Chapter 290e - Cardiac Manifestations of Systemic Disease

Question 1

What syndrome can explain the concomitant failure of the pulmonic and tricuspid valves?

Answer 1

Carcinoid Syndrome.

Question 2

One of the following doesn’t cause dilated cardiomiopathy - Diabetes, Protein-calorie malnutrition, thiamine deficiency and HIV. Identify it.

Answer 2

Diabetes.

Question 3

Which thyroid alteration can explain symptomatic bradycardia?

Answer 3

Hypothyroidism.

Question 4

What is the explanation for the association between diabetes and coronary artery disease?

Answer 4

“(…) its pathogenesis involves endothelial dysfunction, increased lipoprotein peroxidation. increased inflammation, a prothrombotic state, and associated metabolic abnormalities.”

Question 5

How do you define an anginal equivalent? Name them.

Answer 5

An anginal equivalent is an atypical ischemic symptom. It comprises nausea, vomiting, dyspnea, pulmonary edema, arrythmias, heart block, or syncope, and are more frequent in diabetic patients.

Question 6

What is the percentage of “silent ischemia” in diabetic patients?

Answer 6

90%

Question 7

What coronary intervention improves survival more significantly in multivessel disease in diabetic patients?

Answer 7

Surgical bypass is superior to percutaneus coronary intervention.

Question 8

Which mecanisms explain edema in protein deficiency?

Answer 8

Reduced serum oncotic pressure and myocardial dysfunction.

Question 9

How to differentiate pathophisiologically Kwarshiorkor from marasmus?

Answer 9

Kwarshiorkor is due to protein malnutrition while marasmus occurs in the presence of calorie malnutrition.

Question 10

What mecanisms explain malnutrition in advanced heart failure?

Answer 10

“(…) patients with severe cardiac failure in whom gastrointestinal hypoperfusion and venous congestion may lead to anorexia and malabsorption.”

Question 11

Thiamine deficiency is more frequent in risk groups. Name them.

Answer 11

“this hypovitaminosis may occur (…) particularly in East Asia, where polished rice deficient in thiamine may be a major dietary component. In Western nations where the use of thiamine-enriched flour is widespred, clinical thiamine deficiency is limited primariy to alcoholics, food faddists, and patients receiving chemotherapy.”

Question 12

How to explain the thiamine deficiency in patients with chronic heart failure?

Answer 12

“reduced dietary intake and a diuretc-induced increase in the urinary excretion of thiamine.”

Question 13

What ECG abnormalities are expected in beriberi?

Answer 13

“The electrocardiogram (ECG) may reveal decreased voltage, a prolonged QT interval, and T-wave abnormalities.”

Question 14

When are inotropics and diuretics important in relantionship to the replenishment of thiamine in beriberi? Is it after or before this replenishment? Justify yourself.

Answer 14

After.
“these agents may be important after thiamine repletion, since the left ventricle may not be able to handle the increased work load presented by the return of vascular tone.”

Question 15

Since hyperhomocysteinemia is an atherosclerotic risk and probably most of the cases are explained by the deficiency of vitamin B6, vitamin B12 and folate, the replenishment of these reduces the cardiovascular risk.
True or False?

Answer 15

False.

“however, the clinical cardiovascular benefit of normalizing elevated homocysteine levels has not been proved.”

Question 16

In obese patients, the eccentric hypertrophy and dilation of the left ventricle is, in part, explained by the volume overload.
True or False?

Answer 16

True.
“In part as a result of chronic volume overload, eccentric cardiac hypertrophy with cardiac dilation and ventricular diastolic and/or systolic dysfunction may develop.”

Question 17

What is the single most efficacious measure to treat cardiac disease associated with massive obesity? Is there any dangerous outcomes related to this measure?

Answer 17

Weight reduction
“rapid weight reduction may be dangerous, as cardiac arrhythmias and sudden death owing to electrolyte imbalance have been described.”

Question 18

How many cases of hyperthyroidism are accompanied with sinus tachycardia and atrial fibrilation?

Answer 18

~40% and ~15% of the cases, respectively.

Question 19

How many cases of hypothyroidism are accompanied with pericardial effusion?

Answer 19

About one-third.

Question 20

What do you expect to find in an ECG from a patient with myxedema?

Answer 20

“The ECG generally reveals sinus bradycardia and low voltage and may show prolongation of the QT interval, decreased P-wave voltage, prolonged AV conduction time, intraventricular conduction disturbances, and nonspecific ST-T-wave abnormalities.”

Question 21

What conditions might be associated with a pathologically pale heart?

Answer 21

Kwarshiorkor, marasmus and hypothyroidism.

Question 22

Carcinoid syndrome might have cardiac envolvement. Which structures are normally affected by this condition? How many patients might be affected?

Answer 22

“Some 50% of patients with carcinoid syndrome have cardiac involvement, usually manifesting as abnormalities of the tricuspid or pulmonic valves.”

“Carcinoid heart disease most often presents as tricuspid regurgitation, pulmonic stenosis, or both.”

Question 23

Carcinoid syndrome with cardiac envolvement occurs without hepatic metastasis.
True or False?

Answer 23

False.

“These patients invariably have hepatic metastases that allow vasoactive substances to circumvent hepatic shunt.”

Question 24

Since carcinoid syndrome occurs due to secretion of vasoactive amines, the use of somatostatin analogues ammeliorates valvular abnormalities.
True or False?

Answer 24

False.
“Treatment with somatostatin analogues (e.g., ocreotide) or interferon alpha improves symptoms and survival in patients with carcinoid heart disease but does not appear to improve valvular abnormalities.”

Question 25

What characterizes the hypertension in a patient with acromegaly?

Answer 25

“Hypertension occurs in up to one-third of patients with acromegaly and is characterized by suppression of the renin-angoitensin-aldosteron axis and increases in total-body sodium and plasma volume.”

Question 26

What manifestation of rheumatic arthritis is more associated with pericardial effusion?

Answer 26

Rheumatic nodules.

Question 27

How extensive might be the aortic inflammation in the seronegative arthopathies? How common is it?

Answer 27

“The aortic inflammation usually is limited to the aortic root but may extend to involve the aortic valve, mitral valve, and ventricular myocardium, resulting in aortic an mitral regurgitation, conduction abnormalities, and ventricular dysfunction. One-tenth of these patients have significant aortic insufficiency, and one-third have conduction disturbances; these are more common in patients with peripheral joint involvement and long-standing disease.”

Question 28

Aortic regurgitation might precede the onset of arthritis in young male patients who have a seronegative arthropathy.
True or False?

Answer 28

True.

Question 29

Which conditions might have coronary arteritis but rarely results in myocardial ischemia?

Answer 29

Rheumatic Arthritis and Systemic Lupus Erythematosus.