The semeiology of

cardiovascular system

Department of pediatrics
The cardiovascular system represents one
from the most important systems of
child’s organism through its functions:
• transport:
 Of nutritive substances,
 oxygen,
 metabolites,
• The support of immune protection,
• Humoral regulation of multiple
physiological processes.
In contrast with adult, in children, indifferently from
age, the cardiac pathology is dominated by:
 congenital cardiac malformations
 cardiopathies

In the last years the tendency of incidence increasing

is mentioned referring to the follows:
 disturbances of rhythm and conductibility
 hypotension
 Arterial hypertension.
Morpho-functional peculiarities of
cardiovascular system in different stages of
development
The ontogenesis of cardiovascular system begins in the II week
of gestation, in mesoderma, by the appearance of
primitive ,, cardiac tube”, from which is forming:
• Common arterial trunk, from which ulteriorly the magistral
vessels will forming (aorta and pulmonary artery);
• Cardiac bulb, from which the right ventricle will developing;
• primitive ventricle– predecessor of left ventricle;
• primitive atrium– preceeds the both atria;
• venous sinus, from which the great veins will forming.
In the III week two layers appear from cardiac
tube:
 internal, from which the endocardium will
developing;
 external, from which the myocardium and
epicardium will proceed.
The IV week- the heart with 2 cavities will forming
The IV week- the conducing system is constituted
of:
 Sinus node,
 Atrioventricular node,
 His fascicle,
 Bahman fascicle,
 Supplementary pathways (Kent etc.)
The V week – the heart with 3 cavities

The VI-VII week:

 The division of common arterial trunk
in pulmonary artery and aorta,
 Division of unique ventricle in the left
and right ventricle (forming of
interventricular septum).
 Fetal circulation
The setting up of placentar
circulation begins in theVIII week
of intrauterine development.
Thus, the oxygenated blood from
placenta, through ombilical vein,
gets in the foetus liver, where
being divided in a lot of pathways
reaches in vena portae and the
fortus liver receives the most
oxygenated blood.
Through venous channel(Arantius)
another part of blood is getting to
inferior vena cava, being mixed
with venous blood, arrived from
inferior parts of foetus body and
liver and is flowing in the right
atrium, where is also flowing the
superior vena cava which brings
the venous blood from the
superior part of body.
 Fetal circulation
The blood arrived on 2 these
pathways in the right atrium
will not be completely mixed,
the most part, arrived through
inferior vena cava, through
foramen ovale will pass in the
left atrium, left ventricle and
ascendent aorta.

The blood from superior vena

cava will getting from right
atrium in right ventricle.

In the left atrium also arrives the

blood from nonfunctional
pulmonary veins, but this
quantity of blood is not
important from gas exchange.
 Fetal circulation
The blood from left ventricle
through ascendent aorta in
systole reaches in the vessels
irrigating the superior part of
body(aa. Anonyma, Carotis,
Subclavia sin.),
About 10% of blood from right
ventricle through pulmonary
artery, gets in the not
functioning lungs and through
pulmonary veins is returning
in the left atrium.
The most part of blood from
pulmonary artery, through
arterial channel (Botallo),
arrives in the descendent
aorta, lower of vessels that
irrigate the brain, heart and
superior part of body.
 The fetal circulation is characterizing by:
1. Existence of fetal
communications between the
right and left part, also
between magistral vessels–
respectively two right-left
shunts.
2. Significant increasing of
minute-volume of big
circulation due to the absence
of pulmonary function.
3. Preferential ensurence with
richly ooxygenated blood of
vital organs(brain, heart, liver,
superior members) through
ascendent artery and its arch.
4. Practically equivalent pressure
in aorta and pulmonary artery.
 Postnatal circulation
After infant’s birth and first inspiration realizing,
the pulmonary resistance decreases and a lot
of modifications are producing:
• The stopping of ombilical circulation
concomitantly with ligaturing and sectioning
of ombilical cord.
• Elimination or extraction of placenta.
• Decreasing of vascular pulmonary resistance
and substantial increasing of vascular
pulmonary debit .
• Increasing of peripheral vascular resistance
and decreasing of peripheral sanguine debit .
• Closing of venous channel (Arantius), of
arterial duct (through decreasing of de
prostaglandin E1 production), of foramen
ovale
• The maturation of pulmonary vascularization
and decreasing of arterial pulmonar pressure
at the level of vascular bed
The heart of new-born has in reserve an
important potential of adaptation:
• Decreasing of blood viscosity through increasing
of figurate elements number (erythrocytes,
leucocytes);
• Stopping of placentar circulation, which
diminishes the volume of circulant blood with
25-30% and reduces the covered distance of
this;
• After birth the loading of left ventricle
increases and the loading of right ventricle
gradually decreases.
The physiologic evolution of pregnancy, without
the action of noxious factors, especially
teratogenic, ensures also the adequate
development of cardiovascular system.

In the contrary case the serious disturbances of

ontogenesis, with the forming of congenital
cardio-vascular malformations can be
produced.
The functional peculiarities of cardio-
vascular system in children
• The child’s organism has net superior necessities to
the heart due to more intense metabolism.
• The heart function has more favourable conditions
in comparison with adults due to the absence in
children of chronic intoxication (alchool, nicotine,
diverse professional noxious factors etc.).
• The cardio-vascular system in children has the
restoration possibilities more than in adults.
• The nervous regulation of cardiac activity in
children is represented by predomination of
sympathetic system on the parasympathetic.
• The physiologic tachycardia is characteristic for
children, respectively high frequency of cardiac
contractions (in new-born 120-140 beats/min.).
• The lability of cardiac contractions frequency is
an important peculiarity of the child. It can be
in:
 screaming,
 crying,
 movement (accelerating),
 sleeping (diminishing).
The frequency of cardiac contractions per
minute in function of age
0 -24 hrs 94 – 145 1 – 3 yrs 98 – 164

1 - 7 days 100 – 175 3- 5 yrs 65 – 132

8 – 30 days 115 – 190 5 – 8 yrs 70 – 115

1 – 3 months 124 – 190 8 – 12 yrs 55- 108

3 – 6 months 110 – 180 12 – 16 yrs 55 - 102

6 – 12 112 – 178
months
The establishing of correct and complete diagnosis in
a cardio-vascular disease in children needs the
using of following diagnostic methods:
1. Anamnesis
2. Physical examination, including:
 inspection
 palpation
 percussion
 auscultation
3. X-ray chest
4. Noninvasive graphic examinations:
a) echocardiography;
b) phonocardiogram;
c) Methods of nuclear cardiology, pulmonary
radiocardiography, radiospirometry;
d) tomodensitometry (computer triaxial
tomography )
5. Invasive examinations: catheterism and
angiography
6. Investigation of fetal rhythm (fetal
cardiology).
Anamnesis
There is a directed discussion with the sick child
and with his parents, in which the information
about his antecedents and the history of actual
disease, with the evidence of present complaints
and of motives to presentation at physician can
be obtained.
Heredo-collateral antecedents
The presence at another family members of:
• Congenital cardiopathies,
• Existence of consanguinity,
• Dismorphisms specific for some congenital
malformations,
• Cardiomegalies,
• Sudden unexplained death in youths.
Personal antecedents
Were observed in the first three months of pregnancy the
follows?
• Toxic aggressions (intoxications or alcohol
consumption by mother),
• Hormonal treatments,
• Exposures to radiation or viral infections (rubeola,
rujeola, flu etc.)
Especial attention to:
 antenatal history and cirumstances of birth,
 Duration of pregnancy,
 Birth weight,
 Apgar scale,
 presentation,
 Cyanosis at birth,
 Difficulties in alimentation.
To concretize:
• Evolution of growing and development from the
birth and until the moment of addressing
(physical and neuropsychic development),
• Resistance to infections,
• Presence of pulmonary infections (cardiopathies
with left-right shunt),
• Appearance of acute pulmonary edema (mitral
stenosis, arterial hypertension etc.),
• syncopes (aortic stenosis),
• limping at the level of inferior members at effort
(coarctation of the aorta).
The principal symptoms of cardio-
vascular system affection
Palpitations are the expression of cardiac
organic or functional arrhythmia.
They can be generated by neuro-vegetative
dystonia, by some functional states and, more
rarely in children, by some organic lesional
background.
Precordial pains are alarming for patient, they
can be manifested under the form of:
• sting,
• precardialgies,
• pression,
• burn,
• thoracic constriction etc.,
• with precordial localizing.
If they have cardiac origin, they will be produced by:
 coronarian insufficiency (aortic stenosis),
 some congenital cardiopathies,
 pulmonary hypertension etc.
There are a lot of situations (acute articular
rheumatism, some myocardites, pericardites,
endocardites, extrasystoles) which can produce
precordial pains by noncoronarian cause.
The pains with precordial localization can also appear
in intercostal neuralgia, but they can be easely
diffetentiated.
• Cyanosis by cardiac type is central, appears
when the reduced hemoglobin exceeds 5% and
can be accentuated at effort.

• Dyspnoea, relatively precocious symptom , is

the result of tissue oxygenation disturbances; is
met at effort (dyspnoea of effort), in rest
(orthopnoea) or suddenly (paroxystic dyspnoea,
sometimes nocturnal, acute pulmonary edema).
The swoon
• Loss of consciousness by short time, but with the
keeping of vital functions (circulation and
respiration).
Syncope
• Loss of consciousness, by short time, without
keeping of vital functions:
• Marked decreesing until the stopping of cardiac
contractions;
• Absence of pulse;
• Decreasing until the stopping of respiration.
• Falling of arterial pressure;
• neurological manifestations;
• duration 3-4 minutes, after 5 minutes the
decerebration is producing.
There is a difference between syncope and swoon,
both having as background the disturbances of
cerebral irrigation – reducing of cerebral debit.
The physical examination of a child with
cardio-vascular system affections
• The physical examination of cardio-vascular
system includes the same stages and methods as
the general physical examination: inspection,
palpation, percussion and auscultation.
• The examination includes not only precordial
region or only cardio-vascular system, but the
entire organism, because every sign can be very
important.
The peculiarities of cardio-vascular
system inspection methods in children:
1.The inspection of cardio-vascular system in children
is performing in conditions in which the child is
quiet or in the time of his sleeping.
2. The general inspection of entire organism and local,
at the level of cardiovascular system is performing.
3.There will be appreciated the constitutional type,
the anthropometric parameters, the physical
delaying being characteristic for children with
severe cardiac affections, especially with congenital
cardiac malformations.
4. The attention will be attracted to the presence of some
stigmas of disembryogenesis/genetic syndromes (Marfan
syndrome, Down syndrome/disease, Noonan syndrome,
Turner, Klinefelter syndromes, Ellis von Creveld syndrome,
etc), which include also the cardiac affection.

5. The teguments and adipose subcutaneous tissue will be

inspected, being ascertaining the presence or absence of
cyanosis, edemas, pallor, annular erythema, or another
cutaneous lesions suggestive for a cardiopathy.

6. The inspection of cervical anterior region will evidence the

turgidity/pulsation of jugular veins.

7. The inspection of precordial region will ascertaining the most

frequent pulsations of the heart and magistral vessels.
The peculiarities of palpation method in
cardio-vascular system examination in
children
In children the palpation represents a method to
verify the found at inspection signs and to find
anothers.
• The palpation can give information about:
• Cardiac volume,
• Apexian beat (more upper in suckling babies),
• Fremitus and gallop,
• Character of pulse,
• Quality of peripheral circulation etc.
.
The apex beat in children is palpating in the
precordial region with the palm and after that
with the tips of the fingers:
• In children until 2 years it is situated in the IV
left intercostal space 2 cm exteriorly from left
medioclavicular line;
• In 2-5 years age – in the IV intercostal space 1
cm exteriorly from left medioclavicular line;
• In more than 5 years age – in the V intercostal
space on the left medioclavicular line.
Supplementarly the apex beat is also characterized
by mobility and amplitude.
At palpation of precordial area there can be
constated:
Palpator equivalents of sounds or cardiac
murmurs (fremitus).
Systolic and diastolic fremitus, (palpator
transmission of existent murmurs) is
appreciating in children only in the case of
organic valvular lesions:
• The diastolic fremitus on apex– in mitral
stenosis;
• Parasternal systolic fremitus – in
interventricular septal defect or in potent ductus
arteriosus (Botallo).
• Systolic fremitus in the II intercostal right
space– in aortic stenosis.
• The pulse in children is more difficult for
evaluation due to age peculiarities.
• As a rule, the pulse is palpating on radial and
femoral artery (its absence denotes the
coarctation of the aorta).
The characteristics of pulse include:
 frequency,
 amplitude,
 rhythm,
 capacity.
• The frequency of pulse in children can be
appreciated also by big fontanelle, temporal,
carotidian arteries pulsation.

• The frequency of cardiac contractions normally

must coincide with the frequency of pulse,
contrary there is a deficit of pulse.
The peculiarities of cardio-vascular
system percussion method in children
• Percussion of the heart partially loosed its past
value, due to paraclinical accessible contemporary
methods with more exact results (radiography,
ultrasonography).
• The obtained at percussion results are also
influenced by the experience of applying it
physician, having in children a real value only in the
age after 4 years. The method remain however
useful in conditions of endowment absence, in the
case of intransportable patients or in diverse
emergencies.
• At precordial area percussion two tonalities can
be heared, comparatively with pulmonary
sonority:
 submatity - relative dullness (defines the
heart covered by lungs);
 matity- absolute dullness (not covered by
lungs).
• The heart percussion at dullness appreciation is
performing with finger taping directly on the
chest, in horizontal position of the child.
The technique of percussion:
I. Delimitation of heart apex- superficial
percussion- verify the obtained at palpation
data:
- 3 lines are percussing:
• vertical, from down to up, on the
medioclavicular line, until matity meating;
• horizontal - from lateral to medial, on the
line passing through the anteriorly determined
point – apex beat will be situated at the
intersection of these two lines;
• the third„verify” line is the bisectrix of
angle determined by the first two lines, and the
first percussed dullness on this line must
coincide with determined apex beat.
II. The determining of superior margin of
hepatic dullness (lung interposing):
- It is performed by deep percussion;
- It is percussing from down to up- usually on the
right medioclavicular line.
III. The determining of right heart margin:
• It is performing by superficial percussion;
• It is percussing- parallel with the ribs perpendicular
on sternum- on the II-V (VI) spaces, until the
dullness meeting, and uniting the points of dullness
from each intercostal space we obtain a line
corresponding to the right heart margin;
• In normal heart it not exceeds the right margin of
sternum;
• The angle formed by superior margin of liver and
right margin of heart is naming „cardiohepatic
angle” which must not exceed 90°.
IV. The determining of left heart
margin:
• Performing of superficial percussion;
• The percussion begins from II intercostal space
until the heart apex (apex beat);
• It is performing from periphery to the center –
moving parallel to the ribs;
• In normal conditions, the left margin of the
heart is on the line uniting the normal apex beat
with subdull zones.
• In normal mode it must not exceed the lateral
margins of manubrium.
The limits of relative cardiac dullness in children are relatively
more that in adults (,,dilated heart”):
Age until 2 years:
 right: right parasternal line;
 left: 1,5-2 cm exteriorly from medioclavicular left line;
 superior: rib II.
Age of 2 - 7 years:
 right: 0,5-1 cm exteriorly from parasternal right line;
 left: 0,5-1 cm exteriorly from medioclavicular left line;
 superior: II intercostal space.
Age of 7-12 years:
 right: right sternal line;
 left: left medioclavicular line;
 superior: rib III.
The cardiac dullness is increased at percussion in pericarditis,
myocarditis, dilative cardiomyopathies and decreased in
pulmonary emphysema and in pneumothorax.
The peculiarities of
cardio-vascular system auscultation method in
children
• The auscultation constitutes the most
advantageous physical method for heart
examination. The auscultation and auscultation
points respect the same rules as in adult, but an
stethoscope adequate to the age of patient is
using.
The auscultation in the child requires many ability
and knowledge of cardiovascular system
peculiarities. Thus, in suckling and infant the
supplementary factors during auscultation can
appear (agitation on examination, crying,
absence of cooperation), which can influence the
conclusions of examinator. From this motive it is
recommended to perform auscultation, as
possible, when the child is quiet or when he
sleeps.
The auscultation will be performed in all points,
on the all area of precordial dullness, on the
route of vessels and posterior between scapula
and vertebral column. The method allows to
appreciate the cardiac frequency, the rhythm
and character of normal or superposed
(clackments, clicks) sounds, of murmurs etc.
 ANATOMIC LOCALIZATION OF HEART VALVES
AND POINTS OF AUSCULTATION

Aortic valve and Pulmonary valve

Aortic point
Mitral valve and
Tricuspid valve mitral point
and tricuspid
point
Sound 1 (S1)
- Intense sound, by low tonality, prolonged (0,10-0,14 sec.);
maximal intensity in the mitral and tricuspid points.

Sound 2 (S2)
- Exclusively formed from ample vibratory group, generated by
closing of group aortic and pulmonary valves, with duration of 0,05
– 0,09 sec.
-between S1-S2 there is a little pause corresponding to mechanical
systole, and between S2-S1 there is a big pause (diastole)
Sound 3 (S3)
- Corresponds to rapid ventricular filling; reduced tonality, is
hearing at 0,12-0,16 sec.after S2.; gives palpatory sensation

Sound 4 (S4)
- Physiological in childhood
- Sound by atrial origin; situated at 0,12 sec. before S1
Splitting of sound 2:
- physiological
- pathological
- paradoxal (closing of
pulmonary valve
followed by closing of
aorta)
• The cardiac sounds in children are more
frequent, more intense (the suckling has more
thin thorax), with the tendency to equalization
(in suckling).
• During the child’s growing, the I sound is
accentuating on apex, and the II sound - on
pulmonary artery, sometimes splitting variably
with respiration.
• The presence of III sound in youths is
physiological, due to good tonus of myocardium,
which makes it to vibrate in the phase of rapid
diastolic filling.
• Its presence in myocarditis equates with the gallop
rhythm and signify myocardic hypotonia.
• The diminishing of cardiac sounds intensity
appears in: myocardites, pericardites, pulmonary
emphysema etc.;
• The increasing of I sound intensity appears in
mitral stenosis, and of II sound in arterial
hypertension.
• The both sounds are accentuated at effort, emotions,
hyperthyroidism etc.
• The rhythm disorders are found most frequent at
auscultation, and ECG must precise the nature of
cardiac arrhythmia.
Auscultatively:
- The first cardiac sound in children, meaning the
beginning of ventricular systola, is auscultating
maximally on apex;
- the II sound closes the ventricular systole , more
intensively is auscultating on the basis of heart;
- the II sound on pulmonary artery is auscultating
accentuated or splitted due to topographic
sitting of pulmonary artery near to the thoracic
wall and due to the preponderant activity of
right ventricle;
- In the first 3 months the cardiac sounds have
practically the same intensity, and the pauses are
equal (embryocardia).
• Cardiac murmurs, appreciated auscultatively,
are characterized by the place of producing,
duration, intensity, timbre, propagating and
with or without association of fremitus.
Degrees of intensity by Levine
(Freeman-Lee)
• degree 1(1/6): audible only in a room with
reduced level of noise; are merosystolic
• degree 2 (2/6): murmurs by low intensity
• degree 3 (3/6): medium intensity, not heard at
partial detaching of stethoscope from the thorax
• degree 4 (4/6): increased intensity, are
listening at partial detaching of stethoscope from
the thorax
• degree 5 (5/6): high intensity, are listening
with the stethoscope at small distance from the
thorax
• degree 6 (6/6): are listening at distance from
thoracic wall or by direct hearing.
After the period of appearance the murmurs
are classified in:
 systolic
 diastolic
 systolo-diastolic
 continuous
After duration they can be:
 protosystolic
 mezosystolic
 telesystolic
 holosystolic
The cardiac murmurs are also classifying in:
 organic;
 functional.
The organic murmurs are characterizing by:
high intensity, as a rule by 4-6 degree, are
propagating out from the heart limits, are
accompanied by fremitus.

The organic murmurs also can be:

• valvular – in congenital or acquired valvular
defects;
• myocardial – which appear in inflammatory
processes or in myocardium dystrophy;
• organic murmurs in the case of congenital
anomalies of heart/magistral vessels.
Functional murmurs can have a different genesis
and localization, as a follows:
 anemic - which appear at rheologic
circulant blood peculiarities modification ( in the case of
anemia, thyrotoxicosis, fever);
 cardiopulmonary - appear at respiratory
pathways compression;
 functional murmurs due to magistral
vessels compression;
 hypertonic murmurs, due to papillar
muscles hypertonia;
 murmurs at pulmonary artery, at its
bifurcation;
 myocardic murmurs, which appear in
children as a result of long-term maitaining of chronic
bacterial foci (chronic tonsillitis), with direct toxico-
infectious action on the heart.
4.2.C. Murmurs of atrial ejection (in mitral and tricuspidian stenosis)
- conditions of appearance and auscultation characteristics
Systolic murmurs:
 are auscultatively perceived on the basis of
heart in cardiac congenital pathologies;
 are auscultatively perceived on apex in
acquired pathologies;
 are auscultatively perceived on the heart
basis in stenosis.
Diastolic murmurs:
 Have at origin the acquired valvulopathies;
 Being perceived on apex suggest the
acquired stenosis;
 Being perceived at basis can characterize the
acquired valvular insufficiency.
• The measurement of arterial pressure is
obligatory in pupil and adolescent, and if
necessary will be performed in suckling baby
and infant.
The measurement of arterial pressure will taking
into consideration:
Patient position (sitting or recumbent),
Dimension of the cuff (adecuate for age),
type of apparatus,
Normal values for the child’s age etc.
Obtained values will be compared with the
respective centilic charts.
In the cases of standard width of cuff the
necessary corrections of obtained values will be
performed.
Correction of systolic and diastolic arterial
pressure values for different ages children in
the case of standard cuffs using
Systolic Diastolic
Correction Correction
Perimeter Perimeter
of arm, cm mm Hg kPa of arm, cm mmHg kPa

15-18 +15 +2,00 15-20 0 0

19-22 +10 +1,33 21-26 -5 -0,67
23-26 +5 +0,67 27-31 -10 -1,33
27-30 0 0 32-37 -15 -2,00