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142 Cards in this Set
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- Back
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"a wave" is associated with:
What is "a wave"? |
S4.
Atrial contraction. |
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What are angina equivalents?
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1) dyspnea-older fat white women, diabetics in particular
2) Back pain |
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What's angina?
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ans: mismatch of supply and demand. activity drives up HR, Inc mycoardial O2 demand, and blood supply is insufficient--> pain, pressure, and tightness.
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Angina:
1) Worsened by: 2) Relieved by: |
1) exertion, cold weather, sex, anxiety, post-prandial
2) rest or nitroglycerin |
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What are 3 types of angina?
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1) Pure spasm, 2) severe obstructive disease-Lumen is >70% narrowed, 3) mixed disease-spasm+lumen narrowed.
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What is unstable angina? What is the key thing about it?
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1) Pain @ rest (w/ minimal activity) or in early waking hours (can awaken you).
2) cannot differentiate spasm from unstable angina. 3) Key: it is ADMITTABLE. |
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The Big 4 risk factors for CAD:
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HTN
Obesity DM Smoking |
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Cardiac Physical exam:
What blood pressures do you take? which should be higher? If not?? |
3BPs: 2 arms and 1 leg. Leg BP should be > than arm!
If arm>leg: coarctation of aorta |
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Weak distal pulses suggest:
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LVH caused by:
AS, AR, MR HTN, IHSS. |
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Where do you take a leg blood pressure?
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cuff 2 cm above the patella. listen to the popliteal artery.
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Bruits:
Unilateral Bruit, slow upstroke, normal decline--> |
bruit for atherosclerosis
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Bruits:
Rapid upstroke, delayed decline --> |
bruit: IHSS (idiopathic hypertropic subaortic stenosis)
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Bruits:
Delayed upstroke, delayed decline --> |
bruit: Aortic Stenosis
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Bruit:
Rapid upstroke, rapid decline --> |
bruit: aortic regurgitation (think: Rapid Regurgitation)
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height of the Internal jugular vein (jugular vein distension) indicates what?
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ans: Right Atrial pressure.
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Normal JVP=
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5cm above the sternal angle
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JVP at level of the mandible:
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ans: 10 cm
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JVP at the level of the ear lobe:
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ans: 12 cm
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What is a positive hepatojugular reflex and what does that indicate?
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ans: a JVD upon upper abdominal pressure. If it stays UP with both inspiration and expiration, ti is positive. It is a sign of Right Sided volume overload.
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Distention of neck veins with INspiration: (what is it, and what does it indicate?)
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ans: Kussmaul's sign. A sign of pericardial effusion and impending respiratory failure.
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Venous wave form: all are____
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ans: Pathological
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Venous wave form:
a wave: What is it? associated with? Caused by? |
ans: Atrial contraction,
associated with S4. Caused by: Aortic stenosis, IHSS, Ischemic heart disease, Aging, Pulmonary stenosis, Tricuspid stenosis in sinus rhythm, mitral stenosis in sinus rhythm. |
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A Large "A wave": causes?
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ans: Paroxymal atrial tachycardia (2:1) or AFlutter (also, 2:1)
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Venous wave form:
What are Cannon A waves, and what do they indicate? |
ans: large intermittent A waves. 3rd degree heart block.
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Venous wave form:
What are c-waves? |
ans: isovolumetric contraction
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What are v-waves? And what do you look for?
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ans: ventricular contraction. Look for R-sided signs.
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what is x-descent?
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ans: acute pericardial effusion--tamponade.
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what is y-descent?
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ans: slow pericardial effusion--SLE, chronic renal failure.
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S1 heart sound: What is it?
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ans: Closure of the mitral/tricuspid valves.
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Increased S1?
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indicates Mitral Stenosis, short PR intervals, Increased CO
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Decreased S1?
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ans: indicates chronic mitral regurg, 1st degree AV block, DECreased CO
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S2 heart sound: What is it?
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ans: Closure of aortic/pulmonic valves.
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What is normal splitting of S2?
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ans: Split in inspiration, and together in expiration.
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What is fixed splitting of S2, and what does it indicate?
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ans: split in both inspiration and expiration. It indicates ASD (Atrial septal defect).
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What is wide splitting of S2, and what does it indicate?
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ans: volume overload.
by: PDA, AR, delayed closure of LV, and pregnancy. |
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What is paradoxical splitting of S2? What are some causes?
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ans: split in EXpiration, together in inspiration. causes: LBBB, aortic stenosis, transvenous pacemakers, pulmonary htn
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What is S3 heart sound?
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ans: The sound of systolic heart failure (S-CHF). It is closer to S2 (early diastole). It is volume overloading a non-compliant ventricle.
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How is S3 best heard and what accentuates it?
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ans: Best heard in the L-lateral position with the bell.
Accentuated by hand-grip. Note: it can be normal up to 40 yo. |
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What is S4 heart sound?
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ans: The sound of diastolic heart failure. (HTN). Inability of the heart to relax causes S4. it is closer to S1. Accentuated by hand-grip. Caused: Aortic stenosis, htn, IHSS, Ischemic heart disease.
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These sounds are accentuated by hand grip.
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ans: S3 and S4 are accentuated by this.
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These murmurs get long w/ inspiration/leg raising/squatting:
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ans: Early-Mid systolic murmurs of TR and PS.
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Inspiration/leg raising does what to R-sided murmurs?
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ans: these maneuvers INC preload, so these murmurs get longer.
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What effect does squatting have on the cardiovascular system and what effect does this action have on R and L sided murmurs? (exception)
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ans: Squatting INC preload and afterload so both types of murmurs get longer with squatting.
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What is the difference between hand-grip and inspiration/leg raising?
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ans: Handgrip increases afterload and makes LEFT sided murmurs get longer. Inspiration INC Preload and makes R-sided murmurs get longer.
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What effect does valsalva/standing have on the cardiovascular system, and what effect does this have on R and L sided murmurs? (exception)
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ans: Valsalva DEC both preload and afterload and cause both Left and Right sided murmurs to get shorter. (Defecate-->dec Pre-and-afterload-->dec murmur time)
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What are the early-mid Systolic murmurs?
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ans: Systolic is b/t S1 and S2.
Pulm. Stenosis, Tricuspid Regurg, Atrial Septal Defect, IHSS, Acute Mitral Regurg. |
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How is IHSS the EXCEPTION to the rule?
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ans: the Black Sheep of the Left-sided murmurs b/c 1) Valsalva and standing causes murmur to get LONGER, 2) Squatting causes murmur to get shorter.
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What effect does Valsalva have on preload and afterload, and why?
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ans: INC intrathoracic pressure, therefore DEC preload and afterload.
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What is IHSS?
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ans: idiopathic hypertrophic subaortic stenosis (also Hypertropic obstructive cardiomyopathy). It is a volume-dependant state.
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What is an acute MR? where does it radiate?
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ans: Left-sided murmur that radiates to the base of the heart. It is a papillary muscle dysfunction.
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Any new murmur with acute MI is _____ until proven otherwise.
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ans: Mitral Regurg. (esp. with inferior wall MI).
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What are the two mid-late systolic murmurs? What's significant about these?
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ans: Mitral Valve Proloapse and Aortic Stenosis. These are the most common murmurs.
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What murmur is not precipitated by exertion?
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ans: Mitral Valve prolapse.
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With MVP, the click and murmur move closer to S1 with ____ and closer to S2 with _____.
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ans: Closer to S1 with Valsalva, closer to S2 with inspiration.
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What are the holosystolic murmurs?
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ans: Chronic Mitral Regurg, Tricuspid Regurg, and Ventricular Septal Defect.
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This murmur doesn't change with any type of maneuver.
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ans: Atrial Septal Defect
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This murmur is worse with exertion, radiates to the neck with carotid bruits, and gets longer with handgrip.
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ans: Aortic stenosis. Think elderly woman with htn, dm.
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This murmur is at the apex and radiates to the axillary region.
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ans: Chronic MR (holosystolic murmur)
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Murmur heard best at the 5th ICS at the L sternal border, and gets longer with inspiration.
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ans: Tricuspid Regurg. (R-sided murmur).
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Murmur heard best at the L sternal border @ the 4th/5th ICS that gets longer w/ handgrip and shorter with inspiration.
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ans: Ventral Septal Defect (VSD--Left-sided murmur)
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What differentiates TR from VSD?
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ans: TR is a R-sided murmur so it gets longer with inspiration. VSD is a L-sided murmur and gets SHORTER with inspiration.
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This murmur has a classic EKG finding of RBBB.
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ans: Atrial Septal Defect.
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Murmur is best heard at the 2nd L ICS, and typically does NOT radiate elsewhere. It also has a click that disappears with inspiration.
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ans: Pulmonic Stenosis.
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What are the Diastolic murmurs?
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ans:
Rumbles: Tricuspid Stenosis, Mitral Stenosis. Blows: Atrial Regurgitation, Pulmonic regurgitation. |
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You hear an opening snap, diastolic rumble. This is often 15-20 years post a certain infection.
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ans: Mitral Stenosis, L-sided murmur.
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Diastolic murmur from rheumatic heart disease is _____
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ans: Carry Coombs murmur.
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Graham Steell murmur
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ans: Pulmonic regurgitation (early diastolic murmur heard best at 2nd intercostal space.
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Mitral murmur heart in aortic regurgitation--a mid-diastolic rumble heard best at the apex
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Austin Flint murmur.
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does it take more ATP to relax or contract?
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ans: takes more ATP to relax.
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What is the amount of myocardial stretch at the end of diastole?
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ans: preload.
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How do you treat heart failure in the ER?
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ans: High Loop diuretics, O2 mask, Nitrates (dilate the venous system--also, Morphine).
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What do high-loop diuretics do to tx Heart failure in the ER?
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ans: they drop preload pressure and reflexitively drop LVEDP.
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What is the EF of systolic heart failure? How do you measure it?
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ans: EF<45%. TTE, nuclear study, TEE (lowest accuracy).
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How do tx Systolic heart failure?
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ans: Block RAAS everywhere! lasix+ACE-I+(ARB)+Aldactone
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loop diruetics
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lasix (Furosemide) or Bumex (Bumetanide)
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ACE-I (and what effect do they have?):
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Captopril, enalapril, Lisinopril, Ramipril (will drop levels of Angiotensin II)---and will prevent remodeling.
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ARB:
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Losartan, Valsartan (prevents ATII from binding to receptor)
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Aldactone
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blocks aldosterone receptors.
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what does digoxin do?
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improves functionality and contractility but has NO effect on mortality
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Beta-Blocker--and when do you start it?
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Coreg (Carvedililol), Toprolol XL (Metoprolol succinate) start 48hrs before d/c.
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Norvasc (amlodipine)?
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Calcium channel blocker
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Other meds to control HTN in systolic heart failure:
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Ca-channel blocker, alpha-blockers, vasodilator
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What is diastolic heart failure? How do you treat it?
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normal/hypernormal pump (EF>45%). similiar to systolic HF, but don't use Digoxin!! Use BB!
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What has the highest failure rate in the hospital?
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systolic failure and hyponatremia.
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What is the diagnostic sound of acute heart failure? What do you use to hear it?
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ans: S3. Use the BELL!!
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___ is the sound of cardiomyopathy. Best heard where/how?
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ans: S4. Best heard in the L Lateral recumbent.
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What hears like a deer hopping in the woods?
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S3/S4 Gallop. b/c of the huge Increase in LVEDP and the Increase in preload.
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What are the 3 MCC of cardiomyopathy? What is the eventual endpoint of cardiomyopathy?
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ans: CAD, Htn, DM (and 4th most common: thyroid disease, hypo and hyper).
endpoint: A-fib. |
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Will you have S4 in A-fib??
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ans: NO!! you no longer have a contracting atrium, so you won't have an S4.
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1)Where do you want your MI? 2)EKG indication?
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ans: 1) Posterior MI--practically benign.
2) V1 and V2. J-point depression in lead 1. |
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muscular complication of posterior MI:
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ans: pseudoaneurysm which = cardiac urgency
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1) electrical complication of posterior MI? 2) How do you tx? 3) how do you NOT tx?
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ans: 1) Bradycardia and a
1st, 2nd, or 3rd degree heart block. 2) tx w/ Atropine then a pacemaker if that doesn't work, 3) do NOT tx w/ epinephrine |
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Inferior MI:
1) EKG changes. 2) blood supply. |
1) ST elevation in II, III, & aVF.
2) RCA (in 85%), Circumflex (in 15%). |
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What are the branches of the RCA?
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ans: SA node, AV node, posterior descending, LA branch, RV marginal branch, terminal R, PDA.
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how do you know you have an RV MI?
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ans: STEMI in II, III, and aVF;
JVD, Kussmaul's sign, Hepatojugular reflux, RV4--reversal of chest leads. |
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What are the afterload reducers (meds)?
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ans: ACE-I, IV Nitroglycerin, Hydralazine, IV nitroprusside, infra-aortic balloon pump (therapy of choice).
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What causes the acute mitral regurg found in inferior wall MIs? when does the MR appear?
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ans: 1) infarction of the posterior papillary muscle.
2) in the 2nd or 3rd 24-hours after an inferior wall MI. |
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What are minor muscular complications of Inferior Wall MIs?
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ans: Ventral Septal defect, LA infarction, pseudoaneurysm at base or true aneurysm at apex.
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What are the electrical complications of Inferior Wall MI?
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ans: same as posterior wall! Bradycardia or 1st, 2nd, or 3rd degree heart block.
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1) What are the EKG changes for an Anterior Wall MI?
2) blood supply? |
ans: ST elevation in V1-V3, V4.
2) LAD |
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What are the muscular complications of Anterior wall MI?
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ans:
CHF, aneurysm formation |
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What are the electrical complications of Anterior wall MI?
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ans:
VTach PVCs Mobitz Type II or 3rd degree heart block (w/ POOR prognosis) |
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Blood supply and EKG changes on a High Lateral wall MI?
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Circumflex artery
ST elevation in I and aVL. |
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Blood supply and EKG changes on a Low Lateral wall MI?
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diagonal branch of LAD,
ST elevation in V4, V5, V6. |
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muscular complications of lateral wall MI:
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ans:
CHF True aneurysm Wall rupture--acute pericardial tamponade and death!! |
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electrical complications of lateral wall MI:
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ans:
PVCs and VTach |
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What is normal pericardial fluid?
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ans: 15-25ccs
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What is the main difference in the treatment of diastolic HF compared to systolic HF?
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ans: do NOT use digoxin, use BB.
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How do you treat systolic HF?
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ans: 1) block RAAS everywhere. Lasix+ACE-I+(ARB)+Aldactone, 2) Digoxin to improve contractility, 3) BB (Coreg or Toprolol), 4) Others: CCB (Norvasc-amlodipine), alpha-blockers (hytrin, cardura, catapres, aldomet), and a vasodilator (Hydralazine).
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What combination of tx for systolic HF has decreased mortality, reshospitalization, and in-hospital death?
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ans: Lasix+ACE-I+(ARB)+Aldactone
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Ortner's syndrome is and shows up as what?
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ans: 1) progressive hoarsness due to compression of recurrent laryngeal nerve. 2) widened mediastinum.
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What's the normal size of aorta?
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ans: 3.2cm.
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Small aneurysm?
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ans: 3.2-3.9cm
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Moderate aneurysm?
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ans: 4.0-5.9cm
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Large aneurysm?
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ans: 6.0-8.0cm; 25% per year.
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Which aortic problem is Painful?
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ans: Aortic Dissection.
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What is the most common area for pain in thoracic aortic dissection?
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ans: right b/t the scapulas.
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Most common area of aortic dissection:
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ans: Retroperitoneal space. in a closed space--> tamponade.
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What's the best way for an aortic dissection to rupture?
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ans: internal rupture. back into the vessel.
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What is usually the way the thoracic aorta rupture?
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ans: into the pleural space and the pt. asphyxiates.
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Whats the most common cause of aneurysmal dissection?
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ans: atherosclerotic plaque.
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What is the velocity of dissection?
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ans: the velocity of flow across the wrent.
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What are the non-dilatation dissections?
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ans: iatrogenic dissection, post-chest trauma, myocardial contusions, malignant ventricular arrhythmias.
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A week after an invasive procedure is the peak rate for what to occur?
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ans: a non-dilatation Iatrogenic dissection.
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When is the peak for a non-dilatation dissection following a post-chest trauma?
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ans: 72 hours.
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What is the most common area of PVD narrowing in non-diabetic patients?
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ans: Superficial femoral artery.
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What is the most common area of PVD narrowing in diabetic patients?
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ans: Popliteal trifurcation.
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How do you quantitate PAD? And what is the quantity to dx PAD?
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ans: Ankle-Brachial Index=
ASBP/BSBP. ABI< or = 0.90. |
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PAD: mild disease:
Sx? Claudication? |
ans: 0.80-0.90; usually asymptomatic and do not have intermittent claudication.
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PAD: Moderate Disease? Sx? Claudication?
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ans: 0.65-0.79. Claudicate by 2 city blocks (1000 feet)
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PAD: Severe disease? Claudication?
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ans: 0.50-0.64. Claudicate by 1/2-1 block=250-500 ft.
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PAD: Resting ischemia?
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ans: <0.50.
claudicate in your home. |
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What is the end stage of PAD?
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ans: Rubor-Pallor syndrome
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What is the PAD manifestation of ED?
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ans: Internal iliac vessel.
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What are the PAD reasons for syncope?
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ans: Carotid sinus oversensitivity.
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If BP in one arm is significantly less than the other---what do you suspect?
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ans: Subclavian Stenosis
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What is the normal difference between BPs in each arm?
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ans: 25mmHg
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What are the Sx in Aortic Stenosis?
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ans: SAD: Syncope, Angina Pectoris, Dyspnea.
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What are the Sx in Aortic Regurgitation?
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ans: DAPSS: Dyspnea, Angina, Palpitations, Syncope, and Sudden Death.
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If you find a widened pulse pressure >40, water hammer pulse, eccentric LVH, S3, and head and uvula bob.....
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ans: Physical findings for Aortic Regurgitation.
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How do you treat Aortic Regurgitation?
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ans: ***Afterload Reducers b/c the pt. is in volume overload. These meds include: Nifedipine, ACE-I, ARBS, Hydralazine. And you can do Valve replacement.
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How do you tx. PAD?
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ans: Stop smoking, exercise daily, dec Htn, dec hyperlipidemia, tx.DM, PDIs (phosphogiesterase Inhibitors), Plavix, and Coumadin.
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