the cardiovascular system - amazon s3rutgers+b… · · 2015-05-011 the cardiovascular system...

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The Cardiovascular System

Presented by Carol J. Sadley, M.Ed., PA-C

Rutgers University Physician AssistantCertification and Recertification

Examination Review CourseJune 3, 2014

Rutgers PANCE/PANRE Review Course

Perhaps you’ll want this printedon your next T-shirt?

I LOVE CARDIOLOGY


Cardiovascular System Overview

SymptomsHistoryHistoryPEDiagnostic Studies


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Cardiology practice question

A 75 y/o retired publisher presents for a routine check up. He has a h/o CHF, HTN, and hyperlipidemia. He is doingHTN, and hyperlipidemia. He is doing well and taking his meds as prescribed. On physical exam of the CV system, which of the following would you expect to find?


Choices:

A. PMI in 5th ICS, left MCLB. PMI in 5th ICS, left anterior axillary line

PMI in 3rd ICS left MCLC. PMI in 3rd, ICS, left MCLD. PMI in 8th ICS, left anterior axillary line


Answer:

A. PMI in 5th ICS, left MCLB. PMI in 5th ICS, left anterior

axillary lineaxillary lineC. PMI in 3rd, ICS, left MCLD. PMI in 8th ICS, left anterior axillary line


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Common Symptoms

Chest pain/angina pectorisDyspneaSyncope/pre syncope/dizzinessSyncope/pre-syncope/dizzinessFluid retention/edema/CHFPalpitationsCough


Chest Pain/Angina Pectoris

Onset/Provoking or relieving factorsQualityRadiation of painRadiation of painSeverity and siteTiming/durationAssociated symptoms: SOB, DOE, N, V, diaphoresis


Dyspnea

Exertional (may be anginal equivalent)Paroxysmal Nocturnal DyspneaOrthopneaDyspnea at rest


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Syncope/pre-syncope/dizzy

Results from decreased cerebral blood flowMay be due to arrhythmia (eg bradyMay be due to arrhythmia (eg brady or tachy, heart block, runs of VT), low BP, or low cardiac outputTest with BP, EKG, Holter monitor, or tilt-table test (r/o vasovagal response)


Fluid Retention

Results from reduced cardiac function –often from elevated R-sided pressuresAppears as dependent (pedal or other)Appears as dependent (pedal or other) edemaCommonly associated with CHF


Palpitations

“Awareness of the heartbeat”Rate changesRegular vs irregular beatsRegular vs. irregular beatsAnxiety secondary to increased catecholamineFrequently found with atrial/ventricular arrhythmias


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Cough

Most likely pulmonary in etiologyCardiac association mostly dry or non-productiveproductiveSeen in heart failure and ACE-inhibitor medication use


History

HPIPast Medical History

Rheumatic fever, thyroid disease, DM,Rheumatic fever, thyroid disease, DM, congenital or previous heart disease

Atherosclerotic Risk FactorsFam hx, DM, HTN, smoking, lipids, maleAge, stress/Type A, sedentary, obesity, too few fruits/veggies, too much ETOH


Physical Examination

BP ReadingsProper techniqueOrthostatic changes (>20mm syst drop)Orthostatic changes (>20mm syst. drop)Pulse pressure: difference between systolic and diastolic readings(widened suggests large stroke volume)(narrowed suggests small stroke volume)


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Peripheral Pulses

Rate: fast/slowRhythm: regular/irregularGradation: 1 4; 2 normalGradation: 1-4; 2 = normalPalpable vibration = thrillAudible murmur heard over blood vessel = bruit


Peripheral Pulses – cont.

Bifed/bisferiens pulse: beating 2 X in systole as seen in HOCM, ARDicrotic pulse: exaggerated, early diastolic wave seen in HFPulses alternans: alternating strong/weak pulse force seen in HFParadoxical pulse: >10mmHg drop in systolic BP during inspiration in Obstructive Lung Dz and tamponade


Peripheral Pulses – cont.

CarotidBrachialRadialRadialFemoralDorsalis Pedis –top of footPosterior Tibialis – medial malleolus


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Abdominal Aorta

Width is especially important in males after age 65, especially with HTN, smoking, renal dz, and CADsmoking, renal dz, and CADPalpate for width (< 3 cm normal)Listen for bruits over abdominal aorta, renal arteries, iliac arteries


Jugular Venous Pulses

Provide information about central venous pressures and right-heart functionfunctionPositive HJR (>1cm increase in JVP with sustained pressure over liver) in CHF ‘a’ wave = atrial contraction (giant in TS)

‘v’ wave = ventricular contraction (large in TR)


Lungs

Mostly for respiratory disease evaluationRales/crackles at bases commonly found in congestive heart failurefound in congestive heart failureWheezing occasionally in L heart failurePleural effusions in CHF


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Cardiac Auscultation

StethoscopeBell = low frequency sounds: ventricular filling as heard in MS – left lateral positiong p

Diaphragm = high frequency sounds: used for most murmurs as heard in AR – sitting up


First Heart Sound – S1

AKA: “lub”; shorter in duration

Results from closure of mitral andResults from closure of mitral and tricuspid valves: loud in MS, diminished in severe LV dysfunction


Second Heart Sound – S2

AKA: “dub”; longer in duration Closure of aortic and pulmonic valves

+ split with inspiration (physiologic)+ split with inspiration (physiologic)ASD results in constantly/fixed split S2LBBB, LVH, AS can all cause reversed splitting: split during expiration


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Third Heart Sound – S3/gallop

Early, rapid LV filling (normal in young)Associated with LV overload conditions or dilatation (eg CHF)or dilatation (eg CHF)Heard best at apex in LL decubitus position with bell (low pitched sound)“Kentucky” sounding


Fourth Heart Sound – S4

Results from vigorous atrial contraction into resistant/stiff LVOften heard with LVH or MIOften heard with LVH or MIHeard best at apex in LL decubitus position with bell“Tennessee” - soundingNever heard in atrial fibrillation


Other Heart Sounds

Midsystolic Click – MVPHeard best at apex and LLSB with diaphragm (high-pitched sound)p g ( g p )Body position often varies the sound

Opening Snap – MS Heard best medial to apex and along LLSB with diaphragm


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Heart Murmurs

Systolic – more common with no disease presentDiastolic – always disease-relatedyGraded I-VI/VI or 1-6/6

I: barely audible; II, III: getting louderIV: associated with thrillV: heard with edge of stethoscopeVI: heard with stethoscope off chest


Systolic Murmurs

Most common: crescendo/decrescendo (aka ‘diamond shape’) found in normal hearts, AS, PShearts, AS, PSInnocent flow murmur: I, II/VI, early systole; 80% of kids; pregnant females (aka ‘mammary souffle’); decreased with sitting up: no problem


Systolic Murmurs

Holo or pansystolic, and/or >III/VI: almost always cardiac pathology involvedinvolvedMost common = AV valve regurgitation/ (MR or TR) and VSD


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Diastolic Murmurs

Always abnormal and associated with some pathologyMost common is high-pitchedMost common is high-pitched, decrescendo murmur = PR, ARDiastolic ‘rumble’ = e.g. MS


Continuous Murmurs

Heard throughout systole and diastole

Patent Ductus Arteriosus mostPatent Ductus Arteriosus = most common (aka ‘to-and-fro’ murmur); has “machinery-like” quality


Diagnostic Studies

EKG/ECG – electrocardiogram, ambulatoryECHO – echocardiogram or stress ECHOStress Testing – exercise, nuclear,Stress Testing exercise, nuclear, pharmacologicNuclear ImagingEPS – electrophysiologic studiesCalcium Scoring/EBCTMRI/MRACardiac Catheterization/Angiography


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EKG/ECG - electrocardiogram

12-lead EKG – baseline, immediate, low cost, non-invasiveHolter monitor – 24 hoursHolter monitor – 24 hoursEvent recorder – longer (days/weeks), may be implanted in patient (months)SAECG – signal averaged ECG: look for “late potentials “


Holter Monitor and Event Recorder

Commons.wikipedia.org/wiki/Holter_moniter


ECHO - echocardiogram

Ultrasound of heart: good for anatomy and structural problems; can be done at bedsidePulsed Doppler: investigates blood flowgColor-flow: shows regurgitant flowTEE: transesophageal-good for posterior structures (eg LA thrombi or MV vegetations)Stress ECHO: good for ischemia (hypokinetic wall motion), after MI, or for view of valves and chamber size


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ECHO allows exact measurements

Commons.wikimedia.org/wiki/Echocardiogram


Test of autonomic nervous system functioning:

Tilt-table testing: often utilized to R/O a vasovagal response as a cause of syncope; this test should be performed y p ; pprior to more invasive testing


Nuclear Imaging

Thallium XST (also sestamibi and tetrafosmin)-good for detecting perfusion defects/IHD or scar tissueCT/SPECT/PET: vessel dz, myocardial perfusion, wall motionEBCT: electron beam; +/- calcificationsMRI/A: use increasing; no radiation; uses gadolinium for contrast; may be too slow in emergency cases; no metal


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Spect Scanning

Commons.wikimedia.org/wiki/Heart_spect_imaging_jpgUMDNJ PANRE/PANCE Review Course (becoming Rutgers July 1, 2013)


Stress Testing

XST: used to detect ischemia, CAD, cardiac response to exercise; TM or bikeNuclear XST: use with LBBB or w/ ?Nuclear XST: use with LBBB, or w/ ? results from XST(aka thallium/’mibi’/cardiolyte)

Pharmacologic: with adenosine, dipyridamole/Persantine, LexiscanNow, only contraindication (in stable patient) is symptomatic AS


Treadmill Exercise Stress Test

Commons.Wikimedia.org/wiki/Thallium_Stress_Test


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Thallium Stress Test Results

Sadley, personal filesRutgers PANCE/PANRE Review Course

EP Studies - electrophysiologic

Performed in cath labUsed to detect and treat certain rhythm disordersdisordersCertain identified arrhythmias (eg WPW, SVT, A-fib) treated pharmacologically or with RFA (radio-frequency ablation, aka catheter ablation) or cryotherapy


Electrophysiologic Studies involve mapping the heart’s electrical activity

Commons.Wikimedia.org/wiki/Electrical_conduction_system_of_the_heart


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Cardiac Catheterization

Best used to evaluate and treat CADCoronary angiography (visualize vessels)vessels)Angioplasty (PTCA)Angioplasty with stent placement (bare metal or drug-eluting stents)


Cardiac Catheterization/Angiogram

Commons.Wikimedia.org/wiki/Percutaneous_coronary_intervention


Cardiac catheterization shows narrowed vessel

Sadley, personal fileRutgers PANCE/PANRE Review Course

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Sources:Bickley, Lynn S., Bates Guide to Physical Examination and History Taking, 11th Ed., Philadelphia, PA; LWW, 2013McPhee S Papadakis M Rabow M CurrentMcPhee, S. Papadakis, M. Rabow, M , Current Medical Diagnosis & Treatment 2013, 52nd Ed., USA; McGraw-Hill Co., 2013Scheidt, S., Basic Electrocardiography, Vol. 36, Summit, NJ; CIBA-GEIGY Corp., 1996www.commons.wikimedia.orgwww.healcentral.org


A 58 y/o female is diagnosed with CHF. PE reveals an exaggerated, diastolic wave in her peripheral pulses. What term best describes this finding?

54%

1. Bifed pulseDicrotic pulse

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A 59 y/o patient has a history of mitral stenosis. Which of the following physical exam techniques would best aid in hearing this murmur?

30%

66%1. Have the pt. lean

forward and exhale2. Have the pt. squat

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p qduring auscultation

3. Palpate the radial pulse while auscultating over the carotid pulse

4. Use the bell of the stethoscope


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A 25 y/o male with a h/o anxiety presents c/o “palpitations” that occur intermittently, in short episodes, throughout the week. An EKG performed at presentation is normal. What should be done next?

70%1. Exercise stress test2. Holter monitor

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3. Pharmacologic stress test

4. Watchful waiting—no additional testing at this time


Thank you and good luck!


the cardiovascular system - amazon s3rutgers+b… · · 2015-05-011 the cardiovascular system...

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