CARDIOVASCULAR

Definitions
 Cardiac Output: volume of blood ejected from each ventricle during 1 minute (HR x SV)
o Stroke Volume: Volume of blood ejected each heart beat
 Preload: the load that stretches the cardiac muscle before contraction
o The volume of blood in the RV at the end of diastole constitutes its preload for the next
beat
 Myocardial contractility: ability of the cardiac muscle, when given a load to shorten.
o Increases when stimulated by action of the sympathetic nervous system
o Decreases when blood flow/oxygen delivery to the myocardium is impaired
 Afterload: degree of vascular resistance to ventricular contraction.
 Pulse Pressure: difference in Systolic and diastolic (EX: 140/80. Pulse pressure = (140-80) = 60)

Valve Sounds
 Aortic valve: Right 2nd intercostal space
 Pulmonic Valve: Left 2nd/3rd interspace close to
sternum
 Tricuspid Valve: Lower left sternal border
 Mitral Valve: Cardiac Apex
PQRST
 P: atrial depolarization
 Q: Septal depolarization
 R: ventricular depolarization
 S: following R
 T: ventricular repolarization // recovery
Jugular Venous Pressure
 Reflects right arterial pressure (= central
venous pressure and right ventricular end diastolic
pressure)
 Best estimate from the right internal jugular
vein
 JVP is best assess from pulsations in the right
internal jugular vein, which is directly in line with
the superior vena cava and right atrium.
 To estimate level of JVP – find the highest point
of oscillation in the internal jugular vein
 Measured in vertical distance above sternal angle (Angle of Louis)
 3 Peaks
o A: Atrial contraction
o C: Carotid transmission (closure of tricuspid valve)
o V: Venous filling
Carotid Pulse
 Look at: carotid upstroke, amplitude and contour, presence/absence of thrill or bruit
 Amplitude and contour: assessed by placing patient HOB 30 degrees, then place index and middle
finger or thumb on carotid in the lower third of neck
o Amplitude correlates with pulse pressure
o Contour named by speed of upstroke – normal is brisk (smooth, rapid, follows S1
immediately)
 *Never palpate both sides of carotid at the same time [Symbol] decreases blood flow can result in
syncope
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 Pulsus Alternans: rhythm of the pulse remains regular but force of arterial pressure alternates
between strong and weak ventricular contractions
o Almost always indicates severe left ventricular dysfunction
o Usually felt with palpating radial or femoral arteries
o Alternating loud and soft korotkoff sounds or a sudden doubling of the apparent heart rate
as the cuff pressure declines = Pulsus Alternans
 Paradoxical Pulse: greater than normal drop in systolic BP during inspiration
o 10 – 12 mmHg = paradoxical pulse
 Carotid Artery Thrills and Bruits
o Auscultate for bruit (murmur like sound) – place diaphragm at the upper portion of neck
just below angle of jaw
 Brachial Artery: used for patient with carotid obstruction, kinking or thrills
o Pt’s arm should rest with elbow extended with palm up
o Use index and middle finger or thumb of opposite hand
The Heart
*For a cardiac exam, stand on the patients right side. Pt should be supine with HOB at 30 degrees.
*To Assess PMI, have patient lay on left side – brings ventricular apex closer to chest wall.

S1 & S2
S1 ---Systole --- S2 ------ Diastole ------ S1 --- Systole --- S2
 Diastole last longer than systole
 S1 is usually louder than S2 at the apex, S2 is usually louder than S1 at the base
 S1 diminished in: first degree heart block
 S2 diminished in: aortic stenosis

INSPECTION

PALPATATION
 Heaves, Lifts, Thrills; S1, S2, S3 and S4
o Heaves and Lifts: Use palm or fingerpads against chest
 Produced by enlarged right or left ventricle or atrium
o Thrills: press ball of hand (near wrist) on chest to check for buzzing caused by turbulent
flow. If present ausculate for murmur. If thrill present it is atleast a grade 4 murmur
o S1 & S2: Place right hand on chest with left middle and index finger to palpate carotid
upstroke
 For S3 and S4 apply lighter pressue
 Left Ventricular Area
o Apical Impuse/PMI
 If unable to palpate supine, have patient lay in left lateral decubitus position
 If still unable, have pt exhale fully and stop breathing
 Location:
 Vertical position: 5th or 4th intercostal space
 Horizontal position: distance in cm from midclavicular line
 Diameter
 Supine patient – less than 2.5cm (may feel larger in L lat decubitus)
 Amplitude
 Normal = small, brisk and tapping
 Young adults may have hyperkinetic impulse during excitement
 Duration *Most useful for ID hypertrophy of left ventricle
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 Auscultate heart sounds as your palpate apical impulse. Estimate proportion
of systole occupied by the apical impulse.
o Palpable S3 and S4
 Left lateral decubitus, palpate apical impulse with one finger as patient exhales and
briefly stops breathing
 S3: brief early middiastolic impulse
 S4: outward movement just before S1
 Right Ventricular Area {Left sternal border 3rd, 4th, 5th interspaced
o Supine, head elevated to 30degrees. Pt exhale and briefly stop breathing & palpate for
systolic impulse of RV.
 If impulse noted – ass location, amplitude and duration
o If increased AP diameter – have patient inhale and stop breathing – palpate for RV in
epigastric area with your hand flattened, press index finger under rib cage and up towards left
shoulder
 Pulmonic Area {Left 2nd interspace}
o Overlies pulmonary artery
 Aortic Area {Right 2nd interspace}
o Overlies aortic outflow tract
o Pulsations suggest: dilated or aneurysmal aorta
PRECUSSION
 Palpation has replaced percussion for estimating heart size
AUSCULATION
6 Points of Auscultation
o RIGHT 2nd interspace – aortic
o LEFT 2nd interspace – pulmonic
o LEFT 4th and 5th interspace – tricuspid
o LEFT 5th midclavicular line – mitral (Apex)
 Stethoscope
o Diaphragm – best for high pitched sounds of S1 and S2, the murmurs of aortic and mitral
regurgitation and pericardial friction rubs
o Bell – best for low pitched sounds of S3 and S4 and murmur of mitral stenosis
 Use at apex then move medially along the lower sternal border
 Apply LIGHT pressure; rest hand on chest to help maintain light pressure
 Pattern of Auscultation
o Start with pt’s head and upper chest elevated 30 degrees – start at base or apex. Listen first
with diaphragm then bell.
 Important Maneuvers
o Mitral stenosis: Pt in left lateral decubitus postion – brings left ventricle closer to chest
wall
 Accentuates left sided S3 and S4
o Aortic regurgitation: Sit up, lean forward, exhale completely and stop breathing
 Use diaphragm along left sternal border and apex
 Could miss soft diastolic decrescendo murmur if not in this position.
 ID Systole and Diastole
o As you auscultate chest, palpate right carotid artery in lower third of neck.
 S1 falls just before the carotid upstroke and S2 follows carotid upstroke
 Base: S2 louder than S1
 Apex: S1 is louder than S2
o Systole: interval between S1 and S2
o Diastole: interval between S2 and S1
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S1 ---Systole --- S2 ------ Diastole ------ S1 --- Systole --- S2
 Heart sounds
o Split S2:
 Listen in 2nd and 3rd interspace
 Note: Width, Timing and intensity
 Expiratory splitting = valvular abnormalities
o Extra Sounds in Systole
 Ejection sounds or systolic clicks
 Most common: systolic click of mitral valve prolapse
o Extra Sounds in Diastole
 S3, S4, or opening snap
 S3 and S4 in athletes is normal
 Heart Murmurs
o Timing:
 Systolic Murmur: falling between S1 and S2
 Murmur that coincide with carotid upstroke = systolic murmur
 Mid systolic: begin after S1 and stop before S2 – arise from aortic or
pulmonic valve [Aortic stenosis, hypertrophic cardiomyopathy, pulmonic
stenosis]
 Pansystolic: Starts with S1 and Stops with S2 – occurs with regurgitant flow
across AV valves [mitral & tricuspid regurgitation, ventricular septal defect]
 Late systolic: starts mid/late systole and persist up to S2. - mitral
valve prolapse
 Diastolic murmur: falling between S2 and S1
 Usually represent valvular heart disease
 [[ Aortic regurgitation & Mitral stenosis]]
 Early diastolic: starts after S2 fades until S1 – regurgitation across
aortic/pulmonic
 Mid diastolic: start short time after S2 and fades – turbulant flow across AV
valve
 Late diastolic: starts late in diastole up to S1
o Shape
 Cresendo: grows louder {presystolic murmur of mitral stenosis}
 Decresendo: grows softer {early diastolic murmur of aortic regurgitation}
 Crescendo-Decrescendo: first rises then falls
 Plateau: same internsity throughout
o Location of Maximum intensity
 Where you hear it in the intercostal space and its proximity to sternum
 EX: 2nd right interspace often originates in aortic valve
o Intensity
 Grading
 Grade 1 – very faint, heard only if “tuned in”
 Grade 2 – quiet but heard immediately
 Grade 3 – moderately loud
 Grade 4 – Loud, palpable thrill
 Grade 5 – Very loud, with thrill
 Grade 6 – very loud with thrill (may be heard with stethoscope off chest)
o Pitch
 Low, medium or high
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o Quality
 EX: blowing, harsh, rumbling and musical
Right sided murmur = increase with inspiration
Left sided murmur = increased with expiration
EX: Medium pitched, grade 2/6, blowing decrescendo diastole murmur, best heard in 4th intercostal space
with radiation to the apex

Hypertrophic cardiomyopathy – supine patient to bear down. Place hand on mi abdomen and ask patient
to strain against it. Place stethoscope on patient's chest and listen at the left lower sternal border
**INCREASES during strain phase

Heart Failure & Pulmonary hypertension – inflate 15 mmHG higher than systolic. Have patient bear down
for 15 seconds then return to normal breathing. Keep inflated and listen for korotkoff sounds over
brachial artery.
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