1. Assessment of Cardiovascular System

2. Lecture Objectives: Anatomy and physiology of cardiovascular system.
History taking and physical examination

3. Structure of the Cardiovascular system

4. Anatomical Structure of the Heart

5. Common abbreviations used to refer to chambers:
RA – right atrium
RV – right ventricle
LA – left atrium
LV – left ventricle
AV – atrioventricular valve
Left AV – left atrioventricular valve
Right AV - right atrioventricular valve
SL – semilunar valve

6. Topographical Landmarks
Each area corresponds to one of the hearts 4 valves.
Aortic area - 2nd ICS to right of sternum (closure of the aortic valve loudest here).
Pulmonic area - 2nd ICS to left of sternum (closure of the pulmonic valve loudest here).
Tricuspid - 5th ICS left of sternal border (closure of tricuspid valve).
Mitral - 5th ICS left of the sternum just medial to MCL (closure of mitral valve).

7. Normal Heart Sounds The first heart sound - systolic S1:
Signals the closure of AV valves and the beginning of systole.
Consists of mitral M1 and tricuspid T1 components.
Is loudest at the apex

8. The second heart sound - diastolic S2:
Signals the closure of semilunar valves and the end of systole.
Consists of aortic A2 and pulmonic P2 components.
Is loudest at the base.
S1 & S2 correspond respectively to the familiar "lub dub" often used to describe the sounds.

9. Other Heart Sounds Murmurs:
are produced by vibrations within the heart chambers or in the major arteries from the back and forth flow of blood.
are classified as:
1. Innocent, occurring in individuals with no anatomic or physiologic abnormality.
2. Functional, occurring in individuals with no anatomic cardiac defect but with a physiologic abnormality such as anemia.
3. Organic, occurring in individuals with a cardiac defect with or without a physiologic abnormality.

10. The conduction system of the heart consists of four structures:
1. The sinoatrial (SA) node, located within the right atrial wall near the opening of the superior vena cava
2. The atrioventricular (AV) node, also located within the right atrium but near the lower end of the septum
3. The atrioventricular bundle (bundle of His), which extends from the atrioventricular node along each side of the interventricular septum
4. Purkinje fibers, which extend from the atrioventricular bundle into the walls of the ventricles. The electric impulses from this conduction system can be recorded on an electrocardiogram.

11. Conduction System

12. Electrocardiography (ECG)
records the electrical impulses generated from the heart muscle and provides a graphic illustration of the summation of these impulses and their sequence and magnitude.

13. The ECG waves
P wave represents the electric activity associated with the sinoatrial node and the spread of the impulse over the atria. It is a wave of depolarization.
QRS complex (wave) is composed of three separate waves: the Q wave, the R wave, and the S wave. They are all caused by currents generated when the ventricles depolarize before their contraction. Because ventricular depolarization requires septal and right and left ventricular depolarization, the electrical wave depicting these events is more complex than the smooth P wave.
P-R interval is measured from the beginning of the P wave to the beginning of the QRS complex. It is termed P-R instead of PQ because frequently the Q wave is absent. This interval represents the time that elapses from the begin Q-T intervalning of atrial depolarization to the beginning of ventricular depolarization.

14. The ECG waves
The T wave represents repolarization of the ventricles. The Q-T interval begins with the QRS complex and ends with the completion of the T wave. It represents ventricular depolarization and repolarization. This interval varies with the heart rate. The faster the rate, the shorter the Q-T interval. Therefore in children this interval is normally shorter than in adults.
The S-T segment is normally an isoelectric (flat) line that I connects the end of the S wave to the beginning of the T wave.
The T-P interval represents atrial and ventricular polarization in anticipation of the next cardiac cycle.

15. Pumping Ability 4 to 6 L of blood per min throughout the body
Preload – venous return
Afterload – the opposing pressure the ventricles must generate to open aortic valve.

16. Physical Examination Objectives: Subjective data. Health history data.
Preparation.
Inspection: general appearance,
Palpation: peripheral pulses, apical impulse.
Percussion.
Auscultation: heart sounds, murmurs.

17. Subjective data

18. Chest pain:
Angina – an important cardiac symptom.
“Clenched fist” sign is characteristic of angina.
Onset, location, character, aggravating and/or relieving factors
Character: crashing, stabbing, burning,
Associated symptoms: sweating, shortness of breath, nausea or vomiting,

19. Subjective data Dyspnea: Orthopnea:
Cause, onset, duration, affection by position,
Does shortness of breath interfere with activities of daily living?
Orthopnea:
Is the need to assume a more upright position to breathe.
Note the exact number of pillows used.

20. Subjective data
Cough: duration, frequency, type, coughing up sputum (color, odor, blood tinged, aggravating and/or relieving factors.
Fatigue: onset, relation to time of day?
Cyanosis or pallor: occurs with myocardial infarction or low cardiac output.

21. Subjective data Edema: Nocturia:
Swelling of legs or dependent body part due to increased interstitial fluid.
Onset, recent change, relation to time of day, relieving factors, associated symptoms.
Nocturia:
Occurs with heart failure

22. History taking. Past cardiac history: Family cardiac history:
! Last ECG, stress ECG, serum chilesterol measurements, other heart tests?
Family cardiac history:
Family history of hypertension, diabetes, heart problems, coronary artery disease (CAD), sudden death at younger age?
Personal habits (cardiac risk factors): nutrition, smoking, alcohol, exercise, drugs.

23. Inspection Skin colour (cyanosis, pallor) and condition
Any obvious bulging on anterior thorax at the left
Edema
Orhtopnea

24. Palpation
Palpate the apical impulse (the point of maximal impulse, or PMI):
Location: one intercostal space (usually 5th ICS) at left MCL,
Size: normally 1 cm  2 cm,
Duration: short, normally occupies only first half of systole.

25. Palpation

26. Percussion
Is used to estimate approximately heart borders and configuration.
Recently is displaced by the chest x-ray or EchoCG.
Helps to detect heart enlargement
Heart (cardiac) enlargement is due to increased ventricular volume or thickening of heart wall.

27. Auscultation

28. Auscultation Note the rate the rhythm Identify S1 and S2
Listen for extra heart sounds
Listen for murmurs

29. Auscultation (cont.) Rhythm: Regular Irregular:
arrythmia – common variation. Rate ↑ on inspiration and ↓ on expiration.
Regularly irregular
Pulse deficit – occurs with atrial fibrillation, heart failure, detects weak heart contractions.

30. Auscultation (cont.) Identify S1 and S2 Location and amplitude,
Correlation with peripheral pulses, PMI
Correlation with ECG waves
“Lub” or “dup”

32. Thanks for attention!
Questions?