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
Downs syndrome
Marfan s
syndrome
Turner s syndrome
Turner s syndrome
Acromegaly
Acromegaly
General
Examination
Breathlessness
In pain
Febrile
Pallor
Xanthelesma
Xanthelesma
Cleft ear lobes
Central cyanosis
Dental care
Thyroid enlargement
Central cyanosis
Clubbing of the fingers
Splinter heamorrhages
Splinter haemorrhages
Oslers nodes
Janeways lesions
Ankle oedema
Sacral oedema
Pulse
Presence or absence
Rate
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 waves

Cannon 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
Palpation
Apex 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.

Apex beats different types


Tapping apex beat seen in

Mitral stenosis


Apex beats different types

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

Aortic regurgitation
Mitral regurgitation
Left to right shunts.

Apex beats different types

Double or triple impulse occur in

Hypertrophic obstructive
cardiomyopathy

Apex beats different types

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 to
Auscultate over the mitral
area in left lateral position in
expiration with the bell to find
mid diastolic murmur in mitral
stenosis

Never forget to
Auscultate 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
Murmurs
Heart murmurs are caused by
turbulent blood flow through
valves or ventricular outflow
tracts
Characteristics of heart murmurs
Timing
Duration
Character and pitch
Intensity
Location
Radiation
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 murmurs

Early diastolic murmurs

Mid-diastolic murmurs

Early diastolic murmurs

Aortic 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 murmurs

Mitral 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




.`
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

END