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Cardiovascular > Anatomy, physiology, hemodynamics > Flashcards

Anatomy, physiology, hemodynamics Flashcards

1
Q

What does the right coronary artery supply?

A

-RV
-SA and AV nodes
-posterior and inferior surfaces of the LV

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2
Q

What makes up the left coronary system?

A

Circumflex and LAD

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3
Q

What does the left coronary artery supply?

A

-IV septum
-conduction system below the AV node
-anterior and lateral LV walls

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4
Q

What determines end diastolic volume?

A

Ventricular compliance and transmural pressure

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5
Q

By what mechanisms can diastolic compliance be reduced?

A

-myocardial thickening/dysfunction (MI, HTN, valve dysfunction)
-pericardial disease (tamponade)
-extrinsic compression (PEEP, TPTX, RV dilation, impaired chest wall compliance)

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6
Q

What is one common consequence of sudden diastolic dysfunction?

A

Flash pulmonary edema

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7
Q

In diastolic dysfunction what does ventricular filling become dependent on?

A

Terminal-phase atrial contraction (“atrial kick”)

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8
Q

Definition of afterload?

A

Muscular tension that must be developed during systolic per unit of blood flow

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9
Q

How does a normal heart accommodate for changes in afterload?

A

Increases in:
-contractility
-preload
-heart rate

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10
Q

What happens if preload reserves have been exhausted but there is still a rising/elevated afterload?

A

Cardiac output depression

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11
Q

Which ventricle is more sensitive to increasing afterload?

A

RV

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12
Q

What can influence contractility independent of preload or afterload?

A

-sympathetic impulses
-circulating catecholamines
-acid/base and electrolyte disturbances
-ischemia
-anoxia
-chemodepressants
-hormones (high dose insulin)

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13
Q

What is the equation to grossly predict the maximum atrial rate before cardiac output and myocardial perfusion are reduced?

A

(220 - age)/min1

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14
Q

What is the basic definition of CHF?

A

Condition in which the filing pressures of the left heart are increased enough to cause dyspnea or weakness at rest or mild exertion

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15
Q

Is a normal functioning LV sensitive or not sensitive to afterload? How about a failing LV?

A

-normal LV is insensitive to changes in afterload but sensitive to preload
-failing LV is sensitive to afterload and fairly insensitive to preload

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16
Q

What are some radiologic findings that suggest acute heart failure?

A

-perivascular cuffing
-widened perivascular pedicle
-blurring of the hilar vasculature
-diffuse infiltrates

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17
Q

How do infiltrates in acute heart failure differ from those found in ARDS and PNA?

A

AHF infiltrates lack air bronchograms and are usually unaccompanied by an acute change in heart size

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18
Q

What are some radiologic findings that suggest chronic heart failure?

A

-Kerley B lines
-dilated cardiac chambers
-increased cardiac dimensions

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19
Q

What are the 2 endogenous natriuretic peptides are released in response to myocardial stretch (ie. ventricular overload)?

A

-ANP atrial natriuretic peptide
-BNP B-type natriuretic peptide

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20
Q

What effects on other endogenous peptides do cardiac natriuretic peptides have?

A

-lower excessive levels of angiotension 2
-lowers aldosterone
-lowers endothelial 1

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21
Q

What systemic effects do cardiac natriuretic peptide have?

A

-arterial and venous dilation
-enhanced diuresis
-inhibition of sodium reabsorption

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22
Q

Which cardiac natriuretic peptide is only stored in small amounts in ventricular granules so an increase is more indicative of ventricular dysfunction and myocardial stretch?

A

BNP

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23
Q

Other than myocardial stretch what else can cause BNP elevation?

A

-lung diseases
-renal insufficiency
-sepsis
-inflammatory states

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24
Q

What are potential causes of LV insufficiency CHF with normal LV cavity size?

A

-mitral stenosis
-tamponade
-constrictive pericarditis
-acute myocardial infarction
-hypertrophic cardiomyopathy
-diastolic dysfunction

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25
What had the signature echo findings of apical ballooning with preserved ballast basilar contraction?
Takotsubo cardiomyopathy (stress cardiomyopathy) -these findings are temporary
26
What does generalized hypokinesis with normal chamber size on echo reflect and what causes it?
Stunned myocardium -trauma -diffuse ischemia -drug overdose -toxin ingestion -post-tachycardia dysfunction
27
What should be used in CHF with LV insufficiency when there is elevated SVR and/or valvular insufficiency with adequate preload and BP?
ACE inhibitors (captopril, enalapril) and/or systemic vasodilators
28
What medication can help aid in CHF with LV insufficiency with cardiac ischemia?
Nitrates -but can precipitate hypotension in patients with borderline or inadequate filling pressures
29
What is nesiritide?
Recombinant human BNP -for acutely decompensated CHF w/ dyspnea at rest/minimal exertion -affects: vasodilation, diuresis, natriuresis, decreases plasma NE and aldosterone, decreases preload -does not change heart rate -SE: profound hypotension, bradycardia, renal dysfunction
30
Most CHF with RV dysfunction arise from which disease conditions?
-ischemia -infarction -cor pulmonale -ARDS
31
Where does the RV get its blood supply from?
RCA
32
What type of MI typically leads to RV dysfunction?
Seen in 30% of inferior MIs
33
When should RV dysfunction from a MI be suspected?
Systemic venous HTN and ST segment elevation or Q waves over right precordium (V4R)
34
For MI with subsequent RV dysfunction what does prognosis depend on?
-size of infarct -presence or absence of increased PVR
35
What are 3 causes of pulmonary hypertension?
-restricted capillary bed -alveolar hypoxia -acidosis
36
What is the maximum pulmonary arterial pressure that normal RVs can overcome?
35mmHg
37
What is the most common cause of acute cor pulmonale in a patient without prior cardiopulmonary abnormality?
Massive PE
38
What can cause cor pulmonale in a mechanically ventilated patient?
Lung overdistention with capillary compression
39
How much of the pulmonary capillary bed can be obstructed before the pulmonary arterial pressure rises?
One half
40
What values help differentiate RV dysfunction from LV dysfunction?
-CVP -PVR -wedge pressure
41
What are the physical findings of acute cor pulmonale?
Same findings as pulmonary hypertension -hypoperfusion -RV gallop -loud P2
42
What are the physical findings of RV failure and severe pulmonary HTN?
-pulsatile hepatomegaly -systemic venous congestion -parasternal lift -peripheral edema
43
What are the radiographic signs of cor pulmonale?
dilated, sharply tapering central pulmonary arteries with peripheral vascular "pruning"
44
What happens to LV systolic function in true cor pulmonale?
Nothing output should be unaffected
45
What are the basic principles in cor pulmonale management?
-maintain adequate RV filling -reverse hypoxia and acidosis -establish a coordinated cardiac rhythm -reverse atelectasis -treat underlying disease
46
What is the treatment for polycythemia in chronic hypoxemia in RV dysfunction?
Slowly reduce Hct to 55% to reduce blood viscosity and RV afterload -this helps improve myocardial perfusion
47
What are the pros and cons to diuresis in a patient with RV dysfunction and cor pulmonale?
Pro -reduction of RV distention and myocardial tension -improves RV afterload and perfusion -reduction in pulmonary arterial pressure via decreased CO Con -some patients require RV distention and ventricular interdependence to maintain stroke volume so be gentle with diuresis -to ensure no adverse affects closely watch CVP
48
What are the pros to digitalis in a patient with RV dysfunction and cor pulmonale?
-may be helpful in chronic cor pulmonale -rate control of AFib w/ RVR (slow effect) without depressing myocardial function
49
What are the pros and cons to inotropes (dopamine and dobutamine) in a patient with RV dysfunction and cor pulmonale?
Pro -improve LV function -boosts perfusion pressure of RV -improved RV function via ventricular interdependence Con -associated arrhythmias -conduction disturbances -these can disrupt AV coordination that is vital to RV filing
50
What are the pros and cons to inhaled NO in a patient with RV dysfunction and cor pulmonale?
Pro -helps when there's a reversible component to pulm HTN -good bridge to definitive therapy Con -tolerance develops quickly
51
What are causes of acute pericarditis?
-infections (viral, TB, bacterial, fungal) -dissecting aneurysm -rheumatic -Dressler syndrome -anticoagulation -MI -malignancy -uremia -radiation -drugs -trauma
52
What is the characteristic complaint in acute pericarditis?
CP relieved by sitting up and forward; exacerbated by laying down, coughing, deep inspiration, swallowing
53
What is the PE of pericarditis?
Friction rub best heard with patient leaning forward
54
What is an on EKG in patient with pericarditis?
-concave upward ST segment elevation in all leads but AVR and V1 -PR segment depression
55
What is the management of pericarditis?
-monitoring -treat underlying cause -NSAIDS
56
How much pericardial fluid is needed before it is detected on CXR?
250mL
57
What is normal intrapericardial pressure similar to?
Intrapleural pressure and less than LV and RV diastolic pressures -rapid accumulation of pericardial fluid can lead to equalization of RA and LA pressures
58
How does the body compensate for early tamponade?
Increased heart rate and adrenergic tone to maintain CO -means things that reduce venous return or cause bradycardia (hypoxemia, beta-blocker) can quickly lead to shock
59
What are the most common physical findings of tamponade?
-JVD -pulsus paradoxus
60
Why is intubating a patient with cardiac tamponade risky?
-positive pressure can further reduce cardiac filling -vasodilation can drop needed central pressures for compensation
61
What are the general trends seen on Swan-Ganz catheter for pt in distributive shock?
-normal PCWP -increased CO -decreased SVR -increased MVO2
62
What are the general trends seen on Swan-Ganz catheter for pt in cardiogenic shock?
-increased PCWP -decreased CO -increased SVR -decreased MVO2
63
What are the general trends seen on Swan-Ganz catheter for a pt in hypovolemic shock?
-increased SVR -decreased PCWP -decreased CO -decreased MVO2
64
What is the normal value of MVO2 on Swan-Ganz catheter?
65%
65
What is the normal value for SVR on Swan-Ganz catheter?
900-1300dyne-sec/cm^5
66
What is the normal value for CO on Swan-Ganz catheter?
5-7L/min
67
What is the normal value for PCWP on Swan-Ganz catheter?
8-12mmHg
68
What is the initial treatment of choice for a pt w/ acute RHF following a MI?
fluid resuscitation until PCWP > 15 (if using SG catheter)
69
What are the 3 common pathophysiologic pathways to diastolic heart failure?
-impaired ventricular wall relaxation -LA pressure > LV pressure leading to pulmonary edema -increased stiffness of ventricle d/t increased wall thickness and decreased internal diameter -seen in poorly controlled HTN -excess collagen deposition d/t ischemia -impairs contractility
70
On a CVP waveform what mechanical event and cardiac cycle event is represented by the a wave?
atrial contraction end diastole
71
On a CVP waveform what mechanical event and cardiac cycle event is represented by the c wave?
isovolumic contraction early systole
72
On a CVP waveform what mechanical event and cardiac cycle event is represented by the v wave?
systolic filling of the atrium late systole
73
On a CVP waveform what mechanical event and cardiac cycle event is represented by the x descent?
atrial relaxation, systolic collapse mid-systole
74
On a CVP waveform what mechanical event and cardiac cycle event is represented by the y descent?
early diastolic filling, diastolic collapse early diastole
75
How much does an IABP tend to decrease afterload?
by 10-30% -it decreases aortic systolic pressure and end-diastolic aortic pressure -also reduces myocardial oxygen consumption by decreasing isometric phase of LV contraction -decreases LV wall tension by 20% -increases LV EF by up to 30%
76
How do vasodilators increase cardiac function in acute decompensated HF?
increase CO -ex. nitroprusside and nitroglycerin -decrease preload, decrease afterload, decrease myocardial O2 demand, increase CO and SV
77
What murmur is associated w/ AR?
-blowing, decrescendo, diastolic murmur at 3rd intercostal space along L sternal border -low pitched rumbling mid-diastolic murmur at the apex
78
What is the normal EF in females? In males?
-54-74% -52-72%
79
What is pulsus paradoxus and in what disease process is it seen?
-lack of decline in jugular pressure w/ inspiration -constrictive pericarditis
80
Most common primary cardiac tumor?
myxoma (40%)
81
Where are the majority of myxomas found?
L atrium near the fossa ovalis (75%)
82
What is the inheritance pattern of cardiac myxomas?
-familial in young females -sporadic mutations in geriatrics
83
What type of murmur is heard for a ventricular septal defect?
pansystolic murmur
84
How do you differentiate a ventricular septal defect from mitral regurgitation?
measure O2 sat at RV, if > 10 it's a VSD
85
What is the criteria to determine if mitral stenosis requires surgery?
-valve area < 1.5cm^2 (normal 5-7) -pressure gradient is 15mmHg (normal 0)
86
What is the criteria to determine if aortic valve stenosis requires surgery?
-valve area < 1cm (normal 2-3) -pressure gradient > 50mmHg (normal 0) most serious of valvular stenosis and should be corrected before surgery
87
What is used for preload reduction, inotropic support, and afterload reduction in LV heart failure?
-preload reduction: diuretics, venodilators (nitroglycerin) -inotropic support: dobutamine, milrinone, isoproterenol, epinephrine -afterload reduction: arterial vasodilators (nitroprusside, nicardipine)
88
What is used for preload reduction, inotropic support, and afterload reduction in RV heart failure?
-preload reduction: diuretics -inotropic support: dobutamine, epinephrine, dopamine -afterload reduction: pulmonary vasodilators (milrinone, inhaled NO)
89
What does a right shift on the oxygen-hemoglobin dissociation curve indicate? What can cause a right shift?
-hemoglobin has a decreased affinity for oxygen/favors unloading of oxygen -increased temperature -increased 2,3-DPG -increased pCO2 -decreased pH
90
What does a left shift on the oxygen-hemoglobin dissociation curve indicate? What can cause a left shift?
-hemoglobin has an increased affinity for oxygen/reluctance to release oxygen -decreased temperature -decreased 2,3-DPG -decreased pCO2 -increased pH -CO exposure

Cardiovascular (6 decks)

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