Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 1 Systolic time intervals Apex beat Heart sounds Physiology – practice Spring, weeks 7th-9th Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 2 Apex beat, heart sounds Examination of external manifestations of cardiac activity using the senses: ̶Inspection ̶Configuration of the anterior chest - chest shape, postoperative scars and visible pulsations in this area ̶Palpation ̶Apex beat, heaves (systolic lifting of the sternum and left parasternal region), thrills (palpable vibration - murmur) ̶Percussion ̶Very approximate determination of heart size ̶Auscultation Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 3 Apex beat ̶The area where the heart apex is in the contact with the chest wall (1-2 cm medially from the midclavicular line in the 4th or 5th intercostal space ̶ ̶Localization of the maximal apex beat – palpation, inspection ̶ ̶Examined mostly in the supine or half-sitting position ̶ ̶A change in position of the maximal apex beat to the left + visible apex beat – signs of hypertrophy and dilatation of the left ventricle Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 4 Heart sounds – auscultation ̶ ̶Ear ̶Stethoscope ̶Bell ̶Diaphragm ̶ ̶Microphone – phonocardiography Aortic valve Tricuspidal valve Mitral valve Pulmonary valve Heart valves auscultation points Right Left Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 5 Heart sounds – auscultation points C:\Users\Kateřina\Desktop\výuka\praktika\auskultační místa na hrudníku.jpg ̶Aortic valve: ̶2nd intercostal space at the right sternal edge ̶Pulmonary valve: ̶2nd intercostal space at the left sternal edge ̶Mitral valve: ̶5th intercostal space in the midclavicular line = a site of apex beat ̶Tricuspidal valve: ̶5th intercostal space at the lower right sternal edge Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 6 Heart sounds – phonocardiogram ̶1st sound: mitral and tricuspis valve closure ̶2nd sound: aortic and pulmonary valve closure ̶Systolic pause: between 1st and 2nd heart sound ̶Diastolic pause: between 2nd and 1st heart sound ̶3rd sound: at the beginning of diastole, rarely heard mainly in young and athletes, in people older than 30 y. almost always a sign of pathology – dilated left ventricle ̶4th sound: atrial systole, very rarely in children, in adlts always pathological – hypertrophic left ventricle 0 0.8 s 0.4 P QRS T II ECG phonocardiogram III IV I Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 7 First heart sound (S1) ̶As a result of the filling of the ventricle with blood flowing from the atrium, the pressure in the ventricle increases to above the pressure in the atrium, which leads to the closure of the cusp valves (mitral and tricuspid) and simultaneous oscillation of the valvular apparatus ̶Low-frequency sound, almost only from the mitral valve ̶Can be heard about 50 ms after the beginning of the QRS complex, duration of around 100 ms ̶Is best heard above the apex in the left supine position ̶CLINICALLY IMPORTANT: assessment of the loudness of the sound, in particular the finding of a clear increase or attenuation, or split of the first sound Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 8 Second heart sound (S2) ̶Rapid vibrations of the aortic and pulmonary valves, associated with their closure ̶A high-frequency sound that has two components – pulmonary and aortic, pulmonary one delays behind the aortic one, especially during deep inhalation ̶Is best heard above the apex in the left supine position ̶ ̶CLINICALLY IMPORTANT: assessment of the loudness of the sound, in particular the finding of a clear increase or attenuation, or fixed split of the second sound Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 9 Murmurs Heart murmurs are produced as a result of turbulent flow of blood strong enough to produce audible noise. They arise mainly in places where the heart cavity or vessels are either narrowed or have an uneven surface. https://upload.wikimedia.org/wikipedia/commons/thumb/e/e4/Phonocardiograms_from_normal_and_abnormal _heart_sounds.svg/300px-Phonocardiograms_from_normal_and_abnormal_heart_sounds.svg.png Adobe Systems Cardiac cycle ̶Isovolumic contraction (IVC): ̶Contraction of ventricular myocardium leads to an increase in intraventricular pressure, AV valves close around 50 ms after the beginning of QRS, it produces 1st sound ̶Ejection (E): ̶Intraventricular pressure overcomes diastolic pressure in big arteries, semilunar valves open, and blood flows to the arteries ̶Isovolumic relaxation (IVR): ̶Semilunar valves close, rapid decrease in intraventricular pressure even below pressure values in atria, AV valves open ̶Inflow (I): ̶Rapid inflow phase, slow inflow phase (ventricular diastole), atrial systole https://upload.wikimedia.org/wikipedia/commons/thumb/3/38/2027_Phases_of_the_Cardiac_Cycle.jpg/370p x-2027_Phases_of_the_Cardiac_Cycle.jpg Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 11 Cardiac cycle phases: PV (Wiggers) diagram 0 10 80 100 120 50 120 SBP DBP ESV EDV P [mmHg] V [ml] IVR IVC E I Systole = IVC + E IVC = 0.06 s E = 0.21 s Diastole = IVR + I IVR = 0.07 s I = 0.49 s Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 12 Polygraphy ̶Simultaneous recording of several physiological parameters using various non-invasive or invasive methods ̶ ̶Phonocardiography – a graphical recording of heart sounds ̶Electrocardiography – recording of cardiac electrical activity ̶Sphygmography – a graphical record of the arterial pulse ̶!notice: Pulse recorded on a. carotis is shifted in time in relation to aortal pulse! Adobe Systems Department of Physiology, Faculty of Medicine, Masaryk University 13 Polygraphy IVC E IVR I IVC E IVR ECG Sphygmography aorta Phonocardiograpy S1 S2 S1 S2 R Q S S R Q P P T T SBP DBP DBP SBP Adobe Systems 0 0.8 s 0.4 SBP DBP P QRS T S4 S1 S2 S3 Dicrotic notch EML IVC PEP LVET ECG phonocardiogram Pressure in aorta systole diastole diastole Polygraphy EML – electromechanical latency IVC – isovolumic contraction LVET – left ventricular ejection time PEP – pre-ejection period (EML+IVC) The sphygmogram (SpG) corresponds to the shape of the blood pressure curve, but with sphygmography, it is not possible to measure blood pressure values. sphygmogram Adobe Systems 15 0 0.8 s 0.4 115 100 80 5 P – atrial depolarization ECG Phonocardiogram BP in aorta BP in left ventricle QRS – ventricular depolarization T – ventricular repolarization 1st sound – atrioventricular valves closure 2nd sound – aortic and pulmonary valves closure AV valves closure Dicrotic notch – aortic and pulmonary valves closure Blood pressure (mmHg) Systole Diastole Diastole Ejection Inflow Inflow IVC IVR I – inflow IVC – isovolumic contraction E – ejection IVR – isovolumic relaxation Systolic BP BP in left atrium Atrial contraction Systolic BP Diastolic BP in ventricle Diastolic BP in aorta Adobe Systems 0 0.8 s 0.4 P QRS T I II EML LVET ECG phonocardiogram Sphygmogram in carotid mech. systole diastole diastole Polygraphy – in practicals electromechanical systole The pressure wave in the carotid artery is time-shifted compared to the wave in the aorta SpG in aorta Adobe Systems Cardiac contractility indexes – ejection fraction (EF) Solved 4. Look at the screen of echocardiography (heart | Chegg.com https://www.chegg.com/homework-help/questions-and-answers/4-look-screen-echocardiography-heart-ultr asound--look-calculated-volumes-heart-chambers-ca-q45835869 https://www.kardio-cz.cz/data/upload/doporucene_postupy/2016/Doporucene_postupy_pro_diagnostiku_a_l ecbu_akutniho_a_chronickeho_srdecniho_selhani_2016.pdf Adobe Systems Cardiac contractility indexes ̶Relationship between end-diastolic BP (EDBP) and end-diastolic volume (EDV) at rest and during physical exercise ̶Systolic dysfunction – increase in EDV and EDBP during exercise compared to at rest ̶Diastolic dysfunction (relaxation disorder) – EDBP increases in exercise, EDV does not change ̶ ̶Contractility indexes derived from systolic ejection: Sagawa-Suga index A B1 B2 A: normal P-V diagram B: P-V diagram for artificially increased afterload 1: healthy heart 2: failing heart Adobe Systems Cardiac contractility indexes – ∆ P/∆ t ̶Contractility indexes derived from isovolumic systolic phase: ̶In clinical practice, we determine the fastest velocity of increase in pressure during IVC (just before opening of semilunar valves – at the end of IVC) ̶In practicals, we determine a mean velocity of increase in pressure during IVC: (8 mmHg corresponds approximately to the pressure at the end of the diastole, also approximately to the pressure in the left atrium) 0 0.8 s 0.4 115 100 DBP: 80 EDBP: 8 BP in aorta BP in left ventricle IVC ∆t ∆P ∆ P/∆ t A slowed increase in ventricular pressure during IVC is a sign of impaired cardiac contractility Adobe Systems 20 Cardiac contractility indexes – LVET and PEP ̶The ratio of LVET to PEP – shortening of LVET and prolongation of PEP is a sign of decreased cardiac contractility. ̶The heart spends most of its energy on reaching the opening pressure, and there is no energy left for blood ejection 0 0.8 s 0.4 115 100 80 8 BP in aorta BP in left ventricle IVC LVET IVC LVET failing heart failing heart healthy heart