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What is stroke volume
Amount of blood pumped out of the left ventricle during systole
What affects stroke volume
Contractility
Afterload
Preload
What increases stroke volume
Increased contractility
Increased preload
Decreased afterload
Contractility increases with
Catecholamine stimulation via Beta 1 receptors
Increased intracellular Ca2+
Decreased Extracellular Na+
Digoxin
What happens when you activate protein kinase A
Phospholamban phosphorylation which increases Ca2+ ATPase and Increases Ca2+ storage in sarcoplasmic reticulum
Ca2+ channel phosphorylation which increases Ca2+ entry and Increases Ca2+ induced Ca2+ release
If you decrease the activity of Na+/Ca+ exchangers, what happens to calcium
increases
If you decrease the activity of Na+/K+ pumps, what hapens
Increase intracellular Na+
What happens if you have increased intracellular Na+
Increase intracellular Ca2+ concentration because you have a decrease in the Na+/Ca2+ exchanger
What is preload
Amount of blood left in the ventricle after diastole
What is preload approximated by
Ventricular end-diastolic volume
What is afterload approximated by
Mean arterial pressure (MAP)
What does the heart do to compensate for chronic afterload
Hypertrophy of the left ventricle
Arterial vasodilator decrease
Afterload
ACE inhibitors decrease
preload and afterload
ARBs decrease
preload and afterload
Myocardial oxygen demand is increased by
Increased contractility
Increased afterload
Increased heart rate
Increased vessel diameter
Wall tension follows Laplace's law, which states
Wall tension = Pressure x Radius
Stroke volume formula
EDV - ESV
Ejection fraction formula
(EDV - ESV) / EDV
Cardiac output formula
SV x HR
Pulse pressure formula
Systolic Blood Pressure - Diastolic blood pressure
Mean arterial pressure formula
CO x total peripheral blood resistance
Index of ventricular contractility
Ejection fraction
In the early stages of exercise, cardiac output is maintained by
Increased heart rate and increased stroke volume
In the later stages of exercise, cardiac output is maintained by
Increased heart rate
Pulse pressure is directly proportional to
Stroke volume
Pulse pressure is inversely proportional to
Arterial compliance
What increases pulse pressure
Hyperthyroidism
Aortic regurgitation
Aortic stiffening
Obstructive sleep apnea
Anemia
Exercise
What decreases pulse pressure
Aortic stenosis
Cardiogenic shock
Cardiac tamponade
Advanced heart failure
Force of contraction is proportional to
End diastolic length of cardiac muscle fiber (preload)
Increased cardiac contractility with
Catecholamines
Positive inotropes
Decreased contractility with
Loss of functional myocardium
Beta blockers
Nondihydropyridine Ca2+ channel blockers
Heart failure
_____ have the highest total cross-sectional area and lowest flow velocity
Capillaries
What increases volumetric flow rate
Increased flow velocity
Increased cross sectional area
What has less resistance: Vessels in series or Vessels in parallel
Parallel
Viscosity depends mostly on
Hematocrit
What increases inotropy
Catecholamines
Dobutamine
Milrinone
Digoxin
Exercise
What decreases inotropy
Heart failure with reduced ejection fraction
Narcotic overdose
Sympathetic inhibition
What increases venous return
Fluid infusion
Sympathetic activity
What decreases venous return
Acute hemorrhage
Spinal anesthesia
What increases total peripheral resistance
Vasopressors
What decreases total peripheral resistance
Exercise, arteriovenous shunt
Phases of the left ventricle
Isovolumetric contraction
Systolic ejection
Isovolumetric relaxation
Rapid filling
Reduced filling
Period between mitral valve closing and aortic valve opening; period of highest O2 consumption
Isovolumetric contraction
Period between aortic valve opening and closing
Systolic ejection
Period between aortic valve closing and mitral valve opening
Isovolumetic relaxation
Period just after mitral valve opening
Rapid filling
Period just before mitral valve closing
Reduced filling
What is heard at S1
Mitral and tricuspid valve closure
What is heard at S2
Aortic and pulmonic valve closure
What is heard at S3
Turbulence caused by blood from left atrium mixing with increased end diastolic volume
What is head at S4
TUrbulence caused by blood entering stiffened left ventricle
Where is S1 heard the loudest
Mitral area
Where is S2 heard the loudest
Left upper sternal border
Where is S3 heard the loudest
Apex with patient in left lateral decubitus position
What is an S3 sound associated with
Increased filling pressures
Dilated ventricles
Where is S4 heard the loudest
Apex with patient in left lateral decubitus position
What is an S4 heart sound associated with
High arterial pressure
Ventricular noncompliance
What is the other name for jugular venous pulse
Right atrial pressure
A wave in JVP
atrial contraction
A wave is absent in
Atrial fibrillation
C wave in JVP
ventricular contraction
X descent in JVP
Atrial relaxation due to rapid ventricular ejection
V wave in JVP
Increased atrial pressure due to increased volume against tricuspid valve
Y descent in JVP
Atrium emptying into ventricle
A prominent Y descent on JVP is noted in
Constrictive pericarditis
An absent Y descent on JVP is noted in
Cardiac tamponade
What happens to LV, ESV, and SV in aortic stenosis
LV: Increased
ESV: Increased
SV: Decreased
What happens to EDV and SV in aortic regurgitation
EDV: Increased
SV: Increased
What is lost in the waveform in aortic regurgitation
Dichrotic nothc
What happens to LA pressure, EDV, ESV, and SV in mitral stenosis
LA Pressure: Increases
EDV: Decreases
ESV: Decreases
SV: Decreases
What is lost in mitral regurgitation
Isovolumetric phase
What happens to ESV, EDV, and SV in mitral regurgitation
ESV: Decreases
EDV: increases
SV: Increases
What causes ESV to decrease in mitral regurgitation
Decreased resistance and increased regurgitation into LA during systome
What causes EDV to increase in mitral regurgitation
Increased LA volume/pressure from regurgitation leading to increased ventricular filling
What causes increased SV in mitral regurgitation
Forward flow into systemic circulation plus backflow into LA
What causes physiologic splitting of S2
Inspiration causes a drop in intrathoracic pressure, increasing venous return to RV, causing increased RV stroke volume, causing the pulmonic valve to close after the aortic (delayed closure)
Decreased pulmonary impedance can also occur during inspiration, which contributes to
Delayed closure of pulmonic valve
What causes wide splitting of S2
Conditions delaying RV emptying:
- Pulmonic stenosis
- RBBB
What causes fixed splitting of S2
Atrial septal defect
What causes paradoxical splitting of S2
Conditions that delay aortic valve closure
- Aortic stenosis
- LBBB
Normal order of semilunar valve closure is reversed in what conditions
Paradoxical splitting P2 occurs before A2
When can paradoxical splitting be heard
On expiration
What can you hear in the aortic area
Aortic stenosis
Flow murmur (physiologic murmur)
Aortic valve stenosis
What can you hear at the left sternal border
Diastolic murmur
- Aortic regurgitation
- Pulmonic regurgitation
Systolic murmur
- Hypertrophic cardiomyopathy
What can you hear in the pulmonic area
Systolic election murmur
- Pulmonic stenosis
- Atrial septal defect
- Flow murmur
What can you hear in the tricuspid area
Holosystolic murmur
- Tricuspid regurgitation
- Ventricular septal defect
Diastolic murmur
- Tricuspid stenosis
What can you hear in the Mitral area (apex)
Holosystolic murmur
- Mitral regurgitation
Systolic murmur
- Mitral valve prolapse
Diastolic murmur
- Mitral stenosis
With a Standing Valsalva maeuver, what happens to:
- Cardiovascular changes
- Murmurs that increase with maneuver
- Murmurs that decrease with maneuver
Changes: Decreased preload
Murmurs increased: Mitral valve prolapse & Hypertrophic cardiomyopathy
Murmurs Decreased: Most murmurs
With a Passive Leg Raise maeuver, what happens to:
- Cardiovascular changes
- Murmurs that increase with maneuver
- Murmurs that decrease with maneuver
Changes: Increased preload
Murmurs increased: Most murmurs
Murmurs Decreased: Mitral valve prolapse & Hypertrophic cardiomyopathy
With a Squatting maeuver, what happens to:
- Cardiovascular changes
- Murmurs that increase with maneuver
- Murmurs that decrease with maneuver
Changes: Increased preload, Increased afterload
Murmurs increased: Most murmurs
Murmurs Decreased: Mitral valve prolapse & Hypertrophic cardiomyopathy
With a Hand grip maeuver, what happens to:
- Cardiovascular changes
- Murmurs that increase with maneuver
- Murmurs that decrease with maneuver
Changes: Increased afterload leading to increased reverse flow across aortic valve
Murmurs increased: Most other left sided murmurs (Aortic regurgitation, mitral regurgitation, and Ventriclar septal defect)
Murmurs Decreased: Aortic stenosis & Hypertrophic cardiomyopathy
With a Inspiration maeuver, what happens to:
- Cardiovascular changes
- Murmurs that increase with maneuver
- Murmurs that decrease with maneuver
Changes: Increased venous return to right heart & decreased venous return to left heart
Murmurs increased: Most right-sided murmurs
Murmurs Decreased: Most left sided murmurs
Which heart murmurs are heard in systole
Aortic stenosis
Mitral/tricuspid regurgitation
Mitral valve prolapse
Ventricular septal defect
Which heart murmurs are heard in diastole
Aortic regurgitation
Mitral stenosis
Which heart murmurs are continuous
Patent ductus arteriosus
Which murmur has a crescendo-decresendo systolic ejection murmur and soft S2
Aortic stenosis
Which murmur has holosystolic, high pitched "blowing murmur"
Mitral/tricuspid regurgitation
Which murmur has a late systolic crescendo murmur with midsystolic click
Mitral valve prolapse
Which murmur is a holosystolic, harsh sounding murmur heard loudest in the tricuspid area
Ventricular septal defect
