Flashcards in Cardio Quiz 2 Deck (41):
1
Most likely papillary muscle to be damaged in Mitral Regurg
Right coronary artery leading to posteromedial papillary muscle (leads to both medial side of both leaflets)
2
Early aortic stenosis epidemiology
think congenital defect (i.e. Bicuspid aortic valve)
3
What is cor pulmonale?
failure of the right side of the heart brought on by long-term high blood pressure in the pulmonary arteries and right ventricle of the heart.
4
Adverse Effects of Digoxin
1. Low therapeutic index
2. Affects all excitable tissues:
- GI tract
-Visual Disturbances
- Neuro (disoriented, hallucinations)
- Muscular (weakness and fatigue)
- Cardiac (arrhytmias)
3. Toxicity enhanced w/ hypokalemia
4. Drug interactions - quinidine, verapamil, amiodarone)
5
When is digoxin use indicated?
heart failure patients with LV systolic dysfunction (reduced ejection fraction) in A-fib
6
Other Inotropic drugs used in Reduced Ejection Fraction (LV systolic dysfunction)
1. B-agonsists (dobutamine and dopamine)
2. Phosphodiesterase Inhibs (milrinone)
7
Tx Effects of diuretics in Heart Failure
1. Reduce fluid volume and t.f. preload
2. Reduce heart size, improve efficiency and reduce wall stress
3. Reduce edema
8
Isosorbide Dinitrate/ hydralazine combo
Used for Tx of Reduced E.F. heart failure:
- provides mixed arterial and venous dilation
-decreases preload and afterload (increase SV)
-improves survival rate in clinical trials
-use indicated when ACE inhibs or ARBS are not tolerated
9
When do you add Aldosterone Antagonists to Tx regiment in heart failure?
Ex: Spironolactone and Eplerenone
-Used when pt has moderately severe to severe sx'x (class III-IV)
-improves mortality rate and reduces symptoms
10
Non-Drug Tx's in Heart Failure
1. Salt restriction
2. Bi-ventricular pacing
3. Implantable Cardiodefibrillator Devices (ICD)
4. Left ventricular assist device (LVAD)
5. Heart transplant
11
Tx Goals in LV diastolic (preserved EF) heart failure
• Relief of pulmonary and systemic congestion
• Address correctable causes of impaired diastolic function
• Diuretics to reduce pulmonary congestion and peripheral edema
– Use cautiously to avoid under filling of LV
– Could reduce stroke volume
• ACE inhibitors, b blockers, ARBs have no demonstrated mortality benefit
• Because contractile function is preserved, inotropic drugs have no role in this condition
12
Endocarditis:
Predisposing Heart Conditions
• Prosthetic valves (mechanical or bio-)
• Mitral valve prolapse with regurgitation or
thickened leaflets
• Rheumatic heart disease
• Complex congenital heart disease
• Mitral regurgitation, aortic stenosis, aortic
regurgitation, ventricular septal defect
13
Endocarditis:
Risk Factors
• Common denominators: abnormal heart
valves and risk of bacteremia
• Aberrant flow results in platelet-fibrin
thrombus on injured endothelium
• Bacteria enter bloodstream through skin or
mucosal surfaces and adhere to thrombus
• Once inside growing thrombus, bacteria are
resistant to host defenses
14
Peripheral Manifestations of Endocarditis
1. Splinter hemorrhages
2. Conjuctival Petechiae
3. Osler Nodes
4. Janeways lesions
5. Roth spots
Which are painful?
(Osler nodes)
15
I.E. - Microbio associations
- Most common = Strep species
- Acute = Staph aureus
- Prosthetic valves = coag-neg Staph (esp early after valve insertion)
- Elderly = Enterococcus
16
What is significance of Strep bovis?
Associated with colonic lesions
- would want to do endo scope and see if they have colon cancer
17
I.E. - Microbiology more likely in injection drug users?
Pseudomonas, Salmonella, Candida
18
I.E. - what causes Culture Negative Endocarditis ?
HACEK group:
• Haemophilus aphrophilus, paraphrophilus
• Actinobacillus actinomycetemcomitans
• Cardiobacterium hominis
• Eikenella corrodens
• Kingella kingae
*significance is that is takes longer to grow these cultures in lab, thus often missed
*gram negative, pleopmorphic
19
Imaging diagnostics for IE?
Trans-thoracic (TTE) or Trans-esophageal Echo (TEE)
TEE is more sensitive!
(can't r/o IE with negative TTE)
20
Major Duke Criteria? What does this diagnose?
Duke Criteria Diagnose I.E.
Microbiologic
– typical organism from 2 separate blood cxs
– organism from persistently pos. blood cxs
– positive serology for C. burnetti
• Evidence of endocardial involvement
– new valvular regurgitation
– positive echocardiogram
21
when do you add rifampin to IE therapy?
when it is a staph infection or when it is on prosthetic material (remember biofilm formations in osteomyelitis)
-Rifampin has special ability to kill organisms in resting state and biofilm
22
Tx of HACEK organisms
-what can't you use
-what can you use
Can't use vancomycin (b/c these are gram- )
-Used ceftriaxone and Cirpofloxacin
23
What is a mycotic aneurysm?
When bacteria infect the arterial wall or immune complex deposition
-weakens vessel
-usually silent until they bleed
24
Biggest Risk factors for Endocarditis?
1. previous IE
2. Prosthetic Heart Valve
25
Indications for IE prophylaxis
Not at all for any GI/GU procedures
• For manipulation of gingiva or periapical teeth, or
perforation of oral mucosa
• Highest risk cardiac conditions only:
– Prosthetic valve
– Previous IE
– Cardiac transplant with valvulopathy
– Congenital heart disease—unrepaired cyanotic,
for 6 months after repair with prosthetic, or
repaired prosthetic with residual defect
26
Prophylatic Regimen for IE
For dental procedures:
- single dose 30-60 minutes prior of Amoxicillin and Clindamycin (PO).
-if unable to take PO, ampicillin and ceftriaxone (IV)
27
How do you increase forward cardiac output?
decrease afterload (don't give inotroic agents)
28
Arrhythmogenic Right Ventricular Cardiomyopathy
-characteristics
severely thinned RV wall b/c of loss of myocytes
-extensive fatty infiltration and fibrosis
-possibly due to defective desmosomes lining cardiac myocytes
29
"Myofiber disarray" is a buzz word for ______?
Hypertrophic Cardiomyopathy
30
Genes most often mutated in HCM?
– myosin heavy chain β-MHC
– myosin binding protein MYBP-C – cardiac TnT
31
Pathophysiology of HCM (5)
1. Left ventricular outflow tract obstruction
2. Mitral regurgitation (Venturi effect)
3. Diastolic dysfunction
4. Myocardial ischemia
5. Cardiac arrhythmias
32
Treatment of HCM
-Pharm: B-blockers = negative inotropic effect to decrease outflow gradient and prolong diastolic filling
-CCB's: if you don't tolerate B-blockers
-Disopyramide= strong negative inotropic effects
-Surgery= septal myectomy, alcohol-induced septal ablation
-Dual-chamber pacemaker
-Heart Transplant
33
Causes of Restrictive CM
• Idiopathic or
• Secondary to:
– Post-radiation fibrosis
– Amyloidosis
– Sarcoidosis
– Metastases
– Inborn errors of metabolism (Fabry’s disease, Pompe’s disease)
34
Diagnosing RCM
Endomyocardial biopsy--> do a congo red stain (look fro apple-green fluorescence under polarized light)
35
Loeffler Endomyocarditis
(RCM)
endomyocardial fibrosis, large mural thrombi, peripheral eosinophilia (underlying cause), eosinophilic infiltrates in organs
-thickening of basal inferior wall
-endocardial deposition of thrombus
36
Endocardial fibroelastosis
(RCM)
- kids and YA's in Africa
- mural lLV endocardium
- Most common in 1st 2 yrs of life
37
Iron overload in heart is associated with __________ CM?
Dilated CM
-disease = hereditary hemochromatosis
38
Takotsubo Cardiomyopathy
sudden intense emotional or physical stress-leading to acute LV dysfunction
- think octopus jar where apex balloons, but base does not, thus does not allow contents out
-sudden ruch of catecholamines
39
Symptoms of Heart Failure
• Dyspnea on exertion
• Orthopnea (Difficulty breathing when lying flat; “How many pillows...?”)
• Paroxysmal nocturia
dyspnea (PND) (Waking up at night due to shortness of breath)
• Lower extremity edema/swelling
• Ascites
• Decreased
appetite/anorexia
• Weakness/fatigue
40
Right Sided HF signs
– Dependent (pitting) edema
– Jugular venous distension
– Hepatomegaly
– Splenomegaly
– Ascites
– Anorexia
41