Barron's CCRN Review Test Prep.
Describe normal heart sounds. - S1
- Lub
- Caused by closure of AV valves
- Loudest at apex of the heart (midclavicular, 5th intercostal space)
- Marks end of diastole, beginning of systole
S2
- Dub
- Caused by closure of semilunar (aortic, pulmonic) valves
- Loudest at the base (right sternal border, 2nd intercostal space)
- Marks end of systole, beginning of diastole
- Louder with pulmonary embolism
Describe the heart auscultatory points on the chest wall and associated valves. - The
base of the heart is the aortic area, where S2 is loudest. It is as the 2nd intercostal
space, right sternal border.
The apex of the heart is the mitral area, where S1 is loudest. Anatomically, it is at the
5th ICS, midclavicular.
What are abnormal heart sounds in adults? - S3
S4
pericardial friction rub
murmur
Describe the S3 heart sound. - - caused by a rapid rush of blood into a dilated ventricle
occurs early in diastole, right after S3
- heard best at the apex with the bell of the stethoscope
- associated with heart failure; may occur before crackles
- ventricular gallop, "Kentucky"
Caused by:
pulmonary hypertension and cor pulmonale
mitral, aortic, or tricuspid insufficiency
Describe the S4 heart sound. - - caused by atrial contraction of blood into a
noncompliant ventricle
- occurs right before S1
- best heart at the apex with the bell of the stethoscope
- associated with MI, infarction, HTN, ventricular hypertrophy, and aortic stenosis
- atrial gallop, "Tennessee"
In atrial fibrillation, what heart sounds cannot be heard? Why? - S4
,There is no atrial contraction.
What is the formula for pulse pressure? What is a normal value? - SBP - DBP = PP
40-60 mmHg
What do SBP and DBP measure? - SBP is an indirect measurement of CO and stroke
volume.
DBP is an indirect measurement of SVR.
What do narrowing or widening pulse pressures indicate? - A decrease in SBP with little
change or an increase in diastolic pressure is narrowing of pulse pressure.
This is seen most often with severe hypovolemia or a severe drop in CO. (ex. 100/78)
A decrease in DBP that widens pulse pressure may indicate vasodilation, a drop in
SVR; often seen in sepsis, septic shock (ex. 100/38)
Describe the process of heart valves opening and closing. - Normal heart sounds are
due to valve closure. Valves open and close based on pressure changes in chambers
above and below the valve. When the pressure in the chamber above a valve is higher
than that below the, the valve opens. When the pressure drops in the chamber above
the valve and the pressure is greater below the valve, the valve closes.
Systole: ejection, high pressure
Diastole: filling, low pressure
Which is longer, systole or diastole? - Diastole
Why do CO and BP drop with extreme tachyarrhythmias? - There is no time for filling,
therefore less output.
What are 9 causes of valvular heart disease? - 1. CAD
2. ischemia
3. acute MI
4. dilated cardiomyopathy
5. degeneration
6. bicuspid aortic valve
7. rheumatic fever
8. infection
9. connective tissue diseases
What is the difference between murmurs of insufficiency and murmurs of stenosis? -
Murmurs of insufficiency (regurgitation) occur when the valve is closed.
,Murmurs of stenosis occur when the valve is open.
When does mitral insufficiency occur? Mitral stenosis?
When does aortic insufficiency occur? Mitral stenosis? - Mitral insufficiency occurs when
the mitral valve is closed during systole.
Mitral stenosis occurs when the mitral valve is open during diastole.
Aortic insufficiency occurs when the aortic valve is closed during systole.
Aortic stenosis occurs when the aortic valve is open during diastole.
How are murmurs associated with an acute myocardial infarction? - The mitral valve is
attached to the left ventricular wall by the papillary muscles and the chordae tendineae.
Myocardial ischemia can affect mitral valve function and lead to acute mitral valve
regurgitation.
What are modifiable risk factors for acute coronary syndrome? - smoking
atherogenic diet
alcohol intake
physical activity
dyslipidemias
HTN
obesity
DM
metabolic syndrome
Compare unstable angina, NSTEMIs, and STEMIs. - Unstable angina
- chest pain at least, unpredictable, may be relieved with nitroglycerin, troponin
negative, ST depression, T-wave inversion
NSTEMI
- troponin positive, ST depression, T-wave inversion, unrelenting chest pain
STEMI
- troponin positive, ST elevation in 2+ continuous leads, unrelenting chest pain
Describe variant or Prinzmetal's angina. - - unstable angina associated with transient ST
segment elevation
- caused by coronary artery spasm
- occurs at rest, may be cyclic
- may be precipitated by nicotine, ETOH, cocaine
- troponin negative
- nitroglycerin results in CP relief; STs return to normal
How is acute chest pain managed? - - STAT ECG (within 10 minutes)
- aspirin (chewed)
, - anticoagulant
- anti-platelet
- beta blocker (unless ACS due to cocaine)
- treat pain (NTG, morphine)
- cardiac biomarkers, lipid profile, CBC, bytes, BUN/Cr, Mg, PT/PTT
Describe ECG lead changes in acute coronary syndrome and the locations of coronary
artery disease they suggest. - II, III, aVF: right coronary artery, inferior LV
V1, V2, V3, V4: left anterior descending artery, anterior LV
V5, V6, I, aVL: circumflex, lateral LV
V5, V6: low lateral LV
I, aVL: high lateral LV
V1, V2: RCA, posterior LV
V3R, V4R: RCA, RV infarct
Describe an inferior myocardial infarction. - - associated with RCA occlusion
- ST elevation in II, III, and aVF
- associated with AV conduction disturbances
- systolic murmur, MVR secondary to papillary muscle rupture
- tachycardia
Use beta blockers and NTG with caution.
Describe a right ventricular infarct. How would you treat it? What should you avoid? - -
RCA supplies inferior wall of LV and RV, causing RV infarct
- use right-sided ECG
Signs/Symptoms
- JVD, high CVP, hypotension, clear lungs, bradycardia
- ST elevation
Treatment
- fluids
- positive inotropes
Avoid
- preload reducers (nitrates, diuretics)
- caution w/ beta blockers
Describe an anterior MI. - - associated with LAD occlusion
Describe normal heart sounds. - S1
- Lub
- Caused by closure of AV valves
- Loudest at apex of the heart (midclavicular, 5th intercostal space)
- Marks end of diastole, beginning of systole
S2
- Dub
- Caused by closure of semilunar (aortic, pulmonic) valves
- Loudest at the base (right sternal border, 2nd intercostal space)
- Marks end of systole, beginning of diastole
- Louder with pulmonary embolism
Describe the heart auscultatory points on the chest wall and associated valves. - The
base of the heart is the aortic area, where S2 is loudest. It is as the 2nd intercostal
space, right sternal border.
The apex of the heart is the mitral area, where S1 is loudest. Anatomically, it is at the
5th ICS, midclavicular.
What are abnormal heart sounds in adults? - S3
S4
pericardial friction rub
murmur
Describe the S3 heart sound. - - caused by a rapid rush of blood into a dilated ventricle
occurs early in diastole, right after S3
- heard best at the apex with the bell of the stethoscope
- associated with heart failure; may occur before crackles
- ventricular gallop, "Kentucky"
Caused by:
pulmonary hypertension and cor pulmonale
mitral, aortic, or tricuspid insufficiency
Describe the S4 heart sound. - - caused by atrial contraction of blood into a
noncompliant ventricle
- occurs right before S1
- best heart at the apex with the bell of the stethoscope
- associated with MI, infarction, HTN, ventricular hypertrophy, and aortic stenosis
- atrial gallop, "Tennessee"
In atrial fibrillation, what heart sounds cannot be heard? Why? - S4
,There is no atrial contraction.
What is the formula for pulse pressure? What is a normal value? - SBP - DBP = PP
40-60 mmHg
What do SBP and DBP measure? - SBP is an indirect measurement of CO and stroke
volume.
DBP is an indirect measurement of SVR.
What do narrowing or widening pulse pressures indicate? - A decrease in SBP with little
change or an increase in diastolic pressure is narrowing of pulse pressure.
This is seen most often with severe hypovolemia or a severe drop in CO. (ex. 100/78)
A decrease in DBP that widens pulse pressure may indicate vasodilation, a drop in
SVR; often seen in sepsis, septic shock (ex. 100/38)
Describe the process of heart valves opening and closing. - Normal heart sounds are
due to valve closure. Valves open and close based on pressure changes in chambers
above and below the valve. When the pressure in the chamber above a valve is higher
than that below the, the valve opens. When the pressure drops in the chamber above
the valve and the pressure is greater below the valve, the valve closes.
Systole: ejection, high pressure
Diastole: filling, low pressure
Which is longer, systole or diastole? - Diastole
Why do CO and BP drop with extreme tachyarrhythmias? - There is no time for filling,
therefore less output.
What are 9 causes of valvular heart disease? - 1. CAD
2. ischemia
3. acute MI
4. dilated cardiomyopathy
5. degeneration
6. bicuspid aortic valve
7. rheumatic fever
8. infection
9. connective tissue diseases
What is the difference between murmurs of insufficiency and murmurs of stenosis? -
Murmurs of insufficiency (regurgitation) occur when the valve is closed.
,Murmurs of stenosis occur when the valve is open.
When does mitral insufficiency occur? Mitral stenosis?
When does aortic insufficiency occur? Mitral stenosis? - Mitral insufficiency occurs when
the mitral valve is closed during systole.
Mitral stenosis occurs when the mitral valve is open during diastole.
Aortic insufficiency occurs when the aortic valve is closed during systole.
Aortic stenosis occurs when the aortic valve is open during diastole.
How are murmurs associated with an acute myocardial infarction? - The mitral valve is
attached to the left ventricular wall by the papillary muscles and the chordae tendineae.
Myocardial ischemia can affect mitral valve function and lead to acute mitral valve
regurgitation.
What are modifiable risk factors for acute coronary syndrome? - smoking
atherogenic diet
alcohol intake
physical activity
dyslipidemias
HTN
obesity
DM
metabolic syndrome
Compare unstable angina, NSTEMIs, and STEMIs. - Unstable angina
- chest pain at least, unpredictable, may be relieved with nitroglycerin, troponin
negative, ST depression, T-wave inversion
NSTEMI
- troponin positive, ST depression, T-wave inversion, unrelenting chest pain
STEMI
- troponin positive, ST elevation in 2+ continuous leads, unrelenting chest pain
Describe variant or Prinzmetal's angina. - - unstable angina associated with transient ST
segment elevation
- caused by coronary artery spasm
- occurs at rest, may be cyclic
- may be precipitated by nicotine, ETOH, cocaine
- troponin negative
- nitroglycerin results in CP relief; STs return to normal
How is acute chest pain managed? - - STAT ECG (within 10 minutes)
- aspirin (chewed)
, - anticoagulant
- anti-platelet
- beta blocker (unless ACS due to cocaine)
- treat pain (NTG, morphine)
- cardiac biomarkers, lipid profile, CBC, bytes, BUN/Cr, Mg, PT/PTT
Describe ECG lead changes in acute coronary syndrome and the locations of coronary
artery disease they suggest. - II, III, aVF: right coronary artery, inferior LV
V1, V2, V3, V4: left anterior descending artery, anterior LV
V5, V6, I, aVL: circumflex, lateral LV
V5, V6: low lateral LV
I, aVL: high lateral LV
V1, V2: RCA, posterior LV
V3R, V4R: RCA, RV infarct
Describe an inferior myocardial infarction. - - associated with RCA occlusion
- ST elevation in II, III, and aVF
- associated with AV conduction disturbances
- systolic murmur, MVR secondary to papillary muscle rupture
- tachycardia
Use beta blockers and NTG with caution.
Describe a right ventricular infarct. How would you treat it? What should you avoid? - -
RCA supplies inferior wall of LV and RV, causing RV infarct
- use right-sided ECG
Signs/Symptoms
- JVD, high CVP, hypotension, clear lungs, bradycardia
- ST elevation
Treatment
- fluids
- positive inotropes
Avoid
- preload reducers (nitrates, diuretics)
- caution w/ beta blockers
Describe an anterior MI. - - associated with LAD occlusion
