Cardiovascular System Flashcards
What ventricle occupies most of the anterior cardiac surface?
Right ventricle
What chamber of the heart produces the apical impulse?
Left ventricle
In supine patients the diameter of the PMI is approximately what size?
1 to 2.5cm
*A PMI greater than 2.5cm is evidence of left ventricular hypertrophy, or enlargement, seen in HTN and aortic stenosis
If you hear S3 and S4 in patients over the age of 40, what do you need to think of?
These signs are often correlated with heart failure and acute myocardial ischemia.
Closure of what valve produces S1?
Mitral valve
Normally, left ventricular pressure corresponds to what?
Systolic blood pressure
Closure of what valve produces S2?
Aortic valve
This term refers to the load that stretches the cardiac muscle before contraction?
Preload
This term refers to the ability of the cardiac muscle, when given a load, to shorten.
Myocardial contractility
This term refers to the degree of vascular resistance to ventricular contraction
Afterload
What do we call the difference between systolic and diastolic pressures?
Pulse Pressure
What are some factors that influence arterial pressure?
- Left ventricular stroke volume
- Distensibility of the aorta and the large arteries
- Peripheral vascular resistance, particularly at the arteriolar level
- Volume of blood in the arterial system
JVP reflects _____ _____ pressure?
right arterial
We know that women are more likely to present with atypical pain. Such as?
Upper back, neck, or jaw pain, shortness of breath, paroxysmal nocturnal dyspnea, nausea or vomiting.
Anterior chest pain associated with tearing or ripping, that radiates to the back or neck should make you think of?
Aortic dissection
Left lateral decubitus position accentuates what murmurs?
Mitral murmurs, especially mitral stenosis
The “leaning forward” position accentuates what murmurs?
Aortic murmurs, especially aortic regurg
Diastolic murmurs usually indicate?
Valvular heart disease
Systolic murmurs usually indicate?
Valvular heart disease but often occur when the heart valves are normal
Squatting Valsalva: Release phase
- What is the cardiovascular effect?
- What is the effect on mitral valve prolapse
- What is the effect on hypertrophic cardiomyopathy?
- What is the effect on aortic stenosis?
- a) Increased left ventricular volume from increased venous return to heart b) Increased vascular tone which increases arterial blood pressure and increases peripheral vascular resistance
- Decrease prolapse of mitral valve–delay of click and murmur shortens
- Decreased outflow obstruction and decreased intensity of murmur
- Increased blood volume ejected into the aorta, increased intensity of murmur
Standing Valsalva: Strain Phase
- What is the cardiovascular effect?
- What is the effect on mitral valve prolapse?
- What is the effect on hypertrophic cardiomyopathy?
- What is the effect on aortic stenosis?
- a) Decreased left ventricular volume from decreased venous return to heart b) Decreased vascular tone–decreased arterial blood pressure
- Increase prolapse of mitral valve, click moves earlier in systole and murmur lengthens
- Increased outflow obstruction and increased intensity of murmur
- Decreased blood volume ejected into aorta and decreased intensity of murmur
Where do you listen for murmurs?
- Aortic Valve Area–Second right intercostal space, right sternal border
- Pulmonic valve area–second left intercostal space left sternal border
- Tricuspid Valve Area–Fourth left intercostal space, left sternal border
- Mitral valve area–fifth intercostal space, left mid-clavicular line
Facts about Mitral Regurg:
Location: Apex
Radiation: To the left axilla, less often to the left sternal border
Intensity: Soft to loud; if loud, associated with an apical thrill
Pitch: Medium to high
Quality: Harsh, holosystolic
Aids: Unlike tricuspid regurgitation, it does not become louder in inspriation
Facts about Mitral Valve Prolapse:
Can be hereditary, autosomal dominant. Due to abnormal connective tissue–connective tissue can’t stretch.
Women are more symptomatic.
Mid to late systolic click, high-pitched murmur.
Lub-click-dub.
Occurs rights after S1.
Facts about Mitral Stenosis:
Very uncommon, due to rheumatic fever
Right after S2, lub-dub-snap
Leaflets fuse, fishmouth deformity
Left atrium enlarges due to the increased pressure to open the mitral valve
Diastolic murmur, low-pitched
Facts about Aortic Stenosis:
Most common cause: wear and tear
Crescendo-decrescendo murmur
S4 gallop common, harsh, low-pitched
Leads to LVH
BP will drop with exercise
What are some common etiologies of chest pain?
- Angina pectoris
- Myocardial Infarction
- Pericarditis
- Aortic dissection
- Pleuritic Pain
- Radiating pain from other causes
What is the first question you should ask when a patient presents with chest pain?
Can you please quantify the pain?
How severe is the pain? Is the pain pleuritic? Is the pain reproducible? Does it radiate? What was the patient doing at onset?
If a patient presents with shearing pain that radiates to the back, what should you think of?
Aortic dissection–and consider it an aortic dissection until proven otherwise
How is pleuritic pain commonly described?
Sharp, stabbing, unilateral, made worse with effort of deep breath.
If these symptoms are associated with fever, cough, shortness of breath, we should explore an infectious process–pneumonia
What term describes chest pain due to ischemia of the heart muscle–generally due to obstruction or spasm of the coronary arteries?
Angina Pectoris
How is angina pectoris pain described?
Tight, constricting type pain, “elephant sitting on my chest”
Dull, tight, pressing, squeezing, burning, heaviness, band across the chest, weight in center of chest are all adjectives/phrases used to describe?
Angina Pectoris
What associated symptom of angina pectoris is considered an “angina equivalent” and may be the only symptom?
Dyspnea
Where does angina pectoris often radiate to?
Left arm, left shoulder
Does pain typically worse with exertion or at rest?
Exertion, abating at rest
What are somer relieving factors for angina pectoris?
Rest and nitrates
Characteristics of chronic stable angina
- Predictably provoked by exertion
- Relieved by rest
- Etiology–chronic stable coronary stenosis
Characteristics of unstable angina:
- Occurs with minimal exertion and rest
- Pain is new in onset
- Pain is increasing intensity
- Etiology–associated with ruptured plaques and thrombi, causing obstruction
- Spasms may contribute
What term do we use to describe a symptom that a patient has instead of chest pain that may be indicative of CVD, myocardial infarction?
Angina Equivalents
What are examples of angina equivalents?
Shortness of breath, indigestion, weakness, and malaise
Do women typically present with chest pain?
Women are much less likely to present without chest pain, but with “equivalents”
Compared to ischemic pain, how does pericarditis present?
Sharper and more tearing, typically lasts for hours
What makes pericarditis worse?
Changing body positions, breathing
What are some risk factors for pericarditis?
Lupus, RA, kidney failure, cancer, trauma (steering wheel to the chest)
What relieves pericarditis pain?
Leaning forward–is worse laying down
What are some associated symptoms with pericarditis?
Fever, malaise
What do people typically experience before developing pericarditis?
Recent illness–typically viral
On physical exam, what do you often hear with your stethoscope?
Pericardial friction rub
How do we diagnose pericarditis?
May mimic myocardial infarction on ECG; ECHO helpful for detecting fluid
What is a dangerous complication of pericarditis?
Cardiac Tamponade
What is cardiac tamponade?
Pressure from fluid built up in pericardial sac that reaches the point where it restricts blood from returning to the heart
What is Beck’s Triad:
Low blood pressure, distended neck veins, and muffled heart sounds
Describe aortic dissection pain
Sudden onset of sharp ripping, tearing pain that typically radiates to the back or is felt in the back.
Pain can be constant or pleuritic
Can often be confused with MI, esophagitis, or pericarditis
What may you find on physical exam on someone with an aortic dissection?
Loss or delay of radial, femoral, pedal pulses when comparing one side to the other
Heart murmur–if it involves the aortic valve
If blood vessels exiting the aorta are damaged with dissection, paralysis or stroke may occur
What is the over-all mortality rate for aortic rupture?
80%
What are the risk factors for CAD?
- Hypertension
- Smoking
- Hyperlipidemia
- Diabetes
- Family History of premature CHD
What are risk factors for PE?
- Recent surgery
- Fractures
- Prolonged inactivity
- Oral contraceptive use
- Cancer diagnosis
What are risk factors for Aortic dissection?
- Hypertension
- Marfans Syndrome
- Ehlers-Danlos syndrome–extreme laxity of joints
- Polycystic kidney disease
- Pregnancy
- Cocaine use
What is the proper way to auscultate the heart?
Visualize the underlying structures
Sequence of the exam:
- Supine with head of bed elevated to 30 degrees
- Left lateral decubitis
- Sitting, leaning forward
S1 results from the closure of what valve?
Mitral valve (heard loudest at apex)
S2 results from closure of what valve?
Aortic valve
What sounds are heard during splitting of S2?
A2 and P2 (heard during inspiration)
S3 and S4 often correlate with what heart issues?
HF and MI
What is S3 caused by?
Caused by abrupt deceleration of inflow across mitral valve
What is S4 caused by?
Increased LV and diastolic stiffness
What sounds do we use the diaphragm of the stethoscope for?
High-pitched sounds of S1 and S2
Aortic and mitral regurg
Pericardial friction rubs
When sounds do we use the bell for?
Low-pitched sounds of S3 and S4
Mitral stenosis
What techniques can we use to better hear and identify murmurs?
Remember the locations on the chest wall to help identify the valve where it originates
Identify S1 and S2 to determine if murmur is systolic, diastolic, or pansystolic
What skin findings might we find with hypercholesterolemia?
Xanthomas
What cardiac biomarkers are released with myocardial cell death?
Troponins and CK-MB
Between troponin and CK-MB which one is more specific and sensitive for AMI?
Troponin
Elevation in the concentration of troponin or CK-MB is required for the diagnosis of?
AMI
How should we approach labs if we believe a person is having an AMI?
Check troponin at first presentation, if normal repeat at 4-6 hours, can repeat in 12-24 hours if high level of suspicion
When do troponin levels begin to increase?
Within 3-12 hours from pain onset, peak at 24-48 hours, return to baseline over 5-14 days
Should we wait for troponin levels before we start treatment?
No! Don’t wait. Not necessary for diagnosis in patient with ST-segment elevation on ECG and ischemic chest pain.
Pursue thrombolytic therapy or coronary angioplasty if warranted (even when troponins are pending)
What are some lab values we should obtain in someone with HF?
Check plasma concentrations of BNP and or N-terminal pro-BNP in patients with suspected HF?
What’s the problem with obtaining a BNP in patients with symptomatic HF?
Not all patients with symptomatic HF have high plasma BNP or NT-proBNP concentrations and not all asymptomatic patients have low values
How does dyslipidemia typically present?
Typically asymptomatic, but is common and an important predictor of CHD risk
When should we order lipid panels?
For screening purposes (primary prevention)
For monitoring purposes (secondary prevention)
What are goals for total cholesterol?
Goal for HDL?
> 60 mg/dl
Goal for LDL?
Goal for Triglycerides?
What are the 3 big things you do NOT want to miss?
Aortic dissection, PE, MI
What are some red flags that patients present with?
Severe, unrelenting sub-sternal pain
Unstable vital signs
Associated symptoms of moderate to severe shortness of breath
General survey reveals diaphoresis, anxiety
Patient voices feeling of impending doom
What are some major CVD risk factors?
Cigarette smoking, poor diet, family history of premature CVD, hypertension, diabetes, obesity, dyslipidemia, physical inactivity
What are some easy lifestyle changes we can make to avoid developing CAD?
Don’t smoke, have an optimal weight, low or no added salt in diet, regular aerobic exercise, moderate alcohol consumption, diet rich in fruits, vegetables, low-fat diary, fiber
Should we use a Holter monitor for people who are having frequent or infrequent episodes?
Frequent!
They push a button when they feel their symptoms.
Is the Holter monitor internal or external?
External
How long does the Holter monitor typically monitor?
Monitor continuous ECG for 24 to 48 hours
When do we use an event/loop monitor?
Useful for a patient who is having sporadic episodes.
External “card” or can be subcutaneous
How long does event/loop monitor, monitor?
Weeks
How long we use loop monitors for?
Loop monitors can be used for several years–goes underneath the skin
How much space should the heart take up in the chest?
2/3 of the heart on the left, 1/3 on the right
The heart should not take up more than half of the thoracic cavity
When you have CHF what are some things you may see on X-ray?
Interstitial edema, perihilar infiltrates, peribronchial cuffing, cephalization of vessels, and kerley B lines
What do perihilar infiltrates look like on x-ray?
Bat wings
What is peribronchial cuffing?
Fluid surrounding the bronchi. Looks like a clear circle on x-ray
What does cephalization of vessels refer to?
Redistribution of blood to upper lobe vessels
Increased pressure of interstitial fluid compresses lower lobe vessels
Recruitment of upper lobe vessels
Kerley B lines should make you think of what?
CHF
When will the heart appear falsely enlarged on x-ray?
During poor inspiration: higher diaphragm
With abdominal distention: pregnancy, ascities, etc.
Portable (AP) chest films
When may the heart appear deceptively small with x-ray?
Over-inflation of lungs: COPD
When do we sometimes get an obscured image?
Pulmonary effusion and pneumonia
Who should we reserve AP views for?
For patients who cannot stand upright. AP view shows magnification of the heart and widening of the mediastinum
Why are stress echo’s useful?
Useful to look for functional abnormalities under the stress of exercise.
What may we see on an abnormal stress echo?
Decreased wall motion secondary to ischemia
Exacerbation of valvular disorders
Decreased ejection fraction
What does standard stress testing typically reveal?
Reveals exercised induced ischemia–coronary artery disease
Stress induced cardiac arrhythmias
BP response to exercise
Patient’s functional capacity
Do men or women have a high rate of false positive stress test?
Women.
What HR are we trying to achieve during a stress test?
85% or higher of predicted max HR
What images are compared during a nuclear perfusion image?
Rest and stress images are compared
If we see we have a filling defect at rest on a nuclear perfusion image, what are we thinking is going on?
Evidence of an old MI
If we see we have a filling defect after exercise on a nuclear perfusion image, what are we thinking is going on?
Ischemia
What drugs do we use to perform a “chemical” stress test?
Dobutamine/persantine
Areas lacking perfusion reveal a filling defect where contrast does not perfuse
What does a multi-gated acquisition scan evaluate?
Evaluates ventricular function, wall motion, and volume (ejection fraction)
What is the “gold standard” for diagnosing coronary heart disease?
Coronary angiography
Also the most invasive
How is coronary angiography performed?
Catheter is inserted into femoral artery and advanced to origin of coronary arteries.
What are the pros and cons to coronary angiography?
Disadvantages: risk of bleeding, perforation, contrast
Advantage: can fix what’s broken, angioplasty and stent
What do we use ultrasound for?
Most commonly used in evaluation of carotids, aorta, and deep veins of lower extremities.
What do CTA and MRA provide us with?
Two and three dimensional imaging
When is CT/MRA useful?
Diagnosis of abdominal aortic aneurysm (AAA) and aortic dissection
How does AAA present on PE?
Typically found as pulsatile mass on exam
What should you order if you suspect AAA?
CT best if suspect leak
