Cardiology

Question 1

Define Orthopnea

Answer 1

Difficulty breathing in the recumbent position (supine)

Question 2

Define PND

Answer 2

Paroxysmal nocturnal dyspnoea = Patients awaken after 1–2 hours of sleep because of acute shortness of breath

Question 3

Define Trepopnea

Answer 3

Positional dyspnea that is generally noted in either (one) the left or the right lateral decubitus position Due to disease of one lung, one major bronchus, or chronic congestive heart failure

Question 4

Define Platypnea

Answer 4

Dyspnea that occurs only in the upright position

Question 5

Define Hemoptysis

Answer 5

Coughing up of blood

Question 6

Define Cheyne-Stokes respiration

Answer 6

Respiration characterized by a rapid deep-breathing phase, followed by periods of apnea

Question 7

Define Stable angina

Answer 7

predictable pattern of angina onset and offset that is stable over time

Question 8

Define accelerated angina

Answer 8

Angina that occurs at lower levels of exertion or that takes longer to resolve with rest or nitroglycerin; although accelerated angina fits the definition of unstable angina technically, it usually occurs over a longer period and is probably caused by progression of atheromatous coronary disease without plaque rupture.

Question 9

Define Unstable angina

Answer 9

A change in the patient’s normal pattern of angina onset or offset, probably related to plaque rupture

Question 10

Define ACS

Answer 10

Acute coronary syndrome. Although this could include STEMI, the term is commonly used to denote unstable or accelerated angina and NSTEMI.

Question 11

Define Myocardial stunning

Answer 11

Prolonged depressed function of viable myocardium caused by a brief episode of severe ischemia (myocardium can recover with time if recurrent ischemic events are prevented)

Question 12

Define Hibernating myocardium

Answer 12

Chronically depressed function of viable myocardium as a result of severe chronic ischemia (which can be reversed by revascularization)

Question 13

Where can a PA catheter be inserted through?

Answer 13

Can be placed via the jugular, subclavian, or femoral veins

Question 14

What chambers (in what order) does a PA catheter traverse to measure a wedge pressure?

Answer 14

The RA, RV, PA, and then to PCWP (pulmonary capillary wedge pressure)

Question 15

What are the normal filling pressures measure by PA catheter?

Answer 15

1) RA pressure or Central venous pressure (thoracic vena cava) = 0–8 mmHg
2) RV Pressire = 15–30 / 0–8mm Hg
3) PA Pressure = 15–30 / 3–12 mmHg
4) PCWP = 3-12 mmHg

Question 16

What is the PCWP?

Answer 16

Pulmonary capillary wedge pressure (aka PAOP, PC pressure, wedge pressure) It is the approximation of the LA and LV pressures during ventricular filling (LVEDP - end diastolic pressure)

Question 17

How is the PC pressure obtained?

Answer 17

1–1.5 mL of air is pushed into the balloon port of the PA catheter while the PA tracing is watched. When the PA tracing is lost and the PCWP identified, the inflation is discontinued.

Question 18

What is the danger of overinflating the balloon?

Answer 18

PA rupture, which can be fatal

Question 19

What is the PCWP useful for?

Answer 19

For determining the intravascular volume status of the patient (i.e., PCWP >20 volume overloaded; PCWP <3 volume underloaded)

Question 20

How is CO calculated?

Answer 20

Cardiac Output = [HR (beats/min)] * [stroke volume (mL/beat)]

(figure divided by 1000 to get L/min instead of mL)

Question 21

What is the normal CO?

Answer 21

5 ± 1 L/min

Question 22

How is CI calculated?

Answer 22

Cardiac Index = Cardiac output/Body Surface Area

Question 23

What is the normal CI?

Answer 23

3 ± 0.5 L/min/m²

Question 24

What is the Levine sign?

Answer 24

Clenched fist over the midsternum

Question 25

What 7 historical features of chest pain must be identified to differentiate cardiac pain from noncardiac pain?

Answer 25

**PQRST:** 1) **Precipitating factors**—pain that follows exertion, exposure to cold, or meals suggests angina (or GERD); pain that follows retching or a twisting movement suggests alternative causes. 2) **Quality**—sustained squeezing or pressure may be described as “a heavy feeling,” “tightness,” “an elephant sitting on my chest,” or “bandlike.” 3) **Radiation and location**—pain may be central, left, or right sided (a specific location suggests alternative causes); radiation may extend to the neck, left arm, or right arm. Some pains can be tearing or pleuritic. 4) **Relief**—nitroglycerin relieves most angina in 2–5 minutes (a longer duration suggests MI or other causes); relief with leaning forward (positional effects) suggests pericarditis; relief with antacids suggests GI causes. 5) **Risk factors**—a history of CAD, family history, gender, tobacco use, diabetes, hyperlipidemia, and hypertension are risk factors. 6) **Symptoms**—such as dyspnea, nausea, vomiting, belching, diaphoresis, and palpations all suggest angina; patients often express a sensation of impending doom or total denial. 7) **Time and duration**—very brief (seconds) episodes are not angina; prolonged (hours) episodes may indicate infarction or other causes (e.g., pericarditis, dissection).

Question 26

What are the major cardiovascular causes of chest pain?

Answer 26

1) Myocardial ischemia 2) Myocardiac infarction (MI) 3) Aortic dissection 4) Aortic aneurysm 5) Pulmonary emboli ------ 6) Mitral Valve Prolapse (MVP) 7) Pericarditis 8) Pulmonary hypertension

Question 27

List some noncardiovascular causes of chest pain

Answer 27

1) Gastrointestinal (e.g., esophageal spasm, reflux, and rupture; gastric, duodenum, or gallbladder disease) 2) Pleura and lung conditions (e.g., pneumothorax, pleural adhesions) 3) Shoulder-hand syndrome, shoulder girdle 4) Diseases of the chest wall (e.g., thrombophlebitis, herpes zoster infection, costochondritis) 5) Diseases of the spine and mediastinum

Question 28

What are some important causes of hemoptysis?

Answer 28

Multiple Sclerosis Obstructive cardiomyopathy Congenital heart disease with right-to-left shunting Aortic aneurysm Pneumonia Pulmonary infarction Pulmonary carcinoma Pulmonary vasculitis Pulmonary tuberculosis

Question 29

What are some of the causes of dyspnea?

Answer 29

11 Ps: - Pulmonary bronchoconstriction (asthma, COPD) - Pulmonary embolus - Pulmonary hypertension - Pneumonia - Pneumothorax - Pump failure (congestive heart failure) - Pericardial tamponade - Psychogenic - Poison (carbon monoxide) - Peak seekers (high altitude) - Paroxysmal spasm of the vocal cords (vocal cord dysfunction) Others: - Anemia and thyroid disease - Restrictive Lung disease (e.g. idiopathic pulmonary fibrosis) - interstitial lung disease (e.g. silicosis) - Deconditioning and chest wall weakness (muscle or nerve disease)

Question 30

Why is it important to use the appropriately sized BP cuff ?

Answer 30

An undersized BP cuff results in an overestimated BP measurement; an oversized BP cuff results in an underestimated BP measurement.

Question 31

How accurate is a BP cuff ?

Answer 31

± 5mmHg

Question 32

How close should the right and left arm pressures be?

Answer 32

Within 10 mmHg; if \> 10 mmHg, consider subclavian stenosis, aortic coarctation, and aortic dissection

Question 33

What is arcus senilis?

Answer 33

Circumferential light ring around the iris, which is frequently associated with hypercholesterolemia if present in patients younger than 50 years

Question 34

What is ectopia lentis and what is it associated with?

Answer 34

Dislocated lenses; homocystinuria or Marfan syndrome

Question 35

What are the causes of blue sclera?

Answer 35

Ehlers-Danlos syndrome, osteogenesis imperfecta, and Marfan syndrome, which are all associated with aortic root dilation or aneurysm or with MVP

Question 36

What are plaques of Hollenhorst?

Question 37

What are the causes of clubbing?

Answer 37

1) Cyanotic congenital heart disease (e.g. right-to-left shunting, malposition of the great arteries) 2) Pulmonary disease (e.g., hypoxia, lung cancer, bronchiectasis, and cystic fibrosis) 3) IE 4) Biliary cirrhosis 5) Regional enteritis 6) Familial clubbing

Question 38

Where is the normal PMI (apex beat) found?

Answer 38

At the fifth (to sixth) intercostal space at the left midclavicular line

Question 39

What causes an S1?

Answer 39

Closure of the mitral and tricuspid valves

Question 40

What causes a soft S1?

Answer 40

1) Mitral Regurgitation (rheumatic or calcific) 2) Atrioventricular block 3) Aortic regurgitation 4) Severe acute aortic insufficiency (valve closes prematurely)

Question 41

What causes an S2?

Question 42

What is the first sound of a split S2?

Question 43

What causes splitting of S2?

Question 44

What happens to the splitting during respiration?

Answer 44

During inspiration, the venous return to the right atrium is increased (due to negative intrathoracic pressure), resulting in a larger stroke volume and consequent longer ejection cycle (thus pulmonic sound P2 occurs later), with a concomitant reduction in left atrium venous return and a smaller LV stroke volume and shorter ejection phase (earlier A2), resulting in widening of the splitting.

Question 45

What causes a widely split S2?

Answer 45

1) Right Bundle Branch Block 2) LV pacing 3) RV outflow obstruction 4) pulmonary atresia 5) pulmonary hypertension 6) Rarely, severe Mitrial Regurgitation ------- Could be paradoxical splitting: 7) LBBB 8) Aortic stenosis

Question 46

What causes fixed splitting of S2?

Answer 46

i. e. splitting does not vary with inspiration 1) Septal defect (usually atrial septal defect)

Question 47

What is paradoxical splitting of S2?

Answer 47

The pulmonic closure sound (P2) is heard before the aortic closure sound (A2), and splitting therefore occurs during expiration

Question 48

What is included in the differential of paradoxical splitting?

Answer 48

1) Pulmonary hypertension 2) Left Bundle Branch Block 3) Aortic stenosis 4) Hypertrophic cardiomyopathy 5) Patent ductus arteriosus (left-to-right shunt) 6) Tricuspid regurgitation

Question 49

What causes a soft A2?

Answer 49

1) Aortic Stenosis (decreased mobility), or 2) Aortic Insufficiency (fails to coapt)

Question 50

What causes a loud P2?

Answer 50

Pulmonary hypertension

Question 51

What causes an S3?

Answer 51

Unknown, but it occurs in patients with volume-overloaded hearts (RV or LV) or hyperdynamic circulation - In case of **rapid ventricular filling** (e.g. Mitral regurgitation, Ventricular septal defect), or **Poor left ventricular function** (e.g. post-MI) May also be a normal variant in patients younger than 40 years.

Question 52

What causes an S4?

Answer 52

Organized atrial contraction into a stiff ventricle (i.e. ventricular fibrosis it does not occur in AF).

Question 53

Define galloping rhythm

Answer 53

A (usually abnormal) rhythm of the heart on auscultation; It includes three or four sounds (with S3 or/and S4), thus resembling the sounds of a gallop.

Question 54

How are S3 and S4 gallops best heard?

Answer 54

By using the bell of the stethoscope over the apex (S3) or the left sternal border (S4)

Question 55

What is an opening snap?

Answer 55

A high-pitch additional sound heard after the A2 during diastole, usually due to mitral stensosis

Question 56

What is a pericardial friction rub?

Answer 56

A sound heard with irritation of the pericardial/myocardial interface (e.g. pericarditis)

Question 57

What are the general causes of central cyanosis?

Answer 57

Decreased arterial oxygen saturation caused by: * *1) Cardiac (right-to-left shuntin)** - Heart failure - Tetralogy of Fallot - Transposition of great vessels - Tricuspid atresia - \*Eisenmenger syndrome from uncorrected L2R shunt e.g. atrial or ventricular septal defects * *2) Pulmonary (reduced function)** - Hypoventilation - V/Q mismatches (e.g. pneumonia) - Pulmonary venous fistulas - Intrapulmonary shunts 3) **Haemotological (impaired ability of Hgb to bind O₂)** - methemoglobinemia - Sulfhaemoglobinaemia - abnormal Hgb variants

Question 58

What are the causes of peripheral cyanosis?

Answer 58

1) Cutaneous vasoconstriction caused by low CO (e.g. congestive heart failure) 2) Cutaneous vasoconstriction due to cold exposure 2) Raynaud phenomenon (cold, stress)

Question 59

What are the causes of peripheral edema?

Answer 59

1) Cardiac (*increased venous or hydrostatic pressure; renal salt & water retention due to decreased renal perfusion due to decreased CO)* - Congestive cardiac failure - Chronic Venous insufficiency - Constrictive pericarditis - Venous obstruction 2) Liver (*Hypoalbuminaemia which decreases plasma oncotic pressure; renal salt & water retention due to decreased renal perfusion due to splanchnic bed vasodilatation*) - Hepatic cirrhosis 3) Renal (*hypoalbuminaemia; renal salt & water retention*) - Nephrotic syndrome - Renal failure 4) Others - Myxedema (hypothyroidism) - Pregnancy - Lymphatic obstruction - Angioedema (allergy) - Drug side effects (e.g. Fluoxetine, Olanzapine)

Question 60

In the jugular venous tracing shown in Figure 3-1, identify the various numbered waveforms.

Answer 60

1. a wave 2. c wave 3. v wave 4. x descent 5. y descent

Question 61

Identify the various waveforms in the jugular venous tracing, and their timing or event in the cardiac cycle.

Answer 61

The " a " wave corresponds to right **A**trial contraction and ends synchronously with the carotid artery pulse. The peak of the 'a' wave demarcates the end of atrial systole The " c " wave corresponds to right ventricular **C**ontraction causing the tri**C**uspid valve to bulge towards the right atrium. The " x' " (x prime) descent follows the 'c' wave and occurs as a result of the right ventricle pulling the tricuspid valve downward during ventricular systole. (As stroke volume is ejected, the ventricle takes up less space in pericardium, allowing rela**X**ed atrium to enlarge). The x' (x prime) descent can be used as a measure of right ventricle contractility. The " x " descent follows the 'a' wave and corresponds to atrial rela**X**ation and rapid atrial filling due to low pressure. The " v " wave corresponds to **V**enous filling when the tricuspid valve is closed and venous pressure increases from venous return - this occurs during and following the carotid pulse. The " y " descent corresponds to the rapid empt**Y**ing of the atrium into the ventricle following the opening of the tricuspid valve.

Question 62

Define and list the major causes of pronounced a waves.

Answer 62

An abnormally large and abrupt outward movement of the jugular vein that occurs before the first heart sound. The ‘prominent’ a-wave precedes ventricular systole and the carotid pulse upstroke: 1) Right ventricular hypertrophy - Cor pulmonale - Pulmonary hypertension - Pulmonary stenosis - Pulmonary embolus 2) Tricuspid stenosis or atresia 3) ? Mitral valve disease

Question 63

What is the major cause of pronounced v waves?

Question 64

What is the abdominal- jugular (also called hepatojugular) reflux? What's its mechanism?

Answer 64

An increase of 3 cm H2O in JVP with 10–30 seconds of periumbilical pressure. Putting pressure on the right upper quadrant assists in venous return to the right side of the heart via the inferior vena cava. The increased volume of blood returning to the right side of the heart is met with raised end-systolic and -diastolic pressures in the right atrium and ventricle (due to the right-sided dysfunction) and venous blood and pressure is ‘backed up’ into the jugular veins. The right ventricle cannot accommodate additional venous return.

Question 65

What causes Hepatojugular reflux?

Answer 65

1) Any cause of right ventricular dysfunction – systolic or diastolic dysfunction 2) Heart failure and volume overload 3) Elevated right ventricular afterload

Question 66

Define and explain causes of cannon a waves?

Answer 66

A large, abrupt flicker/flicker of the a-wave that occurs after S1 and on the carotid pulse upstroke due to atrial contraction against a closed tricuspid valve: 1) Heart block, in particular third-degree (complete) AV block 2) Ventricular tachycardia 3) Premature junctional beats 4) pulmonary hypertension 5) Severe tricuspid stenosis