Universal Medical and

Business College
Assessment of Cardiovascular
system

By: Hailye Mamo (BSc, MSc)

July, 2024
Addis Ababa, Ethiopia.
 Learning Objectives
 On completion of this chapter, learner will be able to:

Explain the anatomy and physiology of the cardiovascular

system

Describe the components of cardiovascular system

Explain the assessment of cardiovascular system

2
Questions???

• What is cardiovascular system?

• What are the components of CVS?

• Functions of the heart?

• Function of blood?

• How can we assess the CVS?

• Disease that you know from the CVS previously?

3
Anatomy and physiology overview of CVS

Components of cardiovascular system

 Heart- circulates blood through vessels.

 Blood vessels

◦ Arteries- away from the heart

◦ Veins- towards the heart

◦ Capillaries- a connecting network between artery &

veins.

 Blood- transport medium of the body.

4
 a) The Blood
⚫Is classified as a connective tissue, since nearly half of it is
made up of cells.

⚫However, it differ from other connective tissues in that its

cells are not fixed in position, instead they move freely in
the liquid portion of the blood, the plasma.

5
 Composition of Blood
⚫Plasma

◦ Liquid portion of the blood

◦ The plasma itself is 90% water.

◦ Many different substances dissolved or suspended in the

water, make up the other 10%

⚫Formed elements

◦ The cells and fragments of cells

 Erythrocytes, leukocytes and platelets

6
 Functions of the blood
 Transportation
 Oxygen
 Foods and other needed substances
 Waste products
 Hormones
 Regulation
 PH
 Body temperature
 Protection
 Against pathogens
 Blood loss
7
 b)The Blood Vessels:
⚫Together with the four chambers of the heart, B/d vessels
flow blood throughout the body.
Functional classification
 Taking blood to the tissues and back to heart
 Arteries
 Veins
 Capillaries

8
 Structure of blood vessels
• Three coats or layers are found in both arteries &
veins except the capillaries

1. Tunica externa:- The outermost layer of a blood

vessel.

2. Tunica media: The middle layer of a blood

vessel

3. Tunica interna /intima: The innermost layer of a

blood vessel
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10
 Location of Heart
♥ Posterior to sternum

♥ Medial to lungs

♥ Anterior to vertebral column

♥ Base lies beneath 2nd rib

♥ Apex at 5th inter-costal

space

♥ Lies upon diaphragm

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12
 Coverings of the heart
 Pericardium-loose fitting, double layered sac.

 Visceral pericardium-serous membrane that is on the

surface of the heart muscle

 Parietal pericardium- outer layer of sac; secretes

pericardial fluid

 Pericardial fluid- (Serous fluid)-fluid that is between

the parietal and visceral pericardium which prevents
friction as the heart beats.
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14
 Layers of heart tissue
1. Epicardium
2. Myocardium
3. Endocardium

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 1. Endocardium
▸ Inner lining
▸ Smooth surface that permits blood to move easily
through the heart without agglutination.

▸ Continuous with lining of blood vessels

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 2. Myocardium

 Middle layer made of cardiac muscle

 Forms the bulk of the heart wall

 Contains the septum- a thick muscular wall that

completely separates the blood in the right side of the
heart from the blood in the left side.

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 3. Epicardium

 Protective, outer layer of the heart wall same as the

visceral pericardium

 The coronary blood vessels that nourish the heart wall

are located here

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19
20
 Chambers of Heart
1. Right Atrium 2. Right Ventricle

 Thinner wall than  Thicker wall than atria

ventricles  Comprises most of

 Receives deoxygenated anterior surface of heart

blood from vena cava  Circulates deoxygenated

 Passes blood through blood to lungs through

tricuspid valve into the pulmonic valve into

right ventricle pulmonary trunk

By:Hailye. M (BSc, MSc) 7/21/2024 21
 Chambers of Heart cont’d…
3. Left Atrium 4. Left Ventricle
 Receives blood from left
 Receives freshly
atrium
oxygenated blood from
pulmonary vein  Thickest myocardial wall

 Passes blood to left  Forms apex of heart

ventricle through  Sends blood to systemic

mitral valve circulation via aorta

 Aortic valve:-b/n the Lt

ventricle & aorta
22
23
 Heart Valves
 Function: prevent blood from flowing backwards

 Responds to changes in pressure

 Two types of valves in the heart:

1. Atrio-ventricular valves (AV)

2. Semi-lunar valves

24
 A) Atrioventricular valves
► Valve cusps are connected to papillary muscles

► Chordae tendineae tiny collagen cords that anchor cusps

of valve to papillary muscles

25
 A) Atrioventricular valves cont’d…

 Left AV valve (Mitral/bicuspid)

 Contains 2 cusps

 Right AV valve (Tricuspid)

 Contains 3 cusps

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27
 B) Semilunar valves
 Located at exit of ventricles, originate from endothelial
lining of veins

 Heart contains two semilunar valves

1. Pulmonic

2. Aortic (Frequently damaged by HTN)

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29
 Blood circulation
▸ The blood passes through the tricuspid valve into the
right ventricle, which then pumps the blood through the
pulmonic valve into the pulmonary circulation.

▸ After gas exchange in the lungs, oxygenated blood

returns to the left atrium, passes through the mitral
valve, enters the left ventricle, passes through the
aortic valve, and finally enters the aorta.

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32
 Coronary circulation
 Blood in the heart chambers does not nourish the

myocardium

 The heart has its own nourishing circulatory system

 The left and right coronary arteries and their branches

supply arterial blood to the heart.

 These arteries originate from the aorta just above the

aortic valve leaflets.
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 Coronary circulation cont’d…
▸ The right side of the heart is supplied by the Right
coronary artery, which progresses around to the
bottom or inferior wall of the heart.

▸ The posterior wall of the heart receives its blood supply

by an additional branch from the right coronary artery
called the Posterior descending artery.

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35
NB:
▸ The coronary arteries are perfused during diastole.
▸ An increase in heart rate shortens diastole and can
decrease myocardial perfusion.

▸ Patients, particularly those with coronary artery

disease (CAD), can develop myocardial ischemia
(inadequate oxygen supply) when the heart rate
accelerates.

36
 Coronary veins
 Transport deoxygenated blood to coronary sinus
Coronary Sinus drains into right atrium.

37
 The heart beat
 Each heartbeat is called a cardiac cycle.

 When the hart beats, the two atria contract together ; then
the two ventricles ;then the whole heart relaxes.

 Systole is the contraction of heart chambers; diastole is their

relaxation (heart fill with blood).

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 Intrinsic control of heart beat
 The Sinoatrial (SA) node, or pacemaker ,initiates the hear beat
and causes the atria to contract.

 The Atrioventricular (AV) node conveys the stimulus and

initiates contraction of the ventricles .

 The signals for the ventricles to contract travels from the AV

node through the atrioventricular bundle to the smaller
Purkinje fiber.

 The SA node in anormal resting adult heart has an inherent firing

rate of 60 to 100 impulses per minute.
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40
 Extrinsic control of heartbeat

 A cardiac control center in the medulla oblongata speeds

up or slows down the heart beat by ways of the autonomic
nervous system branches : parasympathetic system
(slows heart rate) and sympathetic system(increases
heart rate).

 Hormones epinephrine and norepinephrine from the

adrenal medulla also stimulate faster heart rate.

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 QUESTION:
 What effect will each of the following have on heart rate?
A) Anxiety

B) Fever

C) Hypothyroidism;

D) Caffeine

E) Athletic conditioning.

F) Shock and hemorrhage

42
 Heart sounds
 The normal heart sounds, S1 and S2, are produced
primarily by the closing of the heart valves.

 The time between S1 and S2 corresponds to systole.

 This is normally shorter than the time between S2

and S1 (diastole).

 As the heart rate increases diastole shortens.

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 S1— First heart sound

 Closure of the mitral and tricuspid valves

 Vibration of the myocardial wall also may

contribute to this sound

 It is heard best at the apex of the heart (apical
area)

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 S2— Second heart sound
 Closing of the aortic and pulmonic valves produces the
second heart sound (S2).
 These two valves close almost simultaneously,
but the pulmonic valve usually lags slightly
behind.

 Therefore, under certain circumstances, the two

components of the second sound may be heard
separately (split S2)

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46
 Gallop Sounds (S3)
oProduced by rapid ventricular filling and occurs in
early-mid diastole
o It represents a normal finding in children and young
adults

 4th Heart Sound, S4

oThis is an atrial sound, occurring just before S1.
oIt is always abnormal
oIt represents atrial contraction against a stiffened
ventricle e.g. Due to aortic stenosis or hypertensive
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 Friction Rub
• A harsh, grating sound that can be heard in both
systole and diastole

• It is caused by abrasion of the pericardial

surfaces during the cardiac cycle

• Distinguish it from murmurs that may be heard in

both systole and diastole.

• Can be heard best using the diaphragm of the

stethoscope, with the patient sitting up and
leaning forward. 48
 Cardiac output
 Cardiac output
 Amount of blood ejected from the left ventricle over 1
minute
 In resting adult it is about 5 L per minute

 Is computed by multiplying the stroke volume by

the heart rate

 Stroke volume
◦ Amount of blood that is ejected with each heartbeat
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 Rest and Digest

1. If a person’s heart rate is 72 beats per minute (bpm), and

the heart ejects 70ml per each beats. what is the cardiac
output?

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 Stroke volume
 Is the amount of blood ejected per heart beat

 Is primarily determined by three factors:

 Preload,

 Afterload, and

 Contractility

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 The degree of stretch of the cardiac muscle fibers at the
end of diastole.

 As the volume of blood returning to the heart

increases, muscle fiber stretch also increases
(increased preload),

 Is decreased by a reduction in the volume of blood

returning to the ventricles.

52
 The amount of resistance to ejection of blood from the
ventricle.

 Is increased by arterial vasoconstriction

 The resistance of the systemic BP to left ventricular

ejection is called systemic vascular resistance.
 The resistance of the pulmonary BP to right ventricular
ejection is called pulmonary vascular resistance

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54
55
 Is a term used to denote the force generated by
the contracting myocardium under any given
condition.

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Assessing Patient’s CV Status

• What are the

common signs
& symptoms of
cardiovascular
disorders ?

By:Hailye. M (BSc, MSc)

7/21/2024 57
 Assessing Patient’s CV Status
1. Chest pain: in cardiovascular system the commonest cause for
chest pain are:
 Myocardial infraction, angina ,acute pericardial disease
 ACS (acute coronary syndrome)
 Pain similar to angina ; may be more intense
 Often occurs at rest
 Not relieved by rest; requires analgesic
 Pericarditis
 Described as sharp, stabbing, shooting
 Aggravated by movement
 Tend to be constant
 Relieved by sitting up, leaning forward, shallow breathing

58
 Assessing Patient’s CV Status…
2). Dyspnea

 Subjective sensation of being unable to breath

 Usually caused by congestion from Left Ventricular

Failure (LVF)

Types:
 Dyspnea on exertion (DOE)
 Orthopnea : inability to breathe while lying flat
 Paroxysmal nocturnal dyspnea (PND): night time
episodes of SOB due to lying flat which increases venous
return (preload).
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 Assessing Patient’s CV Status cont’d…

3). Fatigue / Weakness

▸ Symptom of decreased forward CO

▸ Unusual fatigue, sometimes referred to as vital
exhaustion (an early warning symptom of ACS, HF,
or valvular heart disease, characterized by feeling
unusually tired or fatigued, irritable, and dejected)

60
 Assessing Patient’s CV Status cont’d…

4). Fluid retention

 Fluid accumulation in tissues

 Peripheral edema, weight gain, abdominal

distention due to enlarged spleen and liver or
ascites (HF)

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 Assessing Patient’s CV Status cont’d…

5). Syncope/Presyncope
◦ Temporary loss of consciousness,
lightheadedness, dizziness

◦ Cardiac cause most commonly result of inadequate

cardiac output from arrhythmias

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64
 Assessing Patient’s CV Status cont’d…

6). Palpitations
◦ Awareness of heart beat with sudden changes in rate,
rhythm, increased stroke volume.
◦ Associated with : tachycardias, bradycardias, atrial
fibrillation, aortic and mitral regurgitation, signs of
heart failure.

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 Assessing Patient’s CV Status cont’d…
7. Other symptoms
◦ GI

 Nausea, anorexia, vomiting.

 Indigestion or flu like symptoms may be sole s/s of MI.

◦ Extremity pain

 Intermittent claudication indicative of Peripheral Vascular

Disease (PVD) due to decreased blood flow to muscles
during time of increased demand.
 Ischemia from PVD
6
4
66
 Assessing Patient’s CV Status cont’d…

7). Other symptoms…

◦ Decreased urine output

 Indicative of heart failure and hypovolemia

 Look for concomitant weight gain due to CHF

◦ Nocturia

 Sign of heart failure

 Caused by increased preload to heart

6
5
 Assessing Patient’s CV Status cont’d…
 Risk Factors
◦ Non-modifiable
 Age
 Sex
 Family history
 Race
◦ Modifiable
 Cigarette smoking
 Hypertension
 Hyperlipidemia
 Physical inactivity
 Diabetes
 Stress
 Obesity
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 Assessing Patient’s CV Status cont’d…

 Social History
◦ Alcohol intake
◦ Dietary pattern: caffeine , salt intake
◦ Cocaine
◦ Educational level
 Medication History
◦ Prescribed drugs
◦ Over-the-counter drugs(OTC)

67
Cardiovascular physical examination

▸ General Appearance
▸ Vital Signs
▸ Jugular Veins
▸ Heart
▸ Peripheral Pulses

68
 VITAL SIGNS
- Both arms
- BP
- Hypertension, hypotension ,
orthostatic hypotension

- Pulse Pressure

= Heart Rate =Tachycardia, Bradycardia

• Regular, Regularly
• Rhythm
irregular, irregularly
irregular
+ Respirations + Tachypnea/Bradypnea
• Temperature • Fever 7/21/2024 69
 Inspection
 Jaundice

◦ Best seen in sclera

◦ Sign of right – side heart failure (from hepatic

impairment) or chronic hemolysis from
prosthetic heart value.

 Pallor

◦ Indicates anemia

◦ Inspect palm of hands

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 Jugular venous pressure (JVD)
 Recall that jugular veins reflect right atrial pressure
 Steps for JV examination
 Raise the head of the bed or examining table to a 30- to a 45-
degree angle.
 Turn the patient’s head gently to the left
 Identify the top most point of the flickering venous
pulsations
 Place a centimeter ruler upright on the sternal angle
 Place a card or tongue blade horizontally from the top of the
JVP to the ruler, making a right angle
 Measure the distance above the sternal angle in
centimeters: a 3- to 4-centimeter elevation is normal

71
assessment of central venous pressure.

72
Top line – level of the higest visible point
⚫

of distention

⚫ Bottom line – level of the sternal angle

Measure: the vertical distance between

⚫

the sternal angle and the highest level of

jugular distention
73
 Cyanosis
◦ Central cyanosis
 low oxygen saturation of arterial blood.
 Noted on tongue, buccal mucosa and lips
 Indicative of cardiopulmonary disease (heart failure or
pulmonary edema).
◦ Peripheral cyanosis
 Reduced blood flow through extremities due to
vasoconstriction
 Noted on distal aspects of extremities, tip of nose and
earlobes
 Due to cold exposure or obstructive peripheral
vascular disease 74
75
 Palpation
◦ Edema
 Usually not detectable until interstitial fluid
volume is 30% above normal
 Bilateral edema
 Progression from ankles , legs, thighs, genitalia
and abdomen, presacral for bed rest.
 Indicative of heart failure or bilateral venous
insufficiency (unilateral seen in venous
thrombosis and lymphatic blockage of
extremity)

76
 Palpation (continued)
 Palpation of the chest, including the following

◦ Precordium at the right and left second

intercostal spaces

◦ Left third intercostal space

◦ Left fourth intercostal space

◦ Left fifth intercostal space at the midclavicular line

77
Landmarks for palpation of the
chest.

78
 PALPATION(continued)
 Impulses - finger pads

 Thrills (vibrations palpated secondary to a

murmur—turbulent blood flow through a heart valve) -
Bony part of hand, ball of hand.

 Apical impulse (normally 5th ICS and medial to mid-

clavicular line)

 Point of maximum impulse (PMI)

 Left lateral position (heart closer to chest well)

apical impulse more easily palpable
79
 Palpation(continued)…
Major Arteries:
Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Posterior
Tibial, Dorsalis Pedis. Palpate for the pulse on each side.
comparing pulse volume and symmetry.
Do not palpate both carotid arteries at the same time or press
too firmly.
 If you do the patient may faint or become Bradycardia.
 Radial artery is commonly used to assess heart rate and
rhythm.
 Compare the left radial pulse with that of the right.
 Lack of symmetry may indicate impaired circulation
 Localized obstruction
 Abnormally positioned artery.
80
 PERCUSSION
Percussion of the chest for cardiac border

81
 AUSCULTATION

◦ Blood pressure

 Overall reflection of Left Ventricular function

 Systolic represents force of contraction

 Diastolic represents vascular resistance
(afterload)

 Pulse pressure – difference between systolic

and diastolic
82
 HEART BORDERS

◦ Specific areas for examination

 Aortic area: 2nd ICS, RSB

 Pulmonic area: 2nd ICS, LSB

 Tricuspid area: 4th ICS, LSB

 Mitral or Apical area: 5th ICS,

MCL

83
HEART SOUNDS

◦ Closure of valves
 S1
 irst heart sound ―‘’lub‘’; closure of AV
valves heard loudest at mitral and
tricuspid areas; usually lower pitch
than S2
 S2
 second heart sound ― ‘’dub‘’; closure
of semilunar valves; heard best at
aortic and pulmonic areas
84
 HEART SOUNDS…
 S3

 Ventricular gallop

 Heard in early diastole, just after S2

 Due to rapid, early ventricular filling

 Indicates loss of ventricular compliance, diastolic

overloading, heart failure

 Heard best : bell, mitral area if produced by left heart

; along sternal borders if produced by right heart
85
 MURMUR
 Turbulent blood flow
 Often imply significant disease of heart valves, great
vessels, or septal defects

 Timing of murmurs is a must!

 Systolic murmurs occur between S1 & S2

Diastolic murmurs occur between S2 & S1

 Grade 1 – 6 identifies intensity of murmur

86
 Extra cardiac sounds
◦ Pericardial Friction Rubs

 Caused by inflammation of pericardium.

 Rough, scratchy, squeaky sound ―like two pieces

of leather rubbing against each other.

 Best heard with patient leaning forward, holding

breath in full expiration.

87
88
 Diagnostic studies of cardiovascular
system
Cardiac Enzymes Test
⚫Tests performed on samples of blood obtained by vein
puncture to determine the presence of damage to the
myocardial muscle.
⚫When heart cells are damaged or die, they rupture and
release enzymes into the bloodstream.
⚫Levels of these enzymes rise in the serum as a
result.
89
 Diagnostic studies of cardiovascular
system ,,,

⚫Because different enzymes move into the blood at

varying periods after Myocardial Infraction (MI),
enzyme levels should be tested in relation to the time
of onset of chest discomfort or other symptoms.

90
 Diagnostic studies of cardiovascular
system,,,

⚫A common cardiac enzyme test is creatine kinase

(CK), also referred to as creatine phosphokinase
(CPK).

⚫Lactic dehydrogenase and its isoenzymes also are

analyzed in patients who have delayed seeking
medical attention, because these blood levels rise and
peak in 2 to 3 days, much later than CK levels
91
 Diagnostic studies of cardiovascular
system,,,

⚫Myoglobin, an early marker of MI, is a heme

protein with a small molecular weight.
⚫This allows it to be rapidly released from damaged
myocardial tissue and accounts for its early rise, within 1
to 3 hours after the onset of an acute MI.
⚫Myoglobin is not used alone to diagnose MI, because
elevations can also occur in patients with renal or
musculoskeletal disease.
92
 Diagnostic studies of cardiovascular
system,,,

⚫Troponin I is a contractile protein found only in

cardiac muscle.

⚫ After myocardial injury, elevated serum troponin I

concentrations can be detected within 3 to 4 hours; they

peak in 4 to 24 hours and remain elevated for 1 to 3
weeks.

93
 Diagnostic studies of cardiovascular
system,,,
Angiography
⚫X-ray visualization of internal anatomy of heart and
blood vessels after introducing a radiopaque substance
(contrast medium).

 This test Promotes imaging of internal structures that

are otherwise difficult to see on X-ray film and used to
assess blood clot formation, to assess peripheral
vascular disease (PVD).
94
 Diagnostic studies of cardiovascular
system,,,
Echocardiography
⚫It is an ultrasound test that records the motion of the
heart structures, including the valves, as well as the heart
size, shape, and position.

⚫Useful in evaluating structural and functional changes

in a variety of heart disorders.

⚫ No preparation is required for a cardiac ultrasound.

95
 Diagnostic studies of cardiovascular
system,,,
 This test transmits ultrasonic sound waves into the
heart so that the returned echoes can be recorded on
videotape as audio and visual information.
• An ElectroCardioGram (ECG)is recorded at the same
time for comparison purposes.
 Abnormalities that may be seen on the
echocardiogram include heart enlargement, valvular
abnormalities, thickened cardiac walls or septum, and
pericardial effusion.
96
 Diagnostic studies of cardiovascular
system,,,

Electrocardiogram (EKG, ECG)

⚫Graphic record of the electrical action of the heart as
reflected from various angles to the surface of the skin

⚫The ECG shows abnormalities related to

conduction, rate, rhythm, heart chamber
enlargement, myocardial ischemia, myocardial
infarction, and electrolyte imbalances.

97
 Diagnostic studies of cardiovascular
system,,,

⚫ Abnormalities in cardiac function can be detected and

the area of abnormality pinpointed with the aid of the
different views on the ECG.
⚫To obtain an ECG, electrodes are placed on the skin to
transmit electrical impulses to the ECG machine for
recording.
⚫The electrical impulses from the heart appear as waves on
graph paper.
98
99
 Diagnostic studies of cardiovascular
system,,,

Cardiac catheterization
⚫Invasive diagnostic procedure in which a catheter is
introduced into a large vein or artery, usually of an arm or
a leg, and is then threaded through the circulatory system
to the heart.
⚫Used to obtain detailed information about the
structure and function of the heart chambers, valves,
and the great vessels.
100
 Diagnostic studies of cardiovascular
system,,,

⚫Measures pressures in the heart chambers, great blood

vessels, and coronary arteries and provides
information on cardiac output and oxygen saturation.

⚫Fluoroscopy is used, and dye can be injected once the

catheter is in place to visualize the heart chambers and
vessels.

⚫This procedure is often done before heart surgery.

101
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