L9: Cardiovascular Flashcards
1
Q
Precordium
A
Precordium: anterior chest wall overlying the heart
2
Q
Apical Impulse
What is it also called?
What is it?
A
Apical Impulse, AKA Point of Maximal Impulse (PMI)
the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.
3
Q
Jugular venous distension (JVD)
What is it?
A
occurs when the pressure inside the vena cava, a large vein that carries deoxygenated blood back to the heart, causes a bulging neck vein
4
Q
Deformity of the Chest Wall
Pectus excavatum & Pectus carinatum
What are they?
Common/Uncommon?
A
Pectus excavatum (common): sternal depression
Pectus carinatum (uncommon): sternum protrudes
5
Q
Skin Abnormalities:
Herpes Zoster
What can it mimic?
A
Can often mimic MI
6
Q
Anatomy Review
Apex & Base of Heart
Location?
A
Base: Superior aspect of the heart, where the great vessels originate
Apex: Inferolateral tip of the left ventricle
7
Q
Stethoscope: Bell & Diaphragm
Which is best for high- or low-pitched sounds?
Firm or light pressure?
A
- Use both the diaphragm & the bell
-
Diaphragm
- Best for high-pitched sounds of S1 and S2
- Press firmly against the chest wall
-
Bell
- Best for low-pitched sounds of S3 and S4
- Apply lightly, with just enough pressure to make a seal against the chest wall
8
Q
Auscultation of Cardiac Areas
What are the the four key areas?
Where are they located?
What is an additional location?
A
- Four key areas:
- Aortic – 2nd ICS, RSB
- Pulmonic – 2nd ICS, LSB
- Tricuspid – 4th & 5th ICS, LSB
- Mitral (apex) – 5th ICS, MCL
- Others as needed
- Second Pulmonic – 3rd ICS, LSB
- “Inch” stethoscope along
9
Q
Angle of Louis
What is it?
How to find it?
A
The sternal angle (angle of Louis) is the anterior angle formed by the junction of the manubrium and the body of the sternum which varies around 162 degrees in males.
10
Q
Auscultation Rate
Normal, Fast, Slow
What is considered a normal/slow/fast rate?
What is a normal/slow/fast rate called?
Types?
A
-
Normal
- 60 – 100 bpm
- Sinus rhythm or flutter with normal rate, or second-degree AV block
-
Fast
- >100 bpm
- Tachycardia - sinus, supraventricular, ventricular, or flutter
-
Slow
- <60 bpm
- Sinus bradycardia, second- degree AV block, complete heart block
11
Q
Auscultation: Irregular Rhythm
Types of irregular rhythms?
A
- Irregular (arrhythmia or dysrhythmia)
- Rhythmically irregular
- Sporadically irregular (occasional vs. frequent)
- Irregularly irregular
12
Q
Valves
What ar the atrioventricular (AV) valves?
What are the semilunar valves?
What structures do they connect?
A
-
Atrioventricular (AV) valves
-
Tricuspid
- R atrium → R ventricle
-
Mitral
- L atrium → L ventricle
- Semilunar valves
-
Aortic
- L ventricle → aorta → body
-
Pulmonic
- R ventricle → pulmonary artery → lungs for oxygenation
-
Tricuspid
13
Q
What is the path of blood through the heart?
A
- Venous blood arrives in R atrium
- Through tricuspid valve → R ventricle
- Through pulmonary valve → pulmonary artery → lungs
- Oxygenated blood returns to L atrium via pulmonary veins
- Through mitral valve into L ventricle
- Through aortic valve into aorta → to rest of body
14
Q
Cardiac Cycle:
“Lub-Dub”
When is each sound heard?
Diastole/systole is associated with which sound?
A
-
“Lub”
- Closure of AV valves (tricuspid & mitral) very soon after systole begins
-
“Dub”
- Beginning of diastole upon closing of semilunar valves (aortic & pulmonary)
15
Q
First Heart Sound (S1)
Systole or Diastole?
What is the sound?
What causes the sound?
A
-
Systole:
-
Closure of mitral & tricuspid (AV) valves produce the S1 sound → “Lub”
- Louder than S2 at the apex
- Contraction of ventricles
- Aortic & pulmonic valves forced open, and blood is ejected into the arteries
-
Closure of mitral & tricuspid (AV) valves produce the S1 sound → “Lub”
16
Q
Ventricular Systole
What occurs during ventricular systole?
A
- Ventricles contract
- Blood pushed against AV valves (causes them to close)
- Contracting papillary muscles and chordae tendinae prevent valve claps from everting into atria
- Semiluar valves (aortic & pulmonic) forced open → blood ejected into the arteries (pulmonary trunk & aorta)
17
Q
Abnormal S1
Accentuated S1
Diminshed S1
Louder/softer?
Cause?
Examples?
A
-
Accentuated (Louder) S1:
- Due to diseased AV valve or more forceful closure of AV valve
- E.g., Tachycardia, fever, HTN, exercise, anemia, hyperthyroidism, or mitral stenosis
-
Diminished (Softer) S1:
- Due to weak contraction of heart or reduced sound transmission
- E.g., thick chest wall or emphysematous lungs
18
Q
Second Heart Sound (S2)
Systole or Diastole?
What is the sound?
What causes the sound?
A
-
Diastole:
- Closure of the aortic & pulmonic valves produce the S2 sound → “Dub”
- Louder than S1 at the base
- Relaxation of heart
- AV valves open, allowing ventricles to start to refill passively
- Atrial contraction (kick)
- Closure of the aortic & pulmonic valves produce the S2 sound → “Dub”
19
Q
Ventricular Diastole
What occurs during ventricular systole?
A
- Ventricles relax and fill with blood both:
- Passively
- Then by atrial contraction as AV valves remain open
- During ventricular relaxation, some blood from the aorta & pulmonary trunk flows back toward the ventricles filling the semilular valve cusps → forcing them to close
20
Q
Aortic Valve
What is the purpose of the cusps?
A
21
Q
Which is longer, systole or diastole?
A
Diastole slightly longer than systole
22
Q
Spliting of S2: Physiologic Splitting
What are the two components?
Heard during inspuration or expiration?
Which sound is heard first? Why?
A
- May hear two discernible components of S2, during inspiration
- A2 (aortic valve closure)
- P2 (pulmonic valve closure)
- Similar events occur on left & right sides of the heart
- Right-sided pressures are lower than corresponding pressures on the left → sounds occur slightly later on the right
23
Q
Spliting of S2: Pathologic Splitting
A
24
Q
Third Heart Sound (S3)
What is it?
What is it caused by?
What is it also called?
A
- Low-pitched sound created in early diastole by passive, rapid filling of the ventricles with blood from the atria
- Produced by blood filling a chamber that is already volume overloaded, causing rapid distension of the ventricular walls, leading to vibration
- S1 + S2 + S3 = ventricular gallop rhythm
- Heard best with bell at apex
25
**Third Heart Sound (S3)**
When is it non-pathologic? Pathologic?
* **Non-pathologic**
* Children, healthy young adults, and pregnant women may have a non-pathological S3
* **Pathologic S3 (*ventricular gallop*)**
* Over age 40, usually pathologic
* Due to heart failure, anemia, volume overload of ventricle, decreased myocardial contractility
26
**Fourth Heart Sound (S4)**
What is it?
What is it caused by?
What is it also called?
* Low-pitched sound created by second phase of ventricular filling in diastole, as the atria contract and eject blood into the ventricles (during the “atrial kick”)
* Produced by the rush of blood causing vibration of valves, papillary muscles, and ventricular walls
* S1 + S2 + S4 = atrial gallop rhythm
* Heard best with bell at apex
27
**Fourth Heart Sound (S4)**
When is it non-pathologic? Pathologic?
* * May be normal in trained athletes and some older individuals without other heart disease
* ***Pathologic S4 (atrial gallop)***
* Over age 40, usually pathologic
* Due to resistance to ventricular filling; stiffness of heart muscle (reduced compliance)
* HTN, CAD, AS, cardiomyopathy
* Right-sided S4 from pulmonary hypertension or pulmonary stenosis
28
**Murmur**
What is a murmur?
What causes murmur?
* **Murmur:** prolonged heart sound made by blood rushing through
* Narrowed valve
* Leaking valve
* Wall between chambers of the heart
29
**Cardiac Chamber Pressures**
Which has a higher/lower pressure?
Atria vs ventricles
Left vs right side
* Higher pressure on **_left_** side
* Higher pressue in **_ventricles_**
30
**Gradations of Murmurs**
What are the 6 grades of murmurs?
**Grade 1/6:** Barely audible in quiet room
**Grade 2/6:** Quiet, but clearly audible
**Grade 3/6:** Moderately loud
**Grade 4/6:** Loud, associated with _thrill_
**Grade 5/6:** Very loud, heard with stethoscope *_partially_* off chest; obvious _thrill_
**Grade 6/6:** Very loud, heard with stethoscope *_entirely_* off the chest, obvious _thrill_
31
**Systolic Murmurs**
What are the types of systolic murmurs?
Sound type?
Cause?
32
**Aortic Stenosis**
Cause of stenosis?
What type of murmur does it cause?
Where best heard?
Cause of sound?
* _Aortic Stenosis_
* **Narrowed valve:** congenital or calcific disease process
* _Type:_
* Mid-systolic crescendo-decrescendo murmur
* _Heard best at_
* base along right & left sternal borders
* _Cause of sound:_
* _From LV_, blood flows through aortic valve, into aorta → murmur gets *_louder*_ → aortic pressure increases as more blood flows into it from LV, which creates resistance to further inflow from the LV → murmur _*softens_* due to reduced blood flow
* _From RV_, blood flows through pulmonic valve, into pulmonary artery, etc.
* Pressure is not as great as in left-sided system, but similar principles apply
33
**Innocent Systolic Murmur**
What is it?
Common in?
Physiologic in...
Chracteristic features?
* Common in children & young adults
* Physiologic in pregnancy, anemia, fever hyperthyroidism (increased flow across valve)
* Characteristic features:
* Grade ≤2 intensity
* Softer when sitting (vs. supine)
* Short systolic duration (not holosystolic or diastolic)
* Minimal radiation
* Musical/vibratory quality
34
**Atrial Septal Defect (ASD)**
What is an ASD?
What type of murmur does it cause?
* **Atrial Septal Defect:** Congenital anomaly resulting in left-to-right shunting of blood (LA → RA), with RV enlargement & increase flow through pulmonic valve
* Midsystolic murmur (2nd ICS)
* Wide, fixed splitting of S2
35
**Mitral/Tricuspid Regurgitation**
Cause of regurgitation?
Type of murmur caused?
* Pressure in the left & right ventricles is significantly higher than in the atria
* When ventricles contract, leakage of blood from LV to LA (or RV to RA) continues throughout systole
* There is no resistance to the flow
36
**Ventricular Septal Defect (VSD)**
Cause of defect?
Type of murmur caused?
Sound heard?
* Pansystolic (or holosystolic) murmur
* Left-to-right shunt (LV → RV)
* Harsh or blowing pansystolic murmur at LLSB
* LLSB Thrill
37
**Diastolic Murmurs**
What are the types of diastolic murmurs?
Sound type?
Cause?
38
**Aortic Regurgitation**
Cause of regurgitation?
Type of murmur caused?
Where best heard?
* Early diastolic decrescendo murmur
* Leaking aortic valve
* Heard best at apex
39
**Mitral/Tricuspid Stenosis**
Cause of stenosis?
Type of murmur caused?
* Middiastolic Murmur
* Narrowed valve
40
**Mitral Stenosis**
Cause of stenosis?
What type of murmur does it cause?
* Opening snap & diastolic rumble
* Narrowed valve
* Obstructs flow from the LA to LV
41
**Systolic-Diastolic Murmur**
What is it?
* aka “To-and-fro” murmur
* **Aortic stenosis _with_ aortic regurgitation**
* Obstruction to outflow due to a narrowed valve **_and_**
* Failure of complete closure of the aortic valve during diastole, with leakage of blood back into the left ventricle
42
**Continuous vs. "To-and-fro" Murmurs**
* **Continuous**
* Patent ductus arteriosus (machinery-like)
* Failure of channel between aorta & pulmonary artery to close after birth
* **“To-and-fro”** (systolic-diastolic murmurs)
* Aortic stenosis/regurgitation
* Severe aortic regurgitation
43
***Specialized Exam:* Ausculate at cardiac base, leaning forward**
How to perform?
What are you listening for?
* Patient in seated position:
* Ask patient to lean forward, exhale completely & hold breath in expiration
* Listen at the base
* Best for hearing soft murmurs at the base:
* Aortic regurgitation
* Pulmonic regurgitation
* Remember to let the patient breathe
44
**Valsalva**
What is it?
The **Valsalva maneuver** is a breathing method that may slow your heart when it's beating too fast. To do it, you breathe out strongly through your mouth while holding your nose tightly closed. This creates a forceful strain that can trigger your heart to react and go back into normal rhythm.
45
**_Effects of Maneuvers:_**
Standing (or strain phase of valsalva)
Squattting (or release phase of valsalva)
**_On_**
Ventricular volume
Vascular tone
BP
PVR (peripheral vascular resistance)
Exception?
46
_Extra Sounds:_
**Ejection Sound**
What is it?
What is the sound?
Cause?
Heard best with...
* **Aortic or pulmonic ejection click**
* High-pitched; indicates valve disease or dilated aorta or pulmonary artery, or pulmonary hypertension
* Heard best with diaphragm of stethoscope
47
Extra Sounds:
**Systolic Click(s)**
What is it?
Cause?
Sound?
How common?
Mitral Valve Prolapse
* Ballooning of mitral leaflet(s) into the left atrium during systole
* Mid-late systolic click(s) are often present
* Variable pitch
* Mitral regurgitation may also occur, with late systolic murmur
* **Common condition: over 5% of general population; usually benign**
48
Extra Sounds:
**Extracardiac Sounds**
Venous Hum
Pericardial Friction Rub
What are they?
Cause?
Sound?
* Venous hum
* Turbulent blood flow through jugular veins
* Both systolic and diastolic sounds
* Common in children
* Pericardial friction rub
* Inflammation of pericardial sac
* 3 component (triphasic)
* Scratchy/squeaky, intermittent
49
**Jugular Venous Pressure (JVP)**
What is it?
What is it used to evaluate for?
* Indication of pressure in the right atrium (central venous pressure), related to intravascular fluid volume
* Mainly reflects right heart function
* Used in the evaluation of heart failure
* Best assessed from pulsations in the **right** internal jugular vein (or external jugular vein)
* Deep to SCM muscles in neck
* Identify surface pulsations
* Dominant movement is **inward** (carotid pulse is outward)
50
**Internal Jugular vs. Carotid Pulsations**
Palpable?
Describe the pulsation
Are pulsations eliminated by pressure on the veins?
Does height of pulsations change with position?
Does height of pulsations change with inspiration?
51
***Specialized Exam:* Measurement of JVP**
How to measure?
* Stand on patient's right, exam table at 30°
* Patient's head turned slightly to the left
* Find the highest point of oscillation (meniscus) in the right internal jugular vein
* Measure vertical distance above sternal angle
* Add 5cm
* Sum = JVP
* In each position, the sternal angle remains roughly 5 cm above the right midatrium
52
**Abnormal JVP**
**Elevated**
**Decreased**
Definition?
Cause?
Hypervolemia or Hypovolemia?
* Elevated **(\>8 cm above the RA)**
* Heart failure
* Pulmonary HTN
* Increased venous vascular tone
* Pericardial tamponade
* **Hypervolemia:** **anticipate ↑ JVP,** **raise head of bed**
* Decreased
* Blood loss
* Hypovolemia
* Decreased venous vascular tone
* **Hypovolemia: anticipate ↓ JVP,** **lower head of bed**
53
***Specialized Exam:* Hepatojugular (abdominojugular reflex)**
How to do the test?
What is a positive test?
* Patient is supine, exam table at 30°
* Apply firm, sustained pressure (~10 sec) to the abdomen in the RUQ over the liver region
* Observe the neck for an increase in JVP, followed by a decrease as the hand is released
* JVP will transiently increase in all patients with this maneuver, but it is exaggerated in right heart failure
* **\> 3 cm increase or remains elevated is abnormal (positive)**
54
**Thrills**
Define
Cause?
What to do if present?
* **_Thrill:_** Buzzing or vibratory sensation
* May be caused by vigorous blood flow through any narrowed opening (e.g., aortic stenosis, ventricular septal defect, etc.)
* If present, **auscultate** area for murmur
55
**Lifts (or heaves)**
Define
Cause?
* _**Lift (or Heave)**:_ Vigorous cardiac impulse that can be seen/felt through the chest wall
* May be caused by ventricular hypertrophy or hyperdynamic ventricular activity
56
**Where to check for lifts (heaves) and thrills?**
Left Sternal Border (LSB) and Base
57
**Where to palpate for apical impulse?**
Palpate Apex
* Place right hand on chest as pictured, with heel of hand on lower sternum and fingertips at apex
* Palpate for apical impulse
* PMI (point of maximal impulse)
* Represents pulsation of left ventricle
* Note size (5th ICS in MCL)
* Should not exceed 2.5 cm in diameter one intercostal space
* Cardiac impulse ***lateral***to MCL or ***larger***than normal suggests left ventricular enlargement
* **Most prominent impulse may be in the xiphoid or epigastric area due to right ventricular hypertrophy in patients with COPD**
58
***Specialized Exam:* Cardiac Percussion**
What is this test for?
How to test?
What is it useful?
* ***Limited value***
* Estimate cardiac size (when PMI not palpable)
* Begin at about 5th ICS in the midaxillary line and percuss medially, listening for onset of dullness
* More useful, evident with cardiac pathology → cardiomegaly, pericardial effusion, etc.
59
***Specialized Exam:* Auscultate at cardiac apex with bell, left lateral decubitis**
How to examine?
What is this test for?
* Patient in left lateral decubitus position
* Listen at the apex
* Best for hearing low-pitched filling sounds:
* Gallops (S3, S4)
* Murmurs
* E.g., mitral stenosis
60
**Grading Peripheral Pulses**
How are they graded?
3+ Bounding
**2+ Brisk, expected (normal)**
1+ Diminished, weaker than expected
0 Absent or unable to palpate
61
Pulse Pressure
What is it?
How is pulse pressure calculated?
Systolic minus diastolic pressure
(Pulse pressure is the difference between the upper and lower numbers of your blood pressure. This number can be an indicator of health problems before you develop symptoms. Your pulse pressure can also sometimes that you're at risk for certain diseases or conditions)
62
**Carotid Artery Palpation**
* Location of carotid arteries?
* Carotid upstroke?
* Duration?
* Character/quality/describe? When?
* Abnormal carotid upstroke?
* What conditions is it seen in?
* What is the abnormality?
* Palpate (one at a time!)
* Just inside medial border of relaxed SCM muscle, roughly adjacent to cricoid cartilage
* Avoid pressing on carotid sinus
* Adjacent to top of thyroid cartilage
* Carotid upstroke:
* Brisk
* Smooth, rapid, almost immediately follows S1
* Presence of thrills
* Abnormal carotid upstroke
* Cardiogenic shock: small, thready, or weak
* Aortic Regurgitation: bounding
* Aortic stenosis: delayed
63
**Bruits**
**Bruits:** a murmur-like sound arising from turbulent arterial blood flow
64
**Where to check brachial, radial & ulnar arteries?**
**Brachial:** At the bend in elbow, medial to biceps tendon
**Radial:** Lateral flexor surface
**Ulnar:** Medial flexor surface
65
***Specialized Exam:* Allen Test**
How to do?
What does it test for?
What is an abnormal test?
* Used to evaluate patency of ulnar artery
* Prior to puncturing the radial artery for blood gas evaluation
* Ask patient to make a tight fist
* Compress both radial & ulnar arteries
* Ask patient to open hand (pale)
* Release pressure over ulnar artery
* If patent (normal), palm flushes within 3-5 sec
66
**Abdominal Aorta**
How to palpate?
What is an abnormal size?
* Use two hands, above umbilicus
* Slightly left of midline
* Identify aortic pulsations
* Estimate size
* Adults \>50 years (**abnormal**: \>3 cm)
67
**Abdominal Bruits**
Where to auscultate for abdominal bruits?
* Auscultate for bruits:
* Aorta
* Renal arteries
* Iliac arteries
* Femoral arteries
68
**Femoral, popliteal, dorsalis pedis, & posterior tibial arteries**
Where to palpate?
**Femoral:** Below inguinal ligament, midway between ASIS & symphysis pubis
**Popliteal:** Medially behind femur
**Dorsalis Pedis (DP):** Dorsum of the foot, just lateral to extensor tendon of great toe
**Posterior Tibial:** Behind medial malleolus of ankle
69
**Swelling & Edema**
What to do if swelling or edema is present?
* If swelling or edema is present, palpate for pitting edema
* Press firmly, but gently with thumb at least 2 seconds
* Over dorsum of each foot
* Behind each medial malleolus
* Over the shins
70
**Specialized Exam:** Homan Sign
What does it test for?
How to do exam?
* Calf pain on passive dorsiflexion of the foot
* Unreliable for presence of DVT
71
**Where do the following veins run?**
Femoral vein
Great saphenous vein
Small saphenous vein
Perforating vein
