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leaves the right ventricle, bifurcates, and carries the venous blood to the lungs
return the freshly oxygenated blood to the left side of the heart, and the aorta carries it out to the body.
- a tough, fibrous, double-walled sac that surrounds and protects the heart
- *The pericardium is adherent to the great vessels, esophagus, sternum, and pleurae and is anchored to the diaphragm.
the muscular wall of the heart; it does the pumping.
he thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.
the right side of the heart pumps
blood into the lungs
the left side of the heart simultaneously pumps
blood into the body.
- the ventricles relax and fill with blood. This takes up two thirds of the cardiac cycle
- *In diastole, the ventricles are relaxed, and the AV valves, (i.e., the tricuspid and mitral) are open
- *The pressure in the atria is higher than that in the ventricles, so blood pours rapidly into the ventricles
- The heart's contraction
- During systole, blood is pumped from the ventricles and fills the pulmonary and systemic arteries. This is one third of the cardiac cycle.
The closure of the AV valves contributes to the first heart sound (S1) and signals the beginning of systole. The AV valves close to prevent any regurgitation of blood back up into the atria during contraction.
This closure of the semilunar valves causes the second heart sound (S2) and signals the end of systole.
MoRe to the heart
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.
Less to the Left
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. This is a split S2.
- ventricular filling creates vibrations that can be heard over the chest
- The S3 occurs when the ventricles are resistant to filling during the early rapid filling phase (protodiastole). This occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles.
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. The S4 occurs just before S1.
- A murmur is a gentle, blowing, swooshing sound that can be heard on the chest wall.
- Conditions resulting in a murmur are as follows:
- 1.Velocity of blood increases (flow murmur) (e.g., in exercise, thyrotoxicosis)
- 2.Viscosity of blood decreases (e.g., in anemia)
- 3.Structural defects in the valves (narrowed valve, incompetent valve) or unusual openings occur in the chambers (dilated chamber, wall defect)
All heart sounds are described by
- 1.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
- 2.Intensity (loudness)—loud or soft
- 3.Duration—very short for heart sounds; silent periods are longer
- 4.Timing—systole or diastole
The electrical impulse stimulates the heart to do its work, which is to contract. A small amount of electricity spreads to the body surface, where it can be measured and recorded on the electrocardiograph (ECG). The ECG waves are arbitrarily labeled PQRST
depolarization of the atria
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)
depolarization of the ventricles
repolarization of the ventricles
In the resting adult, the heart normally pumps between
4 and 6 L of blood per minute throughout the body
- equals the volume of blood in each systole (called the stroke volume) times the number of beats per minute (rate). This is described as:
- CO = SV × R
- 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
- **When the volume of blood returned to the ventricles is increased (as when exercise stimulates skeletal muscles to contract and force more blood back to the heart), the muscle bundles are stretched beyond their normal resting state to accommodate. The force of this switch is the preload.
the greater the stretch, the stronger is the heart's contraction. This increased contractility results in an increased volume of blood ejected (increased stroke volume).
- 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.
- **Once the ventricle is filled with blood, the ventricular end diastolic pressure is 5 to 10 mm Hg, whereas that in the aorta is 70 to 80 mm Hg. To overcome this difference, the ventricular muscle tenses (isovolumic contraction). After the aortic valve opens, rapid ejection occurs.
- located in the groove between the trachea and the sternomastoid muscle, medial to and alongside that muscle.
- **Note the characteristics of its waveform (Fig. 19-11): a smooth rapid upstroke, a summit that is rounded and smooth, and a downstroke that is more gradual and that has a dicrotic notch caused by closure of the aortic valve
- Empty unoxygenated blood directly into the superior vena cava. Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. Specifically, they reflect filling pressure and volume changes.
- **Because volume and pressure increase when the right side of the heart fails to pump efficiently, the jugular veins expose this.
Two jugular veins are present in each side of the neck
internal jugular and external jugular
lies deep and medial to the sternomastoid muscle. It is usually not visible, although its diffuse pulsations may be seen in the sternal notch when the person is supine
vein is more superficial; it lies lateral to the sternomastoid muscle, above the clavicle.
about two thirds of it is shunted through an opening in the atrial septum
Second, the rest of the oxygenated blood is pumped by the right side of the heart out through the pulmonary artery
The heart's position in the chest is more horizontal in the
infant than in the adult; thus the apex is higher, located at the fourth left intercostal space. It reaches the adult position when the child reaches age 7 years.
Blood volume increases by 30% to 40% during
- ***with the most rapid expansion occurring during the second trimester.
arterial blood pressure in pregnancy ????
decreases in pregnancy as a result of peripheral vasodilation
The blood pressure drops to its lowest point in pregnancy during...
the second trimester, then rises after that. The blood pressure varies with the person's position
between the ages of 20-60 and 60-80 systolic blood pressure increases by about.....
- 20 mm Hg
- ***This stiffening creates an increase in pulse wave velocity because the less compliant arteries cannot store the volume ejected.
The overall size of the heart does not increase with age, but
left ventricular wall thickness increases. This is an adaptive mechanism to accommodate the vascular stiffening mentioned earlier that creates an increased workload on the heart.
No significant change in diastolic pressure occurs with ....
- **A rising systolic pressure with a relatively constant diastolic pressure increases the pulse pressure (the difference between the two).
No change in resting heart rate occurs with
Cardiac output at rest is not changed with
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. Chronic exercise conditioning will modify many of the aging changes in cardiovascular function
The presence of supraventricular and ventricular arrhythmias increases with
Ectopic beats are common in
aging people; although these are usually asymptomatic in healthy older people, they may compromise cardiac output and blood pressure when disease is present.
Tachyarrhythmias may not be tolerated as well in
older people. The 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.
Age-related changes in the ECG occur as a result of histologic changes in the conduction system. These changes include
- •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
The incidence of coronary artery disease increases sharply with
advancing age and accounts for about half of the deaths of older people
The prevalence of heart disease and stroke is higher among....
black adults than in other racial groups: 44.6% for men and 49% for women, as opposed to 37.2% for white men and 35% for white women, and 31.6% for Mexican-American men and 34.4% for Mexican-American women
black and Mexican-American women have higher
cardiovascular risk factors than do white women of the same socioeconomic status. These differences in prevalence show the crucial need to improve screening, early detection, and early treatment
The major risk factors for heart disease and stroke are
high blood pressure, smoking, high cholesterol levels, obesity, physical inactivity, and diabetes. In addition, for some women, the use of oral contraceptives and postmenopausal hormones is a risk factor.
Blacks have a higher incidence of
hypertension than other racial groups, at 42.6% for men and 46.6% for women. The prevalence of HBP in blacks in the United States is among the highest in the world and it is rising
In adults, more white women
smoke (20.4%) than black women (17.2%) or Latinas (10.9%). Tobacco use for black men and white men is about the same.
During childhood (ages 4 to 19 years), Which race has a higher cholesterol
- black children and adolescents have higher total cholesterol, higher low-density lipoprotein (LDL) cholesterol, and higher high-density lipoprotein (HDL) cholesterol (the “good” cholesterol) than do white and Mexican-American children and adolescents.
- **These differences reverse during adulthood when blacks have lower serum cholesterol levels than whites and Mexican-Americans
The following adults aged 18 years and older are overweight or obese:
71% of white men and 58% of white women; 67% of black men and 80% of black women; 75% of Mexican-American men and 73% of Mexican-American women; and 25% of Asians
- an important cardiac symptom, occurs when heart's vascular supply cannot keep up with metabolic demand. Chest pain also may have pulmonary, musculoskeletal, or gastrointestinal origin;
- **it is important to differentiate a squeezing “clenched fist” sign is characteristic of angina, but the symptoms below may be anginal equivalents in the absence of chest pain.
- Diaphoresis, cold sweats, pallor, grayness.
- Palpitations, dyspnea, nausea, tachycardia, fatigue.
- Try to differentiate pain of cardiac versus noncardiac origin.
is the need to assume a more upright position to breathe. Note the exact number of pillows used
is worse at evening and better in morning after elevating legs all night.
Recumbency at night promotes fluid reabsorption and excretion; this occurs with heart failure in the person who is ambulatory during the day.
Carotid sinus hypersensitivity 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.
Diminished pulse feels
small and weak (decreased stroke volume).
Increased pulse feels
full and strong (hyperkinetic states)
A bruit indicates
turbulence due to a local vascular cause, such as atherosclerotic narrowing.
If heart failure is present
the jugular veins will elevate and stay elevated as long as you push.
- Location—The apical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the midclavicular line
- •Size—Normally 1 cm × 2 cm
- •Amplitude—Normally a short, gentle tap
- •Duration—Short, normally occupies only first half of systole
- •Left ventricular dilatation (volume overload) displaces impulse down and to left, and increases size more than one space.
- •Increased force and duration but no change in location occurs with left ventricular hypertrophy and no dilatation (pressure overload)
- a palpable vibration. It feels like the throat of a purring cat. The thrill signifies turbulent blood flow and accompanies loud murmurs. Absence of a thrill, however, does not necessarily rule out the presence of a murmur.
- ***Accentuated first and second heart sounds and extra heart sounds also may cause abnormal pulsations.
Percussion is used to
outline the heart's borders, but it often has been displaced by the chest x-ray or echocardiogram
A thrill in the second and third right interspaces occurs with
severe aortic stenosis and systemic hypertension.
A thrill in the second and third left interspaces occurs with
pulmonic stenosis and pulmonic hypertension.
- Cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilatation are present.**as in mitral regurgitation, aortic regurgitation, and left-to-right shunts.
- occurs with right ventricular hypertrophy, as found in pulmonic valve disease, pulmonic hypertension, and chronic lung disease.
- **You feel a diffuse lifting impulse during systole at the left lower sternal border. It may be associated with retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle.
- The apical impulse is increased in force and duration but is not necessarily displaced to the left when left ventricular hypertrophy occurs alone without dilatation.
- ** as found in aortic stenosis or systemic hypertension.
Patent Ductus Arteriosus (PDA)
Persistence of the channel joining left pulmonary artery to aorta. This is normal in the fetus and usually closes spontaneously within hours of birth.
Clinical Data of PDA
S: Usually no symptoms in early childhood; growth and development are normal.
O: Blood pressure has wide pulse pressure and bounding peripheral pulses from rapid runoff of blood into low-resistance pulmonary bed during diastole. Thrill often palpable at left upper sternal border. The continuous murmur heard in systole and diastole is called a machinery murmur.
Atrial Septal Defect (ASD)
Abnormal opening in the atrial septum, resulting usually in left-to-right shunt and causing large increase in pulmonary blood flow.
Clinical data for ASD
S: Defect is remarkably well tolerated. Symptoms in infant are rare; growth and development normal. Children and young adults have mild fatigue and DOE.
O: Sternal lift often present. S2 has fixed split, with P2 often louder than A2. Murmur is systolic, ejection, medium pitch, best heard at base in second left interspace. Murmur caused not by shunt itself but by increased blood flow through pulmonic valve.
Ventricular Septal Defect (VSD)
Abnormal opening in septum between the ventricles, usually subaortic area. The size and exact position vary considerably.
Clinical Data of VSD
- S: Small defects are asymptomatic. Infants with large defects have poor growth, slow weight gain; later look pale, thin, delicate. May have feeding problems; DOE; frequent respiratory infections; and when the condition is severe, heart failure.
- O: Loud, harsh holosystolic murmur, best heard at left lower sternal border, may be accompanied by thrill. Large defects also have soft diastolic murmur at apex (mitral flow murmur) due to increased blood flow through mitral valve.
Calcification of aortic valve cusps restricts forward flow of blood during systole; LV hypertrophy develops.
Clinical Data of Aortic Stenosis
S: Fatigue, DOE, palpitation, dizziness, fainting, anginal pain.
O: Pallor, slow diminished radial pulse, low blood pressure, and auscultatory gap are common. Apical impulse sustained and displaced to left. Thrill in systole over second and third right interspaces and right side of neck. S1 normal, often ejection click present, often paradoxical split S2, S4 present with LV hypertrophy. Murmur: Loud, harsh, midsystolic, crescendodecrescendo, loudest at second right interspace, radiates widely to side of neck, down left sternal border, or apex.
Calcification of pulmonic valve restricts forward flow of blood.
Clinical Data of Pulmonic Stenosis
O: Thrill in systole at second and third left interspace, ejection click often present after S1, diminished S2 and usually with wide split, S4 common with RV hypertrophy. Murmur: Systolic, medium pitch, coarse, crescendo-decrescendo (diamond shape), best heard at second left interspace, radiates to left and neck.
Pansystolic Regurgitant Murmurs
Due to backward flow of blood from area of higher pressure to one of lower pressure.
Stream of blood regurgitates back into LA during systole through incompetent mitral valve. In diastole, blood passes back into LV again along with new flow; results in LV dilatation and hypertrophy.
Clinical Data of Mitral Regurgitation
S: Fatigue, palpitation, orthopnea, PND
O: Thrill in systole at apex. Lift at apex. Apical impulse displaced down and to left. S1 diminished, S2 accentuated, S3 at apex often present. Murmur: Pansystolic, often loud, blowing, best heard at apex, radiates well to left axilla.
Backflow of blood through incompetent tricuspid valve into RA
Clinical Data of Tricuspid Regurgitation
- O: Engorged pulsating neck veins, liver enlarged. Lift at sternum if RV hypertrophy present, often thrill at left lower sternal border.
- Murmur: Soft, blowing, pansystolic, best heard at left lower sternal border, increases with inspiration.
Diastolic Rumbles of AV Valves
Filling murmurs at low pressures, best heard with bell lightly touching skin
Calcified mitral valve will not open properly, impedes forward flow of blood into LV during diastole. Results in LA enlarged and LA pressure increased.
Clinical Data of Mitral Stenosis
S: Fatigue, palpitations, DOE, orthopnea, occasional PND or pulmonary edema.
O: Diminished, often irregular arterial pulse. Lift at apex, diastolic thrill common at apex. S1 accentuated; opening snap after S2 heard over wide area of precordium, followed by murmur. Murmur: Low-pitched diastolic rumble, best heard at apex, with person in left lateral position; does not radiate.
Calcification of tricuspid valve impedes forward flow into RV during diastole.
Clinical Data of Tricuspid Stenosis
- O: Diminished arterial pulse, jugular venous pulse prominent.
- Murmur: Diastolic rumble; best heard at left lower sternal border; louder in inspiration.
Early Diastolic Murmurs
Due to SL valve incompetence
Physiology of the heart
- From body to inferior vena cava through right atrium through the
- tricuspid to the right ventrical valve through pulmonic valve and pulmonic artery and goes to the lungs and from the lungs through
- pulmonary vein to left atrium through the mitral valve to left ventrical through that
- aorta to the body
test patients on tedmill for 3-5 min and there will be leg pain and then it goes away they test again and the same thing happens around 50%
SA Node is the pass maker you are ....???
born with people can have tachycardia bc their normal pace maker isn’t working
– comes off at end and go into the heat muscle
at home need to sit up when sleeping (needs three pillows )
- loss of conciousness
Physical Examination - Cardiac
*Note any visible apical impulse, heaves or lifts. (heaves abnormal)
*Palpate apical impulse.
*Note size and location.
•Palpate across precordium
*Use palmar aspect to note any pulsations or thrills.
How do you Auscultate the heart??
- Auscultate each precordial landmark first with
- diaphragm (higher pitched sounds); then bell (lower pitched sounds). Listen for
- several cardiac cycles at each landmark. Optimize auscultation by controlling
- extraneous sounds.
Aortic valve area =
2nd ICS; RSB
Pulmonic valve area =
2nd ICS; LSB
Tricuspid valve area =
5th ICS; LSB
Mitral valve area =
5th ICS; MCL
Auscultation equals (ppt)
Precordial Landmarks (ppt)
APE To MAN
Routine for Auscultation (ppt)
Note rate and rhythm
Identify S1 and S2
Assess S1 and S2 separately
Listen for extra heart sounds
Listen for murmurs
S1 sound that you hear are when (ppt)
your mitral and Tricuspid valve are closing at the apex
Auscultation - Murmurs Patient Positions (ppt)
Supine, roll person toward his/her left side and listen with bell.
Sitting up, leaning slightly forward, during exhalation. Listen with diaphragm firmly pressed at base.
Caused by turbulent blood flow and collision currents during diastole and systole.
Heard around area of sound transmission.
Gentle, blowing, swooshing sound.
Causes: Increased velocity of blood (exercise, pregnancy, thyrotoxicosis); decreased viscosity (anemia); structural defects in valves or unusual openings in chambers.
Physical Examination - Neck (ppt)
Palpate carotid pulse, noting rate, rhythm and amplitude. Palpate gently, one at a time.
Auscultate for bruit using bell of stethoscope.
Inspect jugular veins.
Assess for neck vein distention (JVD).
Jugular Vein (ppt)
Internal jugular vein reflects the central venous pressure
This shows the hearts efficiency as a pump
Position the patient from 30 to 45 degrees
Turn the head slightly to the opposite side
Direct a light on the neck area
Use the angle of Louis (sternal angle) as a reference point
Compare the angle to the highest level of venous pulsation
Low-Sodium, Low-Cholesterol Diets (ppt)
◦Dietary Approaches to Stop Hypertension (DASH)
◦Increase vegetables and fruits
◦LIMIT saturated fat
◦Say NO to Trans fats