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List the steps of cardiac blood flow
- 1) Blood from liver enters rt atrium via inferior vena cava. Bood also enters rt atrium from upper body via superior vena cava.
- 2) Rt atrium ---tricuspid---> rt. ventricle.
- 3) Rt. ventricle --pulmonic valve--->pulmonary artery--->lungs.
- 4) Lungs---Lt. artery---> Lt. atrium
- 5)Lt. atrium---mitral valve---> Lt. ventricle
- 6) Lt. ventricle---aortic valve--->body.
Know which valves are associated with which heart sounds...
- Closure of AV (tricuspid and mitral)valves is S1 and signals beginning of systole (lub)
- Closure of SL valves (pulmonic and aortic valves) is S2 and signals end of systole (dub). Can also be thought of as beginning of diastole.
What is PMI and where is it?
- Point of Maximal Impulse
- 5th ICS, MCL. Should be around apex of heart.
What is the difference between systole and diastole?
- Diastole: ventricles relax & fill w/ blood. Atrial kick.
- Systole: contraction and blood pumped out.
- Pressure in Rt side is lower than Left- less energy needed to pump through pulmonary circulation
- Events occur slightly later in Rt side than Left because of route of myocardial deplorization
- In S1= M1 (Mitral) closes before T1 (Tricuspid);
- In S2= A2 (Aortic) closes before P2 (Pulmonic)
Cardiac Heart sounds, significance and locations for ascultation
- First Heart sound (S1) = closure of AV valves (mitral & tricuspid)- beginning of systole; loudest at apex
- Second Heart sound (S2) = closure of semilunar valves (aortic & pulmonic); loudest a base
- Effects of Respiration: Inspiration may cause a split S2; if unsure if split S2 or S3, have pt hold breath while ascultating. If split S2, the split will go away.
Third heart sounds
- Third Heart sound (S3) -(Lub-duppa) Vent. filling sound;
- Occurs in early diastole during early rapid filling phase immediately after S2;
- Dull, soft sound, low pitched- “distant thunder”;
- Heard best in quiet room, at apex, with bell held lightly, person in left lateral position;
- Physiologic (children and young adults)- disappears when person sits up
- Pathologic (Ventricular gallop)- persists when sitting up; sign of HF, volume overload, hyperthyroidism, anemia, pregnancy
Fourth Heart sound
- Fourth Heart sound (S4) (daLub - dup) = Vent. filling sound;
- Occurs at end of diastole, at presystole, when ventricle is resistant to filling; just before S1;
- Very soft sound, very low pitch;
- Need a good bell, for left sided S4: heard best at apex, person in left lateral position, for right sided S4, left lower sternal border and may increase with inspiration;
- Physiologic- adults older than 40 or 50 with no evidence of CV disease- esp. after exercise
- Pathologic (Atrial gallop)- with decreased compliance of ventricle (CAD, cardiomyopathy) & systolic overload (afterload)- aortic stenosis and systemic hypertension
And Even more heart sounds!
- Result of turbulent blood flow and collisions
- Gentle, blowing, swooshing sound
- Can be heard on chest wall
- Velocity of blood increases (flow murmur); exercise, thyrotoxicosis
- Viscosity of blood decreases; anemia
- Structural defects in valves, narrowed valve, incompetent valve
- Unusual openings occur in chambers, dilated chamber, wall defect
- Can occure between S1 and S2 or S2 and S1. Always pathologic if between S2 and S1
- Loudness graded with Roman numerals I-VI with VI being loudest.
How are cardiac sounds documented?
- Frequency or pitch, ie high picted or low pitched
- Intensity/loudness: loud vs. soft. Loudness is measured I-VI
- Timing: systole vs. diastole
Heart's pumping ability and cardiac output
- Cardiac output: SV X HR. Normal ~ 4-6 lt/min
- SV=Stroke Volume, measured by volume of blood pumped during systole.
- Carotic Artery's timing is consistent with systole.
Risk factors for Heart Disease
- High BP
- High cholesterol
Cultural competency for Hypertension (HTN)
- Some groups carry excessive burden of CVD
- Greater % of men than women have HTN until 45 ys- then more similar; after 64 ys- women have greater % than men
- HTN: 2-3X more common among women taking oral contraceptive, esp. obese and older women
- HTN in African Americans is among highest in world increasing!
- Prevalence of HTN:
- 31.8% African Americans
- 25.3% American Indians or Alaska Natives
- 23.3% Whites
- 21% Hispanics and Asians
Cultural competency as related to heart disease
- Nicotine increases risk of MI and stroke by causing:
- Increase in O2 demand with a decrease in O2 supply
- Activation of platelets, activation of fibrinogen; and an adverse change in lipid profile
- Increased risk of MI and stroke especially in women on BC pills. Risk so high should be considered malpractice to Rx pill for known female smokers.
Coltural competency as related to heart disease
- High levels of low-density lipoprotein gradually add to lipid core of thrombus formation in arteries- results in MI and stroke
- Age adjusted prevalence of total cholesterol levels over 200 mg/dl are:
- 51.1% of Mexican American men and 49% of Mexican American women
- 45% of white men and 48.7% of white women
- 40.2% of African American men and 41.8% of African American women
Coltural competency as related to heart disease
Type II Diabetes Millitus (DM)
- Risk of CVD is 2-fold > among persons with DM
- Increased prevalence of DM in U.S. is being followed by an increasing prevalence of CVD morbidity and mortality
- Diabetes causes damage to large BV that nourish brain, heart and extremities; this results in stroke, CAD, and PVD
- ~13% of African Americans > 20 have DM
- 11.8% to 13.1% of Mexican Americans have DM, compared to 6.4% of whites
What is Orthopnea?
Difficulty sleeping. Needs to assume more upright position to breath. Document number of pillows needed for suitable position.
What does a wet cough indicate?
CHF (congestive heart failure). Usually means Rt side of heart is difficient because blood is backing up inside of lungs, but problem can be either side of heart.
What is nocturia?
- Getting up to pee at night.
- Related to HF because when upright, kidneys do not get sufficient BF, but at night, pt is horizontal and BF to kidneys increases which leads to increased renal function.
What do you need to remember to document when taking a pt's family's heart heath Hx?
The age at which family members were diagnosed with their conditions.
Why would you feel/see a lift/heave at the sternal border of the precordium?
Lt and/or rt ventricle hypertrophy (enlarged ventricles)
What is a Thrill?
- A slight vibration palpable at the base of the heart (2nd ICS, lt sternal border)
- Often indicative of murmer.
What is the correct order for auscultating cardiac sounds?
- 1. Note the rate and rhythm
- Sinus arrhythmia-↑w/inspiration, ↓ w/expiration
- Test for Pulse deficit = Auscultate apical rate while palpating radial pulse. The two should be in sync; if not then pulse deficit which indictes weak ventricles, ie Afib, PAC/PVC (Premature Atrial/Ventricular Contraction), heart failure.
- 2. Identify S1.
- 3. Identify S2.
- S1 is louder than S2 at the apex
- S1 coincides with carotid artery pulse
- S1 coincides with R wave on ECG.
- 4. Listen for extra heart sounds
- 5. Listen for murmurs
What is a pericardial friction rub?
- When inflamed tissues of the pericardium rub against thorasic wall.
- Sounds harsh like dry leather.
- Is accompanied by sharp pain.
- Typically after heart attack.
What are some symptoms of Heart Failure?
Murmurs due to valvular defects
- Midsystolic ejection: Aortic/Pulmonic stenosis
- Pansystolic regurgitation: Mitral/Tricuspid regurgitation
- Diastolic rumbles of atrioventricular valves: Mitral/Tricuspid stenosis.
- Early diastolic murmurs: Aortic/pulmonic regurgitation