Clinical Physiology III

Fundamental Physiologic Basis of the Vital

Signs

BMS 100
Week 3
The Cardiac Exam
Heart Anatomy
Surface Anatomy
Chambers
Valves And Great Vessels
Basic Cardiac Physiology
The Cardiac Cycle
Valvular Movements
The Cardiac Physical Exam
Surface Anatomy And Auscultation
Phases Of The Cardiac Cycle And Heart Sounds
Murmurs and Valvular Abnormalities
Locations Of The Major Pulses
 The Heart Chambers – Anatomy review
Note the location of:
• The chambers:
§ The left and right atrium
§ The left and right ventricle
§ The interventricular septum à the thick
muscular wall that separates the left and
right ventricle
• The great vessels:
§ The pulmonary trunk + left & right
pulmonary arteries
§ The aorta
§ The superior and inferior vena cavae
§ The pulmonary veins
Basic Heart Anatomy

Anatomy & Physiology, 2e. p. 755, fig 19.4

https://openstax.org/books/anatomy-and-physiology-2e
 The Heart Chambers – Anatomy review
Note the location of:
• The chambers:
§ The left and right atrium
§ The left and right ventricle
§ The interventricular septum à the thick
muscular wall that separates the left and
right ventricle
• The great vessels:
§ The pulmonary trunk + left & right What
pulmonary arteries chamber is
§ The aorta each great
§ The superior and inferior vena cavae vessel directly
§ The pulmonary veins connected to?
The Heart - Valves
There are two major types of valves that ensure one-way flow
through the heart
• Atrioventricular valves
§ Between the atria and the ventricles – prevent backflow
• So when the left ventricle contracts, blood moves
into the aorta, not the left atrium
• So when the right ventricle contracts, blood moves
into the ______________, not the right atrium
• Semilunar (“half-moon”) valves
§ Between the ventricles and the great arteries
• So when the ventricle relaxes during diastole, blood
isn’t “sucked back” into that ventricle
• Why does that arterial blood still move forwards?
The Heart - Valves
There are two major types of valves that ensure one-way flow
through the heart
• Atrioventricular valves
§ Larger, and more “floppy” in nature
§ Anchored by the chordae tendinae
• Keeps them from “flopping back” (prolapse) into the atria
during ventricular contraction
• Semilunar (“half-moon”) valves
§ Smaller and “tighter”
• Therefore do not require chordae tendinae to anchor
them
Basic Heart Anatomy

Anatomy & Physiology, 2e. p. 755, fig 19.4

https://openstax.org/books/anatomy-and-physiology-2e
 Basic Heart Anatomy – More details
Note:
• Papillary muscles
• Chordae tendinae
• The general shape
of the semilunar
and
atrioventricular
(AV) valves
• What structures
would be located
anteriorly, and
which would be
located
posteriorly?
Anatomy & Physiology, 2e. p. 761, fig 19.9
https://openstax.org/books/anatomy-and-physiology-2e
Anterior And Posterior Views Of The
Heart

Anatomy & Physiology, 2e. p. 758, fig 19.6

https://openstax.org/books/anatomy-and-physiology-2e
Anterior And Posterior Views Of The
Heart

Anatomy & Physiology, 2e. p. 758, fig 19.6

https://openstax.org/books/anatomy-and-physiology-2e
Anterior vs. Posterior Surfaces
• The anterior surface of the heart is obviously easier to
auscultate and palpate than the posterior surface
• Anterior surface – major structures
§ Part of the right atrium (auricle)
§ Right ventricle
§ The “tip” of the left ventricle
• It’s the easiest place to palpate the cardiac impulse in most
people
• Point of Maximal Impulse (PMI)
§ The superior – lateral side of the left ventricle
§ Both semi-lunar valves are somewhat anterior to the AV
valves à see next slides
Valves – the superior aspect

Which phase of
the cycle??
Anatomy & Physiology, 2e. p. 765, fig 19.13 and p. 784, fig. 19.27
https://openstax.org/books/anatomy-and-physiology-2e
Valves – the superior aspect

Which phase of
the cycle??
Anatomy & Physiology, 2e. p. 764, fig 19.12 and p. 784, fig. 19.27
https://openstax.org/books/anatomy-and-physiology-2e
The Heart – Surface Anatomy
• Surface Anatomy?
§ Using superficial (usually palpable) anatomical
landmarks during the physical exam to localize
structures that lie deeper in the body
§ Used for a variety of physical exam maneuvers
• Correlating a sound with a deep anatomical
structure
• Correlating a palpation finding (mass, pain)
with a likely deep anatomical structure
Bones Of The Thoracic Cage

Palpation tips for the

thoracic cage:
• Find the “bump”
between the manubrium
and body of the sternum
• Angle of Louis
• Right below this is the 2nd
intercostal space
• This makes
landmarking and rib-
counting much
easier

Locate these on yourself

right now!
Anatomy & Physiology, 2e. p. 259, fig. 7.32
https://openstax.org/books/anatomy-and-physiology-2e
The Heart – Surface Anatomy

Anatomy & Physiology, 2e. p. 753, fig 19.2 and p. 259, fig. 7.32
https://openstax.org/books/anatomy-and-physiology-2e
The Heart – Surface Anatomy

Where is:
• The right border of the
heart - and what
cardiac structures form
it?
• The inferior surface of
the heart – what
structures form it?
• The left border of the
heart – what structures
form it?

The base of the heart =

where the great arteries
emerge from the superior
aspect
Anatomy & Physiology, 2e. p. 753, fig 19.2 and p. 259, fig. 7.32
https://openstax.org/books/anatomy-and-physiology-2e
The Heart – Surface
Anatomy
Key locations for
auscultation and palpation:
• 2nd intercostal space, left
sternal border
• Corresponds to the
pulmonic valve
• 2nd intercostal space,
right sternal border
• Corresponds to the
aortic valve

Anatomy & Physiology, 2e. p. 753, fig 19.2 and p. 259, fig. 7.32
https://openstax.org/books/anatomy-and-physiology-2e
The Heart – Surface
Anatomy 4th/5th intercostal space,
right sternal border
• Best place to hear
sounds from the left
ventricle and right AV
valve
5th intercostal space, mid-
clavicular line
• **Best place to:
• hear left AV valve and
left ventricular
sounds
• Palpate the PMI

** In a person with a “normal”

left ventricle
Anatomy & Physiology, 2e. p. 753, fig 19.2 and p. 259, fig. 7.32
https://openstax.org/books/anatomy-and-physiology-2e
Another View – Surface Anatomy
The highlighted,
coloured spots are
where the sounds are
“carried” for each valve
• This picture is not
very anatomically
correct – the heart is
very small
• The apex (PMI)
should be
approximately at the
5th ICS, MCL
• The right heart
border (right atrium
and vena cavae)
should not be so far
Anatomy & Physiology, 2e. p. 788, fig 19.30
to the right
https://openstax.org/books/anatomy-and-physiology-2e
The Systemic Pressures And The Cardiac
Cycle
• The following pressure tracing shows:
§ The aortic pressures – red
§ The left ventricular pressures – green
§ The left atrial pressures – yellow

• These pressures are shown at the same time as the

heart sounds that are caused by the:
§ Closing of the atrioventricular valves (mitral valve on the
left side)
§ Closing of the semilunar valves (aortic valve on the left
side)
Systemic Pressures

Anatomy & Physiology, 2e. p. 787, fig 19.29

https://openstax.org/books/anatomy-and-physiology-2e
Systemic Pressures – the Left Atrium
A – the left atrium (LA)
contracts, helping fill the
left ventricle (LV)

B – the LV contracts à
pressure increase causes
the left AV valve to close à
the first heart sound (Lub)

C – The LA fills while the

pressure in the LV is high

D – The pressure in the LV

A B C D E drops, resulting in opening
of the left AV valve

E – the LA fills

Anatomy & Physiology, 2e. p. 787, fig 19.29

https://openstax.org/books/anatomy-and-physiology-2e
Systemic Pressures – The Left Ventricle
A – the relaxed LV
experiences a “bump” in
pressure as the LA fills it

B – the LV contracts à
pressure increase causes
the left AV valve to close à
the first heart sound (Lub)

C – The LV relaxes, and

pressure starts to drop

D – When the LV pressure is

A B C D E less than the LA pressure,
the AV valve opens

E – the LV fills

Anatomy & Physiology, 2e. p. 787, fig 19.29

https://openstax.org/books/anatomy-and-physiology-2e
Systemic Pressures – The Aorta
A – diastolic pressure just
C D prior to ventricular
B
A contraction

B – the LV contracts à
pressure increase
overcomes aortic diastolic
pressure à aortic valve
opens

C – The LV applies maximal

(systolic) pressure to the
aorta

D – When the LV pressure is

less than the aortic
pressure, the aortic valve
closes à second heart
sound (Dub)
Anatomy & Physiology, 2e. p. 787, fig 19.29
https://openstax.org/books/anatomy-and-physiology-2e
Types of Heart Sounds
• It’s always normal to hear a valve closing
§ AV valve à S1 à “Lub”
• This is a lower frequency sound, because the valve itself is a bit
bigger and more “floppy”
• Think of the largest string on a guitar
§ Semilunar valve à S2 à “Dub”
• This is a higher frequency sound, because the valve itself is a
bit smaller and “tigher”
• Think of the smallest string on a guitar
• It’s uncommon to hear a valve opening
§ Some pathologies that affect the cardiac valves can result in
“opening” sounds – they’re usually called opening snaps
Types of Heart Sounds
• Blood flow can be smooth and orderly
§ This is known as laminar flow, and this is normal in the heart
• Blood flow can be rapid, forming disorderly eddies and
vibrations
§ This is known as turbulent flow
§ It is often caused by valvular abnormalities, and can cause a
variety of sounds
• Murmurs
• Extra heart sounds (sometimes)
§ It can be normal in some patients
• Heart sounds are complex acoustical phenomena –
we’ll address them simply today
 Types Of Valvular Abnormalities
• Stenosis – the valve
doesn’t open widely
enough
§ Higher pressures are
needed to push blood
through the narrow valve
§ The higher pressures cause
“noisy” turbulent flow à a
murmur
§ These murmurs are of
course heard while blood
is flowing across the
valve… when the valve
should be open.

Anatomy & Physiology, 2e. p. 764, fig 19.12

https://openstax.org/books/anatomy-and-physiology-2e
 Types Of Valvular Abnormalities
• Stenosis – the valve
doesn’t open widely
enough
§ What would happen if the
aortic valve in this picture
“couldn’t” open widely
enough?
§ When would you hear the
murmur?
• Sometimes valves “scar”
over time due to physical
stresses à narrowing
 Types Of Valvular Abnormalities
• Regurgitation – the valve
doesn’t close fully
§ If the valve doesn’t close,
then backflow occurs
when the chamber before
it relaxes
§ This backflow causes a
“noisy” turbulent flow à a
murmur
§ These murmurs are of
course heard while blood
is flowing across the
valve… when the valve
should be closed
 Types Of Valvular Abnormalities
• Regurgitation – the
valve doesn’t close fully
§ What would happen if
the mitral valve didn’t
close fully after the left
ventricle systole?
§ When would you hear
the murmur?
• Damage to heart valves
can make them unable
to close fully
Anatomy & Physiology, 2e. p. 766, fig 19.14
https://openstax.org/books/anatomy-and-physiology-2e
Fill in following chart on the next slide
• You can hear heart murmurs during ventricular systole or
ventricular diastole
§ If that murmur is due to a valve, it could be because the
valve is damaged and either:
• Can’t close
• Can’t open fully
• The location where the murmur is heard loudest and the
phase of the cardiac cycle (ventricular systole or diastole)
should allow you to deduce
§ Which valve is involved
§ Whether the valve is stenotic or regurgitating
• Try it on your own (example provided) – and then error-
check with a small group
Location Murmur heard during Murmur heard during
ventricular diastole ventricular systole

2nd intercostal space, right

sternal border

2nd intercostal space, left Pulmonic stenosis

sternal border

5th intercostal space, left

sternal border

5th intercostal space, mid-

clavicular line