Cardio Flashcards
1
Q
What two signs do you see on EKG for atrial fibrillation?
A
- Irregularly irregular rhythm
2. No discrete P waves
2
Q
What are risk factors for atrial fibrillation?
A
HTN, Cardiovascular disease, heart failure
They all cause atrial dilation
3
Q
What are consequences of atrial fibrillation?
A
- pooling of blood –> formation of clots –> PE or stroke
4
Q
How do you treat atrial fibrillation?
A
< 48 hours –> synchronized cardioversion (not old afibs because there might be clots that get dislodged)
> 48 hours –> Anti-coagulation with Heparin or Enoxaparin, then Coumadin; Rate control to prevent SVT - Digoxin, Beta blocker, Ca channel blocker; Rhythm control - bring back to sinus rhythm with Sotalol, Amiodarone, Flecainide
5
Q
How do you identify atrial flutter?
A
Sawtooth appearance
Has p waves, more regular rhythm
6
Q
What is a 1st degree AV block?
A
Prolonged PR interval (>200 msec); benign condition that is often asymptomatic
7
Q
What is Mobitz type I block?
A
There is progressive lengthening of PR interval until a beat is dropped (P wave without QRS complex); typically benign (it is a second degree block!)
8
Q
What organism causes AV block?
A
Borrelia burgdorferi - Lyme disease
9
Q
What is Mobitz type II block?
A
There is dropped beat with NO warning. Problematic bc can become 3rd degree heart block. Treated with pacemaker.
10
Q
What is 3rd degree heart block?
A
Atria and ventricles are beating independently of each other; both P waves and QRS waves are present but the P waves bear no relation to QRS complexes. Treated with pacemaker.
11
Q
What do the QRS complexes look like in 3rd degree heart block?
A
They can be narrow (going through normal conduction) or wide
12
Q
What is Wolff-Parkinson-White syndrome?
A
Ventricular pre-excitation syndrome
Abnormal fast conduction pathway from atria to ventricle that is not going through the AV node (bundle of Kent instead); This causes early ventrciular depolarization = delta wave and widened QRS complex
13
Q
Why is it important to identify WPW?
A
It may result in reentry circuit that causes supra ventricular tachycardia
14
Q
a. How do you treat SVT?
b. How do you treat SVT from WPW?
A
a. Adenosine
b. Procainamide or Amiodarone - tones down tachycardia
15
Q
Drugs that prolong QT interval
A
Anti-Arrhythmics (IA, III) Anti-Biotics (Macrolides, Chloroquine) Anti-Cychotis (Haloperidol, Risperidone) Anti-Depressants (TCAs) Anti-Emetics (Ondansetron)
Anti-HIV protease inhibitors
Methadone
16
Q
How do you treat Torsades?
A
Mg
17
Q
What is initial treatment for ventricular tachycardia when there is no pulse?
A
CPR and defibrillation
18
Q
a. What do baroreceptors in aortic arch respond to?
b. They transmit via which nerve?
A
a. Increases in BP
b. Vagus nerve
19
Q
What do baroreceptors in carotid sinus respond to?
b. They transmit via which nerve?
A
a. Increase or decrease in BP
b. Glossopharyngeal nerve
20
Q
Which adrenergic receptors cause vasoconstriction?
A
alpha 1
21
Q
What is the action of atrial natriuretic peptide?
A
It is released from atrial myocytes in response to increased blood volume and atrial pressure –> it causes vasodilation and reduced Na reabsorption by dilating afferent arteriole and constricting efferent arteriole to increase GFR
22
Q
What is the action of brain natriuretic peptide?
A
It is released from ventricular myocytes in response to increased stretch/tension –> has similar response of ANP (vasodilation and decreased Na reabsorption) –> it is useful for diagnosing HF
23
Q
How does Nitroglycerin work to relieve angina?
A
It causes systemic venous vasodilation that decreases preload and reduces the myocardial oxygen demand
24
Q
How do kidneys regulate BP?
A
Juxtaglomerular apparatus senses low BP and that stimulates production of Renin –> eventually makes Angiotensin II –> vasoconstriction and aldosterone production –> retention of Na and water in kidneys
25
What substances work on myosin smooth muscle light chain kinase and how does this affect BP?
cAMP inhibits myosin light chain kinase to inhibit vasoconstriction --> decreased BP
Calmodulin activates myosin light chain kinase to cause contraction and raise BP
26
a. What are CXR findings for aortic dissection?
| b. What are symptoms?
a. Widened mediastinum
| b. Tearing chest pain, sudden onset, radiating to back (with unequal BP in arms)
27
What are the types of aortic dissection?
a. Type A (involves ANY portion of aorta - requires surgery) Type B (distal to aortic arch, in descending aorta - treated medically)
28
What is drug of choice to treat aortic dissection?
B blocker - reduce arterial pressure and slope of rise of BP
29
When should you avoid giving an ACE inhibitor? Why?
If the patient has bilateral renal artery stenosis (they decreased GFR --> renal failure)
30
What drugs can be used for HTN in pregnancy?
```
Hypertensive Mom's Love Nifedipine
Hydralazine
Methyldopa
Labetalol
Nifedipine
```
31
What are adverse effects of Hydralazine? When is it C/I?
It can cause compensatory tachycardia, fluid retention, headache, angina, lupus-like syndrome with anti-histone Abs. C/I in patients with CAD/angina.
32
What is the mechanism of Minoxidil?
Opens K channels and hyper polarizes smooth muscle --> resulting in relaxation of vascular smooth muscle
33
What is a S/E of Minoxidil?
Hair growth
34
Treatment of HTN plus atrial fibrillation
Beta blocker or Diltiazem/Verapamil
35
Which treatments should you avoid in HTN plus bradycardia?
Diltiazem/Verapamil
| B blocker
36
HTN plus renal insufficiency:
a. Treatment
b. Avoid...
a. ACE inhibitor/ARB
| b. ACE inhibitor/ARB if there is bilateral renal stenosis (also may increase K) and K sparing diuretics
37
HTN plus BPH
| a. Treatment
a. Alpha blocker
38
HTN plus Hyperthyroidism
| a. Treatment
Propanolol
39
HTN plus Hyperparathyroidism
a. Treatment
b. Avoid:
a. Loop diuretic
| b. Thiazide diuretic (Ca sparing)
40
HTN plus osteoporosis treatment
Thiazide diuretic (Ca sparing)
41
HTN plus migraines treatment
CCB or B blocker
42
HTN plus essential tremor treatment
Propranolol
43
Treatment of malignant HTN
Nitroprusside (increase cGMP --> dilates veins and arteries; short acting given as IV)
44
What is an adverse effect of Nitroprusside?
Cyanide toxicity
45
Which anti-hypertensives have the following S/E:
a. first dose orthostatic hypotension
b. ototoxic
c. hypertrichosis
d. cyanide toxicity
e. dry mouth, sedation, severe rebound HTN
f. Bradycardia, impotence, asthma exacerbation
g. reflex tachycardia
h. cough
i. avoid in patients with sulfa allergy
j. possible angioedema
k. possible drug induced lupus
l. hypercalcemia, hypokalemia
a. Alpha 1 blockers (Zosins)
b. Loop diuretics (esp with aminoglycosides)
c. Minoxidil
d. Nitroprusside
e. Clonidine (alpha 2 agonist)
f. B blocker
g. Nitrates, hydralazine, dihydropyridines
h. ACE inhibitor, ARB
i. Loop and thiazide diuretics
j. ACE inhibitor, ARB
k. Hydralazine
l. Loops and thiazide
46
a. What do you see on EKG with Prinzmetal angina?
b. What causes Prinzmetal?
c. How do you treat it?
a. ST elevation
b. Coronary artery spasm
c. Calcium channel blocker or Nitrates
47
What are five most deadly causes of chest pain?
```
Aortic dissection
Unstable angina
MI
Tension pneumothorax
PE
```
48
ST segment elevation only during brief episodes of chest pain
Prinzmetal's angina
49
Patient is able to point to localize the chest pain using one finger
Musculoskeletal
50
Chest wall tenderness on palpation
Costochondritis, pulled muscle
51
Rapid onset chest pain that radiates to the scapula
Aortic dissection
52
Rapid onset sharp pain in a 20 year old and associated with dyspnea
Spontaneous Pneumothorax
53
Chest pain occurs after heavy meals and improved by antacids
GERD, Esophageal spasm
54
Sharp pain lasting hours-days and is somewhere relieved by sitting forward
Pericarditis
55
Pain made worse by deep breathing/motion
Musculoskeletal
56
Chest pain in a dermatomal distribution
Shingles
57
Most common cause of non-cardiac chest pain
GERD of musculoskeletal
58
What is a big side effect of HMG CoA reductase inhibitors?
Myopathy
| also hepatotoxicity
59
What is the mechanism of Cholestyramine?
Bile acid resin that prevents intestinal reabsorption of bile acids (live must use cholesterol to make more)
60
What is mechanism of Ezetimibe?
Prevents cholesterol absorption at small intestine brush border
61
a. What is the mechanism of Fibrates?
b. What are their names?
c. Side effects?
a. Upregulate LPL --> Increased TG clearance
b. Gemfibrozil, Fenofibrate
c. Myopathy, cholesterol gallstones
62
What is the mechanism of Niacin?
Raises HDL; inhibits lipolysis in adipose tissue; reduces hepatic VLDL synthesis
63
What are S/E of Niacin?
Red, flushed face
Hyperglycemia
Hyperuricemia
64
a. Best effect on lowering LDL
b. Best effect on raising HDL
c. Best effect on lowering triglycerides
a. Statins
b. Niacin
c. Fibrates (Gemfibrozil, Fenofibrate)
65
How is hypertrophic cardiomyopathy treated?
B blocker
| Non-dihydropyridine calcium channel blocker (Verapamil)
66
What is Loffler syndrome?
Endomyocardial fibrosis with a prominent eosinophilic infiltrate that causes restrictive cardiomyopathy
67
What are signs of bacterial endocarditis?
```
Fever
Roth spots
Osler nodes
Murmur
January lesions
Anemia
Nail-bed hemorrhage
Emboli
```
68
What are the most common causes of bacterial endocarditis? What are features of each?
```
Staph aureus (30%, acute, large vegetations)
Viridans streptococci (20-30%, subacute, insidious onset, smaller vegetations on abnormal valves, dental procedures)
Enterococci (10%)
Staphylococcus epidermidis (5-10%, IV drug users)
```
69
What malignancy is Streptococcus bovis associated with?
Colon cancer
70
What organisms are responsible for culture negative endocarditis?
```
Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
```
71
a. What causes Libman-Sacks endocarditis?
| b. What is it?
a. SLE
| b. Sterile vegetations on both sides of the valve
72
a. What is marantic endocarditis?
| b. What is it caused by?
a. Non-bacterial
| b. Metastatic cancer cells or platelet fibrin aggregates in hypercoagulable states
73
a. What is a retinal hemorrhage with pale center?
| b. When are they seen?
a. Roth spots
| b. bacterial endocarditis
74
What is epinephrine reversal? Administration of what drug causes this?
Epinephrine is an alpha and beta adrenergic agonist that causes increased BP. BUT when an alpha receptor antagonist like Phentolamine is administered first, it blocks the vasoconstrictive action on arterioles and the administration of epinephrine acts ONLY on the beta receptors to cause vasodilation in skeletal muscle and decrease in BP
75
What gives rise to jugular a, v and c waves?
a - atrial contraction
c - ventricular contraction
v - atrial filling against closed tricuspid valve
76
Which heart murmur is associated with weak pulses?
Aortic stenosis
77
What are the JONES criteria?
- Used to diagnose Rheumatic fever; two major criteria and one minor criteria
- Joints (migratory polyarthritis)
- Heart (pancarditis)
- Nodules (subcutaneous, painless)
- Erthyema marginatum (creeping ring like rash, comes and goes)
- Sydenham chorea (chorea of face, hands, upper limbs)
78
What lab and histology findings are associated with Rheumatic heart disease?
Increased anti-streptolysin O titers
Aschoff bodies (granuloma with giant cells)
Anitschkow cells (enlarged macrophages with owl eye appearance)
Mitral valve damage
79
How does pericarditis present?
Sharp pleuritic chest pain, better sitting up and leaning forward
Distant heart sounds
Friction rib on auscultation
Diffuse ST elevation
80
What are EKG findings for acute pericarditis?
Diffuse ST elevation
| PR depression
81
What are long term outcomes of pericarditis?
Can spontaneously resolve or cause chronic constrictive pericarditis (Lupus is most common cause)
82
What sign do you have with chronic constrictive pericarditis?
Kussmaul sign = JVD with inspiration
83
What is the Beck triad of cardiac tamponade?
Hypotension
Distended neck veins
Distant heart sounds
84
What are exam findings for cardiac tamponade?
```
Hypotension
Distended neck veins
Distant heart sounds
Increased HR
Pulsus paradoxus
```
85
a. What is pulses paradoxus?
| b. What diseases do you see it in?
a. Decrease in amplitude of systolic BP by >10mmHg during inspiration
b. Cardiac tamponade, asthma, obstructive sleep apnea, pericarditis, croup
86
Kussmaul's sign vs. Pulsus paradoxus
a. event
b. mechanism
c. disease
a. JVD during inspiration vs. decreased SBP by more than 10 during inspiration
b. decreased capacity of RV vs. decreased capacity of LV
c. constrictive pericarditis > tamponade vs. cardiac tamponade > pericarditis
87
What is EKG finding of cardiac tamponade?
low voltage QRS and electrical alternans (from swinging movement of heart in large effusion)
88
What is most common cardiac tumor?
Metastatic tumor from somewhere else
89
What is most common primary cardiac tumor in adults?
Myxomas - in left atrium
90
What are complications of left atria myxomas?
Multiple syncopal episodes
| If they flop into LV you may hear tumor plop on diastole.
91
What is most common primary cardiac tumor in kids?
Rhabdomyoma
92
What are rhabdomyomas associated with?
Tuberous sclerosis
| includes Astrocytoma and Angiomyolipomas also
93
Focal myocardial inflammation with multinucleate giant cells
Aschoff bodies
94
Chest pain and course rubbing heart sounds in patient with Cr of 5.0
Uremic pericarditis
95
Tree-barking of the aorta
Tertiary syphilis
96
Child with fever, joint pain, cutaneous nodules 4 weeks after a throat infection
Rheumatic fever
97
ST elevation in all EKG leads
Acute pericarditis
98
EKG shows electrical alternans
Cardiac tamponade
99
Most common cause of constrictive pericarditis
In US - Lupus
| In developing countries - TB
100
Granulomatous nodules in the heart are....
Aschoff bodies (seen in rheumatic heart disease)
101
What is the triad of Granulomatosis with polyangiitis (Wegeners)?
Focal necrotizing vasculitis
Granulomas in lung and upper airway
Glomerulonephritis
102
What are the pathology/lab findings in Microscopic polyangiitis?
MPO-ANCA/p-ANCA
| No granulomas
103
What are the pathology/lab findings in Wegeners?
c-ANCA/PR3-ANCA
| Large nodular densities on CXR
104
How do you distinguish GPA (Wegeners) and Goodpastures?
1. GPA - affects lungs and upper airway (soft palate, oropharynx, nasal cavity, sinuses); collapse of bridge of nose (saddle nose) and granulomas on lung biopsy, lung disease (dyspnea and hemoptysis) and kidney disease (hematuria)
2. Goodpastures -
105
How do you treat GPA?
Cyclophosphamide
| Corticosteroids
106
What is classic triad of Henoch Schonlein purpora?
Palpable purpura on buttocks/legs
Arthralgias
Abdominal pain (from intestinal hemorrhage)
Renal disease (tetrad)
107
What vasculitides often follows URI?
Henoch Schonlein purpura
108
What is Churg-Strauss associated with?
Asthma
Sinusitis
Skin nodules
Peripheral neuropathy
109
What is Churg-Strauss?
A small vessel vasculitis with granulomatous vasultitis and eosinophilia
110
What is Polyarteritis nodosa associated with?
Hepatitis B seropositivity
111
What are signs of Polyarteritis nodosa?
Fever, weight loss, headache
Abdominal pain, melena
HTN, neurologic dysfunction, cutaneous eruptions, renal damage
does NOT affect lungs
112
What is presentation of Kawasaki disease?
```
Conjunctival infection
Rash (polymorphous --> desquamating)
Adenopathy (cervical)
Strawberry tongue (oral mucositis)
Hand-foot changes (edema, erythema)
Fever
CRASH (and burn = fever)
```
113
What are potential complications of Kawasaki disease?
Coronary artery aneurysms, thrombosis or rupture may cause death
114
How do you treat Kawasaki disease?
Aspirin - important for preventing thrombosis of coronary artery aneurysms
115
What is Buerger disease?
Vasculitis seen in heavy male smokers < 40 years old
116
What is presentation of Buerger disease?
Intermittent claudication --> gangrene, autoamputation of digits, superficial nodular phlebitis
Raynaud phenomenon is often present
117
a. Who does temporal arteritis affect?
| b. Presentation?
a. Elderly females
| b. Unilateral headache, jaw claudication; may lead to irreversible blindness from ophthalmic artery occlusion
118
What are clinical findings of temporal arteritis?
Elevated ESR
119
What is pulseless disease?
Takayasu arteritis
120
What is Takayasu arteritis?
Causes granulomatous inflammation of arteries of aortic arch --> poor pulses in extremities
121
Who does Takayasu affect?
Young Asian women
122
Vasculitides associated with this history:
a. 2 year old Asian female
b. 20 year old Asian female
c. Associated with asthma
d. Young male smoker
e. Associated with polymyalgia rheumatica
f. Associated with IgA nephropathy
g. Associated with hepatitis B
a. Kawasaki disease
b. Takayasu arteritis
c. Churg-Strauss (Eosinophilic granulomatosis with polyangiitis)
d. Buerger disease
e. Temporal arteritis
f. Henoch Schonlein purpura
g. Polyarteritis nodosa
123
Vasculitides with the following presentation:
a. Elderly woman with jaw claudication and vision loss
b. Strawberry tongue
c. Desquamation of the hands/feet
d. Poor pulses in the arms
e. Palpable purpura on the legs
f. Vasculitis of the kidney and GI tract, spares the lungs
g. Vasculitis of the kidney, upper airway and lungs
a. Giant cell arteritis
b. Kawasaki disease
c. Kawasaki disease
d. Takayasu (pulseless disease)
e. Henoch Schonlein Purpura
f. Polyarteritis Nodosa
g. GPA (Wegeners)
124
What is the treatment for Raynaud phenomenon?
Dihydropyridine Calcium channel blockers because they vasodilate Aspirin - prevents clotting
125
What is Raynaud's disease?
Primary
| Arterial vasospasm causes decreased blood flow
126
Which disease are frequently found in those with Raynaud phenomenon?
Lupus
CREST scleroderma
Buerger disease
Mixed CT disease
127
Benign, raised, red lesion about the size of a mole in older patients
Cherry hemangioma
128
Raised, red area present at birth, increases in size initially then regresses over months to years
Strawberry hemangioma
129
Lesion caused by lymphoangiogenic growth factors in an HIV patient
Kaposi sarcoma
130
Polypoid red lesion found in pregnancy or after trauma
Pyogenic granuloma
131
Benign, painful, red-blue tumor under fingernails
Glomus tumor
132
Cavernous lymphangioma associated with Turner syndrome
Cystic hygroma
133
Skin papule in AIDS patient caused by Bartonella
Bacillary angiomatosis
134
What divides the right and left atria?
Septum primum and septum secundum
135
How is the blood shunted from the right atrium to the left atrium in an embryo?
Through the foramen oval (of septum secundum) and ostium secundum (of septum primum)
136
What grows to separate the atria and ventricle?
Superior endocardial cushion and inferior endocardial cushion
137
What genetic abnormality is commonly associated with endocardial cushion defects?
Trisomy 21
138
What are the abnormalities associated with conotruncal abnormalities? (when the truncus arteriosus rotates to form aorticopulmonary septum/spiral septum)
Transposition of great vessels
Tetralogy of Fallot
Persistent truncus arteriosus
139
What are the abnormalities associated with conotruncal abnormalities? (when the truncus arteriosus rotates to form aorticopulmonary septum/spiral septum)
Transposition of great vessels
Tetralogy of Fallot
Persistent truncus arteriosus
140
How does the ductus arteriosus close at birth?
At birth, there is an increase in O2 from respiration and a decrease in prostaglandins from placental separation --> DA closes
141
How does the ductus arteriosus close at birth?
At birth, there is an increase in O2 from respiration and a decrease in prostaglandins from placental separation --> DA closes
142
What fetal structures do each adult part come from:
a. ascending aorta and pulmonary trunk
b. coronary sinus
c. superior vena cava
d. smooth parts of the L and R ventricles
e. smooth part of right atrium
f. trabeculated left and right atria
g. trabeculated parts of left and right ventricles
a. Truncus arteriosus
b. Left horn of sinus venosus
c. R common cardinal vein, R anterior cardinal vein
d. Bulbus cordis
e. right horn of sinus venosus
f. primitive atria
g. primitive ventricle
143
Which fetal vessel has the highest oxygenation?
Umbilical vein > ductus venosus > inferior vena cava > right atrium
144
Which cell types are rich in smooth ER?
Hepatocytes
| Steroid hormone-producing cells of the cortex
145
What are overdose antidotes for Heparin and Warfarin?
Heparin - Protamine sulfate
| Warfarin - Fresh frozen plasma and vitamin K
146
What is Eisenmenger syndrome?
An uncorrected left to right shunt causes increased pulmonary blood flow and remodeling of the vasculature that causes pulmonary arterial HTN --> RVH compensates and eventually the right pressure becomes so much greater that shunt becomes right to left --> causes clubbing, cyanosis and polycythemia
147
What is Coarctation of the aorta?
Aortic narrowing near insertion of doctor arteriosus; HTN in upper extremities and weak, delayed pulse in lower extremities. With age you see rib notching from the collateral arteries eroding.
148
What are the four defects in Tetralogy of Fallot?
Pulmonary infundibular stenosis (most important determinant for prognosis) --> forces R to L flow across VSD, RVH
Right ventricular hypertrophy (boot shaped heart on CXR)
Overriding aorta
VSD
149
Why does squatting improve cyanosis in Tetralogy of Fallot?
It increases systemic vascular resistance (SVR) --> decreased R to L shunt --> improves cyanosis
150
What is most common cardiac congenital anomaly?
VSD
151
How are aorta and pulmonary trunk attached in transpositions of great vessels?
Pulmonary trunk comes off left ventricle and aorta comes off right ventricle
152
Boot shaped heart
Tetralogy of Fallot, RVH in adult
153
Rib notching
Coarctation of aorta
154
Most common congenital cause of early cyanosis
Tetralogy of Fallot
155
Which type of collagen is found in
a. slippery tissue
b. bloody tissue
a. Type II
| b. Type III
156
What enzymes are used in metabolism of NE?
COMT
| MAO
157
What are clinical applications of Atropine?
```
Decreased airway secretions
Pupillary dilation and cycloplegia
Decreased stomach acid
Decreased gut motility
Decreased urgency
Treats Bradycardia
```
158
What structures do these embryologic structures give rise to?
a. Truncus arteriosus
b. Bulbus cordis
c. Primitive atrium
d. Primitive ventricle
e. Primitive pulmonary vein
f. Left horn of sinus venosus
g. Right horn of sinus venosus
h. Right common cardinal vein and right anterior cardinal vein
a. great vessels --> aorta and pulmonary trunk
b. smooth parts of left and right ventricles (outflow tract)
c. Trabeculated part of atria
d. Trabeculated part of ventricles
e. Smooth part of left atrium
f. coronary sinus
g. smooth part of right atrium
h. superior vena cava
159
When does the heart start beating in the embryo?
4 weeks
160
What is the purpose of cardiac looping?
The primary heart tube loops to establish left-right polarity beginning in the fourth week of gestation
161
Defect in left-right dynein
Dextrocardia
162
Steps of septation of chambers
1. Septum primum grows towards endocardial cushions, narrowing foramen primum
2. Foramen secundum forms in septum primum and foramen primum disappears
3. Septum secundum develops as foramen secundum maintains R to L shunt
4. Septum secundum expands and covers most of the foramen secundum (residual foramen is the foramen ovale)
5. Remaining portion of septum primum forms valve of foramen ovale
6. Septum scandium and septum primum fuse to form the atrial septum
7. Foramen ovale usually closes soon after birth because of increased LA pressure
163
Where do VSDs more commonly occur?
In the membranous septum
164
Heart morphogenesis of ventricles
1. Muscular ventricular septum forms; opening is called inter ventricular foramen
2. Aorticopulmonary septum rotates and fuses with muscular ventricular septum to form membranous inter ventricular septum. closing inter ventricular foramen
3. Growth of endocardial cushions separates atria from ventricles and contributes to both atrial separation and membranous portion of inter-ventricular septum
165
Outflow tract formation
Truncus arteriosus rotates; neural crest and endocardial cell migrations --> truncal and bulbar ridges that spiral and fuse to form aorticopulmonary septum --> ascending aorta and pulmonary trunk
166
Valve development
Aortic/pulmonary: derived from endocardial cushions of outflow tract
Mitral/tricuspid: derived from fused endocardial cushions of AV canal
167
Fetal erythropoiesis occurs where?
Yolk sac: 3-8 weeks
Liver: 6 week - birth
Spleen: 10-28 weeks
Bone marrow: 18 weeks to adult
168
Embryonic hemoglobin
Hemoglobin gower: two zeta and two epsilon chains
169
Fetal hemoglobin
HbF: alpha2 gamma 2
170
How does fetal Hgb affinity for oxygen differ from adult Hgb?
Fetal Hgb has higher affinity for oxygen due to less avid binding of 2,3 BPG - this allows fetal Hgb to extract O2 from maternal Hgb across the placenta
171
Describe fetal circulation
1. Blood enters fetus through umbilical vein and goes through ductus venosus into the IVC (bypasses hepatic circulation)
2. Highly oxygenated blood from IVC enters right atrium: most of it goes through foramen ovale into the left heart and is pumped out to the rest of the body
3. Blood from SVC (deoxygenated) --> goes from right atrium to right ventricle --> main pulmonary artery --> PDA --> descending aorta
172
How is the shunt from right atrium --> PDA --> Aorta possible in fetal circulation?
There is HIGH fetal pulmonary artery resistance
173
What happens to fetal circulation at birth?
When the infant takes it's first breath, the pulmonary vasculature resistance decreases and left atrial pressure increases compared to right atrial pressure. The foramen ovale closes. The increase in O2 and decrease in prostaglandins close the ductus arteriosus
174
What can you use to close PDA?
Indomethacin - inhibits prostaglandins E1 and E2 that keep the PDA open
175
Fetal-postnatal derivatives
a. AllaNtois --> urachus
b. Ductus arteriosus
c. Ductus venosus
d. Foramen ovale
e. Notochord
f. UmbiLical arteries
g. Umbilical vein
a. MediaN umbilical ligament
b. ligamentum arteriosum
c. ligamentum venosum
d. Fossa ovalis
e. Nucleus pulposus
f. MediaL umbilical ligaments
g. Ligamentum teres hepatis (in falciform ligament)
176
Which artery supplies the SA and AV nodes?
RCA; infarct may cause nodal dysfunction (bradycardia or heart block)
177
What does right dominant circulation mean?
The Posterior descending artery arises from the RCA (85% of people)
178
What does left dominant circulation mean?
PDA arises from the LCX (8% of people)
179
Where does coronary artery occlusion most commonly occur?
In the LAD - "widow maker"
180
What part of the heart makes up the posterior part of the heart?
Left atrium
181
Cause of dysphagia or hoarseness
Left atrium enlargement --> dysphagia (compression of esophagus) or hoarseness (due to compression of left recurrent laryngeal nerve)
182
3 properties of heart circulation
1. Heart is perfused during diastole
2. Myocardial oxygen requirement is very high; resting myocardium extracts 75-80% of oxygen from blood - exceeds ALL other tissues
3. Coronary flow is regulated by local metabolic factors including hypoxia and adenosine accumulation
183
What is the pulse pressure? It is proportional to what?
Systolic pressure - diastolic pressure
| Proportional to SV, inversely proportional to arterial compliance
184
How is CO maintained during exercise?
Early exercise - increased HR and increased SV
| Late exercise - Increased HR (SV plateaus)
185
What conditions increase pulse pressure?
```
Hyperthyroidism
Aortic regurgitation
Aortic stiffening
Obstructive sleep apnea
Exercise
```
186
What conditions decrease pulse pressure?
Aortic stenosis
Cardiogenic shock
Cardiac tamponade
Advanced heart failure
187
What does LCX artery supply?
Lateral and posterior walls of left ventricle
| Anterolateral papillary muscle
188
What does LAD artery supply?
Anterior 2/3 of IV septum
Anterolateral papillary muscle
Anterior surface of left ventricle
189
What does PDA supply?
Posterior 1/3 of IV septum
Posterior walls of ventricles
Posteromedial papillary muscle
190
What forms diaphragmatic surface of heart?
Inferior wall of left ventricle
191
What artery supplies right ventricle?
Right marginal artery
192
What three things affect Stroke Volume?
Contractility, Afterload, Preload
| Increased with increased contractility, increased preload and decreased afterload
193
What things increase contractility?
Catecholamines (increased activity of Ca pump in SR)
Increased intracellular Calcium
Decreased extracellular Na (Na/Ca exchanger)
Digitalis (blocks Na/K pump --> increased intracellular Na)
194
What things decreased contractility?
```
Beta 1 blockade (decreased cAMP)
HF with systolic dysfunction
Acidosis
Hypoxia/hypercapnia
Non-dihydropyridine Ca Channel blockers (Verapamil, Diltiazem)
```
195
What increases myocardial oxygen demand? (four things)
Increased contractility
Increased afterload
Increased HR
Increased diameter of ventricle (because it increases wall tension)
196
What approximates preload? What determines this?
Ventricular EDV; depends on venous tone and circulating blood volume
197
What approximates afterload? What determines this?
MAP
| Increased afterload -> increased pressure --> increased wall tension
198
What drugs decrease preload?
Venodilators (nitroglycerin)
199
What things decrease afterload?
Vasodilators (Hydralazine)
| ACE inhibitors and ARBs
200
Normal ejection fraction
>55%; this is an index of ventricular contractility
| EF is decreased in systolic HF, normal in diastolic HF
201
Force of contraction is proportional to what?
End diastolic length of cardiac muscle fiber (preload)
202
Velocity of blood flow from highest to lowest
Aorta, large vessels --> vena cava --> large veins --> small arteries --> arterioles --> small veins --> venules --> capillaries
203
What vessel accounts for most of TPR?
Arterioles
204
Which vessels provide most of blood storage capacity?
Veins
205
How does organ removal affect TPR and CO?
Increases TPR and decreases CO
206
What is biggest determinant of viscosity of blood?
| How does it increase and decrease?
Viscosity depends mostly on Hematocrit
Decreased in anemia
Increased in hyperproteinemic states (like multiple myeloma) and polycythemia
207
Which part of the cardiac cycle has the highest O2 consumption?
Isovolumetric contraction (between mitral valve closing and aortic valve opening)
208
Cause of normal splitting of heart sounds
On inspiration there is drop in intrathoracic pressure that increases venous return --> increased RV filling --> increased RV stroke volume --> increased RV ejection time --> delayed closure of pulmonic valve
209
Cause of wide splitting of heart sounds
Seen in conditions that delay RV emptying (pulmonic stenosis, right bundle branch block) --> delay in RV emptying causes delayed pulmonic sound and exaggeration of normal splitting
210
Cause of fixed splitting of heart sounds
Seen in ASD --> there is left to right shunt that causes increased RA and RV volume --> increased flow through pulmonic valve so that regardless of breath the pulmonic closure is greatly delayed
211
Cause of paradoxical splitting
Seen in conditions that delay aortic valve closure (aortic stenosis, left bundle branch block); normal order of valve closure is reversed so that P2 sound occurs before delayed A2 sound (on inspiration, P2 closes later and moves closer to A2 paradoxically eliminating the split)
212
How does hand grip affect the following?
a. Mitral regurgitation
b. Aortic regurgitation
c. VSD murmur
d. Hypertrophic cardiomyopathy murmur
e. Mitral Valve prolapse
(Increasing Afterload)
a. Increased intensity
b. Increased intensity
c. Increased intensity
d. Decreased intensity
e. Later onset of click/murmur
213
How does Valsalva affect the following?
a. Most murmurs in general
b. Hypertrophic cardiomyopathy murmur
c. MVP
(Decreasing preload)
a. Decreased intensity
b. Increased intensity
c. Earlier onset of click
214
How does rapid squatting affect the following?
a. Hypertrophic cardiomyopathy murmur
b. AS murmur
c. MVP
(Increased venous return, increased preload)
a. Decreased intensity
b. Increased intensity
c. Later onset of click
215
Crescendo decrescendo systolic ejection murmur loudest at heart base
Aortic stenosis
216
Holosystolic high pitched blowing murmur
Mitral/tricuspid regurgitation
217
Mitral regurgitation is often due to...
Ischemic heart disease post MI
218
Tricuspid regurgitation is most often caused by:
RV dilation
219
Causes of Mitral or Tricuspid regurgitation
Rheumatic fever, Infective endocarditis
220
Late systolic crescendo murmur with mid systolic click
Mitral valve prolapse
221
MVP predisposes to:
Infective endocarditis
222
Causes of MVP
Myxomatous degeneration (Marfans, Ehler Danlo)
Rheumatic fever
Chordae rupture
223
Holosystolic harsh sounding murmur loudest at tricuspid area
Ventricular Septal Defect
224
High pitched blowing early diastolic decrescendo murmur
Aortic regurgitation
225
Causes of aortic regurgitation
Aortic root dilation, Bicuspid aortic valve, endocarditis, rheumatic fever
226
Murmur that follows opening snap; delayed rumbling late diastolic murmur
Mitral stenosis
227
Chronic mitral stenosis can cause:
LA dilation
228
Myocardial action potential
a. Phase 0
b. Phase 1
c. Phase 2
d. Phase 3
e. Phase 4
a. Phase 0 = rapid upstroke and depolarization from Na influx
b. Phase 1 = Repolarization; inactivation of Na channels; voltage gated K channels open
c. Phase 2 = Calcium influx through voltage gated Ca channels balances K efflux; Ca triggers Ca release from SR and myocyte contraction
d. Phase 3 = Rapid depolarization by massive K efflux from opening of slower K channels and closure of voltage gated Ca channels
e. Phase 4 = resting potential; high K permeability through K channels
229
How long is the effective refractory period normally?
200 msec
230
What initiates depolarization in cardiac nodal cells?
They spontaneously depolarize during diastole resulting in automaticity due to If channels (funny current responsible for slow mixed Na/K inward current)
231
Pacemaker action potential
a. Phase 0
b. Phase 3
c. Phase 4
a. Phase 0 = upstroke; from opening of voltage gated Ca channels; fast voltage gated Na channels are permanently inactivated because of less negative resting voltage of these cells) --> results in slow conduction velocity that is used by AV node to prolong transmission from atria to ventricles
b. Phase 3 = repolarization; inactivation of Ca channels and activation of K channels -> K efflux
c. Phase 4 = slow spontaneous diastolic depolarization as Na conductance increases
232
What part of pacemaker action potential determines HR?
| What factors affect this?
Slope of phase 4 in the SA node
Decreased by Ach/Adenosine
Increased by Catecholamines
233
How does sympathetic stimulation cause increase HR through pacemaker cells?
They increase the chance that I(f) channels are open
234
a. Normal PR interval
| b. Normal QRS complex
a.
235
What causes U wave?
Hypokalemia, Bradycardia
236
Speed of conduction; fastest to slowest
Purkinje fibers > atria > ventricles > AV node
237
Conduction pathway of heart
SA node --> atria --> AV node --> common bundle --> bundle branches --> fascicles --> Purkinje fibers --> ventricles
238
Blood supply to AV node
| Location of AV node
RCA supplies AV Node
| Located in posteroinferior part of interatrial septum
239
Shifting sinusoidal waveforms
Torsades de pointes
240
What can Torsades de pointes progress to?
Ventricular fibrillation
241
Treatment for Torsades de pointes
Magnesium sulfate
242
Romano Ward syndrome
Autosomal dominant
Congenital long QT syndrome --> increased risk of sudden cardiac death from torsades de points
Pure cardiac phenotype
243
Jervell and Lange-Nielsen syndrome
Autosomal recessive; congenital long QT syndrome that increases risk of sudden cardiac death from torsades de points
ALSO sensorineural deafness
244
Brugada syndrome
Autosomal dominant - most common in Asian males
Pseudo-right bundle branch block and ST elevations in V1-V3
Increased risk of Ventricular tachyacchythmias and SCD
Prevent SCD with ICD
245
WPW
Ventricular pre-excitation syndrome
Abnormal fast accessory pathway from atria to ventricle bypasses the rate slowing AV node --> ventricles depolarize too early and you see delta wave in QRS complex
246
Complication of WPW
Reentry circuit that causes supra ventricular tachycardia
247
Cause of 3rd degree heart block
Lyme disease
248
What is Nesiritide?
Brain natriuretic peptide used in treatment of HF
249
Hypertension, Bradycardia, Respiratory depression
Cushing reaction
250
What is the Cushing reaction?
Increased intracranial pressure constricts arterioles --> cerebral ischemia --> increased pCO2 and decreased pH --> central reflex sympathetic increase in perfusion pressure (HTN) --> increased stretch --> peripheral reflex baroreceptor induced bradycardia
251
PCWP is a good approximation of which pressure?
Left atrial pressure
252
In mitral stenosis how does LA pressure compare to LV diastolic pressure?
LA pressure > LV diastolic pressure; this means PCWP > LV pressure
253
Autoregulation controlled by:
a. Heart
b. Brain
c. Kidneys
d. Lungs
e. Skeletal muscle
f. Skin
a. Local metabolites like adenosine, NO, CO2 and decreased O2 are vasodilatory
b. Local metabolites like CO2 are vasodilatory
c. Myogenic and tubuloglomerular feedback
d. Hypoxia causes vasoconstriction
e. Local metabolites during exercise (lactate, adenosine, K+, H+, CO2) and at rest (sympathetic tone)
f. Sympathetic stimulation most important mechanism: temp control
254
Cause of transposition of great vessels
Failure of aorticopulmonary septum to spiral
255
Most common cause of ASD
Osteum secundum defect
256
Congenital cardiac defect associations:
a. Alcohol exposure in utero
b. Congenital rubella
c. Down syndrome
d. Infant of diabetic mother
e. Marfan syndrome
f. Prenatal lithium exposure
g. Turner syndrome
h. Williams syndrome
i. 22q11 syndrome
a. VSD, PDA, ASD, tetralogy
b. PDA, pulmonary artery stenosis, septal defect
c. AV septal defect
d. Transposition of great vessels
e. MVP, thoracic aortic aneurysm and dissection, aortic regurgitation
f. Ebstein anomaly
g. Bicuspid aortic valve, coarctation of aorta
h. Supravalvular aortic stenosis
i. Truncus arteriosus, tetralogy
257
What is Monckeberg arteriosclerosis?
Medial calcific sclerosis
Calcification of elastic lamina of arteries --> vascular stiffening without obstruction; Intima NOT involved
Pipestem appearance on X-ray
258
Which vessels does Arteriolosclerosis affect? What are the types?
Small arteries and arterioles
1) Hyaline - thickening of vessels walls in essential HTN or diabetes
2) Hyperplastic - onion skinning in severe HTN with proliferation of SMCs
259
How do you treat Prinzmetal angina?
Calcium channel blockers, nitrates and smoking cessation
260
How do you differentiate Unstable angina and NSTEMI?
No cardiac biomarker elevation in unstable angina
| Both may have ST depression or T wave inversion
261
Causes of sudden cardiac death
Lethal arrhythmia after MI
Cardiomyopathy (hypertrophic or dilated)
Hereditary ion channelopathies (Brugada, long QT)
262
0-4 hours after MI
a. Gross
b. Microscope
c. Complications
a. None
b. None
c. Arrhythmia, HF, cardiogenic shock
263
4-24 hours after MI
a. Gross
b. Microscope
c. Complications
a. Dark mottling; pale with tetrazolium stain
b. Early coagulative necrosis; release of necrotic cell contents into blood; edema; hemorrhage; wavy fibers; neutrophils appear; Reperfusion injury may cause contraction bands (due to free radical damage)
c. Arrhythmia, HF, cardiogenic shock
264
1-3 days after MI
a. Gross
b. Microscope
c. Complications
a. Hyperemia
b. Extensive coagulative necrosis; tissue surrounding infarct shows acute inflammation and neutrophils
c. Post-infarction fibrinous pericarditis
265
3-14 days after MI
a. Gross
b. Microscope
c. Complications
a. Hyperemic border; central yellow brown softening; maximally yellow and soft by 10 days
b. Macrophages, then granulation tissue at margins
c. Free wall rupture --> tamponade; papillary muscle rupture --> mitral regurgitation; interventricular septal rupture due to macrophage mediated structural degradation; LV pseudoaneurysm (risk of rupture)
266
2 weeks to several months
a. Gross
b. Microscope
C. Complications
a. Recanalized artery, gray-white
b. Contracted scar complete (Type III collagen replaced by Type I collagen)
c. Dressler syndrome, HF, arrhytmias, true ventricular aneurysm (risk of mural thrombus)
267
When does cardiac troponin rise? How long is it increased?
Rises after 4 hours; is increased for 7-10 days
268
When does CK-MB rise? How long is it increased? What is it useful for?
Rises are 6-12 hours; levels return to normal after 48 hours so it is useful for diagnosing re-infarction following acute MI
269
EKG localization of STEMI
a. LAD - anteroseptal
b. distal LAD - anteroapical
c. Anterolateral (LAD or LCX)
d. Lateral (LCX)
e. Inferior (RCA)
a. V1-V2
b. V3-V4
c. V5-V6
d. aVL, I
e. aVF, II, III
270
Causes of dilated cardiomyopathy (ABCCCD)
```
Alcohol
wet Beriberi
Coxsackie B virus
Chronic cocaine use
Chugs disease
Doxorubicin/Daunorubicin
Hemochromatosis
Sarcoidosis
Peripartum cardiomyopathy
```
271
Eccentric hypertrophy - sarcomeres added in series
Dilated cardiomyopathy
272
Findings in dilated cardiomyopathy
HF, S3, systolic regurgitant murmur, dilated heart on echo, balloon appearance of heart on CXR
273
Systolic or diastolic dysfunction?
a. Dilated cardiomyopathy
b. Hypertrophic cardiomyopathy
c. Restrictive cardiomyopathy
a. Systolic
b. Diastolic
c. Diastolic
274
Myofibrillar disarray and fibrosis
Hypertrophic cardiomyopathy
275
Causes of restrictive cardiomyopathy
Sarcoidosis
Amyloidosis
Postradiation fibrosis
Endocardial fibroelastosis (young children)
Loffler syndrome (eosinophilic infiltrate)
Hemochromatosis
276
Cause of hemosiderin laden macrophages in lungs
Pulmonary edema from increased pulmonary venous pressure --> increased pulmonary venous distension and transudation of fluid
277
Causes of nonbacterial endocarditis
Malignancy
Hypercoagulable state
Lupus
278
Tricuspid valve endocarditis bugs
Associated with IV drug use
| S. aureus, Pseudomonas, Candida
279
Aschoff bodies
granuloma with giant cells; associated with Rheumatic fever
280
Enlarged macrophages with ovoid, wavy rod-like nucleus
Anitschkow cells seen in Rheumatic fever`
281
Causes of acute pericarditis
Idiopathic (most common - probably viral)
Confirmed infection (Coxsackievirus)
Neoplasia
Autoimmune (SLE, rheumatoid arthritis)
Uremia
Cardiovascular (STEMI or Dressler syndrome)
Radiation therapy
282
Equilibration of diastolic pressures in all 4 chambers
Cardiac tamponade
283
Beck triad: hypotension, distended neck veins, distant heart sounds
Cardiac tamponade
284
Kussmaul sign
Chronic constrictive pericarditis (JVD with inspiration)
285
Rhabdomyoma association
Tuberous sclerosis (hamartomas, seizures, astrocytomas, cortical and retinal hamartomas, intellectual disability)
286
Vascular tumor associated with radiation therapy and chronic post mastectomy lymphedema
Angiosarcoma
287
Cancer association with vinyl chloride and arsenic exposure
Hepatic angiosarcoma
288
Blood vessel malignancy in elderly
Angiosarcoma - in sun exposed areas
289
Benign capillary skin papule found in AIDS patients
| Cause?
Bacillary angiomatosis
| Bartonella henselae infection
290
How do you differentiate Kaposi sarcoma and Bacillary angiomatosis?
Both in AIDS patients but Bacillary angiomatosis has neutrophilic infiltrate; Kaposi has lymphocytic infiltrate
291
Benign capillary hemangioma of the elderly
Cherry hemangioma; does not regress
292
Cavernous lymphangioma of the neck
| What is it associated with?
Cystic hygroma
| Associated with Turner syndrome
293
Benign, painful, red-blue tumor under fingernails
Glomus tumor
294
Polypoid capillary hemangioma that ulcerates and bleeds
| Associations?
Pyogenic granuloma
| Trauma and pregnancy
295
Benign capillary hemangioma of infancy; grows rapidly and regresses spontaneously by 5-8 years old
Strawberry hemangioma
296
Histology of Temporal arteritis
Granulomatous inflammation
297
Vasculitis that spares the lungs
Polyarteritis nodosa
298
Palpable purpura on buttocks/legs, arthralgia, abdominal pain
Henoch-Schonlein purpura
| -Associated with IgA nephropathy (Berger disease)
