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Lecture

Hypertrophy of the Heart.docx

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Department
Nursing
Course Code
NURS 203
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All

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Hypertrophy of the Heart Concentric (thick) HPY’d heart vs. Dilated HPY heart: 2 different etiologies, and they involve work. It requires a lot of work to contract and push blood thru a stenotic aortic valve, or increased TPR from HTN. These will cause an increased afterload = concentric HPY. If you have a valvular problem, and have excess volume of blood in the ventricles – increased preload = increased work. Therefore, the frank starling goes into effect b/c stretching and increasing preload in there, and you have to work harder to increase the force of contraction – this produces dilated HPY. Therefore, concentric HPY = afterload problem; dilated HPY = volume overload = preload problem (increased volume) Heart sounds – S1 heart sound = beginning of Systole = mitral and tricuspids close (mitral closes before the tricuspid b/c higher pressures) S2 heart sound = beginning of Diastole = pulmonic and aortic close (variation with respiration – as diaphragm goes down they increase the intrathoracic pressure. Blood is being sucked into the right side of the heart, and the pulmonic valve will close later than the aortic valve. So, the second heart sound has a variation with inspiration – the P2 separates away from A2 b/c more blood coming into the right heart, so the valve closes a little bit later. S3 heart sound = normal under 35 y/o’s. After that, it is pathologic. S1 = beginning of systole and S2 = beginning of diastole; obviously, S3 = early diastole. S3 is due to blood, in early diastole, going into a chamber that is volume overloaded. So, blood from the left atrium is going into overloaded chamber, causing turbulence, which is the S3 heart sound. Only hear S3 heart sound in volume overloaded chamber. It could be from LHF (left ventricle overloaded) or RHF (right vent overloaded), so there are left sided S3’s and right sided S3’s – it means volume overload in the chamber. Analogy: rivers going into ocean – leads to turbulence (ocean is the ventricle with a lot of fluid in it and the river is the blood coming in during diastole; the river hits this large mass of fluid in the ventricle, causing turbulence and an S3 heart sound). S4 heart sound = late diastole – this is when the atrium is contracting and you get the last bit of blood out of the atrium into the ventricles, leading to S4 sound. S4’s occur if there is a problem with compliance. Compliance is a filling term. So, when talking about compliance, referring it’s ability to fill the ventricle. The left atrium is contracting, trying to get blood into a thick ventricle; the ventricle is noncompliant, and therefore resistance will occur. This will create a vibration, leading to an S4 heart sound. An S4 heart sound is due to a problem with compliance. The left atrium is encountering a problem in putting blood in late diastole into the left ventricle and it doesn’t want to fill up anymore. This could be due to 2 reasons: (1) b/c it’s hypertrophied (it doesn’t want to fill anymore–restricting filling up) or (2) it’s already filled up and has to put more blood in an already overfilled chamber. Summary: Slides: Vol overloaded? No S3. So can it have an S4? Yes. If you have HTN, which type of heart will you have? Concentric HPY. So, in HTN, which type of heart sound will you have? S4. Vol overloaded? Yes. So can it have an S3? Yes; can it also have an S4? Yes. Why can it also have an S4? B/c it can’t fill up anymore. Analogy: turkey dinner – all filled up, but always room for desert – lil vibration that occurs when it fills is an S4 heart sound. So you have both S3 and S4 heart sound = gallop rhythm (they have S1, 2, 3, and 4). How do you know if its from the left or right? It is breathing. When you breath in, you are sucking blood to the right side of the heart. All right sided heart murmurs and abnormal heart sounds (ie S3, S4) increase in intensity on inspiration – this is more obvious b/c there is more blood in there, and it emphasizes those abnormal sounds. Prob get them on expiration with positive intrathoracic pressures that are helping the left ventricle push blood out of the heart – this is when abnormal heart sounds and abnormal murmurs will increase in intensity on expiration. So, all you have to do is figure out that there is an S3 heart sound. *****Then, you have to figure out which side it is coming from. Louder on expiration, therefore its from the right side. Example: essential HTN = left; Mitral regurg = right; and Mitral stenosis = middle. Murmurs Stenosis = prob in opening, that is when the valve is opening, and that is when the murmur occurs. Regurgitation = prob in closing the valve, that is when the valve is closing, and that is when the murmur occurs. Need to know where valves are heard best – right 2 ICS (aortic valve), left 2 ICS (pulmonic), left parasternal border (tricuspid), apex (mitral) – this isn’t necessarily where the valve is, but where the noise is heard the best. A. Stenosis: Systolic Murmurs: Who is opening in systole = aortic and pulmonic valves = therefore, murmurs of aortic stenosis and pulmonic stenosis are occurring in systole. Thi
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