Summative Review Flashcards
What does the atrial a-wave correspond to?
atrial systole
occurs when the mitral valve closes
What does the atrial V-wave correspond to?
passive filling of the RA when the tricuspid valve is closed
Differences between exercise and maximal sympathetic stimulation of heart
In exercise, arteries dilate which causes decreased TPR and corresponding decreased afterload
Also, skeletal muscle pumping increases preload in exercise
Similarities between exercise and maximal sympathetic stimulation of heart
Both increase HR and contractility
Both lead to a decrease in ESV due to increased contractility
In sympathetic or exercise does ESV decrease more?
ESV decreases more in sympathetic
Sympathetic = increase TPR = increase afterload
Increase afterload = increase contracility
Increase contracitlity = decrease ESV
Clonidine effects on TPR
clonidine is a alpha 2 agonist
prevents sympathetic simulation so therefore, increases TPR
Which drug norepinephrine or epinephrine produces a larger increase in afterload? Why?
Norepinephrine since it primarily binds B1 and alpha receptors
Epinephrine binds B2 receptors which causes vasodilation
Prazosin and phenoxybenzamine chronotropic / ionotropic effects
Both are alpha antagonists which should cause a decrease in HR and contractility
HOWEVER, the baroreceptor kicks in which causes an increase in HR and contracility
Prazosin and phenoxybenzamine effect on TPR
decrease
How do you calculate the blood pressure needed at heart level to adequately perfuse the brain?
you are going to drop pressure as you go up
so at the heart, you need to add the pressure you will lose along the journey to the pressure you want
P = (needed pressure) + (distance / 13.6)
to calculate pressure lost, divide distance by 13.6 since for every 1 mmHg, you push blood up 13.6 mm
make sure you are doing these calculates in mm
What happens to the vagal response upon standing?
vagal is suppressed because the baroreceptor is doing everything it can to increase HR since SV is decreasing because blood pooling in legs
Difference between calculating systemic vascular resistance and pulmonary resistance?
systemic / coronary: subtract RAP on numerator for anything that passes through systemic circulation / aorta
pulmonary: subtract LAP on numerator for anything that goes through pulmonary circulation
What are the 2 general formulas for calculating MAP?
MAP = CO * TPR
MAP = (1/3)(systole) + (2/3)(diastole)
What are the 2 main pathologies that affect afterload?
HTN and aortic stenosis
As venous compliance increases, what happens to TPR?
TPR decreases
When does the atrial c-wave occur?
before the aortic valve opens
When does ventricular systole end on ECG?
ends after the T-wave
(remember mechanical changes proceed electrical changes)
When arterial BP increases what is the result on aortic valve opening and closing?
opening is delayed and closing is earlier
Why does the atrial pressure c-wave occur?
C-wave occurs as AV opens
When AV opens, there is contraction and the tricuspid valve bulges into the atrium causes a small increase in atrial pressure
What happens if you have immediate AV damage?
you cannot empty the LV
this leads to increased ESV and preload
What happens to ESV and EDV if you dilate the arterioles?
both will be reduced due to less preload
that said, stroke volume should remain the same
What happens to ESV, EDV and stroke volume with dobutamine use?
dobutmaine effects B1
increased contractility = decreased ESV / EDV
stroke volume stays the same despite decreased ESV because of the increase in contracility
What two things increase MSFP?
1) increase in BV
2) decrease in venous compliance
Does mean systemic filling pressure increase during exercise or sympathetic stimulation?
increases during sympathetic stimulation since the arteries are getting squeezed more
actually, says that due to skeletal muscle pumping combined with some sympathetic stimulation, MSFP might actually be slightly higher during exercise
MSFP increases in both!
Does venous compliance or arterial compliance affect MSFP more?
venous compliance
Does venous compliance or arterial compliance affect resistance more?
arterial compliance
What does sympathetic stimulation influence more resistance or MSFP?
resistance more since it constricts arteries primarily, not veins
What is the slope of the cardiac function curve?
related to contractility
What is the slope of the vascular curve?
1/RVR
When does lymph flow increase?
when there is more fluid in the interstitial space
What does the ESPVR slope represent?
directly proportional to contractility
What does the EDPVR slope represent?
opposite of compliance / stiffness
higher slope = less compliant
If a ventricle is stiff, what happens to EDV and pressure?
pressure increases
EDV decreases (would shift left on PV curve)
Affinity of alpha receptors for norepinephrine / epinephrine
Norepinephrine affects alpha receptors more than epinephrine
What is the effect of aortic stenosis on pulse pressure?
aortic stenosis decreases pulse pressure because you cannot eject as much stroke volume into arteries
Dobutamine effects on TPR
normally has no effect as you mostly work on B1 receptors
However, at high doses you effect B2 which would lead to a decrease in TPR
What does sheer stress do during exercise?
sheer stress causes vasodilation
Effects of alpha receptors on HR and contractility
decreased HR and contractility
Effect of beta receptors on HR
increased HR and contractility
Hematocrit and what effects it
Hematocrit is volume of RBCs in serum
If you increase fluid in serum, you decrease the % of space that RBCs occupy and hematocrit decreases
If venous constriction occurs, what happens to compliance?
compliance decreases
Relationship between contractility and ESV
reciprocal
What 4 changes occur on PV curve in response to exercise? Why?
1) EDV increases (BP increased, more blood volume, more venous return)
2) Isovolumetric pressure increases (BP increased, need more to overcome)
3) ESV decreases (contractility is increased)
4) SV increases
Contractility and pulse pressure
increased contractility = wider pulse pressure
If you have high venous compliance, what will happen more?
more blood pooling
venous compliance increases as you age, while arterial compliance decreases
What cells secrete NO during exercise?
endothelial
BP and alpha-1 vs. alpha-2
alpha-1 = increased BP (constriction)
alpha-2 = decreased BP (prevents sympathetic)
What does adenosine trigger? When is it released? Where does it affect?
Triggers vasodilation
Released in respnse to lack of stretch or local metabolites
Affects small coronary arteries
What factor is afterload directly related to?
MAP
What happens to RAP when you stand?
blood is pooling in legs
so, RAP decreases to try to pull more blood back
What protein mostly influences oncotic pressure?
albumin
Where is the carotid notch? What causes it?
Occurs after AV closes on aortic pressure graph (Wigger’s)
Caused by aortic regurgitation backflow
What does “expiratory splitting with no change during inspiration” indicate?
Fixed splitting / ASD
Why does ASD cause fixed splitting?
increased blood flow into right chamber leads to increased right volume
delays the closing of the pulmonic valve since you have more volume to push out
Why does normal physiological splitting occur?
during inspiration, RAP drops and pulls in more blood
this delays closure of the pulmonic valve
What else can ASD be associated with? (3 things)
Systolic ejection murmur: left to right shunting during systole
Early diastolic rumble: left to right shunting as well
S1 accentuated: tricuspid valve has more flow than normal so it slams down
What does amyl nitrate normally do to preload?
dilate vessels which decreases preload
What does squatting do?
squatting increases preload by sending blood back to the heart
What can be a cause of mitral regurgitation?
left ventricle dilation
How can mitral regurgitation cause expiratory splitting?
Expiration points us to left side of heart
A2 is coming early because some fluid is flowing back into the left atrium rather than the aorta which leads to decrease in amount of time aortic valve is open
A2 snaps shut earlier due to decreased volume flowing across it
What effects the timing of MVP click?
increased preload = later click
decreased preload = earlier click
If contractility is increased, what happens to the click in MVP?
earlier click
signs of AVNRT
no p-waves
narrow / normal QRS complex
What can AVNRT accompany?
SVT
What are the treatment options for SVT?
vagal maneuvers
adenosine, beta blockers, Ca2+ blockers
WPW EKG
short PR
delta wave!
QRS is slightly widened
Difference between WPW and AVNRT electrically
WPW has a bypass tract
AVNRT has re-entry circuit localized to AV node
Is WPW most likely antidromic or orthdromic?
orthdromic
Is AVNRT most likely antidromic or orthdromic?
orthodromic
Is VT most likely antidromic or orthdromic?
antidromic
especially if the QRS complexes are wide
What is common treatment of WPW?
ablation
What type of hypertrophy does aortic stenosis cause?
concentric
What type of hypertrophy does mitral regurgitation cause?
eccentric
What does a presystolic heave indicate?
an S4 / stiff LV
What does bicuspid AV predispose you to?
aortic aneurysm
What murmur increases in intensity with less preload?
HCM
What type of disease is HCM?
genetic
High frequency diastolic murmur with opening snap indicates …
mitral stenosis
What happens to opening snap of mitral stenosis as LAP increases?
increases in LAP cause opening snap to be closer to S2
What are some signs of bacterial endocarditis?
hemorrhagic splinter, Janeway lesion (painless), Osler nodes (painful)
Why can you get a murmur from bacterial endocarditis?
fever + hyperdynamic flow due to infection
What are you likely to see on lab values due to bacterial endocarditis?
anemia of chronic disease
Aortic regurgitation murmur
diastolic murmur with decrescendo at left sternal border
If lead I is negative and lead aVF is positive, what is your axis?
axis between +90º - +180º
this is a right shift
Define the left vs right sided leads
Left: 4-6
Right: 1-3
Give the different leads and their associated MI location
Lateral: I, aVL, V5-V6 (LAD or Lcx 1)
Inferior: II, III, aVR (RCA)
Anteroseptal: V1-V4
What are the hallmarks of VT?
wide QRS
AV dissociation
RBBB vs. LBBB
RBBB: wide QRS with V1 positive
LBBB: wide QRS with V1 negative (also bunny ears)
What does digoxin look like on EKG?
peaked T-wave, scooped out ST interval, shortened QT interval
Where can you listen for ASD mumur?
in the pulmonic area
What happens to heart sounds as aortic stenosis worsens?
crescendo-decrescendo moves later in systole
S2 heart sound becomes inaudible
What can cause an S4?
longstanding HTN or HCM
“Young female, otherwise healthy” indicates what condition? What murmur should you check for? Where should you listen?
MVP
opening click with late systolic murmur
listen at apex
“Healthy young athlete with syncope” indicates what condition? What murmur should you check for? Where should you listen?
HCM
systolic murmur
listen at left sternal border
“Immigrant or pregnant” indicates what condition? What murmur should you check for? Where should you listen?
mitral stenosis
diastolic murmur with opening snap
listen at apex
“IV drug abuser” indicates what condition? What murmur should you check for? Where should you listen?
Tricuspid regurgitation
holosystolic murmur
listen at tricuspid area
What does handgrip do in general?
increases afterload and causes more regurgitation
What does increase in afterload do to MVP?
later click of MVP
What does increase in preload due to MVP?
later click of MVP
What does hang grip do to HCM?
increase afterload = transient increase in preload, so this will temporarily relieve HCM and decrease murmur
Laplace’s law and when it occurs
states that increased pressure = increased wall thickness
this occurs in AS, since to overcome increased afterload you need increased pressure. This increase in pressure will lead to increased wall thickening
What can aortic stenosis predispose you to?
aortic aneurysm
What 2 conditions can cause A2 to come quicker than P2 leading to wide splitting on expiration?
VSD and mitral regurgitation
causes persistent splitting
What would an ionotropic agent do to MVP?
ionotropic = increased contractility= decreased ESV
decreased volume = earlier click of MVP
What happens to pulse pressure in aortic regurgiation?
decreased pulse pressure in aortic regurg
Opening click at the beginning of systole that does not move with maneuvers
bicuspid aortic valve
What does aortic regurgitation lead to on carotid pulse?
big upstroke at first to make up for the extra LV volume
then, you fall back down
leads to a large atrial A-wave
What type of cardiomyopathy can aortic regurgitation cause?
eccentric cardiomyopathy
What leads to a large atrial p-wave?
mitral regurgitaiton
If you see pulsus parvus et tarvus what should you think of?
aortic stenosis
LVH on EKG
look at left sided leads V5-V6, etc
if left-sided leads have large R-waves, look and see if there is a left axis deviation too
What happens to diastolic and systolic BP during exercise?
Systolic BP rises because large arteries becomes less compliant
Diastolic BP remains largely the same
What happens to blood flow during exercise?
becomes more turbulent
What happens during aging to veins and arteries?
Veins become more compliant
Arteries become less compliant
Relationship between MSFP and CO
Increase in MSFP increases CO
What 2 mechanisms contribute to increased CO in exercise?
1) MSFP increases due to venoconstriction mediated by the sympathetic system in non-exercising areas
2) TPR decreases due to dilation in exercising arteries
What does acute blood loss due to hematocrit?
drops capililary hydrostatic pressure
leads to fluid rushing in which will dilute the % of RBCs in blood and hematocrit drops
What happens to large arteries with exercise?
they become less compliant, leading to an increase in systolic BP
What adrenergic drug has greatest and which has lowest risk of producing tachycardia?
Greatest: epinephrine
Least: norepinephrine
On PV curve, how can you tell if contractility has been affected? When is this useful to know?
If ESV has decreased, this means that contractility has increased and vice versa
This is useful when determining what change might have occurred on the curve (ex: phenylephrine affects afterload but not contractility)
What does sympathetic stimulation do to slope of vascular function curve?
Slope = 1/RVR
an increase in RVR = decreased slope
What does exercise do to slope of vascular function curve?
Slope = 1/RVR
a decrease in RVR = increased slope
What does the a-wave on pulse correspond to?
atrial contraction
What does the c-wave correspond to on pulse?
right ventricle contraction
With massive blood loss, what will sympathetic system to?
constrict veins
What 2 things is the cardiac function curve affected by?
contractility
afterload
What 2 things is the vascular function curve affected by?
blood volume (MSFP)
venous tone (MSFP)
resistance (affects slope 1/RVR)
Difference in dilating arteries vs. veins
Veins - decrease preload
Arteries - decrease afterload
Harsh late-peaking systolic murmur heard at cardiac base and LSB describes what?
HCM
Carcinoid syndrome indicates …
a problem with the right side of the heart
Narrow splitting of S2 indicates? (right-sided)
Tricuspid regurgitation is causing less blood to need to flow across pulmonic valve
This leads to P2 closing earlier and a narrow splitting
Orthodromic AVRT looks like …
narrow complex tachycardia
Antidromic AVRT looks like …
wide complex tachycardia
What are question stem clues that point you to VT rather than antidromic AVRT?
history of ischemic CM and previous scarring
What phase do class III drugs work on?
phase 2 and 3 of the myocyte action potential
Rhythm vs rate control drugs and associated cardiac action potential
Rhythm: I+III, normal cardiac action potential
Rate: II + IV, SA node
How does adenosine work?
slows SA depolarization and AV nodal conduction
reduces the slope of phase 4 of the pacemaker as well
How does digoxin work?
inactivates the Na-K ATPase pump
more intracellular Na+ = more Ca2+
(also activates parasympathetic; therefore, increases contractility without increases HR)
What corresponds to large v-waves on atrial pressure tracing?
mitral or tricuspid regurgitation
When determining eccentric vs. concentric what can you think about?
Eccentric = more volume (regurgitation can cause)
Concentric = more pressure
What type of hypertrophy does dilated cardiomyopathy display?
volume overload = eccentric hypertrophy
Acute respiratory distress with new holosystolic murmur post-MI indicates …
papillary muscle rupture with mitral regurgitation
Can mitral stenosis cause pulmonary HTN?
yes
mitral stenosis can increase LAP and lead to pulmonary HTN
What is the cause for Afib post MI?
increased LV tension causes increased pressure which increased your risk for AFib
Patient presents with NSTEMI what would be initial thrombolytics?
aspirin, heparin, clopidogrel
What receptor does adenosine work through?
alpha 1
What interval do class 1B drugs shorten?
QT interval
What does tricuspid regurgitation due to JVP?
large JVP due to right atrial back up
What side effects can non-cardioselective B-blockers have?
1) Wheezes / bronchospasm since they work on the lungs (B2)
2) PR interval prolongation (since work on rate control)
What does mild bradycardia with good perfusion indicate?
neurocardiogenic reflex
When do we see neutrophils post-infarct?
1-3 days
When do we see macrophages post-infarct?
3-5 days
Why does stable angina occur?
in post-stenotic regions the vessels are already dilated
they really can’t stretch anymore during exercise to accomodate the increased O2 demand which leads to angina
When is Prinzmetal angina triggered?
in the cold
with circulation issues
What is a common rhythm that occurs post-MI?
AIVR
rate of ventricle contraction goes faster than p-wave
What do you do for AIVR?
continue to observe on telemetry
normally benign and resolve on their own
How do you treat VT?
cardioversion
When do you need to implant a ICD in VT?
if under 48 hours post-MI, you don’t need ICD
if over 48 hours post-MI, scarring has made this happen and there is an increased risk of this happening again. You should get an ICD
Red vs. white clots
Red = coagulation cascade
White = platelets
What drug shows tachyphylaxis? What should you do?
nitrates
you should give a nitrate-free interval
this interval can cause headaches
Xanthoma indicates …
deposition of lipids
familial hypercholesterolima
also corneal arcus
What do you need to do prior to cardioversion
probably need to anticoagulant unless Afib is known to have JUST started
What 3 drugs lower triglycerides?
Niacin
Fibrates
Fish oils
What 3 drugs lower LDL?
statins
Zetia (ezetimide / bile acid resins)
PCSK9-inhibitors
