Bikman - Heart Path Flashcards
What is heart failure? Early and final stages?
Heart cannot pump blood sufficient to meet body’s needs. Generally occurs on one side.
Early stages, compensations can occur:
- Catecholamines
- Frank-Starling mechanism
- Hypertrophy
Eventually:
- Ischemia
What is the Frank-Starling mechanism?
The more time the heart has to fill, the stronger it will contract
Where does R heart failure manifest?
Below the heart
Where does LHF (left heart failure) manifest?
Above the heart
What are some common causes of LHF?
- Systemic hypertension
- Mitral or aortic valve disease
- Primary heart diseases
What are some heart changes observed in LHF?
- LV hypertrophy**
- LV dilation
- LA may be enlarged
What are some consequences of LHF?
- Dyspnea - hard time breathing
- Orthopnea - hard time breathing in certain positions
- Enlarged heart, increased HR
- Rales - fluid accumulating in lung space
- Mitral regurgitation, systolic murmur
What are some common causes of RHF (right heart failure)?
- Cor Pulmonale ( HF due to lung failure)
- Some congenital heart diseases
What are some heart changes observed in RHF?
- RV hypertrophy
- RV dilation
- RA may be enlarged
What are some consequences of RHF?
- Peripheral edema
- Hepatomegaly
- Splenomegaly
Outline the series of events that cause cor pulmonale.
HF due to lung failure, causing RHF.
RV enlargement due to pulmonary hypertension (from primary lung disorder).
There is less O2 in the alveolar capillaries, causing alveolar constriction. The R side of the heart has to do more work since the alveoli constriction increases pressure.
What are the 3 categories of congenital heart disease and what diseases fall under each category.
Left to right (L2R)
- ASD
- VSD
- PDA
Right to left (R2L)
- Tetralogy of Fallot
- Transposition of great arteries
Coactation
- Aortic coarctation
Atrial Septal Defect (ASD)
Too much blood going to the lungs
- May cause pulmonary hypertension
- Sending too much blood to the lungs
- Mixing of oxygenated and deoxygenated blood
Ventricular Septal Defect (VSD)
Too much blood going to the lungs
- Most common
- Most close spontaneously
- Size and location matters
- The higher towards the base the defect is, the more problematic it will be with mixing of blood
Patent Ductus Arteriosus (PDA)
Too much blood going to the lungs
- Allows flow from PA to aorta in the fetus
- Generally closes by day 2 of life
- Size matters
- Moving blood from the aorta and into the pulmonary arteries
Tetralogy of Fallot
Most common cause of cyanotic congenital heart disease.
- VSD
- Pulmonary stenosis
- Overriding aorta
- RV hypertrophy
All 4 of these phenomena happen together
Transposition of great arteries
Requires atrial or ventricular shunt to live.
Embryonic lethal in absence of shunt
Coarctation
Aortic coarctation.
- Narrowing of aorta
- Causes cyanosis and low BP systematically
- Size of blockage matters
What is Ischemic Heart Disease and what are the 4 conditions associated with it? How is the coronary artery blood flow reduced?
Usually a result of reduced coronary artery blood flow.
Myocardial perfusion can’t meet demand.
- By thrombus
- Critical stenosis
- Angina pectoris
- Acute MI
- Chronic IHD
- Sudden cardiac death
What is Angina Pectoris and what are the three types?
Ischemic heart disease.
Intermittent chest pain.
- Stable
- Most common
- Pain on exertion
- Fixed narrowing of CA - Prinzmetal (variant)
- Pain at rest
- CA spasm - Unstable (pre-infarction)
What is acute MI and what are clinical features?
Ischemic heart disease.
Necrosis of myocardium from ischemia.
- Affects 1.5M/year.
- Mostly due to CA thrombosis <20-30min
- Prompt reperfusion can salvage myocardium
Clinical Features:
- Severe, crushing chest pain
- Not relieved by nitroglycerin
- Sweating, nausea
Elevation of what molecule precedes acute MI and why?
CK-MB increases within 2-4hrs, returns to normal within 72 hours.
Cardiomyocytes have a lot of CK-MB, so if they are damaged, CK-MB spills out of cells.
What gross changes may be absorbed with acute MI?
- Mottling - coagulation necrosis
- Mottling - coagulation necrosis; neutrophils come in
- Yellow infarct center - Neutrophils die, macrophages come to eat dead cells
- Yellow center, red borders - granulation tissue
- Scar - collagen
What are the two types of acute MI?
- Subendocardial infarction
- Affects 1/3-1/2 of heart wall
- Inner wall more affected because blood supply goes first to outer wall - Transmural infarction
- Affects more than 1/2 of heart wall
- More serious
Chronic IHD
Ischemic heart disease.
Accumulation of small ischemic insult leads to mechanical failure.
Sudden Cardiac Death
Ischemia heart disease.
Often a result of a lethal arrhythmia without myocyte necrosis.
Hypertensive heart disease
Can affect L ventricle (systemic) or R ventricle (pulmonary)
Cor pulmonale is RV enlargement due to pulmonary hypertension (from primary lung disorder)
Valvular stenosis
Failure to open
Valvular insufficiency/regurgitation
Failure to close
What conditions can valvular heart disease be the cause of?
- Murmurs
- Angina
- CHF
- Fainting
What five conditions are associated with valvular heart disease?
- Valvular stenosis - narrowing of valves
- Aortic stenosis
- Mitral stenosis - Valvular regurgitation - leakage of valves
- Aortic regurgitation
- Mitral regurgitation - Rheumatic valvular disease
- Mitral valve prolapse syndrome
- Infective endocarditis
What is aortic valve stenosis and what are its manifestations? Do we hear it during systole or diastole?
Stiffening and narrowing of the aortic valve.
- Blood has difficulty exiting the heart
- Prolonged ejection sound
Clinical Manifestations:
- Crescendo-decrescendo systolic heart sounds AKA heart murmur
- Decrease in stroke volume
- Increased LV pressure
- Decreased systolic BP
- Hypertrophy of LV
What is aortic regurgitation and what are its manifestations? Do we hear it during systole or diastole?
Failure of the aortic valve to properly close.
- Blood leaks back into the ventricle after ventricular contraction
Clinical Manifestations:
- Diastolic murmur (blowing sound) of high pitch over the LV
- Hypertrophy of LV
- LV failure
- Doppler echocardiography reveals blood flow back through aortic valve
*Aortic valve is not completely closing shut, so the aortic blood is starting to push itself back into the LV which is why we hear it during diastole.
What is mitral stenosis and what are its manifestations? Do we hear it during systole or diastole?
Narrowing or stiffening of the mitral valve (L AV valve)
- Turbulent blood flow during atrial filling and contraction
Clinical Manifestations: - Subtle crescendo *diastolic* murmur - Decreased blood flow from LA to LV - Increased LA pressure - Hypertrophy and dilation of LA - Atrial dysrhythmias (fibrillation) _ Increases pulmonary BP _ Pulmonary edema _ RHF
What is mitral regurgitation and what are its clinical manifestations? Does it occur during systole or diastole?
Failure of the mitral valve (L AV valve) to properly close
- Blood passing into atrium from ventricle during contraction
Clinical Manifestations:
- Systolic murmur
- Hypertrophied LV
- LHF
- Pulmonary hypertension and edema
- Doppler echocardiography reveals blood flow back through mitral valve
What is Rheumatic Valvular Disease and how does it develop?
- Diffuse inflammatory disease caused by immune response to infection by the group A beta-hemolytic streptococci
- Febrile illness
- – Inflammation of the joints, skin, NS, heart
- Left untreated, rheumatic fever causes rheumatic heart disease
Strep > Polyarthritis > Mitral Stenosis, LA enlargement
Mitral Valve Prolapse
Most patients are asymptomatic.
Ballooning of mitral leaflets
The presence of what structure is indicative of RVD?
Aschoff bodies
Which genetic condition is associated with increased risk of valve prolapse?
Marfan’s - insufficiency of collagen synthesis, too elastic
What is Infective Endocarditis?
Microbial invasion of heart valves, endocardium.
Usually mitral and aortic valves.
What are the two types of infective endocarditis?
Splinter hemorrhages seen with both of these.
- Acute
- Highly virulent infection attacks normal valve
- 50% patients die within weeks
- Often requires surgery - Subacute
- Low virulent infection colonizes abnormal valve
- Long course, most recover
What are cardiomyopathies?
Diverse group of disorders in which myocardium dysfunctions.
What are the 3 types of cardiomyopathies?
- Dilated cardiomyopathy
- Congestive cardiomyopathy - Hypertrophic cardiomyopathy
- Hypertension is a leading cause - Restrictive cardiomyopathy
- Deposition of material in myocardium
What causes dilated cardiomyopathy?
Congestive cardiomyopathy.
Ventricle can’t empty!
Causes:
- Viral
- Alcohol/toxin
- Genetic abnormality
70% of patients dead in 5 years
What causes hypertrophic cardiomyopathy?
Ventricle can’t fill!
Causes:
- Hypertension
- Sarcomere mutation
4% of patients die each year
Can be treated with drugs to relax ventricles
What causes restrictive cardiomyopathy?
Deposition of material in myocardium.
Heart wall is stiff; can’t fill!
Causes:
- Idiopathic
- Amyloidosis or sarcoidosis (too much scar tissue)
70% patients dead in 5 years
Insulin increases the amyloid accrual
What are the two disorders of pericardial disease?
- Acute pericarditis
- Causes severe chest pain that worsens with respiratory movements and with lying down
- Dangers: Tamponade, chronic fibrosis - Pericardial effusion
- Tamponade - Physically pressure compressing the heart
What is tamponade?
When the heart can’t fill enough because pressure can’t get low enough for that to happen
Are primary tumors common?
No.
Most are benign. Malignant heart cancers are often metastasized from lung or lymphoma.
