulent blood flow through valves or ventricular outflow tracts

Characteristics of heart murmurs

TimingDurationCharacter and pitchIntensityLocationRadiation

Murmurs are recorded in six gradations:

1/6 murmur is just audible by an expert in optimal conditions

2/6 is quiet 3/6 is moderately loud

4/6 is markedly loud , accompanied by a thrill

5/6 is very loud with a thrill 6/6 is audible without a stethoscope

With reference to valvular lesions

Systolic murmurs imply incompetence of atrioventricular valve or stenosis/sclerosis of semilunar valve.

Diastolic murmurs imply stenosis of atrioventricular valve or incompetence of semilunar valve

Left ventricular ejection murmurs are maximal at the aortic area, lower left sternal edge and apex.

Possible causes include:

• Aortic stenosis

• Hypertrophic obstructive cardiomyopathy

• aortic cusp sclerosis

Ejection systolic murmur maximal over the aortic area:

Aortic stenosis Aortic sclerosis Coarctation of the aorta

Hypertrophic cardiomyopathy

Ejection systolic murmur maximal over the pulmonary area:

• Innocent • pulmonary stenosis • pulmonary hypertension • atrial septal defect

Pansystolic murmurs

Pansystolic murmurs occur throughout systole

Caused by:

• Mitral regurgitation

• Ventricular septal defect

• tricuspid regurgitation

Diastolic murmursEarly diastolic murmurs

Mid-diastolic murmurs

Early diastolic murmursAortic regurgitation - maximal at the 4th interspace below the aortic valve. Maximal if the patient leans forwards. Radiates to the back.

Pulmonary regurgitation - maximal about the third left space.

Mid diastolic murmursMitral stenosis - maximal at the apex with the patient inclined to the left. The murmur begins after the opening snap. The murmur is long if severe and short if mild.

Tricuspid stenosis - maximal at the lower left sternal edge. The murmur is increased by inspiration.

A murmur mimicking mitral stenosis may occur when there is greatly increased flow across the mitral valve. This may occur in

• mitral regurgitation,

•Ventricular septal defect

•Patent ductus arteriosus

Continuous murmur

These occur when there is a communication in the circulation with a continuous pressure gradient throughout the cardiac cycle.

Continuous murmurs are often maximal in late systole

Causes of a continuous murmur include:

• Patent ductus arteriosus • aortic sinus of valsalva aneurysm rupturing into the right heart • pulmonary arteriovenous communications• Bronchial artery anastomosis in pulmonary atresia• Artificial ducts • prosthetic valve• Venous hum

Innocent murmurs

Many babies and children have heart murmurs in the absence of any structural abnormality

If a murmur has any of the following characteristics then it probably is not innocent:

• Pansystolic • diastolic • loud or long • associated with a thrill or cardiac symptoms

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Some hints concerning listening for murmurs:

Time the cardiac cycle by palpating one of the patient's carotid arteries

The bell is good for hearing low-pitched sounds e.G. Mitral stenosis. It should be applied very gently to the skin

The diaphragm is good for listening to high pitched mumurs e.G. Aortic regurgitation

Some hints concerning listening for murmurs:

Left heart murmurs are louder in expiration

Right heart murmurs are louder in inspiration

Exercise makes a mitral stenotic murmur louder

cvs examination edited

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