Assc diseases with congenital valvular disease
Patent ductus arteriosus
aortic coarctation
Path of MVP
expansion of spongiosa
disruption of fibrosa
Risk of mitral annular calcification
thrombi/infective carditis formation
Subacute infective endocarditis with colon cancer
strep bovis
Prosthetic valve early infective endocarditis
staph epidermidis
Peripheral manifestations of infective endocarditis
Roth spots Osler nodes Janeway lesions splinter hemorrhages mycotic aneurysm
IV drug users acute bacterial endocarditis location and bug
R side of heart
S. aureus
Assc with nonbacterial thrombotic endocarditis
adenocarcinoma-> hypercoaguable state
Libman Sacks endocarditis cause and histo
SLE
esoinophilic/granular verrucae
Bugs to tx with aminoglycosides
pseudomonas aeruginosa enterobacteriaceae gram (-) with gentamicin due to + charge
Most common subacute IE bug
viridans strept
Abiotrophia Granulicatella growth and assc
needs L-cysteine or Vit B6
URT/urogenital/GI infection
prone to systemic embolization
IE with negative blood cultures
HACEK bugs
Coxsackie virus with myocarditis
cleaves dystrophin with viral protease 2A
decreases contractility
Parvovirus B19 with myocarditis
replicates in endothelial cells slap cheek (5th disease) maculopapular rash
Corynebacterium diptheriae with myocarditis
toxins A and B, B allows entry, A inhibits EF2
Also conjunctivitis/pharyngeal membrane and bull neck
Borrelia burgdorferi with myocarditis
tick is vector
damage from macrophages killing spirochetes
Trypanosoma cruzi with myocarditis
kissing bugs (reduviids) are vector
rash/edema around eye (Romano’s sign)
T cell lysis of myocytes where it replicates
X-linked dilated cardiomyopathy gene
dystrophin gene mutation
Arrhythmogenic RV cardiomyopathy path and gene
severely thinned (with fat) RV defect of cell adhesion proteins in desomosomes
Naxos syndrome
arrhythmogenic RV cardiomyopathy
kyperkeratosis
plakoglobin gene mutation
Hypertrophic cardiomyopathy path and gene
haphard disarray of myocytes
sarcomeric genes
Endomyocardial fibrosis assc
children/young adults in tropical areas
Loeffler endomyocarditis
endomyocardial fibrosis
lg mural thrombi with eosinophilic inflitrate
Amyloidosis dx and histo
stains with congo red (fluoresces green)
beta sheet folding of proteins
Senile cardiac amyloidosis deposition
transthyretin
Impact of hemachromatosis on heart
iron deposition causes ROS to damage myocardium
results in systolic dysfunction
Atrial myxoma
in adults
ball valve obstruction
Types of myocarditis (4)
lymphocytic
hypersensitivity (drug induced, increased eosinphils)
giant cell (rapid and fatal)
Chagas disease
Rhabdomyoma histo and demographic
in children
spider cells
Most common type of cardiac cancer
metastasis:
lungs/breast
melanoma
lymphoma/leukemia
Impact of carcinoid syndrome on heart
increased vasoactive amines (5HT) cause plaques on R sided valves
Phospholamban and role in increased HR
normally blocks SERCA (Ca2+ reuptake)
phosphorylated by PKA-> allows faster reuptake
with increased HR, need faster relaxation
done by phosphorylating phospholamban
Causes of paradoxical S2 splitting
During expiration, aortic closes later
LBBB
aortic stenosis
anything slowing L ventricular emptying
Cause of fixed S2 splitting
atrial septal defect hallmark
Chronic mitral regurg sound
holosystolic murmur
louder with squat/isometric contraction
Acute mitral regurg sound
early systolic decrescendo
Mitral valve prolapse sound
midsystolic click
late systolic murmur
Triad of tricuspid regurg
Carvallo’s sign (louder with inspiration)
pulsatile JVD
pulsatle liver
Ventricular septal defect sound
harsh holosystolic murmur
Aortic stenosis sound
systolic crescendo-decrescendo
Hypertrophic cardiomyopathy sound
from dynamic obstruction
crescendo-decrescendo
louder with valsalva/standing/amyl nitrate
Major criteria for infective endocarditis
\+ blood cultures (at least 2) endothelial involvment (via echo/new regurg)
Minor criteria for IE
predisposition fever over 100.4 vascular phenomena immuno phenomena echo microbiologic evidence (not proof)
Syncope cause with prolonged standing, emotional stress, or warm environment
neurocardiogenic syncope
Syncope with neck irritation and qualifiers
carotid sinus hypersensitivity
cardioinhibitory with pause over 3 sec
vasodepressor with decrease of 50mmHg without bradycardia
Syncope from cough, micturition, defecation, valsalva, deglutition
situational syncope
Syncope preceded by tongue/tonsillar pain
glossopharyngeal neuralgia
Cause of syncope with particular arm use
subclavian steal syndrome
Orthostatic hypotension numbers
over 20mmHg SBP or 10mmHg DBP change within 3 minutes of standing
Syncope with movement
atrial myxoma
Strept pyogenes lab identification
PYR +
bacitracin sensitive
beta hemolytic
Blood labs for S. pyogenes
ASO titer
anti DNase B test
Major Jones criteria for rheumatic fever
Joint pain Heart Nodules in sub q Erythema marginatum Syndeham's chorea
Cause of Syndeham’s chorea in RF
cross rxn of antistrept Abs with basal ganglia
Hypertrophy type with aortic stenosis
concentric
Hypertrophy type with aortic regurg
eccentric
Mitral regurg sound and things to increase
holosystolic blowing
squat/expiration
Mitral stenosis sound
opening snap
diastolic rumble
Peripheral indication of aortic regurg
parvus et tardus (slow rising pulse)
Aortic regurg sound
early diastolic decrescendo
Causes of wide S2 splitting
RBBB
pulmonic stenosis
Aortic insufficiency sound and what increases sound
early diastolic decrescendo
increases with expiration/leaning forward
Other murmurs assc with Aortic regurg
systolic ejection murmur
Austin Flint murmur (diastolic rumble)
Signs assc with aortic regurg (7)
Duroziez sign- systolic cephalad, diastolic murmur caudad
Wide pulse pressure
Quincke’s pulse-phasic blanching of nails
Hill sign-popliteal over 60mmHg greater than brachial
Corrigan pulse-abrupt upstroke and fall of pulse
Traube sign-pistol shot sound over femoral
Mueller sign-pulsating uvula
Cause of pulmonic regurg
pulmonary HTN or valve deformity
Graham Steell murmur
assc with pulmonic regurg
early diastolic decrescendo murmur
high pitched
increases with inspiration
Pulmonic insufficiency with valve deformity sound
mid diastolic crescendo-decrescendo
low pitched
Mitral stenosis sound and way to increase sound
mid diastolic click with rumble
L lateral recumbent position
Beck’s triad and what it indicates
hypotension
JVD
distant heart sounds
cardiac tamponade
Exaggerated pulsus paradoxus
greater than 10mmHg between expiration and inspiration SBP
sign of cardiac tamponade
Kussmaul sign
Increased JVD with inspiration
cardiac tamponade or constrictive pericarditis
3 modes of echocardiography
M-Mode display (for thickness)
2D imaging
Doppler (for velocity/pressure changes)
Pulsed vs continuous doppler echo
pulsed-senses low gradients, max 2m/s
continuous-high gradients
Viral cause of dilated cardiomyopathy
echovirus
coxsackie B virus
Dilated cardiomyopathy pathology cascade
myocyte degeneration
decreased CO
NE early and angiotensin II late to compensate
cause LV remodeling
Major criteria for heart failure (6)
paroxysmal noctural dyspnea JVD acute pulmonary edema CVP>16cm H20 hepatojugular reflex S3
Tx for dilated cardiomyopathy
diuretics + ACE-I’s
metoprolol or carvedilol
Benefit of digoxin with DCM
inhibits sympathetics (NE)
Presentation of hypertrophic cardiomyopathy
dyspnea
angina
syncope
Sound heart with HCM
S4
Drug tx for HCM
beta blockers/CCB’s/disopyramide
amiodarone for arrhythmia
AVOID nidfedipine
Primary and secondary cardiac amyloidosis
1-monoclonal light chain
2-fragments of serum amyloid A protein
Cardiac amyloidosis appearance on echo
speckling
Tx for aortic stenosis and possible increased risk
surgery is only definitive
increased risk with mitral regurg (doubles)
Drugs for aortic regurg
nifedipine
Aortic regurg surgery indication
LV ef less than 55%
Size >55mm systole, >75mm diastole
Contraindications for acute aortic regurg
beta blockers
IABP
Drugs for mitral stenosis
diuretics- for dyspnea
beta blockers- for Vent rate
anticoagulation
Contraindications for percutaneous intervention of MS
extensive valve calcification
mitral regurg
Chronic vs acute Mitral regurg
chronic-LA hypertrophy, decreased CO, fatigue
acute-normal LA, increased pulmonary venous P, pulmonary edema
Acute mitral regurg drug tx
IV diuretics
IV vasodilators
Chronic mitral regurg drug tx
vasodilators only if HTN present
Another name for MVP
Barlow syndrome
IMA use for CABG
LAD
Graft closure rates
saphenous 50% open at 10 yrs
IMA 95% open at 10 yrs
Post op risk of CABG and prophylaxis for it
A fib
beta blockers
Tx for A. fib post CABG
beta blockers
anticoagulants past 48 hrs
Benefits of mechanical valve replacement
last longer
but needs anticoagulants
Benefits of bioprosthetic valve replacement
no need for anticoagulants
replaced after 10-15 yrs
Greater demo benefited by multivalve surgery
elderly and high risk pts
Acute pericarditis tx for viral
NSAIDS
corticosteroids/colchicine for refractory
Acute pericarditis post MI caution
avoid corticosteroids/NSAIDS
use ASA
Ewart’s sign
dullness to percussion over angle of L scapula
sign of pericardial effusion
Pericardial effusion and EKG
low voltage
electrical alternans
Ventricular interdependence and pericardial effusion
Bulging of septum into LV causes decreased CO with pericardial effusion (during inspiration)
Causes exaggerated pulsus paradoxus
Cardiac cath finding in both pericardial effusion and constrictive pericarditis
equal diastolic P in all chambers of heart
Pericardial knock
early diastolic sound from abrupt cessation of ventricular filling
Constrictive pericarditis and pulsus paradoxus
not present
but increases JVD with inspiration
Constrictive pericarditis and cardiac cath finding
dip and plateau in diastole of both ventricles
Causes of pericardial effusion beside pericarditis
cardiac rupture
myxedema
Cardiac tamponade sx
Beck’s triad: hypotension, JVD, distant heart sound
dyspnea
diaphoresis
pericardial pain
Cardiac tamponade signs on EKG
low voltage
electrical alternans
Cause of primary pericarditis
viral origin
Causes of secondary pericarditis
metastasis
cardiac disease
surgical procedure
Serous pericarditis cause and histo finding
noninfectious: autoimmune, tumors, uremia
epipdercardial fat
Fibrinous/serofibrinous pericarditis
sandy heart surface (bread and butter)
fibrinous exudate
seen in MI
Purulent/suppurative pericarditis
due to infection (pneumonia/lymphatic/hematoginous spread)
creamy, yellow exudate
causes scarring
Hemorrhage pericarditis
commonly caused by metastases
also TB caused
blood in pericardium
Caseous pericarditis
TB, TB and more TB
absolutely no JBeebs
Chronic/healed pericarditis
fibrous thickening
stringy adhesions
no impact on fxn
Adhesive mediastinopericarditis
adherence of outer pericardium to mediastinal structures
increases stress/workload of heart
Constrictive pericarditis
visceral/parietal fusion (dense)
cannot increase CO
TB/radiation/surgery/metastasis caused
wt loss/fatigue/edema
Rheumatoid arthritis on the heart
serous or fibrinous pericarditis
Acute Rheumatic fever
group A strep
pharyngitis -> RF -> chronic heart disease
Acute RF histo
Aschoff bodies with Antischkow myocytes (long thin nucleus)
Rheumatic MVP
commissural fusion/fish mouth look
thick/short chordae tendineae
Chronic RF valve disease histo and impact on valve
lymphocytes
extensive calcification