Basics of cardiology Flashcards
What separates the right auricle from the right atrium?
Sulcus terminalis
Crista terminalis
Name the structures which form the cardiac borders
Right border - right atrium
Left border - left ventricle, left atrial appendage
Anterior border - right ventricle
Posterior border - left atrium, left ventricle
Superior border - atria and great vessels
Inferior border - right ventricle
Name the structures forming the right cardiac border
Right atrium
Name the structures forming the left cardiac border
Left atrial appendage
Left ventricle
Name the structures forming the anterior cardiac border
Right ventricle
Name the structures forming the posterior cardiac border
Left atrium
Left ventricle
Name the structures forming the inferior cardiac border
Right ventricle
Name the structures forming the superior cardiac border
Atria
Great vessels
Explain coronary arterial dominance
Describes the vessel which gives rise to the PDA
Right dominant ∼ 85% (RCA)
Left dominant ∼ 8% (LCX)
Co-dominant ∼ 7%
When does coronary blood flow peak?
Early diastole
Name the source of the left coronary artery
Left aortic sinus of ascending aorta
Name the source of the right coronary artery
Right aortic sinus of ascending aorta
Name the important branches of the left coronary artery
Left anterior descending artery (LADA)
Left circumflex artery
Name the important branches of the right coronary artery
Right marginal artery
PDA
AV nodal artery
SA nodal artery
Describe the course of the left anterior descending artery
Descends between right and left ventricles on anterior surface of heart in the anterior interventricular sulcus towards cardiac apex
Which structures are supplied by the left anterior descending artery
> 50% of left atrium and ventricle Anterior aspect of the left ventricle Anterior ⅔ of the interventricular septum Anterolateral papillary muscle Cardiac apex
Describe the course of the left circumflex artery
Courses left around the heart in the coronary sulcus towards the posterior aspect, ending before the posterior interventricular sulcus and gives off the left marginal artery
Which arteries supply the anterolateral papillary muscle?
LADA
LCX
Which structures are supplied by the left circumflex artery?
Posterolateral left atrium and ventricle
Anterolateral papillary muscle
SA node ∼ 40%
PDA ∼ 15%
Describe the course of the right marginal artery
Courses along diaphragmatic border
Which structures are supplied by the right marginal artery?
Lateral right ventricle
Cardiac apex
Describe the course of the posterior descending artery
Descends between right and left ventricles on posterior surface of the heart in the posterior interventricular sulcus towards cardiac apex
Which structures are supplied by the posterior descending artery?
Posterior ⅓ of the interventricular septum
Posteroinferior aspect of heart
Posteromedial papillary muscle
Which structures are supplied by the AV nodal artery?
AV node
Bundle of His
Which structures are supplied by the SA nodal artery?
SA node
Which is the most commonly occluded coronary artery?
LAD
The occlusion of which coronary vessel will result in cardiac arrythmias?
Right coronary artery
Where do the lymphatics of the heart drain?
Anterior mediastinal nodes
Tracheobronchial nodes
Discuss the innervation of the heart
Somatic nervous system - phrenic nerve
Sympathetic nervous system - cardiac plexus
Parasympathetic nervous system - vagus nerve
What is the visceral layer of serous pericardium?
Epicardium
What is the endocardium composed of?
Endothelium
Loose CT
Subendocardium
What is the subendocardium?
Loose connective tissue containing cardiac Purkinje cells, veins and nerves
What is the myocardium composed of?
Cardiomyocytes
Fibroblasts
Extracellular matrix
Which nerve is responsible for the sensory innervation of the pericardium?
Phrenic nerve
What germ layer gives rise to the heart?
Mesoderm
What do the endocardial cushions give rise to?
Atrial septum
Interventricular septum
Valves
What does the primitive atrium give rise to?
Trabeculated portions of atria
What does the primitive ventricle give rise to?
Trabeculated portions of ventricles
What does the primitive pulmonary vein give rise to?
Smooth portion of left atrium
What does the sinus venosus give rise to?
Right horn - smooth portion of right atrium
Left horn - coronary sinus
What does the cardinal veins give rise to?
SVC
IVC
What causes a defect in cardiac looping?
Defect in dynein arm of microtubules
What does a defect in cardiac looping result in?
Kartegener syndrome
How do you calculate EF?
SV/EDV
Name the 4 phases of the cardiac cycle
Isovolumetric contraction
Systolic ejection
Isovolumetric relaxation
Ventricular filling
During which phases of the cardiac cycle are all valves open?
None
During which phases of the cardiac cycle are all valves closed?
Isovolumetric contraction
Isovolumetric relaxation
Define chronotropy relative to cardiac physiology
Any influence on the heart rate
Define dromotropy relative to cardiac physiology
Any influence on myocardial conductivity
Define inotropy relative to cardiac physiology
Any influence on myocardial contractility
Define lusitropy relative to cardiac physiology
Any influence on myocardial relaxation
Define bathmatropy relative to cardiac physiology
Any influence on myocardial excitability
Which equation describes the relationship between vascular resistance, the length and radius of the vessel, and the viscosity of blood?
Poisueille equation
Name factors that influence blood flow
Blood viscosity
Blood velocity
Lumen diameter
Blood vessel wall smoothness
What Reynold’s number does laminar flow have?
Low
What Reynold’s number does turbulent flow have?
High
How do you calculate MAP?
⅓ systolic pressure + ⅔ diastolic pressure
OR
CO x TPR
What is a normal pulse pressure?
30–40 mmHg
Name causes of a low pulse pressure
Advanced heart failure
Cardiac tamponade
Aortic stenosis
Shock
Name causes of a high pulse pressure
Exercise Hypothyroidism Aortic regurgitation Anemia OSA
What is the importance of Laplace’s law?
Increased vessel thickness results in decreased wall tension
Differentiate vascular compliance from vascular elastance
Compliance - adapt to change in pressure
Elastance - adapt to change in volume
What is the triad of symptoms in Cushing reflex?
Hypertension
Bradycardia
Respiratory depression
Explain the mechanism of Cushing reflex
↑ intracranial pressure → compensatory constriction of cerebral arterioles → ↓ cerebral perfusion → hypercapnia and acidosis → chemoreceptor mediated sympathetic response → ↑ blood pressure → stimulation of aortic arch baroreceptors → activation of the parasympathetic nervous system (vagus) → reflex bradycardia
What is the atrial reflex also known as?
Bainbridge reflex
What is the atrial reflex?
Atrial distension -> incr HR
What is the diuresis reflex also known as?
Gauer-Henry reflex
What is the diuresis reflex?
Incr BP -> decr ADH
Which chemoreceptors are more responsive to chronic hypoxia?
Peripheral > central
How does carotid massage act to reduce the heart rate?
Stimulating the carotid baroreceptors leads to an increased AV node refractory period
Where is central blood pressure regulation localized?
Solitary nucleus in the medulla oblongata
What are the afferent and efferent pathways of central blood pressure regulation?
Afferent - glossopharyngeal nn (carotid) - vagus nerve (aorta) Efferent - sympathetic - parasympathetic
What causes the release of ANP from atrial cardiomyoctyes?
Increased volume
How is RAAS activated?
Release of renin from the juxtoglomerular cells
What is myogenic autoregulation?
Myocytes in the walls of arteries and arterioles react to changes in blood pressure to maintain constant blood flow in the blood vessels (incr BP -> vasoconstriction)
Which receptors does epinephrine have a greater affinity for: alpha 1 or beta 2?
Beta 2 receptors
How does epinephrine concentration affect adrenergic receptors?
Low concentration - greater effect on beta 2
High concentration - stronger effect on alpha 1
What is the hypoxic pulmonary mechanism?
Hypoxia results in pulmonary vasoconstriction
Define hydrostatic pressure
The pressure exerted by any fluid on the wall of an enclosed space
Define osmotic pressure
The minimum pressure needed to prevent the flow of a solvent across a semi-permeable membrane
Define oncotic pressure
Intravascular osmotic pressure generated by proteins
What are the 4 Starling forces?
Capillary hydrostatic pressure
Interstitial hydrostatic pressure
Plasma oncotic pressure
Interstitial oncotic pressure
How do burns, infections and toxins cause edema?
They affect vessel permeability
At what point is the JVP elevated?
> 4cm
How do you estimate the CVP?
JVP + 5cm
Which side should you assess the JVP and why?
Right side
More direct path to SVC
What is the reference range of the CVP?
4-10 cm H20
What are signs of an elevated JVP?
Incr JVP
Kussmaul sign
Hepatojugular reflux
Name causes of elevated JVP
Right sided HF Fluid overload Tricuspid dysfunction Pericardial effusion Constrictive pericarditis Cardiac tamponade SVC syndrome Pulmonary hypertension
Name the components of the JVP waveform
a wave c wave x descent v wave y descent
What is the mechanism behind the a wave of the JVP waveform?
Atrial contraction
What is the mechanism behind the c wave of the JVP waveform?
Tricuspid valve closure
What is the mechanism behind the v wave of the JVP waveform?
Venous refilling of right atrium
What is the mechanism behind the x descent of the JVP waveform?
Atrial relaxation
What is the mechanism behind the y descent of the JVP waveform?
Tricuspid valve opening
Name a cause of an absent a wave in the JVP waveform
Atrial fibrillation
Name a cause of a cv wave in the JVP waveform
Severe TR
Name a cause of an absent x descent in the JVP waveform
TR
RHF
Name a cause of a prominent v wave in the JVP waveform
TR
RHF
Name a cause of an absent y descent in the JVP waveform
TR
Constrictive pericarditis
Name a cause of a prominent y descent in the JVP waveform
Cardiac tamponade
TS
Which conditions can cause pulse bigeminus?
LHF
Digoxin toxicity
What pulse rates can you get?
Tachycardia
Bradycardia
What pulse rhythms can you get?
Regular Regularly irregular Irregularly irregular Pulse deficit Pulse bigeminus
What pulse volumes can you get?
Hyperkinetic Hypokinetic Pulsus paradoxus Reverse pulsus paradoxus Pulsus alternans Dicrotic pulse Pulsus bisfiriens
Name causes of bruits
AV fistulas AV malformations Aneurysms Vascular stenosis Hyperdynamic circulation
Where is De Musset sign seen?
AR
Name causes of an apex beat with a hyperdynamic impulse
High cardiac output
Volume overload
Name causes of an apex beat with a heaving impulse
Pressure overload
Name causes of an apex beat with a hypodynamic impulse
MI Obesity Pericardial effusion L pneumothorax L pleural effusion COPD
Name causes of an apex beat with a tapping impulse
Mitral stenosis
Name causes of an apex beat with a dyskinetic impulse
Left ventricular dysfunction
Name causes of a murmur at Erb’s point
HOCM (systolic)
AR, PR (diastolic)
Name causes of a murmur at the aortic area
AS
AR
Coarctation
Name causes of a murmur at the pulmonary area
PS
PR
ASD
Name causes of a murmur at the mitral area
MS
MR
Mitral valve prolapse
Name causes of a murmur at the tricuspid area
TS
TR
VSD
Which murmur also radiates to the carotid arteries?
Aortic stenosis
Name causes of a pathological 3rd heart sound
Chronic MR AR Heart failure Dilated cardiomyopathy Thyrotoxicosis
Name causes of a pathological 4th heart sound
Ventricular hypertrophy
Ischemic heart disease
Which murmur radiates to the left axilla?
Mitral regurgitation
Which murmur radiates to the interscapular region?
Pulmonary stenosis
How do you remember where which murmur is?
Systolic = stenosis
Therefore diastolic = regurgitation
Which maneuver increases the sound of mitral murmurs?
Left lateral position
Which maneuver increases the sound of aortic murmurs?
Sitting leaning forward
Which maneuver increases the sound of right sided murmurs?
Inspiration
Name the inferior ECG leads
II
III
aVF
Name the lateral ECG leads
I
aVL
V5
V6
Name the anteroseptal ECG leads
V1
V2
V3
V4
What is the P wave in the ECG?
Atrial depolarization
What is the PR interval in the ECG?
Depolarization from SA node -> atria -> AV node -> His-Purkinje system
What is the QRS complex in the ECG?
Ventricular depolarization
What is the ST segment in the ECG?
The duration between ventricular depolarization and repolarization
What is the T wave in the ECG?
Ventricular repolarization
What is the QT interval in the ECG?
Total time of ventricular depolarization and repolarization
Explain your approach to reading an ECG
- Check patient information and standardisation
- Lead II
- aVR
- R wave progression
- ST segment
- T wave
- Lengths of PR, QT, QRS and R
How do you determine cardiac axis deviation?
Look at the QRS complex in lead I and aVF Normal axis = I + aVF + Left axis = I + aVF - Right axis = I - aVF + Extreme right axis = I - aVF -
What does P pulmonale signify?
Right atrial enlargement
What does P mitrale signify?
Left atrial enlargement
What should the duration of a PR interval be?
0.12s-0.2s
Name causes of a decreased PR interval
WPW
Pre-excitation syndromes
Name causes of an increased PR interval
1st degree AV block
What is the cause of progressively lengthening PR interval until a QRS complex is dropped?
Mobitz type I (2nd degree AV block)
What is the cause of a constant PR interval with a constant QRS complex drop?
Mobitz type II (2nd degree AV block)
Name causes of an abnormally wide Q wave
Myocardial injury Ventricular enlargement Altered ventricular conduction Acute PE CHD
Name causes of a dominant R wave
RVH RBBB Posterior MI HCM WPW
Name causes of poor R wave progression/persistent S wave
RVH Cardiac strain LBBB LAFB WPW
What should new onset LBBB with concurrent angina be treated as?
Acute coronary syndrome
How do you remember V1 V6 M W shapes for LBBB vs RBBB?
WilliaM MorroW
Name causes of a LBBB
Cardiac - coronary aa disease - MI - hypertension - cardiomyopathy Hyperkalemia Digoxin toxicity
Name causes of a RBBB
Cardiac - coronary aa disease - MI - mitral stenosis Pulmonary - pulmonary hypertension - PE - COPD Brugada syndrome
Name causes of an ST elevation
Normal young healthy adult STEMI LBBB Pericarditis Perimyocarditis PE Brugada syndrome Left ventricular aneurysm
Name causes of a downsloping/horizontal ST depression
Subendocardial MI
Stress induced MI
Name causes of an upsloping ST depression
Normal in tachycardia
MI if clinically ACS suspected
Name causes of a sagging ST depression
Digoxin
What is Brugada syndrome?
A rare, AD mutation of the cardiac voltage-gated Na channels that leads to abnormal cardiac conduction and sudden death
In which population group is Brugada syndrome found?
Asian men
What signs on an ECG indicate Brugada syndrome?
PseudoRBBB
ST elevation in V1, V2, V3
How do you treat Brugada syndrome?
Implantable cardiac defibrillator
Screen relatives
Name complications of Brugada syndrome
Atrial fibrillation
Sudden death
Name causes of T wave inversion
Coronary aa disease PE BBB Perimyocarditis Digoxin Ventricular hypertrophy ICH Wellens syndrome
Name causes of T wave flattening
Hypokalemia
Hypoglycemia
Hypothyroidism
MI
What is Wellens syndrome?
Severe proximal stenosis of the LAD resulting in unstable angina and deeply inverted/biphasic T waves on leads V2, V3
Name causes of a peaked T wave
Hyperkalemia
Hypermagnesemia
Name causes of a hyperacute T wave
Early STEMI
Prinzmetal angina
Name causes of a biphasic T wave with initial positive deflection
MI
Wellens syndrome
Name causes of a biphasic T wave with initial negative deflection
Hypokalemia
Name causes of a prolonged QT interval
Congenital - Romano Ward syndrome - Jervell and Lange Nielsen syndrome Acquired - drugs - electrolyte disturbance - cardiac abnormalities - arsenic poisoning
Name drugs that can cause a prolonged QT interval
Antiarrythmics
Antidepressants
Antipsychotics
Antihistamines (1st generation)
Which syndrome resulting in a prolonged QT interval is associated with sensorineural deafness?
Jervell and Lange-Nielsen syndrome
Name causes of a shortened QT interval
Hypercalcemia
Hyperkalemia
Digoxin
Congenital
What can cause a prominent U wave?
Hypokalemia
What ECG pattern is seen in pulmonary embolism?
S1Q3T3
What are the most relevant ECG findings in a STEMI?
Early stage - Hyperacute T wave - ST elevation Intermediate stage - Absent R wave - T wave inversion - Pathological Q wave
What are the most important clinical findings in a STEMI?
Acute, retrosternal pain Dyspnea N+V Diaphoresis Anxiety Syncope New S4
What are the most relevant ECG findings in an AV nodal re-entrant tachycardia?
Invisible P wave
Narrow QRS complexes
What are the most important clinical findings in an AV nodal re-entrant tachycardia?
Palpitations
Dyspnoea
Dizziness
Diaphoresis
What are the most relevant ECG findings in an AV nodal reciprocating tachycardiaI?
Orthodromic - narrow QRS - p wave follows QRS Antidromic - wide QRS - shortened PR
What are the most important clinical findings in an AV nodal reciprocating tachycardia?
Palpitations
Dyspnoea
Dizziness
Diaphoresis
What are the most relevant ECG findings in a multifocal atrial tachycardia?
Irregularly irregular
3 varying p wave morphologies
What are the most important clinical findings in a multifocal atrial tachycardia?
Palpitations
Dyspnoea
Dizziness
Diaphoresis
What are the most relevant ECG findings in a paroxysmal atrial tachycardia?
Unusual p wave before normal QRS
What are the most important clinical findings in a paroxysmal atrial tachycardia?
Palpitations
Dyspnoea
Dizziness
Diaphoresis
What are the most relevant ECG findings in a WPW?
Short PR
Delta wave
Widened QRS
What are the most important clinical findings in a WPW?
Palpitations
Dyspnoea
Dizziness
Diaphoresis
What are the most relevant ECG findings in a torsades de pointes?
Wide QRS complex
Dissociated P wave
Fusion complexes
Capture beat
What are the most important clinical findings in a torsades de pointes?
Often asx Palpitations Syncope Angina Dyspnea Dizziness Hypotension Cardiac arrest
What are the most relevant ECG findings in an atrial fibrillation?
Irregularly irregular
Indiscernible P wave
Narrow QRS complex
What are the most important clinical findings in an atrial fibrillation?
Asx
Arrythmia symptoms
Tachycardia with regularly irregular pulse
Thromboembolic events
What are the most relevant ECG findings in atrial flutter?
Sawtooth P wave
Narrow QRS
What are the most important clinical findings in atrial flutter?
Asx
Arrythmias symptoms
Tachycardia with regular pulse
What are the most relevant ECG findings in a ventricular fibrillation?
Indiscernible QRS
Absent p wave
What are the most important clinical findings in a ventricular fibrillation?
Angina Palpitatins Dyspnea LOC Death
What are the most relevant ECG findings in a 1st degree AV block?
PR interval >200ms
What are the most important clinical findings in a 1st degree AV block?
Asx Fatigue Dizziness Syncope Palpitations
What are the most relevant ECG findings in a Mobitz type I?
Progressive PR interval lengthening followed by a beat drop
What are the most important clinical findings in a Mobitz type I?
Asx Fatigue Dizziness Syncope Palpitations
What are the most relevant ECG findings in a Mobitz type II?
Constant PR interval with a beat drop
What are the most important clinical findings in a Mobitz type II?
Asx Fatigue Dizziness Syncope Palpitations
What are the most relevant ECG findings in a 3rd degree AV block?
AV dissociation
What are the most important clinical findings in a 3rd degree AV block?
Asx Fatigue Dizziness Syncope Palpitations
What are the most relevant ECG findings in an acute pericarditis?
Saddle shaped ST elevation
Diffuse PR depression
T wave inversion
What are the most important clinical findings in an acute pericarditis?
Pleuritic chest pain Low grade fever Tachypnea Dyspnea Non-productive cough Pericardial friction rub
What are the most relevant ECG findings in a cardiac tamponade?
Tachycardia
Low voltage QTS
Electrical alternans
What are the most important clinical findings in a cardiac tamponade?
Beck's triad Pulsus paradoxus Pallor Cold sweats Obstructive shock Cardiac arrest
What are the most relevant ECG findings in a hypertrophic cardiomyopathy?
LVH signs
Nonspecific ST/T changes
Septal Q waves
What are the most important clinical findings in a hypertrophic cardiomyopathy?
Asx Dyspnea Chest pain Syncope Palpitations Sudden cardiac death
What are the most relevant ECG findings in a restrictive cardiomyopathy?
Low voltage
BBBs
What are the most important clinical findings in a restrictive cardiomyopathy?
Dyspnea JVP distension Peripheral edema Ascites Hepatomegaly
What are the most relevant ECG findings in a PE?
S1Q3T3
New RBBB
What are the most important clinical findings in a PE?
Dyspnea Tachypnea Sudden pleuritic pain Cough Haemoptysis Decr breath sounds
What are the most relevant ECG findings in a hypokalemia?
Flattened T wave
ST depression
U waves
What are the most important clinical findings in a hypokalemia?
Palpitations Syncope Muscle cramps Muscle weakness Decr DTR N+V Constipation Polyuria
What are the most relevant ECG findings in a hyperkalemia?
Wide QRS
Peaked T wave
Flattened, wide P waves
What are the most important clinical findings in a hyperkalemia?
Muscle weakness Paralysis Paresthesia Decr DTR N+V Diarrhea
What are the most relevant ECG findings in a hypocalcemia?
Prolonged QT interval
What are the most important clinical findings in a hypocalcemia?
Tetany Spasms Cramps Paresthesia Seizures
What are the most relevant ECG findings in a hypercalcemia?
Shortened QT interval
What are the most important clinical findings in a hypercalcemia?
Nephrolithiasis Nephrocalcinosis Bone pain Arthalgia Myalgia N+V Constipation Anorexia PUD Pancreatitis
What are the most relevant ECG findings in a hypomagnesemia?
Prolonged PR
Prolonged QT
What are the most important clinical findings in a hypomagnesemia?
Anorexia N+V Muscle weakness Muscle cramps Tremor Ataxia Nystagmus Seizures
What are the most relevant ECG findings in a right atrial enlargement?
P pulmonale
What are the most relevant ECG findings in a left atrial enlargement?
P mitrale
What are the most relevant ECG findings in a LVH?
Sokolow-Lyon criteria >3.5mV - RV5 - RV6 + SV1 - SV2
What are the most relevant ECG findings in a RVH?
Sokolow-Lyon criteria >1.05mV - RV1 - RV2 + SV5 - SV6 Right axis deviation