Witwer CV study guide Flashcards
Do the coronary arteries fill during systole or diastole?
Diastole
What determines the coronary dominance of a heart?
The posterior interventricular branch. If it arises from the left coronary artery the heart is left coronary dominant, if it arises from the right coronary artery, it is right coronary dominant.
Why can tachycardia cause myocardial ischemia? At what rate do we have concern?
If the heart is beating too fast, there is not enough time during diastole for the coronary arteries to get adequate blood supply. Rates above 180 decreases filling time
What is more common, right or left coronary dominance?
Right- 70%
Left -10-15%
Remainder of people are codominant
What are the branches of the left coronary artery?
Left anterior descending
Left circumflex
What are the branches of the right coronary artery?
Right marginal branch
Post Interventricular branch (most commonly)
What areas of the heart are supplied by the LAD?
Ant. left ventricle
Ant. 2/3 of interventricular septum (IVS)
Apex of heart
What areas of the heart are supplied by the left circumflex artery?
Lateral wall of left ventricle
What areas of the heart are supplied by the right coronary artery?
Posterobasal wall of left ventricle
Post. 1/3 of IVS (If right coronary dominant)
Right ventricle
AV and SA nodes
posteromedial papillary muscle in left ventricle
What is the most common place to have a coronary artery infarction?
Right coronary artery - 45%
4 types of ischemic heart disease?
Angina Pectoris
Chronic ischemic heart disease
sudden cardiac death
Acute myocardial infarction
Name some risks of ischemic heart disease
Male>female Advanced age Smoking HTN Lipid abnormalities DM
Underlying cause of majority of ischemic heart disease?
Hardening of the gruel (atherosclerosis)
Are patients with angina at risk for an AMI?
Yes, 10-20% of patients with angina have an AMI or unstable angina within 1 year of onset
Major difference between stable and unstable angina is ________.
A. Unstable is caused by an embolus
B. Unstable angina occurs at rest, while stable is relieved with rest
C. Stable angina occurs at rest, while unstable angina is relieved with rest
D. Unstable angina is less severe
B. Unstable angina occurs at rest, while stable angina is relieved with rest
What is the most common cause of stable angina?
Fixed atherosclerotic coronary vascular disease
What is a common EKG finding in angina?
ST depression. Depression indicates ischemia.
What is prinzmetal angina?
vasospastic angina. Caused by coronary artery vasospasms at rest, with or without ASCVD.
What is a foam cell?
Foam cells are macrophages that have migrated into the intima of an artery and taken in lipids.
What makes up a plaque?
Lipids from dead macrophages and cholesterol accumulates into a plaque
What is more common, essential or secondary hypertension?
Essential hypertension - makes up 85% of HTN
Two major determinants of systolic blood pressure
Stroke volume and compliance of the aorta
What determines the stroke volume?
Preload, afterload and contractility
Major determinant of diastolic blood pressure
Peripheral vascular resistance
Arterial smooth muscle contraction would increase or decrease diastolic BP?
Increase. Smooth muscle contraction increases peripheral vascular resistance
How does excess sodium effect BP?
It increases systolic and diastolic BP
By what mechanism does sodium increase systolic BP?
Increases plasma volume which increases stroke volume
By what mechanism does sodium increase diastolic BP?
Excess sodium produces vasoconstriction of peripheral arterioles, which increases peripheral vascular resistance.
T/F? Incidence of HTN is higher in Caucasians when compared to African Americans.
False. HTN is more common in African Americans
What is malignant hypertension?
Rapid increase in BP accompanied by renal failure and cerebral edema
What is concentric hypertrophy of the heart?
Reduction in the chamber dimension. Increase in wall thickness, capable of generating greater force.
Is concentric hypertrophy of the heart caused by pressure overload or volume overload?
Pressure overload
What is eccentric hypertrophy of the heart?
Normal wall thickness but increased size of the chamber of the heart.
Sarcomeres can be added in parallel or in series. Which way are they added for concentric and eccentric hypertrophy?
Concentric - sarcomeres added in parallel
Eccentric - sarcomeres added in series
What is secondary hypertension?
HTN secondary to another condition
Name a few causes of secondary HTN
Cushing syndrome, pheochromocytoma, neuroblastoma, hyperaldosteronism, coarctation of the aorta, Renal stenosis, Pre-eclampsia Graves disease
What is the organism responsible for rheumatic heart disease?
Group A Strep
Describe the pathogenesis of rheumatic fever
Antibody is created against group a strep M proteins.
These antibodies cross react with similar proteins in human tissue, causing a type II antibody mediated hypersensitivity reaction
What is the most serious complication of rheumatic fever?
Carditis
Antibodies attack heart, causing valvular diseases and heart failure
What is the most common finding in rheumatic fever?
Migratory polyarthritis - 75% of rheumatic fever pt’s have this symptom
Inclusion criteria of the Jone’s criteria
A patient must have evidence of a prior group a strep pharyngitis infection in order to use to jones criteria
How many criteria are necessary to meet the jones criteria?
Either 2 major or 1 major and 2 minor
What are the major jones criteria?
Carditis, migratory polyarthritis, erythema marginatum, or subcutaneous nodules
What are the minor jones criteria?
Previous RF, arthralgia, fever, elevated acute phase reactants, and prolonged PR interval on EKG
What is the purpose of doing an ASO test on a patient with sx of RF?
Shows if the patient has had a group a strep infection
T/F? The cardiac skeleton is made of high density collagenous connective tissue?
True
Function of the cardiac skeleton?
Forms and anchors the valves. Also prevents signals from the SA node from going straight to the AV node, creating a delay.
What are the components of the cardiac skeleton?
The left and right fibrous rings of the heart, with the left being stronger than the right
What valvular disease is common secondary to rheumatic fever?
Mitral valve stenosis
What is mitral valve stenosis?
Narrowing of the mitral valve orifice to less than 2.5cm (normal is 4-6cm)
T/F? Mitral valve stenosis is more common in men.
False, it is more common is women
Describe the murmur heard with mitral valve stenosis
Opening snap followed by early to mid diastolic rumble
What is mitral valve regurgitation?
Regurgitation of blood during systole from left ventricle back into left atrium
What is the most common cause of mitral valve regurg?
Mitral valve prolapse
What is most common? Mitral valve stenosis, mitral valve regurgitation, mitral valve prolapse
Mitral valve prolapse
What is mitral valve prolapse?
When the leaflets of the mitral valve bulge into the left atrium during systole.
Describe the heart murmur associated with MV prolapse
Mid systolic click with mid to late regurgitation murmur
What is the most common of all valvular lesions?
Aortic valve stenosis
If a patient has aortic valve stenosis under age 60, what should you think of?
Congenital bicuspid aortic valve.
What is the likely cause of aortic valve stenosis at age greater than 60?
Calcification of the aortic valve
What is the normal aortic valve orifice area, and when do symptoms appear?
normal is 3cm^2, symptoms appear at 1cm^2 and symptoms are severe at 0.5cm^2.
Describe the murmur of aortic stenosis?
Harsh systolic ejection murmur in right second intercostal space with radiation to neck
What is the most common cause of aortic valve regurgitation?
aortic root dilation
Aortic valve stenosis causes what type of hypertrophy?
Concentric left ventricular hypertrophy secondary to pressure overload
Describe the murmur of aortic valve regurgitation
Early diastolic murmur with s3 and s4 sounds. AKA Austin Flint murmur
A patient is found to have a widened pulse pressure, head nodding with systole (deMusset sign) and a Quincke Pulse in the nailbed. These should lead you to what diagnosis?
Aortic valve regurgitation
Most common cause of tricuspid valve regurgitation
Right heart failure streching the cardiac ring
The following clinical findings should make you think of what diagnosis?
Pulsating liver on ultrasound, JVP with C-V wave
Pansystolic murmur heard along left sternal border
Tricuspid regurg
What valvular disease would be caused by stretching of the pulmonary valve ring?
Pulmonary valve regurg
Most common pathogen of acute endocarditis?
Staph aureus
T/F? The right sides heart valves are more commonly involved in endocarditis.
False, left sided valves involved 90% of the time.
What pathogens are associated with subacute endoarditis
Strep viridans, S bovis, enterococci
What symptoms are attributed to microembolization in endocarditis?
Splinter hemorrhages, janeway lesions, osler nodes
What is Kussmaul sign?
Kussmaul sign is blood refluxing back into neck veins on inspiration
What is pulsus paradoxus?
It is a palpable decrease in systolic BP upon inspiration
What should you think of if a patient has Kussmaul sign and pulsus paradoxus?
Pericardial effusion
What is Beck’s triad of cardiac tamponade?
Hypotension, JVD, muffled heart sounds
A shit load of things can cause myocarditis, try naming a few.
Viruses (adenovirus, coxsackie virus, parvovirus, herpes virus 6, HIV)
Parasites (trypanosoma cruzi (Chaga’s dz), trichinella, toxoplasmosis)
Bacteria (Borrelia burgdorferi, mycoplasma, rickettsia rickettsii)
Fungi (candida, mucor, aspergillus)
Toxins, drugs, RF, and collagen vascular diseases can also cause it
Which of the following is not caused by myocarditis?
A. Global enlargement of the heart
B. Lymphocytic infiltration with areas of necrosis
C. Cardiac dysfunction
D. Dextrocardia
D. Dextrocardia
