Cardio Flashcards
When is the sarcomeric length of left ventricular muscles fibers the greatest?
end of diastole - when the LV is filled with blood
What is the most serious complication of a patient with a heart transplant?
“man with cardiac transplant suddenly dies 5 years later while working in his garden”
Graft vascular disease - from chronic transplant rejection
aka: graft arteriosclerosis - intimal and medial thickening of coronary arteries w/o atheroma formation
NO CHEST PAIN b/c transplanted hearts are denervated
elevated homocyteine is a risk factor for what type of cardiac event?
Thrombotic
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What is the following disease: 10 year old boy tachypnea, tacycardia, hypotension holosystolic murmur interstitial mycardial granuloma (Aschoff body)
Acute rheumatic fever
immune mediated complication of untreated group A streptococcal pharyngeal infection
What is the cause of the following Sx:
Smoker
right sided face and arm swelling
engorgement of subcutaneous veings on the same side of neck
obstruction of Brachiocephalic vein
thrombosis or lung cancer
holosystolic murmur
flat facial profile
protruding tongue
small ears
Trisomy 21 (probably from Meiotic nondisjunction)
What is the disease and organism responsible?
older man
low grade fever, fatigue
diastolic murmur @ LLSB
blood culture: gram + cocci, catalase negative, can grow in hypertonic saline and bile
Enterococcal Endocarditis (possibly from cystoscopy) enterococcal faecalis
What is the histological appearance of acute graft rejection of a heart transplant (2 weeks after transplant)
dense infiltrate of mononuclear cells composed primarily of T cells
What is the most common congenital cardiac malformation in patients with Turner Syndrome?
Bicuspid aortic valve
Mitral stenosis/Mitral regurg is a/w what type of cardiac disease? what is the mechanism of injury?
rheumatic heart disease
M-protein activation of T and B lymphocytes cause immune-mediated damage to the mitral valve, resulting in mitral regurg
5 year old, no neonate care
Cyanotic spells improve with squatting
prominent right ventricular impulse
systolic murmur
what is the disease and etiology?
Tetralogy of Fallot
abnormal neural crest cell migration = anterior and cephalad deviation of the infundibular septum
a patient with Subacute bacterial endocarditis caused by Strep gallolyticus (bovis) should also be screened for what?
colonic neoplasia
What kind of cardiomyopathy is found in alcoholics?
Dilated Cardiomyopathy (cavitary LV lesion, JVD, S3)
dx:
Acute substernal chest pain, sweating, dyspnea
ECG: ST elevation in I, aVL, V1-V3, deep q wave development over several hours
transmural infarct of anterolateral left ventricle
What cardiac condition is related to SLE?
Acute Pericarditis
What is the mainstay treatment for Von Willebrand disease? What is a side effect of this treatment?
Desmopressin (releases vWF/VIII from endothelial stores)
-hyponatremia
What is the etiology of infiltrative cardiomyopathy by amyloid protein
Transthyretin deposition (protein produced in the liver, mutation in TTR gene cause misfolding = amyloid protein)
What is the diagnosis:
- heart murmur
- heart palpitations at night
- moderate exertion = head pounding + involuntary head bobbing
- Widening pulse pressure
Aortic Regurgitation
Which antiarrhythmic drug can cause the side effects:
tachycardia, resting tremor, diarrhea, sweating, anxiety, palpitations (mimics thyroid hormone)
Amiodarone - Class III
What causes Heparin induced thrombocytopenia?
formation of autoantibodies against the heparin-platelet factor 4 complex
which antiarrhythmic drug can cause pulmonary fibrosis?
Amiodarone - Class III
What is the most likely cause:
young child with short stature (3rd percentile)
large hyperpigmented areas on torso and legs
thumb is shorter than normal
pancytopenia
bone marrow aspirate shows scant cellularity
Fanconi anemia - caused by a mutation of DNA repair genes
pts present with short stature, repeated infections, and pancytopenia
What is the most appropriate initial management of acute stroke?
Tissue plasminogen activator (tPA, alteplase)
What role does quinidine therapy play in cardiac dysfunction? What are the side fx of this drug
Class I antiarrhythmic (Na channel blocker - slows conduction in heart)
sidefx:
Cinchonism (headache, confusion, dizziness, tinnitus, nausea, flushing, visual disturbances)
Prolong QT interval
What does an Inferior STEMI look like on ECG? What artery is involved?
ST elevation: II, III, aVF
reciprocal depression: I, aVL
—(distinguishes from pericarditis)
Marginal branch of right main coronary artery
What is the most important cause of thrombocytopenia in hospitalized patients?
Heparin-induced thrombocytopenia (HIT)
What is the mechanism of action of Hirudin, Lepirudin, Argatroban?
Direct thrombin inhibitors - binds to thrombin active site
Which hyperlipidemia medication can also cause gouty arthritis? what other side effect can it cause?
Niacin - decreased renal excretion of uric acid
facial/upper body flushing
Maternal exposure to what medication can cause Ebstein’s anomly in the infant
Lithium - to treat bipolar disorder
What metabolic abnormality is associated with torsades de pointes?
hypomagnesemia
What is the congenital heart defect? hour old infant evaluated for cyanosis BP 61/43 HR 143 RR 72 CXR: large ovoid shaped heart and narrow mediastinum
Transposition of great vessels
enlarged heart + narrowed mediastinum
Egg of string appearance
What does the truncus arteriosus become in an adult?
Ascending aorta and pulmonary trunk
What does the Bulbis cordis become in an adult?
Smooth parts (outflow tract) of left and right ventricle
What does the Left horn of sinus venosus become in an adult?
Coronary Sinus
What does the Right horn of sinus venosus become in an adult?
Smooth part of right atrium (sinus venarum)
What does the right common cardinal vein and right anterior cardinal vein become in an adult?
Superior Vena Cava
Which medications:
1. close
2. keep open
the PDA after birth?
- Indomethacin
2. Prostagland E1 and E2
What part of the heart is the most posterior? what can happen with enlargement?
Left Atrium - enlargement can cause:
- dysphagia (compression of esophagus)
- hoarseness (compression of L recurrent laryngeal N)
What is the mechanism of Digitalis?
blocks Na+/K+ pump = increase intracellular sodium = decrease Na+/Ca2+ exchanger = INCREASe intracellular Ca2+ = increase contractility
What does the Dicrotic Notch correspond with?
Aortic valve closure
In the Jugular Venous Pulse what do the following correspond with:
- a wave
- c wave
- atrial contraction - absent in atrial fibrillation
2. RV contraction (closed tricuspid valve bulging into atrium)
What does the X descent correspond with in a Jugular Venous Pulse?
what causes this wave to be:
1. Absent
2. Prominent
atrial relaXation and downward displacement of closed tricuspid valve during ventricular contraction
- absent in tricuspid regurgitation
- Prominent in tricuspid insufficiency and right HF
What is the v wave in Jugular venous pulse?
increase right atrial pressure due to filling (“villing”) against closed tricuspid valve
What is the y descent in a Jugular venous pulse?
what causes this wave to be:
1. absent
2. prominent
RA emptying into RV, prominent in constrictive pericarditis
- absent in cardiac tamponade
- prominent in constrictive pericarditis
What does a fixed S2 split indicate upon auscultation?
ASD
What is the typical use and mechanism of Milrinone?
selective PDE-3 enzyme inhibitor
-causes vasodilation, inotropy in pts with refractory heart failure due to left ventricular systolic dysfunction
What cardiac structure and nerve is the third pharyngeal associated with? musculoskeletal?
third aortic arch = Common, Proximal Carotid Arteries
glossopharyngeal N
hyoid bone, stylopharyngeus
What is Neprilysin?
Metalloproteinase that degrades natriuretic peptides, glucagon, oxytocin, bradykinin
meds that inhibit neprilysin can be used in heart failure to encourage:
diuretic
natriuretic
vasodilatory effects (BNP, ANP)
Patient is diagnosed with DVT in leg and started in IV heparin
While he is hospitalized he develops a stroke in the MCA
what happened? what auscultation findings should be present?
Paradoxical embolism (thrombus from venous system crosses over into arterial circulation from abnormal connection between R and L cardiac chambers - Patent foramen ovale, ASD, VSD)
Ausc: Wide splitting of S2 that does not change with respiration
What cardiac effects can doxorubicin (chemotherpy) cause?
Dilated cardiomyopathy
hypotension
elevated jugular venous pressure
muffled/diminished heart sounds
identify dz and other observed findings?
CXR, lung Auscultation?
Beck’s triad = Cardiac tamponade (pericardial effusion)
Pulsus paradoxus = exaggerated drop in systolic blood pressure during inspiration
—-“pulse becomes undetectable to palpation during inspiration”
CXR: Enlarged water-bottle-shaped heart, clear lungs
What does valsalva do to heart murmurs?
decreases preload
=decreases intensity of most murmurs
increases HOCM murmur
What does rapid squatting do to heart murmurs?
increases venous return, preload, afterload
decrease intensity of hypertrophic cardiomyopathy murmur
increase intensity of AS murmur
What medications should be avoided in patients with Hypertrophic Cardiomyopathy?
anything that decrease preload: Vasodilators, diuretics
What artery supplies the AV node?
AV nodal branch coming off the Posterior descending artery
-this comes off the Right coronary or Left circumflex artery depending on which side heart dominant the patient is (most are Right dominant)
What is the mechanism of Ivabradine? what is so unique about it?
slows the SA node rate by selective inhibition of funny sodium channels
-this slows rate without affecting inotropy or lusitropy
Which drugs can cause Torsades de Pointes?
ABCDE AntiArrhythmics (Class IA, III) AntiBiotics (macrolides) Anti"C"ychotics (haloperidol) AntiDepressants (TCA's) AntiEmetics (ondansetron)
Congenital long QT syndrome
sensorineural deafness
Jervell and Lange-Nielsen syndrome
–autosomal recessive
What is the innervation for:
- Aortic Arch
- Carotid sinus?
- vagus N to Solitary Nucleus of medulla
2. glossopharyngeal N to Solitary Nucleus of medulla
Patient present with history of congestive HF. has an upset stomach, disturbed color perception, anorexia, nausea, vomiting, diarrhea
what is happening and what can occur if not treated?
What lab findings support this?
Digoxin toxicity - can develop arrhythmia
GI - anorexia, N/V, abd pain
Neuro - Fatigue, Confusion, Weakness, COLOR VISION abnormality
Cardiac - life threatening arrhythmia (A-fib, CHF)
Lab: ELEVATED EXTRACELLULAR POTASSIUM
episodic, transient, attacks of chest discomfort (pressure, squeezing), producing temporary transmural mycardial ischemia with ST elevation (eg in I, aVL, V1-V4)
Prinzmetal (variant) angina
Pt with Mitral regurg goes into surgery and finds a ruptured postero medial papillary muscle. which artery is blocked?
Posterior descending Coronary A.
What heart changes usually accompany a S3?
increased LV end-systolic volume
What lipid lowering medication has a very common adverse effect of facial and upper body flushing? why
also has the side effect of gouty arthritis
Niacin - flushing is caused by prostaglandin release
-can take acetylsalicylic acid to inhibit prostaglandin synthesis
What are adult derivative sof the 6th aortic arch?
proximal pulmonary arteries
on left - ductus arteriosus
What heart defects are a/w congenital rubella?
PDA, pulmonary artery stenosis, septal defects
What heart defect is a/w infant of diabetic mother
Transposition of great vessels
What heart defect is a/w Williams Syndrome?
Supravalvular aortic stenosis
Where is the infarct location and artery involved if there is ST elevations or pathologic Q waves in:
V1-V2?
Anteroseptal (LAD)
Where is the infarct location and artery involved if there is ST elevations or pathologic Q waves in:
v3-v4
Anteroapical (distal LAD)
Where is the infarct location and artery involved if there is ST elevations or pathologic Q waves in:
V5-V6
Anterolateral (LAD or LCX)
Where is the infarct location and artery involved if there is ST elevations or pathologic Q waves in:
I, aVL
Lateral (Left circumflex)
Where is the infarct location and artery involved if there is ST elevations or pathologic Q waves in:
II, III, aVF
inferior (Right coronary artery)
Where is the infarct location and artery involved if there is ST elevations or pathologic Q waves in:
V7-V9, ST depression in V1-V3 with tall R waves
Posterior (Posterior descending artery)
10 year old immigrant shows up with dyspnea, fatigability
dx’d with congenital heart defect as infant, not treated
has toe cyanosis, clubbing with no finger abnormalities
all extremity pulses are full and equal
identify?
Patent ductus arteriosus
- -cyanosis from eisenmenger syndrome
- -differential clubbing/cyanosis WITHOUT BP or pulse discrepancy = pathognomonic for PDA
Which drug should be taken for stable angina if the pt is allergic to aspirin?
Clopidogrel (irreversibly binds to ADP receptor of platelets, inhibiting aggregation) - as effective as aspirin
What artery does the Middle Meningeal A. branch off of?
what foramen does it enter?
Maxillary A.
enters the cranium through the foramen spinosum
A patient treated with an anti-arrhythmic shows a slowing of phase 0 depolarization, and prolongation of phase 3 of the ventricular action potential.
what class of drug is this and what are 3 examples?
Class IA antiarrythmic
Quinidine
Procainamide
Disopyramide
several weeks after MI, autoimmune cause of fibrinous pericarditis
Dressler Syndrome
presence of hemosiderin-laden macrophages in lungs
identify the cause?
Left heart failure
- -increase pulmonary venous pressure = venous distention and transudation of fluid
- -microhemorrhage in pulmonary vessels = RBC’s phagocytosed by Macrophages = “HF CELLS”
What are signs of bacterial Endocarditis?
FROM JANE
Fever
Roth Spots
Osler nodes
Murmur
Janeway lesions
Anemia
Nail-bed hemorrhage (splinter)
Emboli
What are symptoms of Rheumatic Fever?
J(heart)NES
Joint (migratory polyarthritis)
(heart) - carditis
Nodules in skin (subcutaneous)
Erythema marginatum - pink rings on torso, inner limbs
Sydenham chorea - rapid, irregular movement of arms, legs, trunk, face
What type of vasculitis is Temporal arteritis? What demographic? what is a bad complication this can lead to?
Giant Cell arteritis = Large vessel-vasculitis
Elderly females
may lead to irreversible blindness due to ophthalmic artery occlusion
What type of vasculitis is Takayasu arteritis?
Demographic?
Symptoms, Physical exam findings?
Biopsy findings? - where does this affect the most?
Asian females < 40 years old
“Pulseless disease” - weak upper extremity pulses, fever, night sweats, arthritis, myalgias, skin nodules, ocular disturbances
Bx: Granulomatous thickening and narrowing of AORTIC ARCH and proximal great vessels
Asian 4 years old Conjunctival Injection Rash Cervical Adenopathy Red Tongue Edema, erythema of hands and feet Fever
Identify dz and dz type, demographic.
What is another name for this dz?
Kawasaki disease - Medium Vessel-vasculitis AKA “Mucocutaneous Lymph Node Syndrome”
Asian Children < 4 years old Sx: CRASH and BURN Conjunctival injection Rash (polymorpheus - desquamating) Adenopathy (cervical) Strawberry tongue (oral mucositis) Hand-foot changes (edema, erythema) Burn = Fever
may develop CORONARY ARTERY ANEURSYMS
Tx = ASPIRIN, IVIG
Heavy smoker, male < 40 years old Intermittent claudication - gangrene, autoamputation superficial nodular phlebitis Raynauds SEGMENTAL thrombosing vasculitis
what type of disease is this? what is treatment?
Buerger disease (thromboangiitis obliterans) - medium vessel vasculitis
Tx: smoking cessation
Young adults (males) Hepatitis B seropositivity in 30% of patients Fever, weight loss, malaise, headache Abdominal pain, Melena Hypertension, neuro dysfunction cutaneous eruptions, renal damage
Identify dz and etiology, location of involvement
Polyarteritis nodosa
- renal and visceral vessels, NOT pulmonary arteries
- Immune complex mediated (type III)
- Transmural inflammation of the arterial wall w fibrinoid necrosis
Perforation of nasal septum
chronic sinusitis, otitis media, mastoiditis
Hemoptysis, cough, dyspnea
Hematuria, red cell casts
identify dz, related markers, CXR findings
Granulomatosis with polyangiitis (Wegener)
–small vessel vasculitis
Triad:
1. FOCAL necrotizing vasculitis
2. Necrotizing granulomas in the lung and upper airway
3. Necrotizing glomerulonephritis
a/w PR3-ANCA, c-ANCA (anti-proteinase 3)
CXR: large nodular densities
Tx: cyclophosphamide, corticosteroids
Necrotizing vasculitis commonly involving lung, kidneys, skin with pauci-immune glomerulonephritis and palpable purpura
No granulomas
identify dz and related markers
Microscopic polyangiitis - small vessel vasculitis
–presents similar to Wegener (Granulmatosis w polyangiitis)
MPO-ANCA/p-ANCA (anti-myeloperoxidase)
Tx: cyclophosphamide, corticosteroids
asthma, sinusitis, skin nodules/purpura, peripheral neuropathy (wrist/foot drop)
can involve heart, GI, kidneys
identify dz, related markers and lab findings
Churg-Strauss (Eosinophilic granulomatosis with polyangiitis)
-MPO-ANCA, p-ANCA
Increased IgE
Where do atherosclerotic plaque shows a predominance for developing?
What is the descending order of commonality of atherosclerotic plaque formation
large elastic arteries (Aorta, carotid, iliac arteries)
abdominal aorta > coronary arteries > popliteal, internal carotic > circle of willis
What is the most common cause of valvular Aortic Stenosis in developed nations?
Calcific degeneration of the trileaflet aortic valve
What is the most appropriate management for acute pericarditis?
NSAIDs - inhibit production of prostaglandins
What are ECG findings, Sx of
- hypokalemia
- hyperkalemia
- U waves, flattened T waves, arrhythmias, muscle cramps, muscle cramps, spasm, weakness
- Wide QRS, peaked T waves, arrhythmias, muscle weakness
What is the mechanism and possible use of Cilostazol?
Phosphodiesterase III inhibitor - increases cAMP in platelets = inhibits platelet aggregation + vasodilation
–can be used for angina prophylaxis
, intermittent claudication, coronary vasodilation
What are causes of high output heart failure?
PAGET
Pagets Anemia, AV fistula Graves dz Endotoxic shock Thiamine deficiency
What do the following do to Preload/Afterload:
- Mueller Maneuver
- Squatting
- Handgrip
- Valsalva maneuver
- Standing
- Increases preload
- Increases preload
- Increases Afterload
- Decreases Preload
- Decreases Preload
55 year old pt presents to the ED with stabbing chest pain which radiates down his left arm. pain started when he was moving furniture w his son and this is the fourth time this has happened in similar situations. Sublingual Nitroglycerin quickly relieves his sx.
what would be seen on ECG? what is the Nitro for?
Stable Angina
–ST depressions = myocardial ischemia that is NOT TRANSMURAL
(ST elevatiosn are for acute TRANSMURAL ischemia)
`
Nitroglycerin - decreases preload (Venous dilation)
What is the most likely complication in the first several hours during or after an MI?
cardiac arrhythmia
A 55 yr old male w acute MI 2 days ago suddenly develop palpitations and anxiety. ECG shows multifocal premature ventricular contractions
what is most appropriate initial step in managment? what is the mechanism?
cardiac arrhythmias are classic complication of acute MI
LIDOCAINE (Class Ib) = first choice therapy for ventricular arrhythmias a/w MI
mechanism = small reduction in phase 0 slope; shorten action potential; shorten repolarization
Identify abnormality, and mechanism of therapy:
92 year old presents with peaked T-waves and widened QRS on ECG. calcium gluconate is administered.
Hyperkalemai
–Calcium gluconate stabilizes the cardiac cell membrane = prevent fatal arrhythmias
What are the first to meds prescribed with stable angina?
Nitrates and B-blockers
What is the cardiac biomarker used to tell if a reinfarction has occured after an MI four days prior?
CK-MB - first appears 4-6 hrs after symptom onset
–levels peak 24 hours and returns to normal within 3 days.
(troponins also appear 4-6 hours after sx, but stay elevated for up to 10 days)
What are ECG findings of apical hypertrophic cardiomyopathy?
Giant T-wave inversions in precordial leads (V1-V6)
What are two most appropriate initial therapies for Acute aortic regurgitation?
Afterload reduces:
hydralazine
ACE inhibitors
if signs of HF: inotropes too
What is the initial management of Atrial Flutter?
Diltiazem, Verapamil
nondihydropyridine Ca channel blocker
Pt was minor Pulm embolism shows up. What is MOST LIKELY to be seen on EKG?
- Sinus Tachycardia - most likely to be seen
- -S1,Q3,T3 = seen in MASSIVE Embolisms, not minor ones
What symptoms should a patient be monitored for when administered macrolides?
Prolonged QTc interval
A pt prescribed erectile dysfunction meds is noticing a slight blue tint to his visual field. what is happening?
Sildenafil inhibits PDE-5
but also weakly inhibits PDE-6
——PDE-6 is required for transformation of light into electrical signals = cyanopsia or blue vision
Identify dz and etiology:
4 yr old w palpitations, syncope, one seizure episode. has not be verbally communicating despite making eye contact. There is a chance that child is deaf.
Long QT syndromes
- -palpitations syncope, seizures
- -Jervell and Lange-Nielsen
- —-autosomal receccive disorder (mutation in outward-rectifying potassium current)
- -Hearing impairment
*other long QT: Romano-Ward - similar, but NO hearing impairment
What is the treatment of Kawasaki dz (medium vasculitis) ?
Intravenous immunoglobulin
What is the mechanism of fibrates?
enhances activity of LPL - hydrolyzes fatty acids from VLDL
=promotes fatty acid uptake into adipose tissue and less circulating the bloodstream
Identify most likely cause:
3 year old w mild mid-systolic murmur on the mid precordium. No hx of cyanosis of respiratory distress
Still’s murmur
–benign systolic murmurs
what is the normal percentage of oxygen saturation in blood found circulating through the foramen ovale of a fetus?
approximately 65%
