Pathophysiology Flashcards
1
Q
Venous Thromboembolism
(VTE)
A
DVT and PE
2
Q
DVT
Epidemiology
A
- Risk higher in men
- Most common in LE
- Esp. calf veins
- 15-30% propagate to proximal calf veins without treatment
- Risk of PE much higher in proximal DVT
- 40-50% vs 5-10% distal
- UE DVT much less common
3
Q
UE DVT
Risk Factors
A
- Central venous line
- Pacemakers
- Trauma
- Extrinsic compression @ thoracic inlet
4
Q
DVT
Presentation
A
- Pain and swelling of the area
- Many asympatomatic w/ normal exam
- Exam
- TTP, erythema, warmth, swelling distal to DVT
- Palpable tender “cord” in area of DVT
- Dilated superficial veins
- Low grade fever
- Homan’s sign ⇒ calf pain with dorsiflexion
5
Q
SVC Syndrome
A
Can be caused by UE DVT
- Facial swelling
- Blurred vision
- Dyspnea
6
Q
DVT
Diagnosis
A
- D-Dimer
- Fibrin degradation product
- Nonspecific
- Duplex US
- Sensitivity⇒ proximal DVT (90-100%), distal DVT (40-90%)
- Contrast venography ⇒ gold standard
7
Q
DVT
Treatment
A
- Anticoagulation
- IVC filter
- Should be avoided unless can’t anticoag
- Dec. risk of PE short term
- Inc. risk of recurrent DVT
8
Q
Thromboplebitis
A
Superficial inflammation and pain involving a vein.
- Risk ⇒ Virchow’s triad
- Presentation ⇒ firm, tender palpable cord
- Treatment ⇒ local heat and NSAIDS
9
Q
PR Interval
A
0.12 - 0.2 secs
or
< 1 large box
10
Q
QRS Complex
A
< 0.1 secs
11
Q
QT interval
A
< 0.45 secs
12
Q
Axis Determination
A
Use lead II or aVF
13
Q
Inferior Wall
Leads
A
II, III, aVF
14
Q
Anterior Wall
Leads
A
I, aVL, V1-V3
15
Q
Anterolateral Wall
Leads
A
V5, V6
16
Q
Lateral Wall
Leads
A
I, aVL, -aVR
17
Q
EKG Leads
Summary
A
18
Q
Left Anterior Descending
(LAD)
A
Anterior wall of both ventricles
Anterior 2/3 of septum
Anterior papillary muscles
19
Q
Diagonal branches of LAD
A
Anterior surface of LV
20
Q
Left Circumflex
A
Left atrium
Posterior and lateral left ventricle
21
Q
Right coronary artery (RCA)
A
Right atrium and right ventricle
SA and AV nodes
Posterior septum
22
Q
Right marginal artery
A
RV
23
Q
Posterior descending artery
A
Inferior and posterior walls of right ventricle
Posterior 1/3 of septum including posterior papillary muscles
24
Q
Coronary Circulation
Summary
A
25
CAD
Risk Factors
26
CAD
Biomarkers
27
Typical CAD History
Levine's sign ⇒ pt comes in clutching hand to chest
28
Chest Pain
Patterns
29
Physical Exam
During Ischemia
Xanthomas ⇒ cholesterol deposits around joints
Xanthelasmas ⇒ cholesterol deposits around eyes
30
EKG Lead
Patterns
31
Stable Angina
Treatment
* Medical therapy
* **Modify risk factors**
* Lipid lowering drug
* Control BP
* **Drugs to prevent/relieve angina**
* Nitrates
* β-blockers
* CCB
* Late sodium current blockers
* Ranolazine - if fail all others
* **Antiplatelet agents**
* Interventional therapy
* PCI / stent
32
Cardiac Cath
Indications
33
Prinzmetal Angina
34
S3 gallop
Due to volume overload with poor LV function
35
S4 heart sound
Due to noncompliant left ventricle
36
ACS
Treatment
37
STEMI
Treatment
38
NSTEMI and Unstable Angina
Treatment
39
Dressler Syndrome
40
Acute Bacterial Endocarditis
* Normal valve
* Virulent organism
* Onset days - few weeks
* Mortality rate higher
41
Subacute Bacterial Endocarditis
* Abnormal valve ⇒ congenital or degenerative
* Less virulent organism
* Viridans strep
* S. epidermidis
* Enterococcus
* Onset weeks to many months
42
Endocarditis
Risk Factors
* Significant MR ⇒ most common
* MVP ⇒ 20% of NVE cases
* RHD
* Congenital heart disease ⇒ 15% with NVE
* TOF ⇒ highest IE risk
* VSD, bicuspid valve, aortic coarctation
* Degenerative valves ⇒ SBE in elderly pts
* Mitral valve most common
* Hypertrophic cardiomyopathy or asymmetrical septal hypertophy ⇒ aortic valve IE (rare)
43
Endocarditis
Pathogenesis
* **Portal of entry for organism** into bloodstream
* **Turbulent flow ⇒ endothelial damage** ⇒ deposition of fibrin/platelets
* Deposition gives rise to **non-bacterial thrombotic endocarditis (NBTE)**
* **Bacteria adhere** to NBTE and multiply
* More platelet/fibrin deposition ⇒ creates **vegetation** where bacteria replicate
* There can be **direct invasion of virulent organism** in ABE without underlying endothelial damage
44
Endocarditis
Lesion Locations
Valve surface facing lower pressure chamber
* Ventricular surface of semilunar valves
* Atrial surface of AV valves
45
Acute Bacterial Endocarditis
Agents
S. aureus most common
46
Subacute Bacterial Endocarditis
Agents
Viridans strep most common
47
IE Overall
Agents
**S. viridans** most common cause overall
48
Native Valve Endocarditis
Both Staph and Strep ⇒ 70-80% of cases
* Abnormal valves
* Strep including viridans
* S. sanguis, S. salivarius, S mutans
* S. bovis (group D strep)
* Normal valves
* S. aureus
* Enterococci
* S. pneumoniae
* S. pyogenes
49
Prosthetic Valve Endocarditis
* **Early**
* Within 2 months after surgery
* Usually due to contamination from surgery
* More virulent pathogens
* **S. epidermitis most common**
* S. aureus, GNR like Pseudomonas, Enterococci, Candida, Corynebacterium
* **Late**
* \> 60 days after surgery
* Valve is endothelialized
* Pathogens less virulent
* **S. epidermitis ⇒ most common months 2-12**
* **Strep including viridans ⇒ most common \> 12 months**
* Also S. aureus, Entoerocci, Candida
50
IV Drug Users
Endocarditis
* Agents
* **S. aureus most likely**
* Enterococci, Pseudomonas, Candida, beta-hemolytic strep
* Can be polymicrobial
* Location
* **Tricuspid valve most often**
51
Healthcare Associated NVE
S. aureus
Coag-neg strep
Enterococci
52
Dental-Associated
Endocarditis
Viridans strep
53
GI/GU Associated
Endocarditis
Strep. bovis
Enterococci
54
Fungal
Endocarditis
* Seen with immunocompromised hosts
* Vegetations larger and bulkier
* Valvular/chordal perforation possible
* Micro ⇒ PMNs, fibrin, platelets, fungi
55
Culture-Negative
Endocarditis
* May have vegetations, murmur, symptoms of IE with negative cultures
* Causes
* **Prior abx therapy**
* **Fastidious organisms**
* **HACEK group**
* Legionella, Brucella, Coxiella
* Non-infective endocarditis
* Atrial myxoma
56
Non-infective Endocarditis
* Non-bacterial thrombotic endocarditis
* Libman Sacks Endocarditis
57
Non-bacterial Thrombotic Endocarditis
| (NBTE)
* **Small vegetations of fibrin on leaflets**
* No microorganisms
* Can produce emboli
* See in debilitated patients
* Esp. lymphoma, lung CA, pancreatic CA
* Frequently occurs along with DVT/PE
58
Libman Sacks Endocarditis
* **Mitral and tricuspid valvulitis with small, sterile vegetations**
* May be located on undersurfaces of AV valves, valvular endocardium cords, mural
* **Associated with SLE** ⇒ commonly occurs with antiphospholipid syndrome
* Micro ⇒ finely granular, fibrinous eosinophilic material
59
Acute Bacterial Endocarditis
Symptoms
* Generally more fulminant picture
* High fevers
* Heart murmur
60
Subacute Bacterial Endocarditis
Symptoms
* Low grade fever
* May not be present if pt used abx
* May not have murmur
61
Endocarditis
Other Symptoms
* Nonspecific sx common
* Fatigue, night sweats, anorexia, chills, weight loss
* CNS symptoms
* HA, AMS
* Myalgias or arthralgias
* Other sx related to complications
62
Endocarditis
Physical Exam
* Fever and murmur
* Arterial emboli ⇒ 20-50%
* Splenomegaly ⇒ 15-50%
* Clubbing ⇒ 10-20%
* Petechiae ⇒ 10-40%
* **Janeway lesions** ⇒ hemorrhagic, non-painful macules of palms/soles
* **Osler nodes** ⇒ painful, subcutaenous nodules on distal pads of fingers or toes
* **Splinter hemorrhages**
* **Roth spots** ⇒ retinal hemorrhages with small central clearing
63
Endocarditis
Complications
* Cardiac
* Valvular destruction
* CHF
* Myocardial abscess or valve ring abscess
* Suppurative pericarditis
* Emboli
* Embolic complications
* Left-sided lesions
* CVA or brain abscess
* Roth spots
* MI
* Splenic abscess or infarct
* Renal abscess or infarct
* Right-sided
* Pulmonary septic emboli, infarct, PNA
* Mycotic (infected) aneurysms
* Cerebral vessels most common
* Also AA, splenic, coronary, plumonary, mesenteric
* CNS
* Cerebral emboli ⇒ MCA most common
* CVA, arteritis, abscess, cerebritis, meningitis
* Renal
* Embolic infarct
* Multiple abscesses
* Interstitial nephritis
* Glomerulonephritis
64
Endocarditis
Diagnosis
* Tests
* **Blood cultures**
* **ECHO**
* **Duke Criteria**
* Major
* Microbiologic
* Evidence of endocardial involvement
* Minor
* Predisposing heart condition or IVDU
* Fevere
* Vascular phenomena
* Immunologic phenomena
* Microbiologic findings that aren't major
65
Endocarditis
Treatment
* Prolonged abx therapy with bactericidal drugs
* Empiric therapy in suspected IE
66
Endocarditis
Prophylaxis
67
Acute Rheumatic Fever
Acute, immune mediated multisystem inflammatory disease that follows GAS pharyngitis by 10 days to 6 weeks.
Mostly in children.
68
ARF
Clinical Presentation
* **Migratory polyarthritis with fever**
* **Carditis**
* Pericardial friction rubs
* Tachycardia and arrhythmias
* Cardiac dilatation from myocarditis
* Resultant mitral insufficiency or CHF
* 1% die from fulminant RF
69
ARF
Diagnosis
* Major criteria
* Carditis
* Polyarthritis
* Chorea
* Erythema Marginatum
* Subcutaneous nodules
* Minor criteria
* Arthralgia
* Fever
* Elevated ESR and CRP
* Prolonged PR interval
* **Jones Criteria**
* ASO titer + 2 major or 1 major and 2 minor criteria
70
ARF
Pathology
**Anistschkow cell**s ⇒ Mφ with abnormal chromatin
**Aschoff body** ⇒ multinucleated Anistschkow cells
71
ARF
Pericarditis
72
Chronic Rheumatic Heart Disease
Acute rheumatic carditis of ARF can progress to chronic RHD.
* Valve distribution of chronic RHD
* Mitral ⇒ 65-70%
* Mitral and aortic ⇒ 25%
* Tricuspid and pulmonic ⇒ rare
73
Rheumatic Mitral Valve Disease
* **Commissural fusion**
* **"Fish mouth" mitral valve**
* Thickening, shortening, and fusion of chordae tendinae
* Diffuse fibrous thickening of valve cusp
* Fibrosis of leaflets
* Primarily at margin of closure
* Post-inflammatory neovascularization
* Chronic inflammation
* Mineralization
74
Cardiac Valve
Histology
75
Mixed Lesion
Stenosis and insufficiency within the same valve
76
Pure disease
Only stenosis or insufficiency within a valve
77
Isolated disease
Involvemen of a single valve
78
Combined disease
Involvement of more thatn one valve
79
Valvular Lesions
Consequences
* Effect varies from mild to fatal
* Degree of stenosis/insufficiency related to rate of development
* Secondary changes in other organs
* Lungs and liver most
* Pulmonary HTN
80
Congenital vs Acquired
Valvular Lesions
* Acquired stenosis of aortic and mitral ⇒ 2/3 of all valve diseases
* Congenital malformations may inc. severity of acquired disease
81
Mitral and Aortic Valvular Disease
Etiologies
82
Aortic Stenosis
* Critical AS ⇒ **2/3 reduction in area** or **\>50 mmHg gradient**
* Untreated ⇒ usu. die of CHF, 10-20% die suddenly d/t lethal arrhythmia
* Major causes
* **Degenerative calcific aortic stenosis** ⇒ most common
* **Bicuspid Aortic Valve** ⇒ most common congenital valve anomaly
* Senile degeneration
* Chronic RHD
* Diffuse post-inflammatory scarring with commissural fusion
* Congenital aortic stenosis
83
Calcific Aortic Stenosis
* Due to senile degeneration
* Otherwise normal valve
* Bulky calcific deposits in Sinus of Valsalva
* ± osseous metaplasia
84
Bicuspid Aortic Valve
* Most common congenital valve anomaly
* See early calcific stenosis
* 60-70 y/o
* Two patterns
* Anterior/posterior
* Right/left
* **Raphe** ⇒ false commissure
85
Unicommissureal Aortic Valve
86
Acommissural Aortic Valve
87
Aortic Stenosis
Presentation
* Asymptomatic for years until stenosis severe
* Onset of sx ⇒ inc. mortality
* Angina ⇒ syncope ⇒ heart failure
88
Aortic Stenosis
Diagnosis
* Physical exam
* **Systolic ejection murmur, crescendo-decrescendo, best heard in the right 2nd intercostal space**
* Murmur radiates to carotid arteries
* May radiate to apical region ⇒ **Gallivardin's phenomenon**
* Mild AS ⇒ early peaking murmur
* Severe AS ⇒ late peaking murmur
* **Paradoxically split S2** (A2 after P2)
* Critical AS ⇒ **A2 component inaudible/absent**
* Low amp. carotid pulse ⇒ **pulsus parvus**
* Delay in carotid upstroke ⇒ **pulsus et tardus**
* Sustained apical impulse
* Possible EKG findings
* LVH
* LBBB
* Heart block
* Possible CXR findings
* LV prominence
* AV calcification
* Post-stenotic aortic dilatation
* **TTE ⇒ gold standard**
* TEE ⇒ cath or stress test if still unsure
89
Aortic Insufficiency
**A portion of the total SV regurgitates back into the LV.**
* Due to failure of leaflet coaptation in diastole
* AR ⇒ ventricular dilatation ⇒ inc. EDV ⇒ **volume overload**
* Majr etiologies
* **Aortic root dilatation**
* Chronic RHD
* Infective endocarditis
* Diet drug (Phen-Fen) valvulopathy
90
Acute Severe AR
* Presentation
* **Acute heart failure**
* **Cardiogenic shock**
* **Fulminant pulmonary edema**
* Diagnosis
* Tachycardia, hypotension, tachypnea
* **Diastolic Decrescendo murmur**
* May be soft and short w/ early termination
* CXR ⇒ nl LV size w/ pulmonary edema
* TTE/TEE to confirm
* Treatment
* Diuretics to improve pulmonary edema
* Hemodynamic stabilization
* **Urgent surgery**
91
Chronic Severe Aortic Regurgitation
Clinical Presentation
* Exertional dyspnea
* Orthopnea
* Fatigue
* Occational chest pain
92
Chronic Severe Aortic Regurgitation
Diagnosis
* _Physical exam_
* **Diastolic decrescendo mumur** best heard at left or right sternal border with pt leaning forward at end-expiration
* Diastolic flow murmur @ left sternal border without MS ⇒ **Austin-Flint murmur**
* Soft systolic murmur possible
* **Laterally displaced and diffuse PMI**
* **Large pulse pressure**
* **Soft S1**
* **S3 possible** in absence of CHF
* **Quincke's pulse** ⇒ systolic plethora and diastolic nail bed blanching with pressure
* **Musset's sign** ⇒ head bobbing
* **Corrigan's pulse** ⇒ bounding full carotid pulse with rapid downstroke
* **TTE** to confirm dx
* **CXR** ⇒ progressive cardiomegaly
93
Chronic Severe Aortic Regurgitation
Treatment
* Pt may be asymptomatic for years
* Indications for aortic valve replacement
* Severe symptomatic AR
* Severe asympatomatic AR w/ structural LV changes
94
Mitral Valve Insufficiency
**Failure of MV to close completely allows reverse flow from LV to LA during systole.**
* Major causes
* **Abnormalities of leaflets and commissures**
* MVP
* RHD
* IE
* **Abnormalities of tensor apparatus**
* Papillary muscle/chordae rupture or dysfunction
* **Left ventricular abnormalities**
* LV dilatation
* **Abnormalities of mitral annulus**
* Mitral annular calcification
95
Acute Severe MR
* Presentation
* Pts acutely ill
* **Hypotension and shock**
* **Acute pulmonary edema and acute HF**
* Diagnosis
* **Classic holosystolic murmur may be absent**
* **Acute onset of pulmonary edema/HF**
* TTE to confirm
* TEE or cath if unclear
* Treatment
* **Requires urgent surgery**
* **Intra-aortic balloon pump** ⇒ dec. afterload
* Diuretics ⇒ reduce pulmonary edema, hypotension may be prohibitive
* Nitroprusside and hydralazine ⇒ reduce afterload
96
Chronic MR
* Presentation
* Remains asympatomatic for prolonged period
* **Progressive exertional dyspnea and fatigue**
* **CHF sx during late stages**
* Physical exam
* **Classic holosystolic murmur** best heard at LV apex **with radiation to axilla**
* S3 gallop
* Soft S1
* TTE for confirmation and evaluation
* Treatment
* **Mitral valve replacement**
* Severe MR with LV dysfunction or new A. Fib or symptomatic
* Prophylactic MV repair
* Preserves subchordal apparatus and IV geometry
* Consider mortality risk, surgeon, and pt anatomy
97
Mitral Valve Prolapse
"Floppy mitral valve"
**Excess valve tissue results in billowing of tissue between chordal attachments.**
* Affected leaflets enlarged, redundant, thick, rubbery, and nearly translucent
* Chordae stretched and abnormal
* Can thin and rupture ⇒ "**flail leaflet" and MR**
* **One of the most common valvular disorders**
* **Etiology usu. unknown**
* Commonly seen with CT disorders
* Tricuspid valve also affected in 20-40%
98
MVP
Microscopic Appearance
* Myxomatous degeneration of valve
* ↑ mucopolysaccharides
* ↓ collagen
* Expansion of spongiosa w/ disruption of fibrosa
* Type III collagen lost ⇒ ↓ structual integrity
99
MV Prolapse
Murmur
Mid systolic click
100
MVP
Complications
Seen in 3% of patients.
Higher risk in men, older patients.
* Infective endocarditis
* Mitral insufficiency requiring surgery
* Stroke / systemic infarct
* Arrhythmias
101
Mitral Annular Calcification
**Stony hard calcific nodules occuring behind MV leaflets.**
* May not affect function
* Can cause regurgitation or stenosis
* Site for thrombi formation
* Site for infective endocarditis
* Most common
* **Women over 60 y/o**
* **Myxomatous mitral valve**
* **Elevated LV pressure**
102
Mitral Stenosis
**Obstruction to flow from LA to LV leads to pressure gradient across the MV during diastole.**
* Etiology
* **RHD**
* **Infective endocarditis**
* **Tumor**
* Metabolic
* Mitral annular calcification
* Gradual ↑ LA pressure ⇒ pulmonary congestion ⇒ pulmonary edema ⇒ right HF
* Long standing MS ⇒ marked LA enlargement ⇒ risk of developing A. Fib
103
Mitral Stenosis
Presentation
* Progressive dyspnea or fatigue with exertion
* Exacerbated by tachycardia
* A. fib with RVR poorly tolerated
104
Mitral Stenosis
Diagnosis
* Physical exam
* _Early on when leaflets still pliable_
* **"Opening snap" followed by a low-pitched diastolic rumble**
* Best heard with the bell with patient in the left lateral decubitus position
* **Prominent S1**
* _With increasing severity_
* **Loss of opening snap**
* **S1 softens and eventually disappears**
* EKG ⇒ LA enlargement and ultimately RA enlargement with **RBBB**
* CXR ⇒ LA enlargement, pulmonary artery dilatation, RV enlargement in advanced cases
* **TTE** ⇒ gold standard
105
Mitral Stenosis
Treatment
* Mechanical intervention ⇒ **Percutaneous balloon mitral valvuloplasty (PBMV)**
* Symptomatic severe MS
* Asymptomatic severe MS w/ significant pulmonary HTN
* Asymptomatic severe MS w/ new A. Fib
* Symptomatic women during pregnancy
* If poor candidate for PBMV ⇒ **surgical commissurotomy or valve replacement**
* **Anticoagulate** if A. Fib present or hx of prior embolic event
* **Diuretics**
* **Rate control**
106
Peripheral Arterial Disease
| (PAD)
Atherosclerotic vascular disease primarily in BLE.
* Epidemiology
* 20-30% of ppl \> 70
* Men \> women
* Same risk factors as CAD
* Common @ branch points and turbulent areas
* 50-70% of cases asymptomatic
* Usually present with claudication
107
Claudication
* Calf ⇒ femoral-popliteal disease
* Thigh, hip, or butt ⇒ aortoiliac disease
* Pseudo-claudication ⇒ spinal stenosis or MSK
* Not relieved with rest
