Apex beat.
Heart sounds (VI.)
Systolic time intervals
(XIII.)
Department of Physiology
Faculty of Medicine
Masaryk University
2015 © Kateřina Fialová, Eva závodná, Tibor Stračina, Juraj Jakubík,
Ksenia Budinskaya
Apex beat
• External manifestation of heart function
• Maximum in 4th or 5th intercostal space on the left (1-2 cm from
medioclavicular line)
• Observation (inspection), palpation
Heart sounds
• 1st heart sound: Closing of mitral and tricuspid valves
• 2nd heart sound: Closing of aortic and pulmonary valves
• systolic pause: Time interval between 1st and 2nd heart sounds
• diastolic pause: Time interval between 2nd and 1st heart sounds
• 3rd heart sound: In first part of diastole, physiological in young
people; in elderly people sign of decreased
compliance of LV (hypertrophy)
Heart sounds
1st heart sound - CHARACTERISATION
• Vibration of mitral and tricuspid valves due to their rapid closure
(because of increase of pressure in ventricles above the pressure
in atria in the beginning of systole)
• Low-frequency sound takes 100 ms
• Circa 50 ms after beginning of QRS
• Maximum in region of apex beat (laying on left side)
• Clinically relevant: assessment of loudness of heart sound –
intensification or attenuation, or splitting
Heart sounds
2nd heart sound - CHARACTERISATION
• Vibration of aortic and pulmonary valves due to their rapid closure
(because of decrease of pressure in ventricles under the pressure
in aorta at the end of systole)
• High-frequency sound has two components – aortic and
pulmonary; physiological splitting in inspiration (unsplit when the
subject is holding his/her breath in expiration)
• Maximum in region of apex beat (laying on left side)
• Clinically relevant: assessment of loudness of heart sound –
intensification or attenuation, or splitting
Heart sounds
• Auscultation
– By ear
– By stethoscope
– By microphone - phonocardiography
Heart sounds
• Places of optimal audibility of particular valves
Aortic valve
Tricuspid valve
Mitral valve
Pulmonary valve
A
T M
P
T
A P
M
Heart sounds
• Timing of heart sounds: ECG + phonocardiography
Heart cycle
SYSTOLE
DIASTOLE
Isovolumetric contraction (IVC)
Isovolumetric relaxation (IVR)
Ejection phase (EP)
Filling phase (FP)
Heart cycle: PV diagram
0
6-8
80
100
120
50 120
SBP
DBP
ESV EDV
P [mmHg]
V [ml]
IVR IVC
EP
PP
Systole= IVC+EP
IVC=0.06s
EP=0.21s
Diastole= IVR+PP
IVR=0.07s
PP=0.49s
POLYGRAPHY
– recording of several physiological quantities (signals) in the same time
PHONOCARDIOGRAPHY - recording of heart sounds (by microphone)
ELECTROCARDIOGRAPHY (ECG)
SPHYGMOGRAPHY - recording of arterial pulse wave
IVC EP IVR PP IVC EP IVR
ECG
SPG
PCG
S1 S2 S1 S2
R
Q
S S
R
Q
P PT T
SBP
DBP DBP
SBP
IVC EP IVR PP IVC EP IVR
ECG
SPG
LVET
S1S2
PCG
QS2
LVET
QS2
IVC
PEPEML
RR-interval
S2S1
The cardiac contractility indexes
I. Ejection fraction:
𝐸𝐹 =
𝑠𝑡𝑟𝑜𝑘𝑒 𝑣𝑜𝑙𝑢𝑚𝑒
𝑒𝑛𝑑𝑑𝑖𝑎𝑠𝑡𝑜𝑙𝑖𝑐 𝑣𝑜𝑙𝑢𝑚𝑒
x 100 in %
Physiological range of EF is about 60-70%. EF less than 40% could mean systolic dysfunction
(contraction disorder).
II. End-diastolic pressure (EDBP) and end-diastolic volume (EDV)
ratio at rest and after work load
Systolic dysfunction - EDV and EDBP are increased during exercise in comparison with rest
Diastolic dysfunction - EDBP increases during exercise, but EDV does not change
III. Cardiac contractility index derived from the systolic ejection phase
𝐄𝐦𝐚𝐱 =
𝐝𝐏
𝐝𝐕
Sagawa-Suga index
𝐄 𝐦𝐚𝐱 𝟏
𝐄 𝐦𝐚𝐱 𝟐
A
B1
B2
A: normal P-V diagram
B: P-V diagram with increased afterload
1: healthy heart
2: failing heart
The cardiac contractility indexes
IV. The cardiac contractility index derived from the isovolumic phase
of the systole
𝑑𝑃
𝑑𝑡
=
𝐷𝐵𝑃 − 𝐸𝐷𝐵𝑃
𝐼𝑉𝐶
𝑑𝑃
𝑑𝑡
𝑚𝑎𝑥
• in practical we determine the average speed of
pressure development during IVC:
DTK - 8
IVK
The cardiac contractility indexes
time
pressureinventricle
DBP
SBP
EDBP