11 - Heart Flashcards
Most common cause of right-sided heart failure:
left-sided heart failure
Most congenital heart defects arise from _____ weeks AOG
3-8 weeks
Most common genetic cause of congenital heart disease:
Trisomy 21
Most common congenital heart defect in Trisomy 21:
atrioventricular septal defect
most common type of ASD:
secundum
most common congenital heart defect:
VSD
most common type of VSD:
perimembranous
most common cyanotic congenital heart defect:
Tetralogy of Fallot
Enumerate: What are the components of TOF?
- VSD
- overriding aorta
- pulmonary stenosis
- RVH
Most common cause of ischemic heart disease:
atherosclerosis of epicardial coronary arteries
Most sensitive cardiac biomarkers:
cardiac troponins (T and I)
Most specific cardiac biomarkers:
cardiac troponins (T and I)
Identfiy: cardiac biomarker used to assess reinfarction:
CK-MB
Most common cause of sudden cardiac death:
coronary artery disease
Most common mechanism of sudden cardiac death:
lethal arrhythmia
Most common cause of arrhythmia:
ischemic injury
Most common cause of right-sided hypertensive heart disease:
left-sided hypertensive heart disease
Valvular involvement in rheumatic heart disease, in descending order:
- mitral valve
- aortic valve
- tricuspid valve
- pulmonic valve
Most commonly affected valves in infective endocarditis (2):
- aortic valve
- mitral valve
left side!
Most commonly affected valves in infective endocarditis among IV drug users (2):
- pulmonic valve
- tricuspid valve
right side!
Most common cause of myocarditis:
viral infection, most commonly Coxsackie virus
most common primary cardiac tumor in adults:
Myxoma
most common primary cardiac tumor in children:
rhabdomyoma
Most common form of acute pericarditis:
fibrinous/serofibrinous
Most common cause of hemorrhagic acute percarditis
tumors
Most common cause of caseous acute pericarditis:
tuberculosis infection
Most striking clinical finding in acute pericarditis:
pericardial friction rub
The left ventricle is hypertrophied and dilated, with secondary left atrial dilation; the lungs are heavy and boggy, with perivascular and interstitial transudate, alveolar septal edema, and intra-alveolar edema; hemosiderin-laden macrophages (heart failure cells) are present; most common cause of right-sided heart failure.
Left-sided heart failure
Isolated right-sided HF occurring in patients with intrinsic lung disease that result in chronic pulmonary hypertension.
Cor Pulmonale
Long standing severe right-sided HF leads to fibrosis of centrilobular areas, creating this condition.
Cardiac cirrhosis
Most CHDs arise in this period.
3-8 weeks AOG
Most common genetic cause of CHDs.
Trisomy 21
Common radiographic feature of acyanotic CHDs.
Increased pulmonary blood flow
Feature that will distinguish PDA from VSD radiographically.
Prominent aortic knob (because both show LVH/BVH)
Chamber that enlarges in ASD.
Right ventricle
Smooth-walled defect near the foramen ovale, usually without associated cardiac abnormalities; comprises 90% of ASDs; regardless of type, most common congenital heart disease in adults.
Ostium secundum atrial septal defect
Natural history of ASDs.
Spontaneous closure for small to moderate-sized ASDs
Incomplete closure of the ventricular septum leading to left-to-right shunting; the right ventricle is hypertrophied and often dilated; diameter of pulmonary artery is increased because of the increased volume by the right ventricle; most common congenital heart disease overall; most common type is perimembranous (90%).
Ventricular septal defect (VSD)
Natural history of VSDs.
Small defects usually close spontaneously (common: 1st 2 YOL); Vast majority of lesions that close do so before age 4; moderate to large VSDs are less likely to close
Main determinant of clinical outcome in isolated VSDs.
Size (<5mm: clinically asymptomatic; >10mm: clinically with failure to thrive and repeated infections)
5/w infant presents with tachypnea, diaphoresis, and difficulty feeding; a harsh, continuous machinery-like murmur was noted upon auscultation. The most likely diagnosis is:
Patent ductus arteriosus (PDA)
The reason why PDA in preterm infants has a greater chance of spontaenous closure than in term infants.
PDA in term lacks mucoid endothelium and muscular media
Drug that can maintain patency of ductus arteriosus; vital in patients with duct-dependent lesions.
PGE2
The most common cause of cyanotic congenital heart disease. Heart is large and boot-shaped as a result of right ventricular hypertrophy; components are: PS, RVH, VSD; and aorta overriding the VSD.
Tetralogy of Fallot (TOF)
Main determinant of clinical outcome in TOF patients.
Degree of PS
It is a discordant connection of the ventricles to their vascular outflow; defect is an abnormal formation of the truncal and aortopulmonary septa; common in infants of diabetic mothers and in males; radiographically, egg on the side appearance
Transposition of the Great Arteries (TGA)
Absence of direct connection between RA and RV, due to unequal division of the AV canal.
Tricuspid atresia
Characterized by circumferential narrowing of the aortic segment between the left subclavian artery and the ductus arteriosus; DA is usually patent and is the main source of blood to the distal aorta; RV is hypertrophied and dilated; pulmonary trunk is also dilated; clinically presents as lower extremity cyanosis.
Preductal infantile Coarctation of the aorta
Aorta is sharply constricted by a ridge of tissue at or just distal to the nonpatent ligamentum arteriosum; constricted segment is made of smooth muscle and elastic fibers that are continuous with the aortic media, and lined by thickened intima; DA is closed; proximally, the aortic arch and its vessels are dilated; LV is hypertrophic; there is upper extremity hypertension, due to poor perfusion of the kidneys, but weak pulses and low blood pressure in the lower extremities; claudication and coldness of the lower extremities also present; enlarged intercostal and internal mammary arteries due to collateral circulation, seen as rib notching on X-ray.
Postductal adult Coarctation of the aorta
A condition wherein ischemia causes pain but is insufficient to lead to death of myocardium; can be stable (secondary to increased demand), unstable (crescendo; secondary to decreased supply), or Prinzmetal (secondary to coronary vasospasm).
Angina pectoris
A condition wherein the severity or duration of ischemia is enough to cause cardiac muscle death.
Acute myocardial infarction (AMI)
Pattern of infarction caused by occlusion of an epicardial vessel, through a combination of chronic atherosclerosis and acute thrombosis; also referred to as STEMI or Q wave MI; infarct involving 50% of the myocardial wall thickness.
Transmural infarctions
Pattern of infarction caused by plaque disruption or hypotension leading to transient decreases in oxygen delivery, causing circumferential myocardial damage; also referred to as NSTEMI or non-Q wave MI.
Subendocardial infarction
Heart dominance is determined by:
Vessel that gives rise to the posterior IV (descending) branch; either RCA (right dominant) or LCX (left dominant); most common: RCA (90%)
Most common vessel involved in AMI:
Left anterior descending artery (LAD) (40-50%)
Stain used for infarcts more 2-3 hours old for visualization.
Triphenyltetrazolium chloride
Most sensitive and specific cardiac biomarkers:
Cardiac troponins (Troponin I and T)
Injury to infarcts mediated in part by oxygen free radicals generated by increased number of infiltrating leukocytes facilitated by reperfusion; CK-MB is usually used as cardiac biomarker for diagnosis.
Reperfusion injury
Most common site of myocardial rupture.
Ventricular free wall (clinically, cardiac tamponade)
Fibrinous pericarditis post-MI.
Dressler syndrome
Cause of acute MR post MI.
Papillary muscle dysfunction (more common); papillary muscle rupture
This refers to progressive cardiac decompensation (heart failure) following myocardial infaction.
Chronic ischemic heart disease
Typical morphology of chronic IHD (gross and microscopic)
- Left ventricular dilation and hypertrophy (Gross)
- Myocardial hypertrophy, diffuse subendocardial vacuolization and fibrosis (Microscopic)
This can result from a lethal arrhythmia following myocardial ischemia; most common cause is CAD (80%); most common mechanism is a lethal arrhythmia (asystole or ventricular fibrillation).
Sudden cardiac death (SCD)
Typical morphology of systemic hypertensive heart disease.
Left ventricular hypertrophy
Earliest change seen in left-sided HHD.
Increased transverse diameter of myocytes
Typical morphology of acute cor pulmonale (pulmonary hypertensive heart disease).
Right ventricular dilation
Typical morphology of chronic cor pulmonale (pulmonary hypertensive heart disease).
Right ventricular (and often right atrial) hypertrophy
The hallmark of this disease is heaped-up calcified masses on the outflow side of the cusps, which protrude into the sinuses of Valsalva and mechanically impede valve opening; cusps may become secondarily fibrosed and thickened; most common cause of aortic stenosis.
Calcific aortic degeneration/calcific aortic stenosis (most common VHD)
This is characterized by ballooning or hooding of the mitral leaflets; affected leaflets are enlarged, redundant, thick and rubbery; the tendinous cords are elongated, thinned and occasionally ruptured; histologically, there is thinning of the fibrosa layer of the valve, accompanied by expansion of the middle spongiosa layer with increased deposition of mucoid material; usual finding in MVP.
Myxomatous degeneration of the mitral valve
Rationale behind autoimmunity in rheumatic fever.
Molecular mimicry (Streptococcal M proteins and cardiac self-antigens)
Gell and Coombs classification of ARF.
Type II
Required criteria in diagnosing rheumatic fever.
Evidence of previous GABHS infection (ASO in pharyngitis, and anti DNAse B in pyoderma)
Jones major criteria in diagnosing rheumatic fever.
- Carditis
- Migratory polyarthritis
- Subcutaneous nodules
- Erythema marginatum
- Syndenham chorea
Jones minor criteria in diagnosing rheumatic fever.
- Fever
- Arthralgia
- Elevated acute phase reactants (e.g. CRP)
Pathognomonic sign for rheumatic fever; myocardial inflammatory lesions composed of plump activated macrophages (Anitschkow cells), plasma cells, and lymphocytes; can be seen in all three layers of the heart in ARF (pancarditis); rarely seen in chronic RHD (due to replacement by fibrous tissue).
Aschoff bodies
Characterized by organization and subsequent scarring, as a sequelae of rheumatic fever; mitral valve most commonly involved with leaflet thickening, commissural fission and shortening, thickening and fusion of the chordae tendinae; fibrous bridging across valvular commissures create fish mouth or buttonhole deformity
Chronic Rheumatic Heart Disease
Serious infection characterized by microbial invasion of heart valves or mural endocardium, often with destruction of the underlying cardiac tissues; the heart valves are invaded by friable, bulky and potentially destructive lesions called vegetations that are usually in the form of large, irregular masses on the valve cusps that may extend into chordae.
Infective endocarditis (IE)
Endocarditis of previously normal valves, the most common causative agent is S. aureus.
Acute bacterial endocarditis
Endocarditis affecting previously damaged or abnormal valves, commonly caused by viridans streptococci.
Subacute bacterial endocarditis
Clinical criteria used in diagnosing infective endocarditis.
Duke criteria
Characterized by deposition of sterile, non-inflammatory, nondestructive and small (1mm) masses of fibrin, platelets and other blood components on cardiac valves, along the line of closure of leaflets or cusps.
Nonbacterial thrombotic endocarditis (NBTE)
Sterile vegetations that can develop on the valves of patients with SLE; small, granular, pinkish vegetations 1-4mm in diameter and can be located on the undersurface of AV valves, on the cords or endocardium.
Libman-Sacks endocarditis (LSE)
The lesions of this disease are distinctive, glistening white intimal thickenings on the endocardial surfaces of the cardiac chambers and valve leaflets; lesions are composed of smooth muscle cells and sparse collagen fibers embedded in an acid mucopolysaccharide-rich matrix; usually right-sided (causing tricuspid insufficiency and pulmonic stenosis).
Carcinoid heart disease
Cardiomyopathy characterized by progressive cardiac dilation and systolic dysfunction; heart is characteristically enlarged and flabby, with dilation of all chambers; the ventricular thickness may be less than, equal to or greater than normal; characterized by systolic dysfunction; implicated agents and diseases include: alcohol, myocarditis, doxorubicin, and hemochromatosis.
Dilated cardiomyopathy
Most common mutated gene in cases of DCM.
Titin (20%)
Type of DCM secondary to an autosomal dominant genetic defect on desmosomes that result in right ventricular failure with arrhythmia and sudden death.
Arrhythmogenic right ventricular cardiomyopathy (ARVC)
Characterized by myocardial hypertrophy, abnormal diastolic filling and ventricular outflow obstruction; the heart is thick-walled, heavy and hypercontracting; there is an asymmetrical septal hypertrophy described as banana-like; histologically, there is severe myocyte hypertrophy and disarray with interstitial fibrosis; a common cause of sudden death in young athletes.
Hypertrophic cardiomyopathy
Most common mutated gene in cases of HCM.
b-myosin heavy chain
The ventricles are of approximately normal size or slightly enlarged, the cavities not dilated, and the myocardium is firm; biatrial dilation is common; microscopically, there is interstitial fibrosis, varying from minimal to patchy to extensive and diffuse; characterized by diastolic dysfunction.
Restrictive cardiomyopathy
Most common cause of myocarditis.
Viral (Coxsackie A, B, enteroviruses)
Parasitic etiologies of myocarditis.
T. cruzi (Chagas disease), Trichinella spiralis (most common helminthic)
Immune causes of myocarditis.
Hypersensitivity, giant-cell myocarditis
Type of pericarditis found in patients with uremia or viral infection; the exudate imparts an irregular appearance to the pericardial surface (bread and butter pericarditis).
Fibrinous pericarditis
Bacterial pericarditis manifests with this type of exudate.
Fibrinopurulent pericarditis
Heart is completely encased by dense fibrosis that it cannot expand normally during diastole; sequela of chronic pericarditis.
Constrictive pericarditis
Abnormal fluid accumulation in the pericardial sac; can be serous (from CHF or hypoalbuminemia); serosanguinous (from blunt chest trauma, malignancy, ruptured MI, or aortic dissection), or chylous (from mediastinal lymph node obstruction).
Pericardial effusion
Most common tumor of the heart.
Metastatic tumor
Most common primary tumor of the adult heart; major clinical manifestations of this cardiac tumor are due to valvular ball-valve obstruction, embolization or a syndrome of constitutional symptoms.
Myxoma
The most frequent primary tumor of the heart in infants and children; generally small gray-white myocardial masses composed of a mixed population of cells, the most characteristic of which are large, rounded or polygonal cells containing numerous glycogen-laden vacuoles separated by strands of cytoplasm, so-called spider cells.
Rhabdomyoma
Most common indications for cardiac transplantation.
DCM and IHD
Primary problem requiring surveillance.
Allograft rejeciton
Single most important long-term limitation for cardiac transplantation.
Allograft arteriopathy
