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)
̶A rapid increase in pressure at the beginning of ventricular systole and sudden opening and
vibration of the mitral and tricuspid valves
̶Low-frequency sound, almost only from the mitral valve
̶Heard about 50 ms after the beginning of the QRS complex, duration of around 100 ms
̶Best heard above the apex in the left supine position
̶CLINICALLY IMPORTANT: assessment of heart sound's volume, especially amplification or attenuation
of heart sounds, 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
̶Best heard above the apex in the left supine position
̶
̶CLINICALLY IMPORTANT: assessment of heart sound's volume, especially amplification or attenuation
of heart sounds, 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
SpG
aorta
FCG
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 indices – 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 indices
̶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 indices 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 indices – ∆ P/∆ t
̶Contractility indices 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 indices – 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