Bates: Cardiology (mostly Red)

What is PMI?
What is PMI?
PMI: point of maximal impulse.

(The impulse locates the left border of the heart and is normally found in the 5th interspace 7 cm to 9cm lateral to the midsternal line, just medial to the left midclavicular line)

In a supine patient, what is a normal diameter of a PMI?
Normal: 1 to 2.5cm

If a PMI is greater than 2.5cm, what is it evidence of? When is it seen?
LVH (left ventricular hypertrophy)

seen in HTN and aortic stenosis

What else, other than the PMI being greater than 2.5cm, is evidence of LVH?
displacement of the PMI lateral to the midclavicular line or greater than 10 cm lateral to the midsternal line

S3 and S4 are considered normal in what age patients?
under the age of 40

If patients are over the age of ___, s3 and s4 are highly correlated with what cardiac diseases?
40, heart failure and AMI (acute myocardial ischemia)

What does S3 correspond to?
an abrupt deceleration of inflow across the mitral valve

What does s4 correspond to?
increased left ventricular and diastolic stiffness which decreases compliance

________ is the period of ventricular contraction.
_________ is the period of ventricular relaxatin
________ is the period of ventricular contraction.
_________ is the period of ventricular relaxatin
systole, diastole

During systole, which valves are open and closed? What does this do?
aortic valves open: allowing ejection of blood from the left ventricle into the aorta

mitral valve is closed: preventing blood from regurgitating back into the left atrium

During diastole, which valves are open and closed? What does this do?
aortic valve is close: preventing regurgitation of blood from the aorta back into the left ventricle

mitral valve is open: allow blood to flow from the left atrium into the relaxed left ventricle

What is the the term heart failure preferred over “congestive heart failure”?
because not all patients have volume overload on initial presentation

What are the factors influencing arterial pressure (4)?
– left ventricular stroke volume
– distensibility of the aorta and the large arteries
– peripheral vascular resistance, particularly at the arteriolar level
– volume of blood in the arterial system

The jugular veins provide an important index of what?
right heart pressures and cardiac function

JVP (jugular venous pressure) reflects what pressure?
right atrial pressure, which in turn equals central venous pressure and right ventricular end-diastolic pressure

What are the common or concerning symptoms of cardiac health (4)?
chest pain, palpitations, SOB, edema

What is one of the most serious of all patient complaints?
chest pain

What are the common symptoms seen in 50% of patients with AMI?
classic exertional pain, pressure
or
discomfort in the chest, shoulder, back, neck or arm in angina pectoris

What are the atypical descriptors of a patient with AMI?
cramping, grinding, prickling,
or rarely: tooth or jaw pain

What is the annual incidence of exertional angina in population 30 years or older?
1 per 1,000

What term is increasingly used to refer to any clinical syndromes caused by acute myocardial ischemia?

What are these clinical syndromes?

acute coronary syndrome

unstable angina, non-ST elevation myocardial infarction, and ST elevation infarction

What are some causes of chest pain in the absence of coronary artery disease (CAD) on angiogram and require specialized testing?
microvascular coronary dysfunction and abnormal cardiac nocioception

Half of women with chest pain and normal angiograms will have what dysfunction?
microvascular coronary dysfunction

Anterior chest pain, often tearing or ripping, and often radiating into the back or neck, occurs in what?
acute aortic dissection

See Table 9-1, Selected Heart Rates
and Rhythms, and Table 9-2, Selected
Irregular Rhythms, for selected heart
rates and rhythms (pp. 391-392).

symptoms or signs of irregular heart action warrant what diagnostic testing?
ECG

What irregularly irregular heart action can be identified at the bedside?
atrial fibrillation

History clue: Transient skips and flip-flops may be possible ____
premature contractions

history clue: rapid regular beating of sudden onset and offset may be possible ________
paroxymal supraventricular tachycardia

history clue: rapid rate of <120 beats per minute, especially if starting and stopping more gradually may be possible_______
sinus tachycardia

Shortness of breath is a common patient concern and may present what 3 things?
dyspnea, orthopnea, or paroxysmal nocturnal dyspnea (PND)

Sudden dyspnea may indicate:
pulmonary embolus
spontaneous PTX
anxiety

When does orthopnea occur?
Left ventricular heart failure or mitral stenosis
and
obstructive lung disease

When does PND occur?

What is this sometimes mimicked by?

left ventricular heart failure, mitral stenosis

mimicked by: nocturnal asthma attacks

Dependent edema appears in what parts of the body?

What are the possible causes?

lowest body parts: feet, lower legs when sitting, or sacrum when bedridden

cardiac (heart failure), nutritional (hypoalbuminemia) or positional

How does edema present, and what are the common causes?
periorbital puffiness (eyelids puffy or swollen)
tight rings (on fingers)
cause: nephrotic syndrome: renal disease

enlarged waistline (clothes tighter around the middle)
cause: ascites and liver failure

See Promoting Lifestyle and Risk
Factor Modi#cation on pp. 358-360
for discussion of assessing patient
readiness to make health-promoting
behavior changes; see also Chapter
3, Interviewing and the Health
History (p. 72) for a discussion of
motivational interviewing.37

See Chapter 4, Beginning the Physical
Examination: General Survey,
Vital Signs, and Pain, pp. 112-113,
for discussion of the bene#ts of
restricting dietary sodium

Restricting dietary sodium to <1,500 mg/day may benefit, how?
reduce risk in CVD (cardiovascular disease) and controlling hypertension

See Table 4-4, Obesity: Stages
of Change Model and Assessing
Readiness, p. 138, and Chapter 8,
Thorax and Lungs, pp. 293-331, for
examples of how this model can be
applied to clinical counseling.

See discussion on Tobacco Cessation,
Chapter 8, Thorax and Lungs,
pp. 302-304

See discussion of Optimal Weight,
Nutrition, and Diet, Chapter 4,
Beginning the Physical Examination:
General Survey, Vital Signs,
and Pain, pp. 108-112.

See Chapter 4, Beginning the Physical
Examination: General Survey,
Vital Signs, and Pain, especially
pp. 119-124.

What is the most accurate way to eliminate the white coat effect?

What does this reading correlate with?

automated blood pressure measurement, taken when the patient rests alone in a quiet room

Correlates best with the current standard, 24-hour blood pressure monitoring

Where does the internal jugular vein lie?
Where does the internal jugular vein lie?
deep to the sternomastoid muscles in the neck

At what degrees should the head of the bed be raised for the internal jugular vein to be visible, and the vertical distance from the sternal angle or right atrium can be measured?
At what degrees should the head of the bed be raised for the internal jugular vein to be visible, and the vertical distance from the sternal angle or right atrium can be measured?
60 degrees (B)

In what patients, would it be more beneficial for the patient to lie flat to see the neck veins?

What is the drawback?

hypovolemic

venous pressure is increased (so elevating the pt’s head to 60 degrees or even 90 degrees may be required)

Where is the sternal angle?
Where is the sternal angle?
5cm above the right atrium

What are the steps for measuring the jugular venous pulse?
What are the steps for measuring the jugular venous pulse?

Jugular Pulse vs. Carotid Pulse?
Jugular Pulse vs. Carotid Pulse?

Increased JVP is highly correlated with what?
acute and chronic right and left-sided heart failure;
tricuspid stenosis, chronic pulmonary HTN, superior vena obstruction;
and pericardial disease such as tamponade and constrictive pericarditis

In what patients will the venous pressure appear elevated on expiration only?

What happens to the veins on inspiration?

Does this indicate heart failure?

obstructive lung disease

vein collapse on inspiration

does NOT indicate heart failure

What is the normal measured venous pressure: from calculating the sternal and distance above the right atrium?
What is the normal measured venous pressure: from calculating the sternal and distance above the right atrium?
Venous pressure measured at <3-4 cm above the sternal angle, or <8-9 cm total distance above the right atrium is considered normal.

an elevated JVP is 98% specific for what?
an increased left ventricular end diastolic pressure and low ventricular ejection fraction,
and
increases risk of death from heart failure

Local kinking or obstruction is the usual cause of _______
unilateral distention of the external jugular vein

JVP: first elevation, __ wave, reflect the slight rise in atrial pressure that accompanies atrial contraction. It occurs just before __ and before the _______
JVP: first elevation, __ wave, reflect the slight rise in atrial pressure that accompanies atrial contraction. It occurs just before __ and before the _______
a wave, s1 and carotid pulse

The tricuspid valve is closed, the chamber begins to fill, and right atrial pressure begins to rise again, creating the second elevation, the __ wave
The tricuspid valve is closed, the chamber begins to fill, and right atrial pressure begins to rise again, creating the second elevation, the __ wave
v

you can think of the __ wave as atrial contraction and the _ wave as venous filling
a, v

The suddent collapse of the x descent late in systole is more prominent, occuring just before __. The y descent follows __ early in diastole
S1, s2

Prominent a waves occur when?
increased resistance to atrial contraction,
~ tricuspid stenosis

first degree atrioventricular block, supraventricular tachycardia, junctional rhythms
~ pulmonary HTN, pulmonic stenosis

Absent a waves occur when?
atrial fibrillation

When do large v waves occur?
tricuspid regurgitation and constrictive pericarditis

For irregular rhythms, see Table 9-1,
Selected Heart Rates and Rhythms,
p. 391, and Table 9-2, Selected
Irregular Rhythms, p. 392.

A unilateral pulsatile bulge indicates what in the carotid artery?
A unilateral pulsatile bulge indicates what in the carotid artery?
that it is tortuous and kinked

What are some causes of decreased pulsations?
decreased SV,
local factors: atherosclerotic narrowing or occlusion

Pressure on the carotid sinus may cause what reflex?
drop in pulse rate or blood pressure

See Table 9-3, Abnormalities of the
Arterial Pulse and Pressure Waves,
p. 393.

Small, thready or weak pulse occurs when?
cardiogenic shock

bounding pulse occurs when?
aortic insufficiency

The carotid upstroke is delayed in _______
aortic stenosis

What are the two types of pulses that vary beat to beat?
pulsus alternans and bigeminal pulse

What type of pulse varies with respiration?
paradoxical pulse

alternately loud and soft Korotkroff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines indicates ______

Placing the patient in what position may accentuate this finding?

pulsus alternans

upright position may accentuate this #nding.

The level identified at first hearing Korotkoff sounds is the _______ systolic pressure during the respiratory cycle
highest

The level identified at hearing sounds throughout the cycle is the ________ systolic pressure
lowest

The difference between the highest and lowest levels of more than 10 mmHg indicates what kind of pulse?
paradoxical pulse

What does a paradoxical pulse indicate?
pericardial tamponade,
possible constrictive pericarditis,
but MOST commonly OBSTRUCTIVE AIRWAY DISEASE

a murmur like sound arising from turbulent arterial blood flow is called?
bruit

What are bruits (heard over the carotid artery) most commonly caused by?

What are other causes?

atherosclerotic narrowing of internal carotid

others: tortuous carotid artery with intraluminal turbulence, external carotid arterial disease, aortic stenosis, hypervascularity of hyperthyroidism, and external compression from thoracic outlet syndrome

The prevalence of asymptomatic carotid bruits increases with ____.

What is the age when it reaches 8%?

age.

75 years of age and older

Sensitivity and specificity of carotid bruits has an associated doubling of risk of what?

In what disease does it vary from 30-90%?

TIA, stroke, and CAD

carotid stenosis

If you hear a bruit, what should you do? Why?
pursue further investigation, bc it does not correlate with the degree of underlying stenosis

If you position the patient in a left lateral decubitus (turned to the left side), a low-pitched extra sounds such as an S3, opening snap. this indicates?
diastolic rumble of mitral stenosis

If you position the patient sitting, leaning forward, after full exhalation, you hear soft descend high-pitched. this indicates?
(pg.369)
diastolic murmur of aortic insufficiency

The intensities of S1 and S2 may be abnormal or, at rapid heart rates, the duration of diastole may shorten, making the durations of systole and diastole indistinguishable. Since the carotid upstroke always occurs in systole immediately after s1, sounds or murmurs coincidently with the upstroke are systolic; sounds or murmurs occurring after completion of the upstroke are diastolic. ___ is diminished in first degree block; __ is diminished in aortic stenosis
S1, S2

On rare occasions a patient may have _______, a heart situated in the right chest cavity with a right-sided apical impulse, seen in genetically transmitted transpositions present at birth.
dextrocardia

Use _______ to help locate the heart border, the liver and the stomach
percussion

In full situs inversus, the heart, tri-lobed lung, stomach and spleen are seen on the ______ (r/l) and the liver and gallbladder are on the ___(r/)
right, left

For thrills, press the ball of your head firmly on the chest to check for a buzzing or vibratory sensation from underlying vascular turbulence from heart murmurs.

The presence of a thrill changes ___________. (pg. 371)

the grading of the murmur (as described on pp. 382)

Successful palpation is less likely
in patients with _________?
a thickened chest
wall or increased anteroposterior
diameter

The apex beat is palpable in only
____%-_____% of healthy adults in
the supine position and in ____ of
healthy adults in the left lateral
decubitus position, especially those
who are thin.
25% to 40%; 50%

See Table 9-4, Variations and
Abnormalities of the Ventricular
Impulses, p. 394.

Pregnancy or a high left diaphragm
may displace the apical impulse
____________
upward and to the left

Lateral displacement from cardiac
enlargement is seen in what 3 diseases?
heart failure,
cardiomyopathy, and ischemic heart disease

Displacement of the heart also occurs
from deformities of the ____________
thorax and mediastinal shift

Lateral displacement outside the
midclavicular line makes cardiac
enlargement and a low left ventricular
ejection fraction_____ and ______
times more likely, respectively.
Lateral displacement outside the
midclavicular line makes cardiac
enlargement and a low left ventricular
ejection fraction_____ and ______
times more likely, respectively.
3-4 and 10

Palpate the diameter of the apical impulse. In the supine
patient, it usually measures less than 2.5 cm, about the size of a quarter,
and occupies only one interspace. It may feel larger in the left lateral
decubitus position.

In the left lateral decubitus position,
a di#use PMI with a diameter greater
than 3 cm indicates ____________.

left ventricular enlargement

If PMI is greater than 4 or 5 cm when the patient is supine, _________ is almost 5 times more likely.
left ventricular overload

Amplitude. Estimate the amplitude of the impulse. It is usually small and
feels brisk and tapping. Some young adults have an increased amplitude,
or _______, especially when excited or after exercise; its duration,
however, is normal.
Amplitude. Estimate the amplitude of the impulse. It is usually small and
feels brisk and tapping. Some young adults have an increased amplitude,
or _______, especially when excited or after exercise; its duration,
however, is normal.
hyperkinetic impulse

Increased amplitude may also
reflect what 5 diseases?
hyperthyroidism,
severe anemia,
pressure overload of the left ventricle (as in aortic stenosis),
or
volume overload of the left ventricle (as in mitral regurgitation).

Duration is the most useful characteristic of the apical impulse for identifying hypertrophy of the left ventricle. To assess duration, listen to the heart sounds as you feel the apical impulse, or watch the movement of your stethoscope as you listen at the apex. Estimate the proportion of systole occupied by the apical impulse. Normally it lasts through the first_____ of systole, or often less, but does not continue to the second
heart sound.
two-thirds

A sustained, high-amplitude impulse that is normally located suggests what disease?

What is it caused by?

If the impulse is displaced laterally, what should you consider?

left ventricular hypertrophy

from pressure overload (HTN)

volume overload

A sustained low-amplitude (hypo kinetic) impulse is seen in what disease?
A sustained low-amplitude (hypo kinetic) impulse is seen in what disease?
dilated cardiomyopathy

A brief middiastolic impulse indicates what heart sound?

And impulse just before the systolic apical beat itself indicates what heart sound?

S3, S4

If an impulse is palpable, assess its location, amplitude, and duration. A brief
systolic tap of low or slightly increased amplitude is sometimes felt in______ people, especially when stroke volume is increased by conditions such as anxiety.
thin or shallow-chested

A marked increase in amplitude
with little or no change in duration
occurs in chronic volume overload
of the right ventricle, which can
occur in __________ (pg. 374)
atrial septal defect

An impulse with increased amplitude
and duration occurs with pressure
overload of the right ventricle,
as in what 2 diseases?
pulmonic stenosis or pulmonary
hypertension

In obstructive pulmonary disease, hyperinflated lung may prevent palpation of an _________
in the left parasternal area.

The impulse is felt easily, however,_______ where heart sounds are also more audible.

enlarged right ventricle

high in the epigastrium

A prominent pulsation in the pulmonic area (left 2nd interspace) often accompanies _________.

A palpable S2 suggests increased pressure in the ________
A prominent pulsation in the pulmonic area (left 2nd interspace) often accompanies _________.

A palpable S2 suggests increased pressure in the ________

dilatation or increased flow in the pulmonary artery

pulmonary artery (pulmonary HTN)

A palpable S2 in the aorta area (right 2nd interspace) suggests _____.

A pulsation here suggests _______________.

htn

dilated or aneurysmal aorta

On percussion: A markedly _________ may have a hypokinetic apical impulse that is displaced far to the
left.

A _________ may make the impulse undetectable

dilated failing heart

large pericardial effusion

Heart sounds and murmurs that originate in the four valves radiate ______ (widely, narrowly).

What should you use (anatomical location/valve area) to describe where murmurs and sounds are best heard?
Heart sounds and murmurs that originate in the four valves radiate ______ (widely, narrowly).

What should you use (anatomical location/valve area) to describe where murmurs and sounds are best heard?

widely, anatomical location

Stethoscope:
What part is better for picking up the relatively high-pitched sounds of S1 and S2, the murmurs of aortic and mitral regurgitation, and pericardial friction rubs?
diaphragm

Stethoscope:
What part of the stethoscope is more sensitive to low-pitched sounds of S3 and S4 and the murmur of mitral stenosis?
bell

Where should you place the diaphragm?
Listen throughout the precordium
with the diaphragm, pressing it firmly against the chest.

Where should you place the bell?
Use the bell at the apex,
then move medially along the lower sternal border. Resting the heel of your
hand on the chest like a fulcrum may help you to maintain light pressure

left lateral decubitus position accentuates what?
left-sided S3 and S4 and mitral murmurs,
especially mitral stenosis

Ask the patient to sit up, lean forward, exhale completely, and stop breathing
in expiration, this position accentuates what?
aortic murmurs

(You may easily miss the soft diastolic murmur of aortic regurgitation unless you listen at
this position.)

Normal S1 splitting is detectable along the ______
lower sternal border

S1 is louder at more ______, and PR intervals are _________
rapid heart rates

PR intervals are shorter

When either A2 or P2 is absent, as in disease of the respective valves, S2 is persistently ___________. (pp 379)
single

expiratory splitting suggests ______
an abnormality

persistent splitting (of heart sounds) results from delayed closure of the _______ or early closure of the ____________
pulmonic valve (delayed closure)

aortic valve (early closure)

A loud P2 suggests _____
pulmonary HTN

What is the most common extra heart sound?
systolic click of mitral valve prolapse

diastolic murmurs usually indicate ______
valvular heart disease (pp 380)

systolic murmurs may indicate valvular disease but often occur when the heart valves are _______
normal

murmurs detected during pregnancy should be promptly evaluated for possible risk to the risk and the need for termination, especially from what two conditions? (pp380)
aortic stenosis, pulmonary htn

midsystolic murmurs typically arise from what?
midsystolic murmurs typically arise from what?
blood flow across the semilunar (aortic and pulmonic) valves

pansystolic murmurs often occur what kind flow across which valves?
pansystolic murmurs often occur what kind flow across which valves?
regurgitant (backward) flow across the atrioventricular valves

What is the murmur of mitral valve prolapse that is often, but not always, preceded by a systolic click?
What is the murmur of mitral valve prolapse that is often, but not always, preceded by a systolic click?
late systolic murmur

Early diastolic murmurs typically accompany what flow and across what valves?
Early diastolic murmurs typically accompany what flow and across what valves?
regurgitant flow across incompetent semilunar valves

middiastolic and presystolic murmurs reflect what kind of flow across what valves?
middiastolic and presystolic murmurs reflect what kind of flow across what valves?
turbulent flow across atrioventricular valves

late diastolic murmur
late diastolic murmur

continuous murmur
continuous murmur

Continuous murmurs are commonly seen with what patients?
congenital patent ductus arteriosus and AV fistulas, and dialysis patients

(neither is valvular in origin)

What other conditions also have systolic and diastolic components?
venous hums and pericardial rubs

What is the configuration of a presystolic murmur of mitral stenosis in normal rhythm?
What is the configuration of a presystolic murmur of mitral stenosis in normal rhythm?
crescendo murmur

configuration of early diastolic murmur of aortic regurgitation?
configuration of early diastolic murmur of aortic regurgitation?
decrescendo murmur

Configuration of midsystolic murmur of aortic stenosis and innocent flow murmurs?
Configuration of midsystolic murmur of aortic stenosis and innocent flow murmurs?
crescendo-decrescendo murmur

configuration of pansystolic murmur of mitral regurgitation?
configuration of pansystolic murmur of mitral regurgitation?
plateau murmur

A murmur best head in the 2nd right interspace often originates where?
at or near the aortic valves

A loud murmur of ___________ often radiates into the neck in the direction of arterial flow, especially on the right side.
aortic stenosis

In mitral regurgitation, the murmur often radiates to the _____, suggesting the role of bone conduction
axilla

If you have an identical degree of turbulence, would the murmur be louder in a thin person or in a very muscular/obese person?

What else may diminish the intensity of murmurs?

thin person

emphysematous lungs

what murmur is fully described as : a “medium-pitched, grade 2/6, blowing decrescendo diastolic murmur, heard best in the 4th left interspace, with radiation to the
apex”?
aortic regurgitation

Murmurs that tend to vary respiration more likely come from what side of the heart?
right side more than the left (pp 382)

In a 60-year-old person with angina, you might hear a harsh 3/6 midsystolic crescendo-decrescendo murmur in the right 2nd interspace radiating to the neck.
What do these sxs suggest?
What should you assess next?
What do you check the apical impulse for?
How do you listen to aortic regurgitation?
These endings suggest aortic stenosis but could arise from aortic sclerosis (lea!ets sclerotic but not stenotic), a dilated aorta, or increased low across a normal valve.

Assess any delay in the carotid upstroke and the intensity of A2 for evidence of aortic stenosis.

Check the apical impulse
for left ventricular hypertrophy.

Listen for aortic regurgitation as the
patient leans forward and exhales
(pp 383)

Valsalva Maneuver
Valsalva Maneuver

Four phases of valsalva manuever

The murmur of _________ is the only systolic murmur that increases during the “strain phase” of the Valsalva maneuver due to increased outflow tract obstruction.
hypertrophic cardiomyopathy

manuevers to identify systolic murmurs
manuevers to identify systolic murmurs

In patients with severe heart failure, Korotkoff sounds are heard during the phase 2 strain phase, but not during phase 4 release, what is this response termed?
square wave response

The ________ is correlated with volume overload and elevated left ventricular end-diastolic pressure and pulmonary capillary wedge pressure, in some studies outperforming brain natriuretic peptide.
square wave response

“The JVP is 5 cm above the sternal angle with the head of bed elevated to 50 degrees. Carotid upstrokes are brisk; a bruit is heard over the left carotid artery. The PMI is diffuse, 3 cm in diameter, palpated at the anterior axillary
line in the 5th and 6th intercostal spaces. S1 and S2 are soft. S3 present at the
apex. High-pitched harsh 2/6 holosystolic murmur best heard at the apex, radiating to the axilla.” suggests what?
suggests heart failure with volume overload with possible left carotid occlusion and mitral
regurgitation.

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