Cardiology Flashcards
Atrial Chamber Septation
The foramen ovale (of the septum secundum) and the foramen secundum (of the septum primum) maintain blood flow between the two chambers in the embryo
Adult Derivatives of the Atria
Pg 268 in STEP BOOK
Aortic Arches
1 = maxillary artery 2 = stapedial artery, hyoid artery 3 = common carotid artery and proximal part of the internal carotid artery 4 = left (adult aorta arch) right (proximal part of the right subclavian artery) 6 = proximal part of the pulmonary arteries and ductus arteriosus
5th arch degenerates
3rd and 4th are most important
Aorticopulmonary septum
- membranous portion of the ventricular septum
- comes from neural crest cells
- if there is no 180 degree turn = Transposition of great vessels
- failure of neural crest migration = persistent truncus arteriosus
Ventricular septal defects usually occur in the membranous septum
Ebstein’s Anomaly
Apical displacement of the septal and posterior tricuspid valve leaflets leading to atrialization of the right ventricle
- the leaflets are unusually deep in the right ventricle
- congenital defect of endocardial cushions of the tricuspid valve
- causes tricuspid regurgitation
- the high right atrial pressure keeps the PFO and allows for deoxygenated blood to go to the peripheral system causing cyanosis
Can be due to use of lithium or benzodiazepine during pregnancy
Increased risk of wolf Parkinson’s white syndrome and SVT
Fetal Erythropoiesis
Young Liver Synthesizes Blood
Yolk sac (3-8 weeks)
Liver (6weeks-Birth)
Spleen (10-28 weeks)
Bone marrow (18 weeks to adult)
Fetal postnatal derivatives
Pg 271 of STEP
Left to Right Shunts
PDA = treat with indomethacin (blocks prostaglandin synthesis)
ASD
VSD
Uncorrected left to right shunt causes pulmonary hypertension causing RVH and then right side pressure exceeds left = Eisenmenger syndrome (R–>L shunt)
Coarctation of Aorta
Infantile = pre-ductal = Associated with Turner Syndrome
Adult = post-ductal
- notching of rib on X-Ray due to intercostal arteries becoming dilated
Disorders Associated with Cardiac Malformations
Turner Syndrome
- infantile coarctation of aorta = preductal
- Bicuspid Aortic Valves
Down Syndrome
- endocardial cushion defects = ASD (ostium primum type), VSD, AV septal defects
Digeorge Syndrome 22q11
- Tetralogy of Fallot
- Truncus Arteriosus
Congenital Rubella
- PDA
- Pulmonary Artery Stenosis
- septal defects
Marfan Syndrome
- Aortic insuficiency due to abnormal aortic valves
- MVP
- thoracic aortic aneurysm and dissection
Infants of Diabetic Mom
- Suffer from Transposition of Great Vessels
Alcohol exposure in Utero
- VSD, PDA, ASD, tetralogy of Fallot
Prenatal Lithium exposure = Ebstein anomaly
Williams Syndrome = Supravalvular aortic stenosis
Right to Left shunts
Pg288 of STEP book
Boot Shaped Heart in INFANT
Tetralogy of Fallot
Most common cause of congenital anomaly
VSD
Most common cause of early cyanosis = Tetralogy of Fallot
Atrial Septal Defects
Ostium Secundum = missing tissue is more commnon than ostium primum
Exercise and CO
Initially
- Increase CO due to increased SV & HR
Sustained Exercise
- CO maintained due to increased HR
Preload
Pressure at EDV
- Atrial Pressure
- End-diastolic pressure
- CVP
Preload increased by
- Exercise
- increased blood volume
- pregnancy
Preload decreased by
- ventilators = nitrates (nitroglycerin)
After load
MAP
- TPR
Vasodilators decreases After load = hydralazine
Starling Curve
274
Normal EF = >55%
Cardiac and Vascular Function Curves
Pg 275
Contractility increases with decreased extra cellular Na+
Contractility decreases with acidosis and hypoxia
ACE inhibitors and ARBs decrease both preload and after load
Pulse Pressure
Proportional to SV
Inversely proportional to arterial compliance
Increase in PP
- hyperthyroidism, aortic regurgitation, aortic stiffening (isolated systolic hypertension in elderly), obstructive sleep apnea (increased SNS), exercise
Decrease PP
- aortic stenosis, cardio genic shock, cardiac tamponade, advanced HF
Ejection Fraction
Decreases in systolic Heart failure
Normal in diastolic heart failure
Left Atrial Pressure
Normally LV diastolic pressure
Heart Failure
Pages 297
BNP
- produced by cardiac cells in response to ventricular stretch
- causes vasodilation and natriuresis
- secreted when left ventricle is stretched due to heart failure
MEASURED TO HELP DIAGNOSE CHF >100
What stage is the most O2 consumption occuring?
Isovolumetric Contraction
Kaplan Notes 25-30 Cardio
JVP Pressure Tracing
Absent A wave = A-fib, RA infarct, or atrial flutter
Absent X descent = Tricuspid regurg
Page 276 on STEP book
Treatment of CHF
Acute/Decompensated CHF (NO LIP) with Pulmonary Edema
- Nitrates = dilate veins to reduce preload
- Oxygen
- Loop Diuretic = removes fluid from the lung
- Inotropic drugs = dobutamine
- Positioning = sit patient up so blood doesn’t pool in heart but pools in legs.
don’t give Beta blocker
Chronic CHF
= Improvement of Survival = ACE inhibitors, ARBs, Aldosterone antagonists, Certain Beta-blockers (metoprolol, carvedilol, bisoprolol) , Nitrates + Hydralazine (AA patients only)
= Symptomatic Relief = Diuretics, Digoxin, Vasodilators (hydralazine and nitrates)
Chronic CHF can become Acute CHF = LOOK AT STORY
INCREASED CAPILLARY hydrostatic pressure
- CHF = increases CVP
- Venous thrombosis
- Compression of veins
- Sodium and Water retention
Increased Capillary permeability
- infections and septic shock
- toxins
- burns
Pitting Edema vs Non-Pitting
Pitting
- excess amount of fluid in absence of additional colloid (protein)
Non-pitting edema
- a lot of colloid in interstitial fluid (protein) balances fluid
Shock
Pg 297
Location of Central Lines (catheters put into central veins)
Femoral = easiest with least risk but the line cant stay more than 5-7 days due to risk of infection
Subclavian = remains longer 3-4 weeks, highest risk of pneumothorax don’t do in patients that have COPD or lung tumors
Internal Jugular = remains in 3-4 weeks, risk of puncturing carotid artery
LOOK AT PICTURES
Femoral Sheath
Femoral artery and vein only in the sheath
- nerve is not found in the sheath
What is Kf? What increases Kf?
Kf = capillary permeability
- increased by bacterial toxins, burns, and sepsis
What are the antidotes to the following?
Copper, gold, arsenic = penicillamine
Arsenic, Mercury, gold = dimercaprol, succimer
TPA, Streptokinase = Aminocaproic acid
Digitalis = Anti-digoxin antibody fragments
Pressure Volume Loop
Pg 276 of STEP book
Splitting
277 of STEP book
Shock Pathophysiology
MAP
Auscultation of Heart Sounds
Aortic Valve is heard = Right 2nd intercostal space
Pulmonic Valve = Left 2nd intercostal space
APTM
Benign Heart Murmurs if there is no presentation of disease
- Split S1
- Split S2 on inspiration
- S3 in a patient
Bedside Maneuvers
Handgrip
- increased afterload = increased Mitral regurg
- later onset of MVP
Valsalva maneuver
- reduces preload and afterload
- makes most heart murmurs quieter except hypertrophic cardiomyopathy
- earlier onset of MVP
Squatting
- increases preload
- later onset of MVP
- increased AS murmur
- decreased HCM murmur
Sounds Heard best in Left Lateral Decubitus position
- mitral stenosis
- mitral regurgitation
- left-sided S3
- left-sided S4
Heart Murmurs
Pg 279 and 278 of STEP book
Membrane Potentials
K+ –> -75 to -95mV
Na+ –> +50mV
Ca2+ –> +20mV
Action Potentials of Ventricles
Phase 2 = Calcium influx triggers Calcium release from Sarcoplasmic reticulum and induces myocytes contraction
Between phase 0-3 = Effective Refractory Period
- you can’t illicit another action potential
- increasing this period slows the heart down
Action Potential of Pacemakers
No phase 1 or 2
Phase 4 = freely permeable to K+, funny channels (gradual increase in Na+ conduction = causes pacemaker)
Phase 0 = due to calcium influx
Pg 280-281 in STEP book
Fomepazol
Inhibits alcohol dehydrogenase
Anti-Arrhythmics
No Bad Boy Keeps Clean
No = Class 1 = Na+ channel blockers - decreases slope of phase 0 in the myocyte Bad Boy - Class 2 = Beta blockers - act on phase 4 Keeps = Class 3 = K+ channel blockers - act on phase 3 Clean = Class 4 = CCB - act on phase 0
Limb Leads
See Pictures
QRS complex deflection is telling you where the electrical signal of the heart is
Look at limb lead 1 and 2 = to tell you the axis of the heart - if + = normal Normal = -30 - +90 LAD = -30- -90 RAD= +90 - +180
EKG
Each tiny box = 0.04sec
One big box = 0.2 sec
PR interval
- normally
Anaphylactic Shock Treatment
Epinephrine
Cardio genic Shock Treatment
Dobutamine = affects more of the heart
Septic Shock
Use Norepinpehrine
- stimulates the alpha 1 without Beta 2 to clamp down vessels
Arrhythmias
PG 283-284 of STEP book
Cushings Reflex
Increased intracranial pressure
- increases SNS and increases BP
- causes increased PSNS ==> reflex bradycardia and respiratory depression
Pg 286
Triad - increased systemic BP, bradycardia, respiratory depression
Smooth Muscle Cell Contraction
See Picture
Cardiac Output Regulation
Liver = receives largest portion of CO Kidneys = receives highest blood flow per gram of tissue Lungs = receive 100% of CO from RV Heart = extracts 80% of oxygen from blood = myocardial profusion occurs during diastole --> NO, CO2, adenosine dilate coronary arteries
In the case of CAD = Nitroglycerin decreases oxygen demand by causing systemic venous vasodilation which reduces preload (doesn’t vasodilate the coronary arteries because they are already maximally vasodilated)
Skeletal muscle
- local metabolites during exercise = K+, H+, CO2 increases vasodilation
Hypertension
Hypertension = BP > 140/90
Pre-Hypertension = BP >120/80
Normal = 180/120 without acute end organ damage
- Hypertensive Emergency = BP >180/120 severe hypertension with evidence of acute end organ damage
White Coat Hypertension
- high BP only when in the doctors office
- compare home BP with Doctor BP
- treat based on home BP numbers
Masked Hypertension
- normal readings in office but higher levels at home
LVH = concentric thickness
- increases myocardial oxygen demand
- less compliant ventricle/stiffen = S4
- decreases LV lumen
Aortic Dissection
- tearing chest pain that radiates to the back = creates false lumen
- widening mediastinum on CXR
- risk factors: Marfan syndrome and Hypertension
- do CT scan
- Type A = dissection involving Ascending Aorta = emergency surgery
- Type B = distal aorta distal to the left subclavian artery = medical management (use beta blocker)
Paroxysms of increased SNS = anxiety, palpitations, diaphoresis ==> Pheochromocytoma
Foramen Ovale
Can lead to paradoxical emboli
Abdominal Aortic Aneurysm
See Pictures
- you need to do serial ultrasound every 6 months
>5cm ==> surgical repair
Coronary Anatomy
Pg 272
LAD is where most occlusions occur = anterior wall MI
Right Dominant circulation = 80% of people
= PDA arises from RCA
Left Dominant Circulation = 8% of people = PDA comes from LCX
CoDominant = 7% of people = PDA arises from both LCX and RCA
Causes of Chest Pain
See Pictures
Costochondritis = inflammation where ribs meet sternum
Arteriolosclerosis
Thickening of the small arteries and arterioles
Hyaline: thickening of vessel walls in essential hypertension or diabetes mellitus = very pink
Hyper plastic: “onion skinning” in severe hypertension with proliferation of smooth muscle cells.
Mockeberg (medial calcific sclerosis)
- uncommon
- affects medium-sized arteries
- calcification of elastic lamina of arteries –> vascular stiffening without obstruction.
- Pipestem appearance on X-Ray
- Does not obstruct blood flow; intima not involved
- calcification occurs in media
Ischemic Heart Disease
Prinzmetal - transient ST elevation on ECG
Stable Angina - ST segment depression
Unstable Angina = ST segment depression
MI
- subendocardial = NSTEMI = ST segment depression + cardiac enzymes
- Transmural = STEMI = ST segment elevation + cardiac enzymes
Antianginal Therapy
Decrease Preload and decrease after load
- nitrates and beta blockers
Decrease myocardial oxygen demand
Evolution of an MI
Pg 294 & 295
Check Picture
Troponin I is the most specific enzyme to cardiac muscle
Dressler Syndrome = Chest pain, pericardial friction rub, autoimmune pericarditis, and persistent fever occurring several weeks after an MI
MI Treatment and Cardiomyopathies
Check Picturess
Pg 296
Hepatitis B Phases
See Pictures
Fibrinous Pericarditis
- Uremia = chest pain and course rubbing heart sounds in patients with Creatinine of 5
- Rheumatoid Arthritis
- Dressler Syndrome
Serous Pericarditis
- Lupus
- Rheumatic Fever
Suppurative Pericarditis
Pus in pericardial space due to infection
Hemorrhagic Pericarditis
TB or melanoma
Acute Pericarditis
- Pleuritic Chest pain = sharp, worse with inspiration, better when sitting up and leaning forward
- Distant heart sounds
- Friction rub on auscultation
- Diffuse ST segment elevation
- Diffuse PR segment depression
Can resolve without scarring or leads to chronic constrictive pericarditis (lupus, kussmaul sign = JVD during inspiration)
- most common cause in US = Lupus
- most common cause in developing countries = TB
Cardiac Tamponade
- causes decreased CO
- distant heart sounds, JVD
- pulsus paradoxus = decrease in amplitude in systolic BP by more than 10mmHg during inspiration (also seen in asthma, croup, OSA, and COPD)
- there is equillibration of all 4 cardiac chambers
- will see electrical alternans = alternating amplitude QRS complex beat to beat (specific but not sensitive)
Syphilitic Heart Disease
- disruption of vaso vasorum
- dilation of aorta and aortic valve ring
- aortic regurg
- aortic stenosis
- thoracic aortic aneurysms
- calcification of aorta
TREE bark appearance on inside of aorta
Tuberous Sclerosis
- astrocytoma
- rhabdomyomas
- angiomyolipoma
Vascular Pathologies
Pg 301-303
Sturge-Weber Disease = port wine stain in ophthalmic division trigeminal nerve
- seizure, early onset glaucoma, intellectual disability,
Lymphangiosarcoma
- lymphatic malignancy associated with persistent lymph edema
Aortic Aneurysm
Myxamatous changes with pooling of proteoglycans in the media layer of large arteries are found in cystic medial degeneration
- predisposes people to aortic dissections and aortic aneurysms
- medial degeneration is frequently seen in younger individuals with Marfan syndrome
Wide mediastinum
Aortic Dissection
Beta blockers
- mask the symptoms of hypoglycemia by blocking the typical adrenergic warning symptoms such as tremor and palpitations
- so don’t give to a diabetic
Organ Removal
increases the TPR and decreases CO
