Bates Ch. 9 Cardiovascular

Middiastolic and presystolic murmurs reflect

turbulent flow across the AV valves. Presystolic murmurs found in Mitral Stenosis

Paradoxical Pulse

Paradoxical pulse, or "pulsus paradoxus," is considered to refer to a phenomenon in which the peripheral pulse is markedly diminished, or even abolished, during ordinary or quiet inspiration; it promptly reappears during expiration. If the sign is less pronounced, a blood pressure cuff is needed. Systolic pressure decreases by >10-12 mm Hg during inspiration. A paradoxical pulse occurs in pericardial tamponade, exacerbations of asthma and COPD, and constrictive pericarditis.

Nephrotic Sydrome s/s

Periorbital puffiness (especially in morning) and tight rings (ie wedding ring on finger)

Clinic blood pressure measurements are:

Unreliable. Although multiple averaged measurements improve precision. Automated home and ambulatory blood pressure readings are more reliable, accurate, and better correlated with cardiovascular outcomes than clinic readings.

A murmur best heard in the 2nd right interspace often originates

at or near the aortic valve.

Mitral Stenosis presents on auscultation as:

Low-pitched extra sounds such as an S3, opening snap, diastolic rumble

midsystolic murmurs typically arise from

blood flow across the semilunar (aortic and pulmonic) valves. Seen in aortic stenosis and innocent flow murmurs

An elevated JVP is highly correlated with

both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis

Late systolic murmur: Usually starts in mid or late systole and persists up to S2. This is a murmur of:

mitral valve prolapse and is often, but not always, preceded by a systolic click (see p. 406); the murmur of mitral regurgitation may also be late systolic.

Paroxysmal nocturnal dyspnea (PND) may be mimicked by:

nocturnal asthma attacks

Bisferiens pulse

A bisferiens pulse is an increased arterial pulse with a double systolic peak, detected during moderate compression of the artery. Causes include pure aortic regurgitation, combined aortic stenosis and regurgitation, and, though less commonly palpable, hypertrophic cardiomyopathy

The presence of a thrill changes the grading of:

A murmur

Aortic Regurgitation on auscultation presents as:

A soft decrescendo higher-pitched diastolic murmur

A unilateral pulsatile bulge is seen in:

A tortuous and kinked carotid artery

JVP Wave Abnormalities

Abnormally prominent a waves occur in increased resistance to right atrial contraction, as in tricuspid stenosis; also in severe 1st-, 2nd-, and 3rd-degree AV block, supraventricular tachycardia, junctional tachycardia, pulmonary hypertension, and pulmonic stenosis. Absent a waves signal atrial fibrillation. Increased v waves occur in tricuspid regurgitation, atrial septal defects, and constrictive pericarditis.

Anterior chest pain, often tearing or ripping and radiating into the back or neck, occurs in

Acute Aortic Dissection

Bruits are caused by:

Although usually caused by atherosclerotic luminal stenosis, bruits are also caused by a tortuous carotid artery, external carotid arterial disease, aortic stenosis, the hypervascularity of hyperthyroidism, and external compression from thoracic outlet syndrome. Bruits do not correlate with clinically significant underlying disease.

You may easily miss the soft diastolic decrescendo murmur of aortic regurgitation unless you listen in this position:

Ask the patient to sit up, lean forward, exhale completely, and briefly stop breathing after expiration

BP Technique

At higher arm levels, the blood pressure recordings will be lower; at lower levels, the blood pressure recordings will be higher.

Absent a waves signal

Atrial Fibrillation

Causes of chest pain in the absence of coronary artery disease on angiogram include:

Microvascular coronary dysfunction and abnormal cardiac nocioception, which require specialized testing. Roughly half of women with chest pain and normal angiograms have microvascular coronary dysfunction.

Abnormalities of the Arterial Pulse and Pressure Waves

Normal pulse pressure is approximately 30-40 mm Hg. The pulse contour is smooth and rounded. (The notch on the descending slope of the pulse wave is not palpable.)

Congestive Heart Failure is now broken down into these two terms because of differences in treatment

Heart failure with preserved ejection fraction (EF) and heart failure with reduced EF

When palpating impulses from the RV in the right ventricular area, keep in mind

Palpation is less useful in patients with a thickened chest wall or increased AP diameter

A sustained left parasternal movement beginning at S1 suggests

pressure overload from pulmonary hypertension and pulmonic stenosis or the chronic ventricular volume overload of an atrial septal defect. A sustained movement later in systole can be seen in mitral regurgitation.

Sudden dyspnea occurs in

pulmonary embolus, spontaneous pneumothorax, and anxiety.

Liver failure and ascites s/s

Enlarged waistline

Alternately loud and soft Korotkoff sounds or a sudden doubling of the apparent heart rate as the cuff pressure declines signals:

pulsus alternans (which is indicative of severe left heart failure). Placing the patient in the upright position may accentuate this finding

Fixed splitting

refers to wide splitting that does not vary with respiration, often due to prolonged right ventricular systole, seen in atrial septal defect (when the pulse is regular) and in right ventricular failure.

Pressure on the carotid sinus may cause

reflex bradycardia or drop in blood pressure.

These findings suggest heart failure with volume overload with possible left carotid occlusion and mitral regurgitation.

"The JVP is 5 cm above the sternal angle with the head of bed elevated to 50°. Carotid upstrokes are brisk; a bruit is heard over the left carotid artery. The PMI is diffuse, 3 cm in diameter, palpated at the anterior axillary line in the 5th and 6th intercostal spaces. S1 and S2 are soft. S3 is present at the apex. High-pitched harsh 2/6 holosystolic murmur best heard at the apex, radiating to the axilla." These findings are NORMAL: "The JVP is 3 cm above the sternal angle with the head of bed elevated to 30°. Carotid upstrokes are brisk, without bruits. The PMI is tapping, 1 cm lateral to the midclavicular line in the 5th intercostal space. Crisp S1 and S2. At the base, S2 is louder than S1 with physiologic split of A2 > P2. At the apex, S1 is louder than S2. There are no murmurs or extra sounds."

A2 with Increased Intensity

(A2 can usually be heard only in right 2nd interspace): occurs in systemic hypertension because of the increased pressure load and when the aortic root is dilated, attributed to the increased proximity of the aortic valve to the chest wall.

Pathologic Splitting

(Audible splitting occurs during expiration and suggests heart disease.)

The pressure when Korotkoff sounds are first heard is

the highest systolic pressure during the respiratory cycle.

Dependent edema appears in

the lowest body parts: the feet and lower legs when sitting, or the sacrum when bedridden.

The pressure when sounds are heard throughout the cycle is

the lowest systolic pressure.

Displacement of the PMI lateral to the midclavicular line or >10 cm lateral to the midsternal line occurs in

Left Ventricular Hypertrophy (LVH) and also in ventricular dilatation from myocardial infarction (MI) or heart failure.

S1 is diminished in ___________

1st degree heart block

The apex beat is palpable in

25% to 40% of adults in the supine position and in 50% to 73% of adults in the left lateral decubitus position, especially those who are thin. Obesity, a very muscular chest wall, or an increased AP diameter of the chest may obscure detection.

Some authors report that when estimating the pt's JVP at 30° to 45°, the estimated JVP may be

3 cm lower than catheter measurements from the right midatrium. Note that the height of the venous pressure as measured from the sternal angle is similar in all three positions, but your ability to measure the height of the column of venous blood, or JVP, differs according to how you position the patient. JVP measured at >3 cm above the sternal angle, or >8 cm above the right atrium, is considered elevated or abnormal.

S4 (Extra Heart Sound in Diastole)

An S4 (atrial sound or atrial gallop) occurs just before S1. It is dull, low in pitch, and best heard at the apex with the bell. Listen at the lower left sternal border for a right ventricular S4 (or in the subxiphoid area if obstructive lung disease). An S4 is occasionally normal, especially in trained athletes and older age groups. More commonly, it is due to ventricular hypertrophy or fibrosis causing stiffness and increased resistance (or decreased compliance) during ventricular filling following atrial contraction. Causes of a left-sided S4 include hypertensive heart disease, aortic stenosis, and ischemic and hypertrophic cardiomyopathy. A left-sided S4 is heard best at the apex in the left lateral decubitus position, with a cadence like "Tennessee." The less common right-sided S4 is heard along the lower left sternal border or below the xiphoid. It often gets louder with inspiration. Causes include pulmonary hypertension and pulmonic stenosis. An S4 is also associated with delayed conduction between the atria and ventricles. This delay separates the normally faint atrial sound from the louder S1 and makes it audible. An S4 is never heard when there no atrial contraction (absent during atrial fibrillation). Occasionally, a patient has both an S3 and an S4, producing a quadruple rhythm of four heart sounds. At rapid heart rates, the S3 and S4 may merge into one loud extra heart sound, called a summation gallop.

S2 is diminished in ___________

Aortic Stenosis

The murmur of aortic stenosis often radiates to

the neck in the direction of arterial flow, especially on the right side.

Causes of Edema:

Cardiac related: right or left ventricular dysfunction; pulmonary hypertension; Pulmonic: obstructive lung disease Nutritional: hypoalbuminemia and/or positional.

S/S of Acute MI

Classic exertional pain, pressure, or discomfort in the chest, shoulder, back, neck, or arm in angina pectoris. Atypical descriptors also are common, such as cramping, grinding, pricking or, rarely, tooth or jaw pain.

Systole is the period of ventricular _________.

Contraction. Systole represents the time during which the left and right ventricles contract and eject blood into the aorta and pulmonary artery (through the open aortic and pulmonary valves), respectively. The mitral and tricuspid valves are closed, preventing blood from regurgitating back into the left/right atriums. The mitral valve closing produces S1 sound.

In the left lateral decubitus position, a diffuse PMI with a diameter >3 cm signals

Left ventricular enlargement. a diameter of >4 cm makes left ventricular overload almost 5 times more likely.

Squatting/Standing Systolic Click

In mitral valve prolapse, findings vary from one examination to the next and often change with body position. Several positions are recommended to identify the syndrome: supine, seated, squatting, and standing. Squatting (and the Valsalva release phase) delays the click and murmur due to increased venous return; standing (and the Valsalva strain phase) moves them closer to S1

Examination of Carotid Pulse

Includes the carotid upstroke, its amplitude and contour, and the presence or absence of thrills or bruits. The carotid pulse provides valuable information about cardiac function, especially aortic valve stenosis and regurgitation. To assess amplitude and contour, the patient should be supine with the head of the bed elevated to about 30°. First inspect the neck for carotid pulsations, often visible just medial to the SCM muscles. Then place your index and middle fingers or left thumb on the right carotid artery in the lower third of the neck and palpate for pulsations.

In Pulsus alternans and a bigeminal pulse, the pulse:

Is regular but varies in force beat to beat. The rhythm of the pulse remains regular, but the force of the arterial pulse alternates because of alternating strong and weak ventricular contractions. Pulsus alternans almost always indicates severe left ventricular dysfunction.

JVP location changes with position

JVP measured at >3 cm above the sternal angle, or >8 cm above the right atrium, is considered elevated or abnormal. A hypovolemic or septic patient may have to lie flat before you see the neck veins. In contrast, when there is volume overload, you may need to elevate the patient's head to 60° or even 90° to locate the oscillation point.

A sustained high-amplitude apical impulse significantly increases the likelihood of

LVH (L Ventricular Hypertrophy) from the pressure overload seen in hypertension. If such an impulse is displaced laterally, consider volume overload.

A loud P2 suggests

Pulmonary Hypertension

Wide physiologic splitting of S2

Refers to an abnormal increase in the normal usual splitting of S2 during inspiration that persists throughout the respiratory cycle. Wide splitting is caused by delayed closure of the pulmonic valve (as in pulmonic stenosis or right bundle branch block) or early closure of the aortic valve (mitral regurgitation). Right bundle branch block is illustrated here.

Diastole is the period of ventricular __________

Relaxation. Diastole represents the period of time when the ventricles are relaxed (not contracting). Throughout this period, blood is passively flowing through the open tricuspid and mitral valves from the atrium into the ventricles. Aortic and Pulmonic valves are closed. The aortic valve closing produces the S2 sound.

S1

Sound during contraction of heart (systole). Closure of the mitral valve produces the first heart sound, S1. (Mitral and Tricuspid valves close as blood is pushed through Aortic and Pulmonic valves)

S2

Sound during diastole (relaxation). Aortic valve closure produces the second heart sound, S2. Aortic and pulmonic valves closed during Diastole.

Systolic clicks

Systolic clicks are usually caused by mitral valve prolapse—an abnormal systolic ballooning of part of the mitral valve into the left atrium related to leaflet redundancy and elongation of the chordae tendineae. The clicks are usually mid- or late systolic. Prolapse of the mitral valve is a common cardiac condition, affecting about 2% to 3% of the general population, with equal prevalence in men and women. Systolic clicks may also be of extracardiac or mediastinal origin

JVP

The JVP is best assessed from pulsations in the right internal jugular vein, which is directly in line with the superior vena cava and right atrium.

PMI

The LV's tapered inferior tip is often termed the cardiac apex. It is clinically important because it produces the apical impulse, identified during palpation of the precordium as the point of maximal impulse (PMI). This impulse locates the left border of the heart and is normally found in the 5th intercostal space at or just medial to the left midclavicular line. The PMI is not always palpable, even in a healthy patient with a normal heart.

Movement of JVP

The dominant movement of the JVP is inward, coinciding with the x descent. In contrast, the dominant movement of the carotid pulse, often confused with the JVP, is outward.

Opening Snap (Extra Heart Sound in Diastole)

The opening snap (OS) is a very early diastolic sound caused by abrupt deceleration during the opening of a stenotic mitral valve. It is best heard just medial to the apex and along the lower left sternal border. If loud, an OS radiates to the apex and to the pulmonic area, where it may be mistaken for the pulmonic component of a split S2. Its high pitch and snapping quality help to distinguish it from an S2, but it becomes less audible as the valve leaflets become more calcified. It is heard better with the diaphragm.

Diastole

The period of time when the ventricles are relaxed (not contracting). Blood is passively flowing from the left atrium (LA) and right atrium (RA) into the left ventricle (LV) and right ventricle (RV). The blood flows through atrioventricular valves (mitral and tricuspid) that separate the atria from the ventricles. The RA receives venous blood from the body through the superior vena cava (SVC) and inferior vena cava (IVC). The LA receives oxygenated blood from lungs through four pulmonary veins that enter the LA. At the end of diastole, both atria contract, which propels an additional amount of blood into the ventricles.

Pulsus alternans

The pulse is completely regular, but has alternating strong and weak beats (unlike bigeminy). If there is only a slight difference between the strong and weak beats, detection requires use of a blood pressure cuff. Pulsus alternans indicates left ventricular failure and is usually accompanied by a left-sided S3.

Small Weak Pulse

The pulse pressure is diminished, and the pulse feels weak and small. The upstroke may feel slowed, the peak prolonged. Causes include (1) decreased stroke volume, as in heart failure, hypovolemia, and severe aortic stenosis; and (2) increased peripheral resistance, as in exposure to cold and severe heart failure.

Large Bounding Pulse

The pulse pressure is increased, and the pulse feels strong and bounding. The rise and fall may feel rapid, the peak brief. Causes include (1) increased stroke volume, decreased peripheral resistance, or both, as in fever, anemia, hyperthyroidism, aortic regurgitation, arteriovenous fistulas, and patent ductus arteriosus; (2) increased stroke volume because of slow heart rates, as in bradycardia and complete heart block; and (3) decreased compliance (increased stiffness) of the aortic walls, as in aging or atherosclerosis.

Heart Sound Splitting

The second heart (S2) sound is produced by the closure of the aortic and pulmonic valves. The sound produced by the closure of the aortic valve is termed A2 and the sound produced by the closure of the pulmonic valve is termed P2. When these sounds are distinguishable from each other a split S2 can be heard. Of the two components of the S2, A2 is normally louder, reflecting the high pressure in the aorta. It is heard throughout the precordium. In contrast, P2 is relatively soft, reflecting the lower pressure in the pulmonary artery.

The most common extra heart sound is

The systolic click of mitral valve prolapse

Systole

The time during which the left and right ventricles contract and eject blood into the aorta and pulmonary artery, respectively. During systole, the aortic and pulmonic valves open to permit ejection into the aorta and pulmonary artery. The atrioventricular valves are closed during systole, therefore no blood is entering the ventricles; however, blood continues to enter the atria though the vena cavae and pulmonary veins.

Extra Heart Sounds in Systole

There are two kinds of extra heart sounds in systole: (1) early ejection sounds and (2) clicks, commonly heard in mid- and late systole.

Clues in the patient history to identify palpitations include:

transient skips and flip-flops (possible premature contractions); rapid regular beating of sudden onset and offset (possible paroxysmal supraventricular tachycardia); and a rapid regular rate of <120 beats per minute, especially if gradually starting and stopping (possible sinus tachycardia).

Bigeminal Pulse

This disorder may mimic pulsus alternans. A bigeminal pulse is caused by a normal beat alternating with a premature contraction. The stroke volume of the premature beat is diminished in relation to that of the normal beats, and the pulse varies in amplitude accordingly

P2 Decreased or Absent:

This usually occurs from the increased AP diameter of the chest associated with aging. It can also result from pulmonic stenosis. If P2 is inaudible, no splitting is heard.

Diastolic murmurs usually represent

Valvular Heart Disease

P2 with Increased Intensity:

When P2 is equal to or louder than A2, suspect pulmonary hypertension. Other causes include a dilated pulmonary artery and an atrial septal defect.

S3 (Extra Heart Sound in Diastole)

You will detect physiologic S3 frequently in children and young adults to the age of 35 or 40 years, and often during the last trimester of pregnancy. Occurring early in diastole during rapid ventricular filling, it is later than an OS, dull and low in pitch, and heard best at the apex in the left lateral decubitus position. The bell of the stethoscope should be used with very light pressure. A pathologic S3 or ventricular gallop sounds like a physiologic S3. An S3 in adults over age 40 years is usually pathologic, arising from high left ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of the rapid filling phase of diastole. Causes include decreased myocardial contractility, heart failure, and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts. Listen for a left-sided S3 at the apex in the left lateral decubitus position. A right-sided S3 is usually heard along the lower left sternal border or below the xiphoid with the patient supine, and is louder on inspiration. The term gallop comes from the cadence of three heart sounds, especially at rapid heart rates, which sounds like "Kentucky."

A fully described murmur example:

a "medium-pitched, grade 2/6, blowing decrescendo diastolic murmur, best heard in the 4th left interspace, with radiation to the apex" (aortic regurgitation).

A simplified way to remember the three peaks is:

a for atrial contraction c for carotid transmission (although this may represent closure of the tricuspid valve) and v for venous filling.

An identical degree of turbulence would cause a louder murmur in

a thin person than in a very muscular or obese person. Emphysematous lungs may diminish the intensity of murmurs.

Expiratory splitting suggests

a valvular abnormality. S2 is normally heard late in inspiration

JVP (Jugular Venous Pressure)

accurately predicts elevations in fluid volume in heart failure. But its prognostic value for heart failure outcomes and mortality is unclear.

an S3 corresponds to

an abrupt deceleration of inflow across the mitral valve. (It results from increased atrial pressure leading to increased flow rates, as seen in congestive heart failure, which is the most common cause of a S3.) The third heart sound, also known as the "ventricular gallop," occurs just after S2 when the mitral valve opens, allowing passive filling of the left ventricle. The S3 sound is actually produced by the large amount of blood striking a very compliant LV.

An elevated JVP is >95% specific for

an increased left ventricular end diastolic pressure and low left ventricular EF, although its role as a predictor of hospitalization and death from heart failure is less clear.

An elevated JVP is >95% specific for:

an increased left ventricular end diastolic pressure and low left ventricular EF, although its role as a predictor of hospitalization and death from heart failure is less clear.

A 60-year-old woman with angina might have a harsh 3/6 midsystolic crescendo-decrescendo murmur in the right 2nd interspace radiating to the neck. These findings are consistent with

aortic stenosis but could arise from aortic sclerosis (leaflets are sclerotic but not stenotic), a dilated aorta, or increased flow across a normal valve. Assess any delay in the carotid upstroke and the intensity of A2 for evidence of aortic stenosis. Check the apical impulse for LVH. Listen for aortic regurgitation as the patient leans forward and exhales.

In aortic regurgitation, the carotid pulse is

bounding. Each time the L ventricle contracts and pushes blood through the insufficient (regurgitating) AV allows blood to leak back into the LV. This condition causes widening (dilation) of the LV. In turn, larger amounts of blood leave the heart with each contraction. This leads to a strong and forceful pulse (bounding pulse). Over time, the heart becomes less able to pump blood to the body.

Congenital patent ductus arteriosus and AV fistulas, common in dialysis patients, produce

continuous murmurs that are nonvalvular in origin. Venous hums and pericardial friction rubs also have both systolic and diastolic components

Causes of decreased carotid pulsations include

decreased stroke volume from shock or MI and local atherosclerotic narrowing or occlusion.

In aortic stenosis, the carotid upstroke is

delayed

Persistent splitting results from

delayed closure of the pulmonic valve or early closure of the aortic valve. Does the split disappear as it should, during exhalation? If not, listen again with the patient sitting up

A prominent pulsation in the Pulmonic Area—The Left 2nd Interspace often accompanies

dilatation or increased flow in the pulmonary artery. A palpable S2 points to increased pulmonary artery pressure from pulmonary hypertension

A pulsation in the Aortic Area—The Right 2nd Interspace suggests a

dilated or aneurysmal aorta. A palpable S2 can accompany systemic hypertension.

In patients with obstructive lung disease, the JVP can appear:

elevated on expiration, but the veins collapse on inspiration. This finding does not indicate heart failure.

To estimate the JVP in a hypovolemic or septic patient, they may have to lie:

flat before you see the neck veins

A diffuse sustained low-amplitude (hypokinetic) apical impulse is seen in

heart failure and dilated cardiomyopathy

Lateral displacement of the apical impulse toward the axillary line from ventricular dilatation is seen in

heart failure, cardiomyopathy, and ischemic heart disease; and also in thoracic deformities and mediastinal shift.

An elevated JVP is

highly correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis.

A hyperkinetic high-amplitude impulse may occur in

hyperthyroidism, severe anemia, pressure overload of the left ventricle from hypertension or aortic stenosis, or volume overload of the left ventricle from aortic regurgitation. Normally, the amplitude of the PMI is small and feels brisk and tapping

In obstructive pulmonary disease, hyperinflation of the lungs may prevent palpation of the

hypertrophied RV in the left parasternal area. The RV impulse is readily palpated high in the epigastrium where heart sounds are also more audible.

A markedly dilated failing heart may have a

hypokinetic apical impulse displaced far to the left. A large pericardial effusion may make the impulse undetectable via percussion

An s4 corresponds to

increased left ventricular end diastolic stiffness which decreases compliance. Heard immediately after atrial contraction phase as blood is forced into as resistant/stiff ventricle The fourth heart sound (S4), also known as the "atrial gallop," occurs just before S1 when the atria contract to force blood into the left ventricle. If the left ventricle is noncompliant, and atrial contraction forces blood through the atrioventricular valves, a S4 is produced by the blood striking the left ventricle.

Lateral displacement of the apical impulse from the midclavicular line makes

increased left ventricular volume and a low left ventricular EF 5 and 10 times more likely, respectively

In Jugular Venous Pulsations, an abnormally prominent a waves occur in:

increased resistance to right atrial contraction, as in tricuspid stenosis; also in severe 1st-, 2nd-, and 3rd-degree AV block, supraventricular tachycardia, junctional tachycardia, pulmonary hypertension, and pulmonic stenosis

The murmur of hypertrophic cardiomyopathy is the only systolic murmur that

increases during the "strain phase" of the Valsalva maneuver due to increased outflow tract obstruction.

Orthopnea and Paroxysmal nocturnal dyspnea (PND) occur in:

left ventricular heart failure, mitral stenosis and also in obstructive lung disease.

A PMI >2.5 cm is evidence of

left ventricular hypertrophy (LVH) from hypertension or aortic stenosis

The left lateral decubitus position accentuates

left-sided S3 and S4 and mitral murmurs, especially mitral stenosis. Auscultate in this position, otherwise, you may miss these important findings.

Increased v waves occur in

tricuspid regurgitation, atrial septal defects, and constrictive pericarditis.

If there are symptoms or signs of irregular heart action:

obtain an ECG. This includes atrial fibrillation, which causes an "irregularly irregular" pulse often identified at the bedside.

A2 Decreased or Absent:

occurs in calcific aortic stenosis due to valve immobility. If A2 is inaudible, no splitting is heard.

In full situs inversus, the heart, trilobed lung, stomach, and spleen are

on the right, and the liver and gallbladder are on the left.

A brief early to middiastolic apical impulse represents a

palpable S3; an outward movement just before S1 signifies a palpable S4.

A difference between the highest systolic pressure and the lowest systolic pressure of ≥10 mm Hg to 12 mm Hg constitutes a:

paradoxical pulse, found most commonly in acute asthma and obstructive pulmonary disease. It also occurs in pericardial tamponade and at times in constrictive pericarditis and acute pulmonary embolism

In most adults over age 40 years, the diastolic sounds of S3 and S4 are

pathologic, and are correlated with heart failure and acute myocardial ischemia.

When either A2 or P2 is absent, as in aortic or pulmonic valve disease, S2 is

persistently single. S2 normally splits into two components on deep inspiration. A thick chest wall may make the pulmonic component of S2 inaudible.

Pansystolic (Holosystolic) murmurs often occur with:

regurgitant (backward) flow across the AV valves. Seen in Mitral Regurgitation

Early diastolic murmurs typically reflect

regurgitant flow across incompetent semilunar valves. Seen in aortic regurgitation.

In patients with severe heart failure, blood pressure

remains elevated and there are Korotkoff sounds during the phase 2 strain phase, but not during phase 4 release, termed "the square wave" response. In healthy patients, phase 2, the "strain" phase, is silent; Korotkoff sounds are heard after straining is released during phase 4. This response is highly correlated with volume overload and elevated left ventricular end-diastolic pressure and pulmonary capillary wedge pressure.

Anascara is

severe generalized edema extending to the sacrum and abdomen.

Murmurs during pregnancy

should be promptly evaluated for possible risk to the mother and fetus, especially those of aortic stenosis or pulmonary hypertension

In dextrocardia, a rare congenital transposition of the heart, the heart is

situated in the right chest cavity and generates a right-sided apical impulse. Use percussion to help locate the heart border, the liver, and stomach.

The PMI is located on the right side of the chest in

situs inversus and dextrocardia

In cardiogenic shock, the carotid pulse is

small, thready, or weak

Paradoxical or reversed splitting

splitting that appears on expiration and disappears on inspiration. Closure of the aortic valve is abnormally delayed so that A2 follows P2 in expiration. Normal inspiratory delay of P2 makes the split disappear. The most common cause is left bundle branch block.

Thrills in aortic stenosis are transmitted to the carotid arteries from the

suprasternal notch or 2nd right intercostal space.

In mitral regurgitation, the murmur often radiates to

the axilla, supporting transmission by bone conduction.

Acute coronary syndrome is increasingly used to describe the clinical syndromes caused by acute myocardial ischemia, which include

unstable angina, non-ST elevation MI, and ST elevation infarction. Both men and women with acute coronary syndrome usually present with the classic symptoms of exertional angina; however, women, particularly those over age 65, are more likely to report atypical symptoms that may go unrecognized, such as upper back, neck, or jaw pain, shortness of breath, paroxysmal nocturnal dyspnea, nausea or vomiting, and fatigue, making careful history taking especially important.

Pregnancy or a high left diaphragm may shift the apical impulse

upward and to the left.

Systolic murmurs suggest

valvular disease but can be physiologic flow murmurs arising from normal heart valves.

A paradoxical pulse

varies with respiration (there is a greater than normal drop in systolic blood pressure during inspiration). If the pulse varies in amplitude with respiration, suspect cardiac tamponade (if there is jugular venous distention, dyspnea, tachycardia, muffled heart tones, and hypotension)

Left-sided heart murmurs generally increase

with expiration

Right-sided heart murmurs generally increase

with inspiration

To measure the JVP in a fluid overloaded pt:

you may need to elevate the patient's head to 60° or even 90° to locate the oscillation point.

The prevalence of asymptomatic carotid stenosis in the United States is

∼1% for stenoses occluding 75% to 90% of the lumen, and increases significantly with age. The 5-year risk of ipsilateral stroke from asymptomatic stenoses of over 70% is ∼5%.

Carotid artery stenosis causes

∼10% of ischemic strokes and doubles the risk of CHD (congenital heart disease).

JVP Waves

■The first elevation, the presystolic a wave, reflects the slight rise in atrial pressure that accompanies atrial contraction. ■ The following trough, the x descent, starts with atrial relaxation. It continues as the RV, contracting during systole, pulls the floor of the atrium downward, and ends just before S2. ■The c wave corresponds to right ventricular contraction causing the tricuspid valve to bulge backwards into the right atrium. ■ In the v wave, the tricuspid valve closes and the R atrium begins to fill again. ■When the tricuspid valve opens early in diastole, blood in the right atrium flows passively into the RV, and right atrial pressure falls again, creating the second trough, or y descent.