Week 2 CV Study Guide (everything) Flashcards
Where is the base of the heart located in the chest
The Base of the heart is the right and left 2nd intercostal spaces next to the sternum.
What produces the apical impulse
The tapered inferior tip of the heart(‘s Apex)
What is the PMI and where on the chest is it located
The apical impulse, identified during palpation of the precordium as the PMI
Located: 5th intercostal space, 7-9cm lateral to the midsternal line, typically at or just medial to the left midclavicular line.
Be able to discuss the flow of blood through the heart
Superior and inferior vena cavas → right atrium → tricuspid valve → right ventricle → pulmonary valve → pulmonary arteries → lungs → pulmonary veins → left atrium → mitral valve → left ventricle → aortic valve → aorta and the aortic arch → body
Describe Systolic blood flow
Systole: the ventricle contract (pressure generated by the left ventricle during systole when it ejects blood into the aorta and the arterial tree)
- The right ventricle pumps the blood into the pulmonary arteries (pulmonic valve is open)
- The left ventricle pumps blood into the aorta (aortic valve is open)
Describe Diastolic blood flow
Diastole: the ventricles relax (pressure generated by blood remaining in the arterial tree during diastole when the ventricles are relaxed)
- Blood flows from the right atrium-> right ventricle (tricuspid valve is open)
- Blood flows from the left atrium-> left ventricle (mitral valve is open)
Describe the pressures generated by SBP:
SBP:
pressure generated by the LV during systole, when the LV ejects blood into the aorta and the arterial tree
- pressure waves in the arteries create pulses
Describe the pressures generated by DBP:
DBP:
pressure generated by blood remaining in the arterial tree during diastole, when the ventricles are relaxed
pressure waves in the arteries create
pulses
Diastole:
ventricles relax
Systole:
ventricles contract
Preload=
volume overload
Afterload =
pressure overload
Equation for CO =
CO = SV x HR
Equation for BP=
CO x SVR
Chest pain R/T cardiac disease:
most important symptom of cardiac disease
Chest pain R/T symptomatic blockage:
-CP symptoms typically occur w/70% blockages
but
-can occur w/50%
Chest pain in R/T groups of patients who have atypical s/s and what are their symptoms?
women, diabetics, and the elderly
jaw pain, fatigue, weakness, shortness of breath, and upper back pain
atypical s/s :
jaw pain fatigue weakness SOB upper back pain
Differential Dx of CP:
- Angina
- Myocardial Infarction
- Other Ischemic C-V Origins (Aortic stenosis/ regurgitation, uncontrolled htn, severe anemia/hypoxia, tachycardia/ arrhythmias, pulmonary HTN.)
- Non-ischemic C-V Origins (thoracic/aortic aneurysms, aortic dissection, pericarditis, mitral valve prolapse, murmur)
- Pulmonary- PE, pneumonia, pleurisy, tumor
- Gastrointestinal- GERD often occurs at night, cardiac early AM
- Psychogenic
- Neuromusculoskeletal- costochondritis- history of injury, sports, coughing, late-stage pregnancy, young without cardiac history
What is the true symptom of CAD:
angina Pectoris
What is angina caused by and due to?
- Caused by the hypoxia to the myocardium which leads to anaerobic metabolism and the production of lactic acid. The acid irritates the actual heart muscle and makes it hurt.
- Due to an imbalance of oxygen delivery to the heart and the oxygen need of the heart.
Levin’s Sign:
Pt’s describe angina by clenching their fist and placing it over the sternum.
Differential Dx of CP and Angina
- Usually substernal
- Radiation - chest, shoulder, neck, jaw, arms
- Deep visceral (pressure)- intense, not excruciating
- Duration- min no sec (5-15 min)
- Associated with nausea, vomiting, diaphoresis, pallor
- Precipitated by exercise and emotion
- Becomes unstable when occurs during sleep, at rest, or increases in severity/ frequency
- Relief with rest or NTG
Differential Dx of CP and MI
- Same type OF PAIN as angina
- Duration greater than 15 mins
- Occurs spontaneously, often sequela of unstable angina
- Relieved with morphine, successful reperfusion of block coronary artery
Differential Dx of CP and other CV ISCHEMIC origins:
- Aortic Stenosis/Regurgitation
- Uncontrolled Hypertension- usually hypertension is asymptomatic
- Severe Anemia/Hypoxia
- Tachycardia/Arrhythmias
- Pulmonary Hypertension
Pericarditis:
inflammation of the pericardium
Pericarditis occurs:
what medical problems?
•Occurs as a complication of MI or CABG, or in patients with connective tissue disease
Pericarditis s/s:
sharp and stabbing,
radiates to trapezius ridge
aggravated by inspiration
coughing, recumbency, and rotation of trunk, and lessened by sitting upright and leaning forward
Pericarditis Tx:
•Relief - analgesics & anti-inflammatory meds
Thoracic/Aortic Aneurysms
•Pressure on trachea or esophagus- dyspnea, cough, hoarseness, dysphagia
Aortic Dissection
- Sudden, excruciating pain (knife-like, tearing)
- Migrating pain (depends on location of tear)
- Frequently, hemodynamic instability
- Appearance of shock with normal or elevated BP
- Absent or unequal peripheral pulses
MVP patients complain of:
Palpitations
S/S of MVP
- Left anterior superficial, rarely visceral pain- may complain of PALPATIONS
- Variable in character
- Lasts minutes, not hours
- Spontaneous onset with no pattern
- Relieved with time
What may MVP progress to in 10% of women?
Mitral Regurgitation
Chest Pain Questions:
“ O.L.D. C.A.R.T.S.”
•Onset—when did it start?
•Location/Radiation—where is it located?
•Duration—how long has this gone on?
•Character—does it change with any specific activities? Does the patient
use any descriptive words to describe the quality of the symptom?
•Aggravating factors – what makes it worse?
•Reliving factors – what makes it better?
•Timing—is it constant, cyclic, or does it come and go?
•Severity—how bothersome, disruptive, or painful is the problem
Sinus tachycardia S/S:
•Usually gradual onset and offset
S/S of Paroxysmal SVT:
•Sudden, abrupt onset and offset
List 11 non-cardiac reasons tachy arrhythmias may occur:
1.Hyperthyroidism 2 Respiratory disease 3 Infection 4 Sepsis 5 Anemia 6 Blood loss 7 Illegal drugs 8 Medications 9 Heat stroke 10 Emotions 11 Exercise
Major complications of A-Fib :
Peripheral Embolization
and CVA
A-Fib may present as:
[Know 4 of 9]
- Hypertension
- Hyperthyroidism
- Acute MI
- Pericarditis
- Coronary Artery Disease
- Congestive Heart Failure
- Valvular Heart Disease
- Acute or Chronic ETOH abuse
- Post-operative state
VT may present as:
- Sudden cardiac death;
- VT degenerated into VF
Brady: Lab work needed?
- Electrolyte Abnormalities
- Thyroid function
- Any therapeutic drug levels (dig, theophylline, antidepressants)
50.) The presence of a thrill over the heart will indicate you will hear a _______ at grades _______?
hear a loud murmur (grades 4-6)
51.) List 4 cardiac areas of auscultation and their location.
Listen at all cardiac areas:
Aortic –2nd ICS, RSB
Pulmonic—2nd ICS, LSB
Mitral–cardiac apex, 5th ICS, MCL
Tricuspid—left lower sternal border
52.) What type of sounds is the bell of the stethoscope used for?
The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis.
53.) What type of sounds is the diaphragm of the stethoscope used for?
The diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs.
54.) What does “A.P.E.T.M.” mnemonic stand for? What does it assess?
A- Aortic (Right Base) P- Pulmonic (Left Base E- Right Ventricular Area T- Tricuspid (Left lateral M- Mitral (Apex)
“APE To Man”
55.) Normally only the ______of the valves can be heard?
Normally only the closing of valves can be heard.
56.) What produces the 1st and 2nd heart sounds and what position are they heard best?
Closure of the tricuspid and mitral valves (AV valves) produce the 1st heart sound.
Closure of the aortic and pulmonic valves produce the 2nd heart sound.
S1- heard best at apex
S2- heard best at base
57.) What is hearing the opening of the valves of the heart indicative of?
Opening of valves can only be heard if they are very damaged (opening “snap” “click”)
58.) Briefly discuss a physiological split of S2.
A physiological split of the S2 is common and varies with respiration- S2 splits on inspiration and is heard best as a single sound on expiration.
59.) Briefly discuss fixed splitting of S1 and s2.
Fixed splitting of S1 & S2 can occur with pathological conditions such as BBB, PVC, RVF, ASD, pulmonic stenosis and mitral regurgitation.
60.) Where does 80% of ventricular blood filling occur?
When AV valves open, the period of rapid filling of ventricles occurs. 80% of ventricular filling occurs now.
61.) What is the S3 sound and who is it normal in?
gallop sound- fluid overload.
S-3 is normal in children and young adults. (Under 30)
62.) When is S3 not common and what does it indicate?
Not common in people over the age of 30. It means there is volume overload of the ventricle.
63.) Where does the other 20% of blood volume come from and what heart sound is it?
At the end of diastole, atrial contraction contributes to the additional 20% filling of the ventricle. If the left ventricle is stiff and non-compliant, you will hear an S4.
64.) If you cannot hear an S4 heart sound, what is it indicative of?
You only hear an S4 if the ventricle is stiff and non-compliant. Thus to not hear one is indicative of a normal heart.
65.) The presence of an ___________ and ____________ creates a cadence resembling the gallop of a horse.
S3 and S4
66.) What position and what part of the stethoscope is used to determine if S3 and S4 are present?
While listening at the apex and left lower sternal border with the bell, you’ll be able to determine if an S3 or S4 are present.
67.) How do you know if you are hearing S1 heart sound?
To interpret heart sounds correctly, you must clearly identify what sound is S1. To do this, palpate the carotid artery while you listen.
The sound that you hear when you feel the carotid pulse is S1.
68.) Heart murmur sounds _____ through ____ must have an accompanying thrill.
Grades 4 through 6 must have accompanying thrill.
69.) Be familiar with the intensity of murmurs. So describe to me Grades 1-6.
Grade I = lowest intensity, not heard by inexperienced listener
Grade II = low intensity, usually audible to everyone
Grade III = medium intensity but no palpable thrill
Grade IV = medium intensity with a thrill
Grade V = loudest murmur audible when stethoscope is on the chest. Has a thrill
Grade VI = loudest intensity, audible when stethoscope is removed from the chest. Has a thrill
70.) Systolic murmur are heard under what two physiologic conditions?
May be caused by turbulence across the aortic or pulmonic valves if they are stenosed.
May be caused by turbulence across the mitral or tricuspid valves if they are incompetent (regurgitant).
71.) What 2 sounds does a systolic murmur fall between?
The murmur falls between S1 and S2
Sounds like, LUB-shhh-dub
72.) What causes a diastolic murmur (2 physiological events)
Mitral and tricuspid stenosis can cause a diastolic murmur
Aortic or pulmonic regurgitation can cause a diastolic murmur.
73 a.) Pericardial Friction Rubs:
May result from what 3 events?
May result from irritation of the pericardium from infection, inflammation, or after open heart surgery.
73 b.) Pericardial Friction Rubs:
When is it best heard?
Best heard when patient sits and holds breath.
73 c.) Pericardial Friction Rubs:
How do you distinguish a pericardial friction rub from a pleural friction rub?
A rub that disappears when the patient holds his breath does NOT come from the heart. This is probably a pleural friction rub.
74.) What are you assessing when you order a CBC for a cardiac event?
WBC:
- WBC: increases with inflammation and phagocytosis (MI, hematoma, and pericarditis) and can also occur with steroid use
74.) What are you assessing when you order a CBC for a cardiac event?
RBC:
- RBC, Hgb, Hct, Indices: evaluate for anemia as a cause of chest pain and dyspnea, while also evaluating for initiation and continued use of anticoagulant and antiplatelet therapy
74.) What are you assessing when you order a CBC for a cardiac event?
Platelets:
- Platelets: evaluating safety for initiation and coninued use of anticoagulant and antiplatelet therapy and possible decreases due to adverse drug effects (HIT, H2 blockers: Pepcid, Tagamet, and Zantac, Aspirin, and Plavix)
75.) Know reasons for increases and decreases in Na and K+ levels.
- (NA) Increases: dehydration, increased NA intake
- (NA) Decreases: volume overload, decreased NA intake, diuretics
- (K) decreases: diuresis, decreased K intake, diarrhea, nausea and vomiting, gastric suction, hypoglycemia, alkalosis
- (K) increases: renal failure, dehydration, acidosis, hyperglycemia, increased K intake, ACE inhibitors, RBC hemolysis
76.) What range must the K+ be on a MI patient? What other conditions require this range of K+?
- Potassium should be maintained between 4.0-5.0
- Also needed for:
acute MI
cardiomyopathy
hx of ventricular arrhythmias
diuretic therapy (as long as there is normal renal function)
77.) What cardiovascular issues are present in Hyperkalemia
- Hyperkalmia: bradycardia, heart block, idioventricular rhythms, vtach, vfib, ventricular arrest, muscle weakness, and tetany
77.) What cardiovascular issues are present in Hypokalemia?
- Hypokalmia: PVC’s, atrial tachycardia, vtach, fvib, and leg cramps
78.) What does CO2, BUN, Glucose, and Cr levels suggest?
- CO2: measures bicarbonate level of blood, measures metabolic state
- BUN: increased level (azotemia) with impaired renal function caused by CHF, dehydration, shock, stress, acute MI, increased levels also with renal disease and GI bleed
- Glucose: may elevate with stress such as with MI
- CR: increased level indicates worsening renal function
79.) Why would liver function tests be elevated in CHF?
May elevate in CHF due to hepatic congestion
80.) LFT may increase when using anti-lipidemic drugs, it is usually not a problem unless it is ___ times normal range.
2
a. Name 3 abnormalities caused by thyroid:
Arrhythmias, Fatigue, Anemia
What lab level should you check first before a full thyroid panel?
Start by checking TSH and if abnormal then check full thyroid panel
82.) When is CK released in the body? Where is it found? Under what conditions will you see it elevated?
- Released: when there is injury to cells
- Found: in heart, skeletal, and brain muscle cells
- Elevates with: acute MI, myocarditis, post-CABG, cardioversion (defib), possibly rhabdomyolysis, may see with cocaine intoxication and adverse effects from statin drugs with hypercholesterolemia
83.) Understand the use for CK-MB and MB Index.
- CK-MB: specific to myocardium
- Increases with acute MI, myocarditis, post-CABG and cardioversion, and may elevate with chronic renal failure
○ Acute MI, MB occurs in serum in 6-12 hours and remains for 18-32 hours
○ Presence is diagnostic of MI
Understand the use for MB Index.
- MB Index: percentage of MB in comparison with total CK
84.) Diagnosing and confirming an acute MI requires what lab at what intervals?
Three sets of cardiac isoenzymes (CK-MB and MB Index) should be ordered 8 hours apart.
85.) Understand normal values; peaks; and use of the following labs.
Troponin I
a. Troponin I: more specific and unique to heart muscle that is released with very small amounts of muscle damage as early as 1-3 hours after injury. Useful for delayed diagnosis in MI.
Understand normal values; peaks; and use of the following labs.
Troponin T:
Troponin T: may also elevate in unstable angina, myocarditis, chronic renal failure, acute muscle trauma, rhabdomyolysis, polymyositis, and dermatomyosis
- Troponin I normal is < 0.35 ng/ml
Peaks: 12-48 hours (levels return to normal in 7-10 days)
- Troponin T normal is < 0.2 ng/ml
Understand normal values; peaks; and use of the following labs.
Myoglobin:
b. Myoglobin: oxygen binding protein of striated muscle that is released with injury to muscle. It is used as an early marker for muscle damage in MI
Peaks: 8-10 hours (returns to normal in 24 hours)
Elevates in 2-4 hours
BNP:
BNP: hormone that is produced by ventricles of the heart that increases in response to ventricular volume expansion and pressure overload (marks systolic and diastolic dysfunction); useful in diagnosing CHF
o Normal: is <100ng/L
o Peak: > 500pg/mL indicated HF
cholesterol numbers
- FYI: normal total cholesterol is < 200, normal LDL is < 130, normal HDL is > 40, and normal triglycerides is < 150
87.) Is it possible to have an MI with a normal EKG?
yes
88.) What is the most common type of Transthoracic echo (TTE)?
Transthoracic echo (TTE)????
89.) What is a transesophageal (TEE) usually ordered for?
Ordered to evaluate for vegetation on the heart, valvular disorder and thrombi
90.) What tests are done to evaluate for myocardial ischemia?
Stress Testing:
- Exercise treadmill testing
- Myocardial perfusion imaging (MPI) aka Misnomer or Thalium Scan: exercise, Persantine, Adenosine, Dobutamine
- Stress echocardiogram: exercise, dobutamine
91.) What does MUGA stand for in the MUGA scan? What does it determine?
Multiple Gated Angiography that determines ejection fraction (almost always done with MPI now)
92.) Name 3 types of CT and their diagnostic use:
- Helical CT: uses IV contrast to diagnose aortic dissection or pulmonary emboli
- Plain CT: diagnoses abnormal masses (with or without contrast), hematoma, or retroperitoneal bleed (better with IV contrast)
- Ultrafast CT: detection of coronary artery calcification as indicator of atherosclerosis and NO contrast is used; the higher the score, the more calcium detected
- ) What do the following indicate on an EKG:
a. Peaked T wave:
b. T wave inversion:
c. U waves:
d. QT
e. ST
f. Q waves:
a. Peaked T wave: hyperkalemia
b. T wave inversion: ischemia
c. U waves: hypokalemia
d. QT prolongation: toxic drug effects
e. ST elevation: acute injury
f. Q waves: transmural MI
93.) What differentiates arterial insufficiency from venous insufficiency?
refer to sheet
94.) Arterial Insufficiency is a high risk for?
Patients with peripheral arterial disease (PAD) often have underlying atherosclerosis. Other diseases, such as diabetes, HTN, CAD, carotid or renal artery disease, chronic kidney disease, and obesity, should also raise the index of suspicion for arterial insufficiency. Smoking is a strong risk factor for all vascular disease. Patients over the age of 50 are at increased risk for PAD. (Goolsby & Grubbs, 2019, pg. 232).
95.) What type of veins are a precursor to chronic venous insufficiency?
Often a precursor to chronic venous insufficiency, varicose veins are usually caused by occupations that involve prolonged standing or sitting in one place, overweight, pregnancy, or a familial tendency. (Goolsby & Grubbs, 2019, pg. 233)
96.) What are the risk factors for thrombophlebitis?
refer to sheet
97.) Is PE an issue with thrombophlebitis?
The prognosis of thrombophlebitis is good, unless the patient develops pulmonary embolism. Recurrent pulmonary embolism may occur. (Goolsby & Grubbs, 2019, pg. 230)
98.) What is the first sign of thrombophlebitis in 50% of patients?
In about 50% of cases, symptoms are absent, and pulmonary embolism may be the first sign. Other signs include SOB, chest pain, or hemoptysis. (Goolsby & Grubbs, 2019, p. 231)
