BASIC CARDIOVASCULAR

INVESTIGATION

Bruke B. (BPharm, MSc clinical pharmacy, PhD in cardio

therapy, clinical pharmacy) WCU, Ethiopia

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THE HISTORY
 isthe cornerstone of a cardiovascular workup
 The elements of a comprehensive history
 the chief complaint,
 present problems,
 past medical history,
 review of systems,
 and social history
 Chief complaint : is a short brief statement as to
the reason why the patient seeks medical care (get
to the point)
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 HPI: The duration, any prior Hx of the same
problem, the severity of the problem, and
whether there are any limitations on the
patient’s daily activities

 Character, any types of motion or other things

that / the discomfort, any association with
additional Sy/Sx, and whether the
discomfort is increasing in frequency or
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 Chest pain : is one of the most important symptoms
you will assess as a practitioner

 “Do you have any pain or discomfort in your chest?”

 “Is the pain related to exertion?”

 “What kinds of activities bring on the pain?”

 “How intense is the pain, on a scale of 1 to 10?”

 Does it radiate into the neck, shoulder, back, or down

your arm?”
 “Are there any associated symptoms like shortness of
breath, sweating, palpitations, or nausea?”
 “Does it ever wake you up at night?”
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 “What do you do to make it better?”
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Examples:
 Exertional chest pain with radiation to the left
side of the neck and down the left arm in
angina pectoris.

 Sharp pain radiating into the back or into

the neck in aortic dissection.

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 Palpitations: are an unpleasant awareness of the
heartbeat.
 Patients use various terms : skipping, racing,
fluttering, pounding, or stopping of the heart

 May result from an

 irregular heartbeat,
 from rapid acceleration or slowing of the heart,
 or from increased forcefulness of cardiac contraction

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 Shortness of breath: is a common patient concern
and may be reported as dyspnea, orthopnea, or
paroxysmal nocturnal dyspnea/PND

o Dyspnea: is an uncomfortable awareness of

breathing that is inappropriate to a given level of
exertion

o Orthopnea is dyspnea that occurs when the patient

is lying down and improves when the patient sits up.

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 Orthopnea suggests
 left ventricular heart failure or mitral stenosis;
 it may also accompany obstructive lung disease

o Paroxysmal nocturnal dyspnea/ PND: describes

episodes of sudden dyspnea and orthopnea that

o awaken the patient from sleep,

o usually 1 or 2 hours after going to bed,
o prompting the patient to sit up, stand up, or go to a
window for air.

 May be associated wheezing and coughing 10

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 PND suggests left ventricular HF or mitral stenosis
and may be mimicked by nocturnal asthma
attacks

 Edema refers to the accumulation of excessive fluid

in the interstitial tissue spaces and appears as
swelling.

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 Family Hx is very important because of the
genetic links involved in many CV diseases
 from early myocardial infarction,
 strokes,
 diabetes,
 valvular heart disease,
 hypertension and familial hypercholesterolemia

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PHYSICAL EXAMINATION
 Blood pressure/BP

 After letting the patient rest for at least 5

minutes in a quiet setting, choose a correctly sized
cuff and position the patient’s arm at heart level,
either resting on a table if seated or supported
at mid chest level if standing.

 Make sure the bladder of the cuff is centered over

the brachial artery

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 Inflate the cuff about 30 mm Hg above the pressure at
which the radial pulse disappears

 As you deflate the cuff, listen first for the sounds of at

least two consecutive heartbeats—these mark the
systolic pressure.

 Then listen for the disappearance point of the

heartbeats, which marks the diastolic pressure

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 The initial part of P/E consists of inspection of the
precordium for normal patterns of rise and fall
and any abnormal markings or shape.
 The chest is then palpated for
 normal pulses,
 thrills (humming vibrations like the throat of a purring
cat),
 and heaves (lifting of the chest wall)

 Thrills may indicate murmurs

 Heaves may indicate enlargement of one of the
heart chambers or an abnormal vessel such as
an aneurysm 15

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 HEART RATE
 For heart rate, measure the radialpulse using the
pads of your index and middle fingers, or assess the
apical pulse using your stethoscope

 The apical pulse (the point of maximum impulse) is

helpful to estimate heart size and rotation.

 PMIis usually located in 5th intercostal space in

midsternal line and radiates in an arc of 1 to 2 cm.
 Heightened intensity and/or displacement laterally
suggests, Left or right ventricle enlargement,
 And reduced intensity may be a sign of fluid overload16
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or pericardial effusion
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APICAL PULSE

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 THE CAROTID
PULSE
 The carotid pulse is examined for its intensity
and, concurrently with the apical pulse, for
concordance within the cardiac cycle

 Decreased pulsations may be caused by

 Decreased stroke volume,
 Also be due to local factors in the artery such as
atherosclerotic narrowing or occlusion.

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CAROTID
PULSE

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JUGULAR VENOUS PRESSURE

 is usedas an indirect measure of right atrial

pressure
 Venous pressure measured at
 >3 cm or possibly 4 cm above the sternal angle,
 or more than 8 cm or 9 cm in total distance above the
right atrium, is considered elevated above normal

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JVP

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JVP
 Increased pressure suggests

 Right sided HF
 or, less commonly, constrictive pericarditis, tricuspid
stenosis, or superior vena cava obstruction

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 HEART SOUNDS
 Auscultation with a stethoscope is used to
characterize heart sounds.
 The normal heart sounds

 S1 :first heart sound—closure of the mitral and

tricuspid valves and
 S2: second heart sound—aortic and pulmonic

valves.

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SOUNDS…

S2 becomes split during inspiration because of delayed

closure of the pulmonic valve
prolongation of right ventricle systole secondary to an
increase in venous return

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SOUNDS…NORMAL
 S1 has two components, an earlier mitral and a
later tricuspid sound.
 The softer tricuspid component is heard best at
the lower left sternal border, and it is here that
you may hear a split S1

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 SOUNDS…ABNORMAL
 S3 :thirdheart sound; and S4: fourth heart sound;
and murmurs, are not considered normal but
provide important diagnostic information
 High-pitched sounds :
 S1 and S2, murmurs of aortic and mitral regurgitation,
and pericardial friction rubs are best heard with the
diaphragm.
Low-pitched sounds :
 The bell is preferred for low-pitched sounds such as S3
and S4.

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 SOUNDS ….S3
 The S3 heart sound, or ventricular gallop, is an
abnormal low pitched sound usually heard at the
apex of the heart
 Caused by rapid filling and stretching of the left
ventricle when the left ventricle is somewhat
noncompliant.
 This heart sound is characteristic of
 volume overloading, as in CHF(especially left-sided HF),
 tricuspid or mitral valve insufficiency,
 and atrial and/or ventricular septal defects
 A physiologic S3 is heard commonly in children and
may persist into young adulthood 27

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 SOUNDS….. S4
 The S4 diastolic sound is a dull, low-pitched
postsystolic atrial gallop (rapid blood flow)
 usually caused by reduced ventricular compliance

 Present in conditions such as

 aortic stenosis,
 hypertension,
 hypertrophic cardiomyopathies, and
 coronary artery disease
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 HEART MURMURS
 Murmurs are auditory vibrations heard on
auscultation, and they occur because of turbulent
blood flow within the heart chambers or
through the valves.

 Timing. First decide if you are hearing a systolic

murmur, falling between S1 and S2, or a diastolic
murmur, falling between S2 and S1

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 MURMURS….
 Systolic murmurs are usually midsystolic or
pansystolic
 A midsystolic murmur begins after S1 and stops
before S2.
 Brief gaps are audible between the murmur and the
heart sounds.
 A pansystolic
(holosystolic) murmur starts with S1
and stops at S2,
 without a gap between murmur and heart sounds.

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 MURMURS….
 Murmurs generally & diastolic murmurs usually
indicate valvular heart disease

 Midsystolic
murmurs most often are related to
blood flow across the semilunar (aortic and
pulmonic) valves

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 ELECTROCARDIOGRAM
 The electrocardiogram (ECG or EKG) is a graphic
recording of electric potentials generated by the
heart.
 records only the depolarization (stimulation) and
repolarization (recovery) potentials generated by
the atrial and ventricular myocardium
 The signals are detected by means of metal
electrodes attached to the extremities and chest
wall and are then amplified and recorded by the
electrocardiograph

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ECG USE/INDICATION

 ECG leads actually display the instantaneous

differences in potential between these electrodes.

 ECG Detects
 Arrhythmias,
 Conduction disturbances, and myocardial ischemia,
 Other findings related to life-threatening metabolic

disturbances (e.g., hyperkalemia)

 Or increased susceptibility to sudden cardiac death
(e.g., QT prolongation syndromes).
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 ECG LEADS

 The standard external 12-lead ECG uses two sets of

leads:
 limb and chest
 Limb lead nomenclature is as follows: lead I, right
arm/left arm; lead II, right arm/left leg; lead III, left
arm/left leg.
 The augmented limb leads aVR, aVL, and aVF.

 Unipolar chest leads are positioned across the chest

and labeled V1 to V6.
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 ECG LEADS…
 V1is positioned slightly to the right of the midline
 V6 is positioned in the left midaxillary line

 Leads aVR and V1 are considered right sided leads

 so they appear inverted

 leads aVL, I, II, V5 and V6 are left-sided leads

 so they appear upright on the ECG

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 ECG LEADS….
 Leads II, III, and aVF are inferior leads.
 Leads V1 to V4 are anterior wall leads

 lead I = left arm – right arm voltages,

 lead II = left leg – right arm, and

 lead III = left leg – left arm.

 aVR = right arm, aVL = left arm, and aVF = left leg
(foot).

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 ECG PAPER RECORD
 Recording of the ECG has several standard
features.
 The paper is divided into squares of 1 mm
 Each 10 mm (10 small boxes) is equivalent to 1 mV.
 Paper speed is 25 mm per second.
 Each small box on the tracing paper equals 0.04
second
 and each big box is 0.2 second.

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 ECG READING
 The ECG pattern is named alphabetically and is read
from left to right, beginning with the P wave.

P Wave
 Electrical activation (depolarization) of the right
and then the left atrium as a result of discharge from
the SA nodes causes an upward or –tve deflection in
lead II called the P wave

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 Basic ECG
waveforms and
intervals. Not
shown is the R-R
interval, the time
between consecutive
QRS complexes

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ECG READING….

 The normal duration of P wave is up to 0.12 second,

 Amplitude of 0.25 mV (i.e., 2.5 small boxes).

 Since this vector points toward the positive pole of lead

II and toward the negative pole of lead aVR,
 The normal P wave will be positive in lead II and negative
in lead aVR.

 Activation of the atria from an ectopic pacemaker in

the lower part of either atrium or in the AV junction
region may produce retrograde P waves (negative in
lead II, positive in lead aVR)
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 ECG READING….
 The PR segment is created by passage of the
impulse through the AV node and the bundle of His
and its branches,
 Measures the duration of effective depolarization

has a duration of 0.12 to 0.21 second

QRS Complex
 primarily traces the electrical depolarization of the
ventricles.
 Initially, there is a negative deflection, the Q wave,

followed by a positive deflection, the R wave, and

finally a negative deflection, the S wave
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ECG READING….
 ST segment

 is a plateau phase following the QRS complex

which extends from the end of the QRS complex (
the J point) to the beginning of the T wave

 is normally on or slightly above the baseline.

 Configuration changes, convexity upward or
downward, identify the presence of myocardial
ischemia.
 Myocardial infarction (MI) is classified based on
this segment as ST elevated (STEMI) and non ST
elevated MI (NSTMI) 44

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ECG READING….

 The QT interval

 is measured from the start of the QRS complex to

the end of the T wave.
 varies with heart rate and is corrected (QTc) for
heart rates greater than 60 beats per minute.
 The normal QTc is less than 0.42 second in men
and 0.43 second in women.

 Indicator of prolongation of effective refractory

period for example secondary to slow AV
conduction….Used to characterize TdP 45

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ECG READING….

 T Wave

 Repolarization of the ventricle

 Normally proceed in the reverse direction from
depolarization (i.e., from ventricular epicardium to
endocardium).

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 NORMAL ECG READING

Normal electrocardiogram from a healthy subject. Sinus rhythm is present

with a heart rate of 75 beats per minute. PR interval is 0.16 s; QRS interval
(duration) is 0.08 s; QT interval is 0.36 s; QTc is 0.40 s; the mean QRS axis is about
+70°. The precordial leads show normal R-wave progression with the transition zone
(R wave = S wave) in lead V3
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 ECHOCARDIOGRAM
 The echocardiogram (ECHO) is the use of
ultrasound to visualize anatomic structures,
such as the valves, within the heart and to
describe wall motion
 the procedure of choice in the Dx and evaluation of
 valvular dysfunction (aortic and mitral stenosis and
regurgitation and endocarditis),
 wall motion abnormalities associated with ischemia,
 and congenital abnormalities, such as ventricular or
atrial septal defects

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ECHO…
 Images obtained from ECHO are used to
estimate
 chamber wall thickness and
 left ventricle ejection fraction,
 assess ventricular function, a
 nd detect abnormalities of the pericardium such
as effusions or thickening

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 CARDIAC ENZYMES AND HORMONES
BNP >100 pg/mL (>29 pmol/L)
 Important to screen HF and to monitor response to treatment
 CK-MB: rises with in 4-8 hrs & returns to normal by 48-
72 hrs
◦ CK-MB 0–12 units/L
 cTnT & cTnI: rises with in 2-4 hrs but remains elevated
for 7-10 days after AMI.
◦ cTnI <0.03 ng/mL; cTnI >2.0 suggests acute myocardial
injury.
 Troponin is specific than CK-MB for myocardial
damage, elevated sooner and remains elevated longer
than CK-MB.
 CK-MB & cTn are used in the diagnosis of MI, but cTn is
more specific and recommended than CK-MB
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