Cardio Flashcards
S1:
As systole begins, ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valves closed, preventing backflow. This valve closure produces the first heart sound “lub”
S2:
When the ventricles are almost empty, the pressure in the ventricles falls below that in the aorta and pulmonary artery, allowing the aortic and pulmonic valves to close.
S3:
As ventricular pressure falls below atrial pressure, the mitral and tricuspid valves open to allow the blood collected in the atria to refill the relaxed ventricles. Diastole is a relatively passive interval until ventricular filling is almost complete. This filling sometimes produces a third heart sound
Filling of V’s in early diastole
S4:
Then the atria contract into non compliant ventricles
This is never physiological, always abnormal
Seen in HTN and hypertrophic cardiomyopathy
Late diastole
Explain how the relationship between the duration of the systolic and diastolic phases changes at higher heart rates.
As heart rate increases, systole and diastole become more similar in length. With slower heart rate, diastole is longer than systole.
Define the term pulse pressure.
Pulse pressure: difference between the upper and lower (systolic and diastolic) numbers of your blood pressure. This number can be an indicator of health problems before you develop symptoms. Your pulse pressure can also sometimes that you’re at risk for certain diseases or conditions – valve regurgitation
List expected cardiovascular system changes that occur during pregnancy
Blood volume, cardiac output,
PREGNANCY: The pregnant patient’s blood volume increases 40% to 50% over the prepregnancy level. The rise is mainly due to an increase in plasma volume, which begins in the first trimester and reaches a maximum after the 30th week. The heart works harder to accommodate the increased heart rate and stroke volume required for the expanded blood volume. The left ventricle increases in both wall thickness and mass. The blood volume returns to prepregnancy levels within 3 to 4 weeks after delivery. HR increases in first trimester, peaks in second trimester, and decreases 3rd. The cardiac output increases approximately 30% to 40% over that of the nonpregnant state and reaches its highest level by about 25 to 32 weeks of gestation. As the uterus enlarges and the diaphragm moves upward in pregnancy, the position of the heart is shifted toward a horizontal position, with slight axis rotation.
List expected cardiovascular system changes that occur in older adults.
OLDER ADULTS: Heart size may decrease with age unless hypertension or heart disease causes enlargement. The left ventricular wall thickens and the valves tend to fibrose and calcify. Stroke volume decreases, and cardiac output during exercise declines by 30% to 40%. The endocardium thickens. The myocardium becomes less elastic and more rigid so that recovery of myocardial contractility is delayed. The response to stress and increased oxygen demand is less efficient. Tachycardia is poorly tolerated, and after any type of stress, the return to an expected heart rate takes longer.
Jugular venous pulse
a wave
a wave The upward a wave, the first and most prominent component, is the result of a brief backflow of blood to the vena cava during right atrial contraction. This peaks slightly before the first heart sound (S1).
Atrial contraction
jugular venous pulse
C wave
The upward c wave is a transmitted impulse from the vigorous backward push produced by closure of the tricuspid valve during right ventricular systole.
tricuspid closure with bulging from ventricular contraction
julular venous pulse
x slope
The downward x slope is caused by passive atrial filling. This ends with the initiation of the v wave.
Jugular vennous pulse
v wave
The upward v wave is caused by the increasing volume and concomitant increasing pressure in the right atrium. It occurs after the c wave, late in ventricular systole.
passive build up of blood in R atria while tricuspid still closed
jugular venous pulse
y slope
y slope The y slope following the v wave reflects the open tricuspid valve and the rapid filling of the right ventricle.
passive emptying into the Ventricle when tricuspid opens
Explain how to distinguish the internal jugular venous pulse wave from the carotid artery pulse wave.
Quality and Character
Explain how to distinguish the internal jugular venous pulse wave from the carotid artery pulse wave.
Effect of Respiration
JVP
Effect of Respiration Level of pulse wave decreased on inspiration and increased on expiration
Carotid
No effect
Explain how to distinguish the internal jugular venous pulse wave from the carotid artery pulse wave.
Venous Compression
JVP
Venous Compression Easily eliminates pulse wave
carotid
No effect
Describe the proper technique to properly measure the right internal jugular venous pressure; define what is considered an abnormally high pressure.
TECHNIQUE: Place the patient in the supine position using a bed or examining table with an adjustable back support. Use a light to supply tangential illumination across the right side of the patient’s neck to accentuate the appearance of the jugular venous pulsations. When the supine patient is initially placed flat, note the engorgement of the jugular veins. Gradually raise the head of the bed until the jugular venous pulsations become evident between the angle of the jaw and the clavicle. Place a ruler with its tip at the midaxillary line (the position of the heart within the chest) at the level of the nipple and extended vertically. Place the second ruler at the level of the meniscus of the JVP, extended horizontally to where it intersects the vertical ruler. The vertical distance above the level of the heart is noted as the mean JVP in centimeters of water.
A value of less than 9 cm H 2 O is the expected value.
Less than 3cm if using angle of Louis at 45 degree angle
Describe the proper technique to properly assess hepatojugular reflux. Define an abnormal hepatojugular reflux finding and discuss the clinical significance of a positive finding.
30-60 seconds hold, if increases by >1cm then positive for reflex
Define the terms ventricular heave, parasternal lift and palpable thrill.
Parasternal heave/ lift/thrust: precordial impulse that may be felt (palpated) in patients with cardiac or respiratory disease. Precordial impulses are visible or palpable pulsations of the chest wall, which originate on the heart or the great vessels
Thrill: Palpable murmur (Grade IV or higher)
Discuss potential causes for, and clinical significance of thrills and heave findings.
CAUSES: Parasternal heave occurs during right ventricular hypertrophy (i.e. enlargement) or very rarely severe left atrial enlargement
where is S1 best heard?
S 1: toward the apex where it is usually louder than S 2 ( Box 15.6 ). At the base, S 1 is louder on the left than on the right but softer than S 2 in both areas. It is lower in pitch and a bit longer than S 2 , and it occurs immediately after diastole
where is S2 best heard?
S 2 : aortic and pulmonic areas. It is of higher pitch and shorter duration than S 1 . S 2 is louder than S 1 at the base of the heart; still, it is usually softer than S 1 at the apex
Best areas to hear S1/S2 splitting or S3/S4 gallop?
Splitting: mitral and tricuspid valves or the pulmonic and aortic valves do not close simultaneously.
→ Splitting of S 1 is not usually heard because the sound of the tricuspid valve closing is too faint to hear. Rarely, however, it may be audible in the tricuspid area, particularly on deep inspiration.
→ S 2 is actually two sounds that merge during expiration. The closure of the aortic valve (A 2 ) contributes most of the sound of S 2 when it is heard in the aortic or pulmonic areas. A 2 tends to mask the sound of pulmonic valve closure (P 2 ). During inspiration, P 2 occurs slightly later, giving S 2 two distinct components ; this is a split S 2 . Splitting is more often heard and easier to detect in the young; it is not well heard in older adults.
When S 3 becomes intense and easy to hear, the resulting sequence of sounds simulates a gallop; this is the early diastolic gallop rhythm. It may be best heard when the patient is in the left lateral decubitus (recumbent) position. (Ken-TUCK-y)
S 4 may also become more intense, producing a readily discernible presystolic gallop rhythm. S 4 is most commonly heard in older patients, but it may be heard at any age when there is increased resistance to filling because the ventricular walls have lost compliance (e.g., in hypertensive disease and coronary artery disease) or with the increased stroke volume of high-output states (e.g., in profound anemia, pregnancy, and thyrotoxicosis). (TEN-nes-see)
Which heart sounds afe best heard with diaphragm or bell?
S1: Diaphragm
S2: Diaphragm
S3: Bell
S4: Bell
Describe the appropriate patient positioning techniques for cardiac auscultation.
Opening snap: Any position
S1: any position
Systolic click: sitting/supine
S2: sitting/supine
S3: Supine/left lateral
Quadruple rhythm: supine/left lateral
Summation gallop: Supine/l lateral
Ejection sounds: sitting/supine
Discuss normal and abnormal findings accentuated by each auscultation positioning maneuver.
Cardio
Study murmurs
Differentiate a murmur’s intensity per the Grade I – VI scale.
Grade I Barely audible in quiet room
Grade II Quiet but clearly audible
Grade III Moderately loud
Grade IV Loud, associated with thrill
Grade V Very loud, thrill easily palpable
Grade VI Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible
hypertrophic obstructive cardiomyopathy murmur
systolic diamond
aortic sclerosis murmur
loud musical or soft murmur in systole
List criteria differentiating between innocent and pathologic heart murmurs.
usually in children or adolescents
innocent murmurs are usually grade I or II, usually midsystolic, without radiation, medium pitch, blowing, brief, and often accompanied by splitting of S 2 . They are often located in the second left intercostal space near the left sternal border. Such murmurs heard in a recumbent position may disappear when the patient sits or stands because of the tendency of the blood to pool.
Describe and distinguish between each of the following “extra” heart sounds.
Ventricular S3 gallop and S4 gallops:
When S3 becomes intense and easy to hear, the resulting sequence of sounds simulates a gallop; this is the early diastolic gallop rhythm. It may be best heard when the patient is in the left lateral decubitus (recumbent) position.
S4 may also become more intense, producing a readily discernible presystolic gallop rhythm. S 4 is most commonly heard in older patients, but it may be heard at any age when there is increased resistance to filling because the ventricular walls have lost compliance
Summation (S3 + S4 combined) gallop:
Summation gallop is the combined presence of S3 and S4 with tachycardia
Aortic/pulmonic early-systolic (ejection) click:
Ejection clicks are high-pitched sounds that occur at the moment of maximal opening of the aortic or pulmonary valves. They are heard just after the first heart sound.
Mid-to-late mitral valve systolic (non-ejection) click:
systolic sounds occurring at AV valves in prolapse of mitral/tricuspid valves d/t myxomatous degeneration of valve
Mitral valve opening snap (accentuated S1):
This occurs because the increased left atrial pressures in early mitral stenosis force the mobile portion of the mitral valve leaflets far apart.
Pericardial friction rub:
A pericardial friction rub is a grating, to-and-fro sound produced by friction of the heart against the pericardium – indicative of pericarditis
Describe the proper method for assessing for the presence of varicose veins.
Inspect the legs for superficial varicosities when the patient is standing. With varicosities, the veins appear dilated and often tortuous. If varicose veins are suspected, have the patient stand on his or her toes 10 times in succession. Palpate the legs to feel the venous distention. When the venous system is competent, the distention of the veins disappears in a few seconds. If the distention of the veins is sustained for a longer time, suspect venous insufficiency.
Describe signs suggestive of venous insufficiency, superficial venous thrombophlebitis, and deep vein thrombophlebitis (DVT).
Note any redness, thickening, and tenderness along a superficial vein, suggesting thrombophlebitis of a superficial vein. Suspect a deep vein thrombosis if swelling, pain, and tenderness occur over a vein. It cannot be confirmed on physical examination alone and requires diagnostic imaging.
Homan’s Sign:
passive dorsiflexion of foot with knee flexed = calf pain
Finding suggestive of venous insufficiency
Compare and contrast generalized edema (anasarca) and localized edema. Discuss some conditions associated with each.
Generalized edema: massive and generalized (anasarca). It is caused by a variety of clinical conditions like heart failure, renal failure, liver failure, or problems with the lymphatic system
Localized edema: Typically, this involves one organ or part of the body. Clinically important examples of localized edema are brain edema, lung edema, or accumulation of fluid in the thoracic cavity (hydrothorax) or abdominal cavity (ascites).
Distinguish between pitting (dependent, orthostatic) edema and non-pitting (brawny) edema and discuss conditions associated with each.
Pitting edema: swollen part of your body has a dimple (or pit) after you press it for a few seconds.
- CHF
- Liver dz
- Kidney dz
- DVT
- Pregnancy
Non-pitting: If you press your finger to a swollen area, it will usually bounce right back
- Venous insufficiency
- Angioedema
- Myxedema
Describe how to quantify pitting edema on a scale of 0 to 4+ and by the level of involvement.
Trace = does not meet criteria to classify as 1+
1+ Slight pitting, no visible distortion, disappears rapidly - 2mm
2+ A somewhat deeper pit than in 1+, but again no readily detectable distortion; disappears in 10–15 seconds -4mm
3+ Noticeably deep pit that may last more than a minute; dependent extremity looks fuller and swollen - 6 mm
4+ Very deep pit that lasts as long as 2–5 minutes; dependent extremity is grossly distorted - 8 mm
