Cardiovascular anatomy 3

Question 1

Describe the x-descent of the jugular venous pulse

Answer 1

• Downward displacement of closed tricuspid of closed tricuspid valve during rapid ventricular ejection phase
• Reduced or absent in tricuspid regurgitation and right HF because pressure gradients are reduced

Question 2

Describe the v-wave of the jugular venous pulse

Answer 2

Increased right atrial pressure due to filling (“villing”) against closed tricuspid valve.

Question 3

The y-descent is prominent in?

Answer 3

Constrictive pericarditis

Question 4

The y-descent is absent in?

Answer 4

Cardiac tamponade

Question 5

Describe the y-descent

Answer 5

RA emptying into RV

Question 6

Constrictive pericarditis JVP features

Answer 6

The y-descent is prominent

Question 7

Cardiac tamponade JVP features

Answer 7

The y-descent is absent

Question 8

Atrial fibrillation JVP features

Answer 8

The a-wave is absent

Question 9

Types of heart sound splitting

Answer 9

Normal splitting Wide splitting Fixed splitting Paradoxical splitting

Question 10

Describe normal splitting

Answer 10

Inspiration -> drop in intrathoracic pressure -> increased venous return -> increased RV filling -> increased RV stroke volume -> increased RV ejection time -> delayed closure of the pulmonic valve Decreased pulmonary impedance (increased capacity of the pulmonary circulation) also occurs during inspiration, which contributes to delayed closure of the pulmonic valve

Question 11

Describe wide splitting

Answer 11

Seen in conditions that delay RV emptying (e.g. pulmonic stenosis, right bundle branch block)

Question 12

Wide splitting occurs in?

Answer 12

Causes delayed pulmonic sound (especially on inspiration) an exaggeration of normal splitting

Question 13

Describe fixed splitting

Answer 13

ASD -> left-to-right shunt -> increased RA and RV volumes -> increased flow through pulmonic valve such that, regardless of breath, pulmonic closure is greatly delayed

Question 14

Fixed splitting occurs in?

Answer 14

Heard in ASD

Question 15

Describe paradoxical splitting

Answer 15

Normal order of valve closure is reversed so that P2 sound occurs before delayed A2 sound, therefore on inspiration, P2 closes later and moves closer to A2, thereby paradoxically eliminating the split (usually heard in expiration)

Question 16

Paradoxical splitting occurs in?

Answer 16

Conditions that delay aortic valve closure (e.g. aortic stenosis, left bundle branch block), usually heard in expiration

Question 17

Where is the aortic valve best auscultated?

Answer 17

2nd intercostal space right sternal border

Question 18

Where is the pulmonic valve best auscultated?

Answer 18

2nd intercostal space left sternal border

Question 19

Where is the tricuspid valve best auscultated?

Answer 19

5th intercostal space left sternal border

Question 20

Where is the mitral valve best auscultated?

Answer 20

5th intercostal space left mid-clavicular line

Question 21

Where is aortic stenosis best auscultated?

Answer 21

Right 2nd intercostal space right sternal border

Question 22

Where is aortic valve sclerosis best auscultated?

Answer 22

Right 2nd intercostal space right sternal border

Question 23

What part of the cardiac cycle does aortic regurgitation occur?

Answer 23

Diastolic murmur

Question 24

Where is aortic regurgitation best auscultated?

Answer 24

3rd intercostal space left sternal border

Question 25

Where is pulmonic regurgitation best auscultated?

Answer 25

3rd intercostal space left sternal border

Question 26

Where is hypertrophic cardiomyopathy best auscultated?

Answer 26

3rd intercostal space left sternal border

Question 27

What part of the cardiac cycle does pulmonic regurgitation occur?

Answer 27

Diastolic murmur

Question 28

When is the murmur of hypertrophic cardiomyopathy best heard?

Answer 28

Systolic murmur

Question 29

Where is pulmonic stenosis best auscultated?

Answer 29

2nd intercostal space left sternal border

Question 30

Where is Atrial Septal Defect best auscultated?

Answer 30

2nd intercostal space left sternal border

Question 31

Where is tricuspid regurgitation best auscultated?

Answer 31

5th intercostal space left sternal border

Question 32

Where is a ventricular septal defect murmur best auscultated?

Answer 32

5th intercostal space left sternal border

Question 33

Where is tricuspid stenosis best auscultated?

Answer 33

5th intercostal space left sternal border

Question 34

What part of the cardiac cycle does Tricuspid regurgitation occur?

Answer 34

Holosystolic murmur

Question 35

What part of the cardiac cycle does a ventricular septal defect murmur occur?

Answer 35

Holosystolic murmur

Question 36

What part of the cardiac cycle does Tricuspid stenosis occur?

Answer 36

Diastolic murmur

Question 37

What part of the cardiac cycle does mitral regurgitation occur?

Answer 37

Holosystolic murmur

Question 38

What part of the cardiac cycle does mitral valve prolapse occur?

Answer 38

Systolic murmur

Question 39

What part of the cardiac cycle does mitral stenosis occur?

Answer 39

Diastolic murmur

Question 40

Where is mitral regurgitation best auscultated?

Answer 40

5th intercostal space left mid-clavicular line

Question 41

Where is mitral valve prolapse best auscultated?

Answer 41

5th intercostal space left mid-clavicular line

Question 42

Where is mitral stenosis best auscultated?

Answer 42

5th intercostal space left mid-clavicular line

Question 43

What effect does inspiration have on heart sounds?

Answer 43

Increases venous return to the right atrium and increases the intensity of right heart sounds

Question 44

What effect does hand-grip have on heart sounds?

Answer 44

Increases afterload and thereby increasing the intensity of MR, AR and VSD murmurs Decreases the intensity of hypertrophic cardiomyopathy and AS murmurs In mitral valve prolapse, there is an later onset of the click/murmur

Question 45

What effect does the Valsalva maneuver have on heart sounds?

Answer 45

Decreases the intensity of most murmurs (including AS) Increases the intensity of hypertrophic cardiomyopathic murmurs In mitral valve prolapse there is an earlier onset of click/murmur

Question 46

What effect does rapid squatting have on heart sounds?

Answer 46

Increases venous return, increases preload, increases afterload Decreases the intensity of hypertrophic cardiomyopathic murmurs In mitral valve prolapse there is a later onset of click/murmur

Question 47

What are the systolic murmurs?

Answer 47

Aortic stenosis pulmonary stenosis Mitral regurgitation Tricuspid regurgitation VSD MVP Hypertrophic cardiomyopathy

Question 48

What are the diastolic murmurs?

Answer 48

Aortic regurgitation Pulmonic regurgitation Mitral stenosis Tricsupid stenosis

Question 49

Describe the murmur of aortic stenosis?

Answer 49

Crescendo-decrescendo systolic ejection murmur and soft S2 (ejection click may be present) LV >> aortic pressure during systole. Loudest at the heart base; radiates to carotids. “Pulsus parvus et tardus” - pulses are weak with a delayed peak. Can lead to syncope, angina and dyspnea on exertion (SAD). Most commonly due to age-related calcification in older patients (> 60 years old) or in younger patients with early-onset calcification of bicuspid aortic valve.

Question 50

Common cause of Aortic stenosis

Answer 50

Age-related calcification in >70 years old or a congenital bicuspid aortic valve <70 years old