BATES The Cardiovascular system

1. Know the basic anatomy of the surface projections of the heart and great vessels.
a. Right ventricle – occupies most of the anterior cardiac surface; narrows superiority and
joins the pulmonary artery at the level of the sternal angle
b. Left ventricle – forms the left lateral margin of the heart; its tapered inferior tip is called
the cardiac apex; produces the apical impulse (point of maximal impulse during
palpation) found in the 5th intercostal space
c. The great vessels lie above the heart
i. Pulmonary artery – bifurcated into left and right branches
ii. Aorta – curves upward from the left ventricle to the level of the sternal angle,
where it arches posterior lay to the left and then downward
iii. Superior and inferior venue cavae – channel venous blood from the upper and
lower portions of the body into the right atrium
2. Know the cardiac chambers, valves and circulation.
a. Chambers – right atrium, right ventricle, left atrium, left ventricle
b. Valves – mitral, tricuspid, aortic, pulmonic valves
c. Circulation – SVC/ICV —> RA —> tricuspid valve —> RV —> pulmonic valve —> lungs —>
LA —> mitral valve —> LV —> aortic valve —> aorta —> rest of the body
3. Know the events in the cardiac cycle.
a. Systole – period of ventricular contraction
i. Open valves – aortic and pulmonic
ii. Closed valves – mitral and tricuspid
b. Diastole – period of ventricular relaxation
i. Open valves – mitral and tricuspid
ii. Closed valves – aortic and pulmonic
4. Know the relation of auscultatory findings to the chest wall. (VERY IMPORTANT)

a.
5. Know the characteristics of heart murmurs.
a. Heart murmurs – heart sounds attributed to turbulent blood flow
i. Diagnostic of valvular heart disease
b. Stenosis valve – has an abnormally narrowed valvular orifice that obstructs blood flow
c. Aortic regurgitation – a valve that fails to fully close allows blood to leak backward in a
retrograde direction
6. Know the basics of an EKG.
a. P wave – atrial depolarization
b. QRS complex – ventricular depolarization
i. Q wave – downward deflection from septal depolarization
ii. R wave – upward deflection from ventricular depolarization
iii. S wave – downward deflection following an R wave
 c. T wave – ventricular repolarization
7. Know the relationship between arterial pulses and blood pressure.
a. Arterial pulse – a pressure wave moving rapidly through the arterial system
b. Blood pressure – peaks in systole and falls in diastole
i. Measured with a blood pressure cuff
8. Know the relationship between jugular venous pressure and pulses.
a. Jugular venous pressure – reflects right atrial pressure, which in turn equals central
venous pressure and right ventricular end-diastolic pressure
i. Best estimated from the right internal jugular vein
b. Jugular venous pulsation – oscillations of filling and emptying in the jugular veins during
diastole and systole
9. Know the changes with age.
a. Aging may affect the location of the apical impulse, the pitch of heart sounds and
murmurs, the stiffness of the arteries, and blood pressure
10. Learn how to take an appropriate health history noting common or concerning symptoms.
a. When assessing cardiac symptoms, it is important to quantify the patient’s baseline
level of activity
11. Learn about health promotion and counseling.
a. Screen for global risk factors
b. Calculate 10-year and lifetime CVD risk using an online calculator
c. Track individual risk factors – HTN, diabetes, dyslipidemia, smoking, FHx, obesity
12. What are common or concerning symptoms related to the cardiovascular system?
a. Chest pain, palpitations, SOB, swelling, syncope
13. What are the proper examination techniques of the cardiovascular system?
a. Blood pressure – choose a correctly sized cuff, position the patient’s unclothed arm at
heart level, inflate the cuff approximately 30 mmHg above the pressure at which the
brachial or radial pulse disappears
b. Heart rate – palpate the radial pulse using the pads of index and middle fingers
c. Jugular venous pressure – patient’s head elevated on the table at 30 degrees, turn the
patient’s head slightly to the left/right, find the highest point of oscillation in the
internal jugular vein, extend a card horizontally from this point and a cm ruler vertically
from the sternal angle, measure the vertical distance above the sternal angle where the
horizontal card crosses the ruler, add this distance to 5 cm, the sum is the JVP
d. Carotid pulse – place index and middle fingers on the carotid artery in the lower third of
the neck and palpate for pulsation, press just inside the medial border of a relaxed SCM
muscle. Never palpate both carotid arteries at the same time (may induce syncope)
14. What is the best technique for inspection and palpation?
a. Inspection – shine a tangential light across the chest wall over the cardiac apex to make
PMI more visible
b. Palpation – use palm and/or hold finger pads flat against the chest to palpate heaves
and lifts
i. For thrills, press the ball of the hand firmly on the chest to check for a buzzing or
vibratory sensation caused by underlying turbulent flow
ii. For S1 and S2, using firm pressure, place right hand on the chest wall. With left
index and middle fingers, palpate the carotid upstroke to identify S1 and S2 just
before and just after the upstroke
15. What is the best technique for auscultation?
 a. Auscultation the heart with a stethoscope with the patient’s head and upper chest
elevated at 30 degrees
b. Start at either the base or apex, listening first with the diaphragm, then with the bell
c. Mitral stenosis – ask the patient to roll into the left lateral decubitus position, place the
bell lightly on the apical impulse
d. Aortic regurgitation – ask the patient to sit up, lean forward, exhale completely, and
briefly stop breathing after expiration, press the diaphragm on the chest and listen along
the left sternal border and at the apex, pausing periodically so the patient may breathe
16. What is the best technique for percussion?
a. Starting well to the left on the chest, Percuss from resonance toward cardiac dullness in
the 3rd, 4th, 5th, and 6th interspaces
17. What are the basic attributes of heart murmurs?
a. Timing – systolic or diastolic
b. Shape – determined by its intensity over time
c. Location – determined b the site where the murmur originates
d. Radiation – reflects site of origin and intensity of the murmur, the direction of blood
flow, and bone conduction in the thorax
e. Intensity – graded on a six-point scale and expressed as a fraction
f. Pitch – high, medium, or low
g. Quality – blowing, harsh, rumbling, and musical
18. What are the special techniques when examining the cardiovascular system?
a. Standing and squatting – identifies prolapsed mitral valves, distinguishes hypertrophic
cardiomyopathy from aortic stenosis
b. Valsalva maneuver – involves forcible exhalation against a closed glottis after full
inspiration, causing increased intrathoracic pressure
c. Isometric handgrip – increases the systolic murmurs of mitral regurgitation, pulmonic
stenosis, and ventricular septal defect and also the diastolic murmurs of aortic
regurgitation and mitral stenosis
d. Transient arterial occlusion – transient compression of both arms by bilateral blood
pressure cuff inflation to 20 mmHg greater than peak systolic blood pressure augments
the murmurs of mitral regurgitation, aortic regurgitation, and ventricular septal defect
19. Be familiar with the tables at the end of the chapter.