CARDIAC EXAM

Tutorial 8: Heart & Blood Vessels - LEARNING OBJECTIVES

By the end of this session, you will be able to:

1. Recognize the elements and significance of the jugular venous pulse

2. Know the physiology and sound of S1 and S2
3. Know the physiology and sound of S3 and S4
4. Identify systole and diastole by palpation and listening
5. Describe heart murmurs
6. Hear and understand the mechanism of three common systolic murmurs

SECTIONS OF CARDIAC EXAM

Examination of the heart includes:

Inspection: of jugular venous pulse and point of maximal impulse

Palpation: of point of maximum impulse, and precordium for lifts, heaves

and thrills

Auscultation: for valve closing sounds (S1 and S2), extra sounds (S3 and
S4), murmurs, clicks and rubs

INSPECTION: JUGULAR VENOUS PULSE

the jugular venous pulse (JVP) shows you visible changes in pressure in the
right atrium

JVP is visible because there is no valve between the internal jugular vein and
the right atrium

Clinical uses of the jugular venous pulse:

To provide an estimate of the central venous pressure (CVP)

To give a view of the cardiac cycle

 PHASES OF JUGULAR VENOUS PULSE: ACxVy

A: atria contract; blood flows back briefly into superior vena cava

C: closure of tricuspid valve stops forward flow of blood out of atrium

x: downslope as atria begin to fill

V: volume of atria increases with filling, again increasing pressure

y: downslope as tricuspid valve opens at end of systole and ventricles begin to

fill

MEASURING THE JUGULAR VENOUS PULSE

The jugular venous pulse lies behind the sternocleidomastoid muscle

To see the jugular venous pulse, observe the sternocleidomastoid for visible
pulsations from the underlying internal jugular vein

To measure the JVP, incline the patient to 30-45 degrees and use tangential
light.
 ESTIMATING CENTRAL VENOUS PRESSURE (right atrial pressure)

In a patient with suspected congestive heart failure (CHF) or fluid overload,

the JVP provides a rapid bedside estimate of central venous pressure

The manubriosternal angle (at the second rib insertion) is 5 centimeters above
the right atrium. So right atrial pressure equals the highest level of the jugular
venous pulse above the manubriosternal angle plus 5 cm.

Normal right atrial pressure is 5 to 10 cm of water. So: a jugular venous pulse

more than 5 cm above the sternal angle is a sign of fluid overload or abnormal
cardiac function.

DIAGNOSING COMPLETE HEART BLOCK USING THE JUGULAR

VENOUS PULSE

In complete heart block, electrical impulses can no longer travel from the
atria to the ventricles, and atria and ventricles beat independently.

When the right atrium contracts against a closed tricuspid valve, you see
dramatic, irregular "cannon A waves" in the jugular venous pulse.

LOCATION OF HEART IN THE CHEST

RV - Right ventricle: anterior

LV - Left ventricle: left heart border, apex, posterior

RA - Right atrium: right heart border

LA - Left atrium: posterior

 PMI: POINT OF MAXIMUM IMPULSE

The point of maximal impulse (PMI) is the (sometimes) visible and (usually)
palpable contraction of the left ventricle (LV) during systole

It is usually located at the 5 th intercostal space in the left midclavicular line,

an imaginary line down from the middle of the clavicle

In slender people and those with emphysema, it can be lower and more
medial

A normal PMI is approximately dime-sized

Its normal duration is brief (longer is "sustained" and may be a sign of heart
failure)

Normal intensity is not strong (if intense, it is described as a "lift" or "heave")

About 75% of people have a palpable PMI

 THE FOUR CARDIAC LISTENING AREAS / VALVE AREAS

the aortic area or right sternal border (RSB) is at the right 2nd intercostal
space, just under and to the right of the angle of Louis (sternal angle)
the pulmonic area or left upper sternal border (LUSB) is at the left 2 nd
intercostal space
the tricuspid area or left lower sternal border (LLSB) is at the left fourth
intercostal space
the mitral area or apex is at the PMI -- the 5 th intercostal space in
midclavicular line

NOTE: valves are not always loudest in their assigned areas.

For instance, the murmur of aortic stenosis is often louder at the LLSB
than at the aortic area.
Loud murmurs may be in several areas and difficult to localize the
named area is often the direction of flow, not the location of the valve.
 PALPATION OF PARASTERNAL AREA AND BASE

use your fingertips or the ulnar surface of your hand; these are better at
feeling vibration

lifts in the parasternal area (left sternal border) may mean right ventricular
hypertrophy (thickening)

thrills (vibration) palpable in the precordium means you have a palpable heart
murmur (intensity of IV/VI on a !/V! to VI/VI scale)

the location of the thrill is where the murmur is loudest.

AUSCULTATION OF THE HEART

be sure to use both sides of the stethoscope to examine the heart

the diaphragm is best for hearing high-pitched sounds, including S1, S2 and
most heart murmurs

the bell is bests for hearing low-pitched sounds, including S3, S4 and a few
murmurs (e.g. mitral stenosis)

use LIGHT TOUCH when using the bell. Pressure turns it into a diaphragm
 AUSCULTATION: WHAT MAKES NOISES IN THE HEART?

Valves closing: atrioventricular - mitral and tricuspid (S1) and

semilunar -- aortic and pulmonic (S2)
Blood striking the left ventricle: S3 and S4
Increased flow across normal valves - for instance, in pregnancy,
anemia, or hyperthyroidism
Turbulent flow through an abnormal valve

S1 and S2

The Lub-dub sound of the heart is S1-S2.

S1:

S1 is the sound made when the mitral and tricuspid (atrioventricular or

AV) valves close. It marks the beginning of systole
S1 is loudest at apex or left lower sternal border
S1 is usually single; but may be narrowly split at the LLSB. This is
normal.

S2:

S2 is the sound made when the aortic and pulmonic (semilunar) valves
close. It marks the beginning of diastole.
S2 is loudest at the base. The top of the heart is the base.
S2 usually splits with inspiration.

S2 SPLITTING

The aortic valve (A2) closes before the pulmonic valve (P2) during
inspiration

This is caused by increased blood flow into the lungs during inspiration. Thus
the pulmonic valve closes later, producing a split S2 during inspiration.
 The normal S2 closes with expiration.

The pulmonic valve has less pressure across it and is quieter than the aortic
valve. Thus, a split S2 is audible only in the pulmonic area - the left upper
sternal border.

The S2 split is usually narrow, so it isn't easy to hear in most normal people

Abnormal conduction can cause a fixed split S2 (which never closes) or

paradoxical split (which is split in expiration and closes with inspiration)

RHYTHM

Rhythm is usually regular.

Healthy young people often have a sinus arrhythmia: their pulse is slower in
expiration.

GALLOPS: S3 and S4

Both S3 and S4 are caused by blood striking the left ventricle

S3 and S4 are heard at the apex (PMI) only

S3 and S4 are both diastolic sounds

S3 and S4 are low-pitched sounds, so they are heard with the bell of your
stethoscope.

S3

S3 is heard early in diastole, just after S2

The S3 sound is made by rapid ventricular filling just after the mitral valve
opens

Healthy athletic young people may have a normal S3

 S3 is most often a sign of a flaccid left ventricle and may be heard in patients
with congestive heart failure

Mnemonics for the sound and meaning of S3 are: Sloshing-in or It's-Floppy

S4

S4 is a low-pitched sound, so like S3, it's best heard with the bell of your
stethoscope at the apex (PMI)

S4 occurs late in diastole, just before S1

The S4 sound is caused by atrial contraction just before the mitral valve
closes

So: if the atria don't contract, such as in patients with atrial fibrillation, you
will not hear an S4)

S4 is not normal

A stiff left ventricle causes S4. Conditions that cause a stiff left ventricle
include longstanding hypertension and acute myocardial infarction (heart
attack).

The mnemonic to remember the sound and meaning of S4 is: a-stiff-wall.

HEART MURMURS

Heart murmurs are produced by turbulence.

Causes of heart murmurs include:

 increased blood flow across normal valves - for example, in pregnancy
or hyperthyroidism, or an innocent murmur), or
turbulent flow through abnormal valves: tight valve (stenosis) or leaky
valve (regurgitation or insufficiency)

HOW TO DESCRIBE HEART MURMURS

Intensity, timing (systolic or diastolic), quality, location;

e.g.: II/VI systolic ejection murmur (SEM) at the left upper sternal border
(LUSB).

HEART MURMURS: INTENSITY

I/VI: need quiet room and trained ear to hear. First year medical students can't
usually hear a I/VI murmur.

II/VI: audible to anyone who listens attentively

III/VI: loud, but not palpable

IV/VI: loud and palpable: it produces a precordial thrill

V/VI: audible with your stethoscope placed perpendicular to chest wall

VI/VI: audible without a stethoscope

HEART MURMURS: TIMING

Systolic: between S1 and S2 (during systole)

If you are unsure of a murmur's timing: while listening, palpate the carotid
pulse (felt during systole) or PMI (also occurs during systole)
Most common murmurs occur in systole

Diastolic: after S2

HEART MURMURS: QUALITY

Diamond-shaped murmurs are also called ejection murmurs. With these

murmurs, you can still hear S1 and S2. Diamond-shaped murmurs are a sign of
valvular stenosis or are flow murmurs

Constant intensity murmurs may blur S1 and S2. They are typical of valvular
regurgitation (insufficiency)

Murmurs may be musical (often innocent), blowing (regurgitant or innocent),

or Harsh (stenosis)

COMMON SYSTOLIC MURMUR: INNOCENT FLOW MURMUR

Intensity of an innocent murmur is II/VI or softer

Timing is early systolic

Quality is blowing; diamond-shaped

 Innocent flow murmur is heard at the pulmonic area (LUSB)

If you think you are hearing an innocent murmur at the LUSB, listen closely
for S2 splitting. If S2 has a fixed split, your patient may have an atrial septal
defect.

COMMON SYSTOLIC MURMUR: MITRAL REGURGITATION

intensity can be from I/VI to IV/VI

it is typically holosystolic -- heard throughout systole, often blurring S1 and

S2

Quality is blowing; constant intensity

Mitral regurgitation murmurs are loudest at the apex and often radiate to the
axilla

Patients with mitral regurgitation may also have an S3

COMMON SYSTOLIC MURMUR: AORTIC STENOSIS

aortic stenosis murmurs are often III/VI or louder in intensity

they are diamond-shaped and have a harsher quality

Aortic stenosis murmurs are most often loudest in the aortic area (RSB),
though they may also be loudest in the tricuspid area (LLSB)

Patients with more severe or longstanding aortic stenosis often develop an S4

sound, too.

COMMON SYSTOLIC MURMUR: MITRAL VALVE PROLAPSE

Intensity of mitral valve prolapse(MVP) is usually I/VI to II/VI

Mitral valve prolapse murmurs are heard best at the apex

 MVP murmur is classically a late systolic murmur preceded by one or more
midsystolic clicks

MVP is common in slender young women, in whom it is usually benign

A COMMON DIASTOLIC MURMUR: AORTIC INSUFFICIENCY

Intensity of aortic insufficiency murmur is often only I/VI to II/VI

It occurs early in diastole

Quality is blowing

Aortic insufficiency murmur is loudest in the aortic or tricuspid area

Aortic insufficiency murmurs are louder if the patient squats or clenches their
hands. This increases systemic vascular resistance, increasing regurgitation)

FRICTION RUB

a friction rub is a leathery, squeaky sound made by rubbing of adjacent

pericardial surfaces as the heart beats

pericardial rubs are heard often after heart surgery,

Pericardial rub may be a sign of pericarditis (inflammation of the

pericardium), occasionally after myocardial infarction (heart attack)

Rubs are heard throughout cardiac cycle

The classic rub has three components