Cardiovascular

Question 1

Pack Year Hx Formula

Answer 1

• # of cig packs (20 cigs in pack) x # of smoking yrs = pack yr

Question 2

Chest pain (CP) or chest discomfort ⇒ often signals…

Answer 2

CAD

Question 3

Anterior chest pain, often tearing or ripping, radiating to back or neck ⇒ indicates…

Answer 3

acute aortic dissection

Question 4

Acute coronary syndrome

Answer 4

• any of clinical syndromes caused by acute MI, including…
  
  • unstable angina
  • non-ST elevation MI (minor coronary artery is blocked ⇒ blocks blood supply to heart)
  • ST elevation infarction (major coronary artery is blocked ⇒ blocks blood supply to heart)

Question 5

Causes of palpitations

Answer 5

• irregular heartbeat
• rapid acceleration or slowing of heart
• increased forcefulness of cardiac contraction

Question 6

CP causes

Answer 6

• MI
• aortic dissection (when aorta start to split open)
• pero/myo/endo-carditis (infection of diff heart layers)

Question 7

Orthopnea

Answer 7

• dyspnea that occurs when pt is lying down
• Improves when pt sits up
• Make sure that reason pt uses extra pillows or sleeps upright is SOB and no other causes

Question 8

Paroxysmal nocturnal dyspnea (PND)

Answer 8

• episodes of sudden dyspnea and orthopnea that wakes pt from sleep, usually 1-2 hours after going to bed, prompting them to sit up, stand up, or go to window for air
• May have associated wheezing and coughing
• Episode usually subsides but may recur at abt same time on subsequent nights

Question 9

Dependent edema (what + causes)

Answer 9

• appears in lowest body parts– feet and lower legs when sitting or sacrum when bedridden
• Causes:
  
  • cardiac (HF)
  • peripheral vascular disease
  • nutritional (hypoalbuminemia)
  • positional

Question 10

Peripheral edema indicates…

Answer 10

HF

Question 11

Apical Impulse/Point of maximal impulse (PMI)

Answer 11

• point on chest wall where heart’s impulse can be most strongly felt, which is typically located near the apex of the left ventricle
• Abnormal: if you can’t find pulse in that spot ⇒ displaced ⇒ might be cardiomyopathy (enlarged heart) or HF
• Apical impulse easily palpated in children and slender adults
• As anteroposterior chest diameter increases ⇒ harder to palpate apical pulse
• Obesity/thick chest wall makes apical pulse palpation difficult
• Most prominent precordial impulse may not be at apex of left ventricle
  
  • In pts w/ COPD, most prominent palpable impulse (PMI) may be in xiphoid or epigastric area as result of right ventricular hypertrophy

Question 12

S1

Answer 12

• closure of mitral valve produces this sound
• In some pathological conditions, early systolic ejection sound (Ej) accompanies opening of aortic valve
• Decreased sound in ⇒ first-degree heart block
• “Lub” sound in “lub-dub” heart sound

Question 13

S2

Answer 13

• closure of aortic valve produces this sound
• May hear opening (OS) sound after S2 if valve leaflet motion restricted ⇒ like in mitral stenosis
• Decreased sound in ⇒ aortic stenosis
• “Dub” sound in “lub-dub” heart sound

Question 14

S3

Answer 14

• rapid deceleration of column of blood filling and pounding against ventricles’ walls
• associated w/ HF
• Often heard in children and young adults as a “third heart sound” + in elite athletes
• In older adults, called “S3 gallop” ⇒ indicates pathologic change in ventricular compliance like too much fluid as in HF

Question 15

S4

Answer 15

• atrial contraction to force blood to left ventricle makes this sound
• Happens before S1
• Associated w/ CAD
• Indicates atherosclerotic disease (hardening of arteries) ⇒ snapping sound bc atrium is losing elasticity
• Means there’s pathologic change in ventricular compliance
  
  • Compliance: ease w/ which heart muscle relaxes as it fills w/ blood
  • Poor compliance ⇒ produces stiff ventricle w/ reduced ability to expand as it receives blood
• normal in adults

Question 16

Murmurs

Answer 16

• swishing-like, longer duration sounds due to turbulent blood flow
• Associated w/ S1 or S2
• Indicates valve problems
• best heard in 2nd right intercostal space, often originating at/near aortic valve
• Cause: Stenotic valves can cause this bc abnormally narrowed valvular orifice that obstructs blood flow like in aortic stenosis ⇒ causes murmur
  
  • loud murmur aortic stenosis often radiates to neck in direction of arterial flow, esp on right side
  • Stenosis: narrowing
  • If aortic valve is narrowed ⇒ produces turbulent blood flow
• Regurgitant murmur: when valve fails to fully close like in aortic regurgitation or insufficiency ⇒ lets blood leak backward in retrograde direction ⇒ regurgitant murmur

Question 17

Split Sounds

Answer 17

• Split S1: split closing of mitral and tricuspid valves
  
  • earlier mitral sound: louder, means high pressures on left side of heart, heard loudest at cardiac apex
  • later tricuspid sound: softer, heard best at lower sternal border
• Split S2: split closing of aortic and pulmonic valves during inspiration
  
  • During inspiration, filling time of right heart increases ⇒ increases stroke volume and lengthens duration of right ventricle compared to left ventricle ⇒ delays closure of pulmonic valve P2 ⇒ splits S2 into two audible components
    
    • Stroke volume: amt of blood ejected by ventricle w/ each heartbeat
  • Hard to hear in obese pts or ppl w/ increased anteroposterior diameter chest walls

Question 18

Auscultation Points (aortic, pulm, erb’s, tricuspid, mitral)

Answer 18

• Aortic valve: 2nd intercostal space to right of sternal border
• Pulmonic/Pulmonary valve: 2nd intercostal space to left of sternal border
• Erb’s point: 3rd intercostal space to left of sternal border
• Tricuspid valve: 4th intercostal space to left of sternal border
• Mitral valve: 5th intercostal space midclavicular line

Question 19

Inspection/ Palpation of JVP

Answer 19

• What: JVP palpation gives info abt pt’s volume and cardiac status by showing pressure of right atrium
• If pt has JVD/↑ JVP elevate bed to → 45, 60, 90*
• If pt has ↓ JVP → have pt lie flat to see neck veins
• Abnormal: ↑ JVP of 98% specific for ↑ left ventricular end-diastolic pressure and ↓ left ventricular ejection fraction

Question 20

Jugular Venous Distention (JVD)

Answer 20

• what: increased jugular venous pressure due to increased blood volume
  
  • Jugular Venous Pressure (JVP): right atrial pressure
• causes
  
  • HF
  • ↑ central venous pressure
  • tricuspid stenosis
  • superior vena cava obstruction
  • constrictive pericarditis
  • anything that interferes w/ filling of right atrium or movement of blood to right ventricle

Question 21

Left Sided HF

Answer 21

• Comes in diastolic or systolic forms
• Systolic HF: left ventricle can’t contract normally ⇒ ↓ ejection fraction of < 40% (norm is 50%) = ↓ amt of blood that comes from left ventricle w/ each pump
  
  • Cause: CAD w/ MI Hx
  • Lower ejection fraction you get ⇒ more fatigued you get + higher incidence of depression
• Diastolic HF: left ventricle can’t relax properly ⇒ preserved ejection fraction
  
  • Cause: aging heart muscles
• S&S:
  
  • SOB/DOE (dyspnea on exertion)
  • Crackles/Rales at bases: crackles start at base and works way up bc of gravity and fluid in lungs
  • Tachypnea: ↑ RR
  • Diaphoresis: excessive sweating due to fluid retention
  • Weight gain
  • Fatigue
  • Extra heart sounds
  • Mental status changes: depends on severity
  • Capillary refill > 3 secs

Question 22

Right Sided HF

Answer 22

• what: seeing more congestion of fluid backing up in periphery
• S&S:
  
  • Hepatomegaly
  • Splenomegaly
  • Ascites
  • Dependent pitting edema
  • Edema in lower extremities, likely pitting
  • ↑ JVD (Kussmaul’s sign)
  • Weight gain: bc of fluid retention
  • Anorexia: can progress to cardiac cachexia bc pt just don’t have appetite to eat
  • Extra heart sounds: S3 associated w/ HF

Question 23

Coronary Artery Disease (CAD)

Answer 23

• what: buildup of plaque within coronary arteries ⇒ can lead to MI
• S&S: Angina pectoris: CP related to CAD but person doesn’t actually have MI

Question 24

Pericarditis

Answer 24

• inflammation of pericardium (sac-like tissue that surrounds and protects heart)
• Usually rare and will resolve on its own
• S&S:
  
  • CP that can radiate to left shoulder
    
    • May be relieved w/ leaning forward
  • SOB when reclining
  • Palpitations
  • Low-grade fever
  • Cough
  • Weakness/Fatigue
  • Lower extremity edema ⇒ can lead to cardiac tamponade (abnormal accumulation of fluid between layers of pericardium ⇒ places pressure on heart and possibly impairing cardiac pumping function in severe cases)
• Causes/Risk Factors:
  
  • MI
  • Inflammatory disorders
  • Trauma to chest wall
  • Viral

Question 25

Myocarditis

Answer 25

• what: inflammation of heart muscle/myocardium ⇒ affects heart’s electrical system and muscle cells
• S&S:
  
  • If mild ⇒ may be asymptomatic
  • CP
  • SOB
  • Arrhythmia
  • Lower extremity edema
  • Fatigue/Malaise (if severe ⇒ can lead to HF, MI, sickle cell)
• Causes/Risk Factors:
  
  • Infection (viral, bacterial, fungi)
  • Drug rxn
  • Inflammatory disorders

Question 26

Endocarditis

Answer 26

• what: life-threatening inflammation of cardiac lining/endocardium (lining of heart’s chambers and valves) ⇒ can damage heart valves
• S&S:
  
  • New onset murmur
  • Pallor
  • Diaphoresis
  • SOB
  • CP while breathing
  • Malaise
  • Unintentional weight loss
  • Nausea
  • Splenomegaly
• Causes/Risk Factors: Sepsis

Question 27

Valvular Defects

Answer 27

• what: can occur in any 4 valves of heart
• Abnormal heart ⇒ regurgitation occurs or airway stenosis (leads to murmur)
• Pt can live like this for a while and ⇒ may progress to cardiomyopathy or HF
• S&S:
  
  • CP
  • SOB
  • Murmur
  • Not feeling well / ill-appearing

Question 28

Arrhythmias

Answer 28

W/ arrhythmias of atrium like in A-fib ⇒ blood starts to pool ⇒ heart doesn’t pump efficiently ⇒ clotting ⇒ clots get stuck in smaller vessels bc clots can travel and get stuck in heart (causes MI), lungs (causes pulmonary embolism), brain (causes stroke)

Question 29

Midsystolic murmur

Answer 29

• Begins after S1 and stops before S2
• Cause: blood flow across semilunar (aortic and pulmonic) valves

Question 30

Pansystolic (Holosystolic) murmur

Answer 30

• Starts w/ S1 and stops at S2 w/o gap between murmur and heart sounds
• Cause: regurgitant (backward) flow across atrioventricular valves

Question 31

Late Systolic murmur

Answer 31

• Starts mid or late systole and persists up to S2
• Cause: mitral valve prolapse and often, but not always, followed by systolic click

Question 32

Early Diastolic murmur

Answer 32

• Starts immediately after S2 w/o discernible gap and usually fades to silence before nxt S1
• Often w/ regurgitant flow across incompetent semilunar valves

Question 33

Mid- Diastolic murmur

Answer 33

• Starts short time after S2 and fades before next S1
• Means: turbulent flow across atrioventricular valves

Question 34

Late Diastolic (Presystolic) murmur

Answer 34

• Starts late in diastole and usually continues up to S1
• Means: turbulent flow across atrioventricular valves

Question 35

How to Document CP

Answer 35

• If pt has MI + CP ⇒ pt won’t be able to pinpoint where pain is ⇒ pain more diffuse throughout chest
  
  • Pt would describe pain as “feeling like there’s an elephant sitting on chest”
• If pt has crushing chest pain w/ pain radiation to left arm ⇒ MI (🚩)
• If pt has CP that gets worse when moving around/changing positions ⇒ likely musculoskeletal issue
  
  • If musculoskeletal issue ⇒ pt can pinpoint pain
• If pt has CP that increases w/ activity and trying to get more oxygen but pain keeps increases ⇒ more serious issue
• NV, diaphoresis (excessive sweating not caused by exercise or hot temps), palpitations, SOB, CP ⇒ identify first if it’s an MI

Question 36

How to Document Murmurs

Answer 36

• Timing & Duration: at what part of cycle is murmur heard? Is it associated w/ S1 or S2 or is it continuous?
• Pitch: high/low-pitched? (low best heard w/ bell)
• Quality: type of sound: harsh, raspy, vibratory, musical, blowing?
• Intensity Grades 1-6:
  
  • 1: barely audible, faint, heard only after being “tuned in,” maybe not heard in all positions
  • 2: quiet but clearly audible, heard immediately after placing stethoscope on chest
  • 3: moderately loud
  • 4: loud w/ palpable thrill
  • 5: very loud w/ easily palpable thrill, may be heard w/o stethoscope
  • 6: very loud w/ palpable and visible thrill, don’t need stethoscope to hear it
• Location: where is murmur heard loudest?
  
  • Murmurs originating in right side of heart ⇒ tend to vary w/ respiration more than left-sided murmurs
• include respiration and pt position

Question 37

BP Categories

Answer 37

• normal: < 120 / < 80
• elevated: 120 - 129 / < 80
• HTN stage 1: 130 - 139 / 80 - 90
• HTN stage 2: 140 + / 90 +
• HTN Crisis: 180 + / 120 +

Question 38

red flags

Answer 38

• If pt has crushing chest pain w/ pain radiation to left arm ⇒ MI
• CP w/ activity
• BP of 180 + / 120 + (HTN Crisis)

Question 39

age-related considerations INFANTS

Answer 39

• At birth they have…
  
  • Closure of ductus arteriosus
  • Closure of foramen ovale
• Murmurs common 48hrs after birth bc of closures of ductus arteriosus and ovale
• Benign S3 common
• Sinus arrhythmias common w/ inspiration and expiration
  
  • Rhythm itself varies: may speed up w/ inspiration and slow down w/ expiration

Question 40

age-related considerations CHILDREN & OLDER ADULTS

Answer 40

apical impulse (PMI) should be easily palpated

Question 41

age-related considerations PREGNANCT WOMEN

Answer 41

• Normal
  
  • Blood vol increases 40-50% from pre-pregnancy lvls ⇒ ↑ increased cardiac output, HR, edema
  • ↑ CO2 and HR
  • Split S1 sound heard
  • S3 sound heard
  • Systolic ejection murmur (SEM) heard over pulmonic region (2nd intercostal space to left of sternal border)
• Monitor for Abnormalities
  
  • Pre-eclampsia: ↑ BP and proteinuria ⇒ seizures ⇒ death of fetus and mother
  • Eclampsia: seizures ⇒ death of fetus and mother
  • Peripartum cardiomyopathy: heart enlarges near delivery time

Question 42

age-related considerations GERIATRICS

Answer 42

• ↓ Myocardium size
• Left ventricle wall thickens
• ↓ stroke volume (SV), CO2, myocardial elasticity
• More difficult to find apical impulse due to ↑ AP diameter
• S4 more common
  
  • Caused by atherosclerosis, MI, or aging ⇒ need to investigate pt-specific cause
• Exercise may reverse or slow some age related changes

Question 43

Prevention of CVD

Answer 43

• Aspirin usage monitor
  
  • 40 - 59 yo ⇒ higher risk for CVD so use cautiously
  • 60+ yo ⇒ not recommended bc of bleeding risks
• Diet: Cholesterol & Lipid management
  
  • DM management so that fasting glucose lvl is < 110 mg/dL and HgA1c is < 7%
• Conversion of Afib to normal sinus rhythm or, if chronic, put on anticoagulants
• DM (II) and metabolic syndrome increases person’s risk for CVD ⇒ monitor those