1
Q
What are the effects of LV Hypertrophy on:
- LV compliance
- Kidney perfusion and AngIiotensin II
- Beta-Myosin Heavy chain Expression
A
- Decreased LV compliance
2.
Decreased renal perfusion (due to dec. CO)
Increased AgII
- increased Beta-myosin heavy chain (to upregulate contractile sarcomere proteins)
2
Q
Hyperacute Transplant Rejection
- Time of onset
- Mediators/cells
A
- Within minutes
- Pre-existing recipient Antibodies activate complement
3
Q
Acute Transplant Rejection
- Time of onset
- Mediators/cells
A
- 1-4 Weeks
- T-cells and B-cells
(cellular and humoral response)
4
Q
Chronic Transplant Rejection
- Time of Onset
- Cells/Mediators
A
- Months to years
- T and B cell response
(cellular and humoral)
5
Q
Familial Dilated Cardiomyopathy
- Caused by what gene mutation?
- What protein does the gene code for?
- What is that proteins function?
A
- Mutation in the TTN Gene
- That gene is needed to make Titin
(these patients cannot make titin)
- Titin is needed to hold the sarcomere together
(lack of it causes myocardial dysfunction)
6
Q
- When is wide splitting seen?
- How is it affected by breathing?
A
- Conditions that delay RV (pulmonic valve) empting?
- pulmonic stenosis
- right bundle branch block
- Pulmonic sound further delayed by inspiration
7
Q
Normal Splitting
- Is S1 or S2 split?
- What are the order of sounds?
- How is it effected by breathing?
A
- Split S2 (in Aortic2 and Pulmonary2)
- S1–>A2–>P2
- Inspiration delays P2
8
Q
Fixed Splitting
- When is heard?
- How is it effected by breathing?
A
- Heard in Atrial-Septal Defects (ASD)
- Not affected by breathing
(regardless of breath P2 is greatly delayed)
9
Q
Paradoxical Splitting
- When is it heard?
- What are the order of sounds?
- How is it effected by breathing?
A
- Heart in conditions that delay aortic valve closure
- aortic stenosis
- Left bundle branch block
2.
S1 –> P2 –> A2
- Heard best on Expiration
(inspiration pushes P2 closer to A2)
10
Q
What bacteria can cause endocarditis in already damaged heart valves and how?
A
Strep. Viridans
- Enter blood through mouth (ex: during dental procedure)
- Bacteremia (by binding to fibrin and platelets in blood)
- Adhere to valves
11
Q
Whats are the effects of aging on the heart? (4)
A
- decreased LV chamber size
- sigmoid-shaped ventricular septum
- increased collagen content
- lipofuscin pigment within cardiomyocytes
12
Q
What are the effects of LV hypertrophy on contractility?
A
Reduced contractility
13
Q
Myxoma
- What is it?
- Where/how does it present?
- Histology
A
- Benign cardiac tumor
- Left Atrium, obstructs mitral valve
- Scattered cells with a mucopolysaccharide stroma
14
Q
What heart pathology presents with:
- Head bobbing
- Bounding femoral and carotid pulses
A
Aortic Regurgitaion
15
Q
What murmur is heard with aortic stenosis?
A
Crescendo-Decrescendo systolic ejection murmur
16
Q
What murmur is heard with tricuspid/mitral regurgitation?
A
Holosystolic, high pitched “blowing murmur”
17
Q
What murmur is heard with mitral valve prolapse?
A
Late systolic crescendo murmur with midsystolic click
18
Q
What murmur is heard with a ventricular-septal defect?
A
Holosystolic, harsh sounding murmur
19
Q
What murmur is heard with aortic regurgitation?
A
Early diastolic, blowing decrescendo murmur
20
Q
What murmur is heard with a PDA?
A
Continuous machine-like murmur
21
Q
- When is S3 heard?
- In what population is it normal?
A
1. Early diastole
- Normal in:
- children
- young adults
- pregnant women
22
Q
In what conditions (abnormal) do we hear an S3?
A
- Mitral Regurgitation
- Heart Failure
- Dilated Cardiomyopathy
(Associated with increased filling pressures)
VOLUME OVERLOAD
23
Q
- When is S4 heard?
- What is it associated with?
- In what population is it normal?
A
- Late diastole
- Ventricular Noncompliance
(ex: hypertrophy/cardiomyopathy) - Healthy older adults
24
Q
Plaque Rupture
- What is the likelihood of plaque rupture dependant on?
- How can cells affect plaque rupture?
A
1. Plaque stability
(not size)
- Inflammatory Macrophages can secrete metalloproteinases destabilizing plaque and causing rupture
25
What is the relationship between **blood flow** (J) and vessel **radius** (r) ?
Flow (J) is proportional to the vessel radius raised to the 4th power
**FLOW = r4**
26
**_Cardiac Tissue Conduction Velocity_**
Place from fastest so slowest
* Atrial Muscle
* AV node
* Ventricular muscle
* Purkinje system
1. **Purkinje System**
2. **Atrial Muscle**
3. **Ventricular muscle**
4. **AV node**
Mnemonic: "Park At Venture AVenue"
27
What effect does **_squatting_** have on the on vasuclar resistance?
**Squatting increases _systemic_ vascular resistance**
28
Why can **squatting** improve symptoms in a patient with a **Tetralogy of Fallot**?
Squatting **increases the systemic vascular resistance** which **reduces right-to-left shunting** which will allow **more blood to enter the pulmonary circuit**
(it will harder for unoxygenated blood to exit via the aorta so LV pressure will increase which will slow down shunt)
29
1. What it **_pulsus paradoxus_**?
2. How is it usually detected?
1. A **\>10mm Hg drop in systolic BP during inspiration**
2. It is often detected when **taking/measuring BP with a cuf**f
NOTE:
At **_high pressures_** we will only hear korotkoff sounds during **expiration.** At **_lower pressures_** we will hear korotkoff sounds during both **expiration** and **inspiration**
30
What can cause **_pulsus paradoxus_**? (4)
1. **Cardiac Tomponade** (most common)
**2. Pericardial Disease**
3. **Severe Asthma**
4. **COPD**
31
How can blood flow from ischemic areas be **shifted to _non_ ischemic areas**?
Via the use of **_Pharmacologic Vasodilators_**
* **_adenosine_**
* **_dipyridamole_**
(they mimic the vasodilation that occurs with exercise, shifting blood to areas of greater demand)
32
When cells within the **heart**, **brain** or **skeletal** muscle are injured, what **_enzyme_** leaks into circulation?
**_Creatine kinase_**
(due to cell membrane damage, the hallmark of irreversible damage)
33
**_Jugular Venous Pulse (JVP)_**
What does the **_a wave_** represent?
Right Atrial Contraction
34
**_Jugular Venous Pulse (JVP)_**
What does the **_c wave_** represent?
**_RV Contraction_**
(due to Bulging of Tricuspid Valve in to RA due to **RV contraction)**
35
**_Jugular Venous Pulse (JVP)_**
What does the **_x_** **_descent_** represent?
Right Atrial Relaxation
36
**_Jugular Venous Pulse (JVP)_**
What does the **_v wave_** represent?
Filling "**v**illing" of right atrium
37
**_Jugular Venous Pulse (JVP)_**
What does the **_y descent_** represent?
**passive empying of RA** in RV once tricuspid opens
38
**_Marfan Syndrome_**
1. How does it present?
2. Major Complications
1. Clinically presents as
* **Tall/thin build with long extremities**
* **scoliosis**
* **pectus excavatum (caved in chest)**
* **Vision problems**
2. _Major complications_ is heart problems
* **aortic dissection** (most common cause of death)
* **mitral valve prolapse**
39
What type of **collagen** is seen in **scars**?
| (_Any_ type of scar)
**Type I collagen**
(most common type in body)
NOTE: also seen in tendons, ligaments, bone, skin, blood vessels, etc.
40
What are the effects of **_Prostacyclin_**?
**1. Inhibits platelet aggregation**
**2. Causes Vasodilation**
(it opposes the effects of Thromboxane A2)
41
**_Cardiac Tamponade_**
1. How does it clinically present? (3)
2. What is it highly associated with?
1. Presents as:
* **hypotension**
* **elevated JVP**
* **muffled heart sounds**
2. **Pulsus Paradoxus**
42
Why do we see a **greater** amount of _Angiotensin II_ than _Angiotensin I_ in the **pulmonary vein** compared to the pulmonary artery?
Since Angiotensin I gets converted into Angiotensin II when it enters the **small** **pulmonary vessels in the lungs** by ACE.
NOTE: **RV--\> pulmonary a. --\> lungs --\> pulmonary vein--\>LA**
43
**_Atrial Fibrillation_**
1. How does it clinically present?
2. How does it present on ECG
1. Presents as:
* Palpitations
* Tachycardia
* irregularly iregular heart rhythm
2. varying R-R intervals with an abscense of p-waves
44
**_Acute Pericarditis_**
1. How does it present?
2. What is the most common cause?
1. Presents as:
* **chest pain**
* **friction rub** on auscultation
* **ST elevation** on ECG
* **pericardial effusion** on echocardiogram
**2. Viral infection**
45
**_Hypertrophic Cardiomypathy_**
1. Which part of heart is enlarged?
2. When inherited, what genes/proteins are involved?
1. Left Ventricle
2. **Sarcomere genes** are affected
* **beta-myosin heavy chain proteins**
* **myosin-binding protein C**
46
What is **strep. gallolyticus (formerly bovis) endocarditis** associated with?
**_Colon Cancer_**
NOTE: Whenever S. gallolyticus is cultured in the blood, a colonoscopy must be done to check for colon cancer
47
What are the cardiovascular manifestations of **SLE** (lupus)?
1. Atherosclerosis
**_2. Libman-Sacks Endocarditis_**
* **sterile vegetations** that arise on **_BOTH_ surfaces of the mitral valve**
48
**_Renal Artery Stenosis_**
1. What usually causes it?
2. How does it present?
3. What can occur to kidneys over time and why?
1. **Atherosclerosis**
**2. Refractory/Resistant Hypertension**
(hypertension that does not respond to drugs or normal treatment)
3. **Atrophy of kidneys** due to chronic O2 and nutrient deprivation
49
**_Lipofuscin_**
1. What is it a sign of?
2. How does it occur?
3. What does it look like?
4. In who and where is it commonly seen?
1. **Aging** and **Wear+Tear**
2. Via **lipid peroxidation** or **free-radical injury**
3. **Yellow-brown intracytoplasmic granules**
4. In the **heart** and **liver** of **aging**, **cachectic**(wasting) or **malnourished** individuals
50
What is the most likely complication of having a **bicuspid aortic valve?**
They are much more likely to develop **_aortic stenosis_** in their **50s** (10 years ealier than the aortic stenonis caused by calcification of the aortic valve)
51
What parameter must be the same in both the **_systemic circulation_** and the **_pulmonary circulation_**?
**Flow** must be the same
(the volume output of the RV must match the LV)
52
What does **_Adenosine_** do and how?
**It decreases HR**
(via decreasing the rate of spontaneous depolarization in cardiac pacemaker cells - phase 4)
**It increases potassium condunctance and inhibts Ca2+**
53
**_Stanford Type B Aortic Dissection_**
1. In what part of aorta does it occur?
2. From where does it originate?
1. The **Descending Aorta**
2. The **Left Subclavian Artery**
54
**_Stanford Type A Aortic Dissection_**
1. In what part of aorta does it occur?
2. From where does it originate?
1. The **Ascending Aorta**
2. The **Sinotubular Junction**
55
1. Which **_Renal Vein_** can get compressed by the Aorta and SMA? (L or R)
2. What can this result in?
The **_Left_** Renal Vein
Can cause retrograde blood flow to testes that can result in a **Varicocele** (dilation of pampiniform plexus)
56
**_Subclavian Steal Syndrome_**
1. What causes it?
2. What does it result in?
1. **stenosis of the subclavian artery**
2. It results in **reversal in blood flow** from the **controlateral verterbreal artery** to the **affected vertebral artery**
57
What affects does a ***Carotid Sinus Massage*** have on:
1. Parasympathetic Tone
2. SA node conduction
3. AV node conduction
4. AV node refractory period
1. **increased** parasympathetic tone
2. **decreased** SA Node conduction
3. **decreased** AV Node conduction
4. **increased** AV Node refractory period
58
**_Atrial Flutter_**
1. How does it appear on ECG?
2. What causes it?
3. Where does it occur?
1. **Sawtooth** pattern
2. A large **re-entrant** circuit
3. Between the **Tricuspid Valve and IVC** in the _right atrium_
(cavotricuspid isthmus)
59
Where is the **_AV node_** located?
Which artery supplies it?
in the **Right Atrium**, near the **opening of the coronary sinus**
**Supplied by the _PDA_**
60
What are the contents of the **femoral triangle**?
(from lateral to medial)
1. Femoral **Nerve**
2. Femoral **Artery**
3. Femoral **Vein**
"NAV"
61
What can the **_pulmonary artery occlusion pressure_** be indicative of?
**Left Atrial Pressure**
62
**_Traumatic Aortic Rupture_**
1. Where does it most commonly occur in the aorta?
2. What normally holds that part in place?
1. At the **_Isthmus_** of the aorta
2. It is normally tethered to the **_ligamentum arteriosum_**
63
**_Atrial Fibrillation_**
1. How does it present on ECG?
2. What determines the **ventricular contraction rate** in a patient with AF?
1.
* **absent p-waves**
* **irregularly irregular R-R intervals**
* **narrow QRS complexes**
2. The **_AV node refractory period_** will determine the number of atrial impulses that reach the ventricles for contraction
64
What would an **elevated PCWP** be indicative of?
**Increased Left Atrium Pressure**
| (most likely due to mitral stenosis)
65
What artery supplies the **_inferior surface of the heart_**?
**_PDA_**
(Inferior surface of heart = diaphragmatic surface of LV)
66
When the **LAD** is occluded, what vessel do we use as a graft?
**The left internal mammary/throracic artery**
67
**_Sodium Nitroprusside_**
1. What does it do?
2. How does it effect SV, CO and BP?
3. Major Adverse effect?
1. Balanced **vasodilarion of veins + arteries**
2. **_Co_: Same**
**_SV_: Same**
**_BP_: decreased**
3. Can cause **cyanide poisoning**
68
When **coronary arteries (other than the LAD)** are occulded, what vein do we use as a graft?
From where is it accessed?
**The Great Saphenous Vein**
Accessed inferolaterally to the **pubic tubercle**
69
When does the majority of **blood flow** to the following occur:
## Footnote
**1. Left Ventricular Myocardium**
**2. Right Ventricular Myocardium**
1. **Diastole**
(due to LV coronary vessels being compressed during systole)
2. **It is constant**
**(**RV contraction does not result in compression of its vessels)
70
What structure is dervived from the embryonic **_cardinal veins?_**
## Footnote
**SVC**
71
How and when can the LV Gallops (**S3 & S4**) best be heard?
They are best heard with the bell of the stethoscope with the patient in the **_lateral decubitus position_** at **_end expiration_**
72
**_Hand Grip Maneuver_**
1. What effect does it have on heart pressures?
2. How would it effect an Aortic Stenosis Murmur?
2. How would it effect a VSD murmur?
1. It would **_increase afterload (_****decrease SV****_)_**
2. **Decreased** sounds
3. **Increased** sounds
73
**_Neprilysin_**
1. What does it do?
2. Why is this significant?
1. it **inactivates ANP and BNP**
2. In _HF with HTN_, we give **Neprilysin inhibitors (Sacubitril**) and **ARB's** which results in vasodilation and diuresis
74
What is typically seen in the **lungs** during **heart failure**?
**Alveolar Hemosiderin-laden Macrophages**
75
What are the 3 specific features that distinguish cardiac circulation form skeletal/visceral circulation?
**1. The Left Ventricle is only perfused during diastole**
**2. Myocardial Oxygen extraction is very high**
(takes 70% of O2 from blood)
3. **Myocardial Oxygen demand and coronary blood flow are tight coulples**
(since the heart extracts so much O2, when it increases its O2 demands simply extracting more O2 isnt enough so flow must be increased)
76
What is the **most deoxygenated blood** in the body?
**Cardiac venous blood**
(since myocardium is best at extracting O2)
77
Where is the SA Node located?
At the junction of the **_SVC_** and **_Right Atirum_**
78
**_Atrial Natriuretic Peptide (ANP)_**
1. From where is it secreted?
2. What stimulates its secretion?
3. What are its effects?
4. What is it inhibited by?
**1. Atrial Cardiomyocytes**
2. Stretching of atrium due to **hypertension** or **hypervolemia**
3. **peripheral vasodilation** and **increased urinary excretion of sodium and water**
**4. Sacubitril (a neprilysin inhibitor)**
79
What it is the limiting factor for **LV Myocardial blood supply**?
**Duration of Diastole**
(since LV myocardium cannot be perfused during systole)
80
What is the normal pressure in the **Left Ventricle**?
What is the normal pressure in the **Aorta**?
**120/10**
81
How does **aortic regurgitation** classically present?
**- hyperdynamic pulse**
**- head bobbing**
**- wide pulse pressure**
82
What are the effects of **_aortic regurgitation_** on the following pressures:
1. **LV systolic** pressure
2. **LV diastolic** pressure
3. **Aortic systolic** pressure
4. **Aortic diastolic** pressure
1. increased (\>120)
2. increased (\>10)
3. increased (\>120)
4. **decreased** (\<80)
Aortic Regurgiation: **LV(160/30)** & **Aorta(160/60)**
83
Why is the SA Node the de-facto pacemaker of the heart?
Because it stifles impulses generated by other cells in the conduction system since it **_fires more rapidly_**
84
How does a **_First-degree AV block_** appear on ECG?
**PR interval is _prolonged_ (\>200msec) but they are all _equal_**
(usually asymptomatic)
85
How does a **_Second-degree Mobitz Type 1 AV block_** appear on ECG?
**_Progressive lengthening_ of PR interval until a beat is dropped**
(usually asymptomatic)
86
How does a **_Second-degree Mobitz Type 2 AV block_** appear on ECG?
How is it treated?
Complications?
**_Dropped Beat without_ changes in PR interval**
Treated with a pacemaker
May progress to a Third-degree block
87
How does a **_Third-degree (complete) AV block_** appear on ECG?
How is it treated?
What is it associated with?
**The atria and ventricles beat independently**
(P waves and QRS complexes are not related)
Treated with a pacemaker
Associated with Lyme Disease
88
What embryologic malfunction results in the **Tetrology of Fallot?**
Deviation of the infundibular septum
89
What embryologic malfunction results in **Transposition of the Great Vessels?**
Failure of the **aorticopulmonary septum to rotate**
(remains linear instead of spiral)
90
Why does **_Verapamil_** decrease cardiac myocytes contraction but not skeletal muscle?
Since Verapamil blocks **_L-type Calcium channels_** which are needed to provide the **intial extracellular calcium influx** into cardiomyocytes **(Ca induced Ca release)**
Skeletal muscle does not depend on extracellular calcium influx via L-type calcium channels for calcium release
91
**_Isolated Systolic Hypertension_**
1. What is it?
2. In what population is it usually seen?
3. Why does it occur?
1. elevated systolic with normal diastolic BP
2. **Elderly (\>60)**
3. Due to age-related **stiffening** and **decreased compliance** of the aorta and other major peripheral arteries
92
What relieves symptoms in patients with a **hypertrophic cardiomyopathy**?
What pharmacology can be used to achieve this?
**Increased LV Volume**
**Beta blockers** (decrease HR giving more time for filling)
93
What maneuvers **_decrease_** **preload/volume** in the heart?
What effect would these maneuvers have on a **hypertrophic cardiomyopathy murmur**?
**Valsalva Maneuver** & **Standing up**
**Increase mumur intensity**
(hypertrophic cardiomyopathy symptoms get relieved with increased blood in the left ventricle)
94
What is the difference between a **hypertensive** **_urgency_** and **_emergency_**?
**_Hypertensive Urgency_**: severe HTN with no end-organ damage
**_Hypertensive Emergency:_** severe HTN with end-organ damage
(Note: severe hypertension is **\>180/120**)
95
What drugs are given in for a **_hypertensive emergency_**?
- **_Clevidipine_** (Ca channel blocker)
- **_Fenoldopam_** (Dopamine D1 agonist)
- **_Labetalol_** (B-blocker)
- **_Nicardipine_** (Ca channel blocker)
- **_Nitroprusside_** (causes release of NO)
96
**_Hypertrophic cardiomyopathy_**
1. What makes it worse?
2. Which medications should be avoided in these patients?
1. **Decreased LV Volume**
2.
- **_Vasodilators_** (dihydropyridine Ca blockers, Nitrates, ACEI)
- **_Diuretics_**
97
1. What are the 3 **_Nitrate drugs_**?
2. What do they do?
3. How do they do it?
1.
* **Nitroglycerin**
* **Isosorbide Dinitrate**
* **Isosorbide Mononitrate**
2. **Vasodilation** (**_Veins_**\>arterioles)
3. **Increase _cGMP_**
98
**_Hydralazine_**
1. What does it do?
2. How does it do it?
**1. Vasodilation** (**_arterioles_**\>veins)
**2. increase _cGMP_**
99
How do **_ANP_** and **_BNP_** work?
How is this related to **erectile dysfunction**?
1. ANP and BNP **increase cGMP** which causes vasodilation
2. ED can be treated with **Sildenafil** which **inhibits PDE5** which **decreases degradation of cGMP**
100
What are absolute **contraindications** to the use of **_Oral Contraceptives (OCP)_**? (6)
1. Women older than 35 that smokes
2. Hypertriglyceridemia
3. Liver disease
4. History of thrombolic event or stroke
5. History of an estrogen-dependent tumor
6. Pregnant
101
**_Niacin_**
1. What is its main use?
2. What are its major side-effects and what mediates them?
3. How can these side-effects be reduced?
1. Raise HDL levels
2. Skin flushing and warmth via prostaglandins
3. Aspirin (inhibits prostaglandin production)
102
Which type of **_Beta-blocker_** is best to use **post-MI**? Why?
**_B1-selective antagonists_** (names A--\>M)
- **a**cebutolol
- **a**tenolol
- **b**etaxolol
- **b**isoprolol
- **e**smolol
- **m**etoprolol
103
**_Digoxin_**
1. What/When can it be used
2. What is its mechanism?
1.
**_HF_**: can increase contractility
**_AFib_**: inc. parasympathetic tone via stimulation of vagus n.
2.
- **Inhibition of Na/K ATPase**--\>inhibition of Na/Ca exchanger
- direct stimulation of **vagus nerve**
104
**_Doxorubicin/Daunorubicin Chemotherapy_**
1. What can it cause?
2. How can this be prevented?
**1. Dilated Cardiomyopathy**
2. Dexrazoxane (iron-chelating agent)
105
How do nitrates cause vasodilation?
1. Nitrate broken down into **NO + S-Nitrosothiols**
2. They activate **cGMP**
3. **Dephosphorylation of light chain myosin**
4. Vascular smooth muscle relaxation
(**large veins\>small veins\>arterioles**)
106
What type of drug would you give if you wanted to **increase contractility** and **decrease vascular resistance**?
**A Nonselective Beta adrenergic agonist**
**(_Isoproterenol_ --\> B1=B2)**
Trick: iso = equal
**B1 stimulation**: increase HR + contractility
**B2 stimulation**: vasodilation
107
What major change is seen on **ECG** after administration of a **Beta-Blocker**?
**Prolonged PR Interval**
**(due to decreased AV Node Conduction)**
108
Which anti-arrhythmic is best at treating **_ischemia-induced ventricular arrythmias_**?
**Class IB Antiarrhythmics**
**(Lidocaine, Mexiletine, Phenytoin)**
109
Which drugs are best for treating the urinary symptoms of **_Benign Prostatic Hyperplasia (BPH)_**?
What else can they treat?
**_alpha-1 blockers_**
**(Prazosin, Terazosin, Doxazosin)**
They can also be used to treat **hypertension**
(alpha-1 stimulation causes increased SM contraction)
110
Which medications **_reduce mortality_ in Heart Failure**?
1. ACE Inhibitors ("prils")
2. ARBs ("sartans")
3. B-Blockers ("ol")
4. Spironolactone
"Building **AABS** reduced mortality in HF"
111
**_Cilostazol_**
What are its 2 major functions?
1. **inhibits platelet aggregation**
2. **arterial vasodilator**
112
What is the major determinant of **symptom severity** in a patient with **Tetralogy of Fallot**?
The severity of the **_RV Outlow Tract Obstruction_**
113
In an **_RCA Occlusion,_** what leads would be elevated?
**Leads II, III, aVF**
**(inferior heart leads)**
114
In an **_LAD Occlusion,_** what leads would be elevated?
**Leads V1, V2, V3, V4**
**(Anterior and Septal heart leads)**
115
In an **_LCX Occlusion,_** what leads would be elevated?
**Leads I, aVL, V5, V6**
**(Lateral heart leads)**
116
At what point would a **_Mitral Stenosis Murmur_** be heard?
**_Point C_**
Mitral Stenosis results in a diastolic mumur
(opening snap followed by a mid diastolic murmur)
117
The image below shows the % of O2 saturation is differing parts of the heart. What abnormality is likely seen in this patient?
(NOTE: abnormality not shown in picture)
**_Ventricular Septal Defect_**
(there is an increase in %O2 from the RA to RV)
118
Before starting **Statin Therapy**, what test must be done?
**Liver Transaminase levels** should be measured before starting statin therapy
(Statins can cause hepatotoxicity and myalgias)
119
Which cardiovascular abnormality/pathology is associated with **ruptured cerebral aneurysms**?
**Coarction of the Aorta**
(it is associated with increased **berry aneurysms**)
120
**_Digoxin Toxicity_**
1. What is its most lethal complication?
2. How can it be treated?
**1. Ventricular Arrythmias**
2. **Class IB Antiarrythmics** (Lidocaine, Mexiletine, Phenytoin)
121
What are the symptoms of **_Digoxin Toxicity_**?
**_GI_**: anorexia, nausea, vomitting, abdominal pain
**_Neurologic_**: fatigue, confusion, **color/vision disturbances**
**_Cardiac_**: ventricular arrythmias
122
What can be done to **increase forward flow** in _**mitral regurgitation**?_
What type of **drug** can be used to achieve this?
**Decrease systemic vascular resistance**
**Vasodilators**
123
**_Milirinone_**
1. What are its effects?
2. How are they mediated?
1.
Cardiomyocytes: **increase contractility**
Vascular Smooth Muscle: **vasolidation**
2. **inhibits PDE-3** which **reduces cAMP degredation**
(increases cAMP)
124
**_Coronary Sinus_**
1. What does it do?
2. To where does it deliver its blood?
1. It collects blood from the myocardial veins
2. It delivers the unoxygenated blood to the **_Right Atrium_**
125
**_Enlarged Coronary Sinus_**
1. What does it indicate?
2. How is it most commonly caused?
**1. Increased RA Pressure**
**2. Pulmonary Hypertension**
126
1. What can be given to **close a PDA**?
2. What can be given to **keep open a PDA**?
1. **Indomethacin**
"**E**ndomethacin **E**nds a PDA"
2. **Prostaglandins**
"P**G**E keeps a PDA **G**oing"
127
1. What are the cardiac manisfestations of **_Carcinoid Syndrome?_**
2. What is measured to confirm carcinoid syndrome?
**1. _Right_ Heart Valvular _Fibrous Plaques_**
(does not usually effect Left Heart)
2. **Urinary 5-HIAA**
(5-hydroxyindoleacetic acid)
128
How does a **_Restrictive Cardiomyopathy_** present?
Same as a Hypertrophic Cardiomyopathy
(both result in **_diastolic_** dysfunction)
**-LA enlargement**
**-LV hypertrophy**
**-Normarl ejection fraction**
129
**_Alteplase Fibrinolytic Therapy_**
1. How does Alteplase work?
2. What is the most common adverse effect?
1.
Alteplase **_binds fibrin_** in the thrombus
It then **_activates plasmin_** which lyses the clot
2. **_Hemorrhage_** (**Intracerebral** or **GI**)
130
At the level of the **_mid-esophagus_**, what is:
a. **Anterior** to the esophagus
b. **Posterior** to the esophagus
**a. Left Atrium**
**b. Descending Aorta**
131
What classically presents as:
## Footnote
**-Tearing chest pain**
**-Unequal BP in arms**
## Footnote
**Aortic Dissection**
**(_intimal_ tear of aorta)**
132
Blockade of which **recepter** can cause **_orthostatic_** **hypertension**?
**alpha-1 adrenergic receptors**
| (terasozin, doxasozin)
133
How does **_exercise_** affect the following?
1. CO
2. **Arterial** blood gas (O2/CO2)
3. **Venous** blood gas (O2/CO2)
1. increased CO
2. Arterial blood gas remains the **_same_**
**3. Venous O2 is decreased and CO2 is increases**
134
**_Septic Shock_**
1. **Hyperthermia** or **hypothermia**
2. Inc or Dec **_SVR_**
3. Inc or Dec **_CO_**
1. Either
2. Decreased SVR
3. Increased CO
135
How would an **_occulusion of the Right Coronary Artery_** affect the following?
1. CO
2. PCWP
3. CVP
**1. Decreased CO**
(since there is less blood in the left heart so SV will be down)
**2. Decreased PCWP**
(Since the RV cant pump as well so less blood in the LA)
**3. Increased CVP**
(due to impaired forward flow so blood is backed up)
136
What are the 4 most common clinical findings in a **Cardiac Tamponade?**
1. Hypotension
2. Elevated JVP
3. Muflled heart sounds
4. Pulsus Paradoxus
137
How come pregnant women can become **_hypotensive_** when lying in the **supine position**?
## Footnote
**Compression of the IVC** --\>
Reduced venous return --\>
Decreased CO --\>
**Hypotension**
138
1. What is a **_Permissive_** Effect?
2. What is a **_Additive_** Effect?
3. What is a **_Synergistic_** Effect?
1. When one hormone allows the other to exert its **maximal** effect
2. When the combined effect is **equal** to the sum of the 2 individual effects
3. When the combined effect is **greater than** the sum of the 2 individual effects
139
How do **_Nitrates_** effect the following:
1. LV End-diastolic pressure
2. Systemic Vascular Resistance
3. Peripheral Venous Capacitance
**1. Decrease**
(since they decrease cardiac preload - more blood in veins)
**2. Decrease**
(since they can modestly dilate arterioles)
3. **Increase**
140
Which drug class would this 'new drug' most ressemble?
**Class IB Antiarrythmics**
(Lidocaine, Mexiletine, Phenytoin)
NOTE: order from strongest to weakest: **C A B**
141
In which cardiomyopathy do patients most likely develop a **mural thrombus**?
Dilated Cardiomyopathy
142
What is the most frequent cause of death **2 hours post-MI?**
Ventricular Arrythmias
143
In the CT scan, what is:
B = ???
C = ???
B = IVC
C = Abdominal Aorta
144
**_Patent Foramen Ovale_**
1. How does it result?
2. What can become a major complication of it?
1. Failure of **septum primum and septum secundum to fuse** after birth
2. If RA pressure increases above LA, it can cause a right to left shunt which can in turn result in a **paradoxical emboli** in the systemic circulation
145
What statitistical method is best for comparing the means of 2 groups?
Two-sample T test
146
An infant born with a flat facial profile, protruding tongue, small ears, upslanting palpebral defects and cardiac defects is most indicative of a child with what?
Down Syndrome
147
How does down syndrome occur?
**maternal meiotic nondisjunction**
(fetus recieves 3 copies of chromosome 21)
148
Would this holosystolic murmur be more indicative of **mitral or tricuspid regurgitation?**
**_Tricuspid Regurgitation_**
(the intensity increases with inspiration and **inspiration increases the intensity of right heart sounds**)
149
A patient presenting with bacterial endocarditis following a cytoscopy (urinary procedure) is most likely infected with which bacteria?
**Enterococcus**
150
What murmur is this?
Where would it be the loudest?
**_Aortic Regurgitation_**
- loss of aortic dicrotic notch
- steep diastolic decline of aortic pressure
- High peaking LV and aortic systolic pressures
**_Point C_**
(just after closer of aortic valve)
151
What is the pathway for which an **embolus** would be able to enter the **_retinal artery_** and cause vision impairment?
**1. Internal Carotid --\>**
**2. Opthalmic Artery --\>**
**3. Retinal Artery**
152
How would **_atenolol_** affect the following:
1. Cardiomyocite cAMP
2. Juxtaglomerular cAMP
3. Vasuclar smooth muscle cAMP
Atenolol is a **_beta-1 selective antagonist_**
1. **Decreased**
(b1 found in cardiomyocytes --\> dec. **HR** and **contractility**)
2. **Decreased**
(b1 found in juxtaglmerular cells --\> decreases **Renin**)
3. **No change**
(**b2** found in vascular smooth muscle)
153
What are the effects of an **_AV shunt_** on the following:
1. Preload
2. EDV
3. TPR
4. Afterload
**1. increased Preload**
(increased venous return to heart)
**2. Increased EDV**
**3. Decreased TPR**
(less resistance since blood bypases arterioles)
**4. Increased Afterload**
154
Which 2 endogenous factors are most responsible for controlling coronary blood flow?
1. **_Nitric Oxide_** (NO) --\> _large_ coronary arteries, prearteriolar vessels
2. **_Adenosine_** --\> _small_ coronary arteries
155
What **cardiovascular defect** is ?? associated with:
## Footnote
**1. Down Syndrome**
**2. Digeorge Syndrome**
**3. Friedreich Ataxia**
**1. ASD (ostium primum)**
**2. Tetralogy of Fallot**
**3. Hypertrophic Cardiomyopathy**
156
What **cardiovascular defect** is ?? associated with:
**1. Kartagener Syndrome**
**2. Tuberous Sclerosis**
**1. Situs Inversus**
**2. Rhabdomyomas**
157
What **cardiovascular defects** are **Turner Syndrome** associated with?
**Coarction of the Aorta**
**Bicuspid Aortic Valve**
158
What **cardiovascular defects** are **Marfan Syndrome** associated with?
**Aortic Dissection**
**Aortic Aneurysm**
**Mitral Valve Prolapse**
159
What are the 2 ways/formulas to calculate **Cardiac Output**?
1.
**CO = SV X HR**
2.
**CO = rate of O2 consumption / (Arterial O2 - Venous O2)**
160
**_Angioedema_**
1. What is it?
2. How is it usually caused?
1. **Swelling of the skin**, most commonly of the **tongue**, **lips** and **eyelids**. Can also affect **larynx** (causing stridor)
2. Side-effect of **ACE inhibitors** due to **Bradykinin** **accumulation**
(increases vascular permeability)
161
If a patient with a heart transplant begins to reject the transplant **2 weeks** after it was planted, what are the main features we would see in this type of rejection?
**_ACUTE REJECTION_** (1-4 weeks)
**Vasculitis of graft vessels** with a **dense lymphocytic infiltrate** (mainly T-cells)
162
In a patient who has a **holosystolic murmur that is best heard at the apex of the heart that radiates to the axilla**, would he be more likely to develop an S3, S4, mid-systolic click or opening snap?
This patient has **Mitral Regurgitation**
(best heard at apex = mitral valve)
(radiates to axilla = blood is flowing back)
Mitral regurgitation is likely to result in an **_S3_**
(due to volume overload = S3)
163
From **hours 0-4** following a myocardial infarction what **light microscopic changes** would we most likely see?
**_None_**
## Footnote
**(first changes begin after 4 hours)**
164
What does this patient have?
At which point would intensity of this murmur be loudest?
**_Aortic Stenosis_**
(LV pressure **\>** aorta pressure, they should normally be equal)
**_Point B_**
(murmur will be loudest where we have the greatest pressure difference between the LV and aorta)
165
What syndrome does this patient most likely have?
What causes it?
**Wolf-Parkinson White Syndrome**
(note the **Delta Wave**)
Caused by an **accessory pathway (bundle of Kent) that bypasses the AV node**
166
Before intiating **amiodarone therapy** what must we first test?
**Serum TSH levels**
167
A person wearing a tight short collar develops hypotension.
What nerve mediates the Afferent and Efferent Limb of this reflex?
**_Carotid Sinus Reflex_**
**Afferent limb: Glossopharyngeal n.**
(carotid sinus--\>medulla)
**Efferent Limb: Vagus n.**
(medulla --\> heart, parasympathetic stimulation)
168
An **arterial puncture above the inguinal ligament** increases the risk of blood collection into where?
**Retroperitoneal Space**
169
What medication improves survival in patients with HF?
ACE Inhibitors
ARBs
B-blockers
Spironolactone
170
In what organ did this problem most likely originate? How?
**The Heart**
This is a **splinter hemorrhage** caused by **endocartitis**.
Caused by microemboli from the small valvular vegetations
171
What should we inject into a patient who was recieving a venous drip of **norepinephrine** whose skin around the injection site has become cold hald and pale?
**Phenotolamine** (an alpha blocker)
The skin is sufferent from major alpha-1 mediated vasoconstriction due to norepinephrine
172
In **polyarteritis nodosa**, the arteries of which organ are most commonly spared?
## Footnote
**lungs**
173
In a patient with pulmonary hypertension, would we expect increased, normal or decreased values of the following:
1. Thomboxane A2
2. Nitric Oxide
3. Prostacyclin
4. Endothelin
1. increased
2. decreased
3. decreased
4. increased
pulmonary HTN occurs due to increased proliferative and vasoconstrictive mediators (endothelin, TXA2) and decreased antiproliferative and vasodilatory mediators (NO, Prostacyclin)
174
A patient presents with pulsus paradoxus but has no pericardial disease, what is the next most likely cause?
**_Asthma_** or **_COPD_**
(obstructive lung disease results in **hyperinflated lungs**)
175
A patient presents with a **loud S2** and an accentuated **palpable impulse at the left sternal border**.
What is the most likely diagnosis?
**_Pulmonary Hypertension_**
_Loud S2:_ forceful pulmonic valve closure
_Palpable Impulse:_ RV hypertrophy due to increased pressure
(RV Heave)
176
What is the most common trigger of atrial fibrilation?
Abberant electrical activity in the **_pulmonary veins_**
177
Which part of the heart would most likely be affected in a patient who was stabbed in the left 4th intercostal space along the sternal border?
**_Right Ventricle_**
(makes up the majority of the anterior heart)
178
What ions are represented in this photo
1 = Sodium
2 = Calcium
3 = Potassium
179
What arteries are most suceptible to **atherosclerosis**?
1. Abdominal aorta
2. Coronary arteries
3. Popliteal artery
4. Carotid artery
"after an ABs workout, i grab a CORONa and POP my collar up to my CAROTID"
180
What is **mitochondrial vacuolization** a sign of?
**Irreversible cell injury**
(it signifies that the mitochondria are permanently damaged and unable to make ATP)
181
Whats the best way to assess the degree of mitral stenosis?
The **_A2-to-opening snap_** time interval
(the **shorter** the interval the **more severe**)
182
A young woman presents with weak pulses, myalgias, arthralgias and fatigue.
What is the most likely diagnosis?
**_Takayasu Arteritis_**
(granulomatous thickening of large vessels)
183
Which **amino acid** plays a role in **vasodilation**?
**_Arginine_**
| (it is a precursor Nitric Oxide)
184
A 4 yeard old asian child present with fever, bright red tongue, rash, and conjunctival injection.
What is the most likely diagnosis?
**_Kawasaki Disease_**
## Footnote
**_C_**onjunctival Injection
**_R_**ash
**_A_**denopathy (cervical)
**_S_**trawberry Tongue
**_H_**and and feet edema and rash
**Fever** **(KAWASAKI motorcycles _CRASH_ and Burn)**
185
What is the most significant complication that can lead to death in a patient with Kawasaki disease?
Coronary Artery aneurysms
186
In a 14 year old girl whose 10th percentile for height and weight, has a short thick neck, broad chest and short 4th metacarpals, what **cadiac defects** is she most at risk for?
**_Turner Syndrome_**
## Footnote
**- coarction of the aorta**
**-bicuspid aortic valve**
187
LV EDV = 125 ml
LV ESV = 75 ml
What is the **Ejection Fraction**?
EF = SV / EDV
= 50/125
**= 40%**
188
What are the **normal** morphological changes in an **aging heart?**
- decrease LV apex to base dimension
- sigmoid shaped ventricular septum
- increased collagen deposition
- cytoplasmic lipofuscin (brown pigment) in cardiomyocytes
189
A patient presents with neurological symptoms and signs heart failure, in what **vitamin** would he deficient?
**_Thiamine (Vit. B1)_**
Deficiency results in **Beriberi**
**(peripheral neuropathy, heart failure)**
190
A genetic defect that **prolongs the QT interval** most likely effects which type of membrane channel?
Potassium Channels
191
Pacemaker leads most commonly travel through what?
Where is this located?
**Coronary Sinus**
Atrioventricular groove
192
What can cause a **_dilated_** cardiomyopathy?
**_A_**lcohol abuse
**_B_**eriberi
**_C_**hagas
**_C_**oxsackie virus
**_C_**ocaine use
**_D_**oxorubicin
**_"ABCCCD_**ilated"
193
**_Sick-sinus Syndrome_**
1. what is it?
2. how does it present?
2. how it seen on ECG?
1. age related degeneration of **SA node**
2.
**bradycardia, reduced CO** which can lead to syncope
3.
Delayed p-waves until a **_p-wave is dropped_**
194
How is the chest pain seen in **_Costochondritis_** typically seen?
Chest pain that is **reproducible with palpation and worsened with movement or changes in position**
195
**_Foam cells_**
1. What do they lead to?
2. What are they primarily composed of?
1.
Atherosclerotic plaque
2.
Macrophages
196
**_Amyloid Cardiomyopathy_**
1. What type of myopathy is it most likely to cause?
2. How will the walls of the heart be effected?
3. Systolic or diastolic dysfunction?
1. **_Restrictive_** Cardiomyopathy
2.
Ventricular walls become thickened
**_Dilated left Atrium cavity size_**
**_Normal Left Ventricle cavity size_**
3. **_Diastolic_** Dysfunction
197
What will happen to this benign vascular tumor over time?
First in will **increase in size**
Then it will **regress**
198
A patient presents with a **loud S2** and a **accentuated palpable impulse** along the upper left sternal border.
What is the most likely diagnosis?
**_Pulmonary Hypertension_**
| (RV Heave)
UWorld - Cardio
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