Patho Week 8

Heart Sounds:

* closure of the mitral and tricuspid valves

S1

Heart sounds:

closure of the aortic and pulmonic valves

S2

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

S2 split

* 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

* 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

fifth intercostal space, left midclavicular line

mitral valve

second intercostal space, right sternal border

aortic valve

* 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

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

physiologic murmurs

* 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

Symptoms include:

shortness of breath, dizziness, chest pains, or palpitations

pathologic murmurs

Grades of heart murmur:

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

grade 1

Grades of heart murmur;

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

grade 2

Grades of heart murmur;

* moderately loud

grade 3

Grades of a heart murmur:

loud with a palpable thrill

grade 4

grades of a heart murmur:

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

grade 5

Grades of a heart murmur:

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

grade 6

Common causes of _____________ include:

* Rheumatic fever
* Associated with aging, atherosclerosis
* Few symptoms

mitral stenosis

Common causes of _____________ include:

* RHD
* Endocarditis
* Marfan’s syndrome
* Ankylosing spondylitis

aortic insuffieciency

Common causes of _____________ include:

* Aortic sclerosis
* RHD
* Congenital valve defect

aortic stenosis

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

Common causes of _____________ include:

Myxomatous degeneration

Mitral valve prolapse

Used to diagnose valve disorders:

* Noninvasive, transducer placed on chest wall

transthoracic echocardiography

Used to diagnose valve disorders:

* Transducer inserted into esophagus
* More sensitive than TTE

* transesophageal echocardiography

Used to diagnose valve disorders:

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

doppler echocardiography

Medical treatment for valve disorders:

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

nitrates

Medical treatment for valve disorders:

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

beta-adrenergic blockers

Medical treatment for valve disorders:

* Medications that reduce clot risk

anticoagulants

Medical treatment for valve disorders:

* Medications that reduce blood volume overload

diuretics

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

Surgical treatments for valve disorders:

* Valv____
* Valv____
* Valve ______
* ______ heart
* Invasive _______

otomy, uloplasty, replacement, open, percutaneous

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

Risks vs Benefits of a _______ valve:

* ______ risk of clot formation
* _______ therapy needed
* Last ______

mechanical, increased, anticoagulant, longer

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

Patho of Mitral Stenosis:

*  _____ blood flow from left into ____ ventricle

impedes, atria, left

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

Symptoms of Mitral Stenosis:

* pulmonary ______
* _______ with exertion,
* paroxysmal ______ dyspnea,
* orthopnea

edema, dyspnea, nocturnal

Risks of Mitral Stenosis:

* Increased risk of ______ fibrillation and stroke

atrial

Commonality of mitral stenosis:

very common

Patho for Aortic stenosis:

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

calcification, aortic

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

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

Risks of Aortic stenosis:

valve replacement

Commonality of aortic stenosis:

very common

Patho of mitral insufficiency:

* Mitral valve does not ____ properly

close

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

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

Risks of Mitral Insufficiency:

afib and heart failure

Commonality of mitral insufficiency:

very rare

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

Characteristics of aortic insufficiency:

* Austin Flint murmur
* LV impulse _____ through the chest wall
* Murmur: high-pitched, blowing, _____ ______ murmur

visible, decrescendo, diastolic

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

Characteristics of Hypertrophic cardiomyopathy:

* ______ disorder
* Enlarged LV compromises the functioning of aortic and mitral ______
* Murmur
* Diamond-shaped ______ murmur

genetic, valves, systolic

Risks of Hypertrophic cardiomyopathy:

* atrial and ventricular ________
* Atrial fibrillation
* ______
* Non-sustained ventricular _______
* Sudden ______ due to ventricular dysrhythmias

dysthymias, PVCs, tachycardia, death

Commonality of hypertrophic cardiomyopathy:

rare

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

* MVP Syndrome:
* Benign MVP with sporadic episodes of prolapse of _____
* Patient may describe dizziness, palpitations, atypical chest ____, anxiety

leaflet, pain

Expected treatment of MVP

doesn’t require treatment

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

Treatment of pulmonary stenosis

percutaneous balloon valvotomy

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

Treatment of pulmonic insufficency

valve replacement

Risk factors for tricuspid stenosis;

* _________ventricle infarction
* _________ heart disease
* Infective Endocarditis
* Pulmonary _________

right, rheumatic, HTN

Greatest risk factor for developing HF:

hypertension

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

heart failure

Pre-existing Heart Conditions:

MI, CAD, metabolic syndrome, DM

* 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

* 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

* 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

increase in afterload=

increase in cardiac workload

Effects on the heart:

* Force of contraction
* Ca++ and SNS activation
* Positive _______ agents
* Digitalis
* Positive _______ agent

inotropic

Effects on the heart:

* Rate of heart
* Digitalis and beta blockers
* Negative ______ effect
* Epinephrine and SNS activation
* Positive _______ effect

chronotropic

Four Major pathologic:

* Increased _____ volume or volume overload
* Impaired _______ filling
* _________ of ventricular muscle
* _________ ventricular contractile function

fluid, ventricular, degeneration, decreased

* ____ sided heart failure due to pulmonary issues
* COPD-→hypoxia-→pulmonary vasoconstriction-→____ workload on ____ side of heart

right, hypoxia, increased, right

List the seven causes of heart failure

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

Causes of HF:

Cardiomyopathies:

ischemia, dilated, restrictive, hypertrophic

Myocardial fibrosis and scarring of heart

ischemic cardiomyopathy

Enlargement of ventricles

dilated cardiomyopathies

HF:

* can not fill

restrictive cardiomyopathies

* Usually LV muscle enlarged, encroaches on ejection of blood into aorta
* Primary: genetic
* Secondary: due to HTN

hypertrophic cardiomyopathies

Causes of HF:

* Irregular heart rhythm may precipitate failure
* Both tachyarrhythmias and bradyarrhythmia

dysrhythmia

Causes of HF:

* Endocarditis, myocarditis

cardiac infection

Causes of HF:

Acute RV failure due to increased pulmonary artery pressure

pulmonary embolism

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

Causes of HF:

* LV must generate more pressure to eject blood


* LVH develops

aortic stenosis

* 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

* When the heart cannot keep up with the normal demands of the body
* Weakened heart muscle
* Typical heart failure

low output

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

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

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

Symptoms of _______ sided heart failure:

* Dyspnea 
* Cough 
* Orthopnea
* PND 
* Weak peripheral pulses 
* Decreased cerebral perfusion; confusion, disorientation 

left

Forward effects of Left sided heart failure:

decrease perfusion, activate SNS, RAAS

Backward effects of Left sided heart failure:

* ______ pressure backup into _______ circulation
* ______, orthopnea, paroxysmal nocturnal dyspnea (_)

hydrostatic, pulmonary, crackles, PND

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

Forward effects of right sided heart failure

weakness and fatigue

Implications of heart sounds:

* High ventricular volume and pressure

S3

Implications of heart sounds:

* atrium contracting against noncompliant ventricle

S4

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

Medication that:

* Block angiotensin-converting enzyme
* Cornerstone of heart failure treatment

ACE inhibitors

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

angiotensin II receptor blocker