cardio Flashcards
Pt with a history of Hodgkin lymphoma presents with systolic dysfunction (decreased ejection fraction, narrowing pulse pressure, and JBD)
Dilated cardiomyopathy secondary to doxorubicin treatment
Which class of antiarrythmics should be avoided in DM pt’s due to their ability to mask hypoglycemia?
Beta blockers
In a pt with Pulmonary HTN and an allergy to sulfa drugs, which medication should be recommended for diuresis?
Ethacrynic acid - only non sulfa-based loop diuretic
Acetazolamide, Furosemide, HCTZ all contain sulfa
A Turner patient is likely to have which two cardiac anomalies?
Coarctation of the aorta
Bicuspid aortic valve
Pt presents with hypotension, JVP, and pulsus paradoxus. Condition and ECG findings?
Tamponade
Alternations of QRS height with each beat (electrical alterans)
Child presents to ED for arrythmias due to an underlying congenital condition. These arrythmias are worsened by AV nodal block
Wolff-Parkinson-White
The pt has an AV accessory tract that bypasses the AV node going straight from the atrium to the ventricle
Loop diuretics are commonly given for what condition and how do they work?
Dilated cardiomyopathy
Block the Na/K/Cl cotransporter in the loop of Henle.
A young female from Guatemala dies suddenly while lifting a heavy object. Her only cardiac history is a new murmur that started 3-4 years ago. Bx at autopsy shows an area of perivascular fibrinoid necrosis within the myocardium
Rheumatic heart dz
Histology describes an Aschoff nodule
Nausea, vomiting, shortness of breath, diaphoresis suggests?
angina secondary to acute coronary syndrome (MI)
Pt with a rumbling late diastolic murmur preceded by an opening snap heard over the apex
Mitral stenosis due to a previous step pharyngitis infection (rheumatic heart dz)
Cardiac symptoms associated with SLE
Libman-Sacks endocarditis
Small sterile vegetations on BOTH sides of the mitral valve
SLE pt
In a patient with atrial flutter (rapid succession of identical atrial depolarization waves following ST elevation) why would you choose to administer esmolol over metoprolol
It is short acting
Good trial drug to see if the pt can tolerate a Beta Blocker
Pt with a history of HTN and DM in the ED with complaints of severe chest pain radiating to the lower back and asymmetric pulses in the upper extremities. What is the potentially fatal complication of this condition?
Pt has acute aortic dissection
Complication = rupture into any body cavitiy, including causing obstructive shock due to tamponade (most common COD)
PT with CHF exacerbation and peripheral edema becomes tachypneic following treatment. Crackles and tactile fremitus present bilaterally. What medication is responsible?
Mannitol
Furosemid is first line treatment to diures a CHF pt and spironolactone has been shown to improve mortality.
Mannitol is contraindicated because the pt can become hypernatremic and have worsening pulmonary edema due to volume expansion.
What is the difference between direct-acting and indirect-acting sympathomimetics?
Direct-acting enter the CNS less readily than the indirect acting
Direct-acting bind postsynaptic adrenergic receptors, these are more selective.
Indirect-acting cause catecholamine release from pre synaptic terminals (amphetamine)
Young African male with fever, weight loss, diffuse myalgias and arthralgia, abdominal pain. Areas of ulceration and mottled purple discoloration on his lower extremities. Past medical history significant for HTN and Hep B. Elevated WBC count, ESR, and CRP
Polyarteritis nodosa (PAN)
Necrotizing immune complex inflammation of medium-sized, muscular arteries.
Histology would show fibrinoid necrosis
ANA, and RF negative
35 year old with no medical history presents with progressive shortness of breath occurring with activity, weight gain, with a recent history of a URI. Cause of the heart failure?
Viral myocarditis (coxsackie, influenza, adenovirus, echovirus, CMV, HIV) Causes CHF secondary to dilated cardiomyopathy. Direct cytotoxicity via receptor-mediated entry of virus into cardiac myocytes
In a patient with pheochromocytoma what medication will antagonize the vascular and cardiac action of NE?
Letalol - non selective alpha and beta receptors
NE acts on a1, a2, and b1
vascular = a1
Cardiac = b1
Vessel associated with 3rd aortic arch?
Common carotids, internal carotids
Vessel associated with 5th aortic arch?
None. This arch regresses
Vessel associated with 1st aortic arch?
Maxillary a.
Vessel associated with 4th aortic arch?
ascending arch of the aorta, proximal portion of subclavian
Vessel associated with 2nd aortic arch?
Stapedial, hyoid a.
Vessel associated with 6th aortic arch?
pulmonary a.
Neonate with patent PDA probably due to mother experiencing what during pregnancy?
Rubella
CMV during pregnancy causes?
mental retardation, microcephaly, deafness
Effects of epinephrine
a1, a2, b1, b2 stimulation Relaxes bronchial smooth muscle Vasodilation (b2) in small dose Vasoconstriction (a1) in large dose Increased HR and contractility (b1)
Effects of phenoxybenzamine
nonselective and irreversible alpha antagonist
MI and renal occlusions lead to what type of necrosis?
Coagulative
Treatment used to abolish AV nodal arrhythmias such as paroxysmal supraventricular tachy (PSVT)
Adenosine
Slows conductions through the AV node via cellular hyperpolarization
Fibrates increase HDL by increasing the activity of?
Peroxisome proliferator-activated receptor alpha (PPAR-alpha)
A healthy man has a loud S1 and a wide split S2. During inhalation and exhalation the split remains fixed.
Atrial Septal Defect
Defect in interatrial septum due to deficient tissue
What is increased dromotropy?
Increase in conduction velocity through the AV node due to increased inward Ca
What is increased inotropy?
Increased contractility due to increased inward Ca
What is increased chronotropy
Increase in heart rate due to an increase in the firing rate of the SA node due to increase in the inward Na current
Occlusion of which vessel would jeopardize blood supply to the vertebral a.?
Subclavian a.
Turner’s syndrome is associated with preductal or postductal coarctation of the aorta?
Preductal
Commonly presents with a smaller left arm to to compromised flow in the left subclavian a.
What item in a patients history would make a physician advise against using a nonselective beta blocker, such as timolol, for HTN
Asthma
Don’t want to antagonize bronchial beta 2
What effect do beta blockers have on:
HR
Stroke volume
MAP
All decreased
Negative chonotropic - decrease hr
Negative ionotropy - decrease contractility and SV. This decreases CO and MAP
A pt with Monday dz presents to the clinic. What is a serious complication of this exposure?
Cardiac arrest
Monday dz = withdrawl from occupational nitroglycerine exposure. Vasodilation on work days and vasoconstriction on the weekends
Older male Pt with fatigue, muscle pain, weight loss x 3 mo. Unusually dark stools, palpable purpura along extremities. Reddish sputum. Bx = necrotizing vasculitis with lesions at the same age
microscopic polyangiitis
p-ANCA
Can cause glomerulonephritis and pulmonary capillaries late in dz
At birth, what incidental finding is suggestive of an underlying congenital abnormality
A single umbilical a.
Carries deox blood from fetus to mom
How does the heart accommodate the increased oxygen demand during a stress test?
Increased coronary a. diameter and increased coronary blood flow
Sudden death following an MI is caused by?
Arrhythmia due to abn re entry currents
What is the positioning of the internal jugular vein within the carotid sheath
In internal jugular vein is lateral to the common carotid a. and anterior to the vagus nerve
kid with fever, conjunctivitis, erythema of the oral mucosa, cervical lymphadenopathy
Kawasaki dz
small and medium vessels
Tx - supportive care
At risk of developing coronary aneurysms and MI
If a pt is crashing and has hypotension and clammy skin, activation of which receptors will have the most rapid increase in artherial pressure
Stimulation of a1 receptors on vascular smooth muscle
vasoconstriction = venous return
Use NE to achieve this
B2 = vasodilation
Pt with progressive fatigue and a diastolic rumbling murmur
Mitral stenosis secondary to rheumatic fever. See a drop in LA and LV pressure
A pt that takes captopril and HCTZ is wanting to get pregnant. What would you change?
D/c captopril, increase dose of HCTZ
ACEI and ARBs are contraindicated in pregnancy
Safe for preggo: HCTZ, labetalol, methyldopa, beta block, CCB, hydralazine
What is recommended for management of acute HTN during pregnancy
Labetalol
methyldopa
Which beta blocker is used to treat arrhythmia by prolonging repolarization of the AP
Sotalol Has class II and III properties. Class III prolongs repolarization by blocking outward K
Pt with the crescendo-decrescendo systolic murmur, dyspnea, exertion, fatigue, syncope, angina, late pulses, LVH
Aortic stenosis
calcification of the valve leaflets from proliferate and inflammatory changes
5 year old female with cracked lips, red palms and soles, conjunctivitis, cervical lymphadenopathy
Kawasaki dz
Coronary aneurysm is a feared complication
Self limiting
which vasculitis dz spares the lungs?
Polyarteritis nodosa
ANCA -
Necrotizing vasculitis. Asian infant. Conjunctivitis, rash, adenopathy, strawberry tongue, hands and feet
Kawasaki
CRASH
Potential for coronary aneurysms
Tx - IVIG, ASA
Younger male with heavy smoking with gangrene
Buerger dz
Tx - smoking cessation
Poor pulses in extremities, young asian women, high ESR
Takayasu
Port wine stain following trigeminal n.
Sturge-Weber dz
At risk of seizures
hemangioma in kids
Strawberry hemangioma
Spontaneous regression
Drugs that can cause SLE?
Procainamide Quinidine Minocycline Isoniazid Valoproate Hydralazine Penicillamine Sulfasalazine
Wolff-Parkinson-White syndrome treatment that can cause hypothyroidism like side effects
Amiodarone
Class II antiarrhythmic
Can also cause hyperthyroidism, pulmonary fibrosis, photodermatitis
Effect of carotid massage in arrhythmias?
Slowed SA node automaticity and slowed conduction velocity through the AV node
Mechanism of beta blockers
Decrease in Na and Ca currents
Inhibit the Gs and decrease intracellular cAMP
Decreases slope of phase 4
Which HTN drug also slows the damaging effects of DM on the renal and CV systems
ACEI
6 hours post MI bx would show contraction bands on microscopy due to?
Elevated intracellular Ca
Brown atrophy of the heart in an older patient is caused by?
Lipofuscin
“wear and tear” pigment that deposits in organs in the elderly
Bx of myocardium in a pt with hypertrophic cardiomyopathy
Disarray of bundles of myocytes and sarcomeres within cells
A young male pt has syncope with activity. S4 gallop at the apex, mild systolic ejection murmur at LLB. Decreases in intensity when he squats and increases with Valsalva. Dx and tx
Hypertrophic cardiomyopathy
Beta blocker (Atenolol) or cardica specific Na channel blocker (verapamil)
S4 due to stiff hypertrophied ventricle
ejection murmur = obstruction of outflow tract due to enlarged septum
A pt with stable angina is given sublingual nitroglycerine inorder to do?
Decrease preload, decreases myocardial oxygen demands
A pt presents to the ED with chest pain but cardiac enzymes are negative and ECG is normal. Dx?
GERD
Sensory nerve fibers are in which horn of the spinal cord?
Posterior
Histologically the Aschoff bodies in rheumatic heart dz contain?
Multinucleated giant cells and large Anitschkow cells
A 67 year old woman was started on a new HTN drug and is now complaining of fatigue, drowsiness and depressed mood. The drug is?
Clonidine
alpha2 agonist - can cause dry mouth, constipation, ED, sleep disturbance, HA, confusion
Which peptide hormone regulates HTN by increasing urinary output and decreases total peripheral vascular resistance?
ANP from atrial cardiomyocytes
Effect is prolonged by neprilysin
Seen in Systolic HF because it causes a back up of fluid
An MI with ischemia along the inferior surface of the heart is caused by occlusion of?
Right coronary a.
Unless pt has left dominant circulation
When comparing the averages of two groups of people, what statistical test is best?
Two ample t-test
When comparing raw values in categorical data, which statistical test is best?
Chi squared
A pt with familial Pulmonary HTN has likely developed this condition due to
Vascular smooth muscle proliferation due to BMPR2
AD, but does follow a two hit hypothesis
When verapamil is added to a pt’s history, it will cause vasodilation by relaxing smooth muscle but has no effect on skeletal muscle. Why?
Skeletal m. does not depend on extracellular calcium influx
A pt with a new murmur has a culture positive for strep gallolyticus (S. bovis). Additional work up should include?
Colonic neoplasia
S. gallolyticus = group D strep that causes subacute endocarditis that is part of the normal flora of the colon and is associated with colon cancer.
Where is the AV node located?
endocardial surface of the RA, near the insertion of the septal leaflet of the tricuspid valve and the orifice of the coronary sinus.
Where is the SA node located?
Upper anterior RA at the opening of the SVC
Acquired QT prolongation is most often caused by which class of medications?
Class Ia III and antiarrhythmics (quinidine, stalol), abx (macrolides, fluoroquinolones), methadone, antipsychotics (haloperidol)
What is sotalol?
Class III antiarrhythmic (K+ blocker) used to treat a fib by prolonging the action potential, but this can cause QT interval prolongation
What does permissiveness refer to when two drugs are administered together?
one hormone allows another hormone to exert is maximal effect (ie cortisol potentiates NE by upregulating alpha1 receptors)
A couple of months after initiating ACEI therapy and pt presents with angioedema. Why?
Bradykinin accumulation
Symptoms are similar to hereditary C1 inhibitor deficiency
NO pruritus or uticaria
A pt is found unconscious in apt and is bradycardic on exam. Symptoms improve following glucagon administration. Why?
Pt OD’d on beta blockers causing depressed contractility, bradycardia, and varying degrees of AV block.
Glucagon increases intracellular cAMP and increases cardiac myocyte contractility within minutes.
What is coronary steal?
When a vasodilator is administered to a pt with a pt with an atherosclerotic plaque. Causes blood to flow away from the occluded vessel and further underperfuse the tissues fed by the occluded vessel
In a pt with mitral regurgitation, what would increase the forward flow of blood?
Decreasing LV afterload
Bx of myocardial tissue 2 hours post MI?
Normal
Minimal change 0-4 hrs
holosystolic murmur that increases in intensity during inspiration
Tricuspid regurgitation
In a pt with a hx of mitral valve prolapse presenting with infective endocarditis caused by S. viridians, what is the adherence site for these bacteria?
Fibrin-platelet aggregates
S. viridians produces dextrans which adhere to fibrin. this is why they require a host with a previously damaged mitral valve
Cause of death in digoxin toxicity?
Arrhythmias
How does atenolol affects cAMP levels in:
Cardiomyocytes
Juxtaglomerular cells
Vascular smooth muscle
Atenolol = b1 selective antagonist, inhibits Gs
Cardiomyocyte, juxtaglomerular cell - decreased
Vascular smooth muscle - no change
Nitrates increase in the intracellular levels of cGMP which in turn does what?
Decreases activity of myosin light-chain kinase and myosin light chain dephosphorylation - vascular smooth muscle relaxation
What determines the severity of symptoms in a kid with tetralogy of Fallot?
Right ventricular outflow tract obstruction
Significant RVOT shunts more deoxy blood across the VSD to the aorta making a cyanotic kiddo
What is the function of dobutamine?
Beta adrenergic agonist. Agonist at B1
Activates Gs to increase adenylate cyclase activity and increase [cAMP].
Positive inotrope, chronotrope
No vascular effect
What is responsible for the rapid idecrease in cytoplasmic calcium levels in cardiomyocyte relaxation?
Na/Ca exchanger
A pt presents with hypotension, distended jugular v. and clear lungs due to?
RV MI
See decreased CO, Pulmonary cap wedge pressure
Increased CVP
What is kussmaul sign?
Paradoxical rise in JVP with constrictive pericarditis. This is caused by volume-restricted RV is unable to accommodate the inspiratory increase in venous return
What is safe to use on a pregnant woman with a DVT?
Low molecular weight heparins. Do NOT cross the placenta
enoxaparin
Which antiarrythmic prolongs the QT interval and has the lowest incidence of torsade de pointes
Amiodarone
Class III antiarrhythmic used in SVT and ventricular arrhythmias. Inhibit outward K+
NO is made from which amino acid?
arginine
Most likely cause of widening pulse pressure?
Aortic regurgitation
What could be given to a pt with a prolonged PR interval to better control their HTN?
Nifedipine (dihydropyridines; also amlodipine, felodipine)
Acts at vascular smooth muscle causing vasodilaiton. No cardiac activity
Which congenital cardiac abnormality is associated with cerebral aneurysms?
Coarctation of the aorta
Likely the aneurysm is a berry aneurysm in the circle of willis
Concentric ventricular hypertrophy is caused by?
Hypertension
Decreases chamber size in the ventricle, leads to dilated cardiomyopathy and decreases cardiac contraction force
An MI presents in leads I and aVL. Which artery is occluded?
Left circumflex a.
Lateral aspect of LV
How do you measure the degree of severity in mitral stenosis?
A2-to opening snap time interval (length of time between S2 and opening snap
shorter = more severe
In a pt with decompensated heart failure, what systems are triggered in an attempt to compensate for the decreased CO?
RAAS and sympathetic nervous system
Causes increased afterload (vasoconstriction), excess fluid retention, and deleterious cardiac remodeling
Hypertrophic cardiomyopathy is caused by a mutation in?
Mutations in the sarcomere: Beta-myosin heavy chain, myosin-binding protein C
AD
A pt with a rare vascular tumor that is associated with arsenic or polyvinyl chloride exposure. Tumor is CD31+. Dx?
Livery angiosarcoma
CD 31 = Platelet endothelial cell adhesion molecule (PECAM1)
An isolated enterococci strain substitues D-lactate for D-alanine in PPG synthesis. This decreases pentapeptide binding for which abx?
Vanco
binds D-ala D-ala
On autopsy a pt has multiple small nondestructive masses attached to the edges of the mitral valve leaflet. Masses are made of platelet rich thrombi but negative for bacterial growth. Cause?
Advanced malignancy
Platelet rich thrombi = nonbacterial thrombotic endocarditis
A pt is started on low dose chlorthalidone monotherapy. What would be expected to change in his serum levels?
Cholesterol
Thiazides reduce secretion of insulin and uptake of peripheral glucose - worse blood glucose in DM pts
increases LDL cholesterol and triglyceride levels
A pts autopsy demonstrates a LA with diffuse fibrous thickening and distortion of the mitral valve leaflets, commissural fusion at the leaflet edges, narrowing of the mitral valve orifice. Dx?
Mitral stenosis secondary to rheumatic fever
A pt presenting with exertional dyspnea has an enlarged coronary sinus on echo. Dx?
Pulmonary HTN
The coronary sinus communicates directly with the RA and will become dilated by anything that causes dilation of the RA, usually elevated RA pressure is caused by Pulmonary HTN
Prior to initiating statin therapy, which lab value should be checked?
Liver transminase levels (LFTs). Statins increase risk of hepatotoxicity and muscle toxicity
A pt found under a tree after a storm has fixed publis, fern leaf pattern of erythematous marks and second degree burns. COD?
Cardiac arrhythmia
Lightning injury
After BNP/ANP bid a receptor (ANP receptor), what happens?
guanyl cyclase converts guanosine-5-triphosphate to cGMP leading to vaso=dilation (similar to NO and sildenafil)
Sildenafil increases cGMP levels by inhibiting
Phosphodiesterase 5 (decreases cGMP degredation)
A pt with a family history of MI’s and stroke is most likely to develop atherosclerotic plaques in which vessel?
Abdominal aorta
after the abd aortia in order: coronary a., popliteal a. , internal carotids, circle of Willis
In a pt with severe aortic regurgitation (due to IE), what maintains CO?
Increase in LV SV
A pt with milk plasma is at the greatest risk of developing?
Acute pancreatitis, lipemia retinalis, xanthomas
Pt has familial chylomicronemia
Most frequent cause of sudden cardiac death in a pt with an acute MI?
Ventricular fibrillation
What changes are seen in irreversible cell injury?
Mitochondrial vacuolization and phospholipid-containing amorphous densities occur in irreversible damage
mitochondrial swelling = reversible
Pt with fatigue and dyspnea has a murmur that is best head when he sits up and leans forward
Aortic regurgitation
Peak intensity right after aortic valve closure
Most likely side effect of isosobride dinitrate?
Throbbing headaches, cutaneous flushing, lightheaded, hypotension, reflex tachy
Tx used in angina, causes systemic vasodilation
Spironolactone acts on the?
late distal tubule and collecting duct
antagonize ADH which normally wastes K+ in order to retain fluid
A pt has neary total occlusion of the LAD but there is no evidence of necrosis despite chest pain. why?
atherosclerotic plaques that grow very slowly can be compensated because arterial collaterals develop around the point of occlusion.
At autopsy a pt’s cardiac tissue shows endocardial thickening and fibrosis of tricuspid and pulmonary vales
Carcinoid heart dz
deposits of fibrous tissue in the endocardium lead to tricuspid regurgitation, pulmonic valvulopathy and right sided HF
Dx with 5-hydroxyindoleacetic acid (5-HIAA) which is an end product of serotonin metabolism
3 symptoms characteristic in carcinoid syndrome?
episodic flushing, secretory diarrhea, wheezing
If the left renal v. is compressed between the aorta and superior mesenteric a., what is the pt at risk of developing?
Varicocele
A pt with a bicuspid aortic valve is likely to develop?
Aortic stenosis in his 50’s
Vs senile calcific stenosis which presents around 65
Beta blockers reduce blood pressure through what two mechanisms?
- Reducing myocardial contractility and hr
2. Decreasing renin release (beta 1 receptors on juxtaglomerular cells
A arterial bx on a pt with girant cell arteritis will be most similar to a bx of a pt with?
Takayasu (tends to target the aortic arch)
Granulomatous inflammation of the media
On EKG, a delta wave suggests?
Wolff-Parkinson-White
In the formation of an atherosclerotic plaque, which cells are involved first?
Endothelial cells
What is the pathological change in a pt with a AAA?
Chronic transmural inflammation
Leads to degredation of elastin and abn collagen remodeling
Which drug class can increase systolic and diastolic blood pressure and slows hr?
Selective alpha 1 agonist (phenylephrine, methoxamine)
Vasoconstriction increases blood pressure, baroreceptors in the carotid sinus will cause reflexive brady
In the setting of a fib, which organ is least likely to have an infarct?
Liver, because it has dual blood supply
In hypertrophic cardiomyopathy, the intensity of the murmur will increase with which murmur?
Standing
Decreases preload
Why do pregnant women get supine hypotension?
Decreased venous return due to obstruction of the IV by the uterus
a Pt with afib is put on a medication to control his heart rhythm, but this medication increases his risk of?
Torsades de pointes due to QT prolongation Caused by class III antiarrhythmics (sotalol, amiodarone, dofeticide)
What is pulsus paradoxus?
Exaggerated drop (>10 mmHg) in systolic bp during inspiration Assoc with: cardiac tamponade, severe asthma, COPD, and constrictive pericarditis
A pt with pulsus paradoxus presents with dyspnea, tachypnea, prolonged expiration and bilateral wheezing. Dx and tx?
COPD
Beta-adrenergic agonist (increases intracellular cAMP
PDA’s are derived from which aortic arch?
6th
a pt presents to ED with HA and oliguria and a bp of 240/150. Dx and pathology?
Hypertensive crisis (diastolic pressure >130) Onion-like concentric thickening of arteriolar walls due to laminated smooth muscle cells (SMC) and reduplicated basement membranes. This thickening causes renal artery stenosis which activates RAAs and skyrocket the bp(malignant nephrosclerosis)
A pt hospitalized for dyspnea has macrophages with golden cytoplasmic granules that turn dark blue with Prussian blue staining. Dx?
HF due to LV dysfunction. Caused increasedpulmonary pressure and edema. This caused alveolar hemorrhage and RBC’s ere phagocytized by macrophages. Prussian blue stain detects iron
hemosiderin laden macrophages (siderophages)
Most common cause of a crescendo-decrescendo systolic murmur in an elderly pt?
Aortic or pulmonary stenosis due to calcified valve (hemodynamic stress, atherosclerotic inflammation)
Intensity does not correlate to severity
What would be seen on histology 1-3 days post MI?
Coagulation necrosis (loss of nuclei, striations), PMN infiltrate
What would be seen on histology 3-7 days post MI?
Disintegration of dead PMNs and myofibers. Macrophage infiltration at the borders
What would be seen on histology 7-10 days post MI?
Phagocytosis by macrophages
Begin to form granulation tissue
What would be seen on histology 10-14 days post MI?
Well developed granulation tissue with neovascularization
What would be seen on histology 2wks-2mo post MI?
Progressive collagen deposition and scar formation
What medication could improve a pts HTN and urinary flow?
Alpha 1 - antagonist (promote urinary flow and vasodilation) Used in BPH and HTN No effect on the heart Doxazosin, Prazosin, Terazosin SE's - orthostatic hypotension, vertigo
When are beta blockers indicated in a pt with HTN?
- Evidence of coronary artery dz
2. CHF
What is the first line treatment of essential HTN?
Hydrochlorothiazide
DCT - blocks reasorbtion of Na, Cl and water
Avoid in pts with DM, gout, or hypercalcemia
At autopsy a pt has a thicker myocardium around the RV than the LV. Dx?
Pulmonary HTN
RVH due to cor pulmonale
What is the progression of vascular changes in a pt with pulmonary HTN?
- Muscularization of small a.
- Medial hypertrophy and intimal hyperplasia
- Intimal fibrosis (onion skinning)
- Formation of capillary tufts (plexiform lesion)
A boy that has excessive bleeding following minor trauma has: Bleeding time WNL PTT WNL PT long Deficiency?
Factor VII
Extrinsic Pathway
(WEPT)
An otherwise healthy young pt has syncope and prolonged QT interval. What is the pathology?
Mutation in the membrane potassium channel proteins
K+ determines the the cardiac myocyte AP
How do you distinguish the two congenital syndromes that cause QT prolongation?
- Jervell and Lange-Nielsen syndrome = ar, with neurosensory deafness
- Romano-Ward syndrome = AD, no deafness
Both will predispose the pt to torsades de pointes -> syncopal episode -> sudden cardiac death
Arrange the conduction velocity through the heart from fastest to slowest
Purkinje system Atrial muscle Ventricular muscle AV node "Park at Venture Ave" Making the purkinje system the fastest ensures that the heart contracts in a bottom-up fashion
A pt has repeat episodes of Prinzmetal (variant) angina
(occurs at night, transient ST elevation, no coronary dz on stress test)
What is most likely to trigger the chest pain?
Dihydroergotamine = migraine tx. Constricts vascular smooth muscle via stimulation of alpha-adrenergic (partial agonist) and serotonergic receptors
Coronary vasospasm does cause brief myocardial ischemia
Other triggers: cigarettes, cocaine, amphetamines, triptans
An elderly pt has a sigmoid shaped ventricle at autopsy. LM shows increased collagen and myocytes with a brownish perinuclear cytoplasmic inclusion. Dx?
Normal aging
At autopsy a pt has amyloid deposition in the cardiac atria with no other organ involvement. Amyloid is most likely composed of which polypeptide fragment?
Natriuretic peptide
Precursor proteins for localized amyloidosis:
cardiac atria = ANP
Thyroid gland = calcitonin
Pancreatic islets = islet amyloid protein (amylin)
Cerebrum/cerebral blood vessels = Beta amyloid
Pituitary gland = prolactin
Following sudden cardiac death, what is seen on autopsy?
Massive cardiac hypertrophy and myofiber disarray
Dx = Hypertrophic cardiomyopathy, most common cause of SCD in athletes
A pt with a hx significant for stroke presents with hematuria and renal infarction on CT. Dx?
Thromboemboli most likely from a fib
Emboli from LA or ventricular clots or valvular vegetations etc.
What is the best way to monitor anticoagulation in a pt receiving warfarin?
Porthrombin time
International Normalized Ratio
Use a PTT to monitor heparin
pt presents with fatigue, lightheadedness following a URI. Hypotensive, tachycardic. Pulse is unpalpable during inspiration and JVD. Dx?
Cardiac tamponade
Hypotension + pulsus paradoxous + elevated JVP and muffled heart sounds.
Pt presents with occasional dizziness. On doppler U/S a pt has retrograde flow in the left vertebral a. instead of normal anterograde flow. Which artery is most likely to occluded?
Left subclavian
Subclavian steal syndrome occurs due to severe stenosis of the proximal subclavian a. which leads to reversal in blood flow from the contralateral vertebral a. to the ipsilateral vertebral a.
Syx are related to arm ischemia and vertebrobasilar insufficiency
A pt is put on heparin for DVT. He develops right sided weakness and facial droop. Head CT reveals L sided middle cerebral a. stroke. What would be found on PE?
Splitting of S2 that does not change with respiration
Paradoxical embolismoccurs when a DVT crosses into the arterial circulation via an abn connection between the right and left cardiac chambers.
Atrial L to R shunt causes wide and fixed splitting of S2 and facilitate paradoxical embolism due to periods of transient shunt reversal (ie coughing)
What is the typical progression of a strawberry angioma?
First increase in size and then regress
Grow in proportion to the growth of the child, before eventually regressing. Usually regress by 7.
Describe the flow of ions in a cardiac pace maker cell.
Phase 0 (upswing) - Calcium in Phase 3 (downswing) - Potassium out Phase 4 (maintain action potential) - Inward Na+
An IVDU has endocarditis with Staph aureus. The pathology of her chest pain is most similar to?
PE secondary to DVT
The cause of pleuritic chest pain is septic emboli dislodged from the tricuspid valve
Co-administration of a statin and a fibrate increases a pts risk of?
Myoglobinuria due to rhabdo
A pt presents with recurrent nose bleeds and telangiectasias. Dx?
Osler-Weber-Rendu syndrome
Hereditary hemorrhagic telangiectasia
AD, telangiectasis occasionally rupture and cause epistaxis, GI bleed or hematuria
A pt is started on a ARB and HCTZ but we do not see any changes in his HTN or renin activity. Why?
Medication noncompliance
If he was taking his ARB we would see an increase in his renin activity
Older pt presents with sudden onset right arm weakness and difficulty speaking which resolved in 20 min. What SE is associated with the first line treatment for this?
GI bleeds
Aspirin
She most likely had a TIA, aspirin will help to prevent ischemic stroke
Following an MI ECG shows sT elevation in II, III, and aVF. Which vessel is occluded?
Right coronary a.
Ischemia of inferior wall in left ventricle. Can also see sinus node dysfunction
ECG shows elevation in V1-V4. Where is the occlusion?
Leeft anterior descending
ECG shows elevation in V5, V6 and some in I and vVL. Where is the occlusion?
Left circumflex
A 10 year old presents with restlessness and involuntary jerking. PE - rapid, irregular jerking movements involving his face arms and legs. Pt is at risk for developing?
Valvular heart dz
Pt is presenting with sydenham chorea - involuntary rapid irregular jerking movements of the face, arms and legs. Associated with group A strep and a major clinical manifestation of rheumatic fever.
Blood oxygen content will have the greatest difference between the aorta and?
Coronary sinus
Myocardial oxygen extraction exceeds that of any other tissue or organ in the body. Can only meet increased oxygen demand by increasing flow
Diastolic heart sound just before S1?
S4
Head in pts with reduced ventricular compliance (HTN related heart dz, aortic steonosis, hypertrophic cardiomyopathy)
Caused by a sudden risk in EDP following atrial contraction
Pt with a fib and CHF presents with n/v and vision difficulties. Hyperkalemic. Which med is causing this?
Digoxin
Toxicity = cardiac arrhythmia and GI ipset and confusion/weakness with visual syx
Elevated K+ due to inhibition of Na/K ATPase pumps
Type of necrosis seen following an MI?
Coagulative necorsis
Pt has a mid-to-late systolic click over the apex. Dx and the abnormality was most likely caused by?
Mitral valve prolapse
Caused by defect in the mitral valve connective tissue that predisposes to myxomatous degeneration of the mitral leaflets and chordae tendinae
Murmur is reduced by squatting - increased venous return makes the leaflets more normally arranged
Diastolic murmurs
Mitral Stenosis
Tricuspid Stenosis
Aortic regurg
Pulmonic regurg
Compare obstruction of the SVC (SVC syndrome) to obstruction of the braciocephalic v.
SVC syndrome - Involves swelling of BOTH sides of the face, neck, chest, and arms
Braciocephalic - Involves swelling of the IPSILATERAL face, neck, chest, and arms (ie just symptoms on one side of the body)
Which type of collagen would be seen in the fibrosis of heart tissue?
Type I
Seen in most mature scars
If you see R to L shunting in an adult what defect is most common?
ASD, patent foramen ovale
Incomplete fusion of atrial septum primum and secundum
Common in adults after a stroke
Murmur with weak pulses
Aortic stenosis
Crescendo-decrescendo systolic murmur at 2nd-3rd right sternal border
Aortic stenosis
Early diastolic decrescendo murmur along upper left side of sternum
Pulmonic regurg
Late diastolic decrescendo murmur at lower left sternum
Tricsupid stensosis
Pansystolic murmur at the apex radiating to left axilla
Mitral regurg
Late systolic murmur preceded by a mid-systolic click
Mitral valve prolapse
Crescendo-decrescendo systolic murmur over 2nd and 3rd intercostal on left sternal border
Pulmonic stenosis
Pansystolic at LL sternal border radiating to the right lower sternal border
Tricuspid regurg (adult IVDU) or VSD (kid)
Rumbling late diastolic murmur with an opening snap over 5th intercoastal
Mitral stenosis
Continuous machine-like murmur
Patent Ductus arteriosis
High Pitched diastolic murmur with a wide pulse pressure
Aortic regurg
Why does squatting improve Tetrology of Fallot syx?
Increases systemic vascular resistance -> decreases Right to left shunting -> increases pulmonary blood flow -> improves oxygenation
Tyramine ingestions is a problem for?
MAOI’s -> hyptertensive crisis
MAO = mitochondrail enzyme that degrades excess MAO NT’s
It also detoxifies tyramine in the GI
A pt has elevated homocysteine due to a mutated methylene tetrahydrofolate reducatse. What molecule is he unable to make from homocysteine?
Methionine
Folate cycle is required to make methionine from homocysteine
Increased risk of thrombotic events due to endothelial damage
B6 deficiency would decreases his ability to convert homocystein to cystathionine -> cysteine
Elderly pt has Normal LV end systolic volume but elevated Pressure. Why?
Diastolic Heart failure = decreased ventricular compliance, normal LVEF and LV end diastolic volume but elevated LV pressure
Causes = HTN, obesity and infiltrative disorders (transthyretin-related amyloidosis, sarcoidosis)
LV diastolic pressure is determined by 1. LVED volume and 2. Ventricular compliance
Decreased compliance = increased pressure
Stiff heart
What can lead to dilated cardiomyopthy?
Alcoholic cardiomyopathy Doxorubicin therapy Selenium deficiency Viral myocaditis Cause LV systolic dysfunction = Increased LV volume and pressure volume curve would shift right due to a thining ventricular wall (increased compliance, floppy heart)
What is tranthyretin?
Carrier of thyroxine and retinol
mutations -> misfolding -> amyloid protein that infiltrates the myocardium (hence infiltrative cardiomyopathy)
What is functional mitral regurg?
Product of hemodynamic changes. Increased preload (ie volume overload) can cause functional regurg
Eliminate murmur with preload reduction and afterload reduction
How do you calculate the number of individuals that would need to be treated to prevent a negative outcome in one pt?
Number needed to treat
NNT=1/ARR
Risk 1 - Risk 2 = ARR
Tx for diptheria?
IgG against circulating proteins
What are ways to calculate CO?
CO = SV x HR CO = rate of O2 consumption/AV O2 difference
When do you use chi-square vs. ANOVA?
Anova - test the association between the means of two variables
Chi-square - measures the association between two variables
Thiamine deficiency causes?
Wernicke-Korsakoff
Beriberi - peripheral neuropathy, heart failure
Location of the aV node?
Interatrial septum near to opening of the coronary sinus
What causes a pt to have elevated systolic HTN but normal diastolic pressure
Aortic stiffening
associated with aging
Which medication can significantly prolong QT interval but low incidence of torsade de pointes?
Class III, class IA antiarrhythmics Class I A - Disopyramide, Procainamide, Wuinidine Class III (block outward K+) - Amiodarone, Dronedarone, Dofetilide, Sotalol
Which cardiac chamber is immediately anterior to the esophagus?
Left Atrium
TEE is able to visualize LA, atrial septum and mitral valve very well
What structure would be visualized immediately posterior to the esophagus on TEE?
Descending aorta
Useful if investigating dissection or aneurysm
How do arteriovenous shunts affect the hemodynamics?
Increased preload, decreased afterload
See LVEDP vs LVEDV curve shift to the right
Young pt, wide fixed split S2. Dx?
ASD
Need surgery to prevent chronic pulmonary HTN and Eisenmenger syndrome
Which component of the atherosclerotic plaque is capable of synthesizing structurally important collagen isoforms and extracellular matrix?
Vascular smooth muscle cells
Progressive plaque enlargement -> ECM remodeling and VSMC death -> increased plaque vulnerability
Fibroblasts are NOT involved in atherosclerosis and rarely found in the intima
Natriuretic peptides are metabolized by?
Neprilysin, a metalloprotease
Aortic dissections are typically triggered by?
When overwhelming hemodynamic stress leads to tearing of the aortic intima allowing blood to dissect the aortic media causing an intramural hematoma. Get medial stiffening due to decreased blood flow Ascending aorta - class A Descending aorta - class B
Tenderness on palpation at the sternal border
Costochondritis (costosternal syndrome, anterior chest wall syndrome ) - occurs after repetitive activity
What hemodynamic changes are seen in a chronic arteriovenous return
Increased CO (due to increased sympathetic tone, decreased peripheral resistance, increased venous return) Acute AV - decrease TPR, increased CO, Wincreased venous return
Where does the ligamentum arteriosum connect to the aorta?
Descending aorta
Can be torn in sudden deceleration injuries (ie MVA)
PE finding in cardiac tamponade?
Drop in pulse amplitude during inspiration (Pulsus paradoxus)
What increases following dobutamine infusion
Myocardial oxygen consumption
Beta adrenergic agonist (mostly Beta 1)
Lab test to dx carcinoid?
Urinary 5-hydroxyindoleacetic acid
5-HIAA
See deposits of fibrous tissue in the endocardium on the right half of the heart
Pt presents with pericarditis 4 days post MI. Why?
Inflammatory rxn to cardiac muscle necrosis in the adjacent visceral and parietal pericardium
tx - aspirin
Pt presents with pericarditis 1wk-months post MI?
Dressler’s syndrome
Pericardial inflammation due to autoimmune reaction to necrotic tissue
The primary event in an aortic dissection?
Focal intimal tear
The primary event in abdominal aortic aneurysm formation?
Transmural inflammation of the aortic wall
Leads to elastin degradation -> ABN collagen remodeling -> weakening of the aortic wall leading to aneurysm formation
How do you correct venous blanching at the site of NE infusion?
Alpha 1 antagonist prevent necrosis (phentolamine)
QT prolongation is due to a mutation in?
Membrane K+ channel proteins
Gram positive cocci that can synthesize dextrans from sucrose?
Strep viridians
Cause infective endocarditis following dental carries
Wide and fixed split S2
PFO
Can throw emboli and cause a stroke
What is the most important mediator of coronary vascular dilation?
Nitric oxide
A pt with Left sided HF (orthopnea and crackles) has pulmonary HTN due to?
Vasoconstriction due to pulmonary venous congestion
What decreases in exercise?
Total systemic vascular resistance
LVEDP - increases
Skull fx at the junction of the frontal, parietal, temporal, and sphenoid bones causes damage to which vessel?
Maxillary a.
Fx at the pterion
Can cause an epidural hematoma (middle meningeal a.)
A pt has an acute MI with complete thrombotic occlusion. What is his COD?
Ventricular arrhythmias (v tach, v fib) Most common cause of sudden cardiac death in the first 48 hours after an acute MI
Blood flow is equal to?
1/r^4
How do you determine the severity in mitral regurg?
Presence of an audible S3
What indicates L sided heart failure?
Supine dyspnea relieved by sitting up
A pt with rheumatic heart dz presents with dysphagia. Why?
Left atrium enlargement
How do you compensate for aortic regurgitation?
Increase in LV SV
The effects of adenosine are blocked by?
Theophylline (used in COPD pts)
A pt has a laterally directed anterior chest stab wound along the 5th intercostal space at the midclavicular line. What is at greatest risk of injury?
The left lung
All of the cardiac structures are medial to the midclavicular line (apex might reach the ACL but LV was not an answer option)
Cardiac manifestations in SLE?
Pericardial inflammation (most common, sharp chest pain relieved by sitting up and leaning forward Libman-Sacks - fibrinous lesions on both sides of the heart valve, typically asymptomatic but can cause valvular insufficiency
2 most common cardiac findings in Marfan?
MVP - CHF (#2 COD)
Cystic medial degeneration of the aorta -> aortic dissection if untreated (#1COD)
Homocystinuria pts are at an increased risk of?
Thrombotic events (MI, stroke)
Opening snap with diastolic rumbling murmur over the apex?
Mitral stenosis
See this with mitral valve opening (bottom left corner on P-V loop)
Which class of medications cause QRS prolongation but little effect on QT interval duration?
Na+ channel blockers (phase I)
Na+ influences QRS
K+ - influences T wave
Following starting a new medication pt presents with second degree AV block. What is the med?
Nondihydropyridine Calcium channel blockers (Diltiazem, verapamil).
Av node block = negative chronotropic effect
Worsening HF in pts with reduced LV fxn
Pt is given metoprolol to improve headaches and HTN. How does this work?
Decreases level of circulating renin
Reduce contractility/hr
Why is po isosorbide dinitrate given at higher doses than sublingual nitroglycerin?
High first pass metabolism lowers bioavailability (undergoes hepatic metabolism prior to release into the systemic circulation)
Has nearly complete intestinal absorption
Polyarteritis nodosa will spare which artery?
Pulmonary
Segmental, transural, necrotizing inflammation of medium and small arteries.
Ischemia infarction or hemorrhage of most organs (incl skin in 33%) but lung is rarely involved
Pt dies 5 days post MI due to?
Profound hypotension
Rupture of the ventricle free wall
5-14 days post MI
MOA of ACh and adenosine?
Reduce the rate of spontaneous depolarization in cardiac pacemaker cells by prolonging phase 4
Literally stop their heart
What reduces the cytoplasmic calcium level during to promote muscle relaxation?
Na+/Ca2+ exchanger
MOA of dobutamine
activates Gs -> activates adenylate cyclase -> cAMP
B agonist, mostly B1
Enhances Ca2+ mediated myocardial contractility
In left dominant circulation, which vessel supplies the AV node?
Arises from the dominant coronary a.
So if left cominant, left circumflex a.
If right dominant -> righ coronary a.
What determines coronary dominance?
The coronary a. that supplies blood to the posterior descending a. (PDA)
Epinephrine + X will cause a rise in diastolic bp but no change in hr.
Propanolol
Epinephrine - increases systolic blood pressure (a1b1), hr (b1) and increases diastolic pressure at a low does
Pretreatment with a beta blocker will prevent vasodilation and tachycardia, but won’t prevent vasoconstriction (a mediated)
Following a RVMI what would be expected for: CO, PCWP, CVP?
CO, PCWP - decreased
CVP - increased
RVMI presents with hypotension (low CO) elevated jugular venous pressure (increased CVP) but clear lungs (low PCWP)
What are the NL PCWP’s?
RA - 1-6
RV - 15-30/1-6
Pulmonary a. 15-30/6-12
LA/PCWP/LVEDP - 6-12
Chest pain that improves when a patient sits up and leans forward?
Pericarditis
Friction rub
Differential clubbing and cyanosis without discrepancy in blood pressure or pulse?
PDA
Lower extremity cyanosis - coarctation
Whole body cyanosis - TOF
Common complication of varicose veings?
Skin ulcers (venous stasis) Thromboembolism
During catheterization a branch of the pulmonary a. is occluded by the balloon and the pressure beyond this point corresponds to?
LA
A pt is started on chlorthalidone monotherapy. What serum changes will be seen?
Cholesterol
Thiazide diuretics raise serum calcium, uric acid, glucose, cholesterool and triglyceride levels
They lower Na, K, and Mg
Following alteplase administration a pt is found comatose with asymmetric pupils and irregular breathing pattern. What happened?
Intracerebral hemorrhage
PCI is a preferred tx due to lower rates of ICH
Alteplase converts plasminogen to plasmin
pt has orthostatic hypotension due to blockade of which adrenergic receptor?
Alpha 1 antagonist
Also look for diuretics and autonomic dysfunction
