Cardiology_2 Flashcards
Truncus arteriosus gives rise to what?
ascending aorta and pulmonary trunk
which congenital cardiac defect is associated with 22q11 syndromes?
truncus arteriosus • ToF
which congenital cardiac defects are associated with Down syndrome?
ASD • VSD • AV septal defect (endocardial cushion defect)
which congenital cardiac defects are associated with congential rubella?
septal defects • PDA • PA stenosis
which congenital cardiac defects are associated with turner syndrome?
coarctation of the aorta (preductal)
which congenital cardiac defects are assciated with Mafan’s syndrome?
aortic insufficiency and dissection (late complication)
which congenital cardiac defects are associated with infants of diabetic mothers?
transposition of great vessels
hypertension is defined as what?
BP >= 140/90
what are the risk factors for hypertension?
↑ age • obesity • smoking • genetics • black>white>asian
90% of hypertension is what?
1° (essential) and related to ↑ CO and ↑ TPR
10 % of hypertension is what?
mostly 2° to renal disease
features of malignant hypertension?
severe • >180/120 • rapidly progressing
hypertension predisposes to what?
athersclerosis • LVH • stroke • CHF • renal failure • retinopathy • aortic dissection
what are the signs of hyperlipidemia?
atheromas • xanthomas • tendinous xanthoma • corneal arcus
what are atheromas?
plaques in blood vessel wall
what are xanthomas?
plaques or nodules composed of lipid-laden histiocytes in the skin, especially the eyelids
what do you call a xanthoma of the eyelid?
xanthelasma
what is a tendinous xanthoma?
lipid depost in the tendon, especially the achilles
what is corneal arcus?
lipid deposit in cornea, nonspecific (arcus senilis)
what are the 3 classes of arteriosclerosis?
Monckberg • arteriosclerosis • atherosclerosis
what is Monckberg arteriosclerosis?
calcification in the media of the arteries, especially radial or ulnar
severity of monckberg arteriosclerosis?
usually benign • does not obstruct blood flow • intima not involved
typical presentation of monckberg arteriosclerosis?
pipestem arteries
what are the two subtypes of arteriosclerosis?
hyaline • hyperplastic
what is hyaline arteriosclerosis?
thickening of small arteries in essential hypertension or DM
what is hyperplastic arteriosclerosis?
onion skinning in malignant hypertension
what is atherosclerosis?
fibrous plaques and atheromas form in intima of arteries
what type of disease is atherosclerosis?
disease of elastic arteries and large and medium sized muscular arteries
what are the modifiable risk factors for atherosclerosis?
smoking • hypertension • hyperlipidemia • diabetes
what are the non-modifiable risk factors for atherosclerosis?
age, gender (↑ in men and postmenopausal women), and positive family history
what is important in the pathogenesis of atherosclerosis?
inflammation
what is the progression of atherosclerosis?
endothelial cell dysfunction → macrophage and LDL accumulation → foam cell formation → fatty streaks → smooth muscle cell migration (involves PDGF and FGF), proliferation and ECM deposition → fibrous plaque → complex atheromas
important histological finding in atherosclerosis?
cholesterol crystals
what are the complications of atherosclerosis?
aneurysms • ischemia • infarcts • peripheral vascular disease • thrombus • emboli
what is the relative frequency of location of atherosclerosis?
abdominal aorta > coronary artery > popliteal artery > carotid artery
what are the symptoms of atherosclerosis?
angina • claudication • but can be asymptomatic
what is an aortic aneurysm?
localized pathologic dilation of the aorta
what are the 2 types of aortic aneurysm?
AAA • TAA
AAA is associated with what?
atherosclerosis
AAA occurs more frequently in who?
hypertensive male smokers> 50yo
TAA is associated with what?
hypertension, cystic medial necrosis (Marfan’s) and historically 3° syphilis
what happens in aortic dissection?
longitudinal intraluminal tear forming a false lumen
aortic dissection associated with what?
hypertension • bicuspid aortic valve • cystic medial necrosis • inherited connective tissue disorders (Marfans)
aortic dissection presents how?
tearing chest pain radiating to the back
in aortic dissection, CXR shows what?
mediastinal widening
possibilities for the false lumen in aortic dissection?
can be limited to the ascending aorta, propagate from the ascending aorta, or propagate from the descending aorta
aortic dissection can result in what?
pericardial tamponade • aortic rupture • death
what are the ischemic heart disease manifestations?
angina • coronary steal syndrome • myocardial infarction • sudden cardiac death • chronic ischemic heart disease
pathology involved in angina?
CAD narrowing >75% • no myocyte necrosis
stable angina is mostly 2° to what?
atherosclerosis
presentation of stable angina?
ST depression on ECG • retrosternal chest pain with exertion
Prinzmental angina occurs when?
at rest 2° to coronary artery spasm
ECG finding in prinzmental angina?
ST elevation
pathology involved in unstable angina?
thrombosis with incomplete coronary artery occlusion
presentation of unstable/crescendo angina?
ST depression on ECG • worsening chest pain at rest or with minimal exertion
what happens in coronary steal syndrome?
vasodilator may aggravate ischemia by shunting blood from area of critical stenosis to an area of higher perfusion
myocardial is most often due to what?
acute thrombosis due to coronary artery atherosclerosis with complete occlusion of coronary artery with myocyte necrosis
ECG findings in MI?
ECG initially shows ST depression progressing to ST elevation with continued ischemia and transmural necrosis
what is sudden cardiac death?
death from cardiac causes within 1 hour of onset of symptoms, most commonly due to a lethal arrhythmia (V-fib)
sudden cardiac death is associated with what?
CAD up to 70% of cases
what is chronic ischemic heart disease?
progressive onset of CHF over many years due to chronic ischemic myocardial damage
relative frequency of coronary artery occlusion in MI?
LAD >RCA > circumflex
what are the symptoms of MI?
diaphoresis • nausea • vomiting • severe retrosternal pain • pain in left arm and or jaw • shortness of breath • fatigue
what are the gross findings within 0-4h of MI?
none
what are the LM findings within 0-4h of MI?
none
what are the risks within 0-4h of MI?
arrhythmia • CHF • exacerbation • cardiogenic shock
what are the gross findings within 4-24h of MI?
infarct and dark mottling; pale with tetrazolium stain distal to occluded artery
what are the LM findings within 4-12h of MI?
early coagulative necrosis • edema • hemorrhage • wavy fibers
what is the risk within 4-12h of MI?
arrhythmia
what are the LM findings within 12-24h of MI?
contraction bands from reperfusion injury • release of necrotic cell content into blood • beginning of neutrophil migration
what is the risk within 12-24h of MI?
arrhythmia
what are the gross findings within 1-3 days of MI?
hyperemia
what are the LM findings within 1-3days of MI?
extensive coagulative necrosis • tissue surrounding infarct shows acute inflammation • neutrophil migration
what is the risk within 1-3 days of MI?
fibrinous pericarditis
what are the gross findings within 3-14days of MI?
hyperemic border; • central yellow-brown softening • maximally yellow and soft by 10 days
LM findings within 3-14days of MI?
macrophage infiltration followed by granulation tissue at the margins
what is the risk within 3-14 days of MI?
free wall rupture leading to tamponade, papillary muscle rupture, ventricular aneurysm, interventricular septal rupture due to macrophages that have degraded important structural components
what are the gross findings 2weeks-months post MI?
recanalized artery • gray white
LM findings 2 weeks-months post MI?
contracted scar complete
risk 2weeks-months post MI?
dressler’s syndrome
what is the gold standard for dx of MI in first 6h?
ECG
use of cardiac troponin I in diagnosis of MI?
rises after 4 hours and is elevated for 7-10 days; more specific than other protein markers
use of CK-MB in diagnosis of MI?
useful in diagnosing reinfarction following acute MI because levels return to normal after 48 hours
CK-MB predominantly found where?
in myocardium but can also be released from skeletal muscle
ECG changes in MI?
ST elevation (transmural infarct) • ST depression (subendocardial infarct) • Q waves (transmural infarct)
necrosis in transmural infarct?
↑ necrosis
subendocardial infarcts due to what?
ischemic necrosis of < 50% of ventricle wall
transmural infarct affects how much of cardiac structure?
affects entire wall
subendocardial infarct affect what structure?
subendocardium especially vulnerable to ischemia
ECG in transmural infarcts?
ST elevation • Q waves
ECG in subendocardial infarct?
ST depression
Q waves in V1-V4, where is the infarct?
Anterior wall (LAD)
Q waves in V1-V2, where is the infarct?
Ateroseptal (LAD)
Q waves in V4-V6, where is the infarct?
anterolateral (LCX)
Q waves in I, aVL, where is the infarct?
lateral wall (LCX)
Q waves in II, III, aVF, where is the infarct?
inferior wall (RCA)
in MI, what is an important cause of death before reaching hospital?
cardiac arrhythmia
cardiac arrhythmia in MI is common when?
in first few days
what are the complications of MI?
cardiac arrhythmia • LV failure and pulmonary edema • Cardiogenic shock • Ventricular free wall rupture • papillary muscle rupture • IVS rupture • ventricular aneurysm formation • postinfarction fibrinous pericarditis
what is Dressler’s syndrome?
autoimmune phenomenon resulting in fibrinous pericarditis (several weeks post MI)
factors associated with cardiogenic shock in MI?
large infarct- high risk of mortality
in MI ventricular free wall rupture →?
cardiac tamponade
in MI, papillary muscle rupture→?
severe mitral regurgitation
in MI, IVS rupture→?
VSD
factors associated with ventricular aneurysm formation in MI?
↓ CO • risk of arrhythmia • embolus from mural thrombus
when is the greatest risk for ventricular aneurysm formation in MI?
1 week post MI
what is the most common cardiomyopathy?
dilated (congestive) cardiomyopathy 90%
dilated cardiomyopathy is usually what origin?
often idiopathic, up to 50% familial
specific etologies of dilated cardiomyopathy include what?
ABCCCD • Alcohol abuse • wet Beriberi • Coxsackie b virus myocarditis • chronic Cocaine use • Chaga’s disease • Doxorubicin toxicity • hemochromatosis • peripartum cardiomyopathy
what are the findings in dilated cardiomyopathy?
S3 • dilated heart on U/S • balloon appearance on chest X ray
what is the treatment for dilated cardiomyopathy?
Na+ restriction • ACE inhibitors • diuretics • digoxin • heart transplant
what happens in hypertrophic cardiomyopathy?
hypertrophied interventricular septum is too close to mitral valve leaflet, leading to outflow tract obstruction
60-70% of hypertrophic cardiomyopathy are of what origin?
familial • AD • βmyosin heavy chain mutation
hypertrophic cardiomyopathy is associated with what?
Friedreich’s ataxia
morphologic findings in hypertrophic cardiomyopathy?
disoriented, tangled, hypertrophied myocardial fibers
what is a cause of sudden death in young athletes?
hypertrophic cardiomyopathy
what are the findings in hypertrophic cardiomyopathy?
normal sized heart • S4 • apical impulses • systolic murmur
what is the treatment for hypertrophic cardiomyopathy?
β blocker or non-dihydropyridine calcium channel blocker (verapamil)
what ensues in hypertrophic cardiomyopathy?
diastolic dysfunction
gross appearance in hypertrophic cardiomyopathy?
asymmetric concentric hypertrophy (sarcomeres added in parallel)
pathogenesis of hypertrophic cardiomyopathy?
proximity of hypertrophied interventricular septum to mitral leaflet obstructs outflow tract, resulting in systolic murmur and syncopal episodes
major causes of restrictive/obliterative cardiomyopathy include what?
sarcoidosis • amyloidosis • postradiation fibrosis • endocardial fibroelastosis • Lofflers syndrome • hemochromatosis
what is endocardial fibroelastosis?
thick fibroelastic tissue in endocardium of young children
what is Loffler’s syndrome?
endomyocardial fibrosis with a prominent eosinophilic infiltrate
what ensues in restrictive/obliterative cardiomyopathy?
diastolic dysfunction
what is CHF?
a clinical syndrome that occurs in patients with an inherited or acquired abnormality of cardiac structure or function, which is characterized by a constellation of clinical symptoms (dyspnea, fatigue) and signs (edema, rales)
in CHF RHF most often results from what?
LHF
isolated RHF is usually due to what?
cor pulmonale
which drugs reduce mortality in CHF?
ACE inhibitors • β blockers • ARBs • spironolactone
when do you not give β blockers in CHF?
acute decompensated HF
which drugs are used for symptomatic relief in CHF?
thiazides • loop diuretics
which drugs improve symptoms and mortality in select patients with CHF?
hydralazine with nitrate therapy
what are the abnormalities seen in CHF?
cardiac dilation • dyspnea on exertion • LHF • RHF
what is the cause of cardiac dilation in CHF?
greater ventricular EDV
what is the cause of DOE in CHF?
failure of cardiac output to ↑ during exercise
what are the manifestations of LHF in CHF?
pulmonary edema/PND • orthopnea
what is the cause of pulmonary edema/PND in CHF?
↑ pulmonary venous pressure→ pulmonary venous distentions and transudation of fluid
histological finding in LHF in CHF?
presence of hemosiderin laden macrophages (heart failure cells) in the lungs
what is the cause of orthopnea in CHF?
↑ venous return in supine position exacerbates pulmonary vascular congestion
what are the manifestations of RHF in CHF?
hepatomegaly (nutmeg liver) • peripheral edema • jugular venous distention
what is the cause of hepatomegaly (nutmeg liver) in CHF?
↑ central venous pressure → ↑ resistance to portal flow
rarely, hepatomegaly in RHF leads to what?
cardiac cirrhosis
what is the cause of peripheral edema in CHF?
↑ venous pressure → fluid transudation
what is the cause of jugular venous distention in CHF?
↑ venous pressure
what are the symptoms of bacterial endocarditis?
Bacteria FROM JANE: • Fever • Roth spots • Osler nodes • Murmur • Janeway lesions • Anemia • Nail-bed hemorrhage • Emboli
what is the most common symptom of bacterial endocarditis?
fever
what are roth spots?
round white spots on retina surrounded by hemorrhage
what are osler’s nodes?
tender raised lesions on finger or toe pads
what are janeway lesions?
small, painless, erythematous lesions on palm or sole
what is necessary for diagnosis of bacterial endocarditis?
multiple blood cultures
organism that causes acute bacterial endocarditis?
S aureus
virulence of organism that causes acute bacterial endocarditis?
S aureus (high virulence)
presentation in acute bacterial endocarditis caused by S aureus?
large vegetations on previously normal valves
what is the onset of acute bacterial endocarditis caused by S aureus?
rapid onset
organism that causes subacute bacterial endocarditis?
viridans streptococcus
virulence of the organism that causes subacute bacterial endocarditis?
low virulence
presentation in subacute bacterial endocarditis?
smaller vegetations on congenitally abnormal or diseased valves
subacute bacterial endocarditis can be sequelae of what?
dental procedures
what is the onset of subacute bacterial endocarditis?
more insidious onset
endocarditis may be nonbacterial secondary to what?
malignancy • hypercoagulable state • lupus (marantic/ thrombotic endocarditis)
S bovis is present in which cause of endocarditis?
colon cancer
S epidermidis is present in which cause of endocarditis?
prosthetic valves
which valve is most frequently involved in bacterial endocarditis?
mitral
tricuspid valve endocarditis is associated with what?
IV drug use (dont TRI DRUGS)
tricuspid endocarditis is associated with which organisms?
S aureus • Pseudomonas • Candida
what are the complications of bacterial endocarditis?
chordae rupture • glomerulonephritis • suppurative pericarditis • emboli
rheumatic fever is a consequence of what?
pharyngeal infection with group A β hemolytic streptococci
early deaths in rheumatic fever due to what?
myocarditis
late sequelae of rheumatic fever include what?
rheumatic heart disease
relative frequency of valves affected by rheumatic heart disease?
mitral > aortic»_space; tricuspid (high pressure vavles affected most)
early lesion in rheumatic fever is what?
MR
what is the late lesion in rheumatic fever?
MS
Rheumatic fever is associated with what?
Aschoff bodies • Anitschkow’s cells • elevated ASO titers
what are Aschoff bodies?
granuloma with giant cells
what are anitschkow’s cells?
activated histiocytes
immunology of rheumatic fever?
Type II HSR; not a direct effect of bacteria • Ab to M protein
symptoms of Rheumatic fever?
FEVERSS: • Fever • Erythema marginatum • Valvular damage • ESR ↑ • Red hot joints (migratory polyarthritis) • Subcutaneous nodules • St. Vitus’ dance (Sydenham’s chorea)
acute pericarditis commonly presents with what?
sharp pain, aggravated by inspiration, and relieved by sitting up and leaning forward • friction rub
ECG findings in acute pericarditis?
widespread ST-segment elevation and/or PR depression
acute fibrinous pericarditis is caused by what?
Dressler’s syndrome, • uremia • radiation
fibrinous pericarditis presents with what?
loud friction rub
what are the causes of serous pericarditis?
viral • noninfectious inflammatory diseases
course of viral serous pericarditis?
often resolves spontaneously
non infectious inflammatory diseases that cause acute serous pericarditis?
RA • SLE
what causes suppurative/purulent pericarditis?
bacterial infections with pneumococcus or streptococcus
frequency of purulent pericarditis?
rare with antibiotics
what happens in cardiac tamponade?
compression of heart by fluid (blood effusions) in pericardium leading to ↓ CO
what happens to pressures in cardiac tamponade?
equilibration of pressures in all 4 chambers
what are the findings in cardiac tamponade?
hypotension • ↑ venous pressure (JVD) • distant heart sounds • ↑ HR • pulsus paradoxus
what is pulsus paradoxus?
↓ in amplitude of systolic blood pressure by >=10mHg during inspiration
pulsus paradoxus seen in what?
severe cardiac tamponade • asthma • OSA • pericarditis • croup
what happens in syphilitic heart disease?
3° syphilis disrupts the vasa vasorum of the aorta with consequent atrophy of the vessel wall and valve ring
in syphilitic heart disease you may see what?
calcification of the aortic root and ascending aortic arch
syphilitic heart disease leads to what appearance?
tree bark appearance of the aorta
syphilitic heart disease can result in what?
aneurysm of the ascending aorta or aortic arch and aortic insufficiency
what are the most common primary cardiac tumors in adults?
myxomas
90% of cardiac myxomas occur where?
in the atria (mostly left atrium)
myxomas are usually described as what?
ball valve obstruction in LA associated with multiple syncopal episodes
what is the most frequent primary cardiac tumor in children?
rhabdomyomas
cardiac rhabdomyomas are associated with what?
tuberous sclerosis
most common heart tumor is what?
mets from melanoma or lymphoma
what is Kussmaul’s sign?
↑ in JVP on inspiration instead of normal ↓
what happens in Kussmaul’s sign?
inspiration → negative intrathoracic pressure not transmitted to the heart→ impaired filling of RV → blood backs up into the venae cavae→ JVD
Kussmaul’s sign may be seen in what?
constrictive pericarditis • restrictive cardiomyopathies • RA or RV tumors • cardiac tamponade
Raynaud’s phenomenon affects what type of vessels?
small vessels
what happens in Raynaud’s phenomenon?
↓ blood flow to the skin due to arteriolar vasospasm in response to cold temperature or emotional stress
Raynauds phenomenon is most often seen where?
fingers • toes
when is it called Raynaud’s disease?
when primary (idiopathic)
when is it called Raynaud’s syndrome?
when secondary to a disease process such as mixed connective tissue disease, SLE, or CREST
temporal arteritis generally affects who?
elderly females
symptoms in temporal arteritis?
unilateral headache (temporal artery) • jaw claudication
temporal arteritis may lead to what?
irreversible blindness die to ophthalmic artery occlusion
temporal arteritis is associated with what?
polymyalgia rheumatica
temporal arteritis most commonly affects which vessels?
branches of carotid artery
pathology/labs seen in temporal arteritis?
focal granulomatous inflammation • ↑ ESR
what is the treatment for temporal arteritis?
high dose corticosteroids
Takayasu arteritis typically affects who?
asian females <40yo
symptoms of takayasu arteritis?
pulselessness disease: • fever • night sweats • arthritis • myalgias • skin nodules • ocular disturbances
pathology/labs seen in takayasu arteritis?
granulomatous thickening of aortic arch, proximal great vessels • ↑ ESR
what is the treatment for takayasu arteritis?
corticosteroids
what are the large artery vasculitis disorders?
temporal arteritis and takayasu arteritis
what are the medium vessel vasculitis disorders?
polyarteritis nodosa • kawasaki disease • Buerger’s disease (thromboangitis obliterans)
polyarteritis nodosa affects who?
young adults
viral association with polyarteritis nodosa?
HBV seropositivity in 30% of patients
symptoms of polyarteritis nodosa?
fever • weight loss • malaise • headache • abdominal pain • melena • HTN • neuro dysfunction • cutaneous eruptions • renal damage
polyarteritis nodosa typically involves which vessels?
renal and visceral vessels, not pulmonary arteries
immunology of polyarteritis nodosa?
IC mediated
pathology/labs seen in polyarteritis nodosa?
transmural inflammation of the arterial wall with fibrinoid necrosis • lesions are of different stages • many aneurysms and constrictions on arteriogram
treatment for polyarteritis nodosa?
corticosteroids • cyclophosphamide
kawasaki disease affects who?
asian children < 4yo
symptoms associated with kawasaki disease?
fever cervical lymphadenitis • conjunctival injection • changes in lips/oral mucosa (strawberry tongue) • hand-foot erythema • desquamating rash
children with kawasaki disease may develop which complications?
coronary aneurysms → MI, rupture
treatment for kawasaki disease?
IV immunoglobulin and aspirin
Buerger’s disease affects who?
heavy smokers, males <40yo
symptoms in Buerger’s disease?
intermittent claudication may lead to gangrene, autoamputation of digits, superficial nodular phlebitis • raynauds phenomenon
what is the pathology seen in buerger’s disease?
segmental thrombosing vasculitis
what is the treatment for buergers disease?
smoking cessation
what are the small vessel vasculitis disorders?
microscopic polyangitis • Wegener’s granulomatosis (granulomatosis with polyangitis) • Churg strauss syndrome • Henoch Schonlein purpura
what is microscopic polyangitis?
necrotizing vasculitis commonly involving lung, kidneys, and skin with pauci immune glomerulonephritis and palpable purpura
pathology/labs seen in microscopic polyangitis?
no granulomas • p-ANCA
what is the treatment for microscopic polyangitis?
cyclophosphamide and corticosteroids
what are the upper respiratory tract symptoms of wegener’s granulomatosis?
perforation of nasal septum, • chronic sinusitis • otitis media • mastoiditis
what are the lower respiratory symptoms of Wegener’s granulomatosis?
hemoptysis • cough • dyspnea
what are the renal manifestations of wegener’s granulomatosis?
hematuria • red cell casts
what is the triad that characterizes wegener’s granulomatosis?
focal necrotizing vasculitis • necrotizing granulomas in the lung and upper airway • necrotizing glomerulonephritis
what are the labs seen in wegeners granulomatosis?
c-ANCA • CXR: large nodular densities
what is the treatment for wegeners granulomatosis?
cyclophosphamide • corticosteroids
what are the symptoms of Churg-strauss syndrome?
asthma • sinusitis • palpable purpura • peripheral neuropathy (wrist/foot drop) • can also involve heart, GI, pauci-immune glomerulonephritis
pathology/labs seen in Churg strauss syndrome?
granulomatous, necrotizing vasculitis with eosinophilia • p-ANCA, elevated IgE level
what is the most common childhood systemic vasculitis?
henoch-schonlein purpura
henoch-schonlein purpura often follows what?
URI
what is the classic triad of henoch schonlein purpura?
skin: palpable purpura on buttocks/legs • arthralgia • GI: abdominal pain, melena, multiple lesions of same age
pathology seen in henoch schonlein purpura?
vasculitis secondary to IgA complex deposition • associated with IgA nephropathy
what is a strawberry hemangioma?
benign hemangioma of infancy
strawberry hemangioma appears when?
first few weeks of life (1/200 births)
course of strawberry hemangioma?
grows rapidly and regresses spontaneously at 5-8 years of age
what is a cherry hemangioma?
benign capillary hemangioma of the elderly
course of cherry hemangioma?
does not regress
incidence of cherry hemangioma?
frequency ↑ with age
what is a pyogenic granuloma?
polypoid capillary hemangioma that can ulcerate and bleed
pyogenic granuloma is associated with what?
trauma and pregnancy
what is a cystic hygroma?
cavernous lymphangioma of the neck
cystic hygroma is associated with what?
Turner syndrome
what is a glomus tumor?
benign painful red-blue tumor under fingernails
glomus tumor arises from what?
modified smooth muscle cells of the glomus body
what is bacillary angiomatosis?
benign capillary skin papules found in AIDS patients
bacillary angiomatosis is caused by what?
Bartonella henselae infections
bacillary angiomatosis is frequently mistaken for what?
kaposi sarcoma
what is angiosarcoma?
rare blood vessel malignancy typically occuring in the head, neck, and breast areas
angiosarcoma is associated with what?
patients receiving radiation therapy, especially for BRCA and hodgkins lymphoma
course of angiosarcoma?
very aggressive and difficult to resect due to delay in diagnosis
what lymphangiosarcoma?
lymphatic malignancy associated with persistent lymphedema (post radical mastectomy)
what is kaposi sarcoma?
endothelial malignancy most commonly of the skin but also mouth, GIT, and respiratory tract
kaposi sarcoma is associated with what?
HHV-8 and HIV
kasposi sarcoma is frequently mistaken for what?
bacillary angiomatosis
what is sturge-weber disease?
congenital vascular disorder that affects capillary sized blood vessels.
Sturge-weber disease manifests how?
with port wine stain (nevus flammeus) on face • ispilateral leptomeningeal angiomatosis (intracerebral AVM) • seizures • early onset glaucoma
what are the antihypertensive therapies for essential hypertension?
diuretics • ACEI • ARBs • Ca channel blockers
what are the antihypertensive therapies used in CHF?
diuretics • ACEI/ARBs (compensated CHF) • K+ sparing diuretics
β blockers must be used cautiously in what?
decompensated CHF
β blockers are contraindicated in what?
cardiogenic shock
what are the antihypertensive therapies used in DM?
ACEI/ARBs • Ca channel blockers • diuretics • β blockers • α blockers
ACEIs are protctive against what in DM?
diabetic nephropathy
which drugs are Ca channel blockers?
nifedipine • verapamil • diltiazem • amlodipine
MOA of Ca channel blockers?
block voltage dependent L type calcium channels of cardiac and smooth muscle and thereby reduce muscle contractility
relative effect on smooth muscle of Ca channel blockers?
Vascular smooth muscle- amlodipine=nifedipine>diltiazem>verapamil
relative effect on heart of Ca channel blockers?
heart- verapamil>diltiazem>amlodipine=nifedipine • Verapamil-ventricle
clinical use of Ca channel blockers?
hypertension • angina • arrhythmias (not nifedipine) • prinzmental’s angina • Raynauds
toxicity of Ca channel blockers?
cardiac depression • AV block • peripheral edema • flushing • dizziness • constipation
MOA of hydralazine?
↑cGMP→smooth muscle relaxation • vasodilates arterioles > veins • ↓ afterload
clinical use of hydralazine?
severe hypertension • CHF • first line tx for htn in pregnancy, with methyldopa • frequently coadministered with β blocker to prevent reflex tachycardia
toxicity of hydralazine?
compensatory tachycardia (CI in angina/CAD), fluid retention, nausea, HA, angina • Lupus like syndrome
commonly used drugs for malignant hypertension treatment?
nitroprusside • nicardipine • clevidipine • labetalol • fenoldopam
features of nitroprusside for malignant hypertension?
short acting • ↑ cGMP via direct release of NO
toxicity of nitroprusside?
can cause cyanide toxicity
MOA of fenoldopam?
dopamine D1 receptor agonist→ coronary, peripheral, renal, splanchnic vasodilation→ ↓BP and ↑ natriuresis
MOA of nitroglycerine, isosorbide dinitrate?
vasodilate by releasing NO in smooth muscle, causing ↑ cGMP in and smooth muscle relaxation • dilates veins»arteries • ↓preload
clinical use of GTN, ISDN?
angina • pulmonary edema
toxicity of GTN, ISDN?
reflex tachycardia, hypotension, flushing, HA, “monday disease” in industrial exposure
what is monday disease in industrial GTN, ISDN exposure?
development of tolerance for the vasodilating action during the work week and loss of tolerance over the weekend results in tachycardia, dizziness, and HA upon reexposure
what is the goal of antianginal therapy?
reduction of myocardial O2 consumption (MVO2) by decreasing >=1 of the determinants of MVO2: EDV, BP, HR, contractility, ejection time
effect of nitrates on EDV?
↓
effect of β blockers on EDV?
↑
effect of nitrates+ β blockers on EDV?
no effect or ↓
effect of nitrates on BP?
↓
effect of βblockers on BP?
↓
effects of nitrates + βblockers on BP?
↓
effect of nitrates on contractility?
↑ (reflex response)
effects of β blockers on contractility?
↓
effect of nitrates + βblockers on contractility?
little/no effect
effect of nitrates on HR?
↑ (reflex)
effect of βblockers on HR?
↓
effect of nitrates + β blockers on HR?
↓
effect of nitrates on ejection time?
↓
effect of β blockers on ejection time?
↑
effect of nitrates + βblockers on ejection time?
little/no effect
effect of nitrates on MVO2?
↓
effect of β blockers on MVO2?
↓
effect of nitrates + βblockers on MVO2?
↓↓
how do Ca channel blockers compare to the effects of nitrates and beta blockers on MVO2?
nifedipine is similar to nitrates • verapamil is similar to beta blockers
which are the partial β agonists contraindicated in angina?
pindolol and acebutalol
effect of HMG-CoARI’s on LDL?
↓↓↓
effect of HMG-CoARIs on HDL?
↑
effect of HMGCoARI’s on TG?
↓
MOA of HMGCoARIs?
inhibit conversion of HMG-CoA to mevalonate, a cholesterol precursor
AE of HMGCoARIs?
hepatotoxicity (↑LFT) • rhabdomyolysis
effect of niacin on LDL?
↓↓
effect of niacin on HDL?
↑↑
effect of niacin on TG ?
↓
MOA of niacin?
inhibits lipolysis in adipose tissue; • reduces hepatic VLDL secretion into circulation
AE of niacin?
red, flushed, face which is ↓ by aspirin or long term use • hyperglycemia (acanthosis nigricans) • hyperuricemia (exacerbates gout)
effect of bile acid resins on LDL?
↓↓
effect of bile acid resins on HDL?
slightly ↑
effect of bile acid resins on TG?
slightly ↑
MOA of bile acid resins?
prevent intestinal reabsorption of bile acids; liver must use cholesterol to make more
AE of bile acid resins?
patients hate it- • tastes bad and causes GI discomfort • ↓ absorption of fat soluble vitamins • cholesterol gallstones
effect of ezetimibe on LDL?
↓↓
effect of ezetimibe on HDL ?
no effect
effect of ezetimibe on TG?
no effect
MOA of ezetimibe?
prevent cholesterol reabsorption at small intestinal brush border
AE of ezetimibe?
rare ↑ in LFTs • diarrhea
effects of fibrates on LDL?
↓
effects of fibrates on HDL?
↑
effects of fibrates on TG?
↓↓↓
MOA of fibrates?
upregulate LPL→↑TG clearance
AE of fibrates?
myositis • hepatotoxicity • cholesterol gallstones
PK of digoxin?
75% bioavailability • 20-40% protein bound • t1/2=40h • urinary excretion
MOA of digoxin?
direct inhibition of Na+/K+ ATPase leads to indirect inhibition of Na+/Ca++ exchanger/antiport • ↑[Ca++]i → positive inotropy • stimulates vagus → ↓ HR
clinical use of digoxin?
CHF • atrial fibrillation
why use digoxin in CHF?
↑ contractility
why use digoxin in atrial fibrillation?
↓conduction at AV node and depression of SA node
