Cardiac Cycle and Sounds Flashcards
Where is the aortic area?
second intercostal space, right sternal border
Where is the pulmonic area?
second intercostal space, left sternal border
Where is Erb’s point?
Third intercostal space, left sternal border
Where is tricuspid area?
fourth (or fifth) intercostal space, left sternal border
Where is mitral area or apex?
fifth intercostal space, left midclavicular line
What are the normal heart sounds for an adult?
S1 (lub), S2 (dub)
When is systole (in regards to the heart sounds)?
between S1 and S2
When is diastole (in regards to the heart sounds)?
between S2 and S1
When is a murmur heard?
- flow of blood through a valve is turbulent
- valve is non-compliant, incompetent, stiff, or damaged
When is a murmur concerning?
it is associated with symptoms
Is there always a problem or underlying disease if there is a murmur?
NO, not always
How should a murmur be evaluated?
echocardiogram
What is SBP?
the pressure exerted upon the artery during heart contraction
What is DBP?
the pressure exerted upon the artery wall during heart rest
When does the mitral valve open?
during atrial contraction
What sound is associated with the mitral valve closing?
S1
What sound is associated with the aortic valve closing?
S2
What is the order of valves opening and closing during the cardiac cycle starting during atrial contraction?
- atrial contraction = mitral valve opens
- isovolumic ventricular contraction = mitral valve closes
- isovolumic ventricular contraction = aortic valve opens
- isovolumic ventricular relaxation = aortic valve closes
What is associated with the mechanical phenomenon of the cardiac cycle?
aortic pressure wave, ventricular pressure wave, atrial pressure wave, ventricular volume wave, jugular venous wave, heart sounds
What is associated with the electrical phenomenon of the cardiac cycle?
sino-atrial nodal firing, internodal pathway conduction, atrio-ventricular nodal activation, bundle of HIS, right bundle branch and left bundle branch, left anterior and posterior fascicle, purkinje fibers
What does the P wave indicate?
atrial systole (late ventricular diastole)
What does the PR interval indicate?
atrial diastole (slow conduction thru AV node)
What does the QRS complex indicate?
ventricular systole (atrial diastole/repolarization)
What does the ST segment indicate?
late ventricular systole
What does the T wave indicate?
ventricular diastole/repolarization
What is the AV valve on the right side of the heart? High or low pressure system?
tricuspid valve,
low pressure system
What is the AV valve on the left side of the heart? High or low pressure system?
bicuspid (mitral) valve,
high pressure system
What is the semilunar valve on the right side of the heart? High or low pressure system?
pulmonic valve,
low pressure system
What is the semilunar valve on the left side of the heart? High or low pressure system?
aortic valve,
high pressure system
What makes the S1 sound?
closure of AV valves
What makes the S2 sound?
closure of semilunar valves
What does S3 sound like?
“Ken-tuckee”
What makes the S3 sound? Who is it normal in?
a vibratory sound that occurs from blood filling the relaxed and empty ventricle. Heard when AV valves are open.
normal in children.
What pathology can the S3 sound indicate?
CHF, cardiomyopathy with stiff ventricular walls
What does S4 sound like?
“Tenness-ee”
What makes the S4 sound?
atrial filling from high pressure from SVC/IVC and pulmonary venous return
When does the S4 sound occur?
before the S1 sound
What is regurgitation?
turbulent flow sound when blood is moving in an opposite direction from what it should
What is stenosis?
turbulent flow when blood is moving through a stiff damaged valve
When does a systolic murmur occur?
during ventricular systole (between S1 and S2)
When can a diastolic murmur be heard?
ventricular diastole (between S2 and S1)
What is the mneumonic for the 4 locations on the chest?
APTM (All Physicians Take Money)
What murmur is heard at the aortic valve?
ejection murmur (aortic stenosis)
What murmur is heard at the tricuspid valve?
pansystolic murmur - tricuspid regurgitation or ventricular septal defect
mid-to-late diastolic murmur - tricuspid stenosis or atrial septal defect
What murmur is heard at the left sternal border?
early diastolic murmur - aortic regurgitation or pulmonic regurgitation
What murmur is heard at the pulmonary valve?
ejection murmur - pulmonic stenosis
What murmur is heard at the mitral valve?
pansystolic murmur - mitral regurgitation
mid-to-late diastolic murmur - mitral stenosis
What would you grade a soft murmur heard in quiet surroundings?
1
What would you grade a soft murmur heard in noisy surroundings?
2
What would you grade a prominent heard murmur?
3
What would you grade a loud murmur with a thrill?
4
What would you grade a loud murmur heard with edge of the stethoscope tilted against the chest + thrill
5
What would you grade a loud murmur heard 5-10 mm from the chest + thrill?
6
What are the characteristics of pathologic murmurs?
- > =grade 3
- holosystolic timing
- maximum intensity at left upper sternal border
- harsh or blowing
- abnormal second heart sound
- systolic click
- diastolic murmur
- increased intensity with upright position
- gallop rhythm (S3 or S4)
- friction rub
What are the characteristics of innocent murmurs?
- <=grade 2
- softer intensity when sitting compared to supine
- short systolic duration
- minimal radiation
- musical or vibratory quality
Which valves are open and which are closed during ventricular systole?
open: semilunar (aortic and pulmonic)
closed: AV (tricuspid and mitral)
What is aortic stenosis?
crescendo-decrescendo murmur
Most likely presentation: Old-SAD - syncope, angina, dyspnea
calcified aortic valve
radiates UP to the carotids
What is pulmonic stenosis?
restricted flow through stenotic pulmonary valve (heard during systole)
Which valves are open and which are closed during atrial systole?
open: AV (tricuspid and mitral)
closed: semilunar (pulmonic and aortic)
What is tricuspid stenosis?
restricted/disrupted flow through stenotic tricuspid valve (heard during diastole)
What is mitral stenosis?
restricted/disrupted flow through stenotic mitral valve (heard during diastole)
What murmurs are louder during inspiration?
tricuspid and pulmonic (RINspiration)
What murmurs are louder during expiration?
mitral and aortic
LEXpiration
In most cases, how does a changing preload change the the murmur?
increasing preload = louder murmur
decreasing preload = softer murmur
What are the exceptions to the general rules of preload?
- HOCM (hypertropic obstructive cardiomyopathy)
- MVP (mitral valve prolapse)
How is HOCM an exception to the general rule of preload?
increase in preload improves aortic murmur by pushing the septum away from the aortic outflow track, allowing blood to be ejected more easily. A decrease in preload causes worsening aortic murmur due to less blood to push the outflow track open, obstructing and disrupting the blood flow.
How is MVP an exception to the general rule of preload?
leaflests of mitral valve prolapse into the left atria under normal pressure and blood flow. increased preload improves the “mid-systolic click” heard with MVP by allowing the prolapsed leaflets to return to their normal orientation.
What is afterload?
pressure the ventricles have to generate to move blood forward into the atrial system (PVR)
What is the effect of a change in afterload? What are the exceptions?
increased afterload = louder
decreased afterload = softer
Exceptions: HOCM and MVP are opposite
What murmur radiates to the carotids?
aortic stenosis
What is the most likely murmur in an older patient with syncope, angina, and dyspnea?
aortic stenosis
What murmur radiates to the axilla?
mitral regurgitation
Where is mitral regurgitation best heard?
apex
What is mitral regurgitation?
holosystolic murmur radiating to the axilla. best heard at apex. “Rheu-mitral”
What is mitral regurgitation associated with?
history of rheumatic fever
What is tricuspid regurgitation?
holosystolic murmur associated iwth IVDA. “Want to TRI some drugs?”
What has a early blowing diastolic murmur?
aortic regurgitation. “AR thar she BLOWS”
What is aortic regurgitation? Presentations?
early blowing diastolic murmur.
- connective tissue disorders
- Marfan’s syndrome
- “head bobbing”
- water hammer pulse
- femoral bruits
What murmur has an opening “snap”?
mitral stenosis
What is mitral stenosis?
opening snap
RHEU mitral - history of rheumatic fever
“The OS is MS”
When should you be concerned for HOCM?
- family history of sudden cardiac death at a young age (20-30 yo)
- Exception to the preload/afterload loudness general rule
When should you think mitral valve prolapse?
-midsystolic “click”
-clinical presentation of a young woman with a psychiatric history
-myxomatous valvular disease in the question stem
“See the MVP to be the MVP and everything will click”
What are some other murmurs?
atrial septal defect, ventricular septal defect, patent ductus arteriosus
When do you use the diaphragm?
for general cardiac auscultation
When do you use the bell?
identify low pitch heart sounds (S3 and S4 gallops)
