cardiovascular exam 3 Flashcards
in a healthy heart what is usually the PMI?
left ventricular impulse
what is the left ventricular impulse generated by?
generated by the movement of the ventricular apex against the chest wall during contraction
normal descriptors of left ventricular PMI
-location= fourth or fifth intercostal space at the midclavicular line
-diameter= discrete, or <2 cm
-amplitude= brisk and tapping
-duration= <2/3 of the systol
hyperkinetic ventricular impulse
from transiently increased stroked volume- does not necessarily indicate heart disease
sustained ventricular impulse
increased afterload, from chronic pressure load
diffuse ventricular impulse
increased preload; ventricular dilation from chronic volume overload
conditions that can accentuate S1
tachycardia, mitral stenosis
conditions that can diminish S1
-1st degree heart block, left bundle branch block, and myocardial infarction
-also can be caused by mitral valve closure occurring before ventricular contraction- this is seen in severe aortic regurgitation
what can cause varying S1
1-complete heart block
2-totally irregular rhythm (atrial fibrillation)
*mitral valve closure varies in loudness
what causes split S1
-delayed closure of tricuspid valve
-best heard along lower left sternal border
-more prominent split of S1 than normal occurs in right bundle branch block *must be distinguished from s4 and early systolic click
effect of respiration on physiologic splitting of S2
-normal splitting accentuated by inspiration which increases interval between a2 and p2
-splitting disappears on expiration
what is the diameter of the pmi in supine patients?
1-2.5 cm
when might the pmi be located on the right side of the chest?
dextrocardia
what is a PMI greater than 2.5 cm indicative of?
left ventricular hypertrophy, hypertension, dilated cardiomyopathy
where might the PMI be in COPD patients?
PMI may be in the xiphoid or epigastric area due to right ventricular hypertrophy
because of their location the mitral and tricuspid valves are often called what?
atrioventricular valves
what are the aortic and pulmonary valves often called?
semilunar valves bc valve leaflets are shaped like half moons
what do s3 and s4 sounds mean in adults
pathologic
correlated with systolic and diastolic heart failure
what heart sound correlated to an abrupt decelration of inflow across from the mitral valve?
s3
what heart sound corresponds to increased left ventricular end diastolic stiffness which decreases compliance?
s4
what sound does closure of the mitral valve and tricuspid valve in the right side of the heart produce?
s1
what accompanies the opening of aortic valves in some conditions?
an early systolic ejection sound
what does maximal left ventricular pressure normally correspond to?
systolic blood pressure
what produces the heart sound S2
aortic valve closure, as well as the closure of the pulmonic valves
when might the opening of the mitral valve be audible as a pathologic opening snap (OS)?
if the valve leaflet motion is restricted, as in mitral stenosis
when do right side cardiac events occur relative to the left side?
usually occur slightly later than those on the left
which component of S2 is normally louder and why?
A2, bc high pressure in aorta
does splitting of s1 vary with respiration?
no
what are heart murmurs attributed to?
they are attributed to turbulent flow and usually indicate valvular heart disease
what causes regurgitation?
when valves close abnormally
muscular contraction is as follows
first the atria then the ventricles
cardiac output
Stroke volume x heart rate
what are the two common manifestations of heart failure determined by?
ejection fraction (the percentage of ventricular volume ejected during each heartbeat and is normally 60%)
*HF with preserved EF
*HF with reduced EF
preload
load that stretches the cardiac muscle before contraction
afterload
degree of vascular resistance to ventricular contraction
myocardial contractility
ability of the cardiac muscle to shorten when given a load
causes of decreased ventricular preload
exhalation, dehydration, pooling of blood in capillary bed of the venous system
factors affecting blood pressure
-LV stroke volume
-distensibility of aorta and the large arteries
-peripheral vascular resistance, particularly at the arteriolar level
-volume of blood in arterial system
jugular venous pressure
reflects right atrial pressure=central venous pressure and RV end diastolic pressure
*best estimated from right internal jugular vein
3 peaks of jugular venous pulsations
a= atrial contraction
c= carotid transmission
v= venous filling
when do abnormally prominent cannon A WAVES occur?
-they occur in increased resistance to right atrial contraction: ex; 1,2,3 degree AV block, supraventricular tachycardia, junctional tachycardia, pulmonary hypertension, and pulmoniv stenosis
when are A WAVES absent?
atrial fibrillation
when do increased v waves occur?
occur in tricuspid regurgitation, atrial septal defects, and constrictive pericarditis
what causes peripheral edema?
fluid build up that can be caused by the right ventricle not moving blood adequately
what is the end result of all heart disease?
pump malfunction
the final category of heart disease is valvular heart disease. it usually presents without symptoms, but when symptoms are present they usually relate to…
a failing heart
common or concerning symptoms of the cardiovascular exam
-Chest pain
-Palpitations
-Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
-Swelling (edema)
-Fainting (syncope)
describe the symptoms that my occur in acute aortic dissection
Anterior chest pain, often tearing or ripping and radiating into the back or neck
describe common symptoms of WOMEN over 65 with acute coronary disorder
women, particularly those over age 65, are more likely to report atypical symptoms that may go unrecognized, such as upper back, neck, or jaw pain; shortness of breath; paroxysmal nocturnal dyspnea; nausea or vomiting; and fatigue, making careful history-taking especially important
what is increasingly used to describe the clinical syndromes caused by acute myocardial ischemia, which include unstable angina, non–ST elevation MI, and ST elevation infarction
acute coronary syndrome
serious dysrhythmias that do not produce palpitations
ventricular tachycardia
Sudden dyspnea occurs in
pulmonary embolus, spontaneous pneumothorax, and anxiety.
Orthopnea and PND (paroxysmal nocturnal dyspnea) occur in
left ventricular heart failure and mitral stenosis and also in obstructive lung disease
dependent vs anasarca edema
Dependent edema appears in the lowest body parts: the feet and lower legs when sitting, or the sacrum when bedridden. Anasarca is severe generalized edema extending to the sacrum and abdomen.
Ask, “Do you experience any nighttime episodes of sudden dyspnea that awakens you usually 1 or 2 hours after falling sleep, prompting you to sit up and stand up?” This is called
paroxysmal nocturnal dyspnea (PND)
what is syncope?
a transient loss of consciousness followed by recovery
The more concerning causes of syncope
The more concerning causes of syncope involve the heart not providing adequate blood flow to the brain, as occurs in end-stage heart failure and arrhythmias
In the physical examination of the cardiovascular system, remember to answer the following questions to assess the integrity of the pump:
Is the forward pump function normal?
Is the heart normal in size?
Is there evidence of valvular heart disease?
is there pulmonary edema?
key components of the cardiovascular exam
-Note general appearance and measure blood pressure and heart rate.
-Estimate the level of jugular venous pressure.
-Auscultate the carotids (bruit) one at a time.
-Palpate the carotid pulse including carotid upstroke (amplitude, contour, timing) and presence of a thrill.
-Inspect the anterior chest wall (apical impulse, precordial movements).
-Palpate the precordium for any heaves, thrills, or palpable heart sounds.
-Palpate and locate the PMI or apical impulse.
-Palpate for a systolic impulse of the right ventricle, pulmonary artery, and aortic outflow tract areas on the chest wall.
-Auscultate S1 and S2 in six positions from the base to the
apex.
-Identify physiologic and paradoxical splitting of S2.
-Auscultate and recognize abnormal sounds in early diastole, including an S3 and OS of mitral stenosis and an S4 later in diastole.
-Distinguish systolic and diastolic murmurs, using maneuvers when needed. If present, identify their timing, shape, grade, location, radiation, pitch, and quality.
A growing literature documents the poor reliability of clinic blood pressure measurements
Multiple averaged measurements improve precision, especially when using automated home and ambulatory blood pressure readings, which are more reliable, accurate, and better correlated with cardiovascular outcomes than clinic readings
how is the JVP best assessed
from pulsations in the right internal jugular vein, which is directly in line with the superior vena cava and right atrium
movement of JVP vs carotid pulse
The dominant movement of the JVP is inward, coinciding with the x descent.34 In contrast, the dominant movement of the carotid pulse, often confused with the JVP, is outward
JVP levels fall and rise with
JVP falls with loss of blood or decreased venous vascular tone and increases with right or left heart failure, pulmonary hypertension, tricuspid stenosis, AV dissociation, increased venous vascular tone, and pericardial compression or tamponade.
effect of JVP and position of pt
but your ability to measure the height of the column of venous blood, or JVP, differs according to how you position the patient.
distinguishing internal jugular and carotid pulsations
INTERNAL JUGULAR PULSATIONS
-Rarely palpable
-Soft biphasic undulating quality, usually with two elevations and characteristic inward deflection (x descent)
-Pulsations eliminated by light pressure on the vein(s) just above the sternal end of the clavicle
-Height of pulsations changes with position normally dropping as the patient becomes more upright
-Height of pulsations usually falls with inspiration
CAROTID PULSATIONS
-Palpable
-A more vigorous thrust with a single outward component
-Pulsations not eliminated by pressure on veins at sternal end of clavicle
-Height of pulsations not effected by position
-Height of pulsations not affected by inspiration
bruit
a murmur-like sound arising from turbulent arterial blood flow. Ask the patient to stop breathing for ∼10 seconds, then listen with the diaphragm of the stethoscope, which generally detects the higher-frequency sounds of arterial bruits better than the bell
it is important to auscultate the carotid arteries prior to palpating the carotid pulse.
As the presence of carotid atherosclerosis could potentially narrow the carotid arteries
The most feared complication of carotid artery palpation
is the dislodgment of an atherosclerotic plaque, which could result in stroke.
do Bruits
correlate with clinically significant underlying disease
no
Carotid artery stenosis causes ∼_____% of ischemic strokes and ______ the risk of coronary heart disease
10, doubles
A tortuous and kinked carotid artery may produce a
unilateral pulsatile bridge
causes of decreased pulsations include
decreased stroke volume from shock or MI and local atherosclerotic narrowing or occlusion.
why should you never palpate both carotid arteries at the same time?
may decreased bf to brain and induce syncope
what might pressure on the carotid sinus cause?
bradycardia or drop in BP
when is the carotid pulse thready and when is it bounding
The carotid pulse is small, thready (barely detectable), or weak in cardiogenic shock; the pulse is bounding in aortic regurgitation.
Pulsus alternans almost always indicates
severe left ventricular dysfunction.
pulsus alternans
In pulsus alternans, the rhythm of the pulse remains regular, but the force of the arterial pulse alternates because of alternating strong and weak ventricular contractions
what is the effect on cardiac upstroke seen in aortic stenosis?
it is delayed
what position might accentuate pulsus alternans?
the upright position
Paradoxical pulse or pulsus paradoxus
is a greater-than- normal drop in systolic blood pressure during inspiration.
paradoxical pulse is found in
is found in pericardial tamponade, a life-threatening condition. It is also (more commonly) found in acute asthma and obstructive pulmonary disease. It also occurs in constrictive pericarditis and acute pulmonary embolism.
To assess the PMI and extra heart sounds such as S3 or S4
ask the patient to turn to the left side—the left lateral decubitus position, which brings the ventricular apex closer to the chest wall. To bring the left ventricular outflow tract closer to the chest wall and improve detection of aortic regurgitation, have the patient sit up, lean forward, and exhale.
The relative intensity of S1 and S2
S1 is usually louder than S2 at the apex; S2 is usually louder than S1 at the base.
sounds before and after cardiac upstroke
Since the carotid upstroke always occurs in systole immediately after S1, sounds or murmurs coinciding with the upstroke are systolic
sounds or murmurs following the cartoid upstroke are diastolic
when is palpation less useful?
Palpation is less useful in patients with a thickened chest wall (obesity) or increased AP diameter (obstructive lung disease).
palpating s1 and s2
To palpate S1 and S2, using
firm pressure, place your right hand on the chest wall. With your left index and middle fingers, palpate the carotid upstroke to identify S1 and S2 just before and just after the
upstroke. S1 and S2 are usually not palpable
palpating s3 and s4
position the patient in the left lateral
decubitus position, then palpate the cardiac apex gently with one finger as the patient exhales and briefly stops breathing. By marking an X on the apex, you may be able to palpate these brief early and late diastolic ventricular movements that are synchronous with pathologic third and fourth heart sounds.
situs inversus totalis
the heart, trilobed lung, stomach, and spleen are on the right, and the liver and gallbladder are on the left.
dextrocardia with situs inversus
a rare congenital transposition of the heart, the heart is situated in the right chest cavity and generates a right-sided apical impulse. Use percussion to help locate the heart border, the liver, and stomach.
describing the apical impulse
It is always best to describe the apical impulse in relation to the midsternal or midclavicular line, or the anterior axillary line if the apical impulse is displaced
palpable S2,
also known as a “pulmonary artery tap,” points to
increased pulmonary artery pressure from pulmonary hypertension.
auscultating with the bell vs diaphragm
The diaphragm. The diaphragm is better for picking up the relatively high- pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs. Listen throughout the precordium with the diaphragm, pressing it firmly against the chest.
The bell. The bell is more sensitive to the low-pitched sounds of S3 and S4 and the murmur of mitral stenosis. Apply the bell lightly, with just enough pressure to produce an air seal with its full rim. Use the bell at the apex, then move medially along the lower sternal border.
fundamental prerequisite for identifying
events in the cardiac cycle.
The correct timing of systole and diastole
diastolic vs systolic murmurs
Diastolic murmurs usually represent valvular heart disease. Systolic murmurs point to valvular disease but can be physiologic flow murmurs arising from normal heart valves
Important Topics for Health Promotion and Counseling
-Challenges of cardiovascular disease prevention
-Health disparities in cardiovascular disease
-Assessing cardiovascular disease risk factors
Step 1: Screen for individual cardiovascular disease risk factors
Step 2: Calculate 10-year and lifetime global cardiovascular disease risk using a web-based calculator
Step 3: Address individual risk factors—hypertension, diabetes, dyslipidemias, metabolic syndrome, smoking, family history, and obesity
where does a murmur best heard in the right intercostal space usually originate?
at or near the aortic valve
how is the pitch of a murmur categorized?
high medium or low
where does the murmur or aortic stenosis usually radiate?
it usually radiates down the neck in the direction or arterial flow especially on the right side
where does the murmur or mitral regurgitation usually radiate?
it often radiates to the axilla supporting transmission by bone conduction
right sided and left sided murmurs usually increase w what part of respiration?
right sided= inspiration
left sided= expiration
what murmur is distinguished from all other murmurs by an increase in intensity during squatting-to- standing action (95% sensitivity, 84% specificity) and by a decrease in intensity during standing-to-squatting action (95% sensitivity, 85% specificity)
hypertrophic obstructive cardiomyopathy
“the square wave” response
In patients with severe heart failure, blood pressure remains elevated and there are Korotkoff sounds during the phase 2 strain phase, but not during phase 4 release, termed “the square wave” response
effect of isometric handgrip
increases the systolic murmurs of mitral regurgitation, pulmonic stenosis, and ventricular septal defect as well as the diastolic murmurs of aortic regurgitation and mitral stenosis
transient arterial occlusion
Transient compression of both arms by bilateral blood pressure cuff inflation to 20 mm Hg greater than peak systolic blood pressure augments the murmurs of mitral regurgitation, aortic regurgitation, and ventricular septal defect
murmurs differentiated from other systolic murmurs by augmentation of their intensity with handgrip and transient arterial occlusion
mitral regurgitation and ventricular septal defect
important topics for cardiovascular health promotion and counseling
-Challenges of cardiovascular disease prevention
-Health disparities in cardiovascular disease
-Assessing cardiovascular disease risk factors
Step 1: Screen for individual cardiovascular disease risk factors
Step 2: Calculate 10-year and lifetime global cardiovascular disease risk using a web-based calculator
Step 3: Address individual risk factors—hypertension, diabetes, dyslipidemias, metabolic syndrome, smoking, family history, and obesity
-Promoting lifestyle changes and risk factor modification
health behaviors of ideal cardiovascular health
Body mass index <25 kg/m2
Not smoking
Being physically active
Following a healthy diet
health factors of ideal cardiovascular health
Untreated total cholesterol <200 mg/dL
Blood pressure <120/<80 mm Hg Fasting blood glucose <100 mg/dL
screening for individual CV risk factors
Begin routine screening at 20 years for individual risk factors and for any family history of premature heart disease (age <55 years in first-degree male relatives and age <65 years in first-degree female relatives)
causes of secondary hypertension
Causes include obstructive sleep apnea, chronic kidney disease, renal artery stenosis, medications, thyroid disease, parathyroid disease, Cushing syndrome, hyperaldosteronism, pheochromocytoma, and coarctation of the aorta
risk factors of primary hypertension
risk factors include age, genetics, black race, obesity and weight gain, excessive salt intake, physical inactivity, and excessive alcohol use
