Cardiovascular Flashcards
Verapamil is a nondihydropyridine calcium channel bocker tht acts by blocking ____ calcium channels
L-type
Verapamil prevents the initial ____ influx into cariac myocytes and vascular smooth muscle
Calcium
Why are skeletal muscles no effected by calcium channel blockers
They do not rely on calcium influx to contract
Mechanical coupling betwwen receptors –> calcium release for SR
What changes on myocardial biopsy seen 0-4 hrs post MI
None
What changes on light microscopy are seen 4-12 hours following MI
Wavy fibers with narrow, elongated myocytes
What changes are seen 12-24 hours after MI on light microscopy
Myocyte hypereosinophilia with pyknotic (shrunken) nuclei
What changes on light microscopy are seen 1-3 days post MI
Coagulation necrosis (loss of nuclei and striations) Prominent neutrophilic infiltrate
What changes are seen on light microscopy 3-7 days post MI
Didintegration of dead neutrophils and myofibers
Macrophage infiltration at border area
What changes are seen on light microcscopy 7-10 days post MI
Robust phagocytosis of dead cells by macrophages
Beginning formation of granulation tissue at margins
What changes are seen on light microscopy 10-14 days post MI
Well-developed granulation tissue with neovascularization
What changes are seen on light microscopy 2-8 weeks following an MI
Progressive collagen deposition and scar formation
1-3 days after an MI, neutrophils infiltrate the border zone of the injured tissue in response to what proinflammatory cytokines
IL-6
IL-8
Where do potassium sparing diuretics act
Collecting duct
Increased sodium delivery to the late distal tbule and cortical collecting duct causes sodium reabsorption at the expense of potassium due to what molecules activity?
Aldosterone (increase ENaCs and Na/K pumps)
Stanford type A refers to aortic dissections that involve any part of the _____
Ascending aorta
Stanford type B refers to all aortic dissections involving the ______
Descending aorta
Type B dissections involving the descending aorta typically originate close to the origin of the ______ artery
Left subclavien
Type A aortic dissections usually originate in the ____ junction
Sinotubular
In treatment of hypovolemic shock, rapid infusion of blood or normal saline increases intravasucular volume and ventricular preload which has what effect on frank starling mechanism
Incrased preload –> stretch myocardium and increase end diastolic sarcomere length –> increase stroke volume and cardiac output
Classic clinical features of down syndrome inlude ___ facial profile, epicanthal folds, __-slanting palpebral fissures, protruding ____, and ___ ears
Flat
Up
Tongue
Small
Cranial nerve from pharyngeal arch 1
Trigeminal
Cranial nerve from pharyngeal arch 2
Facial
Cranial nerve from pharyngeal arch 3
Glossopharyngeal (IX)
Cranial nerve from pharyngeal arch 4
Superiorlaryngeal branch of vagus (X)
Cranial nerve from pharyngeal arch 5
None, it is obliterated
Cranial nerve from pharyngeal arch 6
Recurrent laryngeal branch of CN X
Aortic arch derivative from pharyngeal arch 1
Maxillary artery
Aortic arch derivative from pharyngeal arch 2
Stapedial artery (regresses)
Aortic arch derivative from pharyngeal arch 3
Common carotid artery
Proximal internal carotid artery
Aortic arch derivative from pharyngeal arch 4
True aortic arch
Subclavian arteries
Aortic arch derivatives from pharyngeal arch 5
None, it is obliterated
Aortic arch derivatives from pharyngeal arch 6
Pulmonary arteries
Ductus arteriosus
What are beta blockers used in acute MI patients
Reduce myocardial oxygen demand by lowering HR, contractility, and afteroad
Why is metoprolol a better option than some other beta blokers for a patient with COPD
It is beta 1 selective so will no produce bronchospasms
Once secreted, ANP and BNP bind to natriuretic peptide receptors to activate guanylate cyclase to form cGMP which stimulates ____ and ______ to alleviated volume overload
Diuresis
Peripheral vasodilation
Sacubitril MOA
Neprilysin inhibitor (decreased breakdown of ANPnad BNP)
Beriberi is due to what vitamin deficiency
Thiamine (B1)
B1 (thiamine) deficiency can cause Beriberi which has what clinical manifestation
Peripheral neuropathy
Heart failure
Dry Beriberi is charecterized by symmetrical peripheral neuropathy of the distal extremeties, with resulting sensory and motor impairments. Wet Beriberi includes the addition of _____
Cardiac involvemnt (cardiomyopathy, high-outpt congestive heart failure, peripheral edema, tachycardia)
Subclavian steal syndrome occurs due to hemodynamically significatn stenosis of the subclavian artery proximal to the origin of the ____ artery
Vertebral
Patients with subclavien artery stenosis are often asymptomatic but when symptoms occur they are typically related to ____ or ______
Arm ischemia (fatigue, pain, paresthesia) Vertebrobasilar insufficiency (dissiness, vertigo, drop attacks)
ACE inhibitors reduce ___ secretion –> ____ retention
Aldosterone
Potassium
The final stage of healing of a myocardial infarction begins approximately 2 weeks after infarction and involves increased deposition of type ___ collagen
One
Does systemic vascular resistance increase or decrease after birth (compared to fetal circulation)
Increase
Fetal systemic vascular resistance is low due to low resistance in the placenta
Does pulmonary vascular resistance increase or decrease when a baby is born (compared to fetal circulation)
Decrease
Hypoxic vasoconstriction in nonventilated lung during fetal life
Does left ventricular contribution to cardiac output increase or decrease when a baby is born (compared to fetal circulation)
Increase
Ductus arteriosus allows right heart output to be the majority in fetal life
Hemosiderin laden macrophages in the lungs are usualy a result of what
Chronic passive lung congestion in the setting of heart failure
Isolated systolic hypertension in an elderly patient is likely do to what
Increased arterial stiffness –> decreased aorta compliance–> high pressure during systole
MOA isoproterenol
Non selecive B agonist
Decrease vascular resistance via B2 and increase cardiac contractility B1
What is the most comon congenital cardiac malformation in patients with Turner syndrome
Bicuspid aortic valve
A nonstenotic bicuspid aortic valve can manifest as an early __, high frequency ____ over her right second interspace
Systolic
Click
Short stature, short and thick neck, broad chest, and shortened fourth metacarpals arecharacteristic of ______
Turner syndrome
Labetalol blocks what receptors
Beta 1, beta 2, alpha 1
how can aortic coarctation in a child or young adult present clinically
lower extremity claudication
blood pressure discrepancy between upper and lower extremities
delayed or diminished femoral pulses
an echocardiogram showing an aorta lying anterior to the pulmonary artery is diagnostic of _____
transposition of the great arteries
diltiazem MOA
nondihydropyridine calcium channel blocker
what causes a systolic murmur along the left sternal border that decreases in intensity with maneuvers that increase left ventricular blood volume such as leg elevation or handgrip
hypertrophic cardiomyopathy
why is Digoxin effective at controlling ventricular rate in atrial fibrillation at rest, but not during exercise
digoxin slows AV node conduction by increaseing parasympathetic tone (vagus nerve) which is relatively low during exercise compared to sympathetic tone
Retinal artery occlusion is caused by thromboembolic complications of atherosclerosis traveling from the ____ artery to the ____ artery to the retinal artery
internal carotid
ophthalmic
low dose dopamine infusion stimulates what receptors causing what effect?
D1 (in renal and mesenteric vasculature)
vasodilation and increased blood flow
high doses of dopamine stimulates what receptors causing what effect
beta 1 and alpha 1 –> increased cardiac output and elevated systemic vascular resistance
at the high end of the dose range, the increase in afterload can result in decreased cardiac output
what are the functions of atrial and brain natriuretic peptide?
vasodilation
salt and water excretion
list the following in order from slowest to fastest conduction speed:
atrial muscle
purkinje fibers
AV node ventricular muscle
AV node
ventricular muscle
atrial muscle
Purkinje system
describe the murmur heard in an neonate with a patent ductus arteriosis
continuous, machinelike murmur (from left to right shunting)
Production of ____ by the placenta maintains a patent ductus arteriosus and smooth muscle dilation
prostaglandin E2
A bubble study is performed by injecting agitated normal saline intravenously and observing for microbubbles in the left heart which would signify what?
right to left intracardiac shunts
ie patent foramen ovale and atrial septal defect
the pulmonary artery occlusion pressure/wedge pressure, is determined by entering and inflating a balloon catheter into a branch of the pulmonary artery. This is used to determine the pressure in what anatomic location?
left atria
and left ventricular end diastolic
Autosomal dominant mutations in the TTN gene, which encodes for the sarcomere protein titin, are the most common cause of familial ____ cardiomyopathy
dilated
what are the second messengers (ie. IP3, cAMP) for A1, A2, B1, B2, mus 2, and mus 3 receptors?
A1 --> IP3 A2 --| cAMP B1 --> cAMP B2 --> cAMP mus 2 --| cAMP mus 3 --> IP3
aortic compliance progressively decreases with age which causes what changes in pulse pressure, diastolic pressure, and systolic pressure in elderly with cardiovascular disease
pulse pressure: increased
diastolic: slight decrease
systolic: increased
(“isolated systolic hypertension”)
diastolic blood pressure is directly related to _____
systemic vascular resistance
pulse pressure is the amount that arterial pressure increases above diastolic pressure during left ventricular contraction, it is directly related to ___ and inversely related to _____
stroke volume
aortic complaince
how does aortic stenosis cause angina in the absence of obstructive coronary artery disease
increased myocardial oxygen demand due to an increase in left ventricular mass and ventricular wall stress
A 5 year old patient that has cyanotic spells during mild exertion that are improved by squatting are consistent with what congenital malformation
tetralogy of fallot
squatting decreases right to left shunting causing less blood to bypass the stenotic pulmonary valve
tetralogy of fallot is characterized by what 4 distinct anatomic abnormalities
VSD
overriding aorta over right and left ventricles
right ventricular outflow tract stenosis
right ventricular hypertrophy
what are the 3 classic findings of cardiac tamponade that make up the Beck triad
hypotension
elevated jugular venous pressure
muffled heart sounds
what is pulses paradoxus?
exaggerated drop in systolic blood pressure (>10 mmHg) during inspiration (seen in cardiac tompanade)
triamterene MOA
directly inhibits ENAC channels (epithelial sodium channels preventing sodium from entering principal cells)
what is the cause of hypotension in septic shock
widespread vasodilation –> decreased systemic vascular resistance
(also increased vascular permeability)
how does septic shock effect cardiac index
increased (to compensate for hypotension)
why is there a high mixed venous oxygen saturation in septic shock
hypotension –> increased cardiac index –> high blood flow rate –> prevents tissues from extracting oxygen from blood completely
what is the characteristic pressure tracing finding in patients with mitral valve regurge
early and large V wave
when is an S3 heart sound heard in relation to normal heart sounds
after S2
when is a S4 heart sound heard in relation to normal heart sounds
before S1
what causes an S4 heart sound
blood being forced into a stiff ventricle (diastolic dysfunction)
oxygenated blood from the placenta is delivered into the fetus via the _____
umbilical vein
Blood from the umbilical vein is first delivered to the liver where it bypasses the hepatic circulation via the ______ and then enters the ____ before reaching the heart
ductus venosus
inferior vena cava
what congenital heart malformation will show a narrow-appearing mediastinum on chest xray
transposition of the great arteries
due to abnormal position of the aorta directly ontop of the pulmonary artery
Kawasaki disease can lead to what cardiovascular complication
coronary artery inflammation –> coronary artery aneurysm
____ disease is a vasculitis of medium sized arteries that presents with persistent fever for >5 days, bilateral conjunctivitis, cervical LAD, and mucocutaneous involvement
Kawasaki
A ____ hormone has no effect on a physiologic process by itself but allows another hormone to exert its maximal effects on that process
permissive
ex. cortisol exerts permissive effect on catecholamines to potentiate vasoconstriction and bcronchodilation
does the right ventricle or aortic root have higher pressure during systole? during diastole?
aorta has higher pressure than the right aortic root in both systole and diastole
______ presents as decompensated heart failure following a symptomatic viral predrome and should be suspected especially in young patients with this presentation
dilated cardiomyopathy due to viral myocarditis
chronic aortic regurge following infective endocarditis results in compensatory _____ which increases stroke volume in order to maintain cardiac output
eccentric hypertrophy
volume overload –> eccentric hypertrophy
what anatomical region controls the rhythm of ventricular contractions during A fib
AV node
The ______ artery supplies the AV node in 90% of patients and the SA node
right coronary
High degree AV blood is usually do an MI involving what vessel? while low degree AV block is usually due to an MI involving what vessel?
high degree: left anterior descending low degree (within the AV node): right coronary artery
_______ is characterized by an opening snap followed by a rumbling diastolic murmur that is best heard over the cardiac apex
mitral stenosis
Increased left ventricular diastolic pressure in a patient with mitral stenosis suggests concomitant ____ valve dysfunction
aortic
selective arteriolar vasodilators can lead to sodium and fluid retention with peripheral edema by what mechanism
arteriolar dilation –> decreased vascular resistance –> baroreceptor activation –> sympathetic activation –> renin-angiotensin-aldosterone axis stimulation
Pulsus paradoxus refers to an exaggerated drop (>____ mm Hg) in systolic blood pressure during inspiration
10
Pulsus paradoxus is defined by a decrease in systolic blood pressure of >10 mmHg with inspiration and is most commonly seen in patients with _____
cardiac tamponade (can also occur in severe asthma, chronic obstructive pulmonary disease, and constrictive pericarditis)
Acute obstructive pulmonary exacerbations are primarily treated with beta adrenergic agonists to product what response
relaxation of bronchial smooth muscle
Beta adrenergic agonists control acute asthma and COPD exacerbations by causing bronchial smooth muscle relaxation via increased intracellular ______
cAMP
What 2 structures cause left ventricular outflow tract obstruction in hypertrophic cardiomyopathy
mitral valve leaflet
interventricular septum
A large, pedunculated mass in the left atrium is most likely what?
atrial myxoma
Cardiac myxomas often show _____ rich stroma with scattered myxoma cells and ________ as characteristic findings
mucopolysaccharide
hemosiderin laden macrophages
What are 2 side effects associated with statin therapy
hepatotoxicity (test liver enzymes)
muscle toxicity
statin MOA
inhibit HMG CoA reductase
ezetimibe MOA
decrease cholesterol absorption
What are the major lipid effects of each of the following? statin ezetimibe bile acid sequestrants niacin fibrates fish oil/omega 3 FA
statin: decrease LDL and triglycerides
ezetimibe, bile acid sequestrants: decrease LDL
niacin: decrease LDL, increase HDL
fibrates and omega 3: decrease triglycerides and increase HDL
Niacin MOA in treating hyperlipidemia
decreases: FA release, VLDL synthesis, and HDL clearance
The AV node is located on the endocardial surface of the right atrium, near the insertion of the septal leaflet of the ___ valve and the orifice of the _____
tricuspid
coronary sinus
A patent foramen ovale is a one way tissue valve in the atrial septum that opens only when ______
right atrial pressure exceeds left atrial pressure
During the release /relaxation phase of a valsalva maneuver, ____ increases and encourages the opening of a patent foramen ovale
right atrial pressure (preload/venous return)
Is systemic vascular resistance increased or decreased in patent ductus arteriosis
decreased
In the presence of a patent ductus arteriosus, venous return to the left atrium and ventricle are increased or decreased?
increased
What 2 mechanisms of Cilostazol helps treat claudication symptoms in peripheral arterial disease
inhibits platelet phosphodiesterase therefore inhibiting breakdown of cAMP (cAMP inhibits platelet aggregation)
direct arterial vasodilator
upper extremity hypertension and diminished lower extremity pulses indicates what diagnosis
coarctation of the aorta
what compensatory mechanism is seen in aorta coarctation which also causes the continuous murmur that can be auscultated over the back at the left paravertebral area
collateral blood flow
blood will travel retrograde through intercostal arteries into the descending aorta to bypass the defect
What receptor stimulates increased cAMP in juxtaglomerular cells
B1
most cases of infective endocarditis involve what valve
tricuspid
How does vancomycin cause red man syndrome (flushing, erythema, pruritis) when injected too quickly
vancomycin directly activates mast cells which release vasoactive mediators (ie histamine)
Prolonged beta blockade leads to upregulation of beta receptors and increased sensitivity to circulating ____, causing an enhanced beta adrenergic response on abrupt beta blocker cessation
catecholamines
In hypertensive emergency, end organ damage manifests in the kidneys as malignant nephrosclerosis, characterized by ___ necrosis and hyperplastic arteriosclerosis which has ____ appearance
fibrinoid
onion skin
What vascular changes result from administration of nitroprusside
balanced vasodilation of veins and arteries
what causes decreased systemic vascular resistance in hyperthyroidism
increased metabolic demand in peripheral tissues and direct effect of thyroid hormone on vascular smooth muscle causes peripheral vasodilation
what effects does hyperthyroidism have on diastolic, systolic, and pulse pressure
diastolic: decreased
systolic and pulse pressure: increased
What intracellular changes lead to vascular smooth muscle relaxation following nitrate administration
Nitric oxide –> guanylate cyclase –> increased cGMP –> dephosphorylation of myosin light chain –> vascular smooth muscle relaxation
what class I sodium channel blockers prolongs action potential , lengthens the action potential, and has no change on the action potential?
lengthens: 1A
shortens: 1B
no change: 1C
Explain coronary steal
inducing dilation of coronary arterial arteries excentuates myocardial ischemia because ischemic areas are already maximally dilated at rest and blood will flow to non ischemic areas
______ is a metalloprotease that cleaves and inactivates both ANP and BNP
neprilysin
Sacubitril, a neprilysin inhibitor, leads to increased levels of ___ and ____ and promotes beneficial effects in heart failure
ANP
BNP
ANP and BNP induce ____ and ____ by antagonizing the actions of RAAS and also protect against the deleterious myocardial remodeling and fibrosis that occur in heart failure
vasodilation
diuresis
Because neprilysin is responsible for inactivating ______ , inhibition of neprilysin further stimulates deleterious vasoconstriction and fluid retention
angiotensin II (neprilysin also breaks down ANP and BNP)
In treating heart failure, neprilysin inhibitors are combined with a _____ blocker to mitigate negative effects of neprilysin
angiotensin II receptor blocker
ex. sacubitril-valsartan
ST elevation in leads II, III, and a VF indicate myocardial ischemia to what region of the heart due to what artery occlusion
inferior wall of left ventricle
right coronary artery
ST elevations in leads V1- V4 indicate ischemia to what region of the heart due to what artery occlusion
anteroseptal
LAD
ST elevations in V5 and V6 indicate ischemia to what region of the heart and are due to occlusion of what coronary vessel
lateral wall of left ventricle
left circumflex artery
what effect does statin therapy have on LDL receptors
inhibited HMG-CoA reductase –> decreased cholesterol production –> increased LDL receptor expression –> increased uptake of circulating LDL
A significantly lower oxygen saturation in the left foot than the right arm of a neonate suggests what?
extracardiac right to left shunt across PDA
deoxygenated blood from pulm artery is flowing into aorta
primary mitrovalve prolapse is characterized by myxomatous generation, aka deterioration of which: endocardium myocardium connective tissue parietal pericardium coronary vessles
connective tissue
Coronary autoregulation allows coronary blood flow to be primarily driven by myocardial oxygen demand over a wide range of perfusion pressures. It is mostly accomplished by alterations in vascular resistance via release of ____ and ____ in response to myocardial hypoxia
adenosine
nitric oxide
Rapid rise-rapid fall pulsation with each ventricular contraction that manifests as widened pulse pressure, rapid distension and collapse of carotid arteries (corrigan sign) and “to-and-fro” bruit over the femoral arteries (Duroziez sigh) is characteristic of what?
aortic regurgitation
what is the normal pressure in the left ventricle?
120/10
what is the normal pressure in the aorta?
120/80
What indirect effect to medications that increase systemic vascular resistance such as phenylepherine and norepinephrine have on heart rate
indirectly decrease heart rate
increase SVR –> baroreceptor –> CNS –> decrease heart rate
Stasis dermatitis is characterized by chronic erythema, fibrosis, and reddish-brown discoloration due to deposition of _____ (from breakdown of extravasated red cell)
hemosiderin
The classic auditory finding in patients with ______ is harsh, crescendo-decrescendo systolic ejection murmur heard best in the right second intercostal space with radiation to the carotids
aortic stenosis
Thoracic aorta aneurysm most commonly present with chest or back pain but compression of nearby structures as it expands can cause what symptoms?
dysphagia
hoarseness
cough
dyspnea
When using the femoral artery for cardiac catheterization, cannulation above the inguinal ligament can significantly increase risk of hemorrhage into what region
retroperitonium
clonidine MOA
alpha 2 agonist —> decreases presynaptic release of NE and decreases sympathetic outflow
during systole coronary vessels are compressed by surrounding muscle, as a result, what portion of the heart is most prone to ischemia and infarction
subendocardial left ventricle
Risk of left ventricular free wall rupture occurs how long following an MI
up to 2 weeks following an MI but usually happens within 5 days
QT prolongation caused by what drug, in contrast with other drugs, is associated with a very low risk of torsades de pointes
amiodarone
What 2 watershed zones in the colon are most susceptible to ischemia in cases of severe systemic hypotension
splenic flexure
rectosigmoid junction
A fib can be detected on ECG by an absence of organized _____
P waves
How can mitral valve stenosis cause hoarseness
mitral stenosis –> enlarged left atria –> impingement of left recurrent laryngeal nerve (Ortner syndrome)
what heart condition causes head bobbing
aortic regurgitation
what heart toxicity is a side effect of doxorubicin use
dilated cardiomyopathy
Where is the optimal cannulation site for the femoral site? (where should you enter/try to access the femoral vein for catheterization)
immediately medial to femoral artery (femoral nerve and artery are lateral to the femoral vein) and below the inguinal ligament
assign the following pressures to catheter locations in a normal, healthy heart: mean 6-12 15-30/1-6 mean 1-6 15-30/1-6
RA: mean 1-6
RV: 15-30/1-6
Pulmonary artery: 15-30/6-12
left atrial/PC wedge pressure/LVEDP: mean 6-12
What is the single most important risk factor for the development of intimal tears leading to aortic dissection
hypertension
What congenital heart defect causes cyanotic “tet” episodes during feeding or squatting
tetralogy of fallot
murmur disappears during these tets
what are 3 major risk factors for development of abdominal aortic aneurysm
age >65
smoking
male sex
in pacemaker cells, phase 0 depolarization is mediated by what ion
calcium
What organism causes rheumatic fever
group A strep
What are Aschoff bodies which are seen on histology of a myocardial biopsy in rheumatic heart disease
interstitial myocardial granuloma
what are Anitschkow cells which are seen on histology of a myocardial biopsy in rheumatic heart disease
plump macrophages with abundant cytoplasm and central, slender chromatin ribbons
During cardiogenic shock secondary to an MI, how are coronary perfusion pressure, central venous pressure, and pulmonary capillary wedge pressure effected
central venous pressure: increased
pulmonary capillary wedge pressure: increased
coronary perfusion pressure: decreased
ANP and BNP have what effects on the following:
GFR
renin secretion
PCT Na resorption
GFR: increased
renin: decrease
Na reabsorption in PCT: decreased
The common cardinal veins of the developing embryo drain directly into the sinus venosus (which drains into the primitive atrium), these cardinal veins ultimately give rise to the ______and other constituents of the systemic venous circulation
superior vena cava
What cause of aortic stenosis is characterized by fusion of valve commissures due to repetitive inflammation
rheumatic valve disease
What causes a harsh ejection type systolic murmur heard best at the base of the heart with radiation to the base of the neckq
aortic stenosis
What should immediately be administered to neonates that are born cyanotic with tetralogy of fallot
prostaglandin E1 to prevent closure of the ductus arteriosus
Atheroembolic disease typically occurs after an invasive vascular procedure due to mechanical dislodgement of ______
atherosclerotic plaque (–> showering of cholesterol-rich microemboli into circulation)
Needle-shaped cholesterol clefts in vessels are diagnostic of what?
atheroembolic disease
What organ is frequently damaged due to atheroembolic disease
kidney
also, skin, GI tract, and CNS
Angina results from restricted coronary blood flow due to a fixed atherosclerotic lesion that obstructs > ____% of the coronary artery lumen
70
The circulatory system is a continuous circuit, and therefore the _____of the left ventricle must closely match the _____ of the right ventricle
volume output
volume output
(blood flow per minute)
How does an arteriovenous fistula allows blood to shunt from arterial circulation to venous circulation, what effect does this have on afterload, preload, and stroke volume
afterload: decreased (reduced systemic vascular resistance as blood bypasses high resistance of systemic arterioles)
preload: increased
stroke volume: increased
The primary purposes of rate control are to minimize symptoms and what other preventative reason?
prevent tachycardia induced cardiomyopathy
Diliazem MOA
nondihydropyridine calcium channel blockers
How does anaphylactic shock effect central venous pressure, pulmonary capillary wedge pressure, cardiac index (left ventricular output), and, systemic vascular resistance
CVP: decreased
PCWP: decreased
LV output: increased (bc increased HR)
SVR: decreased
What treatment for hyperlipidemia has a main side effect of flushing, warmth, and itching? What is released in response to this medication that causes these symptoms?
niacin
prostaglandins (primarily PGD2 and PGE2)
Why are pharmacologic vasodilators (nitroprusside) helpful in mitral regurge?
they decrease systemic blood pressure –> decreased afterload –> increase forward flow –> reduce pulmonary congestion
Lower extremity clubbing and cyanosis (but not in upper extremity) without pulse discrepancy is caused by a large patent ductus arteriosus with what complication
Eisenmenger syndrome
(reversal of shunt flow from left to right to right to left –> deoxygenated blood now being pumped through ductus arteriosus to the lower extremities)
In patients with carotid sinus hypersensitivity, why might shaving result in syncope?
carotid sinus baroreceptors detect increased blood pressure –> increased parasympathetic tone and decreased sympathetic tone –> slows heart rate and induces vasodilation
The inferior wall of the left ventricle forms most of the inferior surface of the heart and is supplied by the ______ artery
posterior descending
Atrial left-to-right shunts (ie ASD) cause what change on auscultation
wide and fixed splitting of S2
Decreased diastolic pressure and increased left ventricular diastolic pressure are consistent with what valvular malformation
aortic regurgitation
The most common cause of alveolar hemosiderin-laden macrophages, indicating alveolar hemorrhage is what
chronic elevation of pulmonary capillary hydrostatic pressure in the setting of left-sided heart failure
dofetilide MOA
class III antiarrhythmic, block potassium channel
sotalol MOA
class III antiarrhythmic, blocks potassium channels
What is the equation used to determine the flow based on the radius of a vessel or vice versa
flow = radius^4
what equation can be used to determine the resistance in a vessel
resistance = (viscosity of blood x length of blood vessel)/ radius of vessel^4
How does hypovolemic shock cause metabolic acidosis
reduced organ perfusion –> lactic acidosis (–> compensatory hyperventilation/respiratory alkalosis)
in order to live with transposition of the great arteries, initial management includes maintaining a left-to-right mixing lesion via a patent _______ and a patent ______
ductus arteriosus
foramen ovale
____ presents with sharp pleuritic chest pain that is relieved by sitting up and leaning forward
pericarditis
Losartan MOA
ARB (angiotensin II receptor blockers)
The ductus arteriosus is derived from the ___ aortic arch
sixth
First aortic arch –> what adult derivative?
part of maxillary artery
second aortic arch –> what adult derivative?
hyoid and stapedial artery
third aortic arch –> what adult derivatives
common carotid artery and proximal internal carotid artery
fourth aortic arch –> what adult derivative?
aortic arch (left) proximal right subclavian artery (right)
sixth aortic arch –> what adult derivative?
proximal pulmonary arteries and ductus arteriosus (left)
In response to artery stenosis, how does coronary autoregulation alter perfusion pressure and blow flow
perfusion pressure decreases
coronary blood flow remains near normal (due to autoregulation causing vasodilation)
ANP and BNP activate __ to increase intracellular _____
guanylyl cyclase
cGMP
phosphodiesterase inhibitors decrease the degradation of ____
cGMP
elevated intracellular ____ levels lead to relaxation of vascular smooth muscle and vasodilation
cGMP
During pregnancy what changes are seen in preload, afterload, stroke volume, and cardiac output
preload: increased
afterload: decreased
stroke volume: increased
cardiac output: increased
How are each of the following effected in cardiac tamponade? central venous pressure right atrial cavity size left atrial pressure stroke volume
CVP: increase
RA cavity size: decreased
LA pressure: increased
stroke volume: decreased
what type of organism is borrelia burgdorferi (causes of lyme disease)
bacterial spirochete
The likelihood of plaque rupture is related to plaque stability rather than plaque size or degree of luminal narrowing. Inflammatory macrophages in the intima may reduce plaque stability by secreting ____
metalloproteinases
degrade extracellular matrix proteins
How is ejection fraction maintained despite apoptosis and necrosis due to normal aging?
myocyte hypertrophy
What antiarrhythmics prolong the QRS duration with little effect on the QT interval
class 1C (flecainide)
what is heard on auscultation of an atrial septal defect
systolic ejection murmur and wide and fixed splitting of S2
Loss of cardiomyocyte contractility occurs within _____ after the onset of total ischemia. When ischemia lasts longer than ____ , ischemic injury becomes irreversible
60 seconds
30 min
describe the course of the saphenous vein
origin: medial side of foot –> anterior to medial malleous –> medial leg and thigh –> drains into femoral vein just inferolateral to pubic tubercle
what maneuvers increase the intensity of a hypertrophic cardiomyopathy murmur
decreasing preload or afterload: abrupt standing, valsalva strain phase
what condition causes engorged pulmonary capillaries and intraalveolar, acellular, pink material that is more prominent at the base of the lungs
pulmonary edema
How can chronic alcohol use lead to cardiogenic shock and acute respiratory failure
dilated cardiomyopathy –> exacerbation of heart failure and pulmonary edema
Rank the sodium channel binding strength of class 1A, 1B, and 1C antiarrhythmics
1C>1A>1B
1C demonstrate the most use dependence due to slow dissociation, 1B have least use dependence
The ____ composes a majority of the anterior surface of the heart and is at risk of injury with penetrating trauma at the mid- and lower- left sternal border
right ventricle
The most common trigger for atrial fibrillation is aberrant electrical foci in what anatomic structure?
pulmonary veins (near their ostia into the left atrium)
How are the following affected by cardiac amyloidosis: ventricular wall thickness diastolic relaxation ventricle cavity size atrial cavity size
ventricular wall thickness: increased
diastolic relaxation: decreased
ventricle cavity size: normal or decreased
atrial cavity size: increased
isosorbide dinitrate MOA
nitrate: systemic vasodilation
main adverse effects of nitrate therapy
headache, cutaneous flushing, lightheadedness, hypotension, reflex tachycardia
How do QRS complexes generated by the HIS bundle differ from impulses generated from purkinje or system?
HIS is more narrow and purkinje generate wider QRS
What arrhythmia is caused by wolf parkinson white pattern
atrioventricular reneentrant tachycardia due to accessory conduction pathway that bypasses the AV node
In tetralogy of fallot, during tet episodes, what heart pressure changes cause cyanosis
increased Right ventricular outflow obstruction –> increased right ventricular pressure –> right to left shunting through VSD and less oxygenated blood
What 4 channels/receptors are blocked by amiodarone
fast sodium channels
L-type calcium channels
beta receptors
potassium cahnnels
two common mutations that cause hypertrophic cardiomyopathy include single point missense mutations in the genes for ____ and ____
beta myosin heavy chain and myosin-binding protein C
Beta blockers mainly decrease conduction in what part of the heart? What effect does this have on ECG?
AV node
prolonged PR
Congenital long QT syndrome is most often caused by genetic mutations in the ___ channel protein that predisposes to the development of life threatening ventricular arrhythmias (torsades)
potassium
How does hypovolemia due to sodium and/or water loss such as vomitting and diarrhea effect hematocrit, albumin, and uric acid concentration
all increased (RBC and albumin trapped in intravascular space and hypovolemia triggers increased absorption of uric acid in the PCT due to increased Na absorption in the PCT)
leads I and aVL correspond to the lateral limb leads on ECG, ST elevations in these leads indicate infarction of the lateral aspect of left ventricle which is supplied by the ____ artery
left circumflex
The carotid sinus reflex has an afferent limb that arises from the baroreceptors and travels to vagal nucleus and medullary centers via the _______ nerve
glassopharyngeal nerve (IX)
What is the most common mechanism of cardiac death due t acute myocardial infarction
ventricular fibrillation
What is the most common pathogen to cause purulent pericarditis, particularly in the setting of a portal from the skin to the bloodstream (ir catheter) or pericardium (recent chest surgery)
staph aureus
Metolazone MOA
thiazide diuretic
Surgical closer of a patent ductus arteriosus causes what immediate changes to the left ventricular preload and afterload
LV preload: decreased
LV afterload: increased
When the cells within the heart, brain, or skeletal muscle are injured, the enzyme ____ leaks across the damaged cell membrane and into circulation
creatinine kinase
What 4 stimuli, plus shear forces, activate specific membrane receptors on endothelial cells leading to an increase in cytosolic calcium levels and result in vasodilation
acetylcholine
bradykinin
serotonin
substance P
In order to cause vasodilation, endothelial nitric oxide synthase synthesizes nitric oxide from _____, NADPH, and O2
arginine
In order to cause vasodilation, Nitric oxide is synthesized and diffuses into adjacent cells where it increases formation of ____
cGMP
The posteriomedial papillary muscle is supplied soley by what artery, making it susceptible to ischemic rupture
posterior descending artery
Papillary muscle rupture is a life threatening complication that typically occurs ____ days after MI and presents with acute mitral regurge and pulmonary edema
3-5
______ demonstrates rapid and regular atrial activity in a sawtoothed pattern on ECG
atrial flutter
Typical atrial flutter is caused by a large reentrant circuit that traverses what site which is the target site for ablation?
cavotricuspid isthmus of right atrium (area between the tricuspid valve and inferior vena cava of in the right atrium)
What cause of mitral stenosis is characterized by diffuse fibrous thickening and distortion of the mitral valve leaflets along with commissural fusion at the leaflet edges
rheumatic fever
_____ is a congenital cardiac defect associated with secondary hypertension and is a risk factor for cerebral aneurysm development
coarctation of the aorta
what effect does dobutamine have on heart rate
increase
The posterior surface of the heart is mostly formed by the ____ which when enlarged can cause external compression of the mid-esophagus with dysphagia (cardiovascular dysphagia)
left atumia
How does adenosine terminate a reentrant circuit tachyarrhythmia
hyperpolarizes the nodal pacemaker and conducting cells to briefly block conduction through the AV node
what are the most frequent adverse effects associated with adenosine (4)
flushing, chest burning (due to bronchospasm), hypotension, and high grade AV block
On a normal jugular venous pulse wave tracing, what do the 3 positive waves indicate (in order: A, C, V)
A: atrial contraction
C: bulging of tricuspid valve into right atrium in early systole
V: passive increase in pressure and volume of right atrium as it fills in late systole and early diastole
what do the troughs of the jugular venous pulse represent (in order: x-descent and y-descent)
x-descent: relaxation of the right atrium
y-descent: abrupt decrease in right atrial pressure during early diastole after the tricuspid valve opens and the right ventricle begins to passively fill
The blood in the what vessel is the most deoxygenated blood in the body?
coronary sinus
myocardial oxygen extraction exceeds that of any other tissue or organ
plaque like deposits of fibrous tissue on the right sided endocardium causing tricuspid regurge and right sided heart failure is pathognomonic for what syndrom
carcinoid syndrome
serotonin –> fibroblast growth
Elevated 24 hour urinary _____ can confirm the diagnosis of carcinoid syndrome
5-hydroxyindoleacetic acid (end product of serotonin metabolism)
A patient presenting with an new systolic murmur during an MI which resolves after treatment likely had damage to what structure
papillary muscle (--> mitral regurge) (timely restoration of blood flow can improve papillary muscle dysfunction and lead to resolution of the regurgitation)
digoxin produces what cellular ion levels to improve myocyte contractility
inhibit Na-K ATP –> increased intracellular sodium –> decreased sodium-calcium exchanger activity –> increased intracellular calcium
How can cardiac output be determined by using the rate of oxygen consumption
cardiac output = (rate of O2 consumption) / (arteriovenous O2 content difference)
What holosystolic murmur increases in intensity with inspiration
tricuspid regurge (decreased intrathoracic pressure --> more blood to right heart and increased pulmonary vessel capacity --> decreased blood to left heart)
subungual splinter hemorrhages (flame shaped hemorrhagic streaks in the nail bed) appear as a consequence of microembli due to what underlying pathology
infectious endocarditis
what 2 physical exam findings on the hands indicate a diagnosis of infectious endocarditis
subungual splinter hemorrhages (hemorrhagic streaks under nail beds) Janeway lesions (small, macular, erythematous or hemorrhagic, nontender lesions on the palms and soles)
what mechanism makes fenoldopam a useful agent in treating patients in hypertensive emergency with renal insufficiency
D1 agonist –> vasodilation of most arterial bed and particularily prominently causes renal vasodilation –> increased renal perfusion and natriuresis
______ is characterized by an elevate heart rate with a regular rhythm and narrow QRS complexes due to an abnormal electrical impulse originating above the ventricles
supraventricular tachycardia
Abdominal aortic aneurysm is associated with what changes to the wall of the aorta, leading to weakening and progressive expansion of the aortic wall
chronic transmural inflammation and extracellular matrix degradation
Myxomatous degeneration with pooling of proteoglycans in the medial layer and an intact intima layer in a large artery is consistent with what diagnosis
aortic aneurysm
Marfan syndrome is a frequent cause of cystic medial degeneration in younger patients
Mutation in ____ gene results in elastic tissue fragmentation which predisposes patients with Marfan syndrome to aortic aneurysms
fibrillin-1
The most common site of injury of a traumatic aortic rupture is the aortic ____, which is tether by the ligamentum arteriosum and is relatively fixed and immobile compared to the adjacent descending aorta
aortic isthmus
In unilateral renal artery stenosis, the contralateral kidney is exposed to high blood pressure that typically shows what changes of hypertensive nephrosclerosis
arteriolar wall thickening due to hyaline or hyperplastic arteriosclerosis (concentric smooth muscle cell proliferation in response to pressure (onion skinning ))
In a graph showing the normal pattern of blood flow across the mitral valve, the first, larger wave (E wave) represents what? what does the second, smaller wave (A wave) represent?
Ewave: passive ventricular filling
A wave: atrial contraction
If present, when is an S3 heart sound heard best
during passive ventricular filling of diastole
Heart failure leads to transudative or exudative pleural effusion? which is characterized by low or high protein and lactate dehydrogenase
transudative
low protein and lactate dehydrogenase
what type of pleural effusion has low glucose content
malignant or infectious pleural effusion due to consumption by bacteria, neutrophils, and/or malignant cells
Class ____antiarrhythmics are potent sodium channel blockers that have increased effect at faster heart rates (use dependence)
class 1C
What chemotherapy drug has a risk of cardiotoxicity that manifests as a decrease in myocardial contractility without cardiomyocyte destruction or myocardial fibrosis that is often reversible with discontinuation of therapy
Trastuzumab
_____ is a chronic, large artery vasculitis that primarily involves the aorta and its branches
Takayasu arteritis
Takayasu arteritis is more common in what patient population
women of reproductive age and asians
Characteristic histopathology findings of Takayasu arteritis include mononuclear infiltrates and ______ of the vascular media, leading to arterial wall thickening and occlussion
granulomatous inflammation
Clinical presentation of Takayasu arteritis
constitutional symptoms (fever, weight loss, fatigue)
arterio-occlusive symtpoms: claudication, BP discrepancies, bruits, pulse deficits
visual and neurologic deficits
arthralgias and myalgias
elevated inflammatory markers (ESR, CRP)
Pathologic abnormalities in Takayasu arteritis closely resemble giant cell (temporal) arteritis, however, giant cell usually effects what type of patients in comparision with TA patients
giant cell: paients >50
TA: younger women of child bearing age
What vein obstruction presents like superior vena cava syndrome but only on one side of the body (unilateral face and arm swelling)
brachiocephalic
During exercise what change happens to the LV end diastolic volume, systemic vascular resistance, stroke volume and afterload
LVEDV: increased (increased venous return/preload)
SVR: decreased
SV: increased (increased preload and contractility)
afterload: increased (increased contractility and stoke volume –> increased systolic pressure)
dobutamine MOA and second messenger
B agonists (B1>B2) Gs
Heart failure with preserved ejection fraction develops due to what?
diastolic dysfunction (frequently occurs in setting of prolonged systemic hypertension which increased afterload and caused concentric hypertrophy)
In hypovolemia, which of the following are increased or decreased: ANP, heart contractility, baroreceptor firing
ANP: decreased
heart contractility: increased
baroreceptor firing: decreased
How do nitrates reduce angina?
vasodilation (predominantly venodilation)–> decreased preload –> decreased LVEDP –> decreased myocardial oxygen demand
(mild arterial dilation also slightly decreases SVR/afterload)
What causes increased arterial resistance in heart failure
decreased cardiac output and inadequate oxygen delivery to tissues -> increased sympathetic output and increased RAAS activation
_____ occurs 2-4 days following an MI and is an inflammatory reaction to cardiac muscle necrosis
peri-infarction pericarditis
presents as sharp pleuritic chest pain that may be exacerbated by swallowing or coughing
What is the major pathologic contributor to atrial fibrisllation
atrial remodeling
Why is the right ventricle more protected from ischemic damage than the left ventricle during an MI
RV has less muscle mass and afterload –> less O2 demand –> has large capacity to increase oxygen extraction during ischemia
low systolic pressure of RV –> coronary perfusion throughout cardiac cycle (LV only perfused during diastole)
a decrescendo diastolic murmur at right upper sternal border and bilateral pulmonary crackles is caused by what valve disease
aortic regurge
What complication of aortic dissection can cause jugular venous distention, hypotension, and reduced point of maximal impulse
tamponade (from dissection extending proximally into pericardium causing blood to fill pericardial space)
what complication of aortic dissection can cause blood pressure asymmetry in upper extremities
extension of dissection plane into the subclavian artery
How does SVR change in cardiogenic shock due to heart failure
increased (peripheral vasoconstriction to maintain blood pressure)
How is pulmonary artery systolic pressure affected by cardiogenic shock due to left ventricular heart failure
increased
(LV systolic failure –> increased LVEDV which is transmitted backward to incease pulmonary capillary wedge pressure and pulmonary arterial pressure
Does use of medications to raise HDL levels improve cardiovascular outcomes?
no, instead focus on lowering LDL cholesterol with HMG-CoA reductase inhibitor (statin)
Adenosine activates ____ ion channels and inhibits ___ channels to what effect in the heart
activates potassium
inhibits L-type calcium
slow sinus rate and increase AV nodal conduction delay
what is the most reliable auscultatory indicator of the degree of mitral stenosis
A2-opening snap interval (shorter interval indicates more severe)
what is Kussmaul sign
a paradoxical rise in JVP with inspiration
What medication is as effective as aspirin for preventing cardiovascular events and should be used in patients with aspirin allergy
Clopidogrel
Clopidogrel irreversibly blocks the ___ component of ADP receptors on platelet surface and prevents platelet aggregation
P2Y12
describe myocardial hibernation
in chronic myocardial ischemia, myocardial metabolism and function are reduced to match a concomitant reduction in coronary blood flow –> decreased contractility but revascularization and restoration of blood flow improves LV function
describe ischemic preconditioning
brief repetitive episodes of myocardial ischemia prior to myocardial infarction can delay cell death after complete coronary occlusion and therefore provide greater time for myocardial salvage with coronary revascularization
Total resistance for a group of vessels (R1, R2, R3) arranged in parallel is what?
1/total resistance = 1/R1 + 1/R2 +1/R3
How is total resistance in vessels (R1, R2, R3) arranged in a circuit series calculated
total resistance = R1 + R2 + R3
Digoxin toxicity typically presents with cardiac arrhythmias, nausea, vomiting, confusion, weakness, and visual symptoms. Elevated serum ____ is a sign of digoxin toxicity
potassium
How do beta blockers improve symptoms of hypertrophic cardiomyopathy
decrease HR and LV contractility –> increase LV blood volume and reduce LV outflow obstruction
what congenital heart defect is characterized by a continuous murmur heard best in the left infraclavicular region with maximal intensity at S2
patent ductus arteriosus
The ____ valve is most frequently affected by infective endocarditis and ___ is the most common underlying valvular disease predisposing to the development of infective endocarditis
mitral
mitral valve prolapse (particularly when it is associated with coexistent mitral regurgitation)
In patients with Tetralogy of Fallot, during a tet spell, squatting increases ____ which thereby increases pulmonary blood flow and improves oxygenation status
systemic vascular resistance (–> decreased right to left shunting)
Granulomatosis with polyangitis is a ____ vessel vasculitis and _-ANCA positive
small
C
Besides constitutional symptoms of fever, arthralgia, and weight loss, what 3 areas are usually symptomatic in granulomatosis with polyangitis
upper airway (otitis media, nasal crusting/ulcer, rhinorrhea) lower airway (hoarseness, cough, stridor, hemoptysis, pulmonary infiltrates) kidney (rapidly progressive glomerulonephritis)
What are histologic findings of granulomatosis with polyangitis
necrotizing arteritis with granulomatous inflammation (epithelioid histiocytes, multinucleated giant cells) and mixture of surrounding inflammatory cells
what causes a presystolic sound on auscultation
left ventricular hypertrophy
S4
Mitochondrial vacuolization is a sign of what?
irreversible cell injury (mito is permanently unable to generate ATP)
adverse effect of class III antiarrhythmics (ibutilide, dofetilide, sotalol)
torsade de pointes
Left ventricular gallops (S3 and/or S4) are best heard at the end of expiration, why?
decreased lung volume and and it brings the heart closer to the chest wall
In a patient with left ventricular hypertrophy, A fib is especially dangerous, why?
in left ventricular hypertrophy, atrial contraction contributes significantly to left ventricular filling (loss of atrial contraction –> decreased LV preload –> hypotension)
In aortic regurgitation, the characteristic decrescendo diastolic murmur is heard best when the patient is in what postural position
leaning forward
The pressure tracing for aortic regurgitation is characterized by loss of the _____
aortic dicrotic notch
and steep diastolic decline in aortic pressure, and high-peaking systolic pressures
In calcific aortic valve disease, fibroblasts differentiate into ____-like cells
osteoblast
aberrant bone matrix deposition with progressive valvular calcification and stenosis
what effect do abrupt standing and valsalva straining have on on left ventricular blood volume
decrease
Days to weeks post MI, _____ and other anti-inflammatory cytokines downregulate the inflammatory response and stimulate fibroblast migration and proliferation causing extensive type I and III collagen deposition
transforming growth factor beta
Migratory superficial thrombophlebitis, Trousseau syndrome, should raise suspicion for _____
cancer
hypercoagulability
Janeway lesions, nontender, macular, and erythematous lesions on palms and soles of feet are seen in what pathologic condition?
infective endocarditis (result of septic embolization from valvular vegetations)
In dilated cardiomyopathy as seen following doxorubicin treatment, how are LVED pressure and RA pressure changed
both increased
Alteplase MOA
tPA analog (triggers fibrinolysis and can restore myocardial perfusion in patients with ST elevation who cannot undergo timely percutaneous coronary intervention)
What causes high output heart failure
decreased systemic vascular resistance (ie large arteriovenous fistula) –> increased venous return and increased CO
What cells form the fibrous cap (composed of collagen, elastin, proteoglycans) of mature atheromas
vascular smooth muscle cells
What causes decreased left ventricular chamber size, sigmoid shaped ventricular septum, increased collagen deposition, and accumulation of cytoplasmic lipofuscin pigment within cardiomyocytes?
normal aging
stress-induce (takotsubo) cardiomyopathy is caused by a ___ surge in the setting of physical or emotional stress leading to systolic dysfunction and what characteristic finding on echocardiogram
catecholamine
balloon shape LV
In the a VSD of a neonate, how are RA, RV, LA, nd LV pressures changed?
RA: unchanged RV: increased LA: increased LV: increased (increased blood enters the RV from LV which then flows to LA and LV to increase their pressures as well)
what murmur is heard in VSD
holosystolic murmur
why can acetylcholine induce a angina in patients with vasospastic angina
normally acetylcholine -> NO release –> vasodilation; but in these patients who have endothelial dysfunction, they do not release NO therefore have vasoconstriction in response to acetylcholine
In ascites due to right heart failure, how are the following affected: portal capillary oncotic pressure, portal capillary hydrostatic pressure, portal capillary permeability
portal capillary oncotic pressure: no change
portal capillary hydrostatic pressure: increased
portal capillary permeability: no change
In left sided heart failure due to concentric hypertrophy of the LV due to HTN, how are the following affected: LV compliance, angiotensin II signaling, cardiac myosin heavy chain-beta expression
LV compliance: decreased
Angiotensin II: increased
cardiac myosin: increased
What is the most common cause of claudication
atherosclerosis (specifically resulting from fixed stenoses caused by lipid filled intimal plaques that bulge into the arterial lumen)
Aortic dissection develops when overwhelming hemodynamic stress leads to tearing of the aortic ______ with blood subsequently dissecting through the aortic media
intima
A complete atrioventricular canal defect is comprised of an atrial septal defect, a VSD, and a common AV valve. It is the most common congenital cardiac anomaly associated with what genetic dissorder?
Down syndrome
VSD is often not detectable at birth but becomes audible around 4-10 days as ____ declines
pulmonary vascular resistance (allows for significant left-to-right shunting)
Digoxin is cleared by the _____
kidney
glucagon second messenger in cardiac myocytes
adenylate cyclase –> cAMP
isosorbide dinitrate MOA
venous dilator
why should isosrobide dinitrate be avoided in treating hypertrophic cardiomyopathy
venous dilation –> decreased venous return –> decreased LV volume –> decreased cardiac output
When would atropine be useful in treating a patient for acute MI
sinus bradycardia often occurs due to nodal ischemia and an increase in vagal tone triggered by infarction of myocardial tissue
enhance vagal tone can be counteracted by anticholinergic effects of atropine
In chronic heart failure, what compensatory mechanism initially offsets factors favoring edema
increased lymphatic drainage
What is the most common cause of pericarditis
viral infection
Vegetations are caused by bacterial colonization and growth on a sterile ______ that forms on damaged/disrupted endothelial surface of valvular apparatus
fibrin-platelet nidus
Using nitrates together with PDE inhibitors cause a profound systemic hypotension because they both increase intracellular ____ which causes vascular smooth muscle relaxation
cGMP
Jervell and Lange-Nielsen syndrome is an autosomal recessive disorder characterized by profound bilateral sensorineural hearing loss and congenital long QT syndrome. The condition occurs secondary to mutations in genes that encode _____
voltage-gated potassium channels
A slow growing, stable atherosclerotic plaque, as opposed to a fast growing plaque, allows for what compensatory mechanism to take place in order to reduce myocardial necrosis and scarring
collateral vessel growth
What class of antibiotics can cause QT prolongation
macrolides (erythromyocin)
what is the most common adverse effect of fibrinolytic therapy
hemorrhage
Cardiovascular manifestations of lupus include what? (4)
accelerated atherosclerosis
small vessel necrotizing vasculitis
pericarditis
Libman-Sacks endocarditis
what is Libman-Sacks endocarditis
small, sterile vegetations on both sides of the valve
the vegetations are composed of sterile platelet thrombi intertwined with strands of fibrin, immune complexes, and mononuclear cells
A patient with pleuritic type chest pain radiating to the shoulder, a triphasic friction rub, diffuse ST elevation, and recent history of skin rash and joint pain likely has what type of pericarditis
fibrinous
can be due to lupus, MI, uremia, and other rheumatologic diseases
What irreversible remodeling is preventable with surgically repairing an ASD
hypertrophy of the pulmonary arteries (–> pulmonary hypertension –> eisenmenger syndrome)
Atherosclerosis develops most rapidly in areas with bends and branch points that encourage turbulent flow. What 2 areas tend to develop atherosclerosis earliest in life and have the highest overall atherosclerotic burden?
abdominal aorta
coronary arteries
Chronic hypertension leads to increased local expression of the vasoconstrictors __ and ___ in the heart which likely have a prominent role in development of left ventricular hypertrophy (heart remodeling
angiotensin II
endothelin
After birth, as the relative pressure in the pulmonary artery and aorta change, a patent ductus arteriosus murmur evolves from ___ only to _____ before the PDA closes and the murmur disappears
systolic
continuous
Secondary mitral regurgitation is commonly causes by ____ which causes dilation of the mitral valve annulus and restricted movement of the chordae tenineae and subsequent regurgitation
decompensated heart failure –> increased left ventricular end diastolic volume
Milrinone MOA
phosphodiesterase 3 inhibitor (–> increased cAMP –> calcium influx which increases contractility and reduced calcium myosin light chain kinase interaction which causes vasodilation and decreased preload and afterload)
What happens to the S2 split on inspiration in pulmonary stenosis
widens
_____ is a systemic vasculitis of medium sized muscular arteries that causes segmental fibrinoid necrosis, infiltration of vessel wall with mononuclear cells and neutrophils, and internal and external elastic laminae damage which may cause microaneuysms
polyarteritis nodosa
polyarteritis nodosa typically attacks what organs
kidneys skin neurologic system GI tract (lung is typically spared)
alcohol induced cardiomyopathy causes what type of heart failure
dilated cardiomyopathy –> systolic dysfunction
_______ is a protein produced by the liver, mutations in the TTR gene cause for it to misfold and produce amyloid protein that infiltrates the myocardium –> infiltrative cardiomyopathy
transthyretin
During a transesophageal echocardiogram, what chamber of the heart lies in closest proximity to the probe
left atrium
Which of the following lies posterior to the esophagus and would be best visualized by a transesophageal echocardiogram: descending aorta superior vena cava pulmonary veins pulmonary arteries
descending aorta
Ion pump failure due to ATP deficiency during cardiac ischemia causes intracellular accumulation of ___ and ____ which draw free water into the cell causing cell and mitochondrial swelling
Na
Ca
how does hypertrophic cardiomyopathy differ from hypertensive heart disease
hypertrophic cardiomyopathy: localized thickening predominantly affecting interventricular septum; also causes cariomyocyte disarray
hypertensive heart disease: uniform thickening of LV walls
Peripartum cardiomyopathy is a rare cause of ____ cardiomyopathy that may be related to impaired function of angiogenic growth factors
dilated
lipofuscin appears yellow-brown pigment contained within intracytoplasmic granules in myocardium which is composed of ______
lysosomal breakdown products including lipid polymers and protein complex phospholipids that result from free radical injury and lipid peroxidation (accumulate with age)
syncope with diastolic dysfunction, hepatomegaly, and skin hyperpigmentation is suggestive of what disorder?
hereditary hemochromatosis
Unlike the diffuse ventricular wall thinning that occurs in most dilated cardiomyopathies, what cause of cardiomyopathy results in localized apical wall thinning with large apical aneurysm development
Chagas disease
central and south america
What is the GI manifestation of Chagas disease
destruction of myenteric plexus –> progressive dilation and dysfunction of esophagus and, less commonly, the colon
what changes are seen in the myocardium 0-4 hours post MI
minimal change
what changes are seen in myocardium 4-12 hours post MI
early coagulation necrosis, edema, hemorrhage, wavy fibers
what changes are seen 12-24 hours post MI
coagulation necrosis and marginal contraction band necrosis
how long post MI can you see neutrophilic infliltrate
1 day (1-5days)
how long following an MI can you see macrophages
5 days (5-10 days)
how long following an MI does granulation tissue and neovascularization start to form
10-14 days
how long following an MI does collagen deposition and scar formation start to occur
2 wks (-2months)
What is seen on histopathology of thromboangiitis obliterans (Buerger disease)
highly cellular, inflammatory intraluminal thrombi (containing neutrophils and multinucleated giant cells) in the arteries and veins with sparing of the vessel wall and internal elastic lamina
What segmental, thrombosing vasculitis often extends contiguously into veins and nerves
thromboangiitis obliterans (Buerger disease)
