Cardiovascular Flashcards
1
Q
What are the three factors that increase Preload (EDV or EDP)
A
- Exercise
- increase in Blood Volume (e.g. overtransfusion)
- Excitement ( increase in Sympathetic Tone )
2
Q
How is Cardiac Output maintained during early exercise vs. late exercise?
A
Early Exercise: increasing both HR and SV
Late Exercise: increasing HR (SV plateaus)
3
Q
What factors affect the viscosity of blood?
-What increases viscosity?
A
- polycethemia
- Hyperproteinemic states (e.g. multiple myeloma)
- hereditatry spherocytosis
4
Q
What factors affect the viscosity of blood?
-What decreases viscosity?
A
-Anemia
5
Q
What accounts for most of the peripheral resistance?
A
Arterioles!
6
Q
What is the normal ejection fraction
A
55%
7
Q
What are the three different types of pericardititis?
A
- FIBRINOUS:
- Serous
- Purulent/Suppurative
8
Q
What causes each of the three different types of acute pericardititis?
A
FIBRINOUS:
- Dressler's Syndrome
- Uremia
- Radiation
-SEROUS:
-Viral Pericarditis
-Noninfectious Inflammatory Diseases
(RA, SLE)
-PURULANT/SUPPURATIVE:
-bacteria (pneumococcus &
streptococcus)
9
Q
What are the findings in Cardiac Tamponade?
-name 7
A
-Pulsus Paradoxus
-Decreased Cardiac Output …with a small heart
-Hypotension (or reduced MAP)
-Jugular Venous Distention ( because SVC cannot
empty)
-Tachycardia
-Distant heart sounds
-Equilibration of diastolic pressures in all 4 chambers of the heart
10
Q
In which conditions do we normally find Pulsus Paradoxus?
-name 5
A
Asthma Cardiac Tamponade Obstructive Sleep Apnea Pericarditis Croup
11
Q
Name 2 conditions that can arise from enlargement of the Left Atrium?
A
- Dysphagia due to compression of the esophagus
- Hoarseness due to compression of the left recurrent laryngeal nerve
12
Q
Which method is best for diagnosing left atrial enlargement?
–what two other conditions can be best diagnosed by the same method?
A
TransEsophageal Echocardiography
- Other conditions:
1) aortic dissection
2) thoracic aortic aneurysm
13
Q
Demographic Dominance of coronary circulation is determined using which artery/branch of the coronary circulation?
A
The PD: posterior descending/interventricular artery.
- In 85% of the pop,it arises from the RCA
- In 8%, it comes from the left circumflex coronoary artery (LCX)…a branch of the LCA
- In 7%, the PD comes from both the RCA and the LCX–in which case we call it codominance
14
Q
Which artery supplies the RV?
A
Right Marginal A
15
Q
Which artery supplies the SA and AV nodes?
A
RCA
16
Q
Which artery supplies the LV
A
ANTERIOR SURFACE:
-left anterior descending artery
POSTERIOR&LATERAL SURFACE:
-left circumflex Artery (LCX)
17
Q
Structures supplied by the LAD of the coronary arteries?
A
- anterior surface of LV
- anterior 2/3 of the IV septum
- anterior papillary muscle
- Apex
18
Q
What structure(s) is/are supplied by the PD branch of the coronaries?
A
posterior 1/3 of the IV septum
19
Q
Which disease can result in 3rd degree AV (heart ) block?
A
Lyme Disease!!!
20
Q
4 effects of ANP on the kidney?
-name 4
A
All effects are in opposite to the effects of aldosterone:
1) constricts renal effecrent arterioles
2) dilates renal afferent arterioles
3) decreased Sodium reabsoprtion
4) Diuresis
NET EFFECT: reduction in blood pressure
21
Q
On an EKG , what does an inversion of a T-wave indicate?
A
Recent MI
22
Q
When is a U-wave seen on an EKG?
A
In states of hypokalemia or bradycardia
23
Q
Rank in order, the conduction speed of the different parts of the heart electroconduction system.
A
Purkinje Cells>Atria>Ventricles>AV node
24
Q
Rank in order, the pacemaker preference/order of the different components of the heart system.
A
SA node> AV node > Bundle of His/Purkinje fibers/Ventricles
25
What are the 3 ways in which a fast cardiac action potential (ventricular) differs from a skeletal action potential?
1. Has a plateau phase which is due to the balance of calcium influx and potassium efflux
2. Spontaneously depolarizes during diastole leading to funny currents repsonsible for slow mixed Na+/K+ inward current
3. The cardiac APs in each cell are coupled together via gap junctions
26
Give examples of factors that increase contractility (i.e ionotropy) of the heart.
-name 3
1) Increased HR (calcium clearance is less efficient so intracellular Ca builds up)
2) Sympathetic stimulation: phosphoryation of phospholamban allows faster relaxation and therefore Calcium is easily recycled
3. Digoxin: increases intracellular calcium stores
4. Decrease in extracellular Na+ (hence affecting Na+/Ca+ exchanger)
NB: increase in contractility results in increase in SV
27
What is the effect of vEnodilators on the heart?
| What is the effect of vAsodilators on the heart?
Venodilator (e.g nitroglycerin): lower PRELOAD
Vasodilators (e.g. hydralazine) lower AFTERLOAD
28
Give examples of factors that reduce contractility (hence S.Volume indirectly)
1. Bradycardia (low heart rate)
2. Beta Blockers
3. Calcium channel blockers
4. Venodilators (reduce preload)
5. Acidosis ---decreases Troponin C's affinity for
Ca2+
6. Heart Failure
7. Hypoxia/Hypercapnia:- ---decreases Troponin
C's affinity for Ca2+
29
What factors increase the O2 demand of the heart?
-increasing HR
-Increasing contractility
-Increasing afterload (proportional to arterial
pressure)
-cardiac hypertropy...due to increased wall tension
30
What are the normal pressures in each chamber of the heart?
| -include the aorta and the pulm artery as well
RA: <12mmHg
RV: 25/5mmHg
LV: 130/10mmHg
AORTA: 130/90mmHg
Pulm Artery: 25/10mmHg
31
What do each of the 4 hears sounds S1-S4 resemble?
S1: Mitral and Tricuspid closing
-loudest at mitral area
S2: Aortic and Pulmonary valve closing
-loudest at left sternal border
S3: During rapid ventricular filling (increasing filling
pressure)
-normal in pregnancy and children
-pathologic: Dilated ventricles, CHF,mitral
regurgitation
S4: Atrial kick pushing against a hypertrophied
heart...can be present in chronic hypertension
32
To which variables does the carotid sinus baroreceptor respond?
To which variables does the aortic arch baroreceptor respond?
CAROTID SINUS: increase AND decrease in BP
AORTIC SINUS: BP increase ONLY.
33
What is the Cushing Reaction (vasopressor triad)?
This is a triad of responses that take place when Intra-Cranial-Pressure (ICP) rises.
--Bradycardia
--Respiratory Depression
--Hypertension via widening of pulse
pressure
34
How do the following organs maintain constant blood flow over time?
HEART:
LUNG:
KIDNEY:
SKIN:
BRAIN:
SKELETAL MUSCLE:
HEART: local metabolites (CO2, adenosine, NO)
-all three are vasodilatory
LUNG: Hypoxic Pulmonary Vasoconstriction (ensures only ventilated areas are perfused)
KIDNEY: myogenic and tubuloglomerular feedback
SKIN: sympathetic nervous system, which regulates temperature
BRAIN: CO2 levels (i.e. pH)
SKELETAL MUSCLE: local metabolites (lactate, adenosine, K+)
35
How do the following substances affect blood flow (venous and arteriole) in their sites of release?
1. Serotonin:
2. Histamine:
3. Bradykinin:
4. Prostglandins
a) Prostacyclin:
b) Thromboxane A2:
1. Serotonin: arteriolar constriction
2. Histamine: arteriolar dilator and venous constrictor
3. Bradykinin: arteriolar dilator and venous constrictor
4. Prostglandins
a) Prostacyclin: vasodilator in several vascular
beds
b) Thromboxane A2: vasoconstrictor in several
vascular beds
36
Which classes of drugs are used to treat Primary (essential) Hypertension?
-Name 4
- Diuretics
- L-type calcium channel blockers
- ACE inhibitors
- Angiotensin II receptor blockers (ARBs)
37
Which 7 diseases can one be predisposed to if they have hypertension?
- CHF
- Renal Failure
- LVHypertrophy
- Athereclerosis
- stroke
- retinopathy
- aortic dissection
38
What are the 3 different types of arteriosclerosis and how do they differ from each other?
MONCKENBERG (calcification):
-Calcification of the MEDIA layer of medium-seized arteries (radial and ulnar usually)..which is usually benign. It does not obstruct blood flow.
ARTERIOSCLEROSIS (onion skinning + other):
Two types affecting intima:
a) Hyaline: thickening of small arteries in
essential HTN or DMellitus due to deposition
of portein in the wall
b) Hyperplastic: "onion skinning" of smaller
arteries in malignant HTN
Onion skin = concentric wall thickening
-due to hyperplasia of the smooth muscle of
the vessels
ATHERESCLEROSIS (foam cells):
Fibrous plaques and atheromas formation in the INTIMA of small arteries
39
What are the modifiable and non-modifiable risk factors of atherosclerosis?
MODIFIABLE:
- hypertension
- diabetes
- smoking
- hyperlipidemia
NON-MODIFIABLE:
- positive family Hx
- age
- gender (males and post-menopausal women)
40
Which factors promote S.Muscle cell migration from media to intima in the progression of atherosclerosis?
FGF and PDGF
41
What are the 2 single-most important factors required in the development of atherosclerosis?
Inflammation and Endothelial Dysfunction
42
Which arteries are common sites for atherosclerosis, rank them in order?
-name 4
Abdominal Aorta>Coronary Artery>Popliteal A>Carotid A
43
What are some of the possible complications of
atherosclerosis?
-name 6
- thrombus
- emboli
- aneurysm
- ischemia
- infarction
- peripheral vascular disease
44
What are the 3 symptoms of atherosclerosis>
| trick
- Claudication
- Angina
- asymptomatic (in some people, hence the "tricky" part)
45
What are the main causes of acute and subacute bacterial endocardititis?
ACUTE: usually occurs in normal heart valves
S. Auresu
SUBACUTE: usually in diseased oro congenitally abnormal valves
-Viridans streptococcus
(usually a sequelae of dental procedures)
46
What is the main bacteria found in the endocardititis of prosthetic valves?
S. Epidermidis in the 1st 6 months, then
S. Aureus and the Viridans group are the main culprits afterwards
***if patient with new valve develops new murmur, take ECG and blood cultures
47
What is the main bacteria found in the endocardititis of colon cancer?
Srep. Bovis
48
What is the main bacteria found in the endocardititis of GI Surgery?
Enterococci
49
What is the main bacteria found in the endocardititis of total parenteral nutrition?
Fungi (this is OT a bateria!!!)
50
What is the main bacteria found in the endocardititis of alcoholic or the homeless?
Bartonella Henselae
51
What are the 8 classical findings (presentation) in Bacterial Endocardititis?
MNEMONIC = " FROM JANE"
F= Fever , which is the common symptom
R=Roth's spots
O=Osler's Nodes
M=new Murmur
J=Janeway lesions
A=Anemia
N=Nailbed splinter hemorrhages
E=Emboli
52
Name the 3 different types of cardiomyopathies and mention if sytolic or diastolic dysfunction ensues in each of those myopathies
1. DILATED (congestive cardiomyopathy):
- most common type ~90%
- results in dilation of the chambers of the heart
- systolic dysfuntion ensues (because of )
- eccentric hypertrophy
2. HYPERTROPHIC Cardiomyopathy:
-concentric hypertrophy
-diastolic dysfunction because there is a filling
problem
3. RESTRICTIVE (obliterative cardiomyopathy):
-least common of the 3
-diastolic dysfunction ensues because its a
filling problem
**no effective therapy is known
53
What are the possible etiologiess of dilated cardiomyopathy?
| -name 9
- Idiopathic (most common) & ~50% are familial
- chronic alcohol abuse
- wet beriberi
- coxsackie B virus myocardititis
- chronic cocaine use
- Chaga's disease
- Doxorubicin toxicity
- hemochromatosis
- peripartum cardiomyopathy
54
What is the mode of inheritance of hypertrophic cardiomyopathy?
And which genetic condition is often associated with this heart condition?
Autosomal Dominant
| -Fredreich's Ataxia
55
What are the possible etiologiess of resrictive (obliterative) cardiomyopathy?
-name 6
- Sarcoidosis
- Amylodoidosis
- Postradiation Fibrosis
- Endocardial Fibroelastosis
- Loffler's Syndrome
- Hemochromatosis
56
What is Loffler's Syndrome?
One of the causes of restrictive cardiomyopathy due to fibroplastic thickening of the endocardium
--It is endomyocardial fibrosis with a prominent eosinophilic infiltrate
57
What are the causes of left heart failure?
| -name 3
- Systolic Dysfunction due to decreased contractility and/or increased afterload
- Diastolic Dysfunction due to impaired ventricular filling, relaxation, or compliance
58
What are the causes of Right-heart failure?
| -name 2
1. Left heart failure!!
| 2. Cor Pulmonale
59
Name 4 main clinical findings in Left Heart Failure
-Orthopnea
-Dyspnea
-Pulmonary Edema (rales)
-Paroxysmal Nocturnal Dyspnea
-Histologically: Presence of hemosiderin laden
macrophages
60
Name 4 main clinical findings in Right Heart Failure
- Peripheral Edema (usually pitting on the ankles)
- Hepatomegaly (nutmeg liver)
- Slenomegaly
- Jugular Venous Distention
***NBB: Organomegaly such as nutmeg liver only happen with long-standing CHRONIC congestive failure....it doesn't happen in the acute setting
61
Which drugs are used in the treatment of heart failure?
| Which ones reduce mortality, which ones are for symptomatic relief?
REDUCE MORTALITY:
- B-blocker
- ARB
- ACE Inhibitor
- Spironolactone
SYMPTOMATIC RELIEF:
-loop and thiazide diuretics
REDUCE MORTALITY AND SYMPTOMS(both):
-hydralazine with nitrate
62
What are the 2 common types of aortic aneurysms and what causes each?
AAA:
-causes by atherosclerosis, esp in men over 50
who smoke
Thoracic Aortic Aneurysm:
-caused by a number of conditions
1) tertiary syphilis--affects the ascending
portion
2) HTN
3) Cystic Medial Necrosis (Marfan
Syndrome)
63
What is the classical imaging finding in an aortic dissection?
-name 2
-False Lumen:
due to LONGITUDINAL intraluminal tear
-Mediastinal Widening on CXR
64
What are the causes of aortic dissection?
| -name 4
- HTN
- Bicuspid aortic valve
- cystic medial necrosis
- Inherited CT disorders (e.g. Marfan Syndrome)
65
Which condition leads to the classic"tree bark" appearance of the aorta?
-what causes that?
- Tertiary Syphillis
- It causes obliterative endarteritis (disruption of the vasa vasorum) of the proximal aorta (ascending/aortic roott)...consequently leading to atrophy of the vessel
- Tertiary Syphillis can also cause aneurysms in the aortic root
66
What kind of a a reaction is Rheumatic Fever?
.It is an immune reaction: Type II hypersensitivity
just like MG. Lambert-Eaton, and Graves Disease
* ****it's the antibodies reacting against your own valve/heart tissue.
* *** It's a cross-reactivity of the antibodies against M-protein of the Group A beta-hemolytic streptococci cross-reacting with cardiac antigens
67
Which heart valves are most affected in Rheumatic Fever?
| -what is special about these valves?
.Mitral>>>>Aorta>>>>Tricuspid
OFTEN mitral stenosis
__It's the high pressure valves that are most affected
68
How is Rheumatic Fever treated, generally?
.Itself is NOT an infection so antibotics will not work!!!!
--Need to give steroids or salicylic acid to reduce inflammation and pain
-as for the Group A infection itself, use penicillin to treat
69
What are the major (5) and minor (8) criteria of clinical findings included in the Jones criteria for Rheumatic Fever symptoms following srep throat (pharyngeal infection)
MAJOR:
- St. Vitus Dance ( Sydenham's Chorea)
- Carditis (new onset murmur)
- Erythema Marginatum
- Migratory polyarthritis
- Subcutaneous Nodules
```
MINOR:
-Fever
-arthralgia
-valvular damage (esp Mitral Regurg or Mitral
Stenosis in chronic R.Fever)
-increased ESR and/or CRP
-long PR interval
-ASO titer
-Anemia
-high WBC count
```
70
What are the classic histologic findings in Acute Rheumatc Fever?
-name 3
Aschoff Bodies (granuloma with giant cells) consisting of
- Aschoff cells and
- Anitschkow's cells (activated histiocytes)
- -NB: Aschoff bodies contain both anitschkow and aschoff cells
71
What is the early lesion in Rheumatic Fever?
What is the late lesion in Rheumatic Fever?
EARLY: mitral regurgitation
LATE: mitral stenosis
72
How does the following bedside maneuvers affect the intensity of heart sounds (murmurs)?
***describe mechanism
INSPIRATION:
INSPIRATION:
-increase intesmtiy of right heart
EXPIRATION:
-increase intesmtiy of left heart
HAND GRIP (increases sytemic resistance):
-increase intesity of MR, AR,VSD murmurs
-decrease intensity of AS, hypertrophic
cardiomyopathy murmurs
-increase murmur intensity of MVP(later onset
of click/murmur)
VALSALVA (decrease venous return):
- decrease intensity of most murmurs
-increase intensity of hypertrophic
cardiomyopathy murmurs
-decrease murmur intensity of MVP(early
onset of click/murmur)
RAPID SQUATTING:
-decrease intensity of hypertrophic
cardiomyopathy murmurs
--increase murmur intensity of MVP(later
onset of click/murmur)
73
How does the following bedside maneuvers affect the intensity of heart sounds (murmurs)?
***describe mechanism
EXPIRATION:
EXPIRATION:
| -increase intesmtiy of left heart
74
How does the following bedside maneuvers affect the intensity of heart sounds (murmurs)?
***describe mechanism
HAND GRIP:
HAND GRIP :
-increase intesity of MR, AR,VSD murmurs
-decrease intensity of AS, hypertrophic
cardiomyopathy murmurs
-increase murmur intensity of MVP(later onset
of click/murmur)
MECHANISM: increased sytemic resistance
75
How does the following bedside maneuvers affect the intensity of heart sounds (murmurs)?
***describe mechanism
VALSALVA:
VALSALVA:
- decrease intensity of most murmurs
-increase intensity of hypertrophic
cardiomyopathy murmurs
-decrease murmur intensity of MVP(early
onset of click/murmur)
MECHANISM: decreased venous return
76
How does the following bedside maneuvers affect the intensity of heart sounds (murmurs)?
***describe mechanism
RAPID SQUATTING:
RAPID SQUATTING:
-decrease intensity of hypertrophic
cardiomyopathy murmurs
--increase murmur intensity of MVP(later
onset of click/murmur)
MECHANISM: increased venous return = increased preoad = increased afterload with prolonged squatting
77
Name the systolic heart sounds
Aortic/Pulmonic Stenosis
Mitral/Tricuspid Regurgitation
Ventriculr septal defect
Mitral Valve Prolapse
78
Name the diastolic heart sounds
.-Aortic/Pulmonic Regurgitation
-Mitral/Tricuspid Stenosis
79
What are the 4 physiologic maneuvers used to aid in the characterization of cardiac murmurs?
1. beathing (inspiration vs. expiration)
2. rapid squatiing
3. hand grip
4. valasalva maneuver
5. standing
80
Describe the characterization and nature of a Mitral/Tricuspid Regurgitation.
--which maneuvers enhance the MR?
--which maneuvers enhance the TR?
"Holosystolic High-Pitched Blowing Murmur"
MR ENHANCED BY: maneuvers that increase TPResitance (e.g. squatting or handgrip) or those increasing LA return (e.g. expiration)
TR ENHANCED BY: maneuvers that increase RA return (e.g. inspiration)
81
Describe the characterization and nature of a Aortic Stenosis.
--which 3 cardiac-related conditions can result from Aortic Stenosis?
"Crescendo-Descrescendo systolic ejection murmur following Ejection Click"
-The Ejection Click is due to abrupt halting of the valve leaflets
RESULTING CONDITIONS: Syncope, Angina, Dyspnea on exertion---from CHF
mnemonic = S.A.D
82
Describe the characterization and nature of a Ventricular Septal Defect.
--which maneuvers enhance this murmur?
"Holosystolic, harsh-sounding murmur"
ENHANCED BY: hand grip maneuver which increases afterload
83
Describe the characterization and nature of an Aortic Regurgitation.
- -which maneuvers enhance this murmur?
- -which maneuvers decrease the intensity of this murmur?
"Immediate High-Pitched Blowing Diastolic Decrescendo Murmur"
ENHANCED BY: Hand grip
DIMINISHED BY: Vasodilators
84
Describe the characterization and nature of a Patent Ductus Arteriosus.
--what normally causes a PDA?
"Continous Machince Like Murmur"
CAUSE: Congenital Rubella or Prematurity
Before birth: Blod flows from Left Pulm A to Aorta
After Birth: Direction of flow reverses..
If the ductus arteriosus remains patent (PDA), then Pulm HTN may ensue---which may end as Eisenmenger Syndrome in the worst case if it remains uncorrected
85
Describe the characterization and nature of a mitral stenosis
--which maneuvers enhance this murmur?
"High-pitched opening snap after S2 followed by a descrescendo murmur or rumble that intensifies at the end of diastole"
ENHANCED BY: maneuvers that increase LA return e.g. expiration
** The diastolic rumble is best heard in a lateral decubitus position.
86
Describe the characterization and nature of a mitral valve prolapse
--which maneuvers enhance this murmur?
"Late Systolic Crescendo murmur with midsystolic click"
ENHANCED BY: The murmur occurs earler in maneuvers that decrease venous return (e.g. valsalva or Standing)
87
Does actual blood flow across an ASD cause a murmur?
Why or why not?
NO!!
Because there is no pressure gradient!
The murmur presents with a pulmnary flow murmur and then later progreses to a louder diastolic murmur of pulmonic regurgitation from dilation of the pulmonary artery.
88
In which areas of asucultation do we normall hear the following sounds?
FLOW MURMUR (e.g. ASD or PDA):
AORTIC REGURGITATION:
VENTRICULAR SEPTAL DEFECT:
AORTIC REGURGITATION:
HYPERTROPHIC CARDIOMYOPATHY:
PULMONIC REGURGITATION:
```
FLOW MURMUR (e.g. ASD or PDA):
-pulmonic area
```
AORTIC REGURGITATION:
-left sternal border
VENTRICULAR SEPTAL DEFECT:
-tricuspid regurgitation
AORTIC REGURGITATION:
-left sternal border
HYPERTROPHIC CARDIOMYOPATHY:
-left sternal border
PULMONIC REGURGITATION:
-left sternal border
89
What is Torsades de Pointes?
What is the treatment?
What is the commonest risk factor
DEFINITION: It is ventricular tachycardia that is characterized by shifting sinusoidal waveforms on ECG.
--it can progress to ventriclar fibrillation
TREATMENT: Magnessium Sulfate
RISK FACTOR: prolonged QT interval can predispose to Torsades de Pointes
90
Which congenital Syndrome can present with Torsades de Pointes?
Jervell and Lange Nielsen syndrome: severe congenital sensorineural deafness
91
What are the 2 common types of cardiac tumors?
| -Which age groups do they affect?
Cardiac Myxoma =most common primary cardiac tumor in adults...Usally found in the atria here it causes ball-valve obstructions of the mitral valve and embolization of tumor fragments
Cardiac Rhabdomyoma=most common primary cardiac tumor in children
- --associated with tuberous sclerosis
- -usually found in the ventricles
NB: Metastases like the pericardium, where they cause pericarditis
92
What are the usual locations of the two types of cardiac tumors?
--which secondary conditions are associated with each of these tumors?
Cardiac Myxoma: usually in the left atrium e.g. septum ot mitral valve
---associated with multiple syncopal episodes
Cardiac Rhabdomyoma= arises within the myocardium
----associated with tuberous sclerosis (Aut. Dominant disorder manifesting with cortical tubers, harmatomas, hypopigmented "ash-leaf spots on skin, renal angiomyolipoma and cardiac rhabdomyoma")
93
Which condition is associated with the classic desription of "ball valve obstruction"?
Cardiac Myxoma
94
What are the common metastasis that lead to secondary cardiac tumors?
-name 4
--Which part of the heart do they predilect?
```
Melanoma
Lymphoma
bronchogenic carcinoma (lung)
Breast
pancreatic or esophageal carcinoma
```
--They commonly involve the pericardium, resulting in pericardial effusion
95
Describe the diastolic pressure in cardiac tamponade.
Why is that so?
There is diastolic pressure equalization in all 4 chambers.
| The reason is that there is collapse of the RA and RV during diastole
96
What does the ECG show in acute pericarditis?
Widespread ST segment elevation with upright T waves and/or PR depression
97
How do patients with acute pericarditis relieve their symptoms--usually before any cinical intervention?
--Describe the nature of their pain
Sitting up and leaning forward
-Pain is usually some form of pleuritic chest rub which worsens on inspiration and when coughing.
====because of the inflammation, they usually have a friction rub present
98
What is the "Kussmaul's Sign"?
| -In which conditions do you find it?
This is a paradoxial rise in JVP during inspiration i.e. we normally expect the JVP to fall on inspiration, but in this sign: there is a actually marked Jugular Venous Distention!!
---The reason is that upon inspiration: there negative intrathoraic pressure is not transferred to the pericardium and the RA and RV have impaied filling-->leading to JVDistention!! i.e. stiff right heart
--Conditions like chronic restrictive pericardititis or cardiac tamponade can produce the Kussmaul's sign
99
What are the three types of Angina and how does each one show on an ECG?
A: STABLE...transient ST elevation during pain
B. PRINZMETAL/VARIANT...ST elevation
C. UNSTABLE...no ST elevation, but depression follows
100
What causes each of the three types of Angina?
A: STABLE...caused by atherosclerosis and occlusion
B. PRINZMETAL/VARIANT...cuased by coronary artery vasospasm Rx = vasodilator or Ca2+ channel blocker
C. UNSTABLE/CRESCENDO...caused by a ruptured plaque that then lodges wothout complete coronary artery occlusion
101
Coronary Steal Syndrome?
| What sort of agents trigger this phenomenon?
Vasodialtors such as dipyridamole can aggravate ischemia by shunting blood away from areas that are not being perfused enough already.
--seen espeically in coronary arteries
102
What usually causes sudden cardiac death?
Death within ~ 1 hour of onset of symptoms...
-caused by lethan arythmias such as Ventricular Fibrillation
103
Which coronary arteries are most commonly occluded in an MI? Rank them in order of frequency.
LAD>RCA>Circumflex
104
Name 7 classic presentation signs of an MI
- crushing retrosternal chest pain,
- pain radiating to neck, jaw and left arm
- nausea
- diaphoreis
- vomitting
- SOB
- Fatigue
105
What are the 2 types of infarcts?
| -describe their appearance on an ECG
Subendocardial= ST depression
Transmural Infart= ST elevation and Q waves (caused by coagulative necrosis)
-sometime we see inverted T-waves
106
What are the 6 complications that could arise as a result of an MI?
--which one/s usually lead to death?
- Cardiac Arrhythmia= most important cause of death before reaching the hospital
- LV failure and Pulm Edema
- Cardiogenic Shock
- Cardiac Rupture (ventricular wall or septum rupture)
- Ventricular Aneurysm formation
- Postinfarction fibrinous pericardititis
- -Dressler's Syndrome
107
What is the risk of each complication of an MI during the evolution of an MI?
First 2 days: Arrythmia
1 to 3 days: Fibrinous Pericarditis
3-14 days:
-free wall rupture leading to cardiac
tamponade, muscle rupture, aneurysm
-Macrophages responsible for this stage:
they weaken everything during this period of
chronic inflammation
2 weeks-several months: Dressler's Syndrome
108
Which ECG leads show Q-waves when there is an infarction in the following area of the heart?
- INFERIOR WALL
- which artery is usually occluded?
avF, II, and III leads
-RCA artery
109
Which ECG leads show Q-waves when there is an infarction in the following area of the heart?
- ANTERIOR WALL
- which artery is usually occluded?
V1-V4 leads
-LAD artery
110
Which ECG leads show Q-waves when there is an infarction in the following area of the heart?
- ANTEROSEPTAL
- which artery is usually occluded?
V1-V2 leads
-LAD artery
111
Which ECG leads show Q-waves when there is an infarction in the following area of the heart?
- ANTEROLATERAL
- which artery is usually occluded?
V4-V6 leads
-LCX artery
112
Which ECG leads show Q-waves when there is an infarction in the following area of the heart?
- LATERAL WALL
- which artery is usually occluded?
I and aVL leads
LCX artery
113
Where do the following structures arise from in cardiac development:
AORTA AND PULMONARY TRUNK:
CORONARY SINUS:
SVC:
AORTA AND PULMONARY TRUNK:
-truncus arteriosus
CORONARY SINUS:
-left horn of sinus venosus
SVC:
-right common cardial vein
114
Where do the following structures arise from in cardiac development:
TRABECULATED RA and LA:
TRABECULATED LV and RV:
TRABECULATED RA and LA:
-priitive atria
TRABECULATED LV and RV:
-primitive ventricle
115
Where do the following structures arise from in cardiac development:
OUTFLOW TRACTS (smooth parts) OF LV and RV?:
SMOOTH PART OF RA:
```
OUTFLOW TRACTS (smooth parts) OF LV and RV?:
-Bulbus Cordis
```
SMOOTH PART OF RA:
-Right Horn of Sinus Venosus
116
From which types of cells does the Truncus Arteriosus arise?
Whch three congenital conditions can arise from pathologies of Truncus Arteriosus?
Neural Crest Cells migrating there
CONDITIONS:
- great vessel transposition
- tetralogy of Fallot
- persistent TA
117
Describe the composition of the interventricular septum.
| -which parts make up the structure and where do they come from?
Muscular portion
and
Membranous Portion which arises from the AorticoPulmonary Septum
NB: Endocardial Cushions separate atria from ventricles
118
Which common congenital condition usually forms in the membranous portion of the interventricular septum?
VSD
--it results into a very loud harsh holosystolic murmur
119
How is the forament ovale formed in the developing heart?
What causes the Foramen Ovale to close soon after birth?
--Which structures contribute to the closure of the ovale?
FORMATION:
-septum secundum contains a permanent
opening=foramen ovale
-septum primum forms the valve of the FOvale
CLOSURE:
-increase in pressure in the LA as the baby
takes its first breath and resistace in
pulmonary system falls
CLOSING STRUCTURES:
-fusion of septum secundum and septum
primum
120
Name the 4 different locations for fetal erythropoiesis, both in the prenatal period and after birth.
Yolk Sac: 3-10 wks
Liver: 6 week--to birth
Spleen: 15 to 30th week
Bone Marrow: 22 week to adult
121
How is fetal hemoglobin different from Adult Hemoglobin?
| -name 2
ADULT: 2alpha + 2Beta subunits
FETUS: 2alpha + 2Gamma subunits
Fetal Hgb has low affinty for 2,3 BPG so affinty for O2 is higher--hence oxygen is moved across the placenta
122
In the fetal blood circulation, which are the 2 ways by which blood bypasses pulmonary circulation?
Ductus Arteriosus (blood to trunk and lower extremity)
Foramen Ovale (blood to head and other parts?)
123
In the fetal blood circulation, how does oxygenated blood from mum bypasses the portal circulation?
Ductus Venosus shunts blood from Umbilical vein and drains into the IVC
124
How is deoxygenated blood carried back to the placenta?
Umbilical Artery
125
What are the post-natal derivates of the following sructures:
UMBILICAL VEIN:
UMBILICAL ARTERY:
DUCTUS VENOUS:
UMBILICAL VEIN:
-Ligamentum Teres, which is contained in a
falciform ligament
UMBILICAL ARTERY:
-Medial Umbilical Ligaments
DUCTUS VENOUS:
-Ligamentun Venosum
126
What are the post-natal derivates of the following sructures:
DUCTUS ARTERIOSUS:
FORAMEN OVALE:
DUCTUS ARTERIOSUS:
-Ligamentum Arteriosum
FORAMEN OVALE:
-Fossa Ovalis
127
What are the post-natal derivates of the following sructures:
ALLANTOIS:
NOTOCHORD
ALLANTOIS:
Urachus-MediaN umbilical Ligament
NOTOCHORD:
-nucleus pulposus
128
Which organ receives 100% of cardiac output?
Lungs
129
Which organ receives the largest share of systemic cardiac output?
Liver
130
Which organ receives the highest blood flow per gram of tissue?
Kidney
131
Name the Congenital Heart diseases that result in
EARLY CYANOSIS?
--Which one is the most common?
-What type of shunt do these conditions form?
Mnemonic is 5Ts:
- Tetralogy of Fallot = most common
- persistent Truncus Arteriosus
- Transpositioning of great vessels
- Tricuspid Atresia
- Total Anomalous Pulmonary Venous Retun(TAPVR)
They all form Right-to-Left shunts hence the early cyanosis
132
Name the congenital Heart conditions which result in LATE CYANOSIS?
-which one is the most common?
- ASD = causes a loud S1 and a fixed split S2
- the S2 is split due to increased flow to the pulmonic valve HENCE delayed closure
- VSD = most common
- PDA treated with indomethacin
133
What are some of the sequelae of Eisenmenger Syndrome?
-Why?
COMPLICATIONS:
Cyanosis
Clubbing
Polycythemia
WHY:
Syndrome is caused by an uncorrected VSD, PDA, or ASD which then leads to reversal of the shunt into right-to-left due to increasing pulmonary resistance
134
Name the 4 conditions that give rise to the Tetralogy of Fallot?
-Which genetic disorders are associated with this Heart Condition?
- Overriding Aorta
- RVHypertrophy
- Pulmonic Stenosis
- VSD
-----associated with 22q11 mutations e.g.
Di George
135
What is a "tet spell"
-describe the classical symtoms?
How are tet spells managed at home before going to the hospital?
Tetralogy Spell which is really Hypoxic Spell
TRIAD:
- blue color
- seizure
- passing out
MANAGEMENT, DIY: Squatting
-by compressing the femoral artery, SVR
increases and the pressure gradient in
the shunt is reduced
136
What causes the D-transposition of great vessels in cardiac development?
Other than surgical correction, how can this condition be made compatible with life?
CAUSE:
- failure of aorticopulmonay septum to spiral
-resulting in aorta exiting from RV and Pulm A
exiting from LV
****Usually common in children of diabetic mothers
MANAGEMENT: condition is not compatible with life unless if there is a shunt present to allow adequate mixing of blood e.g. VSD, PDA, PFO
137
What is coarctation of the aorta?
--what are the subtypes of the condition and how do they present clinically?
DEF:
-abnormal narrowing of the aorta in the area
surrounding the ductus arteriosus
SUBTYPES:
a) Infantile Type (preductal) - check femoral
pulse on exam
b) Adult Type (postductal)- occurs distal to the
ductus
- check femoral pulse
138
Which conditions are associated with the different subtypes of aortic coarctation?
INFANTILE (preductal):
-Turner's Syndrome
ADULT (post-ductal):
-Bicuspid Aortic Valve
-Rib Notching (whch results from collateral
circulation to the extremeties increasing the
pressure in the intercostal arteries, which then
ultimately erode the ribs causing them to
notch)
- HTN in UPPER extremeties
139
What are the complications of a Patent Ductus Arteriosus?
- --What can be used to close a PDA?
- --What can be used to open a PDA?
COMPLICATIONS:
-Increased pulm hypertension leading to
RVH and or LVH and Congestive Failure
OPEN/CLOSE:
- Close with infdomethacin (an NSAID)
- kept open with PGE (prostaglandin)
140
Describe the mumur assocated with a PDA
Continous Murmur with a machine-like sound
141
Which heart defects are associated with the following Disorders:
TURNER SYNDROME:
MARFAN'S SYNDROME:
-name 2
DIABETIC MOTHER:
TURNER SYNDROME:
-coarcttation of the aorta (preductal)
MARFAN'S SYNDROME:
- Aortic Insufficiency
- Aortic Dissection
INFANT OF DIABETIC MOTHER:
-Transposition of the great vessels
142
Which heart defects are associated with the following Disorders:
22q11 SYNDROMES:
-name 2
DOWN SYNDROME:
-name 3
CONGENITAL RUBELLA:
22q11 SYNDROMES:
- Truncus Arteriosus
- Tetralogy of Fallot
DOWN SYNDROME:
- ASD
- VSD
- AV septal defect (endocardial cushion effect)
CONGENITAL RUBELLA:
- PDA
- septal defects
- Pulm Artery Stenosis
143
Name the 4 gross/anatomical signs of hyperlipidemia?
XANTHOMA:
-lipid-ladenhistiocytes in the skin, esp in
eyelids=xanthalasma
ATHEROMA:
-plaques in blood vessels
TENDINOUS XANTHOMA:
-lipid depostion in tendons, esp Achilles
CORNEAL ARCUS:
lipid deposition in cornea. If deposition is non-
specific = arcus senilis
144
How do patients with an aortic dissection usually present?
TEARING CHEST PAIN RADIATING TO THE BACK
145
What is cystic medial necrosis-CMN?
| Which circulatory condition is it related to?
CMN results from loss of elastic muscle fibers in the aortic media, with subsequent accumulation of mucus-like polysaccahrides in cyst-like spaces between the fibers.
- --Associted with Aortic Dissection
- --Marfan's Syndrome
146
What is Raynaud's Phenomenon?
-What are the 2 subtypes and which groups of people are often affected?
DEF:
-Arteriolar vasospasm of small arteries induced
by cold or stress
```
TYPES:
a) Raynaud's Phemomenon/primary
-often idiopathic and affects women
usually
b) Raynaud's Syndrome
-usually secondary to a disease process
such as SLE or CREST
-usually affects males
```
147
Name the 2 types of large-vessel vasculitis
Temporal (Giant Cell) Arteritis
Takayasu's arteritis
148
Name the 3 types of medium vessel vasculitis
Poyarteritis Nodosa
Kawasaki Disease
Buerger's (Thromboangiitis Obliterans)
149
Name the 4 types of small-vessle vasculitis
Microscopic Polyangiitis
Wegener's Granulomatosis (granulomatosis with polyangiitis-GPA)
Churg-Strauss Syndrome
Henoch-Schonlein Pupura
150
What are the relationship between Granulomatosis with Polyangiitis and Microscopic Polyangiitis?
MP is similar to GPA, except that there are no respiratory findings in MP
151
Which antibodies distinguish the following three types of Vasculitis?
- -GPA
- -Churg Strauss Syndrome
- --Microscopic Polyangiitis
GPA ----------------> c-ANCA positive
Microscopic Polyangiitis---------->p-ANCA
Church-Strauss -------------------->p-ANCA positive
-also associated with high IgE
152
What is the hallmark of Churg-Strauss Syndrome?
- -what other classical presentations are included?
- name 3
HALLMARK:
-asthma
OTHERS:
- Sinusitis
- Palpable Purpura
- Peripheral Neuropathy (e.g. foot/wrist drop)
153
How do the four types of NECROTIZING vasculitis differ from each other i.e. what is unique about each one of those?
GPA (Wegeners):
-Focal Necrotizing Vasculitis
CHURG-STRAUSS:
-Necrotizing Vasculitis with Eosinophilia
MICROSCOPIC POLYANGIITIS:
-No granulomas!!
POLYARTERITIS NODOSA
-fibrinoid necrosis
-unlike the 3 above, it affects medium-sized
vessels
-typically involves renal and visceral vessels
154
What is the trad of GPA (Wegener's Vasculitis)?
1) Focal Necrotizing Vaculitis
2) Necrotizing Granulomas in the lung and upper
airway
3) Necrotizing Glomerulonephritis
155
What is the most common childhood systemic vasculitis?
| ---what condiition does it normally follow?
Henoch-Schonlein Purpura
--usually follows Upper Respiratory Infections
156
What is the classical triad of Henoch-Schonlein Purpura?
1) SKIN: palpable purpura on buttocks/legs
2) Arthralgia
3) GI: abdominal pain, melena, multiple lesions of
same age
157
How is GPA normally treated?
Cyclophosphamide and Cortcosteroids
158
What is the typical presentation of Temporal (Giant Cell) Arteritis?
-name 2
Which irreversible damade could result from this disease?
What other major musculoskeletal condition is associated with this condition?
PRESENTATION:
- Jaw Claudication
- Unilateral Headache
IRREVERSIBLE DAMAGE:
-blindness due to opthalmic artery occlusion
ASSOCIATED:
-polymyagia rheumatica
159
What is the catch-phrase "street name" for Takayasu's Disease?
What causes this?
Which age group is usually affected?
STREET NAME:
-Pulseless Disease
CAUSE:
-Pulselessness results because the disease is
inflammation of the aorta and its branhes or
any elastic arteries, hence pts present with
loss of pulse
AGE: Asian women under 40
160
How is Buerger's Disease (Thromboangiitis Obliterans) treated?
Smokig Cessation!!!!!!!!! = treatment
----intermittent necrosis may lead to gangrene, autoamputation of digits, superficial nodular phlebitis
161
Name 6 classical hallmarks/presentation of Kawasaki Disease
-Injection Conjunctivitis
- Strawberry Tongue (changes in lips and oral
mucosa)
- Hand/Foot Erythema
- Desquamating Rash
- Fever
- Cervical Lymphadenitis
NB: Preferential Artery involvement is the Coronary Artery!!
162
What severe heart conditon may develop in Kawasaki Disease?
How is Kawasaki usually treated?
SEQUELAE:
-coronary aneurysms ---->resulting in MI or
Rupture
TREATMENT:
- IV Immunoglobulin
- Aspirin...
163
Which vessels are normally affected in Sturge-Weber disease?
What are the manifestations of Sturge-Weber?
VESSELS:
-small vessels i.e. capillaries
MANIFESTATIONS:
-nevus flammeus (port-wine stains) on face
- ipsilateral leptomeningeal angiomatosis
or intracerebral AVM
- Seizures
- Early-onset Glaucoma
164
Which 2 vascular tumor disorders are often associated with each other? What causes each these blood vessel conditions?
1) KAPOSI SARCOMA:
- caused by HHV-8 and is associated with HIV
2) BACILLARY ANGIOMATOSIS:
- caused by Bartonella Henselae infections
- also found in AIDS patients
165
Which disease is associated with "Strawberry Tongue"
Kawasaki Disease
166
Whuch genetic condition is often associated with Cystic Hygroma?
Turner Syndrome
---Cystic Hygroma---->forms fluid-filled cysts reuslting from carvenous lymphangioma of the eck
167
Which capillary tumor is often under finger nails?
Glomus Tumor
168
Which very aggressive tumor is often associated with patients recieving radiation therapy (esp Breast Cancer) or those with Hodgkin's Lymphoma?
--In which areas does that malignancy typicaly form?
Angiosarcoma
--rapidly metastasizes
Usualy occurs in head,neck, and breast areas
169
Which vascular tumor disorder is often assoiated with persistent lymphedema, e.g. post-radical mastectomy?
Lymphangiosarcoma
170
Which vascular tumor has the most misleading name?
Pyogenic Granuloma!!! : It's a hemangioma that can ulcerate and bleed
MISNOMER:
---it is formed from trauma or pregnancy and is not infectious so its NOT pyogenic!
---It is also not a true granuloma because its a capillary hemangioma.
171
Whatare the 2major difference between a strawberry and and a chery hemangioma?
STRAWBERRY:
--affects infants in the first few wks of life
---spontaneously regresses at 5-8 yrs of
age
CHERRY:
-affects elderly and frequency increases with
age
-does not spontaneously rregress
****both tumors are benign
172
Name the 2 mechanisms by which Angiotensin raises systemic BP
1) directly causes blood vessels to constrict
[increase SVR]
2) induces the adrenal gland to release renin, which leads to more Na+ reabsorption and water uptake
[increase volume status]
173
Which L-type ca2+ channel blockers have the greatest effect on vascular smooth muscle and which ones exert the greatest effect on the heart?
HEART:
-Verapamil
-Diltiazem
both of which are greater than the two below
VASCULAR SM:
-amplodipine
-nifedipine
both of which are greater than the two above
NB: All 4 drugs still work on both the heart and vascular smooth muscle
This means in an person with CHF, giving verapamil will have more severe consequences than giving amplodipine because of verapamil's high negative ionotropism
174
Hydralazine exerts it's greatest effects on which type of blood vasculature?
dialtes ARTERIES!!!!
---so it reduces afterload mostly!
175
Hydralazine exerts it's greatest effects on which type of blood vasculature?
dilates VEINS!!!!
--so it reduces preload mostly!
176
Which 5 drugs are commonly used in the treatment of malignant hypertension?
Of these, which two main ones are used and where do they exert ther effect?
MAIN ONES:
1) Nitroprusside: direct relase of NO via cGMP
2) Fenoldopam: cause vasodilation by acting as a
dopamine D1 receptor agonist
OTHER DRUGS:
- nicardipine
- clevidipine
- labetalol
177
Name the 5 different types of diuretics out there and give an example of each
1) Osmotic e.g. mannitol
2) Carbonic A. Inhibitor e.g. acetozolamide
3) Loop e.g. Furosemide [aka Lasix]
4) Thiazide e.g. HCT
5) K-sparing e.g Spironolactone
178
What is the mechanism of HMG-CoA Reductase as a Lipid-Lowering Agent?
inhibits the rate-determining step in cholesterol synthesis:
HMG-CoA---------->Cholesterol
179
What is the mechanism of Niacin (vit B3) as a Lipid-Lowering Agent?
decreases formation and secretion of VLDL hence reuslting in low LDL formation
180
What is the mechanism of Bile Acid Resin as a Lipid-Lowering Agent?
Binds to bile acids in the small intestine to prevent their reabsorption:
NB: Liver needs bile acids to make more cholesterol
181
What is the mechanism of Ezetimibe as a Lipid-Lowering Agent?
Blocks cholesterol absorption at the small intestine brush border
182
What is the mechanism of Fibrates (e.g. Gemfibrozil) as a Lipid-Lowering Agent?
Upregulate LPLipase hence increasing Triglyceride clearance
183
What falls into each of the first classes of Antiarrhythmic drugs?
- How does each group affect AP duration
- Example of drugs?
CLASS I ===Na+ channel blockers
IA: increase AP duration, lower ventricular
conduction
**Increase QT interval
e.g. Quinidine, Pocainamide, Disopyramide
IB: Increase AP threshold in abnormal cells,
therefore descrease AP duration
lower ventricular conduction
***
e.g.Lidocaine, Mexiletine, Tocainide
IC: decrease ventricular conduction
NO EFFECT ON AP DURATION!!!!
***Increase QRS interval
e.g. Flecainide, Propafenone
184
What are the 2 actions of Digoxin?
1) increasing contractility by inhibiting the Na+/K+ pump
2) decreases conduction at the AV node and also depresses the SA node hence decreases heart rate. It is used in A.Fibrillation because of this.
185
What falls into the second class of Antiarrhythmic drugs?
How are Action Potential and conductivity affected?
-Example of drugs?
CLASS II:
B-blockers
-Decrease AV nodal conduction and
increases PR on ECG
e.g. Metoprolol, propanolol,esmolol (short-
acting), atenolol, timolol
186
What falls into the third class of Antiarrhythmic drugs?
How are Action Potential and conductivity affected?
-Example of drugs?
CLASS III:
K+ channel blockers
Prolong Ventricular Action Potential,
inrease ERP therefore increasing QT on
ECG
e.g. Amiodarone, Ibutilide, Dofetilide, Solatol
187
What falls into the fourth class of Antiarrhythmic drugs?
How are Action Potential and conductivity affected?
-Example of drugs?
```
CLASS IV:
Ca2+ channel Blockers
- Decrease condcution Velocity, increase
ERP, and PR interval
e.g. Verapamil, Diltiazem
```
188
Which drugs fall into the "OTHER" group class of Antiarrhythmic drugs?
How are Action Potential and conductivity affected?
-Example of drugs?
Adenosine and Mg2+
ADENOSINE:
-Hyperpolarizes the cells by increaseing K+
efflux
-Used in SVT
Mg2+: Mechanism is unknown
-Used in Torsades de Pointes and in
Digoxin Toxicity
189
Which 4 drug class types have been shown to decrease remodelling and hence reduce mortality in patients with CHF?
Angiotemsin II and Adosterone are both believed to play a role in remodelling. So drugs tht inhibit these two will work.
1) ACE Inhibitors e.g captopril, lisinopril
2) Aldosterone ANtagonist i.e Spironolactone
3) Agiotemsin Receptor blocker e.f. Losartan
(also used in Marfan's Syndrome due to its
anti-TGF-B activity)
Additionall,
4) B-blockers have also been shown to reduce
remodelling in CHF
190
Which condition is associated with ball-valve obstructions?
Cardiac Myxoma: most common primary cardiac tumor in adults
191
Which heart murmur is best heard in the lateral decubitus position?
Mitral Stenosis
| --a late diastolic murmur which follows an opening snap
192
A double bubble sign on X-ray is indictive of what condition?
Duodenal Atresia: which can be seen in conditions such as Down Syndrome.
193
What do U-waves show on an ECG?
| -name 3
They are belived to be due to repolarisation of the papillary muscle.
They indicate 2 things:
a) HyPOkalemia
b) Bradycardia
194
Name three cardiac or peripheral vascular conditions that are associated with Turner's Syndrome?
1) Coarctation of the aorta
2) Cystic Hygroma: usually acellular carvenous
lymphangioma of the neck.
3) Bicuspid Aortic Valve
195
Name 11 findings that may be present in Turner's Syndrome
1) Hypothyroidsm
2) Bicuspid Aortic Valve
3) Coarctationof the aorta
4) Cystic Hygromas
5) Infertility
6) Gonadal Dysgenesis
7) Shield (broad) Chest
8) High arched palate
9) Short stature
10) Webbed Neck
11) Lymphedema of the extremeties
NB: Turner's Syndrome = 45 XO
196
Which heart sound is often found in CHF?
S3 gallop ...inidicative of heart failure.
197
Mutations in the following genes lead to what kind of diastolic dysfunction cardiomyopthaies?
a) Amyloid B deposition
b) Myosin-beta Chain mutation
a) AMYLOID B DEPOSITION:
- restrictive (obliterative) cardiomyopathies
b) MYOSIN-B-CHAIN MUTATION:
-hypertrophic cardiomyopathy (which often
causes suddden death in atheletes)
198
Which cardiomyopathy is caused by coxsackie B virus myocarditis?
Dilated (congestive) cardiomyopathy
199
What is the most common cause of abdominal aortic aneurysm?
-name 1
What is the most common cause of thoracic aortic aneurysm?
-name 4
AAA:
- Atherosclerosis
TAA:
- Hypertension
- Marfan Syndrome
- Cystic Medial Necrosis
- Tertiary Syphillis
200
What are the 4 different types of vasodilators?
| How do their mechanisms differ and give examples of each class.
1) Ca2+ channel blockers---lead to smooth muscle relaxation:
- Verapamil
- Diltaziem
- Nifedipine
- Amlodipine
2) Drugs acting through NO:--->cGMP----->MLCP
- hydralazine
- nitroprusside
3) D1 receptor agonist:
- fenoldopam
4) Drugs opening K+ channels:
- diazoxide: ((inhibit insulin
release) )
- minoxidil
201
Which muscarinic receptors are found on the heart?
| -where are the receptors located and what's the effect on the heart?
M2 muscarinic receptors!!
Located on the SA node where they reduce the HR and the contractiliy i.e. increase parasympathetic tone via the vagus nerve
202
Which vasculitis type can cause Angina or any coronary-related heart disease?
Kawasaki Disease
203
Name diseases that may affect the balance between osmotic forces and filtration forces during capillary exchange.
Specifically, name the 4 mechanisms of disturbing this balance and give examples of pathologies that give rise to this.
```
1) Increase Capillary permeability (increease Kf
constant)
- Burns
- Toxins
- Infections
```
2) Increase hydrostatic pressure:
-Heart Failure (increase in Atrial Pressure
and Backflow)
3) Increase in the ECF fluid colloid osmotic
pressure
- e.g. Lymphatic Blockage
4) Decrease plasma proteins
- Liver failure
- Nephrotic Syndrome
204
Which type of heart complication is at the highest risk of developing during acute inflammation (neutrophils) during an MI?
ACUTE:
-Neutrophil presence during an MI increase
risk of FIBRINOUS PERICARDITIS!!
205
Which 3 types of heart complications are at the highest risk of developing during chronic inflammation (macrophages) during an MI?
CHRONIC:
1-Macrophages eat up all the necrotic debris
and in doing so, there is a high risk of
rupture of the wall leading to
CARDIACTAMPONADE.
2-If rupture occurs to the IV Septum, a
SHUNT may develop too!!!
```
3-If rupture occurs to the papillary muscle,
mitral regurgitation(insuficiency)
```
206
Which disease can chronic ischemic heart disease progress to?
CHF
207
What is the mechanism of the mainstay treatment for Heart Failure?
ACE inhibitor!! E.G. captoril, lisinopril,etc
208
Which congenital heat condition is associated with Fetal Alcohol Syndrome?
VSD
209
Most common Atrial Septal Defect?
Ostium SecunduM...due to excessive resorption of septum primum or inadequate formation of the septum secundum
210
A child with a simian crease is also likely to have which type of Atria-related cardiac defect?
The child has Down Syndrome
--If there is ASD present, the OSTIUM PRIMUM subtype is most commonly associated
211
A diabetic woman is likely to gve birth to a child with what kind of birth defect?
Transposition of great vessels
212
What is the primary defect in Ticuspid Atresia?
Its a congenital condition in which the tricuspid valve orifice fails to open, and no blood flows to the RV.
Becuase no blodd goes to the RV, there is hypoplasia of the RV.
In ths condition, there is usually as ASD so a R-to-L shunt often develops resulting in early cyanosis
213
Which murmur produces a Wide pulse pressure murmur?
NB: This murmur can be heard at the lower left sternal border!!!
Explain how the wide pulse presssure forms?
Aortic Regurgitation.
During Systole, not all the blood is pumped out through the aorta so the diastolic pressure is unusually low.
Then in systole, because there is left over blood from the previous cycle, Stroke Volume isVERY high, resulting in large systolic pressure.
Since Pulse pressure = Systole Pressure - Diastole Pressure, we see wide pulse pressures in ARegurgitation
RESULT: Hyperdynamic Circulation: Bounding Pulses and Head Bobbing
214
Which systolic murmur can increase risk of infectious endocarditis?
Mitral Valve Prolapse...is a true risk factor for infective endocarditis
215
Which two types of murmurs are often generated with Acute Rheumatic Disease versus Chronic Rheumatic Disease?
ACUTE RD:
-MItral Regurgitation
CHRONIC RD:
-Mitral Stenosis
216
What is the significance of the low virulence of Strep Viridans when it comes to endocarditis?
Because of the low virulence, it means that this bug can only infect previously damaged valves/tissue!! High yield!
---the smaller vegentations that form on the valves do not really affect the functioning of the valve.
BUT high virulence S.Aureus can affect previously OK valves and it forms large vegetations that affect the valve functioning
217
Prothetic heart devices are associated with which cardiac condition?
--Name the most common bug.
Prosthetic valves are known to be associated with S. Epidermidis which causes ENDOCARDITIS
218
What is the greatest cardiac risk faced by patients with underlying colorectal carcinoma?
-What organism causes that comorbidity?
ENDOCARDITIS!!
--caused by S. Bovis
In other words, if a patient presents with endocarditis caused by S. Bovis, make sure to check that patient for colorectal cancer
219
Which organisms lead to endocarditis with egative blood cultures?
The HACEK organisms...which are fastidious normal gram negative oral flora:
- Haemophillus Aphrophillus
- Actinobacillus Actinomycetemcomitans
- Cardiobacterium Hominis
- Eikenella Corrodens
- Kingella Kingae
220
What are the other causes of andocarditis, besides bacteria?
-name 3
--which valve is often involved?
NON-BACTERIAL ENDOCARDITIS:
-forms sterile vegentations and often involves the
mitral valve (regurgitation because the
vegetations form in the closure area of the valve)
Causes:
- Lupus (libbman-sacks endocarditis-MR)
- Malignancy
- Hypercoagulable state
221
Which virus commonly causes myocarditis?
Coxsackie Virus!!
This then causes dilated cardiomyopathy--->Systolic Dysfunction
222
Name 2 drugs (one recreational and nother therapeutic) that may cause dilated cardiomyopathy?
THERAPEUTIC: doxorubicin [used in cancer]
RECREATIONAL: coccaine
223
What is the classical histologic finding in hypertrophic cardiomyopathy?
Disoriented, tangled hypertrophied myaocardial fibers.
They are not arranged neatly in a linear fashion...but are just all over the place: #mess
224
What is the most common cause of restrictive cardiomyopathy in children?
Disease called ENDOCARDIAL FIBROELASTOSIS
in which a thick fibroelastic tissue froms in the endocardium of children
225
What are the two major differences between Takayasu's Arteritis and Giant Cell Arteritis?
They are essentially the same in that they both have FOCAL GRANULOMATOUS INFLAMMATION, but
1)TAKAYASU:
-affects mostly Asian women under 40 years
-involves mostly the aortic arch and proximal
great vessels, leading to pulselessness and
neurologic deficits
G.C. ARTERITIS:
-Affects mostly elderly women
-Tends to affect the branches of the caroid
artery mostly, e.g. temporal artery and
opthalmic artery
NB: Both are treated with corticosteroids
226
What are some of the findings in Polyarteritis Nodosa?
- name 5
- -Is there any particular organ that is usually spared?
It affects many (poly) arteries that supply organs-EXCEPT lungs!!
-So depending on which visceral organ is affected, findings may include:
-Melena or Abdominal Pain (if mesenteric A
involved)
-HTN if Renal Artery affected
-Neurologic Deficits if CNS arteries are afected
-Cutaneous Eruptions as skin vessels are
affected
-Renal Damage
227
Which type of vasculitis is associated with presence of serum hepatitis B antigens?
30% of Polyarteritis Nodosa patients are Hepatitis B seropositive
228
What is common between vasculitis and malignant hypertension?
They both have fibrinoid necrosis
229
Which vaculitus is associated with "string of pearls" on imaging?
Why?
Polyarteritis Nodosa
WHY: The fibrinoid necrosis in blood vasculature is patchy and at different satges of healing. Beacause of destrcution of arterial muscles, aneurysms can form at differrent points in the artery resulting in the string of peals appearance [like a Catholic rosary]
230
Whuch organ/s is/are usually targeted in Buerger's Disease (i.e. thromboangiitis obliterans)?
- what are the presentations of the disease?
- name 4
DIGITS!!!
- Presents with
1) gangrene and
2) autoamuptation of digits, along with
3) superficial nodular phlebitis(vein inflammation)
4) Raynaud's Phenomenon
231
Which 3 organs are often involved in Wegener's Granulomatosis?
Lung
Kidney
Nasopharynx
===>Focal Necrotizing Granuloma
232
What are the 3 differences between Wegener's (GPA) Vasclitis and Microscopic Polyangiitis (MPA)?
DIFFERENCES:
1) GPA= c-ANCA and MPA = p-ANCA
2) GPA involves nasopharynx, MPA involves skin
i. e. palpable pupura
3) GPA = granulomas and MPA =no granuloma
233
What are the 4 similarities between Wegener's (GPA) Vasclitis and Microscopic Polyangiitis (MPA)?
```
SIMILARITIS:
1) both involve kidney and lung
2) both treated by cyclophosphamide and
corticosteroids
3) Relapses are common in both
4) both are small vessel vaculitis
```
234
What are the 5 differences between Churg-Strauss (CS) vasculitus and Microscoic Polyangiitis (MPA)?
--Why do we have to make this distinction? What is it that makes them similar?
Since both are p-ANCA positive and both affcet small vessels, it's important to make a distinction.
1)CS patients usually have asthma and sinusitis
2)CS is associated with peripheral eosinophilia
(elevated
IgE level)
3)CS forms granulomas
4)CS has peripheral neuropathy often
manifestng as wrist/foot drop
5)CS can involve the heart and GI
NB: Both have pauci-immune glomerulonephritis
and papable purpura
235
What is the physiological Definition of HTN?
What is the physiological Definition of malignant HTN?
BENIGN HTN:
Systemic pressure greater than 140/90
MALIGNANT HTN:
Systemic pressure greater than 180/120
236
Which 2 diseases cause the HYALINE form of arteriosclerosis?
Hyaline arteriosclerosis is due to deposition of proteins into the vessel wall. Causes are
1) BENIGN HTN:
-more pressure forces proteins to deposit into
the wall
2) DIABETICS:
-patients get non-enzymatic glycosylation of
walls, which makes vessles leaky thus
allowing proteins to leak into the vessel wall
237
Which disease causes the ONION-SKINNING form of arteriosclerosis?
Malignant Hypertension.
--This can have fibrinoid necrosis of vessel wall with accompanying end-organ ischemia
238
What is the major difference between a Mobitz type I and a Mobitz type II AV block.
Both are 2nd degree AV blocks characterized by "dropped beats" i.e. a P-wave not preceded by a QRS complex such that the P: QRS ratio can be 2:1 or 3:1.
DIFFERENCE:
-In Mobitz Type I (Wenckebach), the PR interval
progressivley shortens before the beats are
dropped, but in Type II; the PR interval length
stays the same
NB: B-blockers can lead to this + bradycardia
239
What is the difference between post strep glomerulonephritis and post strep rheumatic fever?
Both result following Group A (S.Pyogenes)Infection
Rheumatic Fever: Type II Hypersensitivity Reaction
IgG or IgM binding to a
cell/tissue
Glomerulonephritis: Type III Hypersensitivity Rxn
- Circulating Immune-Complex-
antigen-Antibody complexes
activate complement and attract
PMNs
-Innate Immunity not enough to clear the
antigen
240
Which antineoplastic drug often caused dilated (congestive) cardiomyopathy?
DOXORUBICIN...serious cardiotoxicity
241
In which area of the chest do you hear a
I) VSD
2) PDA?
VSD---tricuspid area (lower left sternal border)
PDA----Pulmonic Area (upper left sternal border)
242
What is the primary defect in Kartagener Syndrome?
DEF:
-Defective dynein protein which is needed in cilia
or sperm motility or motility in the fallopian tube
243
How do patients with Kartagener Syndrome often present?
- name 3
Which other condition is often associated with Kartagener?
PRESENTATION:
- infertility
- recurring sinusitis + ear infections
- bronchiectasis
OTHER ASSOCIATION:
-Situs Inversus
244
What do abormally tall T-waves indicate on an ECG??
Hyperkalemia!!!
--Which may be secondary to severe burns or trauma which leads to extruding of excess K+ outside the damaged cells
245
How do patients with Kartagener Syndrome often present?
- name 3
Which other condition is often associated with Kartagener?
PRESENTATION:
- infertility
- recurring sinusitis + ear infections
- bronchiectasis
OTHER ASSOCIATION:
-Situs Inversus
246
What do abormally tall T-waves indicate on an ECG??
Hyperkalemia!!!
--Which may be secondary to severe burns or trauma which leads to extruding of excess K+ outside the damaged cells
247
Which ASD defect is often associated with Down's Syndrome?
Ostium Primum ASD...which is usually due to edocardial cushion defect.
HOWEVER, ostium secundum is the most common defect, which is usually due to excessive resorption of the septum primum or inadequate formation of the septum secundum.
248
Which condition classically presents with pain in the supine positon and relief when sitting up and leaning forward?
- -What other findings might you expect?
* *Name 5
Pericarditis!!!
OTHER FINDINGS:
- Friction Rub
- Sharp pain as opposed to crushing/pressure
pain
- Pain that radiates to the neck/arm..which can
be easily mistaken for an MI
-Diffuse ST elevation
-Pulsus Paradoxus (esp if there is an
accompanying effusion/tamponade)
249
Fetal Alcohol Syndrome is associated with which type of congenital heart disease?
VSD
250
Which three conditions do we normally use Digoxin for?
1) CHF...increased contractility--but no effect on
remodelling. [Positive Ionotrop]
2) A. FIB:...decreased conduction through the AV
node and depression of the SA node.
3) ATRIAL FLUTTER...because the drug depresses
the SA node
NB: Digoxin stimulates the vagas nerve, so we see
decreased HR as it depresses the SA node.
251
What predisposing factors increase the risk of Digoxin Toxicity?
i. e. What potentiates the effects of this drug?
- name 3
1) Anything that decreases the excretion of the
drug through kidneys e.g. renal failure
2) Anything that decreases serum K+ levels
[hypokalemia], e.g.non-K+ sparing diuretics such
as Furosemide, Thiazides, etc
3) Quinidine: This Class IA antiarrhytmic
decreases the digoxin clearance by displacing
digoxin from the tissue-binding sites.
252
Sulfasalazine is mainly used to treat which diseases?
- Ulcerative Colitis
- Chrohn's
- RA (as a disease-modifying agent)
253
A diatolic murmur which has an opening snap that follows an S2 is often secondary to which bacterial condition?
Rheumatic Fever usually causes mitral stenosis.
254
What are the two classical hemodynamic findings in Complete Heart Block?
---What cuases these findings?
1) INCREASED HEART RATE
So cardiac output is normal due to increased
stroke volume
i.e. CO = SV x HR
2) WIDE PULSE PRESSURE:
-e.g. 130/60 with a pulse pressure of 70!!
This is caused by the increased stroke volume
which means that more blood must be
accomodated in the arterioles, so there is
greater rise and fall in pressure during systole
and diastole.
255
Iregularly irregular heartbeats are characteristic of which condition?
-Which drug do we use to treat this conditon AND what aspect (mechanism) of this drug do we use in treating the above-mentioned condition.
Atrial Fibrillation.
Treated by DIGOXIN
-Digoxin slows down conduction through the AV node thus reducing ventricular rate.
--It also mimics vagal action, so Dogoxin slows depresses the SA node, thus bringing down the HR.
256
In Atrial flutter, which drugs are used to restore rate and which ones are used to restore rhythm?
RATE:
- Beta blocker
- Calcium Channel Blocker
RHYTHM:
- Class IA or IC
- Class III drugs
257
A patinet who presents with rhinitis, asthma, and chronic macualopapular rash is most likely diagnosed with_______?
---What is the other lab-related expected finding in this condition?
Churg-Strauss Vasculitis!!!!
EXPECTED FINDING:
Granulomatous Necrotizing Vaculitis with
elevated IgE i.e. Eosiophilia
258
What is the frequent cause of aortic stenosis in the elderly?
Calcification of the valve leaflets.
NB: Another major cause of AS is bicuspid aortic valve, but this often manifests ealier (40s) than much later in the case of clacification
259
In which chest area is an aortic regurgitation most heard?
Lower left sternal border!!! It's a misnomer i.e. the only exception.
NB: A pulmonic regurgitation may be heard in the same area too!
260
On a pressure-tracing graph, what does it mean/show when at the end of diastole, the LA pressure is significantly higher than the LV pressure?
Shows that there is mitral stenosis.
261
A male smoker younger than 40y.o with gangrenous digits and ulceration of fingertips is a classic description for what disease?
Buergers Disease (aka Thromboangiitis Obliterans)--which is a medim vessel vasculitis
262
Which 2 beta-Blockers have an intrinsic sympathomimetic activity, which would then increase the O2 consumption of the heart resulting in them being contraindicated in pateints with an
Angina?
The Partial Beta-Blockers:
Acebutalol and Pindolol
263
What are the peripheral and central cardiovascular responses to anemia?
-name 2 for each
PERIPHERAL:
-vasodiation to increase flow and compensate for
reduced oxygen delivery
-increased O2 extraction
CENTRAL:
- Increased HR
- Increased Stroke Volume---hence CO
264
What are the peripheral and central cardiovascular responses to anemia?
-name 2 for each
PERIPHERAL:
-vasodiation to increase flow and compensate for
reduced oxygen delivery
-increased O2 extraction
CENTRAL:
- Increased HR
- Increased Stroke Volume---hence CO
265
What are the peripheral and central cardiovascular responses to anemia?
-name 2 for each
PERIPHERAL:
-vasodiation to increase flow and compensate for
reduced oxygen delivery
-increased O2 extraction
CENTRAL:
- Increased HR
- Increased Stroke Volume---hence CO
266
Large vegetations and leaflet perforations are associated with what kind of heart disease?
LARGE VEGETATIONS:
-acute bacterial endocarditis
SMALL VEGETATIONS:
-these usually form around the rim of closure and
are ofte due to maantic (non-bacterial
thrombotic) endocarditis
267
Which ae the 4 antihypertensive drgs used in pregnancy?Name them in order of preference.
1. Methyldopa= always first line of treatment
- labetalol
- hydralazine
- nifedipine
