Quiz 2- Cardiac Flashcards
pathway of blood
SVC/IVC
RA
tricuspid valve
RV
pulmonic valve
pulmonary arteries
lungs
pulmonary veins
LA
mitral valve
LV
aortic valve
aorta
body
normal CXR
curved ribs/diaphragm
HEART pushing towards L SIDE; normal size
clear lungs
cardiac cycle (rest to rest)
SYSTOLE- ventricular contraction
DIASTOLE- ventricular relaxation (need for ventricular filling)
S1- closing of mitral/tricuspid (end of diastole/beginning of systole)
S2- closing of aortic/pulmonic (end of systole/beginning of diastole)
conduction (coordination of muscle contraction)
assessment of rate/rhythm/ECG
SINUS NODE- normal pacer, autonomic, 60-100 bpm
AV NODE- at atrial septum, impulse delayed then passes (allows for filling)
bundle of His/bundle branches/perkinje fibers- impulse travels to both ventricles
if muscle damage- will not contract effectively
EKG
P WAVE- atrial depolarization (atria contract)
P-R INTERVAL- filling of ventricles
QRS- traveling of impulse thru bundle of His to R/L perkinje fibers; ventricular depolarization (ventricles contract)
T- WAVE- repolarization of ventricles
abnormal QRS
wide QRS with left ventricular hypertrophy
cardiac landmarks
AORTIC- 2nd ICS RSB, S2>S1
PULMONIC- 2nd ICS LSB, S2>S1
ERB’s- 3rd to 4th ICS LSB, S2=S1; helpful to listen for baseline
TRICUSPID- 5th ICS LSB, S1>S2
MITRAL- 5th ICS L MCL, S1>S2
line from aortic to pulmonic= BASE OF HEART (top)
line from tricuspid to mitral= APEX OF HEART (bottom)
cardiac health history cues
SOB
chest pain
syncope- possible dysrhythmia
fatigue
palpitations- consider caffeine intake
claudication- time of ischemia
early satiety/abdominal fullness- CHF
need to obtain a full HPI of CC and rule out cardiac cause with history and physcial exam
child cardiac cues
WOB
pallor/cyanosis
limited activity
change in HR
past medical history for cardiac
CHILDHOOD ILLNESS- heart murmurs, congenital heart disease, rheumatic fever
surgery- CABG
vaccines
cardiac family history
age of onset is very important!
cardiac
endocrine
neuro
vascular
common cardiac presenting symptoms
fatigue/activity intolerance
chest pain
shortness of breath
fatigue/activity intolerance
most prevalent cardiac symptom
chest pain
symptom analysis
stable angina
unstable angina- chest pain at rest; random pattern; no provoking activities
other causes- GERD, coughing trauma, pulmonary
calssifications: CLASS I= angina with strenuous acitvity
CLASS II= angina with ordinary activity, mild limitation of activities
CLASS III= angina with low level of activity, marked restriction of activity
CLASS IV= angina at rest (unstable)
stable angina
predictable pattern
rate pressure product (RPP): amount of activity they can do before pain/symptoms; educate pt to stay below this threshold
shortness of breath
DOE (how much activity?)
orthopnea
paroxysmal nocturnal dyspnea (wake from sleep with SOB)
talk test- singe happy birthday without SOB
heart failure classification:
CLASS I= no limitation of activity
CLASS II= slight limitation of activity, comfortable at rest but ordinary activity results in fatigue/SOB/palpitations
CLASS III= moderate limitation, comfortable at rest but less than ordinary activity causes fatigue/SOB/palpitation
CLASS IV= unable to carry out any activity without discomfort, symptoms present at rest
non modifiable cardiac risk factors
risk reduction
age, gender, genetics (family hx)
modifiable cardiac risk factos
can modify/medicate/change
HTN, HLD, DM
lifestyle cardiac risk factors
patient must modify/change
smoking, sedentary lifestyle, diet, obesity, hostility prone behavior
coronary artery calcium score
calcium in coronary arteries is a sign of plaque buildup
based on the amount of calcium observed on special CT scan
pts whose 10 year risk is between 5-20% should be tested
ASCVD risk estimator for coronary artery calcium score
includes age, gender, race, total/HDL cholesterol, SBP/DBP, HTN, DM, and smoking status to determine 10 year risk
also provides benefits of starting statin/ASA/BP meds
hyperhomocysteinemia
high serum homocysteine levels (amino acid from meats) creates a pro coagulaable state
discussed as a risk factor for ATHEROSCLEROSIS, associated with INCREASED RISK OF MI, and linked to higher risk of VTE
associated with low levels of B6, B12, folate, and renal disease
cannot use as a biomarker b/c levels can decrease with B6/B12/folate supplementation, but pt can still have atherosclerosis
CRP
reflects ongoing inflammation (not specific to cardiac disease)
inflammation is a known factor in the development of atheroschlerosis and subsequent CVD events- increases vulnerability of an atherosclerotic lesion to erosion/rupture
CRP is not routinely done, but is widely available
scores <1= LOW RISK, 1-2.9= MODERATE RISK, >3= HIGH RISK
CHADS/chads2-vasc
model to determine if anticoagulation therapy is needed based on risk
SCORE OF 0= now risk, no anticoags needed
SCORE OF 1= low/moderate risk, consider anticoags
SCORE 2 OR MORE= moderate/high risk, should otherwise be an anticoag candidate (still need to consider the whole patient)
infant cardiac risk factors
family history/siblings with congenital heart disease
premature birth, perinatal/prenatal fetal distress
MATERNAL EXPOSURE- ETOH, coxsackie B, CMV, influenza, lithium, mumps, rubella, x-rays, drugs, smoking
CHROMOSAMAL ABNORMALITIES- trisomy 21, 13, 18
maternal age over 40 years
cardiac inspection
face, overall color, WOB
CHEST SHAPE AND SIZE- AP/transverse ratio, barrel chest, convex/concave sternum
CHEST MARKINGS- vessel dilation, varicose veins, visible retractions, lesions
VISIBLE PULSATIONS- usually abnormal, but may see aortic pulsation on abdomen of very thin pt
extra-cardiac inspection
NAILS- capillary refill, clubbing (low perfusion; smokers/COPD/CHF), shape changes, splinter hemorrhages (endocardititis, vasculitis, micro emboli; can be normal in patient who works a lot with hands)
MOUTH- dental hygiene, piercings; high arch in palate often seen with MVP
BMI/PROPORTIONS- waist circumfereance >40 in males of >35 in females; apple vs pear shape= central vs peripheral obesity; higher risk of CVD with apple shape
JANEWAY LESION- seen in acute bacterial andocarditis; flat, on palms/soles, PAINLESS**
OSLER’S NODE- associated with infective endocarditis; PAINFUL** erythametous nodules
MARFAN SYNDROME- often missed; cardiac issues including incompetent valves; tall and slender, long legs/arms/toes, arachnodactyly (long/slender fingers)
XANTHOMAS- lumps containing lipids in periphery; common in older adults and people with high blood lipids; if around the eyes, call XANTHELASMA
ARCUS SENILIS- ring around eye that is lipid deposit; common/normal in older adult, sign of high cholesterol in young adult
cardiac palpation
symmetrical pattern at all landmarks
PMI 5th intercostal MCL (should be about the size of fingertip/contained, gentle tapping)
THRILL- fine vibration, indicates turbulence in the blood flow (abnormal)
HEAVE- strong outward thrust at PMI, ventricle contracting up into hand (abnormal)
VITAL SIGNS- HR/RHYTHM, strength (weak vs bounding), sites (should assess bilateral pulses), skin temp warm/cold
location of thrill
aortic area during systole (aortic stenosis), apex during systole (mitral regurgitation), pulmonic area during systole (pulmonic stenosis), LSB 4
what may a heave indicate?
ventricular hypertrophy
pulses
check temporal, carotid, brachial, radial, femoral, popliteal, post tib, dorsalis pedis
present, grade, symmetry
TWO SCALES (need to indicate which scale you are using)
ABNORMAL PULSES
ALLEN TEST: test for occlusion of the radial/ulnar artery
AORTA PALPATION
BLOOD PRESSURE
two scales for pulses
3+- 3/3= bounding; 2/3=normal, 1/3=weak, 0/3=absent
4+- 4/4=bounding, 3/4=normal, 2/4=weak, 1/4= thready, 0/4=absent
abnormal pulses
pulsus magnus- bounding
pulsus parvus- weak
pulsus alterans- alternating
pulsus paradoxus- r/t blood pressure
pulsus paradoxus
abnormally large decrease in SBP/pulse wave amplitude during inspiration
NORMAL FALL IS <10 MMHG
excessive decline can indicate tamponade, adhesive pericarditits, severe lung disease, advanced heart failure, and other conditions
allen test
pressure applied to ulnar/radial to occlude both, have pt elevate arm and make fist for 30 seconds, then open (hand should be blanched), release ulnar side
color should return to hand within 7 seconds= +ALLEN (adequate blood flow)
aorta palpation
identify pulsation if visible
press deeply on either side of the aorta- midline abd, above umbilicus
NORMAL SIZE- 3 cm or less, average 2.5 cm; if >5.5 cm may need surgery
risk factors for AAA*- >65 yo, smoking, male gender, 1st degree relative with AAA, auscultated bruit
edema
RATE THE DEGREE- 0=no pitting, +1= mild, +2= moderate, +3= severe; +4=severe
also record where edema is located
ankle brachial index (ABI)
predicts severity of peripheral arterial disease
measurable with doppler ultrasound; perform on each side
right ankle SBP/right arm SBP=ABI (complete bilaterally)
right ankle SBP/right arm SBP=ABI
normal= 1 or >
at risk= 0.9
borderline ischemia= 0.6-0.8
severe ischemia= <0.5
what is the significance of JVP?
it is an indication of function of the R side of heart
should see no engorgement of EJ
high level of engorgement=higher RA pressure
how to examine R EJ
right side of pt, HOB at 45 degrees, pt turn head to left
identify top of venous pulsation in neck (inward pulsation, not palpable), then measure distance between top of pulsation and sternal angle
angle of louis (sternal angle) down to RA= approx 5 cm
your result +5cm=JVP
if you get >9cm above RA when examining right EJ, what does this mean?
increased RA pressure
right side HF is the most common
constrictive pericarditis, tricuspid stenosis, SVC obstruction, valsalva phenomenon (laughing, coughing)
HJR- hepatic jugular reflux
apply firm pressure to liver border for 30 seconds
positive test= >4cm JVP risk for >10 seconds
what does a positive HJR (hepatic jugular reflux) suggest?
suggests CHF
falsely positive if valsalva (pt bearing down, abdominal guarding)
normal heart sounds
best heard with diaphragm of stethoscope
S1 “LUB”- closing of mitral/tricuspid valves (end of diastole/beginning of systole), loudest at apex (mitral/tricuspid areas), upstroke of pulse/rise of QRS
S2 “DUB”- closing of aortic/pulmonic valves (end of systole/beginning of diastole), loudest at base (aortic/pulmonic areas)
abnormal heart sounds
best heard with bell of stethoscope
split S2 “lub-d dub”
S3” lub-dub-d” or “ken-tuc-KY”
S4 “d-lub-dub” or “ten-ne-see”
rubs
bruits
split s2 “lub-d dub” sound
RESPIRATORY EFFECT: normal/physiologic- r/t respirations b/c of volume changes; if and when pt holds breath, stutter goes away= physiological
PARADOXICAL: abnormal/pathologic; sound doesn’t go away with breath hold; seen with LBBB b/c impulse takes longer to get to L ventricle
FIXED: abnormal/pathologic; always there and doesn’t vary; seen with atrial-septal defect and RHF
S3 “lub-dub-d” or “ken-tuc-ky”
ventricular gallop, best heard at apex (bottom) during early systole (just after s2)
result of blood splashing into ventricles
PATHOLOGIC: seen in CHF, sign of being “wet”
PHYSIOLOGIC: increased flow state in someone under 30, pregnancy
s4 “d-lub-dub” or “ten-ne-see”
always pathologic, atrial gallop, occurs with atrial contraction at the end of diastole (just before s1), found in stiff heart (recent MI, HTN)
rubs
caused by movement of inflammatory adhesions between visceral/parietal pericardial layers
high pitched/squeaking sound like rubbing leather together
may be systolic or diastolic and systolic
heard at different times depending on cause
components: atrial contraction, ventricular filling, ventricular contraction
best heard with patient leaning forward/breath held on expiration- brings heart closer to chest wall
bruits (abnormal vascular sound)
caused by turbulent flow in blood vessels
listen for carotid, aortic, renal, iliac, and femoral bruits
biggest risk: HTN
hard to differentiate between carotid bruit and aortic stenosis radiating into neck
murmurs
sound created by turbulent flow in heart (in periphery=bruit)
TIMING- diastolic (between S2 and S1)= heart disease; systolic (between S1 and S2)= heart disease or can be normal
SHAPE- intensity over time (crescendo, decrescendo, or crescendo-decrescendo)
LOCATION- site of max intensity/loudest (aortic and mitral most common)
RADIATION- can you hear it elsewhere?
PITCH- high, medium, low
QUALITY- blowing, harsh, rumbling, musical
INTENSITY- graded on 1-6 scale
intensity of murmur
graded on 1-6 scale:
1/6- faint, only heard if you know it’s there
2/6- quiet, but heard immediately
3/6- moderately loud
4/6- loud with PALPABLE THRILL
5/6- very loud, heard with stethoscope partially off of chest wall, PALPABLE THRILL
6/6- loudest, heard with stethoscope completely off of chest wall, PALPABLE THRILL
questions to identify valvular disorders
where is the loudest?
when does the murmur occur?
what is the valve doing during the cardiac cycle when you hear it?
does it radiate?
possible cause of valve dysfunction?
what is the valve doing during the cardiac cycle when you hear the murmur? *systole vs. diastole**
systole- tricuspid/mitral CLOSED (regurg); aortic/pulm
OPEN (stenosis)
diastole- tricuspid/mitral OPEN (stenosis); aortic/pulm CLOSED (regurg)
mid-systolic murmur
heard between S1 and S2
loudest during mid systole (crescendo-decrescendo)
holosystolic murmur
heard between S1 and S2, does not get louder or softer
aortic murmurs
radiates into neck
STENOSIS***- mid-systolic, heard in aortic area (2nd ICS-RSB)
INSUFFICIENCY***- diastolic decrescendo, heard in aortic area (2nd ICS-RSB)
mitral murmurs
radiates into axillary area
STENOSIS***- diastolic murmur, heard in mitral area/apex (5th ICS-MCL)
REGURGITATION ***- systolic murmur, heard in mitral area/apex (5th ICS-MCL)
common systolic murmurs: MR PASS MVP
Mitral Regurg
Physiologic
Aortic Stenosis
Systolic
Mitral Valve Prolapse
common diastolic murmurs: MS ARD
Mitral Steosis
Aortic Regurg
Diastolic
mitral valve prolapse
MID-SYSTOLIC CLICK (from leaflet opening back up)+ LATE MURMUR (2nd half of systole; when valve should be closed)
PRIMARY: familial/non-familial, marfans, or other connective tissue diseases
SECONDARY: CAD, rheumatic heart disease, vegetation, ASD, anorexia, dehydration, straight-back syndrome/pectus excavatum
general population aged 60 years or older (recommendations)
initiate pharmacologic treatment to lower blood pressure if SBP>150 mmHg or DBP >90 mmHg
treat to a goal of <150/90
older patients with other perfusion issues, can’t lower blood pressure too much or have other issues such as syncope
general population <60 years (recommendations)
initiate pharmacologic treatment to lower blood pressure if DBP>90 mmHg
treat to goal of DBP <90 mmHg
special recommendations for black and non black patient groups, kidney disease and diabetes
black patients do not do as well on ACE/ARBS- start on CCB/thiazide
