CV PV Lecture (1) PDF

Cardiovascular and Peripheral Vascular KIMYA BARADARAN, MSPAS, PA-C  Anatomy  Most anterior cardiac surface is R ventricle  L ventricle lies behind R ventricle except for apex  Base is at the top, apex at the bottom  PMI (point of maximal impulse) is at the...

Cardiovascular and Peripheral Vascular KIMYA BARADARAN, MSPAS, PA-C  Anatomy  Most anterior cardiac surface is R ventricle  L ventricle lies behind R ventricle except for apex  Base is at the top, apex at the bottom  PMI (point of maximal impulse) is at the 5th ICS, mid-clavicular line  Cardiac impulse best palpated  Circulation  Blood enters the R side of the heart through the vena cava  Blood flows to the lungs via pulmonary artery (deoxygenated)  Blood returns to the L side of the heart via pulmonary veins (oxygenated)  Blood flows to the systemic circulation via the aorta  Valves  Mitral & Tricuspid valves  between atria & ventricles  called atrioventricular (AV) valves  Pulmonic & Aortic valves  between ventricles and great vessels  called semilunar valves Putting it All Together… Question 1  A common heart arrhythmia called atrial fibrillation is when the top chambers of the heart cause fast and irregular heartbeats. One procedure to treat this is an ablation which involves burning tissue most often around the blood vessel(s) that empty into the left atrium. Where does this ablation occur?  a. Pulmonary arteries  b. Pulmonary veins  c. Inferior vena cava  d. Aorta  Cardiac Cycle  Systole  Diastole  Ventricles contract  Ventricles relax  Tricuspid and Mitral valves close (S1  Aortic and Pulmonary valves close (S2 LUBB) DUBB)  Aortic and Pulmonic valves open  Tricuspid and Mitral valves open  Blood pushed into pulmonary artery  Blood flows into ventricles and aorta  Atria contract S1 –systole S2- diastole trIcuspid mItral  Heart Sounds  Closure of valves responsible for heart sounds  Heart sounds labeled S1 (lub) and S2 (dub)  S1 is the start of systole: mitral & tricuspid close while aortic & pulmonic valves open  S2 is the start of diastole: aortic and pulmonic valves close while mitral & tricuspid open  Cardiac Cycle  Systole (S1)  Loudest at apex  Correlates with carotid pulse & apical impulse  Lower pitch  Diastole (S2)  Loudest at base  Higher pitch  Shorter duration than S1  Splitting of S2  Normal heart: S2 is heard as 1 sound on expiration  Normal heart: S2 plits into A2 and P2 on inspiration  More blood fills RV —> delayed PV closure  Best heard in the 2nd left ICS with diaphragm  Semi-recumbent position  Expiratory splitting is abnormal!  Extra Heart Sounds: S3  S3 - ventricular gallop  Lots of blood rushes into compliant ventricle  Can indicate fluid overload - systolic heart failure  Beginning of diastole right after S2  “Kentucky”  Extra Heart Sounds: S4  S4 - atrial gallop  Blood pushed against stiff ventricle  Diastolic heart failure, LVH  End of diastole right before S1  “Tennessee” Question 2  You often hear the heart sounds referred to as “Lub-dub”. In this case, what does “lub” refer to?  a. Opening of the mitral and tricuspid valves  b. Opening of the aortic and pulmonic valves  c. Closing of the mitral and tricuspid valves  d. Closing of the aortic and pulmonic valves  e. Sound of blood hitting the walls of the atria as they fill with blood  f. Sound of blood hitting the walls of the ventricles as they fill with blood Obtaining the Cardiac-focused History What are some Cardiac ROS Qs?  Chest Pain/discomfort  Orthopnea  Dyspnea/SOB  Lower extremity edema  Dyspnea on exertion  Palpitations  Paroxysmal nocturnal  Syncope dyspnea  Chest Pain  Think the worst first!  History is crucial  Rule out myocardial infarction (MI), angina pectoris, dissecting aortic aneurysm  Differential Diagnosis  Cardiac  GI  MI  GERD/acid reflux  Angina  Esophageal spasm  Pericarditis  MSK  Myocarditis  Muscle strain  Pulmonary  Costochondritis  Pleural effusion  Rib fracture  Pulmonary embolism  Psychiatric  Vascular  Anxiety/panic attack  Aortic dissection  History  Open-ended —> specific questions  “Do you have discomfort or pain in your chest?” Onset  OLDCAAARTS Location Duration/Progression Character Associated symptoms Alleviating & Aggravating Radiation Timing Severity  History  Onset  What were you doing when it started?  Location Sub-sternal, left-sided  Duration Seconds, minutes, hours  Character Pressing/squeezing/heaviness (MI/anginal) Tearing/ripping (AA) Burning (GERD)  History  Associated symptoms  Alleviating factors Diaphoresis  Rest, NTG Dyspnea  Antacids Nausea  Aggravating factors Weakness  Exercise  Emotional stress Dizziness  Big meals  Lying down  History  Radiation  Timing Shoulders/arms Constant Neck, jaw When did it start? Back Getting worse? Intermittent How often? How long? More frequent?  Severity  Scale of 1-10  Risk factors  Prior hx  Stress  Smoker  Family hx  Hyperlipidemia  Cocaine  Hypertension  Sedentary  Diabetes mellitus Question 3  Which of these chest pain descriptions sound MOST concerning for a cardiac cause?  a. Burning substernal pain that increases with lying down  b. Sharp right-sided pain that increases with deep breathing and palpation  c. Bilateral chest wall pain that is associated with a recent onset of productive cough  d. Left sided squeezing pain that radiates to the jaw and worsens with exertion  e. Left sided chest pressure radiating down bilateral arms that comes on during emotional stress Understanding Cardiac Sounds  Stethoscope  Diaphragm  High pitched sounds: S1, S2, majority of murmurs  Pericardial friction rubs  Bell  Low pitched sounds S3, S4 and some other murmurs  Mitral stenosis (must be on PMI)  If press too hard becomes a diaphragm  The Physical Exam  Patient position is supine with 30 degrees head elevation  Examiner stands on right side of patient  Other positions  Left lateral decubitus (LLD)  Sitting up and leaning forward  Exam Components  Jugular Venous Pressure (JVP)  Carotid Pulse  Heart  Jugular Venous Pressure (JVP)  JVP is measure of pressure on R side of heart  Heart can be thought of as two separate pumps, R & L  JVP measured by observations of pulsations in internal jugular vein in neck and measured level of blood column observed in vein  Jugular Venous Pressure (JVP)  Jugular vein can be thought of as column of blood extending from right atrium to neck  JVP column noted > 4 cm above sternal angle is abnormal  CHF —> R atrial pressure will be elevated —> JVP will be elevated  Kussmaul's sign Sternal angle/ Angle of Louis  Carotid Pulse  Inspect for pulsations  Palpate pulse for amplitude, rate and thrills  Between sternocleidomastoid muscle and trachea  Thrill (vibration) - high flow of blood  Carotid pulse occurs with the apical impulse at S1  One side at a time!!!  Auscultate for bruits - turbulent blood flow  Use bell  Heart Examination  Inspection  Anterior precordium Visible thrills Point of maximum intensity (PMI) or apical impulse  Palpation  Right 2nd ICS, left 2nd ICS, LL Sternal border, apical pulse Lifts, heaves and PMI Left Lateral Decubitus position accentuates PMI  Heart Examination  Auscultation Entireprecordium with Diaphragm R sternal border @2nd ICS (aortic) Left sternal border @2nd ICS (pulm) Left sternal border @ 3rd/4th ICS(tricusp) Left 5th ICS, mid-clavicular line (mitral) or apex  Auscultation Auscultate the aortic valve at the right sternal boarder 2nd intercostal space Auscultate the pulmonic valve at the left sternal boarder 2nd intercostal 2nd intercostal space space Auscultate the tricuspid valve at the left sternal boarder 3rd and 4th 3rd/4th ICS intercostal space 5th ICS Auscultate the mitral valve at the 5th intercostal space, midclavicular line Apple Pie Tastes Marvelous Positional Murmurs  Positional Murmurs Sitting up and leaning forward exhale completely Accentuates aortic murmurs Left lateral decubitus Accentuates mitral murmurs  Positional Murmurs: Left Lateral Decubitus  Ausculate with the Bell Light pressure - low pitched sounds L3rd ICS, L 4th ICS, and 5th ICS @ MCL(apex) ---Accentuates Mitral Stenosis Question 4  An 65-year old female patient presents to your office due to increasing dyspnea on exertion x 1 month. During your cardiac examination you notice a 2/6 systolic murmur that is loudest over the left 5th intercostal space. It is louder in the left lateral decubitus position and when listening with the diaphragm. What is the most likely cause of the patient’s symptoms?  a. Tricuspid regurgitation  b. Tricuspid stenosis  c. Mitral regurgitation  d. Mitral stenosis  e. Pulmonary regurgitation  f. Pulmonary stenosis  Heart Sounds  Heart sounds caused by closure of valves (and blood flow)  Opening of valves silent except when pathology present  On L side of heart S1 = MV closure and S2 = AV closure  On R side of heart S1 = Tricuspid closure and S2 = Pulmonic closure  Heart Sounds  S1 usually loudest at apex  S2 usually loudest at base  Systole – interval between S1 and S2  Diastole - interval between S2 and S1  The interval between S1 and S2 (systole) shorter than interval between S2 and S1 (diastole) until HR gets to 120 bpm  Look at it in action… https://www.youtube.com/watch?v=dBwr2GZCmQM Peripheral Vascular Exam Peripheral Vascular Disease  Any disease of the circulatory system outside of the brain or heart  Any of the blood vessels  Often synonym for peripheral artery disease (PAD) Peripheral Arterial Disease (PAD)  Atherosclerotic occlusion of arteries in lower extremities  Presents chronically as claudication: “angina in the legs”  Presents acutely as critical limb ischemia  Femoral & popliteal arteries most commonly involved  Ankle-brachial index: arterial doppler Chronic or Acute  Risk Factors for PAD  Advanced age  Smoking  Diabetes  Hyperlipidemia  Hypertension  Anatomy  Two Parts of circulatory system Arteries: carry oxygen-rich blood from the heart to the organs Veins: carry oxygen-depleted blood/wastes through the kidneys & liver, and filtered out Systems interconnected by web-like vessels called capillaries Venous blood Anatomy  Arteries--UE  Brachial  Medial antecubital space  Radial & Ulnar  Flexor surface  Radial - lateral  Ulnar - medial  Interconnected by vascular arches  Anatomy  Arteries--LE Femoral Midway between ASIS and pubic symphysis Popliteal Behind the knee Posterior Tibialis (posterior) Behind medial malleolus Dorsalis Pedis (anterior) Dorsal, lat to big toe extensor tendon  Anatomy  Venous system – removes fluids, toxins, wastes, CO2 from tissues Deep veins: carry 90% blood return Superficial: not well supported Thin walled, no contractility One way valves Communicating veins in between Veins from UE —> SVC Veins from LE —> IVC Both empty into RA  Anatomy  Veins--LE Femoral (deep) Great Saphenous (superficial) Small Saphenous (superficial)  Anatomy  Lymphatic system  Drain lymph fluid —> venous circulation Key player in immune function Lymph nodes digest cellular debris and produce antibodies  Anatomy  Epitrochlear nodes  Ulnar surface of forearm and hand  Axillary nodes  Rest of the arm  Femoral nodes  Horizontalgroup: low and, buttocks, ext genitalia, anal/ perianal  Vertical group: thigh, leg, and foot  Anatomy  Fluid Exchange  Capillary bed - blood circulates from arteries to veins  Arterial end fluid: from artery to tissue  Hydrostatic pressure gradient  Venous end fluid: from tissues to vein  Colloid oncotic pressure of plasma protein  Disturbance in forces can disrupt equilibrium  Anatomy  Lymph capillaries drain extracellular fluid  Lymphatic dysfunction causes increased interstitial fluid —> edema  Can be primary (genetic) or secondary (trauma, surgery, cancer, etc) Lymphedema Usually not dependent!  Review of Systems  Pain in extremities  Hair loss  Claudication  Skin color &  Tenderness texture changes  Cold  Skin lesions  Numbness  Swelling  Discoloration  Pallor or erythema  Review of Systems  Pain in arms or legs?  Other potential causes: MS, skin, nervous system, referred pain  Pain with activity that resolves with rest? Intermittent claudication – exercise induced pain  Results from decrease in (arterial) blood supply  Reproducible  Vs neurogenic claudication (spinal stenosis)  Review of Systems  Coldness, numbness or pallor  Decrease in arterial blood flow to extremity  Acute or gradual onset  Hair loss: chronic PAD  Non-healing ulcers  RF: smoking, HTN, DM, HLD, hx MI or CVA  Review of Systems  Color change of fingers in cold weather?  Raynaud’s disease: arterial vasoconstriction  Color changes: pallor —> cyanosis —> rubor  +/-swelling, pain, tingling  Review of Systems  Swelling of distal extremities - venous cause  Timing - end of day?  Provoking/alleviating factors - After being on feet? Decreases with elevation?  Skin color - hyperpigmentation (brownish), cyanosis  Texture changes - thickening, dryness  Lesions - ulcers (but no gangrene)  Arterial Insufficiency  Acute or chronic  Symptoms  Intermittent claudication, pallor, pain, coldness, numbness, ulcers, gangrene  Acute Arterial Insufficiency  Sudden arterial occlusion due to an embolus or thrombus  Sudden onset of painful, cold, pale extremity  +/- numbness, paresthesia, weakness  Decrease or absence of pulse  Concern – gangrene ACUTE PAD IS A LIFE OR LIMB SITUATION!  Chronic Arterial Insufficiency  Gradual decrease in blood  Pallor, thin shiny skin, flow to extremity thickened nails  Atherosclerosis  Hair loss  Intermittent claudication  Painful ulcers  Cool extremity  Toes, pressure points  Dependent rubor  Gangrene can result  Decreased pulses  DR EP: Dependent Rubor Elevation Pallor  Screening for PAD  Ankle Brachial Index (ABI)  Ratio of the systolic BP in the lower legs to the systolic BP in the arms  ABI = SBP-Ankle / SBP-Arm  Doppler ultrasound registers pulse  BP cuff is inflated until the pulse ceases  BP cuff is deflated until pulse returns = SBP  PAD Interventions  Foot care/well fitting shoes  Stop smoking!!!  Treatment of underlying disease  Antiplatelets, statins  Revascularization  Venous Insufficiency  Acute or chronic  Signs/symptoms  Edema (pitting)  Skin darkening  Skin thickening  Ulcers  Pain? (aching/none)  Chronic Venous Insufficiency  Gradual development of pitting edema  Gradual skin changes to dark brown(“brawny”) thickened, dry  Ulcers around ankles – medial, often painless  Dependent edema +/- aching  LE is warm to touch, pulses present  Chronic Venous Insufficiency  Often due to DVT or thrombophlebitis 1. Vein inflammation 2. Valves of veins destroyed 3. Valvular reflux 4. High venous pressures 5. Skin darkens & thickens 6. Dermatitis & ulcers  Other causes: cancer, trauma, varicose veins  Chronic Venous Insufficiency  Venous stasis ulcers  Painless, large, irregular borders  Shallow moist granulation bed  Usually medial ankle  Acute Venous Insufficiency  Sudden onset of pain, swelling, redness of lower extremity  Causes: DVT or thrombophlebitis Deep venous thrombosis Painful, swollen leg, calf tenderness, palpable cords Concern: pulmonary embolism….FATAL! Superficial thrombophlebitis Localized warmth, induration, redness, tenderness, superficial palpable cord (no edema) Varicose Veins  Dilated & tortuous  Failure of valve within veins  Primary or secondary  Can affect both deep and superficial  May be asymptomatic or achy  Mimics  Cellulitis  Acute bacterial infection of the skin  Localized redness over extremity  No palpable cord  Erythema Nodosum  Inflammatory, painful, red lesions on the anterior lower legs  Pregnancy, sarcoidosis, TB, strep infection  Others: nocturnal leg cramps, generally cold extremities Question 5  An 80-year old patient with hx of HLD presents with “right leg pain”. States the pain has been 5/10 severity and occurring intermittently for 6 months. It usually occurs when he walks but for the past day, he has had the pain at rest and it is now 8/10. On examination, the patient’s right leg is colder and more pale than his left and you cannot identify a pulse. What is the next best step?  a. Order an urgent right lower extremity arterial ultrasound w/ABI  b. Order an urgent right lower extremity venous doppler  c. Advise the patient to go to the ER  d. Message your vascular surgery PA colleague  Physical Exam  Divide into upper and lower extremities  Full exposure of extremities  Inspection  Size  Symmetry  Swelling Color Nail beds  Upper Extremity Exam  Palpation  Pulses Radial, brachial (compare bilaterally) 3+ (bounding), 2+ (expected), 1+(weak), 0 (absent)  Temperature  Epitrochlear nodes swelling, tenderness  Special Test: Allen Test (ulnar artery)  Lower Extremity Exam  Inspection  Full exposure – groin to toes  Color & texture of skin and nails Rubor, pallor, cyanosis Lesions, rashes, scars  Swelling of calf  Edema in lower leg or foot  Distribution of hair  Varicose veins  Lower Extremity Exam  Palpation  Pulses: femoral, popliteal, dorsalis pedis, posterior tibialis  0-2+: absent, weak, full, bounding  Temperature  Inguinal nodes  Pitting edema?  Girth of extremity  Tenderness of calf  Lower Extremity Exam  Special tests  Postural color changes  Elevate - pallor  Dependent - rubor  Homan’s sign (DVT)  Pain with dorsiflexion  Poor sensitivity  THANK YOU! *Powerpoint slides were made in collaboration with Jan Stottlemeyer