Cardio Flashcards
(238 cards)
1
Q
Cardiac looping
A
week 4
primary heart tube loops to estabilish left right polarity
2
Q
Kartaneger syndrome
A
defect in left right dyenin can lead to dextrocardia via ciliary dyskinesia
3
Q
Septation and chambers
A
- Septum primum grows toward endocardial cushions, narrowing foramen primum
- Foramen secundum forms in septum primum
- Septum, secundum develops on the right side of septum primum, as foramen secundum maintains right left shunt
- Septum secundum expands and covers most of the foramen secundum. Residual foramen is foramen ovale
- remaining portions of septum primum forms one way valve of the foramen ovale
- septum primum closes against septum secundum sealing the foramen ovale soon after birth
- Septum secundum and septum primum fuse during infancy forming atrial septum
4
Q
PFO
A
caused by failure of the septum primum and septum secundum to fuse after birth
lead to paradoxical emboli
5
Q
Ventricle morphogenesis
A
- Muscular interventricular septum forms.
- Aorticopulmonary septum rotates and fuses with muscular ventricular septum to form membranous interventricular septum, closing interventricular foramen
- growth of endocardial cushions separates atria from ventricles and contributes to both atrial septation and membranous portion of the interventricular septum
6
Q
VSD
A
membranous septum Most common Holosystolic harsh sounding murmur tricuspid area asymptomatic at birth May lead to LV overload and HF
7
Q
Outflow tract formation
A
Neural crest and endocardial cell migrations –> truncal and bulbar ridges that spiral and fuse to form articopulmonary trunk
8
Q
Conotrunal abnormalities
A
associated with failure of NCC to migrate
transposition of the great vessels, tetralogy of Fallot, persistent truncus arteriosus
9
Q
Valve Development
A
Aortic/pulmonary- derived from endocardial cushions of outflow tract
mitral and tricuspid- fused endocardial cushions of the AV canal
10
Q
Truncus arteriosus
A
ascending aorta and pulmonary trunk
11
Q
bulbus cordis
A
smooth parts of left and right entricles
12
Q
Primitive ventricle
A
trabeculared part of left and right ventricles
13
Q
Primitive atrium
A
trabeculated part of left and right atria
14
Q
left horn of sinus venosus
A
coronary sinus
15
Q
right horn of sinus venosus
A
smooth part of right atrium
16
Q
endocardial cushion
A
atrial septum, membranous interventricular septum, AV and semilunar valves
17
Q
right common cardinal V and right anterior cardinal V
A
SVC
18
Q
Posterior, subcardinal and surpacardinal V
A
IVC
19
Q
primitive pulmonary V
A
smooth part of L atrium
20
Q
Fetal circulation
A
- Blood entering fetus through the umbilical V is conducted via ductus venosus into the IVC, bypass hepatic circulation
- most of the oxygenated blood reaching the heart via IVC is directed through foramen ovale into the L atrium
- Deoxygenated blood from SVC passes through the RA –> RV –> main pulmonary A –> Ductus arteriosus –> descending aorta
At birth, infant takes deep breath –> decrease resistance in pulmonary vasculature –> increase LA pressure –> foramen ovale closes
High O2 and low prostaglandins –> closure of ductus arteriosus
21
Q
Indamethacin
A
close patent ductus arteriosus –> Ligamentum arteriosum
22
Q
Prostaglandin E 1 and 2
A
Keep PDA open
23
Q
Ductus arteriosus
A
Ligamentum arteriosum
24
Q
Ductus venosus
A
Ligamentum venosum
25
Foramen ovale
Fossa ovalis
26
Allantois --> urachus
median umbilical L
27
Umbilical A
Medial umbilical L
28
Umbilical V
Ligamentum teres hepatis
29
Notochord
nucleus pulposus
30
Enlargement of the LA
compression of the esophagus and or the L recurrent laryngeal N --> hoarseness
31
Most commonly injured part of the heart
RV
32
Pericardium
```
Fibrous pericardium
Parietal layer of serous pericardium
Visceral layer of serous pericardium
Pericardial cavity lies between parietal and visceral layers
innervated by phrenic N
```
33
Pericarditis
can cause referred pain to neck arms or shoulders
34
LAD
anterior 2/3 of interventricular septum, anterolateral papillary muscle and anterior surface of LV
Most common occlusion
35
PDA
supply AV node, posterior 1/3 of intraventricular septum, posterior 2/3 walls of ventricles and posteromedial papillary M
36
RCA
supplies SA node
| infarct may cause nodal dysfunction
37
Right dominant
Posterior descending A arise from RCA
38
Left dominant
Posterior descending A arise from LCX
39
Stroke volume
increased by high contractility, low afterload and high preload
SV= EDV-ESV
40
Contractility
increase with catecholamine stimulation via B1 receptor, high intracellular Ca2+, low extracellular Na+, digitalis
decreased with B1 blocker, HF, acidosis, hypoxia, CCB
Ejection fraction = ventricular contractility
41
Preload
depend on venous tone and circulating blood volume
| Vasodilators decrease preload
42
Afterload
increase wall tension --> increase pressure --> increase afterload
Arterial vasodilators decrease afterload
LV compensates fro increase afterload by thickening to decrease wall stress.
43
Myocardial O2 demand
increase with high contractility, high afterload, high HR, high diameter of ventricle
44
Cardiac Output
SV x HR
45
Pulse pressure
SBP-DBP
directly proportional to SV
increase in hyperthyroidism, aortic regurgitation, aortic stiffening, obstructive sleep apnea, anemia, exercise
decrease in aortic stenosis, cardiogenic shock, cardiac tamponade, advance HF
46
MAP
CO x TPR
| 2/3DBP + 1/3 SBP = DBP + 1/3 PP
47
Starling curve
Force of contraction is proportional to end diastolic length of cardiac muscle fiber (preload)
increase contractility with catecholamines and positive inotropes
decreased contractility with loss of functional myocardium, B blockers, CCB, dilated cardiomyopathy
48
Resistance, pressure, flow
capillaries have highest total cross sectional area and lowest flow velocity
Pressure gradient drives flow from high pressure to low pressure
Arterioles account for TPR and veins provide most blood storage capacity
49
PV loop
1. isovolumetric contraction- period between mitral valve closing and aortic valve opening HIGHES O2 CONSUMPTION
2. Systolic ejection- period between aortic valve opening and closing
3. isovolumetric relaxation- period between aortic valve closing and mitral valve opening
4. Rapid filling- period just after mitral valve opens
5. reduced filling- period before mitral valve closes
50
S1
Mitral and tricuspid close
| LOUDEST AT MITRAL AREA
51
S2
Aortic and pulmonary valve close
| LOUDEST AT LEFT UPPER STERNAL BORDER
52
S3
early diastole, during rapid ventricular filling phase.
HEARD AT APEX with patient in L lateral decubitus position
Associated with increased filling pressures (MR, AR, HF)
normal in children, athletes, pregnant
53
S4
in late diastole
HEARD AT APEX with patient in left lateral decubitus position
high atrial pressure
associated with ventricular hypertrophy
54
a wave
atrial contraction
| absent in a fib
55
c wave
RV contraction
56
x descent
downward displacement of closed tricuspid valve during rapid ventricular ejection phase. Reduced or absent in tricuspid regurgitation and right HF because pressure gradients are reduced
57
v wave
high RA pressure due to filling agasint closed tricuspid valve
58
y descent
RA emptying into RV
| Prominent in constrictive pericarditis, absent in cardiac tamponade
59
Aortic stenosis
```
High LV pressure
high ESV
no change in EDV
low SV
systolic murmur
crescendo - descendo systolic ejection murmur
soft S2
loudest at base and radiates to carotids
lead to syncope, angina, dyspnea
age related calcification
```
60
Mitral Regurgitation
no true isovolumetric phase
low ESV due to low resistance and high regurgitation into LA during systole
high EDV due to high LA volume from regurgitation --> ventricular filling
high SV
Holosystolic high pitched murmur
loudest at apex and radiates to axilla
ischemic heart disease, mitral valve prolapse or LV dilation
Rheumatic fever and infective endocarditis
61
Aortic regurgitation
No true isovolumetic phase
high EDV
high SV
high pitched blowing early diastolic decrescendo murmur
heard at base or left sternal border
Bicuspid aortic valve, endocarditis, aortic root dilation, rheumatic fever
62
Mitral stenosis
```
high LA pressure
low EDV
low ESV
low SV
follow opening snap
delayed rumbling mid to late diastolic murmur
late rheumatic fever
```
63
Physiological splitting of S2
inspiration --> drop in intrathoracic pressure --> high venous return --> high RV filling --> high RV SV --> high RV ejection time --> delayed closure of pulmonic valve
64
Wide splitting of S2
conditions that delay RV emptying, pulmonic stenosis, RBBB
| causes delayed pulmonic sound
65
Fixed splitting of S2
ASD
| left to right shunt --> high RA and RV volume --> high flow through pulmonic valve --> delayed pulmonic valve closure
66
Paradoxical splitting of S2
conditions that delay aortic valve closure
Aortic stenosis, LBBB
Normal order of semilunar valve closure is reversed so that P2 sound occurs before delayed A2 sound
split heard in expiration
67
Aortic systolic murmur
aortic stenosis
flow murmur
aortiv valve stenosis
68
Left Sternal border murmurs
Diastolic- aortic regurgitation, pulmonic regurgitation
| Systolic- hypertrophic cardiomyopathy
69
Pulmonic systolic ejection murmuur
pulmonic stenosis, ASD, flow murmur
70
Tricuspid murmus
holosystolic- VSD, tricuspid regurgitation
| diastolic- tricuspid stenosis
71
Mitral murmur
holosystolic- mitral regurgitation
systolic- mitral valve prolapse
diastolic- mitral stenosis
72
Stadning Valsalva position
decrease preload
murmurs that increase- mitral valve prolapse and hypertrophic cardiomyopathy
murmurs that decrease- most murmurs
73
passive leg raise
increase preload
murmurs that increase- most murmurs
murmurs that decrease- mitral valve prolapse and hypertrophic cardiomyopathy
74
Squatting
increase preload, increase afterload
murmurs that increase- most murmurs
murmurs that decrease- mitral valve prolapse and hypertrophic cardiomyopathy
75
Hand grip
increase afterload
murmurs that increase- AR, MR, VSD
murmurs that decrease- AS, hypertrophic cardiomyopathy
76
Inspiration
increase venous return to right heart and decrease venous return to left heart
murmurs that increase- right sided murmurs
murmurs that decrease- left sided murmurs
77
Mitral valve prolapse
late systolic crescendo murmur with midsystolic click via chordae tendinae
hear over apex
loud just before S2
benign
caused by myxomatous degeneration, rheumatic fever, chordae rupture
78
Patent ductus arteriosus
```
continuous machine like murmur
left infraclavicular area
loudest at S2
congenital rubella or prematurity
patency maintained by PGE and low O2
late cyanosis of lower extremities
```
79
Torsades de pointe
polymorphic ventricular tachy
shifting sinusoidal waveforms on ECG
can progress to V fib
caused by drugs that decrease K+, Mg2+, Ca2+
80
Congenital long QT syndrom
inherited disorder of myocardial repolarization due to ion channel defects
increase risk of cardiac death due to torsades de pointes
Romano- Ward syndrome- AD pure cardiac phenotype
Jervell and Lange Nielson syndrome- AR, sensorineural deafness
81
Brugada syndrome
AD Asian males
Pseudo RBBB and ST elevation in V1-3
increased risk of t-tach and SCD
prevent SCD with implantable cardioverter defibrillator
82
Wolf parkinson White syndrome
ventricular pre-excitation syndrome
abnormal fast accessory conduction pathway from atria to ventricle bypass the rate slowing AV node --> ventricles begin to partially depolarize earlier --> delta wave with wide QRS and short PR interval
83
A- fib
chaotic and erratic baseline with no discrete P wave between irregularly spaced QRS complex
irregularly irregular
HTN, CAD, post binge drinking
84
Atrial flutter
rapid succession of identical back to back atrial depolarization
Sawtooth
85
V-fib
erratic rhythm with no identifiable waves
| Fatal without CPR and defibrillation
86
First Degree AV block
PR interval is prolonged
| benign and asymptomatic
87
Mobitz Type 1
Second degree AV block
progressive lengthening of PR interval until a beat is dropped
asymptomatic
regularly irregular
88
Mobitz Type 2
Second degree AV block
dropped beats that are not preceded by a change in length of PR interval
may progress to third degree
89
Third degree AV block
atria and ventricles beat independently of each other
p waves and QRS complexes not rhythmically associated
caused by lymes
90
Atrial natriuretic peptide
released from atrial myocytes in response to increase blood volume and atrial pressure
via cGMP
vasodilation and decrease Na+ reabsorption at the renal collecting tubule
Dilate afferent and constrict efferent --> diuresis
91
B type natriuretic peptide
Released by ventricular myocytes in response to tension
longer half life to ANP
diagnose HF
92
Aortic Arch receptor
transmit to vagus N to solitary nucleus of medulla
93
Carotid sinus
transmits via glossopharyngeal N to solitary nucleus of medulla
94
Baroreceptor
Hypotension --> low arterial pressure --> low stretch --> low afferent baroreceptor firing --> high efferent sympathetic firing and low efferent parasympathetic --> vasoconstriction, HR, contractility
95
Cushing reflex
high ICP constricts arterioles --> cerebral ischemia --> high pCO2 and low pH --> central reflex sympathetic high in perfusion pressure --> high stretch --> peripheral reflex baroreceptor induced brady
96
Chemoreceptors
Peripheral- carotid and aortic bodies are stimulated by high pCO2 and low pH and O2
Central- changes in pH and pCO2 of brain interstitial fluid
97
Increase capillary pressure
HF
98
increase capillary permeability
toxins, infection, burns
99
increase interstitial fluid colloid osmotic pressure
lymphatic blockage
100
decrease plasma oncotic pressure
nephrotic syndrome, liver failure, protein malnutrition
101
Right to left shunt
```
early cyanosis
maintain PDA
Truncus arteriosus (1 vessel)
Transposition (2 vessels)
Tricuspid atresia
Tetralogy of Fallot
TAPVR
```
102
Persistent truncus arteriosus
truncus arteriosus fails to divide into pulmonary trunk and aorta due to failure of aorticopulmonary septum formation
most also have VSD
103
D transposition of great vessels
aorta leave RV and pulmonary trunk leaves LV --> separation of systemic and pulmonary circulation
not compatible with life unless have VSD, PDA, or PFO
104
Tricuspid atresia
no tricuspid valve
hypoplastic RV
need ASD and VSD
105
Tetralogy of Fallot
anterosuperior displacement of the infundibular septum
pulmonary infundibular stenosis, RVH (boot shpaed), overriding aorta, VSD
tet spells
squatting
associated with 22q11 syndromes
106
Total anomalous pulmonary venous return
pulmonary V drain into right heart circulation
| associated with ASD and PDA
107
Ebstein anomaly
displacement of tricuspid valve leaflets downward into RV
| associated wtih tricuspid regurgitation, accessory conduction pathways, right sided HF
108
ASD
```
defect in interatrial septum
wide fixed split S2
ostium secundum defects most common
paradoxical emboli
Associated with Downs
```
109
Eisenmenger syndrome
uncorrected left to right shunt --> high pulmonary blood flow --> remodeling of vasculature --> pulmonary arterial hypertension --> shunt becomes right to left
cause late cyanosis, clubbing and polycythemia
110
Coarctation of the heart
arotic narrowing near insertion of ductus arteriosus
associated with bicuspid aortic valve, Turners
Hypertension in upper extremities and hypotension in lower extremities
Notched rib appearance of CXR
complications- HF, increased risk of cerebral hemorrhages, endocarditis
111
Fetal alcohol syndrome
VSD, PDA, ASD, tetralogy of fallot
112
Congenital rubella
PDA, pulmonary stenosis, septal defects
113
Down syndrome
AV septal defect, VSD, ASD
114
infant of diabetic mother
transposition of great vessels, VSD
115
Marfan
mitral valve prolapse, thoracic AA and dissection, aortic regurgitation
116
prenatal lithium
ebstein anomaly
117
Turner
bicuspid aortic valve, coarctation of aorta
118
Williams syndrome
supravalvular aortic stenosis
119
22q11 syndromes
truncus arteriosus, tetralogy of fallot
120
Hypertension
persistent systolic BP >130 and diastolic BP >80
| increase with age, obesity, DM, physical inactivity, salt intake, alcohol, smoking, FamHx, AA
121
Hypertensive urgency
severe >180/120 without acute end organ damage
122
Hypertensive emergency
severe HTN with evidence of acute end organ damage
123
Xanthoma
plaques or nodules composed of lipid laden histiocytes in skin
124
Tendinous xanthoma
lipid deposit in tendon
| Achilles
125
Corneal arcus
lipid deposit in cornea
elderly
early in life with hypercholesteremia
126
arteriosclerosis
hardening of arteries with wall thickening and loss of elasticity
127
Arteriolosclerosis
affects small arteries and arterioles
hyaline- thickening of vessel walls secondary to plasma protein leak into endothelium in essential HTN or DM
hyperplastic- onion skinning with proliferation of smooth muscle cells
128
Monckeberg sclerosis
medium sized arteries
calcifications of internal elastic lamina and media of arteries --> vascular stiffening without obstruction
pipestem appearance on X ray
does not obstruct blood flow
129
atherosclerosis
disease of elastic arteries and large and medium sized muscular arteries
Abdominal aorta > coronary A > popliteal A > Carotid A > circle of willis
risk factors- smoking, HTN, dyslipidemia, DM, age, sex, FamHx
Angina, claudication
endothelial cell dysfunction --> macrophage and LDL accumulation --> foam cells --> fatty streaks --> smooth M migration --> ECM deposition --> plaque ---> atheroma --> calcification
130
Abdominal Aortic Anerurysm
associated with atherosclerosis
risk factors- smoking, age male, Fam Hx
palpable pulsatile ab mass
131
Thoracic aortic aneurysm
associated with cystic medial degeneration
risk factor: HTN, bicuspid aortic valve, connective tissue disease, tertiary syphilis
May lead to aortic valve regurgitation
132
Traumatic aortic rupture
due to trauma and deceleration injury
commonly at aortic isthmus
X ray may reveal widened mediastinus
133
Aortic dissection
longitudinal intimal tear forming a false lumen.
Associated with HTN, bicuspid aortic valve, inherited connective tissue disorder
Can present with tearing, sudden onset chest pain radiating to back unequal BP in arms
Mediastinal widening
Type A- proximal involves ascending aorta. May result in acute aortic regurgitation or cardiac tamponade
Type B- involves only descending aorta
134
Angina
chest pain due to ischemic myocardium secondary to coronary A narrowing or spasm, no myocyte necrosis
135
Stable angina
secondary to atherosclerosis
exertional chest pain in classic distribution
ST depression
resolve with rest and nitro
136
Vasospastic angina
occurs at rest secondary to coronary artery spasm
transient ST elevation
smoking is risk factor only
triggered by cocaine, alcohol, triptans
treat with CCB, nitrates and stop smoking
137
Unstable angina
thrombosis with incomplete coronary artery occlusion
may have ST depression and T wave inversion
NO CARDIAC BIOMARKER ELEVATION
increase in frequency or intensity of chest pain or any chest pain at rest
138
Coronary steal syndrome
distal coronary stenosis, vessels are maximally dilated at baseline
administer vasodilators --> blood is shunted toward well perfused areas --> ischmeia in myocardium perfused by stenosed vessels
139
Sudden cardiac death
death from cardiac causes within 1 hour of onset of symptoms via lethal arrhythmia
associated with CAD, cardiomyopathy, hereditary ion channelopathies
140
Chronic ischemic heart disease
progressive onset of HF over many years due to chronic ischemic myocardial damage
141
Myocardial infarction
Due to rupture of coronary A atherosclerotic plaque --> acute thrombosis, increase cardiac biomarkers
142
NSTEMI
subendocardial infarcts
subendocardium vulnerable to ischemia
ST depression
143
STEMI
transmural infarts
full thickness of myocardial wall involved
ST elevation and Q waves
144
commonly occluded coronary A
LAD > RCA> circumflex
145
Symptoms of MI
diaphoresis, nausea, vomiting, severe retrosternal pain, pain in left arm or jaw, SOB, fatigue
146
0-24 hour of MI
dark mottling
early coagulative necrosis --> cell content released into blood, edema, hemorrhage, WAVY FIBERS
reperfusion injury --> free radicals and increase calcium --> hypercontraction of myofibrils
complications --> ventricular arrhythmia, HF, cardiogenic shock
147
1-3 days after MI
extensive coagulative necrosis, tissue surrounding infarct shows acute inflammation with neutrophils
complications -->postinfarction fibrinous pericarditis
148
3-14 days after MI
macrophages then granulation tissue
complications --> free wall rupture (tamponade, papillary muscle rupture) --> mitral regurgitation, interventricular septal rupture due to macrophage mediated structural degradation --> left to right shunt. LV pseudoaneurysm
149
2 weeks to months after MI
contracted scar complete
| Complications --> Dressler syndrome, HF, arrhythmias, true ventricular aneurysm
150
D(x) MI
first 6 hours - EKG --> STEMI vs NSTEMI, peaked T waves
Cardiac troponin I rises after 4 hours, peak at 24 hours and is high for 7-10 days
CKMB rises after 6-12 hours- d(x) reinfarction
151
LAD infarct
V1-V2
152
Anteroapical distal LAD
V3-V4
153
LAD/LCX
V5-V6
154
Lateral (LCX)
I, aVL
155
inferior (RCA)
II, III, aVF
156
Posterior PDA
V7-V9, ST depression in V1-V3 with tall R waves
157
Cardiac arrhythmia
occurs within the first few days after MI
| IMPORTANT CAUSE OF DEATH
158
Postinfarction fibrinous pericarditis
1-3 days post MI
159
Papillary muscle rupture
2-7 days after MI; posteromedial papillary M rupture increase risk due to single blood supple from PDA
severe mitral regurgitation
160
Interventricular septal rupture
3-5 days after MI
| macrophage mediated degradation --> VSD > high O2 saturation and pressure in RV
161
Ventricular pseudoaneurysm formation
3-14 days post MI- free wall rupture contained by adherent pericardium or scar tissue
low CO risk of arrhythmias, embolus from mural thrombus
162
Ventricular free wall rupture
5-14 days post MI- free wall rupture --> cardiac tamponade
LV hypertrophy and previous MI protect against free wall rupture
sudden death
163
True ventricular aneurysm
2 weeks to several months post MI- outward bulge with contraction
associated with fibrosis
164
Dressler syndrome
several week post MI
autoimmune phenomenon
fibrinous pericarditis
165
LV failure and pulmonary edema
secondary to LV infarction, VSD, free wall rupture, papillary muscle rupture with mitral regurgitation
166
Acute coronary syndrome treatments
unstable/ NSTEMI- anticoagulation, antiplatelet + ADP receptor inhibitor, B blockers, ACEi, statins. Symptom control with nitro and morphine
STEMI- + reperfusion therapy
167
Dilated Cardiomyopathy
Most common
idiopathic or familial (TTN mut)
HF, S3 systolic regurgitatnt murmur, dilated heart, balloon appearance on CXR
T(x) Na+ restriction, ACEi, B blockers, diuretics, mineralcorticoid receptor blockers, digoxin, ICD, heart transplant
eccentric hypertrophy
168
Takotsubo cardiomyopathy
broken heart syndrome
| ventricular apical ballooning increased by sympathetic stimulation
169
Hypertrophic obstructive cardiomyopathy
familial, AD sarcoplasmic protein mutations, HTN, Friedreich ataxia
syncope during exercise --> sudden death due to ventricular arrhythmias
S4, systolic murmur, mitral regurgitation
T(x): stop athletics, B blockers or CCB
concentric hypertrophy
asymmetric septal hypertrophy and systolic anterior motion of mitral valve --> outflow obstruction --> dyspnea
170
Restrictive cardiomyopathy
postradiation fibrosis, loffler endocarditis, endocardial fibroelastosis, amyloidosis, sarcoidosis, hemochromatosis
thick myocardium
171
Loffler endocarditis
associated with hypereosinophilic syndrome
| eosinophils in myocardium
172
Heart failure
cardiac pump dysfunction --> congestion and low perfusion
| dyspnea, orthopnea, fatigue, S3 heart sound, rales, JVD, pitting edema
173
Systolic dysfunction
low EF, high EDV, low contractility secondary to MI or dilated cardiomyopathy
174
Diastolic dysfunction
preserved EF, normal EDV, low compliance
| secondary to myocardial hypertrophy
175
Left Heart Failure
orthopnea- SOB when supine
Paroxysmal nocturnal dyspnea- breathlessness awakening from sleep
pulmonary edema- high pulmonary venous pressure
176
Right heart failure
Hepatomegaly (nutmeg liver)
JVD
peripheral edema
177
Hypovolemic shock
```
hemorrhage, dehydration, burns
skin cold and clammy
LOW preload
low CO
high afterload
Treat with IV fluids
```
178
Cardiogenic shock
```
Acute MI, HF, valvular dysfunction, arrhythmia
skin cold and clammy
LOW CO
high afterload
treat with inotropes, diuresis
```
179
obstructive shock
```
cardiac tamponade, pulmonary embolism, tension pneumothorax
skin cold and clammy
LOW CO
high afterload
treat by relieving obstruction
```
180
Distributive shock- sepsis, anaphylaxis
skin warm
low preload
high CO
LOW afterload
181
Distributive shock- CNS injury
skin Dry
low preload
low CO
LOW afterload
182
Cardiac tamponade
compression of the heart by fluid in pericardial space
low CO
Becks triad- hypotension, distended neck veins, distant heart sounds
High HR, pulsus paradoxus
183
pulsus paradoxus
low amplitude of systolic BP >10 during inspiration
| constrictive pericarditis, obstructive pulmonary disease, tamponade
184
Acute bacterial endocarditis
S aureus. Large vegetations on preciously normal valves.
| Rapid onset
185
Subacute bacterial endocarditis
viridan strep
smaller vegetations on congenitally abnormal or diseased valves
dental procedures
gradual onset
186
Bacterial endocarditis
fever, new murmur, roth spots, osler nodes, janeway lesions, splinter hemorrhages
associated with glomerulonephritis, septic arterial or pulmonary emboli
(-) culutre --> coxiella burnetti, bartonella
Mitral valve most frequent
Tricuspid if IV drugs (s. aureus, pseudomonas, candida)
S. bovis- colon cancer
s- epidermidis- prosthetic valves
Native valve endocarditis --> HACEK
187
Rheumatic Fever
pharyngeal infection via group A B hemolytic strep
Mitral > aortic >> tricuspid
Associated with Aschoff bodies, Anitschkow cells, high anti strep O, high anti DNase B
Type 2 hypersensitivity
JONES- joint, carditis, nodules, erythema marginatum, syndeham chorea
188
Syphilitic heart disease
tertiary
disrupt vasa vasorum of aorta with atrophy of vessel wall and dilation of aorta and valve ring
calcifications of aortic root, ascending aortic arch and thoracic aorta
tree bark appearance
189
Acute pericarditis
sharp pain, aggravated by inspiration and relieved by sitting up and leaning forward
widespread ST segment elevation or PR depression
idiopathic, cocksakie B neoplasia, autoimmune, uremia, CV, radiation
T(x) NSAIDs, colchicine, glucocorticoids, dialysis
190
Myocarditis
global enlargement of heart and dilation of all chambers.
dyspnea, chest pain, fever, arrhythmias
caused by viral infection, parasitic, bacterial, toxins, rheumatic fever, drugs, autoimmune disease
complications: sudden death, arrhythmias, heart block, dilated cardiomyopathy, HF, mural thrombosis with systemic emboli
191
Giant cell arteritis
```
elderly females
CAROTID A
focal granulomatous inflammation
unilateral HA, temporal A tenderness, claudication of jaw
Irreversible blindness
associated with polymyalgia rheumatica
High ESR
T(x) high dose corticosteroid to prevent blindness
```
192
Takayasu arteritis
Asian females <40 years
pulseless disease, fever, night sweats, arthritis, myalgias, skin nodules, ocular disturbances
Granulomatous thickening and narrowing of aortic arch and proximal great vessels
High ESR
T(x) corticosteroids
193
Buerger Disease
Heavy smokes, males <40 years
intermittent claudication
gangrene, autoamputation of digits, superficial nodular phlebitis
Raynaud phenomenon
Segmental thrombosing vasculitis with vein and nerve involvement
T(x) stop smoking
194
Kawasaki Disease
Asian children <4 years
conjunctival injection, rash, adenopathy, strawberry tongue, hand foot changes, fever
Develop coronary A aneurysm, thrombosis/ rupture --> death
T(x): IVIg and aspirin
195
Polyarteritis nodosa
middle age men
Hep B
fever, weight loss, malaise, HA, ab pain, melena, HTN, neuro problems, cutaneous eruptions, renal damage
Renal and visceral vessels, not pulmonary A
T(x): corticosteroids and cyclophosphamide
196
Behcet syndrome
Recurrent aphthous ulcers, genital ulcers, uveitis, erythema nodosum
via HSV or parvovirus
Immune complex vasculitis
HLA B51
197
Cutaneous small vessel vasculitis
7-10 days after medication or infection
palpable purpura, no visceral involvement
immune complex mediated leukocytoclastic vasculitis
198
Eosinophilic granulomatosis with polyangiitis
Asthma, sinusitis, skin nodules, purpura, peripheral neuropathy
Can involve heart, GI, kidneys
granulomatous necrotizing vasculitis with eosinophilia
MPO ANCA, high IgE
199
Granulomatosis with polyangiitis
Upper respiratory tract- perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis
lower respiratory tract- hemoptysis, cough, dyspnea
Renal- hematuria, red cell casts
Focal necrotizing vasculitis + necrotizing granulomas in lung and upper airway + necrotizing glomerulonephritis
PR3 ANCA
large nodular densities on CXR
T(x)- cyclophosphamide, corticosteroids
200
IgA vasculitis
Henoch Schnolein purpura
childhood
follow URI
palpable purpura on leg/butt +arthralgia + ab pain (intussception)
secondary to IgA immune complex deposition
Associated with IgA nephropathy
T(x): supportive
201
Microscopic polyangitis
necrotizing vasculitis in lung, kidneys and skin
pauci immune glomerulonephritis and palpable purpura
No granulomas
MPO ANCA
T(x) cyclophosphamide, corticosteroids
202
Mixed cryoglobinemia
```
viral infection (HCV)
palpable purpura, wekness, arthralgia
peripheral neuropathy and renal disease
precipitate in cold
mixed IgG and IgM complex deposition
```
203
Myomas
primary cardiac tumor in adults
in LA
ball valve obstruction in the LA
IL 6 produced --> constitutional symptoms
tumor plop is early diastole
gelatinous material, myxoma cells in glycosaminoglycans
204
Rhabdomyoma
primary cardiac tumor of children associated with tuberous sclerosis
hamartomatous growths
205
Kussmaul sign
high JVP on inspiration instead of decrease
| may be seen with constrictive pericarditis, restrictive cardiomyopathy, RHF, massive pPE, RA or ventricular tumors
206
Hereditary hemorrhagic telangiectasia
Osler Weber Rendu
AD disorder of blood vessels
blanching lesions on skin and mucous membranes, recurrent epistaxis, skin discoloration, arteriovenous malformations, GI bleed, hematuria.
207
Primary HTN treatment
thiazide diuretics, ACEi, ARBs, CCB
208
HTN with HF treatment
Diuretics, ACEi, ARBs, B blockers, aldosterone antagonists
209
HTN with DM treatment
ACEi, ARBs, CCB, thiazide diuretics, B blockers
210
HTN in asthma treatment
ARBs, CCB, thiazides, cardioselective B blockers
211
HTN in pregnancy treatment
Hydralazine, labetolol, methyldopa, nifedipine
212
Dihydropyridines
-pine
block VGCC (L-type) of cardiac and smooth muscle --> decrease muscle contractility
Dihydropyridines- HTN, angina, Raynaud
Nimodipine- subarachnoid hemorrhage
Nicardipine- HTN urgency/emergency
Adverse: gingival hyperplasia, peripheral edema, flushing, dizziness
213
Non- dihydropyridines
diltiazem, verapamil
block VGCC (L-type) of cardiac and smooth muscle --> decrease muscle contractility
HTN, angina, a fib/flutter
Adverse: gingival hyperplasia, cardiac depression, AV block, hyperprolactinemia, constipation
214
Hydralazine
increase cGMP --> smooth muscle relaxation, vasodilate arterioles, decrease afterload
used for severe HTN, HF, safe for pregnancy
Adverse: compensatory tachy, fluid retention, HA, angina, drug induced lupus
215
Hypertensive emergency treatment
Nitroprusside- short acting vasodilator, increase cGMP via release of NO. Can cause CN- tox
Fenoldopam- D1 agonist --> coronary, peripheral, renal, splanchnic vasodilation. lower BP, increase natriuresis. Can cause hypotension and tachy
216
Nitrates
Nitroglycerin, isosorbide dinitrate, isosorbide mononitrate
vasodilate by increase NO in vascular smooth muscle --> increase cGMP and smooth muscle relaxation
used for angina, acute coronary syndrome, PE
adverse: reflex tachy, hypotension, flushing, HA
217
Nitrate therapy
decrease EDV, BP, Ejection time, MVO2
| increases Contractility and HR
218
B blocker therapy
decrease BP, ejection time, MVO2, contractility and HR
219
Nitrates + B blockers
Lower BP and MVO2
220
Ranolazine
inhibit late phase of inward sodium current --> decrease diastolic wall tension and O2 consumption. DOES NOT EFFECT HR or BP
used in angina refractory
Adverse: constipation, dizziness, HA, nausea
221
Sacubitril
neprilysin inhibitor, prevent degradation of ANP and BNP, AngII, substrate P --> increase vasodilation, lower ECF volume
used in combo with valsartan to treat HFrEF
Adverse: hypotension, hyperkalemia, cough, dizziness, contra with ACEi
222
HMG CoA reductase inhibitors
statins
lower LDL, TG, higher HDL
inhibit HMG CoA to mevalonate
Adverse: hepatotoxicity, myopathy
223
Bile acid resins
cholestyramine, colestipol, colesevelam
lower LDL
higher HDL and TG
prevent intestinal reabsorption of bile acids
Adverse: GI upset, decreased absorption of other drugs and fat soluble vitamins
224
Ezetimibe
lower LDL
prevent cholesterol absorption at small intestine brush border
Adverse: increase LFT and diarrhea
225
Fibrates
```
-fibrozil
lower LDL and TG
high HDL
upregulate LPL --> increase TG clearance
activate PPARa to induce HDL synthesis
Adverse: myopathy, cholesterol gallstones
```
226
Niacin
low LDL and TG
high HDL
inhibit lipolysis in adipose tissue, reduce hepatic VLDL synthesis
Adverse: flushed face, hyperglycemia, hyperuricemia
227
PCSK9 inhibitors
```
-ocumab
low LDL, TG
high HDL
inactivate LDL receptor degradation --> increase LDL removal in blood stream
Adverse: myalgias, delirium, dementia
```
228
Fish oil and marine Omega 3 FA
high LDL, HDL
low TG
decrease FFA delivery to liver and decrease activity of TG synthesizing enzymes
Adverse: nausea
229
Digoxin
inhibit Na+/K+ ATPase --> inhibit Na+/Ca2+ exchanger --> increase calcium --> + inotropy --> stimulate vagus N --> decrease HR
used in HF, A fib
Adverse: cholinergic effects, blurry yellow vision, arrhythmias, AV block
contra in renal failure, hypokalemia
antidote- slowly normalize K+, cardiac pacer, anti digoxin Fab fragments, Mg2+
230
Class 1A Na+ blockers
Quinidine, procainamide, disopyramide
Moderate Na+ block. increase AP duration, increase effective refractory period, increase QT interval
used for atrial and ventricular arrhythimias SVT and VT
Adverse: cinchonism, reversible SLE, HF, thrombocytopenia, torsades, increase QT interval
231
Class 1B Na+ blockers
```
Lidocaine, mexiletine
weak Na+ block
decrease AP duration
used in acute ventricular arrhythmias
Adverse: CNS stimulation/depression, CV depression
```
232
Class 1C Na+ blockers
```
Flecanide, propafenone
strong Na+ blocker
prolong ERP in AV node
used in SVTs, a fib
Adverse: proarrhythmic contra in structural and ischemic heart disease
```
233
Class 2 B blockers
-lol
Decrease SA and AV node activity by low cAMP and calcium
decrease slope of phase 4
used in SVT, ventricular rate control for a fib and flutter
Adverse: impotence, exacerbation of COPD and asthma, CV effects, sedation, dyslipidemia (metoprolol)
234
Class 3 K+ blockers
amiodarone, ibutilide, dofetilide, sotalol
increase AP duration ERP and QT
used in a fib and flutter, V tach
Adverse: torsade de pointe
amiodarone- pulmonary fibrosis, hepatotox, hypothyroid, corneal deposits, skin deposits, neuro, constipation, CV
235
Class 4 CCB
diltiazem verapamil
decrease conduction velocity, high ERP, PR
used to prevent nodal arrhythmias, rate control for a fib
Adverse: constipation, flushing, edema, CV
236
Adenosine
increase K+ out of cell --> hyperpolarize the cell and decrease AV conduction
Diagnose and terminate SVT
short acting
blunted by theophyline and caffeine
Adverse: flushing. hypotension, chest pain sense of impending doom, bronchospasm
237
Magnesium
effective in torsades de pointes and digoxin tox
238
Ivabradine
prolong slow depolarization by inhibiting funny channels
used in chronic stable angina in patients that cannot take B blockers
Adverse: luminous phenomena.visual brightness, hypertension, brady
