The Cardiovascular System - Amazon S3Rutgers+B… · · 2015-05-011 The Cardiovascular System...
Transcript of 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
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Perhaps you’ll want this printedon your next T-shirt?
I LOVE CARDIOLOGY
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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?
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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
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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
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Chest Pain/Angina Pectoris
Onset/Provoking or relieving factorsQualityRadiation of painRadiation of painSeverity and siteTiming/durationAssociated symptoms: SOB, DOE, N, V, diaphoresis
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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)
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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
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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
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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Continuous Murmurs
Heard throughout systole and diastole
Patent Ductus Arteriosus mostPatent Ductus Arteriosus = most common (aka ‘to-and-fro’ murmur); has “machinery-like” quality
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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 “
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Holter Monitor and Event Recorder
Commons.wikipedia.org/wiki/Holter_moniter
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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
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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
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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)
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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
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Treadmill Exercise Stress Test
Commons.Wikimedia.org/wiki/Thallium_Stress_Test
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Thallium Stress Test Results
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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
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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)
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Cardiac Catheterization/Angiogram
Commons.Wikimedia.org/wiki/Percutaneous_coronary_intervention
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Cardiac catheterization shows narrowed vessel
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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
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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
Bife
d puls
e
Dicr
otic p
ulse
Pulsus a
ltern
ans
Pulsus p
aradoxu
s
20%
7%
20%2. Dicrotic pulse3. Pulsus alternans4. Pulsus paradoxus
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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
Hav
e the p
t. lea
n for...
Hav
e the p
t. squat
du...
Palpate
the r
adial
pul..
Use
the b
ell of
the s
t...
30%
2%2%
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
Exe
rcise
stre
ss te
st
Holte
r monit
or
Phar
macolog
ic str
ess..
.
Watc
hful
waitin
g—no..
.
2%
28%
0%
3. Pharmacologic stress test
4. Watchful waiting—no additional testing at this time
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Thank you and good luck!
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