1
Q
What does the truncus arteriosus become?
A
- Ascending aorta
2. Pulmonary artery
2
Q
What does the bulbus cordis become?
A
Becomes the conus cordis with inturn becomes the smooth part of L/R ventricular outflow tracks
3
Q
What does right / left horn of sinus venosus become?
A
Right: Smooth part of right atrium
Left: coronary sinus
4
Q
What forms the SVC?
A
Right anterior cardinal vein and common cardinal vein
5
Q
Where does the SVC drain?
A
Right side of heart
6
Q
When does heart start beating?
A
4th week, think, “4 chambers” and also 4 limbs
7
Q
What is dextrocardia?
A
When heart is located in right side of thorax
- Spleen and liver often commonly switched as well
8
Q
What is kartagener syndrome?
A
Mutation in L to R dynein microtubule protein of cillia:
- Dextrocardia
- Infertility
- URIs
9
Q
What is the septum primum?
A
- Small piece of tissue to come down between L / R atria forming the ostium primum
- Reaches down to fuse w/ endocardial cushion
- Once it connects to cushion on bottom, top undergoes apoptosis forming ostium secundum
10
Q
What happens when septum primum fuses with endocardial cushion?
A
- Ostium secundum forms where septum primum was so R/L atria still have a communication
- Septum secundum begins to come down to flap over it `
- Septum 1 / 2 are now flapping next to each other with one coming from top and one from bottom
11
Q
What is an ostium?
A
Synonym for foramen
12
Q
What becomes the foramen ovale?
A
The foramen secundum
13
Q
What is the goal in forming foramen ovale?
A
- Creating a valve / flap to prevent blood flowing from left to right atrium
- The septum primum at bottom is acting as valve with higher pressure in R atria allowing it to open
- Blood can / and is wanted to flow R / L allowing oxygenated blood from mother to enter L atria
14
Q
What happens to foramen ovale at birth?
A
- Pressure in R atria drops dramatically as pulm circuit opens when baby breathes
15
Q
What is the fossa ovalis?
A
Remnant of the foramen ovale once pulm circuit opens and the septum 1 / 2 push together and fibrose
16
Q
What is an embolism on brain indicative of?
A
Patent foramen ovale allowing DVT to move from R to L atria and into brain
***Normally DVTs will embolize in lung
17
Q
What is cause of paradoxic embolism in brain?
A
Patent foramen ovale
18
Q
Does muscular part of ventricular septum form from top of bottom of chambers?
A
Left and right ventricular muscular walls meet medially at bottom pushing muscle up from bottom to top
- Interventricular foramen is left and will be close by membranous interventricular septum coming from top
19
Q
What is membranous interventricular septum derived from?
A
- Endocardial cushion
- Comes from top to bottom to close ventricular foramen
- **More likely to break as muscle is stronger
20
Q
What causes transposition of great vessels?
A
Failure of AV septum to properly rotate is it descends
21
Q
What is problem of great vessel transposition?
A
- Aorta connected to RV
- Pulm A connected to LV
22
Q
What is necessary for great vessel swapping to be viable?
A
One of the following allowing blood to mix:
- VSD
- ASD
- Patent ovale
23
Q
Cause of tetralogy of fallot? What is seen?
A
Anterior and lateral displacement of of ventricular septum:
- Pulmonary stenosis
- Open VSD with R -> L shunt
- RVH
- Overriding aorta: sits over VSD
24
Q
What is persistent truncus arteriosus?
A
- No septum formed to separate pulm artery and aorta
- One vessel draining both ventricles
25
What forms valves?
Endocardial cushion tissue
26
What is an atretic valve?
Valve that does not form
27
Which side is tricuspid on?
RIght
28
What is an atretic tricuspid valve?
- One that does not effectively separate Right A / V
| - RV becomes extremely tiny and LV is huge
29
What is ebstein's anomaly?
- Problem with apoptosis of tricuspid = leaflets tethered to myocardium
- Right ventricle becomes atrialized as it appears RA descends into RV
30
When does fetal erythropoiesis being?
Week 3 in the yolk sac
31
When and where is fetal blood made?
```
"Young liver synthesizes blood"
Yolk sac
Liver: week 6 - birth
Spleen: 10 - 28 week
Bones: week 18
```
32
What happens in beta thalassemia?
Hepatosplenomegaly because parts of body that synthesized blood in utero not begin to do so again
33
Why does fetal hemoglobin have higher O2 binding affinity?
Binds 2-3 BPG much less avidly
34
What is 2-3 BPG byproduct of? What does it do?
- Glycolysis
- Binds and stabilizes deoxy hgB decreasing O2 binding
- This occurs to increase O2 delivery
35
Where is highest fetal O2 saturation?
Umbilical vein
36
Fate of blood in umbilical vein?
Portal circulation / vein: 1/3
| Ductus venosus: other 2/3 bypasses liver
37
What does ductus venosus connect to?
IVC bypasses liver
38
What do the great vessels supply?
The brain
39
What type of blood is in SVC in fetus? To where does it go
- Very low oxygenation as it is returning blood from brain
- Heads to RV or lungs
- The rest is shunted across ductus arteriosus which is AFTER great vessels as we do not want low O2 blood going to brain
- Allows deoxygenated blood to aorta then to veins and umbilical artery
40
What happens to DA when baby is separated from placenta?
- High O2 in lungs = dilation
| - Cutting cord = great decrease in PGE2 causing uterus and DA to contract
41
What is ligamentum arteriosum?
Remnant of ductus arteriosus
42
What drug closes PDA?
- Want to inhibit COX to drop PGE
| - INDOMETHACIN is drug of choice
43
What is allontos?
- Outgrowth of yolk sac helping form umbilical vessels
- Proximal portion drains urinary bladder and becomes urachus
- Normally becomes median umbilical ligament
44
What do umbilical arteries become?
Medial umbilical ligament
45
What is median umbilical ligament derived from?
Urachus
46
What does umbilical vein become?
Ligamentum teres hepatis
47
What is fossa ovalis?
Remnant of foramen ovale
48
What is remnant of ductus arteriosus?
Ligamentum arteriosum
49
What loops the ligamentum arteriosum?
Left recurrent laryngeal nerve
50
What does PDA sounds like?
Pan systolic / diastolic machine like murmur
51
Infection associated with congenital PDA?
Rubella
52
What is a holosystolic murmur at left sternal border?
VSD
53
What does sorbitol dehydrogenase turn sorbitol into?
Fructose
54
What does RNA polymerase I, II, III do?
I: Ribosomal RNA, only in nucleolis
II: Messenger RNA
III: tRNA
55
Does a larger or smaller alveoli have higher pressure in it?
Smaller, causing air to flow into larger alveoli
56
What does surfactant do?
Decreases surface tension
57
What allows for an indirect inguinal hernia?
Patent processes vanginalis
58
What can patent process vanginalis lead to?
1. Hydrocele
| 2. Indirect inguinal hernia
59
Type of hernia seen in kids?
Indirect inguinal
60
Difference between malingering and factitious disorder?
In malingering you are looking to gain something tangible, nothing other than attention is gained in factitious
*Goal is to assume sick role in factitious
61
What does the 12th rib overly?
Kidney
62
Treatment to prevent HIV transmission if woman is pregnant?
Antiretrovirals
63
What does V1 / 2 stimulation cause?
V1: vasoconstriction and PG release
V2: ADH response
64
What do the Various HPVs cause?
1 - 4: skin warts
6, 11: Condyloma accuminata
16, 18: Cancer
65
What drains the testes?
Para aortic nodes
66
What do the deep inguinal nodes drain?
1. Glans penis
2. Superficial nodes
3. Posterior calf
67
What do superficial inguinal node drain?
1. Scrotum
| 2. Nearly all cutaneous lymph from belly button to feet
68
Sign of chronic organ rejection?
1. Vascular wall thickening q
| 2. Fibrosis
69
What are the causes of early cyanosis?
Right to left shunts "eaRLy"
1. Truncus arteriosus
2. Transposition of great vessels
3. Tricuspid atresia
4. Tetralogy of Fallot
5. TAPVR
70
What is persistent truncus arteriosus? Other defect often associated?
- Septum that divides ascending aorta and pulm artery did not develop
- Caused by failure of neural crest cells
- Blood from R/L V are mixing before leaving heart
* *Almost always seen with VSD as the septum that would divide great vessels would also form membranous portion of ventricular septum
71
What is transposition of great vessels?
- Aorta comes off RV
- Pulm artery comes off LV
* **Blood does not mix at all so another defect is necessary to make viable
72
What is tricuspid atresia? What is needed to make viable?
- Little to no communication between RV/RA
| * **ASD and VSD necessary for life
73
What is happening in tetralogy? Treatment?
1. VSD
2. Overriding aorta
3. Pulmonary artery stenosis: forces blood through VSD which is where cyansosis comes from
4. RVH
***Boot shaped heart seen on CXR
Fix the VSD
74
What is boot shaped heart on CXR indicative of?
Tetralogy of Fallot
75
What is a tet spell?
- Cyanosis seen in kid with tetralogy of fallot due to decreased O2 flow to brain
- Fix by doing a squat to increase PVR which forces blood back through pulmonary circulation
76
What is a kid squatting indicative of?
Tetralogy of fallot
77
What is TAPVR?
- Both R/L pulmonary vein drain to RA
| - Should be going to LA so no oxygenated blood is making to body
78
What is Ebstein anomaly? Cause?
- Often caused by Li
- Tricuspid valve does not separate and is tethered down to RV wall causing extension into RA "Atrialization of RV"
- Massive tricuspid regurg since valves can't close
- Right sided HF is main game
79
What is atrialization of RV indicative of?
- Ebstein anomaly
80
What are the L -> R shunts in order of frequency?
VSD > ASD > PDA
| *VSD most likely to close on own
81
Normal cause of VSD?
- Endocardial cushion defect leading to failure of membranous portion of septum
82
What makes the ostium secundum? What causes senundum ASD?
- Perforation in septum primum during development
| - Septum secundum does not grow to cover ostium
83
Where does the DA connect?
- Connects aortic arch distal to L subclavian
- Is connecting the pulm artery and aorta
- Allows blood to flow from RV to aortic arch while in womb to go to lower body
- Foramen ovale is sending blood from R->L though great vessels to upper extremities
84
What happens in PDA?
- Pulm vascular resistance has dropped so oxygenated blood from aorta is shunted back into lungs rather than rest of body
85
Continuous machine like murmur?
PDA
86
Presentation of PDA?
- Machine like murmur
- Upper extremities well perfused because great vessels are before PDA
- However, when heads for descending, blood is shunted to lungs as lower resistance = lower extremity cyanosis
87
What is eisenmenger syndrome?
- Reversal of L/R shunt to R/L shunt
- Increase in pulmonary flow from L/R = vascular remodeling and pulm HTN = reversal of shunt as systemic is now lower pressure
* **Late cyanosis as remodeling takes time
88
What does endothelin 1 do?
1. Vasoconstric
| 2. Recruit vascular smooth muscle
89
How does clubbing occur?
- Low O2 in blood
90
Associations with Coarctation of aorta?
1. Turner syndrome
| 2. Bicuspid aorta
91
Presentation of coarctation?
- BP in upper extremities > lower
92
Blood flow in coarctation?
1. Narrowing of descending aorta pushes blood to Internal thoracic
2. From thoracic to anterior intercostals, to posterior intercostals
3. Posterior connects with aorta distal to coarctation = normal flow resumed
* **Leads to characteristic notching under ribs
93
Where do intercostals run related to ribs?
Inferior
94
What is rib notching indicative of?
Coarctation of aorta
95
What is misplaced in tetralogy?
Infundibular septum
96
Presentation of fetal alcohol syndrome?
1. Thin upper lip
2. Small eye openings
3. Smooth philtrum
4. Short palpebral fissures
5. VSD / ASD / PDA
97
Cardiac effects of Down syndrome?
- Endocardial cushion defects as chromosome 21 codes for this area
- Cushion = septum formation
- Ostium primum ASD
98
CV problems in diabetic mother?
- Transposition of great vessels
99
CV problem in marfans?
1. Mitral valve prolapse
2. Aortic regurg
3. Aortic aneurism from weak walls
100
What does Li put the heart at risk or?
Ebstein's anomaly
101
Heart association in turner's?
1. Bicuspid aorta
| 2. Coarctation
102
Cardiac anomaly in Williams syndrome?
- Supravalvular aortic stenosis
103
What does mutation in 22q11 cause re. heart?
1. Tetralogy
2. Truncus arteriosus
* *Problem with neural crest communication
104
What does BP need to be for HTN and urgency?
HTN: > 140
Urgency: > 180
105
Normal cause of secondary HTN?
RAAS activation:
1. HYPERaldosteronism
2. Decreased RBF
106
What is fibromuscular dysplasia?
- Cause of secondary HTN in young women
| - Fibrosis of tunica media leading to aneurysmal like dilatation of artery blocking renal blood flow
107
Tunica layers of vessels from in to out?
1. Intima
2. Media
3. Externa
108
What is happening in papilledema?
- Swelling of optic disk
- Sign of hypertensive emergency
- Caused by swelling = decrease drainage of CSF out of eye area
- Increased pressure damages retinal A/V
109
What is vasa vasorum?
Small vessels providing outer layers of vessels with flow
110
What is corneal arcus?
- Blue ring in cornea from deposition of cholesterol
111
Difference between arteriosclerosis and arteriolosclerosis?
Arteriolosclerosis: Extra LO means smaller vessels
112
When is hyaline arteriolosclerosis seen?
1. HTN - high pressure pushes proteins in basement membrane damaging endothelium = collagen
2. Diabetes mellitus - non enzymatic glycosylation = ROS
- Damages endothelium via cytokines
113
When is onion skinning seen?
Extremely high BPs
114
What happens in monkeberg?
- Idiopathic deposition of Ca
| - Pipe stemming of arteries
115
Female risk factor for atherosclerosis?
> 50 yo: post menopause as estrogen was protective by increasing HDL
116
What does LDL do to vessels?
- Attached to proteoglycans in vessel wall so attach
- Become oxidized = ROS damaging endothelium
- Endothelial cells express VCAM1 "Vascular cell adhesion molecule 1"
- Also release MPC1 "Monocyte chemotactic protein 1"
* **Combination of these 2 allow macs to enter vessel walls
117
What is VCAM1?
"Vascular cell adhesion molecule 1"
| - Produced by endothelial cells in response to LDL damage
118
What recruits smooth muscle in atherosclerosis?
- Macs production of PDGF moves muscle from media to intima
| - Fibroblast GF tells fibroblasts to deposit as well
119
Where is greatest risk for AAA and why?
- Below renal bifurcation as vessel here has no vaso vasorum
120
Presentation of aortic aneurism?
1. Pulsatile mass
| 2 Low BP: from bleeding
121
Risk factors for thoracic aortic aneurism?
1. HTN
2. Marfan's
3. Ehlers Danlos
4. Tertiary syphilis: enter vaso vasorum leading to inflammation
122
What is cystic medial degeneration?
- Degeneration of elastin and vascular smooth muscle in media = tissue replaced with cysts
- Cause of thoracic aneurysm
123
What do deceleration injuries often cause?
Thoracic aneurysm
124
What is aortic isthmus?
Transition zone between ascending and descending aorta at most risk for rupture
125
Last thing to tear before aortic rupture?
Adventitia
126
What is happening in aortic dissection? Presentation?
- Intimal tear allowing blood flow into media
Presents with:
1. Sudden onset, tearing chest pain radiation to back
2. Unequal BP in arms: compression of left subclavian but not right
3. Tamponade blood around heart
127
What is "Sudden onset tearing chest pain radiation to back" indicative of?
Aortic dissection
128
Type A or B dissection more dangerous?
A, which is Ascending and unstable with risk of tamponade
129
What is stable angina?
- Chronic, fixed stenosis of vessel causing angina in times of increased demand
- Only impact SUBendocardial layer
- Resolves with rest
- ST depression seen
130
What is prinzmetal angina?
- TRANSMURAL ischemia from vasospasm = ST elevation
131
Things that can cause prinzmetal?
1. Triptans
2. Tobacco
3. Cocaine
132
Treatment of prinzmetal?
1. Remove triggers
2. Ca blocker to stop spasm
3. Nitrate: dilation
133
Does unstable angina improve with rest?
No
134
What is chronic ischemic heart disease?
- Chronic ischemic events = fibrosis
| - Leads to HF
135
What causes ST elevation?
Transmural ischemia
136
What causes ST depression?
Subendocardial depression
137
What does the right coronary supply?
SA / AV nodes
138
Why does MI pain radiate to arm?
Both areas use same dorsal root ganglia in C7 - T5 distribution
139
What is seen and risk in 0-4 hours post MI?
```
Seen: nothing
Risk:
1. Arrhythmia
2. HF
3. Cardiogenic shock
*Anaerobic metabolism = decrease ATP = malfunctioning Na/Kase and K accumulation in extracellular = arrhythmia
```
140
What is seen and risk in 4-24 hours post MI?
```
Seen:
1. Early coag necrosis
2. Release of cellular debris
3. Edema / hemorrhage
4 PMNs
5. Reperfusion
Complications:
1. Arrhythmia
2. HF
3. Cardiogenic shock
```
141
What is seen and risk in 3-14 days post MI?
```
Seen:
1. Macs
2. Granulation tissue at borders
Risk:
1. Free wall rupture
2. Mitral regurge
3. Septal rupture
4. LV pseudoaneurysm
```
142
What does tetrazolium stain do?
Bind LDH spilled by necrotic cells in MI to visualize it
143
What is seen and risk in > 2 weeks post MI?
```
Seen:
1. Scar
Risk:
1. Dressler syndrome
2. HF
3. Arrhythmias
4. True ventricular aneurysm
```
144
What is seen and risk in 1-3 days post MI?
```
Seen:
1. Extensive coagulative necrosis
2. Acute inflammation with neutrophils
Risk:
1. Postinfarction Fibrinous pericarditis
```
145
What does infarct of LAD lead to
Rupture of septum and VSD
146
Vessel feeding papillary muscle?
Posterior descending
147
What is pseudoaneurysm?
Aneurysm at high risk for rupture because it only has 1 layer instead of 3
148
What is dressler syndrome?
Macs are eating cardiac tissue and accidently present to T cell causing immune system to attack heart
- Seen > 2 weeks post MI
149
What is ischemia?
Decreased blood flow to a tissue
150
Do cells die in stable angina?
No, this is reversible injury
151
What is hallmark of reversible injury?
Cellular swelling
152
% stenosis required for angina?
70%
153
How long does pain in stable angina last?
> 20 minutes: after this irreversible cell death
154
Hall mark of subendocardial ischemia?
- ST depression, this is what occurs in stable angina
155
Is unstable angina complete or incomplete occlusion?
Incomplete
156
Unstable angina ST elevation or depression?
Depression: both stable and unstable are depressed
157
What infarcts in LAD MI?
Anterior LV and anterior portion of ventricular septum
158
What infarcts in Right coronary artery MI?
Posterior LV and posterior portion of ventricular septum
159
Most sensitive and specific marker of MI?
Troponin I
- Rises in 2 - 4 hours
- Peaks in 24
- Returns to normal in 1 week
160
Use of CKMB?
Good at detecting new MIs
- Peaks in 24
- Rises in 4
- Back to normal in 72
* ***As such you can tell if new MI after 3 days whereas with troponin it stays elevated for 10 days
161
What is contraction band necrosis?
- From Ca entering necrotic cells via reperfusion causing them to contract
162
Hallmarks of coagulative necrosis?
1. Pyknosis
2. Kereoexis
3. Karyolysis
163
When is yellow pallor seen in MI?
Entire inflammatory phase of PMNs and macs:
| - 1 - 7 days
164
When are fibrinous pericarditis, chest pain, and friction rub seen?
- Days 1 - 3 as PMNs are mediating this
165
What is cardiac tamponade?
When fluid gets between heart and pericardium (fibrous sac surrounding heart)
- Can be from LV rupture that occurs when mac each necrotic debris in days 4 - 7
166
What feeds papillary muscles?
Right coronary artery
167
What is hallmark of granulation tissue?
1. Plump fibroblasts
2. Collage
3. Blood vessels
168
What type of collagen is present in scar?
Type I
169
Normal cause of sudden cardiac death?
1. Fatal ventricular arrhythmia
170
Which cardiomyopathies lead to left sided heart failure?
1. Dilated
| 2. Restrictive
171
Signs of left sided heart failure?
1. Pulmonary edema
2. Dyspnea
3. Paroxysmal nocturnal dyspnea
4. Orthopnea
5. Crackles
172
What are heart failure cells?
Hemosiderin laden macrophages
- From left sided heart failure when engorged capillaries rupture and blood pools in lung, macs eat them and become that color
173
Systemic consequences of left sided heart failure?
1. Decreased forward perfusion
| 2. Causes RAAS activation
174
Most common cause of right sided heart failure?
1. Left sided heart failure
2. Left to right shunt
3. Chronic lung disease = cor pulmonale
175
Signs of right sided heart failure?
1. JVD
2. HSM
3. Dependant pitting edema
4. Cirrhosis / nutmeg liver
176
Most common fetal heart defect and what is its association?
VSD associated with fetal alcohol syndrome
177
Heart sound in ASD? Why?
Spit S2: extra volume on right side = delayed closure pulmonic valve
178
Heart defect in rubella?
PDA
179
What does the DA do?
Connect aorta to pulmonary artery after the great vessels
180
What is cyanosis in lower extremities later in life indicative of?
PDA
181
Where is coarctation in infantine form?
- Distal to arch, proximal to PDA
- Lower extremity cyanosis: Coaractation makes area distal to it lower pressure allowing blood from PDA to move to lower pressure area and head to lower exctremities as is distal to arch
- Often seen in turners
182
How does adult coarctation present?
- Malformation distal to arch proximal to PDA
- Blood forced up great vessels = HTN in upper extremities
* HYPOtension and low pulse in lower extremities
183
Association of adult coarctation?
Bicuspid aortic valves
184
Markers of Group A strep infection?
1. Anti ASO titers
| 2. Anti DNAse B titers
185
What is the JONES criteria?
```
Joints: migratory polyarthritis
O - Pancarditis
Nodules in skin
Erythema migratosums
Sydenham's chorea
```
186
Valves involved in rheumatic fever?
1. Mitral - always and first
| 2. Aortic - rarely
187
What are aschoff bodies and when are they seen?
- Fibrinoid material and macrophages seen in cardiac tissue in rheumatic fever myocarditis
- Anitschkow cells in middle - histiocytes with slender wavy nuclei
188
When are Anitschkow cells seen?
Rheumatic fever myocarditis
189
Most common cause of death during acute phase rheumatic fever?
Myocarditis
190
How does pericarditis present?
Friction rub - seen in RF
191
What is happening to valves in RF?
Mitral: thickening of chordae tendinae and cusps
Aortic: Fusion of commisures
192
When is fusion of aortic commissures seen?
RF
193
What distinguishes wear and tear aortic stenosis from that seen in RF?
RF will also have mitral valve issues and aortic valve will show fusion of commissures
- Normal aortic stenosis will not have these issues
194
What is systolic click with crescendo decrescendo murmur indicative of?
- Aortic stenosis: crescendo is from blood rushing out then dying down as blood finally forces valve open
195
Impact of aortic stenosis on left ventricle?
CONCENTRIC hypertrophy
196
When is blood flowing in aortic regurg? Causes?
During diastole:
1. Most often caused by aortic root dilatation
2. Aortic aneurysm
3. Valvular damage from IE
197
What is early blowing diastolic murmur indicative of?
Aortic regurg
198
Presentation of aortic regurg?
"Hyperdynamic circulation"
1. Bobbing head
2. Bounding pulses
3. Pulsatile nail beds
4. Early blowing diastolic murmur
199
What happens to LV in aortic regurg?
1. LV dilation
| 2. ECCENTRIC hypertrophy: involves one aspect of ventricle
200
What is midsystolic click indicative of?
MV prolapse
201
What heart sound does MV prolapse make?
Midsystolic click
202
What does papillary muscle rupture lead to?
- Mitral regurg
| - Often seen post MI
203
What is holosystolic blowing murmur usually indicative of? When is it louder?
MV regurg
| - Louder on squatting and expiration
204
Sound of MV regurg?
Holosystolic blowing murmur louder when exhaling / squatting
205
Whey is mitral regurg louder on expiration?
- Expiration = more blood in LA increasing backwards pressure
206
Difference in effect of active / chronic RF on valve?
Acute: regurg
Chronic: Stenosis
207
Sound of mitral stenosis?
Opening snap followed by diastolic rumble
208
What is following sound indicative of:
| Opening snap followed by diastolic rumble
Mitral stenosis
209
Sequelae of mitral stenosis?
1. Pulm congestion / HTN
| 2. A fib: from stretching of atrium = abnormal wall movement an thrombi
210
What is endocarditis usually impacting?
- Inflammation of the endocardium that lines cardiac valves
| - Usually caused by bacterial infection
211
Most common cause of endocarditis? Tell me more about it?
Strep viridans
- Low virulence - Infects previously damaged valves
- Small vegetation that do not destroy valves
212
Pathogenesis of strep v. ?
- Damage endocardial surface develops thrombotic vegetations of platelets and fibrin
- Transient bacteremia = bacteria being caught in these vegetations
213
Most common cause of endocarditis in IV drug abuse? Characteristics?
S. Aureus
- High virulence
- Non damaged valves
- Large vegetations destroying valves
- Likes tricuspid as coming from circulation
214
Bug in endocarditis of prosthetic valves?
S. Epidermidis
215
Bug in endocarditis of colorectal carcinoma?
S. Bovis
216
What is next step if ptn has endocarditis with S bovis?
Check for colorectal carcinoma
217
What causes endocarditis with negative blood cultures?
```
"Hacek Group"
Haemophilus
Actinobacillus
Cardiobacterium
Eikenella
Kingella
```
218
Signs of endocarditis?
1. Fever
2. Murmur
3. Janeway lesions - non tender
4. Osler's nodes - Painful
5. Anemia of chronic disease
6. Splinter hemorrhages in nail bed
219
What does hepcidin do?
- Released by liver in disease states to trap iron
- Ferritin will be high
- TIBC will be how
220
What is libman sacks endocarditis?
- Sterile vegetations from lupus
* *Vegetations on both sides of cardiac valve
- Mitral regurg
221
What happens in dilated cardiomyopathy?
- Massive dilation of all heart chambers
- Leads to systolic dysfunction and BIventricular HF
- Mitral / tricuspid regurg and arrhythmia
222
Causes of dilated cardiomyopathy?
1. Coxsackievirus
2. Alcohol
3. Cocaine
4. Doxorubicin
5. Pregnancy
223
Cause of hypertrophic cardiomyopathy?
Autosomal dominant mutations in sarcomere proteins
224
Features of hypertrophic cardiomyopathy?
1. Decreased CO: heart so tight can't be filled
2. Sudden death from arrhythmias - young athletes
3. Syncope with exercise
225
How does hypertrophic cardiomyopathy appear on imaging?
Myofiber hypertrophy with disarray
226
What is happening in restrictive cardiomyopathy?
- Decreased compliance of ventricular endocardium
| - Restricts filling during diastole
227
Causes of restrictive myocardiopathy?
1. Amyloid
2. Sarcoid
3. Hemochromatosis
4. Endocardial fibroelastosis in kids
5. Loeffler syndrome
228
What is Loeffler syndrome?
Eosinophilic infiltrate into wall of heart = fibrosis = restrictive cardiomyopathy
229
Presentation of restrictive cardiomyopathy?
1. Low voltage EKG
| 2. Diminished QRS
230
What is the following indicative of:
1. Low voltage EKG
2. Diminished QRS
Restrictive cardiomyopathy
231
What does myxoma look like? Presentation?
- Benign mesenchymal proliferation
- Abundant ground substance
- Causes syncope from mitral valve obstruction
232
When is rhabdomyoma seen in heart?
- Usually in ventricle of child
| - Associated with tuberous sclerosis
233
Most common tumor in heart?
Metastasis usually to pericardium
234
When does acute rejection occur? What is seen?
1 - 4 weeks post transplant
- Dense infiltrate of macs and T cells
- Result of host T cell sensitivity to donor MHC
235
What is cause of tetralogy of fallot?
- Deviation of infundibular septum due to abnormal neural crest cell migration
236
Which heart chamber lays over esophagus?
LA
237
What vessel is posterior to esophagus?
Descending thoracic aorta
238
What is pulsus paradoxus? What does it indicated?
- Fall of systolic > 10 on inspiration
| - Indicates cardiac tempanonde
239
Triad of signs indicative of cardiac tamponade?
1. JVD
2. Muffled heart sounds
3. HYPOtension
240
What is hibernating myocardium?
- Reduced myocardial metabolism and function due to chronic state of ischemia
- Normal function can return when reperfused
241
How long after infarct will ATP levels drop to levels preventing contraction?
60 seconds
| - Due to cessation of aerobic glycolysis and start of anaerobic
242
After how long is myocardial ischemia irreversible?
30 Minuts, function will return if perfusion restored but there will be a lag
243
Impact of adenosine on vessels?
Vasodilator - as ATP runs out and is broken down, it will help to keep blood flowing
244
What is the following indicative of:
- Narrow QRS
- Absent B
- Irregularly irregular intervals
A-Fib: AV node controls rate of ventricular contraction
245
What controls rate of ventricular contraction in A fib?
AV node
246
What does myxomatous degeneration with pooling of proteoglycans in media indicate?
Cystic medial degeneration that can cause Aortic aneurysm
| - Often seen in marfans
247
What is clubbing and cyanosis in distal extremities indicative of?
PDA - PDA is delivering oxygenated blood distal to left subclavian which is providing it to the lower extremities
248
What causes cells to swell during ischemia?
Increased intracellular [Na/Ca] due to failure of pumps from lack of ATP
249
Facial features of downs?
1. Flat face
2. Protruding tongue
3. Small ears
4. Epicanthal folds
5. Upslanting palpebral fissures
250
What is composition of amyloid found in atrai?
Missfolded beta pleated sheets of ANP
251
What sounds would decreased compliance of hypertrophic atrial myocardium make?
Fourth
252
Describe the marfanoid habitus?
1. Problem with eye lense
2. Increased arm:height
3. Breast bone abnormalities
4. Hypermobile joints
5. Scoliosis
6. Long fingers
7. Flat feet
8. Tall and slender
9. Decreased upper:lower body
253
Mutation in marfans?
- Mutation in glycoprotein fibrillin 1
254
Heart disease in marfan's?
1. Mitral valve prolapse
| 2. Cystic medial degeneration of aorta = aortic disection which is most common cause of death
255
Effects of ANP?
1. Vasodilation
2. Diuresis
3. Natriuresis
* Dilates afferent, inhibits aldosterone, inhibits renin and Na resorption
256
Causes of CONcentric LV hypertrophy?
Increased wall thickness:
1. HTN
2. Aortic stenosis
257
Causes of ECCentric LV hypertrophy?
Increased cavity size:
1. Volume overload
2. Aortic / mitral regurg
3. MI
4. Dilated cardiomyopathy
258
What is holosystolic murmur at left sternal border that increases with hand grip?
VSD
259
Do nitro and morphine reduce MI mortality?
No, only provide symptomatic relief
260
What happens in dilated cardiomyopathy?
- Myocyte damage leading to decreased systolic function
- This increases wall tension
* **Heart responds by adding sarcomeres in series
261
When are sarcomeres added in series?
Dilated cardiomyopathy
262
Causes of dilated cardiomyopathy?
1. Alcohol: acetaldehyde is toxic
2. Wet beriberi: Lack of B1, thiamine
3. Coxsackie B
4. T cruzi
5. Cocaine: mitchondrial damage
6. Doxorubicin: Intercalates DNA
7. Hemochromatosis
8. Pregnancy
263
What does cytochrome C do?
- Activate caspases = apoptosis
264
What heart sound heard in dilated cardiomyopathy?
S3
265
2 people hypertrophic cardiomyopathy usually seen in?
1. Young athlete
| 2. Friedreich's ataxia
266
Genetics of hypertrophic cardiomyopathy? What is happening?
- AD mutation in beta myosin heavy chain leading to haphazardly arranged sarcomeres
- Inflammation leads to fibroblast deposition of collagen
- Sarcomeres added in PARALLEL = concentric thickening
- Causes diastolic dysfunction as ventricle is not compliant
267
When are sarcomeres added in parallel?
Hypertrophic cardiomyopathy
268
Heart sound heard in hypertrophic cardiomyopathy?
S4
269
What happens in restrictive cardiomyopathy?
- Infiltration of myocardium restricts filling
270
Causes of restrictive cardiomyopathy?
1. Endocardial Fibroelastosis
2. Loeffler
3. Sarcoid / Amyloid
4. Hemochromatosis
5. Radiation
271
What happens to heart in Loeffler syndrome?
Eosinophils release MBP on heart = necrosis and fibrosis of heart
272
Genetics of friedreich's ataxia?
GAA repeat in frataxin gene
273
What is problem in diastolic heart failure?
- Stiff ventricle / decreased compliance
274
What are orthopnea and paroxysmal nocturnal dyspnea signs of?
Left sided HF
275
What causes acute endocarditis and what are virulence factors?
S. Aureus
1. Hyaluronidase: damages valves
2. Leukocidin: creates pores in myocytes
276
Signs of bacterial endocarditis?
1. Osler nodes - Ouch ouch
2. Janeway's lesions
3. Roth spots
4. New onset murmur
5. Anemia of chronic disease
277
Which valve does S aureus like to infect?
- Tricuspid: introduced to stream from IVDs
278
What causes subacute endocarditis?
Strep Viridans
| - Needs a previously infected valve to cause damage
279
What are vegetations on both sides of valves indicative of?
SLE - libman sachs endocarditis
280
What is pain on inspiration that is relieved by sitting up and leaning forward indicative of?
Acute pericarditis
281
What is cardiac tamponade?
Pathologic compression of heart chambers by fluid in pericardial space
282
Presentation of cardiac tamponade?
1. HYPOtension from decreased filling
2. Distended neck veins
3. Distant heart sounds: blocked by thick layer of fluid
4. Pulsus paradoxus
283
Major fear in giant cell arteritis?
Blindness from involvement of ophthalmic artery
| - Need to give steroids immediately to prevent this
284
What do 50% of persons with giant cell arteritis have?
Polymyalgia rheumatica
285
Disease associated with polyarteritis nodosa?
HBV
286
Vessels commonly impacted by polyarteritis nodosa?
1. Renal - can activate RAAS
2. Hepatic
3. Splanchnic - Sharp abdominal pain
287
Presentation kawasakis?
1. Red tongue
2. Desquamating rash on hands and feet
3. MI
4. Swollen eyes / lips
288
Another name for granulomatosis with polyangiitis?
Wegener's
289
What is involved in wegener's?
1. Kidneys
2. Lungs
3. Nasopharynx
290
How does microscopic polyangiitis differ from wegener's?
- No granulomas, no nasal involvement
| * **Palpable purpura are seen
291
Staining in wegener's / microscopic?
Wegener's: C-ANCA
| Polyangiitis: P-ANCA
292
What is seen in Churg strauss?
1. IgE
2. Eosinophils
3. Allergic rhinitis
4. Asthma
5. Neuropathy: wrist drop / foot drop
293
What is perivascular foci of collagen and giant cells indicative of?
Rheumatic fever
294
When is free wall likely to rupture in MI and what is presentation?
5 - 14 days:
1. Tamponade
2. JVD
3. Distant heart sounds
4. HYPOtension / shock
295
When is IV septum likely to rupture and how does present?
3 - 5 days:
1. New holosystolic murmur
2. Stepped up O2 level between LV and RV
296
When will papillary muscle rupture and presentation?
3 - 5 days
1. Acute pulmonary edema
2. Severe mitral regurg
297
When does RV fail in MI and presentation?
Acute
1. Kussmaul sign
2. Hypotension with clear lungs
298
Cardiac defect in turner's?
1. Bicuspid aorta
| 2. Coarcted aorta
299
Cardiac defect in tuberous sclerosis?
Rhabdomyoma
300
Cardiac defect in marfan?
Cystic medial necrosis:
1. Aortic dissection
2. Aortic aneurysm
3. Mitral valve prolapse
301
Cardiac abnormality in digeorge?
Tetralogy of fallot
302
What would prevent diphtheria infection?
IgG against circulating protein capsule
303
Sequelae of aortic regurg?
1. LV EDV increases
2. Eccentric hypertrophy
3. Hypertrophy increased chamber size and stroke volume
304
What does ST elevation in 1/AVL indicate?
Left circumflex MI
305
What does ST in V1-4 and V1-2 indicate?
V1-4: LAD infarct
| V1-2: Distal LAD infarct
306
What does ST in V1-6, I, and AVL indicate?
Left main coronary occlusion
307
What does ST in II, III, AVF indicated?
Right coronary occlusion
308
What is supine HYPOtension syndrome?
- From baby pressing against SVC giving mom HYPOtension when laying down
309
What does pulmonary capillary wedge pressure approximate?
Left atrial pressure
310
Cardiac tissue velocity from Fast to slow?
```
"Park At Ventura Avenue"
Purkinje
Atrial
Ventricular
AV node
```
311
What is wide and fixed splitting of S2 indicative of?
ASD
312
What is S3 indicative of and where is it best heard?
LV failure heard best with bell over apex in left lateral decubitus position
313
Measurements seen in diastolic HF?
1. Increased LVEDP
2. Normal LVEDV
3. Normal EF
314
First step in atherosclerosis?
Endothelial injury
315
What causes coronary sinus dilation?
Elevated right heart pressure from pulmonary HTN
316
Cause of pulsus paradoxus other than pericardial disease?
1. Asthma
| 2. COPD
317
Presentation of osler weber rendu syndrome?
1. Nosebleeds
| 2. Mucosal telangiectasias
318
What heart abnormality can berry aneurysms be associated with?
Coarctation of aorta
319
What is cause of platelet rich non bacterial thrombi to mitral valve?
Malignancy
USMLE: step 1
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