CVB SAS/Misc Review Flashcards
Many questions and images are taken from Dr. Mutharasan's SAS and lecture slides
On an ECG, the QRS axis is -45 degrees.
Direction of QRS in Lead I:
Direction of QRS in Lead aVF:
What kind of deviation is this?
Direction of QRS in Lead I: Up
Direction of QRS in Lead aVF: Down
Left Axis Deviation
Which segments make up the PR interval?
1 + 2
What is the effect of reduced aortic compliance on pulse pressure?
Pulse pressure increases
- SBP increases and DBP decreases
How is ejection fraction calculated?
(EDV-ESV)/EDV
What is the most likely etiology of a II/IV decrescendo diastolic murmur best heard at the base of the heart?
Aortic regurgitation
Which layer of the ventricle has the longest refractory period?
Midmyocardium
Which segments make up the QT interval?
3 + 4 + 5
On an ECG, the QRS axis is +45 degrees.
Direction of QRS in Lead I:
Direction of QRS in Lead aVF:
What kind of deviation is this?
Direction of QRS in Lead I: Up
Direction of QRS in Lead aVF: Up
No deviation: 0 to +90 = normal ECG axis
Which of the receptors on macrophages recognize modified LDL?
Scavenger receptors
Note: These receptors are NOT downregulated the way normal LDL receptors are
Point 0 represents LV End Diastolic Pressure (LVEDP) at baseline.
Which point best represents the LVEDP in a stiff left ventricle?
The blue line in general
A stiffer left ventricle would result in increased pressure at every volume (especially higher volumes), becuase the ventricle cannot stretch as well to accomodate volume
Which chamber of the heart rests against the esophagus?
Left Atrium
Your patient presents with symptoms of heart failure. You determine that the Point of Maximal Impulse is located in the 6th intercostal interspace and is 3.5 cm in diameter.
A. Pulmonary Hypertension
B. Mitral Stenosis
C. Dilated Cardiomyopathy
D. Amyloidosis
C. Dilated Cardiomyopathy
What ligand does Gp IIb/IIIa bind to?
Fibrinogen
Which structure labels the pulmonary valve?
A
Which factor belongs in the orange box?
Fibrinogen
Compared to the Hgb concentration earlier in the morning before the trauma, what is the Hgb concentration immediately upon blood loss?
Hgb concentration immediately upon blood loss remains the same
Mechanisms that would increase blood volume (but dilute Hgb concentration) have not yet kicked in
Which factor belongs in the orange box?
Prothrombin
Describe the aPPT test
How is the assay performed?
Which coagulation pathway is activated?
Mix plasma with silicate to activate factor XII and initiate the intrinsic coagulation pathway. Adding calcium results in conversion of fibrinogen to fibrin in 30 to 40 seconds.
Which ECG feature is labeled by segment 2?
PR Segment
During exercise, what happens to pulmonary vascular resistance?
PVR decreases
Which structure labels the aortic valve?
B
Which of the following pictures shows a large vein?
C - Has longitudinal smooth muscle
(Arteries have concentric smooth muscle)
What is the mechanism behind enoxaparin’s (a LMWH) anti-coagulant effects ?
LMWH is a factor Xa inhibitor (with some Factor IIa activity)
This inhibits the clotting cascade (after the intrinsic and extrinsic pathways converge, so therefore it inhibits both)
What does aortic regurgitation do to preload and afterload?
Aortic regurgitation increases both preload and afterload
Correctly order the events in the platelet’s role in hemostasis:
Secretion
Activation
Adhesion
Aggregation
- Adhesion
- Activation
- Secretion
- Aggregation
Describe the PT test
How is the assay performed?
Which coagulation pathway is activated?
Plasma is mixed with a high concentration of tissue factor to activate FVII & overwhelm TFPI, initiating the tissue factor (extrinsic) coagulation pathway; calcium is added and fibrin is formed in 10 to 15 seconds.
Why is the systolic blood pressure higher at the red arrow?
Post-extrasystolic potentiation
- Before the red arrow, there is a wide QRS complex (low SBP, weak contraction
- Then, there is a long pause; Intracellular Ca2+ builds up
- The beat that the arrow is pointing to has a stronger contraction as a result
In the cardiac cycle, when is cytosolic calcium concentration the highest in the ventricle?
When the ventricle is contracting (during systole)
Which of the following pictures shows a muscular artery?
D - Scalloped endothelium when the artery is contracted
A patient is suffering from multiple gunshot wounds.
Which coagulation factor is most responsible for initiating coagulation in this patient?
Tissue factor
Any time there is tissue damage or blood vessel injury, tissue factor initiates coagulation
Factor XI works to amplify the tissue factor pathway; the tissue factor pathway generates a priming amount of thrombin, which activates Factor XI
Factor XII can initiate coagulation and activate Factor XI in the absence of tissue factor
What is the Systemic Vascular Resistance in the Circuit (dynes*sec*cm-5)?
1000
A patient taking warfarin for atrial fibrilation has an INR of 9
How should the patient be treated?
Therapeutic INR for atrial fibrilation is 2-3; 9 is very high
To speed up coagulation (decrease the effects of warfarin), give vitamin K or fresh frozen plasma (contains clotting factors)
Which structure is labeled by D?
Where in the heart is it?
Tricuspid valve
Between the right atrium and right ventricle
Curve A is the normal hemoglobin saturation curve. Which curve best represents the hemoglobin saturation curve in the setting of low pH?
Curve C
Right shift = the tissue is crying out for oxygen, so the hemoglobin unloads it
(Low pH decreases hemoglobin’s affinity for oxygen)
Normal splitting of the second heart sound occurs during….
Inspiration (Pulmonic valve will close after aortic valve)
The presence of pathological Q waves suggests the presence of…
Groups of cells that have lost the ability to generate action potentials
What is the Systemic Vascular Resistance in the Circuit (dynes*sec*cm-5)?
97.56
(No matter how high the resistance, an extra pathway will lower total resistance)
Which receptor or pathway does ticagrelor target?
A. Inhibits the ADP P2Y12 platelet receptor
B. Inhibits Thromboxane A2 synthesis
C. Inhibits platelet cAMP Levels
D. Inhibits GPIIb/IIIa receptors
A. Inhibits the ADP P2Y12 platelet receptor
Inhibiting this receptor prevents decreases in cAMP that cause platelet activation
Note: Gp IIb/IIIa, Thromboxane A2, ADP, and decreased cAMP all cause platelet aggregation (Gp IIb/IIIa via fibrinogen).
They are all potential targets of anti-coagulants.
In a patient with atrial fibrillation, which physical finding would be impossible?
A. S1
B. S2
C. S3
D. S4
D. S4
S4 is due to blood hitting a stiff ventricle during atrial contraction (at the end of diastole)
If a patient has atrial fibrillation, there is no meaningful activity of the atria; thus, they cannot contract
After MI, when would you expect to see macrophages, fibroblasts, and an overal mottled appearance on histology?
5-7 days
(This is the danger zone when ventricular walls might rupture)
At his annual exam, a patient reports that he has noticed chest pressure radiating into his jaw walking up the stairs to the El, getting better after about 5 minutes of rest on the platform.
What is the most appropriate clinical diagnosis?
Stable Angina
What is the name of the center cranial nerves IX and X synapse onto in the baroreceptor reflex?
Nucleus Tractus Soltarius
During which portion of the ECG does the ventricular volume approach its minimum value?
At the onset of the T wave
6 hours after a patient presents to the ER with STEMI, what changes in histology are you likely to see?
Contraction band necrosis/coagulative necrosis
Present 4-24 hours after MI
Which factor belongs in the orange box?
Fibrin
Which of the following pictures shows an arteriole?
B
During crossbridge cycling, when the thick filament moves in relation to thin filament, ADP is bound to _________.
During crossbridge cycling, when teh thick filament moves in relation to thin filament, ADP is bound to myosin.
What ligand does Gp Ia-IIa bind to?
Collagen
Which of the following correctly labels the neointima?
A
If Cell A attains the membrane voltage depicted in th blue line, which cells will depolarize?
Cells A, B, C, D
What is the mechanism / quality of the heart murmur found in mitral regurgitation (assume no prolapse)
A. Holosystolic murmur best heard at the base
B. Holosystolic murmur best heard at the apex
C. Crescendo-decrescendo murmur best heard at the base
D. Crescendo-decrescendo murmur best heard at the apex
B. Holosystolic murmur best heard at the apex
Note: A murmur heard on the back or in the axilla is usually mitral regurgitation
Which ECG feature is labeled by segment 3?
QRS complex
In embryonic development, what septum plays an important role in separating the developing aortic and pulmonary valves?
Spiral septum
Which factor belongs in the orange box?
What is its role in coagulation?
VIIIa
Together, FVIIIa and FIXa form the tenase complex, which activates FX to FXa
What are the 4 major maneuvers of the physical exam, in the correct order?
What is the exception to this order?
Inspection, palpation, percussion, auscultation
Exception: the carotid arteries. Listen first, and don’t palpate if you hear evidene of plaques
The Green depicts baroreceptor firing before blood loss. Which of the Red tracings depicts baroreceptor firing if blood pressure is high?
C
Decreased BP = decreased firing
Increased BP = increased firing
Which of the following correctly labels the intima?
A
Which structure is labeled by C?
Where in the heart is it?
Mitral valve aka bicuspid valve
Between the left atrium and left ventricle
What ligand does Gp Ib bind to?
Von Willebrand Factor
Which factor initiates clotting in the extrinsic pathway?
Tissue factor
(extrinsic = not in the blood, in the tissues instead)
Which of the following pictures shows a vein?
A - Little muscle in the vessel
Which major structures of the heart are separated by the formation of the spiral septum?
Ventricles
Bulbus cordis
Semilunar valves
Truncus arteriosus
Which of the following classify as MI type I?
Which are MI type II?
Type I = plaque rupture with thrombus
Type II = everything else
Which of the histological sections below is most similar to the coronary arteries and their larger branches?
D (shows a muscular artery)
What is usually responsible for a murmur that is a low-pitched decrescendo rumble at the apex of the heart?
Mitral stenosis
If Cell A attains the membrane voltage depicted by the red line, which cells will depolarize?
Cells A and B
This equation calculates what value?
SVR
The most important benefit of adjunctive antithrombotic therapy after fibrinolysis (thrombolytic therapy) is:
Prevention of re-occlusion of the infarct vessel
Which of the following is the most potent stimulant of cerebral blood flow?
A. CO2 concentration
B. O2 concentration
C. H+ concentration
A. CO2 concentration
Which ECG feature is labeled by segment 1?
P wave
What rhythm abnormality does this ECG show?
Atrial Fibrilation
The solid lines represent the vascular function and cardiac function curves.
Which line best represents the vascular function curve after transfusion?
B
Venoconstriction can also cause this
Which antiplatelet agent directly prevents decreases in intracellular cAMP?
Dipyridamole
Where is compressive resistance (R3) the greatest?
A. At the epicardium
B. In the midmyocardium
C. At the endocardium
C. At the endocardium
Which factor belongs in the orange box?
XIa
Which factor belongs in the orange box?
Thrombin
Which of the following correctly labels the adventitia?
C
On an ECG, the QRS axis is +120 degrees.
Direction of QRS in Lead I:
Direction of QRS in Lead aVF:
What kind of deviation is this?
Direction of QRS in Lead I: Down
Direction of QRS in Lead aVF: Up
Right Axis Deviation
Which of the following pictures shows an elastic artery?
E - The wavy parts are elastic lamellae, characteristic of elastic (large) arteries
The Green depicts baroreceptor firing before blood loss. Which of the Red tracings depicts baroreceptor firing after blood loss?
A
Decreased BP = decreased firing
Increased BP = increased firing
A patient with heart failure has a thickened left ventricle.
Are they more likely to have HFpEF or HFrEF?
HFpEF
Thickening of the LV is usually associated with diastolic dysfunction, while dilation of the LV is associated with systolic dysfunction
In anatomical cases where there is a double superior vena cava, what structure does the left superior vena connect to?
Coronary Sinus
Which of the following cytokines elaborated by macrophages is considered anti-inflammatory?
A. Interleukin-1
B. Interleukin-10
C. Tumor Necrosis Factor
D. Platelet-Derived Growth Factor
B. Interleukin-10
Which ECG feature is labeled by segment 5?
T wave
If the JVP is visible to 7 cm vertically above the sternal angle, approximately what is the JVP?
12 cm
What level of the circulation is most responsible for developing resistance?
Arterioles
How does increased ADP affect coagulation?
Describe the pathway
Increased ADP = Increased coagulation
ADP binds to the ADP P2Y12 receptor.
This lowers intracellular cAMP
Low intracellular cAMP -> platelet activation
(Ticagrelor, clopidogrel, prasugrel, and ticlopidine all inhibit this pathway)
Which factor belongs in the orange box?
IX -> IXa
What is the result of decreased cAMP on platelet activation?
Decreased intracellular cAMP promotes platelet activation
Needle A is half as long as Needle B, but Needle B has twice the inner diameter as Needle A. Which needle offers LOWER resistance to laminar flow?
Needle B
According to Pousielle’s law, increasing radius/diameter increases flow more than increasing length decreases it
S3 is the sound of a large volume of blood striking a ____________ ventricle, and may be physiologic.
S4 is the sound of blood striking a ____________ ventricle during ___________, and is almost always pathologic
S3 is the sound of a large volume of blood striking a very compliant ventricle, and may be physiologic. (Children, athletes, pregnant women)
S4 is the sound of blood striking a stiff ventricle during atrial contraction, and is almost always pathologic
After MI, when would you expect to see wavy fiber changes on histology?
1-4 hours after MI
If the extrinsic pathway is not activated to produce a priming amount of thrombin, what activates FXI to FXIa, to initiate the intrinsic clotting cascade?
Polyphosphate, released from injured tissues and platelets, activates FXII -> FXIIa. FXIIa activates FXI -> FXIa, and the rest of the clotting cascade follows
FXIIa also activates prekallikrein to kallikrein, which promotes autoactivation of FXII -> FXIIa
Which of the following medications represents an anti-anginal drug that may be considered?
A. Lisinopril
B. Digoxin
C. Hydrochlorothiazide
D. Amlodipine
E. Apirin
F. Atorvastatin
D. Amlodipine
Which ECG feature is labeled by segments 1 and 2 together?
PR interval
Which image best represents stable angina?
A
You are rounding on a patient 1 day after his MI, and you hear a 3-component rub. Which of the following most likely explains your physical exam finding?
A. Ventricular Aneurysm
B. Papillary Muscle Rupture
C. Ventricular Free Wall Rupture
D. Dressler Syndrome
E. Post-infarction pericarditis
E. Post-infarction pericarditis
Point 0 represents LV End Diastolic Pressure (LVEDP) before transfusion. Which point best respresents the LVEDP after transfusion?
Point E
Transfusion = increased LV volume, which causes an increase in pressure
What is the major molecular mechanism mediating cytosolic Ca2+ decrese during ventricular relaxation?
SERCA - pumps Ca2+ into the SR
What is the recommended dietary threshold for saturated / trans-fatty acids?
(AHA/ACC guidelines)
<7%
You are rounding on the patient 1 day after his MI and you hear a 2-component rub. Which of the following most likely explains your physical exam finding?
A. Ventricular Aneurysm
B. Papillary Muscle Rupture
C. Pleuritis
D. Dressler Syndrome
E. Post-infarction pericarditis
C. Pleuritis
Which ECG feature is labeled by segment 4?
ST segment
Considering the Starling equation, which of the following parameters changes immediately after hemorrhage, driving absorption of fluid into the circulation from the interstitium?
(P = hydrostatic pressure, Pi = oncotic pressure)
A. Pcapillary
B. Pinterstitium
C. Picapillary
D. Piinterstitium
A. Pcapillary
Pcapillary decreases, allowing fluid from the interstitium into the capillary to compensate for lost volume
While a person is running, what is likely to happen to calcium concentrations in the vascular smooth muscle in the quadriceps (thigh muscle) territory?
Calcium concentration is likley to decrease
Vascular smooth muscle must dilate (relax) to allow increased blood flow to the thigh muscles
Which factor belongs in the orange box?
Factor X -> Factor Xa
Which is the aortic tracing?
2
LV will always have lower diastolic BP than the aorta
Based on the current evidence that has influenced the AHA/ACC Guidelines, the most atherogenic aspect of the current US diet is…
Excess intake of saturated / trans-fatty acids by 90% of the populations, who exceed the recommended threshold of <7% in the diet.
What is a possible consequence of extending the refractory period of the midmyocardium?
The midmyocardium already has the longest refractory period.
Lengthening the refractory period even fruther can set up reentry, leading to arrhythmia
Which factors belong in the orange box?
Tissue factor + VIIa
Curve A is the normal hemoglobin saturation curve. Which curve best represents the hemoglobin saturation curve in the setting of low temperature?
Curve B
(Capillaries near the lungs will be cooler than capillaries near exercising muscle)
How can you distinguish the carotid from the jugular venous pulse?
The jugular venous pulse is biphasic (it will kind of flicker)
