Cardiovascular Health Assessment

Week 5: Cardiovascular Health Assessment

• Systole begins with the closure of the tricuspid and mitral valves, which is S1 and is loudest at the apex
• S2 marks the end of systole, with the closure of the pulmonic and aortic valves, and sounds loudest at the base
• S3, occurring after S2, indicates conditions like CHF or MI, sounds similar to "Kentucky" or "Lub-dub-dub"
• S4, best heard in the mitral and tricuspid areas, may be due to poorly compliant ventricles, and indicates CHF or MI, sounds similar to "Tennessee" or "Dub-Lub-Dub"
• Turbulent blood flow causes murmurs

Murmurs

• Stenosis indicates an abnormally narrowed valve, treatment to include cholesterol management
• Regurgitation involves blood flowing backward
• Bruits indicate turbulent flow outside the heart in arteries
• Intensity is graded on a scale from 1 to 6, including location, radiation from point of maximal impulse (PMI), pattern, timing, pitch, quality, intensity.

Cardiac Output (CO) and Related Factors

• CO is the amount of blood pumped out of the heart each minute, normally 4-8 L/min
• CO is determined by heart rate (HR) multiplied by stroke volume (SV) CO = HR x SV
• Three main elements influencing CO are preload, contractility, and afterload
• Normal HR is between 60-100 beats per minute
• SV is the amount of blood ejected from the ventricle with each heartbeat and the normal range is 60-130 mL/beat

Chest Pain Assessment

• Acute coronary syndrome, aortic dissection, pulmonary embolism, tension pneumothorax, pericardial tamponade, mediastinitis, and esophageal rupture must be ruled out first
• Assess vital signs and patient's general well-being, onset/duration, characteristics, location/severity, any associated symptoms and treatments tried.
• Diagnostics include ECG, CXR, blood work, CTA, or Stress ECHO
• Prophylactic meds like penicillin should be recorded

Shortness of Breath (SOB) Terminology

• Dyspnea manifests as difficulty breathing inappropriate to the situation
• Orthopnea is difficulty breathing when lying down, improves with sitting, document number of pillows needed to achieve comfort
• Paroxysmal nocturnal dyspnea is sudden onset of SOB that awakens from sleep

Abdominal Aortic Aneurysm (AAA) and Palpitations

• Screening recommended for all men over 65, especially smokers
• Asymptomatic until rupture
• Palpitations refer to awareness of heartbeat
• When assessing palpitations, ask about rate, rhythm, and consistency (fast/slow, regular/irregular, intermittent/constant)
• Anxiety or hyperthyroidism, and diagnosis via ECG, TSH, and cardiac monitoring should be explored

Edema: Fluid Accumulation

• Excessive fluid in the extracellular interstitial space, causes range from local issues to systemic conditions
• When gathering information include location, duration (constant/intermittent), improvement with rest/elevation and whether pitting is present

Fatigue: Impact on Daily Living

• Inability to perform regular Activities of Daily Living (ADLs)
• Linked with chest pain, SOB, edema, cough, or palpitations
• Beta-blockers can contribute to fatigue

Syncope: Loss of Consciousness

• Linked with palpitations, dysrhythmias, exertion, or sudden neck movements (carotid sinus effect)
• May also be related to vertebral artery occlusion, or shifts in posture
• Carotid sinus effect causes bradycardia, vasodilation and hypotension. Orthostasis, or postural changes, like standing from seated position should be assessed

Cardiac Health: Medical History

• Includes questions about prior cardiac surgeries or hospitalizations and rhythm disorders
• Acute rheumatic fever, any unexplained fever, vasculitis must be asked

Cardiovascular Health: Family Factors

• Enquire about family history of long QT Syndrome, diabetes, heart disease, dyslipidemia, hypertension, congenital defects

Personal and Social Factors

• Enquire about employment and physical requirements, environmental hazards
• Must ask about tobacco use, nutritional status, alcohol/drug use

Cardiac: Inspection

• Performed to detect apical impulses, pulsations, heaves and lifts
• Apical impulse should be visible at about the midclavicular line in the 5th left intercostal space

Assessment: Palpation Basics

• Palpation is done to detect apical impulses, thrills, heaves, or lifts
• Precordial palpation sequence includes apex, then up the left sternal border, then base, then down the right sternal border, and into the epigastrium or axillae
• Apical impulse, point of maximal impulse (PMI)
• Palpate for a fine, palpable rushing vibration, often a palpable murmur
• Ensure the apical impulse is not visible in more than one space

Palpation: Assessing Heart Sounds and Carotid Artery

• If more vigorous than expected characterize apical impulse as a heave or lift
• PMI assesses rate and rhythm, frequency, intensity, duration and pathology

Cardiovascular Auscultation

• Cardiac areas must be assessed while listening for rate, rhythm, frequency, duration
• Aortic area: right 2nd intercostal space
• Pulmonic area: left 2nd intercostal space
• Erb's Point to listen: left 3rd intercostal space
• Tricuspid and Mitral areas: lower left sternal border, left 5th intercostal space

Cardio Health Promotion: Controlling Hypertension

• JNC 8, screen general nonblack population using Thiazides, CCB, ACEI, ARB as first line
• Thiazides, CCB should be used as first line, screen general black population using this
• Treatment includes ACEi or ARB
• Do NOT be on both ACEi and ARB together
• Refer to hypertension specialist, if more than 3 drugs are needed

Lab Testing - Lipid Levels

• Total cholesterol is desirable if <200
• Borderline levels measure 200-239
• High levels indicates >240
• LDL cholesterol desired levels should be <100
• Borderline high measure 130 -159 and high levels measure 160-189 and very high measures >190

High and Low HDL levels

• High (good) levels of HDL Cholesterol: >60
• Low (bad) levels of HDL Cholesterol: <40

Peripheral Vascular System: The Four "P"s

• Inspect precordium for apical impulse, pulsations or heaves
• Four P's of assessment are pain, pallor, pulselessness and paresthesia

Peripheral Vascular: Claudication Explained

• Claudication is skeletal pain from muscle ischemia, appearing during exercise, relieved with rest
• Note any pulses, bruits, loss of body warmth or atrophied skin

Peripheral Vascular: Jugular Venous Pressure

• The jugular pulse is visualized, but cannot be palpated
• To assess JVD/JVP, place patient HOB to 45 degrees, pillow, slightly turned left
• Tangential lighting should be implemented to assess RIJ oscillations

Allen's Test for Vascular Flow

• Compress both ulnar, and radial arteries with closed fist, open fist and release one artery to confirm blood flow in alternative artery

Vein Assessments and Risks

• Veins need to be assessed for obstruction and insufficiency
• Calf pain upon passive dorsiflexion often indicates thrombosis
• Look for pain, swelling and tenderness over muscles
• Measure edema levels and varicose veins

Arterial Insufficiency

• Narrowing of the arteries, commonly pelvis and legs

PAD: Symptoms and Variances

• Cramping, pain, tired legs or hip muscles that worsen during walking/activity and subsides with rest
• Look for cool, pale extremity, decreased pulses, sharp pains, intermittent claudication, dry ulcer formation with necrotic tissue
• Differ from acute peripheral arterial occlusion

Venous Insufficiency: Clinical Assessment

• Inadequate return of venous blood from the legs to the heart

PVD: Symptoms and Appearances

• Tired, heavy, achy, cramping in the legs; pain worsens when standing and improved with leg elevation and activity
• Look for warm, flushed, edematous, aching pain or weeping venous ulcers

Vascular: History Taking

• Onset, duration, character, continuous burning, skin changes need to be obtained
• Ask if they are limping or waking at night with leg pain
• Ask about related circumstances or associated symptoms and related medication

Vascular Assessment

• Cardiac surgery or hospitalization
• Enquire about acute rheumatic fever, unexplained fever
• Vasculitis should be noted

Vascular Risk factors

• Hypertension, dyslipidemia or diabetes are risks to circulation
• Note family history of thrombosis, PVD or AAA

Personal/Social Hx: Vascular Risks

• Enquire about Employment, tobacco use, nutritional status and BMI

Vascular: Palpation

• Assess carotid, brachial, , femoral, popliteal, dorsalis pedis, posterior tibial
• Assess artery rate and rhythm, contour and amplitude looking at scale
• Ensure an amplitude is palpated using this scale: 4: bounding aneurysmal

Causes of Chest Pain: Pericarditis

• Substernal pain that may radiate to the neck/left arm
• Sharp pain with sudden onset
• Symptoms include discomfort and friction from palpitations
• Deep breathing and a supine positon make it worse

Chest Wall Pain: Costochondritis

• Pain anywhere over the Chest Wall
• May also be sharp or gradual with pain localized
• Exacerbated by palpations and alleviated by time depending, heat may also relieve pain

Chest Pain differentials: Aortic Aneurysm and Embolism

• Excruciating and tearing pain felt in neck, upper abdomen and epigastric area
• Sudden onset and found in Smokers
• Pulmonary cause results in Sharp and Stabbing
• Sudden Onset and may be a sense of impending doom

Chest Pain differentials: Pneumothorax

• Caused by SOB, Hypoxia
• Severe Pain and sudden onset, pain alleviated analgesics use of a chest tube insertion

Chest Pain differentials: Peptic Ulcer

• Patients describe burning pain during eating times
• Onset quickly subsidies within 20 minutes
• Use of antacids alleviate pain

Vascular Chest Pain differentials

• Angina: Pains radiates from sub sternal areas
• Feeling heaviness in chest and radiating to jaw or shoulder
• NTG alleviates pain
• Myocardial Infarction across the chest that may radiate to jaw, neck, arms, and back
• Pressure, burning, aching, tightness; accompanied by: SOB, diaphoresis, weakness, anxiety, nausea
• Sudden onset, usually ½ to 2 hrs
• Exacerbated by exertion or anxiety
• Pain Alleviated by narcotic analgesics

Cardiovascular System: Other causes of Chest Pain

• Other possible causes: reflux, esophageal motility disorders, peptic ulcer, gallstones, ischemic heart disease, chest-wall syndromes, pericarditis, pleuritis, pneumonia, lung cancer, aortic aneurysm, aortic stenosis, herpes zoster (deep pain before rash)
• Major symptoms of heart disease: chest pain, dyspnea, syncope, exercise intolerance or CHF
• During physical examination evaluate BP: both arms and pulses in both legs

Heart Failure

• Dyspnea on exertion (cardinal sign for left sided HF), fatigue, weakness, nocturnal non-productive cough, orthopnea, paroxysmal nocturnal dyspnea, wheezing, weight gain of >2kg/week are all symptoms of CHF
• Objective results such as rales, wheezing, peripheral edema, S3 gallop (d/t vascular overload, hepatomegaly, JVD, ascites, enlarged or displaced PMI; hypotension, tachycardia or narrow pulse pressure, cool extremities should also be noted
• Diagnostics: BNP >400, elevated BNP can also be cause by pulmonary embolism, renal failure, or acute coronary syndromes; resp alkalosis, CXR: enlarged heart, interstitial and alveolar edema
• Echo will estimate LVEF, RV function, ventricular size, wall thickness and valvular abnormalities
• Left side HF is more common, right sided comes from left side failure or pulmonary conditions

Endocarditis

• Subjective experiences include fever, chills, cough, SOB and weight loss
• Those with IV drug use, catheterization, colon cancer, hemodialysis, or prosthetic valve are at greater risk
• Murmur, signs of HF, or splinter hemorrhages in nail beds are all objective results

Angina

• Decreased myocardial oxygen supply and/or increased demand will results angina
• Location: substernal may radiate to jaw, neck, arms, and back
• Characteristics include aching, squeezing, pressure, heaviness, or burning, usually subsides within 10 minutes
• Eating, physical activity, smoking, cold weather, stress, anger, hunger, or lying down all contribute to angina
• Rest and/or NTG results in pain relief. Physical findings can include a Levine’s sign, or “Clenched fist sign”
• Physical findings such as the Levine’s sign: “Clenched fist sign” will be present

Heart Murmurs

• Grade goes from 1-6
• Listen for timing, pitch, intensity, pattern, quality, location/radiation, respiration phase variations
• Regurgitation: valve doesn’t close properly, leading to backward flow of blood
• Prolapse: valve slips out of place or flaps don’t close properly
• Stenosis: valve opening narrows, restricting blood flow
• Mitral Regurgitation sounds as a High pitched systolic murmur; heard best at the apex. Can be caused: rheumatic fever, Marfan Syndrome (inherited disorder of connective tissue)

Maneuvers Affecting Murmurs

• Inspiration: increases right sides sound Tricuspid stenosis/regurgitation and Pulmonic stenosis can result
• Valsalva: will increases sounds of mitral stenosis or mitral valve prolapse
• Squatting: increases sounds of aortic regurgitation, aortic stenosis, mitral regurgitation, mitral stenosis and decreases sounds of mitral valve prolapse

12 -Lead ECG

• Limb leads: I, II, III, aVR, aVL, aVF
• Chest (Precordial( Leads: V1, V2, V3, V4, V5, V6
• Heart rate: 60 – 100 bpm
• Stroke volume: 50 – 70 ml
• Cardiac output: 5.7 L/min
• HR x Stroke volume = cardiac output
• PR interval: 0.12 – 0.20 sec
• QRS: 0.08 – 0.10 sec
• QT interval: 0.4 – 0.43 sec
• RR interval: 0.6 – 1.0 sec
• One small square: 0.04 sec
• One large square: 0.2 sec
• 5 large squares: 1 sec

Sinus Rhythms

• Normal sinus rhythm
• Sinus bradycardia
• Sinus tachycardia

Atrial Dysrhythmias

• Premature atrial contraction (PAC)