202 Heart and Neck

acute chest pain that occurs when myocardial demand exceeds its o2 supply

aka aortic insufficiency. incompetent aortic valve that allows backward flow of blood into left ventricle during diastole.

calcification of aortic valve cusps that restricts forward flow of blood during systole

the L semilunar valve. separates L ventricle and aorta.

tip of heart pointing down toward the 5th ICS

aka point of maximal impulse, PMI. pulsation created as the L ventricle rotates against the chest wall during systole, normally at the 5th ICS in the MCL.

broader area of the heart's outline located at the 3rd R and L ICS.

cup-shaped endpiece used for soft, low-pitched sound

bulbous enlargement of distal phalanges of fingers and toes that occurs with chronic cyanotic heart and lung conditions.

severe narrowing of the descending aorta, a congenital defect of the heart

right ventricular hypertrophy and heart failure due to pulmonary hypertension

dusky blue mottling of the skin and mucous membranes due to excessive amt of reduced hemoglobin in blood

flat endpiece used for hearing relatively high-pitched heart sounds

heart's filling phase

difficult, labored breathing

swelling of legs or dependent body part due to increased interstitial fluid

traditional auscultatory area in 3rd L ICS

occurs with closure of AV valves, signaling beginning of systole

aka S4 gallop, atrial gallop. very soft, low-pitched, ventricular filing sound that occurs in late diastole

the addition of a 3rd or 4th heart sound, makes the rhythm sound like cadence of galloping horse

technique of inching stethoscope across precordium thru auscultatory areas while listening to heart sounds

increase in thickness of myocardial wall that occurs when the heart pumps against chronic outflow obstruction, e.g., aortic stenosis

aka mitral insufficiency. incompetent mitral valve allows regurgitation of blood back into L atrium during systole

calcified mitral valve impedes forward flow of blood into L ventricle during diastole

uncomfortable awareness of rapid or irregular heart beat

opposite of a normal split S2 so that the split is heard in expiration, and in inspiration the sounds fuse to one sound

high-pitched scratchy extracardiac sound heard when the precordium in inflamed

normal variation in S2 heard as two separate components during inspiration

area of chest wall overlying the heart and great vessels

aka pulmonic insufficiency. backflow of blood thru incompetent pulmonic valve into the R ventricle

calcification of pulmonic valve that restricts forward flow of blood during systole

R SL valve, separating the R ventricle and pulm artery

occurs with closure of the SL valves, and signals the end of systole

abnormal mid-diastolic heard sound heard when both the pathologic S3 and S4 are present

temporary loss of consciousness due to decreased cerebral blood flow (fainting), caused by ventricular asystole, pronounced bradycardia, or ventricular fibrillation

soft, low-pitched, ventricular filling sound that occurs in early diastole (S3 gallop) and may be an early sign of heart failure

palpable vibration on the chest wall accompanying severe heart murmur

R AV valve

L AV valve

area on anterior chest overlying the heart and great vessels

reminder: the "precordial thump" from CPR

• what: midthoracic cavity that contains the heart and great vessels
• where: 2nd to 5th ICS, R sternal border to L MCL

• 5th ICS, 7-9 cm L of midsternal line (at approximately MCL)
• If apex extends past MCL (i.e., is more lateral) --> heart is enlarged/hypertrophied; sign of disease.

reminder: apex of heart is inferior to base, apices of lungs are superior.

Right side is mostly anterior, L is mostly posterior

• pericardium
• epicardium
• myocardium
• endocardium

attached to vessel, esophagus, sternum and pleura; anchored to the diaphragm. Heart sits in pericardial sac that must be cut through to get to the heart in surgery

outside layer (but deep to pericardium)

heart sits in pericardial sac that must be cut through to get to heart in surgery

middle, muscle layer of heart. Thickest on L ventricle

inside lining of heart, in chambers and valves. Electrical system embedded within

unidirectional, passive open and close

• L: mitral / bicuspid
• R: tricuspid

attach AV vales to papillary muscles and provide stability to valves during systole (when AV valves are open). rupture of them (as can happen in severe MI) may be life threatening b/c failed valves = immediate death

• R: pulmonic
• L: aortic

• conduction - electrical system that initiates and conducts heart beat (b/c electricity causes muscle contraction)
• hemodynamic - moves blood thru heart and vessels, depends on pressure changes

endocardial

SA node is pacemaker. Normally fires at 60-100 bpm

SA node --> AV node --> Bundle of His --> Perkinje fibers

• P: depolarization of atria. Spread of stimuli thru atria. Is SA node not firing, no P wave is present.
• PR: time b/w stimulation of atria to stim of ventricles
• QRS: depolarization (i.e., contraction) of ventricles. Spread of stim thru ventricles.
• T: repolarization of ventricles. Resting phase. *Repolarization = *Rest
• U: final ventricular repolarization. Not always seen on ECG

Lower (including abd): inferior vena cava --> RA --> R AV valve / tricuspid valve --> pulmonic / R SL valve --> pulmonic arteries --> lungs/alveoli --> pulmonary veins --> LA --> L AV valve / mitral / bicuspid valve --> LV --> aortic / L SL valve --> aorta --> body

Upper (head and neck): superior vena cava ... rest is same as lower body.

Excessively high atrial pressures because no valves between L atrium and pulm veins or between R atrium and venae cavae.

On R: Blood back flows into veins of neck and PV system --> distended neck veins and peripheral edema

On L: Blood back flows into lungs --> pulm congestion (e.g., crackles/rales)

• Cardia output. CO ~= 4-6 L/min.
• SV ~=70 ml/beat

• dehydration
• bleeding
• fluid overload

SV: amt of blood ejected by L ventricle with 1 heart beat

aka LVEDV: L ventricular end diastolic vol

increased LV vol causes more stretch on myocardial muscles fibers at end of diastole. --> > stretch = stronger muscle contraction.

goal is maximize preload (vol) in order to maximize LV contraction and CO. But excessive preload leads to decreased CO and HF.

the greater the stretch of muscle fibers (compliance), the stronger the contraction. why preload is a good thing (up to a point).

aka SVR (systemic vascular resistance) or PVR (peripheral vascular resistance)

definition: opposing pressure the ventricle must generate to open aortic valve during systole.

excessive afterload increases myocardial workload and O2 consumption

causes: arteriosclerosis, HTN, SNS stim, excess ETOH intake

• Produced by closing of valves.
• Louder on side of heart (mitral > tricuspid, aortic > pulmonic) b/c takes more force to move blood to periphery from L side

• aortic - 2nd ICS, R sternal border
• pulmonic - 2nd ICS, L sternal border
• erb's - 3rd ICS, L sternal border (good location for referred sounds, for picking up on murmurs)
• tricuspid - 4th ICS, L sternal border
• mitral - 5th, MCL

• 1. listen to all sites with diaphragm AND bell
• 2. listen for aortic murmurs (with pt sitting and leaning forward is best
• 3. listen for extra heart sounds (L lateral decubitus (i.e., sidelying) position is best)

• AV valves close (mitral and tricuspid)
• SL valves open (aortic, pulmonic)
• diastole ends, systole begins

• aortic/pulmonic valves close
• mitral/tricuspid valves open. begins with rapid filling phase, then atrial kick.
• systole ends, diastole begins

• atrial kick: atrial contraction that ejects last 25% of SV into ventricles
• S4

• extra heart sound.
• e.g., S3, S4

• S1--------S2, S3
• ken-------tuc/ky

• indicates ventricular resistance to early passive filling
• in early diastole

• decreased ventricular compliance (early sign of HF)
• high output conditions like hyperthyroid, pregnancy

• S4, S1----------->S2
• ten/nes-----------see

• indicates ventricular resistance to filling during atrial kick
• in late diastole, immediately before S1
• causes: HTN, increased afterload

having S3 and S4

• def'n: blowing/swooshing sound that occurs with turbulent flow thru valves or great vessels
• causes:
• -increased velocity (exercise)
• -decreased viscosity (thin blood)
• -decreased volume (anemia)
• -defective valves (forward or back flow)
• -septal defects

• -occur when valve is open
• -stiff valves prevent adequate forward flow
• -cause harsh murmur

• -occur when valve is closed
• -aka insufficiency
• -results in backward flow due to poor valve closure
• -turbulent sound

• -aortic/pulm stenosis (when SL valves open)
• -mitral/tricuspid insufficiency/regurgitation (when AV valves closed)
• -discern by auscultating for where murmur is loudest

heard in systole, after S1

• -mitral/tricuspid stenosis (AV valves open)
• -aortic/pulm regurgitation (SL valves closed)

heard in diastole, after S2

description of murmurs.

holod: b/w S2 and S1

holosys: b/w S1 and S2

• aka functional murmur
• not r/t valve, cardiac, or other pathology
• common in childhood d/t increased blood flow

• cardiac - angina, MI, valve prolapse
• pulmonary - pneumonia, pleurisy (inflamed pleura that surround lungs)
• pericardial - pericarditis
• musculoskeletal/chest wall - costochondritis, arthritis
• GI - ulcer, hernia, esophagitis, indigestion
• neurotic - anxiety

imbalance b/w o2 supply and demand --> therefore, more common with exercise

should resolve in a couple min with rest and/or tx (NTG/nitroglyercin) --> may progress to an MI if not treated

similar to angina/myocardial ischemia, diaphoresis, n/v, palpitations, sense of impending doom

atypical: SOB (esp. in women), sharp chest pain, fatigue

• age (>=45 if male; >=55 or postemenopausal if female)
• HTN or HTN tx
• smoking
• hyperlipidemia
• diabetes
• family history of premature CAD in 1st degree relative (male <55, female <65)

• dyspnea
• DOE = dyspnea on exertion
• PND = paroxysmal nocturnal dyspnea (classic sx of HF)

• cholestrol level
• murmurs
• congenital heart disease
• rheumatic fever
• swollen joints
• heart surgery
• last ECG
• stress test (ETT) results
• family hx (HTN, CAD, DM, obesity, congential heart disease, genetically transmitted diseases)

• diet (high fat, sodium)
• smoking (b/c it vasoconstricts)
• ETOH (increases afterload)
• exercise (increases HDL, myocardial muscle tone)
• medications (digitalis, diuretics, beta blockers, Ca channel blockers)

• 30-45 degrees.
• R side

3-4 cm above sternal angle

• estimate of RA pressure
• JVP = JVP + 5 cm (distance of RA from sternal angle)
• norm: <= 9 cm H20

p.s. I have no idea what cm h2o means, but it's in the lecture notes.

4th or 5th ICS, L MCL. palpable in ~1/2 adults

• sustained forceful thrusting of ventricle during systole
• sign of enlarged heart
• visualized and palpable at apex

• palpable vibration
• sign of heart murmur, esp. loud, harsh ones
• palpate across precordium at each valve site