Cardiac Flashcards
The nurse practitioner is auscultating the heart of a patient who has left ventricular hypertrophy. Where and when would it be expected to hear an additional heart sound associated with this condition?
fifth intercostal space,left midclavicular lien, heard druing diastole
S4 heart sounds can be common in
older adults
S4 heart sound is abnormal in
infants and children
S4 heart sound heard at the
apex of the heart left lateral decubitis position with bell of stethescope
S3 heart sound is heard in
heart failure
S3 heart sound not part of
uncontolled HTN
The Eighth Report of the Joint National Committee (JNC 8) guidelines for hypertension recommend that any adult over the age of 18 with a diagnosis of diabetes should have a goal blood pressure of
140/90
A 70-year-old man was recently diagnosed with left ventricular hypertrophy by his cardiologist. The physical assessment may reveal what extra heart sound that is associated with left ventricular hypertrophy?
S4
A 34-year-old Black patient with metabolic syndrome presents to the clinic with a blood pressure of 141/85 mm Hg. Which of the following medications is considered the most appropriate first-line therapy for this patient?
amlodipine (norvasc)
Calcium channel blockers and thiazide diuretics are considered more effective in the Black population because they are considered cardioprotective.
A harsh systolic murmur with a crescendo-decrescendo pattern suggests
aortic stenosis
The gold standard tool for the diagnosis of aortic stenosis is an
echo
Which of the following murmurs would produce a thrill that could be palpated on exam of an adult patient?
mitral stenosis
A thrill is a vibratory sensation felt by palpating an overlying area of turbulence and is usually caused by an incompetent heart valve. A palpated thrill comes from a loud murmur. Mitral stenosis typically produces a diastolic murmur that is best heard at the apex with the patient in the left lateral position.
Infective endocarditis usually refers to infection of one or more heart valves or it could indicate infection at a surgically placed intracardiac device. Among intravenous drug users, approximately 50–70% of infective endocarditis cases affect the
Tricuspid
Causes of pericarditis may include
viral infections such as Epstein-Barr virus, influenza, gout, rheumatoid arthritis, and systemic lupus erythematosus (D).
A pansystolic murmur that radiates to the axilla likely indicates
mitral regurgitation
contraindicated in patients with second-degree AV heart blocks, as they alter the conduction through the AV node
Symptoms of a second-degree atrioventricular (AV) heart block include fatigue, dyspnea, chest pain, syncope, and even sudden cardiac arrest. Nondihydropyridine calcium channel blockers, such as diltiazem (C),
Gerd avoid what medication
CCB
This systolic murmur can best be heard at the apex of the heart or the left fifth intercostal space when the patient is lying in the left lateral decubitus position.
Holosystolic murmurs are typically associated with regurgitations.
is characterized by a holosystolic blowing murmur at the apex and, in some cases, an audible S3 heart sound.
Mitral regurgitation
What is the standard first-line medication for hypertension in elderly patients?
A.Amlodipine
B.Lisinopril
C.Hydrochlorothiazide
D.Chlorthalidone
lisinopril
A patient with severe primary hypercholesterolemia presents for a routine checkup. The patient has been compliant with the prescribed high-intensity statin regimen; however, the low-density lipoprotein cholesterol (LDL-C) is 120 mg/dL. Which of the following therapies will be added next?
A.Fibrate agent
B.Ezetimibe
C. PCSK9 inhibitor
D.Niacin
Answer: B. Ezetimibe
High-intensity statin therapy is indicated for patients with severe primary hypercholesterolemia (LDL-C level ≥190). If the LDL-C level remains ≥100 mg/dL, adding ezetimibe is a reasonable next step. A PCSK9 inhibitor can be considered if the LDL-C level on statin plus ezetimibe remains ≥100 mg/dL and the patient has multiple factors that increase risk of atherosclerotic cardiovascular disease (ASCVD) events. Niacin and fibrates are triglyceride-lowering drugs and have mild LDL-lowering action; however, they are not routinely recommended in combination with statin therapy.
A patient presents complaining of palpitations, fatigue, and mild shortness of breath. A 12-lead EKG reveals rapid, regular atrial activity in a sawtooth pattern at about 300 beats/min and a regular ventricular rate of about 155 beats/min. Which of the following agents can be used for rate control for this arrhythmia?
A.Diltiazem
B.Digoxin
C.Amlodipine
D.Amiodarone
Answer: A. Diltiazem
The patient is experiencing atrial flutter, an abnormal cardiac rhythm characterized by rapid, regular atrial depolarizations (about 300 beats/min) and a regular ventricular rate (about 150 beats/min). Typical P waves are absent, and the atrial activity presents as a sawtooth pattern in leads II, III, and aVF. Rate control in atrial flutter involves administration of a non-dihydropyridine calcium channel blocker (e.g., verapamil, diltiazem) or a beta-blocker. Digoxin is used less frequently due to its side effects and toxicity (it is indicated with concurrent heart failure). Amiodarone, an antiarrhythmic agent, is rarely used as a rate control agent. Reversion to normal sinus rhythm is often accomplished by catheter ablation for definitive treatment (cardioversion is also reasonable). Ibutilide is the drug of choice for pharmacologic reversion as an alternative option.
A patient is newly diagnosed with stage 1 hypertension, and American College of Cardiology (ACC) guidelines call for lifestyle modifications but not medication therapy. In how many months should the patient return for follow-up?
A.1
B.3
C.9
D.12
Answer: B. 3
Patients with a new diagnosis of elevated blood pressure or with stage 1 hypertension that does not require pharmacologic treatment should return for follow-up in 3 to 6 months. Patients who require pharmacologic treatment for stage 1 or stage 2 hypertension should return in 1 month for reassessment and potential adjustment to therapy. Patients with normal blood pressure should return for reassessment annually as part of their usual well visit.
A patient presents complaining of leg pain that occurs while walking but is relieved by rest after a few minutes. Upon physical examination, the patient’s skin appears pale, dry, shiny, and hairless. The patient has an ulceration on the tip of the big toe. Based on this presentation, which of the following initial diagnostic tests is indicated?
A.Lower extremity duplex ultrasound
B. CT scan of the lower extremity
C.Exercise testing
D ABI
Answer: D. Ankle-brachial index
The patient is presenting with clinical features suggesting lower extremity peripheral artery disease. Intermittent claudication is classically defined as muscle pain that is induced by exercise and relieved with rest. Physical exam findings are often significant for a nonhealing wound or ulcer; skin discoloration or gangrene; and dry, shiny, hairless skin due to diminished blood flow. Diagnosis of arterial stenosis or occlusion (as a result of peripheral artery disease) is confirmed with the ankle-brachial index (a result ≤0.9 has a high degree of sensitivity and specificity for diagnosis). Exercise testing can be obtained if patients with a classic history of claudication have a normal resting ankle-brachial index. Additional vascular imaging (such as a duplex ultrasound or CT) is generally not necessary for establishing a diagnosis of peripheral artery disease but can be useful to identify treatment therapies for intervention.
A 35-year-old patient presents with complaints of persistent headaches, palpitations, and excessive sweating. They mention a family history of early-onset hypertension and are concerned about their own blood pressure. On examination, the blood pressure is measured at 170/100 mmHg. Lab investigations reveal elevated levels of urinary catecholamines. What is the most likely diagnosis?
A.Primary hypertension
B.Secondary hypertension due to pheochromocytoma
C.Renal artery stenosis
D.Resistant hypertension
Answer: B. Secondary hypertension due to pheochromocytoma
The patient’s symptoms of headaches, palpitations, and excessive sweating, along with elevated blood pressure and elevated levels of urinary catecholamines, are classic signs of pheochromocytoma.
A 56-year-old patient presents for a routine check-up and is found to have a blood pressure (BP) reading of 150/88 mmHg. Physical examination reveals no abnormal findings except for a body mass index of 32. The individual denies any symptoms and has not experienced any recent changes in weight, diet, or exercise routine. The patient’s fasting glucose level is 100 mg/dL. What will the nurse practitioner include in the initial treatment plan?
A.Prescribing a statin
B.Recommending lifestyle modifications and a follow-up visit in 6 months
C.Prescribing a beta-blocker
D.Prescribing an angiotensin-converting enzyme (ACE) inhibitor and a thiazide diuretic
Answer: D. Prescribing an angiotensin-converting enzyme (ACE) inhibitor and a thiazide diuretic
This patient is presenting with stage 2 hypertension and a fasting glucose level consistent with prediabetes. Current American College of Cardiology guidelines recommend starting the patient on a regimen of two BP-lowering medications from different classes. First-line options include thiaizide diuretics, calcium channel blockers, and ACE inhibitors. The patient should also be instructed on lifestyle modifications, including diet and physical activity, to address both hypertension and diabetes risk. The patient should be reassessed in 1 month to determine the effectiveness of BP control and to adjust therapy as necessary
A 52-year-old patient visits the clinic expressing concerns about a new feeling of fatigue and mild shortness of breath during routine activities. They have a history of hypertension and occasional alcohol consumption. While auscultating at the mitral area with the bell of the stethoscope, the nurse practitioner detects a soft, low-pitched sound just before the first heart sound. How should this additional heart sound be identified?
A.Split S2 sound due to respiratory variations
B.S3 sound indicative of rapid ventricular filling
C.S4 sound suggesting a non-compliant or stiff left ventricle
D.Summation gallop due to the presence of both S3 and S4 sounds
Answer: C. S4 sound suggesting a non-compliant or stiff left ventricle
The clinical presentation and auscultation findings point toward an S4 heart sound, which suggests a non-compliant or stiff left ventricle. This is frequently observed in conditions such as hypertension, ischemic heart disease, and cardiomyopathy. The sound is caused by the atrial contraction pushing blood into a stiff left ventricle. While a split S2 sound represents an audible separation of the aortic and pulmonic valve closings and can be normal, an S3 sound occurs immediately after S2 and indicates conditions like congestive heart failure. A summation gallop is a rare finding that refers to the presence of both S3 and S4 sounds, which can sometimes be heard together, especially during tachycardia. The additional sound does not suggest a summation gallop.
A 45-year-old male patient presents with a history of sedentary lifestyle. The patient’s waist circumference is 39 inches, fasting glucose level is 110 mg/dL, blood pressure is 119/78 mmHg, triglyceride level is 155 mg/dL, and high-density lipoprotein (HDL) cholesterol level is 44 mg/dL. How many factors for metabolic syndrome are present in this patient?
A.1
B.2
C.3
D.4
Answer: C. 3
Metabolic syndrome is a cluster of interconnected risk factors, including central obesity (waist size >40 inches in male patients), fasting glucose greater than 100 mg/dL, hypertension, triglycerides level in excess of 150 mg/dL, and/or low HDL level (<50 mg/dL). Patients must meet at least three of these criteria to be classified as having metabolic syndrome. This patient meets three criteria: fasting glucose, blood pressure, and triglycerides level.
A 68-year-old patient presents with complaints of worsening shortness of breath on exertion and occasional swelling in the ankles over the past 6 months. The patient has a past medical history of hypertension and type 2 diabetes. On physical examination, the nurse practitioner notes a regular rate and rhythm of the heart but identifies an additional heart sound immediately after the second heart sound (S2) when listening over the apex with the bell of the stethoscope in the left lateral decubitus position. Based on the clinical presentation and auscultation findings, how should the nurse practitioner interpret this additional heart sound?
A.S3 heart sound suggestive of congestive heart failure
B.S4 heart sound indicative of a stiffened or hypertrophic left ventricle
C.Split S2 sound typically related to respiratory variations
D.Pathological murmur requiring immediate intervention
Answer: A. S3 heart sound suggestive of congestive heart failure
The patient has symptoms consistent with heart failure, such as exertional dyspnea and ankle swelling. On auscultation, an extra heart sound immediately following the second heart sound (S2) is suggestive of an S3 heart sound. An S3 heart sound, especially in older adults, is often associated with congestive heart failure and can be a sign of decreased left ventricular function. This sound represents rapid filling of the ventricle during the early filling phase. In contrast, an S4 heart sound occurs just before the first heart sound (S1) and is associated with a stiffened or hypertrophic left ventricle, often seen in conditions like left ventricular hypertrophy. A split S2 refers to the audible separation of the aortic and pulmonic valve closings and can be a normal finding, especially during inspiration. A pathological murmur is a sustained sound heard between S1 and S2 or between S2 and S1, and while it may warrant further assessment, the described sound does not match the pattern of a murmur.
Upon cardiac examination, the nurse practitioner hears a loud, high-pitched, blowing murmur at the apex of the heart, which radiates to the axillary area. The murmur is indicative of:
A.Aortic regurgitation
B.Mitral stenosis
C.Aortic stenosis
D.Mitral regurgitation
Solution: D
Mitral regurgitation.
A loud, high-pitched, blowing murmur is indicative of mitral regurgitation, a pansystolic murmur. Aortic regurgitation is a high-pitched diastolic murmur. With mitral stenosis, the murmur is heard as a low-pitched rumbling sound at the apex of the heart. In aortic stenosis, the murmur is heard as a harsh and loud murmur at the right side of the sternum, and the murmur may radiate to the neck.
The presence of the S4 heart sound may be absent in which of the following conditions?
A.Aortic stenosis
B.Atrial fibrillation
C.Myocardial infarction
D.Hypertensive heart disease
Solution: B
Atrial fibrillation.
Because effective atrial contraction is required for production of the S4 heart sound, patients with atrial fibrillation may not demonstrate this sound. Aortic stenosis, myocardial infarction, and hypertensive heart disease are all associated with the S4 heart sound.
The nurse practitioner is reviewing the results of an echocardiogram that was ordered for a patient with infective endocarditis; valve vegetation is noted. Which of the following heart murmurs would be present on physical exam?
A.Aortic stenosis
B.Mitral regurgitation
C.S4 late diastole
D.Wide splitting of S1
Solution: B
Mitral regurgitation.
Infective endocarditis can result in leaflet destruction and the presence of a valve vegetation, which causes mitral regurgitation. Splitting of the S2, not S1, can also occur. Aortic stenosis and S4 are not associated murmurs.
what oral medication can rapidly decrease a patients BP i
clonidine (catapres) a2 adrenergic agonist
Clonidine (Catapres), an α2 adrenergic agonist, is an effective oral medication that rapidly reduces blood pressure within a few hours. In contrast, other medications like β blockers, ACE inhibitors, and thiazide diuretics work over a longer period (days to weeks) and may not be suitable for the initial treatment of severe hypertension.
left sided heart failure
Function: The left side of the heart receives oxygen-rich blood from the lungs and pumps it throughout the body.
Consequences: Pulmonary congestion and fluid overload leads to symptoms
Dyspnea (shortness of breath)
Orthopnea (difficulty breathing when lying down)
Respiratory crackles (rales)
Cough
right sided heart failure
Function: The right side of the heart receives oxygen-deficient blood from the body and pumps it through the pulmonary vasculature.
Consequences: Often a result of left-sided heart failure, right-sided heart failure causes more chronic symptoms affecting other body systems
Dependent edema (swelling in lower extremities)
Hepatomegaly (enlarged liver)
Abdominal fullness
is a crescendo-decrescendo murmur, best heard at the second intercostal space to the right of the sternum.
aortic stenosis
A low ejection fraction in a patient with a prosthetic valve replacement increase
thromboemboic events
An S3 heart sound is abnormal in older adults, often an indication of
heart failure
In some patients, the S3 heart sound may be normal.
Children
Pregnancy
Young adults < 40
Athletes
presentation of bacterial endocarditis is
fever (most common), chills, night sweats, murmurs (most commonly aortic regurgitation), petechiae or splinter hemorrhages of the nail bed, Osler’s nodes (painful nodules on fingertips and toes), Janeway lesions (non-tender macules on palms and soles), anorexia, malaise, myalgias/arthralgias, dyspnea, cough and pleuritic pain.
Treatment for bacterial endocarditis is
vanco or gentamicin
s most consistent with left ventricular heart failure, indicating elevated left ventricular end-diastolic pressure.
S3 gallop
Chronic venous insufficiency presents with
varicose veins, lower extremity swelling, and leathery-looking skin on the lower extremities.
Memory trick: “4 P’s & 1 T” - Prosthetic heart valves, Prior infective endocarditis
Patched congenital heart disease, Persistent cyanotic heart disease, & Transplant with valve issues.
is characterized by a holosystolic blowing murmur at the apex and, in some cases, an audible S3 heart sound.
mitral regurgitation
Prosthetic heart valves increase thrombosis risk, and the target INR with warfarin therapy for mechanical mitral valve patients is
2.5 - 3.5
is the leading cause of death in the United States, followed by cancer, COVID-19, and other causes.
cardiovascular disease
Postural orthostatic tachycardia syndrome (POTS) often causes
fatigue, lightheadedness, weakness, vision changes, and dizziness upon standing.
what is the baseline workup for pt with for newly dx HTN
fasting plasma glucose level
The murmur associated with pulmonary regurgitation is a
high-pitched early diastolic murmur, best heard in an upright position at left upper sternal border.
NYHA Class III heart failure involves symptoms
(dyspnea, fatigue, palpitations) with less than ordinary physical activity, but resolution of symptoms at rest.
Some conditions are considered absolute contraindications for thrombolytic therapy due to the increased risk of bleeding:
Intracranial neoplasm
Prior intracranial hemorrhage (ICH)
History of ischemic stroke within the past three months
Head trauma within the past three months
Bleeding disorders
Active bleeding (except menstruation)
Possible aortic dissection
Women with myocardial ischemia may experience atypical symptoms
Sudden onset of weakness
Sudden onset of weakness is reported more commonly in women than in men with myocardial ischemia. This often leads to a concern for systemic illness and the possibility of cardiovascular disease is overlooked.
Unstable angina is marked by
chest pain at rest that progressively worsens and does not improve with rest or nitroglycerin.
common cause of T-wave inversions on ECG, indicating the progression of ischemia.
Acute coronary syndrome
Acute coronary syndrome can cause T-wave inversion, this typically occurs after the ischemia progresses.
ST-segment changes are the most important ECG findings associated with
acute coronary syndrome
is an early diastolic murmur heard best at the third to fourth left intercostal space near the sternal border.
aortic regurgitation
Beta-blockers can improve the symptoms of heart failure by
reducing circulating catecholamines and their effects.
