Ce Chap 14: Heart

Front 1

Heart function

Back 1

Circulate blood through the body and lungs, in two separate circulations

Front 2

Heart position

Back 2

In mediastinum, to the left of midline, just above diaphragm, cradled between medial and lower borders of the lungs, behind the sternum and 3-6 costal cartilages

Front 3

Precordium

Back 3

Area of the chest overlying the heart

Front 4

Dextrocardia

Back 4

Heart is a mirror image of the normal heart

Front 5

Situs inversus

Back 5

Heart and stomach are placed to the right and the liver to the left

Front 6

Pericardium

Back 6

tough, double-walled, fibrous sac encasing and protecting the heart, several mL of fluid between the two layers for low friction

Front 7

Epicardium

Back 7

thin outermost muscle layer, covers the surface of the heart and extends into the great vessels

Front 8

Myocardium

Back 8

thick muscular middle layer, responsible for pumping action

Front 9

Endocardium

Back 9

innermost layer, lines the chambers of the heart and cover the heart valves and small muscles that open and close the valves

Front 10

Atria

Back 10

small, thin-walled structures acting as reservoirs for blood returing to the heart from the veins throughout the body

Front 11

Ventricles

Back 11

large, thick-walled chambers the pump blood to the lungs and body, primary muscle mass of the heart

Front 12

Anterior surface of the heart

Back 12

right ventricle

Front 13

Left border of the heart

Back 13

left ventricle

Front 14

Apical impulse

Back 14

created by the pumping of the left ventricle, felt in the 5th left intercostal space at the midclavicular line

Front 15

Right border of the heart

Back 15

right atrium

Front 16

Posterior aspect of the heart

Back 16

left atrium

Front 17

Size of heart

Back 17

12 cm long, 8 cm wide at widest point, 6 cm AP diameter

Front 18

Atrioventricular valves

Back 18

tricuspid and mitral valves

Front 19

Tricuspid valve

Back 19

three cusps, separates right atrium from right ventricle, open on atrial contraction, close on ventricular contraction

Front 20

Mitral valve

Back 20

two cusps, separate left atrium from left ventricle, open on atrial contraction, close on ventricular contraction

Front 21

Semilunar valves

Back 21

each have three cusps, pulmonic and aortic valves

Front 22

Pulmonic valve

Back 22

separates the right ventricle from the pulmonary artery, open on ventricular contraction, closed when ventricles relax

Front 23

Aortic valve

Back 23

lies between the left ventricle and aorta, open on ventricular contraction, closed when ventricles relax

Front 24

Systole

Back 24

ventricles contract, ejecting blood from the left ventricle into the aorta and from the right ventricle into the pulmonary artery, pressure change forces mitral and tricuspid valves to close, produces S1 heart sound (the lubb)

Front 25

Diastole

Back 25

ventricles dilate, which draws blood in as the atria contract

Front 26

S1

Back 26

lubb, produced by the closing of the mitral and tricuspid valves at the start of systole, ventricular pressure increases to close those valves while also opening the aortic and pulmonary valves

Front 27

S2

Back 27

dubb, produced by the closing of the aortic and pulmonary valves when ventricular pressure falls, has two components- A2 and P2, as ventricular pressure falls, mitral and tricupsid valves open

Front 28

S3

Back 28

produced by the passive filling of the ventricles during diastole

Front 29

S4

Back 29

produced by the atrial contraction to completely fill the ventricles during diastole

Front 30

Splitting

Back 30

occurs because the pressure on the right side is lower than the left, so the right side sounds occur slightly behind the left side sounds

Front 31

SA

Back 31

site of electrical impulse generation and pacing, located in wall of right atrium

Front 32

AV node

Back 32

located in atrial septum, receives impulse from SA node, impulse is delayed and then passes down bundle of His to Purkinje fibers

Front 33

Ventricular contraction

Back 33

initiated at the apex and proceeds toward the base

Front 34

ECG

Back 34

graphic recording of electrical activity during the cardiac cycle, records electrical current generated by movement of ions in and out of the myocardial cell membranes

Front 35

Depolarization

Back 35

spread of stimulus through the heart muscle

Front 36

Repolarization

Back 36

return of stimulated heart muscle to resting state

Front 37

P wave

Back 37

spread of stimulus through the atria, atrial depolarization

Front 38

PR interval

Back 38

time from initial stimulation of the atria to initial stimulation of the ventricles, 0.12-0.20 seconds

Front 39

QRS complex

Back 39

spread of stimulus through theventricles, ventricular depolarization, less than 0.1 seconds

Front 40

ST segment and T wave

Back 40

return of stimulated ventricular muscle to a resting state, ventricular repolarization

Front 41

U wave

Back 41

small deflection sometimes seen just after T wave

Front 42

QT interval

Back 42

time elapsed from onset of ventricular depolarization until the complete repolarization, varies with cardiac rate

Front 43

Foramen ovale

Back 43

fetal circulation from right atrium to left atrium to bypass the lungs

Front 44

Ductus arteriosis

Back 44

fetal circulation from the right ventricle to the aorta to bypass the lungs, closes 24-48 hours after birth

Front 45

Ventricle size ratio

Back 45

2:1 left:right, achieved by 1 year of age

Front 46

Fetal heart size

Back 46

lies more horizontal, apex is in 4th left intercostal space, reaches adult position by 7 years

Front 47

Maternal circulation

Back 47

blood volume increases 40-50% due to increased plasma volume (which increases 50% with single pregnancy, 70% with twins), left ventricle increases in thickness and mass, blood volume returns to normal 3-4 weeks after delivery, cardiac output increases 30-40% and returns to normal 2 weeks after delivery, position of heart is more horizontal

Front 48

Elderly circulation

Back 48

heart size decreases (except in HTN/heart disease), LV wall thickens and valves fibrose and calcify, heart rate slows, stroke volume decreases, cardiac ouput during exercise declines by 30-40%, endocardium thicken, myocardium is less elastic, irritability is increased (response to stress is less efficient), tachycardia is poorly tolerated, return to normal heart rate takes longer, first degree AV block, BBB, ST-T waves abnormalities, premature systole, L anterior hemiblock, L ventricular hypertrophy and atrial fibrillation

Front 49

Anginal chest pain

Back 49

substernal, provoked by effort, emotion, eating; relieved by rest and nitroglycerin; accompanied by diaphoresis, occasionally nausea

Front 50

Pleural chest pain

Back 50

precipitated by breathing or coughing; described as sharp; present during respiration; absent when breath is held

Front 51

Esophageal chest pain

Back 51

burning, substernal, occasional radiation to shoulder; nocturnal occurrence, when lying flat; relief with food, antacids, sometimes nitroglycerin

Front 52

Peptic ulcer chest pain

Back 52

infradiaphragmatic and epigastric; nocturnal occurrence and daytime attacks relieved by food; unrelated to activity

Front 53

Biliary chest pain

Back 53

usually under R scapula, prolonged in duration; occurs after eating; will trigger angina more often than mimic it

Front 54

Arthritis/bursitis chest pain

Back 54

usually lasts for hours; local tenderness or pain with movement

Front 55

Cervical chest pain

Back 55

associated with injury; provoked by activity, persists after activity; painful on palpation of movement

Front 56

Musculoskeletal chest pain

Back 56

intensified or provoked by movement, particularly twisting or costochondral bending; long lasting; associated with focal tenderness

Front 57

Psychoneurotic

Back 57

associated with anxiety; poorly described; located in intramammary region

Front 58

Light exercise

Back 58

walking 10-15 steps, preparing simple meal, retrieving newspaper from outside door, pulling down bedspread, brushing teeth

Front 59

Moderate exercise

Back 59

making the bed, dusting and sweeping, walking a short block, office filing

Front 60

Moderately heavy exercise

Back 60

climbing one or two flights of stairs, lifting full cartons, long walks, sex

Front 61

Heavy exercise

Back 61

jogging, vigorous athletics, cleaning the entire house, raking leaves, mowing lawn, shoveling snow

Front 62

Cardiac disease risk factors

Back 62

gender (men more at risk, women after menopause and with oral contraceptives), hyperlipidemia, elevated homocysteine, smoking, FH, DM, obesity, sedentary lifestyle, personality type

Front 63

Cholesterol recommendations

Back 63

total cholesterol less that 200, LDL of 100, LDL with previous MI/DM of 70

Front 64

Apical impulse

Back 64

5th intercostal space, MCL, usually less than 1 cm

Front 65

Heave or lift

Back 65

apical impulse that is more vigorous than expected

Front 66

Lift on left sternal border

Back 66

caused by right ventricular hypertrophy

Front 67

Apical impulse loss of thrust

Back 67

overlying fluid or air, displacement beneath the sternum

Front 68

Displacement of apical impulse to right

Back 68

dextrocardia, diaphragmatic hernia, distended stomach or pulmonary abnormality

Front 69

Thrill

Back 69

fine, palpable, rushing vibration, palpable murmur, often over the base of the heart in the right or left 2nd intercostal space; indicates turbulence or a disruption of the expected blood flow related to defect in semilunar valves, pulmonary HTN or atrial septal defect

Front 70

Thrill

Back 70

murmur of IV or more can be felt

Front 71

Aortic stenosis thrill

Back 71

felt in systole at suprasternal notch or 2nd and 3rd R intercostal spaces

Front 72

Pulmonic stenosis thrill

Back 72

felt in systole at suprasternal notch or 2nd and 3rd L intercostal spaces

Front 73

Ventricular septal defect thrill

Back 73

felt in systole at 4th intercostal space

Front 74

Mitral regurgitation thrill

Back 74

felt in systole at apex

Front 75

Tetralogy of Fallot thrill

Back 75

felt in systole at L lower sternal border

Front 76

Patent ductus arteriosus thrill

Back 76

felt in systole at L upper sternal border, often with extensive radiation

Front 77

Aortic regurgitation thrill

Back 77

felt in diastole at R sternal border

Front 78

Aneurysm of ascending aorta thrill

Back 78

felt in diastole at R sternal border

Front 79

Mitral stenosis thrill

Back 79

felt in diastole at apex

Front 80

Percussion

Back 80

CXR is a better tool for determining size of the heart, change from resonant to dull from axilla to sternum in intercostal spaces indicates position of the heart

Front 81

Where are heart sounds best heard?

Back 81

in areas where the blood flows after it passes through the valve

Front 82

Aortic valve

Back 82

2nd R intercostal space at R sternal border

Front 83

First pulmonic valve

Back 83

2nd L intercostal space at L sternal border

Front 84

Second pulmonic valve

Back 84

3rd L intercostal space at L sternal border

Front 85

Tricuspid valve

Back 85

4th L intercostal space along lower L sternal border

Front 86

Mitral valve

Back 86

apex of the heart in 5th L intercostal space at MCL

Front 87

S1 and carotid

Back 87

S1 corresponds with the rise (upswing) of the carotid pulse

Front 88

Split S2

Back 88

best heard in pulmonic area during inspiration

Front 89

Bacterial endocarditis

Back 89

bacterial infection of the endothelial layer of the heart and valves; seen in individuals with valvular defects, congenital or acquired, and IV drug users; symptoms- fever, fatigue, murmur, sudden onset of CHF; signs- neurologic dysfunctions, Janeway lesion, Osler nodes

Front 90

Janeway lesion

Back 90

small erythematous or hemorrhagic macules appearing on the palms and soles

Front 91

Osler nodes

Back 91

appear on the tips of fingers and toes, caused by septic emboli

Front 92

Congestive heart failure

Back 92

heart fails to propel blood forward with its usual force, resulting in congestion in the pulmonary or systemic circulation; seen in patients with decreased cardiac output, can be L (systolic or diastolic) or R sided; symptoms- fatigue, orthopnea, breathing difficulty, SOB, edema; signs- develop gradually or suddenly, systolic has narrow pulse pressure, diastolic has wide pulse pressure

Front 93

Diastolic CHF

Back 93

result of advanced glycation cross-linkage collagen, creating a stiff ventricle unable to dilate actively, occurs in older adults and patients with DM whose tissue is exposed to glucose

Front 94

L sided heart failure

Back 94

dyspnea, orthopnea, tachycardia, decreased systolic or pulse pressure, third heart sound, crackles in lungs, abdominojugular reflux, edema may or may not be present

Front 95

Pericarditis

Back 95

sudden inflammation of the pericardium; if is persists a pericardial effusion may increase and result in cardiac tamponade; symptoms- sharp/stabbing chest pain, worse with movement or inspiration, most severe when supine, relieved when leaning forward; signs- scratchy, grating, triphasic friction rub, compromises ventricular systole, early diastolic ventricular filling and late diastolic atrial systole, easily heard L of sternum in 3rd and 4th intercostal spaces

Front 96

Cardiac tamponade

Back 96

excessive accumulation of effused fluids or blood between the pericardium; constrains cardiac relaxation- impairs access of blood to R heart, causes- pericarditis, malignancy, aortic dissection and trauma; symptoms- anxiety, restlessness, chest pain, difficulty breathing, discomfort (relieved when sitting upright or leaning forward), syncope, pale gray or blue skin, palpitations, rapid breathing, swelling of abdomen or arms or neck veins, signs- Beck's triad, may scar and constrict- limiting cardiac filling, heart sounds are muffled, BP drops, pulse is weak and rapid, paradoxic pulse is exaggerated

Front 97

Beck's triad

Back 97

jugular venous distention, hypotension and muffled heart sounds

Front 98

Cor pulmonale

Back 98

enlargement of the R ventricle secondary to pulmonary malfunction; usually chronic, chronic cause- COPD, acute causes- massive PE and ARDS, alterations in pulmonary circulation leads to pulmonary arterial HTN which puts load on R ventricular emptying; symptoms- fatigue, tachypnea, exertional dyspnea, cough, hemoptysis, signs- evidence of pulmonary disease, wheezes and crackles, increased chest diameter, labored respirations with chest wall retractions, distended neck veins with prominent A or V waves, cyanosis, L parasternal systolic heave, loud S2 in pulmonic region

Front 99

Myocardial infarction

Back 99

ischemic myocardial necreosis caused by abrupt decrease in coronary blood flow to a segment of the myocardium; mostly affects L ventricle, causes- atherosclerosis and thrombosis; symptoms- deep substernal or visceral pain that radiates to the jaw, neck and L arm, may be mild; signs- dysrhythmias, S4 is present, distant heart sounds, soft systolic blowing apical murmur, thready pulse, BP varies with HTN in early phases

Front 100

Myocarditis

Back 100

focal or diffuse inflammation of the myocardium; cause- infection agents, toxins or autoimmune diseases like amyloidosis; symptoms- initial are vague, fatige, dyspnea, fever, palpitations; signs- cardiac enlargement, murmurs, gallops, tachycardia, dysrhythmias, pulsus alternans

Front 101

Conduction disturbances

Back 101

either proximal to the bundle of His or diffusely throughout the conduction system; causes- ischemic, infiltrative or neoplastic, antidepressants, digitalis, quinidine, symptoms- transient weakness, syncope, gray-out may precede the event, strokelike episodes, rapid or irregular heartbeat, signs- labile heart rates, rhythm disturbances

Front 102

Causes of syncope

Back 102

C-cardiac; valve stenosis, Stokes-Adams attack, conduction disturbances, A- arteriovenous; steal syndromes, N- nervous; psychologic, autonomic, vagal, coughing, A- anemia; altered blood CO, D- drugs, diabetes, alcohol poisons, A-altitude, acute fevers

Front 103

Sick sinus syndrome

Back 103

arrhythmias caused by a malfunction of the sinus node; causes- secondary to HTN, arteriosclerotic heart disease, rheumatic heart or idiopathic, symptoms- fainting, transient dizziness, light-headedness, seizures, palpitations, angina; signs- dysrhythmias, CHF

Front 104

Tetralogy of Fallot

Back 104

4 cardiac defects- VSD, pulmonic stenosis, dextroposition of the aorta and R ventricular hypertrophy; surgery is recommended, symptoms- dyspnea with feeding, poor growth, exercise intolerance, paroxysmal dyspnea with loss of consciousness and central cyanosis, signs- parasternal heave and precordial prominence, systolic ejection murmur over 3rd intercostal space, radiating to L side of neck, single S2 heard, older children have clubbing

Front 105

Ventricular septal defect

Back 105

opening between the L and R ventricles, 30-50% close spontaneously in 2 years, symptoms- recurrent respiratory infections, rapid breathing, poor growth, CHF, signs- arterial pulse is small, jugular venous pulse is unaffected, holosystolic murmur- loud, coarse, high-pitched, best heard at L sternal border in 3-5 intercostal spaces, lift along L sternal border and apical area, smaller defect- louder murmur, more easily felt thrill

Front 106

Patent ductus arteriosus

Back 106

failure of the ductus arteriosus to close after birth, increases pressure in pulmonary circulation and increased workload of R ventricle, symptoms- small may be asymptomatic, larger- dyspnea on exertion, signs- dilated and pulsatile neck vessels, wide pulse pressure, harsh loud continuous murmur in 1-3 intercostal spaces and lower sternal border, machine-like quality, murmur unaltered by postural change

Front 107

Atrial septal defect

Back 107

congenital defect in the septum dividing the L and R atria, symptoms- often asymptomatic, heart failure in adults, signs- diamond shaped systolic ejection murmur- loud, high pitched and harsh heard over pulmonic area, accompanied by brief, rumbling, early diastolic murmur, does not radiate, systolic thrill and parasternal thrust, S2 is widely split

Front 108

Acute rheumatic fever

Back 108

systemic connective tissue disease occuring after streptococcal pharyngitis or skin infection; may cause valve involvement of mitral or aortic, valve becomes stenotic and regurgitant, 5-15 years most commonly affected, prevention- adequate treatment of infection; symptoms- fever, inflamed swollen joints, flat or slightly raised, painless rash with pink margins and pale centers and ragged edge (erythema marginatum), aimless jerky movements (Sydenham chorea or St. Vitus dance), small painless nodules beneath skin, chest pain, palpitations, fatigue, SOB; signs- murmurs of mitral regurgitation and aortic insufficiency, cardiomegaly, friction rub, CHF

Front 109

Kawasaki disease

Back 109

condition causing inflammation in walls of small and medium arteries throughout the body, including coronaries; AKA mucocutaneous LN syndrome, 80% affect infants and children under 5; symptoms- high fever longer than 5 days, conjunctivitis, cracked red and inflamed lips, strawberry tongue, white coating on tongue or prominent papillae, cervical lymphadenopathy, erythema of palms and soles, joint pain and swelling, irritability, tachycardia

Front 110

Atherosclerotic heart disease

Back 110

caused by deposition of cholesterol, other llipids and a complex inflammatory process, leads to wall thickening and narrowing of the lumen; symptoms- may be asymptomatic, angina, SOB, palpitations, FH, signs- dysrhythmias and CHF

Front 111

Mitral insufficiency/regurgitation

Back 111

abnormal leaking of blood through the mitral valve, from L ventricle to L atrium; symptoms- acute has decompensated CHF, SOB, pulmonary edema, orthopnea, PND, decreased exercise tolerance, chronic compensated may be asymptomatic, sensitive to small changes in volume, prone to develop CHF; signs- high-pitched pansystolic murmur radiating to axilla, may have third heart sound

Front 112

Angina

Back 112

pain caused by myocardial ischemia, oxygen demand exceeds supply, can be recurrent; symptoms- substernal pain or intense pressure radiating to neck, jaws and arms, SOB, fatigue, diaphoresis, faintness, syncope; signs- tachycardia, tachypnea, HTN, diaphoresis, crackles, reduction in S1 intensity, S4

Front 113

Senile cardiac amyloidosis

Back 113

amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart, contractility is reduced, causes heart failure; symptoms- palpitations, lower extermity edema, fatigue, reduced activity tolerance; signs- pleural effusion, arrhythmia, lower extremity edema, dilated neck veins, hepatomegally or ascites, ECG/echo sows small, thickened L ventricle, R ventricle may be thickened

Front 114

Aortic sclerosis

Back 114

thickening and calcification of aortic valves, usually asymptomatic, midsystolic ejection murmur