Cardio Flashcards
What are the 3 pacemaker structures in the heart?
SA node, AV node/bundle of His, and Purkinje cells
Which cells are the ‘native’ pacemakers of the heart. How fast do they beat?
SA node (60-100 bpm)
Which nerve root:Innervates part of hamstring via tibial protion of sciatic nerveIs responsible for the achilles tendon reflexHas a dermatome that includes the lateral part of the foot
S1
Which nerve root:Innervates part of hamstring via tibial protion of sciatic nerveIs responsible for the achilles tendon reflexHas a dermatome that includes the lateral part of the foot
S1
What is the automaticity of the AV node/bundle of his?
50-60 bpm
What are the nerve roots for the femoral nerve?
L2-L4
What are the nerve roots for the femoral nerve?
L2-L4
What is the automaticity of the purkinje cells?
30-40 bpm
What action does the femoral nerve perform?
Knee and hip extension
What action does the femoral nerve perform?
Knee and hip extension
What is first degree AV block?
Lengthened PR interval-more than .2 sec
What are the nerve roots for the obturator nerve?
L2-L4
What are the nerve roots for the obturator nerve?
L2-L4
What is 2nd degree AV block (Mobitz type I)?
Intermittent failure of AV conduction resulting in a progressively lengthened PR interval that eventually results in a P wave with no QRS.
What does the obturator nerve do?
Hip adduction
What does the obturator nerve do?
Hip adduction
What is 2nd degree AV block (Mobitz type II)?
Failure of AV conduction that occurs without the progressively lengthening PR interval. Spontaneous P waves with no QRS intervals.
What nerve root is responsible for the patellar reflex?
L4
What nerve root is responsible for the patellar reflex?
L4
What is 3rd degree AV block?
Atria and ventricles are completely electrically dissociated from each other.
What is the dermatome of L4?
Medial aspect of the foot
What is the dermatome of L4?
Medial aspect of the foot
How does 3rd degree AV block present?
Widened pulse pressure. Heart rate of 30-45 min.
What does the deep peroneal nerve do?
Dorsiflexion of the foot
What does the deep peroneal nerve do?
Dorsiflexion of the foot
What is a common presentation of a bicuspid aortic valve?
Usually asymptomatic but can have a systolic click or ejection murmur (aortic stenosis).
What is the root of the deep peroneal nerve
L4
What is the root of the deep peroneal nerve
L4
What changes does severe aortic stenosis cause? Name 3
Increased LVP and LV work Increased LV oxygen consumption Increased adenosine accumulation in cardiac tissue-acts as a vasodilator to increase blood flow through the coronary circulation
What vessels are torn in a subdural hematoma?
Cerebral bridging veins
What vessels are torn in a subdural hematoma?
Cerebral bridging veins
What is a common cause of acute bacterial endocarditis in IVDU?
S aureus
What are the radiographic findings of a subdural hematoma?
Crescent shapedDoesn’t cross midline but can involve the falxCrosses many suture lines
What are the radiographic findings of a subdural hematoma?
Crescent shapedDoesn’t cross midline but can involve the falxCrosses many suture lines
What does S aureus endocarditis look like on imaging?
Large, penetrating valvular lesions
What does meningeal vessel damage result in?
Epidural hemorrhage
What does meningeal vessel damage result in?
Epidural hemorrhage
What happens if bacterial vegetations from infected heart valves embolize to the brain?
Makes brain abscesses that appear as ring enhancing lesions on CT scan.
What are the radiographic findings of an epidural hemorrhage?
Biconvex appearance, never dips into the falx
What are the radiographic findings of an epidural hemorrhage?
Biconvex appearance, never dips into the falx
What is the truncus arteriosus?
A primitive tube consisting of the ascending aorta and pulmonary trunk. Normally by birth, a septum develops separating these structures.
What is the cushing reflex?
Hypertension and bradycardia in response to changes in cerebral perfusion pressure.CPP= MAP-ICP
What is the cushing reflex?
Hypertension and bradycardia in response to changes in cerebral perfusion pressure.CPP= MAP-ICP
What happens in the case of a persistent truncus arteriosus? What other defects would there be?
The truncus arteriosus receives blood from the right and left ventricules, leading to mixing of oxygenated and deoxygenated blood and cyanosis. There would also be a VSD, since the ventricular septum is formed by the same structure that is supposed to separate the ascending aorta from the pulmonary trunk.
What is Guillan Barre syndrome?
Acute idiopathic inflammatory polynueropathy that usually follows a URI or GI infection.
What is Guillan Barre syndrome?
Acute idiopathic inflammatory polynueropathy that usually follows a URI or GI infection.
What is the genetic defect in Marfan Syndrome? What is the pattern of inheritance?
Autosomal dominant from mutated fibrillin gene.
Describe the pathogenesis of Guillan Barre
Autoimmune attack of myelin in peripheral nerves
Describe the pathogenesis of Guillan Barre
Autoimmune attack of myelin in peripheral nerves
What are the clinical features of Marfan Syndrome? (3)
Mitral valve prolapse (mitral regurg)-midsystolic click followed by a murmur Increased risk of aortic dissection Dislocation of the lens
What does loss of the extensor plantar reflex indicate?
UMN lesion involving contralateral motor cortex or cortical spinal tract
What does loss of the extensor plantar reflex indicate?
UMN lesion involving contralateral motor cortex or cortical spinal tract
What type of heart disease can be seen in a patient with RA? What is the implicated factor?
Restrictive cardiomyopathy. Due to deposition of amyloid (from amyloid associated protein/AA) in the myocardium.
What does rupture of the MMA result in?
Epidural hematoma
What does rupture of the MMA result in?
Epidural hematoma
What is the pathophysiology of restrictive cardiomyopathy? How does this manifest clinically?
Decreased compliance and impaired diastolic filling leading to increased diastolic pressures resulting in: elevated systemic and pulmonary venous pressures–>JVD/hepatomegaly/peripheral edema
What can be a complication of MMA rupture and why?
Anisocoria since the MMA goes through the foramen spinosum, which is near where CNIII exits the skull in the middle cranial fossa.
What can be a complication of MMA rupture and why?
Anisocoria since the MMA goes through the foramen spinosum, which is near where CNIII exits the skull in the middle cranial fossa.
How do the carotid baroreceptors regulate BP?
Stretch of these baroreceptors leads to CN IX to send signals to the medulla that decreases blood pressure.
What are the cells and molecule primarily responsible for MS plaques? Are there axons left?
Demyelination but preservation of axons. Th1 cells that secrete interferon gamma cause the demylination by activating macrophages.
What are the cells and molecule primarily responsible for MS plaques? Are there axons left?
Demyelination but preservation of axons. Th1 cells that secrete interferon gamma cause the demylination by activating macrophages.
During carotid occlusion what happens?
The body thinks there is lower blood pressure (Less afferent CN IX activity to medulla). Results in increased sympathetic tone and decreased parasympathetic tone.
CNVII nuclei damage results in what?
Whole side of face drooping
CNVII nuclei damage results in what?
Whole side of face drooping
Where are M2 receptors and what do they do?
M2 parasympathetic receptors are only found in the heart. Stimulation decreases HR, contractility, conduction velocity and automaticity. Does not affect MAP!
Cortex damage controlling face expression results in what? Why?
Only lower side of face drooping since upper facial muscles can get signals from both hemispheres
Cortex damage controlling face expression results in what? Why?
Only lower side of face drooping since upper facial muscles can get signals from both hemispheres
What is the major risk factor for aortic dissection?
Systemic hypertension
What nucleii can be damaged in lateral medullary syndrome? What does this result in?
Vestibular and cochlear resulting in nausea and vomiting (Vestibular nuclei)Dysphagia from nucleus ambiguus (X)Loss of pain/temp in ipsilateral face (V)Loss of pain/temp in contralteral body (spinothalamic tract)Horner syndrome (loss of sympathetic innervation to the eye-miosis/ptosis)
What nucleii can be damaged in lateral medullary syndrome? What does this result in?
Vestibular and cochlear resulting in nausea and vomiting (Vestibular nuclei)Dysphagia from nucleus ambiguus (X)Loss of pain/temp in ipsilateral face (V)Loss of pain/temp in contralteral body (spinothalamic tract)Horner syndrome (loss of sympathetic innervation to the eye-miosis/ptosis)
What is the common presentation of an aortic dissection?
Acute chest pain that radiates to the back
What artery is frequently occluded to give lateral medullary syndrome?
PICA
What artery is frequently occluded to give lateral medullary syndrome?
PICA
What is the equation for TPR?
TPR=(mean arterial pressure - right atrial pressure)/cardica output. RAP assumed to be 0
Where does intraparenchymal hemorrhage often affect?
Basal ganglia/internal capsule
Where does intraparenchymal hemorrhage often affect?
Basal ganglia/internal capsule
What happens in transposition of the great vessels?
Aorta leaves RV, pulmonary artery leaves LV
What goes through the foramen ovale?
Mandibular nerve which is responsible for mastication
What goes through the foramen ovale?
Mandibular nerve which is responsible for mastication
How do you treat transposition of the great vessles?
With alprostadil, a PGE1 analog that maintains a patent ductus arteriosus (that connects pulmonary trunk and aorta) to allow for increased blood oxygenation in the aorta.
Where does the auriculotemporal nerve sense?
Anterior half of the external ear canal
Where does the auriculotemporal nerve sense?
Anterior half of the external ear canal
What is the most common cardiac tumor in children? How does it present?
Rhabdomyoma. Often presents with cardiac outlfow obstruction.
Where does the auricular branch of vagues sense?
Posterior half of external ear canal
Where does the auricular branch of vagues sense?
Posterior half of external ear canal
What are cardiac rhabdomyomas associated with?
Tuberous sclerosis
Where does the greater auricular nerve sense
Lower part of auricle
Where does the greater auricular nerve sense
Lower part of auricle
How does tuberous sclerosis present?
Neurocutaneous disorder with adenoma sebaceum (red papules on the face), epilepsy and mental retardation.
Where does the lesser occipital nerve sense on the ear?
Upper part of auricle
Where does the lesser occipital nerve sense on the ear?
Upper part of auricle
Aside from modulating cardiac contractility what else does digoxin do? What can digoxin be used for because of this?
Digoxin decreases conduction through the AV node, therefore it can be used for A fib with rapid ventricular rate
What are the 5 places that CN IX affects?
1) somatic sensation from posterior pharynx2) Taste/somatic sensation from posterior 1/3 of tongue3) Afferents from carotid body/sinus4) Motor efferents to stylopharyngeus5) Parasympathetic efferents to parotid gland
What are the 5 places that CN IX affects?
1) somatic sensation from posterior pharynx2) Taste/somatic sensation from posterior 1/3 of tongue3) Afferents from carotid body/sinus4) Motor efferents to stylopharyngeus5) Parasympathetic efferents to parotid gland
What is the treatment of choice for A fib in patients without heart failure?
Beta blockers (esmolol, metropolol) CCBs (verapamil, diltiazem)
Where does the olfactory bulb project to?
Piriform cortex
Where does the olfactory bulb project to?
Piriform cortex
What happens to coronary blood flow during systole? What condition is this exacerbated in?
Decreases because coronary blood vessels are compressed? Aortic stenosis exacerbates this.
What happens if the thyroglossal duct proximal end doesn’t regress?
Thyroid cyst lesion on midline of the neck
What happens if the thyroglossal duct proximal end doesn’t regress?
Thyroid cyst lesion on midline of the neck
What heart sound is heard with dilated cardiomyopathy?
S3
Pilocytic astrocytoma: kids or adults?
Kids/young adults
Pilocytic astrocytoma: kids or adults?
Kids/young adults
What chemotherapeutic is associated with an increased risk of developing dilated cardiomyopathy?
Doxorubicin
Pilocytic astrocytoma: location?
Posterior fossa
Pilocytic astrocytoma: location?
Posterior fossa
What heart murmur can develop as a consequence of aortic dissection?
Aortic insufficiency (a diastolic murmur)
Pilocytic astrocytoma: IHC
Rostenthal fibers, immunostaining with GFAP
Pilocytic astrocytoma: IHC
Rostenthal fibers, immunostaining with GFAP
What diseases have increased aortic pulse pressure?
Arteriosclerosis (because of high systolic BP), aortic regurgitation (because of low diastolic BP)
Sensory and motor fibers, wrist and elbow flexion, elbow extension, arm abduction. Sensation over deltoid and first 3 digits. Which nerve root?
C6
Sensory and motor fibers, wrist and elbow flexion, elbow extension, arm abduction. Sensation over deltoid and first 3 digits. Which nerve root?
C6
What diseases have decreased aortic pulse pressure?
Aortic stenosis (decreased systolic pressure), mitral stenosis (less volume in LV so less systolic pressure)
Lens opacification is seen in what disease process?
Cataracts
Lens opacification is seen in what disease process?
Cataracts
What disease has increased diastolic pressure in the aorta?
Mitral stenosis
Imipramine is what?
TCA that blocks serotonin, NE re-uptake
Imipramine is what?
TCA that blocks serotonin, NE re-uptake
What diseases have decreased diastolic pressure in the aorta?
Aortic regurgitatiion, PDA
HIV encephalitis shows what histologically?
Multi-nucleated giant cells
HIV encephalitis shows what histologically?
Multi-nucleated giant cells
What is one potentially fatal complication of an MI?
Ventricular wall rupture
What muscles do the superior gluteal nerve innervate?
Gluteus medius and minimus
What muscles do the superior gluteal nerve innervate?
Gluteus medius and minimus
What does ventricular rupture result in?
Cardiac tamponade which can present with Beck’s triad: hypotension, JVD and muffled heart sounds
Where does the superior gluteal nerve exit the greater sciatic foramen?
Upper border of the sciatic foramen
Where does the superior gluteal nerve exit the greater sciatic foramen?
Upper border of the sciatic foramen
What is coarctation of the aorta?
Narrowing of the aorta?
What muscle does the inferior gluteal nerve innervate?
Gluteus maximus
What muscle does the inferior gluteal nerve innervate?
Gluteus maximus
Describe preductal (infantile) coarctation of the aorta
Narrowing of the aorta proximal to the ductus arteriosus. Causes excessive flow in intercostal arteries, leading to rib notching PDA
Where does the inferior gluteal nerve exit the greater sciatic foramen?
Lower border of the sciatic foramen
Where does the inferior gluteal nerve exit the greater sciatic foramen?
Lower border of the sciatic foramen
Describe postductal (adult) coarctation of the aorta.
Narrowing of the aorta distal to the opening of the ductus arteriosus. Most survive into adulthood. Disparity in pressure between the upper and lower extremities
What does the pudendal nerve innervate?
The perineum
What does the pudendal nerve innervate?
The perineum
What is the clinical presentation of patients with HCM?
Younger individuals Dyspnea, chest pain. Postexertional syncope.
Where does the pudendal nerve exit the sciatic formaen?
The lower border.
Where does the pudendal nerve exit the sciatic formaen?
The lower border.
What is the primary problem in HCM?
Diastolic dysfunction
What does the sciatic nerve innervate?
The posterior compartment of the thigh and leg (hip and knee flexion), the plantar foot muscles.
What does the sciatic nerve innervate?
The posterior compartment of the thigh and leg (hip and knee flexion), the plantar foot muscles.
What would you expect to see with imaging/PE for HCM? (5)
Systolic murmur at left lower sternal border, accentuated by squatting/increased afterload S4 (due to stiffening of the ventricle walls. A (4) stiff (1) wall (2). ECG: anterior motion of the mitral valve Closing and reopening of the aortic valve LV hypertrophy
Where does the sciatic nerve exit the greater sciatic foramen?
The lower border.
Where does the sciatic nerve exit the greater sciatic foramen?
The lower border.
What is the treatment for HCM? Why?
Beta-blockers. Improve diastolic filling
What muscles does the obturator nerve innervate?
Adductors and medial rotators of the thigh.
What muscles does the obturator nerve innervate?
Adductors and medial rotators of the thigh.
Which drug can worsen re-entrant tachycardias? Why?
Re-entrant tachycardias are caused by accessory pathways between the atria and ventricles. Digoxin can worsen this by slowing conduction through the AV node.
Where does the obturator nerve exit the greater sciatic foramen?
It doesn’t, it exits via the obturator canal.
Where does the obturator nerve exit the greater sciatic foramen?
It doesn’t, it exits via the obturator canal.
Would one expect a VSD patient to be cyanotic?
No
What is the common presentation of retinoblastoma?
Mutlifocal or bilateral tumors in the eye.
What is the common presentation of retinoblastoma?
Mutlifocal or bilateral tumors in the eye.
What is the typical clinical presentation of VSD? (2)
Increased O2 sat in right ventricle Holosystolic murmur at left lower sternal border.
What is the genetic abnormality underlying familial retinoblastoma? What chromosome is it on? What other cancers is it associated with?
Loss of Rb tumor suppressor, which normally prevents the cells from exiting G1, allowing tumor growth. It’s located on chromosome 13. Also associated with osteosarcoma
What is the genetic abnormality underlying familial retinoblastoma? What chromosome is it on? What other cancers is it associated with?
Loss of Rb tumor suppressor, which normally prevents the cells from exiting G1, allowing tumor growth. It’s located on chromosome 13. Also associated with osteosarcoma
What can be a side effect of captopril (and other ACE inhibitors)?
Chronic cough
What would be the presentation of sporadic retinoblastoma?
Unilateral
What would be the presentation of sporadic retinoblastoma?
Unilateral
What is an alternative to an ACE inhibitor that doesn’t cause coughing?
Angiotensin II receptor antagonist, like losartan.
What is the IHC of retinoblastoma?
Neruoepithelial cells that form rosettes.
What is the IHC of retinoblastoma?
Neruoepithelial cells that form rosettes.
How does spironolactone work?
K+ sparing diuretic that blocks aldosterone receptors in the distal nephron.
What is the first step in catecholamine synthesis?
Conversion of tyrosine to dopa by tyrosine hydroxylase (rate limiting step)
What is the first step in catecholamine synthesis?
Conversion of tyrosine to dopa by tyrosine hydroxylase (rate limiting step)
What is a side-effect of spironolactone?
Gynecomastia in men, since it has an antiandrogenic effect.
How is dopa converted into dopamine?
By dopa decarboxylase
How is dopa converted into dopamine?
By dopa decarboxylase
What does bradykinin do?
Its a potent vasodilator
Where and how is dopamine converted into norepinepherine?
In terminal vesicles, dopamine beta-hydroxylase acts on dopamine to produce norepinepherine.
Where and how is dopamine converted into norepinepherine?
In terminal vesicles, dopamine beta-hydroxylase acts on dopamine to produce norepinepherine.
What are the two things that ACE inhibitors do?
Prevent bradykinin degradation (vasodilates) and angiotensin II formation.
How is epinepherine made?
NE is converted to epinepherine by the enzyme phenylethanolamine-N-methyltransferase (PNMT), which is induced by cortisol during periods of stress. SAM is the methyl donor. This enzyme exists in the cytoplasm and can act make epi if NE diffuses out of terminal vesicles. Epi can be repackaged into vesicles and then secreted.
How is epinepherine made?
NE is converted to epinepherine by the enzyme phenylethanolamine-N-methyltransferase (PNMT), which is induced by cortisol during periods of stress. SAM is the methyl donor. This enzyme exists in the cytoplasm and can act make epi if NE diffuses out of terminal vesicles. Epi can be repackaged into vesicles and then secreted.
What are the electrolyte imbalances caused by ACE inhibitors?
Primarily hyperkalemia, but sometimes mild hyponatremia.
You see apatient with difficulty extending the left thigh and flexing the knee. He aslo has pain in the posterior thigh, the lateral leg and foot. What does he have?
Compression of the sciatic nerve (sciatica).
You see apatient with difficulty extending the left thigh and flexing the knee. He aslo has pain in the posterior thigh, the lateral leg and foot. What does he have?
Compression of the sciatic nerve (sciatica).
What non-cardiac markers can signify an MI?
Elevation of AST and LDH
What are the clinical findings that differentiate diffuse lewy body disease from parkinsons? (name 3)
1) Dementia is more common with diffuse lewy body disease than in Parkinsons Disease (but PD patients can have dementia)2) Involvement of cortical regions is more common in diffuse Lewy Body disease3) Lewy Body disease has extrapyramidal symptoms and visual hallucinations.
What are the clinical findings that differentiate diffuse lewy body disease from parkinsons? (name 3)
1) Dementia is more common with diffuse lewy body disease than in Parkinsons Disease (but PD patients can have dementia)2) Involvement of cortical regions is more common in diffuse Lewy Body disease3) Lewy Body disease has extrapyramidal symptoms and visual hallucinations.
What vessels does fibromuscular dysplasia affect?
Renal arteries
What is the treatment of choice for OCD?
SSRIs (fluoxetine) are treatment of choice.Clomipramine is a TCA that also can be used to treat OCD
What is the treatment of choice for OCD?
SSRIs (fluoxetine) are treatment of choice.Clomipramine is a TCA that also can be used to treat OCD
What patient population does fibromuscular dysplasia usually affect?
Middle aged women
What are cells that derive from the neural crest (7)?
Pseudounipolar cells of spinal and cranial gangliaAutonomic gangliaSchwann cellsChromaffin cells of adrenal medullaOdontoblastsMelanocytesMeninges (pia and arachnoid)
What are cells that derive from the neural crest (7)?
Pseudounipolar cells of spinal and cranial gangliaAutonomic gangliaSchwann cellsChromaffin cells of adrenal medullaOdontoblastsMelanocytesMeninges (pia and arachnoid)
What are the imaging findings of fibromuscular dysplasia?
Sting of beads pattern
What is arnold chiari type I malformation?
Cerebellar tonsils herniate through the foramen magnum. Usually asymptomatic, but can have headache and neck pain
What is arnold chiari type I malformation?
Cerebellar tonsils herniate through the foramen magnum. Usually asymptomatic, but can have headache and neck pain
What is the common presentation of ASD?
Exercise intolerance
What is arnold chiari type II malformation?
Hindbrain, cerebellar vermis and fourth ventricle herniate into the foramen magnum.
What is arnold chiari type II malformation?
Hindbrain, cerebellar vermis and fourth ventricle herniate into the foramen magnum.
What are the physical findings of an ASD? (2)
Systolic ejection murmur (from large amount of blood exiting RV). Heard at left midsternal border. Wide, fixed splitting of S2, since more blood in the pulmonary artery
What other condition is associated with Arnold-Chiari type II?
MeningomyelocelesHydrocephalus (due to CSF obstruction)Brainstem dysfunction (poor swallowing
What other condition is associated with Arnold-Chiari type II?
MeningomyelocelesHydrocephalus (due to CSF obstruction)Brainstem dysfunction (poor swallowing
What is the equation for MAP?
MAP = XO * TPR
How does benign essential tremor usually present?
Progressive bilateral, postural tremor usually not associated with other neurologic symptoms.Usually a 6-12 Hz tremor primarily affecting the arms
How does benign essential tremor usually present?
Progressive bilateral, postural tremor usually not associated with other neurologic symptoms.Usually a 6-12 Hz tremor primarily affecting the arms
What class of drugs should be avoided in asthmatics? Why?
Beta-blockers. B2 blockers are in the lungs and would result in bronchoconstriction.
How do you treat benign essential tremor?
Antagonist of beta adrenergic receptors
How do you treat benign essential tremor?
Antagonist of beta adrenergic receptors
Where are beta-1 receptors?
In the heart
How do benzo’s work?
Increase the frequency of GABAa channel opening
How do benzo’s work?
Increase the frequency of GABAa channel opening
Which are the beta 1 specific beta blockers and which ones are non-specific?
Beta1: A-M Beta2: N-Z
What is status epilepticus? How does it present? What are the drugs of choice?
30 min + of continuous seizure activity or repetitive seizures while in a continuus unconscious state. Patient usually falls to the floor. Benzos are the drugs of choice for this.
What is status epilepticus? How does it present? What are the drugs of choice?
30 min + of continuous seizure activity or repetitive seizures while in a continuus unconscious state. Patient usually falls to the floor. Benzos are the drugs of choice for this.
What is the inheritance pattern for familial hypercholesterolemia?
Autosomal dominant
What is myasthenia gravis?
Autoantibodies against skeletal muscle nACh receptors
What is myasthenia gravis?
Autoantibodies against skeletal muscle nACh receptors
What is the genetic cause of familial hypercholesterolemia?
Mutations in the receptor for LDL
How is myasthenia gravis treated?
With Achesterase inhibitors (neostigmine and pyridostigmine) which act by carbamylating Achesterase.
How is myasthenia gravis treated?
With Achesterase inhibitors (neostigmine and pyridostigmine) which act by carbamylating Achesterase.
What is the clinical presentation of acute pericarditis?
Sharp, knife-like chest pains.
What is used to treat migraines? What is the molecular target of these drugs.
The triptans: 5-HT 1D/B agonists
What is used to treat migraines? What is the molecular target of these drugs.
The triptans: 5-HT 1D/B agonists
How do patients with acute pericarditis try to relieve their symptoms?
By leaning forward
What are the ECG findings for acute pericarditis?
Diffuse ST elevations with upright T waves.
What is a potential effect of over use of beta-1 selective blockers?
Varying degrees of heart block
What happens to arteries and arterioles in untreated hypertension? What happens to the wall-to-lumen ratio?
Hypertrophy of arteries and erterioles. Wall-to-lumen ratio increases, decreasing the diameter of the lumen
What is a cardiac condition associated with SLE?
Libman Sacks endocarditis
What is libman-sacks endocarditis?
Small granular vegetations develop on valve leaflets, resulting in a fibrotic process leading to insufficiency or stenosis of the valves.
What is the triad observed in Wegners granulomatosis?
Upper airway focal necrotizing vasculitis Upper/lower respiratory tract necrotizing granulomas Necrotizing glomerulitis with c-ANCA antibodies
What does the EKG of a patient with atrial fibrillation look like? Why?
No P waves because there is no synchronous depolarization. Irregularly irregular R-R intervals because action potentials arrive at the AV node at random intervals leading to an erratic ventricular rhythm.
What is used for long-term anti-coagulation for patients with high-risk Afib?
Warfarin
What parts of the heart does the Left circumflex coronary artery supply?
Lateral and posterior walls of left ventricle
What parts of the heart does the LAD supply?
Supplies anterior 2/3 of the interventricular septum, anterior papillary muscle and anterior surface of the left ventricle
What does the posterior descending artery supply in the heart?
The posterior half of the interventricular septum
What does left vs right dominant coronary circulation mean?
Determines whether posterior descending artery (that supplies the posterior half of the interventricular septum) arises from the RCA (80%) or the LCX (20%)
What pharmacologic agents inhibit cardiac remodeling in CHF?
ACE inhibitors such as captopril that block conversion of angiotensin I to angiotensin II
What is hyperplastic arteriolosclerosis?
Concentric and laminated onionskin arteriolar thickening with reduplicated basement membrane (proliferation of SMCs)
What causes hyperplastic arteriosclerosis?
Malignant hypertension
What class of drugs does isoproterenol belong to?
Beta agonist
What drug decreases VLDL, LDL and triglyceride levels while increasing HDL levels?
Niacin (vitamin B3
What are the side effects of niacin?
Facial flushing
What can be given to decrease the facial flushing symptoms seen with niacin treatment?
Aspirin
Where does mitral regurigitation radiate to?
Radiates to the axilla
What is responsible for the systolic ejection murmur observed in ASD?
Increased volume in the RV, leading to tubrulent flow past the pulmonic valve
What drug class is associated with exacerbation of heart failure?
CCBs like Verapamil
What is a cardiac myxoma? Who is it common in? Is it benign?
A primary cardiac neoplasm that is more common in females. It is benign as a cancer but can cause sudden cardiac death from mechanical obstruction.
Where do cardiac myxomas usually appear?
The left atrium
What is the histology of cardiac myxomas?
Stellate mesenchymal cells with a myxoid background (mucus like), inflammatory and endothelial cells
What vessel defect is maternal diabetes associated with?
Transposition of the great vessels
What is transposition of the great vessels?
Aorta comes from RV and pulmonary trunk comes from LV.
What cardiac abnormalities can anemia result in?
High output heart failure with a high EF (normal is 50-60)
How does anemia result in high output heart failure?
Decreased oxygen tension leads to compensatory dilation of arteries/arterioles, leading to increased venous return to the heart. This results in more output via the frank starling mechanism in an effort to get oxygen to oxygen starved tissues. Results in a higher than normal EF
What is the mechanism of nitroglycerin action?
Dilates both arteries and veins
What would nitroglycerin do the LVEDP and LVESP?
Decreased LVEDP because veins dilate, decreasing venous return LVESP decreases because there is less resistance to ejection
Which classes of anti-hypertensives can cause lipid abnormalities?
Metropolol and thiazides
What happens to LV EDV in premature ventricular contraction? Why?
Decreases, since atria didn’t fill ventricles.
What happens to atrial pressure in a premature ventricular contraction? Why?
Abnormally high atrial pressure since atria contract against closed AV valves.
What are three drugs used to treat chronic hypertension in pregnant women? (3)
Methyldopa Labetalol Nifedipine
How does methyldopa work? What is it used for?
Stimulates alpha 2 on pre-synaptic axon terminals. Used to decrease sympathetic outflow thus treat hypertension in pregnant women.
What is procainamide used for?
Treating ventricular arrythmias
How does procainamide work?
Stabilizes cardiac membranes and depresses action potential phase 0
What is a complication of procainamide administration?
Drug induced lupus
Review netter’s cards 1-68 through 1-71
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What are the 3 lab/PE findings you would expect to see with aortic regurgitation? Where would you expect to hear the murmur?
Blowing diastolic murmur heard best at the left sternal border Very wide pulse pressure Large stroke volume
In a patient with pulmonary disease and Afib what drug class would you give? Name one example.
CCBs-verapamil
How can infantile form of aortic coarctation present? Why?
Cyanosis only in the lower body. This occurs because there is low BP past the coarctation and the PDA is open, leading to shunting of deoxygenated from PA into the distal part of the aorta-to the lower extremities resulting in cyanosis.
What is Churg-Strauss syndrome? What are the clinical (1) and lab (1) findings?
Necrotizing vasculitis affecting multiple organ systems. Asthma and eosinophilia
Fibrinous pericarditis: What precedes it? What is the clinical presentation (3)? What is the treatment?
Preceded by an MI (2 to 10 weeks prior) Fever, pleuritic chest pain and pericardial friction rub Treat with NSAIDs and steroids sometimes
What is minoxidil? How does it work?
Peripheral vasodilator that acts by opening potassium sensitive ATP channels to hyperpolarize SMCs
What is temporal/giant cell arteritis? What is a complication?
Focal granulomatous inflammation (with giant cells) that commonly involves branches of the carotid system. Complication: blindness from involvement of the opthalmic artery
What artery is frequently involved in paraxdoxical movement of the heart wall?
LAD
What is the amyloid protein deposited in the heart in patients with RA? Where does it come from?
AA from the liver
What is stable angina?
Angina that occurs with exertion.
What is the best enzyme to measure for an MI?
Troponins (T and I)
What is Loeffler endocarditis? What patient populations are susceptible?
Restrictive heart disease caused by endomyocardial fibrosis and associated with eosinophilia Associated with tropical climates
What happens to renin in polycystic kidney disease?
Goes up leading to hypertension
How can syphillis affect the aorta?
Obliterates the vasa vasorum leading to dilatation of the aorta, the aortic valve ring and wrinkling of the initmal surface.
What cardiac abnormalities are seen in Turner syndrome? (2)
Coarctation of the aorta Bicuspid aortic valve
What contributes to the webbed neck in turner syndrome?
Cystic hygromas
How does norepinepherine increase blood pressure?
Signals through Gq which causes PIP2 to make DAG and IP3. IP3 releases calcium which leads to smooth muscle contraction
When is ventricular rupture observed post-MI?
Between 5 and 10 days after the original MI.
When do arrythmias resulting from MIs occur?
2 days post MI
What is type I hypersensitivity?
IgE mediated mast cell histamine release
What is type II hypersensitivity?
Autoantibodies generated.
What is type III hypersensitivity?
Immune complex deposition
What is type IV hypersensitivity?
Mediated by T-lymphocytes, causing granuloma formation.
What is a normal stimulus for VEGF secretion?
Exercise
A woman has unilateral headache, visual changes, tenderness of the temples and an elevated ESR. What is her diagnosis?
Temporal/giant cell arteritis
What is the predominant cause of sudden cardiac death in older patients?
Ischemic heart disease
During ventricular fibrillation what will happen to the RA pressure?
Increase
What happes to pressure in the circulatory system following Vfib?
Pressures will equilibriate throughout the arterial and venous systems resulting in pressure become MSFP
What can PDA result in clinically?
Pulmonary hypertension (since increased blood volume in the pulmonary system.
Where do the umbilical arteries arise from?
From the internal iliac arteries
What do the umbilical arteries do?
Carry unoxygenated blood from fetus to the placenta
What happens to the umbilical arteries after birth? What do they become?
They are obliterated and become the medial umbilical ligaments
When does coronary blood flow drop the most?
During isovolumic contraction
What can acetazolamide cause in terms of electrolyte changes?
Hypokalemia, metabolic acidosis and an alkaline urine.
Where does the LDL receptor exist?
The liver
What class of drugs increases the risk of digoxin toxicity? Why?
Diuretics because they cause hypokalemia
What vavlular changes does one see in valves affected by rheumatic fever?
Fibrous bridging between thickened, calcified leaflets
What does CHF cause in the liver?
Venous stasis in central sinusoids leading to central hemorrhagic necrosis. Results in nutmeg liver.
What anti-hypertensive medication can blunt the effects of hypoglycemia? Why?
Beta blockers, since the adrenergic system signal a hypoglycemic state
What is amiodarone used to treat?
Supraventricular and ventricular tachycardia
What are the effects of amiodarone?
Blocks potassium channels Prolongs repolarization Widens the QRS Prolongs the QT interval
Can deposition of amyloid lead to enlargement of organs other than the heart?
Yes, it can lead to widespread organomegaly
What is the mineral compisition of deposits in calcific aortic stenosis? How do they look on H and E
Calcium phosphates. Acellular blue material.
What are the 3 changes seen in chronic severe hypertension?
Decreased numbers of arterioles Thick walled arterioles Increased TPR
What is digoxin toxticity? What exacerbates it?
Cardiac dysrthymia. Hypokalemia increases severity.
What history is usually seen for a subendocardial infarction? Why?
Severe hypotension, since the endocardium is the farthest from the arterial supply
What is the ECG findings in a subendocardial infarction?
Flat ST segments or ST depression on various leads.
What is the afferent nerve for the aortic arch baroreceptor reflex?
X
What is the afferent nerve for the carotid sinus baroreceptor reflex?
IX
What happens to the firing rate of nerves IX and X in response to increased blood pressure?
Increased firing rate
What is the predominant nervous input to the heart?
Parasympathetic
What is the major parasympathetic input to the heart that controls HR?
X
What is the relationship between velocity and cross sectional area of a blood vessel?
Inversely proportional. Blood moves slowest through capillaries since they have the largest cross sectional area.
What is the mechanism of action of digoxin?
Inhibits sodium potassium ATPase
What is digoxin used to treat? (2)
CHF and supraventricular tachycardia
What is long QT syndrome and what is the clinical sequelae of it?
Genetically acquired prolongation of the QT interval associated with syncope and sudden death
What drugs are contraindicated in long long QT syndrome?
Class IA and III
What drug should be given to control hypertension in patients with diabetes and hyperuricemia?
ACE inhibitors (like captopril) for patients with diabetes and renal disease
What cardiac problems are seen in down syndrome patients? What is the etiology?
Endocardial cushion defects due to failure of neural crest cells to migrate properly
What benzo’s are good to treat alcoholics going through withdrawal?
LOT: lorazepam, oxazepam, temazepam. Their excretion is not as affected by liver disease as the other benzo’s.
What is graft vascular disease?
A complication of heart transplantation. Characterized by intimal thickening of the coronary arteries.
What sign is seen in cardiac tamponade? What is this sign?
Pulsus paradoxus: Reduction of systolic pressure greater than 10 mm Hg with inspiration.
What happens to the LV in aortic coarctation?
Hypertrophy
When are inflammatory cells first seen following irreversible ischemic injury?
2-3 days.
Aside from diastolic dysfunction what other cardiac abnormalities would one observe in a patient with HCM? (1)
Increased EF
What is unstable angina?
Recurrent episodes of angina on minimal effort or at rest
What is the etiology of unstable angina?
Slow thrombosis of a coronary artery with or without an underlying atherosclerotic process
What does excessive nitric oxide administration result in?
Methemoglobinemia resulting in cyanosis.
What can be pharmacologically done for methemeoglobinemia?
Methylene blue.
What is a consequence of long-standing angina pectoris histologically? What is the etiology?
Loss of myocytes with fibrosis and vacuolization in the subendocardium. Due to sustained ischemia
What beta blocker is contra-indicated in patients with angina? Why?
Acebutolol/penputalol/pindolol, since they have intrinsic sympathomimetic activity and so do not decrease myocardial oxygen consumption significantly.
What is Monckeberg arteriosclerosis (medial calcific sclerosis)?
A benign condition in the elderly where the media of small to medium arteries calcify
What embryonic structure gives rise to the smooth part of the RA and coronary sinus?
Sinus venosus
What is the genetic basis Kartagener disease? What are the clinical sequelae?
Dynein genetic defect Impaired clearance of respiratory debris, sperm motility impaired and situs inversus resulting in dextrocardia
What is an ostium primum ASD? What is the embryonic structure implicated?
Malformations of AV vavles due to endocardial cushion defect.
What congenital disease is associated with ostium primum ASDs?
Down syndrome
What is a complication of MI that happens later (4-8 weeks post infarct)?
Ventricular aneurysm
What class of drugs can cause drug induced gout?
Thiazide diuretics
What are the class 1B anti-arrythmics?
Mexiletine, tocainide (PO) and lidocaine (IV)
What are the class 1A anti-arrythmics?
Quinidine, Proainamide, Disopyramide
What are the class 1C anti-arrythmics?
Flecainide, prpafenone
What do class 1 anti-arrythmics do?
Block sodium channels
What do class II anti-arrythmics do?
beta blockers
What do the class 3 anti-arrythmics do?
K+ channel blockers
What are the class 3 anti-arrythmics?
AIDS: amiodarone, Ibutilide, Dofetilide, Sotalol
What do the class IV anti-arrythmics do?
Block calcium channels
What are the class IV anti-arrythmics?
Cerapamil, diltiazem
What can iron overload result in cardio wise?
CHF
What is takaysu arteritis?
Granulomatous vasculitis involving aortic arch vessels (narrowing of the aortic arch)
What population does Takayasu arteritis commonly affect?
Young asian women
What is the pathognomic vascular finding in takayasu arteritis?
Absence of peripheral pulsess in the upper extremities
What can atherosclerotic disease in the carotid result in?
Microemboli to the ipsilateral eye resulting in transient, recurrent vision loss (amaurosis fugax.
What sized arteries does polyarteritis nodosa usually affect?
Small to medium sized arteries
What type of necrosis is seen in patients with polyarteritis nodosa?
Fibrinoid necrosis
What is Kawasaki disease?
Fever for at least 5 days Desquamative rash of fingers/toes Cervical adenopathy Bilateral conjunctivitis Strawberry tongue Oral lesions
What cardiac abnormalities are present in Kawasaki disease?
Coronary artery aneurysms
What is the genetic defect in type I hyperchylomicronemia?
Apoprotein CII
What does apoportein CII do?
Turns on lipoprotein lipase.
What does Apoporotein CII deficiency lead to?
Very high chylomicron levels
What drug can be used to ‘coat’ stress ulcers? What is its mechanism of action?
Sucralfate: polymerizes in the acidic environment
What is Crigler-Najjar syndrome? What is found lab wise?
Lack of glucuronyl transferase preventing the glucuronidation of bilirupin by hepatocytes. Leads to high levels of unconjugated bilirubin in the plasma.
What does MCAD deficiency result in?
Accumulation of C8-C10 acylcarnitines
What does MCAD do? What does this result in during a fasting state.
Beta oxidation of fatty acids. During a fasting state there are low ATP levels.
What is the consequence of having low ATP levels during fasting as a result of MCAD deficiency?
Urea cycle fails, leading to the accumulation of ammonia in the blood.
What 3 hormones have a trophic effect on the GI tract and exocrine pancreas?
Gastrin, CCK and secretin
What are the H2 blockers?
Cimetidine, ranitidine, famotidine, nizatidine
What do the H2 blockers do?
Decrease H+ secretion by parietal cells.
Which H2 blocker inhibits p450 and has anti-andriogenic effects?
Cimetidine
What is Menetrier disease?
Hyperplastic gastrophathy characterized by enlarged rugal folds. Protein losing enteropathy
What cells hyperproliferate in menetrier disease?
Mucus producing cells of the stomach causing the protein losing enetropathy.
What is ursodiol used to treat? What does ursodiol do?
Used to treat cholesterol gallstones. Acts by reducing cholesterol synthesis and secretion into bile.
What is the cause of chagas disases?
Trypansoma cruzi
What are 3 clinical features of chagas disase?
Cardiac failure, megaesophagus and megacolon.
What is Gilbert syndrome?
Mild defect in UDP-glucuronyltransferase. Leads to asymptomatic unconjugated hyperbilirubinemia.
What is the nerve responsible for the relaxation of the internal anal sphicnter?
Pelvic nerve
What is the nerve responsible for the sensation of needing to defecate?
Pelvic nerve
What innervates the external sphincter?
The pudendal nerve
What anti-microbial can produce disulfram like effects (nausea and vomiting etc with alcohol consumption
Metronidazole
What is the inferior rectal nerve a branch of?
The pudendal nerve
What is meconium ileus?
When abnormally viscous pancreatic secretions get stuck in the small bowel.
What does meconium ileus look like on imaging?
Air fluid levels in the small bowel.
What condition causes meconium ileus?
Cystic fibrosis.
What do hyperplastic polyps look like microscopically?
Sawtooth glandular epithelium composed of goblet cells and columnar epithelium.
How does diverticulitis present clinically?
peri-umbilical pain that later becomes RLQ pain.
What is pathognomic of a sliding hiatal hernia?
Gastroesophageal junction is found significantly above the esophageal hiatus of the diaphragm
What 2 veins are anastamosed to make a portosystemic shunt in patients with hypertension?
The splenic vein (which normally goes to the liver) is anastamosed to the left renal vein which drains directly into the IVC, thus bypassing portal circulation.
What vein produces external hemorrhoids when it is varicosed?
The inferior rectal vein
What vein produces internal hemorrhoids when it is varicosed?
The superior rectal vein
What provides circulation to the lower anal canal?
The inferior rectal artery and vein
What does cytotoxin A and B of C diff do?
A: attracts granulocytes B: cytopathic
What stimulates gastric acid secretion (3)?
Histamine Gastrin Vagal stimulation
What are the 2 biomarkers for carcinoid tumors?
5-HIAA Chromogranin A (CgA)
What is used to treat carcinoid tumors? How does it work?
Octreotide. Somatostatin analog that binds to receptors on carcinoid tumors and inhibits the synthesis and release of tumor hormones. Also slows the growth of the tumor.
Normally is there more conjugated or unconjugated bilirubin in the portal vein?
More unconjugated bilirubin.
What does CCK do? (3)
Stimulates gallbladder contraction and secretion of pancreatic enzymes Inhibits gastric acid secretion by promotion production of somatostatin
What is the pathogenesis of hepatic encephalopathy?
The liver doesn’t perform the urea cycle which is responsible for getting rid of ammonia. Ammonia increase causes encephalopathy.
What is used to treat hepatic encephalopathy? How does it work?
Lactulose. Reduces ammonia absorption from the GI tract.
How does annular pancreas present?
Bilious vomiting vomiting, and a double bubble sign on X ray. Also polyhydramnios as a fetus.
What is the etiology of annular pancreas?
Bifid ventral pancreatic bud wraps around and squeezes the duodenum.
What should you suspect if you see a child with painless rectal bleeding?
Meckel’s diverticulum
What does metoclopramide do? What is the clinical use of this?
Antagonizes dopamine receptors, used as an anti-emetic agent.
Review the blood supply of the GI system
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What is Reye syndrome?
Life threatening condition with derangement of metabolism following a viral illness. Can be deadly.
What is the histology of the liver in Reye syndrome?
Microvesicular steatosis.
What is the arterial supply to the esophagus?
Esophageal branch of left gastric artery-a branch of the celiac trunk. Left inferior phrenic artery
What is the arterial supply of the lesser curvature of the stomach? What is it a branch of?
Anastamoses between right and left gastric arteries. Celiac
What is the arterial supply for the greater curvature of the stomach? What is it a branch of?
Anastamoses between the right and left gastro-omental artery. Celiac
What is the venus drainage of the lesser curvature of the stomach? Does it go into the portal circulation?
The left and right gastric veins which go into the portal circulation.
What is the venous drainage of the greater curvature of the stomach? Does it go into the portal circulation
The left and right gastro-omental veins. They drain into the portal circulation via the superior mesenteric vein.
What arteries supply the proximal portion of the duodenum? What is it a branch of?
The gastroduodenal artery and the superior pancreaticoduodenal artery, which is a branch off the gastroduodenal/gastroepiploic artery.
Celiac artery from the aorta gives rise to all of this
What arteries supply the distal part of the duodenum? What is it a branch of?
The inferior pancreatico-duodenal artery. SMA
What artery supplies the jejunum and ileum?
The SMA
What vein drains the jejunum and ileum?
The SMV
What artery supplies the cecum? What is it a branch of?
The ileocolic artery, a branch of the SMA
What artery supplies the transverse colon? What is it a branch of?
The middle colic artery, SMA
What arteries supplies the the descending and sigmoid colons?
The Left colic and sigmoid arteries, branches of the IMA
What arteries feed the pancreas? What is it a branch of?
Inferior and superior pancreaticoduodenal arteries, branches of the SMA.
What veins drain the pancreas?
Pancreatic veins that drain to the splenic vein.
What artery supplies the liver? What is it a branch of?
The hepatic artery, from the celiac.
What artery supplies the gallbladder? What is it a branch of?
The cystic artery, from the right hepatic artery.
How does necrotizing enterocolitis present?
Septic shock, with high leukocytes. Also with feeding intolerance, abdominal distension and bloody stools.
What would one see on laporotamy with necrotizing enterocolitis?
Gangrene of the terminal ileum and ascending colon.
How does bowel obstruction present?
High pitched, tinkling bowel sounds
What drugs are contraindicated in patients with bowel obstruction? Name one example
Pro-kinetics like metoclopramide
What is barret’s esophagus?
Metaplasia of the non-keratinized squamous epithelium of the esophagus to columnar epithelium characteristic of the stomach.
What causes barret’s esophagus?
Long-standing gastroesophageal reflux.
What is zollinger ellison syndrome?
Gastrinomas that form in the pancreas
What does ZES result in in the stomach?
Continuous HCl secretion
What is Boerhaave syndrome?
Esophageal rupture after sever retching
What are the clinical signs of boerhaave syndrome? (3)
Severe retrostenal pain Evidence of air in inappropriate locations in the chest. Tachypnea and tachycardia.
Where are the endocrine cells that produce GI hormones?
Scattered throughout the GI tract.
Where is the only GI hormone produced in the antrum of the stomach?
Gastrin
What are the 4 clinical features often observen in cirrhosis?
Ascites Jaundice Gynecomastia Cognitive deficiets.
Are the lesions in Crohns disease continuous or skipping?
Skipping
Are the lesions in ulcerative colitis continuous or skipping?
Continuous
What cell type would be increased in ZES? Why?
Parietal cells: gastrin has a hypertrophic effect.
What cell type would be decreased in ZES? Why?
G cells in the stomach since gastrin is being produced by the tumor cells.
What happens if scleroderma affects the esophagus? Why?
Lack of esophageal motility in the distal esophagus. Distal esophageal muscle is replaced with fibrotic tissue.
What metabolic disease predisposes to vaginal candadiasis?
Diabetes
What does ischemic bowel disease look like macrosopically?
Sharply demarcated, dark and hemorrhagic section of bowel.
Study the Brachial Plexus
What artery is the main artery of the anterior arm?
What artery courses in the anatomic snuffbox?
Review the sensory innervation of the foot/leg
