1
Q
MC cause of cardiomyopathy
A
Cocksackie B Virus
2
Q
Digoxin: Mechanism
A
- Blocks Na/K ATPase which causes buildup of intracellular Ca → increased contractility
- Increases parasympathetic tone by acting on Vagus nerve → decreased rate of AV conduction
3
Q
Digoxin: Toxicity
A
- Toxicity: yellow-green vision, arrhythmia (potentially fatal)
- Hyperkalemia in acute digoxin toxicity, but hypokalemia makes patient more susceptible to effects of digoxin
4
Q
Endocarditis in IV drug users
A
Staph Aureus
5
Q
Endocarditis w/ S. Bovis
A
Colon Cancer
6
Q
Endocarditis w/ Prothetic Valves
A
S. epidermis (if 60 days)
7
Q
Endocarditis after Dental Procedure
A
Viridans/Mutans
8
Q
Chemoreceptors: Central vs Peripheral
A
- Central: (in medulla) senses high CO2
- Peripheral: (in carotid and aortic bodies) senses low O2, and also high O2
9
Q
Chemoreceptors in COPD
A
Blunted response to pCO2 (hypercapnia)
10
Q
Carotid Sinus
A
- Most of BP regulation (responsible for 80% of the response to hypotension)
- Fires more with HTN (increased stretch) and tachycardia
- Cut nerve connections → less signals → body thinks it is hypotensive → HTN + tachycardia
11
Q
Carotid Sinus Massage
A
Causes parasympathetics to decrease the AV node conduction (by prolonging the refractory period)
12
Q
Baroreceptors: Carotid vs Aortic
A
- Stretch increases signals
- Carotid: afferent is glossopharyngeal (hering’s nerve); Both increases and decreases in BP sensed
- Aortic: afferent is vagus; Only increases in BP sensed
13
Q
VSD Murmur
A
Loud holosystolic murmur
14
Q
ASD Murmur
A
Wide, fixed splitting of S2
15
Q
Mitral Regurgitation Murmur
A
Holosystolic blowing murmur radiating to apex (aw/ Rheumatic fever)
16
Q
Aortic Regurgitation Murmur and Signs
A
- Blowing diastolic murmur (decrescendo)
- Loudest in early diastole, end of expiration
- Quinke pulse, and head bobbing
- Wide/Increased pulse pressure
17
Q
Delayed Closure of Pulmonic Valve Sound
A
Wide, fixed split S2
18
Q
Mitral Valve Prolapse Murmur
A
Mid-systolic click with a regurgitation murmur following
19
Q
Mitral Stenosis Murmur
A
Opening snap w/ diastolic rumble
aw/ Rheumatic Heart Disease
20
Q
Aortic Stenosis Murmur
A
Crescendo-decrescendo (systolic)
21
Q
Aortic Regurgitation Murmur
A
Decrescendo (diastolic)
22
Q
Effect of Digoxin w/ Diuretic
A
Hypokalemia –> PVC (premature ventricular contractions)
23
Q
Subendocardial infarction can be a result of _____
A
Prolonged hypotension
24
Q
Dressler’s Syndrome
A
Autoimmune pericarditis 2-10 wks post-MI
25
Senile Cardiac Amyloidosis
Transthyretin
26
Amyloid Light Chain (AL) vs Amyloid Associated (AA)
AL: primary/systemic
AA: secondary or autoimmune
27
Wedge Pressure
- Should equal left-ventricular end diastolic pressure
| - If wedge is much higher, then indicates stenosis of mitral valve
28
Valve Affects w/ IV drug use
Tricuspid --> regurgitation
29
Mitral Stenosis
Right atrial pressure is much greater than left ventricular pressure near the end of diastole
30
Bicuspid Aortic Valve
Aortic stenosis w/ ejection click
- aw/ Turner's
- Calcifies due to wear and tear after age 60
31
Pressure Volume Loop: Contractility
Increased Slope
32
Pressure Volume Loop: Stroke Volume vs Preload
SV: Increased Width
Preload: Increased Width to the Right
33
Pressure Volume Loop: Arterial Pressure/BP
Increase height
34
Churg-Strauss
Vasculitis w/ eosinophilia
- aw/ atopic dermatitis and asthma
- granulomatous
- MPO and p-anca
35
Metoprolol + Thiazides cause ______
Dyslipidemia
36
Pathophysiology of Aortic Dissection
```
Medial change (cystic medial degeneration w/ intimal tear)
- smoking and high BP
```
37
Pathophysiology of Aneurysm
Intimal streak (atherosclerosis)
- MC abdominal
- Thoracic in Marfan's
38
Infective Endocarditis
o Fever, new murmur, janeway lesions, osler nodes, roth spots, and splinter hemorrhages
39
Endocarditis w/ Negative blood cultures
HACEK (difficult to grow)
40
____ can Infect Normal/Undamaged Valves
Staph aureus
41
Non-infective Endocarditis: Causes
- Hypercoagulable state associated vegetations
- Underlying adenocarcinoma
- Libman Sacks
42
Libman-Sacks:
Non-infective endocarditis (aw/ SLE): vegetations on surface and undersurface
43
Severity of a MR Holosystolic Murmur Indicated by ______
Presence of S3 gallop
| - Accentuated on expiration
44
Dilated Cardiomyopathy: Sound and Causes
(S3 - Kan- kakee)
[turbulent blood flow into ventricles, heard during rapid filling]
- coxsackie B myocarditis, genetic mutation (in cytoskeletal proteins like dystrophin or mitochondrial enzymes of ox phos), alcohol, doxorubicin, pregnancy, hemochromatosis
45
Hemochromatosis: Defect
HFE defect (intestinal absorption)
46
Hypertrophic Cardiomyopathy: Sound and Cause
(S4)
[Heard immediately after atrial contraction as blood is forced into stiff ventricle]
- usually genetic cause (Genetic mutation in sarcomere proteins [disorganized])
- Syncope with exercise due to functional aortic stenosis due to hypertrophied ventricular septum
- LV obstruction due to anterior leaftlet of mitral valve and hypertrophied interventricular septum
- normal coronary arteries
47
Restrictive Cardiomyopathy: Effect and Causes
- Low QRS amplitude
- Decreased compliance
- Loffler syndrome, amyloidosis, or sarcoidosis
48
Loffler Syndrome
Endomyocardial fibrosis and eosinophilia that causes Restrictive Cardiomyopathy
49
Rhabdomyoma
MC primary tumor of heart in children
| - aw/ Tuberous Sclerosis
50
Hyaline Arteriolosclerosis
From benign hypertension or diabetes
51
Hyperplastic arteriolosclerosis
From malignant hypertension
| - onion skinning of arterioles
52
Buerger's Disease
Segmental vasculitis in Asian male smokers → claudication and gangrene/ulcers
53
Nitrates: Mechanism/Effects
Act primarily as venodilators to relieve stable angina by decreasing preload
- Can cause reflex tachycardia
54
Treat Nitrate-induced Reflex Tachycardia w/ _______
Beta blockers
55
Polyarteritis Nodosa
Transmural inflammation of arteries w/ fibrinoid necrosis
- Fever, malaise, melena, weight loss
- Hep B in 10-30%
56
Alpha-1 (3 effects)
- Vasoconstriction
- Dilates (mydriasis)
- Contracts sphincters of bladder and intestine
57
Beta-2 (6 effects)
- Relaxes uterus (inhibits contractions)
- Bronchodilation
- Ciliary muscle relaxation
- Increase aqueous humor
- Increase insulin release
- Vasodilation
58
Treat Hypertensive Emergency w/ ______
Nitroprusside or Fenoldopam
- Nitroprusside (equal effect on arteries and veins --> decreases preload and afterload)
- Fenoldopam (arterial dilation and natriuresis)
59
Pulsus Paradoxus Definition
Decrease by greater than 10 in systolic BP on inspiration) (eg. w/ cardiac tamponade)
60
Assessing Pulsus Paradoxus
- Inflate a cuff above systolic, slowly release and will only hear Korotkoff sounds on expiration, keep lowering and will hear it throughout
- Inspiration causes increased venous return → increased right heart volume (normally this should have little effect on left side) but in conditions impairing expansion into pericardial spaces (tamponade, restrictive pericarditis etc ) → increased RV pressure pushes IV septum towards left and blocks outflow → decreased systemic BP on inspiration
61
Treat B-Blocker Overdose w/ _______
Glucagon
- Raises HR and Contractility independent of adrenergic receptors
- Increases cAMP in cardiac myocytes
62
Conduction Velocity: Fast to Slow
Purkinje > Atrial muscle > ventricular muscles > AV node
| - (park at ventura avenue)
63
Myocardium Stops Contracting at ____ of ischemia
1 min
64
Myocardial Damage Irreversible After _____
30 min (If ischemia resolves in less than 30, contractility will gradually return to normal (hrs-days))
65
Cardiac Output Equation
CO = O2 consumption / arteriovenous difference in O2 content
or
CO = SV*HR
66
Carcinoid Syndrome and Tumors
- Fibrous endocardial thickening in right side of heart because MAO in lung breaks down the serotonin and bradykinin before reaching left side
(Pulmonic stenosis and/or restrictive cardiomyopathy)
- 5-HIAA in urine
- Carcinoid Tumors: uniform nests or glands; minimal to no variation in cell size and shape
- MC in the ileum; frequently in appendix and rectum; derived from enterochromaffin cells
- No sx till it metastasizes
67
Jugular Venous Pulse Curve: a,c,x,v,y
a: R atrial contraction
c: R ventricle contraction → bulging of tricuspid
x: R atrial relaxation
v: Inflow of venous blood
y: Tricuspid opens → passive emptying of R atrium
68
Romano-Ward
QT prolongation (congenital): K+ channel mutation w/out deafness
69
Jervell-Lange-Neilson
QT prolongation (congenital): K+ channel mutation + deafness
70
Nitroprusside --> Cyanide Toxicity
Nitrites convert Fe2+ to Fe3+ Methemoglobin which binds cyanide tightly
71
Treating Cyanide Toxicity
- Amyl Nitrite followed by Thiosulfate to excrete it
| - Can also use hydroxycobalamin
72
Adenosine: Mechanism and Side effects
- Very fast acting antiarrhythmic
- Slows AV node conduction to treat paroxysmal SVT
- Side effects: flushing, chest burning, hypotension
73
_____ Increases VSD Holosystolic Murmur
Handgrip → increases afterload
74
Systolic pressure gradient between the left ventricle and aorta is suggestive of _______
Left ventricular outflow (eg aortic stenosis)
| - Would not be expected in dilated cardiomyopathy
75
Transient Reperfusion Arrhythmias
Caused by fibrinolytics (tPA) but they are usually benign
76
Paradoxical emboli
Can be facilitated by atrial left to right shunts (wide flixed split S2) during periods of transient shunt reversal (straining or coughing)
77
Calcium Efflux Prior to Relaxation in Myocardium
Accomplished through Ca2+ ATPase & Na/Ca Exchange
78
Saline Infusion in a Hypovolemic Patient will _______
Increase the intravascular volume → increased preload → increased SV and CO
79
Transudate in CHF
Will have low LDH content (low in protein)
80
In newborn, catheter through umbilical vein can reach right atrium via _______
Ductus venosus (which does not completely close for a week)
81
Coronary Sinus Dilation
Coronary sinus may become dilated due to pulmonary hypertension (which increases right sided heart pressure)
82
Common Cardinal Veins become:
SVC
83
_______ Regulates Contraction of Ventricles During AFib
AV node
84
Beta-1 (3 effects)
- Renin release
- Heart contractility
- HR increase
85
Muscarinic Receptor 1
CNS and enteric nervous system
86
Muscarinic Receptor 2
Decrease HR/atria contractility
87
Muscarinic Receptor 3
Increased gland secretions, bronchoconstriction, bladder contraction, gut peristalsis, accommodation
88
Dopamine 1 Receptor
Relaxes renal vasculature
89
Dopamine 2 Receptor
In brain
90
H1 Receptor
Allergy
91
H2 Receptor
Gastric Acid
92
V1 Receptor
Vascular constriction
93
V2 Receptor
ADH Effects
94
Distributive Shock
warm and dry with decreased wedge pressure and vasodilation
95
Cardiogenic Shock
cold and clammy, with high wedge pressure and vasoconstriction
96
Hypovolemic Shock
cold and clammy, with low wedge pressure and vasoconstriction
97
Ductus arteriosis derived from ____ Aortic Arch
6th
98
Sinus Venosus (Rt and Lft Horn) → _______
- Right horn: smooth R atrium
| - Left horn: Coronary Sinus
99
Primitive Pulmonary Vein → ________
Smooth L atrium
100
Bulbus Cordis → _____
Smooth part/outflow tract of ventricles
101
Umbilical Vein → ______
Round ligament (ligamentum teres)
102
Umbilical Arteries → ______
Medial ligaments
103
Allantois → ______
Median Ligament
104
Preload Increases w/: ______, _______, & ________
- Increasing venous tone
- Increasing blood volume
- Inspiration
105
MSFP (Mean systemic pressure):
Fullness of vasculature with blood (changes with volume/venous tone); intercept with X axis
106
Right Sided Murmurs Increase w/
Inspiration (due to increased venous return)
107
S1
mitral and tricuspid close (just before contracting ventricles)
108
S2
aortic and pulmonary close (just before relaxing ventricles)
109
S3 Normal in:
pregnancy and children due to natural increased compliance
| - (seen in dilated cardiomopathy but is pathologic)
110
Non-Pacemaker Cardiac Cell Depolarization
Rapid depol by Na in → then start to inactivate → Ca influx and K efflux create plateau → Ca channels close and K continues to efflux out causing repolarization
111
Pacemaker Cell Depolarization
4-0-3
Slow depolarization by funny channels (Na influx), spontaneous depol → Ca upstroke → Ca channel inactivated and K efflux to repolarize
- Sympathetic stimulation --> chance of funny channel being open so → increased HR
112
Ach and Adenosine
- Decrease rate of depolarization to lower HR (Act on Phase 4)
- Slope of phase 4 determines HR
113
Drugs to Avoid and Use in WPW
Avoid Digoxin, beta blockers, or CCBs
| - Use IV amiodarone and procainamide
114
AV Block: 1st degree
Prolonged PR
115
AV Block: 2nd degree (Mobitz I)
Lengthening of PR till beat is dropped
116
AV Block: 2nd degree (Mobitz II)
Randomly dropped beat
117
AV Block: 3rd degree
Complete heart block, atria and ventricle beating independently
118
Adult-Type Coarctation: Increased risk of _______
Berry aneurysms and rupture of those aneurysms
119
Polymyalgia Rheumatica
aw/ Temporal Arteritis
120
Coronary Steal Syndrome
Ischemia can be worsened in areas distal to an occlusion with addition of a coronary vasodilator (eg adenosine or dipyradamole)
121
Endogenous substant that vasodilates and promotes diuresis
ANP/BNP
| - mediates aldosterone escape
122
Vascular reaction to endothelial injury
Endothelial dysfunction stimulates PDGF and smooth muscle cells to proliferate in the intima instead of the media
123
Free wall ventricular rupture
Causes pericardial tamponade --> shortness of breath and profound hypotension
124
S3 can be heard with:
Dilated Cardiomyopathy or Restrictive
125
Expiring while in decubitus position, increases __________ heart sound
S3
| - less air in lungs and heart closer to chest wall so it is easier to hear
126
Venous Return Curve Affected by:
```
hemorrhage (decreased)
fluid infusion (increased)
```
127
Cardiac Output Curve Affected by:
MI, narcotics (decreased)
| Inotropes, Chronic anemia, catecholamines (increased)
128
Isolated Diastolic Heart Failure
Filling Problem, not systolic (eg. hypertrophic cardiomyopathy)
Ejection fraction will be preserved
End diastolic volume will be Normal, but decreased compliance will cause the End diastolic pressure to be increased
129
In LV failure, accumulation of fluid in lung interstitium causes ________ compliance
decreased
130
1st line for Atrial Fibrillation
Beta blockers and Ca Channel Blockers (Digoxin is 2nd line)
131
Transesophageal Echo
Left Atrium will be anterior
| Descending Aorta will be posterior
132
Valsalva
Increases Vagal tone and can be used to abolish paroxysmal SVT tachycardia
- rectus abdominus is most important in increasing the intraabdominal and intrathoracic pressure
133
Long-term compensatory response to Aortic Regurg
Increased LV preload and Eccentric LV hypertrophy
134
Supine Hypotension Syndrome
Can be seen in pregnancy >20 weeks due to compression of the IVC by uterus reducing venous return and CO
135
Tricuspid Regurgitation
Holosystolic Murmur
| Increases with Inspiration (because it is right sided) due to increased venous return
136
Normal Aging of Heart
Decreased LV chamber size, sigmoid-shaped ventricular septum, myocardial atrophy w/ increased collagen deposition, cytoplasmic lipofuscin accumulation in myocytes
137
Salicylate Poisoning
Respiratory Alkalosis and Metabolic Acidosis
| pH slightly low
138
Aorta derived from _______ Aortic Arch
4th
139
Right Subclavian Artery derived from ________ Aortic Arch
4th
140
Third Aortic Arch Makes:
Common carotid and proximal internal carotid arteries
141
Second Aortic Arch makes:
Stapedial and Hyoid arteries
142
First Aortic Arch makes:
Maxillary Artery
143
PDA: keep open w/
PGE
144
PDA: close w/
PGE inhibitor (indomethacin) or NSAIDS (inhibits COX to prevent PG formation)
145
A1V1 =
A2V2
146
Chronic Aortic Stenosis w/ Afib
Can cause acute pulmonary edema/CHF because the hypertrophied LV depends greatly on atrial contraction to fill it. Loss of atrial contraction/kick due to afib can reduce preload and CO --> systemic hypotension and backup into LA and lungs
147
Cough Syncope
Increased intrathoracic pressure during a coughing episode decreases venous return --> transient decrease in CO and cerebral perfusion
148
IVC Obstruction
Symmetric bilateral lower extremity edema and often prominently visible abdominal wall collateral venous circulation
149
Cardiac Tamponade
- Electrical alternans means a big pericardial effusion (and usually cardiac tamponade)
- heart cannot fill properly, preload decreases
- hypotension and tachycardia
- fluid backup leads to elevated JVP (pulsus paradoxus)
- distant heart sounds
150
Effect of Lyme Disease on Heart
Carditis causing 3rd degree heart block
151
Isolated Systolic Hypertension
Commonly an age-related stiffening (decrease in compliance) of aorta
152
Aschoff Bodies
Interstitial myocardial granulomas
Typically found in acute rheumatic carditis
(caterpillar cells)
153
Abnormal migration of neural crest cells through primitive truncus arteriosus and bulbis cordis
Tetralogy of Fallot
Truncus Arteriosus
Transposition of Great Vessels
154
Most useful measure for assessing degree of Mitral Stenosis
A2 to opening snap time interval
| closure of aortic valve to opening of mitral
155
Nitroglycerin vs Nitroprusside
Nitroglycerin: dilates veins --> decrease preload
Nitroprusside: dilates veins and arteries --> decrease both preload AND afterload
156
MC Cardiac Abnormality predisposing to Native Valve Bacterial Endocarditis
Mitral Valve Prolapse
157
Myxomatous changes in media of large arteries predisposes to development of: ________ and ________
aortic dissections and aortic aneurysms
| cystic medial degeneration
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