Cardio Flashcards
fluid overload and an S3?
dilated cardiomyopathy
what med can abort PSVT by slowing atrioventricular (AV) conduction velocity and increasing the AV node refractory period
- bronchoconstriction is a potential side effect
adenosine
- adverse effects include vasodilation and bronchoconstriction
what med
• Inhibits Na+/K+ ATPase (improved contractility)
• Increases parasympathetic tone (vagus mediated)
digoxin
- positive inotropy: increased calcium in the cell increases contractility
holosystolic murmur best heard over the left lower sternal border
tricuspid regurg
increased serotonin production, which stimulates fibroblast growth, thereby resulting in plaque-like deposits
- tricuspid leaflets are the most common site for these plaques to deposit on, causing the leaflets to thicken and fibrose, leading to decreased compliance and ultimately tricuspid regurgitation
carcinoid heart disease
what valve abnomalities become louder with inspiration?
right sided murmurs
- pulmonary and tricuspid
what valve abnormalities become louder with exhalation?
left sided murmurs
- mitral and aortic
is oncotic pressure measured at the arteriolar or venous end?
venous
Net filtration = (Pc-Pi) - (Oc-Oi)
capillary hydrostatic - interstitial hydrostatic
capillary oncotic - interstitial oncotic
what is the most common congenital heart malformation?
bicuspid aortic valve
holosystolic blowing murmur that is heard loudest over the left lower sternal border
- widely split S2 and a palpable thrill
VSD
one of the most common cardiac tumors in children and infants and are composed of hamartomatous cardiac tissue
- very strong association with tuberous sclerosis
cardiac rhabdomyoma
- AD: TSC1 mutation (chromosome 9) or TSC2 (chromosome 16)
ECG leads V1-4
left anterior descending artery
ECG leads II, III, aVF
right coronary artery
ECG leads I, aVL, V5, V6
left circumflex artery
ECG changes involving V1–V6, I, and aVL?
left coronary artery (both LAD and left circumflex downstream are affected)
occurs secondary to autosomal dominant mutations that can affect the beta-myosin heavy chain of the sarcomere
- more commonly in African American males
- patients present with features such as syncope, dyspnea on exertion, and a systolic outflow murmur heard at the left sternal border
hypertrophic cardiomyopathy
levels rise in 3 to 4 hours, peak at about 24 hours, and remain elevated for about 7 days
troponin
rises 3 to 12 hours post–myocardial infarction and decreases over 1 to 3 days.
CPK-MB
infective endocarditis typically affects which heart valve?
tricuspid
- MC organism is S. aureus
gummas, pupils that do not react to light
- Xray: widening of the mediastinal shadow, displacement of the trachea or left mainstem bronchus and blurring of the aortic knob
tertiary syphilis
- is rare and most commonly affects the cardiovascular and central nervous system
- MC CV manifestation involves thoracic aneurysm formation in the ascending aorta due to obliterative endarteritis of the vasa vasorum
what drug class are known to slow the progression of diabetic nephropathy and, thus, are the drugs of choice for hypertension in in diabetics
ACE-I’s
-prils
drugs of choice for hypertension in patients with angina or a history of myocardial infarctions
beta blockers
drugs of choice for hypertension in patients with benign prostatic hyperplasia
alpha blockers
- tamsulosin
initial drug of choice for essential hypertension with no other co-morbidities
thiazide diuretics
1) cough and angioedema are possible side-effects
2) they cause hyperkalemia
3) they increase survival in congestive heart failure
4) they are contraindicated in bilateral renal artery stenosis and pregnancy
ACE-I’s
AV dissociation and the atria and ventricles move at their own rates, separately from one another
third degree AV block (complete heart block)
prolonged PR interval?
first degree AV block
PR interval gets progressively longer until a beat is dropped, then resets itself
Mobitz type I second degree AV block (Wenckebach)
- the majority of cases are due to disturbance in the AV node, no treatment is necessary unless there is an offending medication that can be discontinued
characterized by missed beats, which may form the 2:1 or 3:1 pattern in which there are 2 or 3 P waves before every QRS wave
Mobitz type II
- QRS complex is likely wide
Familial dysbetalipoproteinemia occurs because of a defect in what?
apolipoprotein E (Apo E)
- Apo E is located on chylomicron remnants, IDL, and HDL
- deficiency results in elevated chylomicron remnants, VLDL, IDL, and LDL, with normal amounts of HDL
found on VLDL, IDL, and LDL
- necessary for lipid recognition by the LDL receptor located on hepatocytes
apo B100
what is the MCC of premature death in pt w/ Marfans?
aortic dissection
multiple hemngioblastomas, d/t mutation on Xsome 3?
VHL
where is the mutation for ADPKD?
PKD1 gene on chromosome 16
CGG triplet repeats on the X chromosome
fragile X
- FMR1 gene
OMM: left-sided thoracoabdominal diaphragmatic congestion and reduced excursion represents what?
lymphatic congestion created by an enlarged abdominal aorta blocking proper lymphatic circulation
peaked T waves?
HYPERkalemia
- treat w/ calcium gluconate (prevents progression of fatal arrhythmias)
- traumatic crush injury which results in massive tissue damage with necrosis of muscle -> muscle has a large store of potassium that will be released
deletion at chromosomal location 22q11?
- cleft palate/lip
- TOF
DiGeorge
- embryonic developmental defects of the head, neck, brain, heart, kidneys
- structures derived from the 3rd and 4th pharyngeal pouches including the thymus and parathyroid glands
- T cells will not reach full maturation without a thymus
condition occurs when the terminal portion of the duodenum becomes entrapped and compressed in the angle formed by the abdominal aorta and SMA
- N/V, sharp postprandial abd pain
SMA syndrome
- Under certain circumstances, including scoliosis, surgical lengthening of the spine, retroperitoneal tumors, abdominal trauma, and peritoneal adhesions, the SMA shifts. This shift moves the peritoneal fat and lymphatic tissue that cushion the duodenum; the duodenum then becomes compressed in this narrowed angle
what three structures are derived from the vitelline arteries
SMA, IMA, and celiac artery
shunt that connects the pulmonary artery to the aorta and bypasses the pulmonary circulation
ductus arteriosus
what pharyngeal arch?
- maxilla, mandible, hard palate, malleus, incus, muscles of mastication, trigeminal nerve, and maxillary artery
PA 1
carry deoxygenated blood to the placenta from the fetus in utero
umbilical arteries (2)
what gives rise to the superior vesical arteries (supply bladder)
umbilical arteries
allows oxygenated blood from the placenta to bypass the portal circulation
umbilical vein
what is the fick principle?
Cardiac Output = oxygen consumption / (arterial O2 content - venous O2 content)
what is secreted by cardiomyocytes in the ventricle as a response to ventricular stretching, often in the setting of volume overloaded states such as CHF
Brain natriuretic peptide (BNP)
- promotes natriuresis (pee out Na)
- inhibits RAAS
ANP is released in response to atrial stretch
propranolol
nonselective beta blocker
- can exacerbate COPD/asthma sx d/t beta-2 blockade!
calcium channel blocker that is selective for relaxing smooth muscle of the arterioles. Thus, these drugs are used as antihypertensives but are associated with reflexive tachycardia, edema, and episodes of constipation
amlodipine
alpha2 adrenergic agonist, which acts in the presynaptic central nervous system to reduce sympathetic activity
clonidine
- reduce heart rate and blood pressure
enhances the activity of lipoprotein lipase, which hydrolyzes fatty acids from very low density lipoprotein (VLDL)
fibrates
- tx for hypertriglyceridemia
- PPARα agonist -> induce lipoprotein lipase, the enzyme that allows for VLDL breakdown
prevents the absorption of cholesterol from the gastrointestinal (GI) tract
ezetimibe
high resistance to outflow from the LA
- LA enlargement due to increasing left atrial volume and pressure
- LV and pressure are normal
- the elevated atrial pressure can cause pulmonary hypertension, resulting in pulmonary congestion, lung crackles, hemoptysis, and dyspnea
mitral stenosis
- in mitral regurg, LV volume would be expected to be increased (not normal)
what infectious process causes mitral stenosis?
rheumatic heart disease
- strep pyogenes
- chronic inflammation that leads to thickening of mitral valve leaflets and formation of fibrous tissue and calcific deposits
- dyspnea, hemoptysis, left atrial enlargement
crescendo/decrescendo systolic murmur auscultated at the right upper sternal border
aortic stenosis
- decreased stroke volume, decreased systolic and mean arterial pressure, and elevated LV pressures
crescendo/decrescendo systolic murmur that increases with Valsalva
hypertrophic cardiomyopathy
- non-uniform ventricular hypertrophy that causes obstructions of the outflow tract leading into the aortic valve
systolic murmur with a fixed split S2
- MC in females
atrial septal defect
- usually asx, some may develop atrial arrhythmias, pulmonary arterial hypertension, and right heart failure
holosystolic murmur at the apex, may radiate to the axilla
- LV volume is increased
mitral regurg
diabetes (fatigue, polydipsia, polyuria, weight loss), liver failure, skin hyperpigmentation, and cardiac symptoms
- hepatomegaly, skin pigmentation, and arthritis
- Bronze diabetes
hereditary hemochromatosis (AR)
- excess iron is then deposited in parenchymal cells of many organs, causing dysfunction
- when iron deposition of the myocardium occurs, dilated cardiomyopathy, restrictive cardiomyopathy, or arrhythmias may be seen
- tx is weekly phlebotomy
hypertrophy of LV = diastolic dysfunction
- young athlete w/syncope, SOA
- murmur increases with valsalva
hypertrophic cardiomyopathy
medial umbilical ligaments are remnants of what?
urachus -> umbilical arteries
what do the umbilical arteries branch off of?
internal iliac arteries
holocystolic murmur at left lower sternal border, radiates to right lower sternal border and epigastrum
- peripheral edema, jugular venous distention, and ascites are common
- caused by endocarditis of the valve leaflets
tricuspid regurg
midsystolic click followed by a crescendo murmur
MVP
holosystolic, high-pitched and blowing murmur heard loudest at the cardiac apex, and it radiates toward the axilla
mitral regurg
what effect does valsalva have on cardiac output?
initially increases, then decreases CO
- when straining/holding breath, increased thoracic pressure decreases venous return
are baroreceptors in the carotid sinus or aortic arch more sensitive to drops in pressure?
carotid sinus
increase in LDL and total cholesterol?
Type IIa familial dyslipidemia aka hypercholesterolemia
what are the only 4 antihypertensives currently recommended for treatment of elevated blood pressures in pregnancy
labetalol, hydralazine, nifedipine, and methyldopa
methyldopa (a2-agonist is preferred, hydralazine least good)
what effect does inspiration have on venous return?
it increases venous return (due to negative pressure)
- increased VR -> more blood in right side of heart -> increases sound of right sided murmurs
muscarinic blocker used to treat symptomatic bradycardia
- causes tachycardia and will shorten PR interval
atropine
what heart problem does TB cause?
constrictive pericarditis
what med closes a PDA?
indomethacin
PGE1 analog used to keep the ductus arteriosus patent
alprostadil
prominent occiput, small mouth, micrognathia, pointy ears, short sternum, and horseshoe kidney
- rocker bottom feet
- VSD
edwards trisomy 18
holosystolic murmur at the mid to lower left sternal border
- normal S2
ventricular septal defect
- ASD has fixed split S2
aortic intimal tear that connects the aortic media with the aortic lumen
aortic dissection
what organism causes subacute endocarditis secondary to dental procedures?
strep mutans
- catalase neg, alpha hemolytic
what murmur decreases stoke volume (SV) and systolic and mean arterial pressures
- increases pressure in the left ventricle (LV)
aortic dissection
- commonly in elderly
- intensity decreases with sustained hand grip (increased afterload)
- crescendo/decrescendo at right upper sternal border
what would increase the intensity of aortic stenosis murmur?
increasing preload (squatting) - decreasing preload should decrease murmur (valsalva)
crescendo/decrescendo systolic murmur that increases in intensity with the Valsalva maneuver
hypertrophic cardiomyopathy
what murmur would you expect post myocardial infarction with papillary muscle rupture?
mitral regurg
what dangerous side effect can b-blockers have in diabetics?
they can mask the symptoms of hypoglycemia
what 3 drugs can increase uric acid levels?
aspirin, niacin (for hyperlipidemia), and a thiazide diuretic
when would you see:
- Janeway lesions: nontender maculae on the palms and soles
- Osler nodes: tender subcutaneous nodules usually found on the distal pads of the digits
- Roth spots: retinal hemorrhages with small, clear centers; rare and observed in only 5% of patients
- Subungual (splinter) hemorrhages: dark red linear lesions in the nail beds
- Petechiae: a common but nonspecific finding
subacute bacterial endocarditis
what med inhibits the rate-limiting step in cholesterol synthesis, the formation of mevalonate by HMG-CoA reductase
- can cause rhabdomyolysis
statins
- presents as muscle aches and dark urine
what is a side effect of bile acid sequestrants such as cholestyramine?
decreased absorption of fat soluble vitamins
role of prostaglandins vs thromboxane?
- prostaglandins cause vasodilation, swelling and erythema, also sensitizes nerve endings, and fever
- thromboxane enhances platelet aggregation
aspirin irreversibly INHIBITS these!
why is acetaminophen not considered an NSAID?
it lacks anti-inflammatory effects
sawtooth patern on ECG?
atrial flutter
what anytiarrhythmic specifically targets potassium channels?
amiodarone
- prolongs action potential (delay repolarization)
- side effects: pulmonary fibrosis, thyroid instability, blue skin, corneal deposits, hepatotoxicity, drug interactions
- Verapamil
* Diltiazem
calcium channel blockers
what anti-arrhythmic prolongs phase 0 and duration of action potential
- causes lupus-like effects?
procainamide
heart failure with reduced ejection fraction is what kind of dysfunction?
systolic dysfunction d/t impaired contractility
what is the drug of choice for SVT?
adenosine
what class of antiarrhythmics are unique in that they decrease the duration of the action potential by shortening repolarization (phase 3)?
Class IB
- lidocaine
calcium channel blocker that is used to treat hypertension in pregnancy
nifedipine
- has a much greater affinity for vascular calcium channels than for calcium channels in the heart and, therefore, is not used as an antiarrhythmic agent
when would you see an accentuated V wave on a JVP wave?
tricuspid regurgitation
- blood is pushed back into the atrium through the closed but leaky tricuspid valve during ventricular contraction
- V wave = right atrium
what is the initial step of atherosclerosis?
fatty streaks
- thickening of the intima with accumulation of macrophages (foam cells) and extracellular matrix
Baroreceptors respond to hypotension by increasing what?
sympathetic tone
- increases HR to compensate for the decreased cardiac output
- causes tachycardia
what is contraction alkalosis?
people taking too many diuretics
- hypovolemia and hypotension stimulate renin production, ultimately leading to increased angiotensin II
- Ang II stimulates aldosterone secretion from the adrenal cortex, which resorbs sodium, exchanging it with potassium and hydrogen, which are excreted in the urine
- leads to hypokalemia and metabolic alkalosis
what is the only nonsulfa based loop diuretic, prescribed for people who have sulfa allergy?
ethacrynic acid
what effect does sustained hand grip have on aortic stenosis?
An increase in afterload (eg, sustained isometric hand grip exercise) → decreases flow through the aortic valve → decreased intensity of AS murmur
what causes Type IIa familial dyslipidemia?
decrease in LDL receptors
what causes Type I familial dyslipidemia (hyperchylomicronemia)?
primarily due to a lipoprotein lipase deficiency
how does an overdose on thiazide diuretic cause alkalosis?
hypokalemia activates K/H transporters that exchange intracellular K for H, decreasing the amount of H in the serum
short PR interval and delta waves?
wolf-parkinson white syndrome - treat with class Ia sodium channel blockers: procainamide, quinidine, and disopyramide
Mitral stenosis (MS) has a much lower pressure gradient than aortic stenosis (AS), so MS has a deeper pitch of sound than AS
AS = harsh, blowing MS = holocystolic
early, wide QRS complexes that are not preceded by a P wave
premature ventricular contractions
what aortic layer contains extensive smooth muscle and elastic tissue that allow the aorta to withstand high, pulsatile pressures
tunica media
- adventitia = outermost
- intima = innermost
occurs when there is a tear in the tunica intima, leading to the formation of a false lumen between tunica intima and media
aortic dissection
type A vs B dissections
- Type A involve the ascending aorta (including retrograde extension from the descending aorta) -> need surgery
- Type B are limited to the descending aorta only -> controlled with meds
what is the most specific diagnostic testing modality for PE?
CT pulmonary angiography
what does ANP do?
acts on the kidney to cause Na+ and water loss
- inhibits Na reabsorption (inhibits aldosterone?)
benign pediatric murmur that commonly presents in healthy children at 2 to 7 years of age
Still murmur
- low-pitched (midsystolic) murmur with a musical or vibratory quality best heard with the bell
fever, myalgias, rash, arthralgias, arthritis, pericarditis, pleuritis, and serositis
- anti-histone antibodies
drug-induced lupus
- hydralazine, procainamide
tx for patients with atrial fibrillation who can not tolerate the adverse effects of beta-adrenergic receptor blockers (COPD/asthma patients, type 2 diabetics, and those with peripheral vascular disease)?
verapamil
what is a prominent adverse event of nonselective alpha blockers?
reflex tachycardia
what is a common adverse event of selective alpha-1 antagonists?
urinary incontinence
- they inhibit alpha-1–mediated contraction (so they dilate) the urinary sphincters
familial lipoprotein lipase deficiency
type 1
- deficiency of lipoprotein lipase (interacts with Apo-IIC)
familial hypercholesterolemia with defective LDL receptor
type 2a
familial hypercholesterolemia with mutant apolipoprotein B 100
type 2b
familial dysbetalipoproteinemia
type 3 hyperlipidemia
what is the treatment of choice for heart failure with reduced ejection fraction?
beta blockers
- stay away from diltiazem (negative inotropy is bad for rEF)
what is a potential complication for any patient with chronic renal failure?
uremic pericarditis
what nondisjunction has an increased risk of a bicuspid aortic valve leading to early-onset AS
turner syndrome
- can see bicuspid aortic valve or coarctation of aorta
hOw do you calculate bioavailability?
MD = CP x CL ÷ F
- MD is the maintenance dose
- CP is the desired plasma concentration
- CL is clearance
- F is bioavailability
any drug given intravenously has 100% bioavailability
MC cyanotic congenital heart lesion in the newborn, and may be associated with maternal diabetes
Transposition of the great vessels
how do you calculate ejection fraction?
EF = SV / EDV
continuous, machinery murmur
PDA
why do people in DKA also have hyperkalemia?
acidotic state shifts potassium from intracellular fluid to extracellular fluid in exchange for excess hydrogen ions, resulting in hyperkalemia, causing EKG changes
hypercyanotic spells with agitation, crying, and fevers and has a crescendo-decrescendo systolic murmur on exam in the pulmonic region
- upturned cardiac apex on chest x-ray
TOF
- mc cyanotic heart lesion in children
- develops from anterior malalignment of the interventricular septum
NOTE: aortic dextroposition = overriding aorta
mid-diastolic rumble with an opening snap best heard at the cardiac apex.
mitral stenosis
- caused by rheumatic heart disease
heart failure with worsening dyspnea and possible pulmonary edema
- holosystolic murmur at the apex with radiation to the axillae
mitral regurg
- look for SOA, hemoptysis d/t pulmonary congestion
holosystolic murmur at the left lower sternal border
tricuspid regurg
systolic hypertension in the upper extremities with diminished or delayed femoral pulses (brachio-femoral delay)
- prolonged capillary refill and claudication
- may go unnoticed into adulthood
coarctation of the aorta
- obstructive lesion caused by thickening of the aortic wall media, leading to narrowing of the descending aorta
- seen in Turner’s syndrome
myxomatous degeneration of the mitral valve
- results in an accumulation of the glycosaminoglycan dermatan sulfate within the connective tissue matrix of the valve and results in a redundancy of the valve
mitral regurg
valsalva maneuver
decreases preload (decreases blood returning to heart) - will *lengthen* MVP murmur
mitral stenosis and aortic regurg are what kind of murmur?
diastolic
mitral/tricuspid regurg and VSD are what kind of murmur?
holocystolic
squatting
increases venous return
what meds are known to increase survival in patients with heart failure and reduced ejection fraction.
- but cause hyperkamelima -> lengthening PR interval and prolonging QRS
ACE-I’s, ARB’s
- inhibiting RAAS -> less aldosterone -> increasing risk of hyperkalemia
what would cause a shortened QRS and Qt interval?
hypercalcemia
“must know” points about ACE-inhibitors:
1) cough and angioedema are possible side effects
2) they can cause hyperkalemia
3) they increase survival in systolic heart failure
4) they are contraindicated in bilateral renal artery stenosis because they exacerbate renal failure in these patients
5) they can slow the progression of diabetic nephropathy
6) they are contraindicated during pregnancy
what is most likely COD post-MI?
arrhythmia
- 5-10 days later, ventricular wall rupture common as well as mural thrombus
why give phenylephrine to TOF child?
to increase systemic vascular resistance to the point where blood will start shunting preferentially into the lungs and bypass the VSD
two uses for indomethacin?
- closing PDA
2. acute gout flares (d/t anti-inflammatory properties)
what is Multifocal atrial tachycardia associated with?
COPD
- irregular rhythm that has different shaped P waves for each electrical complex due to different atrial foci
Hemosiderin-laden macrophages are a sign of what?
excess red blood cells in the lung tissue
- known as “heart failure cells.”
splitting of the S2 heart sound that narrows upon inspiration, which audibly eliminates the split
left BBB
blowing diastolic murmur with a wide pulse pressure
- bounding pulses, and the head may even bob due to the tremendous pressures created in the vasculature
aortic regurg
