Heart Anatomy and Circulation

• Revision of Heart Anatomy Study Notes

Surface Anatomy of the Heart

• Point 1: The lower border of the second left costal cartilage is located one and a half inches from the median plane.
• Point 2: The upper border of the third right costal cartilage is located one inch from the median plane.
• Point 3: The upper border of the sixth right costal cartilage is located one inch from its junction with the sternum.
• Point 4: The apex is located at the left fifth intercostal space, three and a half inches from the median plane.

Heart Chambers, Valves, and Circulation

• The heart consists of chambers including the right atrium, right ventricle, left atrium, and left ventricle.
• Valves in the heart include the tricuspid valve, pulmonary valve, mitral valve, and aortic valve.
• Blood flows from the superior and inferior vena cava into the right atrium, then through the tricuspid valve to the right ventricle, through the pulmonary valve to the pulmonary artery, to the lungs, and then the pulmonary vein to the left atrium
• Blood continues to the left ventricle through the mitral valve and exits trough the aortic valve to the aorta which pumps throughout the body

Layers of the Heart Wall

• The heart wall consists of three layers: the epicardium, myocardium, and endocardium.

Surfaces of the Heart

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

Borders of the Heart

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

Conduction System of the Heart

• Key Structures: Sinoatrial (SA) node, Atrioventricular (AV) node, Interatrial pathway, Internodal pathway, Left and Right bundles of His, and Purkinje fibers

Coronary Arteries

• The heart's major arteries are the left coronary artery, the right coronary artery and the circumflex artery.
• The left anterior descending artery is a major branch.

Cardiac Examination

• History taking involves questions about occupation, habits, past surgeries, diseases, medications, onset of symptoms, and family history.

Assessment Parameters

• Assess the patient's decubitus or position, body build, color, mental state, and other problems.
• Squatting position is used in cases of tetralogy of Fallot to relieve cyanosis thus increasing oxygen saturation by kinking the femoral arteries and increasing systemic vascular resistance

Tetralogy of Fallot Characteristics

• It is a cyanotic congenital heart disease involving four pathologies: pulmonary stenosis, right ventricular hypertrophy, overriding aorta, and ventricular septal defect.
• Cyanosis decreases with squatting by reducing the amount of deoxygenated blood reaching the heart, thus increasing the amount of oxygen.

Hemodynamics of Squatting

• Squatting has two phases: an immediate drop in venous return and a sustained increase in venous return with raised systemic vascular resistance.
• Trapping desaturated blood in the lower extremity gives quick relief, and increased aortic after load redirects blood to the pulmonary artery.
• Compressing the abdomen mechanically pushes blood into the aorta, avoiding brain hypoxia.

Other Positions

• Long sitting position helps with orthopnea by relieving pressure on the diaphragm and reducing venous return.
• Prayers position is leaning forward to decrease pressure on the heart wall and decrease pain sensation.

Body Build Observation

• Cachetic body builds can indicate advanced left-sided heart failure due to low oxygen to body tissue and nutrition
• Obese body builds can indicate right-sided heart failure due to venous stasis and edema, and may indicate coronary isssues
• Inverted pyramid body build indicates coarctation of the aorta.

Body Build Abnormalities

• Marfan's syndrome patients have a lean body, thin face, and long spiderlike fingers seen in atrial septal defect.
• Infantilism is a failure to fully develop due to sever cardiac diseases starting in childhood

Color Assessment

• Malar flushes are red or blue discoloration in the butterfly of the nose and checks seen in tight mitral stenosis.
• Pale color indicates face pallor from rheumatic fever or aortic disease.
• Jaundice is yellowing of mucus membranes from bilirubin, most apparent in the eyes.
• Cyanosis is a discoloration of the skin from hemoglobin.

Central vs Peripheral Cyanosis

• With central cyanosis, the lips, nose, hands, ears, and limbs are affected and is increased while exercising.
• With peripheral cyanosis, the lips, nose, hands, ears, and limbs are affected and is decreased while exercising.

Differential Cyanosis

• Is bluish coloration is the lower body but not the head caused by patent ductus arteriosus (PDA).
• Upper extremity is pink because the brachiocephalic trunk gives blood flow proximal to the PDA

Mental Status

• Includes assessing mood, level of coordination, and level of consciousness.

Other Problems

• Nodules show endocarditis(rheumatic fever), puffy eyelids indicate heart failure, and jerky emotional movements show rheumatic chorea

Venous vs Arterial Pulsation

• Arterial: Carotid, Medial/anterior to SCM, Better felt, and Synchronous
• Venous: Jugular, Lateral/posterior to SCM, Better seen, Before/after heartbeats

Clubbing

• Clubbing fingers show hypertrophy of nail connective tissue with loss of the normal hand angle of 160 indicating poor oxygen
• In the lower limbs, it indicates pulmonary hypertension
• Blue clubbing indicates cyanotic congenital heart disease
• Pale clubbing indicates infective endocarditis
• Lower extremities show cardiac edema, and necks show nodding and pulsing

Vital Signs Tests

• Palpate for pulse rate, rhythm, contour, volume around the body
• Pulse deficit arises when the pulse rate is high and the cardiac impulses aren't felt throughout the body/periphery
• Blood pressure should be measures on both arms while supine and again after standing

Local Examination for Auscultation

• Inspect for previous operations and skeletal deformities
• Palpate over Suprasternal/pericardial/parasternal/epigastric areas for apex beat
• Auscultate for veins and listen for heart area sounds

Skeletal Deformities

• Can shift apex and heart
• Scoliosis
• Kyphosis
• Kyphoscoliosis
• Barrel chest
• Pectus excavatum (funnel chest)

Suprasternal Pulsation

• Can be natural or come from tension, stress, anxiety, exercises, or fever
• Pathologically: Carotid pulsation or CHF

Pericardial Area

• Is the area of chest over laying the heart; Should be equal bilaterally
• Shape can indicate heart health -Bulge can indicate childhood disease, tumor, or excess fluid.

Parasternal Area

• Pulsations on 3rd-5th intercostal show Pulmonary hypertension
• Pulsations on the 2nd show systemic hypertension
• Pulsations on the pulmonary area (lt 2nd ICS) show pulmonary hypertension, A dilatation

Apex Beat Assessment

• The apex beat is the heart point of maximum impulse, indicating the lower most point of cardiac impulse
• Lower Left ventricle point
• Typically palpable on the 5th intercostal, 8cm from Mid sternal. 3cm size

Shifting of Apex

Shifting indicates external disease, internal disease, or dextrocardia.

• Shifted by
• fibrosis of apex of lung
• COPD wall
• cardiac/tumor causes

Apex Beat Abnormalities

• Abnormally the pulse feels intense during hypetrophy/stenosis, and heavy for left ventrical and stenotic forces
• Can also have a heavy duartion as sign of heart disease
• Heavy and weak signs can indicate high ventrical and low ventrical activity

Epigastric Area Abnormalities

• Long sitting patients only
• Vertical hand movement on epigastric area
• pulse beat can show aorta issues. Pulsing and issues with sides (thumb points to liver), and side finger points to the heart

Thrills

• Murmurs are vibrations from hear or vessels
• Should be noted with other sounds in fourth grade
• Can be noticed throughout valve points alongside murmurs

Juglar/Venous Pressure And Hepatojagular

Vertical distance that points at internal juglar

• Patient with jugular has more pressure and potential Vena Cava Obstructio
• Pressure can be tested with the Hepatojugalur test which may increase heart or liver pressure

Percussion

Percussion tests are performed to confirm the locations of the heart, liver, and stomach

• Heavy pressure must be used on all tests, but the light pressure can be used on lungs.
• Dulness can indicate potential blood/fluid buildup around area
• Lung tests use Pulmonary and Aortic areas alongside resonant and dull points.

Auscultation

• A means of listening to various parts for sounds, used with 5 steps
• A: heart sounds
• B: Murmurs
• C: Rubs

Heart Sounds

• First 4 heart sounds: (S1, S2, S3, S4) indicate different heart steps, with splitting (S3) can indicate valve blockage
• This takes approximately 0.8s
• Stethoscope has a diaphram for high sounds, a bell for low

High vs Low Sounds At Valves

• FIRST: MITRAL TRICUSPID: LUP: Apex
• SECOND: PV AND AO: DUP: Pulminary Ares
• THIRD: Ventricular GALLOP: Ventricular overload Apex
• FOURTH: ATRIA: Gallop to pump ventricle bell Apex

Splitting S1 and S2

• Split S1 and S2 are used to define how the heart beat
• S2: in deep breath-venous return to cause later sounds , and abnormal heart and valve operation

Galloping Sounds

• Extra sound with beat
• Extra heart sound and tachycardia indicate athlete and pregnancy, but show hear failure too

Problems with Valves

• 3 points that can form: thickening from closing/opening, affection and tone of music, and backwardness

Murmur Steps

• Murmurs form through abnormal musical sounds
• Systolic murmurs cause regurge
• 3 types: systolic, diastolic and machinery
• Diastrolic, pulmanry, tricuspid stenosis

Pericardial Rubs

• Abnormal sounds during systole
• Happens during percardial issues or friction
• Can occur during short breath