Cardiovascular Examination

The Normal Heart - Coronary Artery Anatomy

Left Main CA
Circumflex
Left Anterior Descending CA
Right CA
Marginal Branch
Layers of the Arterial Wall
PENDAHULUAN.
Anatomi arteria coronarria dan jantung normal
Pengertian volume ventrikel kiri



End Systolic Volume (ESV)
Volume akir sistol
(akir kontraksi ventrikel)

Stroke Volume (SV) = EDV - ESV

Ejection Fraction (EF) = SV
EDV
Normal darah yg dipompo
ventrikel kiri: 62%
Hambatan pompa jantung
adalah indikator terbaik dari
kemampuan kerja jantung dan
prognosa kondisi jantung.
End Diastolic Volume (EDV)
Volume akir diastol
(volume akir pengisian ventrikel)
1. Cardiac Output (COP) = Heart Rate X Strooke Volumes
2. Cardiac Index = COP
body surface area
3. Preload: Volume darah yang masuk ventrikel saat diastole (End
Diastole Volume= reflects stretch of the cardiac muscle cells)
4. Afterload: Tahanan ventricular selama systole (Kemampuan
otot ventrikel untuk mendorong darah ke aorta)
5. Frank Starling Law of the Heart - Kemampuan kontraksi otot
ventrikel terbesar mulai pre load secara bertahap.
6. Myocardial Contractility Kekuatan kontraksi otot jantung dan
perkembangannya sampai preload.
7. Regulated by:
1. sympathetic nerve activity (most influential)
2. catecholamines (epinephrine norepinephrine)
3. amount of contractile mass
4. drugs
Pengertian
Starlings Law of the Heart and Contractility
SV

left
ventricular
performance
preload (venous return)
u contractility
normal
contractility
d contractility
(heart failure)
0
120
dP/dt dP/dt
Normal
Heart Failure
(lemah jantung)
dP/dt = change in pressure per unit of time
Gambaran
peningkatan saat
dan akhir tekanan
diastol
Curves saat tekanan ventrikel
indikasi kemampuan kontraksi
Dan fungsi jantung.
Perubahan tekanan per tahap
Pada jantung normal SV= 60-80 CC Jantung terlatih SV= 90-250 CC
Jantung sakit SV = 40-50 CC
Kemampuan kontraksi
dipengaruhi oleh
1. Kekuatan otot jantung.
2. Fleksibilitas otot jantung.
3. Tahanan perifer (aorta, jaringan, vena
4. Peningkatan max selisih preload dan
afterload (dP/dt from LV pressure curve)
5. Pengaruh Positive/negative iontropic.
6. Ejection fraction (EF = SV/EDV) used in
clinical practice
7. Hormonal (epineprin atau norepineprin)
increase contractility assumed with
increase EF with Ca, NE, digitalis,
exercise; with [K]o, [Na]o

Contractility related to :
1. sympathetic adrenergic nerves
a. catecholamines: epinephrine
norepinephrine
b. Obat: digitalis
sympathomimetics
anesthetics, barbiturates
2. Hilangnya kemampuan kontraksi otot
misalnya MCI, cardiomyopathy.

1. Perbedaan tekanan oksigen antara darah arteri dan vena.
Arteriovenous Oxygen Difference (AVO
2
D)
PENGUKURAN DALAM ml % - ml O
2
/ 100 ml blood
2. Oxygen Consumption (VO
2
) Jumlah oksigen yang
dibutuhkan darah untuk metabilism dalam menghasilkan
energi/
1. absolute measures: L / min , ml / min
2. relative measures: ml / kg body wt. / min
3. Fick equation: VO
2
= COP X Selisih O2 arteri
dan vena
3. Maximum Oxygen Consumption (VO
2max
) Jumlah oksigen
yang mampu disediakan secara maksimal per menit untuk
metabolism dalam menghasikan energi
1. Tak langsung 220-usia = 60-80 % VO2 maks.
2. Spirometri .


Definisi

4. Myocardial Oxygen Consumption VO
2
of
the heart muscle (myocardium)
"estimated" by RPP: HR X Sistole BP.

5. Functional Aerobic Impairment:

predicted VO
2max
- attained VO
2max
predicted VO
2max
mild 27% - 40%
moderate 41% - 54%
marked 55% - 68%
severe > 69%
Definisi
1. Systolic Blood Pressure (SBP) pressure measured in brachial
artery during systole (ventricular emptying and ventricular
contraction period)
2. Diastolic Blood Pressure (DBP) pressure measured in brachial
artery during diastole (ventricular filling and ventricular
relaxation)
3. Mean Arterial Pressure (MAP) "average" pressure throughout
the cardiac cycle against the walls of the proximal systemic
arteries (aorta)
1. estimated as: .33(SBP - DBP) + DBP
4. Total Peripheral Resistance (TPR) - the sum of all forces that
oppose blood flow
1. length of vasculature (L)
2. blood viscosity (V)
3. hydrostatic pressure (P)
4. vessel radius (r)

Definitions
TPR = ( 8 ) ( V ) ( L )
( p ) ( r
4
)
This examination is a particularly important skill to master
but is also one of the more complex ones. It not only
involves a thorough examination of the heart, but also of
the hands, face, neck and other areas of the body.
1. Start, as with all examinations, by introducing yourself
and explaining to the patient what you plan to do and
ensure that you have their consent. You should also
have a chaperone present. Now is a good point to ask
the patient to remove their top so that the chest is
entirely exposed and place them on the bed with
their trunk at 45.

Perform a patient introduction

2. Firstly, you should start by observing the
patient from the end of the bed. You should
note whether the patient looks comfortable.
Are they cyanosed or flushed? Is their
respiration rate normal? Are there any clues
around the bed such as PCA machines, GTN
sprays or an oxygen mask? You should
comment on each of the areas to the
examiner.

Observe the patient from the end of the bed

3. Next you should look at the patients hands.
Initially note how warm they feel as this gives
an indication of how well perfused they are.
Particular signs which you should be looking
for are nail clubbing, splinter haemorrhages,
palmar erythema and nicotine staining.

Look at the patients hands

4. Now is a good time to take the radial pulse. It is
not a suitable pulse for describing the character
of the pulsation, but can be used to assess the
rate and rhythm. At this point you should also
check for a collapsing pulse a sign of aortic
incompetence. Remembering to check that the
patient doesnt have any problems with their
shoulder, locate the radial pulse and place your
palm over it, then raise the arm above the
patients head. A collapsing pulse will present as
a knocking on your palm.
Locate the radial pulse and place your palm
over it

Raise the arm above the patients head

5. Examine the extensor aspect of the elbow for
any evidence of xanthomata.
6. At this point you should say to the examiner that
you would like to take the blood pressure. They
will usually tell you not to and give you the
value.
7. Next you should move up to the face. Look in
the eyes for any signs of jaundice (particularly
beneath the upper eyelid), anaemia (beneath
the lower eyelid) and corneal arcus. You should
also look around the eye for any xanthelasma.

Look in the eyes for any signs of jaundice,
anaemia, and corneal arcus

8. Whilst looking at the face, check for any
malar facies, look in the mouth for any signs
of anaemia such as glossitis, check the colour
of the tongue for any cyanosis, and around
the mouth for any angular stomatitis
another sign of anaemia.

Exam around the patient's face

9. Next, move to the patients neck to assess their
jugular venous pressure (JVP). Ask them to turn their
head to look away from you. Look across the neck
between the two heads of sternocleidomastoid for a
pulsation. If you do see a pulsation you need to
determine whether it is the JVP if it is then the
pulsation is non-palpable, obliterable by compressing
distal to it and will be exaggerated by performing the
hepatojugular reflex. Having warned the patient that
it may cause some discomfort, press down on the
liver. This will cause the JVP to rise further. If you
decide the pulsation is due to the JVP, note its vertical
height above the sternal angle.

Assess the patient's jugular venous pressure
(JVP)

10. It is now time to move the examination to the chest,
or praecordium. Start by inspecting the area,
particularly looking for any obvious pulsations,
abnormalities or scars, remembering to check the
axillae as wel
11. Palpation of the praecordium starts by trying to locate
the apex beat. Start by doing this with your entire
hand and gradually become more specific until it is
felt under one finger and describe its location
anatomically. The normal location is in the 5th
intercostals space in the mid-clavicular line. However,
it is not uncommon to not feel the apex beat at all.
Try to locate the apex beat

12.Next you should palpate for any heaves or
thrills. A thrill is a palpable murmur whereas
a heave is a sign of left ventricular
hypertrophy. A thrill feels like a vibration and
a heave feels like an abnormally large beating
of the heart. Feel for these all over the
praecordium.

Palpate for any heaves or thrill

13. Palpate for any heaves or thrill
14. You now move onto auscultation. This is done for all four valves of the heart in
the following areas:
Mitral valve where the apex beat was felt.
Tricuspid valve on the left edge of the sternum in the 4th intercostal space.
Pulmonary valve on the left edge of the sternum in the 2nd intercostal space.
Aortic valve on the right edge of the sternum in the 2nd intercostal space.
15. You should listen initially with the diaphragm noting how many heart sounds you
can hear are there any extra to the two normal sounds? Are there any
murmurs? Are the heart sounds normal in character? Can you hear any rub? If
you hear any abnormal sounds you should describe them by when they occur
and the type of sound they are producing. Feeling the radial pulse at the same
time can give good indication as to when the sound occurs the pulse occurs at
systole. Furthermore, if you suspect a murmur, check if it radiates. Mitral
murmurs typically radiate to the left axilla whereas aortic murmurs are heard
over the left carotid artery.

16.You may also wish to listen with the bell of
your stethoscope for any low pitched
murmurs.
Mitral valve location

Tricuspid valve location

Pulmonary valve location

Aortic valve location

17.To further check for mitral stenosis you can
lay the patient on their left side, ask them to
breathe in, then out and hold it out and
listen over the apex and axilla with the bell of
the stethoscope.
Further check for Mitral Stenosis
18.Aortic incompetence can be assessed in a
similar way but ask the patient to sit forward,
repeat the breathe in, out and hold exercise
and listen over the aortic area with the
diaphragm.
Assess for Aortic incompetence
19.Finally you should assess for any oedema.
Whilst the patient is sat forward, feel the
sacrum for oedema and also assess the
ankles for the same.
Assess for any oedema