exported flash cards

Question

Describe the AP of a non cardiac pacemaker cell

Answer 1

sodium= phase 0 rapid vertical upstroke potassium= tip/point of the AP, aka phase 1= early short replarization (K out and decreased Na conductance) calcium= phase 2, the horizontal delay before repolarization (inward Ca counteracts K out) potassium= phase 3 repolarization resting membrane potential (-90mV)= phase 4, flat line horizontal... near equalibrium potential of potassium in cardiomyoctes and purkinje cells

Answer 2

adenosine and dipyridamole are vasodilators selective for coronary vessels Basically when there is ischemia (chronic due to atherosclerosis), collateral vessels are made to keep the heart perfused. Then these drugs come in and vasodilate the heart, BUT the ischemic areas are already maximally dilated, so dilation of the normal (coronary arterioles) vessels steals blood from the ischemic areas and exacerbates the myocardial ischemia... "coronary steal" Adenosine and dipyridamole use this principle in perfusion imaging studies during exercise to detect areas of ischemia not otherwise seen in the resting heart

Answer 3

Prostaglandins dilate the afferent arteriole (before the glomerulus), which increases GFR by bringing in more blood flow relative to the efferent arteriole blocking prostaglandins with NSAIDS blocks this affect

Answer 4

angiotensin 2 causes constriction of the efferent arteriole which increases GFR by having more blood flow come in relative to the smaller size of the efferent arteriole ACEI blocks this affect angiotensin 2 also increases aldosterone so ACEI block this increase and hold onto potassium

Answer 5

shortened ST segments and the scooped out appearance of the ST segment

Answer 6

milrinone (phosphodiesterase inhibitor that inhibits the breakdown of cAMP which increases contractility and vasodilation) and nesiritide (synthetic BNP, increases cGMP, vasodilation, and natriuresis)

Answer 7

vagus nerve stimulation increases parasympathetic effects on the heart (and is why digoxin can act as an antiarrhythmia drug to slow down the SA and AV nodes)

Answer 8

nausea, vomiting, abdominal pain, and YELLOW VISION (xanthopsia) hypokalemia exacerbates toxicity. renal problems and other drugs can impair excretion. digoxin with a very narrow theraputic index

Answer 9

True. Indicated in DM patients with albuminuria or in DM with hypertension to prevent progression of kidney disease!

Answer 10

hypotension tachycardia jugular venous distension (with clear lungs) pulsus paradoxus (loss of palpable pulse during inspiration... >10 mmHg decrease in systolic BP because inspiration increases blood flow to the right heart but when the heart's expansion is impaired the increased RV volume causes the interventricular septum to bow into the LV which decreases LV end diastolic volume and stroke volume causing systolic pressure to drop) causes include recent viral illness causing a viral pericarditis with significant pericardial fluid accumulation (due to inflammation)

Answer 11

increase increases venous return

Answer 12

hypotension tachycardia jugular venous distension pulmonary edema pulsus paradoxus not seen

Answer 13

cardiac tamponade asthma COPD constrictive pericarditis

Answer 14

breath sounds absent on affected side hyperresonance (too much air) to percussion on affected side tachypnea tachycardia hypotension distended neck veins tracheal deviation to the contralateral side

Answer 15

each arch has a cranial nerve and an aortic arch 1st arch= first aortic arch (regresses except for maxillary artery) and trigeminal nerve 2nd arch= second aortic arch (regresses) and facial nerve (muscles of facial expression, some ear and hyoid associated structures) 3rd arch= common and proximal internal carotid arteries (inward of sternocleidomastoid muscle) and glossopharyngeal nerve... also the hyoid bone and stylopharyngeus muscle 4th arch= true aortic arch and subclavian arteries, superior laryngeal branch of the vagus nerve... also muscles of pharynx and soft palate and some laryngeal muscles 5th arch= obliterated during fetal development 6th arch= pulmonary arteries and ductus arteriosus, recurrent laryngeal branches of the vagus nerve

Answer 16

elevations in pasma homocysteine due to genetic mutations in critical enzymes and vitamin (cofactor) deficiencies most common genetic cause= MTHFR def... TetraHydroFolate Reductase regenerates methyl tetrahydrofolate with FAD as a cofactor (also low vit B's- cobalamin B12, pyridoxine B6, folate B9)... supp with vit B not shown to help CV risk or mortality high plasma homocysteine= independent clot risk (due to endothelial damage) homocysteine ----(remethylation via methionine synthase using methyl THF + B12)------> methionine homocysteine -----(transsulfuration)-----> cystathionine ----- (cystathionase + B6) ----> cysteine

Answer 17

methionine

Answer 18

Nitroprusside is a short acting balanced venous and arterial vasodilator thus it will decrease preload and afterload (to the LV) decrease in preload (LVEDP)= shifts the whole cycle to the left towards lower volumes (preload is specifically the right-most line on the cycle) decrease in afterload (mean systolic intraventricular pressure)= squishes the cycle down vertically from the top (with the top line=afterload reflecting lower pressure) No change in stroke volume (the width of the cycle)

Answer 19

fibrinolytic= binds fibrin in the clot and converts the entrapped plasminogen into plasmin (which lyses the clot by hydrolyzing fibrin matrix bonds) given to achieve myocardial reperfusion for acute MI within 12 hours of onset (percutaneous coronary intervention is preferred because it has lower rates of intracerebral hemorrhage and recurrent MI)

Answer 20

abrupt decreased LOC (comatose) asymmetric pupils irregular breathing most common ADR of fibrinolytic therapy is hemorrhage

Answer 21

causes an ischemic stroke with fluctuating symptoms and may have periods of improvement

Answer 22

severe tearing chest pain radiating between the scapula common in HTN patients or marfan(fibrillin mut)/ehlers (collagen mut) danlos syndrome patients CXR with widened mediastinum

Answer 23

results in paradoxical cardiomyocyte dysfunction Basically: arrythmias myocardial stunning (prolonged but reversible contractile dysfunction) myocyte death

Answer 24

GI bleed | recent surgery

Answer 25

The common cardinal veins embryonic development has three vein origins: 1. umbilical (degenerates) 2. vitelline (form the portal system) 3. cardinal veins (systemic venous circulation)

Answer 26

Atrial fibrillation seen in patients after excessive alcohol consumption (otherwise healthy patient, usually temporary)

Answer 27

torsades de pointes (polymorphic ventricular tachycardia)... and sudden death can be congenital or acquired (chronic heavy alcohol use)

Answer 28

observer bias

Answer 29

concluding there is no different when one actually exists it is a random error not a systematic error/bias

Answer 30

endothelial cells atherosclerosis is initiated by repetitive endothelial cell injury leading to chronic inflammatory state underlying the intima of large elastic arteries and medium/large muscular arteries ``` repetitive injury from: HTN hyperlipidemia smoking DM homocysteine toxins (alcohol) viruses immune reactions ..... these expose subendothelial collagen or cause endothelial cell dysfunction ``` endothelial cell dysfunction leads to increased permeability, monocyte and lymphocyte migration into the intima, platelet adhesion (denudation and exposure of the subendothelial collagen), smooth muscle cells migrate into the intima and proliferate (due to growth factors released by monocytes and platelets), LDL cholesterol gets into the intima due to permeability, macrophages take up LDL to produce foam cells, SMCs deposit the LDL and produce more extracellular matrix (collagen and proteoglycans), this leads to fatty streaks (lipid laden foam cells), this leads to a fibrofatty atheroma-----> atherosclerosis

Answer 31

SMCs that have migrated to and proliferated in the intimal layer in which plaque forms

Answer 32

the main pathogen in the non-enterococcal group D strep family it causes subacute bacterial endocarditis (without pre-existing valvular abnormality) with symptoms similar to S viridans its a normal part of the colon flora... when it causes bacteremia or endocarditis then 25% of the time the strep gallolyticus is associated with colonic cancer when a blood culture grows strep gallolyticus you should do a colonoscopy!

Answer 33

staph aureus

Answer 34

strep viridans

Answer 35

a direct renin inhibitor can cause hyperkalemia due to decreased aldosterone levels

Answer 36

L type calcium channels in heart and smooth muscle smooth muscle calcium channels blocked by dihydropyridines (-dipine suffix) non dihydropyridines are block cardiac calcium channels (verapamil, diltiazem)... contractility and decreased activity of SA and AV nodes

Answer 37

due to reflex tachycardia Thus it is contraindicated in patient's with unstable angina or MI all CCBs can worsen heart failure

Answer 38

2. Potent vasodilators (hypotension leads to reflex tachycardia/SNS activation and increased renin levels=ADRs) - IV CCBs (dihydropyridines) - hydralazine (safe for pregos, arterial vasodilator only)... add BB or nitrate for reflex tachycardia... can cause drug induced lupus - nitroprusside (a nitrate, systemic vasodilation via NO-increase cGMP=smooth muscle relaxation).. problem=metabolized to cyanide---> lactic acidosis/seizures - fenoldopam (DA 1 receptor antag= increased cAMP= arterial vasodilation, esp renal a. and coronary a... also causes natriuresis) 1. IV beta blocker (esmolol, metoprolol- anti beta 1.... labetalol- anti alpha and beta)... can be added to help minimize reflex tachycardia of the vasodilators

Answer 39

1. Thiazides (chlorthalidone may be better) 2. ACEI/ARBs (with HF, MI, DM) 3. CCBs (good for African Americans and elderly...dihydropyridines) (and beta blockers I think) if BP >20/10 then combine two antihypertensives

Answer 40

systolic above 180 | diastolic above 120

Answer 41

``` HTN >180/120 blurry vision headache lung crackles neuro symptoms (end organ damage symptoms here) ```

Answer 42

To prevent ischemia lower by 10-20% in the first hour then 5-15% in next 23 hours

Answer 43

turbulent flow across a small VSD makes a loud holosystolic murmur best heart over the left lower sternal border (may be absent if the VSD is large because there is less resistance) VSD= failure of PROLIFERATION of endocardial cushions (normally forming the membranous part of the interventricular septum)

Answer 44

A bifid carotid pulse with a brisk upstroke ("spike and dome").... remember LVOT obstruction during systole also thought of as a systolic crescendo-descrescendo murmur

Answer 45

precordial, continuous machine like murmur pulm a. will have elevated SpO2

Answer 46

because equalization of the left and right atrial pressure minimizes the respiratory variation in ventricular blood flow

Answer 47

cyanotic congenital heart disease or late features of ASD/VSD (due to Eisenmenger syndrome)

Answer 48

selective arteriolar vasodilators (hydralazine, minoxidil) reduce vasc resistance but cause a reflex SNS activation because baroreceptors get activated SNS= increase HR/contractility/CO and simulation of RAAS (sodium and fluid retention leading to tachycardia and peripheral edema....these offset the BP lowering effect and limit the long term use)... the SNS activation here does not raise BP above baseline unless stopped abruptly in resistant hypertension you can add on a sympatholytic or diuretic to combat these ADRs

Answer 49

persistent dry bradykinin cough and angioedema (localized to subcutaneous or submucosal unlike peripheral edema)

Answer 50

MAO inhibitors (tranylcypromine, phenelzine) increase synaptic monoamine levels by inhibiting monoamine degredation in order to treat atypical or resistant depression MAOi also block degredation of dietary tyramine (indirect sympathomimetic), allowing it to enter systemic circulation and cause SNS hyperactivity and HTN emergency dietary tyramine= aged cheeses, cured meats, draft beer ("fancy meats and cheeses")

Answer 51

antidepressants that inhibit reuptake of monoamines (norepi and serotonin) imipramine, amitriptyline, clomipramine

Answer 52

presynaptic selective dopamine and norepi reuptake inhibitor treats major depression and tobacco dependence ADRs= seizures contraindicated in bulimia or anorexia patients

Answer 53

staph (+) from strep (-)

Answer 54

separates staph into positive and negative groups positive= staph aureus (ferments mannitol, yellow pigment)... endocarditis of IV drug abusers and most common cause of osteomyelitis negative= staph epidermidis (novobiocin susceptible)/haemolyticus/saprophyticus (novobiocin resistance)/etc staph epidermidis is a skin contaminant that can cause an opportunistic infection including endocarditis to prosthetic valves and septic arthritis to prosthetic joints

Answer 55

continuous machine like murmur appreciated between the scapulae

Answer 56

incompatible with life unless there is a coexisting connection like a patent foramen ovale, septal defect, or PDA to allow oxygenated blood to mix with systemic circulation patient normal on initial presentation but as the PDA closes around 1-3 days old they get cyanotic, tachypneic, and tachycardic (elevated lactate as a consequence of anaerobic metabolism in the presence of poorly oxygenated blood) etiology of TGA= failure of normal spiraling of the aorticopulmonary septum in utero (thus aorta is anterior and inferior implying its connection off of the RV and pulmonary artery connection to LV)... basically you get two parallel circulations without communication when the PDA closes

Answer 57

failure of FUSION of the urethral folds to fuse

Answer 58

failure of OBLITERATION of the second branchial cleft the cyst usually present as a draining sinus at the angle of the mandible

Answer 59

failure of conotruncal SEPTATION presents with cyanosis and respiratory distress echo shows a large single arterial trunk and overriding large VSD

Answer 60

Staph aureus causes infective endocarditis in IV drug users resulting in tricuspid regurg Tricuspid regurg= early systolic murmur best heard in tricuspid area accentuated by inspiration (because inspiration increases blood flow to the right heart)

Answer 61

The right most vertical line= preload The top most vertical line= afterload

Answer 62

higher pressures would be reached during ejection phase and a greater volume of blood would be ejected during contraction (loop would get wider) ex= infusion of dobutamine

Answer 63

a two sample t test

Answer 64

to model the linear relationship between a dependent variable and an independent variable described in terms of a trend line ex= number of cigarettes smoked per day and the number of yearly hospitalizations in COPD patients

Answer 65

linear regression is a single number that is reported to describe the strength and magnitude of the association (ex= number of cigarettes smoked per day and the number of yearly hospitalizations in COPD patients) correlation coefficient is a measure of strength and direction of a linear relationship (ex= correlation coefficient describing the association between estrogen and breast cancer risk in post menopausal women) basically it seems that correlation coefficient compares things that are more closely linked

Answer 66

with categorical data evaluate whether the expected frequency of an occurrence is consistent with the observed frequency ("goodness of fit")

Answer 67

epidemiologic method of analyzing pooled data from several studies, therby increasing the statistical power beyond the individual study

Answer 68

Angiotensin 2 receptor blockers (-sartans) competitively bind and block the effects of angiotensin 2 resulting in vascular smooth muscle relaxation and decreased aldosterone secretion because this decreases BP, renin levels increase (and thus also increases angiotensin 1 and 2)....answer was ARB= increase in renin, angiotensin 1 and 2, decrease in aldo, no change in bradykinin bradykinin levels are unaffected cause ACE is left alone in the lungs

Answer 69

beta 1 blockers would inhibit renin release and thus supress the entire RAAS cascade (somewhat blunted by the lowered BP)

Answer 70

Epi: beta1=beta2>alpha1 increases HR and contractility (via beta 1) increases systolic BP (via beta 1 and alpha 1) low dose epi decreases diastolic BP (because beta2>alpha1)... beta 2 is vasodilation high dose epi increases diastolic BP (alpha1>beta2)

Answer 71

propranolol

Answer 72

isoproterenol

Answer 73

phentolamine

Answer 74

phenylephrine

Answer 75

acute= decrease in TPR resulting in increased CO and venous return. chronic= SNS and kidneys compensate for the chronic fistula by increasing cardiac contractility, vascular tone, and circulating blood volume... also increase the mean systemic pressure

Answer 76

almost always affects the mitral valve affects mitral and aortic valves in 25% of the cases (combined aortic stenosis and regurg which can predispose to infective endocarditis) infective endocarditis from ARF can cause embolization causing stroke (one sided hemiparesis) due to embolism from either clot formed during atrial dilation (from mitral stenosis) or endocarditis related valvular vegitation

Answer 77

collections of lipid laden macrophages (foam cells)

Answer 78

it is due to an atrioventricular conduction tract bypassing the AV node (an atrioventricular accessory pathway) in WPW there is an extra conduction pathway (called the accessory bypass tract or bundle of kent) directly connecting the atria to the ventricles allowing for pre excitation of the ventricles characteristic EKG triad: 1. short PR interval 2. widened QRS 3. slurred broad upstroke of the QRS complex (delta wave) WPW also associated with AV reentrant tachycardia

Answer 79

Wolf Parkinson White Syndrome delta wave looks like a bunch of peaked t waves but the upstroke of the QRS complex is slanted and not vertical

Answer 80

``` headaches cutaneous flushing light headedness hypotension reflex tachycardia ``` avoid in patients with HOCM, RV infarction, and who are also on phosphodiesterase inhibitors (synergistic affect)

Answer 81

idiopathic infiltrative disease caused (amyloidosis, sarcoidosis, hemochromatosis) radiation fibrosis endomyocardial fibrosis The infiltrative causes lead to significant ventricular hypertrophy ``` cardiac amyloidosis [amorphous and acellular pink material=amyloid... congo red stain shows apple green birefringence under polarized light microscopy] results from abnormal extracellular deposition of insoluble proteins such as: monoclonal light chains (AL amyloidosis) mutated transthyretin (familial ATTR amyloidosis) wild type transthyretin (senile systemic amyloidosis) ```

Answer 82

cardiac myxomas are the most common primary cardiac neoplasm with 80% being in the LA symptoms= syncope and heart failure histo= numerous bland stellate cells in a background of myxoid ground substance

Answer 83

presents with restrictive or dilated cardiomyopathy along with conduction defects and arrythmias (can cause sudden death) histo= non caseating granulomas with giant cells

Answer 84

trypanosoma cruzi infection causes myopericarditis and cardiomyopathy in Latin America histo= multiple parasitic protozoa within the myocardial fibers with dense cellular infiltrate and myofiber destruction

Answer 85

excessive iron deposits in the myocardium causing conduction abnormalities and restrictive or dilated cardiomyopathy histo= excessive iron deposition in the myocardium confirmed with prussian blue stain

Answer 86

during diastole (diastole duration shortened during increased HR) thus during exercise, diastole time decreases and becomes the major limiting factor for coronary blood supply normally during exercise, flow mediated dilation and vasodilators (adenosine and NO) ensure adequate coronary blood supply

Answer 87

true mitral valve: anterolateral papillary muscle= dual blood supply from LAD and left circumflex posteromedial papillary muscle= blood supply from only the posterior descending artery (from right coronary artery in right dominant circulation or left circumflex in left dominant circulation)

Answer 88

Block sodium channels (by binding to open or inactivated sodium channels) to decrease the slope of phase 0 upstroke.... slowing the upstroke slows conduction of the AP through the tissue (this widens the QRS... QRS widens more with faster heart rates due to the use dependence) "use dependence" this drug affects tissues with greater depolarization activity more

Answer 89

``` 1A (1. quinidine-prom queen, causes cinchonism [tinnitus, HA, dizz] and thrombocytopenia 2. procainamide-prom king, lupus like syndrome [ANA ab increased] 3. disopiramide-"disappears", negative ionotrope)... also block k+ channels to prolong refractory period... use for WPW syndrome (SVT)... class 1A causes QT prolongation (precipitates torsades due to the K+ blocking) ``` 1B (1. lidocaine- "LIED", 2. phenytoin- "friendly towing", anti-epileptic drug with some 1B properties 3. mexiletine- mexican flag)... shorted phase 3 repolarization by blocking sodium channels during depolarization= shorten AP duration... more selective for tissues with sodium channels (ventricles and purkinje system rather than the atria because they have longer APs)= thus they treat ventricular arrhythmias (esp ischemic tissue)... most common ADRs of 1B= neuro [parasthesias, tremor, convulsions] 1C (1. flecainide- corn flakes, 2. propafenone- purple phone)... No affect on k+ (no affect on AP duration)... good for atrial and ventricular arrhythmias... great for afib... because of pro-arrhythmic affects, 1C is contraindicated in patients with structural heart problems or ischemic heart disease Sodium channel binding strength(use dependence): 1C (strongest use dependence and slowest dissociation)> 1A>1B (least use dependence

Answer 90

Troponin I rises 2-4 hours after infarction peaks at 24 hours normal by 7-10 days

Answer 91

CK-MB rises 4-6 hours after infarction peaks at 24 hours normal by 72 hours

Answer 92

Aspirin/heparin supplemental O2 nitrates beta blocker (prevent arrhythmia and decrease oxygen demand) ACEI (prevent increase in LV volume/dilation)

Answer 93

Contraction band necrosis (from calcium returning to cells upon reperfusion and causing contraction) Reperfusion injury (via oxygen free radicals)

Answer 94

MI Coagulative necrosis [dark discoloration] 1 day inflammation (neutrophils then macrophages) [yellow pallor] 1 week granulation tissue [red border emerges as GT enters from edge of infarct] 1 month scar [white scar]

Answer 95

MI -cardiogenic shock (massive infarction), CHF, arrhythmias Coagulative necrosis -arrhythmia 1 day inflammation (neutrophils then macrophages) - fibrinous pericarditis (chest pain with friction rub) - rupture of ventricular free wall (tamponade) or interventricular septum (shunt) or papillary muscle (mitral insuff) 1 week granulation tissue 1 month scar (type 1 collagen) -aneurysm, mural thrombosis, Dressler syndrome

Answer 96

after an acute MI (when a scar forms after about a month) theoretically what happens is during damage antigens are released and you get antibodies made to your own pericardium (pericarditis)

Answer 97

ASD (ostium primum type)

Answer 98

PDA asymptomatic at birth but later in life its a holosystolic MACHINE like murmur in eisenmenger syndrome you can get lower extremity cyanosis because the connection occurs after the major branches of the aorta Prostaglandin E keeeeeeps the PDA open, thus tx= indomethacin(inhibits PGE)

Answer 99

Tetrology of fallot

Answer 100

transposition of the great arteries treat with prostaglandin E to keeeeep the PDA open

Answer 101

Turner's syndrome infantile form, also associated with a PDA coarctation is between the arch and PDA (lower extremity cyanosis)

Answer 102

bicuspid aortic valve No PDA coarctation is distal to the aortic arch (thus HTN in BUE and weak pulses in BLE)... shows up as notching of the ribs on CXR because the collateral vessels form across the intercostals and they get engorged

Answer 103

antibodies to M protein resemble human tissue

Answer 104

What you need to diagnose ARF prior GAS infection (ASO or anti DNase B titer) minor criteria (fever, elevated ESR) ``` Major criteria: J (joints- migratory polyarthritis) O (heart problems- draw O like a heart... pancarditis: endocarditis, myocarditis, pancarditis) N (nodules- subcutaneous) E (erythema marginatum) S (sydenham chorea) ``` Heart=pancarditis leaving vegetations and damaging mitral valve (+/- aortic valve), anschoff bodies in myocardium with anitschkol cells (myocarditis is what kills patients) friction rub from pericarditis

Answer 105

relapse of the acute phase over and over by repeat exposures to GAS you get chronic rheumatic valve disease mitral stenosis +/- aortic stenosis (fusion of the commissures= "fish mouth appearance") complication is endocarditis

Answer 106

systolic ejection click followed by a crescendo-decrescendo murmur

Answer 107

tertiary syphilis infection Aortic regurg= early blowing diastolic murmur... they get "hyperdynamic circulation"= bounding pulses, pulsatile nail beds, and head bobbing (due to widened pulse pressure)

Answer 108

LV dilation | basically hypertrophy of one part of the ventricle not the entire concentric ventricle

Answer 109

MVP the click sound is like a parachute opening due to pressure usually asymptomatic but if severe then replace the valve

Answer 110

hemosiderin laden macrophages

Answer 111

strep viridans = IE in previously damaged valves s/p dental procedures staph aureus = IE of tricuspid valve in IV drug users staph epidermidis= IE of prosthetic valves strep bovis= IE in patients with underling colon cancer ``` IE with negative blood cultures= HACEK organisms (theyre difficult to grow) Hemophilus Actinobacillus Cardiobacterium Eikenella Kingella ```

Answer 112

with IE you can get vegetations that break off and become septic emboli consequences of septic emboli: Janeway lesions (non tender red lesions on palms and soles) Osler nodes (painful lesions on fingers and toes) splinter hemorrhages of the nail beds

Answer 113

Sterile vegetations on both sides of the mitral valve associated with SLE results in mitral regurg

Answer 114

``` #1= idiopathic genetic mutation myocarditis (coxsackies virus) alcohol abuse drugs (doxorubicin, cocaine) pregnancy ```

Answer 115

genetic mutation in sarcomere proteins AD histo= myocyte dysarray

Answer 116

``` Amyloidosis sarcoidosis (granulomas) hemochromatosis (iron) endocardial fibroelastosis (children) Loeffler syndrome (eosinophil infiltration of the heart leads to fibrosis of the endocardium and myocardium) ``` EKG= low voltage EKG with diminished QRS amplitude

Answer 117

benign cardiac tumor made of mesenchymal proliferation with a gelatinous appearance histo= abundant ground substance most common primary cardiac tumor in adults in LA as pedunculated mass... blocks mitral valve and causes syncope

Answer 118

benign cardiac tumor (hamartoma) of cardiac muscle Most common primary cardiac tumor in children, associated with tuberous sclerosis ventricular tumor

Answer 119

breast lung skin lymphoma goes to pericardium and causes a pericardial effusion

Answer 120

Vitamin B's are water soluble 1= thiamine decarboxylation of alpha keto acids (carb metabolism) (beriberi- periph neuropathy and HF..... wernicke korsakoff syndrome) 2= riboflavin mitochondrial electron carrier (FMN, FAD) (angular cheilosis, stomatitis, glossitis... anemia) 3= niacin electron transfer reactions (NAD/NADP) (Pellagra-dermatitis, dementia, diarrhea the three "D"s.... peripheral neuropathy) 6=pyridoxine transamination of amino acids (AA synthesis) (cheilosis, stomatitis, glossitis) 9= folate/folic acid hydroxymethyl/formyl carrier (purine and thymine synthesis) (megaloblastic anemia... neural tube defects) 12= cobalamin isomerase and methyltransferase cofactor (DNA and methionine synthesis) (megaloblastic anemia.... neurologic deficits)

Answer 121

Beriberi (infantile vs adult) (dry vs wet) ``` infantile= 2-3 m old with cardiac symptoms, cyanosis, SOB, vomiting adult= dry or wet dry= peripheral neuropathy (sensory and motor) wet= peripheral neuropathy + cardiac symptoms (CHF symptoms) ``` ``` Wernicke korsakoff syndrome (CNS problems in alcoholics) confusion ataxia oculomotor eye movement issues permanent memory deficits ```

Answer 122

vit C (ascorbic acid) def petechial hemorrhages gingival swelling impaired wound healing weak immune response rash at the base of hair follicles

Answer 123

dry scaling and fissuring of the mouth at the lips and corners Characteristic of riboflavin def (B2) or pyridoxine def (B6) B2 also has anemia

Answer 124

Class 1 (procainamide, flecainide, lidocaine) work on phase 0- rapid depolarizaiton Class IV drugs, aka CCBs (verapamil, diltiazem... nondihydropyridines) work on phase 2-plateau phase (L-type calcium channels)... negative inotropes Class III (amiodarone, sotalol, dofetilide) work on phase 3- late repolarization by potassium... prolong repolarization/AP duration/CT interval and maintain sinus rhythm in paroxysmal afib

Answer 125

Its another name for hereditary hemorrhagic telangiectasia (pink spider like lesions to the skin and mucosal membranes....rupture of which cause bleeding) AD affects lips, nose, oral, resp, GI, GU (rarely brain, liver, spleen)

Answer 126

same thing as neurofibromatosis type 1 inherited peripheral nervous system tumor syndrome they get neurofibromas, optic nerve gliomas, lisch nodules (pigmented nodules of the iris), and cafe au lait spots

Answer 127

AD nervous system tumor syndrome bilateral cranial nerve 8 schwannomas and multiple meningiomas

Answer 128

encephalotrigeminal angiomatosis rare congenital neurocutaneous disorder with cutaneous facial angiomas and leptomeningeal angiomas mental retardation, seizures, hemiplegia, skull radiopacities with characteristic "tram track" calcifications

Answer 129

rare AD condition of tumors and cysts capillary hemangioblastomas (retina or cerebellum), cysts or cancers in the kidney, liver, and pancreas at risk for bilateral renal cancer

Answer 130

AD tumor syndrome with cutaneous angiofibromas (adenoma sebaceum), visceral cysts, and hamartomas also get renal angiomyolipomas and cardiac rhabdomyomas complications include seizures cysts to kidney, liver, and pancreas CNS hamartoma

Answer 131

high systolic BP and normal diastolic BP seen in patients above 60 yo and is responsible for 60-80% of HTN in the elderly systolic BP >140 is an important modifiable risk factor for stroke and heart disease ISH is due to increased arterial stiffness, aka decreased compliance of arteries (including the aorta) associated with aging (also associated with endothelial dysfunction, decreased elastin, and increased collagen deposition) other causes of ISH are increase in CO due to severe aortic regurg or other causes (anemia, hyperthyroidism)

Answer 132

in would activate RAAS the increased volume and intreased TPR would elevate both systolic and diastolic BP

Answer 133

cardiac pressure volume loops represent the left ventricle AV shunts increase cardiac preload (because they bring blood back to the venous system faster) AV shunts also decrease afterload (because the blood bypasses arterioles and thus lowers total peripheral resistance) AV shunts: increase preload decrease afterload (preload= right most vertical line... afterload= top most horizontal line) high volume AV shunts can eventually cause high output cardiac failure

Answer 134

elevated right sided heart pressure secondary to pulmonary HTN most heart venous drainage transverses the coronary sinus to the right atrium... it communicates freely with the RA and thus anything that dilates the RA will dilate the coronary sinus other causes= anomalous venous drainage into the CS and anomalous pulmonary venous return (pericardial effusion would cause an extrinsic compression of the CS)

Answer 135

Fastest conduction velocity: Purkinje system> Atrial muscle> Ventricular muscle> AV node (slowest) mnemonic: Park At Venture AVenue impulse goes from SA node--> atrial myocardium-->AV node (slowest...delay allows for ventricles to fill during diastole)---> His purkinje system (fastest to ensure that ventricles contract in the bottom up fashion)---> ventricular myocardium

Answer 136

Nitrates treat the chest pain of chronic stable angina Nitrates exert their effects by direct smooth muscle relaxation resulting in: vasodilation (vein>arteries) *decreased preload (by decreasing LV end diastolic volume) modestly decreased afterload mild coronary artery dilation and reduction of vasospasm *decreased myocardial oxygen demand

Answer 137

beta blockers and non dihydropyridine CCBs

Answer 138

1. elevated capillary hydrostatic pressure 2. decreased plasma oncotic pressure 3. sodium and water retention 4. lymphatic obstruction (moderate increases in interstitial fluid accumulation can be offset by a compensatory increase in lymphatic drainage)... edema really only occurs when the capacity to reabsorp gets overwhelmed

Answer 139

a bicuspid aortic valve harsh crescendo decrescendo systolic ejection murmur best heard in the right second intercostal space with radiation to the carotids

Answer 140

an echocardiography with a "bubble study" to identify right to left intracardiac shunts associated with a patent foramen ovale (PFO) or an ASD PFO= incomplete fusion of the atrial septum primum and secundum (normal fusion is induced with umbilical cord clamping and decreased pulmonary vascular resistance which lowers RA pressure and increases LA pressure) incomplete fusion in 25% of normal adults right to left shunt (with a clot) can occur with valsalva release which raise RA pressure above LA pressure PFOs are much more common than ASD

Answer 141

thrombus extraction followed by a rapid surge of serum creatine kinase (due to cell membrane damage) the cells within the damaged tissue paradoxically die at an accelerated pace through apoptosis or necrosis after resumption of blood flow mechanisms of reperfusion injury: 1. oxygen free radical generation 2. severe irreversible mitoch damage ("mitoch permeability transition") 3. inflammation attracting neutrophils that cause damage 4. complement pathway activation * creatine kinase gets into circulation when the cells are injured

Answer 142

false glutathione peroxidase reduces cellular injury by catalyzing free radical breakdown acetaminophen overdose liver toxicity is when glutathione peroxidase gets overwhelmed

Answer 143

strep viridans associated with dental caries DEntal... DExtrans

Answer 144

GAS pyogens

Answer 145

a nonselective beta agonist increases cardiac contractility (positive inotrope)= beta 1 decreases vascular resistance and arterial blood pressure (due to vasodilation)

Answer 146

binds M2 in the heart (lowers HR, slows conduction velocity) M3 in the vasculature (vasodilation indirectly via NO)

Answer 147

activates potassium channels increasing potassium conductance (leads to transient conduction delay through the AV node) also causes peripheral vasodilation and decreases contractility

Answer 148

alpha 2 agonist in the brainstem leads to decreased SNS outflow leads to decreased peripheral resistance, decreased HR, and decreased BP

Answer 149

beta 1 blocker negative inotrope negative chronotrope

Answer 150

alpha 1 agonist with mild beta 1 agonist properties thus vasoconstriction and increased contractility

Answer 151

sympathomimetic drug with pure alpha agonist activity vasoconstriction

Answer 152

(amlodipine, nifedipine) effective anti HTN monotherapy ADRs= peripheral edema flushing dizziness headache peripheral edema= preferential dilation of arterioles (increases hydrostatic pressure and fluid extravasation) ACEI and ARBs block RAAS which leads to venodilation and can normalize the increased hydrostatic pressure caused by the CCB

Answer 153

alpha 1= vasc sm m contraction, mydriasis (pupil dilation), increased internal urethral sphincter tone and prostate contraction increase in BP with reflexive (delayed) decreased HR (baroreceptor stimulation increasing PNS on heart and PNS inhibits SA node activity to slow conduction through AV node to decrease contractility)= alpha 1 agonist (phenylephrine, methoxamine) alpha2= CNS mediated decrease in BP, decreased IOP, decreased lipolysis, decreased norepi release, increased platelet aggregation

Answer 154

the abnormal shape causes increased hemodynamic stress which accelerates normal aging and causes premature atherosclerosis and calcification of the aortic valve The deposits accumulate as early as adolescence and lead to aortic stenosis in >50% patients (symptoms on average begin around 50 yo....10 years premature)

Answer 155

significant stenosis of the subclavian artery before branching into the vertebral artery... subclavian stenosis is due to atherosclerosis #1 (also takayasu arteritis and complications of heart surgery) the low pressure on the other side of the stenosis causing blood to flow from the vertebral to the subclavian (and "stealing" blood from the other vertebral artery (and thus away from the brainstem) ``` symptoms: asymptomatic arm ischemia vertebrobasilar insufficiency (dizz, vertigo, drop attacks) signif BP difference between arms ```

Answer 156

Similar to subclavian steal syndrome except that its in patients with hx of CABG using the internal mammary artery blood flow through the IMA can reverse and steal from the coronary circulation during increased demand Symptoms would reflect coronary ischemia

Answer 157

in the inter-atrial septum near the opening of the coronary sinus on the endocardial surface of the RA near the insertion of the septal leaflet of the tricuspid valve and the orifice of the coronary sinus (sort of the wall between the atria, near the bottom and somewhat posterior)

Answer 158

upper anterior right atrium at the opening of the superior vena cava

Answer 159

``` mediators: acetylcholine bradykinin serotonin substance P shear stress forces ``` these activate receptors on endothelial cells that increase cytosolic calcium which activates the conversion: arginine + NADPH +O2-----(eNOS)---->NO + citrulline NO diffuses into adjacent smooth muscle cells and increases guanylyl cyclase> increase cGMP> protein kinase G> reduction in cytosolic calcium> relaxation of vascular smooth muscle

Answer 160

emergency also shows signs of end organ damage ``` ACS encephalopathy pulmonary edema AKI brain hemorrhage aortic dissection eye problems ```

Answer 161

short acting, selective, peripheral dopamine 1 agonist (no effect to alpha or beta receptors) DA1 stimulation increases adenylyl cyclase which increases cAMP ----> vasodilation of most arteries (leading to decrease in systemic BP) vasodilation is prominent in the kidney for fenoldopam which increases renal perfusion and natriuresis (helpful for HTN emergency with AKI)

Answer 162

hydralazine is a direct arteriolar vasodilator with no effect on kidney perfusion/natriuresis not used in HTN emergency because it is associated with reflex SNS activation (which increases HR and contractility and causes sodium/water retention)

Answer 163

main infections come from patient's skin or health care worker's hands (gram positive cocci infect most... staph aureus and coag neg staph) CDC recommends: 1. hand hygiene with alcohol sanitizer or soap prior to sterile gloves 2. barrier precautions (including surgical drape) 3, prepare insertion site with chlorhexidine antiseptic 4. use subclavian or internal jugular (femoral vein infected more often) 5. promp removal when not needed

Answer 164

about 60 seconds of total myocardial ischemia (aerobic glycolysis becomes anaerobic within seconds, not enough ATP is made and depletion is rapid, and lactate builds up) when ischemia lasts less than 30 minutes, loss of contractility ("myocardial stunning") is reversible (returning to normal over hours to days) during the hypoxia, ATP -->-->-->adenosine which vasodilates to meed myocardial demand (but adenosine gets depleted, cellular homeostasis fails, and ischemic injury becomes permanent)

Answer 165

continuous murmur heard best in the left infraclavicular region with maximal intensity at S2 PDA most often seen in premature babies and cyanotic congenital heart disease

Answer 166

Beta blockers (carvedilol, metoprolol) because it improves survival in patients with HF due to LV systolic dysfunction, it also decreases myocardial oxygen demand by reducing contractility and slowing ventricular rate... it also decreases afterload improves survival due to limiting cardiac remodeling only use Beta Blockers after the patient is stabilized otherwise it could impair CO other drugs that improve long term survival in HF patients: ACEI ARBs Aldosterone antagonists (spironolactone, eplerenone)

Answer 167

Vancomycin normally works by binding "D-ala-D-ala" terminals in the bacterial cell wall and preventing the formation of peptidoglycan (inhibits the second stage of cell wall synthesis) resistance to vanco occurs when the cell wall precursor proteins change their cell wall structure from "D-ala-D-ala" into "D-ala-D-lactate" so it screws up the vancomycin's binding site

Answer 168

1. beta lactamases (penicillinase) are made by the bug and used to destroy the penicillin's beta lactam ring making the drug ineffective (cephalosporins, carbapenems, and penicillinase resistant penicillins like nafcillin and methicillin are not susceptible to the actions of penicillinase) 2. some bugs have modified penicillin binding proteins in their peptidoglycan cell walls which don't allow beta lactam antibiotics to bind and work (this is MRSA's resistance mechanism)

Answer 169

bacterial cell wall synthesis inhibitor rarely ever used because its super ototoxic cycloserine inhibits the incorportation of D-ala into the UDP-MUrNAc-oligopeptide during cell wall synthesis

Answer 170

polymyxin binds to the cytoplasmic membrane and disrupts it/interfering with the permeability of the membrane

Answer 171

inhibits protein synthesis by binding the 30S subunit and inhibiting binding of aminoacyl-tRNAs

Answer 172

increased efflux of the drug from within the bacterial cell via active-efflux pump or by production of a protein that allows translation to take place even when tetracycline is present within the bacterium

Answer 173

amikacin is an aminoglycoside aminoglycosides inhibit the 30S subunit preventing bacterial protein synthesis

Answer 174

by inactivation through aminoglycoside modifying enzymes these enzymes are largely plasmid encoded and serve to phosphorylate, adenylate, or acetylate the abx and thus lead to decreased ability of the abx to bind the ribosomal subunits pseudomonas are resistant to aminoglycosides by decreasing their entry into the bacterium

Answer 175

They have similar intracellular signaling Atrial and Brain natriuretic peptides (ANP and BNP) bind ANP receptors which are linked to guanylyl cyclase---> increase CGMP---> vasodilation NO activates the same cGMP as the guanylyl cyclase from ANP and BNP Penile erection is initiated by Ach and NO from PNS leading to increase cGMP and vasodilation of arteries supplying the corpus cavernosum sildenafil is a phosphodiesterase 5 inhibitor that stops degredation of cGMP thus enhancing the effect of PNS activation on erectile tissues

Answer 176

because nitrates (nitroglycerin, isosorbide mononitrate) work by releasing NO and sildenafil prevents cGMP degredation (which is the next step beyond NO release) you can get excessive cGMP induced vasodilation and severe hypotension

Answer 177

LQT type 1 and LQT type 2 (due to genetic mutations in k+ channel proteins that contribute to the outward rectifying potassium current) decreased outward potassium causes prolonged refractory period, prolonged AP duration, and prolonged QT ``` complications= torsades (ventricular arrhythmia) palpitations syncope seizures sudden cardiac death ```

Answer 178

left sided heart failure

Answer 179

failure of endocardial cushion fusion results in an ostium primum ASD, a VSD, and a single AV valve (this leads to left to right shunt, AV valve regurg, excess pulmonary blood flow, and HF symptoms)... AV valve regurg= holosystolic murmur best heard at the apex... increased pulm blood flow= mid diastolic rumble most common cardiac defect in down syndrome (autosomal trisomy)

Answer 180

DiGeorge syndrome (thymic aplasia, T cell def, hypoparathyroidism, hypocalcemia) associated with TOF, truncus arteriosus, and transposition of the great arteries

Answer 181

marfan= fibrillin 1 mut associated with cystic medial necrosis of the aorta (resulting in aortic dissection and aortic valve regurg) also can cause MVP

Answer 182

friedreich ataxia= mut in frataxin, a mitochondrial protein important for iron homeostasis and resp function characterized by spinocerebellar degeneration associated with HOCM

Answer 183

tuberous sclerosis= mut in tuberin and hamartin develop cardiac rhambdomyomas in the heart they also get cutaneous angiofibromas, CNS hamartomas, and renal cysts

Answer 184

bicuspid aortic valve and coarctation of the aorta

Answer 185

class IV anti arrhythmics (NDHP CCBs) block L type calcium channels in cardiac slow response tissues which cause slowing of phase 4 spontaneous depolarization phase 4 slanted slower upstroke is controlled by sodium (funny current) and calcium (T type and L type)

Answer 186

afterload decreased preload increased LV EF increased (frank starling says that an increased preload and a decreased afterload result in an increased ejection fraction)... but much of the stroke volume is lost to regurg meaning a reduced cardiac output and thus cardiogenic shock Frank Starling: contractility is directly proportional to end diastolic volume (preload)... increase preload and or decrease afterload= increase contractility (which increases ejection fraction)

Answer 187

A= involves ascending aorta B= only the descending aorta brachial BP discrepancy suggests compromise of the brachiocephalic trunck on the arm with the lower BP risk factors= HTN (medial hypertrophy of aortic vasa vasorum and reduced blood flow to the media... leads to degeneration, dilation and stiffness, increased wall stress, and ultimately an intimal tear and dissection

Answer 188

medial calcific sclerosis a form of arteriosclerosis characterized by calcium deposits in the medial layer of muscular arteries.... may cause ISH due to arterial hardening clinically asymptomatic and insignificant (think mammograms)

Answer 189

causes a form of aortitis characterized by obliterative endarteritis of the vasa vasorum (this as well as aortitis with medial inflammation from autoimmune conditions like takayasu and giant cell arteritis) cause weakening of the aortic wall and predispose aortic aneurysm>>dissection

Answer 190

aspirin decreases the risk of adverse CV events irreversible COX1 inhibition prevents synthesis of TXA2 (a potent stimulator of platelet aggregation and vasoconstriction) ADRs= aspirin can exac pre existing resp symptoms or cause allergic reactions next best drug is clopidogrel (an irreversible P2Y 12 blocker) which blocks part of the ADP receptor on the platelet surface so that the platelet cannot aggregate clopidogrel is as effective as aspirin for prevention of CV events

Answer 191

apixaban is a direct factor Xa inhibitor that prevents platelet activation and fibrin clot formation warfarin inhibits an enzyme needed to synthesize active vitamin K which will reduce synthesis of vit K dependent clotting factors (2,7,9,10) both apixaban and warfarin are used to prevent or treat thromboembolic events (not CAD)

Answer 192

a phosphodiesterase inhibitor that is occasionally used in patient's with symptomatic PVD (ex= claudication)

Answer 193

indirect thrombin inhibitors that bind with antithrombin and convert it from a slow to rapid inactivator of thrombin and factor Xa used for patients with ACS (unstable angina or MI)... not for stable angina

Answer 194

its a platelet glycoprotein 2b3a inhibitor that inhibits the final common pathway of platelet aggregation occasionally used in ACS patients but not stable heart disease

Answer 195

NSAID used for pain management with osteoarthritis use of nonselective and selective COX2 NSAIDS increases the risk for adverse CV events

Answer 196

fibrates and nicotinic acid therapy

Answer 197

the reduced cardiac output is detected as an initial drop in BP which triggers a compensatory neurohumoral stimulation directed at maintaining BP and tissue perfusion ``` compensatory response: increased SNS stimulation of RAAS release of antidiuretic hormone (improve CO and contractility, increase fluid, and vasoconstrict) ``` the increased afterload= exac HF, fluid retention, poor renal perfusion RAAS= edema, pulm congestion (CHF) deleterious cardiac remodeling

Answer 198

Brain natriuretic peptide released by ventricles in response to stretching (volume overload) helps to diagnose CHF exacerbation ``` (like ANP) it causes: vasodilation natriuresis decrease in BP (to alleviate the symptoms of HF) ```

Answer 199

yes always (unlike S3) auditory question of an S4 heart sound in a 65 yo man with long history of HTN, DM2, and ex-smoker (otherwise he exervises and has normal BMI)... heart sound heard at the apex s4= left ventricular hypertrophy or restrictive cardiomyopathy

Answer 200

onion like concetric thickening of arteriolar walls = "hyperplastic arteriolosclerosis" due to laminated smooth muscle cells and reduplicated basement membranes this can lead to renal arteriolar stenosis and activation of RAAS worsening the vicious cycle patients can also have hypertensive encephalopathy (HA, irritable, ALOC, CNS dysfunction)

Answer 201

more oxygen in pulmonary artery because the heart is so great at extracting oxygen from the blood (better than any other organ in the body), the cardiac's veins have the least oxygen of any blood in the body (more than systemic venous blood) because pulmonary artery has a mixture of coronary sinus venous blood and systemic venous blood it thus has more oxygen

Answer 202

amiodarone (class 3 anti arrhythmic)... the one with properties off all the four classes the low incidence of torsades is due to a more homogeneous effect on vantricular repolarization compared to the other drugs

Answer 203

AT BASELINE: the PR interval (not just the P wave alone)... pre excitation=short PR interval with an early upslope of the QRS "delta wave", and a wide QRS this 21 year old male probably has WPW syndrome (pre excitation syndrome and the most common re entry circuit responsible for recurrent paroxysmal narrow QRS atrial tachycardia... when being affected QRS narrows) the accessory conduction pathway= bundle of kent

Answer 204

elderly men who recently underwent cystoscopy (GU) or colonoscopy or obstetric procedure Enterococci cause UTI (#1), intra abdominal and pelvic infections, and wound infections gamma hemolytic (aka no hemolysis on agar) catalase negative (formerly a strep species) pyrrolidonyl arylamidase positive Lancefield group D gram positive cocci grow in HYPERTONIC 6.5% SALINE AND BILE enterococcus faecalis (80-90%) and enterococcus faecium (10-15%) super hard to treat because resistant to lots of abx tx= ampicillin (cell wall active agent) and an aminoglycoside

Answer 205

small saclike structure in the LA that is particularly susceptible to thrombus formation

Answer 206

when one hormone allows another to exert its maximal effect ex= norepi alone produces a limited degree of vasocontriction but when pretreated with cortisol (which has no vasoactive effect alone), norepi vasocontriction was markedly increased here, cortisol was upregulating alpha 1 receptors on vasc smooth muscle cells (it makes sense then that low cortisol levels seen in adrenal insuff will contribute to hypotensive crisis by decreasing vasc responsiveness to angiotensin 2 and norepi)

Answer 207

combining two drugs with similar action additive= sum of two individual drugs effects synergistic= when the combined effects exceeds the sum of the individual drugs

Answer 208

helps improve response to a variety of stressors cortisol increases vasc and bronchial smooth muscle reactivity to catecholamines cortisol increases glucose release by the liver in response to glucagon

Answer 209

the decreased drug responsiveness in a short period following one or more doses (aka rapidly developing tolerance)

Answer 210

bicuspid aortic valve the aortic valve opens and the LV pressure continues to rise in the beginning of systole with forward blood into the aorta

Answer 211

sotalol (beta blocking properties too) amiodarone dofetilide

Answer 212

jaw claudication headache facial pain vision loss biopsy= granulomatous inflammation of the media (also seen in takayasu arteritis which affects the aortic arch and sometimes its branches, this is in young females less than 40 yo) patients 50 yo+

Answer 213

characterized by segmental fibrinoud necrosis of the small vessels microscopic polyangiitis microscopic polyarteritis hypersensitivity vasculitis

Answer 214

segmental transmural necrotizing inflammation of medium to small sized arteries necrotic tissue and deposits of immune complexes, complement, and plasma proteins cause a fibrinoid necrosis (consistent with immune complex vasculitis)

Answer 215

thrombosing vasculitis of medium and small sized arteries (principally the tibial and radial arteries) commonly seen in heavy cigarette smokers with onset before age 35 the smoking disease in young people that causes auto amputation of fingers and toes

Answer 216

thrombosing vasculitis of medium and small sized arteries (principally the tibial and radial arteries) commonly seen in heavy cigarette smokers with onset before age 35 the smoking disease in young people that causes auto amputation of fingers and toes

Answer 217

Marfan syndrome which is associated with aortic aneurysms and dissections myxomatous changes= pathologic weakening of connective tissue (found in cystic medial degeneration= basket weave pattern of elastic tissue) marfan syndrome is a frequent cause of cystic medial degeneration in young patients. its AD defect in extracellular glycoprotein fibrillin1 (which helps form scaffolding for elastic fibers) beta aminopropionitrile (a chemical found in sweet peas) causes inhibition of lysyl oxidase (which cross links elastin and collagens) and can cause changes in the elasticity of the aorta that mimics the myxomatous degeneration seen in marfans syndrome

Answer 218

AR congenital long QT syndrome with cong sensorineural deafness too

Answer 219

increased SNS and RAAS (low BP detected by the baroreceptor firing (picked up by the medullary vasomotor center) and by the JGA detecting low renal perfusion)

Answer 220

lyme disease

Answer 221

released from a stretched atria telling kidneys to pee out volume and relax vasculature cause its overwhelmed

Answer 222

ACEI/ARB= blocking the RAAS pathway would cause a feedback increase in serum renin levels Diuretic= induced hypovolemia decreases renal blood flow which increases renin and activates RAAS low sodium intake woud also increase renin SNS blockers (beta blockers and clonidine)= reduce renin levels primary hyper-aldo= would suppress renin production and cause low serum renin levels plasma renin activity measures the amount of angiotensin 1 generated per time (assesses RAAS)

Answer 223

an axial CT of the abdomen near L1 shows that the IVC lies anterior (in front of) the right renal artery (and also anterior to the aorta) the IVC is formed by the union of the right and left common iliac veins at L4-L5 and drains into the right atrium at the level above the diaphrage T8

Answer 224

venous clot heads to the brain when there is a PFO, ASD, VSD, or large pulmonary arteriovenous malformation murmur= left to right shunting causing a wide and fixed S2 splitting ASD can also sound like a [mid systolic ejection] murmur over the left upper sternal border due to increased flow across the[pulmonic valve] and a mid diastolic [rumble] due to increased flow across the [tricuspid valve] you can have transient reversal of the left to right shunt during high right sided pressure (aka early systole, straining, coughing, or pooping)

Answer 225

aortic regurg amyl nitrit causes vasodilation (reduces systemic BP thus reduces regurg flow)

Answer 226

mitral or tricuspid stenosis= diastolic murmur with presystolic (aka late diastolic) accentuation due to atrial contraction in mild stenosis the murmur may only be heard during the accentuation phase in late diastole afib can cause the murmur to disappear completely

Answer 227

earlier because there is reduced LV volume with inspiration because there is less blood returning to the left heart (during inspiration blood rushes to the lungs to be oxygenated and thus away from the heart)

Answer 228

funny sodium channels during phase 4 (pacemaker cells) ``` heart rate drugs: beta blockers non dihydropyridine CCBs digoxin ivabradine ``` ivabradine is the only one that slows heart rate (negative chronotrope) without inotropic or lusitropic (relaxing) effect ivabradine= inhibits funny sodium channels to slow SA node firing thus prolonging the slow depolarization phase (4)... used in certain HFrEF patients with persistent symptoms despite appropriate medications it reduces risk of hospitalization due to HF ``` class 1 antiarrhythmics slow conduction velocity but dont signif alter HR class 3 antiarrhythmics dont have a role for management of CHF ```

Answer 229

the left lung although the right ventricle is the most anterior, the stab wound being on the vertical nipple line would injure the cardiac apex most likely which is made of the left ventricle the heart is behind the sternum and is anteriorly covered by the lungs PMI (point of maximal impulse)= fifth left intercostal space between the fifth and sixth ribs at the left midclavicular line (aka the stab wound aka the apex of the heart)

Answer 230

``` severe chest pain not relieved with rest or nitroglycerin diaphoresis dyspnea nausea light headedness palpitations ``` peaked T waves (hyperkalemia) then ST elevation (minutes to hours) Q waves hours to days

Answer 231

from top to bottom if the ekg was to draw a line down the middle it goes: lateral inferior anterior/septal lateral lateral= I, aVL, V5, V6 inferior= II, III, aVF anterior/septal= (V3/V4)/ ((V1/V2)

Answer 232

75% at least

Answer 233

LV end diastolic pressure is increased LV end diastolic volume is normal LV EF is normal =problem filling with blood! diastolic HF is a common cause of acute decompensated HF (when it causes pulmonary issues) causes= decreased LV compliance (ischemia) or increased wall stiffness (amyloid deposition, hypertrophy) increased LV end diastolic pressure brings the bottom-most line of the pressure volume loop upwards (to shrink the cycle) the bottom most line represents compliance

Answer 234

cuts off the IVC "supine hypotension syndrome" or "aortocaval compression syndrome" ``` causes hypotension pallor sweating nausea dizziness ``` occurs >20 weeks gestation severe= LOC and fetal demise

Answer 235

natriuretic peptides BNP also protects against the deleterious myocardial remodeling and fibrosis that occurs in HF Neprilysin is a metalloprotease that cleaves and inactivates endogenous peptides including BNP, glucagon, oxytocin, bradykinin (thus inihibiting neprilysin increases endogenous natriuretic peptides and helps in HF)

Answer 236

SVC and RA= 1-6 mmHg RV= 15-30 systole/ 1-6 diastole (same as RA) Pulm artery= 15-30 systole/ 6-12 diastole PCWP aka LA ("PA occlusion pressure")= 6-12 LV= 90-140 systole/6-12 diastole

Answer 237

loud come from small VSDs (asymptomatic patients) soft or absent come from large VSDs (HF in infancy= difficulty feeding, tachypnea, failure to thrive) VSD= harsh holosystolic murmur heard at the left lower sternal border listen to more murmurs online

Answer 238

increases afterload in the VSD it increases the murmur

Answer 239

inspiration= increases blood to right heart and decreases blood to left heart valsalva strain and abrupt standing= decrease preload and afterload (valsalva= trying to force yourself to exhale really hard while your nose and mouth are shut... to increase intrathroacic pressure) squatting= increase preload and afterload passive leg raise= increase preload handgrip= increase afterload

Answer 240

aortic regurg

Answer 241

aortic stenosis

Answer 242

the ligamentum arteriosum

Answer 243

aPTT measures intrinsic (12>11>9) + kininogen/kallikrein PT measures extrinsic (7) + tissue factor final common pathway measured by both (10>prothrombin>thrombin>fibrinogen>fibrin>clot) hemarthroses= bleeding into joint spaces (hemophelia) hemarthroses and excessive bleeding after a tooth extraction are suggestive of a clotting factor def (coagulopathy)... present with deep tissue bleeding into joints, muscles, and sub Q platelet def on the other hand cause mucocutaneous bleeding (nose bleed or petechiae)

Answer 244

factor 8 def isolated prolonged aPTT

Answer 245

factor 11 def rare AR isolated prolonged aPTT

Answer 246

factor 12 AR disorder no clinically signif bleeding despite aPTT prolongation

Answer 247

vWF is both a carrier for F8(protection from degredation) and mediates platelet adhesion to the endothelium prolonged bleeding time prolonged or normal aPTT bleeding time indicates platelet function

Answer 248

L type calcium channels bring calcium into myocytes during depolarization ryanodine receptors in the sarcoplasmic reticulum sense this and spit out a shit ton more calcium intracellularly that shit ton extra calcium from the SR diffuses through myofilaments to bind troponin C this causes tropomyosin to move so actin and bang myosin and contract the muscle the last stage of excitation contraction coupling is myocyte relaxation where calcium leaves the cytoplasm via the sodium calcium exchange (NCX) and calcium ATPase pump called (SERCA) NCX removes 1 ca from inside the cell for every 3 sodium going inside the cell SERCA Ca ATPase actively transfers calcium into the SR by sacrificing ATP

Answer 249

its a calcium binding messenger protein that regulates intracellular calcium activity and transcription factor signalling in smooth muscle cells (aka not heart or skeletal muscle)

Answer 250

myocardial cells increase in size because of intracellular calcium accumulation during ischemia, ATP causes ion pump failure which causes accumulation of sodium and calcium within the cell (net solute GAIN) this draws in free water and causes cellular and mitochondrial swelling

Answer 251

class 1B! (lidocaine) weakest sodium channel blockers and dissociate the fastest of the class 1 (thus the negligible effects on normal tissues) they bind sodium channels in the inactivated state class 1B is great for ischemic induced ventricular arrhythmias because ischemic tissue has a higher resting membrane potential causing delayed recovery from the inactivated state and thus class 1B has increased binding!

Answer 252

-tilide drugs are class 3 anti arrhythmics potassium channel blockers acute termination of a flutter/fin prolongs the QT and predisposes torsades

Answer 253

sudden decrease in LV preload (causing severe hypotension and acute pulmonary edema) thus cardioversion is indicated for acute afib in severe aortic stenosis patients (sudden HF precipitated by acute afib in 10% of AS patients)

Answer 254

remember this looks at the right heart a= Atrial contraction (notably absent in afib patients) c= ventriCular Contraction and bulging of the triCuspid x= atrial relaXation v= Venous blood passively filling the right atrium y= passive emptYing of the RA into the RV before contraction

Answer 255

thickening and calcification of the pericardium (white around the enlarged heart) causes a rapid Y descent (deeper and steeper passive RA emptYing) causes= radiation, cardiac surgery, tuberculosis

Answer 256

mitral stenosis (mid diastolic rumble) causes LA dilation sufficient to impinge on the left recurrent laryngeal nerve (hoarseness) neurapraxia=failure of nerve conduction due to injury (by the LA in this case)

Answer 257

drugs that exhibit strong use dependence (lengthens the QRS duration in a rate dependent manner) ex= flecainide (flakes) ``` class 1C anti arrhythmics (treats atrial tachycardias)... bind fast sodium channels to prolong QRS ``` ``` class 1c are the slowest to dissociate and thus have the strongest use dependence (sodium blocking effects intensify as the HR increases due to less time for medication to dissociate from the receptor).... at high HR they can prolong the QRS (which can be proarrhythmic) ``` class 3 agents show reverse use dependence (slower the HR the more the QT interval is prolonged)

Answer 258

varicocele compression causes retrograde blood flow to the testes and dilation of the pampiniform plexus... compression could also be due to a mass "nutcracker effect" also causes hematuria, flank pain, or abdominal pain (kidney stone presentation ish)

Answer 259

mitral regurg indicator= doppler echocardiograph but easier than that is to look for an S3 (would indicate severe mitral regurg when there is an S3 because that means there is LV volume overload)

Answer 260

1. reduce myocardial contractility and HR 2. decrease renin release by the kidney*** ``` useful for HTN patients with comorbidities like: migraine essential tremor stable angina prior MI afib ``` SNS increases renin via beta 1 receptors on JGA cells, thus beta blockers like metoprolol inhibit renin release

Answer 261

class 1C is one of the only one that widens QRS complexes (because they block sodium channels)... class 1 A a little bit of QRS widening but has significant QT prolongation QRS= ventricle depolarization (aka phase 0 in the cardiac myocyte AP) QT interval= ventricular depolarization and repolarization (total duration of the ventricular AP)... but since depolarization is so rapid, QT interval basically just measure ventricular repolarization 1C= flecainide (flakes) and proafenone (purple phone)...

Answer 262

``` class 3 antiarrhythmics (amiodarone, sotalol, dofetilide) ``` causes QT prolongation

Answer 263

the activated Gs subunit activates adenylyl cylase which turns ATP into cAMP... increased cAMP activates protein kinase A... basically cAMP= contraction or signalling so a beta 1 blocker atenolol will decrease cAMP in the heart (less contractility and signalling), will decrease cAMP in JGA cells (less signalling because renin is blocked and less contraction theoretically if renin is being squeezed out) and will have no effect on vasc smooth muscle cAMP (because there are no beta 1 receptors in the vasc) beta 2 receptors found in vasc and bronchial smooth muscle (propranolol is a beta 1 and 2 blocker)

Answer 264

cAMP (Gs>>>>increased cAMP>>> PKA>>>>contraction/signalling) phosphatidylinositol (Gq>>>PLC>>>degrates membrane lipids into DAG and IP3>>>calcium release from SR)

Answer 265

ACEI can cause first dose hypotension (significant in patients with volume depletion or heart failure... such as those taking diuretics because they have high renin and the ACEI causes abrupt removal of ang2 vasocontriction which results in drop in peripheral vasc tone and precipitous drop in BP) to prevent this, therapy should be started at a low dose and titrated up kidneys arent the answer because creatinine levels are fine

Answer 266

lymphangiosarcoma rare malignant neoplasm of the endothelial lining of lymphatic channels due to chronic dilation of lymphatic channels

Answer 267

macrocytic lymphatic malformation associated with turner syndrome occur in children at the neck or axilla

Answer 268

a port wine stain birthmark with malformed dilated blood vessels in the superficial dermis permanent

Answer 269

hyperplasia or neoplasm of spindle shaped cells (containing markers of smooth muscle and vascular endothelial damage) associated with HIV and immunocompromised states

Answer 270

its a rare malignant vascular endothelial cell cancer associated with carcinogens like: arsenic (pesticides) thorotrast (former radioactive contrast medium) polyvinyl chloride (plastic widely used in industry)

Answer 271

also called a strawberry type hemangioma cutaneous, small, bright red, slightly elevated lesion (here on a baby butt)... benign vasc tumor that over time will first increase in size (in proportion to the child) then regress spontaneously at or before puberty (typically fade 1-3 yo)... 95% gone by 7 yo composed of unencapsulated aggregates of closely packed thin walled capillaries

Answer 272

the interventricular septum and the MITRAL VALVE LEAFLET harsh cresc-decresc systolic murmur at the apex and left sternal border that changes with intensity with maneuvers

Answer 273

in a patient with constrictive pericarditis (due to radiation for example), you would expect JVP to be increased because of the right heart failure... well JVP normally drops during inspiration because blood rushes to the lungs but in kussmauls sign, patients with constrictive pericarditis get a paradoxical rise in JVP because the volume restricted right ventricle cannot accomodate the inspiratory increase in venous return by sending it all to the lungs

Answer 274

mitral regurg at the apex VSD at the left lower sternal border

Answer 275

pulmonary hypertension

Answer 276

S3= reduced wall compliance (maximally dilated) seen in restrictive cardiomyopathy pericardial knock= sharper more accentuate S3 heard earlier in diastole... due to reduced compliance due to an external force (like constrictive pericarditis)

Answer 277

S4-----S1----S2---S3--- | P) (QRS) (before T) (after T

Answer 278

atherosclerosis of larger arteries (lipid filled intimal plaques) pain= ischemia in thigh= external iliac, or common femoral, or superficial femoral, or profunda femoris in penis (ED)= aortoiliac atherosclerosis cuts off blood flow to internal pudendal branches of the internal iliac

Answer 279

Maintenance dose= Cpss x CL/ [bioavailability fraction] Cpss= steady state plasma conc CL= clearance bioav=1 for IV drugs ex= abx is first order kinetics, volume of distribution is 70 L, clearance is 0.5 L/min... how much should be administered every 6 hours to maintain Cpss of 4mg/L? Maintenance dose= 4mg/L x 0.5 L/min= 2mg/min but they asked in 6 hour intervals... 2mg/min x 60 min/hr x 6 hrs= 720 mg

Answer 280

Vd x 0.7/CL Vd= volume of distribution steady state conc or elimination takes 4-5 half lives

Answer 281

Vd x Cpss/ [bioavailability fraction] in patients with kidney or liver disease, the loading dose is the same but the maintenance dose is decreased

Answer 282

segmental vasculitis extending into contiguous veins and nerves Buerger's disease (thromboangiitis obliterans of smokers)... acute and chronic vasculitis of medium and small arteries, mostly the tibial and radial arteries symptoms= distal lower extremity vasc insuff... calf/foot/hand claudication, superficial nodular phlebitis, raynauds, severe distal pain even at rest..... later complications= ulcerations and gangrene toes/feet/fingers presumably a heavy smoker who has thus developed immune hypersensitivity to tobacco smoke heavy cig smokers under 35 is classic patient (often seen in israel, japan, and india) tx= stop smoking

Answer 283

``` lichtenberg figures (erythematous cutaneous marks in a fern leaf pattern) second degree burns ``` lightening injuries are associated with 25% fatality rate.. 2/3rd die in the first hour due to fatal arrhythmias and resp failure (>70% with long lasting complications) fixed and dilated or asymmetric pupils in lightening injury caused by damage to the ANS from the lightening asses for mechanical trauma and fractures due to rapid heating of surrounding air which causes shock waves that travel through and damage the body

Answer 284

ventricular fibrillation Vfib is the most frequent mechanism of sudden cardiac death in the first 48 hours after an acute MI and is related to electrical instability due to the lack of perfusion in the ischemic myocardium

Answer 285

decreased LV chamber size particularly apex to base (shortening of the heart all together it looks like) which causes the septum to acquire a sigmoid shape with the basilar portion bulging into the LVOT atrophy of the myocardium resulting in increased interstitial connective tissue (often with amyloid deposition) in cardiomyocytes there is progressive accumulation of cytoplastmic granules with brown lipfuscin pigment (indigestible byproducts of membrane lipid oxidation) ``` so again in summary: small LV sigmoid septum more connective tissue brown pigment ```

Answer 286

segmental, transmural, necrotizing inflamm to small and medium arteries of any organ renal artery involvement is common PAN spares pulmonary arteries and bronchial arteries (polyarteritis nodosa leaves the lungs alone) bead like aneurysm formation, especially the mesenteric cutaneous sx= livedo redticularis and palpable purpura

Answer 287

hypoxia causes vasoconstriction in the pulm vessels and causes vasodilation in other organs (hypoxia in the lungs occurs in order to divert blood to better oxygenated segments of the lung)

Answer 288

oxygen, adenosine (potent vasodilator), NO

Answer 289

myogenic (stretch induced contraction) and tubuloglomerular (macula densa of JGA cells cause vasoconstriction of the afferent arteriole when it senses too much solutes and water) feedback (maintain GFR at a range of BPs)

Answer 290

lactate (anaerobic states), adenosine (potent vasodiator), potassium (released by contracting muscle and works to increase the amount of blood in vessels when levels are higher)

Answer 291

sympathetic stimulation

Answer 292

NFP= [(capillary pressure-interstitial fluid pressure) - (plasma colloid osmotic pressure-intersitial fluid colloid osmotic pressure)] basically hydrostatic pressure minus oncotic pressure.... then within that, always capillary minus intersitium

Answer 293

Net fluid flow= (Net filtration pressure) x (filtration constant for capillary permeability aka Kf) insults (like toxins, infections, or burns) increase capillary permeability and thus increase the Kf (filtration constant) which causes edema lymph obstruction increases interstitial oncotic pressure pulling water out of capillaries

Answer 294

aortic arch receptors transmit impulses along the vagus nerve to the medulla during high blood pressure (because vagus nerve gives back PNS)

Answer 295

carotid sinus receptors transmit impulses along the glossopharyngeal nerve in response to high and low blood pressures (baroreceptors!)

Answer 296

pH and Pco2 (both influenced by arterial CO2) central chemoreceptors responsible for the cushing reaction (physiological nervous system response to ICP resulting in cushings triad= HTN, resp depression, and bradycardia... due to brain ischemia)... often seen in terminal stages of acute head injury and may indicate herniation

Answer 297

Baroreceptors

Answer 298

peripheral = low PO2 (<60), high PCO2, and low pH..... central = not sensitive to oxygen

Answer 299

the kidney

Answer 300

the descending aorta (with no ascending involvement) specifically they originate close to the origin of the left subclavian artery (just past the bifurcation of those major three branches off of the aortic arch) as a reminder, type A originate in the sinotubular junction these areas specifically because of increased pressure and shearing forces here in patients with severe HTN both types can propagate distally to the thoracic aorta

Answer 301

right sided face and arm swelling engorgement of subcutaneous veins on the right the brachiocephalic vein drains the internal jugular vein an the subclavian vein (both on the same side) both the brachiocephalic veins combine to form the SVC, thus brachiocephalic obstruction causes symptoms of SVC syndrome BUT ONLY ON ONE SIDE of the body SVC obstruction would be the whole face/neck/chest, and both arms

Answer 302

peptide hormones increased when the heart's walls are stretched they increase cGMP... dilate the afferent arteriole and constrict the efferent arteriole.... causes increased GFR and natriuresis/diuresis... they also inhibit renin secretion and sodium reabsorption

Answer 303

in the right atrium near the opening of the SVC (upper left ish area) the AV node on the other hand is in the RA near the septal cusp of the tricuspid valve (lower right ish area)

Answer 304

giving fluid increases volume and preload the increased preload stretches the heart and increases end diastolic sarcomere length according to frank starling, increasing preload causes an increase in stroke volume and cardiac output CO= SV x HR

Answer 305

aortic regurg precordial impulse is hyperdynamic and displaced laterally and downward bounding pulses= wide pulse pressure (increase in total stroke volume with abrupt distension and rapid falloff of peripheral artery pulses) head bobbing= "de Musset sign" due to large LV stroke volume being transfered to the head and neck early diastolic blowing decrescendo murmur

Answer 306

hypokalemia hypomagnesemia ``` drugs: class 1A class 3 abx (macrolides, fluoroquinolones) methadone antipsychotics (haloperidol) ```

Answer 307

vascular smooth muscle cells within the intima are stimulated to synthesize extracellular matrix proteins (including mostly collagen, but also some elastin, and proteoglycans) that form the fibrous cap of typical mature atheromas

Answer 308

(the elephant poster on the wall of the digoxin video) milrinone is a phosphodiesterase (PDE) 3 enzyme inhibitor occasionally used as an inotropic agen in patients with refractory heart failure due to LV systolic dysfunction PDE inhibitors decrease the degredation of cAMP, the increased cAMP causes calcium influx into cardiac myocytes and increases cardiac contractility it also inhibits cAMP breakdown in vascular smooth muscle cells causing systemic arterial and venous dilation.... this decreases BP so be careful in patients with hypotension (increased inotropy and vasodilation will increase renal blood flow)

Answer 309

angioedema is subcutaneous swelling in the face, throat, lips, mouth, and genitalia. side effect of ACEI because of bradykinin (that isnt degraded)

Answer 310

aneurysm>dissection esp AAA (atherosclerosis also predisposes to aortic aneurysms)

Answer 311

AAA tertiary syphilis results in spirochetal endarteritis that affects the vasa vasorum in the adventitia of the ascending thoracic aorta this weakens the aortic wall and predisoposes to AAA

Answer 312

sterile platelet rich thrombi attached to mitral valve leaflets commonly associated with advanced malignancy (often in mucinous adenocarcinomas.... circulating mucin is procoagulant) also associated with chronic inflammatory disorders like: antiphospholipid syndrome SLE (libman-sacks endocarditis) DIC in patients with sepsis NBTE starts with endothelial injury caused by circulating cytokines which triggers platelet deposition (during a hypercoagulable state) vegetations= bland thrombus with strans of fibrin, immune complexes, and mononuclear cells (white thrombus) they can be microscopic up to super large (verrucous endocarditis) most of these are asymptomatic vegetations from NBTE are more likely to embolize than IE vegetations

Answer 313

the most common primary cardiac cancer in the atria histo= made of scattered cells in a vascular mucopolysaccharide stroma

Answer 314

cor pulmonale due to pulm artery HTN pericardial disease myocardial fibrosis and conduction system disease

Answer 315

``` transient flushing burning in the chest (bronchospasm) SOB high grade AC block (and sense of impending doom) ``` adenosine is the drug of choice for paroxysmal supraventricular tachycardia 10 second adenosine slows conduction through the AV node by hyperpolarizing the nodal pacemaker and conducting cells this is the chemical stress test drug

Answer 316

lidocaine (class 1B)= neurologic symptoms procainamide (class 1A)= drug induced lupus syndrome

Answer 317

(class 4) CCB, most cardioselective of the CCBs potent neg inotrope was the old favorite before adenosine causes constipation and gingival hyperplasia

Answer 318

positive inotrope and slows conduction through the AV node ``` causes fatigue blurry vision changes in color perception nausea vomiting diarrhea abdominal pain confusion delirium ```

Answer 319

typically occurs 5-14 days after an acute MI after inflammatory infiltration and DURING COAGULATIVE NECROSIS (which weaken the connective tissue) rupture appears as a slit like tear with preference for the LV due to highter pressures death due to cardiac tamponade--> profound shock----> rapid progression to electromechanical dissociation (death) prior history of MI reduces the risk of rupture because there is already fibrosis (scar) formation and collateral circulation.... likewise LV hypertrophy is protective of rupture

Answer 320

ventricular arrhythmias

Answer 321

it means that it was due to transient hemodynamic factors causing LV dilation or papillary muscle ischemia rather than a fixed mitral valve lesion (aka reversible by decreasing preload and increasing afterload) acute LV dilation sufficiently seperates otherwise normal mitral valve leaflets, permitting regurg the most common anatomical abnormality causing mitral regurg is mitral prolapse (aka myxomatous degeneration) a fixed anatomic MR would be caused by something like chordae tendineae rupture

Answer 322

amiloride triamterene spironolactone or k+ supplements hyperkalemia can be in patients taking ACEI alone if the patient has renal insuff... otherwise its in patients on an ACEI taking a potassium sparing diuretic

Answer 323

a thiazide diuretic that blocks NaCl symporters on the distal tubule

Answer 324

because of dual blood supply from the portal vein and the hepatic artery if the hepatic artery becomes occluded the portal venous supply and retrograde flow through accessory vessels is sufficient to sustain the parenchyma not the case for a transplanted liver because the collateral blood supply is severed during transplantation

Answer 325

most likely to infarct: CNS> myocardium> kidney> spleen> liver

Answer 326

``` very high doses of aspirin cause salicylism: vertigo tinnitus hearting loss hyperpnea (stimulates resp drive) ``` the hyperpnea causes resp alkalosis the salicylate accumulation causes a concurrent metabolic acidosis

Answer 327

a thiazolidinedione which increases insulin sensitivity in patients with DM2 due to binding of peroxisome proliferator activated receptors long term use is associated with urinary bladder cancer

Answer 328

``` >60 yo smoking HTN male family history ``` leads to oxidative stress, VSMC apoptosis, and CHRONIC TRANSMURAL INFLAMMATION of the aorta macrophages release matrix metalloproteinases and elastases that degrade extracellular matrix components (elastin, collagen) leading to a weakening and progressive expansion of the aortic wall also contributing is ischemia of the tunica media and thickening of the intima remember that a pulsatile central abdominal mass is an aneurysm not a dissection

Answer 329

in the aortic media there is replacement of smooth muscle, collagen, and elastic tissue with cystic mucoid spaces this occuring at the aortic root predisposes them to aortic aneurysm and dissection

Answer 330

until 4 hours after severe ischemia then after 4 hours you can see early signs of coagulative necrosis, edema, hemorrhage, and wavy fibers (soon including contraction band necrosis)

Answer 331

LV hypertrophy= increased wall thickness (concentric= due to increased afterload) or cavity size (eccentric= remodeling, decreased wall thickening with associated increase in chamber size due to volume overload) concentric= uniform thickening of the ventricle with narrowing of the cavity patients may develop diastolic dysfunction and LA enlargement causing CHF LV enlargement causes LA enlargement not the other way around LA enlargement would cause pulm problems

Answer 332

developed= MVP (for native valve IE) nondeveloped= ARF

Answer 333

left circumflex artery (think of lateral as the left side of the heart towards the patient's back) lateral means lateral left ventricle left circumflex comes off the left main coronary artery

Answer 334

LAD supplies the anterior left ventricle and interventricular septum anterior/septal leads= v1-v4 proximal LAD occlusion will occlude all the leads (v1-v4) but distal LAD occlusion spares the septum (v3 and v4 affected only)

Answer 335

right coronary artery supplies the right ventricle and the inferior left ventricle thus you'll get an inferior MI (leads 2,3, avF)

Answer 336

LA extrinsic compression of the esophagus "cardiovascular dysphasia"

Answer 337

reduced by 50% basically 2^4 is 16 so you know its two and since youre getting smaller, you know the 2 is in the denominator (and thus its divided in half)

Answer 338

right heart failure with circulatory collapse and resp failure

Answer 339

due to vasoconstriction due to pulmonary venous congestion left heart backs up into the lungs the high pressures cause endothelial damage and capillary leakage of serum proteins in to the interstitium this leads to decreased production of NO and increased endothelin (vasoconstrictor) this causes increased vasc tone over time remodeling of the pulm vasc occurs due to smooth muscle cell proliferation (medial hypertrophy) and collagen deposition (intimal thickening and fibrosis) (in this case the remodeling isnt as bad as it is in idiopathic PAH so its usually partially reversible if you fix the left heart issue) remember that although pulm artery pressures are rising due to left heart disease, pulmonary arterial flow remains constant or decreases as HF worsens

Answer 340

MC receptor antagonists (basically aldosterone receptor antagonists)= spironolactone and eplerenone these block the deleterious effect of aldosterone on the heart causing regression of myocardial fibrosis and improvement of ventricular remodeling MC-R antag reduce morbidity and improve survival in patients with CHF and decreased EF thus they are recommended in addition to standard HF meds (ACEI and beta blockers)

Answer 341

an insoluble pigment composed of lipid polymers and protein complexed phospholipids lipofuscin is considered a sign of "wear and tear" or aging this yellow brown finely granular perinuclear pigment is the product of free radical injury and lipid peroxidation commonly seen in the heart and liver of aging or cachectic malnourished patients

Answer 342

hemosiderin= iron overload melanin= oxidation product of tyrosine metabolism

Answer 343

AD sarcomere gene single point missense mut (encodes myocardial contractile proteins) ex: beta myosin heavy chain myosin binding protein C

Answer 344

dystrophin= x linked familial dilated cardiomyopathy and also skeletal myopathies (duchenne and becker muscular dystrophy... both have CV involvement) fibrillin 1= marfan syndrome IK membrane potassium channel= congenital long QT syndrome transthyretin= hereditary cardiac amyloidosis

Answer 345

``` valvular abnormalities: ARF causing rheumatic heart disease MVP prosthetic valves cong heart disease ``` immigrant with hx heart disease= rheumatic heart disease this causes degeneration of the mitral valve due to chronic valvular inflammation and scarring remember that rupture of chordae tendineae is a complication of endocarditis or MI, not a risk factor

Answer 346

disruption of normal endocardial surface (mostly at areas of maximal turbulence to blood flow... aka where there was previous damage) next comes platelet and fibrin deposition forming a sterile fibrin platelet nidus (nidus= site of deposition) bacteria colonize the sterile nidus which activates coagulation

Answer 347

kallikrein activates bradykinin activation of the kallikrein-kinin system (KKS) plays a major inflammatory role in the lung (on epithelial cells) (the role of KKS in the plasma is unknown)

Answer 348

the pressure at which a tube or vessel deforms due to pressure from outside the tube collapsing pressure= 2 x (surface)tension/(alveolar)radius

Answer 349

nitrates oxidizes hemoglobin into methemoglobin methemoglobin binds cyanide (allowing cytochrome oxidase to function... this is part of the ETC) after nitrates give thiosulfate to bind the cyanide-methemoglobin complexes to form thiocyanate which can be renally excreted

Answer 350

methylene blue remeber METHemoglonin is treated with METHylene blue

Answer 351

the posteroinferior wall of the left ventricle is supplied by the posterior descending artery (Right dominant heart this comes off of the right coronary artery) the right coronary artery also supplies the SA node too (will cause bradycardia and hypotension)

Answer 352

statins and fibrates (esp gemfibrozil) gemfibrozil and fenofibrate impairs the hepatic clearance of statins leading to excessive blood levels also possible with concurrent use with niacin or ezetimibe but not as much as with fibrates statin assoc myopathy= mild muscular pain (resolves when stopping statin)... severe myopathy= elevated creatine kinase and occasional rhabdomyolysis statins also cause hepatitis

Answer 353

bile acid sequestrants (like cholestyramine) reduce the GI absorption of statins

Answer 354

niacin causes flushing, hyperglycemia, and hepatotoxicity

Answer 355

hypotension elevated jugular venous pressure muffled heart sounds causes late diastolic collapse of the RA due to displacement of the pericardial fluid with ventricular expansion (a large RV in a confined space causes fluid to move up and take the space that the RA used to) also get pulsus paradoxus= exaggerated drop in systolic blood pressure during inspiration ("drop in pulse amplitude during inspiration")... inspiration= increased venous return causing the septum to bow into the LV (thus also, the LV will now have lower preload and stroke volume) aka decreased systolic pulse pressure during inspiration

Answer 356

pulsus alternans due to a change in systolic BP seen in severe LV dysfunction electrical alternans= beat to beat variation in the QRS complex amplitude seen in large pericardial effusion or cardiac tamponade and is due to the swinging motion of the heart in the pericardial fluid

Answer 357

a dicrotic pulse (one peak for systole and another for diastole) it is due to an accentuated diastolic dicrotic wave after the dicrotic notch (of the aortic pressure wave) seen in patients with severe systolic dysfunction and high systemic arterial resistance

Answer 358

a hyperkinetic pulse it is due to the rapid ejection of a large stroke volume against a low afterload occurs with aortic regurg and high output conditions (like thyrotoxicosis or AV fistula)

Answer 359

causes pulsus parvus et tardus (a palpable pulse as described with diminished stroke volume and prolonged ejection time) due to a fixed LV outflow tract obstruction (aortic stenosis)

Answer 360

exaggerated drop (>10mmHg) in systolic BP with inspiration ``` seen in: cardiac tamponade severe asthma COPD hypovolemic shock constrictive pericarditis ```

Answer 361

when norepi is being infused into a vein and the IV site becomes cold, hard, and pale (showing blanching, induriation, and pallor) basically what happens is the norepi is leaking and causing intense alpha 1 vasoconstriction and is leading to local tissue necrosis you can prevent the necrosis with an alpha blocker injection (give antidote= 10-15cc of sodium chloride solution with 5-10mg of PHENTOLAMINE mesylate with a syringe and fine hypodermic needle) must be given within 12 hours of extravasation norepi alpha1>alpha2>beta1 use norepi for shock and severe hypotension (but it causes a reflex bradycardia)

Answer 362

beta> alpha ``` use for: anaphylaxis cardiac arrest open angle glaucoma asthma/broncospasms hypotension ```

Answer 363

midodrine (alpha 1 agonist) for orthostatic hypotension phenylephrine (alpha 1>alpha 2) for wide angle glaucoma, pupillary dilation, vasoconstriction, nasal decongestion clonidine/alpha methldopa (central acting alpha agonist, decreases central adrenergic outflow) used for HTN, does not decrease blood flow to the kidney isoproterenol (beta 1=beta 2) used for heart block dopamine (low dose vasodilation and natriuresis D1=D2... medium dose tachycardia beta 1.... high dose vasoconstriction alpha 1, inotropic and chronotropic) for shock and increasing renal perfusion, and heart failure fenoldopam (D1 agonst) for HTN bromocriptine (D2 agonist) for parkinsons disease and prolactinemia dobutamine (beta 1>beta 2 and positive inotrope) for cardiogenic shock, acute HF, and cardiac stress testing metaproterenol/albuterol/salmeterol (beta 2 agonist) for acute asthma and long term asthma (sal) ritodrine/terbutaline (beta 2 agonist) for reduction of premature uterine contractions

Answer 364

aortic regurg in developed nations the most common cause is aortic root dilation (best heard on the right) or bicuspid aortic valve the accompanying fatigue and DOE are likely due to left heart failure

Answer 365

mitral regurg some blood from the LV is pumped forward (forward stroke volume) and some is forced backwards by the incompetent mitral valve (regurg strok volume) the forward flowing amount of blood is determined by LV afterload (thus decreasing afterload will increase forward flow)... you can achieve this with an arterial vasodilator (which will also help with HF symptoms) main tx= surgery though

Answer 366

increases preload because there is more time in diastole for the ventricle to fill now and thus the stroke volume will also increase

Answer 367

1. history of clot 2. an estrogen dependent tumor 3. women over 35 who smoke heavily 4. hypertriglyceridemia 5. decompensated or active liver disease (impairs steroid metabolism) 6. pregnancy

Answer 368

lidocaine mexiletine great for treating ischemia induced ventricular arrhythmias because the weak binding and rapid dissociation allows rapid dissociation of the drug from the normal tissues the strongest binders and slowest dissociators have high use dependence and are great for terminating tachyarrhythmias (conduction delay side effect can promote arrhythmias)

Answer 369

free wall rupture causes hemopericardium and cardiac tamponade they get PROFOUND HPOTENSION AND SHOCK with rapid progression to pulseless electrical activity and death

Answer 370

constitutional symptoms of cancer (myxomas produce a large amount of IL6) mid diastolic rumbling murmur at the apex positional dyspnea large pedunculated mass in the LA 80% occur in the LA histo= scattered cells within a mucopolysaccharide stroma with [abnormal blood vessels and hemorrhaging= due to the large amounts of vascular endothelial growth factor produced by myxomas... this is seen as hemosiderin deposition which is brown]... these tumors are friable symptoms are due to valve obstruction by the tumor

Answer 371

coarse filamented branching septate hyphae

Answer 372

symptoms of pancytopenia anemia neutropenia thrombocytopenia ``` aka weakness easy fatigability infections ecchymoses epistaxis ```

Answer 373

the posterior descending interventricular artery right dom= right coronary artery (70%) left dom= left circumflex artery (10%) codominant= both (20%)

Answer 374

the AV nodal artery most often arises from the dominant coronary artery (because the AV node gets blood from the posterior descending interventricular artery)

Answer 375

sharp and pleurtitic decreases with sitting up and leaning forward most common type is fibrinous or serofibrinous pericarditis physical exam= pericardial friction rub (high pitched, leathery, and scratchy) ``` causes: MI ARF uremia viral infection (causing exudate) ```

Answer 376

paradoxical increase in JVP with inspiration often seen in chronic constrictive pericarditis

Answer 377

brief, high freq, precordial sound heard shortly after S2 in patients with constrictive chronic pericarditis

Answer 378

blood clots from the left heart

Answer 379

cancer hypercoagulability is common to paraneoplastic syndrome seen in visceral adenocarcinomas of the pancreas, colon, and lung adenocarcinomas produce a thromboplastin like substance capable of causing chronic intravascular coagulations that can disseminate and tend to migrate (=hypercoagulability) migratory superficial thrombophlebitis = "trousseau syndrome" ... the man diagnosed his own visceral cancer after discovering it!... it causes superficial venous thromboses that appear in one site, resolve and recur in another site [same trousseau that named the arm BP spasm sign associated with hypocalcemia]

Answer 380

bleeding because malabsorption results in vit k def and def of vit k clotting factors

Answer 381

reactive arthritis

Answer 382

basic is CO= SV x HR with Fick principle: (using a swan ganz catheter) CO= rate oc O2 consumption/arteriovenous O2 content difference consumption determined with an oxygen meter by measuring the rate of disappearance of oxygen in exhaled air

Answer 383

blood O2 content= (O2 binding capacity x % saturation) + dissolved O2

Answer 384

1. Jervell and Lange Nielsen syndrome AR with neurosensory deafness 2. Romano ward syndrome AD no deafness both predispose torsades, syncope, and sudden cardiac death

Answer 385

PDA comems from the 6th aortic arch PDA presenting with failure to thrive, SOB, and exerise intolerance in a 4 yo boy with continuous murmur, bounding peripheral pulses and palable thrill symptoms reflect a left to right shunt that is causing LV volume overload and symptoms of heart failure (the failure to thrive and resp distress) the murmur is machine like but they didnt mention that and its accompanied by a palpable thrill due to turbulent blood flow through the PDA tx: premie infants= meds (PGE2 synthesis inhibitors- indomethacin) older patients= surgical ligation or percutaneous ODA occlusion

Answer 386

1= maxillary artery 2= hyoid artery and stapedial artery 3= common carotid artery and proximal internal carotid artery 4= aortic arch (on left) and proximal right subclavian (on the right) 6= proximal pulmonary arteries and ductus arteriosus (on left)

Answer 387

most commonly sporadic defects in the mitral valve connective tissue proteins characterized by myxomatous degeneration (pathologic deterioration of the connective tissue) of the leaflets and chordae tendineae

Answer 388

associated with inherited connective tissue disorders marfans ehlers danlos syndrome osteogenesis imperfecta remember that heart valves are made of connective tissue! (no muscle)

Answer 389

S3 and S4 (LV gallops) are best heard with the bell at the apex in the left lateral decubitus position at end expiration the sound is louder because lung volume is decreased which brings the heart closer to the chest wall

Answer 390

SLE women of childbearing age immune complex mediated injury CV manifestations: accelerated atherosclerosis vasculitis of small arteries and arterioles fibrinoid necrosis in any tissue verrucuous (libman sacks) endocarditis (thick valves with sterile vegetations on both sides) renal involvement (Diffuse proliferative glomerularnephrITIS)... diffuse thickening of glomerular capillary walls with "wire loop" immune complex deposition

Answer 391

churg strauss syndrome small vessels necrotizing vasculitis allergic rhinitis, asthma, and peripheral eosinophilia

Answer 392

wegener granulomatosis small vessels necrotizing vasculitis upper resp symptoms, sinusitis, otitis media and lower resp, shortness of breath, hemoptysis and renal disease but! the wegener GPA renal disease is focal necrotizing crescentic glomerulonephritis

Answer 393

transvenously passing the lead from the right atrium into the coronary sinus (the atrioventricular groove on the posterior heart) and advancing it into one of the lateral venous tributaries to get to the LV

Answer 394

PAH is mean pulm artery BP >25 at rest due to an inactivating mutation of BMPR2 AD with variable penetrance 2 hit hypothesis: predisposition for dysfunctional endothelial and smooth muscle cell proliferation a second insult (infection, drugs, ion channels defects) activates the disease ``` increased endothelin (vasoconstrictor) decreased NO (dilator) decreased prostacyclin (dilator and platelet inhibitor) ``` thus hereditary PAH has VSMC proliferation, intimal thickening and fibrosis, increased vasc resistance, and pulm HTN

Answer 395

PLATELETS endothelial dysfunction promotes: platelet adhesion/aggregation growth factors cytokines These promote migration of smooth muscle cells from the media to the intima to proliferate: PDGF (platelet derived growth factor) from platelets that have locally adhered platelet's TGF beta (chemotactic for SMCs) dysfunctional endothelial cells infiltrating mactophages

Answer 396

prostacyclin (prostaglandin I 2) which is in the camily of eicosanoids (arachidonic acid derivatives which act as local hormones) prostacyclin inhibits platelet aggregation and adhesion to the vascular endothelium.... it also vasodilates, increases permeability, and attracts leukocytes thromboxane A2 is a prostaglandin that does the opposite (inhances aggregation and vasoconstricts) damaged endothelial cells are prone to clots because they lose the ability to synthesize prostacyclin synthetic prostacyclin is used to treat pulm HTN, peripheral vasc disease, and raynaud syndrome

Answer 397

suspect dilated cardiomyopathy (viral injury and autoimmune reaction to virally altered myocytes)caused by viral myocarditis dilation and enlargement= eccentric hypertrophy ``` other causes of dilated cardiomyopathy: genetics toxicity (alcohol) pregnancy (peripartum) hemochromatosis ```

Answer 398

low= mechanoreceptors and chemoreceptors increase SNS high= HR

Answer 399

down due to substantial arteriolar vasodilation in active skeletal muscles mediated by the local release of adenosine, potassium ATP, CO2, and lactate (thats why there is only a modest increase in blood pressure) during strenuous activity the muscles can recieve up to 85% of the total CO

Answer 400

acute pericarditis facial rash proteinuria ``` clinical: constitutional symptoms arthritis butterfly rash and photosensitivity serositis clotting CNS ``` ``` labs: blood changes decreased complement (3 and 4) ANA ab (sensitive) anti DNA ab anti SM ab (specific) kidney changes ``` SLE also causes pericardial effusion, verrucous (libman sacks) endocarditis, and increased risk of CAD

Answer 401

cAMP in cardiac muscle cells alpha 1 vasoconstriction via the IP3 pathway beta 1 inotropy conduction and chronotropy due to Gs pathway (with baroreceptor mediated reflex bradycardia) thus HR is unchanged or decreases

Answer 402

alpha 1 works on IP3>Ca2+>DAG alpha 2 decreases cAMP (decrease release of norepi and insulin) beta 1 increases cAMP beta 2 increases CAMP (bronchodilation and vasodilation)

Answer 403

statins cause liver toxicity and muscle toxicity (do LFTs before starting... routine monitoring only if liver injury [fatigue, malaise, anorexia]) ezetimibe decreases cholesterol absorption and causes hepatotoxicity if given with statins BAS prevent bile acid reabsorption and cause nausea, bloating, cramping, and malabsorption of other drugs and fat vitamins niacin decreases FA release, VLDL synthesis, and HDL clearance and causes flushing, itching, liver toxicity, and gout fibrates activated PPAR alpha and decrease VLDL synthesis... they decrease TG the most and cause muscle toxicity and gallstones fish oil decreases VLDL synthesis and apo B synthesis and causes a fishy taste

Answer 404

``` LPL def familial hyperTG (heterozygous) chylomicronemia (homozygous) ```

Answer 405

adrenal enzyme inhibitors

Answer 406

anti digoxin ab fragments severe toxicity presents with life threatening arrhythmias and end organ dysfunction

Answer 407

large veins (the chemical structure is shown and there are three branches with NO2 at the end of each one) nitroglycerin decreases preload (decreases ventricular wall stress and thus oxygen demand)

Answer 408

small arteries and arterioles such as CCBs and alpha 1 blockers

Answer 409

complications from poor blood flow: ``` skin ulcerations (over medial malleolus is common) painful clots stasis dermatitis poor wound healing superficial infections ``` claudication on the other hand is an issue of the arteries... you dont get DVTs cause varicose veins are superficial

Answer 410

painful white leg "milk leg" consequence of iliofemoral venous thrombosis occuring in peripartum women pregnancy predisposes DVTs because of pressure on the deep pelvic pains producing venous stasis and hypercoagulability

Answer 411

ANP is secreted by atrial cardiomyocytes neprilysin is a metalloprotease that inactivates several peptide hormones like bradykinin, glucagon, enkephalins, and natriuretic peptides (ANP/BNP) drugs can be given to inhibit neprilysin (like sucabitril) to prevent degredation of ANP) ANP (stimulates cGMP): dilates afferent arterioles in the kidney, inhibits renin secretion, limits sodium reabsorption, restricts aldosterone secretion, vasodilates, increases permability, decreases blood volume

Answer 412

prevents ARF (and thus need for cardiac surgery)... ARF is the most common cause of acquired valvular heart disease and CV death in developing countries though though post strep glomerulonephritis is a consequence of GAS infection, early abx have not been shown to reduce the risk of PSGN (have been shown to prevent ARF)

Answer 413

yes they reduce HR reduce CO reduce myocardial oxygen demand they reduce short term morbidity minimize the infarct size improve long term survival contraindications= bradycardia or heart block hypotension overt heart failure (pulm edema) avoid beta blockers that are non cardioselective (propranolol, nadolol) becaue they cause bronchospasm in patients with lung problems

Answer 414

predominant actions on beta 1 receptors metoprolol atenolol bisoprolol nebivolol may also use combined beta and alpha receptor blockers like carvedilol and labetalol in patients with lung diseases (just not the noncardioselective ones)

Answer 415

was given one where the bottom of the aorta line is low and close ish to the LV bottom line (and I had to remember what normal looked like) basically it showed a wide pulse pressure in the aorta, loss of the dicrotic notch this abnormal profile plus the question stem (including fatige, DOE, murmur best heard when leaning foward) was hinting at the patient having aortic regurg aortic regurg is loudest right when the aortic valve closes

Answer 416

exacerbation with swallowing= posterior pericardium is involved radiation to the neck= inferior pericardium is involved because it is adjacent to the phrenic nerve that supplies the diaphragm pericarditis can be a complication in 10-20$ of post MI patients its usually localized over the necrotic myocardium it is short lived and goes away within 1-3 days of aspirin therapy

Answer 417

autoimmune reaction to the pericardium and serosal surfaces weeks to months after an MI treat with aspirin NSAIDS glucocorticoids

Answer 418

for muscarinic and AR odd numbers= Gq even numbers= Gi all beta (1,2,3) = Gs

Answer 419

the serotonin of carcinoid heart disease (neuroendocrine tumor that is well differentiated, found in the small intestine and colon, and metastasizes to the liver) the secrete serotonin* histamine and vasoactive intestinal peptide (these are all metabolized in the liver thus the liver mets) results in right heart failure carcinoid syndrome causes: flushing watery diarrhea bronchospasm/wheezing diagnosis via 5-HIAA (5-hydroxyindoleacetic acid)... this is the end product of serotonin metabolism

Answer 420

vanillylmandelic acid

Answer 421

chronic rhematic fever results in mitral stenosis (can precipitate atrial fibrillation or atrial mural thromboses) mid diastolic murmur with an early diastolic opening snap

Answer 422

aortitis aortic aneurysm aortic regurg

Answer 423

internal carotid (atherosclerosis)>ophthalmic artery>retinal artery