Bates-Cardio Flashcards
What is PMI?
Point of maximal impulse
Where is the PMI normally located?
5th intercostal space, 7-9cm lateral to midsternal line. (at or just left of mid-clavicular line.
A PMI greater than ____ is indicative of left ventricular hypertrophy.
2.5cm
Displacement of the PMI lateral to the mid-clavicular line or >10cm lateral to midsternal line suggests what?
Left ventricular hypertrophy
In patients with right ventricular hypertrophy, where is the PMI more likely felt?
Near the xiphoid or epigastric area.
Trace the flow of blood through the body from the Right atrium through to the vena cavae
right atrium, tricuspid valve, right ventricle, pulmonary valve, pulmonary artery, pulmonary veins, left atrium, mitral/ bicuspid valve, left ventricle, aortic valve, aorta, body, inf/sup vena cava, right atrium
During systole, the aortic valve is ____ and the mitral valve is ___
aortic = open
The first heart sound, S1, represents what action?
At the beginning of ventricular systole, the mitral valve snaps shut.
Normally, maximal left ventricular pressure corresponds to ___
Systolic blood pressure
The second heart sound, S2, occurs when ____
The aortic pressure exceeds that of the left ventricle and forces the aortic valve closed
In children and young adults, S3 may arise from ____ and is termed a _____.
- rapid deceleration of the column of blood against the ventricular wall
S3 can be normal in ____ but is usually pathologic in ____.
- normal in children or adolescents
S4 can sometimes be heard, indicating what event?
Atrial contraction
Where does an S4 sound occur?
immediately precedes S1 of the next beat and reflects a pathologic change in ventricular compliance
Where would a systolic murmur be heard? >
Between S1 and S2
Where is a Diastolic murmur heard?
Between S2 and S1.
A “split” S2 suggests what?
may be normal asynchronous closure of Aortic and pulmonary valves with inspiration, Splitting during exhalation could suggest stenosis, cardiomyopathy, or LBBB. If doesn’t change between inspiration or expiration, considered a “fixed split” that suggests septal defect.
Electrical vectors approaching a lead result in what type of deflection?
positive/ upward
Electrical vectors moving away from the lead cause what type of deflection?
negative/ downward
An isoelectric line suggests what
negative and positive deflections cancel each other out creating a flat line.
What does the p wave show?
Atrial depolarization
What is occurring during the QRS complex?
ventricular depolarization
What does the T wave represent?
Ventricular repolarization / recovery
What is preload?
load that stretches the cardiac muscle before contraction (volume in the ventricle at the end of diastole.
What is myocardial contractility?
The ability of the cardiac muscle when given a load, to shorten.
What is afterload?
degree of vascular resistance to the ventricular contraction.
Why is the term “heart failure” preferred over “congestive heart failure” now?
not all patients have volume overload on initial presentation
Name 4 factors that influence arterial pressure:
L ventricular stroke volume, distensibility of the aorta and large arteries, peripheral vascular resistance (esp at arteriolar level), volume of blood in arterial system
Jugular venous pressure reflects pressure where?
Right atrial pressure (which is equal to central venous pressure)
Where is JVP most accurately measured?
Right internal jugular vein (more direct anatomical channel to heart)
What do you find in order to estimate JVP?
highest point of oscillation in internal jugular vein
What is the normal level of head elevation when checking for JVP
supine with head elevated 30 deg.
Chest pain often suggests ____, afecting 15 million people in the US
coronary heart disease
Annual incidence of exertional angina is ____ in the population 30 years or older.
1 in 1000
What term is used to refer to any clinical syndromes caused by acute myocardial ischemia including unstable angina, non-STEMI, and STEMI?
acute coronary syndrome or ACS
Anterior chest pain is often described as tearing or ripping and radiating into the back or neck in what condition?
Acute aortic dissection
What are palpitations?
unpleasant awareness of the heartbeat. May feel like “skipping, racing, fluttering, pounding or stopping”
What is the only arrhythmia that could be reliably identified at the bedside? How does it present?
atrial fibrillation - irregularly irregular
What is orthopnea?
dyspnea that occurs when the patient is lying down and improves when they sit up.
How is orthopnea usually quantified?
According to the number of pillows the patient uses for sleeping.
In what condition s is orthopnea most common?
left heart failure, mitral stenosis, or obstructive lung disease
What is PND?
paroxysmal nocturnal dyspnea -episodes of sudden dyspnea and orthopnea that awaken the patient from sleep around 1-2 hrs after going to bed.
What conditions may commonly present with PND?
Left heart failure, mitral stenosis
What condition may mimick PND?
nocturnal asthma attacks
Interstitial tissue can absorb up to what percent weight gain before pitting edema appears.
10%
Where does dependent edema typically appear?
Lower body parts such a sthe feed and lower legs when sitting, or sacrum if bedridden
In liver and renal disease, edema may be seen where?
periorbtal, hands (nephrotic syndrome), waistline (ascites)
What components make up cardiovascular disease?
congenital cardiovascular defects, stroke, heart failure, heart disease, hypertension
What are the 4 categories of hypertension according to JNC7?
normal, pre-hypertensive, stage 1 hypertension, and stage 2 (extreme) hypertension
What does JNC7 suggest is “indespensible” with regards to HTN management/ prevention?
Adoption of healthy lifestyles by all people.
What is optimal BMI?
18.5-24.9 kg/m2
What is the normal elevation of the head when assessing JVP?
30 degrees
In hypovolemic patients, the JVP will likely be ____ and you may need to ____ to see the point of oscillation.
- low
In hypervolemic patients, the JVP may be _____ and you should ____
high, raise the head of the bed
One major way to differentiate between carotid and Jugular pulsations is what?
Jugular vein pulses cannot be palpated. Additionally, height of pulsations from carotid do not change by position, pressure, or inspiration.
What does increased jugular venous pressure suggest?
right sided CHF, constrictive pericarditis, tricuspid stenosis, or superior vena cava obstruction
What is considered elevated with regards to JVP readings?
pressure >3-4cm above sternal angle, or more than 8-9 cm total distance above right atrium.
What is an elevated JVP reading specific for>
incrased L ventricular end diastolic pressure, and low left ventricular ejection fraction.
What is the usual cause of unilateral distention of the external jugular vein?
local kinking or obstruction.
What would produce a unilateral pulsatile bulge in the neck?
tortuous and kinked carotid artery
Placing pressure on the carotid sinus may result in what?
Reflex drop in HR or blood pressure
What is the pulse amplitude? How could it be described?
it is basically the pulse pressure - may be strong, small, weak, thready, bounding
What is the contour of the pulse?
The speed of the upstroke, duration of the summit, and speed of downstroke.
Delayed carotid upstroke occurs in what disorder?
aortic stenosis
What is a “thrill”?
a humming vibration that may e detected while palpating, associated with the feel of a cat purring
What is a bruit?
an auscultated murmur-like sound of vascular, non-cardiac origin that could suggest blockage
A(n) _______ may radiate to the neck and sound like a carotid bruit
aortic valve murmur
The prevalence of asymptomatic carotid bruits increases with _____/
Age
In what position should your patient be in to pick up low-pitched extra sounds such as S3, opening snap, or diastolic rumble of mitral stenosis?
left lateral decubitus - listen at the apex with the bell of the stethoscope
The soft crescendo diastolic murmur of aortic insufficiency is best heard with your patient in what position?
sitting, leaning forward after full exhalation. listen along L sternal border and apex with the diaphragm
At the apex, is S1 or S2 louder? At the base?
apex = S1 louder
In first-degree heart block, S1 is ____
decreased
In aortic stenosis, S2 is ____
decreased
what is dextrocardia?
a heart situated on the right side of the chest
What is situs inversus?
all major abdominal organs (heart, liver, stomach) are on opposite sides of the thorax from normal.
Dextrocardia with normal liver and stomach is usually associated with what?
Congenital heart disease
In what situations does the PMI differ from the Apical impulse?
Some pathologic conditions may produce a pulsationthat is more prominent than the apex beat such as enlarged right ventricle, dilated pulmonary artery, or aneurysm of the aorta
Lateral displacement of the apical impulse outside the midclavicular line increases likelihood of what?
cardiac enlargement and a low- left ventricular ejection fraction
Pregnancy or high left diaphragm may displace the apical impulse in which direction?
upward and to the left.
In the supine patient, the diameter of the apical impulse usually measures less than ___
2.5cm
In the L lateral decubitus position, a diffuse PMI with a diameter greater than ___ indicates____
3 cm
The amplitude of the PMI is usually described how?
brisk and tapping
An increased amplitude of the PMI may suggest what?
hyperthyroidism, severe anemia, pressure overload of L ventricle, or volume overload of L ventricle
Sustained, low-amplitude impulse at PMI may result from what?
dilated cardiomyopathy
In obstructive pulmonary disease, hyperinflated lungs may prevent palpation of an enlarged R ventricle in the normal L parasternal area. Where can you feel it easily instead?
high in the epigastrum where heart sounds are also often heard best
When auscultating heart sounds, the “aortic area” is found where?
2nd intercostal space just right of the sternum
When auscultating heart sounds, the “pulmonic area” is where?
2nd left interspace
Where would you listen for the tricuspid valve?
Lower Left sternal border (4-5 interspace)
Where would you listen for the mitral valve?
Near the apex/ PMI
The relative high-pitched sounds of S1 and S2, aortic and mitral regurgitation murmurs, and pericardial friction rubs are best heard using the ____
diaphragm
Sounds of S3 and S4, and the murmur of mitral stenosis are best heard using the ____.
bell
What position is useful for accentuating S3 and S4, and mitral murmurs especially mitral stenosis?
Left lateral decubitus position
What position is useful for accentuating aortic murmurs?
Sitting up, leaning forward, with a hold after full exhalation
Murmurs that coincide with the carotid upstroke are considered ____
systolic
Diastolic murmurs are usually an indication of what?
valvular heart disease
Systolic murmurs may indicate ____, but often occur with ____ heart valves
- valvular disease
Splitting of S1 is: normal/abnormal
normal
Where would you listen for splitting of S2?
2nd and 3rd L interspaces.
In disease of heart valves (a or p2) S2 will be _____
singular
S2 normally splits during
inspiration
In a split S2, which sound (a2 or p2) is louder? What does the opposite suggest?
A2 is usually louder, a loud P2 suggests pulmonary hypertension
Systolic click is commonly heard with ____
mitral valve prolapse
What is the most common extra sound in systole?
The systolic click of mitral valve prolapse
What are three common extra sounds in diastole?
S3, S4, opening snap
How can murmurs be easily differentiated from heart sounds?
by their longer duration
When does a midsystolic murmur occur?
begins after S2, stops before S2 with brief gaps between murmur and heart sounds
Midsystolic murmurs typically arise from what?
blood flow across semi-lunar valves
what is a pansystolic or holosystolic murmur?
A murmur that starts with S1 and stops at S2, without a gap between the murmur and heart sounds
Pansystolic murmurs often occur with ____.
regurgitant (backward) flow across AV valves
Describe a late systolic murmur.
usually starts in mid- or late systole and persists up to S2
The murmur of a mitral valve is which kind? and usually preceded by what sound?
- late-systolic murmur, usually preceded by a systolic click
Describe an early-diastolic murmur.
starts immediately after S2 (no discernable gap), and fades into silence before S2 (decrescendo)
Early diastolic murmurs typically relfect what?
regurgitant flow across incompetent semilunar valves
Describe a mid-diastolic murmur.
Mid-diastolic murmur starts shortly after S2 and decrescendos fading away or merging into a late diastolic murmur
Middiastolic and presystolic murmurs reflect what?
turbulent flow across AV valves
A late diastolic murmur___
starts late in diastole and continues up to S1
What is a continuous murmur? When is it seen?
starts in systole and continues through S2 into, not necessarily through diastole. May be seen with patent ductus arteriosus
A crescendo murmur grows ____
louder
A decrescendo murmur grows ___
softer
A plateau murmur is described as ___
Having the same intensity throughout
The presystolic murmur of mitral stenosis is: crescendo/decrescendo/both/plateau
crescendo
The midsystolic murmur of aortic stenosis and innocent flow murmurs are: crescendo/decrescendo/both/plateau
crescendo-decrescendo
The early diastolic murmur of aortic regurgitation is: crescendo/decrescendo/both/plateau
decrescendo
The pansystolic murmur of mitral regurgitation is: crescendo/decrescendo/both/plateau
plateau
How are murmurs typically graded?
on a 6 point scale in the form of a fraction. Numerator = intensity of the murmur at its loudest point. Denominator indicates scale
Emphysema may (increase/diminish) the intensity of murmurs.
diminish
Murmurs are ____ in thin people than very muscular or obese
louder
When grading murmurs, a palpable thrill indicates grade ___ or above
4
A grade 1/6 murmur is:
very faint, heard only after listener is “tuned in”, and not in all positions
A grade 2/6 murmur is:
quiet but heard immediately after placing the stethoscope on the chest
A grade 3/6 murmur is:
Moderately loud
A grade 4/6 murmur is:
loud with palpable thrill
A grade 5/6 murmur is:
very loud, with palpable thrill. May be heard when stethoscope is partly off chest
A grade 6/6 murmur is:
very loud with palpable thrill. May be heard with stethoscope entirely off chest
Name the murmur: Medium-pitched, grade 2/6, blowing decrescendo diastolic murmur, heard best in 4th left interspace with radiation to the apex.
aortic regurgitation
murmurs originating in the ___ of the heart tend to vary more with respiration than the other side.
Right side
What is a functional murmur?
short, early, midsystolic murmur that decreases in intensity with maneuvers that reduce L ventricular volume such as standing, sitting up, and straining in the valsalva maneuver.
Having the patient stand and strain in valsalva would result in ____ sounds of mitral valve prolapse, ____ outflow obstruction, and ____ volume into aorta.
increase, increase, decrease
In squatting or release of valsalva, mitral valve prolapse ____, hypertrophic cardiomyopathy ____ and aortic stenosis ___
decreases (delay of click and murmur shortens); decreases outflow obstruction (decreases intensity of hypertrophic cardiomyopathy murmur); and increases blood ejected into aorta (increases intensity of murmur from aortic stenosis)
What is the only murmur that increases in intensit during the valsalva maneuver?
the murmur of hypertrophic cardiomyopathy
What is pulsus alternans?
rhythm of the pulse is regular, but the force alternates due to alternating strong and weak ventricular contractions.
Pulsus alternans almost always indicates what? How is it best felt?
Indicates severe left-sided heart failure, usually best felt by applying light pressure on teh radial or femoral arteries.
Alternately loud and soft korotkoff sounds or a sudden doubling of the apparent heart rate as cuff pressure declines indicates ___
pulsus alternans
What position accentuates alternation in pulsus alternans?
Sitting upright
What is a paradoxical pulse?
a greater than normal drop in systolic pressure during inspiration.
A normal difference between korotkoff sounds with expiration is usually ____.
3-4mmHg
A difference between lowest and highest systolic pressure during respiratory cycle greater than ____ indicates a paridoxical pulse
10 mmHg
Paradoxical pulse suggests what pathophysiology?
pericardial tamponade, possible constrictive pericarditits, or obstructive airway disease
An irregular rhythm with rhythmic or sporadic irregularities suggests?
early beats, PACs, PJCs, or PVCs, or sinus arrhythmia
An irregularly irregular rhythm is usually due to ____, but could also be ___
- atrial fibrillation
A regular rhythm > 100bmp suggests?
sinus tachycardia (100-180bpm)
A regular rhythm with a normal rate (60-100) suggests what?
normal sinus rhythm (60-90)
A regular rhythm with a slow rate suggests what?
sinus bradycardia (<60)
In PACs or PJCs, the S1 may ___ and S2 may be ___
S1 may differ from normal S1 intensity, S2 may be decreased
in PVCs, S1 may ____ and S2 may be ___
S1 may differ in intensity from normal S1, S2 may be decreased, both are likely to be split
The heart sounds in sinus arrhythmia are typically ____
normal
The S1 in atrial fibrillation usually
varies
What is a bisferans pulse?
increased arterial pulse with a double systolic peak.
What are possible causes of bisferiens pulse?
aortic regurgitation, combined aortic stenosis with regurgitation, and occasionally hypertrophic cardiomyopathy
What is a bigeminal pulse?
may mimic pulsus alternans. Usually caused by a normal beat followed by a premature contraction.
What are the 4 descriptors of the classical left ventricular PMI?
location: 4th-5th left interspace, approximately 7-10 cm lateral to midsternal line
- normal location, diameter ~ 2cm, more forceful tapping, lasting <2/3 systole
hyperkinentic (anxiety, hyperthyroidism, severe anemia)
- normal location, >2cm diameter, more forceful tapping, duration sustained up to S2
Sustained - Pressure overload (hypertension, aortic stenosis)
What are the three types of ventricular impulses?
hyperkinetic, sustained, and diffuse
What is a hyperkinetic ventricular impulse?
transiently increased stroke volume - doesn’t necessarily indicate disease.
what is a sustained ventricular impulse?
results from ventricular hypertrophy from chronic pressure load (increased afterload)
What is a diffuse ventricular impulse?
caused by ventricular dilation from chronic volume overload (increased preload)
The Right ventricular impulse is usually only felt when?
in infancy.
- displaced to the left and possibly downward, >2cm duration, diffuse amplitude, slightly sustained duration
Diffuse -Volume overload (aortic or mitral regurgitation)
Why is S1 more diminished in first-degree heart block?
delayed impulse from atria to ventricles gives mitral valve time to float back to place before forced shut, therefore closes more quietly
What causes a diminished S1?
anything that results in decreased movement or forceful movement of the mitral valve (calcification, decreased L ventricular contraction, etc)
What causes an accentuated S1?
when the mitral valve is open wide at the onset of ventricular systole and is closed quickly by pressure. (tachycardia, short PR rhythms, high CO as in exercise, or mitral stenosis)
What causes varying S1?
mitral valve being in varying positions before being shut by ventricular contraction (heart blocks, irregular rhythms)
What causes a split S1?
if deemed abnormal, may be result of right bundle branch block or PVCs
What does wide splitting of S2 refer to?
increase in usual splitting that persists throughout the respiratory cycle. may be caused by delayed closure of pulmonic valve, or early closure of the aortic valve (mitral regurgitation
What is fixed splitting of S2?
wide splitting that doesn’t alter with respiration. It occurs with atrial septal defect, or right ventricular failure
What is the most common cause of paradoxical splitting?
left bundle branch block
What are the two types of extra heart sounds in systole?
- early ejection sounds
What are early ejection sounds?
usually occur shortly after S1, high-pitched, have a sharp, clicking quality. Suggestive of cardiovascular disease
What does an aortic ejection sound indicate?
dilated aorta, or aortic valve disease from congenital stenosis or a bicuspid valve
What does a pulmonic ejection sound indicate? Where is it usually heard?
usually heard in 2nd and 3rd L interspaces. causes include dilationof pulmonary artery, pulmonary hypertension, and pulmonic stenosis
What is the normal cause of systolic clicks?
mitral valve prolapse.
What is an opening snap?
a very early diastolic sound usually produced by the opening of a stenotic mitral valve. Usually heard with diaphragm
How can you distinguish an opening snap from S2?
it is high-pitched with a snapping quality that occurs just AFTER S2.
You may detect a physiologic S3 in ____
children and adults up to age 35 or 40
Another name for a pathologic S3 is a ___
ventricular gallup
What does a pathologic S3 in patients older than 40 suggest?
altered left ventricular compliance, causes include decreased contractility, CHF, and volume overload from mitral or tricuspid regurgitation
What is another name for an S4 sound?
atrial gallup
When does S4 occur?
Just before S1
What is a common cause of S4 sound?
increased resistance to ventricular filling following atrial contraction related to decreased compliance of the ventricular myocardium
If a patient has both an S3 and S4, they are said to have a _____ rhythm
quadruple
At rapid heart rates, the S3 and S4 of a quadruple rhythm may merge into one loud extra heart sound called a _____
summation gallup
What are the three major pansystolic (holosystolic) murmurs?
mitral regurgitation, tricuspid regurgitation, and ventricular septal defect
How can you distinguish between the murmurs of mitral and tricuspid regurgitation?
Tricuspid regurgitation murmurs may increase slightly with respiration. Mitral regurgitation murmurs do not become louder on respiration
Midsystolic murmurs may be ____ , _____, or _____.
Innocent (no detectable structural or physiologic abnormality),
_____ helps to distinguish midsystolic murmurs from pansystolic murmurs, in addition to a crescendo-decrescendo pattern in midsystolic.
a gap between the murmur and the S2.
Hypertrophic cardiomyopathy, aortic stenosis, and pulmonic stenosis produce _____ _murmurs.
Pathologic
A murmur caused by _____ is found at the R 2nd interspace, is often loud with a thrill, and is heard best with the patient sitting and leaning forward.
Aortic stenosis
A murmur caused by _____ is heard at the 3rd and 4th interspaces, radiates down teh L sternal border but not to the neck, medium-pitched, and decreases with squatting but increases with valsalva and standing.
Hypertrophic cardiomyopathy
A murmur from ____ is heard at the 2nd and 3rd left interspaces, radiates toward L shoulder, and may or may not have a thirll.
Pulmonic stenosis.
What two disorders are most commonly associated with a diastolic murmur?
Aortic regurgitation and mitral stenosis
What are the two basic types of diastolic heart murmurs?
early decrescendo murmurs, or rumbling diastolic memors
What does an early decrescendo diastolic murmur signify>
regurgitant flow through an incompetent semilunar valve, usually the aortic
What does a rumbling diastolic murmur in mid or late diastole suggest?
stenosis of an AV valve, usually the mitral
Identify the cause of the murmur: located at the 2nd to 4th interspaces between S2 and S1. Radiates to the apex or R sternal border,usually grade 1-3/6. Blowing decrescendo sound and is heard best with pt sitting and leaning forward with breath held after exhalation
Aortic regurgitation
usually limited to the apex, little or no radiation, may be grade 1-4/6, decrescendo low-pitched rumbling sound, increased with pt in L lateral position or with lild exertion. Usually accompanied by an opening snap
Mitral stenosis
What are three major examples of continuous heart sounds?
venous hum, pericardial friction rub, or patent ductus arteriosus.
continuous murmur without silent interval that is heard loudest in diastole. Located above medial 1/3 clavicles, especially onthe right. described as humming or roaring.
venous hum - benign sound produced by turbulence of blood in the jugular veins - common in children
two to three short components, variable location usually heard best in the third L interspace, little radation, and may increase when the patient leans forward, exhales, and holds breath. “scratchy/ scraping” sound
pericardial friction rub
continuous murmur, often with a silent interval in late diastole. Loudest in late systole. Usually loud and may be associated with a thrill
Patent ductus arteriosus
