what do bulbus cordis and the 2 horns of sinus venosus become?
bulbus cordis - smooth parts (outlfow tracts) of L and R ventricles
L horn of SV - coronary sinus
R horn of SV - smooth part of RA
sites of fetal erythropoiesis
yolk sac til 10 wks
liver 6 wks to birth
spleen 15-30 wks
bone marrow 22 wks onward
drugs to close or keep open the ductus arteriosus
close w/ indomethacin
keep open w/ PGE1&2
median umbilical ligament is remnant of
allantois
nucleus pulposus is remnant of
notochord
what coronary artery normally supplies SA and AV nodes?
RCA
left vs right dominant coronary circulation - which is more common and what does it mean
right more common
dominant is based on what side the posterior descending artery arises from
Fick principle
CO = rate of O2 consumption / (Arterial O2 conc - venous O2 conc)
3 things that affect stroke volume
contractility, afterload, preload
4 things that inc myocardial O2 demand
inc afterload
inc contractility
inc HR
inc heart size (wall tension)
eqn for vascular resistance
8 * viscosity * length / (pi r^4)
5 phases of cardiac cycle
isovolumetric contraction systolic ejection isovolumetric relaxation rapid filling reduced filling
atrial waveform components
a wave - atrial contraction c wave - RV contraction x descent - atrial relaxation v wave - atrial filling y descent - blood flow from RA to RV
what kind of conditions would cause wide, fixed, or paradoxical splitting of S2?
wide - delayed RV emptying
fixed - ASD / L>R shunts
paradoxical - delayed LV emptying
holosystolic, high pitched “blowing murmur”
mitral/tricuspid regurg
causes of mitral or tricuspid regurg
mitral - ischemic heart dz, mitral valve prolapse, LV dilation
tricupsid - RV dilation
either - rheumatic fever / infective endocarditis
crescendo-decrescendo systolic ejection murmur
aortic stenosis
“pulsus parvus et tardus”
aortic stenosis
2 causes of aortic stenosis
age related calcific aortic stenosis
bicuspid aortic valve
holosystolic harsh sounding murmur
VSD
late systolic crescendo murmur w/ midsystolic click
mitral valve prolapse
high pitched blowing diastolic decrescendo murmur
aortic regurg
causes of aortic regurg
aortic root dilation
bicuspid aortic valve
endocarditis
rheumatic fever
opening snap followed by delayed rumbling late diastolic murmur
mitral stenosis
cause of mitral stenosis
rheumatic fever
continuous machine like murmur
PDA
phases of cardiac action potential
0 - rapid upstroke, opening of Na channels
1 - initial repolarization - inactivation of Na, opening of voltage gated K
2 - plateau - Ca channels
3 - rapid repolarization - massive K efflux
4 - resting potential - high K permeability
U wave
hypokalemia, bradycardia
cause and tx of torsades de pointes
anything that prolongs QT interval
MgSO4
“sawtooth” p waves
atrial flutter
threshold for 1st deg AV block
PR interval > 200 ms
infectious cause of complete heart block
Lyme dz
ANP - what stimulates secretion and what does it do
stim by inc blood volume or atrial pressure
causes general vascular relaxation and natriuresis - “escape from aldosterone” mech
difference in what central vs peripheral chemoreceptors respond to
central - determined by arterial CO2, does not respond to PO2
peripheral - respond to dec PO2, inc PCO2, or dec pH
which organ gets largest share of systemic cardiac output?
liver
congenital heart dzs causing early cyanosis (blue babies)
R>L shunts 5 Ts: Tetralogy of Fallot (MC)** Transposition of great vessels persistant Truncus arteriosus Tricuspid atresia Total anomalous pulm venous return
MC congenital cardiac anomaly
VSD
causes of late cyanosis (blue kids)
VSD, ASD, PDA
Eisenmenger’s syndrome
uncorrected ASD, VSD, PDA lead to compensatory pulm vasc hypertrophy > progressive pulm HTN > cyanosis, clubbing, polycythemia
tetralogy of fallot
pulm infundibulum stenosis
RVH
overriding aorta
VSD
coarctation of aorta - main consequence and difference between infantile and adult type
can cause aortic regurg
infantile - preductal, assoc w/ Turner syndrome
adult - postductal
who is at greater risk for transposition of great vessels?
infant of diabetic mother
Monckeberg arteriosclerosis
calcification in media of arteries. usually benign - no obstruction b/c intima not involved
causes of thoracic aortic aneurysm
HTN, Marfan’s, tertiary syphilis
path process in aortic aneurysms due to Marfan’s
cystic medial necrosis
ECG finding in stable angina
ST depression
MCC sudden cardiac death
Vfib
At what time point do neutrophils infiltrate an MI?
1-3 d after
diagnosis of MI - 3 methods and which is best for what
ECG (ST elevation/depression, pathologic Q waves) - gold standard in 1st 6 hrs
Cardiac Troponin - rises after 4 hrs and stays for 7-10d. Most specific
CK-MB - not as specific, but good for dx reinfarction after acute MI b/c levels return to nl after 48 hrs
Dressler’s syndrome
autoimmune phenomenon resulting in fibrinous pericarditis several wks after an MI
MC cardiomyopathy
dilated (congestive)
causes of dilated cardiomyopathy
HPI:
hemochromatosis, peripartum, idiopathic
ABCCCD:
Alcohol, wet Beriberi, Coxsackie B, Cocaine, Chaga’s, Doxorubicin
cardiomyopathies showing eccentric vs concentric hypertrophy
eccentric - dilated
concentric - hypertrophic
MCC hypertrohpic cardiomyopathy
familial (AD)
Loffler’s syndrome
endomyocardial fibrosis w/ prominent eosinophilic infiltrate
“heart failure” cells
hemosiderin laden macrophages found in lungs - due to pulm edema from CHF
Roth’s spots, Osler’s nodes, and Janeway lesions - what are they and what are all 3 assoc w/?
Roth’s spots - round white spots on retina surrounded by hemorrhage
Osler’s nodes - tender raised lesions on finger/toe pads
Janeway lesions - small painless erythematous lesions on palm/sole
all assoc w/ bacterial endocarditis
MC cause of acute and subacute endocarditis
acute - staph aureus
subacute - viridans strep
tricuspid valve endocarditis assoc w/
IV drug use
order of valves affected by rheumatic heart dz
mitral > aortic»_space; tricuspid
sx of rheumatic fever
FEVERSS fever erythema marginatum valvular dmg ESR up red hot joints subq nodules St. Vitus' dance / Sydenham's chorea
Aschoff bodies and Anitschkow’s cells assoc w/
rheumatic fever / heart dz
3 types of acute pericarditis and general causes of each
fibrinous - Dressler’s syndrome after MI, uremia, radiation
serous - viral or noninfectious inflammatory
suppurative/purulent - bacterial
pulsus paradoxus - def and assoc condition
dec in amplitude of SBP by >10 mmHg during inspiration (not paradoxical, just exaggerated)
assoc w/ cardiac tamponade
“tree bark” appearing aorta
syphilitic heart dz
MC primary heart tumor in adults vs kids
adults - myxoma
kids - rhabdomyomas
Kussmaul’s sign
inc in JVP on inspiration (nl would be dec)
due to impaired filling of RV, may be seen w/ constrictive pericarditis, restrictive cardiomyopathy, right heart tumors, cardiac tamponade
dzs assoc w/ Raynaud’s phenomenon
mixed CT dz, SLE, CREST (limited systemic sclerosis)
temporal arteritis - who, unique sx/complications, assoc conditions, type of inflammation, tx
who - elderly females sx - unilateral HA, jaw claudication, blindness from ophthalmic artery occlusion assoc - polymyalgia rheumatica type - focal granulomatous tx - corticosteroids
Takayasu’s arteritis - who, unique sx/complications, type of inflammation, tx
who - Asian females weak UE pulses
type - granulomatous thickening of aortic arch / great vessels
tx - corticosteroids
polyarteritis nodosa - who, unique sx/complications, assoc conditions, type of inflammation, tx
who - young adults
sx - abd pain, HTN, neuro dysfn, cutaneous eruptions, renal dmg
assoc - Hep B
type - transmural inflam from immune complexes
kawasaki’s dz - who, unique sx/complications, tx
who - asian toddlers
sx - cervical lymphadenitis, “strawberry tongue”, desquamating rash, hand/foot erythema, can lead to coronary aneurysms
tx - IVIG and aspirin
Buerger’s dz / thromboangiitis obliterans - who, unique sx/complications, type of inflammation, tx
who - young male smokers
sx - intermittend claudication, gangrene / amputation of digits, Raynaud’s phenom
type - segmental thrombosing
tx - smoking cessation
microscopic polyangiitis - sx, type of inflammation, what vessels, tx
sx - glomerulonephritis w/ palpable purpura
type - necrotizing, no granulomas, P-ANCA
vessels - lung, kidney, skin
tx - cyclophosphamide, steroids
Wegener’s granulomatosis - sx, type of inflammation, what vessels, tx
sx - chronic sinusitis, perf of nasal septum, hemoptysis, hematuria
type - focal necrotizing vasculitis, necrotizing granulomas in lungs, necrotizing glomerulonephritis, C-ANCA
vessels - resp and renal
tx - cyclophosphamide, steroids
Churg strauss - sx, type of inflammation
sx - asthma, sinusitis, palpable purpura, peripheral neuropathy
type - granulomatous, necrotizing w/ eosinophilia, P-ANCA
Henoch-Schonlein purpura - who, sx, assoc w/
who - children after UTI
sx - palpable purpura on buttocks, arthralgia, abd pain / melena
assoc - IgA nephropathy
MC childhood systemic vasculitis
Henoch Schonlein purpura
ANCA vasculitis
P-ANCA: microscopic polyangiitis, Churg Strauss
C-ANCA: Wegener’s
cystic hygroma
cavernous lymphangioma of neck. assoc w/ Turner syndrome
glomus tumor
benign, painful red-blue tumor under fingernail
another lesion frequently confused for Kaposi Sarcoma
bacillary angiomatosis - caused by Bartonella henselae in AIDS pts
who tends to get angiosarcoma?
pts getting radiation therapy (esp in chest - breast CA, hodgkin’s)
Sturge Weber dz
congenital vascular disorder affecting small vessels. port wine stain on face, intracerebral AVM, seizures, early onset glaucoma
when to not use beta blockers in heart dz
decompensated CHF (use w/ caution if at all), NEVER in cardiogenic shock
order of CCBs from most affecting vasculature to most affecting heart
vasc: amlodipine = nifedipine > diltiazem > verapamil : heart
cardiac tox of CCBs
cardiac depression and AV block
hydralazine - mech, special use, important tox
inc cGMP > smooth muscle relax > dec afterload
first line for HTN in pregnancy
compensatory tachy, lupus like syndrome
nitroprusside - mech, use, tox
short acting, inc cGMP via direct release of NO
malignant HTN
CN tox
fenoldopam - mech, use
D1 receptor agonist > vasodilation
malignant HTN
nitroglycerin / isosorbide dinitrate - mech, use, tox
vasodilate by NO > inc cGMP. dilate veins»_space; arteries. dec preload
angina, pulm edema
reflex tachy, hypotn, flushing, HA
main goal of anti-anginal therapy
dec myocardial O2 demand
tox of statins
hepatotox, rhabdomyolysis
niacin - mech, tox
inhibit lipolysis in adipose > reduce hepatic VLDL sec > good dec in LDL, good inc in HDL, some dec of TG
hyperglycemia and hyperuricemia
cholestyramine, colestipol, colesevelam - mech, tox
(bile acid resins) prevent intestinal reabs of bile acids > good dec in LDL but little effect on HDL and TGs
disliked - bad taste and GI discomfort, cholesterol gallstones
ezetimibe - mech, tox
cholesterol absorption blocker - good dec in LDL but no effect on HDL or TGs
rare inc LFTs, diarrhea
fibrates - mech, tox
upregulate lipoprotein lipase > inc TG clearance - little effect on LDL/HDL, very good dec in TGs
myositis, hepatotox, cholesterol gallstones
signs of digoxin tox
cholinergic - N/V/D, blurry yellow vision
ECG - inc PR, dec QT, ST scooping, T wave inversion, arrhythmia, AV block
hyperkalemia (bad sign)
antidote for digoxin tox
slowly normalize K lidocaine cardiac pacer anti-digoxin Fab Mg
class 1 antiarrhythmics - mech
Na channel blockers (local anesthetics)
ex of class 1a/b/c antiarrhythmics
1a - quinidine, procainamid, diopyramide
1b - lidocaine, mexiletine, tocainide
1c - flecainide, propafenone
best class of antiarrhythmic to use after MI
1b
which class of antiarrhythmic is c/i in structural heart dz and post-MI
1c
class 2 antiarrhythmic mech
beta blockers
use of class 2 antiarrhythmics
Vtac, SVT, slow ventricular rate during afib and atrial flutter
class 3 antiarrhythmic mech
K channel blockers
class 3 antiarrhythmic ex
AIDS -
amiodarone (this one is actually 1,2,3,4), ibutilide, dofetilide, sotalol
what labs to monitor when using amiodarone?
PFTs, LFTs, TFTs (thyroid)
class 4 antiarrhythmic mech
CCBs
adenosine - mech, use
inc K out of cell > hyperpolarize cardiac cell
drug of choice for dx/abolish SVT
use of Mg as antiarrhythmic
torsades de pointes and digoxin tox