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1
Q

Ascultate Aortic Area

A

Second right intercostal space, right sternal border

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2
Q

Ascultate Pulmonic Area

A

Second left intercostal space, left sternal border

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3
Q

Ascultate second Pulmonic Area

A

Third left intercostal space, left sternal border

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4
Q

Ascultate Tricuspid Area

A

Fourth left intercostal space, left sternal border

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5
Q

Ascultate Mitral Area (Apical)

A

5th left intercostal space, left midclavicular line

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6
Q

Normal HR adult

A

60-90bpm

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7
Q

When listening for S1; what should you palpate?

A

It should corespond with rise of carotid pulse (and it should be high pitched, mod intensity)

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8
Q

Heart sound characteristics (4)

A

Pitch
intensity
Duration
Timing in cardiac cycle

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9
Q

What causes S1? where to hear it best?

A

Start of systole: closure mitral and tricuspid valves (heard most at apex (bottom) of the heart)

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10
Q

What causes S2? where to hear it best?

A

Start of diastole: closure of aortic and pulmonic valves
Heard best at base (top) of the heart
it is shorter and higher pitch than S1

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11
Q

Where is S3 and S4 heard best?

A

Apex of the heart

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12
Q

What heart sounds are heard best at the apex of the heart?

A

S1
S3
S4

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13
Q

What heart sounds are heard best at the base of the heard?

A

S2

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14
Q

Tricks to hear S3, S4 better?

A

Heave patient squeeze my hand or raise his legs

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15
Q

What causes S3?

What is the sound?

Where to hear it

A

Blood filling ventricles makes their walls vibrate early during diastole

Low pitch sound quickly after S2 (galloping rhythm like Kenntucky”

“Galloping rhythm” on expiration

apex of heart it is heard

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16
Q

What causes S4?

What is the sound?

A

vibration of valves, papillae, and ventricular walls later in diastole

occurs just before S1

Galloping rhythm like Tennessee

Atrial gallop on expiration (more in older adults left side because decreased compliance left ventricle)

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17
Q

If cannot hear the heart sounds, what to do?

A

Use bell of stethoscope (small circle)

Have patient in recumbent position on left side

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18
Q

What are ejection clicks?

A

high pitch

faulty opening semilunar (mitral tricuspid) valves

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19
Q

where to hear pulmonic click?

A

pulmonic area

during expiration

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20
Q

where to hear aortic click?

A

aortic area during
less sharp
loud equally inspiration/expiration

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21
Q

what causes mid-late systolic clicks?

A

mitral valve proplapse
apex
accentuated by inspiration

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22
Q

pericardial friction rub

A

surface of inflamed pericardial sac rub against eachother audibly
most distinct apex, may be heard widely during S1 and S2

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23
Q

Murmur auscultate

A

long sound due to backwards flow of blood

note: timing and duration

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24
Q

Murmur Grade I:

A

barely audible

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25
Q

Murmur Grade II:

A

quiet but audible

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26
Q

Murmur grade III:

A

moderately loud

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27
Q

Murmur Grade IV

A

loud with a thrill

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28
Q

Murmur Grade V

A

very loud with palpable thrill

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29
Q

Murmur Grade VI

A

Very loud with palpable and visible thrill

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30
Q

Murmur characteristics to note (5)

A
  1. location
  2. radiation
  3. pattern (crescendo/decrescendo/plataue)
  4. changes with respiration phase
  5. quality (blowing, rumbling, harsh)
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31
Q 
Dyslipidemia
Hypertension
Cigarette Smoking
Diabetes Mellitus
Sedentary Lifestyle
Obesity
A

Modifiable Risk Factors

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32
Q

Modifiable Risk Factors for CAD (6)

A
  1. Dyslipidemia
  2. Hypertension
  3. Cigarette Smoking
  4. Diabetes Mellitus
  5. Sedentary Lifestyle
  6. Obesity
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33
Q

Non-modifiable Risk Factors for CAD (3)

A
  1. Age
  2. Family History
  3. Race
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34
Q

2 other risk factors for CAD

A

Hyperhomocysteinemia

Plasma C-Reactive Protein (CRP) Levels

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35
Q
  1. Age
  2. Family History
  3. Race
A

Non-modifiable Risk Factors for CAD (3)

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36
Q

How to calculate LDL using Friedewald equation ?

When is it accurate?

A

LDL=(Total Cholestoral) - (HDL) - (*TG/5)

  *Only accurate for TG <250
37
Q

CHD or CHD Risk Equivalents(10-year risk >20%)

  1. LDL Goal(mg/dL)
  2. Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)
  3. ConsiderDrug Therapy (mg/dL)
A
  1. <100
    * Optional in very high risk patients <70
  2. > 100
  3. > 130 (100–129: drug optional)
38
Q

2+ Risk Factors (10-year risk <20%)

  1. LDL Goal(mg/dL)
  2. Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)
  3. ConsiderDrug Therapy (mg/dL)
A
  1. < 130
  2. > 130
  3. 10-year risk 10–20%: >130
    10-year risk <10%: >160
39
Q

0–1 Risk Factor

  1. LDL Goal(mg/dL)
  2. Initiate Therapeutic Lifestyle Changes (TLC) (mg/dL)
  3. ConsiderDrug Therapy (mg/dL)
A
  1. < 160
  2. > 160
  3. > 190 (160–189: LDL-lowering drug optional)
40
Q

WHAT DRUGS ARE THERSE

Mevacor
Lovastatin
Zocor
Simvastatin
Pravachol
Pravastatin
Lipitor
Crestor
Lovastatin
Simvastatin
Pravastatin
A

STATINS (Drug Therapy targets LDL: Statins)

41
Q

TG levels:

Normal
Borderline High
High
Very High

A

-Normal <150 mg/dl

  • Borderline High 150-199 mg/dl
  • High 200-499 mg/dl
  • Very High ≥500 mg/dl
42
Q

Hypertension levels

Normal
Prehypertension
Hypertension

A

Normal Values 120/80
SBP <120 and DBP <80

Prehypertension
SBP=120-139 or DBP=80-89

Hypertension 140/90
SBP ≥140 or DBP ≥90

43
Q

What drug is given for uncomplicated HTN?

A

Diuretics, e.g. Hydrochlorothiazide

44
Q

What drug is given for HTN with diabetes?

A

Ace Inhibitors, e.g. Captopril, Enalopril

Angiotensin II Receptor Blockers (ARB),
e.g. Losartan

45
Q

Age

Non-modifiable Risk Factors of CAD

  1. Men
  2. Women
A

Age

  1. Men ≥45 years
  2. Women ≥55 years
46
Q

Family History: Non-modifiable Risk Factors of CAD

  1. male relative
  2. female reltive
A

Family History: *relative = immediate relative (mother, father, brother, sister)

  1. Male relative with known CAD at <55 years
  2. Female relative with known CAD at <65 years
47
Q

Races (2)

Non-modifiable Risk Factors of CAD

A

Race

  1. African American males + females
  2. Hispanic females
48
Q

Why may someone be treated with B6, B12, and folate supplements?

A

to breakdown homocysteine

Normal blood levels <16.2 nmol/ml
Effect on the cardiovascular system is uncertain, endothelial damage vs. altered coagulation

49
Q

What risk factor is treated with aspirin for its anti-platelet and anti-inflammatory properties?

A

Increased plasma C-Reactive Protein levels

  • Elevated levels may be caused by infx
  • Can cause protein initiating coagulation–> increased blood clots + potential for MI
50
Q

What to consider for high risk CAD patients? (4)

A
  1. monitor vital signs, cautious progression
  2. limit exercise intensity: HR of 10-20 beats above rest
  3. musculoskeletal complaint maybe equivalent
  4. Patient education risk and benefit exercise, risk factor modification
51
Q

Electrocardiography

A

ekg

52
Q

What does Electrocardiography: Signal Averaged ECG (SAECG) assess?

A

risk for ventricular dysrhythmias

average ventricular late potentials (electrical signal)
=correspond to delayed depolarization of small areas of myocardium

53
Q

T-Wave Alternans Test?

  1. what it assesses
  2. how performed
A
  1. identify at risk for sudden cardiac death
  2. EKG: measure microvolt variation during bike/treadmill:
    vector + amplitude of T-wave
    *strong (-) predictability
54
Q 
Cardiopulmonary Exercise Testing (CPETT)
1. what it is
2. what it measures 
3. good/bad prognosis 
AT, VO2
A
  1. stress test
    - symptom limited exercise testing
  2. measures: respiratory oxygen uptake (VO2), carbon dioxide production (VCO2) and ventilatory parameters
  3. AT > 14 ml/min/kg reflects good prognosis
    VO2 > 20 ml/min/kg = good prognosis
    VO2 < 10 ml/min/kg = poor prognosis, consider cardiac transplant

Anaerobic Threshold (AT) =when muscle tissue switches to anaerobic metabolism as an additional energy source

55
Q

Stress Testing: Bicycle Ergometry

  1. limitations
  2. similar to treadmill test
A
  1. early fatigue in persons not used to cycling
    lower max VO2 and AT than traditional treadmill tests
  2. Max HR, VE and lactate levels are similar to treadmill tests
56
Q

Standard Bruce Protocol

  1. when used
  2. minute stages
  3. MET increase

Stress Testing:

A

Stress Testing: Treadmill Tests

  1. Common for young and healthy
  2. 3 minute stages
  3. relatively large increase each stage

Std Bruce: 1.7mph 10% 5METS

  1. 5mph 12% 7METS
  2. 4mph 14% 9METS
  3. 2mph 16% 13METS
  4. 0mph 18% 16METS
  5. 5mph 2.0%
57
Q

Modified Bruce Protocol

  1. when used
  2. minute stages
  3. MET increase

Stress Testing:

A
  1. Common for elderly or known CAD

2. Includes 2, 3 minute warm-up stages (1.7 mph @0% grade followed by 1.7 mph @ 5% grade)

58
Q

Naughton Protocol

  1. when used
  2. minute stages
  3. MET increase

Stress Testing:

A
  1. Common for those with heart failure
  2. 2 minute stages
  3. 1 MET level increase per stage

2min stages all at 3.0mph > 0.0% 3METS, 2.5% 4METS, 5.0% 5 METS, 7.5% 6METS, 10% 7METS, …etc

59
Q

Stress test:

  1. When to use Pharmacologic Stress
  2. what it is
  3. what drugs?
A
  1. evaluate ischemia in pts unable to exercise (20-30% of pts)
  2. drug mimic stress of exercise
    monitor symptoms, BP, EKG at regular intervals
  3. Adenosine or Dipyridamole (Persantine): max coronary vasodilation
    –steal blood from diseased vessel to normal vessel
    *** not useful for exercise prescription bc flat HR response
    -indp of HR, can stay on B blocker–> reverse with vasoconstrictor

Dobutamine: increase HR/contractility

  • ** not useful for exercise prescription bc B blocker held
  • ->reverse it with B blocker
60
Q

Stress Testing: 6 Minute Walk

  1. for whom
  2. what it is
A
  1. unable to complete a bicycle or treadmill test
  2. Record total distance in 6 min: 100 ft course, walk fast to cover as much ground as possible in 6 min, allowed to stand rest and continue as able n continue on as able
61
Q

Echocardiography

pro (3)
con (1)

A

US to examine heart (such as transthoracic echocardiogram (TTE)

Pro:

  1. panfree
  2. no harm
  3. cheap

Con:
difficult b/c poor transmission of US through bone and air (lung)

62
Q

Transthoracic Echocardiogram (TTE)

  1. what is done
  2. pro (3)
  3. what it evaluates (6)
A
  1. transducer on chest wall (US)
  2. noninvasive, accurate, quick
  3. Structure, size / thickness chambers, EF (strength),
    valve condition, Pericardium/pericardial space, Aorta, Blood flow
63
Q 
Transthoracic Echocardiogram (TTE)
what it evaluates (6)
A
  1. Structure
  2. size / thickness chambers
  3. EF (strength)
  4. valve condition
  5. Pericardium/pericardial space
  6. Aorta
  7. Blood flow
64
Q

Echocardiography: Transesophageal Echocardiogram (TEE)

  1. what is done
  2. pro
  3. con
  4. what it evaluates (5)
A
  1. Transducer on endoscope passed orally down esophagus
  2. More accurate than TTE : eliminate visual block of bones, lungs, obesity
  3. con:
    invasive and need light sedation + local anesthesia to esophagus
4. Prosthetic valves
Vegetations
Aortic dissection
Intracardiac masses
EF/Myocardial ischemia during surgery
65
Q

Transesophageal Echocardiogram (TEE)

what it evaluates (5)

A
  1. Prosthetic valves
  2. Vegetations
  3. Aortic dissection
  4. Intracardiac masses
  5. EF/Myocardial ischemia during surgery
66
Q

Echocardiography: Contrast Echocardiography

A

Contrast, (agitated saline) injected IV to evaluate for R to L shunt

(+) study = bubbles cross the septum and on echo are seen in the LA or LV confirming either:
Patent Foramen Ovale (PFO)
Atrial Septal Defect (ASD)
Ventricular Septal Defect (VSD)

67
Q

Echocardiography: Stress Echo

A

Eval MI in pts with abnormal resting EKG: look for exercise induced wall motion abnormality that reverse w/ recovery

:echocardiogram (usually TTE) performed:

  1. at rest
  2. during exercise or immediately post exercise
    - bike ergometry
    - immediately post treadmill exercise
    - in conjunction with a pharmacologic stress
    - in conjunction with atrial pacing (increase HR=mimic stress)
68
Q

Echocardiography: Intravascular Ultrasound (IVUS)

  1. what it is
  2. what view you get
  3. what is it an adjunct to
    4, when it is used
  4. cons
A
  1. catheter w transducer inserted into the coronary artery during cardiac cath
  2. =cross-sectional view (can assess atherosclerosis)
  3. supplement to coronary angiography
  4. Usually used during percutaneous coronary interventions-help select and size stents/balloons, and confirm stent properly deployed
  5. Invasive and expensive
69
Q

Use for Chest Radiograph in Cardiovascular Disease (3)

A
  1. size and shape of the heart (normally < 50% of the thorax width)
  2. Position and shape of large arteries
  3. Pulmonary vasculature
70
Q

Use for Chest Radiograph in pulmonary edema (5)

A
  1. cephalization of pulmonary vasculature
  2. Interlobular septal lines, Kerley B lines
  3. Alveolar edema, inner 2/3 of the lung > “butterfly” or “bat wing” appearance
  4. Pleural effusions
  5. Enlarged heart in chronic heart failure
71
Q

Nuclear Stress Test e.g. “Stress Thallium”

A

Myocardial Perfusion Imaging

-to identify areas of decreased blood flow during stress = ischemia or infarct

72
Q

3 Types of Scanners in Nuclear Cardiology (3)

A

SPECT- Single-photon Emission Computed Tomography

PET- Positron Emission Tomography, common at transplant centers

PET/CT- emerging, available at NYPH-CU but not widely available

73
Q

SPECT

A

-Single-photon Emission Computed Tomography

Traditional scan
Radioactive tracers (Thallium-201, Sestamibi)
Allows visualize distribution of MYOCARDIAL BLOOD FLOW

74
Q

PET-

A

Positron Emission Tomography, common at transplant centers

Radioactive tracers -Rubidium (Rb-82), Ammonia (N-13)

=>absolute quantification of MYOCARDIAL BLOOD FLOW

75
Q

Nuclear Cardiology: Perfusion Imaging (Nuclear Stress Test)

-for whom is it indicated?

A

evaluate ischemia in pats with abnormal resting ECG

Images taken at rest and after exercise/pharm stress after radioactive IV injected, absorbed by perfused myocardial cells

SPECT
PET

A reversible defect is c/w ischemia.
A fixed defect is consistent with infarction.

76
Q

Nuclear Cardiology: Myocardial Viability Imaging : what (2) tells you in terms of vascularization?

A

Patients with HIGH HIBERNATION and a LOW EF show improved function post revascularization

–hibernation= tissue with decreased blood flow but intact metabolism as noted by myocardial uptake of FDG

77
Q

Nuclear Cardiology:

  1. What does nuclear stress test evaluate for?
A

Nuclear stress test (e.g. stress thallium/perfusion study) is ordered to evaluate for ischemia

78
Q

What is management option if reversible defect found in nuclear cardiology?

A

If a reversible defect is found, potential management options include:

  1. Pharmacologic
  2. PCI
  3. CABG
79
Q

What is management option if fixed (not reversible) defect found in nuclear cardiology?

A

FIXED defect: order myocardial viability study (PET) to see if hibernating myocardium

If HIBERNATING: management:

  1. PCI or
  2. CABG

NOT HIBERNATING: cardiac transplantation is considered in a patient with:

  1. EF <30% and
  2. VO2 of <10%
80
Q

Which patients considered for heart transplant? (2)

A

If on nuclear testing, a fixed defect is found (infarction) and tissue is NOT HIBERNATING (metabolism not intact):

cardiac TRANSPLANT is considered in a patient with:

  1. EF <30% and
  2. VO2 of <10%
81
Q

Cardiology: MRI: pro (3), con (1)

A
  1. clearest measure of tissue viability
  2. High resolution–> able to differentiate clearly between similar tissues
  3. Non-invasive
  4. Don’t need injection of radioactive tracers

Expensive initial investment

82
Q

What you can see on MRI in cardiology? (5)

A
  1. Cardiac function (EF)
  2. RV and LV
  3. Valvular function
  4. Blood flow or shunting (as in congenital heart disease)
  5. Ischemia or prior infarct
83
Q

Computed Tomography of the Heart

A

Highly sensitive detection of calcium in coronary arteries

84
Q

Cardiac Catheterization:Indications for Diagnostic Cath

5

A
  1. Identify CAD /extent and severity
  2. Confirm valvular disease / quantify severity
  3. other structural heart disease (i.e. CHD)
  4. Seek out cause of symptoms (i.e. SOB)
  5. Cardiac surgery pre-op assessment
    - –> Men > 35 years
    - –> Women postmenopausal
85
Q

Cardiac Catheterization:Potential Complications

A 
arrhythmia
tamponade
Trauma to the artery
Hypotension
rxn to contrast
Hemorrhage
Stroke
Heart Attack
Death
86
Q

Cardiac Catheterization: Right Heart Catheterization

A

Venous approach (femoral, subclavian, jugular, or antecubital; if femoral approach, pt. may be on bed rest up to 2 hours post procedure)
Information derived
Measurement of right heart, pulmonary artery and pulmonary artery wedge pressures
IV Vasodilator (I.e. Sodium Nitroprusside) may be given to evaluate if elevated pressures are fixed (poorer prognosis) or reversible (better prognosis)
Measurement of cardiac output by thermodilution
Endomyocardial biopsy to monitor cardiac allograft rejection

87
Q

Cardiac Catheterization: Left Heart Catheterization

A

Arterial Approach (femoral or brachial)
May be on bedrest for short duration dependent on size of catheter and closure device, check the orders
Information derived
Left ventricular systolic and end diastolic pressures
Gradients across the aortic and/or mitral valves
Left ventriculography
Coronary Arteriography

88
Q

Electrophysiology Studies

A

Diagnose the source of arrhythmia
Evaluate the effectiveness of medical therapy
Predict the risk of sudden cardiac death
Assess the need for PPM, ICD, Radiofrequency Catheter Ablation
Dr. Hassan Garan, one of the most respected electrophysiologists in the country, directs the EP Lab at Columbia

Invasive
Requires local anesthesia and conscious sedation
Catheter with an electrode at the tip is inserted into a peripheral vessel and advanced into the heart
Arrhythmias are “mapped” and the source of arrhythmia can be identified
During catheter ablation the tip of the catheter is heated and a scar is created at the arrhythmia source
The procedure takes ~ 2 hours
The American Society of Heart Rhythms suggests 4-6 hours of bedrest post procedure

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