CARDIOVASCULAR USMLE PEARLS Flashcards
The Kussmaul sign
A sign characterized by distention of the jugular veins during inspiration (due to elevation of jugular venous pressure). Can be seen in patients with constrictive pericarditis, restrictive cardiomyopathy, right ventricular infarction, and tricuspid stenosis.
SLE symptoms
Joint pain, malar rash, and a discoid rash (erythematous patches with scaling and follicular plugging
Signs of acute pericarditis
The acute onset of low-grade fever and pleuritic chest pain that is aggravated by lying down (and thus improved by sitting up)
Pulsus paradoxus
A decrease of 18 mm Hg in systolic blood pressure during inspiration suggests pulsus paradoxus, which may be seen in cardiac tamponade, constrictive pericarditis, and in noncardiac diseases such as asthma, COPD, and tension pneumothorax.
A physical examination finding in which there is a pathologic decrease (> 10 mm Hg) in systolic blood pressure during inspiration. Classically associated with cardiac tamponade and constrictive pericarditis, but can also be seen in noncardiac conditions (e.g., massive pulmonary embolism, hemorrhagic shock, obstructive sleep apnea, obstructive lung disease).
Pericardial knock
A high-pitched, early-diastolic sound that sounds like a premature S3 and is often present in patients with constrictive pericarditis. Caused by the sudden slowing of blood flowing into the ventricle during diastole because relaxation of the ventricle is impaired by the rigid pericardial sac. The knock is best heard between the apex of the heart and the left sternal border.
Triphasic scratchy heart sound of varying intensity
A triphasic scratchy or squeaky heart sound on auscultation suggests a pericardial friction rub, which is highly specific for pericarditis. Acute pericarditis typically manifests with fever and pleuritic chest pain that is usually sharp in nature, improves on sitting and leaning forward, and often radiates to the shoulder. It is the most common cardiac manifestation of SLE, occurring in ∼ 25% of patients.
ECG changes include widespread ST-segment elevation and/or PR depression.
Jugular venous pulsation visible 9 cm above the sternal angle
Elevated jugular venous pulsation can be seen in cardiac tamponade or constrictive pericarditis, both of which are uncommon in SLE. Furthermore, other findings of cardiac tamponade, including dyspnea, hypotension, tachycardia, and jugular venous distention, would be expected. Constrictive pericarditis would cause signs of decreased cardiac output (fatigue) and fluid overload (jugular venous distention, Kussmaul sign).
Holosystolic blowing murmur best heard at the apex
Holosystolic blowing murmur best heard at the apex suggests mitral regurgitation. Libman-Sacks endocarditis, which is caused by noninfectious verrucous vegetations and is seen in SLE, favors the mitral valve and can result in mitral regurgitation. Most patients, however, are asymptomatic.
Holosystolic murmur in the 4th intercostal space along the left sternal border that gets louder during inspiration
A holosystolic murmur in the 4th intercostal space along the left sternal border that gets louder during inspiration is classic for tricuspid regurgitation. Tricuspid regurgitation, unlike other holosystolic murmurs (e.g., mitral regurgitation or ventricular septal defects), increases during inspiration. Inspiration causes a period of negative intrathoracic pressure, allowing for increased venous return to the heart, ultimately producing increased right ventricular stroke volume. This excess blood volume must be entirely ejected through the tricuspid valve, producing the increased intensity of the murmur. The left ventricle stroke volume is affected in the opposite manner with inspiration decreasing venous return from the pulmonary veins, leading to a reduction in left ventricular stroke volume. Consequently, the left-sided holosystolic murmurs of mitral regurgitation and ventricular septal defects do not augment with inspiration.
Why do tricuspid regurgitation murmurs get worse in inspiration?
Inspiration causes a period of negative intrathoracic pressure, allowing for increased venous return to heart, producing increased right ventricular stroke volume. Excess blood volume must be entirely ejected through the tricuspid valve, producing increased intensity of murmur.
Do left-sided holosystolic murmurs get worse with inspiration?
No.
Inspiration causes a period of negative intrathoracic pressure. The venous return from the pulmonary veins is less and that causes a reduction in left ventricular stroke volume. Therefore left sided holosystolic murmurs of mitral regurgitation and ventricular septal defects do not augment with inspiration.
