Cardiovascular Flashcards
PMI is usually heard where?
5th ICS mid-clavicular line
What conditions commonly cause displaced PMI?
Heart failure, cardiomyopathy, and pregnancy
How is PMI displacement different between cardiomyopathy and pregnancy?
In cardiomyopathy, it is usually displaced laterally >3cm
In pregnancy, usually displaced upward towards the left side
Deoxygenated blood enters the heart through what vessels and travels through which structures?
Inferior/Superior vena cava into the RA, tricuspid valve, RV, pulmonic valve, pulmonic artery, lungs and alveoli
Oxygenated blood exits the lungs and enters the heart through what vessel and travels through which structures?
Pulmonary veins, LA, mitral valve, LV, aortic valve, aorta, and general circulation
Which valves produce the S1 heart sounds heart during systole?
Atrioventricular valves (AV): Mitral, Tricuspid
Closure of the mitral and tricuspid valves produce which heart sound?
S1
Which valves produce the S2 heart sounds heart during diastole?
Semilunar valves: Aortic & Pulmonic
Closure of the aortic & pulmonic valves produce which heart sound?
S2
An extra sound, S3 is usually heard at what point in cardiac cycle and may indicate what condition(s)?
Just after S2, sounds like a faint whooshing. Generally due to ventricular filling such as HF, although can be normal in healthy children & adults <40yrs.
An extra sound, S4 is usually heard at what point and may indicate what condition(s)?
Just before S1 and is related to stiff, noncompliant ventricles. Usually indicated L. Ventricular Hypertrophy (LVH).
Can be normal in advanced age due to normal physiological stiffening of the ventricles.
High-pitched sounds such as mitral stenosis are best heard with what part of the stethoscope?
Bell
T/F, the diaphragm of the stethoscope is best to hear high pitched sounds?
False, is best for low-pitched sounds such as lung sounds, mitral regurgitation and aortic stenosis
A physiological S2 split is always a concerning finding, T/F?
False- it is a benign variant. It occurs during inspiration and disappears during expiration
Using the pneumonic, MR. ASS helps the examiner to remember which murmurs?
MR- Mitral Regurgitation
AS- Aortic Stenosis
SYSTOLIC
Using the pneumonic, ARMS helps the examiner to remember which murmurs?
Diastolic:
Aortic Regurgitation
Mitral stenosis
What are the murmur point landmarks?
2nd ICS RSB: Aortic 2nd ICS LSB: Pulmonic 3rd ICS LSB: Erb’s point 5th ICS LSB: Tricuspid 5th MCL: Mitral (Bicuspid) also PMI
When assessing murmur features, the pneumonic SCRIPT is used to organize what information?
S-Site heard C-character (soft, blowing, crescendo, descreshendo) R-Radiation I-Intensity (Grade 1-6) P-Pitch, low or high T-Timing, Systolic or Diastolic
A grade 3 murmur is found to be?
Loud, easily heard once stethoscope is placed on chest
A murmur that also has a palpable thrill is defined as what grade?
Grade 4
Grade 5 Murmur is defined as?
Very loud, will a thrill and audible with the edge of the stethoscope just off the chest
T/F a grade 1 murmur is very soft, barely audible and only under the best circumstances?
True
Which grade murmur is mild to moderately loud?
Grade 2
This murmur is called pansystolic (holosystolic). Sounds loud or blowing, best with the diaphragm. It heard at the apex of the heart (5th ICS/MCL) and may radiate into the axila.
Mitral Regurgitation (systolic)
A midsystolic ejection murmur that is harsh and loud, it is heard best with the diaphram over the 2nd ICS RSB with possible radiation into the neck is which murmur?
Aortic Stenosis (Systolic)
Patients with Aortic Stenosis should be advised about what risk?
To avoid physical exertion because of the risk of sudden death. Should be followed by a cardiologist.
Mitral Valve stenosis is what type of murmur?
Diastolic
This murmur is a low-pitched rumbling murmur heard during diastole (S2) at 5th ICS MCL with a sharp opening snap heard best w/ the bell?
Mitral Stenosis
A high-pitched diastolic murmur heard best at 2nd or 3rd ICS RSB or Erb’s point is indicative of?
Aortic Regurgitation
T/F benign murmurs may have a thrill?
False
The apex of the heart is also defined as this location?
5th ICS MCL
An apical murmur that occurs during S1 (systole) is what?
Mitral Regurgitation
An apical murmur that occurs during S2 (diastole) is what?
Mitral stenosis
A patient with S3 is suggestive of what disorder?
HF
A patient with S4 is suggestive of what disorder?
LVH
Where is the best place to hear a physiological split?
pulmonic area
New onset of murmur, chest pain, general malaise and fever, what condition must be suspected?
Bacterial endocarditis
IV drug abuse (or vascular port related) causes bacterial endocarditis affecting which valve? What pathogen is usually causative?
Tricuspid/ S. Aureus (acute bacterial endocarditis)
Non-IV port or drug abuse causes of bacterial endocarditis affects which valve? What pathogen is usually causative?
Mitral valve Strep Viridans (subacute bacterial endocarditis)
The CHA2DS2-VASc score is used in what condition to determine therapy?
Anticoagulant in A fib
What does the CHA2DS2-VAS2stand for?
C- CHF H- Hypertension A- Age >75 D- DM S- stroke/tia
V- Vascular disease
A- Age (65-75)
S-Sex (women higher risk)
What does a CHADS-VAS score of 2 or greater mean?
Patient should be anticoagulated
What work up should be ordered on a pt w/ new onset AFib?
EKG, BMP (renal, electrolytes), BNP (r/o HF), Troponin, TSH
And echo as well as holter monitor
What are the drugs of choice to control AF?
Beta blockers, CCBs and digoxin (much less so)
When a patient is started on warfarin therapy, what is the usual starting dose and how often is INR monitored?
5mg or less (frail or elderly should start at 2.5)
INR in 3 days, repeating every 2-3 until therapeutic level achieved
What is the goal INR for AF and how often is it checked in stable pt?
2-3, repeated every 4 weeks
What drugs can increase INR while on warfarin therapy?
Glucocorticoids, Fluoroquinolones, Macrolide, PCNS, azole antifungals, bactrim, statins, SSRI/SSNRI, tramadol, and fenofibrate
An alternative to warfarin, Direct-acting anticoagulants (DOACs) are now first line for a fib. What are some examples?
Pradaxa, Xarelto, Eliquis
What should patients with AF be advised about alcohol?
Abstinence lowers recurrence, especially amongst regular drinkers
What are the blocking drugs that are used to halt drug-related bleeding with Eliquis/Xarelto and Pradaxa?
Eliquis/Xarelto (Andexxa)
Pradaxa (Praxbind)
If INR is 4.01-4.99, what is the patient advised to do?
Hold 1 dose
When assessing mitral valve, have the patient move into this position to improve assessment?
Left lateral
When assessing aortic valves, having patient in what position is important to improve assessment?
Sitting up and forward
Prolonged hypertension leads to end organ micro vascular damage, how is this found in the eyes?
AV nicking, silver/copper wire arterioles, papilledema, and flame-shaped hemorrhages
Prolonged hypertension leads to end organ micro vascular damage, how is this found in the kidneys?
Microalbumin and proteinuria
Elevated CR and abnormal eGFR
edema
Prolonged hypertension leads to end organ micro vascular damage, how is this found in the heart?
LVH (S4) CHF (S3) Carotid bruits CAD/MI Decreased peripheral pulses
T/F, patients with sulfa allergies may be prescribed thiazide diuretics?
False
Mitral Regurgitation may lead to this disorder?
Mitral Valve Prolapse
MVP increases patients risk for this disorder(s)?
AFib, thromboemboli, TIA, ruptured chordate tendineae
What drugs used to treat hyperlipidemia should not be mixed with grapefruit juice?
Simvastatin, atorvastatin, and lovastatin
A patient who has syncope during exertion should be evaluated for what valvular disorder?
Aortic stenosis
Patient presents with harsh and noisy systolic murmur heard at 2nd ICS RSB that radiates to carotids is suspicious for what valvular disorder?
Aortic stenosis
T/F patients with aortic stenosis are at high risk for hypotension and syncope after nitroglycerin?
True
A diastolic murmur that is described as high pitched blowing decrescendo heard along 2nd-3rd ICS RSB or Erb’s point is what murmur?
Aortic regurgitation (insufficiency)
Rheumatic fever is the leading cause of the valve disorder?
Mitral stenosis
A holosystolic murmur described as heard at the apex radiating into the axila as a low-pitched rumbling with an opening snap is which disorder?
Mitral regurgitation (insufficiency)
Patients with mitral stenosis are at risk for what cardiac dysrhythmia?
A Fib
This systolic murmur is described as harsh, heard best at the apex with radiation into axila and back?
Mitral regurgitation (insufficiency)
T/F, mitral regurgitation is found in up to 70% adults without associated issue?
True
Pulmonary hypertension due to COPD commonly causes this valve disorder?
Tricuspid regurgitation
A high-pitched pansystolic murmur at 4th ICS parasternal that increases w/ inspiration and decreases with expiration is likely which valve disorder?
Tricuspid regurgitation
What is the most common cause of pulmonary stenosis?
Congenital abnormaliteis
A murmur described as a systolic ejection murmur at 2nd ICS LSB that radiates into the back increasing on inspiration is which valve disorder?
Pulmonary stenosis
Which murmurs are systolic, think MR Peyton Manning AS MVP.
Mitral Regurgitation
Physiological murmurs
Aortic stenosis
Mitral valve prolapse
Which murmurs as diastolic
Aortic Regurgitation
Mitral stenosis
A diastolic murmur that is described as low-pitched heard at the apex of the heart with an opening snap or crescendo sound would be?
Mitral Stenosis
T/F all diastolic murmurs are abnormal?
True
When a valve fails to close it is?
Incompetent (regurgitation)
When a valve fails to open it is considered?
Stenotic
Incompetent mitral valve can lead to?
Decreased cardiac output
T/F DHP CCBs do NOT decrease HR unlike non-DHP CCBs?
True, DHPs such as a amlodipdine and nifedipine do NOT cause bradycardia
How many of the following is needed to diagnose Metabolic Syndrome: truncal obesity, HTN, hyperlipidemia (triglycerides and LDL), FBS >100 or dx DM?
3
Patient presents with acute onset dyspnea, orthopnea, cough, and wheezing. Exam findings with crackles bibasilar, dullness to percussion and S3. What is the likely diagnosis?
Heart failure (left sided)
Patient presents w/ dysnpea, +JVD<4cm, hepatic and splenic enlargement, RUQ abd pain and LE edema. What is the likely diagnosis?
R. Sided HF
An acutely ill patient with high fever, chest pain and malaise is found to have subungal hemorrhages, petechia on palate, Janeway lesions (red spots on palmar surface and soles of feet), Osler nodes(painful nodes on fingers and toes) and Roth spots (retinal hemorrhages) and hematuria is suspicious for what disorder and what diagnostic test is indicated?
Bacterial endocarditis, Stat TEE
MVP is often associated with this connective tissue disorder?
Marfan’s Syndrome
Pt’s c/o weakness, cardiac rhythm strip shows HR in the mid 40s-60s. The PR interval continually lengthens until a QRS complex is dropped. What dysrhythmia is this?
Second degree Type 1
A rhythm strip shows a bradycardia rhythm where PR interval is consistently delayed and intermittently QRS is dropped, what rhythm is present?
2nd Degree HB- Type 2
In a 3rd degree HB, what is the P and QRS relationship? What are the common rates?
There is NO relationship, P to P interval is regular AND QRS are wide but regularly occurring. The rates are very low as the AV node only is firing- 20s-40s
Murmur heard over at 5th ICS MCL that has a mid-systolic click is which disorder?
MVP- often found with Marfan syndrome.
End
During S1(systole), stenosis can be found in which valves?
Mitral and tricuspid
During S2 (diastole), regurgitation can be found in which valves?
Aortic and Pulmonic
During S2 (diastole), stenosis can be found in which valves?
Mitral & tricuspid
