CV and PV system Flashcards
What do you monitor when measuring peripheral pulses?
How they feel. If you can feel them, are they symmetric?
Heave
amplitude is elevated upon palpation
Thrill
Feels like a vibration and is from a valve problem
What does the left lateral decubitus accentuate?
Mitral murmurs
What does valsalva accentuate?
Aortic murmurs and pericarditis
what is a bruit
Noise from turbulence within an artery outside the heart itself
- Typically lower pitch and softer
- Usually best heard with the bell
grading murmurs
1/6: very faint
2/6: quiet, but can easily be heard if in quiet room
3/6: moderately loud
4/6: loud, with palpable thrill
5/6: very loud, thrill, can be heard with stethoscope partially off chest
6/6: very loud, thrill, can be heard with stethoscope OFF the chest
Turbulence
Any arterial area where bruit or murmur is heard, there is turbulence.
Indicates a vulnerable area for atherosclerosis lesions and potential for clots to form
Valvular problems that may cause murmurs or bruits
- Papillary muscle tear or rupture
- Chordae tendonae rupture
- Congenital malformation fibrosis annulus or leaflet
Common causes of murmurs or bruits
Benign- Still’s
patent ductus
septal defects- ASD, VSD
artery stenosis
Less common causes of murmurs or bruits
- Tetraology of Fallot
- Abdominal Aneurysm
- Hyperthyroid state
- Obstructive Hypertrophic cardiomyopathy
S1
Mitra and tricupsid closures. Signals onset of systole
Closely timed with the carotid pulse
S2
Aortic and pulmonic closures. Signals onset of diastole
Causes of S1
May be normal variant ( if heard at LSB) or abnormal from RBB or PVC
Right bundle branch block
There is a delay or absence of conduction along the RBBB after it branches from the bundle of His. This delays conduction through the ventricle on that side creating separate timing for left and right ventricular contraction which then changes the valve timing.
Split S2
May be normal, increasing with inspiration, decreasing with expiration (2-3rd ICS)
Abnormal in pulmonic stenosis or RBBB (no respiratory variation)
S3
Early diastole, closely follows S2
- Best at apex in left lateral decubitus
Occurs at the transition of rapid to slow ventricular filling, ventricular wall is inadequate to accommodate the inflow of blood.
LV myocardial damage causing systolic dysfunction from dilated cardiomyopathy. Due to sudden limitation of normal ventricular relaxation during filling stage in diastole.
Often present in mitral regurgitation
S4
Just before S1, very late diastole just after atrial contraction
Best heard in left lateral decubitus
Caused by vibration of LV from the atrial kick trying to pump the last of the blood in but instead hitting less compliant ventricular wall.. Due to thickening of ventricular walls form a higher work load, and some stiffening.
Ejection click
A sound occuring at the moment of maximal pressure with sudden tensing of a valve root.
If annulus isn’t tight, it will move a little bit due to the pressure
Aortic ejection click
Early systolic- at onset of left ventricular ejection, aortic root suddenly stretched
Due to dilated aorta
Aortic stenosis
Systolic crescendo-decrescendo
- Transmits sound to carotid arteries
Pathology: rheumatic disease, congenital bicupsid valve, calcification of valve
Symptoms: Dyspnea on exertion, angina, and syncope . S4
Aortic regurgitation
- Early diastolic, high pitch blowing decrescendo murmur from initial high pressure back flow through a more narrow orifice
- Dilates the left ventricle (S3) and can cause high pulse pressure and brisk carotid pulse
Pathology of aortic regurgitation
Rheumatic disease
Congenital bicupsid valve
Endocarditis
Pulmonic valve ejection click and pathology
- Sudden root tensioning. Very early systole
Pathology: HTN, aneurysm dilating the root
Pulmonary valve stenosis or regurg can alter stress on root of valve causing click
Systolic crescendo-decresendo murmur
Pulmonary stenosis
Symptoms: exertional dyspnea, chest pain, syncope. Can dilate RV and cause S4
Graham Steell Murmur
Pulmonary regurg
Identical to aortic regurg, but not as loud.
Pathology: anything that causes pulmonary HTN
Tricupside stenosis
Diastolic low pitch rumble
Tricupside regurgitation
Early to holosystolic at left sternal border
Will not radiate to left axilla
Inspiration increases RV filling, accentuating the murmur
Pathology: Ebstein congenital anomaly is a very thin valve structure predisposing to failure. Severe failure can enlarge right atrium increasing risk for arrhythima.
Mitral valve opening snap
Occurs in diastole
When stenotic mitral leaflets are tethered athte orofice but still mobile, as left ventricular emptying lowers intraventricular pressure below the left atrium, they snap into the LV space momentarily before atrial blood flows in
Mitral valve stenosis
diastolic murmur, can be with opening snap
can result in pulmonary htn, JVD, and RV hypertrophy
What causes mitral snap and stenosis?
Rheumatic heart disease
Mitral valve proplapse
Click and murmur
leaflet prolapse = click mitral regurge = murmur
High pitch, short murmur
Mitral insufficiency
Valsalva
Lowers atrial volume.
Standing has same affects
What is mitral valve prolapse associated with?
Unexplained association with anxiety or panic attacks, and palpitations are not an uncommon complaint.
Very uncommonly associated with CHF and sudden death
Holosystolic murmur
mitral valve regurg
can radiate to the left axilla
Symptoms of hypertrophic obstructive cardiomyopathy
- Exercise induced dyspnea
- Angina
- Syncope
Responsible for sudden cardiac death in young athletes
When is murmur intensified in hypertrophic obstructive cardiomyopathy?
By standing from a squat of valsalva maneuver
Study of choice for hypertrophic obstructive cardiomyopathy?
Resting echocardiography
What is important to look for in sports physicals
hypertrophic obstructive cardiomyopathy- even without hearing initial murmur due to sudden death potential with exertion
What is the only systolic ejection murmur that increases in intensity during valsalva?
hypertrophic obstructive cardiomyopathy
LV volume falls, stroke volume falls, walls collapse in, narrows the exit passageway –> intensified murmur
What is accentuated by squatting
Increases the murmur of mitral regurg and lessens hypertrophic obstructive cardiomyopathy murmur
Squatting momentarily increases volume from more venous return and increases arterial blood pressure (afterload)
What is accentuated by standing
Mitral valve prolapse
Standing momentarily decreases volume and therefore right ventricular filling. Not so much volume in LA to prevent back flow
Patent ductus arteriosis
Results from a remaining fistula between aorta and pulmonary artery.
Causes a continuous murmur through all of systole and most of diastole.
Machine like
Pathology of pericarditis
Fluid in the sac
- Infection of pericardium, MI, metastasis to pericardium, post cardiac surgery
- Often associated with recent respiratory viral infection
Pericardial knock
Diastolic knock heard widely over precordium in constrictive pericarditis.
Blood coming in to fill RV, LV chambers finds smaller chambers, stops abruptly and vibrates the walls
Third spacing
The body’s effort to lower work load on the heart by pushing fluid out of the artery and vein, the first and second space, and into whatever other space will take it. We see and hear this the most in the lower legs and lung.
Atherosclerosis
Occurs in the endothelium, the vessel wall itself.
Is the cause of vascular issues that result in stenosis, plaque, and aneurysm
Intermittent claudication
A (not fully) occlusive arterial disease of the limbs
- Symptoms characterized by pain, tension, and weakness of a limb when walking which intensifies with continued walking, resolving only when activity stops
- Most commonly seen in the legs b/l
Also seen in compression of the cauda equina
Symptoms of intermittent claudication
Symptoms occur distal to the site of stenosis or occlusion-
Activity induced pain, positional pain, rest pain, poorly healing wounds
Physical exam of intermittent claudication
Poor pedal pulses, ulcerations, palor, cool, shiny and hairless skin, bruit may be heard
Predisposing factors of intermittent claudication
Diabetes
Smoking
HTN
hyperlipidemia
How to calculate ankle-brachial index (ABI)
ankle pressure/arm pressure
Interpretation of ABI
> 1.3: noncompressible
0.91-1.30: normal
0.41-0.91: mild to moderate peripheral arterial disease
0-0.40 severe peripheral arterial disease
ABI
Treatment of intermittent claudication
- Meticulous foot care
- Smoking cessation
- Lower lipids
- Walk, but not through pain
- Cilostazol, pentoxifylline
- Revascularization procedures
What is the gold standard for targeting surgical intervention in intermittent claudication?
Contrast angiography
True aneurysm
Involves all 3 layers of vessel wall and can dissect
Aneurysm
Dilation of a segment of a blood vessel.
Due to weakening of the wall from atherosclerosis, HTN, vasculitis, and infection.
Painful only when expanding or leaking
Pseduoaneurysm
Dilation or hematoma that may or may not involve layers of the vessel wall which is contained and does not dissect
Thoracic aneurysm
Involves ascending arch and distal aorta
- Pain from sudden dilation, compression of adjacent organs or dissection
- Ascending aneurysm can cause aortic regurg by distorting the ring
- Descending aneurysms are frequently silent, discovered incidentally on CXR
Abdominal aortic aneurysm
- 75% are distal to renal arteries
- Uncommon
Aneurysm treatment
Elective graft - Mortality > 50% if rupture occurs
- Use beta blockers to reduce shear stress unless hypotensive already
Raynaud
Paroxysmal constriction/dilation of small arteries/arterioles
- Constriction producing palor, followed by dilation and initial filling of deoxygenated blood in capillaries producing cyanotic color.
- Disease not associated with other problems
- Phenomenon associated with scleroderma
- 80% are women
Raynaud treatment
- Avoid or stop smoking
- Avoid cold temps
- Avoid beta blockers: block vasodilation receptors leaving vasospastic receptors in sympathetic system unchecked
- Mange stressors
- CCBs
vasculitis
inflammation and damage to vessels, often the lumen, causing stenosis and ischemia to the involved tissue
polyarteritis nodosa
multisystem necrotizing vasculitis of primarily medium arteries
Inflammation thickens vessel wall causing stenosis, ischemia, and possibly infarct to
distal tissues
Characterized by: fatigue, weakness, fever, wt loss, headache, abdominal or other tissue pain
