Heart

What lies between the sternum of the anterior chest?

The heart

What is the precordium?

Area of chest overlying the heart

What is the upper portion of the heart called?

base

What is the narrower lower tip of the heart called?

apex

For a tall slender patient, what position does the heart tend to hang?

Vertical position, more central

For a shorter patient, what position does the heart tend to hang?

More horizontal, more to left side

What is dextrocardia?

heart condition either rotated or displaced, where heart positions more to right

What is situs inversus?

Congenital condition where heart & stomach are placed to right side, liver is on the left side of body

Two thirds of the heart lies on what side of the sternum?

On the Left side

What are the three layers encased in the pericardium?

• Epicardium (outer)

• Myocardium (middle)

• Endocardium (inner)

What side of the heart pumps de-oxygenated blood to the lungs?

Right Side

What side of the heart pumps oxygenated blood to the rest of the body?

Left side

True or false? Pressure within the RV, RA, and pulmonary artery are greater than the L side

True

What are the two cardiac cycle phases?

Systole and Diastole

What happens in systole stage of cardiac cycle?

• Ventricles start to contract

• Forces Mitral and tricuspid (AV) valves close (S1)

• Atria refills at same time

• Pressure of Systole rises until it exceeds in aorta and pulmonary arteries

• Aortic and pulmonic valves open (no sound), allowing for blood to be ejected into arteries

• Pressure falls

• Aortic and pulmonic valves close (S2)

What is happening to the heart during S1 sound?

Mitral and tricuspid valves closing (LUB)

**beginning of systolic cardiac phase where ventricular contraction raises pressure in ventricles forcing these valves close

What is happening to the heart during S2 sound?

Aortic and pulmonic valves closing

What occurs during the diastole cardiac cycle phase?

• Mitral and tricuspid (AV) valves open (no sound)

• Ventricles dilate

• Blood from atria moves/fills into ventricles (S3)

• Atria contracts (S4)

True or false? Blood moving from atria to ventricles can produce S4 sounds d/t rapid ventricular filling.

False. Can produce S3

What heart sound is heard when the atria contracts, allowing for forceful ejection of blood into ventricles?

S4 sound

Which type of examination are you performing when you identify a bruit?

A. inspecting the skin

B. observing chest movement

C. auscultating the artery

D. palpating the artery

C. auscultating the artery

Which events occur during the systolic phase of the cardiac cycle?

A. The atria and the ventricles contract

B. The ventricles contract and the atria relax

C. The atria contract and the ventricles relax

D. The right side of the heart contracts and the left side relaxes

B. The ventricles contract and the atria relax

Mr. Herrara is a 42-year-old patient who presents for routine well visit. On examination during cardiac auscultation, you note a midsystolic murmur with a medium pitch; a coarse thrill is palpated as well. These findings are consistent with which condition?

A. Aortic regurgitation

B. Mitral stenosis

C. Aortic stenosis

D. Pulmonary stenosis

C. Aortic stenosis

Which of the following changes occur at birth in a normal infant?

A. The ductus arteriosus closes

B. Pressure in the right atrium rises

C. The foremen ovale opens

D. The relative mass of the left ventricle decreases

A. The ductus arteriosus closes

In most adults, the apical pulse should be visible at the:

A. costoverebral angle

B. sternal notch

C. Midaxillary line in the fifth right intercostal space

D. Midclavicular line in the fifth left intercostal space

D. Midclavicular line in the fifth left intercostal space

A condition that results in progressive ischemia caused by insufficient perfusion is referred to as:

A. Raynaud’s

B. Peripheral atherosclerotic disease

C. arterial aneurysm

D. venous thrombus

B. Peripheral atherosclerotic disease

Which person is most at risk for developing venous thrombosis? A person:

A. Who takes 0.35 mg of estrogen a day

B. With aortic insufficiency

C. On bed rest for four days following a trauma

D. Who smokes one pack of cigarettes per day

C. On bed rest for four days following a trauma

A disruption to the flow of blood into, though, or out of the heart produces which cardiac sound?

A. S3

B. friction rub

C. prediastolic gallop

D. murmur

D. murmur

Stroke volume is defined as the

A. Amount of blood ejected per minute

B. Amount of blood ejected per heartbeat

C. Combined amount of blood contained within each atria

D. Amount of blood ejected per second

B. Amount of blood ejected per heartbeat

Where would you place your stethoscope to auscultate the aortic valve area?

A. Fourth left intercostal space along the lower left sternal border

B. Second left intercostal space at the left sternal border

C. Second right intercostal space at the right sternal border

D. Third left intercostal space at the left sternal border

C. Second right intercostal space at the right sternal border

Mrs. Bower is a 55-year-old patient who presents to your office with a complaint of fatigue. On palpating the precordium during her examination, a heave OR lift is identified with lateral displacement of the apical pulse. Which problem might this finding indicate:

A. aortic stenosis

B. pericarditis

C. mitral regurgitation

D. left ventricular enlargement

D. left ventricular enlargement (LV hypertrophy)

Mr. Sherman is a 65-year-old patient who has long-standing hypertension. Which clinical finding would you expect?

A. Decreased cardiac irritability

B. Increased stroke volume

C. Decreased blood volume

D. Thickened myocardium 

D. Thickened myocardium 

Opening between the left and right ventricles

ventricular septal defect

Systemic connective tissue disease that commonly occurs after streptococcal infection 

rheumatic fever

Sinoatrial node dysfunction

sick sinus syndrome

Bacterial infection of the endothelial layer of the heart 

endocarditis

Syndrome in which the heart fails to propel blood forward 

heart failure

Elevated serum cholesterol

hyperlipidemia

Inflammation of the pericardium 

pericarditis

Increase in mass and lateral displacement of the left ventricle

left ventricular hypertrophy

Thickening and calcification of the aortic valve 

aortic stenosis

Substernal pain or intense pressure 

angina

What are the atrioventricular cardiac valves?

Tricuspid valve and mitral valve

What are the semilunar cardiac valves?

Pulmonary valve and aortic valve

What does the tricuspid valve separate? How many cusps (leaflets) does this valve have?

Separates RA and RV, has 3 cusps

What does the mitral valve separate? How many cusps (leaflets) does this valve have?

Separates LA and LV, has two cusps

What does the pulmonic valve separate? How many cusps (leaflets) does this valve have?

Separates RV and pulmonary artery; has three cusps

What does the aortic valve separate? How many cusps (leaflets) does this valve have?

Separates LV and aorta; has three cusps

3/4 cardiac valves have three cusps. Which valve only contains two cusps?

Mitral valve

When considering pregnant women, what hemodynamic changes to the heart occurs in this population?

• Maternal blood volume increases 40-50% above pre-pregnant levels

• HR and stroke volume (SV) increase to accommodate blood volume increase

• LV increases in wall thickness & mass

• Heart positions more horizontally

• Diaphragm moves upwards d/t uterine enlargement

When considering older adults, what hemodynamic changes to the heart occurs in this population?

• Heart size can decrease

• LV and endocardium thickening

• Fibrosis and calcification of heart valves

• HR slows

• Stroke volume (SV) and cardiac output during exercise decreases

• Myocardium losses elasticity

• Enhanced electrical irritability

What does cardiac health history revolve around?

Symptomology of chest pain (angina pectoris)

**providers must assume all patients with symptoms of chest pain is related to a cardiac nature to rule out

How would a provider assess HPI of chest pain in relation to cardiac?

the use of OLDCARTS and current medication use

How would a provider assess HPI of fatigue?

• Unusual or persistent

• Inability to keep up with peers

• associated symptoms

• medications: ex. beta blockers

How would a provider assess HPI of cough?

• onset and duration

• character

• Medcations: ex. ACE inhibitors - common is lisinopril

How would a provider assess HPI of dyspnea?

• Aggravated by exertion (at rest or with activity)

• Worsening from onset vs. remains stable

• Lying flat and is relieved by sitting up or with pillows (orthopnea)

• Paroxysmal nocturnal dyspnea

How would a provider assess HPI of loss of consciousness (syncope)?

• Palpitations

• Dysrhythmias

• Unusual exertion

• Sudden turning of neck

• Looking upward

• Change in posture

A patient comes in with complaints of a syncope episode. When assessing subjective data, the patient explains the episode preceded after turning their neck fast. What cardiac structure would the provider assume this would be related to?

Carotid sinus

A patient comes in with complaints of a syncope episode. When assessing subjective data, the patient explains the episode preceded after attempting to look upward at their ceiling. What cardiac structure would the provider assume this would be related to?

The vertebral artery

Under past medical history, what should a provider address when considering the cardiovascular system?

• Cardiac surgery and hospitalization

• Rhythm disorder

• Acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism

• Chronic illness

Under family history, what should a provider address when considering the cardiovascular system?

• Long QT syndrome

• Diabetes

• Heart disease

• Dyslipidemia

• Hypertension

• Congenital heart defects

• Family members with cardiac risk facto

Under personal and social history, what should a provider address when considering the cardiovascular system?

• Employment

• Physical demands

• Environmental hazards

• Tobacco use

• Nutritional status

• Personality assessment

• Relaxation activities

• Use of alcohol and/or drugs

What are common older adult symptoms of a cardiovascular-related disorder?

• Confusion and syncope

• Palpitations

• Coughs and wheezes

• Hemoptysis

• Shortness of breath

• Chest pain and tightness

• Incontinence, impotence, and heat intolerance

• Fatigue

• Leg edema

When assessing the cardiovascular system during inspection, what abnormalities is the provider looking for?

Apical impulse, pulsation, heaves, or lifts

When assessing the cardiovascular system during palpation, what abnormalities is the provider looking for?

Apical impulse, thrill, heaves, or rub

When assessing the cardiovascular system during percussion, what abnormalities is the provider looking for?

trick question, there is little value to percussion in cardiovascular assessment

When assessing the cardiovascular system during auscultation, what abnormalities is the provider looking for?

Systematically evaluate aortic, pulmonic, tricuspid and mitral (apical)

True or false? Remember to inspect, palpate, and percuss before auscultating the heart and lungs.

True

What landmark helps locate the apical impulse?

the mid-clavicular line in the 5th intercostal space

To help visualize a presence of jugular vein distention (JVD), what position should a patient be in?

recombinant position

When performing cardiac palpation, what sequence should a provider follow?

• Palpation of apex

  • Left sternal border

  • Base

  • Right sternal border (into the epigastrium or axillae if circumstance dictates)

• Apical impulse

• Carotid artery palpation

How would you characterize an apical impulse that is more vigorous or forceful than expected?

As a heave or lift

True or false? Point of maximal impulse (PMI) is the point at which the apical impulse is most readily heard.

False, it is the point at which it is most SEEN or FELT

What is a thrill?

a fine, palpable, rushing vibration, sometimes found as a palpable murmur

Because percussion has limited value in defining borders of the heart and determination of size, how is the LV size best judged?

By assessing the location of the apical impulse

If the RV size becomes enlarged, how would the provider expect this cardiac region to anatomically expand?

RV would enlarge in the antero-posterior diameter rather than laterally

What comorbidity can cause unusual muscular development and distortion of cardiac findings?

Obesity

What diagnostic test is best used for defining heart borders?

Chest X-Ray

What are the 5 traditionally designated auscultatory areas to assess for the heart?

• Aortic valve

• Pulmonic Valve

• Second pulmonic area

• Tricuspid area

• Mitral (apical) area

When you auscultate the aortic valve area, what anatomical landmark do you reference?

Second right intercostal space at the right sternal border.

When you auscultate the pulmonic valve area, what anatomical landmark do you reference?

Second left intercostal space at the left sternal border.

When you auscultate the second pulmonic valve area, what anatomical landmark do you reference? What is this area also commonly known as?

Third left intercostal space at the left sternal border; also known as Erb's point.

When you auscultate the tricuspid valve area, what anatomical landmark do you reference?

Fourth left intercostal space along the lower left sternal border

When you auscultate the mitral valve area, what anatomical landmark do you reference?

Apex of the heart in the fifth left intercostal space at the midclavicular line

When you are auscultating the heart, what things are you assessing?

• Rate/rhythm

• Frequency

• Intensity

• Duration

• Pathology

What are some abnormal heart sounds?

• Gallops

• Mitral Snaps

• Ejection Clicks

• Friction Rubs

When a provider evaluates a patient’s heart rhythm what do they obtain?

• The heart rate

• Steadiness of the rhythm (regular)

  • If irregular, determine pattern

If a patient’s heart pattern is irregular and repetitively occurs, what could this indicate?

A cyclic variation of heart rate, such as sinus dysrhythmia

If a patient’s heart pattern is irregular and is unpredictable, what could this indicate?

heart disease or conduction impairment

What is a cardiac murmur?

Extra heart sounds during systole and diastole secondary to some type of disruption of flow

Characteristics of a cardiac murmur depend on what?

• Adequacy of valve function (stenosis/regurgitation)

• Size of valve opening

• Rate of blood flow

• Vigor and thickness of myocardium

What day after conception can a heart beat be found?

Day 23 of gestation

What week of gestation can a heart valve be formed? What week is valve formation complete?

4th week formed, 8th week complete

What is a patent foramen ovale?

A hole between the R & L atriums

What is a patent ductus arteriosus?

An opening between the pulmonary artery and aorta

What part of a blood pressure is preload?

diastole

What part of a blood pressure is afterload?

Systole

When considering preload (diastole), what is occurring in the heart?

Amount of blood in the ventricles at the end of diastole (ventricle relaxation)

**amount of STRETCH at the end of ventricular filling

When considering afterload (systole), what is occurring in the heart?

Amount of resistance of flow the ventricles must OVERCOME to contract and eject blood volume (ventricle contraction)

**amount of pressure the LV of the heart needs to exert force to open the aortic valve during systole

What is the difference between ventricular functions in systole and diastole?

Systole: Ventricular contraction

Diastole: ventricular filling and relaxation