Chapter - 018 - 2 Pic

Heart and Peripheral Vascular
System
Chapter 18
Anatomy and Physiology
• CV system: transports O2, nutrients to tissues;
carries waste to kidneys and lungs
• Heart: size of fist, 60 to 100 beats per minute
– Responds to internal and external stimuli: exercise,
temp change, stress
– Endocrine and nervous systems communicate stimuli
– CV system adjusts: alters diameter of vessels, CO,
blood distribution
Anatomy and Physiology:
Heart and Great Vessels
• Heart: right or left side (two chambers
each): atrium, ventricle
• Right side: blood from venae cavae,
through pulmonary arteries into lungs
• Left side: blood from pulmonary veins,
through aorta into systemic circulation
• Upper part, base; lower part, apex
Heart and Great Vessels
• Behind sternum, above diaphragm, in
mediastinum
– Lies at angle: R ventricle (anterior surface), L
ventricle (posterior surface)
– R atrium: R border of heart, L atrium posterior
• Aorta: curves upward out of L ventricle, bends
posterior/down above sternal angle
• Pulmonary arteries: out of superior aspect R
ventricle near third ICS
Pericardium or Cardiac Muscle
• Three layers
– Pericardium: double-walled sac of connective
tissue encases and protects heart (fibrous; two
serous layers)
• Fibrous (parietal) fibrous sac of elastic tissue; protects
from trauma and infection
• One serous layer next to fibrous; one serous layer
next to fibrous pericardium; second serous layer next
to myocardium
• Fluid between layers decreases friction
• Serous pericardium (epicardium) covers heart surface,
extending to great vessels
Pericardium or Cardiac Muscle
Three layers (cont.)

– Myocardium: thick muscle: controls
pumping action
– Endocardium: lines inner chambers and
valves
Blood Flow Through Heart
• Blood flow through chambers controlled

by four valves
– AV valves: tricuspid(right), mitral (left);
separate atria from ventricle
– Semilunar valves: pulmonic (right ventricle
from pulmonary artery), aortic (left ventricle
from aorta)
Cardiac Cycle
• Diastole (ventricles relaxed; fill with
blood)
– Blood flows into atria from systemic or
pulmonary circulation (positive pressure)
– When atrial pressure greater than ventricular
pressure, AV valves open – allow filling of
ventricles
• 80% flow into relaxed ventricle
• 20%: atrial contraction (kick)
Cardiac Cycle
• Systole (ventricles contracting)
– Pressure in ventricles greater than atrial pressure,
causing AV valve closure (prevent backflow of
blood)
– Pressure in ventricles greater than pressure in
great vessels, semilunar valves open, allowing
blood to flow into great vessels
• Ejection of blood decreases pressure in ventricles –
semilunar valves close
Anatomy and Physiology
Cardiac Cycle
• Systole (ventricles contract): mitral/tricuspid
valves close
– First heart sound: S1 (lub)
• Ventricles almost empty: pulmonic/aortic valves
close
– Second heart sound: S2 (dub)
• Ventricular contraction: increased pressure –
aortic pressure increases as blood flows into
aorta
• S1-S2 heard during cardiac cycle; S3-S4 abnormal
Electrical Conduction
• Electrical stimulation from SA node (R atrium); 60
to 100 per minute
• Internodal tracts (atrial contraction) to AV node
• Travels through bundle of His, Purkinje fibers of
myocardium, causing contraction
• AV node: prevents excessive atrial impulses
reaching ventricles
– SA node fails; electrical impulses generated elsewhere
(slower 40-60)
– SA/AV node failure: bundle branches take over (20-
40/min)
Peripheral Vascular System
• Arteries, capillaries, veins
– Arteries and arterioles
• High pressure from ventricular contraction
• Maintain blood pressure by altering diameter in response
to various stimuli
– Veins and venules: expansible; reservoir for extra
blood (decreases workload on heart)
• Pressure in veins less than arteries
• Valves keep blood moving forward towards heart
Blood Circulation
• Blood leaving heart (aorta): O2 rich– flows
through arteries to arterioles to capillaries
– Capillaries: deliver nutrients/O2 to cells, collect
waste
• Capillaries enlarge to become venules, flow
into veins, ending in R side of heart
(deoxygenated blood)
– Pulmonary circulation: CO2 out/O2 in
– Renal circulation: eliminate waste
System: General Health History
• Present health status
– Chronic illnesses? (describe)
– Taking medications (what/when), side effects; OTC
drugs (aspirin, herbs, cocaine, street drugs; how
often)?
– Exercise: (yes), what/frequency/time?; (no), ever,
what tried, motivated to start/stop?
– Personality type, handle stress? Work factors
(physical/emotional), relaxation (frequency, what?)
– Eating habits (red meat, fat, sodium), whole
grains?
System: General Health History
• Alcohol (type/frequency), caffeine

• Smoke (now/past) what forms, how
long, ever quit (successful?); yes, how
accomplished; no, want to quit?
• Know how smoking affects CV system?
System
• Past medical history
– Congenital heart disease/defect, “growing pains,”
joint pains, recurrent tonsillitis, rheumatic fever,
murmur?
– Increased triglyceride/cholesterol levels, coronary
artery disease (treated, lifestyle changes)?
– Heart/vascular surgery (what/when, success?)
– Heart tests (ECG, stress), when results, any
treatment?
System
• Family history
– History of DM, heart disease, hyperlipidemia,
increased BP, sudden death syndrome
• Problem-based history (symptom analysis)
– Chest pain
• Where feeling, radiate, severity, feel like?
• When started, intermittent or constant?
• Other symptoms?
• What precedes, makes worse or better, what
relieves?
Health History: Heart and
Problem-based history (cont.)
– Shortness of breath
• How long, SOB now, when, how often, lasts how
long?
• Interfere with ADL, walk how many blocks (now or
6 months ago)?
• Other symptoms?
• What makes worse, how many pillows to sleep?
• What makes breathing easier?
• Urinating during the night
– How long, times/night?
– What done to prevent, successful?
• Cough
– When started, frequency, productive, looks
like, any blood?
– Associated with position, anxiety, talking,
activity; what makes worse or relieves?
• Fatigue
– When notice, onset gradual/sudden, worse in am/pm,
work/home, keeping up with friends, too tired to
participate, rest reduce, bed earlier because too tired?
– Vitamins/iron pills, eat foods with iron, heavy menstrual
flow (females)?
– Other symptoms (increased heart rate, HA, pale, sore
tongue/lips, nail changes)
– Unusual feelings in hands, muscle weakness, trouble
thinking
• Fainting
– Last time occurred, doing what before
fainted (dizzy or lose consciousness)?
– Happened before, how often, preceded by
other symptoms?
• Swelling of feet and legs
– First notice, both legs, what makes go away?
– Concomitant symptoms; have pain/sores?
– Female: contraceptives, associated with
period?
• Leg cramps or pain
– Describe, legs feel heavier; location, severity?
– What makes better or worse?
– Changes in skin of legs?
Examination
• General appearance
– Evaluate general condition; lying supine at
45 degrees
• Peripheral vascular: measure blood
pressure
Examination: Peripheral Vascular
• Upper extremities
– Inspect/palpate for skin turgor or integrity
– Inspect and palpate for appearance, color,
temperature, and capillary refill
– Palpate brachial and radial pulses: rate
rhythm, amplitude, contour
Examination: Peripheral Vascular
• Lower extremities
– Inspect and palpate for skin turgor/integrity
– Inspect and palpate for appearance, color
temperature, hair distribution, capillary refill,
and superficial veins
– Perform Trendelenburg test to evaluate
competence of venous valves (varicose veins)
– Palpate femoral, popliteal, posterior tibial,
dorsalis pedis pulses for amplitude
– Calculate ankle-brachial index to estimate
arterial occlusion
Examination: Cardiac
• Inspect anterior chest wall for contour,
pulsations, lifts heaves, retractions
• Palpate apical pulse for location
• Palpate precordium for pulsations,
thrills, lifts, heaves
• Percuss heart borders for heart size
• Auscultate S1-S2 heart sounds for rate,
rhythm, pitch, splitting
• Interpret ECG of conduction of heart
Age-Related Variations: Infants
• Anatomy and physiology

– Oxygenation of fetus through placenta
(nonfunctional lungs)
– Foramen ovale: opening between atria; shunts
blood to L side
• Closes from incresed L atrial pressure (first hour)
– Ductus arteriosus: blood pumped from R ventricle
into aorta
• Closes within 10 to 15 hours after birth
• Health history
– Mother’s health during pregnancy: rubella,
fever, infections, drugs (OTC, Rx, illicit)?
– Breathing changes: more rapid/heavy
(feeding, bowel movement); feeding, tire
easily, take breaks, turn blue around mouth
(feeding/crying); gaining weight/growing?
– Tire easily while playing; naps—how long?
• Examination: procedures and techniques
– BP difficult: electronic sphygmomanometer
with Doppler
– Apical pulse: 4th or 5th ICS, medial to MCL
– Examine in first 24 hours and 2 to 3 days:
fetal circulation converts to systemic/
pulmonic circulation
– Auscultation when quiet: pediatric chest
piece
– If dyspneic, estimate heart size/position
• Examination: normal and abnormal findings

– Heart rate faster when awake, slower when sleeping
– Sinus dysrhythmia (HR increases with inspiration,
decreases with expiration)
– Splitting: common up to 48 hours (transition of
circulation)
– Innocent murmurs (I/II): if no other symptoms,
disappear in 2 to 3 days
– Capillary refill: rapid (<1 sec)
– Acrocyanosis: if no central cyanosis, not
significant  disappears
– Cyanosis (central): indicator of congenital heart
defects
• Note if increases with crying sucking
• After birth, transposition of great vessels, tetralogy
of Fallot, septal defect, pulmonic stenosis
• After first month, pulmonic stenosis, tetralogy of
Fallot, large septal defects
– Murmurs: after 3 days or radiates – refer
• Pressure on liver increases pressure to right atria
– L  R shunt: disappear briefly
– R  L shunt: increased
– Pneumothorax: shifts apical pulse away from
affected area
– Diaphragmatic hernia: shifts heart to R
– Dextrocardia: shifts apical pulse to R

– Weak/thin pulses: decreased cardiac
output/peripheral vasoconstriction
– Bounding pulses: patent ductus arteriosus (L to R
shunt)
– Absent femoral pulses/difference in amplitude
between UEs and LEs: coarctation of aorta
– Increased refill time (>2 sec), dehydration or
hypovolemic shock
Age-Related Variations: Children
– Same as for adult
• Health history
– Tire easily during play (what activities tiring), keep up
(reluctant to play due to inability to keep up), turn blue
or SOB during activities, longer naps, squatting, leg
pains?
– Unexplained fever, frequent respiratory infections (how
many, treated?); strep, joint pain?
– Siblings with heart defect or Down syndrome?
– Auscultation: requires cooperative child; may take longer
to listen to sounds
• Child sitting on table or lap
• 45-degree angle or supine
– Irregular rhythm: child hold breath (hear only heart
sounds)
– Venous hum: turbulent blood flow, low pitched, louder
during diastole
• Stopped with pressure between
trachea/sternocleidomastoid muscle
– Note differences between pulses (femoral/radial)
– Pulse increases on inspiration,decreases on
expiration (sinus dysrhythmia expected finding)
– Venous hum: jugular vein
– Note poor weight gain or cyanosis
• Squatting: compensatory position
• Cyanosis or pallor: poor perfusion from heart defects
• Note if increased with crying; ankle or facial edema
– Note poor feeding or reports of stopping eating to
get breath
• Labored respirations: cardiovascular problem;
weak/absent femoral pulse; coarctation of aorta
Age-Related Variations:
Older Adults
– Aging heart functions well; problem
compensating if stress, blood loss, tachycardia,
exertion, fever
• Increased age; heart size decreased, output less
than 30% to 40% (decreased heart rate, contractility)
• Response to stress, increased O2 demand; less
efficient, longer return to baseline
• Thickening of endocardium or decreased myocardial
contractility causes delayed recovery from
myocardial contractility or irritability
Older Adults
Anatomy and physiology (cont.)
– Arterial walls or superficial vessels:
decreased compliance (dilated, prominent,
tortuous, calcified)
• Increased BP (systolic/diastolic) from increased
peripheral resistance
– Fibrosis or sclerosis of SA node or mitral
and aortic valves causes altered cardiac
function
Older Adults
• Health history
– Experienced confusion, dizziness, blackouts,
fainting, palpitations?
– Short of breath, fatigued, confused,
abdominal or back pain, fainter?
– Same as for younger adult
Older Adults
– Variations in heart rate: slower (increased
vagal tone) or faster
• Extreme ranges require follow-up to determine
significance
• Ectopic beats: may or may not be significant
– S4 common: decreased L ventricular
compliance
Common Problems or
Conditions: Cardiac Disorders
• Valvular heart disease

– Acquired or congenital disorder of valve
– Stenosis (obstruction): blood flow
decreased, creates backflow
– Degeneration (regurgitation): incompetent
closure
– Rheumatic fever or endocarditis causes
most acquired VHD
Common Problems or
• Ventricular hypertrophy: increase in cell
size from chronic overwork
– Aortic stenosis/HTN: increases resistance
that L ventricle must overcome
• Palpable lift during systole; apical pulse
displaced laterally
– Idiopathic pulmonary HTN: increases
resistance that R ventricle must overcome
• Lift along L sternal border, 3rd or 4th ICS
Common Problems or
• Angina pectoris: chest pain from ischemia
– Atherosclerosis common cause: occurs during
activity, stress, cold (increased demand on
heart); at rest from coronary artery spasm
– May occur without atherosclerosis:
(hypertrophy, valve disease, increased
metabolic demands)
– Incidence: 6.6 million; more common in
females than males (age adjusted)
Common Problems or
• Pain: squeezing, suffocating, constricting;
may have HTN (also hypotension)
• Accompanied by gallop rhythm, systolic
murmur, dysrhythmias (supraventricular)
• Duration significant
– Exertion with resting: less than 3 minutes
– Heavy meal or anger: 15 to 20 minutes
– More than 30 minutes: unusual (unstable angina,
developing infarction)
Common Problems:
Cardiac Disorders
• Severe myocardial ischemia results in necrosis
(infarction)
• MI from coronary artery disease: single leading
cause of death in United States (1 in 5 deaths)
• 1.1 million new or recurrent cases each year;
44% die
• L ventricle most common; may affect R ventricle
Common Problems or
• Pain described as worse ever, more than 5
minutes; radiate (L shoulder, jaw, arm); not
relieved by nitroglycerin
• Dysrhythmias common; heart sounds distant;
thready pulse
• Women have different symptoms: fatigue, sleep
disturbance, shortness of breath
– Less than 30% reported chest pain before infarction
Common Problems or
• Heart failure: failure of ventricles to pump
blood efficiently
• Left sided: increased resistance, ventricle
unable to compensate; weak contraction
from cellular death (infarction)
– Ventricles unable to empty, causes blood to
back up into atria and pulmonary capillaries
resulting in pulmonary edema
Common Problems or
• Precordial movement, displaced apical

pulse, palpable thrill, S3, systolic murmur
• Acute phase: bilateral pulmonary
crackles
Common Problems or
• R ventricle failure: hypertrophy from
pulmonary HTN, cell necrosis from
infarction
– Blood backs up into R atrium, progressing
to venae cavae
• Precordial movement at xiphoid or L
sternal border, systolic murmur
• RVF from pulmonary disease; cor
pulmonale
Common Problems or
• Infective endocarditis: infection of endothelial

layer or valves
• Endothelial surface damaged by turbulent
blood flow (valve disease, congenital lesions,
direct injury from IV lines or injections,
catheterization, artificial valves)
• Microorganisms attach to endothelium,
becoming infective vegetation
Common Problems or
• Thrombus forms where endocardium
damaged
– May break away; become emboli, causing
infarctions or abscesses in lungs, brain
kidneys, spleen, extremities
• Heart sounds normal; in late infection,
murmur if valve damaged
Common Problems or
• Pericarditis: inflammation of pericardial layers or

outer myocardium
– Idiopathic or from infarction, uremia, cancer trauma,
infection, surgery, autoimmune reaction
– Exudate: serous, fibrinous, purulent
• Pericardial rub: inflamed layers rub against each
other (2nd, 3rd, 4th ICS, LSB during inspiration)
• Pain: pleuritic,increases with deep breathing, supine
cough
Common Problems or
Conditions: Vessel Disorders
• Hypertension: based on mean of 2 or more, BP
readings on each of 2 or more occasions
– Normal values: <120 systolic, <80 diastolic
– BP = CO x PR
• Increased CO: increased stroke volume or heart rate
• Increased PR: arterial vasoconstriction or excess
vascular fluid
– Cause unknown; increases workload of heart
– No specific symptoms
Common Problems or
• Venous thrombosis or thrombophlebitis:
development of clot in vein; inflammation
without clot
– Stasis, vein damage, hypercoagulability
predispose to thrombosis or thrombophlebitis
– Lower extremity: deep veins
• Dilated, superficial veins, edema redness, ed
circumference of leg
– Upper extremity: superficial veins
• Redness, warmth tenderness; may be visible or
palpable
Common Problems or
• Thromboangiitis obliterans (Buerger’s
disease: inflammation or thrombosis of
medium-sized arteries
– Rare (6/100,000), men (20-40 years), smoke or
chew tobacco; symptoms improve if quits
– Upper and lower extremities involved; asymmetric
• Complaints of cold extremities, paresthesias,
intermittent claudication
Common Problems or
• Involved extremities pale, cold, increased

capillary refill
• Skin ulcers and gangrene fingers or toes
from ischemia
• Symptoms worse with cold or emotional
stress
Common Problems or
• Raynaud’s phenomenon/disease: intermittent
spasm of arterioles of digits, nose, and ears;
bilaterally – lasts minutes to hours
• Diagnosed when 2-year history of symptoms and
no progression of symptoms, no underlying cause
• Idiopathic or secondary to connective tissue
disease (scleroderma, RA, SLE), drug intoxication,
myxedema, 1° pulmonary HTN
• 5% to 10% of population; women more than men
Common Problems or
• Three skin color changes with attack:

white, blue, red in fingers or toes
– Order of change variable, not always three
• White, arteriole spasm; blue, cyanosis;
red, arterioles relax, blood flow restored
– Throbbing or tingling at end of attack
– Attacks: less than 1 minute to hours
Common Problems or
• Aneurysm: dilation of artery from weakness in
arterial wall (aorta, iliac vessels)
• Thoracic: asymptomatic; some report deep,
diffuse chest pain
• Aortic or arc: hoarseness (pressure on laryngeal
nerve); dysphagia (esophageal pressure)
• Abdominal aortic: most common; asymptomatic,
discovered on routine exam/ultrasound, CAT scan
– Pulsatile mass in periumbilical area with thrill or bruit

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Heart and Peripheral Vascular

Three layers (cont.)

• Blood flow through chambers controlled

• Alcohol (type/frequency), caffeine

• Anatomy and physiology

• Examination: normal and abnormal findings

• Examination: normal and abnormal findings

• Valvular heart disease

• Precordial movement, displaced apical

• Infective endocarditis: infection of endothelial

• Pericarditis: inflammation of pericardial layers or

• Involved extremities pale, cold, increased

• Three skin color changes with attack:

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