Advanced Assessment of

the Cardiovascular System

Mary Beerman, RN, MN, CCRN
NUR 602

Interesting facts...
The heart does not rest for more
than a fraction of a second at a time
During a lifetime it contracts more
than 4 billion times
Coronary arteries supply more than
10 million liters of blood to the
myocardium in a lifetime

Interesting facts.
Cardiac output (heart rate X stroke
volume) can vary under physiologic
conditions from 3 to 30 liters/minute
Remember: Normal cardiac output
for adults is 5-6 liters/minute
Cardiac index corrects for body size
(Cardiac output divided by body
surface area)

Common Diseases of the

Heart
Coronary artery disease
Hypertension
Rheumatic heart disease
Bacterial endocarditis
Congenital heart disease

OTHER VERY COMMON

DISEASES OF THE HEART

CONGESTIVE HEART FAILURE

CARDIOMYOPATHY

ARRHYTHMIAS

Review Structure and

Physiology of the Heart in
textbook

Review of Symptoms

Chest Pain
This is the most important symptom
of cardiac disease
Pain could be from pulmonary,
intestinal, gallbladder, or
musculoskeletal sources but it may
be from the heart itself
Every complaint of chest pain must
be taken very seriously!

Differential Diagnoses of
Chest Pain

Angina
Myocardial Infarction
Other Ischemic C-V Origins
Non-ischemic C-V Origins
Pulmonary
Gastrointestinal
Psychogenic
Neuromusculoskeletal

Differential Diagnosis of
Chest Pain - ANGINA
Usually

substernal
Radiation chest, shoulders,
neck, jaw,arms
Deep, visceral (pressure)
intense, not excruciating
Duration- min., not sec. (5-15
min.)

Differential Diagnosis of
Chest Pain - ANGINA
Associated with nausea, vomiting
diaphoresis, pallor
Precipitated by exercise & emotion
Becomes Unstable when occurs
during sleep, at rest, or increases
in severity/frequency
Relief with rest or NTG

Differential Diagnosis of CP
Myocardial Infarction
Same type of pain as angina
Duration greater than 15 min.
Occurs spontaneously, often
sequela of unstable angina
Relieved with Morphine, successful
reperfusion of blocked coronary
artery

Differential Diagnosis of CP
Other C-V Ischemic Origins
Aortic Stenosis/Regurgitation
Idiopathic Hypertrophic Subaortic
Stenosis (IHSS)
Uncontrolled Hypertension
Severe Anemia/Hypoxia
Tachycardia/Arrhythmias
Pulmonary Hypertension

Differential Diagnosis of CP
Nonischemic C-V Origins

Aortic Dissection
Sudden, excruciating pain (knife-like,
tearing)
Migrating pain (depends on location
of tear)
Frequently, hemodynamic instability
Appearance of shock with normal or
elevated BP
Absent or unequal peripheral pulses

Differential Diagnosis of CP
Nonischemic C-V Origins

Pericarditis
Sharp or dull, retrosternal or precordial pain
Radiates to trapezius ridge
Aggravated by inspiration, coughing,
recumbency, & rotation of trunk
Lessened by sitting upright & leaning
forward
Relief - analgesics & anti-inflammatory
meds

Differential Diagnosis of CP
Nonischemic C-V Origins

Mitral Valve Prolapse

Left anterior superficial, rarely
visceral pain
Variable in character
Lasts minutes, not hours
Spontaneous onset with no pattern
Relieved with time

Differential Diagnosis of CP Pulmonary

Pulmonary Embolus /Infarct
Pneumothorax
Pneumonia with pleural
involvement
Pleurisy

Differential Diagnosis of CP Pulmonary

Pleuritic Pain
Visceral Pain arising from inferior portion of
pleura
May be substernal and radiate to costal
margins or upper abdomen
Lasts greater than 30 minutes
Often occurs spontaneously with associated
dyspnea
Worsened with inspiration
Relief time, rest, bronchodilators

Differential Diagnosis of CP Gastrointestinal

Esophageal Spasm
Substernal visceral (pressure) pain,
radiates
Duration 5 to 60 minutes
Spontaneous or provoked by cold
liquids,exercise
Mimics angina
Relief with NTG

Differential Diagnosis of CP Gastrointestinal

GERD/Hiatal Hernia

Substernal & epigastric, rarely radiates

Duration is 10-60 min.
Provoked by recumbency, lack of food
Relieved by food, antacid

Peptic Ulcer Disease

Substernal & epigastric pressure/burning
Duration hours

Differential Diagnosis of CP Gastrointestinal

PUD (Cont.)
Precipitated by lack of food or acidic food
Relief with antacids & food

Biliary Disease
Colicky or continuous, visceral epigastric &
RUQ abdominal pain
Radiates to back & right shoulder
Occurs spontaneous & after heavy meal
Relief analgesics & time

Differential Diagnosis of CP Psychogenic

Nonradiating, variable pain over chest
Duration 2-3 minutes
May be associated with
numbness/tingling of hands & mouth
Precipitated by stress, emotional
tachypnea
Relief by removal of stimulus, relaxation
Causes depression, anxiety, self gain

Differential Diagnosis of CP Neuromusculoskeletal

Thoracic Outlet Syndrome
Degenerative Joint Disease of
cervical/thoracic spine

Superficial pain in arms & neck

Duration variable, gradually subsides
Precipitated by head & neck
movement, palpation
Relief time, analgesia

Differential Diagnosis of CP Neuromusculoskeletal

Herpes Zoster (Shingles)

Pain follows dermatomal distribution of nerve

Costochondritis (Tietzes syndrome)

Superficial pain, reproducible with movement
& palpation
May be localized or in multiple locations
Duration variable
Relief time, analgesia, anti-inflammatory
meds

Ask These Questions

about Chest Pain
Description of character
Location
Duration/Recurrence
Precipitating factors
Associated symptoms
Relieving factors
History of similar symptoms

Angina
Angina Pectoris is the true symptom
of coronary artery disease.
It is caused by hypoxia to the
myocardium which leads to
anaerobic metabolism and the
production of lactic acid. The acid
irritates the actual heart muscle and
makes it hurt

Angina, cont
Angina is due to an imbalance of
oxygen delivery TO the heart and
the oxygen needs OF the heart
Levines Sign---Patients will
describe angina by clenching their
first and placing it over the
sternum.

PALPITATIONS

Palpitations
The uncomfortable sensations in
the chest associated with a range
of arrhythmias.
Patients may describe palpitations
as fluttering, skipped beats,
pounding, jumping, stopping, or
irregularity

EXTRASYSTOLES
Premature

atrial contractions

(PACs)
Premature ventricular
contractions (PVCs)

TACHYARRHYTHMIAS

Sinus Tachycardia
Usually gradual onset and offset

Paroxysmal Supraventricular
Tachycardia (PSVT)
Sudden, abrupt onset and offset

Atrial Fibrillation
Ventricular Tachycardia

CAUSES of ATRIAL
FIBRILLATION

Hypertension
Hyperthyroidism
Acute MI
Pericarditis
Coronary Artery
Disease

Congestive Heart
Failure
Valvular Heart
Disease
Acute or Chronic
ETOH abuse
Post-operative
state

ATRIAL FIBRILLATION

Major complication
Peripheral embolization
CVA

May present as CVA, Transient

ischemic attack, Amaurosis fugax,
ischemic limb, ischemic bowel or
other viscera

VENTRICULAR
TACHYCARDIA

Causes include:

Acute myocardial ischemia/infarct

Chronic Coronary artery disease
Cardiomyopathy
Prolonged QT interval (Congenital,
drug-induced, acquired)

VENTRICULAR
TACHYCARDIA

May present as:

Sudden cardiac death

VT degenerated into VF

Syncope
Wide complex tachycardia

Often hemodynamically well tolerated

BRADY - ARRHYTHMIAS

Heart Block

Sinus Arrest

Common Causes of
Palpitations - DRUGS

Bronchodilators
tachycardia

Beta Blockers, Calcium Channel

Blockers
bradycardia

Digitalis
bradycardia, toxicity causes bradydysrhythmias

Common Causes of
Palpitations More DRUGS

Antidepressants
Prolong QT interval

OTC medications Antihistamines,

Decongestants, Weight Loss
preparations
Extrasystoles, Tachy-dysrhythmias

Common Causes of
Palpitations OTHER

Tobacco

Caffeine

Thyroid disorders

Paroxysmal Nocturnal
Dyspnea (PND)
Occurs at night or when patient is
supine.
Patient awakens after being asleep
about 2 hours and is smothering.
Runs to window to get more air
This is a specific sign of congestive
heart failure

Orthopnea
Dyspnea when lying down
Ask all patients: How many
pillows do you use in order to
sleep?
To quantify the orthopnea, record
3-pillow orthopnea for the past
month

Dyspnea on Exertion
(DOE)
This is usually due to chronic CHF
or severe pulmonary disease
Quantify the severity by asking,
How many level blocks can you
walk before you get short of
breath? How many could you walk
six months ago?

How to Chart about

Dyspnea

The patient has had 1-block dyspnea

on exertion for the past six months.
Before 6 months ago, the patient was
able to walk 4 blocks without
shortness of breath. In addition,
during the past month the patient has
noted 4-pillow orthopnea. Previously
he was able to sleep with just two
pillows.

Common Causes of
Congestive Heart Failure
Uncontrolled Hypertension
Myocardial ischemia/infarct
Arrhythmias
Lack of compliance

Diet
Drugs

Fluid overload

More Common Causes of

Congestive Heart Failure
Blood loss, Anemia
Pulmonary embolism
Systemic infection
Valvular heart disease
Nonischemic Dilated
Cardiomyopathy
Renal Artery Stenosis

SYNCOPE

Syncope
Fainting or syncope is the transient
loss of consciousness that is due to
inadequate cerebral perfusion
Syncope can be from cardiac or
non-cardiac causes

Common Causes of
Syncope
Cardiac
Neurocardiogenic
Orthostatic Hypotension
Metabolic
Neurologic
Psychogenic

Common Causes of Syncope

- CARDIAC

Obstruction to Blood Flow

Valvular stenosis
Hypertrophic cardiomyopathy
Prosthetic valve dysfunction
Atrial myxoma

Common Causes of Syncope

- CARDIAC

Obstruction to Blood Flow (cont)

Pericardial tamponade
Pulmonary hypertension
Pulmonary emboli
Congenital heart disease
Pump failure (MI or ischemia)

Common Causes of Syncope

- CARDIAC

Arrhythmias
Brady-arrhythmias
Sinus bradycardia
Sick sinus syndrome
Atrioventricular block (AVB)
Pacemaker malfunction
Drug-induced bradycardia

Tachy-dysrhythmias

VTach, SVT

Common Causes of Syncope

- NEUROCARDIOGENIC
Vasovagal
Vasodepressor
Carotid sinus hypersensitivity
Situational Cough, Micturition,
Defecation, Deglutition

Vasovagal Syncope
This is the most common type of fainting
and is one of the most difficult to
manage.
It has been estimated that 40% of all
syncopal events are vasovagal in nature
This occurs during periods of sudden,
stressful, or painful experiences such as
getting bad news, trauma, blood loss,
sight of blood

Vasovagal Syncope, cont

There is warning that the fainting

is about to occurpallor, nausea,
weakness, blurred vision,
lightheadedness, perspiration,
yawning, diaphoresis,
hyperventilation, or a sinking
feeling

Carotid Sinus Syncope

This may occur in the elderly who may
have a hypersensitive carotid sinus
If they are wearing a tight shirt or
collar or turn their neck in a certain
way, there is increased stimulation of
the carotid sinus, a sudden fall in
systolic blood pressure, and a
decrease in heart rate.

Common Causes of Syncope

Orthostatic Hypotension

Volume depletion

Antihypertensive medications

Antidepressant medications

Common Causes of Syncope

METABOLIC

Hypoglycemia

Hyperventilation

Hypoxia

Common Causes of
Syncope

NEUROLOGIC
Epilepsy
Cerebrovascular disease

PSYCHOGENIC

Ask These Questions

about Syncope
What were you doing just before you
fainted?
Have you had recurrent fainting
spells? How often do they happen?
Was there an abrupt onset to the
fainting, or did you feel it coming?
Did you totally lose consciousness?

Syncope Questions, cont

In what position were you in when
you fainted? (possible orthostatic
hypotension?)
Was the fainting preceded by other
symptoms like nausea, chest pain,
palpitations, confusion, numbness,
or hunger?

more syncope
questions...
Was fainting episode witnessed by
anyone? Who?
Did you have warning that you were
going to faint?
Did you have any black, tarry BMs
before or after the fainting episode?
Did you experience any loss of urine
or stool during the fainting episode?

And Just One More

On regaining consciousness, did

you know where you were and who
people were around you?

Fatigue
This is a common symptom of
decreased cardiac output. A
common complaint from people
with CHF and mitral valve disorder
Fatigue may be the presenting
symptom of a woman having an MI
Not at all specific to heart disease,
but you must consider it always

Common Causes of
Fatique
Cardiac
Anxiety/Depression
Anemia
Chronic Diseases

Dependent Edema
When peripheral venous pressure is high,
fluid leaks out from the veins into tissues
This is often the presenting symptom of
right ventricular failure
Edema will begin in legs and gets worse
as the day progresses. Least evident in
the a.m. after sleeping with the legs flat,
worse as gravity pulls fluid to legs.

More about Dependent

Edema

This indicates that there is excess fluid

volume and 3rd spacing of fluids.
People on bedrest will have edema of
their sacral area
In severe right or bi-ventricular heart
failure, people often have abdominal
distension, liver engorgement,
constipation, and anorexia
Anasarca may develop. Gross generalized
edema

Ask These Questions

about Dependent Edema
When did you first notice the
swelling?
Do both legs swell equally?
Did the swelling appear suddenly?
What time of the day is it worse?
Does it disappear after sleeping?
Does propping your legs up make it
go away?

More Questions about

Edema...
What medicines do you take
now?
Do you have any kidney, heart, or
liver disease?
Do you have shortness of breath?
Pain in your legs? Ulcers on your
legs?

And, More Questions about

Edema
Have you noticed a difference in
how your clothes fit, especially
around the waist?
Have you noticed recent problems
with constipation?
How is your appetite?

More and More

Do you add salt to food at
mealtime and/or when cooking
Do you eat out in restaurants or
get take-out food frequently?
Do you read labels on food before
purchasing?

Physical Exam for Edema

Press fingers into the dependent areas
for 2-3 seconds.
If pitting is present, the fingers will sink
into the tissue and when fingers are
removed, the impression of the fingers
will remain
Edema is quantified from 1+ to 4+
depending on how deep the indentation
is

The Physical Examination

Inspection

General Appearance
Is the patient in acute distress?
Is breathing labored or easy?
Is there use of accessory muscles?
Is there cyanosis? Pallor?
Are xanthomata present (stony hard,
yellowish masses on extensor
tendons of the fingers. Due to
hypercholesterolemia

Inspection...
Inspect nails. Splinter hemorrhages are
associated with infective endocarditis
Inspect the face. People with
supravalvular aortic stenosis have
wide-set eyes, stabismus, low-set ears,
upturned nose, hypoplasia of the
mandible
Moon face suggests pulmonic stenosis

More inspection...
Expressionless face with puffy eyelids
and loss of the outer 1/3 of the
eyebrow is seen in hypothyroidism
Inspect eyes. Yellow plaques on
eyelids (xanthelasma) may be due
to hyperlipoproteinemia
Opacities of the cornea may be
sarcoidosis

and more inspection...

Conjunctival hemorrhage is
commonly seen with infective
endocarditis
Petechiae on the palate may be seen
with infectious endocarditis
High arched palate may be seen with
Marfans Syndrome
Arm Breadth greater that body height
is also seen in Marfans

Inspection of the Chest

Wall
The heart and chest develop at the
same time in embryo, so anything that
interferes with development of the chest
may interfere with the heart
Pectus Excavatum (caved-in chest) is
seen in Marfans syndrome and
sometimes MVP
Pectus Carinatum (pigeon breast) also
seen in Marfans syndrome

Inspection of the chest,

cont

Are there any visible cardiac

motions?

Inspection of the
extremities
Look for edema (pitting and nonpitting)
Observe color
Babies with atrial septal defects may
have an extra finger or toe.
Long, slender fingers suggest
Marfans with possible aortic valve
deformity

Inspection of Extremities
Continued

Loss of hair may indicate

hypothyroidism or PVD

Assessment of Blood
Pressure
Always measure in both arms
sitting
Then take BP standing

Orthostatic Hypotension
Have the patient lie down for 5 minutes
and measure BP and pulse
Have patient stand and repeat reading
immediately. Allow 90 seconds for
maximum orthostatic changes
A drop in systolic BP of 20 mmHg or
more when standing is orthostatic
There is usually an increase in HR

Rule out Supravalvular

Aortic Stenosis
If there is hypertension in the right
arm, take BP in the left arm as well
In supravalvular aortic stenosis,
there will be hypertension in the
right arm and hypotension in the
left arm

Rule out Coarctation of the

Aorta
If the patient is hypertensive in both
arms, have patient lie on abdomen,
put cuff around lower thigh, listen to
BP at the popliteal artery
A leg blood pressure lower than the
arm BP suggests coarctation
Normally BP higher in leg arteries
than arm

Rule out Cardiac

Tamponade
An exageration of the normal
inspiratory fall in systolic BP (it
should normally fall about 5 mmHg
during inspiration
You should check for a paradoxical
pulse any time there is low arterial
BP and a rapid, feeble pulse

Checking for Paradoxical

Pulse
Have the patient breathe normally,
inflate BP cuff until no sounds are heard.
Gradually deflate cuff until sounds are
heard on expiration only and note this
number
Continue to deflate the cuff until sounds
are heard during inspiration as well.
Note this number

A Positive Paradoxical
Pulse

If the difference in BP exceeds 10

mmHg, this is abnormal and
indicates possible cardiac
tamponade

Assessment of the Arterial

Pulse
Grasp both radial arteries, count
for 30 seconds, and multiply by 2
Determine rhythm. The slower the
rate, the longer you should
palpate.
If the rhythm is irregular, is there a
pattern to the irregularity?

Arterial Pulse, cont

Premature beats are isolated extra beats
in a regular rhythm
A grossly irregular rhythm is most likely
atrial fibrillation
Palpate the carotid artery by standing at
the patients right side with him resting
on his back. Listen first for possible
bruit and do not palpate if you hear one

Arterial Pulse, cont

Never palpate both carotids at the

same time

Jugular Venous Pulse

Remember that the internal jugular vein
provides information about right atrial
pressure
The pulsation of the internal jugular vein
are beneath the sternocleidomastoid
muscle and are visible as they are
transmitted through surrounding tissue
The vein itself cannot be seen

Jugular Venous Pressure,

cont
Because the right internal jugular
vein is straighter than the left, only
the right IJV is evaluated
To determine jugular waveform, have
patient lie without pillow at about 25
degree angle. Turn head slight to the
right and slightly down to relax the
right sternocleidomastoid muscle

Jugular Venous Pulse, cont

Standing on the right side of the patient,
place your right hand holding a pinlight
on the patients sternum and shine the
light tangentially across the right side of
the patients neck.
Shadows of the pulsation will be cast on
the sheet.
Chart: JV pulsation seen at 25
degrees

Jugular Venous Distension

Hepatojugular Reflex
A useful test for assessing high jugular
venous pressure (also called abdominal
compression)
By applying pressure over the liver, you
can grossly assess RV function. People
with RV failure have dilated sinusoids in
the liver. Pressure over right upper
quadrant pushes blood out and
increases JV pressure

How to Check for

Hepatojugular Reflex
Have patient lie in bed, mouth
open, breathe normally to prevent
valsalva maneuver.
Place right hand over RUQ and
apply firm pressure for 10 seconds
Normally there will be a short
increase in venous dilation followed
by fall to baseline

How to Check for

Hepatojugular Reflex Cont.

If there is RV failure, neck veins will

stay elevated during entire time of
compression

Percussion
Not helpful in CV assessment
CXR shows heart size and borders
very accurately

Palpation

Point of Maximal Impulse

(PMI)
Stand on the right side of the patient
with him sitting. Place fingertips at
5th ICS, MCL and you should feel PMI
PMI is usually within 10 cm of the
midsternal line and no larger than 23 cm diameter
PMI that is lateral or displaced
suggests cardiomegaly

PMI, cont
About 70% of the time you will be
able to feel PMI with patient sitting.
If you cant, turn patient to his left
side, lying down.
A PMI that is over 3 cm diameter
indicates left ventricular hypertrophy
and is 86% predictive of increased
left ventricular end diastolic pressure

General Motion
After palpating with the fingertips
for PMI, use palm of your hand to
palpate any large areas of sustained
outward motion (heave or lift)
Palpate all 4 cardiac areas
Any condition that increases the
rate of ventricular filling can
produce a palpable impulse

Have you ever felt a

thrill?
Thrills are superficial vibratory
sensations felt on the skin overlying
an area of turbulence
The presence of a thrill indicates
that you will hear a loud murmur
(grade 4-6)
Simply an indication of what you
will hear when you listen.

Auscultation

General Principles of
Auscultation
Close your eyes when listening
Never listen through any kind of clothing
Listen at all 4 cardiac areas:

Aortic --2nd ICS, RSB

Pulmonic---2nd ICS, LSB

Mitral--cardiac apex, 5th ICS, MCL

Tricuspid---left lower sternal border

Principles of Auscultation,
cont
Normally only the closing of valves can be
heard.
Closure of the tricuspid and mitral valves
(AV valves) produce the 1st heart sound.
Closure of the aortic and pulmonic valves
produce the 2nd heart sound.
Opening of valves can only be heard if
they are very damaged (opening snap
click)

Third Heart Sound

When AV valves open, the period of
rapid filling of ventricles occurs. 80%
of ventricular filling occurs now. At the
END of rapid filling, a 3rd heart sound
may be heard
S-3 is normal in children and young
adults, but not in people over age 30.
It means there is volume overload of
ventricle

What an S3 Sounds Like...

SLOSH-ing-in, Slosh-ing-in,
Slosh-ing-in
Or Ken-tuck-y

Fourth Heart Sound

At the end of diastole, atrial
contraction contributes to the
additional 20% filling of the ventricle
If the left ventricle is stiff and noncompliant, you will hear an S4.
It sounds like this: a- STIFF-wall, aSTIFF-wall, a-STIFF-wall
Or sounds like TEN-ne-see

Gallop Rhythms
The presence of an S3 and an S4
creates a cadence resembling the
gallop of a horse.
Hence the term gallop rhythm

Auscultation Procedure
Stand at the patients right side while
he is flat on his back.
Listen to all 4 valve areas, inching the
stethoscope along from area to area
While listening at the apex and left
lower sternal border with the bell,
youll be able to determine if an S3 or
S4 are present

Procedures, cont
Next have the patient turn to his left
side and listen to the apex for lowpitched diastolic murmurs with bell
Have patient sit upright and listen
everywhere with diaphragm.
Have patient sit and lean forward,
exhale, and hold breath while you listen
with diaphragm to hear high diastolic
murmur

Procedure, cont
To interpret heart sounds correctly,
you must clearly identify what
sound is S1. To do this, palpate the
carotid artery while you listen.
The sound that you hear when you
feel the carotid pulse is S1.
S2 will follow the pulse

Procedure, cont

Please see pictures on pages 255256 of your textbook for approach

to auscultation

Murmurs
They are produced when there is
turbulent blood flow within the heart
Turbulence may be due to a
narrowed opening of a valve
(stenosis) or a valve that does not
close completely, allowing blood to
slosh backwards (regurgitation or
insufficiency)

Describing Murmurs
When in the cardiac cycle do you
hear the murmur? Systole?
Diastole? Pan-systolic?
Location (in which of the 4 cardiac
areas do you hear it the loudest?)
Radiation (does the sound travel
throughout the chest?)
Duration of the murmur

The Intensity of Murmurs

Grade I = lowest intensity, not heard
by inexperienced listener
Grade II = low intensity, usually
audible to everyone
Grade III = medium intensity but no
palpable thrill
Grade IV = medium intensity with a
thrill

Intensity of murmurs,
cont
Grade V = loudest murmur audible
when stethoscope is on the chest.
Has a thrill
Grade VI = loudest intensity,
audible when stethoscope is
removed from the chest. Has a
thrill

Other Ways to Describe

Murmurs
Pitch (high? Low?)
Quality (rumbling? blowing? harsh?
musical? scratchy?)
Is there any relationship to the
respiratory cycle?

Systolic Murmurs
These are ejection murmurs
May be caused by turbulence across
the aortic or pulmonic valves if they
are stenosed
May be caused by turbulence across
the mitral or tricuspid valves if they
are incompetent (regurgitant)

Systolic Murmurs, cont

The murmur falls between S1 and
S2
Sounds like, LUB-shhh-dub

Diastolic Murmurs
Mitral and tricuspid stenosis can
cause a diastolic murmur
Aortic or pulmonic regurgitation
can cause a diastolic murmur
Sounds like this: Lub-dub-shhh

Pericardial Friction Rub

These are extra-cardiac sounds of short
duration that have a sound like
scratching on sandpaper
May result from irritation of the
pericardium from infection,
inflammation, or after open heart
surgery
Best heard when patient sits and holds
breath

Friction Rub, cont

A rub that disappears when the patient
holds his breath does NOT come from
the heart. This is probably a pleural
friction rub
There are three components to a
friction rubone systolic (during
ejection) and two diastolic (during rapid
filling of the heart and again during
atrial contraction)

Refer to excellent charts regarding

Extra Cardiac Sounds and Murmurs
on pages 258-259 in textbook.

Assessment of the
Peripheral Vascular
System

Introduction
Peripheral vascular disease - very
common, may involve arteries or veins.
Arterial diseases include
cerebrovascular, aortoiliac,
femoropopliteal, renal, and aortic
occlusive or aneurysmal disease
Narrowing of vessels causes a
decreased blood supply, resulting in
ischemia.

Abdominal Aortic
Aneurysms
The abdominal aorta is the artery most
frequently involved in the development
of an aneurysm
Usually occur below the renal arteries
Few symptoms until it ruptures. You
may discover a pulsatile mass in the
abdomen
Usually first sign is catastrophic rupture

Microvascular Disease
Diabetes is the most common cause of
microvascular disease
New recommendations - blood sugar
should be covered with insulin in
hospitalized patients for BG over 150
Peripheral venous disease often
progresses to venous stasis and
thrombotic disorders (we fear
pulmonary emboli the most)

Review of Symptoms

Pain
This is the principal symptom of
atherosclerosis. Pain is often in calf,
arch of foot, thighs, hips, or buttocks
while walking (intermittent
claudication)
Leriches Syndromechronic aortoiliac obstruction. Pain in buttocks and
thigh, as well as erectile dysfunction

Skin Changes
Color changes are common with
vascular disease
Chronic arterial insufficiency produces a
cool, pale extremity
Chronic VENOUS insufficiency produces
a warmer-than-normal extremity (leg
becomes red, erosions develop,
increased pigmentation, swelling,
aching, heaviness

Deep Vein Thrombosis

People with DVT have secondary
inflammation of the tissue around
the vein.
This produces warmth, redness, and
fever
Swelling of one leg more than 2 cm
at the ankle or mid-calf should be
considered significant

Edema
Lymphedema results from
obstruction to flow in which there is
stasis of lymph fluid in the tissues
This produces firm, non-pitting
edema
Seen in women post-mastectomy
with lymph node removal

Ulceration
Persistent ischemia of a limb is
associated with ischemic ulceration
and gangrene
Ulceration is almost inevitable once
the skin has thickened and
circulation is compromised
Ulceration can occur with just the
slightest trauma

Ulceration, cont

Rapidly developing ulcers are

commonly caused by arterial
insufficiency, whereas slowly
developing ulcerations are usually
the result of venous insufficiency

Emboli
Thrombi form from stasis or
hypercoagulability
Bedrest, CHF, obesity, pregnancy,
recent extended travel on planes, and
oral contraceptives have been
associated with thrombus formation
and emboli
Symptoms depend on where clot lodges

The Physical Examination

Points to Consider in Exam

Inspect for symmetry of extremities

Examine arterial pulses
Auscultate carotid artery with diaphragm
(slightly elevate head on pillow and turn
slightly away from the side being
auscultated) If a bruit is noted, do NOT
palpate!
Should not be able to palpate abdominal
pulse unless very thin. Err on side of
caution. Get abdominal ultrasound to R/O
aneurysm. Often too late when bulging
mass felt.

Exam, cont
Palpate abdomen deeply but gently for a
mass with laterally expansive pulsation
(surgical mortality for a non-ruptured
abdominal aneurysm is only 5%, but
rupture increases mortality to over 90%)
Listen for bruits over major arteries with
patient lying flat. Listen 2 inches above
umbilicus for presence of aortic bruit

Exam, cont
Renal artery bruits may be heard
about 2 inches above umbilicus and
1-2 inches laterally from mid-line
Palpate femoral pulse. The lateral
corners of the pubic hair triangle is
where you will find the pulse. Feel
both femorals so you can judge
equality

more of the exam...

Palpate popliteal pulseoften hard
to feel. Place thumbs on patella
and press remaining fingers of both
hands in popliteal fossa. Have legs
in mid-flexed position
Palpate dorsalis pedis (top of foot)
and posterior-tibial pulse (inside
ankle bone)

Grading Pulses
0 = absent pulse (check with
doppler!)
1+ = diminished
2+ = normal
3+ = increased
4+ = bounding

Capillary Refill
Evaluate capillary refill by
compressing the toe or fingernail
tufts until they blanche.
Color should return in 3-5 seconds
Prolonged time for color to return
is a sign of arterial vascular
insufficiency

Allens Test:
Evaluating arterial supply in
arms
Occlude the radial artery by firm
pressure. Ask patient to clinch his fist,
then open the fist and observe the color
of the palm
Then compress ulnar artery, clinch fist,
and observe color of palm
Pallor of the palm during compression of
one artery indicates occlusion of the
OTHER artery!

Acute Arterial Occlusion:

The Five Ps
Pain
Pallor
Paresthesia
Paralysis
Pulselessness

Raynauds Disease
Poor peripheral circulation to distal
fingers and toes
You may see three distinct color
changes: white (pallor) due to
decreased blood supply, blue
(cyanosis) due to increased peripheral
extraction of oxygen, and then red
(rubor) due to the return of blood flow

Diagnostic Tests
Venous doppler flow studies
Arterial doppler flow studies

CARDIAC LABORATORY
TESTS

COMPLETE BLOOD COUNT

(CBC)

WBC
Increases with inflammation &
phagocytosis
MI
Large hematoma
Pericarditis

Increases with use of steroids

Treatment of Pericarditis
Treatment of allergic reactions to IV
contrast

RBC, HG, HCT, INDICES

Evaluate for anemia as cause of
chest pain, dyspnea
Evaluate safety for initiation and
continued use of anticoagulant and
antiplatelet therapy

PLATELETS
Evaluate safety for initiation of &
continued use of anticoagulant and
antiplatelet therapy
Decreases may be due to adverse
drug effect

Heparin-induced Thrombocytopenia
(HIT)
H-2 blockers (Pepcid, Tagamet, Zantac)
Aspirin, Plavix

COMPLETE METABOLIC
PROFILE (CMP)

SODIUM (Na)

Increases
Dehydration
Increases Na intake

Decreases

Volume overload
Decreased Na intake
Diuretics

POTASSIUM (K)

MUST keep in tight range

Decreases due to:

Diuresis
Decreased potassium intake
Diarrhea
Nausea & Vomiting
Gastric Suctioning
Hypoglycemia
Alkalosis

POTASSIUM (K)

Increases due to:

Renal failure
Dehydration
Acidosis
Hyperglycemia
Increased potassium intake
ACE inhibitors
Hemolysis

HYPOKALEMIA

Often presents as:

PVCs
Atrial tachycardia
Ventricular tachycardia
Ventricular fibrillation
Leg Cramps

HYPERKALEMIA

Often presents
as:
Bradycardia
Heart block
Idioventricula
r rhythms
VTach

VFib
Ventricular
arrest
Muscle
weakness
Tetany

POTASSIUM

Potassium level should be

maintained 4.0 to 5.0 in cardiac
patients, especially with acute MI,
Cardiomyopathy, history of
Ventricular arrhythmias, and
diuretic therapy (as long as normal
renal function).

CARBON DIOXIDE
Measures bicarbonate level of
blood
Measures metabolic state

BLOOD UREA NITROGEN

(BUN)

Increased level (azotemia) with

impaired renal function caused by:
CHF, Dehydration, Shock, Stress,
Acute MI

Increased levels also with renal

disease and GI bleed

CREATININE (CR)

Increased level indicates

worsening renal function

GLUCOSE (BG)
May

elevate with stress

such as with MI

LIVER FUNCTION TESTS

AST, ALT, Alkaline Phosphatase
May elevate in CHF due to hepatic
congestion
Will elevate in low perfusion states
causing shock liver due to
ischemia. Common with cardiac
arrest S/P resuscitation, prolonged
hypotension, shock states, embolic
event.

Liver Function Tests

May elevate due to anti-lipidemic

drugs. Usually not a problem
unless 2X normal range.

MISCELLANEOUS LABS

Amylase & Lipase

Increases with pancreatitis or GB disease
May order if suspect GI source of chest
pain

Magnesium
Decreased levels cause arrhythmias
Always check in atrial & ventricular
arrhythmias and QT prolongation

MISCELLANEOUS

Thyroid Function Tests

Thyroid abnormalities can cause:
Arrhythmias
Fatique
Anemia

Usually start by checking TSH. If

abnormal, check full thyroid panel

CARDIAC ISOENZYMES

Total CK (Creatine Kinase)

Enzyme found in heart, skeletal, and
brain muscle cells. Enzyme is released
with injury to cells
Increases with acute MI, myocarditis,
post-CABG, cardioversion(defibrillation)
Can also elevate with rhabdomyolysis.
May see with cocaine intoxication &
adverse effect from statin drugs for
hypercholestolemia

CARDIAC ISOENZYMES

CK-MB
Specific to myocardium
Increases with acute MI, myocarditis ,
post-CABG, cardioversion
May also elevate with chronic renal
failure
With acute MI, MB occurs in serum in 612 hrs. & remains for 18-32 hrs.
Presence is diagnostic of MI

CARDIAC ISOENZYMES

MB Index
Percentage of MB in comparison with
total CK

*** Three sets of cardiac

isoenzymes should be ordered 8
hrs. apart to diagnose/confirm
acute MI.

TROPONIN I and T
Troponin I more specific
Unique to heart muscle
Released with very small amounts of
damage as early as 1-3 hrs. after injury
Peaks in 12-48 hrs.
Levels return to normal in 7-10 days.
Useful in delayed diagnosis of MI also

TROPONIN T
May

also elevate in unstable

angina, myocarditis, chronic
renal failure, acute muscle
trauma, rhabdomyolysis,
polymyositis, and
dermatomyosis.

MYOGLOBIN
Oxygen-binding protein of striated
muscle. Released with injury to
muscle.
Used as early marker of muscle
damage in MI
Elevates in 2-4 hrs.
Peaks in 8-10 hrs.
Returns to normal in 24 hrs.

B-type NATRIURETIC PEPTIDE

(BNP)
Hormone produced by ventricles of
the heart that increases in
response to ventricular volume
expansion and pressure overload.
Marker of ventricular systolic and
diastolic dysfunction
Useful in diagnosing CHF
Normal is less than 100 ng/L

CARDIAC DIAGNOSTIC
TESTS

ELECTROCARDIOGRAM
(EKG or ECG)
Cardiac rhythm
Chamber enlargement
Conduction abnormalities
Electrolyte and toxic disorders

Peaked T-waves = Hyperkalemia

U waves = Hypokalemia
QT prolongation = toxic drug effects

EKG cont.

Acute MI

T wave inversion = ischemia

ST elevation = acute injury
Q waves = Transmural MI
CAN HAVE AN MI WITH NORMAL EKG!!
Cannot read with Left Bundle Branch
Block

CHEST X-RAY (CXR)

Heart size
Calcification on valves and arteries
Evidence of CHF

Pulmonary vascular congestion

Pleural effusions

Masses

ECHOCARDIOGRAM
(ECHO)

Structural Abnormalities

Anatomical
Presence of thrombi, vegetations,
Presence of pericardial
effusion/tamponade

Chamber sizes
Valvular function
Left ventricular function

Wall motion, Ejection Fraction (EF)

TYPES OF
ECHOCARDIOGRAM

TRANSTHORACIC (TTE)
Most common

Transesophageal (TEE)
Usually ordered to evaluate for
vegetations, valvular disorders, and
thrombi.

STRESS TESTING

Exercise Treadmill testing

Myocardial Perfusion Imaging (MPI)
Often called misnomer, Thallium scan
Types Exercise, Persantine, Adenosine,
Dobutamine

Stress Echocardiogram
Types Exercise, Dobutamine

All done to evaluate for myocardial

ischemia

RADIONUCLIDE
ANGIOGRAPHY
Often called MUGA scan stands
for multiple gated angiography
Determines ejection fraction
Almost always automatically done
with MPI now

COMPUTED TOMOGRAPHY
(CT)

Helical CT
Uses IV Contrast
Used to diagnose Aortic dissection,
Pulmonary emboli

Plain CT
Abnormal masses (with or without
contrast)
Hematoma or retroperitoneal bleed
better with IV contrast

CT cont.

Ultrafast CT
No contrast used
Detection of coronary artery
calcification as indicator of
atherosclerosis
The higher the score, the more
calcium detected

CARDIAC
CATHETERIZATION
Uses IV contrast
Reveals:

Pressures in chambers/Aorta
LV wall motion and ejection fraction
Visualization of coronary anatomy
Valvular function

ARRHYTHMIA MONITORING
Telemetry
Holter monitor continuous recording of
heart rhythm, usually for 24 hrs.
Event recorder records specific events
to correlate symptoms with possible
arrhythmia, worn for several weeks
Loop recorder implanted in chest wall,
continuous recording, then explanted.

ELECTROPHYSIOLOGY STUDY
(EPS)
Evaluation

of conduction

system
Inducibility of arrhythmias
Effectiveness of
Antiarrythmic therapies

Ventilation-Perfusion Scan
(VQ Scan)
Used

to diagnose
Pulmonary embolism
Will read as high, moderate,
or low probability for PE