BATES Flashcards
How is S3 associated with heart failure in adults over age 40?
S3 corresponds to an abrupt deceleration of inflow across the mitral valve
How is S4 associated with heart failure in adults over age 40?
S4 corresponds to increased left ventricular and diastolic stiffness which decreases compliance
When does the aortic valve shut?
when LV pressure drops below aortic pressure
What happens during inspiration to the heart and how does it affect S2?
The right heart filling time is increased- increases the duration of right ventricular ejection compared to the left ventricle. This delays the closure of the pulmonic valve, splitting S2
Distensibility of venous system from the pulmonary vascular bed contribute to the hangout time of P2.
Of the 2 components of S2, which is louder?
Aortic valve (A2)
Where is S1 in a EKG?
R of QRS wave
Where is S2 in a EKG?
End of T wave
Where is S3 in a EKG?
Between the T and P waves
Where is S4 in a EKG?
Q or QRS
Preload
The load the stretches the cardiac muscle before contraction. The volume of blood in the RV at the end of diastole constitutes its preload for the next beat.
Increased by increasing venous return to the right heart
Causes of decreased preload
- Exhalation
- Decreased LV output
- Pooling of blood in the capillary bed or the venous sytem
myocardial contractility
The ability of the cardiac muscle, when given a load, to shorten
Afterload
The degree of vascular resistance to ventricular contraction
Sources of resistance to LV contraction
- Tone in the walls of the aorta
- Large arteries
- Peripheral vascular tree (small arteries and arterioles)
- Volume of blood already in the aorta
Why is the term heart failure now preferred over congestive heart failure?
Not all pts have volume overload on initial presentation
How to correctly identify S1 and S2
keep fingers on the right carotid artery.
S1 is just before the carotid upstroke
S2 is after the carotid upstroke
What is the diaphragm better at listening for?
High pitched sounds
- S1 and S2, murmurs of aortic and mtiral regurg
- Pericardial friction rubs
What is the bell better at listening for?
Low pitched sounds
- S3 and S4
- Mitral stenosis
What position accentuate S3, S4, and mitral stenosis?
Left lateral decubitus
What position accenuates aortic murmurs?
When the pt sits up, leans forward, exhales completely, and stop breathing in exhalation
When is S1 louder?
At more rapid heart beats
When is S2 persistently single?
When either A2 or P2 is absent
What causes persistent splitting?
Delayed closure of the pulmonic valve or early closure of the aortic valve
What does a loud P2 suggest?
Pulmonary HTN
Murmurs during pregnancy
Should promptly be evaluated for possible risk to the pregnancy and the need for termination, especially from aortic stenosis and pulmonary HTN
When do midsystolic murmurs typically arise?
From blood flow across the semilunar (aortic and pulmonic) valves
When do pansystolic murmurs occur?
With regurgitant flow across the atrioventricular valves
Late systolic murmur
Mitral valve prolapse
What murmurs reflect turbulent flow across the AV vales?
middiastolic and presystolic murmurs
What produces continuous murmurs?
PDA and AV fistulas, common in dialysis pts.
Neither is valvular in origin
Venous hums and and friction rubs also have systolic and diastolic components
Functional murmurs
Short, early, midsystolic murmurs that decrease in intensity with maneuvers that reduce LV volume, such as standing, sitting up.
Often heard in healthy pts and not pathologic
Procedure of valsalva identifying heart failure and pulmonary htn
Inflate the blood pressure cuff 15 mm Hg greater than the systolic BP and have pt Valsalva for 10 sec, then resume normal breathing. Keep cuff locked.
Listen for Korotkoff sounds over the brachial artery throughout
In pts with severe heart failure, Korotkoff sounds are heard during phase 2 strain phase, but not during the phase 4 release- the square root response
This response is highly correlated with volume overload and elevated left ventricular end diastolic pressure and pulmonary capillary wedge pressure
Where is S1 softer than S2?
At the base
When is S1 louder than S2?
At the apex
Diminished S1
- First degree heart block
- When the mitral valve is calcified and immobile
- When LV contractility is reduced
Varying S1
- Complete heart block
- Irregular rhythm
Wide splitting of S2
Delayed closure of the pulmonic valve- pulmonic stenosis or RBBB
Fixed splitting
Wide splitting that doesn’t vary with respiration
- Atrial septal defect
- RV failure
Paradoxical or reversed splitting
Splitting that occurs on expiration. Closure of the aortic valve is abnormally delayed so that A2 follows P2
Increased intensity of A2 in the right 2nd ICS
Systemic htn
Aortic root dilation
Decreased or absent A2
calcific aortic stenosis
Increased intensity of P2
Pulmonary HTN
Dilated pulmonary artery
ASD
Decreased or absent P2
Increased anterioposterior diameter of the chest associated with aging
- Pulmonic stenosis
