ch 20 heart and neck vessels Flashcards
system consists of the heart (a muscular pump) and the blood vessels
cardiovascular (CV)
is the area on the anterior chest directly overlying the heart and great vessels
precordium
heart and great vessels are located between the lungs in the middle third of the thoracic cage
(mediastinum)
lies behind the right ventricle and forms the apex and slender area of the left border.
left ventricle
lies to the right and above the right ventricle and forms the right border
right atrium
is located posteriorly, with only a small portion, the left atrial appendage, showing anteriorly.
left atrium
blood vessels are arranged in two continuous loops, the
pulmonary circulation and the systemic circulation
“top” of the heart is the
base
bottom” is the
apex
During contraction the apex beats against the chest wall, producing an
- fifth intercostal space, 7 to 9 cm from the midsternal line.
apical impulse
lie bunched above the base of the heart.
great vessels
return unoxygenated venous blood to the right side of the heart
superior and inferior vena cava
leaves the right ventricle, bifurcates, and carries the venous blood to the lungs
pulmonary artery
return the freshly oxygenated blood to the left side of the heart
pulmonary veins
carries it out to the body
aorta
is a tough, fibrous, double-walled sac that surrounds and protects the heart
-two layers that contain a few milliliters of serous pericardial fluid. This ensures smooth, friction-free movement of the heart muscle.
pericardium (heart wall has numerous layers)
is adherent to the great vessels, esophagus, sternum, and pleurae and is anchored to the diaphragm.
pericardium
is the muscular wall of the heart; it does the pumping
myocardium
is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.
endocardium
two atrioventricular (AV) valves separate the
atria and the ventricles
right AV valve is the
tricuspid
left AV valve is the
bicuspid or mitral valve
are anchored by collagenous fibers (chordae tendineae) to papillary muscles embedded in the ventricle floor.
valves’ thin leaflets
open during the heart’s filling phase, or diastole, to allow the ventricles to fill with blood
AV valves
, the AV valves close to prevent regurgitation of blood back up into the atria.
-papillary muscles contract at this time so the valve leaflets meet and unite to form a perfect seal without turning themselves inside out.
pumping phase, or systole
are set between the ventricles and the arteries
-. Each valve has three cusps that look like half moons
semilunar (SL) valves
are the pulmonic valve in the right side of the heart and the aortic valve in the left side of the heart. They open during pumping (systole), when blood ejects from the heart.
SL valves
between the vena cava and the right atrium or between the pulmonary veins and the left atrium. For this reason abnormally high pressure in the left side of the heart gives a person symptoms of pulmonary congestion, and abnormally high pressure in the right side of the heart shows in the distended neck veins and abdomen.
no valves
first passive filling phase is called
early or protodiastolic filling.
active filling phase is called
presystole, or atrial systole, or sometimes the atrial kick
atrial systole occurs during
ventricular diastole
ventricular walls contract. This contraction against a closed system works to build pressure inside the ventricles to a high level
(isometric contraction)
closure of the semilunar valves causes the second heart sound
(S2) and signals the end of systole
all four valves are closed, and the ventricles relax
(called isometric or isovolumic relaxation)
pressures in the right side of the heart are much lower than those of the left side because less energy is needed to pump blood to its destination, the
pulmonary circulation
first heart sound the mitral component (M1) closes just before the tricuspid component (T1). And with(diastole) S2, aortic closure (A2) occurs slightly before pulmonic closure (P2).
Events in the Right and Left Sides. (left side close before right)
occurs with closure of the AV valves and thus signals the beginning of systole.
-mitral component of the first sound (M1) slightly precedes the tricuspid component (T1), but you usually hear these two components fused as one sound. You can hear S1 over all the precordium, but usually it is loudest at the apex.
first heart sound (S1)
occurs with closure of the semilunar valves and signals the end of systole. The aortic component of the second sound (A2) slightly precedes the pulmonic component (P2). Although it is heard over all the precordium, S2 is loudest at the base
second heart sound (S2)
That means that during inspiration, intrathoracic pressure is decreased. This pushes more blood into the vena cava, increasing venous return to the right side of the heart, which increases right ventricular stroke volume. The increased volume prolongs right ventricular systole and delays pulmonic valve closure.
Meanwhile on the left side, a greater amount of blood is sequestered in the lungs during inspiration. This momentarily decreases the amount returned to the left side of the heart, decreasing left ventricular stroke volume. The decreased volume shortens left ventricular systole and allows the aortic valve to close a bit earlier. When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately
split S2.(affected by respiration)
volume of right and left ventricular systole is just about equal, but this can be affected by respiration.
MoRe to the Right heart,
Less to the Left
affected by respiration.
Normally diastole is a silent event. However, in some conditions ventricular filling creates vibrations that can be heard over the chest. These vibrations are S3. S3 occurs when the ventricles are resistant to filling during the early rapid filling phase (protodiastole)(1st part of filling). This occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles
Third Heart Sound (S3). (extra heart sound)
S4 occurs at the end of diastole, at presystole, when the ventricle is resistant to filling. The atria contract and push blood into a noncompliant ventricle. This creates vibrations that are heard as S4. S4 occurs just before S1.
S4(extra heart sound)
turbulent blood flow and collision currents
- gentle, blowing, swooshing sound that can be heard on the chest wall
Murmurs
- Velocity of blood increases (flow murmur) (e.g., in exercise, thyrotoxicosis)
- Viscosity of blood decreases (e.g., in anemia)
- Structural defects in the valves (a stenotic or narrowed valve, an incompetent or regurgitant valve) or unusual openings occur in the chambers (dilated chamber, septal defect)
Conditions resulting Murmurs
- Frequency (pitch)—Heart sounds are described as high pitched or low pitched, although these terms are relative because all are low-frequency sounds, and you need a good stethoscope to hear them.
- Intensity (loudness)—Loud or soft
- Duration—Very short for heart sounds; silent periods are longer
- Timing—Systole or diastole
Characteristics of heart Sound
node near the superior vena cava initiate an electrical impulse. (Because the SA node has an intrinsic rhythm, it is the “pacemaker.”)
sinoatrial (SA)
across the atria to the AV node low in the atrial septum.
AV node
conduction system
bundle of His
conduction system
the right and left bundle branches, and then through the ventricles.
P wave—Depolarization of the atria
electrocardiograph (ECG)// electrical impulse stimulates the heart to do its work, which is to contract
PR interval—From the beginning of the P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles)
electrocardiograph (ECG)// electrical impulse stimulates the heart to do its work, which is to contract
QRS complex—Depolarization of the ventricles
electrocardiograph (ECG)// electrical impulse stimulates the heart to do its work, which is to contract
T wave—Repolarization of the ventricles
electrocardiograph (ECG)// electrical impulse stimulates the heart to do its work, which is to contract
is volume—it is the venous return that builds during diastole. It is the length to which the ventricular muscle is stretched at the end of diastole just before contraction
Preload
the greater the stretch, the stronger is the contraction of the heart.
Frank-Starling law
is pressure—it is the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure. It is the resistance against which the ventricle must pump its blood
Afterload
CV assessment
-vessels reflect the efficiency of cardiac function.
carotid artery and the jugular veins
as a pressure wave generated by each systole pumping blood into the aorta
pulse
is a central artery (i.e., it is close to the heart). Its timing closely coincides with ventricular systole.
carotid artery
is located in the groove between the trachea and the sternomastoid muscle, medial to and alongside that muscle
carotid artery
empty unoxygenated blood directly into the superior vena cava
-filling pressure and volume changes. Because volume and pressure increase when the right side of the heart fails to pump efficiently
jugular veins
larger internal jugular lies deep and medial to the sternomastoid muscle.
-not visible, although its diffuse pulsations may be seen in the sternal notch when the person is supine
internal jugular
is more superficial; it lies lateral to the sternomastoid muscle, above the clavicle.
external jugular vein
venous pulse occur because of events in the right side of the heart (no valve in superior vena cava to right aterium)
jugular pulse has 5 components
A wave reflects atrial contraction because some blood flows backward to the vena cava during right atrial contraction.
5 components of the jugular
, is backflow from the bulging upward of the tricuspid valve when it closes at the beginning of ventricular systole (not from the neighboring carotid artery pulsation)
C wave, or ventricular contraction
shows atrial relaxation when the right ventricle contracts during systole and pulls the bottom of the atria downward.
X descent
occurs with passive atrial filling because of the increasing volume in the right atria and increased pressure
V wave
reflects passive ventricular filling when the tricuspid valve opens and blood flows from the RA to the RV.
Y descent
adapts to ensure adequate blood supply to the uterus and placenta, to deliver oxygen and nutrients to the fetus, and to allow the mother to function normally during this altered state
- Blood volume increases by 30% to 50% during pregnancy, most rapid expansion occurring during the second trimester
- arterial BP decreases in pregnancy as a result of peripheral vasodilation. The BP drops to its lowest point during the second trimester and rises after that.
CV system (pregnancy)
fetal heart functions early; it begins to beat at the
end of 3 weeks’ gestation
is more horizontal in the infant than in the adult; thus the apex is higher, located at the fourth left intercostal space (Fig. 20.14). It reaches the adult position when the child reaches age 7 year
heart’s position in the chest (infant)
increase in systolic BP
-caused by thickening and stiffening of the large arteries, which in turn are caused by collagen and calcium deposits in vessel walls and loss of elastic fibers. This stiffening (arteriosclerosis) creates an increase in pulse wave velocity because the less compliant arteries cannot store the volume ejected.
isolated systolic hypertension (Aging)
left ventricular wall thickness increases.
thickens as u age
left ventricular wall thickness increases.
- creates an increased workload on the heart
- Diastolic BP may decrease after the fifth decade.1 Together with a rising systolic pressure, this increases the pulse pressure (the difference between the two).
thickens as u age
No change in resting heart rate occurs with aging.
Cardiac output at rest is not changed with aging.
NO changes occur as u age
decreased ability of the heart to augment cardiac output with exercise. This is shown by a decreased maximum heart rate with exercise and diminished sympathetic response. Noncardiac factors also cause a decrease in maximum work performance with aging: decrease in skeletal muscle performance, increase in muscle fatigue, increased sense of dyspnea. However, aerobic exercise conditioning modifies many of the aging changes in CV function.
CV alterations w/ ageing lifestyle
presence of supraventricular and ventricular dysrhythmias increases with age. Ectopic beats are common in aging people; although these are usually asymptomatic in healthy older people, they may compromise cardiac output and BP when disease is present.
Dysrhythmias.//Aging adult
may not be tolerated as well in older people
-myocardium is thicker and less compliant, and early diastolic filling is impaired at rest. Thus it may not tolerate a tachycardia as well because of shortened diastole.
Tachydysrhythmias ( shortened diastole= higher chance tachy)
- Prolonged P-R interval (first-degree AV block) and prolonged Q-T interval, but the QRS interval is unchanged.
- Left axis deviation from age-related mild LV hypertrophy and fibrosis in left bundle branch.
- Increased incidence of bundle branch block.
Age-related changes in the ECG
is the leading cause of death in those ages 65 years and older
CVD
—no current smoking, no obesity (i.e., BMI <30), physical activity at least once per week, and a healthy diet
four healthful factors (help reduce CVD )
major form of CVD (Cardiovascular disease)
coronary artery disease (CAD)
contributes to CAD because it accelerates the process of atherosclerosis;
increases the workload on the heart, and it increases the oxygen demand on the heart already compromised by atherosclerosis.
hypertension
High levels of low-density lipoprotein (LDL, or the “bad” cholesterol) add to the lipid core of plaque formation in coronary and carotid arteries
-results in MI and stroke.
Serum Cholesterol.
women tend to have smaller coronary arteries than men
leading cause of death in women is CVD,
Sex and Gender Differences.
Prodromal symptoms are those that are intermittent and resolve spontaneously
-most common prodromal symptom linked with ACS (acute cardiac symptoms) is fatigue.
Four prodromal symptoms linked with ACS are discomfort in the jaw or teeth, unusual fatigue, arm pain, and shortness of breath
- nausea, neck pain, right arm pain, jaw pain, dizziness, and syncope than are men
Women may not experience the crushing chest pain
frequent urination @ night
Nocturia
squeezing “clenched fist” sign is characteristic of angina
angina
sweating, ashen gray or pale skin, heart skips beat, shortness of breath, nausea or vomiting, racing of heart
Diaphoresis, cold sweats, pallor, grayness.
Palpitations, dyspnea, nausea, tachycardia, fatigue.
cardiac symptoms
occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load.
Paroxysmal nocturnal dyspnea (PND) (sensation of SOB that awakens after 1 or 2 hrs sleep)
is the need to assume a more upright position to breathe
Orthopnea
Sputum production, mucoid or purulent. Hemoptysis is often a pulmonary disorder but also occurs with mitral stenosis
cough up mucous (risk cvd)
Fatigue from decreased cardiac output is worse in the
evening
Cyanosis or pallor(ashen) occurs with MI or low cardiac output states as a result of
decreased tissue perfusion.
Any swelling of your feet and legs
- (help elevate legs)
- Cardiac edema is bilateral; unilateral swelling has a local vein cause.
Edema. (risk cvd)
—Recumbency at night promotes fluid resorption and excretion; this occurs with heart failure in the person who is ambulatory during the day.
Nocturia
hypertension, elevated cholesterol or triglycerides, heart murmur, congenital heart disease, rheumatic fever (inflammation esp of heart, blood vessels n joints) or unexplained joint pains as child or youth, recurrent tonsillitis, anemia
(risk cvd)
low-dose aspirin if the potential benefit of preventing MI outweighs the potential risk of GI bleeding, Vitamin D replacement is important; vitamin D deficiency increases risk
(risk cvd)
antihypertensives, beta-blockers, calcium channel blockers, digoxin, diuretics, aspirin/anticoagulants
meds for ppl risk cvd
note fatigue during feeding. Infant with heart failure takes fewer ounces each feeding; becomes dyspneic (difficulty breathing) with sucking; may be diaphoretic, then falls into exhausted sleep; awakens after a short time hungry again.
Cyanosis occurs in some congenital defects: tetralogy of Fallot or transposition of the great arteries.
screen for heart disease in infant
Most causes are musculoskeletal pain and respiratory causes, including asthma.
children (cvd)
Gestational hypertension
-associated symptoms: weight gain; protein in urine; swelling in feet, legs, or face
Pregnant Woman
any known heart or lung disease: hypertension, CAD, chronic emphysema, or bronchitis
-Noncompliance (nt taking meds) may be related to side effects or lack of finances
Risk of CVD increases with advancing age
, the person should be supine with the head and chest elevated between 30 and 45 degrees.
assess the jugular veins and the precordium
the person can be sitting up
evaluate the carotid arteries
- Pulse and BP (see Chapter 10)
- Extremities (see Chapter 21)
- Neck vessels
- Precordium
- begin observations peripherally and move in toward the heart
performing a regional CV assessment, use this order
is the condition in which pressure over the carotid sinus leads to a decreased heart rate, decreased BP, and cerebral ischemia with syncope. This may occur in older adults with hypertension or occlusion of the carotid artery.
Carotid sinus hypersensitivity
feels small and weak (decreased stroke volume as in cardiogenic shock).
Diminished pulse
feels full and strong in hyperkinetic states
Increased pulse
indicates turbulence from a local vascular cause and is a marker for atherosclerotic disease. This increases the risk of transient ischemic attack (TIA) and ischemic stroke.
- blowing, swishing sound indicating blood flow turbulence; normally none is present.
bruit (Auscultate the Carotid Artery)
(1) the angle of the jaw, (2) the midcervical area, and (3) the base of the neck. Avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis
Auscultate carotid artery at three levels:
much the same but is caused by a cardiac disorder. Some aortic valve murmurs (aortic stenosis) radiate to the neck and must be distinguished from a local bruit
murmur sounds
you can assess the central venous pressure (CVP) and thus judge the heart’s efficiency as a pump and the intravascular volume status
jugular veins
is caused by local cause (kinking or aneurysm)
Unilateral distention of external jugular veins
above 45 degrees signify increased CVP as with heart failure.
Full distended external jugular veins
is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex
heave or lift
(volume overload) displaces impulse down and to left and increases size more than one space. A diameter of ≥4 cm is likely a dilated heart.15 This occurs with heart failure and cardiomyopathy.
Left ventricular dilation (Cardiac enlargement)// check precordium
with increased force and duration but no change in location occurs with left ventricular hypertrophy (enlargement of organ or tissue) and no dilation (pressure overload)
sustained impulse (Cardiac enlargement)// check precordium
is a palpable vibration. It feels like the throat of a purring cat. The thrill signifies turbulent blood flow and directs you to locate the origin of loud murmurs. However, absence of a thrill does not rule out the presence of a murmur.
thrill (Palpate Across the Precordium)
Second right interspace—
Aortic valve area
Second left interspace—
Pulmonic valve area
Left lower sternal border—
Tricuspid valve area
Fifth interspace at around left midclavicular line—
Mitral valve area
(1) note the rate and rhythm, (2) identify S1 and S2, (3) assess S1 and S2 separately, (4) listen for extra heart sounds, and (5) listen for murmurs.
Auscultation
occurs normally in young adults and children
sinus arrhythmia
—An isolated beat is early, or a pattern occurs in which every third or fourth beat sounds early.
Premature beat
—No pattern to the sounds; beats come rapidly and at random intervals as in atrial fibrillation
Irregularly irregular
signals a weak contraction of the ventricles; it occurs with atrial fibrillation, premature beats, and heart failure
pulse deficit
and thus serves as the reference point for the timing of all other cardiac sounds
S1 is the start of systole
S1 is louder than S2 at the apex;
S2 is louder than S1 at the base.
distinguish S1 from S2 are:
S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1
-S1 coincides with the R wave (the upstroke of the QRS complex) i
S1 n carotid artery pulse
with conditions that place an increased amount of tissue between the heart and your stethoscope: emphysema (hyperinflated lungs), obesity, pericardial fluid
both heart sounds are diminished
means that you are hearing the mitral and tricuspid components separately.
-audible in the tricuspid valve area, the left lower sternal border. The split is very rapid, with the two components only 0.03 second apart
split S1 (normal)
is associated with closure of the semilunar valve
S2
is a normal phenomenon that occurs toward the end of inspiration in some people. Recall that closure of the aortic and pulmonic valves is nearly synchronous. Because of the effects of respiration on the heart described earlier, inspiration separates the timing of the two valves’ closure, and the aortic valve closes 0.06 second before the pulmonic valve. Instead of one DUP, you hear a split sound—T-DUP (Fig. 20.24). During expiration, synchrony returns and the aortic and pulmonic components fuse together. A split S2 is heard only in the pulmonic valve area, the second left interspace.
split S2
is unaffected by respiration; the split is always there.
fixed split
is the opposite of what you would expect; the sounds fuse on inspiration and split on expiration
paradoxical split (opp of split s2)
(which is associated with mitral valve prolapse) is the most common extra sound
midsystolic click
occur in diastole; either may be normal or abnormal
third and fourth heart sounds
occurs with heart failure and volume overload;
S3 (ventricular gallop)
occurs with CAD
S4 (atrial gallop)
may occur with a healthy heart or with heart disease;
systolic murmur
always indicates heart disease.
diastolic murmur
Grade 1—Barely audible; heard only in a quiet room and then with difficulty
Grade 2—Clearly audible but faint
Grade 3—Moderately loud; easy to hear
Grade 4—Loud; associated with a thrill palpable on the chest wall
Grade 5—Very loud; heard with one corner of the stethoscope lifted off the chest wall; associated thrill
Grade 6—Loudest; still heard with entire stethoscope lifted just off the chest wall; associated thrill
Loudness. Describe the intensity of murmur
. Describe the pitch as high, medium, or low. The pitch depends on the pressure and rate of blood flow producing the murmur.
Pitch of murmur
is low-pitched and rumbling, whereas that of aortic stenosis is harsh
murmur of mitral stenosis& aortic stenosis
is caused by increased blood flow in the heart (e.g., in anemia, fever, pregnancy, hyperthyroidism)
functional murmur
S3 and S4 and the murmur of mitral stenosis sometimes may be heard only when on the
left side.
grows softer with standing-to-squatting, and it grows louder with squatting-to-standing.15 HCM is an inherited thickening of the myocardium
murmur of hypertrophic cardiomyopathy (HCM)
is a level of pulsation that is >3 cm above the sternal angle while at 45 degrees . This occurs with heart failure, cardiac tamponade, and constrictive pericarditis. (angle of Louis (sternal angle))
Elevated pressure
heart failure is present, the jugular veins will elevate more than 4 cm and stay elevated as long as you push
perform the abdominojugular test (formerly hepatojugular reflux)
(particularly in the skin), liver size, and respiratory status. The skin color should be pink to pinkish brown
extracardiac signs that may reflect heart status in infants
most important signs of heart failure in an infant are persistent tachycardia, tachypnea, and liver enlargement. -Engorged veins, gallop rhythm, and pulsus alternans also are signs. Respiratory crackles (rales) are an important sign in adults but not in infants.
signs of heart failure in an infant
- Cardiac enlargement, shifts to the left.
- Pneumothorax, shifts away from the affected side.
- Diaphragmatic hernia, shifts usually to right because this hernia occurs more often on the left.
- Dextrocardia, a rare anomaly in which the heart is located on right side of chest.
The apex is displaced with:
Persistent tachycardia is >200 beats/min in newborns or >150 beats/min in infants.
-Expect the heart rhythm to have sinus arrhythmia
infants n neonate tachycardia range
Bradycardia is <90 beats/min in newborns or <60 beats/min in older infants or children
-Expect the heart rhythm to have sinus arrhythmia
infants n neonate bradycardia range
S2 has a higher pitch and is sharper than S1. Splitting of S2 just after the height of inspiration is common, not at birth but beginning a few hours after birth.
infants s1,s2
indicates atrial septal defect
Fixed split S2 (infants)
Murmurs in the immediate newborn period do not necessarily indicate congenital heart disease. They are relatively common in the first 2 to 3 days because of fetal shunt closure. These murmurs are usually grade 1 or 2, are systolic, accompany no other signs of cardiac disease, and disappear in 2 to 3 days
Murmurs in the immediate newborn are normal
are associated with: harsh murmur quality, location (right upper sternal border, left lower sternal border, apex), and timing (pansystolic, diastolic, or continuous)
Congenital defects in infants if murmur is absent
apical impulse is sometimes visible in children with thin chest walls
-any obvious bulge or any heave—these are not normal.?
children
to the left of the sternum with a hyperdynamic precordium signals cardiac enlargement. The bulge occurs because the cartilaginous rib cage is more compliant.
precordial bulge
occurs with right ventricular enlargement; an apical heave occurs with left ventricular hypertrophy.
substernal heave
is common in children. It occurs in early diastole, just after S2, and is a dull soft sound that is best heard at the apex.
Physiologic S3 (Children)
—caused by turbulence of blood flow in the jugular venous system—is common in healthy children and has no pathologic significance. It is a continuous, low-pitched, soft hum that is heard throughout the cycle, although it is loudest in diastole.
venous hum (Children)
is a benign murmur heard just above the clavicles.
-slightly harsh, early or midsystolic, often louder on the left, and will disappear completely by carotid artery compression.
carotid bruit
that are innocent (or functional) in origin are very common through childhood (often termed Still’s murmur).
Heart murmurs (child)
is BP ≥140/90 mm Hg on two separate measures without proteinuria, starting after 20th week of pregnancy. This returns to baseline by 12 weeks after delivery.
Gestational hypertension
usually lowest in the left lateral recumbent position, a bit higher when supine, and highest when sitting
Gestational hypertension
Inspection of the skin often shows a mild hyperemia in light-skinned women because the increased cutaneous blood flow tries to eliminate the excess heat generated by the increased metabolism.
-Palpation of the apical impulse is higher and lateral compared with the normal position because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis.
Pregnant Woman
An exaggerated splitting of S1 and increased loudness of S1 are common, as is a loud, easily heard S3. An ejection systolic murmur is common; heard at left sternal border; grade 1, 2 or 3 in intensity.
-Murmurs of aortic valve disease cannot be obliterated.
Pregnant Woman
from breast vasculature is termed a mammary souffle
-heard in the 2nd, 3rd, or 4th intercostal space;
continuous murmur
gradual rise in SBP is common with aging; the DBP stays fairly constant with a resulting widening of pulse pressure.
Aging Adult
chest often increases in anteroposterior diameter with aging
-makes it more difficult to palpate the apical impulse and hear the splitting of S2. The S4 often occurs in older people with no known cardiac disease. Systolic murmurs are common, occurring in over 50% of aging people
Aging Adult/ heart
is associated with heart failure and is always abnormal over age 35 year
-Occasional premature ectopic beats are common and do not necessarily indicate underlying heart disease.
S3 (older adult)
stable (no change in pain pattern within last 60 days)
-Pressurelike pain (e.g., tightness, squeezing, burning, heaviness that lasts 3-5 minutes precipitated by activity and often resolves with rest and/or nitroglycerin
location/radiation: Generalized substernal or retrosternal: can radiate to teeth, jaw, neck, one or both arms or shoulders; or there may be no pain and only associated symptoms
Possible Associated Symptoms:Diaphoresis, nausea, vomiting, dyspnea, fatigue
Angina pectoris://Cardiovascular (Ischemic)
desc: Pressurelike discomfort often occurring at rest, unrelated to physical or emotional stress
location/radiation: Retrosternal: can radiate to jaw, neck, left arm, or shoulder
Possible Associated Symptoms:Palpitations(noticeably rapid, strong,or irregular heartbeat), syncope, or feelings of syncope
Prinzmetal or variant angina////Cardiovascular (Ischemic)
desc:Heaviness; viselike, squeezing, crushing, tightness; vague, burning, constricting, or pressure; poorly localized pain lasting 20-30 minutes to hours and does not resolve with rest or nitroglycerin
location/radiation:Generalized substernal or retrosternal: can radiate to teeth, jaw, neck, one or both arms or shoulders; or there may be no pain and only associated symptoms
Possible Associated Symptoms: Indigestion-like feeling, nausea, vomiting, dizziness, flushing, perspiration, palpitations, dyspnea, fatigue
Acute coronary syndrome (ACS) (unstable angina, myocardial infarction)//Cardiovascular (Ischemic)
desc:Sudden sharp and stabbing pain relieved often by sitting or leaning forward and worsens by lying down or with inspiration
location/radiation: Substernal, which can radiate to trapezius muscle region
Possible Associated Symptoms: Dry cough, muscle and joint aches, fever
Pericarditis(Cardiovascular (Nonischemic)
desc: Sharp pain not associated with activity
location/radiation: Chest pain without radiation
Possible Associated Symptoms:Fatigue, light-headedness, dyspnea, irregular heartbeat, palpitations, exercise intolerance
Mitral valve prolapse(Cardiovascular (Nonischemic)
desc: Sudden severe pain with change in location and/or tearing sensation lasting for hours
location/radiation: Anterior chest pain with radiation to the neck, jaw, or intrascapular region of the back
Possible Associated Symptoms: Mental status changes, limb pain and weakness, dyspnea
Aortic dissection(Cardiovascular (Nonischemic)
desc:Cardiac-like chest pain with exertion
location/radiation: Chest region
Possible Associated Symptoms: Dyspnea, lower-extremity edema, fatigue
Pulmonary hypertension (secondary)//(Cardiovascular (Nonischemic)
desc: Sharp, stabbing pain worsening with deep breaths
location/radiation: Pain can be experienced in chest, back, shoulder, or upper abdomen
Possible Associated Symptoms: Dyspnea, hemoptysis(coughing up blood), cough
Pulmonary embolism (Pulmonary)
desc: Sharp or stabbing pain associated with cough
location/radiation: Mostly generalized to one side of chest but can have upper abdominal pain
Possible Associated Symptoms: Cough, fever, dyspnea, chills, sputum, myalgia, malaise
Pneumonia (Pulmonary)
desc:Acute/sudden and sharp
location/radiation: Lateral region of the chest but can have referred pain to shoulder
Possible Associated Symptoms: Acute dyspnea, cough
Pneumothorax(Pulmonary)
desc: May be angina-like; however, usually burning sensation with eating large meals reproduced by lying down and relieved by sitting up
location/radiation: Retrosternal region
Possible Associated Symptoms: Cough, regurgitation of food, abdominal pain
Gastroesophageal reflux (Gastrointestinal)
desc: Crushing chest pain
location/radiation: Substernal
Possible Associated Symptoms: Dysphagia, sensation of object in throat or esophagus
Esophageal spasm(Gastrointestinal)
desc: Sudden onset of pain that crescendos and can last for up to 20 minutes, usually after eating a fatty meal
location/radiation: Epigastrium or right upper abdomen that can radiate to right intrascapular region, shoulder, or back
Possible Associated Symptoms: Nausea, vomiting, anorexia, fever
Cholecystitis(Gastrointestinal)
desc: Sudden dull, boring, steady pain unrelieved by lying supine; leaning forward or the fetal position may ease pain
location/radiation: Epigastrium or periumbilical pain radiating to back
Possible Associated Symptoms: Nausea, vomiting, anorexia, and sometimes diarrhea
Pancreatitis(Gastrointestinal)
desc: Unilateral, burning, borelike pain
location/radiation: Chest region in dermatome distribution
Possible Associated Symptoms:Tingling, itching, burning
Herpes zoster//Dermatologic
desc: Sharp, pleuritic-type pain worsens with deep breathing, palpation, or movement
location/radiation: Area from 2nd through 5th intercostal spaces; can radiate to arm, depending on where initial inflammation occurs
Possible Associated Symptoms: Chest tightness, warmth at area of pain
Costochondritis(Musculoskeletal/Neurologic)
desc: Sharp pain with moving, stretching, or pushing movements of the arms; palpation of area reproduces the pain
location/radiation: Area around the strained muscle, sternum, or ribs
Possible Associated Symptoms: Muscle spasm, crepitation, swelling, loss of strength
Chest wall muscle strain(Musculoskeletal/Neurologic)
desc: Heaviness
location/radiation: Chest region
Possible Associated Symptoms: Fatigue, restlessness, withdrawal, weight gain or loss, depressed mood
Depression (Psychogenic)
desc: Sharp pain
location/radiation:Chest region
Possible Associated Symptoms: Palpitations, dizziness, sweating, shaking, restlessness, fatigue, irritability
Anxiety(Psychogenic)
Decreased cardiac output occurs when the heart fails as a pump and the circulation becomes backed up and congested.
Heart Failure
(1) the heart’s inability to pump enough blood to meet the metabolic demands of the body;
(2) the kidney’s compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output. This increases blood volume and venous return, which causes further congestion.
Signs and symptoms of heart failure come from two basic mechanisms
(1) acute, as following a myocardial infarction when the heart’s contracting ability has been directly damaged; or (2) chronic, as with hypertension, when the ventricles must pump against chronically increased pressure.
Onset of heart failure maybe
systolic dysfunction, in which the heart cannot contract properly, resulting in a low ejection fraction (the stroke volume divided by the end-diastolic volume, normally 60% to 80%)
Heart failure involve
is a failure of the heart to relax fully between heartbeats; here the heart muscle wall is stiff and does not fill properly; there is low cardiac output but a normal ejection fraction.
Diastolic dysfunction
(1) position of the atrioventricular (AV) valve at the start of systole,
(2) structure of the valve leaflets,
(3) how quickly pressure rises in the ventricle.
intensity of S1 depends on three factors
Position of AV valve at start of systole—Wide open and no time to drift together
ex:Hyperkinetic states in which blood velocity is increased: exercise, fever, anemia, hyperthyroidism
Loud (Accentuated) S1
Change in valve structure—Calcification of valve; needs increasing ventricular pressure to close the valve against increased atrial pressure
ex: Mitral stenosis with leaflets still mobile
Loud (Accentuated) S1
- Position of AV valve—Delayed conduction from atria to ventricles. Mitral valve drifts shut before ventricular contraction closes it (First-degree heart block (prolonged PR interval))
- Change in valve structure—Extreme calcification, which limits mobility (Mitral insufficiency)
- More forceful atrial contraction into noncompliant ventricle; delays or diminishes ventricular contraction(ex:Severe hypertension—Systemic or pulmonary)
Faint (Diminished) S1
- Position of AV valve varies before closing from beat to beat (Atrial fibrillation—Irregularly irregular rhythm)
- Atria and ventricles beat independently(Complete heart block with changing PR interval)
Varying Intensity of S1
Mitral and tricuspid components are heard separately(normal but uncommon)
Split S1
- Higher closing pressure(ex:Systemic hypertension, ringing or booming S2)
- Exercise and excitement increase pressure in aorta
- Pulmonary hypertension(Mitral stenosis, heart failure)
- Semilunar valves calcified but still mobile (Aortic or pulmonic stenosis)
Accentuated S2
- A fall in systemic blood pressure causes a decrease in valve strength (shock)
- Semilunar valves thickened and calcified, with decreased mobility (Aortic or pulmonic stenosis)
Diminished S2
Ejection click
Aortic prosthetic valve sounds
Early systolic: (
Systolic Extra Sounds)
Midsystolic (mitral) click
Mid/late systolic:
- Opening snap
2. Mitral prosthetic valve sound
Early diastole: Diastolic Extra Sounds
- Third heart sound
2. Summation sound (S3 + S4)
Mid-diastole//Diastolic Extra Sounds
1. Fourth heart sound
2.Pacemaker-induced sound
Late diastole://Diastolic Extra Sounds
Normally the opening of the AV valves is silent. In the presence of stenosis, increasingly higher atrial pressure is required to open the valve. The deformed valve opens with a noise: the opening snap. It is sharp and high pitched with a snapping quality. It sounds after S2 and is best heard with the diaphragm at the 3rd or 4th left interspace at the sternal border, less well at the apex.
Opening Snap
