EXAM #1: REVIEW Flashcards
Draw and label the normal jugular venous pressure wave.
See ppt.
What is the “h” wave on the jugular venous pressure wave?
Continued filling of the RA during diastole
What condition will cause an absence of the “x” wave on the jugular venous pressure waveform?
Tricuspid regurgitation
What is and S3, and what causes it?
- Rapid flow of blood from the atria to the ventricles
- “Rapid ventricular filling”
*Volume overload (CHF) is a cause of S3
What causes a fixed splitting of S2?
Atrial Septal Defect
When does the opening snap of Mitral Valve Stenosis occur?
After the end of S2
What causes S3?
- Rapid flow of blood from the atria to the ventricles
- “Rapid ventricular filling”
What is S4, and what causes it?
Atrial kick into non-compliant ventricles
*This can occur in LVH and MI
What are the three types of systolic murmurs?
1) Ejection
- Aortic and pulmonic stenosis
2) Pansystolic
3) Late systolic
- MVP
List the three pansystolic murmurs.
1) Mitral regurgitation
2) Tricuspid regurgitation
3) VSD
Where is aortic regurgitation best auscultated?
3rd of 4rd LEFT ICS
What are the two components of the EDV?
1) Ventricular filling
2) Atrial kick
Draw and label the ventricular pressure-volume loop.
See ppt.
What is the mechanism of the Frank-Starling principle of the heart?
Length of the sarcomere determines the sensitivity to Ca++
What is the mechanism of the ANREP effect?
Increased LV wall tension causes:
1) Increase cytosolic Na+
2) Increased cytosolic Ca++
3) Increased myocardial contraction
What is the normal conduction velocity and pacemaker rate of the SA node?
- Less than 0.01 m/sec
- 60-100 bpm
What is the normal conduction velocity and pacemaker rate of the atrial myocardium?
- 1.0 - 1.2
- None
What is the normal conduction velocity and pacemaker rate of the AV node?
- 0.02 - 0.05 m/sec
- 40-55 bpm
What is the normal conduction velocity and pacemaker rate of the Bundle of His?
- 1.2 - 2.0 m/sec
- 25-40 bpm
What is the normal conduction velocity and pacemaker rate of the Bundle Branches?
- 2.0 - 4.0 m/sec
- 25-40 bpm
What is the normal conduction velocity and pacemaker rate of the Purkinje fibers?
- 2.0 - 4.0 m/sec
- 25-40 bpm
What is the normal conduction velocity and pacemaker rate of the ventricular myocardium?
- 0.3 - 1.0 m/sec
- none
What effect will a Na+ channel blocker have on the cardiac action potential?
Prolong the absolute refractory period
Outline the contraction phase of excitation-contraction coupling cardiac muscle.
1) Ca++ entry through voltage gated Ca++ channel
2) Ca++ binds RyR2
3) Ca++ release from the SR
4) Ca++ binds troponin
Outline the relaxation phase of excitation-contraction coupling in cardiac muscle.
Ca++ dissociates from troponin
- Some is taken back up into the SR via SERCA, where it binds Calsequestrin
- Some is pumped out of the cell via NCX and the plasma Ca-ATPase
What is the difference between a DAD and an EAD?
DAD= arrhythmia generated in phase 4
EAD= arrhythmia generated in phase 2 or 3
What causes DADs?
Increased Ca++
What causes EADs?
Prolonged action potential duration/ changes in ion flux
List four mechanisms that will prolong the action potential duration.
1) Reduced K+ current
2) Reduced Ca++ current
3) Increased Na+/Ca++ exchange activity
4) Increase late Na+ current
List four examples of re-entrant circuits.
1) WPW
2) AVNRT
3) A-flutter
4) PSVT
List two examples of functional re-entry.
1) Monomorphic VT
2) Polymorphic VT or VF
What types of SDs may lead to cardiac compromise?
Cranial
Cervical
Thoracic
What happens when there is a decrease in left vagal tone?
Ectopic foci
V-fib
What happens when there is an increase in left vagal tone?
AV Block
Overactivation of the SNS can result in what cardiac abnormality?
SVT
What does an increase in right vagal tone result in?
Sinus Brady
What is the effect of increase right vagal tone on the coronary arteries?
Vasoconstriction
List six SDs that can cause cardiac dysfunction.
1) OA
2) Lower cervical
3) Thoracic inlet
4) Rib dysfunction
5) Flattened thoracic kyphosis
6) Abnormal gait
List four tissue changes that will result in a passive arrhythmia.
1) Gap junction changes
2) Fat deposition
3) Fibrosis
4) Changes in cell size
List four passive mechanisms that regulate pulmonary blood flow.
1) Gravity
2) Body position
3) Extravascular pressure
4) Intravascular pressure
What is extravascular compression in the heart?
Compression of the coronary arteries with increased chamber pressure during systole
What does the PR interval correspond to?
Depolarization in the:
- AV node
- His Bundle
- Bundle Branches
- Purkinje fibers
Where are q-waves normal?
aVR II III aVF aVL V4-V6
What is the normal amplitude of T-waves?
- Limb leads= less than 5mm
- Chest= less than 10mm
What causes u-waves?
1) Hypokalemia
2) Quinidine
List the three etiologies of atrial enlargement.
1) Mitral or tricuspid valve disease
2) Ischemia
3) HTN
What are the ECG criteria for RVH?
1) RAE
2) RAD
3) R-wave in V1 greater than or equal to 7mm
List four etiologies of a 2nd degree AV block.
1) Vagotonia
2) Acute inferior MI
3) Drugs
4) Aortic valve disease
List three etiologies of AV dissociation.
1) Acceleration of a subsidiary pacemaker
2) Decreased sinus automaticity
3) Re-entrant ventricular tachycardia
List the four things that will cause a tall r-wave in V1.
1) RVH
2) RBBB
3) WPW
4) Dextrocardia
What are the three general features of premature beats
1) Occur early in the cycle
2) Prevent occurrence of the next normal beat
3) Generate a pause of varying length
What is the definition of Grade 1 PVC?
Less than 30 PVCs an hour
What are the clinical implications of a left premature ventricular beat?
More likely to be caused by IHD and to degenerate to V-fib
Remember, Left= upright in V1
What are the two common types of re-entrant junctional tachyarrhythmias?
1) AV junctional tachycardia
2) AV bypass tachycardia
What are the two subtypes of AV junctional tachycardia?
1) Slow-fast
2) Fast-slow
What are the two subtypes of AV bypass tachycardia?
1) Orthodromic
2) Antidromic
What is the definition of a re-entry ventricular tachyarrhythmia?
3x consecutive QRS complexes
What are the common mechanisms of most ventricular tachyarrhythmias?
Re-entry
1) Mirco or macro re-entry
2) Common with ischemia/ post-MI
List four things that V-Tac is associated with.
1) IHD
2) Cardiomyopathy
3) Valvular disease
4) Drugs
List the three class IA antiarrhythmatics.
- Quinidine
- Procainamide
- Disopyramide
What are the specific adverse effects associated with Class IA antiarrhythmatics that have limited their clinical use?
1) Increase mortality in atrial arrhythmias
2) QT prolongation and Torsdades
3) G6PD hemolytic anemia induction
What adverse effect is associated with the Class IC antiarrhythmatics?
QT prolongation and Torsades
What are the major adverse effects associated with Sotalol?
1) Torsades
2) Excessive beta-blockade
What drugs are used for rhythm control in a-fib?
No IHD= Flecainide or Propafenone
IHD= Sotalol or Amiodarone
What drugs are used for rate control in a-fib?
1) Beta blockers
2) Diltiazem
3) Digoxin
What total serum cholesterol increases the risk for atherosclerosis?
160 mg/dL
What are the two “unusual” risk factors for atherosclerosis?
1) Homocystine
2) Chlamidya pneumonia
What chemotaxant molecule recruits macrophages to sites of endothelial injury/ accumulated lipids?
Monocyte chemoattractant protein 1 (MCP-1)
What are the three morphologic stages of atherosclerosis?
1) Fatty streak
2) Proliferative lesion
3) Atherosclerotic plaque or “atheroma”
What does ABPI stand for?
Anke Brachial Pressure Index
What is the equation for blood pressure?
Blood pressure= CO x SVR
List six etiologies of cardiogenic shock in children.
- Rheumatic fever
- Cardiomyopathy
- Pneumothorax
- Hyperkalemia
- Hypocalcemia
- Congenital heart disease
What are the symptoms of cardiogenic shock in children?
VAGUE!
- Poor feeding
- Decreased activity
Syncope and AMS if severe
List six lab tests that should be ordered for a child in suspected cardiogenic shock.
1) Glucose
2) Electrolytes
3) Ca++
4) Blood gas
5) Cardiac enzymes
6) Viral titers
Once an airway has been established and IV access (or IO) has been attained, how do you manage a child in cardiogenic shock?
1) Boluses of 5-10 mL/kg of isotonic fluid
2) Glucose
3) Maintain temperature
4) Drugs
List the drugs that you would consider for a child in cardiogenic shock.
Dopamine Dobutamine Epinephrine Milrinone Nitroprusside Nitrous Oxide
What drugs are CONTRAINDICATED in the setting of cardiogenic shock?
Phenylephrine
Norepinephrine
What is the definition of a positive family history for CAD in men vs. women?
Men= 1st degree relative under 55
Women= same but under 65
How much does DM increase the risk of a “hard CVD event?”
20%
List the markers for metabolic syndrome.
1) Diabetic dyslipidemia
2) PAH
3) Central abdominal obesity
4) Insulin resistance
List six mechanisms that explain how smoking enhances atherosclerosis.
1) Hemodynamic stress
2) Endothelial injury
3) Lipid changes
4) Enhanced coagulation
5) Arrhythmogenesis
6) Hypoxia
What are four complications of CAD?
1) ACS
2) Sudden cardiac death
3) Dilated cardiomyopathy
4) A-fib/flutter
What are the three major determinants of myocardial oxygen demand?
1) HR
2) Contractility
3) Wall tension
List the labs that are part of the work-up for chest pain.
1) Lipid panel
2) CBC
3) Blood chemistry w/
- Electrolytes
- BUN
- Creatinine
4) UA for:
- Protein
- Glucose
List the five etiologies of non-idiopathic dilated cardiomyopathy.
1) IHD
2) HTN
3) Alcoholism
4) Infectious (Chagas and coxsackie)
5) Metabolic
List three complication of dilated cardiomyopathy.
1) Biventricular CHF
2) Arrhythmia
3) Mitral/tricuspid valve regurgitation
List the signs of LV failure.
- Tachycardia
- Cardiac apex displaced left and down
- Apical lift/thrill
- Murmur
- S3
What heart sound is universal in heart failure?
S3
What lab tests should you order in a patient with alcoholic dilated cardiomyopathy?
1) Blood alcohol
2) Liver transaminases/chem.
3) Vitamin tests. e.g. Thamine
What are the different gross manifestations of hypertropic cardiomyopathy?
1) Increased mass
2) Asymmetric septal hypertrophy
3) Concentric hypertrophy
4) Apical hypertrophy
What are the signs of hypertrophic cardiomyopathy?
1) Displaced/bifid LV
2) Bisferiens carotid pulse
3) Systolic murmur
4) S4
What are the ECG changes that are associated with hypertrophic cardiomyopathy?
1) Increased voltage in anterior leads
2) ST and T-wave changes
3) Q-waves in inferior and lateral leads
4) Ventricular arrhythmia
List the causes of restrictive cardiomyopathy.
1) Amlyoidosis
2) Sarcoidosis
3) Edocardial fibroelastosis
4) Loeffler Syndrome
5) Hemochromatosis
What ECG changes are associated with restrictive cardiomyopathy?
Low voltage and diminished QRS amplitude
What are the two general etiologies of aortic regurgitation?
1) Aortic root dilation
2) Valve damage
What are the different valve defects that are associated with aortic regurgitation?
1) Bicupsid aortic valve
2) Degeneration with age
3) Rheumatic fever
4) Endocarditis
5) Degeneration of a prosthetic valve
What can cause dilation of the aortic root?
1) Trauma
2) Marfan’s Syndrome
3) Syphlitic aneurysm (tertiary syphilis)
4) Aortic dissection
What are the physical exam manifestations of aortic regurgitation?
- Bounding pulse
- Pulsating nail bed
- Head bobbing
- S3
- Ejection click
How is the murmur of aortic regurgitation described?
- Diastolic
- Decrescendo
- “Blowing”
What is commonly associated with aortic regurgitation?
Aortic stenosis
What is the mainstay of treatment for aortic regurgitation?
ACE inhibitors
What are the symptoms aortic stenosis?
1) Angina
2) Syncope with exertion
3) HF
How is the murmur of aortic stenosis described?
- Crescendo/decresendo
- Loud
- Late
What two drugs are specifically indicated for Familial Hyperlipidemia?
1) Mipomersen
2) Lomitapide
What is the MOA of Mipomersen?
Blocks the production of apoB mRNA
*Cannot make VLDL or LDL
What is the MOA of Lomitapide?
Oral MTB inhibitor, which is necessary for ApoB lipoproteins
What is the function of PCSK9?
Expression of LDL receptors
