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The aim of this chapter is to describe some of the techniques used in the assessment of the cardiovascular system, such as auscultation of normal heart sounds, measurement of blood pressure and obtaining a normal electrocardiogram (ECG).
Closure of the heart valves occurs in every cardiac cycle (Fig. 8). The closure of these valves is accompanied by sounds having frequencies between 15 - 400 Hz. These sounds are known as heart sounds and can be heard using two methods; they are the auscultatory and electrophonocardiographic methods. Normally two heart sounds, the first heart sound (SI) and the second heart sound (S2) are audible during a cardiac cycle and can be heard by auscultation, whereas a total of four heart sounds can be recorded using the electrophonocardiographic technique. Auscultation is a difficult skill to acquire and requires a lot of practice by students. By understanding the basis of the cardiac cycle, students can relate, understand and appreciate the importance of heart sounds.
First Heart Sound (SI)
The first heart sound is a soft, lowpitched and prolonged sound lasting approximately 0.15 seconds, with a frequency of 25 - 45 Hz and sounds like "lub". It is due to the closure of the atrioventricular valves at the beginning of the isometric ventricular contraction phase. The first heart sound becomes softer when the heart rate is decreased and becomes louder in pitch when the heart rate increases.
Second Heart Sound (S2)
The second heart sound is a short, sharp and high-pitched sound lasting approximately 0.12 second, with a frequency of 50 Hz and sounds like "dup". It is due to the closure of the semilunar valves at the beginning of the isometric ventricular relaxation phase. In systemic or pulmonary hypertension, S2 is heard louder than normal. During normal breathing, the aortic and pulmonary valves close simultaneously. However, during deep inspiration, S2 may be split due to the aortic valve closing earlier than the pulmonary valve. This is because during deep inspiration, the intrathoracic pressure decreases and more blood is returned to the right side of the heart. Hence, the time taken for the blood to be ejected out into the pulmonary artery is longer resulting in the pulmonary valve closing later than the aortic valve. This splitting of S2 disappears during expiration. The splitting of S2 that occurs during deep inspiration is called physiological splitting. It is often heard among healthy children and young adults. Splitting of S2 can also occur in certain abnormalities of the heart, such as atrial septal defect or conduction block. However, in these abnormal conditions, S2 remains split throughout inspiration and expiration.
The time interval between SI and S2 signifies the ventricular systolic duration, whereas the time interval between S2 and SI signifies the ventricular diastolic duration.
Third Heart Sound (S3)
Sometimes, a third heart sound (S3) can be heard at approximately 0.10 - 0.15 seconds after S2. The third heart sound is commonly heard in children and young adults. The sound is softer in pitch and is due to vibrations that occur when blood rushes into the ventricle as soon as the atrioventricular valves open at the beginning of the filling phase. The presence of S3 in someone above the age of 40 is usually considered abnormal.
Fourth Heart Sound (S4)
The fourth heart sound (S4) that occurs simultaneously with atrial systole is never audible in someone who is normal and healthy. However, in abnormal conditions such as hypertension, conduction block or ventricular failure, S4 can be heard just before SI.
Heart murmurs are due to turbulent flow of blood through abnormal heart valves or septae, eg. congenital septal defects. The duration of a heart murmur is longer than the normal heart sounds. Not all heart murmurs are due to organic cardiac defects. Some murmurs are due to an increased blood flow through the heart valves, as in exercise, pregnancy or anaemia. These are known as functional murmurs. Heart murmurs are classified based on the phase of the cardiac cycle during which they are heard. Systolic murmurs are related to SI and diastolic murmurs to S2. A murmur due to a valvular defect can be best heard at its specific auscultatory area (Fig. 9).
The stethoscope is used for the technique of auscultation. A stethoscope has 2 main components: a "bell" and a "diaphragm". High-pitched sounds are best heard using the diaphragm, such as the murmur in aortic regurgitation, whereas low-pitched sounds are best heard using the bell. The auscultatory areas shown in Fig. 9 are the areas where the heart sounds are best heard. Note that heart sounds can also be heard outside the areas of auscultation over the precordium. In addition, the heart sound that is heard in one area does not necessarily indicate that the origin of the sound is from that area only. 1. Students are encouraged to work in pairs for this procedure.
2. Place the diaphragm of the stethoscope on the areas of auscultation, listen to SI and
S2 and compare their qualities. 3. Try to listen for S3, as this may be heard occasionally in some normal individuals. 4. Ask the subject to take a deep breath. Listen for any differences in the loudness of the heart sounds. Determine whether there is splitting of S2 during deep inspiration. 5. Ask the subject to do some light exercises (e.g. climb up and down the stairs several times); then listen for the heart sounds again. Try to discern for any differences in loudness or the characteristics of the heart sounds. Determine whether any abnormal heart sounds or heart murmurs are audible.
Pulses and Arterial Blood Pressure
Evaluation of the pulses and arterial blood pressure are part °f a routine clinical examination of the cardiovascular system.
The heart is essentially a mechanical pump that ejects blood intermittently into the aorta and consequently produces pulse waves in the arteries. These pulse waves can be palpated at specific points on the arterial tree where the arteries become superficial. The arteries that can
be used for feeling or studying the pulse are the radial, brachial, carotid, femoral, popliteal, tibialis posterior and dorsalis pedis arteries (Fig.10). Any evaluation of the pulse should consider the following parameters: 1. 2. 3. 4. 5. 6. Rate Rhythm Character Volume Nature of blood vessels Presence or absence of a radio-femoral delay
During an examination of the pulse, arterial pulses on both sides of the body must be felt and compared with one another. Usually the radial pulse is used to determine the rate and rhythm of the heart. It is important that the subject be calm during the pulse examination, as anxiety can increase the pulse rate. The radial pulse is palpated once the subject is relaxed. The pulse must be palpated for at least 30 seconds. At rest, the pulse rate ranges from 60 to 100 beats per minute. The pulse rate can increase during exercise, fever and in hyperthyroidism. A pulse rate less than 60 beats per minute can be seen in athletes and in patients with a complete heart block or hypothyroidism.
1. Ensure that subject is in a lying or sitting position for at least 5 minutes. 2. Palpate the radial pulse at the wrist and count for one minute. 3. Ask the subject to stand up straight and immediately count again for one minute. Compare the pulse rate of the subject obtained in the supine and upright postures.
Arterial Blood Pressure
The pressure in the arteries is called the arterial blood pressure (BP). Arterial BP increases during systole and decreases during diastole. The highest pressure in the aorta during each cardiac cycle is called the systolic blood pressure (SBP), and the lowest pressure is known as the diastolic blood pressure (DBP). The difference between SBP and DBP is known as the pulse pressure (PP). The mean arterial pressure (MAP) is calculated as below: MAP = DBP + 1/3 (SBP - DBP) In humans, BP is measured indirectly by the palpation or auscultation method using a sphygmomanometer. Using the palpation method, only the systolic blood pressure can be obtained, whereas, by using the auscultatory method, both SBP and DBP can be determined.
A. 1. 2. 3. 4. Palpation Method Let the subject rest in the sitting position for at least 5 minutes. Place the arm of the subject and the sphygmomanometer at the same level as the Wrap the cuff of the sphygmomanometer firmly around the upper forearm such that Locate the subject's radial pulse. Increase the pressure in the cuff until the radial
heart. Ensure that the mercury meniscus in the manometer can be read at eye level. the lower end of the cuff is at least 2.5 cm above the cubital fossa. pulse is no longer palpable. Then, increase the pressure of the cuff by another 20 mmHg. 5. 6. 7. Immediately, but gradually release the pressure in the cuff until the radial pulse is The pressure at which the radial pulse becomes palpable once again is considered Repeat the procedure three times (with a gap of several minutes in between each palpable once again. Read the pressure value off the manometer column at this point. to be the subject's SBP. reading) and calculate the average SBP.
B. 1. 2. 3. 4. 5. 6. 7.
Auscultation Method Let the subject rest in the sitting position for at least 5 minutes. Place the arm of the subject and the sphygmomanometer at the same level as the Wrap the cuff of the sphygmomanometer firmly around the upper forearm such that Locate the subject's radial pulse. Increase the pressure in the cuff until the radial Place the diaphragm of the stethoscope gently on the cubital fossa over the Gradually release the pressure in the cuff until a tapping sound is heard. Read the Continue to reduce the pressure in the cuff and note the difference in the pitch and
heart. Ensure that the mercury meniscus in the manometer can be read at eye level. the lower end of the cuff is at least 2.5 cm above the cubital fossa. pulse is no longer palpable. Now, increase pressure in the cuff by another 20 mmHg. brachial artery. pressure value off the manometer column at this point. This indicates the SBP. loudness of the sounds heard. The sounds that are heard as the cuff pressure is being reduced are known as Korotkoff sounds. 8. DBP. 9. Repeat this procedure after a gap of several minutes and calculate the average SBP and DBP. At the point where the Korotkoff sounds become muffled and eventually inaudible, read the pressure value off the manometer column. This pressure is considered the
In a normal heart, the cardiac impulse originates from the sinoatrial node (SAN) and spreads through the atrial muscles via the internodal tracts to the atrioventricular node (AVN). From the AVN, the cardiac impulse travels through the bundle of His, left and right bundle branches, and the Purkinje fibres into the ventricular mass. The spread of the cardiac impulse is related to changes in the electrical activity of the heart. By using a pair of surface electrodes and with amplification, changes in the electrical activity of the heart can be recorded from the surface of the body. The technique of recording the changes in the electrical potentials of the heart during a cardiac cycle is called electrocardiography and the recording is known as an electrocardiogram (ECG).
In order for an ECG to have standard interpretation, the site of placement of electrodes on the body surface must be uniform. The arrangements of these paired electrodes on the surface of the body are called leads. Clinically, a complete ECG recording would have 12 leads that are divided into three groups: 1. 2. 3. Standard limb leads Augmented limb leads Precordial/Thoracic/Chest leads
Standard Limb Leads
The standard limb leads consist of Lead I, Lead II and Lead III. Each of the lead records the difference in the electrical potential between two parts of the body. As shown in Fig. 11, Lead I records the potential difference between the right arm and left arm. Lead II records the potential difference between the right arm and left leg and Lead III records the potential difference between the left arm and left leg.
Augmented Limb Leads
Augmented limb leads consist of three leads: aVR, aVL and aVF. The leads record the potential difference between one part of the body and two other body areas. Augmented limb leads are used more frequently than unipolar leads because they increase the amplitude of the potential by 50% without any changes in the ECG waves.
The thoracic leads consist of six leads designated as VI - V6. As shown in Fig 11, the thoracic leads record the potential difference between an active electrode and an indifferent electrode in which the potential has been fixed at zero. To record the ECG, the active electrode is moved from one area to another area of the precordium. The thoracic leads can provide more information than the standard limb leads.
An ECG is a recording of the changes in the electrical potential that occur in the heart throughout the cardiac cycle. The ECG 1 recording represents the depolarisation and repolarisation process, but not the mechanical events of the heart (systole and diastole). A normal ECG tracing consists of a series of deflections, namely the P wave, QRS complex and T wave (Fig. 12). These complexes are connected to one another by an isoelectric line. The isoelectric line represents the time interval during which there is no potential difference between the electrodes. Although the waves can be recorded using different electrodes, the amplitude and shape of each wave differ according to the position of the electrodes.
1. 2. Let the subject recline on the bed. Apply a small amount of electrode gel on
the surface of the wrists and ankles on which the electrodes are to be placed. The electrode gel reduces the resistance offered by the skin. 3. 4. 5. Place and secure the electrodes as Set the recording speed to 25 mm/sec. Switch on the electrocardiograph and turn shown in Fig. 11.
the knob to the respective settings to record the ECG from the standard and augmented limb leads. 6. Obtain the ECG recording of the thoracic leads as shown in Fig. 11 with one active electrode moved from position V1 through to V6.
Determination of the electrical axis from the standard limb Leads I & III (Fig. 13)
a. Measure the nett (effective) amplitude of the QRS complex for Leads I and III in mm. The nett (effective) amplitude of the QRS complex is equal to the amplitude of the Q wave + amplitude of the R wave + amplitude of the S wave. The deflection that is above the isoelectric line has a positive value and the one below a negative value. b. c. Plot the QRS amplitude for Leads I and III on appropriate axes as shown in Fig. 13. Draw a perpendicular line (90°) from the effective amplitude value of the QRS
complex in Lead I and Lead III. Connect the point where the two perpendicular lines intersect to the point in the centre of the circle. This line connecting the two points represents the direction of the electrical axis of the heart.
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