CARDIOLOGY Flashcards
Location of sinus node
Superior aspect of the crista terminalis
Ridge of muscle where the posterior smooth atrial wall derived from the sinus venosus meets the trabeculated anterior portion of the right atrium
Crista terminalis
Sinus rate increases spontaneously at rest or out of proportion to physiologic stress or exertion
Inappropriate sinus tachycardia
Symptomatic sinus tachycardia that occurs with postural change from supine to standing position
Postural orthostatic tachycardia syndrome (POTS)
Postural orthostatic tachycardia syndrome (POTS) is defined as:
Rate increases by 30 bpm or to >120 bpm within 10 min of standing, with no hypotension
Factors that plays prominent roles in the development of coronary atherosclerosis in women than in men (4)
Inflammation
Obesity
Type 2 DM
Metabolic syndrome
Exercise ECG has a higher diagnostic accuracy in the prediction of epicardial obstruction in women than in men. True or false.
False. Lower.
Mechanism of myocardial ischemia
Imbalance between the heart’s oxygen supply and demand
NYHA Class I definition
No limitation of physical activity.
No symptoms with ordinary exertion
NYHA Class II definition
Slight limitation of physical activity
Ordinary activity causes symptoms
NYHA Class III definition
Marked limitation of physical activity
Less than ordinary activity causes symptoms
Asymptomatic at rest
NYHA Class IV definition
Inability to carry out any physical activity without discomfort
Symptoms at rest
Pitfalls in cardiovascular medicine (3):
- Failure by the noncardiologist to recognize important cardiac manifestations of systemic illnesses
- Failure by the cardiologist to recognize underlying systemic disorders in patient with heart disease
- Overreliance on and overutilization of laboratory tests, particularly invasive techniques, for the evaluation of cardiovascular system
Asymptomatic or mildly symptomatic patients with VHD that is anatomically severe should be evaluated periodically, every _______.
6-12 months
Dysplastic pulmonic valves due to mutation in chromosome 12
Noonan syndrome
Mutation in the PTPN1 gene
Noonan syndrome
RV dysfunction from afterload mismatch occurs earlier in the course of PS. True or false.
True. RV adapts less well to this type of hemodynamic burden
Definition of severe PS
Peak systolic gradient across the pulmonic valve of >50 mmHg
Definition of moderate PS
Peak systolic gradient across the pulmonic valve of 30-50 mmHg
Higher pressures needed to fill a noncompliant, hypertrophied RV in pulmonic stenosis causes this wave change
RA a wave elevates (Prominent a wave may be seen in the jugular venous pulse)
This wave change/characteristic signifies functional TR from RV and annular dilation in pulmonic stenosis
Prominent RA v wave
Crescendo-decrescedo, mid-systolic, heard best in the left 2nd ICS
Pulmonic stenosis
The only right-sided murmur that decreases in intensity with inspiration
The ejection sound/ click that precede the murmur of pulmonic stenosis. The PS murmur increase in intensity during inspiration
Percutaneous pulmonic balloon valvotomy indications (2):
Symptomatic patients with a domed valve and a peak gradient > 50 mmHg (or mean gradient > 30 mmHg)
Asymptomatic patients with with a peak gradient > 60 mmHg (or mean gradient > 40 mmHg)
(used only in less than moderate PS)
High-pitched, decrescendo diastolic murmur, along the left sternal border
Graham Steell murmur
4 other terms for MVP
a. Systolic click-murmur syndrome
b. Barlow’s syndrome
c. Floppy-valve syndrome
d. Billowing mitral leaflet syndrome
Most common abnormality leading to primary MR
MVP
One of the causes of MVP is the reduction of production of what type of collagen?
III
MVP is a frequent finding in patients with heritable disorders of connective tissue, such as: (3)
a. Marfan syndrome
b. Osteogenesis imperfecta
c. Ehlers-Danlos syndrome
Which mitral leaflet is mostly affected in MVP
Posterior mitral leaflet
MVP is more common in what population (gender and age group)?
a. Women
b. Ages of 15 and 30 years
In older (>50 years) patients, MVP is more common in what gender?
Men
Mid- or late-(nonejection) systolic click is seen in what valvular abnormality?
MVP
Systolic click followed by a high-pitched, mid-late systolic crescendo–decrescendo murmur is a feature of
MVP
Leaflet involved in MVP when the radiation of the murmur is to the base of the heart
Posterior leaflet prolapse (Jet of MR is directed anteriorly)
Leaflet involved in MVP when the radiation of the murmur is to the axilla and the back
Anterior leaflet prolapse (Jet of MR is directed posteriorly)
Earlier with standing, MVP murmur is increased or decreased?
Increased
During the train phase of the Valsalva maneuver, MVP murmur is increased or decreased?
Increased
During any intervention that decreases LV volume (preload), MVP murmur is increased or decreased?
Increased
During squatting, MVP murmur is increased or decreased?
Decreased
During isometric exercises, MVP murmur is increased or decreased?
Decreased
Indications for MVP repair (5):
a. Symptomatic severe MR
b. LV systolic dysfunction
c. Pulmonary artery hypertension
d. Recent onset AF
e. Flail mitral leaflet
Can be considered for treatment of symptomatic patients at high surgical risk with severe primary MR due to MVP
Transcatheter edge-to-edge repair
Mortality of NYHA FC IV
30-70%
Mortality of NYHA FC IV
5-10%
Compensatory mechanisms become activated in the presence of cardiac injury and/or LV dysfunction allowing patients to sustain and modulate LV function for a period of months to years. What are the 2 known mechanisms
(1) activation of the renin-angiotensin-aldosterone system (RAAS) and the adrenergic nervous system (which are responsible, respectively, for maintaining cardiac output through increased retention of salt and water )
(2) increased myocardial contractility
Refers to the changes in LV mass, volume, and shape and the composition of the heart that occur after cardiac injury and/or abnormal hemodynamic loading conditions
Ventricular remodeling
The cardinal symptoms of HF (2)
fatigue and shortness of breath
The most important mechanism of cardiac dyspnea is pulmonary congestion with accumulation of interstitial or intra-alveolar fluid, which activates ___________, which in turn stimulate the rapid, shallow breathing characteristic of cardiac dyspnea
juxtacapillary J receptors
T or F: Dyspnea may become less frequent with the onset of right ventricular (RV) failure and tricuspid regurgitation
True
It results from redistribution of fluid from the splanchnic circulation and lower extremities into the central circulation during recumbency, with a resultant increase in pulmonary capillary pressure.
Orthopnea
Nocturnal cough is a common manifestation of this process and a frequently overlooked symptom of HF
acute episodes of severe shortness of breath and coughing that generally occur at night and awaken the patient from sleep, usually 1–3 h after the patient retires
paroxysmal nocturnal dyspnea
with persistent coughing and wheezing
even after they have assumed the upright position
Periodic respiration or cyclic respiration that is present in 40% of patients with advanced HF and usually is associated with low cardiac output
Cheyne-Stokes respiration
Cheyne-Stokes respiration is caused by (2)
an increased sensitivity of the respiratory center to arterial Pco2 and a lengthy circulatory time
Electrical diastole is slowing of what action potential phase
slow diastolic depolarization (phase 4)
Phase of action potential upstroke of nodal cells
Phase 0
Phase 0 of nodal cells is mediated by
calcium rather than Na
L-type Ca current
Mechanisms causing bradycardia (2)
- Failure of impulse initiation due to depressed automaticity
- Failure in impulse conduction that is may be due to exit block or fibrosis
The only reliable therapy for symptomatic bradycardia in the absence of extrinsic and reversible etiologies
Permanent pacemaker
SA nodal artery arises from either of these 2
- RCA – 55-60%
* LCx – 40-45%
Membrane potential of SA node
-40 to -60 mV
T or F. SA node has slow phase 0 and rapid phase 4
True
Heritable form of sinus node disease caused by autosomal dominant mutations in the If subunit gene HCN4 on chromosome 15
Tachycardia-bradycardia variant of sick sinus syndrome 2
Heritable form of sinus node disease caused by autosomal recessive mutations in cardiac Na channel gene, SCN5A on chromosome 3
Sick sinus syndrome 1
Heritable form of sinus node disease that presents as ophthalmoplegia, pigmentary degeneration of the retina, and cardiomyopathy
Kearns-Sayre syndrome
Failure of the SA node to discharge, producing a pause without P waves visible on ECG up to 3 s
Sinus pauses
Intermittent failure of conduction from the SA node
Sinus exit block
intermittent conduction from the SA node and a regularly irregular atrial rhythm characterized by intermittent absence of P waves
2nd degree SA block
Progressive prolongation of SA node conduction with intermittent failure of the impulses originating in the SA node to conduct to the surrounding atrial tissue
2nd degree SA block type 1
SA block with no change in SA node conduction before the pause
2nd degree SA block type 2
SA block characterized by no P waves on the ECG
Complete or 3rd degree SA block
Most common tachycardia in the tachycardia-bradycardia in SSS
Atrial fibrillation
Also, atrial flutter and atrial tachycardia
Inability to increase the HR in response to exercise or other stress appropriately
Chronotropic incompetence
Chronotropic incompetence is defined as failure to reach ___ of predicted maximal heart rate at peak exercise or failure to achieve a HR ____ with exercise or a maximal heart rate with exercise less than ___ standard deviations below that of an age-matched control population
85%
> 100 bpm
2 SD
Diagnostic test for carotid sinus hypersensitivity
ANS testing
Normal intrinsic heart rate in ANS testing? And measured after giving these 2 medications (with dose)
117.2-(0.53 x age) bpm
After administration of 0.2 mg/kg propranolol and 0.04 mg/kg atropine
Low IHR in ANS testing is indicative of
SA disease
Longest pause after cessation of overdrive pacing of the RA near the SA node in the electrophysiologic testing
Sinus node recovery time (SNRT)
In EPS testing, ½ the difference between the intrinsic sinus cycle length and a noncompensatory pause after a premature atrial stimulus
Sinoatrial conduction time (SACT)
Drug that shorten SNRT and may improve SA node dysfunction
Digitalis
1st letter in the nomenclature of permanent pacemakers is the
chamber(s) that is paced
2nd letter in the nomenclature of permanent pacemakers is the
chamber(s) in which sensing occurs
3rd letter in the nomenclature of permanent pacemakers is the
response to a sensed event
- O – none
- I – inhibition
- T – triggered
- D – inhibition plus triggered
4th letter in the nomenclature of permanent pacemakers is the
programmability or rate response
R – rate responsive
5th letter in the nomenclature of permanent pacemakers is the
existence of anti-tachycardia functions if present
- O – none
- P – anti-tachycardia pacing
- S – shock
- D – pace + shock
Most commonly programmed modes of implanted single-chamber pacemakers
VVIR
Most commonly programmed modes of implanted dual-chamber pacemakers
DDDR
Permanent pacemakers are most commonly implanted via
subclavian-SVC venous system
Rotation of the pacemaker pulse generator in its subcutaneous pocket can wrap the leads around the generator and produce dislodgement with failure to sense or pace the heart causing
Twiddler’s syndrome
Rare complication in small-sized and light weight pacemakers
Achilles heel of permanent pacing systems
Transvenous leads
Constellations of signs and symptoms due to interruption and failure to restore AV synchrony by the pacing modes
Pacemaker syndrome
Neck pulsation, fatigue, palpitations, cough, condusion, exertional dyspnea, dizziness, syncope, elevation in JVP, canon A waves, and signs and symptoms of CHF
This will minimize the sequelae of pacemaker syndrome
Maintenance of AV synchrony
Class I indications for pacemaker implantation in SA node dysfunction (4)
- SA node dysfunction with symptomatic bradycardia or sinus pause
- Symptomatic SA node dysfunction as a result of essential long-term drug therapy with no acceptable alternatives
- Symptomatic chronotropic incompetence
- Atrial fibrillation with bradycardia and pauses >5 s
Class IIa indications for pacemaker implantation in SA node dysfunction (3)
- SA node dysfunction with heart rates <40 beats/min without a clear and consistent relationship between bradycardia and symptoms
- SA node dysfunction with heart rates <40 beats/min on an essential long- term drug therapy with no acceptable alternatives, without a clear and consistent relationship between bradycardia and symptoms
- Syncope of unknown origin when major abnormalities of SA node dysfunction are discovered or provoked by electrophysiologic testing
Class IIb indication for pacemaker implantation in SA node dysfunction
Mildly symptomatic patients with waking chronic heart rates <40 beats/min
Class III indications for pacemaker implantation in SA node dysfunction (3)
- SA node dysfunction in asymptomatic patients, even those with heart rates <40 beats/min
- SA node dysfunction in which symptoms suggestive of bradycardia are not associated with a slow heart rate
- SA node dysfunction with symptomatic bradycardia due to nonessential drug therapy
Initiating event for cardiac contraction
Depolarization of the heart
Atrial repolarization waveforms in ECG
ST-Ta
Phase of rapid upstroke of action potential
Phase 0
Onset of QRS
Plateau phase of action potential
Phase 2
Isoelectric ST segment corresponds to what phase of action potential
Phase 2
Phase of active repolarization
Phase 3
T wave
Amiodarone effect on QT interval
increase the QT interval
Hypocalcemia effect on QT interval
increase the QT interval
Hypercalcemia effect on QT interval
shorten QT
Digoxin effect on QT interval
shorten QT
Activation of the atria from an ectopic pacemaker in the lower part of either atrium or in the AV junction region causes these p waves
Retrograde P waves
Negative in II, positive in aVR
ECG marker (in terms of U wave) of increased susceptibility to torsades de pointes
Very prominent U waves
RA overload is defined as P wave of
≥2.5 mm
P-pulmonale
Most common arrhythmia in pulmonary embolism
Sinus tachycardia
ECG abnormality typical of pulmonary embolism
S1Q3T3
- Prominent S wave in Lead I
- Q wave in Lead III
- T wave inversion in Lead III
LVH Sokolow lyon and Cornell criteria
- S in V1 + R in V5 or V6 = > 35 mm
* R in aVL + S in V3 > 20 mm in women or >28 mm in men
ECG findings that is a major noninvasive marker of increased risk of cardiovascular morbidity and mortality rates, including sudden cardiac death
ECG evidence of LVH
In RBBB, terminal QRS is oriented to the
Right and anteriorly
In LBBB, terminal QRS is oriented to the
Left and posteriorly
BBB that is more common in subjects without structural heart disease
RBBB
LBBB is the marker of one of 4 underlying conditions associated with increased risk of cardiovascular morbidity and mortality rates
- CAD
- Hypertensive heart disease
- Aortic valve disease
- Cardiomyopathy
Fascicular block where QRS axis is more negative than -45 degrees
LAFB
Fascicular block where QRS axis is more rightward than +110-1200
LPFB
Most common cause of marked LAD in adults
LAFB
Fascicular block that is more common
LAFB
LPFB is extremely rare as an isolated finding
In early transmural ischemia, the T wave is
hyperacute
Subendocardial ischemia manifests as _____ in the ECG
ST segment depression with ST elevation in aVR
Reciprocal ST depressions in leads V1 to V3 is seen in
Posterior wall ischemia
Reversible transmural ischemia due to coronary vasospasm
Prinzmetal’s angina
Ischemic chest pain with deep T-wave inversions in multiple precordial leads (e.g. V1-V4, I and aVL) with or without cardiac enzyme elevations is caused by severe obstruction in
LAD
CVA T wave pattern
Deep, wide T wave inversions
Scooping of the ST-T wave complex is an effect seen in what drugs
Digitalis
Relatively a specific ECG sign of pericardial effusion, usually with cardiac tamponade
Total electrical alternans (P-QRS-T) with sinus tachycardia
Gold standard in the assessment of the anatomy and physiology of the heart and its associated vasculature
Coronary angiography
T or F: Coronary angiography is mandatory prior to cardiac surgery in young patients who have CHD or VHD
False. as long as well-defined by non-invasive imaging or no CAD symptoms
Risk of MI in elective cardiac catheterization
<0.1
Risk of stroke in elective cardiac catheterization
0.01%
Risk of death in elective cardiac catheterization
0.1%
Most common complication of cardiac catheterization
Significant access-site bleeding – 1.5-2.0%
Contrast-induced AKI is defined as
increase in Crea >0.5 mg/dL or 25% above baseline that occurs 48-72 hrs after contrast
Prior to cardiac catheterization, you have to stop Metformin when?
24 hrs prior to the procedure until 48 hrs after – limit risk of lactic acidosis
In order to prevent CIN, when will you give NaHCO3? And dose?
3mL/kg per hour 1 hour prior and 6 hours
Prior to coronary angiography, how much Aspirin will you give patient?
325 mg Aspirin
Additional antiplatelet if procedure is likely to progress to PCI
• Clopidogrel – 600mg loading and 75 mg daily
• Prasugrel – 60 mg LD and 10 mg OD
• Ticagrelor – 180 mg LD and 90 mg BID
In patients who will undergo cardiac catheterization, you hold warfarin how many days prior? And target INR should be?
2-3 days prior
INR <1.7
In patients who will undergo cardiac catheterization, you hold NoAC how many days prior?
1-2 days
24-48 hrs
Vascular access for left heart catheterization (2)
Femoral or radial artery
Vascular access for right heart catheterization (3)
Femoral, brachial, or internal jugular vein
Test that confirm dual blood supply to the hand prior to radial approach of cardiac catheterization
modified Allen’s test or Barbeau test
Preferred access sites for cardiac catheterization to the right heart when IVC filter in place or requires prolonged hemodynamic monitoring
Internal jugular or antecubital veins
Direct thrombin inhibitors that may given instead of heparin for prolonged cardiac catherization (2)
Bivalirudin 0.75 mg/kg bolus, 1.75 mg/kg per hour for the duration of the procedure
Argatroban 350 ug/kg bolus, 15 ug/kg per min for duration of the procedure
During cardiac catheterization, if without VHD (based on pressure tracings), atria and ventricles are “one chamber” during what part of cardiac cycle?
Diastole
During cardiac catheterization, if without VHD (based on pressure tracings), ventricles and their respective outflow tract are “one chamber” during what part of cardiac cycle?
systole
During the hemodynamic study, if there is systolic pressure gradient between LV and aorta, it indicates
Aortic stenosis
During the hemodynamic study, if there is diastolic pressure gradient between the pulmonary capillary wedge (LA) pressure and the LV, it indicates
Mitral stenosis
During the hemodynamic study, a dynamic intraventricular pressure gradient during ventricular systole
HOCM
During a hemodynamic study, following a premature ventricular contraction, there is an increase in the LV-aorta pressure gradient with a simultaneous decrease in the aortic pulse pressure. What do you call this sign? And in what condition is it present?
Brockenbroigh-Braunwald sign
HOCM
Absent in AS
During hemodynamic study, if RA pressure is increased with decreased or absent y descent with diastolic equalization of pressures in all cardiac chambers, it is indicative of what condition?
Cardiac tamponade
Due to impaired RA emptying during diastole
During hemodynamic study, if there is elevated RA pressure with prominent y descent, it is indicative of what condition?
Constrictive pericarditis
Due to rapid filling of the RV during early diastole
Most specific hemodynamic phenomenon for constriction
Discordant pressure changes in the RV and LV with inspiration
• RV systolic pressure increases
• LV systolic pressure decreases
During hemodynamic study, marked increase in RV and pulmonary artery systolic pressures (>60 mmHg), separation of the LV and RV diastolic pressures by > 5 mmHg and concordant changes in the LV and RV diastolic filling pressures with inspiration (both increase) is indicative of
Restrictive cardiomyopathy
The amount of oxygen consumption by an organ is equal o the product of its blood flow (cardiac output) and the difference in the concentration of the substance in the arterial and venous circulation (A-V oxygen difference).
Fick method
Indicator for Fick method
Oxygen
Indicator for thermodilution method
Temperature
Mean pressure gradient / mean flow (cardiac output) =
Ohm’s law
Equates the area to the flow across the valve divided by the pressure gradient between the cardiac chambers surrounding the valve
Gorlin formula
Valve area and mean gradient indicative of severe aortic stenosis
Area <1.0 cm2 and a mean gradient of >40 mmHg
Valve area and mean gradient indicative of moderate-to-severe MS
Area <1.5 cm2 and a mean gradient >5-10 mmHg
Difference in O2 saturation of 5-7% between adjacent cardiac chambers is indicative of
Intracardiac shunts
Determine severity of the intracardiac shunt
Qp/Qs
For ASD, a Qp/Qs ratio of ___ is considered significant
1.5
For VSD, a Qp/Qs ratio of ___ with evidence of LV volume overload is a strong indication for surgical correction
≥2
Should be suspected in patients with subtherapeutic anticoagulation with a low mean INR, a prothrombotic state, recent onset heart failure, cardiogenic shock, cardiac arrest, thromboembolic event or, in asymptomatic patients, an increasing gradient across the prosthetic valve.
Prosthetic valve leaflet dysfunction
Three major coronary vessels evaluated in coronary angiography
Left anterior descending artery
Left circumflex artery
Right coronary artery
It is termed as right dominant when the ____ is the origin of what 3 arteries_____
RCA
AV nodal branch, the posterior descending artery, and the posterior lateral vessels
In terms of coronary circulation, 85% of individuals are right or left dominant?
Right dominant
It is termed as left dominant when the ____ is the origin of what 3 arteries_____
LCx
AV nodal branch, the posterior descending artery, and the posterior lateral vessels
Posterior descending vessel arise from both the right coronary and the posterior lateral vessels from left coronary circulation. This circulation is called _____ and seen in how many % of people?
Codominant circulation
10%
Most common coronary artery anomaly
Separate ostia for the LAD and LCx
Coronary stenosis that is considered significant
> 50%
Percent stenosis is determined visually by
comparing the most severely diseased segment with a proximal or distal “normal segment”
A portion of the vessel dips below the epicardial surface into the myocardium and is subject to compressive forces during ventricular systole
Myocardial bridge – most commonly involves the LAD
returns to normal during diastole unlike the stenosed part
A measure of the relative duration of time that it takes for contrast to opacify the coronary artery fully
Thrombolysis in myocardial infarction (TIMI) flow grade
TIMI flow grade 1
minimal filling of contrast
severe stenosis
TIMI flow grade 2
delayed filling of contrast
severe stenosis
Provides a more accurate anatomic assessment of the coronary artery and the degree of coronary atherosclerosis if with intermediate stenoses (40–70%), indeterminate findings, or anatomic findings that are incongruous with the patient’s symptoms
Intravascular ultrasound (IVUS)
A catheter-based imaging technique that uses near-infrared light to generate images with better spatial resolution than intravascular ultrasound, and image characteristics of the atherosclerotic plaque (lipid, fibrous cap) with high definition and assess coronary stent placement, apposition, and patency
Optical coherence tomography
Provides a functional assessment of the coronary stenosis and is more accurate in predicting long-term clinical outcome than imaging techniques
Fractional flow reserve
Ratio of the pressure in the coronary artery distal to the stenosis divided by the pressure in the artery proximal to the stenosis at maximal vasodilation
Fractional flow reserve
Fractional flow reserve that indicates hemodynamically significant stenosis that would benefit from intervention
<0.8
Bed rest duration for femoral and radial approach
6 hours
2 hours
For narrow QRS-complex tachycardia, ventricular activation is from the
Purkinje system
For wide QRS-complex tachycardia, ventricular activation is from the
Accessory pathway
Most common SVT
Sinus tachycardia
First step in diagnosis of SVT
Consider the possibility of sinus tachycardia
Among SVT, using AV nodal maneuvers or drugs may terminate tachycardia except for
Atrial flutter
Increased AV block with continueation of atrial flutter exposes underlying flutter waves
tachycardia from the normal sinus node area that occurs without an identifiable precipitating factor as a result of dysfunctional autonomic regulation
Inappropriate sinus tachycardia
Regular atrial tachycardia with defined p wave; may be sustained, nonsustained, paroxysmal, or incessant. Frequent sites of origin occur along the valve annuli of left or right atrium, pulmonary veins, coronary sinus musculature, superior vena cava
Focal atrial tachycardia (AT)
organized reentry creates organized atrial activity, commonly seen as sawtooth pattern at rates typically faster than 200 beats/min
Atrial flutter
chaotic rapid atrial electrical activity with variable ventricular rate
Atrial fibrillation
the most common sustained cardiac arrhythmia in older adults
Atrial fibrillation
multiple discrete p waves often seen in patients with pulmonary disease during acute exacerbations of pulmonary insufficiency
Multifocal atrial tachycardia
paroxsymal regular tachycardia with P waves visible at the end of the QRS complex or not visible at all
AV nodal reentry tachycardia (AVNRT)
the most common paroxysmal sustained tachycardia in healthy young adults
AV nodal reentry tachycardia (AVNRT)
paroxysmal sustained tachycardia similar to AV nodal reentry; during sinus rhythm, evidence of ventricular preexcitation may be present (Wolff-Parkinson-White syndrome) or absent (concealed accessory pathway)
Orthodromic AV reentry tachycardia (AVRT)
Either has no discernible p-waves because they are synchronous with the QRS, or p-waves that are negative in II, III, aVF immediately following the QRS (referred to as short R-P tachycardia)
AV nodal reentry tachycardia (AVNRT)
The most abundant superfamily of ion channels expressed in the heart
Voltage-gated channels
the primary carriers of depolarizing current in both the atria and the ventricles
Na and Ca channels
In cardiac physiology, this is a time when little current is flowing, and relatively minor changes in depolarizing or repolarizing currents can have profound effects on the shape and duration of the action profile
Plateau phase
underlies the property of automaticity characteristic of pacemaking cells in the SA and AV nodes, His-Purkinje system, coronary sinus, and pulmonary veins
Spontaneous (phase 4) diastolic depolarization
Normal or enhanced automaticity of subsidiary latent pacemakers if there is failure of more dominant pacemakers
Escape rhythms
Abnormal automaticity may produce what arrhythmias (3)
- Atrial tachycardia
- Accelerated idioventricular rhythms
- Ventricular tachycardia
membrane voltage oscillations that occur during or after an action potential
Afterdepolarizations
most common arrhythmia mechanism
Reentry
Class I antiarrhythmic drugs blocks
Na
Class II antiarrhythmic drugs blocks
β-adrenergic receptor
Class III antiarrhythmic drugs blocks
K
Class IV antiarrhythmic drugs blocks
Ca
Class I antiarrhythmic drug that have moderate potency and intermediate kinetics
Ia – quinidine, procainamide
Class I antiarrhythmic drug that have low potency and rapid kinetics
Ib – lidocaine, mexiletine
Class I antiarrhythmic drug that have high potency and slowest kinetics
Ic – flecainide, propaferone
Antiarrhythmic drugs that have both Class I and Class III actions (3)
Quinidine
Procainamide
Ranolazine
Antiarrhythmic drugs that have the actions of the all 4 classes (2)
Amiodarone
Dronedarone
Dofetilide is what class of antiarrhythmic drugs?
Class III
Ibutilide is what class of antiarrhythmic drugs?
Class III
Class Ia antiarrhythmics
quinidine, procainamide
Class Ib antiarrhythmics
lidocaine, mexiletine
Class Ic antiarrhythmics
flecainide, propaferone
Most common cause of imbalance between myocardial oxygen supply and demand leading to NSTEMI
Plaque rupture
% of NSTEMI patient that has left main coronary artery stenosis
10%
% of NSTEMI patient that has 3-vessel CAD
30%
% of NSTEMI patient that has 2-vessel CAD
20%
% of NSTEMI patient that has single-vessel CAD
20%
% of NSTEMI patient that has no apparent critical epicardial coronary artery stenosis
15%
May show an eccentric stenosis with scalloped or overhanging edges and a narrow neck on coronary angiography and is composed of a lipid-rich core with a thin fibrous caps
Vulnerable plaques
Chest discomfort in NSTEMI is severe and has at least one of 4 features:
- Occurrence at rest (or with minimal exertion)
- lasting >10 min
- Relatively recent onset (i.e., within the prior 2 weeks)
- Crescendo pattern, i.e., distinctly more severe, prolonged, or frequent than previous episodes
Anginal equivalents (4)
- Dyspnea
- Epigastric discomfort
- Nausea
- Weakness
Anginal equivalents are more common in (3)
- Women
- Elderly
- Diabetes mellitus
2 ECG findings in NSTEMI and which of the 2 is the most common?
- New ST-depression – in 1/3 of the patients
* T wave inversion – more common
Preferred markers of myocardial necrosis
Cardiac troponin I or T
Serial ECG and cardiac markers monitoring are done after how many hours of presentation of NSTEMI?
4-6 hours and 12 hours after presentation
Risk of early (30-day) mortality of NSTEMI
1-10%
Risk of recurrent ACS rate during 1st year:
5-15%
7 independent factors for Thrombolysis in Myocardial Infarction Trial:
- Age ≥ 65 years
- 3 or more of the traditional risk factors for coronary heart disease
- Known history of CAD or coronary stenosis of at least 50%
- Daily aspirin use in the prior week
- More than 1 anginal episode in the past 24 h
- ST segment deviation of at least 0.5 mm
- Elevated cardiac specific biomarker above the upper limit of normal
4 additional risk factors for Thrombolysis in Myocardial Infarction Trial (aside from the independent factors)
- Diabetes mellitus
- LV dysfunction
- Renal dysfunction
- Elevated BNP
Ambulation in NSTEMI is permitted if
No recurrence of ischemia or no elevation of cardiac biomarker for 12-24 h
In NSTEMI, initial anti-ischemic treatment should include these 4
- Bed rest
- Nitrates
- Beta blockers
- Inhaled oxygen in patients with O2 sat <90% and/or in those with heart failure and rales
Absolute contraindications for Nitrates (2)
- Hypotension
* Recent use of PDE-5 inhibitors
Target heart rate for NSTEMI
50-60
Recommended for patients with persistent symptoms or ECG signs of ischemia after treatment with full-dose nitrates and beta blockers
Calcium channel blockers (Verapamil and Diltiazem)
Second major cornerstone of treatment of NSTEMI
Antithrombotic therapy
Major cornerstone: anti-ischemic therapy
Initial dose of Aspirin in NSTEMI
162 mg of a rapidly acting preparation (oral non-enteric coated or IV)
Platelet P2Y12 receptor blocker that is rarely used due to poor tolerability
Ticlodipine
Thienopyridine that has irreversible blockade of the platelet P2Y12 receptor
Clopidogrel
Loading dose of Clopidogrel in NSTEMI
600 mg or 300 mg
2 newer P2Y12 inhibitors that are superior to clopidogrel in preventing recurrent cardiac ischemic events in randomized double-blind studies
Prasugrel
Ticagrelor
A thienopyridine that has higher level of platelet inhibition than clopidogrel
Prasugrel
Loading dose and maintenance dose of Prasugrel in NSTEMI
60 mg
10 mg/day
Loading dose and maintenance dose of Ticagrelor in NSTEMI
180 mg
90 mg/day
A novel, potent, reversible platelet P2Y12 inhibitor
Ticagrelor
A P2Y12 inhibitor that may have dyspnea early after administration (most often transient and infrequently serious)
Ticagrelor
Dual antiplatelet therapy (DAPT) have ___% relative reduction in cardiovascular death, MI or stroke compared to aspirin alone
20%
Triple antiplatelet therapy for NSTEMI is composed of
Aspirin + P2Y12 inhibitor + Glycoprotein IIb/IIIa inhibitors
Direct thrombin inhibitor that has similar in efficacy to either UFH and LMWH in treatment of NSTEMI
Bivalirudin
Indirect factor Xa inhibitor that has similar in efficacy to LMWH in treatment of NSTEMI
Fondaparinaux
Patient is closely observed and coronary arteriography is carried out if rest pain or ST-segment changes recur, positive biomarker, or evidence of severe ischemia on a stress test. This approach is called
Selective invasive approach
Severe ischemic pain that occurs at rest that is associated with transient ST-segment elevation
Prinzmetal’s variant angina
Caused by focal spasm of an epicardial coronary artery with resultant transmural ischemia and abnormalities in the LV function
Prinzmetal’s variant angina
Cause of spasm in Prinzmetal’s variant angina is
the hypercontractility of vascular smooth muscle due to adrenergic vasoconstrictors, leukotrienes, or serotonin
Transient coronary spasm on coronary angiography is the diagnostic hallmark of
Prinzmetal’s variant angina
Main therapeutic agents used for Prinzmetal’s variant angina (2)
- Nitrates
* Calcium channel blockers
May increase severity of ischemic episodes in Prinzmetal’s angina
Aspirin
due to sensitivity of coronary tone to modest changes in the synthesis of prostacyclin
5-year survival of Prinzmetal’s angina
~90-95%
How many % of Prinzmetal’s variant angina will experience MI?
20%
In stress myocardial perfusion imaging, which is preferred, exercise stress or pharmacologic stress?
Exercise stress
Downside: submaximal exercise or people unable to exercise
Pharmacologic stress that is used in stress myocardial perfusion imaging (2)
- Coronary vasodilators (adenosine, dipyridamole, regadenoson) – most commonly used
- ß1-receptor agonist (dobutamine)
Simplest application of cardiac CT
CT calcium scoring
Scoring that quantify coronary calcium
Agatson score
Based on Agatson scoring, define minimal, mild, moderate, and severe scores
- Minimal – 0-10
- Mild – 10-100
- Moderate – 100-400
- Severe - >400
T or F. CT calcium scoring has high cardiac prognostic value
True
Techniques for better image in CT coronary angiography (3)
- Breath holding
- Slowing of HR to 60 bpm – using IV or oral ß-blocker
- SL nitroglycerin – to enlarge the coronary lumen just prior to contrast injection
Primary imaging method to assess cardiac structure and function
Echocardiography
How to compute for EF based on EDV and ESV
(EDV – ESV)/EDV
Primary method in the assessment of the diastolic function
Echocardiography
Most accurate noninvasive technique to evaluate structure and ejection fraction of the RV
CMR
Specific pattern of regional RV dysfunction in acute PE wherein there is preservation of the RV wall motion in the basal and apical regions, and dyskinesis in the region of the mid RV free wall
McConnell sign
Highly specific for acute PE
In CIN, renal function usually returns to baseline within ____, without progressing to chronic renal failure
7-10 days
Diagnostic test used to assess the cadiac shunts
Agitated saline / Bubble study
+ bubbles in the left side of the heart – shunt
If it remains on the right chamber, no shunt
Hallmark of myocardial ischemia in stress echocardiography (2)
New regional wall motion abnormalities and reduced systolic wall thickening
Most common form of stress radionuclide imaging tests for CAD evaluation
SPECT myocardial perfusion imaging
One of the most valuable clinical applications of radionuclide perfusion imaging is for
risk stratification
CAC score that is predictive of a higher likelihood of obstructive CAD
High CAC scores (Agatson score > 400)
Agatson score < 400 – less effective in excluding CAD especially in symptomatic patients
For symptomatic patients without prior history of CAD and normal or nearly normal resting ECG who are able to exercise, what test should be used according to ACC/AHA recommendation?
exercise treadmill test
Low risk by exercise treadmill test is defined as those
Achieving >10 METS without chest pain or ECG changes
In patients who are categorized as low risk by exercise treadmill test but with CAD symptoms, what is ACC/AHA recommendation?
treat with medical therapy
High-risk Exercise Treadmill Testing findings (4)
- Typical angina with > 2 mm ST depression in multiple leads
- ST elevation during exercise
- Drop in BP
- Sustained V-tach
In patients who are categorized as high risk by exercise treadmill test, what is the next step based on ACC/AHA recommendations?
coronary angiography
Intermediate-high risk Exercise Treadmill Testing findings (3)
- Low exercise capacity
- Chest pain
- ST depression without high risk features
In patients who are categorized as intermediate-high risk by exercise treadmill test, what is the next step based on ACC/AHA recommendations?
additional testing (stress imaging or coronary CTA)
In patients who are unable to exercise and/or with abnormal resting ECGs (e.g. LVH with strain pattern and LBBB), what is recommended testing strategy?
imaging strategy
In patients who have intermediate-high likelihood of CAD (e.g. diabetics and renal impairment), what is recommended testing strategy?
imaging strategy – due to increased overall sensitivity for diagnosis of CAD and improved risk stratification
Justification of stress imaging
identification of which patients may benefit from a revascularization strategy rather than angiography-derived anatomic stenoses
First imaging test for the assessment of valvular heart disease
Echocardiography
Most cost-effective screening method for VHD
Echocardiography
Indications of echocardiography in VHD (4)
- Cardiac murmurs
- DOB
- Syncope or presyncope
- Preoperative exams in patients undergoing bypass surgery
Tethering of the leaflet tips and relative pliability of the leaflets themselves (hockey stick-type deformation particularly of anterior leaflet) is and echocardiographic finding of
Rheumatic MS
Best technique for imaging for presence or the extent of infarcted myocardium in MI patients
Late gadolinium enhancement imaging by CMR
Why not do echocardiography immediately after MI who underwent reperfusion therapy?
There is partial or complete recovery of ventricular function within several days (EF may be misleading at this time) – myocardial stunning
Best method in the assessment of patients with suspected mechanical complications after MI
Echocardiography
Thrombus in the pericardial space after MI raise suspicion of
cardiac rupture
When should you do a follow-up echocardiography post MI?
1-6 months post MI – assess cardiac function and regional wall motion
First line test in patients presenting with new-onset heart failure
Echocardiography
Cardiotoxicity from drug is defined as a ____ reduction in LVEF to ____ with symptoms of heart failure or _____ drop in LVEF to ____ in patients who are asymptomatic
> 5%
<55%
> 10%
<55%
Distance from the parietal to visceral pericardium for it to be considered a significant effusion
> 1 cm
Cardiac tamponade echocardiographic features (2)
- Diastolic collapse of the RV free wall – pericardial pressures exceed RV filling pressures
- Doppler evidence of respiratory flow variation – equivalent of pulsus paradoxus
Modality that first detects a cardiac mass
Echocardiography
Majority of the cardiac malignancy is
Metastatic
- Direct invasion (lung and breast)
- Lymphatic spread (lymphomas and melanomas)
- Hematogenous spread (renal cell carcinoma)
Atrial myxoma is more common in what chamber
LA
Best technique to assess vegetations because it allows visualization of the typical oscillating motions
Echocardiography
Best method to view both vegetation and abscess, esp in patients with prosthetic valves
TEE
Most common adult congenital cardiac abnormalities
Abnormalities in the interatrial septum
Best way to assess PFO or ASD
Agitated saline (Bubble study)
Use maneuvers such as Valsalva or sniff maneuver – to increase RA pressure since PFO is a one-way flap
Most common ASD in adults
Secundum-type (in the fossa ovalis)
In the dyslipidemia guideline, for non-diabetic individuals aged ____ with LDL-C _____ AND ___ risk factors, without atherosclerotic cardiovascular disease, statins are RECOMMENDED for the prevention of cardiovascular events.
≥ 45 years
≥ 130 mg/ dL
≥ 2
According to the Dyslipidemia guidelines, risk factors for cardiovascular disease include (9)
- male sex
- postmenopausal women
- smoker
- hypertension
- BMI > 25 kg/m2
- family history of premature CHD
- microalbuminuria
- proteinuria
- left ventricular hypertrophy
According to the Dyslipidemia guidelines, for diabetic individuals without evidence of atherosclerosis (ASCVD), are statins recommended for primary prevention of cardiovascular events?
Yes
In general, the 2015 CPG recommends a _____ reduction in LDL-C for appropriate treatment goal with statin therapy
30% or greater
According to Dyslipidemia CPG, what is the treatment goal LDL-C level
<70 mg/dl
According to the Dyslipidemia CPG, for individuals without evidence of ASCVD but aged_____ AND with ____ risk factors*, the use of lipid profile for screening is RECOMMENDED
> 45 years
2 or more
According to the Dyslipidemia CPG, is serial liver function test monitoring recommended in asymptomatic individuals prior to treatment with statin therapy?
No
According to the Dyslipidemia CPG, if patient has elevated AST/ALT while on statin therapy that is ≥ 3x ULN, will you continue the statin or not?
Discontinue. In individuals with very high risk for CVD, may use othe non-statins to lower LDL-C while off statins. Recheck AST/ALT after 2 weeks
According to the Dyslipidemia CPG, if patient has elevated AST/ALT while on statin therapy that is ≤ 3x ULN, will you continue the statin or not?
Continue statin then work up for other possible causes of elevated LFTs especially if with high index of suspicion for other etiologies.
According to the Dyslipidemia CPG, if a patient on statin therapy had myalgias, what diagnostic test should you do?
Creatine kinase. If elevated at 5x ULN, and patient can tolerate the symptom, may continue or reduce statin dose. if cannot tolerate the symptom and no organ damage, discuss the importance of of discontinuing statin treatment. Then may resume at a lower dose or with other statin once symptom resolves
According to the Dyslipidemia CPG, if a patient on statin therapy had myalgias and was noted to have >5xULN elevation of the CK and elevated creatinine, what is the possible diagnosis?
statin-induced rhabdomyolysis
stop the statin for 6 weeks then reassess for possible combination therapy with ezetimibe and low dose statin with alternate or weekly dosing
According to the Dyslipidemia CPG, for diabetic and non-diabetic individuals with or without evidence of ASCVD, are the the use of fibrates and poly-unsaturated fatty acids (PUFA) or omega 3 fatty acids recommended as alternative to statins for the secondary prevention of cardiovascular events?
NOT recommended
The use of fibrates may be considered among patients with a high baseline TG > 204 mg/dl and low HDL-C < 34 mg/dl once LDL-C has been reached on a maximally dosed statin
Infectious disease that has a cardiac involvement in up to 50% of cases with 10% developing AV conduction block that is generally reversible but may require temporary pacing support
Lyme disease
More persistent AV conduction disturbances is seen in these infectious diseases (2)
Chagas disease
syphilis
Cause of AV conduction block which are accelerated forms with mutations i the cardiac sodium channel gene (SCN5A) and other loci in chromosomes 1 and 19
Progressive familial heart block
Congenital AV block in the setting of structurally normal heart is seen in children born to mothers with
SLE
Coronary vasospasm of what artery will cause transient AV block
right coronary artery distribution
MI that predisposes to 2nd or higher grade AV block with more stable, narrow escape rhythms
inferior MI
MI that cause block in distal AV nodal complex, His bundle, or bundle branches and produces wide complex unstable escape rhythms with worse prognosis and high mortality
Anterior MI
In the AV block has normal QES, the site is ____. If with wide QRS, the site is ____
normal: intranodal
wide: distal conduction system
Intermittent failure of conduction of atrial impulses to the ventricles
second degree AV block
progressive increase in PR interval, decrease in RR interval, pause that is less than 2 times the immediately preceding RR interval
Mobitz type 1 (wenckebach block)
Mobitz type 1 block is almost localized to the
AV node (intranode)
Sudden unexpected failure of conduction from atria to ventricles without preceding change in PR interval
Mobitz type 2
Mobitz type 2 is localized at
distal or infra-His conduction system (infranodal)
second degree AV block that is associated with intraventricular conduction delays and is more likely to proceed to higher grades of AV block
Mobitz type 2
due to a large reentry circuit, often associated with areas of scar in the atria
Macroreentrant atrial tachycardia
Arrhythmia due to a circuit that revolves around the tricuspid valve annulus, bounded anteriorly by the annulus and posteriorly by functional conduction block in the crista terminalis
Common or typical right atrial flutter
The wavefront passes between the inferior vena cava and the tricuspid valve annulus, known as the sub-Eustachian or cavotricuspid isthmus, where it is susceptible to interruption by catheter ablation. Thus, common atrial flutter is also known as cavotricuspid isthmus-dependent atrial flutter
Atrial rate of atrial flutter is typically
240–300 beats/min
but may be slower in the presence of atrial disease or antiarrhythmic drugs
It often conducts to the ventricles with 2:1 AV block, creating a regular tachycardia at 150 beats/min
Some patients with atrial fibrillation treated with an antiarrhythmic drug, particularly_____, _____, or _____, will present with atrial flutter rather than fibrillation, since these agents slow atrial conduction velocity and can promote reentry.
flecainide, propafenone, or amiodarone
Atrial flutter can occur in either atrium and are almost universally associated with areas of
atrial scar
T or F. The risk of thromboembolic events in atrial flutter is lower than with atrial fibrillation
False. Similar
For recurrent episodes of common atrial flutter, catheter ablation of the ____ abolishes the arrhythmia in >90% of patients with a low risk of complications that are largely related to vascular access, and rarely heart block.
cavotricuspid isthmus
Management of first episode of atrial flutter
Conversion to sinus rhythm with no antiarrhythmic drug therapy
Antiarrythmic for recurrent atrial flutter (4)
Sotalol
Dofetilide
Disopyramide
Amiodarone
Multifocal AT (MAT) is characterized by a rhythm with at least ____ distinct P-wave morphologies with rates typically between _____
Three
100 and 150 beats/min
It is usually encountered in patients with chronic pulmonary disease and acute illness
Management of Multifocal AT
treating the underlying disease and correcting any metabolic abnormalities
CCB (verapamil and diltiazem) - may slow the atrial and ventricular rate
Amiodarone
T or F. Electrical cardioversion is ineffective in MAT
True
MAT may respond to amiodarone, but long-term therapy with this agent is usually avoided due to its toxicities, particularly
pulmonary fibrosis
CHA2DS2-VASc risk factors
C—congestive heart failure H—hypertension A- Age ≥75 y.o D—diabetes mellitus S – stroke or TIA, embolus V—vascular disease A- Age 65 - 75 y.o Sex—female
Among the CHA2DS2-VASc risk factors, which of them is scored 2 points?
A- Age ≥75 y.o
S – stroke or TIA, embolus
Annual stroke rate for each CHA2DS2-VASc risk factors
0 – 0 1 - 1.3% 2 – 2.2% 3 - 3.2% 4 – 4.0% 5 - 6.7% 6-9 - >9%
Dabigatran is an inhibitor of
Thrombin
Rivaroxaban is an inhibitor of
Factor Xa
Apixaban is an inhibitor of
Factor Xa
Central cyanosis is caused by
significant right-to-left shunting at the level of the heart or lungs
Reduced extremity blood flow due to small vessel constriction
Peripheral cyanosis / Acrocyanosis
Peripheral cyanosis / Acrocyanosis can be aggravated by what drugs
ß-blockers – due to unopposed ⍺-mediated vasoconstriction
Unusually tan or bronze discoloration of the skin that may be seen in systolic HF
Hemochromatosis
Pigeon chest
Pectus carinatum
Funnel chest
Pectus excavatum
Loss of the normal kyphosis of the thoracic spine. This is seen in what cardiac problem?
Straight back syndrome
Seen in patients with MVP
Tender, raised nodules on the pads of the finger and toes
Osler’s nodes
Linear petechiae in the midposition of the nail bed
Splinter hemorrhages
Posterior calf pain on active dorsiflexion of the foot against resistance. This is present in what condition?
Homan’s sign
DVT
Single most important bedside measurement to estimate volume status
JVP
In the measurement of JVP, which vein is preferred?
Internal jugular vein
External jugular vein is valved and not directly in line with the SVC and RA
Venous pressure is the vertical distance between the
top of the jugular venous pulsation and the angle of Louis
Normal JVP
≤4.5 cm at 30º angle
Part of the body that is a better reference for measurement of the JVP
Clavicle
Difference between carotid pulse and venous waveform (2)
Carotid pulse is not easily obliterated with palpation and is monophasic
Venous waveform change with changes in posture or inspiration (unless quite elevated) and is biphasic
Venous waveform that corresponds to the right atrial presystolic contraction
ɑ - wave
Prominent ɑ - wave indicates
Reduced RV compliance
Venous waveform of AV dissociation and right atrial contraction against a closed tricuspid valve
Cannon ɑ wave
In patients with wide complex tachycardia, appreciation of cannon ɑ wave in the JV waveform identifies the rhythm as _____ in origin
Ventricular
ɑ wave is not present in what arrhythmia
Atrial fibrillation
Venous waveform that represents fall in the right atrial pressure
X descent
after inscription of the ɑ wave
Venous waveform that representing closed tricuspid valve pushed into the RA during early ventricular systole
c wave
Interrupts the x descent and followed by further descent
Venous waveform that represents atrial filling or atrial diastole
v wave
Occurs during ventricular systole
Venous waveform that is accentuated in TR
v wave
Venous pressure should _____ by ______ with inspiration
fall by at least 3 mmHg
Rise or a lack of fall of the JVP with inspiration is called ____. This is usually seen in what condition.
Kussmaul’s sign
Constrictive pericarditis
Abdominojugular reflux maneuver is elicited by firm and consistent pressure over the _____ of the abdomen, preferably over the_____, for _____, and reassessment of ____
upper portion
RUQ
15 s
JVP
Positive response of abdominojugular reflux maneuver
sustained rise of > 3 cm in the JVP
Response should be assessed after 10 s of continuous pressure
Venous hypertension
Positive response of abdominojugular reflux maneuver is seen in pulmonary artery wedge pressure
> 15 mmHg in patients with HF
Indicates a volume-overloaded state with limited compliance of an overly distended or constricted venous system
Very low (even 0 mmHg) diastolic BP is seen in what condition (2)
- chronic, severe AR
- large AV fistula
Difference of the BP between the 2 arms must be
< 10 mmHg
Systolic leg pressure is usually _____ than the arm pressure
20 mmHg higher
Higher in chronic severe AR or in PAD
White-coat hypertension is defined as at least ___ separate clinic-based measurements ____ and at least ___non-clinical-based measurements _____ in the absence of any evidence of ______
3
> 140/90 mmHg
2
<140/90 mmHg
target organ damage
Orthostatic hypotension is defined as a fall in the SBP _____ or DBP _____ in response to assumption of the upright posture from a supine position within _____
> 20 mmHg
10 mmHg
3 mins
Aortic pulse is best appreciated in the
epigastrium, just above the umbilicus
Asses the integrity of the arcuate system of the hand
Allen’s test
Performed routinely before instrumentation of the radial artery
Allen’s test
Character of the pulse is best appreciated at the
carotid level
A weak and delayed pulse seen in severe AS
Pulsus parvus et tardus
Slow, notched, or interrupted upstroke seen in AS
Anacrotic pulse
Sharp rise of carotid upstroke and rapid fall-off that is seen in chronic severe AR
Corrigan’s or water-hammer pulse
Bifid pulse
Bisferiens pulse
Seen in advanced AR and HOCM
Fall in systolic pressure > 10 mmHg with inspiration
Pulsus paradoxus
Measured by noting the difference between the systolic pressure at which the Korotkoff sounds are first heard (during expiration) and the systolic pressure at which the Korotkoff sounds are heard with each heartbeat, independent of the respiratory phase
Pulsus paradoxus is fall in systolic pressure _____ with _____
> 10 mmHg
inspiration
Beat-to-beat variability of the pulse amplitude. This is usually seen in what condition?
Pulsus alternans
Seen in severe LV systolic dysfunction
Cervical bruit is a weak indicator of
carotid artery stenosis
Visible right upper parasternal pulsation is indicative of
ascending aortic aneurysm
Normal splitting of S1 is seen in young patient with
RBBB
Tricuspid valve closure is relatively delayed
Narrowly split S2 or a single S2
pulmonary hypertension
Fixed splitting of S2
Secundum ASD
Reversed or paradoxical splitting is the pathologic delay in AV closure that is seen in these conditions (5)
- LBBB
- RV pacing
- Severe AS
- HOCM
- Acute MI
High-pitched early systolic sound that corresponds in timing to the upstroke of the carotid pulse
Ejection sound
The only right-sided acoustic event that decreases in intensity with inspiration
Pulmonic ejection sound
S3 corresponds to
Rapid filling phase of the ventricular diastole
Normal finding in children, adolescents, and young adults
Heart failure in older patients
Low-pitched sound best heard at the LV apex that is predictive of cardiovascular morbidity and mortality in CHF
Left-sided S3
S4 corresponds to
atrial filling phase of the ventricular diastole
Thrill is present in what grade of murmur
grade 4 murmurs or above
Early systolic murmur that may increase in intensity with inspiration heard at the left lower sternal border
Acute TR
Most common cause of midsystolic murmur in adult
Aortic Stenosis
Midsystolic murmur that is loudest in the 2nd right interspace with radiation to the carotids
Aortic Stenosis
Increase in intensity of murmur of TR with inspiraton
Carvallo’s sign
Decrescendo, blowing diastolic murmur at left sternal border with wide pulse pressure and bounding arterial pulses
Chronic, severe AR
Signs of diastolic run-off (2):
- Wide pulse pressure
* Bounding arterial pulses
Low-pitched mid- to late apical diastolic murmur that sometimes can be confused with MS. This murmur is heard in what condition?
Austin Flint murmur
Chronic, severe AR
Low-pitched mid- to late diastolic rumbling best heard at apex on left lateral decubitus position
Mitral stenosis
Continuous murmur at
2nd or 3rd interspace at a slight distance from the sternal border
Continuous murmur heard at supraclavicular fossa that can be obliterated with firm pressure applied to the diaphragm of the stethoscope
Cervical venous hum
Benign
children or adolescents
Enhanced arterial blood flow through engorged breasts causes this continuous murmur
Mammary soufflé of pregnancy
Right-sided events increase in intensity with inspiration and decrease with expiration except
pulmonic ejection sound
Left-sided events _____ in intensity with inspiration and _____ with expiration
Decrease
Increase
Increase murmur in response to maneuvers that increase LV afterload (i.e. hand grip and vasopressors) (3)
MR
VSD
AR
In older patients, murmur of AS may be well transmitted to the apex. What do you call this?
Gallavardin effect
Most heart murmurs decrease in intensity and duration during the strain phase of Valsalva, except (2)
MVP
HOCM
After release of the Valsalva maneuver, right-sided murmurs tend to return to control intensity earlier than do left-sided murmurs
First clue that prosthetic valve dysfunction may contribute to recurrent symptoms
Change in the quality of the heart sounds or the appearance of a new murmur
Prosthetic valves that has same heart sounds with the native valves
Bioprosthetic valves
In patients with prosthetic valve, this may present clinically with signs of shock, muffled heart sounds, and soft murmurs
Prosthetic valve thrombosis
3 components of pericardial friction rub
- Ventricular systole
- Rapid early diastolic filling
- Late presystolic filling after atrial contraction
Pulsus paradoxus that exceeds ____ is seen pericardial tamponade
12 mmHg
With standing, most murmurs______ , with two exceptions: ______ and ______
HOCM – become louder
MVP – lengthens and often is intensified
With squatting, most murmurs become____, except for ______ and ______
Louder
HOCM and MVP usually soften and may disappear
Passive leg raising usually produces the same results.
Murmur often decreases with nearly maximum hand grip exercise
HOCM
Most common primary tumor of the heart
Myxoma
Primary tumors of the heart are rare. Approximately three-quarters are histologically benign
Most common malignant tumor of the heart
Sarcomas
Malignant tumors, almost all of which are sarcomas, account for 25% of primary cardiac tumors
Gender predilection of myxoma
Female
a syndrome of myxomas (cardiac, skin, and/or breast), lentigines and/or pigmented nevi, and endocrine overactivity (primary nodular adrenal cortical disease with or without Cushing’s syndrome, testicular tumors, and/or pituitary adenomas with gigantism or acromegaly)
Carney complex
Inactivating mutations in the tumor-suppressor gene PRKAR1A, which encodes the protein kinase A type I-α regulatory subunit, have been identified in ~70% of patients with
Carney complex
Difference between sporadic and familial myxoma
Sporadic: solitary, arise in interatrial septum in the vicinity of fossa ovalis, pedunculated
Familial: syndromic, younger individuals, multiple, may be ventricular in location, more likely to recur after initial resection
The most common clinical presentation of myxoma mimics that of
mitral valve disease
either stenosis owing to tumor prolapse into the mitral orifice or regurgitation resulting from tumor-induced valvular trauma or distortion
Characteristic auscultation finding in myxoma
Low-pitched sound, a “tumor plop,” during early or mid-diastole
Management of myxoma
Surgical excision using cardiopulmonary bypass
indicated regardless of tumor size
generally curative
Cardiac tumors that may grow as large as 15 cm, may present as an abnormality of the cardiac silhouette on chest x-ray
Cardiac lipomas
Friable cardiac tumors with frond-like projections that are usually solitary
Papillary fibroelastomas
Most common tumors of the cardiac valves
Papillary fibroelastomas
Remnants of cytomegalovirus have been recovered from these cardiac tumors, raising the possibility that they arise as a result of chronic viral endocarditis
Papillary fibroelastomas
The most common cardiac tumors in infants and children (2)
Rhabdomyomas and fibromas
usually occur in the ventricles
Cardiac tumors that are considered haramartomatous growths are multiple in 90% of cases, and are strongly associated with tuberous sclerosis
Rhabdomyomas
Single cardiac tumor that is universally ventricular in location, often calcified, tend to grow and cause arrhythmias and obstructive symptoms,
Fibromas
Rare chromaffin cell tumors that represent extra- adrenal pheochromocytomas
Paragangliomas
Most are located in the roof of the left atrium
Almost all malignant primary cardiac tumors are
Sarcomas
isolated cardiac lymphomas have been rarely described, but usually occur in the context of more systemic disease
In general, sarcomas are characterized by rapid progression that culminates in the patient’s death within weeks to months from the time of presentation as a result of hemodynamic compromise, local invasion, or distant metastases.
most common type of cardiac sarcoma in adults
angiosarcomas
most common type of cardiac sarcoma in children
Rhabdomyosarcomas
Most common metastatic site of cardiac sarcoma
lung
Cardiac tumors that commonly involve the right side of the heart, are rapidly growing, frequently invade the pericardial space, and may obstruct the cardiac chambers or venae cavae
Sarcomas
Sarcomas also may occur on the left side of the heart and may be mistaken for myxomas.
Most common tumors of the heart
Tumors metastatic to the heart
Although cardiac metastases may occur with any tumor type, the relative incidence is especially high in _____ and, to a somewhat lesser extent, _____ and ____
Malignant melanoma
Leukemia and lymphoma – somewhat lesser extent
The most common primary sites from which cardiac metastases originate are (2)
Breast CA
Lung CA
Most often involved part of the heart in cardiac metastases
Pericardium
Followed by myocardium of any chamber, and, rarely, by involvement of the endocardium or cardiac valves
The most common cause of myocardial ischemia
Atherosclerotic disease of an epicardial coronary artery
Central to the pathophysiology of myocardial ischemia
myocardial supply and demand
Major determinants of myocardial oxygen demand (3)
- Heart rate
- Myocardial contractility
- Myocardial wall tension (stress)
Determinants of oxygen supply to the myocardium (2)
- Oxygen-carrying capacity of the blood
2. Adequate level of coronary blood flow
Major determinants of coronary resistance (2)
Prearteriolar vessels
Arteriolar and intramyocardial capillary vessels
Condition that increases the myocardial oxygen demand causing ischemia
Severe left ventricular hypertrophy (LVH) due to aortic stenosis
Can present with angina that is indistinguishable from that caused by coronary atherosclerosis largely owing to subendocardial ischemia
T or F. Severe anemia often cause myocardial ischemia
False. Rarely causes myocardial ischemia by itself but may lower the threshold for ischemia in patients with moderate coronary obstruction
Abnormal constriction or failure of normal dilation of the coronary resistance vessels causing angina
Microvascular angina
Major site of atherosclerotic disease
Epicardial coronary arteries
Branch point of epicardial artery - increased turbulence; predilection for atherosclerotic plaques
Major risk factors of coronary atherosclerosis (5)
- High level of LDL
- Low level of HDL
- Cigarette smoking
- Hypertension
- Diabetes mellitus
Limitation of the ability to increase flow to meet increased myocardial demand is seen in stenosis of how many percent
~50%
Blood flow at rest may be reduced and further minor decreases in the stenotic orifice area can reduce coronary flow dramatically to cause myocardial ischemia at rest or with minimal stress. This is seen in stenosis of how many percent
~80%
Most common cause of segmental atherosclerotic narrowing of epicardial coronary arteries
Plaque
Duration of total occlusion of coronary arteries in the absence of collaterals where in damage is reversible
≤20 min
> 20min of occlusion – permanent damage with subsequent myocardial necrosis
Cardiomegaly and heart failure secondary to ischemic damage of the LV myocardium that may have caused no symptoms before the development of heart failure
Ischemic cardiomyopathy
Stable angina pectoris is due to
transient myocardial ischemia
Patients with angina localizes pain by placing hand over the sternum with a clenched fist. What do you call this sign?
Levine’s sign
Description of angina in terms of
Characteristic:
duration:
Radiation
Characteristic: crescendo-decrescendo
duration: 2-5 min
Radiation: shoulder and to both arms (ulnar surfaces of forearm and hand), back, interscapular region, root of the neck, jaw, teeth, and epigastrium
Rarely localized below the umbilicus or above the mandible
T or F. Angina can radiate to trapezius muscle
False
Angina that occur while patient is recumbent
angina decubitus
Patient may be awakened at night by typical chest discomfort and dyspnea
Nocturnal angina
Due to episodic tachycardia, diminished oxygenation, or expansion of the intrathoracic blood volume that occurs during recumbency. Recumbency causes an increase in cardiac size (EDV), wall tension, and myocardial oxygen demand
Anginal equivalents (4)
- Dyspnea
- Nausea
- Fatigue
- Faintness
Most widely used test for both the diagnosis of IHD and the estimation of risk and prognosis
Treadmill test
Treadmill test is discontinued if with (7)
- Chest discomfort
- Severe shortness of breath
- Dizziness
- Severe fatigue
- ST-segment depression >0.2 mV (2mm)
- Fall in SBP >10 mmHg
- Ventricular tachyarrhythmia
Ischemic ST segment response in treadmill test
- Flat ST
2. Downsloping depression of the ST >0.1 mV below the baseline (i.e. PR segment lasting longer than 0.08 s.
Target heart rate in treadmill test
85% of maximal predicted heart rate for age and sex
T or F. Negative test for treadmill test will rule out CAD.
False.
Does not exclude CAD but makes likelihood of 3-vessel or left main CAD is extremely unlikely
Contraindications of treadmill test (7)
- Rest angina within 48 h
- Unstable rhythm
- Severe aortic stenosis
- Acute myocarditis
- Uncontrolled heart failure
- Severe pulmonary HPN
- Active IE
Failure of the BP to increase or an actual decrease with signs of ischemia during the treadmill test
Ischemia-induced global LV dysfunction
important adverse prognostic sign
Indicative of severe IHD and high risk of future adverse events (2)
- Angina and or severe (>0.2 mV) ST-segment depression at a low workload (before completion of stage II of the Bruce protocol)
- ST-segment depression that persists >5 min after termination of exercise
IV pharmacologic challenge in cardiac imaging uses (3)
Dipyridamole
Adenosine
Dobutamine
IV pharmacologic challenge in cardiac imaging create a coronary “steal” by temporarily increasing flow in nondiseased segments of the coronary vasculature at the expense of diseased segments
Dipyridamole or adenosine
T or F. One of the indication for coronary arteriography is as a routine exam for patients with careers that involve the safety of others
False. Patients with careers that involve the safety of others (e.g., pilots, firefighters, police) who have questionable symptoms or suspicious or positive noninvasive tests and in whom there are reasonable doubts about the state of the coronary arteries.
Coronary arteriography is indicated in male patients ____ old and females ____ old who are to undergo a cardiac operation such as valve replacement or repair and who may or may not have clinical evidence of myocardial ischemia
> 45 years
>55 years
Principal prognostic indicators of IHD (4)
- Age
- Functional state of the LV
- Location and severity of coronary artery narrowing
- Severity of myocardial ischemia
Location of obstruction that has greater risk for coronary events (2)
- Left main (>50% luminal diameter)
2. LAD coronary artery proximal to the origin of the 1st septal artery
Side effect of long-acting nitrates (2)
headache and dizziness
Minimum effective dose of long-acting nitrates should be used and a minimum of 8 h each day kept free of the drug to restore any useful response. Why?
minimize the effects of nitrate tolerance
Therapeutic aim of beta blockers in IHD
relief of angina and ischemia
Piperazine derivative that is useful for patients with chronic stable angina despite standard medical therapy
Ranolazine
Inhibit the late inward sodium current (INa) resulting to limitation of the Na overload of ischemic myocytes and prevention of Ca2+ overload via the Na-Ca exchanger
T or F. Ivabradine has no benefit for patients with IHD with no clinical HF
True
Most common clinical indication for PCI
Symptom-limiting angina pectoris, despite medical therapy, with evidence of ischemia during stress test
Vessels used in CABG (3)
- internal mammary arteries
- radial artery
- Saphenous vein
Preferred procedure in CABG
Anastomosis of one or both of the internal mammary arteries or a radial artery to the coronary artery distal to the obstructive lesion
T or F. In CABG, saphenous vein grafts have higher long-term patency rates compared in internal mammary and radial artery implantations
False.
T or F. In CABG, internal mammary and radial artery implantations are better used for LAD obstruction than saphenous vein
True
T or F. CABG is superior to PCI in preventing death, myocardial infarction, and repeat revascularization
True
Noncontractile or hypocontractile myocardial segments that are viable but are chronically ischemic
Hibernating myocardium
Treated with revascularization
T or F. Stroke risk is higher in PCI than in CABG
False. Lower
PCI is chosen over CABG in patients with (3)
- 1- or 2-vessel CAD
- Normal LV function
- Anatomically suitable lesion
CABG is chosen over PCI in patients with (6)
- 3-vessel CAD
- 2-vessel CAD that includes proximal LAD
- Impaired global LV function (LV EF <50%)
- DM
- Left main CAD
- Lesions unsuitable for catheter-based procedures
CCD functional class I
Ordinary physical activity, such as walking and climbing stairs, does not cause angina. Angina present with strenuous or rapid or prolonged exertion at work or recreation.
CCD functional class II
Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or when under emotional stress or only during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of stairs at a normal pace and in normal conditions.
CCD functional class III
Marked limitation of ordinary physical activity. Walking one to two blocks on the level and climbing more than one flight of stairs in normal conditions.
CCD functional class IV
Inability to carry on any physical activity without discomfort— anginal syndrome may be present at rest.
Nitrates is contraindicated in what cardiac condition
HOCM
Nondihydropyridines CCB
Verapamil and diltiazem
An index of both sodium and potassium intakes that is a stronger correlate of BP than is either sodium or potassium alone
Urine sodium-to-potassium ratio
Determinants of arterial pressure (2)
Cardiac output – determined by SV and HR
Peripheral resistane - determined by functional and anatomic changes in small arteries (lumen diameter 100–400 μm) and arterioles
T or F. Non-chloride salts of sodium has little or no effect on BP
True
An extreme example of volume-dependent hypertension
ESRD
Play important roles in tonic and phasic cardiovascular regulation (3)
Norepinephrine, epinephrine, and dopamine
Mediators of activities of all adrenergic receptors
G proteins
Second messengers
α receptors is occupied and activated more avidly by
Norepinephrine > epinephrine
Adrenergic receptors that are found in the postsynaptic cells in smooth muscle
α1 Receptors
Action of α1 Receptors in the vessel wall and in kidney
Vasoconstriction
In kidney, increase renal tubular absorption of sodium
Adrenergic receptor that is found in presynaptic membranes of postganglionic nerve terminals that synthesize norepinephrine
α2 Receptors
Adrenergic receptor that act as negative feedback controllers when activated by catecholamines
α2 Receptors
Inhibit further norepinephrine release
β receptors is occupied and activated more avidly by
Epinephrine > norepinephrine
Effect of β1 receptor stimulation in cardiovascular and in the kidney
Stimulates the rate and strength of cardiac contraction leading to increase in cardiac output
Stimulates renin release from the kidney
Effect of β2 receptor stimulation in cardiovascular
Relaxation of vascular smooth muscle leading to vasodilation
Phenomenon that is characterized by decreasing responsiveness to catecholamines
Tachyphylaxis
Caused by downregulation of receptors due to sustained high levels of catecholamines
Most blatant example of hypertension related to increased catecholamine production
Pheochromocytoma
Treatment of pheochromocytoma
- Surgical excision of the tumor
- a1 receptor antagonist
- inhibitor of tyrosine hydroxylase
Rate-limiting step in catecholamine biosynthesis
tyrosine hydroxylase
Centrally acting a2 agonist that inhibits sympathetic outflow
Clonidine
Abrupt cessation of this drug will cause rebound hypertension due to upregulation of a1 receptors
Arterial baroreflex is mediated by stretch-sensitive sensory nerve endings in the
carotid sinuses and aortic arch
Increase BP will cause increase firing of baroreceptors and result to decrease in sympathetic outflow eventually leading to decrease in arterial pressure and heart rate
Most renin in the circulation is synthesized in the
afferent renal arteriole
3 primary stimuli for renin secretion:
- Decrease NaCl transport in Macula densa
- Baroreceptor mechanism
- Sympathetic nervous system stimulation of renin-secreting cells via β1 adrenoreceptors
Angiotensin I is converted to angiotensin II in the
Lung
Primary tropic factor for the secretion of aldosterone by the adrenal zona glomerulosa
Angiotensin II
Obstruction of the renal artery causes decreased renal perfusion pressure and renin secretion leading to
Renovascular hypertension
Effect of aldosterone in the kidney
Increases sodium reabsorption by amiloride-sensitive epithelial sodium channels (ENaC) on the apical surface of the principal cells of the renal cortical collecting duct
May cause hypokalemia and alkalosis since electrical neutrality is maintained by exchanging Na for K and H ions
Adrenal aldosterone synthesis and release are independent of renin-angiotensin is seen in what condition
Primary aldosteronism
A compelling example of mineralocorticoid-mediated hypertension
Primary aldosteronism
Resistance to blood flow varies inversely with the ____ power of the radius of the vessel
Fourth
Geometric alterations in the vessel wall without a change in vessel volume
Remodeling
The most common cause of death in hypertensive patients
Heart disease
The strongest risk factor for stroke
Elevated blood pressure
The most common etiology of secondary hypertension
Primary renal disease
The renal lesion associated with malignant hypertension
Fibrinoid necrosis of the afferent arterioles
Macroalbuminuria is a random urine albumin/creatinine ratio of
> 300 mg/g
Microalbuminuria is a random urine albumin/creatinine ratio of
30–300 mg/g
ABI that is diagnostic of PAD
ABI <0.90
Associated with >50% stenosis in at least one major lower limb vessel
The classic symptom of PAD
Intermittent claudication
Cardiovascular disease risk doubles for every _____ increase in systolic and _____ increase in diastolic pressure
20-mmHg
10-mmHg
T or F. Diastolic blood pressure and pulse pressure are more powerful predictors of cardiovascular disease than systolic blood pressure among older individuals
False. Systolic blood pressure and pulse pressure are more powerful predictors of cardiovascular disease than diastolic blood pressure among older individuals.
More comprehensive assessment of the vascular burden of hypertension
Ambulatory blood pressure recordings
T or F. BP tends to be lower in the early morning hours, soon after waking, than at other times of day
False. Higher.
MI and stroke are more common in the early morning hours
Recommended criteria for a diagnosis of hypertension based on 24-h BP monitoring:
Average awake blood pressure
Average asleep blood pressure
Average awake blood pressure ≥135/85 mmHg
Average asleep blood pressure ≥120/75 mmHg
These levels approximate a clinic blood pressure of 140/90 mmHg
High renin patients may have a _____ form of hypertension
vasoconstrictor
Low-renin patients may have _____ form of hypertension
volume-dependent
Hypertension due to an occlusive lesion of a renal artery
Renovascular hypertension
A potentially curable form of hypertension
Large majority of patients with renovascular hypertension have a plaque obstructing mostly the
origin of renal artery
in older arteriosclerotic patients
Patients with renovascular hypertension secondary to fibromuscular dysplasia have an obstruction in the
distal portions of the renal artery
PE finding that is seen in 50% of patients with renovascular hypertension
Abdominal or flank bruit
More likely to be hemodynamically significant if it lateralizes or extends throughout systole into diastole
“Gold standard” for evaluation and identification of renal artery lesions
Contrast arteriography
No single test is sufficiently reliable to determine a causal relationship between a renal artery lesion and hypertension
Functionally significant lesions is defined as lesions that generally occlude _____ of the lumen of the affected renal artery
> 70%
Presence of collateral vessels to the ischemic kidney
T or F. Laboratory evaluation for renal artery stenosis and stent placement should be considered only in those arteriosclerotic patients in whom medical therapy fails to control blood pressure or preserve renal function
True
Most effective medical therapies for renovascular hypertension
ACE inhibitor or an angiotensin II receptor blocker
A useful screening test in primary aldosteronism
PA/PRA
The ratio of plasma aldosterone to PRA
Recommendation: withdraw aldosterone antagonists for at least 4-6 weeks before obtaining the measurements
PA and PA/PRA values that indicates an aldosterone-producing adenoma
Ratio >30:1
PA >555 pmol/L (>20 ng/dL)
A high ratio in the absence of an elevated plasma aldosterone level is considerably less specific for primary aldosteronism since many patients with primary hypertension have low renin levels in this setting
Diagnosis of primary aldosteronism can be confirmed by demonstrating failure to __________after IV infusion of _______ over _____
suppress plasma aldosterone to <277 pmol/L (<10 ng/dL)
2 L of isotonic saline
4 h
Post-saline infusion plasma aldosterone values between 138 and 277 pmol/L (5–10 ng/dL) are not determinant
2 most common causes of sporadic primary aldosteronism
Aldosterone-producing adenoma
Bilateral adrenal hyperplasia
Most accurate means of differentiating unilateral versus bilateral forms of primary aldosteronism
Bilateral adrenal venous sampling for measurement of plasma aldosterone
Catecholamine-secreting tumors (2)
Pheochromocytoma
Paraganglioma
Most common congenital cardiovascular cause of hypertension
Coarctation of the aorta
Occurs in 35% of children with Turner’s syndrome
Causes diastolic hypertension, hypo or hyperthyroidism?
Hypothyroidism causes diastolic hypertension
Hyperthyroidism causes systolic hypertension
Monogenic hypertension cause wherein synthesis of sex hormones and cortisol is decreased
17α-hydroxylase deficiency
Decreased cortisol diminished cortisol-induced negative feedback on pituitary ACTH production increase ACTH increase ACTH-stimulated adrenal steroid synthesis proximal to the enzymatic block increase mineralocorticoids (i.e. desoxycorticosterone) Hypertension, hypokalemia
Enzyme deficiency that results in a salt-retaining adrenogenital syndrome
11β-hydroxylase deficiency
Increased mineralocorticoid synthesis (e.g. desoxycorticosterone)
Decreased cortisol synthesis
Acne, hirsutism, and menstrual irregularities – may be the presenting features when the disorder is first recognized in adolescence or early adulthood
Syndrome caused by constitutive activation of amiloride-sensitive ENaC on the distal renal tubule
Liddle’s syndrome
Excess sodium reabsorption
Cause of monogenic hypertension
Pregnancy can exacerbate hypertension by:
Activation of the mineralocorticoid receptor by progesterone
Average blood pressure reductions of 6.3/3.1 mmHg for every reduction of mean body weight of
9.2 kg
Lowering systolic blood pressure by ____ and diastolic blood pressure by _____ confers relative risk reductions of 35–40% for stroke and 12–16% for CHD within 5 years of the initiation of treatment
10–12 mmHg
5–6 mmHg
The single most effective intervention for slowing the rate of progression of hypertension-related kidney disease
Hypertension control
Anti-HPN that inhibit the Na+/Cl– pump in the distal convoluted tubule and hence increase sodium excretion
Thiazides
Anti HPN that inhibit ENaC in the distal nephron
Potassium-sparing diuretics (Amiloride and triamterene)
Potassium-sparing diuretics
Anti HPN that target the Na+-K+-2Cl– cotransporter in the thick ascending limb of the loop of Henle
Loop diuretics
Reserved for hypertensive patients with reduced GFR (reflected in serum creatinine >220 μmol/L [>2.5 mg/dL]), CHF, or sodium retention and edema
Why does ACE inhibitors causes cough?
It increases the bradykinin levels
ARBs act on what receptors?
AT1 receptors
AT1 receptors – constriction
AT2 receptors – dilation
ARB that is proven to reduce the risk of developing diabetes in high-risk hypertensive patients
Valsartan
ACE and ARBS improve insulin action and ameliorate the adverse effects of diuretics on glucose metabolism
Modest impact on the incidence of diabetes
T or F. ACEi/ARB combinations are less effective in lowering blood pressure than is the case when either class of these agents is used in combination with other classes of agents
True
Oral, nonpeptide competitive inhibitors of the enzymatic activity of renin
Aliskiren
As effective as ACEIs and ARBs if used as monotherapy
More complete blockade
Not considered first-line antihypertensive agent
A nonselective aldosterone antagonist
Spironolactone
Side effects of spironolactone (2)
Gynecomastia (binds to progesterone receptors)
Impotence (binds to androgen receptors)
Selective aldosterone antagonist
Eplerenone
Lesser side effects
T or F. There is no difference in the antihypertensive potencies of cardioselective and nonselective beta blockers
True
T or F. Beta blockers with intrinsic sympathomimetic activity decrease the rate of sudden death, overall mortality, and recurrent myocardial infarction
False. Without ISA
Block both β receptors and peripheral α-adrenergic receptors (2)
Carvedilol and labetalol
Cardioselective beta blocker and has additional vasodilator actions related to enhancement of nitric oxide activity
Nebivolol
CCBs reduce vascular resistance through blockade of what channel
L-channel blockade
A potent direct vasodilator that has antioxidant and NO-enhancing actions and may induce a lupus-like syndrome
Hydralazine
Direct vasodilator that can be used to treat malignant hypertension and life-threatening LV heart failure
IV Nitroprusside
Standard doses of most antihypertensive agents reduce BP by
8-10/4-7 mmHg
Younger patients are more responsive to this anti-HPN drugs (2)
beta blockers and ACEIs
> 50 year old patients are more responsive to this anti-HPN drugs (2)
diuretics and calcium antagonists
____ are inferior to other classes of anti-HPN agents for prevention of cardiovascular events, stroke, renal failure, and all-cause mortality
Beta blockers
_____ may be inferior than diuretics but superior to other classes of agents for the prevention of heart failure
Calcium channel blockers
T or F. ACEIs or ARBs provide better coronary protection than CCB
True
T or F. ACEIs or ARBs provide more stroke protection than other anti-HPN
False. CCBs
Combination treatment with an ACEI (benazepril) plus a calcium antagonist (amlodipine) was superior to treatment with the ACEI plus a diuretic (hydrochlorothiazide) in reducing the risk of cardiovascular events and death among high-risk patients with hypertension. What is this trial
Avoiding Cardiovascular Events through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH Trial)
The maximum protection against combined cardiovascular endpoints is achieved with pressures _____ for systolic blood pressure and _____ for diastolic blood pressure
<135–140 mmHg
<80–85 mmHg
Intensive blood pressure control (systolic blood pressure <120 mmHg) reduced the risk of cardiovascular events and mortality by 25% compared with less intensive control (systolic blood pressure 135–139 mmHg). More intense control may also be associated with a higher incidence of adverse events (e.g., syncope, electrolyte abnormalities, deterioration of renal function). This trial is the
SPRINT trial
Failed to find superiority of intensive blood pressure lowering (<120 mmHg) over standard blood pressure control (<140 mmHg) in reducing the risk of the study’s primary outcome (a composite endpoint of myocardial infarction, stroke, and cardiovascular death) in diabetic patients. This trial is the
ACCORD Trial
Demonstrate a significant reduction of stroke and left ventricular hypertrophy with more intensive therapy
Refers to patients with blood pressures persistently >140/90 mmHg despite taking three or more antihypertensive agents, including a diuretic
Resistant hypertension
More common in patients aged >60 years
Maneuver done in patients with severely sclerotic arteries wherein radial pulse is palpated despite occlusion of the brachial artery by the cuff
Osler maneuver
Pseudoresistant hypertension
In hypertensive emergencies, this determines the rapidity with which blood pressure should be lowered
degree of target organ damage
A syndrome associated with an abrupt increase of blood pressure in a patient with underlying hypertension or related to the sudden onset of hypertension in a previously normotensive individual
Malignant hypertension
Associated with diffuse necrotizing vasculitis, arteriolar thrombi, and fibrin deposition in arteriolar walls
In patients suspected with malignant hypertension, intake of these drugs must be investigated first.
Use of monoamine oxidase inhibitors
Use of recreational drugs (e.g., cocaine, amphetamines)
T or F. In hypertensive encephalopathy, BP must be lowered rapidly
True. BP must be lowered rapidly but inherent risks of overly aggressive therapy is present.
In hypertensive individual, the upper and lower limits of autoregulation of cerebral blood flow are shifted to higher levels of arterial pressure. Rapid lowering of BP to below the lower limit of autoregulation may precipitate cerebral ischemia or infarction due to decreased cerebral blood flow
Initial goal of therapy in hypertensive encephalopathy
Decreased MAP by no more than 25% within minutes to 2 h or to a BP range of 160/100-110 mmHg
T or F. In malignant HPN without encephalopathy, BP must be reduced slowly
True. May be effectively be achieved initially with frequent dosing of short-acting oral agents such as captopril, clonidine, and labetalol
In patients with acute, transient blood pressure elevations after thrombotic stroke that is not candidate for thrombolytic therapy, institute antihypertensive therapy only for patients with SBP _____ or DBP of _____
> 220 mmHg
> 130 mmHg
In patients with acute, transient blood pressure elevations after thrombotic stroke that is candidate for thrombolytic therapy, target SBP and DBP are
SBP is <185 mmHg
DBP is <110 mmHg
In patients with acute, transient blood pressure elevations after hemorrhagic stroke, target SBP is
140-179 mmHg
Treatment of adrenergic crisis as cause of hypertensive emergency
phentolamine or nitroprusside
Pheochromocytoma, cocaine or MAP overdose, clonidine witrawal, acute spinal cord injuries, and interaction of tyramine-containing compounds with monoamine oxidase inhibitors
SBP and DBP of: Normal Prehypertension Stage I Stage II Isolated systolic HPN
Normal: <120, <80 Prehypertension: 120-139; 80-89 Stage I: 140-159; 90-99 Stage II: ≥160; ≥ 100 Isolated systolic HPN: ≥140; <90
Dietary salt reduction for hypertension
<6 g NaCl/d
Moderation of alcohol consumption for hypertension
For those who drink alcohol, consume ≤2 drinks/d in men and ≤1 drink/d in women
Cardioselective beta blockers (2)
Atenolol
Metoprolol
Nonselective beta blocker
Propanolol
Nonselective alpha antagonist used in pheochromocytoma
Phenoxybenzamine
Direct vasodilators used in HPN (2)
Hydralazine
Minoxidil
Normal quantity of pericardial fluid
15–50 mL
Most common pathologic process involving the pericardium
Acute pericarditis
Chest pain that is intensified by lying supine, and relieved by sitting up and leaning forward
Acute pericarditis
rasping, scratching, or grating sound heard most frequently at end expiration with the patient upright and leaning forward
pericardial friction rub
Stage of acute pericarditis where there is widespread elevation of the ST segments, often with upward concavity, involving two or three standard limb leads and V2–V6, with reciprocal depressions only in aVR and sometimes V1
stage 1
Also, depression of the PR segment below the TP segment, reflecting atrial involvement
Stage 2: ST segments return to normal
Stage of acute pericarditis where T waves become inverted
Stage 3
Stage 4: Weeks or months after the onset of acute pericarditis, the ECG returns to normal
Difference between the ST elevation in MI and pericarditis
MI – convex, reciprocal depression is usually more prominent
Acute pericarditis – concave
Patch of dullness and increased fremitus beneath the angle of the left scapula that is audible when base of the left lung may be compressed by pericardial fluid
Ewart’s sign
Chest xray finding of “water bottle” configuration
Massive pericardial effusion
Management of acute pericarditis (4)
- Aspirin 2-4 g/day
- NSAIDs (ibuprofen 600-800 mg tid or indomethacin 25–50 mg tid)
- Gastric protection (omeprazole)
- Colchicine 0.5 mg qd [<70 kg] or 0.5 mg bid [>70 kg] for 3 months
Glucocorticoids (e.g., prednisone 1 mg/kg per day) usually suppress the clinical manifestations of acute pericarditis in patients who have failed therapy with or do not tolerate NSAIDs and colchiine. However, since they increase the risk of subsequent recurrence, full-dose corticosteroids should be given for only 2–4 days and then tapered.
Drug that enhances the response to NSAIDs and also aids in reducing the risk of recurrent pericarditis
Colchicine
predictors of poor prognosis in acute pericarditis (3)
fever >38°C
subacute onset
large pericardial effusion
three principal features of tamponade
- Hypotension
- soft or absent heart sounds
- jugular venous distention with a prominent x (early systolic) descent but an absent y (early diastolic) descent
Beck’s triad
The limitations to ventricular filling are responsible for reductions of cardiac output and arterial pressure
Beck’s triad is seen in
Cardiac tamponade
The quantity of fluid necessary to produce cardiac tamponade may be as small as ____ when the fluid develops rapidly to as much as _____ in slowly developing effusions when the pericardium has had the opportunity to stretch and adapt to an increasing volume
200 mL
>2000 mL
greater than normal (10 mmHg) inspiratory decline in systolic arterial pressure or palpating weakness or even disappearance of the arterial pulse during inspiration
Paradoxical Pulse
important clue to the presence of cardiac tamponade
Paradoxical pulse also occurs in approximately one-third of patients with constrictive pericarditis, and in some cases of hypovolemic shock, acute and chronic obstructive airway disease, and pulmonary embolism
May resemble cardiac tamponade with hypotension, elevated jugular venous pressure, an absent y descent in the jugular venous pulse, and, occasionally, a paradoxical pulse
Right ventricular infarction
Doppler ultrasound shows that tricuspid and pulmonic valve flow velocities increase markedly during inspiration, whereas pulmonic vein, mitral, and aortic flow velocities diminish
Cardiac tamponade
Most common approach for pericardiocentesis
Subxiphoid approach
The most frequent complication of acute idiopathic pericarditis
recurrent (relapsing) pericarditis
Post cardiac injury syndrome is characterized by acute pericarditis that follows (4)
- cardiac operation (postpericardiotomy syndrome)
- blunt or penetrating cardiac trauma
- perforation of the heart with a catheter
- AMI.
The principal symptom of post cardiac injury syndrome is the pain of acute pericarditis, which usually develops ____ after the cardiac injury
1–4 weeks
This syndrome is probably the result of a hypersensitivity reaction to antigen(s) that originate from injured myocardial tissue and/or pericardium.
Post cardiac injury syndrome
Treatment of Post cardiac injury syndrome
aspirin and analgesics
pericarditis that is usually secondary to cardiothoracic operations, by extension of infection from the lungs or pleural cavities, from rupture of the esophagus into the pericardial sac, or from rupture of a valvular ring abscess in a patient with infective endocarditis
Pyogenic (purulent) pericarditis
2 forms of pericarditis seen in CKD patient
- Pericarditis of renal failure (uremic pericarditis)
- dialysis-associated pericarditis
When the pericarditis of renal failure is recurrent or persistent, a pericardial window should be created or pericardiectomy may be necessary.
Pericarditis due to neoplastic diseases results from extension or invasion of metastatic tumors, most commonly (5)
- lung
- Breast
- malignant melanoma
- lymphoma
- leukemia
Most common cause of chronic pericardial effusion (2)
- Tuberculosis
- Myxedema
Neoplasms, SLE, rheumatoid arthritis, mycotic infections, radiation therapy to the chest, and chylopericardium may also cause chronic pericardial effusion and should be considered and specifically sought in such patients
Management of chronic pericardial effusion
Pericardiectomy
Intrapericardial instillation of sclerosing agents may be used to prevent reaccumulation of fluid
This disorder results when the healing of an acute fibrinous or serofibrinous pericarditis or the resorption of a chronic pericardial effusion is followed by obliteration of the pericardial cavity with the formation of granulation tissue
Chronic constrictive pericarditis
Common cause of constrictive pericarditis
TB
Difference between the constrictive pericarditis and cardiac tamponade in terms of ventricular filling
Ventricular filling is unimpeded during early diastole but is reduced abruptly when the elastic limit of the pericardium is reached, whereas in cardiac tamponade, ventricular filling is impeded throughout diastole
The right and left atrial pressure pulses display an M-shaped contour, with prominent x and y descents
constrictive pericarditis
Difference between the constrictive pericarditis and cardiac tamponade in terms of y descent
y descent is absent or diminished in cardiac tamponade
y descent is prominent in constrictive pericarditis
In constrictive pericarditis, the ventricular pressure pulses in both ventricles exhibit characteristic ____ signs during diastole.
“square root”
In constrictive pericarditis, the apical pulse is reduced and may retract in systole. This is called
Broadbent’s sign
The apical pulse is reduced and may retract in systole The heart sounds may be distant; an early third heart sound occurring at the cardiac apex with the abrupt cessation of ventricular filling is often conspicuous
Constrictive pericarditis
The early third sound is the pericardial knock
Pericardial calcification is most common in
Tuberculous pericarditis
Pericardial calcification may, however, occur in the absence of constriction, and constriction may occur without calcification
Diagnostic test for constrictive pericarditis
CT or MRI
echocardiography cannot definitively establish or exclude the diagnosis of constrictive pericarditis
only definitive treatment of constrictive pericarditis
Pericardial resection
should be as complete as possible
In pericardial resection, coronary arteriography should be carried out preoperatively in patients aged ____ to exclude unsuspected accompanying coronary artery disease
> 50 years
This form of pericardial disease is characterized by the combination of a tense effusion in the pericardial space and constriction of the heart by thickened pericardium
Subacute Effusive-Constrictive Pericarditis
Wide excision of both the visceral and parietal pericardium is usually effective therapy
Tuberculous pericardial disease may present as (3)
- pericardial effusion
- chronic constrictive pericarditis
- subacute effusive constrictive pericarditis
If the etiology of chronic pericardial effusion remains obscure despite detailed analysis including culture of the pericardial fluid, a______ should be performed
pericardial biopsy, preferably by a limited thoracotomy
T or F. If definitive evidence of tb pericarditis is still lacking but the specimen shows granulomas with caseation, antituberculous chemotherapy is indicated.
True
If the biopsy specimen shows a thickened pericardium after 2–4 weeks of antituberculous therapy, ______ should be carried out
Pericardiectomy
to prevent the development of constriction
Duration of acute, subacute, and chronic pericarditis
Acute: <6 weeks
Subacute: 6 weeks to 6 months
Chronic: > 6 months
Five functional components of the mitral valve apparatus
- Leaflets
- Annulus
- Chordae tendineae
- Papillary muscles
- Subjacent myocardium
Acute MR can occur in the setting of (3)
- Acute myocardial infarction (MI) with papillary muscle rupture
- Blunt chest wall trauma
- During the course of infective endocarditis (IE) owing to leaflet perforation or destruction
Papillary muscle of the mitral valve that is most often involved in acute MI
posteromedial papillary muscle
because of its singular blood supply
Can result in “acute-on- chronic MR” in patients with myxomatous degeneration of the valve apparatus
Rupture of chordae tendineae
MV leaflets and/or chordae tendineae are primarily responsible for abnormal valve function
primary MR
MV leaflets and chordae tendineae are usually normal but the regurgitation is caused by left ventricular (LV) remodeling with annular enlargement, papillary muscle displacement, leaflet tethering, or their combination
secondary (functional) MR
MR may occur as a congenital anomaly, most commonly as a
defect of the endocardial cushions (atrioventricular cushion defects)
Chronic MR is frequently secondary to
ischemia
may occur as a consequence of ventricular remodeling, papillary muscle displacement, and leaflet tethering, or with fibrosis of a papillary muscle, in patients with healed MI(s) and ischemic cardiomyopathy
Chronic, severe MR is defined by a regurgitant volume_____, regurgitant factor ____, and effective regurgitant orifice area ____
≥60 mL/beat
≥50%
≥0.40 cm2
most prominent complaints in patients with chronic severe MR (3)
Fatigue, exertional dyspnea, and orthopnea
Holosystolic murmur, grade III/VI, most prominent in the apex and radiates to the axilla
MR
Systolic murmur that is transmitted to the base of the heart with cooing or “seagull” quality
MR secondary to ruptured chordae tendineae
Systolic murmur that is transmitted to the base of the heart with musical quality
MR secondary to flail leaflet
The systolic murmur of chronic MR not due to MVP is _______ by isometric exercise (handgrip) but is _____ during the strain phase
of the Valsalva maneuver
Increased
Decreased
because of the associated decrease in LV preload
Direct anticoagulants is contraindicated in this valve conditions (2)
- Rheumatic MS
2. Mechanical prosthetic heart valves
MV surgery that is preferred and has lower risk
Mitral valve repair
Repair usually consists of valve reconstruction using a variety of valvuloplasty techniques and insertion of an annuloplasty ring
Indications for mitral valve repair for chronic severe primary MR: (6)
- Symptomatic
- Asymptomatic patients with LV dysfunction characterized by an EF <60%
- Asymptomatic patients with an LV end-systolic dimension (LV ESD) >40 mm
- recent-onset AF (duration <3 months)
- pulmonary hypertension (defined as a systolic PA pressure ≥50 mmHg at rest or ≥60 mmHg with exercise)
- progressive decrease in LV EF or increase in LV ESD on serial imaging
leading cause of mitral stenosis
Rheumatic fever
Other less common etiologies of obstruction to left ventricular inflow include congenital mitral valve stenosis, cor triatriatum, mitral annular calcification with extension onto the leaflets, systemic lupus erythematosus, rheumatoid arthritis, left atrial myxoma, and infective endocarditis with large vegetations
Pure or predominant MS occurs in ____ of all patients with rheumatic heart disease and a history of rheumatic fever
~40%
“fish-mouth” valve
Rheumatic MS
Normal MV orifice
4-6 cm2
In the presence of significant obstruction, i.e., when the MV orifice area is reduced to ____, blood can flow from the LA to the left ventricle (LV) only if propelled by an abnormally elevated left atrioventricular pressure gradient
hemodynamic hallmark of MS
abnormally elevated left atrioventricular pressure gradient
When the mitral valve opening is reduced to <1.5 cm2, referred to as “severe” MS, an LA pressure of ____ is required to maintain a normal cardiac output (CO).
~25 mmHg
Severe MS has orifice of
1-1.5 cm2
The LV diastolic pressure and ejection fraction (EF) are ____ in isolated MS
normal
In patients with severe MS (mitral valve orifice 1–1.5 cm2), the CO is
normal or almost so at rest, but rises subnormally during exertion
In patients with very severe MS (valve area <1 cm2), particularly those in whom pulmonary vascular resistance is markedly elevated, the CO is subnormal at rest and may fail to rise or may even decline during activity
Very severe MS has orifice of
<1 cm2
Causes of pulmonary hypertension in MS (4)
- passive backward transmission of the elevated LA pressure
- pulmonary arteriolar constriction (the so-called “second stenosis”), which presumably is triggered by LA and pulmonary venous hypertension (reactive pulmonary hypertension)
- interstitial edema in the walls of the small pulmonary vessels
- end stage, organic obliterative changes in the pulmonary vascular bed
The development of ____ in MS often marks a turning point in the patient’s course and is generally associated with acceleration of the rate at which symptoms progress
persistent AF
Presents as a malar flush with pinched and blue facies, with prominent a waves, with normal or low BP
Severe MS
Auscultatory finding that is most readily audible in expiration at, or just medial to, the cardiac apex. This sound generally follows the sound of aortic valve closure (A2) by 0.05–0.12
Opening snap
MS
The time interval between A2 and OS varies inversely with the severity of the MS
Low-pitched, rumbling, diastolic murmur, heard best at the apex with the patient in the left lateral recumbent position; it is accentuated by mild exercise (e.g., a few rapid sit-ups) carried out just before auscultation
MS
Pansystolic murmur along the left sternal border that is louder during inspiration and diminishes during forced expiration is the murmur of _____. What do you call this sign?
TR
Carvallo’s sign
In severe pulmonary hypertension
A high-pitched, diastolic, decrescendo blowing murmur along the left sternal border, results from dilation of the pulmonary valve ring and occurs in patients with mitral valve disease and severe pulmonary hypertension
Graham Steell murmur of PR
Eariest chest X-ray changes in MS (4)
- straightening of the upper left border of the cardiac silhouette
- prominence of the main PA
- Dilation of the upper lobe pulmonary veins
- Posterior displacement of the esophagus by an enlarged LA
Target INR for patients with MS with AF or history of thromboembolism
2-3
Usually, cardioversion in MS with AF (recent onset) should be undertaken after the patient has had at least _____ of anticoagulant treatment to a therapeutic INR
3 consecutive weeks
If cardioversion is indicated more urgently, then intravenous heparin should be provided and TEE performed to exclude the presence of LA thrombus before the procedure
Conversion to sinus rhythm is rarely successful or sustained in patients with severe MS, particularly those in whom the LA is especially enlarged or in whom AF has been present for more than 1 year.
Indication of mitral valvotomy in MS
Symptomatic (NYHA FC II-IV) with isolated severe MS whose effective orifice is < ~1 cm2/m2 body surface area, or <1.5 cm2 in normal- sized adults
Asymptomatic patients or mild/moderate MS with recurrent systemic embolization or severe pulmonary hypertension
Successful valvotomy is defined by a ____ reduction in the mean mitral valve gradient and a ____ of the mitral valve area
50%
doubling
Preferred procedure for pregnant patient with MS
PMBV
Valvotomy should be carried out if pulmonary congestion occurs despite intensive medical treatment
Management of patients with MS and significant associated MR
Mitral valve replacement (MVR)
Indications for mitral valve replacement (MVR)
- Orifice area ≤1.5 cm2
2. NYHA Class III
Sex predilection of AS
Male
~80% of adult patients with symptomatic, valvular AS are male.
Most common causes of AS in adults (3)
Degenerative calcification occurs most commonly on a substrate of
- congenital disease (BAV)
- chronic (trileaflet) deterioration
- previous rheumatic inflammation.
T or F. Rheumatic AS is almost always associated with involvement of the mitral valve and with aortic regurgitation (AR).
True
Most common congenital heart valve defect
Bicuspid aortic valve (BAV)
Occurs in 0.5–1.4% of the population with a 2–4:1 male-to-female predominance
autosomal dominant with incomplete penetrance
Bicuspid aortic valve (BAV) is prominent in what chromosomal disorder
Turner’s syndrome
most common bicuspid AV variant
right-left cusp fusion
associated with enlargement of the ascending aorta along its greater curvature
AS associated with severe obstruction to LV outflow (2)
- Mean systolic pressure gradient >40 mmHg with a normal CO
- Effective aortic orifice area of ~<1 cm2 (or ~<0.6 cm2/m2 body surface area in a normal-sized adult)
AS is rarely of clinical importance until the valve orifice has narrowed to
~1 cm2
because of the ability of the hypertrophied LV to generate the elevated intraventricular pressures required to maintain a normal stroke volume
Once symptoms occur, valve replacement is indicated
T or F. Most patients with pure or predominant AS have gradually increasing obstruction over years but do not become symptomatic until the fourth decade.
False. 6th to 8th decade
Causes of exertional syncope in AS
- Decline in arterial pressure caused by vasodilation in the exercising muscles and inadequate vasoconstriction in nonexercising muscles in the face of a fixed CO
- Sudden fall in CO produced by an arrhythmia
three cardinal symptoms of AS
- Exertional dyspnea
- angina pectoris
- syncope
AF occurrence in AS should suggest the possibility of
associated mitral valve disease
Though it may also occur as a complication of AS at the late course of the disease
In the late stages of AS, when stroke volume______ , the systolic pressure may ____ and the pulse pressure ____.
declines
fall
narrow
Carotid arterial pulse rises slowly to a delayed peak
Pulsus parvus et tardus
Seen in AS
Low-pitched murmur, rough and rasping in character, and loudest at the base of the heart, most commonly in the second right intercostal space, and is transmitted upward along the carotid arteries
AS
The murmur of AS occasionally is transmitted downward and to the apex, where it may be confused with the systolic murmur of mitral regurgitation (MR). This is called
Gallavardin effect
Severe AS is defined by a valve area
<1 cm2
Moderate AS is defined by a valve area of
1–1.5 cm2
Mild AS by a valve area of
1.5–2 cm2
Aortic valve sclerosis is accompanied by a jet velocity of
<2.5 m/s (peak gradient <25 mmHg)
Catheterization is useful in three distinct categories of AS patients:
(1) patients with multivalvular disease, in whom the role played by each valvular deformity should be defined to aid in the planning of operative treatment
(2) young, asymptomatic patients with noncalcific congenital AS, to define the severity of obstruction to LV outflow, because operation or percutaneous aortic balloon valvuloplasty (PABV) may be indicated in these patients if severe AS is present, even in the absence of symptoms
(3) patients in whom it is suspected that the obstruction to LV outflow may not be at the level of the aortic valve but rather at the sub- or supravalvular level.
Calcific AS is a progressive disease, with an annual reduction in valve area averaging ____ and annual increases in the peak jet velocity and mean valve gradient averaging ____ and____, respectively
- 1 cm2
- 3 m/s
7 mmHg
T or F. In patients with severe AS (valve area <1 cm2), strenuous physical activity and competitive sports should be avoided once with symptoms.
False. Should be avoided even on asymptomatic stage
T or F. Medications used for the treatment of hypertension or CAD, including beta blockers and angiotensin-converting enzyme (ACE) inhibitors, are generally safe for asymptomatic AS patients with preserved LV systolic function.
True
Surgical management of AS is indicated in patients with
severe AS (valve area <1 cm2 or 0.6 cm2/m2 body surface area) who are symptomatic
- LV systolic dysfunction (EF <50%)
- BAV disease and an aneurysmal root or ascending aorta (maximal dimension >5.5 cm)
Bioprostheses for AS valve replacement are favored for patients age
> 65 years
Ross procedure
Its use has declined considerably in the United States because of the technical complexity of the procedure and the incidence of late postoperative aortic root dilation and autograft failure with AR
This procedure is preferable to operation in many children and young adults with congenital, noncalcific AS
Percutaneous aortic balloon valvuloplasty
It is not commonly used as definitive therapy in adults with severe calcific AS because of a very high restenosis rate (80% within 1 year) and the risk of procedural complications, but on occasion, it has been used successfully as a “bridge to operation” in patients with severe LV dysfunction and shock who are too ill to tolerate surgery. It is performed routinely as part of the TAVR procedure
