Cardiology 2 Flashcards by Denisse Tiangco

Diseases that involve myocardium directly and not result of conditions such as HTN, congenital, valvular, arterial or pericardial abn

2 forms

Cardiomyopathy

Primary - unknown cause
Secondary - known assoc with organ dysfunction

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Genetic alteration in cardiomyopathy

Dystrophin complex

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Basic structural and fxn unit of muscle

Sarcomere protein

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Ryanodine receptors of SR

Disease

L type calcium ch

Malignant hyperthermia

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Extrinsic protein on RBC membrane and myocyte

Spectrin

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Most common cause of myocarditis

Coxsackie B

Viral replication in myocyte -> myocyte lysis -> delayed apoptosis

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Glycogen storage disease with cardiac involvement

Pompe Disease

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Bacteria notorious for causing myocarditis

Metachromatic granules

Diptheria

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Most common cause of heart transplant

Diminished myocardial contractility, systolic pump function resulting in impaired ventricles leading to cardiac enlargement

Dilated cardiomyopathy

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Most common cause of dilated cardiomyopathy

Idiopathic

peripartum
postmyocarditis

Alcoholic 2nd

Doxorubicin, cocaine
Infiltrative: amyloid

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Most common assoc toxin with chronic dilated cardiomyopathy

Tx abstinence

Alcohol

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This amount of consumption may develop DCM resembling idiopathic or familial DCM

> 90g/d

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Alcohol consumption regularly during weekend or holiday

Acute cardiac rhythm or conduction disturbance mc Supraventricular Tachyarhythmia assoc with heavy ethanol without other clinical evidence of heart disease

Appears after binge drinking

Considered in px without structural heart disease and with new onset artrial fibrillation

Holiday heart syndrome

Abstinence resolution

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Most frequently seen arrhythmia in holiday heart syndrome

Atrial fibrillation

Atrial flutter

Ventricular premature dep PVCs

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A fib causes

Ethanol
Valvular heart disease
Ischemia
Cardiomyopathy
Cocaine
Thyroid

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Pathophysiology of holiday heart syndrome

1 inc secretion of epi and norepi
2 inc sympathetic output
3 rise in level of plasma free fatty acid
4 indirect effect through acetaldehyde (primary metabolite) or fatty acid ethyl ester
5 dec sodium current and affect intracellular pH

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Most common symptom of holiday heart syndrome

palpitation

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Only PE abnormality in Holiday Heart Syndrome

Irregular or thready pulse

Rapid heart rate

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Cardiac dilation and CHF developing during last trimester of pregnancy within 6 mos after delivery

Peripartum cardiomyopathy

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Peripartum cardiomyopathy rf

Multiparous, over 30
Twin pregnancy
Malnutrition
Tocolytic use (terbutaline, ritodrine) 
Premature labor
Preeclampsia (vasospasm)

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Most common drug that causes cardiotoxicity

Rf
>70

Doxorubicin
Danorubicib

Dexrazoxane

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Myocardial hypertrophy
Abnormal diastolic filling
Intermittent ventricular outflow obstruction

Idiopathic hypertrophic subaortic stenosis

Hypertrophic obstructive cardiomyopathy (HOCM)

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Cause of sudden cardiac death in young athletes

Thick walled heavy hypercontracting heart

Hypertrophic cardiomyopathy

Differential: Brugada syndrome

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Hypertrophic cardiomyopathy pathophysiologic abnormality

Diastolic dysfunction

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Most common mutation in hypertrophic cardiomyopathy Half with HCM have family history

Cardiac b myosin heavy chain gene on ch 14

HOCM hallmark

systolic murmur at left sternal border as well as at apex

Most common complaint in HOCM

dyspnea

Inherited metabolic cardiomyo with LVH

Cardiac danon disease Glycogen storage cardiomyo Fabry disease Friedrich ataxia -Frataxin gene

Abnormal diastolic function Dec ventricular compliance/restriction of cardiac filling Ventricular walls are excessively rigid and impede ventricular force Caused by fibrosis, infiltration and hypertrophy

Restrictive cardiomyopathy

Most frequent cause of hemochromatosis

B thalassemia | Multiple transfusion and hemoglobinopathy

Marked subendocardial fibrosis | encroachment of lumen, dec ventricular filling and cardiac failure

Obliterative cardiomyopathy

Apical ballooning syndrome Severe chest discomfort preceded by very stressful emotional or physical event Women >50 ST segment elevation and T wave inversion in chest leads Reversible within 3-7d No long term cardiac dysfunction

Takotsubo stress cardiomyopathy

``` Firm rubbery waxy non compliant heart Diastolic dysfxn Systolic dsyfxn Arrhythmias OH ```

Amyloid cardiomyopathy

Parasite migrates to myocaridium and larvae causes necrosis

Heterophyes

Immune mediated myocarditis from post strep infection (rf) strep pyogenes bec of

M protein

Major causes of myocarditis

Coxsackie B Diptheria T cruzi

Myocarditis sx Dx Best dx

``` Dyspnea Fatigue Arrhythmia Chest pain Murmur ``` Degree of heartblock on ECG Elevation of cardiac enzyme Endomyocardial biopsy

Normal amount of pericardial fluid Thin clear straw colored fluid in pericardial sac ie ultrafiltrate of the plasma

15- 50ml

Restricts anatomic position of heart Minimizes friction between surrounding structures Prevents displacement of heart and kinking of great vessel

Pericardium

Most common form of pericardial effusion

serous | ex CHF, hypoproteinemia

Pericardial effusion of blunt chest trauma

Serosanguinous | ex CPR

Pericarditis infectious agent Pericarditis immunologically mediated

Virus TB Fungi Parasite Scleroderma Postcardiotomy PostMI Dressler syndrome Drug hypersensitivity

Post myocardial infarction pericarditis

Dressler syndrome

Drug induced SLE can produce pericarditis

Procainamide (anti arrhythmic) Hydralazine Isoniazid Methyldopac

Drug causes constrictive pericarditis

Methysergide

Miscellaneous causes of pericarditis

``` MI Uremia Ff cardiac surgery Neoplasia Trauma Radiation ```

Cancer that metastizes to the pericardium

Lung ca

Most often cause of myocarditis

Virus

Inflammatory reaction in epicardial and pericardial surface with scant numbers of PMN lympho and macrophage

Serous pericarditis | RF, SLE, scleroderma, tumor, uremia

Most frequent type of pericarditis Serous fluid mixed with fibrinous exudate Cause: MI, Dressler, uremia, chest radia, RF, SLE and trauma Clinical presentation:

Fibrous/serofibrinous pericarditis Pericardial friction rub

Fibrinous pericarditis is also known as

fibrinous pericarditis

Denotes invasion of pericardial space by infective organism Route: direct extension from neighboring inflamm Thin to creamt pus 400-500 ml Serosal surface reddened granular and coated with exudate Acute inflamm reaction

Purulent or suppurative

Blood mixed with fibrinous or suppurative effusion Most commonly causes by Others: bacterial, diasthesis, TB(caseous) and cardiac surgery

Hemorrhagic Malignancy

Healing of acute lesion resolution or pericardial fibrosis ranging from thick pearly nonadherent epicardial plaque to thin delicate adhesions to massive adhesions

soldier’s plaque

Pericardial sac obliterated and parietal layer tethered to mediastinal tissue

Adhesive mediastinopericarditis | Chronic or healed

Perocarditis symptoms

Chest pain in acute infectious type related to hypersensitivity Pericardial friction rub Reduction in voltage with large effusion on ECG Elevation of ST in ECG returning to normal within hours Pericardial effusion leads to cardiac tamponade Water bottle appearance of cardiac silhouette on radio

Most common cause of tamponade

Neoplastic disease Idiopathic pericarditis Uremia

3 principal features of tamponade

Elevation of intracardiac pressure Limitation of ventricular filling Reduction in cardiac output

Cardiac involvemeny manifesting valvular abnormality from recurrent rheumatic fever

Rheumatic heart disease

Immune mediated disease triggered by antecedent infection assoc with

RHD Most antecedent event: Group A Streptococcus Pyogenes Group A Beta Hemolytic Streptococci GABHS

MC Cause of acquired heart disease in children/young adults Peaks

Rheumatic fever 5-15 years old rare in >30?

Usual presentation of RF

Pharyngitis (sore throat, odynophagia) | Strep skin infection

Most common cause of mitral stenosis 2/3 worldwide

rheumatic fever

Peaks at 25-40 Predominant at females

RHD

Most common cause of heart disease in children in developing countries 95% of ARF cases and RHD occur in developing

RHD

ARF is caused by infection of upper respiratory tract with group A strep pyogenes whose virulence factor is Pathogenesis HLA

M protein HLA DR7 HLA DR4(RA)

Immune response targeted at strep antigens aka of Group A streptococcal carbohydrate a process called recognizing human cell (myocyte)

M protein N-acetylglucosamine Molecular mimicry

Demonstrates cross reactivity with M protein Protein that is helical coiled Antibodies to cardiac valve tissue cross react with leading to valvular damage In IV users most common valve involved

Myosin Laminin N acetylglucosamine targetting mitral valve Tricuspid valve

Modified JONES criteria for RF (MAJOR) CASES

``` Carditis Arthritis Sydenham chorea Erythema marginatum Subcutaneous nodule ```

Modified JONES Minor Criteria:

PEACH FEVER ``` Prolonged PR Elevated ESR Arthralgia C-RP Hx of preceding sore throat or recent strep infection Fever ```

RF Dx

Two major One major and 2 minor + supporting evidence of preceding Group A Strep infection

Most common feature

``` Polyarthritis 60-75 Carditis 50-60 Chorea <2-30 Erythema marginatum and Subcutaneous nodules are rare <5 ```

Exception | Presence of this alone with history of recent streptococcal infection is enough to diagnose RF

chorea

Inflammation of endocardium | valves, myocardium and pericardium (pancarditis)

Carditis

Diastolic rumble and opening snap

Mitral stenosis

Most common valves involved in rf

Mitral 2/3 Aortic 25% Tricuspid infrequent Pulmonic rare

Most common joints affected in rf Occur in 75% Pain is debilitating Highly responsive to NSAIDs and salicylate

Knees, ankles, hip, elbow

Classic rash of ARF Painless small mobile lumps seen overlying bony prominences

Erythema marginatum Subcutaneous nodules

Erythema chronicum migrans

Lyme disease | Bull’s eye / Target rash

Histologic hallmark of subcutaneous nodules Also a histologic marker of rheumatic activity

Aschoff bodies attached to tendon sheaths | Assoc with severe carditis

T lymhpocytic plasma cell

Aschoff bodies

Pathognomonic for RF Caterpillar cells Pancarditis Histiocytes of cardiac myocyte

Anitschkow cell

Irregular thickening induced by subendocardial lesions exacerbated by regurgitant jets usually in L atrium

MacCallum Plaque

1-2mm small vegetation Serve as nidus for infection

Verrucae Infective endocarditis

Chronic RHD thickening the commisural fusion and shortening thickening and fusion of the tendinous cords Calcification and fibrous bridging across valvular commisures

Fishmouth | Buttonhole appearance

Basal ganglia and caudate nucleus involvement Present as single manifestation of RF

Sydenham’s chorea | St. Vitus dance

Trinucleotide CAG repeat | Atrophy of caudate nucleus

Huntington’s disease

Gradual onset Involuntary uncoordinated purposely jerky movements aggravated under stress when patient is awake with emotional instability Speech is indistinct halting and explosive Milkmaids hand Handwriting affected Darting tongue

Sydenham’s chorea

Drug of choice for rheumatic f and prophy

Benthanzine penicillin Orally BID Amox 50mg/kg max 1g daily

drug of choice Used for treatment of arthritis, arthralgia and fever

Aspirin May also take NSAID

Mainstay of primary prevention for ARF

Primary prophylaxis timely and complete Group A strep sorethroat with antibiotics

Mainstay of controlling ARF and RHD | Secondary prevention

Benzanthine pen G 1.2M units 600,000 u if <27 kg