Term
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Definition
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Term
| Let's talk about jugular venous waveforms. What do the wave points (A wave, X descent, C wave, V wave, Y descent) correspond to? |
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Definition
A wave: atrial contraction
X descent: atrial relaXation
C wave: tricuspid valve closure (blood backs up from R atrium into jugular)
V wave: atrial filling (ventricular contraction)
Y descent: tricuspid opening |
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Term
| Where should the normal jugular be visible? What happens in fluid overload? |
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Definition
| In lower 1/3 of neck. With fluid overload (congestion), it is visible higher up the neck (represents increased left atrial pressure) |
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Term
| What does a pronounced jugular A wave represent? |
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Definition
| Incompliant RV (increased atrial afterload, so blood backs up up the jugular). |
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Term
| What does a pronounced jugular V wave represent? |
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Definition
| Tricuspid regurg. (V wave is atrial filling during ventricular contraction, so if valve is incompetent, extra blood is going back to atrium and increasing jugular pressure. |
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Term
| What is hepatojugular reflux and how is it used to assess cardiac function? |
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Definition
Cranial abdominal pressure -> increased venous return to RA
Normal response: minimal JV elevation, immediate return to normal
Persistently elevated or slow return (positive reflux) with R heart disease |
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Term
| Where do you normally hear the apex beat (cardiac impulse), and what do variations signify? |
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Definition
| Left ventral thorax, at left 5th ICS just behind costochondral junction. It should be stronger on left than right side. Caudal displacement suggests hypertrophy. Louder on R than L suggests right side hypertrophy. |
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Term
| What is responsible for the palpable pulse? |
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Definition
| Pulse pressure, i.e. the difference between systolic and diastolic pressure. Pulse is stronger when SV is greater. |
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Term
| What are bounding pulses typical of? |
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Definition
| Aortic insufficiency or PDA. |
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Term
| What is pulsus parvus and what is it associated with? |
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Definition
| Weak pulse. Decreased SV, severe cardiac dz, aortic stenosis, arterial obstruction. |
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Term
| What is pulsus alternans and what does it mean? |
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Definition
| Alternating strong and weak pulse beats (corresponding to up and down SV); usually assoc. with myocardial disfunction or tachyarrythmias resulting in reduced filling. |
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Term
| What is a bigeminal pulse? |
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Definition
| Strong/weak alternating beats, usually from premature beats. |
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Term
| What is pulsus paradoxus? |
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Definition
| Decreased pulse pressure on inspiration, from cardiac tamponade. |
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Term
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Definition
| Late-rising pulse due to aortic stenosis (delayed blood emptying through stenosis). |
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Term
| What are the diaphragm and bell of the stethoscope best for? |
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Definition
Diaphragm: high-frequency sounds (murmurs)
Bell: Low-freq. sounds (normal beats, gallops) |
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Term
| Where do you listen for valve sounds? |
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Definition
P: 2nd ICS: well under the elbow
A: 3rd ICS: at point of elbow
M: 4th ICS: just caudal to elbow
T: 3rd/4th ICS on right |
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Term
| What is heart sound 1 and what does it correspond to? |
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Definition
"Lub." Closure of AV valves.
May be split in normal animals (left/right), esp. larger ones with slower HRs. May be pathologically split with poor LV/RV synchrony, e.g. bundle branch block.
Louder under hyperdynamic conditions, softer with increased HR, reduced systolic function (DCM or cardiac tamponade) and shock. |
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Term
| What is heart sound 2 and what does it correspond to? |
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Definition
"Dup." Closure of semilunar valves.
May be split in normal animals (aortic then pulmonary, since RV ejection takes longer than left), esp. larger ones with slower HRs. Split is accentuated on inspiration. Can be heard loudest over pulm. and aortic valves. |
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Term
| What is nocturnal dyspnea characteristic of? |
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Definition
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Term
| What can cause sudden onset of dyspnea? |
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Definition
| PTE, heartworm dz, spontaneous pneumothorax, "flash" pulmonary edema, severe anxiety. |
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Term
| What must the reduction in SaO2 be before cyanosis is seen? |
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Definition
| <85-90% (thus cyanosis is an insensitive indicator of hypoxemia) |
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Term
| What is the definition of central (vs. peripheral) cyanosis? |
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Definition
| Central affects skin and mucous membranes, whereas peripheral affects one local area. |
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Term
| What does differential cyanosis look like, and what is it virtually pathognomonic for? |
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Definition
| Cranial mucous membranes pink, caudal ones cyanotic. Points to PDA. May have to exercise animal to see this finding. |
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Term
| What are PE findings with RCHF (or biventricular failure)? |
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Definition
Hepatomegaly
Ascites
Pleural effusion
...along with some evidence of heart disease. |
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Term
| How can you differentiate syncopy from a seizure? |
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Definition
| Loss of consciousness due to syncopy (transient interruption of blood flow to the brain) is over soon and recovery is rapid; no post-ictal phase as with seizures. |
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Term
| What is CVP and how is it measured? What is normal? |
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Definition
| Central venous pressure, estimated by the height of the jugular pulse above the thoracic inlet (plus 1-4 cm depending on size of dog for distance btw thoracic inlet and right atrium), should normally be 3-5 mmHg. |
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Term
| What can cause a "giant A wave"? |
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Definition
1. Incompliant right ventricle (hypertrophic ventricle due to pulmonary hypertension, pulmonic stenosis, pulmonary obstruction or tricuspid stenosis, although this is rare).
2. Atrium contracting against a closed tricuspid valve (i.e. atrial/ventricular asynchrony) |
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Term
| What grade murmur may be felt as a thrill? |
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Definition
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Term
| What is paradoxical splitting of the S2 sound? |
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Definition
| The aortic valve, which normally closes slightly before the pulmonic valve, experiences delayed closure due to, perhaps, systemic hypertension or aortic stenosis, and closes AFTER the pulmonary valve. |
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Term
| What is the definition of a gallop? |
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Definition
| Abnormal diastolic sound. |
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Term
| How can you accentuate a gallop during a PE? |
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Definition
| Pressure on the cranial abdomen results in increased venous return, which tends to magnify gallops. |
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Term
| What does an S4 gallop suggest? |
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Definition
| Ventricular hypertrophy. Incompliant ventricle results in sudden deceleration of blood entering from atrium. |
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Term
| When is an S3 sound heard, and what does an S3 gallop suggest? |
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Definition
| Heard at the end of rapid ventricular filling (during diastole). Indicates a large, dilated, failing ventricle. |
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Term
| What is a summation gallop? |
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Definition
| S3 and S4 overlap. Perhaps separately they were too quiet to be heard, but summed together they are loud enough to identify. May be pathologic, but may be normal. If the summation gallop comes and goes as heart rate varies, it's probably an artifact of overlapping heart events (more common in cats, since their HR is higher)....i.e. not pathologic. |
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Term
| What shape does a holosystolic murmur have on a phonocardiogram? What is it characteristic of? |
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Definition
Plateau from S1 to S2.
Characteristic of AV regurg or ventricular septal defect. (aka regurgitant murmur) |
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Term
| What shape does an ejection murmur have on a phonocardiogram? What is it characteristic of? |
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Definition
Diamond shape (crescendo, decrescendo) between S1 and S2.
Characteristic of aortic or pulmonic stenosis or ventricular septal defect. |
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Term
| What shape does a diastolic murmur have on a phonocardiogram? What is it characteristic of? |
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Definition
Triangle pointing to right with base at S1, point at S2 (decrescendo).
Characteristic of semilunar insufficiency. |
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Term
| What is a continuous murmur? |
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Definition
| It is heard all the time (obliterates ALL normal heart sounds). |
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Term
| What does AV valve stenosis look like on a phonocardiogram? |
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Definition
| A mid-diastolic and pre-systolic murmur: a decrescendo beginning at S3, and a crescendo ending at S1. |
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Term
| What effect would hypertension have on regurgitant vs. ejection murmurs? How about hypotension? |
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Definition
| Regurgitant murmurs would get louder, while ejection murmurs would decrease. Opposite with hypotension. |
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Term
| Where is a mitral insufficiency murmur best ausculted? |
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Definition
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Term
| Where is a mitral insufficiency murmur best ausculted? |
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Definition
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Term
| Where is a tricuspid insufficiency murmur best ausculted? |
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Definition
| Over tricuspid valve (right 4th ICS). |
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Term
| Where is a ventricular septal defect murmur best ausculted? |
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Definition
| Over tricuspid valve (right 4th ICS). |
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Term
| What is the most common cause of a diastolic murmur? |
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Definition
| Aortic regurgitation. Pulmonic regurg or AV stenosis would cause a similar murmur but are uncommon. |
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Term
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Definition
I: soft: only heard at one location with difficulty in absence of extraneous noise.
II: soft, heard readily at a specific location (such as single ICS), perhaps with mild spreading of PMI (point of max intensity)
III: medium; heard readily across say 2 ICSs; possibly also on opposite side of thorax.
IV: medium; readily auscultable on both sides of thorax. No thrill.
V: loud; with thrill on one side of thorax.
VI: loud; thrill on both sides of thorax. Audible with stethoscope lifted off thorax. |
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Term
| Are diastolic murmurs common in dogs and cats? |
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Definition
| No. They can be caused by AV stenosis. |
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Term
| Where is an S3 gallop best heard? |
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Definition
| PMI usually at left apex. Low "thud" best heard with bell. |
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Term
| Are S3 and S4 sounds normal or abnormal? |
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Definition
| Pathologic in small animals; can be normal in large. |
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Term
| Where is an S4 gallop best heard? |
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Definition
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Term
| Can an animal in atrial fib have an S4? |
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Definition
| No, because S4 is due to deceleration of blood in the ventricle following atrial kick. |
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Term
| What abnormal heart sounds can iatrogenic fluid overload cause? |
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Definition
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Term
| What is the midsystolic click caused by? |
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Definition
| Mitral valve prolapse ("twanging" of elongated chordae tendinae). |
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