Cardiology Exam 1

L 5th ICS MCL (apex)

Under normal circumstances, where is the PMI?

Right ventricle

What part of the heart makes up majority of the anterior surface of the heart?

Posteriorly

What direction do the LA and LV face in the mediastinum?

Left ventricle

What part of the heart makes up the L border of the heart?

Dull, pressure

Typically not stabbing/sharp

How is angina pain described?

Because the LA faces posteriorly in the mediastinum, and thus sits just anterior to the esophagus and trachea. LAH can begin to compress the esophagus, causing difficulty swallowing

Why might left atrial hypertrophy cause dysphagia?

Posterior-anterior CXR

_____-___ X-rays of the chest are more common, because they reduce distortion and give a better indication of the true size of the heart

In diastole because the ventricles are relaxed. Results in less resistance of blood going into the coronaries

When do the coronaries get the best circulation and why?

At the junction of the SVC and RA

Where is the SA node located?

Atrial arrhythmias can reach much higher rates than the ventricular arrhythmias

The atria have a shorter refractory period than the ventricular myocytes. What does this mean about atrial arrhythmias?

Sympathetic and parasympathetic

What kind of fibers innervate the SA and AV nodes?

Mainly sympathetic fibers

What kind of fibers innervate ventricular myocytes?

Aortic valvular disease and coronary atherosclerosis

What are the two MC causes of cardiac-related angina?

Dull, pressure

How is cardiac-related chest pain usually described?

No. Angina chest pain is typically described as dull pressure and lasts less than 15-20 minutes

A patient comes into the office complaining of sharp, stabbing chest pain that has been going on for 2 days. Do you suspect this chest pain is cardiac in nature (angina)? Why or why not?

Bigeminy

On EKG, a normal contraction followed by an abnormal one is described as ____

1:1 ratio of normal to PVC

Trigeminy

On EKG, two normal contractions followed by an abnormal one is described as ____

2:1 ratio of normal to PVC

Caused by lung disease and issues with gas exchange. Cyanosis is best seen in mucous membranes, such as in the mouth. Fingers and toes will also be cyanotic

What is central cyanosis commonly caused by and where is the cyanosis typically seen?

In peripheral cyanosis, if you warm the patient's hands, color will return due to vasodilation. With central cyanosis, warming the hands would not cause color to return

How can you differentiate central from peripheral cyanosis?

Differential cyanosis (cyanosis in the lower extremities)

You are examining a patient and notice their fingernails are normal in color, but their toenails are cyanotic. What kind of cyanosis is this?

Patent ductus arterioles (PDA)

What condition causes differential cyanosis?

Aortic regurgitation

What valvular pathology commonly causes a widened pulse pressure?

Coarctation of the aorta

Constriction (narrowing) of the aorta, typically on the descending portion

Descending

What part of the aorta is MC affected by coarctation?

Lower Extremities by about 10-12 mmHG

Normally, is BP higher in the UE or LE?

Coarctation of the aorta in the descending portion

A new patient comes into your office for a well check. You measure their BP bilaterally in UE and LE. The BP in the EE is 115/70, and the BP in the UE is 130/74. What is the likely cause of this difference?

High pressures in the UE

Lower pressures in the LE

Compare the BPs in the UE and LE with coarctation of the aorta

Goes down on inhalation

Goes up on exhalation

What happens to BP on inhalation? Exhalation?

Cardiac tamponade

A patient comes into the ER after a severe MVA and a set of vitals are taken. BP on inspiration is 90/60 and on expiration is 110/80. What cardiac pathology is suspected?

10 mmHg

A difference in BP of greater than ____ mmHg on inspiration and expiration is indicative of cardiac tamponade

Heave

A lift when you feel the chest, common in RVH

Thrill

Vibration coming from the chest

Murmurs

What causes thrills?

RVH

What condition commonly causes a precordial heave?

High pressures on the R side of the heart, causing backup into the jugular veins

What does high pressures in the neck veins (i.e. JVD) indicate?

Left sided heart failure. If the left side of the heart is not pumping enough blood out to the body, you will have a reduced CO and diminished arterial pulses

What can be associated with diminished arterial pulses?

R

L

___ sided heart failure might cause a strong pulses int he neck veins

___ sided heart failure might cause diminished arterial pulses

Mitral stenosis

Diastolic murmur that sounds like an opening snap, best heard at the apex

Mitral valve

Which valve is most commonly affected by Rheumatic heart disease?

R 2nd ICS parasternally

Where do you listen to the aortic valve?

L 2nd ICS parasternally

Where do you listen to the pulmonic valve?

L 3rd ICS

S2

Where is Erb's point and what sound is best heard here?

L 4th-5th ICS

Where is the tricuspid valve best auscultated?

L 5th ICS MCL

Where is the mitral valve/apex best auscultated?

Pericarditis. If there is a loss of fluid between the pericardial layers, this can allow friction to occur, causing a rubbing sound

If you hear a rub, what condition can this indicate?

Diminishes the arterial pulses. The blood cannot get from the LA into the LV as well. This causes a backup of blood into the LA and less blood in the LV, leading to a reduction in cardiac output

What would mitral stenosis do to the arterial pulses and why?

Mitral facies

(seen in mitral stenosis)

Pinkish-purple patches on the cheeks is sometimes referred to as a _____ facies

1. Transthoracic (TTE)

2. Transesophageal (TEE)

TTE is more common

What are the two main types of Echocardiography? Which is more common?

Looking at the left atrium and mitral valve

What is transesophageal echocargiography (TEE) good for?

TEE

Which type of echocardiogram is chosen for patients with prior valve replacement surgeries?

Dobutamine or Adenosine Stress Test

What are two pharmacological ways to perform a stress test in a patient?

It acts like exercise and makes the heart work harder

What does dobutamine do to the heart (use in stress testing)?

Adenosine vasodilates all of the coronary vessels. The occluded vessel is still more constricted in comparison to the other coronary vessels. Essentially, vasodilation of all of the other coronary vessels steals the already limited blood flow to the occluded area, recreating angina

What does Adenosine do to the heart during stress testing?

Tachyarrhythmias and systemic HTN

What are two contraindications for a dobutamine stress test?

1. Pain reproduction

2. ECG changes

3. Severe fatigue

4. Reached 85% of their max HR with no symptoms

5. Hypotension

What are the indications for stopping a cardiac stress test?

220-age

How do you determine max HR?

Inject Thallium-201 at the peak of the patient's exercise. Thallium-201 behaves like potassium and enters cells. However, it can only enter healthy cells. The healthy vessels will light up brightly on nuclear imaging. Areas that are ischemic are dimmer. If there is an area of scarring or dead tissue, it would appear dark

Explain how to use a SPECT image to localize and quantify ischemia/infarction

Perform the test when the patient is exercising and look for areas of diminished color. Then repeat the test several hours later. If the entire heart lights up normally, the area is ischemic and can be treated. If it remains dark, the area is infarcted

How can you distinguish ischemic tissue vs. dead tissue using SPECT imaging?

Metabolism, using glucose analog

PET scan of the heart looks at ___

Healthy - fatty acids

Ischemic - glucose

What does the healthy heart primarily use for metabolism? A diseased/ischemic heart will use more _____ for metabolism

SPECT - normal is brighter than ischemic

PET - normal is dimmer than ischemic

In a SPECT scan, normal tissue is ____ than ischemic tissue

In a PET scan of the heart, normal tissue is ____ than ischemic tissue

Inject a radioactive glucose analog. Areas of the heart that are ischemic will use more glucose for metabolism, and will therefore take up this injected glucose, causing them to light up brightly. Dimmer areas of the heart indicate healthy tissue

How do you interpret a PET scan of the heart?

Contrast coronary angiography

What is the gold standard for diagnosing CAD?

Pulmonary capillary wedge pressure (PCWP)

The ______ is used to measure left atrial pressure

Left atrial pressures

The pulmonary capillary wedge pressure is used to measure ____

Mitral stenosis

Hockey stick sign on echo indicates ___

Systole

The period from S1 to S2

Diastole

The period from S2 to the next S1

HR

The faster the HR, the shorter the time spent in diastole

The length of diastole varies with ____

A wave

Wave of the jugular venous pulse that coincides with right atrial contraction. This wave represents transient venous distention caused by back pressure from right atrial contraction

V wave

Wave of the jugular venous pulse that coincides with right atrial diastole. This wave corresponds to the passive filling of the RA from the systemic veins, when the tricuspid valve is closed

Because there are no valves between the jugular veins and the right atrium

Why is jugular venous pressure an accurate representation of right sided heart function?

Tricuspid stenosis

Ifbthe

Which valvular disorder is associated with prominent jugular venous pressure A waves?

Tricuspid regurgitation

If there is regurgitation when the RA is pumping into the RV, blood will flow back into the RA, causing an increased pressure when the RA is supposed to be in diastole

Which valvular disorder is associated with prominent jugular venous pressure V waves?

Apex

High frequency, best heard with the diaphragm of the stethoscope

Where is S1 loudest? What is the frequency of S1? What part of the stethoscope is used to auscultate S1?

Inspiration

Physiologic splitting of S2 can be heard during ____

The volume to the right side of the heart increases

The volume to the left side of the heart decreases

What happens to each side of the heart during inspiration?

The volume to the R side of the heart decreases

The volume to the L side of the heart increases

What happens to each side of the heart on expiration?

P2 is delayed

During physiologic splitting of S2, which sound occurs later/is delayed?

RBBB and pulmonic stenosis

What conditions can cause widened splitting of S2?

S2 is split on inspiration AND expiration, but the split is wider during inspiration. Widened splitting of S2 usually occurs due to delayed closure of the pulmonic valve. Causes include RBBB and pulmonic stenosis

What is widened splitting of S2?

Abnormally widened interval between A2 and P2 that persists unchanged through the respiratory cycle. Split of A2 and P2 is the same in inspiration and expiration

What is fixed splitting S2?

Atrial septal defect

What is the MC cause of fixed splitting S2?

Occurs when there is an audible separation of A2 and P2 during expiration that fuses to a single sound on inspiration. This occurs due to delayed closure of the aortic valve. P2 occurs BEFORE A2 in this case

What is paradoxical splitting of S2?

LBBB and aortic stenosis

What are common causes of paradoxical splitting of S2?

Ejection clicks

They coincide with the opening of the aortic/pulmonic valves

Abnormal early systolic sounds occurring just after S1 are known as ____

Aortic stenosis or pulmonic stenosis

What conditions might cause early ejection clicks during systole?

Mitral or tricuspid valve prolapse

Mid to late systolic clicks are usually associated with ___ or ___

Mitral and tricuspid stenosis

What two valvular disorders are associated with diastolic opening snap?

Mitral stenosis

Opening snap heard best at the apex

Mitral valve prolapse

Mid-systolic click heard best at the apex

Early diastole

S3 follows the opening of the mitral/tricuspid valves during rapid ventricular filling

When in the cardiac cycle does an S3 occur?

Bell (they are both low-pitched spounds)

What part of the stethoscope is best used to auscultate S3 and S4?

Blood flowing rapidly into a dilated/large ventricle (i.e. patients with systolic HF)

What is the pathologic cause of S3?

Left lateral decubitus with the bell over the cardiac apex

What position can a left sided S3 be exacerbated in?

Late diastole when the atria contract

At what point in the cardiac cycle does an S4 occur

Occurs in late diastole when the ventricles contact against a stiffened/non-compliant ventricle. This is common in ventricular hypertrophy

What is the cause of S4?

Murmur

The sound generated by turbulent blood flow

Aortic stenosis

Grade III/VI high-pitched, crescendo-decrescendo systolic murmur, loudest at the upper right sternal border with radiation toward the neck

Aortic stenosis and pulmonic stenosis

What are the systolic ejection murmurs?