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character of the pulse is determined
by
stroke volume and arterial compliance,
andis best assessed by palpating a major
artery, such as the carotid or brachial
artery.
Aortic regurgitation, anaemia, sepsis and
other causes of a large stroke volume
typically produce a bounding pulse with a
high amplitude and wide pulse pressure
Aortic stenosis impedes ventricular
emptying. If severe, it causes a slow-rising,
weak and delayed pulse
Atrial brillation
produces a pulse that is irregular in time
and volume
the rst heart sound (S1) just
precedes the upstroke of the pulse and the
second heart sound (S2) is out of step with it.
If present, a third heart sound (S3) immediately
follows S2, and a fourth heart sound (S4) just
precedes S1. Systolic murmurs are synchronous
with the pulse.
radiation of systolic murmurs, over
the base of the neck (aortic stenosis) and in the
axilla (mitral incompetence).
Listen over the left sternal border with the
patient sitting forward (aortic incompetence),
then at the apex with the patient rolled on to the
left side (mitral stenosis).
JVP is determined by right atrial pressure and is
therefore elevated in right heart failure and
reduced in hypovolaemia
Tricuspid regurgitation produces giant
v waves that coincide with ventricular
systole.
venous pulse has two peaks in each
cardiac cycle
height of the venous pulse varies
with respiration (falls on inspiration) and
position.
Abdominal compression causes the venous
pulse to rise.
The venous pulse is not easily palpable
and can be occluded with light pressure.
Precordium
ngertips over apex (1) to assess for
position and character. Place heel of hand
over left sternal border (2) for a parasternal
heave or ‘lift’. Assess for thrills in all areas,
including the aortic and pulmonary areas
(3). Normal position is the 5th or 6th
intercostal space, at the mid-clavicular line.
Volume overload, such as mitral or aortic
regurgitation: displaced, thrusting
Pressure overload, such as aortic stenosis,
hypertension: discrete, heaving
Dyskinetic, such as left ventricular
aneurysm: displaced, incoordinate
Palpable S1 (tapping apex beat: mitral
stenosis)
Palpable P2 (severe pulmonary
hypertension)
Left parasternal heave or ‘lift’ felt by heel
of hand (right ventricular hypertrophy)
Palpable thrill (aortic stenosis)
Normally, the heart occupies less than 50% of the transthoracic diam-
eter in the frontal plane,
On the right, the silhouette is formed
by the RA and the superior and inferior venae cavae, and the lower right
border is formed by the RV
blood supply
left and right coronary arteries arise from the sinus of the aortic root
Left Coronary artery
Within
2.5 cm of its origin, the left main coronary artery divides into the left ant-
erior descending artery (LAD), which runs in the anterior interventricular
groove, and the left circumflex artery (CX), which runs posteriorly in the
atrioventricular groove.
The CX gives marginal branches that supply the lateral,
posterior and inferior segments of the LV.
The LAD gives branches to supply the anterior
part of the septum (septal perforators) and the anterior, lateral and apical
walls of the LV.
RCA
The right coronary artery (RCA)
runs in the right atrioventricular groove, giving branches that supply the
RA, RV and infero posterior aspects of the LV.
also supplies the SA Node
Post Descending artery
The posterior descending
artery runs in the posterior interventricular groove and supplies the inf-
erior part of the interventricular septum.
Venous system
Drains into the coronary sinus in the AV groove
lymphatics into the thoracic duct
