Chapter 12 - The Heart Flashcards
0
Q
How are sarcomeres arranged in volume overload hypertrophy? What happens to the ventricles
A
Sarcomeres are arranged in series with existing sarcomeres. There is ventricular dilation
1
Q
What happens to the sarcomeres in pressure overload hypertrophy and what happens to the ventricles?
A
Sarcomeres are assembled in parallel and there is a concentric increase in wall thickness
2
Q
What happens to gene expression with hemodynamic overload in the heart
A
Gene expression pattern begins to resemble that seen during fetal cardiac development
3
Q
Left sided heart failure is most likely caused by (4)
A
Ischemic heart disease, hypertension, valvular disease, myocardial diseases
4
Q
Microscopic change in myocytes in left-sided heart failure
A
Hypertrophy and variable degrees of interstitial fibrosis
5
Q
What do the lungs look like in left-sided heart failure? What causes them to be like this?
A
Heavy, wet lungs caused by pulmonary congestion and edema
6
Q
What is seen on chest radiograph that is characteristic of left-sided heart failure
A
Kerley B lines from septal edema
7
Q
What is a sign of previous episodes of pulmonary edema and what makes these signs
A
Heart failure cells, which are hemosiderin laden macrophages that store iron recovered from RBCs that have escaped into edema fluid
8
Q
Symptoms of left sided heart failure
A
Cough, dyspnea, orthopnea, paroxysmal nocturnal dyspnea (choking sensation at night when patient is supine)
9
Q
Pathophysiology of Left-sided heart failure, renal system, and coma
A
Decrease in cardiac output –> decrease in renal perfusion –> renin-angiotensin-aldosterone system –> retains water and sodium –> increased interstitial volume –> pulmonary edema –> decrease secretin of nitrogenous wastes –> hypoxic encephalopathy –> stupor/coma
10
Q
What is diastolic left-sided heart failure
A
Cardiac output is preserved at rest but the left ventricle is abnormally stiff and unable to relax during diastole
11
Q
What are risk factors for diastolic heart failure
A
Patients women over 65, hypertension, diabetes mellitus, obesity, bilateral renal artery stenosis
12
Q
What is commonly a cause of right sided heart failure
A
Left sided heart failure
13
Q
What is pure right sided heart failure called
A
Cor pulmonale
14
Q
What does the heart look like with right sided heart failure
A
It is hypertrophic and the right atrium and ventricle is dilated
15
Q
What other organs are involved in right sided heart failure and what happens to them?
A
Systemic/portal venous congestion (like JVD) –> hepatoplenomegaly (nutmeg liver, cardiac sclerosis/cirrhosis), ankle and pretibial edema, pleural effusions, ascites
16
Q
What does the first heart field form
A
Left ventricle
17
Q
What does the second heart field form
A
The outflow tract, right ventricle and most of the atria
18
Q
When does the second heart field migrate?
A
Day 15
19
Q
What causes the septa tigon of outflow aortic arches III, IV, VI
A
Neural crest cells
20
Q
What does the extra cellular matrix produce in heart development
A
Forms endocardium cushions that participate in valve development
21
Q
What are the main known causes of congenital heart disease
A
Sporadic genetic abnormalities
22
Q
What is the most common genetic cause of congenital heart disease?
A
Down syndrome
23
Q
What are some clinical signs of right to left shunts
A
Hypoxemia, cyanosis result from the mixture of poorly oxygenated blood with systemic arterial blood
24
Consequences of right to left shunts
Paradoxical embolism, clubbing of tips of fingers and polycythemia
25
Some diseases that have right to left shunts
Tetralogy of Fallot, transposition of the great arteries, persistent truncus arteriosus, tricuspid atresia, and total anomalous pulmonary venous connection
26
What are some clinical signs that left to right shunts are associated with
Pulmonary HTN, Hypertrophy, reversal of the shunt (eisenmenger syndrome)
27
Obstructive congenital heart disease examples
Coarctation of the aorta, aortic valvular stenosis, and pulmonary valvular stenosis
28
What type of ASD is most common and where is it located, what kind of shunt is an ASD
Secundum ASD, oval fossa near center of atrial septum, left to right shunt
29
What other less common types of ASDs are there? And where are they located?
Primum (adjacent of AV valves) and sinus venosus (by the entrance of the superior vena cava-associated with anomalous pulmonary venous return to the right atrium)
30
When do ASDs become symptomatic?
Age 30
31
What kind of sound is heard with an ASD, why is this kind of sound heard
Murmur due to excessive flow through the pulmonary valve
32
Where is a patent foramen ovale located? What kind of shunt is it?
In atrial septum at the oval fossa, right to left shunt with fetus
33
What does a patent foramen ovale do in the fetus?
Allows oxygen rich blood from the placenta to bypass the not yet inflated lungs by traveling directly from the right to left atrium
34
What is the most common type of congenital cardiac anomaly, and what kind of shunt is it?
Ventricular septal defect, left to right shunt
35
What types of ventricular septal defect are there? And where are these located? Which is the most common VSD
90% membranous VSD (region of membranous inter ventricular septum), and infundibular VSD (below the pulmonary valve), and in the muscular septum (muscular VSD)
36
What do most VSDs occur with?
Other heart defects
37
Is surgical treatment immediately necessary for a VSD?
No, if the defect is small enough, surgery is delayed in hope of spontaneous closure (30-50% of cases)
38
What is the role of the ductus arteriosus in fetal circulation, and what kind of shunt is it
Shunts blood from the pulmonary artery to the aorta in order to bypass the lungs, left to right
39
What sound is heard on physical exam with a PDA
Machinery like murmur
40
If there is aortic valve atresia, what is required for patient survival
PDA
41
What embryological defect causes an AVSD and what type of shunt is it
Failure of the superior and inferior endocardium cushions of the AV canal to fuse adequately, left to right
42
What are the two most common forms of AVSD
Partial (primum ASD with a cleft anterior mitral leaflet) and a complete (large AV septal defect and a large common AV valve)
43
1/3 of patients with a complete AVSD have what...
Down syndrome
44
What type of shunt is tetralogy of Fallot and what are the features of this disease
Right to left shunt
1. VSD
2. Obstruction of right ventricular outflow tract
3. Aorta overriding the VSD
4. Right ventricular hypertrophy
45
What is the appearance of the heart in tetralogy of Fallot
Boot shaped
46
If the pulmonary valve becomes atretic instead of stenosed, what will you need to survive in tetralogy of Fallot
PDA or dilated bronchial arteries
47
What is pink tetralogy
If the pulmonary stenosis is mild, the tetralogy may resemble an isolated VSD, the shunt may be left to right without cyanosis. If it's severe or enough time develops, the classic tetralogy develops
48
What are the vessel defects in the transposition of the great vessels? What kind of shunt is this
Aorta arises from the right ventricle, pulmonary artery arises from the left ventricle. Right to left shunt
49
What do patients with transposition of the great arteries need in order to survive
A shunt, ASD, VSD, PDA
50
What kind of shunt is a persist ant truncus arteriosus, and what is the anomaly in this disease?
Aorta and pulmonary artery share a common trunk and intermix blood
51
What kind of shunt is tricuspid atresia, and what is usually associated with this disorder?
Usually has an ASD to maintain circulation and it is a right to left shunt
52
What are some obstructive congenital heart anomalies?
Coarctation of hype aorta, pulmonary stenosis and atresia, aortic stenosis and atresia
53
What are the anatomical differences between the 2 types of coarctations
Infantile (aorta constricted between subclavian artery and ductus arteriosus) and adult form (consriction is distal to the ligamentum arteriosum and arch vessels)
54
What symptoms would be noted with the infantile form of coarctation of the aorta
Cyanosis in lower half of the body
55
What disease is associated with coarctation of the aorta
Turners syndrome
56
What symptoms are associated with the adult form of coarctation of the aorta
Hypertension in the upper extremities, weak pulses and hypotension in the lower extremities, claudication and coldness in lower extremities, rib notching (collateral circulation develops pre and post coarctation branches
57
What are som ischemic heart disease syndromes (4)
MI, angina pectoris, chronic ischemic heart disease with heart failure, sudden cardiac death
58
What is the leading cause of death for males and females in the US
Ischemic <3 disease !
59
Symptomatic cardiac ischemia needs to have what percent of the vessel occluded during exercise
75%
60
What percent of the vessel must be occluded in symptomatic ischemia even during rest
90%
61
What are the common coronary arteries involved in atherosclerosis
Left anterior descending (LAD), left circumflex (LCX), right coronary (RCA)
62
What are the differences between the 3 types of angina
Stable: physical/emotional excitement increases cardiac workload, relieved by rest, responds to vasodilators
Unstable: increasingly frequent pain that begins with progressively lower levels of physical activity (pre-infarction)
Prinzmetal: coronary artery spasm, responds to vasodilators, unrelated to physical activity
63
Which is the most common form of angina
Stable angina
64
Population and age group of MIs
Older men (40-65) women protected till menopause
65
What is the time frame for reversible cardiac myocyte damage
Severe ischemia lasting greater than 20-30 minutes
66
In an acute MI at what time after onset does permanent damage occur to the myocardium
2-4 hours
67
What are the types of myocardial infarctions? And what is the difference between them
Transmural (full thickness of the ventricular wall, ST elevation) and sub-endocardial (involves the inner third of the myocardium, non ST elevation), also circumferential subendocardial infarct (from global hypotension) and microinfarcts (from small intramural vessels)
68
Which is the most common type of myocardial infarct
Transmural
69
What areas does the left anterior descending coronary artery cover?
Anterior left ventricle, anterior 2/3 of interventricular septum
70
What areas does the right coronary artery cover?
Right ventricle, posterior part of the interventricular septum, posteroinferior part of the left ventricle, AV and SA nodes
71
What does the left circumflex coronary artery
Supplies lateral wall of the left ventricle
72
Gross order of sequence that occurs in the heart after myocardial infarction
<4hrs (none), 4-24hrs (dark discoloration), 1-3days (yellow pallor), 4-7 days (yellow pallor), 1-3 weeks (red border-granulation tissue on edges), months (white scar)
73
Microscopic changes that occur in the heart after a myocardial infarction
<4hrs (none), 4-24hrs (coagulative necrosis-wavy fibers), 1-3days (neutrophils), 4-7 days (macrophages), 1-3 weeks (granulation tissue with collagen, fibroblasts), months (fibrosis)
74
What does reperfusion injury cause on histology
Contraction band necrosis - hypercontraction of myofibrils in dying cells (influx of Ca2+ into cytosol)
75
Clinical symptoms of an MI
Severe, crushing chest pain for more than 20 minutes that doesn't relieve with nitroglycerin
76
When does each cardiac enzyme rise and return to normal after myocardial infarction
TroponinI elevates 4 hours, peaks at 24 and goes down in 7/10 days
CKMB elevates 4 hours, peaks less at 24 and goes down after 1/3 day
77
Complications of myocardial infarction
Contractile dysfunction, arrhythmias, cardiogenic shock (large infarct), myocardial rupture, pericarditis (dressler syndrome, after 3 days), ventricular aneurysms, mitral regurg (papillary muscle dysfunction)
78
What are the arteries affected in MI in decreasing order
LAD, Right coronary, LCX
79
What causes sudden cardiac death, and when does death occur
A lethal arrhythmia from acute myocardial ischemia Long QT syndrome
80
Most common pre existing condition for sudden cardiac death
Atherosclerosis
81
What is required for the diagnosis for hypertensive heart disease
Hypertension and left ventricular hypertrophy
83
What does the heart look like with right sided heart failure
RVH, dilation, and failure from pulmonary HTN
84
failure of a valve to open completely in the heart
stenosis
85
failure of a valve to close completely om the heart
insufficiency
86
incompetence of a valve stemming from an abnormality in one of its support structures
functional regurgitation
87
2/3 of all cases of valve disease involve what heart valves
aortic and mitral
88
valvular stenosis leads to ___ overload of the heart
pressure overload
89
valvular insufficiency leads to ____ overload of the heart
volume overload
90
most common of all valvular abnormalities
acquired aortic stenosis
91
acquired aortic stenosis is commonly a result of
wear and tear of anatomically normal valves or congenitally bicuspid valves
92
morphological hallmark of non-rheumatic aortic stenosis
heaped up calcified masses within aortic cusps that protrude through the outflow surfaces into the sinuses preventing the opening of the cusps
93
earlier hemodynamically inconsequential stage of calcification found in aortic stenosis
aoric vavle sclerosis
94
symptoms associated with aortic valve stenosis
angina, CHF, syncope
95
most frequent congenital cardiovascular malformation in humans
Congenitally bicuspid aortic valves
96
where does calcium deposit in the mitral valve
peripheral fibrous ring
97
histological change found in mitral valve prolapse
myxomatous degeneration
98
what is myxomatous degeneration found in MVP
attenuation of collagenous fibrosa layer of the valve - dermatan sulfate in the leaflet
99
what genetic disorder is MVP associated with
Marfan syndrome - fibrillin-1
100
MVP is most common in what population
young women
101
how does a patient with MVP present?
asymptomatic and discovered incidentally with a midsystolic click followed by a systolic murmur on physical exam
102
mitral stenosis is seen in what disease
rheumatic heart disease
103
dilation of the ascending aorta from htn and aging
aortic insufficiency
104
organism involved in rheumatic fever
group A stretococcal pharyngitis
105
morphology of rheumatic fever, what type of cells are present? (5)
Anitschkow cells, caterpillar cells, small 1-2mm vegetations-verrucae along the lines of closure, MacCallum plaques, aschoff bodies
106
anatomic changes found in the mitral valve in rheumatic heart disease
leaflet thickening, commissural fusion and shortening, and thickening and fusion of the tendinous cords (fish mouth/button hole)
107
what are Anitschkow cells and caterpillar cells?
macrophages with abundant cytoplasm and central round nuclei where the chromatin is in the center and is slender wavy ribbon like --> RHD
108
What are aschoff bodies?
foci of lymphocytes in rheumatic heard disease post mortem
109
what are MacCallum plaques?
subendocardial lesions may produce irregular thickenings
110
manifestations of rheumatic fever (5)
migratory polyarthritis of joints, pancarditis, subcutaneous nodules, erythema marginatum of the skin, sydenham chorea (involuntary rapid purposeless movements)
111
Jones criteria for diagnosis of theumatic fever
group A strep infection with 2 of the major manifestations or 1 major and 2 minor manifestions (non specific signs)
112
when does acute rhematic fever typically present?
10 days - 6 weeks after a pharyngitis
113
what antibodies can be found with rheumatic fever
Abs to stretolysin O and DNase B in patient serum
114
first attach of rhematic heart disease at what age group
5-15 years old
115
complications of rheumatic fever
acute carditis with pericardial friction rubs, weak heart sounds, tachycardia, and arrhythmias
116
what do the vegetations look like in infective endocarditis
large irregular masses on the valve cusps that can extend into the chordae
117
what does acute infective endocarditis typically infect
a previously normal heart valve by a highly virulent organism
118
what is the difference between acute infective endocarditis and subacute infective endocarditis
the organisms are of lower virulence and cause infections of deformed valves
119
most common pathogen for IV drug users in infective endocarditis
Staph aureus
120
what pathogen infects previously damaged or otherwise abnormal valves in infective endocarditis
Strep viridans
121
what pathogen infects normal valves in infective endocarditis
Staph aureus
122
most common pathogen involved in infective endocarditis
Strep viridans
123
prosthetic valve endocarditis
Staph epidermidis
124
bacteria that don't fit in a certain category that could be involved in infective endocarditis
HACEK --> Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella
125
describe the vegetations in infective endocarditis
friable, bulky, destructive vegetations containing fibrin, inflammatory cells, and bacteria on heart valves
126
if the vegetations from infective endocarditis erode into the underlying myocardium, what can result?
ring abcess
127
most consistent clinical sign of infective endocarditis
fever; murmurs are present in 90% of patients with left sided infective endocarditis
128
long standing infective endocarditis may result in what? (4)
microthromboemboli (like splinter hemorrhages), erythematous nontender lesion on the palms or soles (janeway lesions), subcutaneous nodules in digits (osler nodes), and retinal hemorrhages (roth spots)
129
what do the vegetations of nonbacterial thrombotic endocarditis look like?
bland small vegetations usually attached at the line of closure (bigger and not as numerous as those of rheumatic fever)
130
what population is associated with nonbacterial thrombotic endocarditis
debilitated patients like those wiith cancer or sepsis
131
libman-sacks endocarditis is associated with what disease
SLE lupus
132
what do the vegetations look like in libman sack endocarditis and where are they located
small single or multiple sterile pink vegetations that have a warty appearance on the undersurfaces of the AV valves, endocardium of atria/ventricles, cords
133
what valve is frequently involved in libman sacks endocarditis
mitral valve
134
carcinoid syndrome symptoms
flushing of skin, cramps, nausea, vomiting, and diarrhea
135
what valves does carcinoid heart disease usually involve
tricuspid (most common) and pulmonary valves
136
what product do carcinoid tumors mostly release
serotonin
137
gastrointestinal carcinoid tumors usually induce carcinoid heart disease if...
there is extensive hepatic metastases
138
causes of dilated cardiomyopathies
genetics (mitochondrial and cytoskeleton proteins), toxins (alcohol-thiamine deficiency, doxorubicin), peripartum, previous myocarditis
139
what is the ejection fraction in dilated cardiomyopathy
less than 40%
140
types of cardiomyopathy
restrictive, dilated, hypertrophic
141
pathophysiology behind dilated cardiomyopathy
decreased contractility leading to enlargement of the heart, systolic dysfunction
142
clinical symptoms found in dilated cardiomyopathy
left and right sided heart failure symproms, arrythmias
143
what does the heart look like in people with arrhythmogenic right ventricular cardiomyopathy
righ ventricle wall is very thinned due to loss of myocyte and lots of fatty infiltration and fibrosis
144
arrhythmogenic right ventricular craiomyopathy and hyperkeratosis of plantar palmar skin surfaces
Naxos syndrome
145
what is the gene mutation in Naxos syndrome
plakoglobin
146
most common cause of death in young athletes
hypertrophic cardiomyopathy, diastolic dysfunction
147
genetics of hypertrophic cardiomyopathy
most are autosomal dominant in young people, less commonly sporadic; involves mutations in proteins of the sarcomere
148
what does the heart look like on gross examination in hypertrophic cardiomyopathy
thick interventricular septum
149
on histology of hypertrophic cardiomyopathy, you would see
myofiber disarray
150
auscultation in hypertrophic cardiomyopathy reveals
a harsh systolic ejection murmur
151
restrictive cardiomyopathy is most commonly caused by
amyloidosis, myocardial fibrosis after surgery, radiation, sarcoidosis, metastasis, metabolite deposition from errors of metabolism, hemochromatosis, endocardial fibroelastosis, loeffler syndrome
152
the ventricles are ____ in restrictive cardiomyopathy
noncompliant
153
what is endomyocardial fibrosis and where is it found
disease of kids and young adults in africa and tropics by fibrosis of ventricular endocardium
154
what is loeffler syndrome
endomyocardial fibrosis with eosinophilic infiltrate and mural thrombi
155
what is endocardial fibroelastosis
where a dense layer of fibrosis and elastic tissue is in the endocardium
156
most common cause of myocarditis
virus --> coxsackievirus A and B & enteroviruses, less common are HIV,CMV`
157
protozoan infection with what organism can cause myocarditis
Trypanosoma cruzi - Chagas disease
158
most common helminthic infection associated with myocarditis
Trichinosis
159
bacteria associated with myocarditis
Corynebacterium diphteriae, Borrelia
160
Illness associated with myocarditis
rheummatic fever, lupus, sarcoidosis
161
hypersensitivity myocarditis results from
drugs like antibiotics, diuretics, antihypertensives
162
during active myocarditis, what does the heart look like on gross examination
dilated and enlarged
163
name type of myocarditis: myocyte injury with lymphocytic infiltrate
Viral myocarditis
164
name type of myocarditis: interstitial inflammatory inflitrate with a high proportion of eosinophils
hypersensitivity myocarditis
165
name type of myocarditis: widespread inflammatory infiltrate with giant cells
giant cell myocarditis (myocarditis of uncertain cause)
166
name type of myocarditis: myocyte distended with trypanosomes
myocarditis of chagas disease
167
type of pericarditis associated with noninfectious inflammatory diseases like SLE
serous pericarditis
168
most frequent type of pericarditis
fibrinous and serofibrinous pericarditis
169
causes of fibrinous and serofibrinous pericarditis
post MI, also same causes as serous pericarditis
170
syptoms of fibrinous pericarditis
pericardial friction rub!!, signs of congestive heart failure
171
type of pericarditis from microbes
purulent/suppurative pericarditis
172
symptoms of suppurative pericarditis
same as fibrinous but increased signs of systemic infection
173
common cause of hemorrhagic pericarditis
spread of a malignant neoplasm into pericardial space
174
pericarditis caused by TB
caseous - spread from tuberculous foci within the tracheobronchial nodes
175
heart is encased in a dense fibrous/fibrocalcific scar
constrictive pericarditis
176
what is restricted physiologically in restrictive pericarditis
limited diastolic expansion and cardiac output; heart can't increase its output in response to increased peripheral needs
177
most common primary tumor of the heart in adults; benign/malignant
myxomas; benign
178
most myxomas are located
in the left atrium
179
morphology of myxomas
sessile or pedunculated
180
if the myxoma tumor is mobile what may result
wrecking-ball efefct causing damage to the valve leaflets
181
major clinical manifestations of myxoma tumors are...
due to valvular ball-valve obstruction, embolization, or syndrome with constitutional symptoms
182
most frequent primary tumor of the heart in infants and children
rhabdomyomas
183
rhabdomyomas of the heart are often associated with which disease and what mutation
tuberous sclerosis, TSC1 or TSC2
