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Heart and Neck Vessels (Chapter 19)
Terms in this set (77)
acute chest pain that occurs when myocardial demand exceeds its oxygen supply.
(aortic insufficiency) incompetent aortic valve that allows backward flow of blood into left ventricle during diastole.
calcification of aortic valve cups that resists forward flow of blood during systole.
the left semilunar valve separating the left ventricle and the aorta.
Apex of the heart
tip of the heart pointing down toward the 5th left intercostal space.
point of maximal impulse (PMI);
pulsation created as the left ventricle rotate against the chest wall during systole, normally at the 5th left intercostal space in the midclavicular line. Size; normally 1 x 2 cm. Duration; short, normally occupies only first half of systole.
Base of the Heart
broader area of heart's outline located at the 3rd right and left intercostal spaces.
slow heart rate, less than 50 beats per minute in the adult.
bulbous enlargement of distal phalanges of fingers and toes that occurs with chronic cyanotic heart and lung conditions.
Coarctation of Aorta
severe narrowing of the descending aorta, a congenital heart defect.
right ventricular hypertrophy and heart failure due to pulmonary hypertension.
Cardiac Cycle (Diastole)
the heart's filling phase.
the ventricles are relaxed, the AV valves (tricuspid and mitral) are open. (opening of the normal valve is acoustically silent.)
the pressure in the atria is higher than that in the ventricles-blood pours rapidly into the ventricles.
Early/Protodiastolic filling- the first passive filling phase.
toward the end of the diastole the atria contract and push the last amount of blood (about 25% of stroke volume) into the the ventricle.
Presystole/atrial systole-the active filling phase or the atrial kick.It causes a small rise in left ventricular pressure.
the atrial systole occurs during ventricular diastole, a confusing but important point.
Cardiac Cycle (Systole)
now so much blood has been pumped into the ventricles that ventricular pressure is finally higher than that in the atria; (the mitral and tricuspid valves swing shut.)
the closure of the AV valves contributes to the first heart sound (S1) and signals the beginning of systole.
the AV valves close to prevent any regurgitation of blood back up into the atria during contraction.
for a very brief moment all four valves are closed.
the ventricular walls contract.
this contraction against a closed system works to build pressure inside the ventricles to a high level (Isometric Contraction)
Cardia Cycle (continue)
consider first the left side of the heart.
when the pressure in the ventricle finally exceeds pressure in the aorta, the aortic valve opens, and blood is ejected rapidly.
Cardiac Cycle (note from lecture)
after the ventricle's contents are ejected, its pressure falls.
when the pressure falls below pressure in the aorta, some blood flows backward toward the ventricle, causing the aortic valve to swing shut.
this closure of the semilunar valves causes the second heart sound (S2) and signals the end of systole.
Cardiac Cycle (Diastole Again)
now all four valves are closed, and the ventricles relax (called isometric or isovolumic relaxation)
meanwhile the atria have been filling with blood delivered from the lungs.
atrial pressure is now higher than the relaxed ventricular pressure.
the mitral valve drifts open, and diastolic filling begins again.
Events in the right and left sides
The same events are happening at the same time in the right side of the heart;
-but pressures in the right side of the heart are
much lower than those of the left side because
less energy is needed to pump blood to its
destination, the pulmonary circulation.
Also events occur just slightly later in the right side of the heart because of the route of the myocardial depolarization. (as a result, two distinct components to each of the heart sounds exists, and sometimes you can hear tehm separately).
In the first heart the mitral component (M1) closes just before teh tricuspid component (T1) and with S2 sound, aortic closure (A2) occurs slightly before pulmonic closure (P2).
tough, fibrous, double-walled sac that surrounds and protects the heart.
It has two layers that contain serous pericardial fluid (this ensures smooth, friction-free movement of the the heart muscles).
it is adherent to the great vessels, esophagus, sternum, and plearae and is anchored to the diaphragm.
the muscular wall of the heart.
it does the pumping.
thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves.
Think the heart as a pump
The right side of the heart pumps blood into the lungs;
The left side simultaneously pumps blood into the body.
a thin-walled reservoir for holding blood.
each of the two upper cavities of the heart from which blood is passed to the ventricles.
The right atrium receives deoxygenated blood from the veins of the body;
the left atrium receives oxygenated blood from the pulmonary vein.
a thick-walled which is the muscular pumping chamber.
is one of two large chambers in the heart that collect and expel blood received from an atrium towards the peripheral beds within the body and lungs.
a swinging door like structure that separates the 4 chambers of the heart.
main purpose is to prevent backflow of blood.
4 valves in the heart:
A. two AV (atrioventricular) valves separate the atria and the ventricle.
B. right AV valve is the TRICUSPID, and the left AV valve is the BICUSPID/MITRAL valve.
C. The AV valves open during the heart's filling phase (diastole), to allow the ventricles to fill with blood.
D. During the pumping phase (systole), the AV valves close to prevent regurgitation of blood back up into the atria.
Semilunar (SL) Valve
Are set between teh ventricless and the arteries.
Each valve has three cusps that look like half moon.
The SL valves ar the PULMONIC valve in the right side of the heart and the AORTIC valve in the left side of the heart.
They open during pumping, to allow blood to be ejected from the heart.
There are no vavles between the vena cava and the right atrium or between the pulmonary veins and the left atrium.
For this reason abnormally high blood pressure in the left side of the heart gives a person symptoms of pulmonary congestion, and abnormally high pressure in the right side of the heart show in teh distended neck veins and abdomen.
Direction of Blood Flow
1. From systemic circulation to RA through inferior vena cava.
Superior vena cava drains venous blood from the head and upper extremeties.
From RA venous blood travels through tricuspid valve to RV.
2.From RV venous(deoxygenated) blood flows through pulmonic valve to pulmonary artery.
Pulmonary artery delivers unoxygenated blood to lungs.
3.Lungs oxygenate blood.
Pulmonary veins returns fresh blood to LA.
4.From LA arterial blood travels through mitral valve to LV.
LV ejects blood through aortic valve into aorta.
5.Aorta delivers oxygenated blood to body.
**Remember that circulation is a continous loop. The blood is kept moving by continually shifting pressure gradients. It flows from an area of higher pressure to one of lower pressure.
Normal Heart Sounds
-First heart sound
-occurs with closure of the AV valves and thus signals the beginning of systole.
-the mitral compenent of the first sound (M1)
-slightly procedes teh tricuspid compotent (T1), but you usually hear these two components fused as one sound.
**you can hear S1 over all teh precordium, but usually it is loudest at the APEX.
-second heart sound
-occurs with closure of the semilunar valve and signals the end of the systole.
-the aortic component of the second sound (A2) slightly procedes teh pulmonic component (P2).
**Although it is heard over all the precordium, S2 is the loudest at the base (upper portion).
Effect of Respiration
the volume of right and left ventricular systole is just about equal, but this can be effected by respiration.
Remember this Phrase:
MoRe to the Right heart,
Less to the Left
**when the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separetely. This is a split S2.
Extra Heart Sound
Third Heart Sound (S3)
-normally diastole is a silent event.
-in some conditions ventricular filling creates vibration that can be heard over the chest, S3.
-S3 occurs when the ventricles are resistant to filling during the early rapid filling (Protodiastole).
-this occurs immedietly after S2, when the AV valves open adn atrial blood first pours into the ventricles.
Fourth Heart Sound (S4)
-occurs end of diastole, at presystole, when the ventricle is resistant to filling.
-the atria contract and push blood inot a noncompliant ventricle.
-this creates vibration that are heard and occur just before S1.
a gentle, blowing, swooshing sound that can be heard on the chest wall.
Characteristics of Sound
- either as high pitched or low pitched.
-loud or soft
-very shor for heart sounds; silent periods are longer.
-systole or diastole
Conduction of the heart
60-100 beats per minute
The sequence of electrical events during one full contraction of the heart muscle:
1.An excitation signal (an action potential) is created by the sinoatrial (SA) node.
2.The wave of excitation spreads across the atria, causing them to contract.
3.Upon reaching the atrioventricular (AV) node, the signal is delayed.
4.It is then conducted into the bundle of His, down the interventricular septum.
5.The bundle of His and the Purkinje fibres spread the wave impulses along the ventricles, causing them to contract.
P wave-Depolarization of the atria (contract)
PR interval- from the beginning of teh P wave to the beginning of the QRS complex (the time necessary for atrial depolarization plus time for the impulse to travel through the AV node to the ventricles) (V contracted)
QRS complex- Depolarization of the ventricles (diastole)
T wave-Repolarization of the ventricles (when atrial contracting)
in the resting adult, the heart nomally pumps between 4 and 6 L of blood per minute throughout the body.
this CARDIAC OUTPUT equals the volume of blood in each systole (stroke volume) times the number of beats per minute (rate)
CO = SV x R
is the venous return that builds during diastole (returning to the R atrium).
it is the lenght to which the ventricular muscle is stretched at the end of the diastole just before contraction. (body promote blood flow to the heart)
The greater the stretch, the stronger is the contraction of the heart.
is the opposing pressure the ventricle must generate to open the aortic valve against the higher aortic pressure.
it is teh resistance against which teh ventricle must pump its blood.
difficulty, labored breathing
swelling of legs or dependent body part due to increased interstitial fluid.
traditional ausculatory area in the 3rd left intercostal space.
the addition of a 3rd or a 4th heart sound; makes the rhythm sound like the cadence of a galloping horse.
technique of moving the the stethescope incrementally across teh precordium thorugh the ausculatory areas while listening to the heart sounds.
Left Ventricular hypertrophy(LVH)
increase in thickness of moving of myocardial wall that occurs when the heart pumps gainst chronic outflow obstruction (e.g.aortic stenosis)
Midclavicular line (MCL)
imaginary vertical line bisecting the middle of teh clavicle in each hemithorax.
calcified mitral valve impedes forward flow of blood inot left ventricle during diastole.
uncomfortable awareness of rapid or irregular heart rate.
opposite of a normal split S2 so that the split is heard in expiration, and in inspiration teh sounds fuse to one sound.
Pericardial Friction Rub
high-pitched, scratchy extracardiac sound heard when the precordium is inflamed.
palpable vibration on the chest wall accompanying severe heart murmur
Which abnormal conditions may affect teh location of the apical impulse?
- LEFT VENTRICULAR DILATION (volume overload) displaces impulse down and to the left ans increases size more that one space.
-a SUSTAINED impulse wirh increased force and duration but no change in location occurs with LEFT VENTRICULAR HYPERTROPHY and no dilation (pressure overload)
- PULMONARY EMPHYSEMA makes it non-palpable from the lung sound overridding heart sound.
Explain the mechanism producing normal first and second heart sounds.
First heart sound (S1) occurs with closure of the AV valves and this signals the beginning of systole. The mitral component of the first sound slightly precedes the tricuspid component, but you usually hear these two components fused as one sound. You can hear S1 over all the precordium but usually loudest at the apex.
Second heart sound (S2) occurs with closure of the semilunar valves and signals the end of systole. The aortic component of the second sound (A2) slightly precedes the pulmonic component. Although it is heard over all the precordium, S2 is loudest at the base.
Describe the effects of respiration on the heart sounds.
more to the Right heart less to the left:
during inspiration, more venouse blood is able to enter the vena cava due to decreasing thoracic pressure which ncreases the amt of blood in the right side of heart thus increasign it's volume. Meanwhile on the left side a greater amt of blood is sequestered in the lungs momentarily dec amt returned to left side and thus volume shortening ventricluar systole allowing the aortic to close earlier.
Describe the characteristics of the FIRST HEART SOUND and its intensity at the apex of the heart and at the base.
Intensity depends on (1) position of AV valve at the start of systole (2) structure of the valve leaflets, and (3) how quickly pressure rises in the ventricle
Describe the characteristics of the SECOND HEART SOUND and its intensity at the apex of the heart and at the base.
S2- "Dub"- is the loudest at the base.
Explain the physiologic mechanism for normal splitting of S2 in the pulmonic valve area.
When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately.
Define the THIRD HEART SOUND. when in the cardiac cycle does it occur? describe its intensity, quality, location in which it is heard, and method of auscultation.
Low pitched sound that occurs in early diastole. You will hear this sound at the apex in the left lateral position. Use the bell of the stethoscope. Normal in children and young adults. It is abnormal when it persists in a person. Usually abnormal in adults over the age of 40 and can be an early sign of heart disease or congested heart failure.
Differentiate a physiologic S3 from a pathologic S3.
The S3 may be normal (physiological) or abnormal (pathological). The physiological S3 is heard frequently in children and young adults; it occasionally may persist after age 40 years, especially in women. The normal S3 usually disappears when the person sits up.
In adults, the S¬3 is usually abnormal. The pathological S3 is also called a ventricular gallop or an S3 gallop, and it persists when sitting up. The S3 indicates decreased compliance of the ventricles, as in heart failure.
Define the FOURTH HEART SOUND. when in the cardiac cycle does it occur? describe its intensity, quality, location in which it is heard, and method of auscultation.
The S4 is a ventricular filling sound. It occurs when the atria contract late in diastole. It is heard immediately before S1. This is a very soft sound, of very low pitch. You need a good bell, and you must listen for it. It is heard best at the apex, with the person in left lateral position
Explain the position of the valves during the cardiac cycle in diastole, isometric contraction, systole, and isometric relaxation.
Diastole-av valves (i.e. tricuspid and mitral) are open/semilunar valves close
Systole- av valves shut/semilunar valves open
the pressure exerted on the walls of the veins by the circulating blood.
Jugular venous pulse
The pulse in the right internal jugular vein at the root of the neck; pressure of right atrium.
Carotid Artery Pulsation
higher and medial to medial to muscle, brisk, localized, one wave per cycle, does not vary, palpable, no pressure changes, unaffected by position change.
Jugular Vein Pulsation
lower, more lateral, under or behind sternomastoid muscle, undulant and diffuse, two visible waves per cycle, varies with respiration. Its level descends during inspiration when intrathoracic pressure is decreased, not palpable, light pressure change at the base of the neck (easily obliterate), level of pulse drops and disappears as person sits up.
List the major risk factors for heart disease and stroke as identified in this text.
High Blood Pressure
Serum Cholesterol(LDL bad cholesterol)
Type 2 Diabetes
Define bruit, and discuss what it indicates.
A bruit is a blowing, swishing sound indicating blood flow turbulence. Indicated turbulence due to a local vascular cause, such as atherosclerosis narrowing.
State 4 guidelines to distinguish S1 from S2
• S1 is the start if systole and thus serves as the reference point for the timing of all other cardiac sounds; usually you can identify S1 instantly because you hear a pair of sounds close together (lub-dup), and S1 is the first of the pair
• S1 is louder than S2¬ at the apex; S2 is louder than S1 at the base
• S1 coincides with the carotid artery pulse. Feel the carotid gently as you auscultate at the apex; the sound you hear as you feel is pulse is S1
• S1 coincides with the R wave (the upstroke of the QRS) complex) if the person is on an ECG monitor
1.cadence or relative length of the phase
3.timing of S1 with apical beat or carotid
Define pulse deficit, and discuss what it indicates.
A pulse deficit signals a weak contraction of the ventricle; it occurs with atrial fibrillation, premature beats, and heart failure.
Grading scale for a Murmur
-Grade 1. Barely audible
-Grade 2. Clearly audible, but faint
-Grade 3. Moderately loud, easy to hear
-Grade 4. Loud, associated with a thrill palpable on the chest wall
-Grade 5. Very loud, heard with one corner of the stethoscope lifted off the chest wall.
-Grade 6. Loudest, still heard with entire stethoscope lifted just off the chest wall.
What is an innocent or functional murmur?
Murmurs sometimes heard in children. Common first few days of life (usually grade 1 or 2. Many children have murmurs without heart disease.
-lies deep and medial to the sternomastoid muscle.
-it is usually not visible, although its diffuse pulsations may be seen in the sternal notch when the person is supine.
-is more superficial
-it lies lateral to the sternomastoid muscle, above the clavicle.
The pregnant woman
blood volume increases by 30% to 40% during pregnancy, with the most rapid expansion occuring during the second trimester.
This creates an increase in stroke volume and cardiac output and an increased pulse rate of 10 to 15 beats/minute.
The pulse rate rises in the first trimester, peaks in the third trimester, and return to baseline within the first 10 postpartum days.
BP decreases in pregnancy as a result of peripheral vasodilation.
The BP drops to its lowest point during the second trimester and rises after that.
Infants and Children
The fetal heart functions early
It begins to beat at the end of 3 weeks' gestation.
Life style modifies the development of CV disease;
smoking, diet, alcohol use, exercise patterns, and stress have an immense influence.
Life style also effects the Aging process;
cardiac changes once thought to be caused by aging are partially the result of teh sedentary life.
Genetic: Nature vs Nurture
Hemodynamic changes with Aging
With aging there is an increase in systolic BP.
This is caused by thickening and stiffening of the large arteries.
The valves areas are:
Second right interspace- Aortic valve area
Second Left interspace- Pulmonic valve area
Left lower sternal border- Tricuspid valve area
Fifth interspace at around left midclavicular line- Mitral valve area
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