Exam 1 - CV packet Flashcards
What is the nature of cardiac pain?
Visceral
What are the problems with visceral pain?
Hard to localize, hard to describe, can be due to disorders of nearby structures
Is visceral pain made worse by palpation or changing the patient’s body position?
No
Is pericarditis harder or easier to localize than cardiac pain?
Easier
Is pericardial pain made worse by palpation or changing patient’s position?
NOT by palpation; made worse by lying supine, better by sitting up/leaning forward
Is musculoskeletal chest pain made worse by palpation?
Yes
Potential indicators of heart disease? (6)
- Hx of PAD 2. Dyspnea on exertion/SOB 3. Pre-syncope/syncope 4. Palpitations 5. Normal variant in heart rhythm 6. More serious disturbances in pulse rate
What is the usual cause of pre-syncope?
Global reduction of cerebral perfusion
Is pre-syncope specific to heart disease?
No
What are the benign forms of pre-syncope? (3)
Vasovagal syncope, orthostatic hypotension, situational syncope
When is syncope cause for concern?
When it is recurrent
How is cardiogenic syncope different from benign forms?
Few prodromal symptoms
What is a palpitation?
Disagreeable awareness of a heartbeat
Are palpitations specific to heart disease?
No
What question should you ask when a patient presents with palpitations?
Was the pulse rhythm irregular when pt felt the palpitations?
What does a combo of palpitations and pre-syncope tend to indicate?
Cardiac arrhythmia
Who is normal arrhythmia seen more often in?
Children and aerobically fit young adults at rest
What is a “regularly-irregular” heartbeat?
Increases with inspiration and decreases with expiration
Are “regularly-irregular” heartbeats normal?
Can be normal or abnormal
What are “bigeminal” and “trigeminal” pulses due to?
Premature beats
What is “irregularly-irregular” heart rate associated with?
Atrial fibrillation
What is the most common form of arrhythmia?
Atrial fibrillation
Who is atrial fib most often seen in?
Patients over 60, esp. with coronary heart disease, HTN, COPD, etc
Non-modifiable risk factors for CVD? (3)
- Increasing age 2. Male gender 3. Family history
Starting ages for CVD risk for men and women?
Men = 45 Women = 55
what is normal arterial wall stress called?
“high” wall stress
What does normal high wall stress lead to?
Local expression of nitric oxide/relaxant factors
What does the expression of NO/relaxant factors promote?
vasodilation, inhibits clot formation
Why is decreased arterial stress a major pathophysiological problem?
endothelium now favors vasoconstriction and platelet aggregation
What does vasoconstriction/platelet aggregation lead to, with decreased wall stress?
Increased endothelial permeability and accelerated plaque formation
Why are sudden “spikes” in BP in dysfunctional endothelium a problem?
Increase in wall stress with increased BP can lead to destabilization of established, existing plaque
What increases the risk of endothelial dysfunction?
Factors that decrease arterial stress
What is a built-in problem with regards to endothelial dysfunction?
Bifurcations - disrupt laminar flow
Modifiable cardiovascula risk factors? (6)
- HTN 2. Tobacco smoking 3. Diabetes 4. Sedentary lifestyle 5. Body weight/obesity 6. Pathologic left ventricular hypertrophy
What is the residual risk of HTN?
Damage to arterial endothelium, left ventricular hypertrophy
What is the residual risk of tobacco smoking?
Vasoconstriction
What is the residual risk of diabetes?
Increased vascular permeability
What is the residual risk of pathologic left ventricular hypertrophy?
Presumed change to ventricular myocardium
Blood pressure classification: Normal
Systolic < 80
Blood pressure classification: Pre-hypertension
Systolic 120-139 Diastolic 80-89
Blood pressure classification: Stage 1 HTN
Systolic 140-159 Diastolic 90-99
Blood pressure classification: Stage 2 HTN
Systolic >160 Diastolic > 100
Which reading should you record if pt’s BP is higher in one arm than the other?
Record the higher reading
When SBP and DBP fall into different categories, which should be used to classify the pt’s BP?
The higher category
What is the classification of hypertension based on?
Average of 2 or more properly measured BP readings on 2 or more separate occasions
What BP readings would you not require serial confirmation before making decisions regarding intervention?
SBP >180 or DBP >110
Examination factors that could affect accuracy of BP readings? (8)
Cuff too narrow, cuff not centered, cuff over thick clothing, cuff too loose, elbow too low, arm in dependent position, back unsupported, arm unsupported
Examinee factors that could affect accuracy of BP reading? (6)
White coat HTN, recent tobacco use, recent caffeine use, distended bladder, talking during procedure, having legs crossed
What is primary hypertension?
No identifiable cause found
How many HTN cases are due to primary HTN?
90-95%
When does the onset of primary HTN usually occur?
Between age 25-55
What can exacerbate primary HTN? (4)
obesity, lack of exercise, alcohol, smoking
What is secondary HTN?
underlying cause is identified
What is the most common form of secondary HTN?
Renal vascular HTN
4 cases of target organ damage (TOD) due to HTN?
- retinal damage 2. left ventricular hypertrophy/CVD 3. renal damage 4. CNS disorders/stroke
What is orthostatic hypotension?
Brough on by sudden change in body position, usually from lying down to standing
Guidelines for “true” orthostatic hypotension?
Persistent fall in SBP/DBP of more than 20/10 mmHg within 3 minutes of assuming upright position
What is neurally-mediated hypotension associated with?
Long periods of standing
Who is neurally-mediated hypotension more common in?
Children/young adults
What brings in severe hypotension?
sudden loss of blood, infection, or severe allergic reaction
Contributing factors in low blood pressure? (3)
Dehydration (esp in elderly), alcohol use, medications
Common symptoms of low BP? (5)
blurry vision, confusion, dizziness, fainting, light-headedness
What is considered the prime target in HTN therapy?
LDLs
When is a patient with high LDLs considered very high risk?
Prior heart attack or stroke
When is a patient with high LDLs considered low risk?
0 or 1 of the “traditional” risks
What is the target goal in LDL therapy in a pt that is very high risk?
<70 mg/dL
What is the target goal in LDL therapy in a pt that is high risk?
<100 mg/dL
What is the target goal in LDL therapy in a pt that is moderate risk?
<130 mg/dL
What is the target goal in LDL therapy in a pt that is low risk?
<160 mg/dL
What is the normal triglyceride level?
<150 mg/dL
What is “borderline” triglyceride level?
150-199 mg/dL
What is high triglyceride level?
200-499 mg/dL
What is very high triglyceride level?
> 500 mg/dL
Factors that can lead to hypertryglyceridemia? (3)
- poorly controlled diabetes 2. obesity 3. excessive alcohol consumption
What 2 diseases have long-term hypertriglyceridemia been linked to?
- fatty liver disease 2. pancreatitis
What is the most common problem seen with heart disease?
Transient myocardial ischemia/typical angina
When does the myocardium have a limited ability to increase O2 extraction?
During episodes of increased demand
How is the increased demand for O2 met?
proportional increase in blood flow through the coronary arteries
What is the coronary flow reserve (CFR)?
ability of coronary arteries to increase blood flow in response to increased cardiac metabolic demand
What is the maximal coronary blood flow after full dilation of coronary aa in healthy people?
4-6 times the resting blood flow
In normal blood flow, is there much resistance to blood flow?
No - only about 5% of the arterial resistance
What happens when someone with >50% coronary artery plaque exerts themselves (increases demand)?
Typical angina and Levine’s sign
What could cause an angina in someone with coronary artery plaque >90%?
Little or no exertion needed = possible angina at rest
What is the most common type of angina?
Typical angina
What is a typical angina due to?
coronary artery plaque (“fixed” lesion)
What is the most common trigger of typical angina?
Exertion/exercise
How do angina attacks start?
Abruptly, “seize” the patient
Where is the discomfort in typical angina?
deep to sternum
How is the discomfort in typical angina described?
poorly-localized, visceral
How long do attacks of typical angina usually last?
1-5 minutes
What usually relieves a typical angina?
rest, sublingual nitrogen
What is Levine’s sign?
clenched fist over the sternum, “classic” radiates to left shoulder/arm
What does Levine’s sign suggest?
angina pectoris
Within a group of angina patients, is the location of discomfort always in the same place?
No, varies from pt to pt
Is a given individual’s angina location usually in the same place?
Yes, usually predictable and unvarying
What does the term “umbilicus to eyebrows” refer to?
Suspect angina when pt with CV risk factors describes ANY discomfort ABOVE THE WAIST that is provoked by exercise and relieved by rest
What is atypical angina the result of? (2)
- problems with coronary aa (“conduction” vessels) 2. problems with intramyocardial aa (“resistance” vessels)
What is a Prinzmetal angina?
coronary vasospasm in near-normal coronary aa.
What causes prinzmetal anginas?
sudden elevation in BP, cigarettes
What can prinzmetal angina lead to?
Angina at rest
In normal intramyocardials, is there much resistance?
Yes, 95% of arterial resistance
What happens with dysfunctional intramyocardials?
increased resistance -> less exertion needed -> possible angina AT REST
What makes an angina “atypical”?
Absence of typical presentation
Common symptoms of atypical angina? (4)
- SOB 2. nausea 3. diaphoresis 4. discomfort not located in chest
Who is atypical angina more common in? (2)
- Older, female patients 2. Diabetic patients
What might atypical angina be associated with? (2)
- Prinzmetal angina 2. Microvascular angina
What diseases are believed to cause microvascular abnormalities? (3)
- DIABETES 2. HTN 3. systemic collagen vascular disease
What is acute coronary syndrome (ACS)?
umbrella term used to cover a spectrum of clinical conditions, from unstable angina to MI
What should you do if your pt is experiencing ACS?
Call 911
Possible end results for ACS? (3)
unstable angina, myocardial infarction, sudden cardiac death
What causes “classic” ACS?
obstruction of coronary aa
S/Sx of “classic” ACS?
visceral chest pain/angina of abrupt onset
What percentage of MI pts present with pleuritic pain?
14%
What percentage of MI pts do NOT have chest pain?
33%
Non-pain angina “equivalents” that can present in ACS? (8)
- nausea 2. SOB 3. neck pain 4. jaw pain 5. arm pain 6. fatigue 7. syncope 8. diaphoresis
Can physical exam results be normal even when a pt is experiencing ACS?
Yes
Symptoms of ACS dut to intramyocardial artery disease? (4)
SOB, nausea, diaphoresis, discomfort not in chest
How do many CHF patients appear?
comfortable at rest
CHF risks? (3)
- hx of previous MI/abnormal heart valves 2. congenital heart defects 3. idiopathic, infectious, toxic or familial pathologies involving myocardium
What is “compensated” CHF?
heart failure with relatively normal cardiac output
What are the compensatory mechanisms? (3)
- catecholamine release/stim of symp. Nervous system 2. retention of sodium and water 3. cardiac “remodeling” (dilation or hypertrophy of L ventricle)
What is “decompensated” CHF?
inadequate cardiac output even at rest
What does dilated cardiomyopathy and systolic heart failure result in?
Reduced L ventricular contractility
What is the most common form of chronic heart failure?
dilated cardiomyopathy
What is the most common cause of dilated cardiomyopathy?
Chronic ischemia
What are the best physical findings in severe systolic failure? (2)
Abnormal apical impulse (cardiac heave) and radiographic evidence of cardiomegaly
What is the point of maximal impulse (PMI)?
brief succinct impulse overliying the apex of L ventricle
Normal PMI?
apical beat is succinct, brief, and covers an area <2 cm in diameter
Abnormal PMI?
prolonged contraction/cardiac heave that covers area >3 cm in diameter
What happens with hypertrophic cardiomyopathy and diastolic heart failure?
myocardium becomes inelastic and non-compliant. Muscle can’t relax => slow rate of ventricular filling
What are the best physical findings in severe diastolic failure? (2)
Jugular distension and radiographic evidence of pulmonary venous HTN
Which jugular vein should you examine for abnormal distension if you suspect diastolic failure?
RIGHT internal (and external) jugular vein
What is the cardinal sign of L ventricular CHF?
breathlessness
Will all pts with L ventricular CHF show dyspnea on exertion (DOE)?
may be absent in sedentary pts
Is DOE specific to heart disease?
No
What is orthopnea?
Have to be upright to breathe
What does orthopnea indicate?
pulmonary HTN/pulmonary congestion. Possible early symptom of CHF
When does orthopnea occur?
When pt is awake
When does orthopnea usually resolve?
Rapidly when pt sits up
How is orthopnea measured?
by number of pillows needed to make pt comfortable
What does paroxysmal nocturnal dyspnea (PND) indicate?
pulmonary edema
When does PND occur?
When pt is asleep
When does PND resolve?
might take 30+ minutes in seated position
Is PND more specific for heart disease?
more specific but not absolute
Other S/Sx of L ventricular CHF? (4)
- fatigue/weakness 2. nocturia 3. oliguria 4. cerebral symptoms in advanced/late stage
S/Sx of R ventricular CHF? (4)
- peripheral edema 2. ascites 3. hepatomegaly 4. anasarca
Does R or L ventricular failure usually come first?
L usually first.
What is the most common cause of R ventricular failure?
continuation of L ventricular failure
What is the second most common cause of R ventricular failure?
Cor pulmonale (= heart failure due to chronic lung disease)
What is the most important factor in a cardiac exam?
History and risk factors
In a cardiac exam, what do really obvious clinical findings usually indicate?
Something ominous in nature
What are 2 major concerns in cardiac exams?
Symptomatic arrhythmias, symptomatic cardiac murmurs
