To the naked eye, the two descents are the most obvious events in the normal jugular pulse. Of the two, the sudden collapse of the x descent late in systole is the more prominent, occurring just before the second heart sound. The y descent follows the second heart sound early in diastole.
Changes With Aging
Cardiovascular findings vary significantly with age. Aging may affect the location of the apical impulse, the pitch of heart sounds and murmurs, the stiffness of the arteries, and blood pressure.
The Apical Impulse and Heart Sounds. The apical impulse is usually felt easily in children and young adults; as the chest deepens in its anteroposterior diameter, the impulse gets harder to find. For the same reason, splitting o of the second heart sound may be harder to hear in older people as its pulmonic component becomes less audible. A physiologic third heart sound, commonly heard in children and young adults, may persist as late as the age of 40, especially in women. After approximately age 40, however, an S3 strongly suggests either ventricular failure or volume overload of the ventricle from valvular heart disease such as mitral regurgitation. In contrast, a fourth heart sound is seldom heard in young adults unless they are well conditioned athletes. An S4 may be heard in apparently healthy older people, but is also frequently associated with decreased ventricular compliance from heart disease. (See Table 7-5, Extra Heart Sounds in Diastole, p.__.)
Cardiac Murmurs. At some time over the life span, almost everyone has a heart murmur. Most murmurs occur without other evidence of cardiovascular abnormality and may therefore be considered innocent normal variants. These common murmurs vary with age, and familiarity with their patterns helps you to distinguish normal from abnormal.
Children, adolescents, and young adults frequently have an innocent systolic murmur, often called a flow murmur, that is felt to reflect pulmonic blood flow. It is usually heard best in the 2nd to 4th left interspaces (see p._).
Late in pregnancy and during lactation, many women have a so-called mammary soufflet secondary to increased blood flow in their breasts. Although this murmur may be noted anywhere in the breasts, it is often heard most easily in the 2nd or 3rd interspace on either side of the sternum. A mammary souffle is typically both systolic and diastolic, but sometimes only the louder systolic component is audible.
Middle-aged and older adults commonly have an aortic systolic murmur. This has been heard in about a third of people near the age of 60, and in well over half of those reaching 85. Aging thickens the bases of the aortic cusps with fibrous tissue, calcification follows, and audible vibrations result. Turbulence produced by blood flow into a dilated aorta may contribute to this murmur. In most people, this process of fibrosis and calcification—known as aortic sclerosis—does not impede blood flow. In some, however, the valve cusps become progressively calcified and immobile, and true aortic stenosis, or obstruction of flow, develops. A normal carotid upstroke may help distinguish aortic sclerosis from aortic stenosis (in which the carotid upstroke is delayed), but clinical differentiation between benign aortic sclerosis and pathologic aortic stenosis may be difficult.
similar aging process affects the mitral valve, usually about a decade later an aortic sclerosis. Here degenerative changes with calcification of the mitral annulus, or valve ring, impair the ability of the mitral valve to close nor-îally during systole, and cause the systolic murmur of mitral regurgitation. Because of the extra load placed on the heart by the leaking mitral valve, a murmur of mitral regurgitation cannot be considered innocent.
Murmurs may originate in large blood vessels as well as in the heart. The 'ugular venous hum, which is very common in children and may still be heard irough young adulthood, illustrates this point (see p._). A second, more
^t Souffle is pronounced soo-fl, not like cheese soufflé. Both words come from a French word meaning puff.
important example is the cervical systolic murmur or bruit. In older people, systolic bruits heard in the middle or upper portions of the carotid arteries suggest, but do not prove, a partial arterial obstruction secondary to atherosclerosis. In contrast, cervical bruits in younger people are usually innocent. In children and young adults, systolic murmurs (bruits) are frequently heard just above the clavicle. Studies have shown that, while cervical bruits can be heard in almost 9 out of 10 children under the age of 5, their prevalence falls steadily to about 1 out of 3 in adolescence and young adulthood and to less than 1 out of 10 in middle age.
Arteries and Blood Pressure. The aorta and large arteries stiffen with age as they become atherosclerotic. As the aorta becomes less distensible, a given stroke volume causes a greater rise in systolic blood pressure; systolic hypertension with a widened pulse pressure often ensues. Peripheral arteries tend to lengthen, become tortuous, and feel harder and less resilient. These changes do not necessarily indicate atherosclerosis, however, and you can make no inferences from them as to disease in the coronary or cerebral vessels. Lengthening and tortuosity of the aorta and its branches occasionally result in kinking or buckling of the carotid artery low in the neck, especially on the right. The resulting pulsatile mass, which occurs chiefly in hypertensive women, may be mistaken for a carotid aneurysm— a true dilatation of the artery. A tortuous aorta occasionally raises the pressure in the jugular veins on the left side of the neck by impairing their drainage within the thorax.
In Western societies, systolic blood pressure tends to rise from childhood through old age. Diastolic blood pressure stops rising, however, roughly around the sixth decade. On the other extreme, some elderly people develop an increased tendency toward postural (orthostatic) hypotension—a sudden drop in blood pressure when they rise to a sitting or standing position. Elderly people are also more likely to have abnormal heart rhythms. These arrhythmias, like postural hypotension, may cause syncope, or temporary loss of consciousness.
Common or Concerning Symptoms
■ Shortness of breath, orthopnea, or paroxysmal dyspnea
■ Swelling or edema
Zhestpain or discomfort is one of the most important symptoms you will as-ess as a clinician. As you listen to the patient's story, you must always keep erious adverse events in mind, such as angina pectoris, myocardial infarc-ion, or even a dissecting aortic aneurysm. This section approaches chest symp-
toms from the cardiac standpoint, including chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and edema. For this complaint, however, it is wise to think through the range of possible cardiac, pulmonary, and extrathoracic etiologies. You should review the Health History section of Chapter 6, The Thorax and Lungs, which enumerates the various possible sources of chest pain: the myocardium, the pericardium, the aorta, the trachea and large bronchi, the parietal pleura, the esophagus, the chest wall, and ex-trathoracic structures such as the neck, gallbladder, and stomach. This review is important, since symptoms such as dyspnea, wheezing, cough, and even hemoptysis (see pp. - ) can be cardiac as well as pulmonary in origin.
Your initial questions should be broad . . . "Do you have any pain or discomfort in your chest?" Ask the patient to point to the pain and to describe all seven of its attributes. After listening closely to the patient's description, move on to more specific questions such as "Is the pain related to exertion?" and "What kinds of activities bring on the pain?" Also "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?" . . . "What do you do to make it better?"
Palpitations are an unpleasant awareness of the heartbeat. When reporting these sensations, patients use various terms such as skipping, racing, fluttering, pounding, or stopping of the heart. Palpitations may result from an irregular heartbeat, from rapid acceleration or slowing of the heart, or from increased forcefulness of cardiac contraction. Such perceptions, however, also depend on the sensitivities of patients to their own body sensations. Palpitations do not necessarily mean heart disease. In contrast, the most serious dysrrhythmias, such as ventricular tachycardia, often do not produce palpitations.
You may ask directly about palpitations, but if the patient does not understand your question, reword it. "Are you ever aware of your heartbeat? What is it like?" Ask the patient to tap out the rhythm with a hand or finger. Was it fast or slow? Regular or irregular? How long did it last? If there was an episode of rapid heartbeats, did they start and stop suddenly or gradually? (For this group of symptoms, an electrocardiogram is indicated.)
You may wish to teach selected patients how to make serial measurements of their pulse rates in case they have further episodes.
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