Anatomy of the Heart and Cardiac Examination

• This document is a revision of the anatomy of the heart and a cardiac examination

Surface Anatomy of the heart

• Point 1: The lower border of the 2nd left costal cartilage is one & a half inches from the median plane
• Point 2: The upper border of the right 3rd costal cartilage is one inch from the median plane
• Point 3: The upper border of the Right 6th costal cartilage is one inch from its junction with the sternum
• Point 4: The apex is in the Left 5th intercostal space, 3 1/2 inches from the median plane

Heart Chambers

• The heart includes the right atrium, right ventricle, left atrium, and left ventricle

Heart Valves

• Valves include the tricuspid, pulmonary, mitral, and aortic valves

Heart Circulation

• Blood flows from the superior and inferior vena cava into the right atrium, then to the right ventricle
• From the right ventricle, blood flows through the pulmonary valve to the pulmonary artery
• Blood returns to the left atrium via the pulmonary vein, moves into the left ventricle, and exits through the aortic valve to the aorta

Layers of the Heart Wall

• The heart wall is composed of the epicardium, myocardium, and endocardium

Surfaces of the Heart

• Surfaces include the anterior surface, diaphragmatic surface, right pulmonary surface, and left pulmonary surface

Borders of the Heart

• Borders are the superior vena cava, arch of aorta, right auricle, left auricle, right atrium, right ventricle, left ventricle, inferior vena cava, and apex

Conduction System of the Heart

• Includes the interatrial pathway, sinoatrial (SA) node, atrioventricular (AV) node, right atrium, left atrium, internodal pathway, left branch of bundle of His, right ventricle, right branch of bundle of His, left ventricle, and Purkinje fibers

Coronary Arteries

• Key arteries include the left coronary artery, circumflex artery, right coronary artery, and left anterior descending artery

Cardiac Examination - History

• Includes questions about occupation (stress), habits (junk food and hypercholesterolemia), atherosclerosis, and coronary artery disease
• Includes questions about past surgeries (open heart/CABG), diseases (hypertension and heart failure), and medications (Beta Blockers)
• Includes questions about the onset of present symptoms (sudden for MI/angina) and family history (IHD/HF)

Cardiac Examination - Assessment

• Includes a general and local examination

General Examination

• Assess the patient's decubitus or position, body build, color, mental state, and any other problems

Decubitus Position

• A squatting position is used in patients with tetralogy of Fallot
• Tetralogy of Fallot is a cyanotic congenital heart disease with four pathologies: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect
• Cyanosis decreases with squatting because pressure on blood vessels from the lower limbs reduces deoxygenated blood to the heart and increases oxygen to cells
• Squatting increases pulmonary blood flow and arterial oxygen saturation by kinking the femoral arteries and increasing systemic vascular resistance
• Compressing splanchnic vessels increases systematic venous return and helps trap oxygenated venous blood in the legs

Hemodynamics of Squatting

• The first 15 seconds results in a sudden drop in venous return
• Sustained squatting for 1-2 minutes increases venous return and raises systemic vascular resistance
• Squatting gives a quick relief and in the next 15 seconds, systemic vascular resistance increases, diverting blood into the pulmonary artery
• The compression of the abdomen causes a mechanical push on the splanchnic blood pool into the aorta

Long Sitting Position

• The patient lies on a 45-degree elevated head of the bed during left-sided heart failure
• The main problem is orthopnea induced by a supine position and relieved by sitting
• Orthopnea occurs in supine position because the diaphragm is elevated, venous return increases, and respiratory muscles contract inefficiently

Prayers Position

• The patient is leaning forward with pericarditis
• Position increases intra-abdominal pressure, increasing intra-thoracic pressure relatively, to decrease venous return to the heart thus to decrease the pressure on the heart wall

Body Build

• Thin/cachetic indicates advanced left-side heart failure due to low cardiac output and tissue oxygenation
• Obese indicates right-side heart failure due to venous stasis and generalized edema
• Inverted pyramid indicates coarctation of the aorta.
• Marfan's syndrome indicates lean body build, thin face, long spidery fingers seen in atrial septal defect
• Physical development (infantilism) indicates sever cardiac diseases starting in childhood.

Skin Color

• Malar flushes are mauve discoloration of the nose and cheeks in tight mitral stenosis
• Pale color indicates rheumatic fever; may be due to anemia or vasoconstriction
• Jaundice indicates increased bilirubin levels, seen in the sclera
• Cyanosis indicates increased reduced hemoglobin, seen in peripheral tissues

Differential Cyanosis

• Differential cyanosis is bluish coloration of the lower but not the upper extremity and the head, seen in patients with patent ductus arteriosus (PDA)
• Patients with large ductus develop pulmonary vascular disease and pressure overload of the right ventricle

Central vs. Peripheral Cyanosis

• Central cyanosis is a gas exchange problem, while peripheral cyanosis is due to low cardiac output
• Central cyanosis sites: lips, nose, hands, ears, lower limb
• peripheral cyanosis sites: Lips, nose, hands, ears, lower limb only.
• Increase Central cyanosis With exercise, Heat and anything that increases the heart rate. Decrease with only rest.
• Increase peripheral cyanosis is increased the with Cold, Rest and anything that decreases heart rate. Decrease by Exercise, Heat or Increase heart rate

Mental Status

• Anxiety and depression may follow myocardial infarction
• Assess the level of coordination (cooperative vs uncooperative) and consciousness (alert, confused, automatic, stupor, delirious, semi-comatose, comatose)

Other Problems

• Puffy eye lids indicate heart failure

Rheumatic Chorea

• Involuntary jerky purposeless “pseudo purpose” movement with emotional liability

Venous vs. Arterial Pulsation

• Jugular pulsation in heart or liver issues vs carotid pulsation

Examination of Nodules

• Osler nodules appear in the palm of the hand in endocarditis patients

Venous vs Arterial Pulsation

• Carotid Pulse: Medial or anterior to Sternocleidomastoid (SCM) and better felt than seen.

Other Problems

• Jugular Pulse: lateral or posterior to SCM, better seen than felt and prior to heart beats.

Clubbing Fingers

• Hypertrophy of connective tissue of nail-bed with loss of normal angle; indicates chronic poor oxygen perfusion

Inspection

• Inspect for presence; scars of pervious operations, skeletal deformities,
• Inspect; Suprasternal area, Pericardial area, Parasternal area, apex beat, Dilated veins of chest wall, Epigastric area.

Previous Operations

• Median sternotomy for open heart or chest surgery
• Lateral thoracotomy for valve operation like mitral valve replacement
• Supraclavicular for permanent pacemaker
• Midaxillary line for pcd(pacer-cardioverter-defibrillator)

Skeletal Deformities

• Scoliosis, -kyphosis, -Kyphoscoliosis, barrel chest, pectus excavatum causes shift heart laterally and apex pulsation.

Suprasternal Pulsation

• Supra sternal notch pulsation: tension &stress ,anxiety, exercises or fever
• Pathologically: carotid pulsation, due to aortic regurge
• Pathologically: jugular vein pulsation, CHF

Pericardial Area

• Pericardial area is the area of chest over laying the heart being equal bilaterally.

Parasternal Area

• Lt parasternal (3rd, 4th, 5th intercostal space(ICS) pulsations, right ventricular enlargement due to pulmonary hypertension

Shifting of Apex causes

• Outside Heart: fibrosis of apex of lung push/pull, ABDOMINAL TUMORS.
• Heart: cardiac cause Dextrocardia .

Palpation

• Apex beat is the Lower most and outermost point of cardiac impulse. Contraction of left ventricle during systole.

Apex Best locations

• Normally located at left 5th intercostal space (ICS) midcalavicular line.
• Therapist hand: with your hand under the patient axilla moving medially till you feel the pulse.

Causes of invisible and impalpable apex beat

• Obesity, Chest cause, Thin, Weak contraction cardiac cause

Heart Size Intensity.

Localized LVH intensity Normally: dimed, Abnormally: increases intensity

Character.

Norm:al tapping Abnormally: regurge & ventricular hypertrophy.

Duration.

Normal: brief Abnormally: lasts signs of heart failure

Suprasternal/Epigastric area

• Pt in horizontal line for palpation/long sitting.

Pulse

• Pulse to the thumb is the liver
• Pulse to the left up is the rt venetricle

Thrills

• Palpable murmur in the pericardium. All must be be combined with a murmur. Palpate best with finger tips.

Jugular Vein

• Have head of bed at 45. Patient long sitting and find external jugular vein - find the jugular pulse after rotating head

HJR

• Apply gentle pressure (30:40 mm Hg) for 10 secs up to minute as well as observe the Jugular - test may indicate a cardiac or more hepatic problem.

Percussions

• Confirm normal position of the heart, liver & stomach. Do heavy percussion except Bare area. Asses for dull or resonance of the: A) Pulmonary area and B) Aortic area on upper upper area of the chest. Use Resonance. A dull may indicate a cardiac problem. With the lower part of chest percusion the C) bare area with. Dull use the D) 4th , E) the 3rd and the F) lower 3rd ribs

Auscultation

• Performed while listening to sounds, murmurs or pericardial rubs

Heart Sounds.

• A Cardiac cycle takes 0.8 secs: with Systole taking 0.3secs,
• use both sides of the stethoscope with the diaphragmatic higher pitched area, (S1 & S2) and the bell being the lower sounds .
• Use light touch as pressure when you turn it to the diaphragm

Abnormal Heart Sounds

• S1 = Beginning of systole and is the Closure of M&T valves best heard in the Apex & Diaphragm of stethoscope
• S2 = Beginning of diastole and is the Closure of P&A valves best heart in the Pulmonary & Diaphragm of stethoscope

Conditions

• S3 (Kentucky) is diastole and is the VENTRICULAR gallop , meaning volume overload. Apex, Bell better palpated.
• S4 "atrial"is the end of distole- AtrialGallop with the cause age. Strong atrial pump, with atrium & bell.

N.B

1. Splitting because aortic valve is stronger and closes before the pulm valve (path is is deep inspiration as you go in and go out)

Gallop:

• Tachycardia for both
• 4rd

2. aortic Stenosis=

• Mitral sounds Apex is heard at area where is the bell

Pericaridal Rub

• Abnormal, in systole, and the the Pericarditis with hold

B) Murmurs types

1. Turbulence of blood Systolic, diastole & machinery murmurs

2. With the conditions is pda a systic and diastolic with Machinery Pda

C) Pericardial Rub

Abormal sound in the systole and heart due to pericarities