HEART SOUNDS, PULSE RATE, BLOOD

PRESSURE AND ELECTROCARDIOGRAPHY

Aim
The aim of this chapter is to describe some of the techniques used in the assessment of
the cardiovascular system, such as auscultation of normal heart sounds, measurement
of blood pressure and obtaining a normal electrocardiogram (ECG).

Heart Sounds
Closure of the heart valves occurs in every cardiac cycle (Fig. 8). The closure of these
valves is accompanied by sounds having frequencies between 15 - 400 Hz. These
sounds are known as heart sounds and can be heard using two methods; they are the
auscultatory and electrophonocardiographic methods.

Normally two heart sounds, the first heart sound (SI) and the second heart sound (S2)
are audible during a cardiac cycle and can be heard by auscultation, whereas a total of
four heart sounds can be recorded using the electrophonocardiographic technique.

Auscultation is a difficult skill to acquire and requires a lot of practice by students. By

understanding the basis of the cardiac cycle, students can relate, understand and
appreciate the importance of heart sounds.

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 First Heart Sound (SI)
The first heart sound is a soft, low-
pitched and prolonged sound lasting
approximately 0.15 seconds, with a
frequency of 25 - 45 Hz and sounds like
"lub". It is due to the closure of the
atrioventricular valves at the beginning of
the isometric ventricular contraction
phase. The first heart sound becomes
softer when the heart rate is decreased
and becomes louder in pitch when the
heart rate increases.

Second Heart Sound (S2)

The second heart sound is a short, sharp and high-pitched sound lasting approximately
0.12 second, with a frequency of 50 Hz and sounds like "dup". It is due to the closure of
the semilunar valves at the beginning of the isometric ventricular relaxation phase. In
systemic or pulmonary hypertension, S2 is heard louder than normal.

During normal breathing, the aortic and pulmonary valves close simultaneously.
However, during deep inspiration, S2 may be split due to the aortic valve closing earlier
than the pulmonary valve. This is because during deep inspiration, the intrathoracic
pressure decreases and more blood is returned to the right side of the heart. Hence, the
time taken for the blood to be ejected out into the pulmonary artery is longer resulting in
the pulmonary valve closing later than the aortic valve. This splitting of S2 disappears
during expiration.

The splitting of S2 that occurs during deep inspiration is called physiological splitting. It is
often heard among healthy children and young adults. Splitting of S2 can also occur in
certain abnormalities of the heart, such as atrial septal defect or conduction block.
However, in these abnormal conditions, S2 remains split throughout inspiration and
expiration.

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The time interval between SI and S2 signifies the ventricular systolic duration, whereas
the time interval between S2 and SI signifies the ventricular diastolic duration.

Third Heart Sound (S3)

Sometimes, a third heart sound (S3) can be heard at approximately 0.10 - 0.15 seconds
after S2. The third heart sound is commonly heard in children and young adults. The
sound is softer in pitch and is due to vibrations that occur when blood rushes into the
ventricle as soon as the atrioventricular valves open at the beginning of the filling phase.
The presence of S3 in someone above the age of 40 is usually considered abnormal.

Fourth Heart Sound (S4)

The fourth heart sound (S4) that occurs simultaneously with atrial systole is never
audible in someone who is normal and healthy. However, in abnormal conditions such as
hypertension, conduction block or ventricular failure, S4 can be heard just before SI.

Heart Murmurs
Heart murmurs are due to turbulent flow of blood through abnormal heart valves or
septae, eg. congenital septal defects. The duration of a heart murmur is longer than the
normal heart sounds. Not all heart murmurs are due to organic cardiac defects. Some
murmurs are due to an increased blood flow through the heart valves, as in exercise,
pregnancy or anaemia. These are known as functional murmurs.

Heart murmurs are classified based on the

phase of the cardiac cycle during which
they are heard. Systolic murmurs are
related to SI and diastolic murmurs to S2.
A murmur due to a valvular defect can be
best heard at its specific auscultatory area
(Fig. 9).

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Procedure
The stethoscope is used for the technique of auscultation. A stethoscope has 2 main
components: a "bell" and a "diaphragm". High-pitched sounds are best heard using the
diaphragm, such as the murmur in aortic regurgitation, whereas low-pitched sounds are
best heard using the bell.

The auscultatory areas shown in Fig. 9 are the areas where the heart sounds are best
heard. Note that heart sounds can also be heard outside the areas of auscultation over
the precordium. In addition, the heart sound that is heard in one area does not
necessarily indicate that the origin of the sound is from that area only.
1. Students are encouraged to work in pairs for this procedure.
2. Place the diaphragm of the stethoscope on the areas of auscultation, listen to SI and
S2 and compare their qualities.
3. Try to listen for S3, as this may be heard occasionally in some normal individuals.
4. Ask the subject to take a deep breath. Listen for any differences in the loudness of the
heart sounds. Determine whether there is splitting of S2 during deep inspiration.
5. Ask the subject to do some light exercises (e.g. climb up and down the stairs several
times); then listen for the heart sounds again. Try to discern for any differences in
loudness or the characteristics of the heart sounds. Determine whether any abnormal
heart sounds or heart murmurs are audible.

Pulses and Arterial Blood Pressure

Evaluation of the pulses and arterial blood pressure are part °f a routine clinical
examination of the cardiovascular system.

Arterial Pulses
The heart is essentially a mechanical
pump that ejects blood intermittently into
the aorta and consequently produces
pulse waves in the arteries. These pulse
waves can be palpated at specific points
on the arterial tree where the arteries
become superficial. The arteries that can

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be used for feeling or studying the pulse are the radial, brachial, carotid, femoral,
popliteal, tibialis posterior and dorsalis pedis arteries (Fig.10).

Any evaluation of the pulse should consider the following parameters:

1. Rate
2. Rhythm
3. Character
4. Volume
5. Nature of blood vessels
6. Presence or absence of a radio-femoral delay

During an examination of the pulse, arterial pulses on both sides of the body must be felt
and compared with one another.
Usually the radial pulse is used to determine the rate and rhythm of the heart. It is
important that the subject be calm during the pulse examination, as anxiety can increase
the pulse rate.
The radial pulse is palpated once the subject is relaxed. The pulse must be palpated for
at least 30 seconds. At rest, the pulse rate ranges from 60 to 100 beats per minute. The
pulse rate can increase during exercise, fever and in hyperthyroidism. A pulse rate less
than 60 beats per minute can be seen in athletes and in patients with a complete heart
block or hypothyroidism.

Procedure
1. Ensure that subject is in a lying or sitting position for at least 5 minutes.
2. Palpate the radial pulse at the wrist and count for one minute.
3. Ask the subject to stand up straight and immediately count again for one minute.
Compare the pulse rate of the subject obtained in the supine and upright postures.

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Arterial Blood Pressure
The pressure in the arteries is called the arterial blood pressure (BP). Arterial BP
increases during systole and decreases during diastole. The highest pressure in the
aorta during each cardiac cycle is called the systolic blood pressure (SBP), and the
lowest pressure is known as the diastolic blood pressure (DBP). The difference between
SBP and DBP is known as the pulse pressure (PP). The mean arterial pressure (MAP) is
calculated as below:

MAP = DBP + 1/3 (SBP - DBP)

In humans, BP is measured indirectly by the palpation or auscultation method using a

sphygmomanometer. Using the palpation method, only the systolic blood pressure can
be obtained, whereas, by using the auscultatory method, both SBP and DBP can be
determined.

Procedure
A. Palpation Method
1. Let the subject rest in the sitting position for at least 5 minutes.
2. Place the arm of the subject and the sphygmomanometer at the same level as the
heart. Ensure that the mercury meniscus in the manometer can be read at eye level.
3. Wrap the cuff of the sphygmomanometer firmly around the upper forearm such that
the lower end of the cuff is at least 2.5 cm above the cubital fossa.
4. Locate the subject's radial pulse. Increase the pressure in the cuff until the radial
pulse is no longer palpable. Then, increase the pressure of the cuff by another 20
mmHg.
5. Immediately, but gradually release the pressure in the cuff until the radial pulse is
palpable once again. Read the pressure value off the manometer column at this point.
6. The pressure at which the radial pulse becomes palpable once again is considered
to be the subject's SBP.
7. Repeat the procedure three times (with a gap of several minutes in between each
reading) and calculate the average SBP.

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B. Auscultation Method
1. Let the subject rest in the sitting position for at least 5 minutes.
2. Place the arm of the subject and the sphygmomanometer at the same level as the
heart. Ensure that the mercury meniscus in the manometer can be read at eye level.
3. Wrap the cuff of the sphygmomanometer firmly around the upper forearm such that
the lower end of the cuff is at least 2.5 cm above the cubital fossa.
4. Locate the subject's radial pulse. Increase the pressure in the cuff until the radial
pulse is no longer palpable. Now, increase pressure in the cuff by another 20 mmHg.
5. Place the diaphragm of the stethoscope gently on the cubital fossa over the
brachial artery.
6. Gradually release the pressure in the cuff until a tapping sound is heard. Read the
pressure value off the manometer column at this point. This indicates the SBP.
7. Continue to reduce the pressure in the cuff and note the difference in the pitch and
loudness of the sounds heard. The sounds that are heard as the cuff pressure is being
reduced are known as Korotkoff sounds.
8. At the point where the Korotkoff sounds become muffled and eventually inaudible,
read the pressure value off the manometer column. This pressure is considered the
DBP.
9. Repeat this procedure after a gap of several minutes and calculate the average
SBP and DBP.

Electrocardiography
In a normal heart, the cardiac impulse originates from the sinoatrial node (SAN) and
spreads through the atrial muscles via the internodal tracts to the atrioventricular node
(AVN). From the AVN, the cardiac impulse travels through the bundle of His, left and
right bundle branches, and the Purkinje fibres into the ventricular mass. The spread of
the cardiac impulse is related to changes in the electrical activity of the heart.
By using a pair of surface electrodes and with amplification, changes in the electrical
activity of the heart can be recorded from the surface of the body. The technique of
recording the changes in the electrical potentials of the heart during a cardiac cycle is
called electrocardiography and the recording is known as an electrocardiogram (ECG).

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ECG Leads
In order for an ECG to have standard interpretation, the site of placement of electrodes
on the body surface must be uniform. The arrangements of these paired electrodes on
the surface of the body are called leads. Clinically, a complete ECG recording would
have 12 leads that are divided into three groups:
1. Standard limb leads
2. Augmented limb leads
3. Precordial/Thoracic/Chest leads

1. Standard Limb Leads

The standard limb leads consist of Lead I, Lead II and Lead III. Each of the lead records
the difference in the electrical potential between two parts of the body. As shown in Fig.
11, Lead I records the potential difference between the right arm and left arm. Lead II
records the potential difference between the right arm and left leg and Lead III records
the potential difference between the left arm and left leg.

2. Augmented Limb Leads

Augmented limb leads consist of three leads: aVR, aVL and aVF. The leads record the
potential difference between one part of the body and two other body areas. Augmented
limb leads are used more frequently than unipolar leads because they increase the
amplitude of the potential by 50% without any changes in the ECG waves.

3. Precordial/Thoracic/Chest Leads
The thoracic leads consist of six leads designated as VI - V6. As shown in Fig 11, the
thoracic leads record the potential difference between an active electrode and an
indifferent electrode in which the potential has been fixed at zero. To record the ECG, the
active electrode is moved from one area to another area of the precordium. The thoracic
leads can provide more information than the standard limb leads.

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Normal ECG
An ECG is a recording of the changes in the electrical potential that occur in the heart
throughout the cardiac cycle. The ECG 1 recording represents the depolarisation and
repolarisation process, but not the mechanical events of the heart (systole and diastole).

A normal ECG tracing consists of a series of

deflections, namely the P wave, QRS complex
and T wave (Fig. 12). These complexes are
connected to one another by an isoelectric line.
The isoelectric line represents the time interval
during which there is no potential difference
between the electrodes. Although the waves can
be recorded using different electrodes, the
amplitude and shape of each wave differ
according to the position of the electrodes.

Procedure
1. Let the subject recline on the bed.
2. Apply a small amount of electrode gel on
the surface of the wrists and ankles on which
the electrodes are to be placed. The electrode
gel reduces the resistance offered by the skin.
3. Place and secure the electrodes as
shown in Fig. 11.
4. Set the recording speed to 25 mm/sec.
5. Switch on the electrocardiograph and turn
the knob to the respective settings to record the
ECG from the standard and augmented limb
leads.
6. Obtain the ECG recording of the thoracic
leads as shown in Fig. 11 with one active
electrode moved from position V1 through to V6.

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Determination of the electrical axis from the standard limb Leads I &
III (Fig. 13)
a. Measure the nett (effective) amplitude of the QRS complex for Leads I and III in
mm. The nett (effective) amplitude of the QRS complex is equal to the amplitude of the
Q wave + amplitude of the R wave + amplitude of the S wave. The deflection that is
above the isoelectric line has a positive value and the one below a negative value.
b. Plot the QRS amplitude for Leads I and III on appropriate axes as shown in Fig. 13.
c. Draw a perpendicular line (90°) from the effective amplitude value of the QRS
complex in Lead I and Lead III. Connect the point where the two perpendicular lines
intersect to the point in the centre of the circle. This line connecting the two points
represents the direction of the electrical axis of the heart.

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