cardiology II Flashcards
what are the characteristics of typical angina/
o Typical angina: substernal chest discomfort with the following features
• Oppressive quality (described as “squeezing, pressure, heaviness”) not sharp or stabbing, minute(s)duration
• Provoked by exertion or emotional stress
• Relieved by rest and nitroglycerin (within several minutes)
what are the ischemic causes of angina/
CAD, critical aortic stenosis, severe HTN, coronary spasm, hypertrophic cardiomyopathy, severe pulmonary HTN,
what are the extra cardiac causes of angina/?
Anemia, hypoxia, hyperthyroidism, hyperviscosity,
what are the non cardiac causes of angina/?
GI, pulmonary, musculoskeletal psych
what are the MC causes of acute chest pain?
are acute cardiac ischemia=MI, Unstable angina, stable angina
what is the best way to understand a pts CP?
have them describe it in their own words
what are the close ended questions to ask after a patient describes CP in their own words and what is its significance?
chest pain right now? (acute or chronic) does the chest pain prevent you from doing things you would normally do? (impact on physical activity–stable or unstable)
when evluating someone with angina, what RFs should you consider?
• Check RFs for DM, smoking, HTN, hyperlipidemia, FH of premature CAD, postmenopausal status, PVD, cocaine abuse
these sx of CP reduce the likelihood of what? o Pleuritic chest pain, chest pain reproduced by palpation, sharp or stabbing chest pain, positional chest pain also 1) very brief pain
reduce the likelihood of MI
what are some alarm sx of palpitations and their significance?
syncope or presyncope (if in SVT its fast enough to reduce CO), FH of sudden cardiac death or known arrhythmia, meds that prolong QT (may have started an arrhythmia by landing on QT interval) , hx of heart disease, valvular or hypertrophic or dilated cardiomyopathy
how should you get a detailed description of a pts heart palpitations?
have them tap it out, have them describe the circumstances eliciting it, ask about associated sx, ask about meds, sx: a pounding neck is a “frog sign’ meaning the atria and ventricles are contracting at the same time. a sensation of a skipped beat or flip flopping usually means a premature systole and a compensatory pause.and forceful contraction afterwards.
how often should risk factors for CVD be checked in people over 20?
FH: regularly; smoking, diet, alcohol, activity, BMI, BP, waist circumference, pulse (for afib) at each routine visit (q 2 years or so)
HTN accounts for •
____ of all Mis and strokes
_____ of all episodes of heart failure
_____ of all premature deaths
35%; 49%, 24%
what are some risk factors for HTN?
physical inactivity
microalbuminuria or estimated GFR less than 60 mL/min
family history of premature CVD (
what are the recommended lifestyle modifications for preventing cardiovascular disease and stroke? (hint: they are the same for preventing or managing HTN)
o Optimal weight, or BMI of 18.5-24.9
o Salt intake of less than 6 Gm NaCl or 2.4 Gm of Na/day
o Vigorous exercise at least 30 min/day, 3 days/wk.
o Limit alcohol consumption to
when can s1 be accentuated?
• S1 can be accentuated in tachycardia, rhythms with a short PR (the ventricles contract and close the valve before it can on its own) or in high cardiac output states like exercise, anemia, hyperthyroidism because they have a lot of blood and close it quickly
when can s1 be diminished?
• S1 can be diminished in first degree heart block (delayed conduction to ventricles causes valve to close on its own a little bit already) or if the mitral valve is calcified and relatively immobile like in mitral regurgitation or when left ventricular contractility is markedly reduced like in CHF or coronary artery disease
when is the pulse felt relative to s1?
the pulse is felt right after s1 is heard, because s1 is caused by the ventricles contracting the blood out that causes the pulse
when do you hear s3?
o Occurs after the mitral valve opens and the ventricle fills rapidly causing stretching of the chordae tendinae or possibly from blood decelerating and hitting the ventricular wall.
o Can be normal or physiologic in people under age 40 and is common in the third trimester of pregnancy
• Because there is increased blood volume
• If they are not super athletic or pregnant its probably pathologic
• Think about volume overload
o Past age 40, it is pathologic and indicates volume overload or heart failure.
why/when will the s4 heart sound be heard?
o Occurs just before s1.
o Sound made by the contraction of the atria and blood being forced into a stiff or hypertrophic ventricle.
o Thought to be due to stiff myocardium with decreased compliance.
• You actually hear the blood going into the ventricle because the ventricle can’t stretch
o May be normal in athletes and the elderly.
o Usually heard best at the PMI in the left lateral position.
o Usually is pathologic and causes include:
• Hypertensive heart disease
Need to manage our pts with HTN
Causes ventricles to toughen up
• Coronary artery disease
• Aortic stenosis
Can’t get blood as easily through aortic valve
• cardiopmyopathy
o Will sound like “tennessee”
when will you hear a varying s1?
• S1 will vary in 3rd degree heart block because atria and ventricles are contracting independlty of each other; or heard in irregular rhythms like fib
what are the rep’s for exercise for a 5-10 yo?
- 5 - 10 y Moderate to vigorous physical activity every day (Grade A) Strongly Recommend
- 5 - 10 y (cont) Limit daily leisure screen time (TV/video/computer)(Grade B)Strongly Recommend
- 5 - 10 y (cont)Supportive actions: Prescribe moderate to vigorous activity 1 h/d with vigorous intensity physical activity on 3 d/wk
- Limit total media time to no more than 1-2 hours of quality programming per day
- No TV in child’s bedroom
- Take activity and screen time history from child once a year
- Match physical activity recommendations with energy intake
- Recommend appropriate safety equipment relative to each sport
- Support recommendations for daily physical education in schools
what are the rep’s for exercise for a 11-17 yo?
• 11 -17 y Moderate to vigorous physical activity every day (Grade A)Strongly Recommend
• 11 -17 y (cont.)Limit leisure time TV/video/computer use (Grade B)Strongly Recommend
• 11 -17 y (cont.)Supportive actions:
Encourage adolescents to aim for 1 h/d of moderate to vigorous daily activity, with vigorous intense physical activity on 3 d/wk
• Encourage no TV in bedroom
• Limit total media time to no more than 1-2 hours of quality programming per day
• Match activity recommendations with energy intake
• Take activity and screen time history from adolescent at health supervision visits
• Encourage involvement in year-round, physical activities
• Support continued family activity once a week and/or family support of adolescent’s physical activity program
• Endorse appropriate safety equipment relative to each sport.
what are the rep’s for exercise for a 18-21 yo?
• 18 - 21 y Moderate to vigorous physical activity* every day. (Grade A)Strongly Recommend
• 18 -21 y (cont)Limit leisure time TV/video/computer. (Grade B)Strongly Recommend
• 18 -21 y (cont)Supportive actions:
Support goal of 1 h/d of moderate to vigorous daily activity with vigorous intense physical activity on 3 d/wk
• Recommend that combined leisure screen time not exceed 2 h/d
• Activity and screen time history at health supervision visits
• Encourage involvement in year-round, lifelong physical activities
what can we do as clinicians to prevent CVD in our pts?
• As clinicians, we can aggressively manage patient’s disease and risk factors in an effort to reduce further mortality and morbidity.
: The innermost layer of the heart that lines the chambers of the heart and valves.
• Very smooth
endocardium
he period of the cardiac cycle where blood is ejected from the ventricles.
systole
The period of the cardiac cycle where blood enters a relaxed heart.
diastole
in what stage of the heart cycle do the coronary arteries receive their blood?
diastole
The amount of blood ejected from the left ventricle in one contraction.
stroke volume
Cardiac chest pain precipitated by stress or physical exertion and alleviated by rest and/or nitroglycerin.
• Basically a starving muscle
• The demand for 02 and nutrients exceeds its supply
• Hurts when ischemic
• When HR goes up (i.e. when shoveling or something) and blood flow should go up but it doesn’t because they have blockages in their coronary arteries
•
angina
Shortness of breath precipitated by physical activity.
• Esp associated with myocardial ischemia
• Always keep cardiac patho on your ddx!
dyspnea on exertion
Shortness of breath precipitated by being in a supine position.
• Assos with volume overload from CHF or from kidney dysfunction
• Have hx of not being able to sleep flat
• Feel SOB
orthopnea
what are the risk factors for CVD that can be in the social hx?
smoking
diet/nutrition
alcohol consumption
illicit drugs, especially stimulants (meth, cocaine make HR go up and cause vasoconstriction of peripheral vascular system) and IV drugs
• coronary artery vasospasm from stimulant substances (prinz metal)
• IV users—not cleaning skin—introducing strep and staph
o Have a high suspicious for CVD because of pericarditis those bacteria tend to lodge there
o Often share needles as well
what are non modifiable risk factors that put you at risk for CVD
age >65, male, african american,mexican american, asian americans, some american indians
what are the modifiable risk factors that put you at risk or CVD?
SMOKING, high cholesterol, HTN, stress, DM, overweight/obesity, alcohol consumption, diet and nutrition
what are the associated sx of an MI?
o Associated symptoms: Particularly N&V (nausea and vomiting), Diaphoresis (super sweaty, ashen, not from exercising), SOB, impending doom (a real thing—when you are interviewing a pt and they say they feel like they are going to die—most likely they are right!!, take that complain VERY VERY SERIOUSLY. Make sure they are close to you and you are watching them)
what comprises the peripheral vascular system?
all vessels outside of the heart; in clinical practice viewed as all vessels outside the thorax
what are the 3 kinds of peripheral blood vessels?
arteries, veins,lymphatics
what do the lymphatics do?
- Network of vessels that collect serum leaked into the interstitial tissues in the area of the capillaries.
- Drain back into the venous circulation to re-join the circulating blood volume.
- Contain lymph nodes that filter contaminants prior to re-joining the blood.
The palpable distention of the arteries corresponding with cardiac contraction.
pulse
Palpable turbulence of flow within a vessel.
• Esp if abnormal connection between an artery and a vein
• Palpable
• called a bruit if you feel it with your stethoscope
thrills
Palpable pulsations over an abnormally distended organ.
• Like if hepatomegaly—and we feel between ribs with fingertrips we may feel pulse but not pushing fingers away and pushing out from underneath ribs
heaves
Ischemic pain in an extremity exacerbated by exercise or exertion.
• Blockages in blood vessels from atherosclerosis or exertion
• Often described as cramping in the back of the calves (charley horse)
• 2nd most common is buttocks and thighs
• usually it’s a very well described distance, not variable
• and progressive over time
claudication
Peripheral swelling caused by poor venous and lymphatic return that when pushed on leaves dents
pitting edema
Description of stagnant venous return, usually from the lower extremities.
• Venous is very low pressure, may be hard to fight gravity so it stays in lower extremities
• Can cause dermatitis
stasis
A clot within a vessel.
thrombus
A clot that breaks free and moves through the circulation from its original location to another
embolus
what kinds of things should be included in a peripheral vessel exam?
assess for extremity pain, pallor, swelling, changes in hair skin patterns, color of feet, trendelenburg sign, homan’s sign, ankle/brachial index, sores that do not heal?
what kinds of questions should you ask for evaluating the peripheral vessels?
claudication, cold interolerance, color changes (pallor) pain or cramping in legs with exercise (if so, how far can you go, how long does it take to be alleviated?) sores on hands or feeet that do not heal, change in hair growth on legs, pain or cramping while at rest, FM of DM, high chol, HTN, coagulopathy. hx of vasoactive substances like nictoine, diet pills (sympathomimetcis), illicit drugs, occupation (cold exposure or excessive vibration can irritate nerves and cause vasoconstriction) swelling of lower extremities?
what kinds of questions regarding the PMH or FM should be asked when evaluating PAD?
o Inquire about history of diabetes, hyperlipidemia, smoking, hypertension, coagulopathy, etc.
o Inquire about known cardiac disease.
• Vascular disease is not specific to the heart.
o Uncover any similar episodes the patient has had and any associated evaluation, treatment and response.
• Did they get better or worse after? Did they get drastically worse after getting better for a while?
o Review medications
what kinds of things do we look for in a PE for a cardiovascular pt?
inspection: non healing wounds (at rest or with ulcer/gangrene) dry/hard=let it fall off, if wet/moist, blisteringabnorma, arterial ulcers (“punched out” wound that failed to heal at termination of arterial supply, painful, little bleeding), may have hair losson legs, may have skinny chicken legs, pallor; palpation: lower extremity pulse, thrills, temp, texture, edema may have neuropatic pain if nerves get no blood, paralysis, paraesthesia, critical limb ischemia (5 ps: pain, pallor, parasthesia, pulseless, paralysis); auscultation: bruits
what are the special tests you can perform in a cardiovascular test?
homans (claudication), allens (potency of ulnar and brachial arteries) ankle brachial index,
what kinds of things do we want to negotiate with a pt about their tx plan?
1) the tx we want to do 2) how to tx modifiable risk factors
can we have a profound impact on our pts health as just a provider?
yes; they listen to us more than any other sources
what are some important things to consider when negotiating a tx plan or giving recommendations?
- Let them know we are the authority but that we are on their side
- What we want is in their best interest
- Present them with clear factual data
what supplies do you need with you for a cardiovascular PE?
stethoscope, ruler and something to cross it(JVP), tangential lighting and good lighting in the room, doppler, BP cuff, bed with 30 degrees, quiet room, draping supplies, reflex hammer
what do you assess in a general survey of a pt?
health, nutritional status, weight/BMI, hydration, age, skin lesinos/track marks/places that haven’t healed
from which side should you always do cardiovascular exams?
right side
where is the apical impulse located?
above the 5th intercostal space and in the midclavicular line
what are you looking for with palpation?
heaves, Pmi, thrills,
what do palpable heaves indicated?
often right ventricular hypertrophy
how are thrills best felt?
through the ball of your hand or the ulnar aspect of your hand or your metacarpal phalange joints if it is really hard to feel
after which sound can the carotid pulse be felt?
just after s1 (after mitral valve closes but while aortic valve is open)
how do you palpate s1 and s2?
keep right hand on chest and left hand on carotid pulse–you will feel the pulse right after s1. s2 will be right
what does a palpable aortic valve sound indicate?
dilated aorta or aortic aneurysm
in which cases would a pulmonary artery pulse be palpable?
if the pulmonary artery is dilated or if it is carrying increased blood flow.
in which case would you feel a palpable s2?
pulmonary HTN
what 4 things are you assessing for with PMI?
o Note the characteristics of the apical impulse:
• Location
Which intercostal space, where at in mcl
• diameter
usually the diameter of our fingertip
anything more than that is enlarged (>3 cm indicateds left ventricular enlargement)
• duration
should be very brief if from left ventricle pumping away
if sustained duration, probably suggests sustained PMI
• amplitude
intensity of the tap
what characteristics of a PMI warrant further investigation?
if sustained for half of systole or >3 cm
what can you do if a pts chest hair is interfering with ausculatating/
wet the area or apply KY jelly
what is a helpful way to start when percussing females?
start laterally and move medially
will you be able to hear the valves better downstream or upstreaM/
downstream
should the bell be pressed gently or firmly against the skin?
gently–firmly makes it like a diaphragm
what causes the s3 heart sound?
rapid deceleration of blood against l ventricle wall or pathologic in older adults of stiff ventricles with no compliance
sitting up and leaning forward accentuates which heart sounds?
pericardial rubs, aortic stenosis and aortic regurgitation (brings base closer to chest)
which position is best for hearing s3, s4 and mitral stenosis? which part of the stethoscope should you use?
the left lateral decubitus position, best to the use the bell these are low frequency sounds
what sounds are accentuated by someone standing or straining in valvsalva?
intensity of mitral valve prolapse and hypertrophic cardiomyopathy, decreases intensity of aortic stenosis (all this because it increases arterial BP and venous return to heart
what sounds are accentuated by someone in the squatting and release phase of valsalva? (increases BP and venous return to heart)
intensity of aortic stenosis, decreases intensity of mitral valve prolapse and hypertrophic cardiomyopathy
what things are very important to assess when evaluating a murmur?
o systolic vs. diastolic
o duration: early, pan (all the way across) or late
o pitch: high, medium, low
o quality: harsh, rumbling, blowing
o intensity: eg. crescendo, decrescendo (starts loud and dissipates), crescendo-decrescendo, plateau
o precise location the murmur is best heard
o areas of radiation: eg. axilla, carotids
o variation with respiration and/or change of position
o other associated sounds: S3, S4, ejection click, opening snap (clicks and snaps from stenotic heart valves)
o grade of murmur (table next slide
what are the gradings for heart murmurs?
- 1/6 =very faint; not always heard in all positions
- 2/6 =quiet but not difficult to hear
- 3/6 =moderately loud
- 4/6 =loud +/- thrills
- 5/6 =very loud +/- thrills; may be heard with stethoscope partly off chest
- 6/6 =may be heard with stethoscope completely off chest; +/- thrills
blood pools down from wound to feet=?
stasis dermatitis
where do you assess for abdominal aorta bruits?
abdominal aorta, listen in the midline, 3-5 cm above the umbilicus for bruits and a little bit to the l
what does an elevated jugular venous pulse mean?
if elevated, means volume overload or right atrial congestion
what are the different significances of ABI/
o 0.9 to 1-normal
o 0.75 to 0.9-moderate disease
o 0.5 to 0.75-severe disease
when should you clean your stethoscope?
after each pt with alcohol or at least after if it got wet or someone had an infectious sdisease
when can s1 be accentuated?
in tachycardia, rhythms with a short PR (the ventricles contract and close the valve before it can on its own) or in high cardiac output states like exercise, anemia, hyperthyroidism because they have a lot of blood and close it quickly
when can s1 be diminished/
diminished in first degree heart block (delayed conduction to ventricles causes valve to close on its own a little bit already) or if the mitral valve is calcified and relatively immobile like in mitral regurgitation or when left ventricular contractility is markedly reduced like in CHF or coronary artery disease
• If a2 is louder in the right second interspace, this is usually because of _______ from increased pressure load
systemic HTN
• Decreased or absent a2 in right second interspace occurs from ________
calcific aortic stenosis
• Increased intensity of p2—when p2 is equal to or louder than a2, suspect __________first, then a dilated pulmonary artery and an atrial septal defect.
pulmonary HTN
• Decreased or absent p2 is usually from the ____________from aging. Can also result from pulmonic stenosis
increased anteroposterior diameter of the chest
when is s3 (heard after s2) normal? where is it heard best?
athelte, 3rd trimester pregnancy, people under age 40; heard best over left lower sternal border
where is s4 often heard best?
at the PMI in the left lateral decubitus position
what causes the s4 heart sound?
o Sound made by the contraction of the atria and blood being forced into a stiff or hypertrophic ventricle.
o Thought to be due to stiff myocardium with decreased compliance.
are mid systolic murmurs pathologic?
can be, but not always
are pan systolic murmurs pathologic? what is th e most common cause of them?
yes–caused from blood flowing from a high pressure chamber to a lower pressure one through a structure that should be closed; most common cause is mitral or tricuspid valve regurgitation
when and why are systolic clicks heard? and usually followed by what?
usually mid or late systolic from mitral valve prolapse (think the contracting should be closing the valve but not all the way) and they are usually followed by a late systolic murmur from mitral regurgitation
what is the clinical significance of a venous hum?
its benign–and is common in young children as flow in the jugular veins is turbulent
