Patho Week 8

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Heart Sounds:

  • closure of the mitral and tricuspid valves

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Heart Sounds:

  • closure of the mitral and tricuspid valves

S1

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2

Heart sounds:

closure of the aortic and pulmonic valves

S2

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  • Slight delay in the valve closure, with the aorta closing first and the pulmonary valve

S2 split

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  • As blood flows rapidly from the atria into the ventricles, the vibrations of the blood flow against the ventricular wall can be heard as a third heart sound.

    • Gallops

    • This can be a normal sound in children and young adults, but in older adults it can indicate decreased ventricular muscle elasticity

    • Heart failure

S3

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  • When the left atrium contracts against a noncompliant, stiff left ventricle. Low pitched sound, best heard with the bell piece of the stethoscope.

    • Associated with hypertension, because long-term hypertension causes left ventricular hypertrophy that creates a noncompliant, stiff left ventricle

    • LVH due to hypertension

S4

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fifth intercostal space, left midclavicular line

mitral valve

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second intercostal space, right sternal border

aortic valve

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  • Innocent or functional heart murmurs, may be heard in states of high blood flow within the heart.

  • These heart murmurs are usually faint, and intermittent, occur in a small area of the chest, and usually do not cause symptoms.

physiologic murmurs

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Murmurs caused by anxiety, stress, fever, anemia, overactive thyroid, and pregnancy

physiologic murmurs

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  • Sounds caused by abnormalities of the heart that include valvular deformities, valvular dysfunction, and heart wall defects.

  • Can cause heart failure

  • Require medical intervention to prevent complications

pathologic murmur

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Symptoms include:

shortness of breath, dizziness, chest pains, or palpitations

pathologic murmurs

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Grades of heart murmur:

  • Very faint, heard only after listener has “tuned in”; may not be heard in all positions.

grade 1

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Grades of heart murmur;

  • Quiet, but heard immediately after placing the stethoscope on the chest.

grade 2

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Grades of heart murmur;

  • moderately loud

grade 3

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Grades of a heart murmur:

loud with a palpable thrill

grade 4

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grades of a heart murmur:

very loud, with thrill. May be heard when stethoscope is partly off the chest wall.

grade 5

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Grades of a heart murmur:

  • Very loud, with thrill. May be heard with stethoscope off the chest wall.

grade 6

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18

Common causes of _____________ include:

  • Rheumatic fever

  • Associated with aging, atherosclerosis

  • Few symptoms

mitral stenosis

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19

Common causes of _____________ include:

  • RHD

  • Endocarditis

  • Marfan’s syndrome

  • Ankylosing spondylitis

aortic insuffieciency

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20

Common causes of _____________ include:

  • Aortic sclerosis

  • RHD

  • Congenital valve defect

aortic stenosis

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21

Common causes of _____________ include:

  • MI

  • Mitral valve prolapse (MVP)

    • Mild, asymptomatic

  • Rheumatic heart disease

  • Infective endocarditis

  • Drugs

  • Myxomatous degeneration

  • Mitral annular calcifications

  • Marfan’s and Ehlers-Danlos syndromes

mitral insufficiency

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Common causes of _____________ include:

Myxomatous degeneration

Mitral valve prolapse

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23

Used to diagnose valve disorders:

  • Noninvasive, transducer placed on chest wall

transthoracic echocardiography

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Used to diagnose valve disorders:

  • Transducer inserted into esophagus

  • More sensitive than TTE

  • transesophageal echocardiography

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Used to diagnose valve disorders:

  • Sound waves to measure velocity of blood flow across valves and in chambers; can be colorized

doppler echocardiography

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Medical treatment for valve disorders:

  • Medications that is responsible for vasodilation, reducing ischemic chest pain

nitrates

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Medical treatment for valve disorders:

  • Medications that is responsible for decreasing HR, and peripheral resisitance

beta-adrenergic blockers

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Medical treatment for valve disorders:

  • Medications that reduce clot risk

anticoagulants

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Medical treatment for valve disorders:

  • Medications that reduce blood volume overload

diuretics

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Medical treatment for valve disorders:

  • Prophylactic may be needed

  • Deformed or artificial valves can act as a site for bacterial growth if a patient develops bacteremia

  • Recommended whenever patients

    • undergo dental treatment

    • other invasive procedures (including insertion of an IV)

antibiotics

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Surgical treatments for valve disorders:

  • Valv____

  • Valv____

  • Valve ______

  • ______ heart

  • Invasive _______

otomy, uloplasty, replacement, open, percutaneous

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Why some patients would need prophylactic-antibiotic treatment?

  • ______ or artificial valves can act as a site for bacterial growth if a patient develops _______

  • Recommended whenever patients

    • undergo _______ treatment

    • other _______ procedures (including insertion of an IV)

deformed, bacteremia, dental, invasive

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Risks vs Benefits of a _______ valve:

  • ______ risk of clot formation

  • _______ therapy needed

  • Last ______

mechanical, increased, anticoagulant, longer

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Risk vs Benefit of a ________ valve:

  • Porcine, _______, or human cadaver

  • Less _______

    • 30% of patients need to ______ after 10 years

    • ___% need a replacement after 15 years

bioprosthetic, bovine, durable, replace, 50

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Patho of Mitral Stenosis:

  • _____ blood flow from left into ____ ventricle

impedes, atria, left

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Characteristics of Mitral Stenosis;

  • Murmur at the apex→_____: Low pitched _____, left lateral decubitus position accentuates the murmur

  • Opening _____: rigid mitral valve opening

  • _____ cardiac output as less blood flows into left _______

  • _____ of left ____ as blood can not enter left ventricle

diastolic, rumble, snap, decreased, ventricle, overload, atria

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Symptoms of Mitral Stenosis:

  • pulmonary ______

  • _______ with exertion,

  • paroxysmal ______ dyspnea,

  • orthopnea

edema, dyspnea, nocturnal

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Risks of Mitral Stenosis:

  • Increased risk of ______ fibrillation and stroke

atrial

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Commonality of mitral stenosis:

very common

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Patho for Aortic stenosis:

  • Aortic sclerosis=________ of the ______ valve in the elderly

calcification, aortic

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Characteristics of Aortic Stenosis:

  • Difficult for ___ ventricle to eject blood due to increased ____, leading to __ __ ___

  • Murmur:

    • As the ventricle contracts (during systole), blood flows through the narrowed valve

    • ______, crescendo and low-pitched

    • _______ intercostal space with patient seated and leaning forward

    • Systolic ______ may be present

left, resistance, LVH, systolic, second, thrill

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Symptoms of Aortic stenosis:

  • _______ dyspnea

  • Pulmonary ______ as blood backs up LV to LA to the pulmonary circulation

  • Angina ____ due to poor oxygenation of _____

exertional, edema, pectoris, LVH

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Risks of Aortic stenosis:

valve replacement

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Commonality of aortic stenosis:

very common

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Patho of mitral insufficiency:

  • Mitral valve does not ____ properly

close

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Characteristics of Mitral Insufficiency:

  • Murmur: ________ murmur heard at apex that radiates into ________

  • Portion of blood moves from left ________ into left atria

  • ________ blood for ________ circulation

  • Post-____ due to papillary muscle damage

holosystolic, axilla, ventricle, decreased, coronary, MI

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Symptoms of Mitral Insufficiency:

  • Often _________→assess post MI with echocardiography

    • Diminished ____

    • Pulmonary symptoms due to fluid back up in the lungs

    • Severe chest _____

asymptomatic, S1, pain

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Risks of Mitral Insufficiency:

afib and heart failure

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Commonality of mitral insufficiency:

very rare

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Patho of aortic insufficiency:

  • Deformed aortic valve does not ____ properly

    • Backflow of blood from aorta into ___

    • Dilation and decreased _______ of LV

    • Backup of blood into _______ circulation

close, LV, contraction, pulmonary

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Characteristics of aortic insufficiency:

  • Austin Flint murmur

  • LV impulse _____ through the chest wall

  • Murmur: high-pitched, blowing, _____ ______ murmur

visible, decrescendo, diastolic

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Patho Hypertrophic Cardiomyopathy;

  • The ________ septum of the ___ enlarged

    • Asymmetric vs concentric ______ seen in LVH in response to ______

    • Inhibits _______ of LV blood

interventricular, LV, enlargement, HTN, ejection

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Characteristics of Hypertrophic cardiomyopathy:

  • ______ disorder

  • Enlarged LV compromises the functioning of aortic and mitral ______

  • Murmur

    • Diamond-shaped ______ murmur

genetic, valves, systolic

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Risks of Hypertrophic cardiomyopathy:

  • atrial and ventricular ________

  • Atrial fibrillation

  • ______

  • Non-sustained ventricular _______

  • Sudden ______ due to ventricular dysrhythmias

dysthymias, PVCs, tachycardia, death

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Commonality of hypertrophic cardiomyopathy:

rare

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Patho of Mitral Valve Prolapse:

  • AKA Barlow syndrome, _____ valve syndrome

  • Females: age 14 to 30 years; relatively _______

  • Commonly __________ with unknown cause

  • Myxomatous degeneration of the valve tissues cause _____ closure, as leaflet(s) prolapse upward into LA

  • Mid-systolic click may be present followed by ________ murmur

floppy, common, asymptomatic, poor, systolic

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  • MVP Syndrome:

    • Benign MVP with sporadic episodes of prolapse of _____

    • Patient may describe dizziness, palpitations, atypical chest ____, anxiety

leaflet, pain

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Expected treatment of MVP

doesn’t require treatment

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Pulmonary stenosis;

  • ______ of valve

  • Increased workload on ____ ventricle

    • May cause right ventricle ______

  • Murmur

    • Harsh, ____ crescendo-decrescendo in ___ intercostal space on sternal border

narrowing, right, failure, systolic, 2nd

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Treatment of pulmonary stenosis

percutaneous balloon valvotomy

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Pulmonic Insufficiency:

  • _____ does not close properly

    • _______ of right ventricle

    • Signs of right-side heart ______ may appear

  • Commonly secondary to pulmonary ______

    • Other causes: congenital heart disease, RHD, and endocarditis

  • Murmur

    • Graham Steell murmur; high-pitched, decrescendo _________ murmur

valve, overload, failure, HTN, diastolic

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Treatment of pulmonic insufficency

valve replacement

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Risk factors for tricuspid stenosis;

  • _________ventricle infarction

  • _________ heart disease

  • Infective Endocarditis

  • Pulmonary _________

right, rheumatic, HTN

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Greatest risk factor for developing HF:

hypertension

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A weakened ventricular muscle that is unable to sufficiently pump blood into the arterial circulation to meet the needs of the tissues.

heart failure

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Pre-existing Heart Conditions:

MI, CAD, metabolic syndrome, DM

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  • Women are often diagnosed with HF at an _____ age than men because natural _____ is cardio-protective

    • After menopause, the risk of cardiovascular disease for men and women is ______

    • Greater prevalence of HF among people of ______ origin compared with people of European origin

older, estrogen, equal, african

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  • Amount heart is filled per beat

    • Increased EDV leads to increased SV

  • Volume of blood in ventricles at end of diastole

  • Increased in - Hypovolemia regurgitation of cardiac valves Heart Failure

preload

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  • Resistance that heart pumps against

    • Increased afterload reduces cardiac output

    • Resistance left ventricle must overcome to circulate blood

    • Increased in-people with HTn vasoconstriction

afterload

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increase in afterload=

increase in cardiac workload

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Effects on the heart:

  • Force of contraction

  • Ca++ and SNS activation

    • Positive _______ agents

  • Digitalis

    • Positive _______ agent

inotropic

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Effects on the heart:

  • Rate of heart

  • Digitalis and beta blockers

    • Negative ______ effect

  • Epinephrine and SNS activation

    • Positive _______ effect

chronotropic

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Four Major pathologic:

  • Increased _____ volume or volume overload

  • Impaired _______ filling

  • _________ of ventricular muscle

  • _________ ventricular contractile function

fluid, ventricular, degeneration, decreased

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  • ____ sided heart failure due to pulmonary issues

  • COPD-→hypoxia-→pulmonary vasoconstriction-→____ workload on ____ side of heart

right, hypoxia, increased, right

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List the seven causes of heart failure

cardiomyopathies, dysthymias, cardiac infection, PE, heart valve abnormalities, mitral regurgitation (insufficiency), aortic stenosis

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Causes of HF:

Cardiomyopathies:

ischemia, dilated, restrictive, hypertrophic

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Myocardial fibrosis and scarring of heart

ischemic cardiomyopathy

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Enlargement of ventricles

dilated cardiomyopathies

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HF:

  • can not fill

restrictive cardiomyopathies

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  • Usually LV muscle enlarged, encroaches on ejection of blood into aorta

  • Primary: genetic

  • Secondary: due to HTN

hypertrophic cardiomyopathies

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Causes of HF:

  • Irregular heart rhythm may precipitate failure

  • Both tachyarrhythmias and bradyarrhythmia

dysrhythmia

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Causes of HF:

  • Endocarditis, myocarditis

cardiac infection

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Causes of HF:

Acute RV failure due to increased pulmonary artery pressure

pulmonary embolism

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Causes of HF:

  • May occur after transmural LV MI

  • Valve does not close properly, backward flow into right atrium (decreased blood ejected from LV)

mitral regurgitation

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Causes of HF:

  • LV must generate more pressure to eject blood

  • LVH develops

aortic stenosis

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  • When the body's need for blood is unusually high

  • Heart failure symptoms happen even though the heart is working well

  • Heart output can not meet high circulatory needs

  • Relatively uncommon

  • Thyrotoxicosis, severe anemia

high output

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  • When the heart cannot keep up with the normal demands of the body

  • Weakened heart muscle

  • Typical heart failure

low output

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What kind of Heart Failure;

  • Difficulty ejecting blood

  • Decreased stroke volume and cardiac output

  • Activation of RAAS, SNS, vasoconstriction place more stress on heart

  • Backup of fluid from failed ventricle

systolic

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What kind of heart failure?

  • Difficulty relaxing/filling

  • Stiff or enlarged ventricles can not easily fill

  • EF may be normal (due to reduced EDV)

diastolic

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Symptoms of _______ sided heart failure:

  • JVD

  • Ascites

  • Gastrointestinal disturbances caused by venous congestion

  • Hepatojugular reflux

  • Hepatomegaly

  • Splenomegaly

  • Peripheral edema- ankle or sacral edema; fingers, feet

right

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Symptoms of _______ sided heart failure:

  • Dyspnea

  • Cough

  • Orthopnea

  • PND

  • Weak peripheral pulses

  • Decreased cerebral perfusion; confusion, disorientation

left

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Forward effects of Left sided heart failure:

decrease perfusion, activate SNS, RAAS

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Backward effects of Left sided heart failure:

  • ______ pressure backup into _______ circulation

  • _____, orthopnea, paroxysmal nocturnal dyspnea ()

hydrostatic, pulmonary, crackles, PND

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Backward effects of right sided heart failure:

  • most significant

    • _____: jugular vein distention

    • Increased central ______ pressure (CVP)

    • Hepato_____, splenomegaly, ascites

    • Hepatojugular reflex may be present

    • Venous congestion of _____ tract causing anorexia, nausea

    • Hypoxia and cyanosis may develop

    • Peripheral edema

JVD, venous, megaly, GI

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Forward effects of right sided heart failure

weakness and fatigue

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Implications of heart sounds:

  • High ventricular volume and pressure

S3

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Implications of heart sounds:

  • atrium contracting against noncompliant ventricle

S4

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The repeated simulation of the ____ increases the risk of ______. Imbalances in serum electrolytes, particularly potassium, can have adverse effects on ______ function. Hypokalemia predisposes the heart to _____. In heart failure, serum electrolytes require periodic _______ and correction if abnormal.

RAAS, hypokalemia, myocardial, dysrhythmias, monitoring

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Medication that:

  • Block angiotensin-converting enzyme

  • Cornerstone of heart failure treatment

ACE inhibitors

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Medication that is often used in those who can’t tolerate ACE inhibitors

angiotensin II receptor blocker

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