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Cardiovascular Step 1 Review
UMMSM Board Review Series
Monday, February 6th, 2012
Graham Ingalsbe
[email protected]
Cardiovascular
• Anatomy & Physiology – Cardiac Output, Starling,
Cardiac Cycle, Auscultation, Cell Biology, EKG, Pressures
and Fluids
• Pathology – Congenital Heart Diseases, Hypertension,
Hyperlipidemia, Ischemia/Infarction,
Cardiomyopathies, CHF, Endocarditis, Tumors,
Vaculitides
• Pharmacology – Antihypertensives, Antianginal, Lipidlowering agents, Antiarrhythmics
•
•
•
•
Cardiac Cycle Physiology
Heart Sounds Overview
Cardiac Pearls
Sample Questions
Cardiac Cycle
a wave: atrial
contraction. In late
diastole, atria
propel a final bolus
of blood into each
ventricle
c wave: small rise in
atrial pressures as
the tricuspid and
mitral valves close
and bulge into atria
v wave: passive
filling of the atria
from the systemic &
pulmonary veins
during diastole;
blood accumulates
in atria
S1 & S2
• S1: mitral & tricuspid valves close
– mitral closes before tricuspid
because of higher pressures
– nearly always heard as one sound
• S2: aortic & pulmonic valves close
– Inspiration Decreased
intrathoracic pressure Increased
compliance of pulmonary bed
(hangout time)  pulmonic valve
will close LATER
• Paradoxical split S2: seen in
conditions that prolong LV
emptying (aortic stenosis,
LBBB). Split “eliminated” on
inspiration.
• Widened split S2: seen in
conditions that prolong RV
emptying (pulmonic
stenosis, RBBB)
• Fixed split S2: ASD; left to
right shunt/flow, excess flow
from left heart to pulmonary
bed
S3
• Can be normal in young, healthy
(energetic expansion & filling)
• Occurs in early diastole
• Blood flowing into a
noncompliant chamber (MCC
volume overloaded states)
• Could be left-sided or right-sided
depending on ventricle
• Produces a ventricular gallop
• Idaho
S4
• ALWAYS pathologic
• Coincides w/ atrial contraction in late
diastole & a wave of JVP
• Due to decreased Compliance of LV
– Thickened, stiff ventricle (HTN, MI)
• Left Atrium has to work harder to
push blood into the ventricle
• Could be due to:
– 1) Concentric ventricular hypertrophy
• “atrial gallop”
• Alaska
Murmurs
• Stenosis – opening problem
– Murmurs will be heard when
valve is opening
– Sten: narrow, Os: opening
• Regurgitation – closing problem
– Murmurs will be heard when
valve is attempting to close
Stenosis
• Who is opening in systole?
• Aortic and pulmonic valves
– AS, PS
• Who is opening in diastole?
• Mitral and tricuspid vavles
– Mitral & tricuspid stenosis
Regurgitation
• Who is closing in systole?
• Mitral and tricuspid valves
– Mitral & tricuspid regurgitation
• Who is closing in diastole?
• Aortic and pulmonic vavles
– Aortic and pulmonic
regurgitation
Aortic Stenosis
• Crescendo-decrescendo systolic ejection
murmur
• Best heard at the 2nd intercostal space, right
sternal border
• Radiates to the carotids
• What extra heart sound would appear?
Aortic Stenosis
• Etiology
– Calcification of normal or congenital bicuspid valve
• Pathophysiology
– Obstruction of LV outflow in systole
– Reduction in aortic valve area  concentric LVH
• Patients present SAD
– Syncope (3 years)
– Angina (2 years)
– Dyspnea (Heart failure, 5 years)
• Pulsus parvus et tardus
Mitral Stenosis
• LA is working hard in diastole to push blood into
LV
• Opening snap
• Blood comes rushing into LV: diastolic rumble
• LA can hypertrophy  blood stasis  A fib 
thrombus
• Etiology
Mitral Stenosis
– MCC is recurrent attacks of rheumatic fever
• Pathophysiology
– Narrowing of mitral valve orifice
– Dilated & hypertrophied LA over time
• Patients present with…
1) Dyspnea
2) Dysphagia for solids (big LA on esophagus)
Mitral Regurgitation
•
•
•
•
Blood leaking backwards thru incompetent valve
LA becomes overloaded
Pansystolic, sometimes you can’t hear S1 or S2
Apical murmur, possible S3 & S4
Mitral Regurgitation
• Etiology
– Mitral valve prolapse (most common cause)
– Functional MV regurg (left sided heart failure)
– Infective endocarditis
– Rupture of papillary muscle in MI
– Acute rheumatic fever, Libman Sacks Endocarditis
• Pathophys
– Retrograde blood flow into LA during systole
– Volume overload in LV & LA  LHF
• Patients present with
– Dyspnea, crackles, and cough from LHF
Aortic Regurgitation
• Blood flows back into LV  overloaded 
increased EDV
• Heard after S2 (valve doesn’t close properly)
• High-pitched diastolic blowing murmur
• Heard best in 3rd LIC space
• Can eventually develop S3 & S4
Aortic Regurgitation
• Etiology
–
–
–
–
–
–
–
Long-standing essential HTN (most common cause)
Dilated AV root
Infective endocarditis
Chronic rheumatic fever
Aortic dissection
Coarctation
Syphilitic aortitis, Takayasu arteritis
• Pathophysiology
– Retrograde blood flow into LV
• Patients present with
– Widened pulse pressure, bifid pulse
– bounding pulses, head nodding with systole
Question
A 57 y.o woman with a 6 month history of progressive dyspnea on
exertion is evaluated in the office. Physical exam reveals an
elevated JVP, a grade 2/6 holosytolic murmur at the apex that
radiates to the axilla, an enlarged point of maximal impulse, and
moderate edema up to both shins. An EKG shows left atrial and
ventricular enlargement. CXR shows mild cardiomegaly and
pulmonary congestion. Which of the following is the most likely
diagnosis?
A) Aortic valve regurgitation
B) Aortic valve stenosis
C) Mitral valve regurgitation
D) Mitral valve stenosis
E) Tricuspid valve regurgitation
Question
A 57 y.o woman with a 6 month history of progressive dyspnea on
exertion is evaluated in the office. Physical exam reveals an
elevated JVP, a grade 2/6 holosytolic murmur at the apex that
radiates to the axilla, an enlarged point of maximal impulse, and
moderate edema up to both shins. An EKG shows left atrial and
ventricular enlargement. CXR shows mild cardiomegaly and
pulmonary congestion. Which of the following is the most likely
diagnosis?
A) Aortic valve regurgitation
B) Aortic valve stenosis
C) Mitral valve regurgitation
D) Mitral valve stenosis
E) Tricuspid valve regurgitation
Answer
C) Mitral valve regurgitation
Location: holosystolic, loudest at apex,
radiating to axilla
Pt has signs of LHF: LA & LV enlargement,
pulmonary congestion
Question
A 79 y.o woman is seen in the office for an annual exam. She walks
regularly to and from the bus stop several times per week. It now takes
her 25 min to get to the bus stop, whereas it only took her 10 min a year
ago. She describes dyspnea midway in her walk, causing her to stop and
catch her breath. She does not have angina, syncope or edema.
On physical exam, heart rate is 80/min, and blood pressure is 165/86.
Lungs are clear. There is a sustained apical impulse. S1 is normal, and
there is a single S2 and an S4. A grade 3/6 late-peaking systolic murmur is
heard best at the right second intercostal space with radiation into the
right carotid artery.
Which of the following is the most likely diagnosis?
A) Aortic valve stenosis
B) Hypertrophic cardiomyopathy
C) Mitral valveregurgitation
D) Tricuspid valve regurgitation
E) Ventricular septal defect
Question
A 79 y.o woman is seen in the office for an annual exam. She walks
regularly to and from the bus stop several times per week. It now takes
her 25 min to get to the bus stop, whereas it only took her 10 min a year
ago. She describes dyspnea midway in her walk, causing her to stop and
catch her breath. She does not have angina, syncope or edema.
On physical exam, heart rate is 80/min, and blood pressure is 165/86.
Lungs are clear. There is a sustained apical impulse. S1 is normal, and
there is a single S2 and an S4. A grade 3/6 late-peaking systolic murmur
is heard best at the right second intercostal space with radiation into the
right carotid artery.
Which of the following is the most likely diagnosis?
A) Aortic valve stenosis
B) Hypertrophic cardiomyopathy
C) Mitral valveregurgitation
D) Tricuspid valve regurgitation
E) Ventricular septal defect
Answer
• A) Aortic valve stenosis
• Late peaking systolic murmur, URSB, radiating
to carotids
• Progressive valvulopathy
• Pt has symptomatic disease with exertional
dyspnea & decreased exercise tolerance
Mitral Valve Prolapse
• More common in women
• Associated with Marfans and Ehlers Danlos
syndrome
• Pathophysiology
– Posterior bulging of leaflets into atrium during systole
– Redundancy of leaflets and chordae
• Myxomatous degeneration of mitral valve leaflets due to
excess dermatan sulfate
• Patients present with:
– Most: Asymptomatic
– Palpitations
Mitral Valve Prolapse
• Murmur: mid systolic click, mid-late systolic
crescendo murmur
• Decreased preload causes the click & murmur to
move closer to S1
• Standing, Anxiety, Valsalva
– Increased preload causes it to move closer to S2
• Reclining, Squatting or sustained hand grip
Ventricular Septal Defect
• Defect in interventricular septum
• Harsh pansystolic murmur at lower left sternal
border
• Associations: tetralogy of Fallot, Fetal alcohol
syndrome
• Spontaneously close in 30 – 50% of cases
Atrial Septal Defect
•
•
•
•
Most common adult congenital heart disease
Associations: fetal alcohol syndrome, Down syndrome
Mid-systolic pulmonary flow murmur
Fixed splitting of S2
• Excess blood in pulmonary bed causes delay in closure of
pulmonary valve
Patent Ductus Arteriosus
• Ductus arteriosus remains open
• Associations: congenital rubella syndrome, respiratory
distress syndrome, complete transposition
• Machinery like murmur
• Reversal of the shunt due to increased pulmonary
pressures
– Unoxygenated blood enters the aorta below the subclavian
artery, produces a pink upper body and cyanotic lower body
• Can close with Indomethacin (PGE2 KEEP)
Question
A 19 y.o woman is evaluated in the office for palpitations described as “extra
beats” that do not occur regularly. She has no history of syncope or presyncope,
no cardiovascular risk factors, and no family history of cardiovascular disease. She
does not have signs or symptoms of congestive heart failure and takes no
medications.
On physical exam, vital signs are normal. Lungs are clear. There is no S4 or S3. A
grade 2/6 late systolic murmur is present that is heard best at the apex and
radiates towards the left axilla. A mid-systolic click is heard. Following a valsalva
maneuver and a squat-to-stand maneuver, the midsystolic click moves closer to S1,
but the intensity of the murmur does not change. The rest of the exam is
unremarkable.
Which of the following is the most likely diagnosis accounting for the heart
murmur?
A) Innocent flow murmur
B) Hypertrophic cardiomyopathy
C) Mitral valve regurgitation
D) Mitral valve prolapse
Question
A 19 y.o woman is evaluated in the office for palpitations described as “extra
beats” that do not occur regularly. She has no history of syncope or presyncope,
no cardiovascular risk factors, and no family history of cardiovascular disease. She
does not have signs or symptoms of congestive heart failure and takes no
medications.
On physical exam, vital signs are normal. Lungs are clear. There is no S4 or S3. A
grade 2/6 late systolic murmur is present that is heard best at the apex and
radiates towards the left axilla. A mid-systolic click is heard. Following a valsalva
maneuver and a squat-to-stand maneuver, the midsystolic click moves closer to S1,
but the intensity of the murmur does not change. The rest of the exam is
unremarkable.
Which of the following is the most likely diagnosis accounting for the heart
murmur?
A) Innocent flow murmur
B) Hypertrophic cardiomyopathy
C) Mitral valve regurgitation
D) Mitral valve prolapse
Answer
D) Mitral valve prolapse
Midsystolic click followed by a late systolic
murmur
In MVP, the valsalva maneuver and standing
from squatting position move the clickmurmur complex closer to S1
Question
A 24 y.o woman who is 23 weeks pregnant is evaluated in the office
because of a 2-month history of increasing shortness of breath. On
physical exam, blood pressure is 100/80 and HR is 88/min and
regular, and RR is 26. On cardiac exam, the apical impulse is faint in
the mid left 6th IC space, and there is a forceful sternal heave. A
soft apical systolic murmur, and an opening snap followed by a
grade 2/6 mid diastolic murmur. Which of the following is the most
likely diagnosis?
A) Aortic valve stenosis
B) Mitral valve stenosis
C) Normal findings of pregnancy
D) Patent ductus arteriosus
E) Peripartum cardiomyopathy
Question
A 24 y.o woman who is 23 weeks pregnant is evaluated in the office
because of a 2-month history of increasing shortness of breath. On
physical exam, blood pressure is 100/80 and HR is 88/min and
regular, and RR is 26. On cardiac exam, the apical impulse is faint in
the mid left 6th IC space, and there is a forceful sternal heave. A
soft apical systolic murmur, and an opening snap followed by a
grade 2/6 mid diastolic murmur. Which of the following is the
most likely diagnosis?
A) Aortic valve stenosis
B) Mitral valve stenosis
C) Normal findings of pregnancy
D) Patent ductus arteriosus
E) Peripartum cardiomyopathy
Answer
B) Mitral valve stenosis
Loud S1, opening snap followed by a rumbling
diastolic murmur
Previously undiagnosed mitral stenosis often
first becomes symptomatic during pregnancy
Dilated Cardiomyopathy
• Causes: alcohol, Beriberi, idiopathic, genetic,
Coxsackie B myocarditis, drugs (doxorubicin,
daunorubicin), peri/postpartum state, chronic
cocaine use, organic solvents, acromegaly
• Pathophysiology
– Decreased contractility  SYSTOLIC dysfunction type of
LHF
• Patients present with…
–
–
–
–
–
All chambers dilated (global enlargement)
Regurgitation murmurs
S3
Balloon appearing on CXR
EF usually less than 40%
Hypertrophic Cardiomyopathy
• Most common cause of sudden cardiac death in young
people
• Pathophys: hypertrophy of myocardium
– As blood exits LV, the anterior leaflet of the mitral valve is
drawn against the asymmetrically hypertrophied IVS
– S4, systolic ejection murmur best at LLSB, slow & late-peaking
– DIASTOLIC dysfunction
Restrictive Cardiomyopathy
• Caused by: amyloidosis,
radiation, fibrosis after openheart surgery; Infiltrative
diseases: hemochromatosis,
sarcoidosis
• Pathophys: decreased
ventricular compliance 
DIASTOLIC dysfunction type of
LHF
• Patients present with…
– Progressive LHF and RHF
• Treat underlying cause
Manuevers to Differentiate Systolic Murmurs
• Changing Venous return (preload)
Valsalva
Squat -> Stand
Stand -> Squat
Passive leg elevation
• Changing Systemic Vascular Resistance (afterload)
Hand Grip
Nitrate
Manipulating Venous Return
• Decreased with valsalva and squatting to
standing- HOCM gets louder
• Increased with standing to squatting and
passive leg elevation – HOCM gets softer
SVR (Afterload)
• Hand grip increases afterload – increases
regurg murmurs and VSD (decreased in
HOCM, MVP)
• Nitrate decrease afterload
Valsalva
• Antonio Valsalva (1666-1723) was the first to
describe and drain the eustachian tube
• Manuever changes intrathoracic pressure and
venous return
• Bear down -> increases ITP, decreased return
and therefore LV volume (HOCM and MVP
louder, most others softer)
Question
A 32 y.o man is evaluated in the office during an annual physical.
He is asymptomatic and there is no personal or family hx of cardiac
disease. On physical exam, vital signs are normal. S1 and S2 are
present, and there is an S4. There is a grade 2/6 cresendo
decresendo systolic murmur heard best at the lower left sternal
border. The murmur does not radiate to the carotid arteries. The
valsalva maneuver increases the intensity of the murmur, and
moving from a squatting to standing position decreases the
intensity. Which of the following is the most likely diagnosis?
A) Aortic valve stenosis
B) Atrial septal defect
C) Hypertrophic cardiomyopathy
D) Mitral valve prolapse
E) Ventricular septal defect
Question
A 32 y.o man is evaluated in the office during an annual physical.
He is asymptomatic and there is no personal or family hx of cardiac
disease. On physical exam, vital signs are normal. S1 and S2 are
present, and there is an S4. There is a grade 2/6 cresendo
decresendo systolic murmur heard best at the lower left sternal
border. The murmur does not radiate to the carotid arteries. The
valsalva maneuver increases the intensity of the murmur, and
moving from a squatting to standing position decreases the
intensity. Which of the following is the most likely diagnosis?
A) Aortic valve stenosis
B) Atrial septal defect
C) Hypertrophic cardiomyopathy
D) Mitral valve prolapse
E) Ventricular septal defect
Answer
• C) Hypertrophic cardiomyopathy
• Murmur increases after a Valsalva maneuver
and decreases with standing to squatting
• Does not radiate to carotids
Question
A 38 y.o man is hospitalized with palpitations and dyspnea. He has no significant medical hx and does
not take any medications. He has a 20 pack year smoking hx and drinks alcohol daily. Does not use
illicit drugs.
On physical exam, temperature is 98.5, blood pressure 120/80, and HR is 115. Lungs are clear. Cardiac
exam shows an irregularly irregular rhythm. There is trace edema at both ankles.
Lab studies:
Hemoglobin
14g/dL
Mean corpuscular volume
101 fL
AST
55 U/L
ALT
45 U/L
TSH
4.5 microU/mL
EKG shows normal voltage, normal axis and atrial fibrillation. Echocardiogram shows dilated ventricles
with normal wall thickness and severely decreased systolic fuction (LV EF: 15%). The patient is started
on lisinopril, carvedilol, and warfarin. Later in the hospital course, he spontaneously converts to
regular rhythm and feels well. EKG shows normal sinus rhythm.
Which of the following is the most likely type of cardiomyopathy in this patient?
A) Alcoholic
B) Amyloid
C) Hypertrophic
D) Ischemic
Question
A 38 y.o man is hospitalized with palpitations and dyspnea. He has no significant medical hx and does
not take any medications. He has a 20 pack year smoking hx and drinks alcohol daily. Does not use
illicit drugs.
On physical exam, temperature is 98.5, blood pressure 120/80, and HR is 115. Lungs are clear. Cardiac
exam shows an irregularly irregular rhythm. There is trace edema at both ankles.
Lab studies:
Hemoglobin
14g/dL
Mean corpuscular volume
101 fL
AST
55 U/L
ALT
45 U/L
TSH
4.5 microU/mL
EKG shows normal voltage, normal axis and atrial fibrillation. Echocardiogram shows dilated ventricles
with normal wall thickness and severely decreased systolic fuction (LV EF: 15%). The patient is
started on lisinopril, carvedilol, and warfarin. Later in the hospital course, he spontaneously converts
to regular rhythm and feels well. EKG shows normal sinus rhythm.
Which of the following is the most likely type of cardiomyopathy in this patient?
A) Alcoholic
B) Amyloid
C) Hypertrophic
D) Ischemic
Answer
A) Alcoholic cardiomyopathy
Dilated cariomyopathy
Usually occurs after many years but can occur
after a short period of heavy consumption
Both ventricles are dilated
Pt reports drinking daily
Labs suggest chronic use (macrocytosis –
possible folic acid deficiency), acute episode of
heavy use (mild elevation of aminotransferases,
new onset A fib)
Question
A 34 year old male experiences shortness of breath with minimal
exertion. Physical examination reveals elevated jugular venous
pressure markedly worse with inspiration, a regular rhythm with an
S4 heart sound and 2+ lower extremity pitting edema. Laboratory
studies are normal. Cardiac biopsy revealed green birefringence
with congo red staining. Genetic testing reveals a mutation in the
transthyretin gene. Which of the following is the correct diagnosis?
A) Restrictive cardiomyopathy
B) Dilated cardiomyopathy
C) Constrictive pericarditis
D) Hypertrophic obstructive cardiomyopathy
E) Chagas cardiomyopathy
Answer
A ) Restrictive cardiomyopathy
Amyloidosis of the heart causes a restrictive cardiomyopathy
majority of the cases are due to a mutation in the transthyretin gene resulting in the
abnormal deposition of this protein in the myocardial tissue
The typical stain for amyloid is the congo red stain which displays an “apple green
birefringence”. Restrictive cardiomyopathy can also occur from sarcoidosis or
hemachromotisis
Physical examination reveals an S4 heart sound due to impaired relaxation
Dilated cardiomyopathy (B) can occur from viral myocarditis, alcohol, pregnancy, or
can be idiopathic. An S3 heart sound would be present.
Constrictive pericarditis (C) occurs after prior heart surgery or if many episodes of
pericarditis has occurred. A Kussmal’s sign may also be present, but congo red staining
would be negative.
Hypertrophic obstructive cardiomyopathy or HOCM (D) presents with exertional
symptoms such as syncope or sudden death. An S4 heart sound may also be present,
but again congo red staining would be negative.
Chagas cardiomyopathy (E) is due to infection with Tympanosoma cruzi and is
associated with dilated cardiomyopathy, megaesophagus, and megacolon. Parasites
may be seen on the biopsy.
Question
A man recently was started on a new medication by his PCP
after he was found to have an LDL of 188mg/dL. Several
weeks later he presented to the emergency department
with back pain and blood was detected on urine dipstick,
but urinalysis showed no red blood cells. What medication
was the patient most likely prescribed?
A. Niacin
B. Cholestyramine
C. Ezetimibe
D. Atorvastatin
E. Gemfibrozil
Question
A man recently was started on a new medication by his PCP
after he was found to have an LDL of 188mg/dL. Several
weeks later he presented to the emergency department
with back pain and blood was detected on urine dipstick,
but urinalysis showed no red blood cells. What medication
was the patient most likely prescribed?
A. Niacin
B. Cholestyramine
C. Ezetimibe
D. Atorvastatin
E. Gemfibrozil
Question
A 62-year-old gentleman who was recently diagnosed
with an ST-segment elevation myocardial infarction
acutely develops emesis, cool and clammy skin, dilated
neck veins, and syncope. On examination he has
distant heart sounds. How long ago was his myocardial
infarction?
A. 2-4 hours
B. 1-2 days
C. 3-7 days
D. 1-2 weeks
E. More than 1 month ago
Question
A 62-year-old gentleman who was recently diagnosed
with an ST-segment elevation myocardial infarction
acutely develops emesis, cool and clammy skin, dilated
neck veins, and syncope. On examination he has
distant heart sounds. How long ago was his myocardial
infarction?
A. 2-4 hours
B. 1-2 days
C. 3-7 days
D. 1-2 weeks
E. More than 1 month ago
Cardiac Pearls/Buzzwords
•
•
•
•
•
•
•
•
•
•
•
APT M 2245
Young basketball player passes out? HOCM
SLE gives LSE – sterile vegetations
Antihypertensive drug with terrible rebound hypertension?
Clonidine
Hypertensive crisis coming from a wine tasting? Taking an MAOI
Bipolar woman has child with heart defect? Ebstein’s anomaly
“Tearing” chest pain – aortic dissection
Several weeks after MI with new-onset friction rub – Dressler’s
Lipids
CHF
Vasculidites
Link to Heart Sounds
• http://www.egcrme.com/gcrme/essential_ausc/#/big12pra
ctice
• http://depts.washington.edu/physdx/heart/te
ch.html
General Advice
•
•
•
•
•
Make a schedule, stick to it
Keep a routine
Resources: Less is more
Exercise
Trust yourself

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