The Heart Does One Thing…. Flashcards
A STEMI in the inferior wall of the heart would show ST elevation in which ECG leads?
Leads II, III, and aVF
ST elevation in leads V1-V4 indicates an infarction in which wall(s)?
The anterior/septal walls
Name that heart block!
1st degree AV block
“If the R is far from the P, it means you have a 1st degree”
Which coronary artery feeds the inferior wall of the heart?
RCA
Where can you auscultate the aortic valve?
2nd ICS, right sternal border
Where can you auscultate the pulmonic valve?
2nd ICS, left sternal border
Which valve can you auscultate between the 4th and 5th ICS, @ the LEFT sternal border?
The tRIcuspid valve (between the R atrium and R ventricle)
Which valve can you auscultate @ the 5th ICS, @ the left mid-clavicular line?
The mitraL (mighty, mighty LEFT! Between left atrium and left ventricle)
What does the S1 heart sound represent?
*Systole
*closure of the mitral and tricuspid valves
*auscultate @ mitral area (5th ICS)
What does the S2 heart sound represent?
*Diastole
*Closure of aortic and pulmonic valves
*Auscultate over aortic area (2nd ICS, right sternal border)
Name 3 reasons an S3 heart sound might be present? Where can you auscultate it?
*Listen for S3 over apex
1. Increased preload (ex. fluid overload)
2. Normal in kids and pregnancy
3. VSD, mitral/tricuspid regurgitation
An S4 (pre-systolic) heart sound is caused by the vibration of the atria ejecting blood into ________________ ventricles. **Bonus: name 3 causes.
Non-compliant (a.k.a. “Impaired relaxation”)
**Bonus: ischemia, CAD, pulmonary/aortic stenosis, left ventricular hypertrophy
“A S4 heart sound can be an important sign of diastolic heart failure or active ischemia and is rarely a normal finding. Diastolic heart failure frequently results from severe left ventricular hypertrophy, or LVH, resulting in impaired relaxation (compliance) of the LV. In this setting, a S4 is often heard. Also, if an individual is actively having myocardial ischemia, adequate adenosine diphosphate cannot be synthesized to allow for the release of myosin from actin; therefore, the myocardium is not able to relax, and a S4 will be present.
It is important to note that if a patient is in atrial fibrillation, the atria are not contracting, and it is impossible to have a S4 heart sound.”
https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/s4-heart-sound
In ACS there is an imbalance of ________ supply and demand.
Oxygen
Semilunar valves (aortic and pulmonic) are open during _____________.
Systole (blood out to body and lungs)
AV valves (mitraL and tRicuspid) are open during ____________.
Diastole (filling)
The posterior wall of the heart is perfused by the _______ in 90% of the population, but by the ________ in 10% of people.
RCA; circumflex
The LATERAL wall of the heart (containing the left atrium and the back of the left ventricle) is perfused by the ________.
Circumflex artery
The ____________ wall of the heart contains the R atrium, the SA node, the AV node, the R ventricle, and the back of the septum.
Inferior (fed by RCA)
The _______ perfuses the septal and anterior walls (which include the front and bottom of L ventricle, and the front of the septum).
LAD
The “widowmaker” refers to a blockage in which coronary artery?
The LEFT MAIN (upstream of both the circumflex and LAD = bad news, shock, HD instability)
Coronary arteries are perfused during which phase of the cardiac cycle?
During DIASTOLE (backflow); coronary sinuses are @ the base of the aorta
How do measure preload?
Right side: ________
Left side: _________
Right side: CVP (but not super useful alone — doesn’t tell you if they’ll be fluid responsive)
Left side: PAOP (wedge)
____________ is the resistance ventricles have to overcome as they’re moving blood
Afterload
Increased afterload on the R side of the heart is ____________
Pulmonary vascular resistance
Increased afterload on the left side of the heart is called __________.
Systemic vascular resistance (SVR)
Systole usually accounts for ___ of the cardiac cycle, while diastole accounts for ____.
1/3, 2/3 (shortened c/ tachycardia!)
When can you auscultate a split S1 or S2, and what do they represent?
Best heard during INSPIRATION.
Split S1: mitral closes before tricuspid (R BBB, PVCs, V-pacing)
Split S2: aortic closes before pulmonic (overfilled R ventricle, ASD)
____________ is the forward flow of blood through NARROW, OPEN valves.
StenOsis (not open all the way)
____________ is the backward flow of blood through incompetently closed valves.
Insufficiency (not closed all the way)
_____________ murmurs are heard between S1 and S2; mitral and tricuspid valves are closed (insufficiency), and aortic and pulmonic valves are OPEN (stenosis).
Systolic
___________ murmurs are heard after S2; tricuspid and mitral valves are OPEN, and aortic and pulmonic valves are CLOSED.
Diastolic
Murmur =
Regurgitation =
Stenosis (forward flow through open valves that aren’t totally open)
Insufficiency (backflow through closed valves that aren’t totally closed)
Would mitral insufficiency cause a systolic or diastolic murmur?
Systolic (occurs when valves are closed = regurgitation!)
Why are patients with mitral regurgitation and mitral stenosis prone to developing Afib?
Due to left atrial enlargement
Pink cheeks, pulmonary edema, and pulmonary HTN with a diastolic murmur are all symptoms of:
Mitral stenosis
Medical management of mitral stenosis focuses on reduction of _________ and ________.
Preload and afterload
MI, ruptured chordae tendineae, severe left sided heart failure (dilated), rheumatic fever, endocarditis, and L ventricular cardiomyopathy are all potential causes of what type of valvular dysfunction?
Mitral insufficiency (regurgitation)
Aortic insufficiency occurs when the valve doesn’t close all the way, which results in a backflow of blood and a reduced _________ pressure.
Diastolic (ventricle already partially filled with back flowing blood!)
What can happen to the muscle in the left ventricle if a pt has aortic stenosis?
Hypertrophy!
What is the gold standard test for diagnosis of aortic stenosis?
***ECHO!
TAVR (transcatheter aortic valve replacement) pts should be carefully monitored for signs of bleeding/hematoma, bradycardia and heart blocks, as well as ___________.
Signs of stroke (plaque rupture)
A “sail-shaped” ST segment can indicate _______.
Coronary vasospasm (Prinzmetal’s angina)
(Treat with NTG, CCBs)
The body views plaque rupture as an _______ and responds accordingly, leading to __________ aggregation which can lead to the formation of occlusive thrombi.
Injury; platelet
What do pathologic Q-waves represent?
An old MI (usually days after, persist for life sometime)
Troponin levels rise in about 3-4 hours, peak at about _____to_____ hours, and return to normal levels in about 1-2 weeks.
14-20
What is the goal “door to balloon” time for PCI in the case of a STEMI?
90 minutes or less
The standard “MONA” bundle of treatment is now considered somewhat antiquated; what does “MONA” stand for, and which two elements are now given only if necessary (instead of as part of standard treatment).
“MONA” = Morphine, Oxygen, Nitro, Aspirin
Morphine and Oxygen are now only given as needed
This medication is used indefinitely post-MI in order to disable platelet aggregation
Aspirin
What are two contraindications for administering nitroglycerin to STEMI patients?
DO NOT give to STEMI pts with right ventricular infarction or pts who take phosphodiesterase inhibitors (i.e. Viagra)
Hyperoxemia can contribute to _________ _________ after an MI.
Oxidative injury
Tachycardia, hypotension, back and/or groin pain, and flank ecchymosis are all potential s&sx of what complication following a femoral approach heart cath?
Retroperitoneal bleed
(Note: tachycardia may be masked by beta blockers)
Patients with _______ ventricular failure become preload dependent, and may need IV fluids in order to maximize preload.
Right
A posterior wall MI would show reciprocal changes in which leads?
Leads V1 and V2
A patient has chest pain that improves when sitting up & leaning forward, with ST elevation in leads I&II. What do you suspect is the issue?
Pericarditis
Alpha adrenergic receptors are located in ______ _________.
Blood vessels
Beta1 receptors are located ____________.
On the heart
Beta2 receptors are located ____________.
In the bronchial and vascular smooth muscle
Dobutamine is a positive inotrope that primarily effects _______ receptors.
Beta1 (on the heart)
This vasopressor is the first-line choice in sepsis, and affects alpha and some beta1 adrenergic receptors.
Norepinephrine
Phenylephrine only acts on ________ receptor.
Alpha (in blood vessels)
Longer cardiac bypass time can lead to increased risk of stroke, neurological injury, and ___________.
Bleeding
The pericardial space normal contains about ______ to ______ mL of fluid.
20 to 50
“Beck’s Triad” includes:
1. Elevated CVP with JVD
2. Hypotension
3. Muffled heart sounds
….. and indicates what?
Cardiac tamponade
A greater than 10 mmHg drop in BP during inspiration is called _____ ______.
Pulsus paradoxus (indicates cardiac tamponade)
Amiodarone is safer to use for Afib patients with a _________ ejection fraction (over beta blocker or CCBs)
Decreased (because not a negative inotrope like BBs and CCBs)
For a pt in hypertensive crisis, goal is to reduce BP by _____% over 1-2 hours
25%
A patient describes a “ripping” chest pain radiating to the back. What do you suspect?
Aneurysm (types: TAA, AAA, aortic)
___________ is a direct arterial vasodilator.
Nicardipine
BP difference of greater than 25 mm Hg between arms is a sign of what?
Aortic dissection
