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Assessment of cardiovascular structure Diagnostic studies ECG Echocardiography X- ray The exercise stress Cardiac catheterization

Anatomy & Physiology

Functions of the heart & CV system Pumps blood to tissues to supply O2 & nutrients Remove CO2 & metabolic wastes

Circulation in the Heart

1. Oxygen-poor blood (shown in blue) flows from the body into the right atrium.
2..Blood flows through the right atrium into the right ventricle. 3. The right ventricle pumps the blood to the lungs, where the blood releases waste gases and picks up oxygen.

3. The newly oxygen-rich blood (shown in red) returns to the heart and enters the left atrium. 4. Blood flows through the left atrium into the left ventricle. 5. The left ventricle pumps the oxygen-rich blood to all parts of the body.

Coronary Circulation

Coronary Blood Flow

Valves of the Heart

Tricuspid Directs the flow of blood from the right atrium to the left ventricle. Mitral Valve Directs the flow of blood from the left atrium to the left ventricle. Pulmonic (semilunar) Lies between the right ventricle and the pulmonary artery. Aortic Valve (semilunar) Lies between the left ventricle and the aortic artery.

Part I: Assessment of cardiovascular function

physical assessment

1. Health history
a- Socio - cultural history: Age, sex, occupation, educational level, marital status b- Patient history: Past medical history , Past surgical history C-Family History d- Psychosocial Profile

- Symptom Analysis
1- Chest Pain
- Location: - Substernal, pericardial diffuse, localized - Radiation: -Radiates to jaw, arm, neck - Character: - Dull, aching, pressure, burning tightness, crushing - Intensity: - Mild, moderate, severe - Onset: Sudden, gradual - Duration: - 1 -10, more than 15 min, or continuous - Precipitating factors: - exercise, motion, eating - Relieving factors: - rest, walking, warmth, drugs - Accompanying symptoms : -dyspnea, restlessness, sweating, vomiting, cough, syncope, fatigue

Pain Assessment Techniques

The patient's self-reported pain is often measured by using pain scales Numeric Pain Intensity Scale uses a 0-10 scale to assess the degree of pain. Simple Description Intensity Scale, uses such words as "mild", "moderate", and "severe" to describe the patient's pain intensity.

Visual Analog Scale (VAS) requires patients to mark a point on a 10 cm horizontal or vertical line to indicate their pain intensity, with
0 indicating "no pain and 10 indicating "the worst possible pain".

Substernal or retrosternal pain spreading across chest; may radiate to inside of arm, neck, or Angina jaw Pectoris


Usually related Rest, to exertion, nitroglycerin, emotion, eating, oxygen cold

Substernal pain or pain over precordium; may spread widely throughout chest. Pain Myocardial Infarction in shoulders and hands Angina Pectoris may be present.


>15 min

Occurs spontaneo usly but may be sequela to unstable angina

Morphine sulfate, successful reperfusion of blocked coronary artery

Esophageal Pain
Substernal pain; 560 may be projected min Angina Pectorischest around to shoulders. Recumbency, Food, antacid. cold liquids, Nitro-glycerin exercise. relieves Spasm. May occur Spontaneously .

Pain over chest; may 23 min Stress, be variable. Does not emotional radiate. Patient may tachypnea complain of numbness and tingling of hands and mouth. Removal stimulus, relaxation of

2- Palpitations 3- Syncope Syncopal attacks (dizziness) are another symptom that may signal cardiovascular problems. 4- Edema Edema may be seen with right-sided CHF and vascular disease.

Pitting edema is a depression in the skin from pressure.

To demonstrate the presence of pitting edema, the nurse presses firmly with his or her thumb over a bony surface The severity of edema is described on a five-point scale, from none (0) to very marked (4).

1+ Mild pitting, slight indentation, no perceptible swelling of the leg 2+ Moderate pitting, indentation subsides rapidly 3+ Deep pitting, indentation remains for a short time, leg looks swollen 4+ Very deep pitting, indentation lasts a long time, leg is very swollen

5- Fatigue fatigue is associated with cardiovascular disease. 6- Extremity Changes Changes in the extremities may provide clues about underlying cardiovascular disease. Symptoms such as Paresthesia (numbness, tingling), coolness, and intermittent claudication (pain in calves during ambulation) may be associated with vascular disease, coronary heart disease, or cerebral vascular disease.

7- Dyspnea and Cough Dyspnea may also occur with cardiac disease such as left-sided CHF.

B- Physical assessment
General Appearance Vital Signs Height and Weight

Inspection and palpation

1-Skin Color Turgor Temperature and moisture:-

2- Nails Nails should be assessed for color, shape, thickness, symmetry, and adherence. Normal nail color is some variation of pink Nail thickness generally is 0.3 to 0.65 mm, but it may be thicker in men

Nail abnormalities: -Peripheral vascular disease can produce nail depression, Clubbing

-Clubbing of the fingers is associated with decreased oxygen. In clubbing, the distal tips of the fingers become bulbous, the nails are thickened hard, and curved at the tip, and the nail bed feels boggy when squeezed. - Separation from the nail bed produces a white, yellowish, or greenish color on the non-adherent portion of the nail.

Capillary refill time: is a quickly test to assess the adequacy of circulation in an individual with poor cardiac output. An area of skin is pressed firmly by (say) a fingertip until it becomes white; the number of seconds for the area to turn pink again indicates capillary refill time. Normal capillary refill takes around 2 seconds.

2- Inspection and palpation

1- Inspection of neck

Inspecting the carotid artery and jugular venous system With the patient in a supine position, inspect the carotid and jugular venous systems in the neck for pulsations.
To visualize external venous pulsations, look for pulsations in the supraclavicular area.

To visualize internal venous pulsations, look for pulsations at the suprasternal notch.
Using a penlight to cast a shadow on the neck vessels may help you visualize the pulsations

Carotids have visible pulsation, jugulars have undulated wave.

Carotids not affected by respirations, jugulars are. Carotids not affected by position, jugulars normally only visible when client is supine.
Large, bounding visible pulsation in neck of at suprasternal notch: HTN, aortic stenosis,.

Measuring Jugular Venous Pressure

-Position patient with the head of bed at 30 to 45-degree angle. - Place a ruler vertically, perpendicular to the chest at the angle of Louis (sternal angle).

-identify the highest level of the jugular vein pulsation; if unable to see pulsations, use the highest level of jugular vein distension.
- Place another ruler horizontally at the point of the highest level of the venous pulsation.

- Measure the distance up from the

chest wall.
The normal JVP is less than 3 cm. A central venous pressure can be estimated by adding 5 cm to the JVP


JVP: Right-sided CHF, constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction.

Low JVP: Hypovolemia.

Palpating the Carotid





separately. - Note rate, rhythm, amplitude, contour, symmetry, elasticity, thrills.

Palpating the Jugulars

Palpate jugular veins and check direction of fill. Occluding under the jaw, the jugular should flatten, but the wave form become more prominent. Occluding above the clavicle, the jugular normally distends

Palpating the Precordium - Identify and palpate each cardiac site for pulsations, and thrills: - Apex (left ventricular area), or mitral area fifth intercostals space, midclavicular line.

- Base right (aortic area), second intercostals space right sternal border.

- LLSB (tricuspid area), fourth to fifth intercostal space at left sternal border.

- Base left (pulmonic area), second intercostal space left sternal border.
- Listen at each site with both the bell and the diaphragm.

- Listen at each site with both the bell and the diaphragm.

Thrills are palpable vibrations created by turbulent blood flow. Lifts or heaves are diffuse, lifting impulses. A thrust is a rocking movement.


Diaphragm medium and high frequency sounds Bell low frequency sounds Normally hear closure of valve Sounds from left side of heart louder than equivalent sounds from right side of heart

S1 closure of mitral and tricuspid valves

S2 closure of aortic and pulmonic valves Low pitched sounds S3, S4, mitral stenosis

Right 2nd intercostal space

Aortic Area

Left 2nd intercostal space

Pulmonic Area

Left lower sternal border Tricuspid area Apex over apical impulse Mitral area


the aortic and pulmonic areas are correlated anatomically with the base of the heart.

S3 (also called a ventricular gallop) may be heard in the tricuspid and mitral areas during the early to mid-diastole following the S2 sound. S3 is heard well when the client is in the left lateral recumbent position,

S4 (also called atrial diastolic gallop) may be heard in the tricuspid and mitral areas during the late phase of diastole, before S1 of the next cardiac cycle.
S4 is heard well when the client is in the supine position

Auscultating the Precordium

Auscultate at apex. - Note rate, rhythm, extra sounds, or murmurs. - Note S1, S2, extra sounds, or murmurs. - Listen at each site with both the bell and the diaphragm.

Murmurs and Stenosis

A valve that does not close efficiently, results in the backflow of blood (i.e., insufficiency or regurgitation).

A valve that does not open wide enough may cause turbulent backflow secondary to obstruction or narrowing (i.e., stenosis).

Abnormal finding
Irregular rhythm: Arrhythmia. Accentuated S1: High-output states, mitral or tricuspid stenosis. Diminished S1: First-degree heart block, CHF, CAD. -Variable S1: Atrial fibrillation. S3, low-pitched, early diastolic sound: CHF. S4, low-pitched late-diastolic sound: CAD, HTN, MI.

Ejection fraction (EF)

The ejection fraction (EF) represents the amount of blood pumped out of the heart (left ventricle) with each beat. In the healthy heart, it is around 70%.

An EF below 55% is considered abnormal.

EKG A 12 lead EKG is a graphic record of the electrical forces produced by the heart


Acute Anteroseptal MI

LEADS Leads measure electrical activity between 2 points Movement toward electrode causes positive deflection Movement away from electrode causes negative deflection

A 12 Lead EKG shows electrical activity from 12 different positions in the heart, concentrating on (L) ventricle A 14 Lead EKG includes (R) ventricle activity


Cardiac output
SVCOPreloadAfterloadEjection fraction GOAL is to maintain adequate MAP so perfusion of oxygenated blood to vital organs occurs

Stroke Volume (Sv) & Cardiac Output (Co)

SV amount of blood ejected by 1 ventricle in 1 beat CO volume ejected in 1 min Control of SV and HR = SV&HR are continually adjusted by the body, and are affected by the return of blood from the tissues (think of exercise) CO = SVxHR


Decreased S1:

Slowed ventricular ejection rate/volume Mitral insufficiency Increased chest wall thickness Pericardial effusion Hypothyroidism


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Decreased S1 (cont.):

Cardiomyopathy LBBB Shock Aortic insufficiency First degree AV block

Other Abnormal S1 (cont.):

Increased S1:
Increased cardiac output Increased A-V valve flow velocity (acquired mitral stenosis, but not congenital MS)

Wide splitting of S1:

RBBB (at tricuspid area) PVCs VT


From closure vibrations of aortic and pulmonary valves Often ignored, but it can tell much Divided into A2 and P2 (aortic and pulmonary closure sounds) Best heard at LMSB/2LICS Higher pitched than S1--better heard with diaphragm
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S2 splitting (normal):

Normally split due to different impedance of systemic and pulmonary vascular beds Audible split with > 20 msec difference Split in 2/3 of newborns by 16 hrs. of age, 80% by 48 hours Harder to discern in heart rates > 100 bpm


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S2 splitting (normal, cont.):

Respiratory variation causes splitting on inspiration: pulmonary vascular resistance When supine, slight splitting can occur in expiration When upright, S2 usually becomes single with expiration


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S2 splitting (abnormal):

Persistent expiratory splitting

ASD RBBB Mild valvar PS Idiopathic dilation of the PA WPW


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S2 splitting (abnormal, cont.):

Widely fixed splitting


S2 splitting (abnormal, cont.):

Wide /mobile splitting

Mild PS RVOTO Large VSD or PDA Idiopathic PA dilation Severe MR RBBB PVCs

S2 splitting (abnormal, cont.):

Reversed splitting
LBBB WPW Paced beats PVCs AS PDA LV failure

Single S2:

Single S2 occurs with greater impedance to pulmonary flow, P2 closer to A2 Single and loud (A2): TGA, extreme ToF, truncus arteriosus Single and loud (P2): pulmonary HTN!! Single and soft: typical ToF Loud (not single) A2: CoA or AI
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Extra heart sounds


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S3 (gallop):

Usually physiologic Low pitched sound, occurs with rapid filling of ventricles in early diastole Due to sudden intrinsic limitation of longitudinal expansion of ventricular wall Makes Ken-tuck-y rhythm on auscultation


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S3 (cont.):

Best heard with patient supine or in left lateral decubitus Increased by exercise, abdominal pressure, or lifting legs LV S3 heard at apex and RV S3 heard at LLSB


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S3 (abnormal):

Seen with Kawasakis disease--disappears after treatment If prolonged/high pitched/louder:

can be a diastolic flow rumble indicating increased flow volume from atrium to ventricle

S4 (gallop):

Nearly always pathologic Can be normal in elderly or athletes Low pitched sound in late diastole Due to elevated LVEDP (poor compliance) causing vibrations in stiff ventricular myocardium as it fills Makes Ten-nes-see rhythm
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S4 (cont.):

Better heard at the apex or LLSB in the supine or left lateral decubitus position Occurs separate from S3 or as summation gallop (single intense diastolic sound) with S3


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S4 Associations:

CHF!!! HCM severe systemic HTN pulmonary HTN Ebsteins anomaly myocarditis

S4 Associations (cont.):

Tricuspid atresia CHB TAPVR CoA AS w/ severe LV disease Kawasakis disease


Usually pathologic Snappy, high pitched sound usually in early systole Due to vibrations in the artery distal to a stenotic valve


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Can be associated with:

Valvar aortic stenosis or pulmonary stenosis Truncus arteriosus Pulmonary atresia/VSD Bicuspid aortic valve Mitral valve prolapse (mid-systolic click) Ebsteins anomaly (can have multiple clicks)
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Does NOT occur w/ supravalvar or subvalvar AS, or calcific valvar AS.


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Whoop (sometimes called a honk):

Loud, variable intensity, musical sound heard at the apex in late systole Classically associated w/ MVP and MR Seen w/ VSDs closing w/ an aneurysm, subAS, rarely TR Some whoops evolve to become systolic murmurs
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Friction rub:

Creaking sound heard with pericardial inflammation Classically has 3 components; can have fewer than 3 components Changes with position, louder with inspiration


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Sounds made by turbulence in the heart or blood stream Can be benign (innocent, flow, functional) or pathologic Murmurs are the leading cause for referral for further evaluation Dont let murmurs distract you from the rest of the exam!!
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Laboratory tests
Creatine kinase (CK) and its isoenzyme CK-MB Lactic dehydrogenase Troponin I as low-density lipoproteins (LDL) and high-density lipoproteins (HDL).

Cholesterol (normal level, less than 200 mg/dL) LDL (normal level, less than 130 mg/dL) \ HDL (normal range in men, 35 to 65 mg/dL; in women, 35to 85 mg/dL) have a protective action Triglycerides (normal range, 40 to 150 mg/dL), composed of free fatty acids and glycerol, are stored in the adipose tissue and are a source of energy

Coagulation Studies Partial thromboplastin time (PTT) Prothrombin time (PT)

Chest x-ray and fluoroscopy Electrocardiography

Diagnostic Procedures
1. EKG 12 Lead continuous cardiac monitoring holter monitor 2. Chest x-ray detects enlargement of heart & pulmonary congestion

Diagnostic procedures
3. Echocardiography ultrasound that reveals size, shape and motion of cardiac structures Evaluates heart wall thickness, valve structure, differentiates murmurs 4. TEE transesophageal echocardiography provides a clearer image because less tissue for sound waves to pass through

Diagnostic procedures
5. Angiography / cardiac catherization determines coronary lesion size, location, evaluate (L) ventricular function, measures heart pressures 6. Exercise tolerance test 7. Radionuclide Imaging


Lab Studies
Cardiac enzymes = enzymes are released when cells are damaged (MI). Enzymes are found in many tissues/muscles, and some are specific to cardiac tissue.


Cardiac enzymes = CPK MB (CK-MB),myoglobin, Troponin In general, the greater the rise in the serum level of an enzyme, the greater the degree or extent of damage to the muscle. LDH

LAB studies
2. 3. 4. 5. 6. Electrolytes Lipid panel CBC C Reactive Protein BNP- Human B-Natriuretic Peptide 7. Blood coags-PT/PTT/INR

Cholesterol Level : AHA Recommendation

Total Cholesterol
< 200 mg/dL

200 239
borderline high

240 mg/dL and above

2X risk of CAD

Cholesterol Level : AHA Recommendation

HDL Cholesterol
< 40 mg/dL (men) < 50 mg/dL (women) > 60 mg/dL

Cholesterol Level : AHA Recommendation

LDL Cholesterol
< 100 mg/dL

100 129 mg/dL

Near or above optimal

130 159 mg/dL


160 189 mg/dL


190 mg/dL
Very high

Cholesterol Level : AHA Recommendation

< 150 mg/dL

150 199 mg/dL

Borderline high

200 499mg/dL

500 mg/dL and above

Very high