Cardiovascular - Bates Flashcards
What part of the heart occupies most of the anterior cardiac surface?
Right ventricle
Where is the base of the heart?
At the right and left 2nd interspaces next to the sternum
Where is the apex of the heart?
Normally, in the 5th interspace, 7-9 cm lateral to the midsternal line
What does the PMI locate?
The left border of the heart
What is a normal PMI measurement?
1-2.5 cm in a supine patient (about the size of a quarter)
What does a PMI > 2.5 cm suggest?
LVH (left ventricular hypertrophy)
What does a mislocated PMI > 10cm lateral to the midsternal line suggest?
LVH (left ventricular hypertrophy)
Where might you hear the PMI in a patient with COPD?
At the xiphoid or epigastric area
Name the two atrioventricular valves
Mitral and tricuspid
Name the two semilunar valves
Aortic and pulmonic
An S3 or S4 in adults over 40 indicate what conditions?
HF and acute myocardial ischemia
What do you call the period of ventricular contraction?
Systole
What do you call the period of ventricular relaxation?
Diastole
Pressures in the left ventricle range from ___ to ___ mm Hg
< 5 to 120
What valves are open during systole?
Aortic and pulmonic
What valves are open during diastole?
Mitral and tricuspid
What defines the duration of systole and diastole?
S1 and S2
Which side of the heart usually has the lower pressure?
Right
What produces the sound of S1?
The closing of the mitral and tricuspid valves
What does LV end diastolic pressure correspond to?
Systolic blood pressure
What produces the sound of S2?
The closing of the aortic and pulmonic valves
The opening of the mitral valve is normally silent but may produce an audible “snap” in what condition?
Mitral stenosis
An S3 in children and young adults is most likely:
Normal ,due to rapid deceleration of blood into the ventricle
What is an S3 in older adults called?
A gallop
What does an S3 gallop or an S4 represent?
A change in ventricular compliance
What does S4 mark?
Atrial contraction just before the onset of ventricular systole
Right sided events occur slightly ___ than those on the left
Later
During which part of respiration would S2 most likely split?
During inspiration due to increased right heart fill time
Of the two components of S2, A2 and P2, which is louder?
A2 due to the high pressure in the aorta
Where is an S2 split heard best?
At the left 2nd or 3rd interspace, close to the sternum
Where is an S1 split heard best?
It is loudest at the apex
Does an S1 split vary with respiration?
No
Murmurs are different from heart sounds because they are _____?
Longer in duration
To what are murmurs attributed?
Turbulent blood flow
What has an abnormally narrowed valvular orifice that obstruct flow and causes a distinctive murmur?
Aortic stenosis
What allows blood to leak backward and prevents full closure causing a distinctive murmur?
Aortic regurgitation or insufficiency
Where are sounds and murmurs associated with the mitral valve usually heard?
At the apex of the heart
Where are sounds and murmurs associated with the pulmonic valve usually heard?
At the 2nd and 3rd left interspaces close to the sternum
Where are sounds and murmurs associated with the aortic valve usually heard?
From the right 2nd interspace to the apex
Where are sounds and murmurs associated with the tricuspid valve usually heard?
At or near the lower left sternal border
An ECG has twelve leads. Six of these are in the ___plane and the other six are in the ___ plane.
Frontal, transverse
Electrical vectors that approach a lead cause what kind of a deflection?
An upward or positive deflection
Electrical vectors that move away from a lead cause what kind of a deflection?
A downward or negative deflection
When vectors balance they cause what kind of a line?
Isoelectric or flat line
The P wave represents:
Atrial contraction or depolarization
The QRS interval represents:
Ventricular depolarization
The T wave represents:
Ventricular repolarization or recovery
The electrical impulse slightly ___ the myocardial contraction that it stimulates
Preceeds
What is the term for the volume of blood ejected from each ventricle during 1 minute?
Cardiac output (CO)
The CO is the product of what two measures?
Stroke volume and heart rate
Stroke volume depends on what three things?
1) preload
2) contractility
3) afterload
What is the name of the load that stretches the cardiac muscle before contraction?
Preload
What can increase RV preload?
Inspiration, increased volume of blood flow (exercise), dialated RV of HF
What can decrease RV preload?
Exhalation, decreased LV output, blood pooling in capillary beds or venous system
What term refers to the intrinsic ability of the heart to beat (or the ability of the muscles to shorten with a load)?
Contractility
What can increase contractility?
The SNS
What can decrease contractility?
A decrease in blood flow or decreased oxygen delivery to the muscles of the heart
What term refers to the degree of vascular resistance to ventricular contraction?
Afterload
What affects afterload?
The tone in the aorta, the large arteries and the peripheral vascular tree. Also the blood volume in the aorta.
Blood pressure in the arteries ___ during systole and ___ during diastole.
Peaks, falls
What is the term for the difference between systole and diastole?
The pulse pressure
What are the four factors that influence arterial pressure?
1) LV stroke volume
2) Distensibility of the aorta and large arteries
3) PVR, particularly in the arterioles
4) Volume of the in the arterial system
What provides an important index of right atrial heart pressure or central venous pressure?
Jugular venous pressure (JVP)
What best estimates the JVP?
Right internal jugular vein due to its direct channel into the right atrium
The “a” wave in the jugular veins represents what?
Atrial contraction
The “x” decent in the jugular veins represents what?
Atrial relaxation
The “v” wave in the jugular veins represents what?
Atrial filling - Inflow from the vena cava during RV systole
The “y” decent in the jugular veins represents what?
Atrial emptying - Passive blood flow into the right ventricle
What is a common vessel murmur to children and young adults?
Jugular venous hum
What vessel murmur is innocent in children but may be a sign of atherosclerosis in adults?
Cervical systolic murmur or bruit
What is the most common symptom of CHD?
Chest pain
What ethnic group is affected the most with CHD?
African Americans
Classic symptoms of exertional pain, pressure or discomfort to the chest, shoulder, back, neck, or arm are seen in what % of patients with AMI?
50%
What are some less common descriptors of AMI?
Cramping, grinding, pricking, or tooth/jaw pain
What is the term used to refer to any of the clinical syndromes caused by acute myocardial ischemia (unstable angina, non-STEMI, STEMI)?
Acute Coronary Syndrome
Who is likely to report atypical symptoms such as upper back, neck, or jaw pain, SOB, paroxysmal nocturnal dyspnea, N, V or fatigue?
Women, especially those >65
Anterior chest pain that radiates into the back or neck may be an indicator of what serious problem?
Acute aortic dissection
What is the term for an unpleasant awareness of the heartbeat?
Palpitations
What two types of patients frequently report palpitations?
Hyperthyroid and anxiety
What is the term for an uncomfortable awareness of breathing that is inappropriate to a given level of exertion?
Dyspnea
What is the term for dyspnea that occurs while lying down?
Orthopnea
Sudden dyspnea can occur in:
Anxiety, PE, spontaneous pneumothorax
With what conditions does orthopnea occur?
LVHF, mitral stenosis, obstructive lung disease
What is the term for sudden episodes of dyspnea and orthopnea that awaken the patient from sleep?
Paroxysmal nocturnal dyspnea (PND)
In what conditions does PND occur?
LVHF and mitral stenosis
PND may mimic what condition?
Nocturnal asthma due to wheezing and coughing
What is the term for the accumulation of excessive fluid in the extravascular interstitial space?
Edema
What are some causes of edema?
HF, hypoalbuminemia, position, kidney (nephrotic syndrome) or liver disease (ascites)
What remains the leading cause of death for women and men?
Cardiovascular disease
What group has the highest prevalence for HTN?
African American women (44%)
What is the most important risk factor for CVD at age 50?
Diabetes
An average 55 year old has what lifetime risk of developing HTN?
90%
The diagnosis of diabetes is based on what two values and numbers?
Fasting glucose > 126 mg/dL and HgA1C > 6.5%
What are the components of the metabolic syndrome? (must meet 3+)
1) Waist circumference
2) Fasting plasma glucose
3) HDL cholesterol
4) Triglycerides
5) Blood Pressure
JVP is not useful under what age?
12 years of age
What causes JVP to decrease?
Blood loss
What causes JVP to increase?
RHF, LHF, pulmonary HTN, tricuspid stenosis, pericardial compression or tamponade
How is the JVP measured?
The distance in centimeters above the sternal angle
What is a normal JVP?
< 3-4 cm above the sternal angle or < 8-9 cm above the right atrium
The “a” wave just precedes what?
S1
What can cause decreased carotid pulsations?
Decreased stroke volume or atherosclerosis
The upstroke of the carotid pulse should be ___.
Brisk
The carotid upstroke follows what?
S1 (precedes S2 during systole)
What is it called when the rhythm of the carotid pulse is strong but the force alternates?
Pulsus alternans
Pulsus alternans is best felt where?
The radial or femoral artery
Pulsus alternans almost always indicates what?
Left-sided heart failure
What happens in a parodoxical pulse?
There is a greater than normal drop in systolic blood pressure during inspiration
What does a paradoxical pulse usually indicate?
Pericardial tamponade, constrictive pericarditis or most commonly obstructive airway disease
What is a murmur like sound that sounds like a cat purring?
A bruit
What causes a bruit?
Turbulent blood flow
Sounds and murmurs coinciding with the carotid upstroke are ___.
Systolic
Sounds and murmurs occurring after the completion of the upstroke are ___.
Diastolic
What do you call a heart situated in the right chest?
Dextrocardia
A PMI with increased amplitude may show in what conditions?
Hyperthyroidism, severe anemia or pressure overload of the left ventricle
What should the amplitude of the PMI feel like?
Brisk and tapping
S2 is louder than S1 at what location?
At the base
S1 is louder than S2 at what location?
At the apex
What kinds of sounds does the diaphragm pick up?
high-pitched sounds ( S1 and S2)
What kinds of sounds does the bell pick up?
low-pitched (S3 and S4)
When the patient is in the left lateral decubitis position, listen with the ___.
Bell
When the patient is sitting up and leaning forward, listen with the ___.
Diaphragm
A systolic murmur falls between ___ and ___.
S1 and S2
A diastolic murmur falls between ___ and ___.
S2 and S1
Midsystolic murmurs arise from blood flow across what?
Aortic and pulmonic
Pansystolic murmurs occur with what?
Regurge or backflow across AV valves
A late systolic murmur indicates what?
Mitral valve prolapse
An early diastolic murmur occurs with?
Regurgitant flow across the semilunar valves
A middiastolic murmur picks up?
Turbulent flow across the AV valves
A continuous murmur may be present in what conditions?
Patent ductus arteriosus and AV fistulas
Crescendo murmurs grow ___.
Louder (mitral stenosis)
Decrescendo murmurs grow ___.
Softer (aortic regurg)
Crescendo-decrescendo murmurs ___ and ___.
Rise and fall (aortic stenosis)
Plateau murmurs retain ___.
Intensity (mitral regurg)
Murmurs are graded on a scale from ___ to ___.
1 to 6
Which murmurs tend to vary with respiration?
Right heart murmurs
Having a patient squat may help to identify what kind of murmur?
A prolapsed mitral valve (shortens) or to distinguish hypertrophic cardiomyopathy (decreased intensity) from aortic stenosis (increased intensity)
Having a patient valsalva while standing may help to identify what kind of murmur?
A prolapsed mitral valve (lengthens) or to distinguish hypertrophic cardiomyopathy (increased intensity) from aortic stenosis (decreased intensity)
