Cardiology-Basics Flashcards
Base and apex of the heart
aortic and pulmonary areas to the ___ and ____ of the sternum
aortic and pulmonary areas to the right and left of the sternum
Differences between S1, S2
- Carotid pulse: S1 just precedes, S2: Follows
- Louder at: apex: S1 , base: S2
- Lower pitch and longer: S1, Higher pitch and shorter: S2
Categories of heart sounds
- 1st & 2nd Heart Sounds
- 3rd & 4th Heart Sounds
- Clicks & Snaps
- Murmurs
- Rubs
- Maneuvers
Aortic stenosis
- Harsh late-peaking crescendo-decrescendo systolic murmur
- Heard best- right 2nd ICS
- Radiation to the carotids.
A murmur is characterized by:
- Intensity
- Timing
- Configuration
- Frequency
- Location.
Semilunar valves
The aortic and pulmonary valves
A mid-systolic murmur associated with a single S2 suggests:
Severe aortic stenosis
The most common causes of a mid-systolic murmur are
Benign (innocent) flow murmurs,
Types of murmurs
Systolic
Diastolic
Continous
Early systolic murmurs
- Mitral regurgitation
- Tricuspid regurgitation
- Ventricular septal defect
Midsystolic ejection murmurs
- Innocent midsystolic murmurs
- Increased semilunar blood flow
- Aortic valve sclerosis
- Aortic outflow obstruction (AS etc)
Holosystolic murmurs
- Mitral regurgitation
- Tricuspid regurgitation
- Ventricular septal defect
Late systolic murmur
- Mitral valve prolapse
- Tricuspid valve prolapse
- Ischemic mitral regurgitation
Early diastolic murmur
- Aortic regurgitation
- Pulmonic regurgitation
- Left anterior descending artery stenosis
Mid-diastolic murmurs
- Mitral stenosis
- Prosthetic mitral valve
- Tricuspid stenosis
- Atrial myxoma
- Carey-Coombs murmur
- Austin Flint murmur
- Left-to-right shunts
Late diastolic murmurs
- Mitral stenosis
- Tricuspid stenosis
- Myxoma
- Complete heart block
CONTINUOUS MURMURS
Patent ductus arteriosus
Aortopulmonary window
Shunts
Arteriovenous fistulas
Coarctation of the aorta
Blowing holosystolic murmur
Heard best at the apex
Radiation to the axilla and inferior edge of left scapula.
Possible associated findings:
S2: wide physiologic splitting
S3
MR
An apical diastolic rumbling murmur in pure aortic regurgitation
Austin Flint
Soft holosystolic murmur
Heard best at the LLSB without radiation
Intensity increases with inspiration or pressure over liver
TR
Early diastolic
- high-pitched and “blowing.”
- decrescendo configuration like that of aortic regurgitation;
- differentiation is difficult if not impossible by auscultation alone.
- may increase in intensity during inspiration and can be more localized
- best heard over the left second and third interspaces.
Pulmonic insufficiency
Explanation: Pathologic pulmonic regurgitation is most frequently a result of pulmonic hypertension (Graham-Steell murmur) or residual after Tetralogy of Fallot repair in adults
Low frequency rumbling mid-diastolic murmur, with presystolic component possible
Heard best at apex
Accentuated in left lateral decubitus position
MS
Fixed aortic valve obstruction is distinguished from dynamic subaortic outflow tract obstruction by changes in the murmur with
Valsalva: AS goes down, HOCM goes up
Amyl Nitrite: Both go up
Handgrip: AS goes down, HOCM goes down
Squatting: AS goes up, HOCM goes down
Differentiate between MR and AS murmur in heart failure
MR murmur is pansystolic with radiation to axilla
Differentiate: PS and AS
- Pulmonary stenosis is usually congenital
- In adults, associated with carcinoid.
- PS murmur is best heard in upper LSB
- PS will cause RHF
Severe R from AS
- Severe TR: holosystolic murmur
- Best heard: lower sternal borders
- TR: V wave
Differntiate: AS from aortic sclerosis
- No symptoms
- Brief, not loud
Aortic stenosis murmur conducted to the apex with a musical quality
Gallavardin murmur
Harsh quality midsystolic murmur
Heard best LSB
Increases with decreased venous return
Possible associated findings:
- Sustained apical beat to palpation
- S4 (50% of the time)
HOCM
Differentiating SEM from a regurgitant murmur
Hand grip: decreases the intensity of the ejection murmur
Amyl nitrite: increases the intensity of the ejection murmur
Late systolic murmurs are most commonly caused by
MVP
Early diastolic murmur is usually due to
Aortic or pulmonic regurgitation
Timing of the Mitral stenosis murmur
mid-diastolic, late diastolic murmur, or both.
Causes of a continuous murmur include
- PDA
- Aortopulmonary window (rare, confusingly also refers to radiologic term)
- Some shunts
- AV fistulas
- Coarctation
Low-frequency diastolic sounds that appear to originate in the ventricles
S3, S4
S3, S4 are best heard with:
bell
Aortic, Pulmonary, Tricuspid and Mitral areas
- Aortic: 2 RICS
- Pulmonary: 2 LICS
- Tricuspid: 4 LICS
- Mitral: Apex
Beginning of the middle third of diastole, approximately 0.12 to 0.18 seconds after S2. “Kentucky” with the final syllable (“-CKY”) representing
S3
Significance of S3
- Normal under 40 years
- Normal in some trained athletes
- Should disappear before middle age.
- Re-emergence later: heart failure.
Significance of S4
Decreased left ventricular distensibility.
Thus, S4 is common in hypertensive heart disease, AS, and HOCM
Rx: blood pressure lowering in hypertensive emegency with CHF
IV nitroglycerine
Antihypertensives in pregnancy
- Methyldopa
- Labetalol
CAD.LipidMx
Patient with CAD+myalgias, mildly elevated CK
- Switch statin OR
- lower dose
CHB+Cardiomyopathy+clean coronary+ventricular tachycardias
Most likely Dx
Sarcoidosis
Ascending aorta aneurysm: size requiring surgery
5.5 cm
A 26-year-old woman with a history of hypertension characterized as difficult-to-control and depression is admitted to the hospital to mental health services for treatment of suicidal ideation. Before hospital admission, she was taking amlodipine, 10 mg daily; chlorthalidone, 25 mg daily; methyldopa, 500 mg twice daily; and sertraline, 100 mg daily. All of these medications have been continued during her hospitalization. She has now been hospitalized for 2 weeks, her mental health has stabilized, and she is ready for discharge. However, her systolic blood pressure has been approximately 150 to 170 mm Hg during most of her stay in the inpatient psychiatric unit. She has no physical complaints.
Her available outpatient records reveal similar blood pressure readings over the previous year. Other than the elevated blood pressure, her physical examination findings are normal. Her pulse rate is 70 beats/min, respiratory rate is 12 breaths/min, and BMI is 23.5 kg/m2.
Laboratory data, including serum sodium, potassium, creatinine, and TSH measurements, are normal.
In addition to arranging for an outpatient follow-up appointment in 4 weeks, which of the following is the best course of action for this patient who is being discharged from the hospital?
A. Discontinue sertraline and begin citalopram, 20 mg daily
B. Begin lisinopril, 10 mg daily, and measure serum renin and aldosterone levels
C. Begin losartan, 25 mg daily, and perform duplex Doppler ultrasonography of the renal arteries
D. Begin fosinopril, 10 mg daily, and order an outpatient polysomnography test
E. Begin metoprolol succinate, 25 mg daily, and measure plasma metanephrine levels
Begin losartan, 25 mg daily, and perform duplex Doppler ultrasonography of the renal arteries
Rationale: FMD is a “common” cause of secondary hypertension in young women. There is no hypokalemia to suggest hyperaldosteronism (choice C).
this class of drugs should be considered for patients whose blood pressure remains elevated after treatment with a 3-drug regimen to maximal or near maximal doses. Resistant hypertension may be associated with secondary causes of hypertension includin
spironolactone
An increasing body of evidence has suggested benefits of mineralocorticoid receptor antagonists, such as eplerenone and spironolactone, in improving blood pressure control in patients with resistant hypertension, regardless of circulating aldosterone levels.
