Assessment of Assessment of Cardiovascular Cardiovascular SystemSystem

By B.Lokay, MD, PhDBy B.Lokay, MD, PhD

Lecture Objectives:Lecture Objectives:

Anatomy and physiology of cardiovascular Anatomy and physiology of cardiovascular system.system.

Developmental considerationsDevelopmental considerations Transcultural considerationsTranscultural considerations History taking and physical examinationHistory taking and physical examination Main disorders of cardiovascular system:Main disorders of cardiovascular system:

Congenital heart defects.Congenital heart defects. Valvular defects.Valvular defects. Heart failure.Heart failure.

Structure of the Structure of the Cardiovascular systemCardiovascular system

Anatomical Structure of Anatomical Structure of the Heartthe Heart

Common abbreviations Common abbreviations used to refer to used to refer to chambers:chambers: RARA – right atrium – right atrium RVRV – right ventricle – right ventricle LALA – left atrium – left atrium LVLV – left ventricle – left ventricle

AVAV – atrioventricular – atrioventricular valvevalve Left AVLeft AV – left – left

atrioventricular valveatrioventricular valve Right AVRight AV - right - right

atrioventricular valveatrioventricular valve

SLSL – semilunar valve – semilunar valveNB: No valves are present between major veins and

atria.Hyperpressure leads

to signs of congestion.

Topographical Landmarks Topographical Landmarks of the Heartof the Heart

Topographical Landmarks Topographical Landmarks of the Heartof the Heart

PrecordiumPrecordium – t – thehe part of the ventral surface of the body part of the ventral surface of the body overlying the heart and stomach and comprising the overlying the heart and stomach and comprising the epigastrium and the lower median part of the thoraxepigastrium and the lower median part of the thorax

Topographical LandmarksTopographical Landmarks Each area corresponds to one of the hearts 4 Each area corresponds to one of the hearts 4

valves.valves. Aortic area -Aortic area - 2nd ICS to right of sternum (closure of the 2nd ICS to right of sternum (closure of the

aortic valve loudest here). aortic valve loudest here). Pulmonic area -Pulmonic area - 2nd ICS to left of sternum (closure of the 2nd ICS to left of sternum (closure of the

pulmonic valve loudest here). pulmonic valve loudest here). Tricuspid -Tricuspid - 5th ICS left of sternal border (closure of 5th ICS left of sternal border (closure of

tricuspid valve). tricuspid valve). Mitral -Mitral - 5th ICS left of the sternum just medial to MCL 5th ICS left of the sternum just medial to MCL

(closure of mitral valve). When cardiac output is increased (closure of mitral valve). When cardiac output is increased as in anemia, anxiety, HTN, fever, the impulse may have as in anemia, anxiety, HTN, fever, the impulse may have greater force - inspect for lift or heave. greater force - inspect for lift or heave.

Normal Heart SoundsNormal Heart Sounds

The first heart sound - systolic The first heart sound - systolic SS11:: Signals the closure of AV valves and the Signals the closure of AV valves and the

beginning of systole.beginning of systole. Consists of mitral Consists of mitral M1M1 and tricuspid and tricuspid T1T1

components.components. Is loudest at the apexIs loudest at the apex

The second heart sound - diastolic The second heart sound - diastolic SS22:: Signals the closure of semilunar valves Signals the closure of semilunar valves

and the end of systole.and the end of systole. Consists of aortic Consists of aortic AA22 and pulmonic and pulmonic PP22

components.components. Is loudest at the base.Is loudest at the base.

SS11 & S & S22 correspond respectively to the correspond respectively to the familiar "lub dub" often used to describe the familiar "lub dub" often used to describe the sounds.sounds.

Effect of respiration:Effect of respiration:

MoReMoRe to the to the RightRight heart heart

LessLess to the to the LeftLeft

A split SA split S22 – when the aortic valve closes – when the aortic valve closes significantly earlier than the pulmonic valve, significantly earlier than the pulmonic valve, you can hear the two components separately.you can hear the two components separately.

Other Heart SoundsOther Heart Sounds

Extra Heart Sounds:Extra Heart Sounds: SS3 3

is the result of vibrations produced during ventricular is the result of vibrations produced during ventricular filling. filling.

is normally heard only in some children and young is normally heard only in some children and young adults, but it is considered abnormal in older adults, but it is considered abnormal in older individuals.individuals.

SS44 is caused by the recoil of vibrations between the is caused by the recoil of vibrations between the

atria and ventricles following atrial contraction, at atria and ventricles following atrial contraction, at the end of diastole. the end of diastole.

is rarely heard as a normal heart sound; usually it is is rarely heard as a normal heart sound; usually it is considered indicative of further cardiac evaluation.considered indicative of further cardiac evaluation.

Other Heart SoundsOther Heart Sounds Murmurs:Murmurs:

are produced by vibrations within the heart are produced by vibrations within the heart chambers or in the major arteries from the chambers or in the major arteries from the back and forth flow of blood. back and forth flow of blood.

are classified as:are classified as: 1. 1. InnocentInnocent, occurring in individuals with no , occurring in individuals with no

anatomic or physiologic abnormality.anatomic or physiologic abnormality. 2. 2. FunctionalFunctional, occurring in individuals with no , occurring in individuals with no

anatomic cardiac defect but with a physiologic anatomic cardiac defect but with a physiologic abnormality such as anemia.abnormality such as anemia.

3. 3. OrganicOrganic, occurring in individuals with a cardiac , occurring in individuals with a cardiac defect with or without a physiologic abnormality. defect with or without a physiologic abnormality.

The conduction system of The conduction system of the heart consists of four the heart consists of four structures:structures:

1. The 1. The sinoatrialsinoatrial (SA)(SA) node, node, located within the rig atrial located within the rig atrial wall near the opening of the superior vena cavawall near the opening of the superior vena cava

2. The 2. The atrioventricular (AV)atrioventricular (AV) node, node, also located within also located within the right atrium but near the lower end of the septumthe right atrium but near the lower end of the septum

3. The 3. The atrioventricular bundle (bundle of His),atrioventricular bundle (bundle of His), which which extends from the atrioventricular node along each side extends from the atrioventricular node along each side of the interventricular septumof the interventricular septum

4. 4. Purkinje fibersPurkinje fibers,, which extend from the which extend from the atrioventricular bundle into the walls of the ventricles. atrioventricular bundle into the walls of the ventricles. The electric impulses from this conduction system can The electric impulses from this conduction system can be recorded on an electrocardiogram.be recorded on an electrocardiogram.

Conduction SystemConduction System

Electrocardiography Electrocardiography (ECG)(ECG)

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

The ECG wavesThe ECG waves P waveP wave represents the electric activity associated with the represents the electric activity associated with the

sinoatrial node and the spread of the impulse over the atria. sinoatrial node and the spread of the impulse over the atria. It is a wave of depolarization.It is a wave of depolarization.

QRS complex (wave)QRS complex (wave) is composed of three separate waves: is composed of three separate waves: the the Q waveQ wave, the , the R waveR wave, and the , and the S waveS wave. They are all . They are all caused by currents generated when the ventricles caused by currents generated when the ventricles depolarize before their contraction. Because ventricular depolarize before their contraction. Because ventricular depolarization requires septal and right and left ventricular depolarization requires septal and right and left ventricular depolarization, the electrical wave depicting these events is depolarization, the electrical wave depicting these events is more complex than the smooth P wave.more complex than the smooth P wave.

P-R intervalP-R interval is measured from the beginning of the P wave is measured from the beginning of the P wave to the beginning of the QRS complex. It is termed P-R to the beginning of the QRS complex. It is termed P-R instead of PQ because frequently the Q wave is absent. instead of PQ because frequently the Q wave is absent. This interval represents the time that elapses from the begin This interval represents the time that elapses from the begin Q-T intervalning of atrial depolarization to the beginning of Q-T intervalning of atrial depolarization to the beginning of ventricular depolarization.ventricular depolarization.

The ECG wavesThe ECG waves

The The T waveT wave represents repolarization of the ventricles. represents repolarization of the ventricles. The The Q-T intervalQ-T interval begins with the QRS complex and begins with the QRS complex and ends with the completion of the T wave. It represents ends with the completion of the T wave. It represents ventricular j depolarization and repolarization. This ventricular j depolarization and repolarization. This interval varies with j the heart rate. The faster the rate, interval varies with j the heart rate. The faster the rate, the shorter the Q-T interval. Therefore in children this the shorter the Q-T interval. Therefore in children this interval is normally shorter than in adults.interval is normally shorter than in adults.

The The S-T segmentS-T segment is normally an isoelectric (flat) line is normally an isoelectric (flat) line that I connects the end of the S wave to the beginning that I connects the end of the S wave to the beginning of the T wave. of the T wave.

The The T-P intervalT-P interval represents atrial and ventricular represents atrial and ventricular polarization in anticipation of the next cardiac cycle.polarization in anticipation of the next cardiac cycle.

Pumping AbilityPumping Ability

4 to 64 to 6 L of blood per min throughout the L of blood per min throughout the body body

Preload – venous returnPreload – venous return Afterload – the opposing pressure the Afterload – the opposing pressure the

ventricles must generate to open aortic ventricles must generate to open aortic valve.valve.

Developmental Developmental ConsiderationsConsiderations

Infants:Infants: Transition from fetal circulation to postnatal Transition from fetal circulation to postnatal

circulation. By 9 months anatomical closure circulation. By 9 months anatomical closure of of foramen ovaleforamen ovale occurs. occurs.

SS11 and and SS22 sounds similarly on auscultation. sounds similarly on auscultation. Pulse rate Pulse rate 120/min120/min..

Horizontal position of the heart (till 7-years-Horizontal position of the heart (till 7-years-old).old).

Developmental Developmental ConsiderationsConsiderations

Infants:Infants: Apex impulse is Apex impulse is

located at the 4located at the 4thth intercostal space 1 to intercostal space 1 to 2 cm outward from 2 cm outward from left midclavicular line.left midclavicular line.

Developmental ConsiderationsDevelopmental Considerations The pregnant female:The pregnant female:

By the end of pregnancy blood volume By the end of pregnancy blood volume increases by 30 to 40 %.increases by 30 to 40 %.

Stroke volume and cardiac output are Stroke volume and cardiac output are increased.increased.

BP decreases due to vasodilation.BP decreases due to vasodilation. Pulse rate increases of Pulse rate increases of 10 to 1510 to 15 beats/min. beats/min.

Developmental ConsiderationsDevelopmental Considerations

Developmental ConsiderationsDevelopmental Considerations

An aging adult:An aging adult:

The incidence of CV diseases increases with The incidence of CV diseases increases with age: coronary artery disease, HBP, heart age: coronary artery disease, HBP, heart failure.failure.

Transcultural considerationsTranscultural considerations

Smoking:Smoking: widely spread in some societies. widely spread in some societies. HBP:HBP: Afro-Americans, Mexican-Americans and Native Afro-Americans, Mexican-Americans and Native

Americans have higher risk of hypertension.Americans have higher risk of hypertension. Serum cholesterol:Serum cholesterol: during childhood (4-19 yrs) Afro- during childhood (4-19 yrs) Afro-

American children have higher total cholesterol than American children have higher total cholesterol than Euro- and Mexican-Am. Children. This difference Euro- and Mexican-Am. Children. This difference reverse during adulthood.reverse during adulthood.

Obesity:Obesity: more than 50% of Am. population are more than 50% of Am. population are overweight.overweight.

Diabetes:Diabetes: the prevalence of diabetes increases in all the prevalence of diabetes increases in all groups in USA.groups in USA.

Physical ExaminationPhysical Examination

Objectives:Objectives: Subjective data.Subjective data. Health history data.Health history data. Preparation.Preparation. Inspection: general appearance, precordium.Inspection: general appearance, precordium. Palpation: peripheral pulses, apical impulse.Palpation: peripheral pulses, apical impulse. Percussion.Percussion. Auscultation: heart sounds, murmurs.Auscultation: heart sounds, murmurs. Summary checklist.Summary checklist.

Subjective dataSubjective data

Chest pain:Chest pain:

Onset, location, character, aggravating Onset, location, character, aggravating and/or relieving factorsand/or relieving factors

Character: crashing, stabbing, burning, Character: crashing, stabbing, burning, vise-like.vise-like.

Associated symptoms: sweating, ashen Associated symptoms: sweating, ashen gray or pale skin, shortness of breath, gray or pale skin, shortness of breath, nausea or vomiting, racing of heart, heart nausea or vomiting, racing of heart, heart skips beat.skips beat.

Angina – an important Angina – an important cardiac symptom.cardiac symptom.

““Clenched fist” sign is Clenched fist” sign is characteristic of angina.characteristic of angina.

Subjective dataSubjective data

Dyspnea:Dyspnea: Cause, onset, duration, affection by position, Cause, onset, duration, affection by position, Does shortness of breath interfere with Does shortness of breath interfere with

activities of daily living?activities of daily living?

Orthopnea: Orthopnea: Is the need to assume a more upright Is the need to assume a more upright

position to breathe. position to breathe. Note the exact number of pillows used.Note the exact number of pillows used.

Paroxysmal nocturnal dyspnea Paroxysmal nocturnal dyspnea (PND) occurs with heart failure. (PND) occurs with heart failure. Classically, the person awakens Classically, the person awakens after 2 hrs. of sleep, arises, and after 2 hrs. of sleep, arises, and flings open the window with the flings open the window with the perception of needing fresh air.perception of needing fresh air.

Subjective dataSubjective data

Cough: duration, frequency, type, Cough: duration, frequency, type, coughing up sputum (color, odor, blood coughing up sputum (color, odor, blood tinged, aggravating and/or relieving tinged, aggravating and/or relieving factors.factors.

Fatigue: onset, relation to time of day?Fatigue: onset, relation to time of day? Cyanosis or pallor: occurs with Cyanosis or pallor: occurs with

myocardial infarction or low cardiac myocardial infarction or low cardiac output.output.

Hemoptysis is often a Hemoptysis is often a pulmonary problem, pulmonary problem, but also occurs with but also occurs with

mitral stenosismitral stenosis

Subjective dataSubjective data

Edema:Edema: Swelling of legs or dependent body part due Swelling of legs or dependent body part due

to increased interstitial fluid.to increased interstitial fluid. Onset, recent change, relation to time of Onset, recent change, relation to time of

day, relieving factors, associated symptoms.day, relieving factors, associated symptoms.

Nocturia:Nocturia: Occurs with heart failure in the person who Occurs with heart failure in the person who

is ambulatory during the day.is ambulatory during the day.

History taking.History taking.

Past cardiac history:Past cardiac history: ! Last ECG, stress ECG, serum chilesterol ! Last ECG, stress ECG, serum chilesterol

measurements, other heart tests?measurements, other heart tests? Family cardiac history:Family cardiac history:

Family history of hypertension, diabetes, Family history of hypertension, diabetes, heart problems, coronary artery disease heart problems, coronary artery disease (CAD), sudden death at younger age?(CAD), sudden death at younger age?

Personal habits (cardiac risk factors): Personal habits (cardiac risk factors): nutrition, smoking, alcohol, exercise, nutrition, smoking, alcohol, exercise, drugs. drugs.

Additional historyAdditional history For infants:For infants: mother’s health during pregnancy, mother’s health during pregnancy,

feeding habits, growth, activity.feeding habits, growth, activity. For children:For children: growth, activity, any joint pains or growth, activity, any joint pains or

unexplained fever, frequent headaches or unexplained fever, frequent headaches or nosebleedings, streptococcal infection nosebleedings, streptococcal infection (tonsillitis).(tonsillitis).

For pregnant female:For pregnant female: any high PB during this any high PB during this or previous pregnancies, associated signs or previous pregnancies, associated signs (weight gain, proteinuria), dizziness.(weight gain, proteinuria), dizziness.

For aging adult:For aging adult: any symptoms of heart any symptoms of heart diseases (HTN, CAD) or COPD, any recent diseases (HTN, CAD) or COPD, any recent changes, medications (digitalis), side effects; changes, medications (digitalis), side effects; environment.environment.

PreparationPreparation

Bring to lab:Bring to lab: WatchWatch with second hand, with second hand, StethoscopeStethoscope,, Marking pen and small centimeter ruler,Marking pen and small centimeter ruler, Alcohol swab (to clean endpiece).Alcohol swab (to clean endpiece).

WearWear:: loose T-shirt or some other garment loose T-shirt or some other garment

that allows for practice of physical that allows for practice of physical assessmentassessment

InspectionInspection

Skin colour (cyanosis, pallor) and conditionSkin colour (cyanosis, pallor) and condition Any obvious bulging on anterior thorax at the Any obvious bulging on anterior thorax at the

leftleft EdemaEdema Orhtopnea Orhtopnea

Palpation Palpation

Palpate the Palpate the apical impulseapical impulse (the (the point of point of maximal impulsemaximal impulse, or , or PMIPMI):): Location:Location: one intercostal space (usually 5 one intercostal space (usually 5 thth

ICS) at left MCL,ICS) at left MCL, Size:Size: normally 1 cm normally 1 cm 2 cm, 2 cm, Amplitude:Amplitude: normally a shot, gentle tap, normally a shot, gentle tap, Duration:Duration: short, normally occupies only first short, normally occupies only first

half of systole.half of systole. Ask the client “Ask the client “to exhale then hold itto exhale then hold it” or turn ” or turn

him to the left side.him to the left side.

PalpationPalpation

PalpationPalpation

Palpate across the precordium for:Palpate across the precordium for: Other pulsations,Other pulsations, ThrillThrill – palpable vibration due to strong heart – palpable vibration due to strong heart

murmur (like a purring cat),murmur (like a purring cat), Pericardial friction rubsPericardial friction rubs are scratchy, high- are scratchy, high-

pitched grating sounds, similar to pleural pitched grating sounds, similar to pleural friction rubs, except that they are not friction rubs, except that they are not affected by changes in respiration. affected by changes in respiration.

Accentuated SAccentuated S11 and S and S22.. A diffuse impulse (A diffuse impulse (lift, heavelift, heave).).

Palpation Palpation

Percussion Percussion

Is used to estimate approximately heart Is used to estimate approximately heart borders and configuration.borders and configuration.

Recently is displaced by the chest x-ray Recently is displaced by the chest x-ray or EchoCG.or EchoCG.

Helps to detect heart enlargementHelps to detect heart enlargement

Heart (cardiac) enlargementHeart (cardiac) enlargement is due to increased ventricular is due to increased ventricular volume or thickening of heart volume or thickening of heart

wall.wall.Occurs with HTN, CAD, heart Occurs with HTN, CAD, heart

failure, cardiomyopathyfailure, cardiomyopathy

Auscultation Auscultation

Auscultation Auscultation

A Z-pattern is recommended.A Z-pattern is recommended. Before beginning alert the person for long Before beginning alert the person for long

duration of procedure. duration of procedure. Begin with diaphragm endpiece and use Begin with diaphragm endpiece and use

the following routing:the following routing: Note Note the ratethe rate the rhythmthe rhythm Identify SIdentify S11 and S and S22 Listen for extra heart soundsListen for extra heart sounds Listen for murmursListen for murmurs

Auscultation (cont.)Auscultation (cont.)Rhythm:Rhythm: RegularRegular Irregular:Irregular:

Synus arrythmiaSynus arrythmia – common variation. Rate – common variation. Rate ↑ ↑ on inspiration and ↓ on expiration.on inspiration and ↓ on expiration.

Regularly irregularRegularly irregular Irregularly irregularIrregularly irregular – no pattern to the sounds, – no pattern to the sounds,

beats come rapidly and at random intervals.beats come rapidly and at random intervals. Pulse deficitPulse deficit – occurs with atrial fibrillation, – occurs with atrial fibrillation,

heart failure, detects weak heart contractions.heart failure, detects weak heart contractions.

Auscultation (cont.)Auscultation (cont.)

Identify SIdentify S11 and S and S22

Location and amplitude,Location and amplitude, Correlation with peripheral pulses, PMICorrelation with peripheral pulses, PMI Correlation with ECG wavesCorrelation with ECG waves ““Lub” or “dup”Lub” or “dup”

Give description of origin.Give description of origin. Listen to sounds separately: Listen to sounds separately:

accentuation, split (fixed, paradoxical).accentuation, split (fixed, paradoxical).

Auscultation (cont.)Auscultation (cont.)

Extra heart sounds:Extra heart sounds: Midsystolic clickMidsystolic click SS33: normal, pathological (ventricular gallop): normal, pathological (ventricular gallop) SS44: atrial gallop: atrial gallop

Listen for murmurs:Listen for murmurs: Characteristics:Characteristics: timing, loudness, pitch, timing, loudness, pitch,

pattern, quality, location, radiation, posturepattern, quality, location, radiation, posture

Grading murmursGrading murmurs

Grade I-VIGrade I-VI:: Refers to the severity of a heart murmur (blowing, Refers to the severity of a heart murmur (blowing,

whooshing, or rasping sound), which is the result of whooshing, or rasping sound), which is the result of vibrations caused by turbulent blood flow patterns. vibrations caused by turbulent blood flow patterns.

Murmurs are classified ("graded") depending on Murmurs are classified ("graded") depending on their ability to be heard by the examiner. The their ability to be heard by the examiner. The grading is on a scale with grade I being barely grading is on a scale with grade I being barely detectable. detectable.

An exampleAn example of a murmur description is a of a murmur description is a "grade II/VI "grade II/VI murmur."murmur." (This means the murmur is grade 2 on a (This means the murmur is grade 2 on a scale of 1 to 6).scale of 1 to 6).

Murmurs are classified according to Murmurs are classified according to their timing within the cardiac cycle.their timing within the cardiac cycle.

SystolicSystolic Between S1and Between S1and S2.S2. DiastolicDiastolic Between S2 and S1). Between S2 and S1). Systolic ejectionSystolic ejection Begin after the first heart sound, Begin after the first heart sound,

attain a peak during midsystole, and terminate attain a peak during midsystole, and terminate before the second heart sound.before the second heart sound.

Pansystolic or holosystolicPansystolic or holosystolic During all of systole. During all of systole. Pandiastolic or holodiastolicPandiastolic or holodiastolic During all of During all of

diastole. diastole. ProdiastolicProdiastolic Early diastolic. Early diastolic. PresystolicPresystolic Late diastolic. Late diastolic. ContinuousContinuous Continue through all of systole and all Continue through all of systole and all

or part of diastole.or part of diastole.

Timing of murmursTiming of murmurs

ConclusionConclusion Function can be assessed to a large degree by findings in Function can be assessed to a large degree by findings in

the history: shortness of breath (SOB), edema of the history: shortness of breath (SOB), edema of ankles/legs, pain, pulse rate and rhythm; vital signs, signs ankles/legs, pain, pulse rate and rhythm; vital signs, signs and symptoms of oxygen deficit.and symptoms of oxygen deficit.

Location: Heart lies behind and to the left of the sternum. Location: Heart lies behind and to the left of the sternum. The upper portion or atria (BASE) lies to the back; the The upper portion or atria (BASE) lies to the back; the ventricles (APEX) points forward, the apex of the left ventricles (APEX) points forward, the apex of the left ventricle actually touches the anterior chest wall near the ventricle actually touches the anterior chest wall near the left midclavicular line at or near the 5th left ICS. Known as left midclavicular line at or near the 5th left ICS. Known as point of maximal impulse (PMI) and is where apical beat is point of maximal impulse (PMI) and is where apical beat is assessed. Impulse is a good index of heart size.assessed. Impulse is a good index of heart size.

Landmarks for assessment: The precordium is the area on Landmarks for assessment: The precordium is the area on the anterior chest overlying the heart. Hearts sounds are the anterior chest overlying the heart. Hearts sounds are heard throughout the precordium, but there are 4 major heard throughout the precordium, but there are 4 major areas for examining heart sounds.areas for examining heart sounds.

Techniques of Assessment:Techniques of Assessment:

Inspection- look for lift at apex. Inspection- look for lift at apex. Auscultation- Client should be assessed Auscultation- Client should be assessed

in supine position with head up to 45 in supine position with head up to 45 deg.; examiner stands at right side. Use deg.; examiner stands at right side. Use diaphragm for basic sounds; bell for diaphragm for basic sounds; bell for murmurs and extra sounds. murmurs and extra sounds.

Identify the heart rate, rhythm; bell for Identify the heart rate, rhythm; bell for murmurs aortic, pulmonic, mitral. murmurs aortic, pulmonic, mitral.

Heart Sounds Heart Sounds There are 2 basic normal heart sounds and several There are 2 basic normal heart sounds and several

abnormal ones. Normal: abnormal ones. Normal: SS11 (produced by closure of the atrioventricular valves, (produced by closure of the atrioventricular valves,

mitral and tricuspid)- at mitral area and tricuspid area Smitral and tricuspid)- at mitral area and tricuspid area S11 is is louder than Slouder than S22. The sound is a dull, low pitched “lub.” . The sound is a dull, low pitched “lub.”

SS22 (produced by closure of aortic and pulmonic valve) is (produced by closure of aortic and pulmonic valve) is higher pitched, shorter and is the “dub” sound. Heard best higher pitched, shorter and is the “dub” sound. Heard best at the base (aortic and pulmonic areas) where Sat the base (aortic and pulmonic areas) where S22 is louder is louder than Sthan S11

Systole begins with the Systole begins with the 11stst sound. As ventricles start to sound. As ventricles start to contract, pressure within exceeds the atria, shutting the contract, pressure within exceeds the atria, shutting the mitral and tricuspid valves. Blood is forced into the great mitral and tricuspid valves. Blood is forced into the great vessels. vessels.

When the ventricles have emptied themselves, the When the ventricles have emptied themselves, the pressure in the aorta and pulmonary arteries force the pressure in the aorta and pulmonary arteries force the semilunar valves shut (aortic/pulmonic), which is the 2nd semilunar valves shut (aortic/pulmonic), which is the 2nd sound and diastole (ventricular relaxation) begins. sound and diastole (ventricular relaxation) begins.

Other heart soundsOther heart sounds SS33 – rapid filling of the ventricle with blood; heard – rapid filling of the ventricle with blood; heard

following Sfollowing S22. Can be normal in young adults and . Can be normal in young adults and children; pathologic in elderly. children; pathologic in elderly.

SS44 – atrial contraction and thought to result from – atrial contraction and thought to result from stiffened left ventricle; directly precedes Sstiffened left ventricle; directly precedes S11. Heard . Heard in elderly. in elderly.

Extra sounds: snaps and clicks are associated Extra sounds: snaps and clicks are associated with valves: aortic and mitral stenosis, prosthetic with valves: aortic and mitral stenosis, prosthetic valves. valves.

Murmurs: SMurmurs: S11 or S or S22 is a swishing or blowing is a swishing or blowing sounds caused by sounds caused by Forward flow through a stenotic (narrowed) valve Forward flow through a stenotic (narrowed) valve Increased flow through a normal valve Increased flow through a normal valve Backward flow through a valve that fails to close Backward flow through a valve that fails to close

(insufficiency). (insufficiency).

Murmurs should be identified as systolic Murmurs should be identified as systolic (S(S11) or diastolic (S) or diastolic (S22). Murmurs are common ). Murmurs are common in children and occur often in the elderly. in children and occur often in the elderly.

Try to identify grade of murmur: Grade I Try to identify grade of murmur: Grade I (barely audible) to Grade VI (loud and may (barely audible) to Grade VI (loud and may be heard with the stethoscope not quite on be heard with the stethoscope not quite on the chest or barely touching the chest).the chest or barely touching the chest).

Documentation: Normally, you should be Documentation: Normally, you should be able to note that Sable to note that S11, S, S22 heard without extra heard without extra sounds.sounds.