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Cardiology Flashcards

1
Q

Bulbus cordis gives rise to…

A

Smooth/outflow parts of L and R ventricles

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2
Q

Endocardial cushion gives rise to…

A

Atrial septum
Membranous interventricular septum
AV and semilunar valves

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3
Q

Primitive pulmonary vein gives rise to…

A

Smooth part of L atrium

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4
Q

Right horn of sinus venosus gives rise to…

A

Smooth part of R atrium

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5
Q

Right cardinal veins give rise to…

A

SVC

Note - Target of central line

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6
Q

Embryologic mechanism of dextrocardia (e.g. Kartagener syndrome).

A

Defect in left-right dynein involved in L/R asymmetry during cardiac looping (4 weeks).

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7
Q

Age at which heart beats spontaneously

A

4 weeks

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8
Q

Steps of atrial separation (4)

A

Septum primum (top) grows towards endocardial cushion (bottom) narrowing foramen primum

Foramen secundum forms in septum primum as it continues to close foramen primum

Septum secundum (top) grows down to cover most of foramen secundum - residual is foramen ovale

Septum primum degenerates with remainder forming valve of foramen ovale - after birth fuse to form atrial septum due to increasing LA pressure

Note - Increasing RA pressure (straining) allows R to L shunt and may lead to cryptogenic stroke

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9
Q

Steps of ventricular separation (3)

A

Muscular interventricular septum (bottom) forms with opening called interventricular foramen

Aorticopulmonary septum (truncal/bulbar ridges) rotates and grows down to fuse with muscular septum - forms membranous interventricular septum and closes interventricular foramen

Endocardial cushions grow horizontally to separate atria from ventricles - also contributes to membranous interventricular septum

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10
Q

Mechanism of conotruncal abnormalities…
Persistent truncus arteriosus
Transposition of great vessels
Tetralogy of fallot

A

Failure of neural crest cells to migrate

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11
Q

Fetal circulation

A

Oxygenated blood from umbilical vein joins IVC via ductus venosus - mostly bypasses hepatic circulation

Enters RA and goes directly to LA via foramen ovale

Deoxygenated blood from SVC goes to RA, RV, and pulmonary artery, but is shunted to descending aorta (after left subclavian) via ductus arteriosus - due to high fetal pulmonary artery resistance (low O2 tension)

Deoxygenated blood returns via umbilical arteries off of internal iliacs

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12
Q

Mechanism of closure of fetal circulation

A

Decreased resistance in pulmonary vasculature leads to increased LA pressure - foramen ovale closes

Increased O2 and decreased prostaglandins (E1/E2) from placental separation lead to closure of ductus arteriosus - closed with Indomethacin

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13
Q 
Postnatal derivative of...
Allantois/urachus
Ductus venosus
Ductus arteriosus
Notochord
Umbilical arteries
Umbilical vein
A 
Median umbilical ligament
Ligamentum venosum
Ligamentum arteriosum
Nucleus pulposus
Medial umbilical ligaments
Ligamentum teres
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14
Q

Right acute marginal artery supplies…

A

Right ventricle

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15
Q

Posterior interventricular/Posterior descending artery (PDA) supplies…

Note - 85% have PDA come off of RCA, while minority have PDA come off of LCX

A

Posterior ventricular walls

Posterior 1/3 of interventricular septum

Posteromedial papillary muscles

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16
Q

Left circumflex artery (LCX) supplies…

A

Lateral and posterior walls of LV

Anterolateral papillary muscles (via obtuse/marginal)

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17
Q

Anterior interventricular/Left anterior descending (LAD) supplies…

A

Anterior surface of LV

Anterior 2/3 of interventricular septum

Anterolateral papillary muscle

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18
Q

Blood supply to the SA and AV nodes…

Note - infarct may cause nodal dysfunction resulting in bradycardia and heart block

A

RCA

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19
Q

Fick’s principle

A

CO = rate O2 consumption/(arterial O2 - venous O2)

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20
Q

Maintenance of CO (SV x HR) during early and late exercise

Note - SV = EDV - ESV

A

Early both HR and SV

Late only HR - SV plateaus

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21
Q

Equation for MAP (afterload)

A

CO x TVR

OR

(2/3)Diastolic pressure + (1/3)Systolic pressure

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22
Q

Mechanism for decreased CO in VT

A

Diastole is preferentially shortened with increasing HR, decreasing filling time

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23
Q 
Pulse pressure in...
Hyperthyroidism
Aortic regurgitation
Aortic stiffening (isolated systolic HTN in elderly)
OSA (sympathetic tone)
Exercise
A

Increased

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24
Q 
Pulse pressure in...
Aortic stenosis
Cardiogenic shock
Cardiac tamponade
Advanced HF
A

Decreased

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25
Q

Mechanism of catecholamine induced inotropy (and SV).

A

Phosphorylation of Phospholamban
Decreased inhibition of SERCA (Ca-ATPase)
Increased Ca entry into SR during relaxation

Upon next contraction…
Increased Ca-induced Ca release via RyR2 channels
Increased Ca-Troponin complex removal of Tropomyosin

Note - Na/Ca exchanger moves Ca out of cell instead of into SR during relaxation

Note - In smooth muscle Calmodulin instead of Troponin

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26
Q

Law explaining…

Increased O2 demand with increasing ventricular diameter

LV hypertrophy to compensate for increased afterload

A

LAPLACE’S LAW

Wall tension = (pressure x radius)/(2 x wall thickness)

Increased radius means increased wall tension/O2 demand

Increased wall thickness means decreased wall tension caused by increased afterload

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27
Q

Ejection fraction

Normal is > 55 - decreased in systolic HF but normal in diastolic HF

A

EF = SV/EDV = (EDV - ESV)/EDV

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28
Q

Action of the following on preload and afterload…

Venodilators (e.g. Nitrates)

Arteriolar vasodilators (e.g. Hydralazine)

Nitroprusside

A

Decreased preload (decreased O2 demand, reduced compression of coronary arteries during diastole)

Decreased afterload (activates RAAS)

Decreased preload and afterload (no effect on SV)

Note - ACEi/ARBs also affect both preload and afterload

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29
Q

Relationship between EDV and SV/CO (Frank-Starling curves)

A

Along a curve as EDV (preload) increases SV increases - force of contractility is proportional to end diastolic length of cardiac muscle fibers

As inherent contractility (inotropy) increases curve is shifted to the left - higher contractility at the same EDV

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30
Q

Volumetric flow rate equation

A

Q = flow velocity x cross sectional area (inverse of R)

Note - Capillaries have lowest velocity and highest cross sectional area

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31
Q

Relationship of RA pressure and venous return/CO (vascular function curves)

A

Increasing RA decreases venous return/CO via decreasing pressure gradient

When CO is at 0 (x-intercept) you get mean systemic pressure

When RA pressure is at 0 CO begins to plateau due to collapsing of vena cava

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32
Q

Location of pericardial cavity

A

Between fibrous pericardium/parietal pericardium and visceral pericardium.

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33
Q

Most posterior portion of the heart - responsible for dysphagia and hoarseness

A

Left atrium

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34
Q

Most anterior portion of the heart

A

Right ventricle

Note - Injury directly to LLSB will puncture lung pleura and right ventricle but not the lung

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35
Q

Relationship between Frank-Starling (cardiac) and vascular function curves.

A

Intercept of two curves is where the venous return and CO are equal = operating point of the heart

Note - cardiac function curves maintain an x/y intercept of 0

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36
Q

Cardiac/vascular function curve with increase in contractility

A

http://i.imgur.com/UFwPm59.png

Increased CO at lower RA pressure

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37
Q

Cardiac/vascular function curve with increase in volume/venous tone

A

http://i.imgur.com/Brgkvxj.png

Increased CO at higher RA pressure

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38
Q

Cardiac/vascular function curve with decrease in TPR (exercise, AV shunt)

A

http://i.imgur.com/QKvFuLN.jpg

Increased CO while maintaining same RA pressure

Note - alternatively, increase in TPR (vasopressors) will cause decreased CO while maintaining same RA pressure

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39
Q

Cardiac/vascular function curve in HF

A

http://i.imgur.com/VLyZQxu.png

Decrease in CO due to decreased inotropy (A to B) partially offset by increase in volume/venous tone (A to C)

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40
Q

Phases of left ventricular contraction (PV loop)…

Increased LVP at stable LVV (EDV)

Decreasing LVV (EDV to ESV) at increasing (rapid) then decreasing (reduced) LVP

Decreasing LVP at stable LVV (ESV)

Increasing LVV (ESV to EDV) at relatively stable LVP

A

Isovolumetric contraction - period between mitral valve closing and aortic valve opening (highest O2 consumption)

Systolic ejection - period between aortic valve opening and closing

Isovolumetric relaxation - period between aortic valve closing and mitral valve opening

Rapid/reduced filling - period between mitral valve opening and closing

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41
Q

Effect of increased afterload on PV loop

A

Increased ESV and maximum LVP - decreased SV (area in loop)

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42
Q

Effect of increased preload on PV loop

A

Increased EDV with stable ESV - increased SV (area in loop) without increase in EF

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43
Q

Effect of increased contractility on PV loop

A

Decreased ESV with stable EDV - increased SV (area in loop) and EF

Note - Line from origin of graph to top left point of loop is the Frank-Starling line

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44
Q

Valves/stage of cardiac cycle associated with S1 (loudest at mitral area/apex)

A

Closure of mitral and tricuspid valves at the beginning of isovolumetric contraction/systole

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45
Q

Valves/stage of cardiac cycle associated with S2 (loudest at LUSB)

A

Closure of aortic and pulmonary valves at the beginning of isovolumetric relaxation/diastole

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46
Q

Mechanism/stage of cardiac cycle associated with S3 (loudest at apex in LLD position at end expiration)

(“Kentuk-ey”)

A

Increased filling pressures (MR, HF) or dilated ventricle - occurs with rapid ventricular filling/early diastole

Note - may be normal in children and young adults

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47
Q

Mechanism/stage of cardiac cycle associated with S4 (loudest at apex in LLD position)

(“Ten-nessee”)

A

Increased atrial pressure and ventricular noncompliance (atrial kick against stiff LV) - occurs with atrial systole/late diastole

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48
Q

Stages of JVP…

a wave (absent in afib, prominent in tricuspid stenosis)

c wave

x descent (absent in tricuspid regurg)

v wave

y descent (absent in tricuspid stenosis and tamponade, prominent in constrictive pericarditis)

A

RA contraction

RV contraction resulting in tricuspid valve bulging into atrium

RA relaxation resulting in downward displacement of tricuspid valve during ventricular contraction

Increased RA pressure due to filling against closed tricuspid valve

RA emptying into RV prior to RA contraction

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49
Q

Mechanism of wide splitting as seen in pulmonary stenosis and RBBB

A

Delayed RV emptying delay pulmonic sound especially on inspiration

Exaggeration of normal splitting on inspiration due to increased venous return and decreased pulmonary impedance

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50
Q

Mechanism of fixed splitting as seen in ASD

Note - Also loud S1

A

L to R shunt increases RA/RV volumes so that there is increased flow through pulmonary valve regardless of inspiration

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51
Q

Mechanism of paradoxical splitting as seen in aortic stenosis and LBBB

A

Delayed aortic valve closure causes a “fixed split” during expiration - disappears during inspiration as pulmonary valve closure occurs later and “catches up” to aortic valve closure

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52
Q

Harsh crescendo-decrescendo systolic murmur
Loudest at mid systole - may eliminate S2
Loudest at RUSB (base)
Pulsus parvus et tardus
Radiates to carotids

Note - Concentric hypertrophy (pressure overload)

A

AORTIC STENOSIS

Calcification in older patients
Bicuspid aortic valve in younger patients

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53
Q

Holosystolic, high-pitched blowing murmur
Loudest at apex
Radiates to axilla

Note - Eccentric hypertrophy (volume overload)

A

MITRAL REGURGITATION

Treat with afterload reduction

Post-MI
Infective endocarditis
MVP
LV dilation (functional/reversible)
Acute rheumatic fever (initially)

Note - Acutely regurgitant syndromes present with increased pressure and decreased CO as heart has not had time to adapt

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54
Q

Holosystolic, high-pitched blowing murmur
Loudest at LLSB
Radiates to RSB

Note - Increases with inspiration (unlike MR)

A

TRICUSPID REGURGITATION

RV dilation
Infective endocarditis
Ebstein anomaly

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55
Q

Midsystolic click (chordae tendinae tensing) occurring earlier with inspiration
Late systolic crescendo murmur
Loudest right before S2
Loudest at apex

A

MITRAL VALVE PROLAPSE

Myxomatous degeneration
Chordae rupture
Predisposes to infective endocarditis

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56
Q

Holosystolic harsh murmur

Loudest at LLSB

A

VENTRICULAR SEPTAL DEFECT

Associated with fetal alcohol syndrome

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57
Q

High-pitched “blowing” diastolic decrescendo murmur
Loudest at early diastole - may eliminate S1
Loudest at LUSB and leaning forward
No inspiratory increase (unlike pulm regurg)
Hyperdynamic/bounding pulse (increased systolic, decreased diastolic) - may see head bobbing
Palpitations at night

Note - Eccentric hypertrophy (volume overload)

A

AORTIC REGURGITATION

Aortic root dilatation
Bicuspid aortic valve
Endocarditis

Note - Occasionally occurs from rheumatic fever (fusion of commissures) but will always occur with mitral valve stenosis

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58
Q 
Early diastolic opening snap
Rumbling mid diastolic murmur
Decrescendo with presystolic accentuation
Loudest at apex
PCWP > LVEDP

Note - Patients also tend to have afib if severe, which might make accentuation disappear

A

MITRAL STENOSIS

Chronic rheumatic fever (late lesion) - commissural fusion

Note - More severe stenosis results in shorter A2-OS interval (earlier maximum diameter)

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59
Q

Continuous machine-like murmur
Loudest at left infraclavicular area
Lower extremity cyanosis

A

PATENT DUCTUS ARTERIOSUS

Congenital rubella
Prematurity

Note - Lower extremity cyanosis requires Eisenmenger’s syndrome

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60
Q

Diastolic and systolic murmurs loudest at LUSB

A

Systolic:
HOCM
Pulmonary stenosis
Flow murmur

Diastolic:
Aortic regurgitation
Pulmonary regurgitation

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61
Q

Diastolic and systolic murmurs loudest at LLSB

A

Systolic:
Tricuspid regurgitation
VSD

Diastolic:
Tricuspid stenosis
ASD

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62
Q

Effect of hand grip (increased afterload) on murmurs

A

Increased:
Mitral regurgitation
Aortic regurgitation
VSD

Decreased:
HOCM

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63
Q

Effect of valsalva/standing up (decreased preload) on murmurs…

A

Increased:
HOCM
MVP

Decreased:
Most murmurs (including aortic stenosis)
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64
Q

Effect of rapid squatting/leg raise (increased preload, increased afterload) on murmurs

A 
Increased:
Most murmurs (including aortic stenosis)

Decreased:
HOCM
MVP

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65
Q

Phases (0-5) of cardiac action potential

A

Rapid depolarization due to voltage-gated Na channels

Initial repolarization due to inactivation of voltage-gated Na channels and opening of voltage-gated K channels

Plateau due to balance between voltage-gated K channels and voltage-gated Ca channels (Ca-induced Ca release)

Rapid repolarization due to massive efflux from voltage-gated slow K channels - Ca channels now closed

Resting potential maintained by high K permeability through K channels

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66
Q

Phases (0, 3, 4) of pacemaker action potential

A

Slow upstroke due to opening of voltage-gated L-Ca channels (allows for AV delay) - fast voltage-gated Na channels permanently inactivated due to high resting potential

Repolarization due to inactivation of L-Ca channels and increased activation of K channels

Slow spontaneous diastolic depolarization due to If/funny (Na) current - certain threshold opents T-type Ca channels

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67
Q

Mechanism of effect of Ach/adenosine, catecholamines, and sympathetic activation on HR

A

Ach/Adenosine decrease rate of diastolic depolarization decreasing SA activity, slow AV conduction, and prolong AV refractory period

Catecholamines increase rate of diastolic depolarization increasing SA activity, increasing AV conduction, and shortening AV refractory period

Note - SA node located near SVC opening

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68
Q

Relative speed of conduction of atria, AV node, Purkinje fibers, and ventricles

A

Purkinje (contraction) > atria > ventricles > AV node (delay)

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69
Q

Responsible for conduction to LA from SA node

A

Bachmann bundle

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70
Q

U-wave (after T wave) indicates…

A

Hypokalemia

Bradycardia

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71
Q

Mechanical action of heart during…

QRS (ventricular depolarization)

ST

T-wave (ventricular repolarization)

A

Mechanical function lags behind electrical activity

Isovolumetric contraction

Rapid ejection

Reduced ejection

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72
Q

Normal values for…

PR interval
QRS complex
QT interval

A

0.12 to 0.20
< 0.12
< 0.44 (men) or 0.46 (women)

73
Q

Most common causes of acquired long-QT

“2 Hypos, 4 Antis”

A 
Hypokalemia
Hypomagnesemia
Antiarrhythmics (class IA, III)
Antibiotics (e.g. macrolides)
Antipsychotics (e.g. haloperidol)
Antidepressants (e.g. TCA)
Antiemetics (e.g. ondansetron)
74
Q

Inheritance pattern and presentation of…
Romano-Ward
Jervell/Lange-Nielsen

A

Congenital long QT - K channel defects causing defective myocardial repolarization

Romano-Ward - Autosomal dominant with no deafness

Jervell/Lange-Nielsen - Autosomal recessive with deafness

75
Q

Asian male with…
ECG pattern of pseudo-RBBB
ST elevations in V1-V3
Increased risk of VT/sudden cardiac death

A

BRUGADA SYNDROME

Mutation in L-type Ca channels

Prevent with ICD

76
Q

Delta wave
Wide QRS
Shortened PR
Increased risk of AV-reentrant tachycardia

A

WOLFF-PARKINSON WHITE

Abnormal fast accessory conduction pathway (bundle of Kent) from atria to ventricles bypasses rate-slowing AV node

77
Q

Definitive treatment of atrial flutter

A

Catheter ablation of focus - isthmus between IVC and tricuspid annulus

Note - Focus for afib is AV node (interatrial septum near opening of coronary sinus/tricuspid orifice), or pulmonary veins in LA

78
Q

Treatment of Vfib

A

Defibrillation

79
Q

Regularly irregular rhythm

A

2nd degree Mobitz type I (Wenckebach) AV block

80
Q

EKG presentation of 3rd degree heart block

A

Regular PR and RR intervals but no relationship between P wave and QRS

Note - associated with Lyme and 2nd degree type 2 block

81
Q

Mechanisms (3) of ANP/BNP action in response to increased blood volume and atrial pressure

Note - Contributes to aldosterone escape

A

Increased cGMP
PKG induces smooth muscle relaxation
Decreased TPR
Decreased venous return/preload

Dilation of afferent renal arterioles
Constriction of efferent renal arterioles
Decreased Renin release
Increased GFR and Na filtration without compensatory Na resorption in distal nephron
Diuresis

82
Q

Path of aortic arch/carotid body baro- and chemoreceptors to CNS

A

Aortic arch to Vagus to Solitary nucleus

Carotid body to Glossopharyngeal (IX) to Solitary nucleus

83
Q

Mechanism of baroreceptor function

A

Decreased stretch leads to decreased afferent firing

Increased efferent sympathetic, with decreased efferent parasympathetic (vagus)

Results in increased PVR (sympathetic, RAAS), HR (sympathetic), contractility (sympathetic), and thus BP

84
Q

Mechanism of Cushing reaction (HTN, bradycardia, respiratory depression)

A 
Increased ICP
Constriction of arterioles
Cerebral ischemia
Increased pCO2 and decreased pH
Increased perfusion pressure (HTN)
Increased stretch
Baroreceptor induced bradycardia
85
Q

Difference between central and peripheral (aortic arch, carotid body) chemoreceptors

A

Peripheral chemoreceptors response to decreasing PO2 as well, while central only response to increasing PCO2 and decreasing pH

86
Q 
Normal cardiac pressures for...
RA
RV
PA
LA/PCWP
LV
Aorta
A 
~5
25/5
25/10 (rise in diastolic)
~10 (balloon inflation)
130/10
130/90

Note - PCWP approximates LA pressure, LV diastolic pressure,

87
Q

Initial treatment of R to L shunts - “blue babies”

A

Maintenance of PDA with PGE1/2

88
Q

Lack of aorticopulmonary septum formation

A

PERSISTENT TRUNCUS ARTERIOSUS

Most accompanied by VSD

89
Q

Failure of aorticopulmonary septum to spiral

Associated with maternal diabetes

A

D-TRANSPOSITION OF GREAT VESSELS

Aorta anterior with pulmonary trunk posterior

Separation of systemic and pulmonary circuits require PDA (PGE1/2), VSD, or PFO to be compatible with life

90
Q

Presents with ASD (required) and hypoplastic right heart

A

TRICUSPID ATRESIA

91
Q

Caused by anterosuperior displacement of infundibular septum

A

TETRALOGY OF FALLOT

Pulmonary infundibular stenosis (prognosis)
RVH (boot-shaped heart on CXR)
Overriding aorta
VSD

Treat with…
Squatting (increased SVR reduces R to L shunt) during Tet spells

92
Q

Pulmonary veins connected to SVC, coronary sinus, or portal/hepatic veins

A

TAPVR

Requires ASD or PDA

93
Q

Mechanism for late cyanosis in L to R shunts - “blue kids” with cyanosis, clubbing, and polycythemia

VSD
ASD
PDA

A

EISENMENGER SYNDROME

Uncorrected L to R shunt increases pulmonary blood flow
PAH and RVH
Shunt reverses to R to L

94
Q

Mechanism of lower extremity cyanosis in infantile form coarctation

Note - Associated with Turner syndrome (+bicuspid aortic valve) and Berry aneurysms

A

Coarctation occurs between subclavian and PDA (not present in adult form) - deoxygenated blood will enter aorta past the coarctation (now low pressure) and only reach the lower extremities

95
Q

Most common causes of secondary hypertension

A 
Fibromuscular dysplasia (string of beads)
Primary hyperaldosteronism
96
Q

Two histological types of arteriosclerosis of small arteries/arterioles

A

Hyaline thickening of vessel walls (essential HTN, diabetic microangiopathy) - results in glomerular scarring

Hyperplastic onion skinning and smooth muscle proliferation (malignant HTN) - results in fibrinoid necrosis

97
Q

Arteriosclerosis of medium sized arteries presenting with pipestem appearance on XR

A

MONCKEBERG SCLEROSIS (MEDIAL CALCIFIC SCLEROSIS)

Medial band-like calcification of internal elastic lamina and media - does not involve intima/obstruct blood flow

98
Q

Most common sites (5) of atherosclerosis (most common to least common) - common in elastic and muscular arteries

A 
Abdominal aorta
Coronary arteries
Popliteal artery
Carotid artery
Circle of Willis
99
Q

Mechanism of atherosclerosis

A 
Endothelial cell dysfunction and fatty streaks
Macrophage and LDL accumulation
Foam cell formation/Platelet adhesion
Smooth muscle migration (PDGF, FGF)
Proliferation and ECM deposition
Fibromuscular cap formation

Note - Risk of thrombotic occlusion depends on balance between macrophage Metalloproteinases and collagen deposition

100
Q

Most common site of traumatic aortic rupture

A

AORTIC ISTHMUS

Distal to origin of L subclavian - most immobile due to ligamentum arteriosum

101
Q

Risk factors for Aneurysm vs Dissection

A

Atherosclerosis

Cystic medial degeneration (HTN, bicuspid valve, connective tissue disease)

102
Q

Classification of aortic dissections
AI
AII
B (III)

A

Ascending and descending aorta
Ascending aorta
Descending aorta

Note - Ascending tears begin at sinotubular junction, while descending tears begin at origin of L subclavian

103
Q

Normal resting ECG

ST segment depression on exertion

A

STABLE ANGINA

Confirm with cath (>70% stenosis)

Reduce mortality with…
Aspirin
B-blockers (Atenolol or Metoprolol)

104
Q

ST segment depression (endomyocardial)
T wave inversion
Normal biomarkers

A

UNSTABLE ANGINA

Due to incomplete occlusion - Reversible injury (swelling) just as in stable angina

LMWH (Enoxaparin)
Supplemental O2
Symptom control with Nitrates/Morphine
P2y12 blocker (Clopidogrel, Ticagrelor)
ASA
B-blockers
ACEi
105
Q

Chest pain at rest - usually at night

Transient ST segment elevation (transmural)

A

PRINZMETAL ANGINA (CORONARY ARTERY SPASM)

CCB
Nitrates
Smoking cessation

Avoid ASA/BBs

106
Q

Mechanism of coronary steal.

A

Vessels maximally dilated at baseline distal to stenosis
Vasodilators (e.g. Dipyridamole) dilates normal vessels
Blood shunted towards well-perfused areas
Ischemia in post-stenotic region

107
Q

ST segment depression

Elevated biomarkers

A

NSTEMI SUBENDOCARDIAL INFARCT

Complete occlusion of minor artery or partial occlusion of major artery - Irreversible damage after 30 minutes

LMWH (Enoxaparin)
Supplemental O2
Symptom control with Nitrates/Morphine
P2y12 blocker (Clopidogrel, Ticagrelor)

Reduce mortality with…
ASA
B-blockers
ACEi

Note - Within 60 seconds ATP is depleted but up to 30 minutes still only myocardial “stunning”

108
Q

Age of MI showing…

Dark mottling
Pale with Tetrazolium stain

Coagulative necrosis (damaged/no nuclei)
Wavy fibers
Reperfusion injury
Contraction band necrosis

A

4 - 24 H

Notes:

Reperfusion injury is when increased blood flow leads to formation of ROS and further damage of myofibril membranes/mitochondria - troponins continue to rise after reperfusion

Also see contraction band necrosis (perpendicular to myocyte outlines) for same reason

109
Q

Age of MI showing…

Yellow pallor (may see hyperemia initially)

Extensive coagulative necrosis
Extensive neutrophil invasion
Followed by macrophage invasion

Note - Macrophages laden with myoglobin and hemosiderin

A

1 - 7 D (FIRST WEEK)

Note - Risk for rupture especially if first MI

110
Q

Age of MI showing…

Hyperemic border (granulation)
Central yellow-brown softening

Granulation tissue (fibroblasts, collagen, blood vessels)

A

1 - 3 W (FIRST MONTH)

111
Q

Age of MI showing…

Gray-white area of infarction

Contracted scar on histology

A

> 1 MONTH

Note - Eccentric hypertrophy (volume overload)

112
Q

Timing of troponin…
Rise
Peak
Decline

A

4 hours (EKG before)
24 hours
7-10 days

Note - reinfarction can only be detected by CK-MB (decline at 3 d) prior to 7-10 days

113
Q

ST elevations/Q waves in leads V1-V4

Reciprocal ST depression in III, aVF

A

LAD infarct

114
Q

ST elevations/Q waves in leads I, aVL, V5-V6

A

LCX infarct (3rd most common)

115
Q

ST elevations/Q waves in II, III, aVF

Reciprocal ST depression in I, aVL

A

RCA infarct (2nd most common)

Note - presents with bradycardia, hypotension, Kussmaul sign (increased JVP with inspiration)

116
Q

ST depressions/tall R waves in V1-V3

A

PDA

117
Q

MI complications within first 3 d

A

Arrhythmia (within 24 h)

Postinfarction fibrinous pericarditis (neutrophil damage if transmural)

118
Q

MI complications (4) within first month

A

Papillary muscle rupture (esp. posteromedial - only PDA)
Interventricular septal rupture and shunt
Ventricular free wall rupture/tamponade
Ventricular pseudoaneurysm (cont. free wall rupture)

119
Q

MI complications after first month

A

True ventricular aneurysm/mural thrombus
Dressler syndrome/autoimmune pericarditis
LVF and pulmonary edema

120
Q 
Heart failure
S3 gallop
Systolic dysfunction
Mitral/Tricuspid regurgitation
Dilation on echo
Ballooning on CXR
A

DILATED CARDIOMYOPATHY

Eccentric hypertrophy (volume overload)

Treat with...
Na restriction/Diuretics
ACEi
B-blockers
Digoxin
ICD/Heart transplant
121
Q

Cardiomyopathy associated with…

Autosomal dominant inheritance
Coxsackie myocarditis
Alcohol
Peripartum
Chagas
Doxorubicin
Cocaine
Hemochromatosis
Beriberi (wet)
A

Dilated cardiomyopathy

122
Q

Mechanism and treatment associated with…

Crescendo-decrescendo systolic murmur at LUSB and base
Murmur worse with decreased LV volume (decreased preload/SVR)
S4 gallop
Diastolic dysfunction
Mitral regurgitation (venturi forces)

A

HYPERTROPHIC CARDIOMYOPATHY

Autosomal dominant B-myosin heavy-chain (sarcomere) mutation leading to septal predominant myofibrillar disarray

Treat with…
Cessation of high-intensity athletics
B-blockers
Non-dihydropyridine CCB (eg. Verapamil)

Avoid...
Nitrates
Dihydropyridine CCBs
ACEi
Diuretics
123
Q

Low voltage ECG
Diastolic dysfunction
Kussmaul sign
Increased atrial size with normal ventricular size
Thickened myocardium (endomyocardial fibrosis)
Eosinophilic infiltrate

A

LOFFLER SYNDROME

Restrictive cardiomyopathy

Note - in children differential includes endocardial fibroelastosis

124
Q

HF treatments associated with reduced mortality

A

ACEi
B-blockers
Spironolactone
Hydralazine/Nitrates in African Americans

125
Q

Hemosiderin-laden macrophages (HF cells) in lungs - golden cytoplasmic granules that turn blue with Prussian blue

A

Pulmonary edema

126
Q

Decreased PCWP/preload
Decreased CO
Increased SVR
Cold/clammy skin

A

HYPOVOLEMIC SHOCK

127
Q

Increased PCWP/preload
Decreased CO
Increased SVR
Cold/clammy skin

A

CARDIOGENIC/OBSTRUCTIVE SHOCK

Obstructive includes tamponade/PE

128
Q

Decreased PCWP/preload
Increased CO
Decreased SVR
Warm/dry skin

A

SEPTIC/ANAPHYLACTIC SHOCK

Subtype of distributive shock

129
Q

Decreased PCWP/preload
Decreased CO
Decreased SVR
Warm/dry skin

A

NEUROGENIC SHOCK

Subtype of distributive shock

130
Q

Fever
New mitral regurgitation
Roth spots (white with surrounding hemorrhage) on retina
Painful Osler nodes on finger pads (vasculitis)
Painless Janeway erythema on palms/soles (microemboli)
Splinter hemorrhages (microemboli)
Glomerulonephritis
Arterial or pulmonary emboli

A

INFECTIVE ENDOCARDITIS

Treat with…
IV Vancomycin and Gentamicin

131
Q

Endocarditis associated with…

IVDU/tricuspid regurgitation/pulmonary septic emboli
Acute/normal valves
Prosthetic valves
Subacute/abnormal valves (RF, MVP)
GU/GI manipulation
Colon cancer
Lupus/malignancy
A 
S. aureus, Pseudomonas, Candida
S. aureus
S. epidermidis (coagulase- staph)
Viridans strep (S. mutans, S. mitis)
Enterococcus
S. bovis
Marantic/thrombosis
132
Q

Disease associated with…

Aschoff bodies - Myocardial granuloma
Anitschkow cells - Histiocytes with wavy/rod-like nucleus

A

ACUTE RHEUMATIC FEVER MYOCARDITIS

Note - As opposed to viral myocarditis which shows predominant lymphocytic infiltration

133
Q

Sharp pain on inspiration
Relief with sitting forward
Friction rub
Pulsus paradoxus

Widespread ST elevation with PR depression
Pericardial effusion

Associated with...
Coxsackievirus
Rheumatic fever
STEMI/Dressler
Radiation
Neoplasia
Autoimmune (SLE, rheumatoid arthritis)
Uremia (no ST elevation)
A

ACUTE PERICARDITIS

Treat with…
NSAIDs
Glucocorticoids
Dialysis if uremic

134
Q

CHF
Pericardial knock in early diastole
Kussmaul sign

Low QRS voltage with T-wave flattening
Increased pericardial thickness
Sharp halt in diastolic filling
Atrial enlargement

Associated with...
Tuberculosis
Surgery
Radiation
Neoplasia
Uremia
A

CONSTRICTIVE PERICARDITIS

Treat with…
Diuretics
Pericardiectomy

135
Q

Becks triad - Hypotension, JVD, distant heart sounds
Pulsus paradoxus

Low QRS voltage with electrical alternans
Equal pressures in all 4 chambers during diastole
Late diastolic collapse of RA

A

CARDIAC TAMPONADE

136
Q

Diseases (5) associated with pulsus paradoxus - decreased of > 10 mmHg in systolic BP with inspiration

Mechanism - Equal diastolic pressures in RV/LV allows RV to bulge into LV with increased venous inflow on inspiration limiting LV outflow

A 
Cardiac tamponade
Pericarditis
Asthma
OSA
Croup
137
Q

Mechanism behind syphilitic heart disease

A

Tertiary syphilis disrupts vasa vasorum of aorta with subsequent atrophy of vessel wall

Note - also results in calcification of aortic root/ascending arch (tree bark aorta)

138
Q

Constitutional symptoms
Multiple syncopal episodes
Mid-diastolic rumble at apex
Early diastolic plop sound

Scattered cells with mucopolysaccharide stroma

A

LEFT ATRIAL MYXOMA

Benign, pedunculated mesenchymal proliferation

139
Q

Primary cardiac tumor in children associated with tuberous sclerosis

A

VENTRICULAR RHABDOMYOMA

Benign hamartoma

140
Q

Mechanism behind Kussmaul sign

A

Negative intrathoracic pressure on inspiration not transmitted to heart - impaired filling of RV transmitted back to jugular veins

Often due to constrictive pericarditis, restrictive cardiomyopathy, and RA/RV tumors

141
Q 
Elderly female
Constitutional signs
Unilateral temporal headache
Jaw claudication
Ophthalmic artery occlusion/irreversible blindness

Elevated ESR

Affects carotid artery branches (elastic)
Medial granulomatous inflammation, Intimal thickening, Elastic lamina fragmentation

Associated with Polymyalgia Rheumatica

A

GIANT CELL (TEMPORAL) ARTERITIS

High-dose corticosteroids

142
Q 
Young asian female
Constitutional signs
Ocular disturbance
Neurological disturbance
Weak UE pulses

Elevated ESR

Affects aortic arch and proximal great vessels (elastic)
Medial granulomatous inflammation, Intimal thickening, Elastic lamina fragmentation

A

TAKAYASU ARTERITIS

Corticosteroids

143
Q 
Young adult
Constitutional signs
Hypertension
Bowel angina with melena
Neurologic dysfunction
Livedo reticularis

Elevated ESR
Rosary sign mesenteric/renal aneurysms

Affects medium sized muscular vessels (spares lungs)
Transmural inflammation with fibrinoid necrosis
Immune-complex mediated

Associated with HBV

A

POLYARTERITIS NODOSA

Corticosteroids
Cyclophosphamide

144
Q 
Asian children
Conjunctival injection
Desquamating rash (including palms and soles)
Hand-foot edema
Cervical adenopathy
Strawberry tongue
Fever > 5 days

Early-onset coronary aneurysms/MI due to inflammation

A

KAWASAKI DISEASE (MUCOCUTANEOUS LYMPH NODE SYNDROME)

IVIG
ASA

145
Q 
Heavy middle-aged male smokers
Intermittent claudication
Gangrene and autoamputation of digits
Superficial nodular phlebitis
Raynaud's phenomenon

Necrotizing vasculitis of medium sized vessels
segmental vasculitis extending into contiguous veins and nerves

A

THROMBOANGIITIS OBLITERANS (BUERGER DISEASE)

Smoking cessation

146
Q 
Chronic sinusitis
Nasopharyngeal ulceration
Otitis media/Mastoiditis
Cough
Dyspnea
Hemoptysis
Hematuria due to RPGN

Large nodular densities on CXR
PR3-ANCA/c-ANCA positive

Affects small vessels…
Large necrotizing Granulomas
Adjacent necrotizing vasculitis

A

GRANULOMATOSIS WITH POLYANGIITIS (WEGENER)

Cyclophosphamide
Corticosteroids

147
Q

Cough
Dyspnea
Hemoptysis
No nasopharyngeal involvement

Pauci-immune glomerulonephritis (minimal fluorescence)
MPO-ANCA/p-ANCA positive (cloverleaf fluorescence)

Affects small vessels…
Necrotizing vasculitis
No granulomas

A

MICROSCOPIC POLYANGIITIS

Cyclophosphamide
Corticosteroids

148
Q

Asthma
Sinusitis
Skin nodules or purpura
Peripheral neuropathy

Peripheral eosinophilia
Pauci-immune glomerulonephritis
MPO-ANCA/p-ANCA positive

Affects small vessels…
Necrotizing Granulomas
Eosinophils

A

EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS (CHURG-STRAUSS)

149
Q 
URI in child followed by...
Palpable purpura on buttocks/legs
Arthralgia
Abdominal pain
Hematuria due to IgA nephropathy (Berger disease)

IgA immune complex deposition on small vessels

A

HENOCH-SCHONLEIN PURPURA (HSP)

Self-limited

150
Q

Mechanism of Cor Pulmonale

A

Hypoxia due to chronic lung disease causes vasoconstriction of pulmonary vessels

151
Q

Type of ASD associated with Trisomy 21

A

OSTIUM PRIMUM

Note - Aplasia of ostium secundum most common type

152
Q

Most common metastases to heart

Note - Pericardial effusion

A

Breast
Lung
Melanoma
Lymphoma

153
Q

Vertebral levels at which IVC…

Forms from iliacs
Crosses in front of R renal artery
Drains into RA

A

L4-L5
L1
T8

154
Q

Derivatives of arch vascular derivatives (1-4, 6)

A 
1 = Maxillary artery
2 = Hyoid/Stapedial
3 = Common/Internal carotid
4 = L (aortic arch) R (subclavian)
6 = Pulmonary arteries, PDA
155
Q 
Released by vascular endothelium to...
Inhibit platelet aggregation
Induce vasodilation
Increase vascular permeability
Stimulate leukocyte chemotaxis

Note - decreased in damaged endothelium (e.g. MI)

A

PROSTACYCLIN (PGI2)

From PGH2 via Prostacyclin Synthase

Note - opposes action of TXA2

156
Q

Cause of supine hypotension (e.g pregnancy)

A

Aortocaval compression

157
Q

Fixed-split S2

Midsystolic ejection murmur at LUSB due to increased flow across pulmonary valve

Mid-diastolic rumble murmur due to increased flow across tricuspid valve

A

ATRIAL SEPTAL DEFECT

Note - ASD, VSD, PFO associated with paradoxical embolisms especially on shunt reversal (straining, coughing)

158
Q

Decreased LV length
Sigmoid septum with bulging
Atrophy of ventricle (increased connective tissue)
Lipofuscin pigment (brown perinuclear cytoplasmic inclusions)

A

NORMAL CARDIAC AGING

159
Q

Subendocardial vacuolization and fibrosis

A

CHRONIC ISCHEMIC HEART DISEASE

160
Q

Histological change in cardiac myocytes as a result of long-standing hypertension

Note - Diastolic dysfunction and LA enlargement

A

CONCENTRIC HYPERTROPHY

Note - Due to pressure overload and also seen in aortic stenosis

161
Q

Benign congenital tumor composed of unencapsulated aggregates of thin-walled capillaries that grow before regressing by puberty

A

JUVENILE (STRAWBERRY) HEMANGIOMA

162
Q

Border and contents of femoral triangle

A

Superiorly - Inguinal ligament
Medially - Adductor longus
Laterally - Sartorius

Contents (lateral to medial)...
Nerve (not part of femoral sheath)
Artery
Vein
Lymphatics

Note - Artery is midway between pubic symphysis and anterior superior iliac spine

163
Q

Cardiomyocyte characteristic decreased with diastolic and systolic dysfunction, respectively.

A

Diastolic - Compliance (Normal EF, Normal LVEDV, increased LVEDP)

Systolic - Contractility (Reduced EF, Increased LVEDV, Increased LVEDP)

164
Q 
State causing...
Increased CO/HR/RR
Constant AO2 and ACO2
Decreased VO2 and increased VCO2
Modest increase in MAP
Decreased PVR
A

EXERCISE

Increased tissue demand - more O2 removed and CO2 produced

165
Q

Mechanism of acute pulmonary edema in a patient with aortic stenosis

A

Concentric hypertrophy means filling of LV becomes dependent on atrial kick which is lost in afib

166
Q

Measurement of degree of AS

A

Difference between LVP and AOP during systole - point of maximum difference is point of maximum intensity of murmur

Note - In AR both increase dramatically together so no difference during systole

167
Q

Review of CT imaging of thoracic anatomy

A

https://www.youtube.com/watch?v=b8qSXAH9WxQ

168
Q

Pathologic findings associated with dicrotic pulse

A

High PVR and severe systolic dysfunction

Note - Accompanied by pulsus alternans

169
Q

Pulsatile mass with thrill
Constant bruit
Increased preload
Decreased afterload

A

AV FISTULA

Note - Results in high-output cardiac failure

170
Q

Modifiable risk factors for atherosclerosis

A

HTN
Hypercholesterolemia
Smoking
Diabetes

171
Q

Mechanism of AAA in atherosclerosis

A

Fibrous cap prevents diffusion of O2 into vessel wall - below renal arteries no vasa vasorum for supply

172
Q

Mechanism of enlarged coronary sinus in PAH

Note - Presents as loud S2

A

Increased RA pressure

173
Q

Oral aphthous ulcers
Genital ulcers
Uveitis

A

BEHCET DISEASE

174
Q

Mechanism of vasodilation via Ach, Shear stress, Bradykinin, and Substance P

A 
Increase Ca (endothelium)
Activation of eNOS
Conversion of Arginine to NO
NO diffuses into smooth muscle
Increased cGMP

Note - NO is the single most important mediator of coronary vasodilation/autoregulation (Adenosine for coronary arterioles)

175
Q

prominent intracytoplasmic granules that are tinged yellowish brown ina 78 yo male

A

lipofuscin accumulation due to lipid peroxidation

accumulating in aging cells

176
Q

Advanced malignancy
sterile platelet rich thrombi on mitral valve leaflets

also associated with:
SLE
antiphospholipid syndrome
DIC

A

nonbacterial thrombotic endocarditis

endothelial injury due to circulating cytokines which trigger platelet deposition in presence of hypercoagulable state

177
Q

Location of the left and right bundle branches

A

after leaving the AV node the AP enters the bundle of his and left and right bundle branches

along the interventricular septum

FASTEST (includes purkinje system) to ensure efficient contraction of the ventricles

178
Q

contraction motion of ventricles

A

twisting motion fromt he apex toward the base (bottom-up)

179
Q

Long term management for a patient who has a prosthetic valve

A

warfarin which competitively inhibits vitamin k epoxide reductase and depletes body of biologically active vitamin K

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