CARDIOVASCULA

R
SYSTEM
Submitted by Submitted to
Meghshyam Sharma Miss.mehak Kapoor
Aott
3rd semester
Contents

1. Physical examination of cardiovascular disease

2. Manifestation of cardiovascular disease
Topics in physical examination

■ Vital signs
■ Chest inspection
■ Body inspection
■ Internal jugular vein inspection
■ Edema inspection
■ Cyanosis inspection
■ Pulse inspection
■ Palpation
■ Sound inspection
Manifestation of cardiovascular disease

■ Cardiovascular disease
■ Types of cardiovascular disease
■ Risk factors of cardiovascular disease
 Vital signs

■ Vital signs are necessary for every patient you clinically examine, including heart rate
(HR), respiratory rate (RR),
■ and blood pressure (BP). In most situations, these are measured with basic equipment (a
watch, a sphygmomanometer, and a stethoscope) and are part of a physician’s basic
skills.
 Chest inspection

■ With the anterior chest exposed, observe your patient’s thorax and the rest of their body.
■ Look at the eyes, upper and lower extremities, and neck veins as well.
■ Scars from prior cardiac surgery.
■ A vertical scar on the sternum is an indication of prior open-heart surgery.
■ Chest deformities include pectus excavatum (a sunken sternum and ribs may be a sign
of a connective tissue disease
■ such as Marfan syndrome) and pectus carinatum (“pigeon chest,” a protrusion of the
sternum
 Eyes inspection

■ Yellow plaques around the eyes and eyelids, called xanthelasmas, may signify
hypercholesterolemia.
■ Although sometimes seen in patients without hyperlipidemia, xanthelasmas can be a
sign of a risk factor for cardiovascular disease.
■ Roth spots are observed on the retina with an ophthalmoscope and appear as a red ring
surrounding a white center.
■ These are only seen in about 2% of patients with infective endocarditis but are a classic
sign that medical students are often tested on.
■ The cardiovascular exam includes observing the right internal jugular vein (IJV).
■ This test helps evaluate right heart function and central venou
 Internal jugular vein inspection

Elevate the patient’s head between 15° and 30° while lying supine.
■ Identify the right IJV. This may take some practice. It crosses deep to the
sternocleidomastoid muscle and anterior to the right ear.
■ Ask the patient to turn their head to the left or perform a Valsalva maneuver.
■ The hepatojugular reflux maneuver can also help find the internal jugular vein. Apply
firm pressure to the right upper quadrant of the liver for a few seconds, and the IJV will
fill with blood. A penlight can be very useful while trying to find the IJV .
■ Measure the top of the IJV fluid level in cm above the Angle of Louis (sternal angle).
■ A normal measurement is a vertical height 3 cm above the sternal angle
 Palpation methods

■ The palpation portion of the cardiovascular exam includes evaluating the peripheral
pulses in the neck (for carotid pulses) and extremities;
■ it also palpation of the point of maximum impulse (PMI) on the anterior chest wall.
■ A relatively strong vibration is created when the ventricles contract, transmitted down
the apex of the heart and into the chest wall.
■ The PMI is located at the 5th intercostal space in the left midclavicular line in a healthy
individual
■ Evaluate the extremities for temperature.
■ Gently touch the hands and feet and note their temperatures. A well-perfused extremity
will be slightly warm or at body temperature.
■ A cold extremity indicates poor perfusion or blood being shunted away from the skin. A
warm extremity suggests a reduction of vascular resistance and may be a sign of septic
shock in a patient with severe hypotension.
 Pulse inspection

■ There are a variety of pulse points with which you should be familiar. Some are
regularly used
■ (radial pulse, carotid pulse), and some are infrequently used (femoral pulse).
■ A thorough cardiac exam requires an evaluation of all peripheral pulses. Always
compare the pulses on both sides of the body to detect differences in strength.
Carotid artery
Radial artery
Femoral artery
Popliteal artery
Posterior tibial artery
■ Dorsalis pedis
■ Palpating the extremities is the preferred method for quantifying peripheral edema
■ The two types of edema are pitting and non-pitting edema.[
 Cyanosis inspection

■ Cyanosis, a bluish discoloration of the skin and mucous membranes, implies poor
perfusion.
■ The presence of at least 3 g/dL of reduced or deoxygenated hemoglobin (Hb)
corresponds to an O2 saturation of < 85% if the patient is not anemic. The lower the Hb
level,
■ the lower the O2 saturation needed before cyanosis can be appreciated. Cyanosis does
not appear at a Hb level of 10 g/dL until the O2 saturation is ~ 70%. If you see cyanosis
in a severely anemic patient, this means that the concentration of Hb is very low, and the
patient is critically ill.
■ Cyanosis can be detected in the extremities (peripheral cyanosis) or the lips (central
cyanosis, which is more serious). [4]
 Edema inspection

■ Pitting edema refers to the depressed or indented area that results from pressure applied
over an area of swollen/edematous tissue.
■ It is caused by the displacement of thin, watery, protein-poor (transudative) interstitial
fluid.
■ Although it can affect any part of the body, pitting edema usually occurs in the legs,
feet, and ankles due to venous insufficiency caused by congestive heart failure
■ Edem associated with decreased plasma oncotic pressure (e.g., low serum albumin
associated with liver failure or malnutrition) does not change with dependency.
■ Non-pitting or “brawny” edema is observed when applied pressure does not leave an
indentation.
■ It is usually caused by compression or compromise of lymphatic drainage
(lymphedema) and can also be seen in myxedema of hypothyroidism.
■ The non-compressible subcutaneous tissue contains proteinaceous and possibly
organizing collagenous substances.
 Edema grading

Trace Barely detectable impression when a finger is pressed into the skin
1+ Mild pitting edema, disappears rapidly
2+ Moderate indentation, persists for more than a few seconds
3+ Moderately severe pitting, more profound and persists longer than 2+
■ 4+ Severe pitting that persists for over a minute
■ Place the palm of your right hand on the chest.
■ With the heel of your palm at the left lower sternal border, your fingers should wrap
around the patient’s ribs laterally.
■ Apply some pressure to the chest wall until you feel the heartbeat in your palm.
■ Identify the point of maximum impulse on the chest wall. It will be a small area, no
larger than 2–3 cm wide.
 Obesity inspection

■ Obesity will make this part of the exam difficult.

■ The PMI of a healthy person with a normal and healthy heart will be located near the
5th intercostal space,
■ along the midclavicular line. The PMI of a dilated or hypertrophied left ventricle will be
displaced laterally.
■ A thrill–a vibration associated with turbulent blood flow– may be detected if valvular
disease is present. This is through a damaged or malformed valve.
■ Thrills are located near the area in which the valves are auscultated.
■ Auscultation
■ The detection and recognition of heart sounds play an important role in diagnosing
various cardiac and valvular conditions.
■ Because familiarity with heart sounds has such profound and practical importance,
students undertaking the USMLE are expected to have a good understanding of their
pathophysiology and their clinical applications.
■ Auscultation is best performed on bare skin.
■ Always be sure to maintain your patient’s modesty while examining on the chest.
 Sounds of heart

■ On auscultation, 2 heart sounds are heard from a normal heart, known as “S1” and “S2,”
or the first and second heart sounds.
■ They reflect the turbulence created when the heart valves close. Two extra heart sounds
may also be heard, called the third and fourth heart sounds, “S3” and “S4” may be heard
in both normal and abnormal conditions.
■ A murmur consists of a blowing, whooshing, or rasping sound heard during a heartbeat
as blood flows through the heart’s chambers and valves or blood vessels near the heart.
It can be a sign of a benign/physiologic or pathologic condition.
■ murmur is a sound that is produced by turbulent blood flow across a heart valve. The
turbulent flow can occur for two reasons.
■ blood flowing across an abnormal heart valve or increased blood flowing across a
normal heart valve.
■ Heart murmurs may be classified as physiological or innocent murmurs or pathologic
murmurs based on their etiology. [20]
■ Stenosis is the abnormal narrowing of a valve orifice, commonly seen when age-related
calcific deposits (“degenerative calcification”) occur in the aortic valve.
■ Stenosis is also seen in a mitral valve damaged by scar tissue from healed rheumatic
heart disease (RHD).
■ mostly seen in developing countries, or by myxomatous disease and fibroelastic
deficiency, more common in developed countries.
■ Regurgitation refers to the abnormal backward flow of blood from a high-pressure
chamber to a low-pressure chamber, often due to an incompetent valve (i.e., a valve that
cannot close properly).
■ An example is valvular aortic regurgitation (AR), most commonly due to congenital or
degenerative abnormalities of the aortic leaflets, aortic root, and ascending aorta in
developed countries.
■ At the same time, RHD remains the most common cause of severe AR worldwide
 First sound

■ The first heart sound, S1, corresponds to the closure of the atrioventricular valves—the
tricuspid and mitral valves of the heart.
■ S1 represents the start of ventricular systole. The closure of the mitral valves precedes
the closure of the tricuspid valves,
■ but this is only minimally different so that S1 is usually heard as a single sound. S1 is
best heard at the apex of the heart, which points to the left of the body and is located
near the PMI in a healthy individual).
 Second heart sound

■ The second heart sound, S2, corresponds to the closure of the semilunar valves—the
aortic and pulmonary valves of the heart.
■ S2 signifies the end of ventricular systole and the beginning of diastole.
■ S2 is shorter, softer, and slightly higher pitched than the first heart sound. A reduced or
absent S2 indicates pathology due to an abnormal aortic or pulmonic valve.
 Extra heart sound

■ Extra” heart sounds include the third and fourth heart sounds called S3 and S4. S3 is a
mid-diastolic,
■ low-pitched sound that occurs after S2 during the rapid passive filling of the ventricle.
When there is an audible S3.
■ the heart sounds are described as having a gallop rhythm, resembling a galloping horse,
especially at rapid heart rates.
■ which sounds like the word “Kentucky.” S3 is also called a ventricular gallop.
 Fourth heart sound

■ The fourth heart sound (S4) is a late diastolic sound. It is a bit higher-pitched than S3.
An S4 sound can produce a gallop rhythm but with a cadence that matches the word
“Tennessee.”
■ It is never heard when there are no atrial contractions (it is absent in atrial fibrillation).
S4 is caused by decreased ventricular compliance.
■ the most common causes of a left-sided S4 include hypertensive heart disease, aortic
stenosis, and ischemic and hypertrophic cardiomyopathy.
■ As in pulmonary hypertension and pulmonary stenosis, reduced right ventricular
compliance can also cause a right-sided S4.
 Difference between heart sounds

Heart Sound Causes

Normal Heart Sounds
First heart sound (S1) Closure of the mitral and tricuspid valves
Second heart sound (S2) Closure of the aortic and pulmonary valves
Extra Heart Sounds
■ Third heart sound (S3) A physiological S3 is caused by rapid diastolic filling (e.g., pregnancy, thyrotoxicosis, and
sometimes in children).
■ A pathological S3 is caused by reduced compliance of the left ventricle (e.g., left ventricular failure, aortic
regurgitation, mitral regurgitation, patent ductus arteriosus, and a ventricular septal defect) or reduced compliance of
the right ventricle (right ventricular failure, constrictive pericarditis).
■ Fourth heart sound (S4) Decreased ventricular compliance of the left ventricle (aortic stenosis, mitral regurgitation,
hypertension, angina, myocardial infarction) or the right ventricle (pulmonary hypertension, pulmonary stenosis)
Midsystolic murmur Increased flow through a normal valve (physiologic or innocent
murmur), aortic stenosis, pulmonary stenosis, hypertrophic cardiomyopathy, atrial septal
defect
Late systolic murmur Mitral regurgitation (MR), due to papillary muscle dysfunction,
mitral valve prolapse, or infective endocarditis
■ Pansystolic murmur Mitral regurgitation, tricuspid regurgitation, ventricular
septal defect (VSD), aortopulmonary shunts
Early diastolic murmur Aortic regurgitation, pulmonary regurgitation
■ Mid-diastolic murmur Mitral stenosis, tricuspid stenosis, atrial myxoma (rare),
acute rheumatic fever murmur (Carey Coombs murmur of mitral valvulitis)
Presystolic murmur Mitral stenosis, tricuspid stenosis, atrial myxoma
■ Continuous murmur Patent ductus arteriosus, arteriovenous fistula, venous hum
 Cardiovascular disease

■ Cardiovascular disease (CVD) is any disease involving the heart or blood vessels.[3]
CVDs constitute a class of diseases that includes: coronary artery diseases (e.g. Angina,
heart attack),
■ heart failure, hypertensive heart disease, rheumatic heart disease, cardiomyopathy,
arrhythmia, congenital heart disease
■ , valvular heart disease, carditis, aortic aneurysms, peripheral artery disease,
thromboembolic disease, and venous thrombosis.[3][4]
 Types of cardiovascular disease

There are many cardiovascular diseases involving the blood vessels. They are known as
vascular diseases.[citation needed]
Coronary artery disease (coronary heart disease or ischemic heart disease)
Peripheral arterial disease – a disease of blood vessels that supply blood to the arms and
legs
Cerebrovascular disease – a disease of blood vessels that supply blood to the brain (includes
stroke)
■ Renal
There are also many cardiovascular diseases that involve the heart.
Cardiomyopathy – diseases of cardiac muscle
Hypertensive heart disease – diseases of the heart secondary to high blood pressure or
hypertension
■ Heart failure – a clinical syndrome caused by the inability of the heart to supply
sufficient blood to the tissues to meet their metabolic requirements
 Risk factors in cardiovascular
disease
■ There are many risk factors for heart diseases: age, sex, tobacco use, physical inactivity,
■ non-alcoholic fatty liver disease, excessive alcohol consumption,
■ unhealthy diet, obesity, genetic predisposition and family history of cardiovascular
disease, raised blood pressure (hypertension), raised blood sugar (diabetes mellitus),
■ raised blood cholesterol (hyperlipidemia), undiagnosed celiac disease, psychosocial
factors, poverty and low educational status, air pollution, and poor
 Genetic

■ Cardiovascular disease in a person’s parents increases their risk by ~3 fold,[25] and

genetics is an important risk factor for cardiovascular diseases.
■ Genetic cardiovascular disease can occur either as a consequence of single variant
(Mendelian) or polygenic influences.
■ There are more than 40 inherited cardiovascular disease that can be traced to a single
disease-causing DNA variant, although these conditions are rare
■ Most common cardiovascular diseases are non-Mendelian and are thought to be due to
hundreds or thousands of genetic variants (known as single nucleotide polymorphisms
■ , each associated with a small effect
 Age

■ Age is the most important risk factor in developing cardiovascular or heart diseases,
with approximately a tripling of risk with each decade of life.
■ Coronary fatty streaks can begin to form in adolescence.
■ It is estimated that 82 percent of people who die of coronary heart disease are 65 and
older.
■ Simultaneously, the risk of stroke doubles every decade after age 55
 Sex
■ Men are at greater risk of heart disease than pre-menopausal women.
■ Once past menopause, it has been argued that a woman’s risk is similar to a man’s
■ although more recent data from the WHO and UN disputes this.
■ If a female has diabetes, she is more likely to develop heart disease than a male with
diabetes.
■ Women who have high blood pressure and had complications in their pregnancy have
three times the risk of developing cardiovascular disease compared to women with
normal blood pressure who had no complications in pregnancy.
Tobacco

■ Cigarettes are the major form of smoked tobacco.

■ Risks to health from tobacco use result not only from direct consumption of tobacco,
but also from exposure to second-hand smoke.
■ Approximately 10% of cardiovascular disease is attributed to smoking;
■ however, people who quit smoking by age 30 have almost as low a risk of death as
never smokers.
 Physical activity

■ Insufficient physical activity (defined as less than 5 x 30 minutes of moderate activity

per week, or less than 3 x 20 minutes of vigorous activity per week) is currently the
fourth leading risk factor for mortality worldwide.
■ In 2008, 31.3% of adults aged 15 or older (28.2% men and 34.4% women) were
insufficiently physically active.
■ The risk of ischemic heart disease and diabetes mellitus is reduced by almost a third in
adults who participate in 150 minutes of moderate physical activity each week (or
equivalent).
■ In addition, physical activity assists weight loss and improves blood glucose control,
blood pressure, lipid profile and insulin sensitivity. These effects may, at least in part,
explain its cardiovascular benefits.[3]
 Diet

■ High dietary intakes of saturated fat, trans-fats and salt, and low intake of fruits,
vegetables and fish are linked to cardiovascular risk, although whether all these
associations indicate causes is disputed.
■ The World Health Organization attributes approximately 1.7 million deaths worldwide
to low fruit and vegetable consumption.
■ Frequent consumption of high-energy foods, such as processed foods that are high in
fats and sugars, promotes obesity and may increase cardiovascular risk
■ The amount of dietary salt consumed may also be an important determinant of blood
pressure levels and overall cardiovascular risk.
■ There is moderate quality evidence that reducing saturated fat intake for at least two
years reduces the risk of cardiovascular disease.
■ High trans-fat intake has adverse effects on blood lipids and circulating inflammatory
markers,
■ and elimination of trans-fat from diets has been widely advocated.In 2018 the World
Health Organization estimated that trans fats were the cause of more than half a million
deaths per year.[45
 Celiac disease

■ Untreated celiac disease can cause the development of many types of cardiovascular
diseases,
■ most of which improve or resolve with a gluten-free diet and intestinal healing.
■ However, delays in recognition and diagnosis of celiac disease can cause irreversible
heart damage.
 Sleeping
■ A lack of good sleep, in amount or quality, is documented as increasing cardiovascular risk
in both adults and teens.
■ Recommendations suggest that Infants typically need 12 or more hours of sleep per day,
adolescent at least eight or nine hours, and adults seven or eight.
■ About one-third of adult Americans get less than the recommended seven hours of sleep per
night, and in a study of teenagers,
■ just 2.2 percent of those studied got enough sleep, many of whom did not get good quality
sleep. Studies have shown that short sleepers getting less than seven hours sleep per night
have a 10 percent to 30 percent higher risk of cardiovascular disease.
Thank you 😊