CV Lecture Flashcards
What is the MC chief complaint for cardiac events?
Chest pain
What is the true symptom of CV disease?
Angina pectoris
What is angina pectoris?
- Crushing, squeezing chest pain
- Usually on exertion
- True symptom of CVD
Define preload
End diastolic volume at the beginning of systole directly related to stretch (Starling’s law)
Define stroke volume
Volume of blood pumped from one ventricle of the heart with each beat
Define afterload
Amount of resistance that the L side of the heart has to overcome to eject blood (“squeeze”)
How can fever affect HR and respirations?
Increases both
How can hypothermia affect HR and respirations?
Decreases both
How do you directly measure blood pressure?
Insertion of intra-arterial catheter (A-line)
How do you indirectly measure BP?
BP cuff and stethoscope
What can happen to BP if cuff is too small?
Falsely elevated
What BP finding indicates supravalvular aortic stenosis?
Difference in BP of 20+ mmHg between arms
What BP finding indicates coarctation of aorta?
- If BP is high in both arms, take BP in the legs
- If legs have lower BP, then could be coarctation of aorta
What does jugular venous pulse reflect?
RA pressure
What are the components of a jugular venous pulsation?
a wave
x descent
v wave
y descent
What is the “a” wave?
- Part of JVP
- Atrial contraction
- Reflects slight rise in atrial pressure that accompanies contraction
- Occurs before S1 and carotid pulse
What is the “x descent”?
- Part of JVP
- Atrial relaxation
- Ventricles contract
What is the “v wave”?
- Part of JVP
- Venous filling
- Atria begin to fill
What is the “y descent”?
- Part of JVP
- Atria empty
- Blood flows into RV
What does the hepatojugular reflex assess?
RV function
Why does the hepatojugular reflex occur?
Inability of R side of heart to accommodate increased venous return
What is the normal response of hepatojugular reflex?
Jugular veins show a transient increase during first few cardiac cycles of compression followed by a fall to baseline
What are the different types of carotid upstroke?
- Brisk (normal)
- Delayed (possible AS)
- Bounding (possible AR)
Use finger pads to palpate for ____ in the CV PE
Heaves or lifts
Use ball of hand to palpate for ____ in the CV PE
Thrills
What is a laterally displaced PMI suggestive of?
Cardiomegaly
The PMI can be described as:
- Tapping (normal)
- Sustained (suggests LV hypertrophy from HTN or AS)
- Diffuse (suggests dilated ventricle from CHF or cardiomyopathy)
In the L lat decubitus position, a PMI 3+ cm is an indicator of:
LV enlargement
If the PMI is displaced to the right, this may indicate:
RV hypertrophy
How may the PMI present in a COPD patient?
Felt in the epigastrium
If the PMI is palpated in the normal position in a COPD patient, what can this indicate?
Cardiomegaly
Presence of a heave with a lateral retraction felt along the left parasternal border is suggestive of:
RV hypertrophy
Name where all of the auscultation points are on the chest
- Aortic: R 2nd ICS
- Pulmonic: L 2nd ICS
- Erb’s point: L 3rd ICS
- Tricuspid: L 4th ICS
- Mitral: L 5th ICS mid-clavicular line
Apex in L lateral decubitus position with the bell will detect:
Mitral stenosis murmur (low pitched diastolic)
Diaphragm of stethoscope on the chest is best used to listen for:
High pitched sounds like S1, S2, S4 and most murmurs
Bell of stethoscope on the chest is best used to listen for:
Low pitched sounds like S3 and rumble of mitral stenosis
Which heart sounds are accentuated by inspiration?
S3 and S4 originating in R side of heart
Why are most murmurs or sounds originating in R side of heart accentuated by inspiration?
Because of increased return of blood that occurs and increased RV output
S1 is muffled or decreased in patients with:
- Pleural and pericardial effusions
- COPD
- PTX
- Obesity
Normally, the tricuspid valve closes a split second ____ the mitral valve
After
aka splitting of S1
When can splitting of S1 occur?
- PVCs of LV origin
- RBBB
- LV pacing
- ASD
- Severe TS
What is reverse splitting of S1?
When tricuspid valve closes BEFORE mitral
-Occurs with LBBB, RV pacing, severe MS, left atrial myxoma
When is the intensity of A2 increased?
- Pulm HTN
- Coarctation of aorta
- Aortic aneurysm in thin ppl
- Tetralogy of Fallot
- Transposition of great vessels
When is the intensity of A2 decreased?
- Aortic dissection
- Aortic stenosis
- Decreased systemic arterial pressure
When is the intensity of P2 increased?
- PA HTN
- ASD
Normally, the aortic valve closes ____ the pulmonary valve
Before
S2 split
What is reverse splitting of S2?
Aortic valve closes AFTER pulmonic valve
aka paradoxical split
When does an S3 occur?
Rapidly rushing flow of blood from atria is suddenly decelerated by the ventricle when it reaches its elastic limit
In a normal ventricle, when does S3 occur?
Hyperdynamic states
Volume loaded conditions
In a ventricle with decreased compliance, when does an S3 occur?
With a normal amount of blood entering during diastole
Is S3 always normal or always abnormal?
- It can be pathological
- Can also be a normal variant in 40 yo or younger
What does an S3 present with heart failure indicate?
Poor prognosis
Conditions associated with pathological S3:
- Ischemic heart disease
- MR or TR
- Systemic and pulm HTN
- Acute AR
- Volume overload (renal failure)
Describe S4
Late diastolic sound heard just before S1 that corresponds to late ventricular filling through active atrial contraction
Conditions a/w S4:
- LVH from systemic HTN
- RVH from pulm HTN or stenosis
- IHD from acute MI or angina
- Ventricular aneurysm
How do S1 and S2 differ from S3 and S4?
- S1 and S2 are high pitched and best audible with diaphragm
- S3 and S4 are low pitched and best heard with bell
What is an opening snap?
- High pitched diastolic sound
- Produced by rapid opening of mitral valve in MS or tricuspid in TS
- Closer to A2 means more severe stenosis
What is a systolic ejection click?
- High pitched, early part of ventricular systole
- Can be valvular or vascular
- Intensity decreases with increased valve calcification
What is a non-ejection systolic click?
- High pitched systolic sound that follows S1
- A/w mitral or tricuspid valve prolapse
What 3 factors can contribute to development of heart murmurs?
- High flow rate through normal or abnormal orifices
- Forward flow through a constricted or irregular orifice OR into a dilated vessel or chamber
- Backward or regurgitant flow through an incompetent valve
How do we identify or describe heart murmurs?
- Timing (systole or diastole)
- Location
- Radiation
- Duration
- Intensity (graded)
- Pitch
- Quality (harsh, blowing, etc.)
- Relationship to respiration
- Relationship to position
How are murmurs described by shape?
- Crescendo (rises in intensity from S1 to S2)
- Decrescendo (decreases in intensity after S2)
- Crescendo-decrescendo (rises and then falls between S1 and S2)
- Plateau
Describe the murmur of AS:
- Mid to late systolic
- Crescendo-decrescendo
- Medium pitch
- Ejection click
- S4
- Narrow pulse pressure
- Parvus tardus pulse
- Radiates to carotid
Describe the murmur of MR:
- Early systole
- Radiates to axilla
- High pitched
- Blowing
- S3
How is PMI affected with MR?
Laterally displaced and diffuse
Describe the murmur of PS:
Similar to AS just in pulmonic area
Describe the murmur of TR:
Similar to MR just in tricuspid area
What does a ventral septal defect (VSD) sound like and where is it best heard?
- Holosystolic
- High pitch
- Harsh
- Radiates to R of sternum
- Best heard in tricuspid area
How does a venous hum sound and where is it best heard?
- Continuous
- High pitch
- Roaring/humming
- Radiates to R side of neck
- Heard best above clavicle
What does an innocent murmur sound like?
- Widespread (systolic)
- Diamond shaped
- Medium pitch
- Twanging/vibratory
- Minimal radiation
What are the systolic murmurs?
- AS/PS
- MR/TR
- VSD
- Venous hum
- Innocent murmur
What are the diastolic murmurs?
- AR/PR
- MS/TS
Describe murmur of MS:
- Decrescendo
- Low pitch
- Rumbling
- Opening snap
- Mid diastole
- NO radiation
Describe murmur of AR:
- Early diastole
- Decrescendo
- NO radiation
- High pitch
- Blowing
- S3
- Wide pulse pressure
- Laterally displaced PMI
What is an Austin Flint murmur?
Apical diastolic murmur a/w AR - mimicking MS
How do continuous murmurs develop?
Results from a communication between high pressure arterial and low pressure venous chamber or vessel
What is the best example of a continuous murmur?
Patent Ductus Arteriosus (PDA)
Describe Patent Ductus Arteriosus (PDA)
- Abnormal communication b/w aorta and PA
- Occurs end of systole into diastole
- Blowing
- High pitched
- Most pronounced at S2
