Cardiovascular Flashcards
(297 cards)
1
Q
Does the myocardium do anaerobic metabolism?
A
No. It is always aerobic because fatigued heart muscle is bad
2
Q
In what part of the heart cycle is the LV perfused? Other parts of the heart?
A
Diastole. Systole compresses the intramural coronary vessels too much. Other parts are perfused all the time
3
Q
What is the Law of Laplace?
A
Myocardial wall tension is proportional to cavity pressure, cavity dimension, and 1/ wall thickness
T oc P*L/WT
4
Q
How do beta-blockers treat angina?
A
Slow heart rate -> longer diastole -> more coronary blood flow filling
5
Q
What is the molecular cause of angina?
A
Production of ischemic metabolites like adenosine
6
Q
Acute myocardial infarction is also called ___________
A
Unstable angina
7
Q
What happens acutely in coronary occlusion?
A
Impairment of re-uptake of calcium into the SR
-> depletion of high-energy phosphates, intracellular acidosis
8
Q
What is the main shortcoming of the ECG?
A
Insensitive at rest (also not super sensitive and specific during exercise)
9
Q
2 anti-platelet drugs
A
Aspirin Plavix (clopidogrel)
10
Q
What are the 2 most common vessels used for coronarybypass surgery?
A
Mammary artery
Saphenous vein
11
Q
What is the primary component of large arteries, small arteries, and arterioles?
A
Elastin
Collagen
Smooth muscle
12
Q
Nitric oxide is synthesized from ___________ by ___________
A
Arginine
Nitric oxide synthase
13
Q
Can LDL enter the endothelium?
A
Not under normal conditions. It can only enter disrupted/abnormal endothelium
14
Q
Foam cells secrete ___________ that degrade the fibrous cap of the atherosclerotic plaque
A
Matrix metalloproteases
15
Q
2 markers of cardiac necrosis
A
Cardiac-specific troponins
Creatinine kinase MB isoenzyme
16
Q
What is the composition of venous and arterial thrombi? Where do they occur? What drug classes are used to treat?
A
Venous: fibrin and RBC-rich. Occur in areas of stasis. Treat with anticoagulants.
Arterial: platelet-rich. Occur in areas of high flow. Treat with antiplatelets.
17
Q
Which heparins can bind antithrombin+thrombin?
A
At least 18 saccharide units. Otherwise it just binds antithrombin?
18
Q
What is the route of administration for heparin?
A
IV – immediate
SubQ – delayed
It is not absorbed from the gut!
19
Q
What is the antidrug to heparin?
A
Protamine
It is a strongly + charged drug that complexes with the strongly – charged heparin
20
Q
What are the advantages to low molecular weight heparin?
A
Longer half-life
Better bioavailability
More predictable dose response, so can be given outpatient
21
Q
What does warfarin do?
A
Inhibits recycling of vitamin K, depleting it and some clotting factors (2,7,9,10,protein C)
22
Q
Which drug acts in the plasma to directly inhibit the activity of factor Xa?
A
Rivaroxaban
23
Q
Which drug do you use to prevent deep vein thrombosis after hip-knee replacement surgery?
A
Rivaroxaban
24
Q
Which drug acts in the plasma to directly inhibit thrombin?
A
Dabigatran
25
What does streptokinase do?
Activates plasminogen
It's from strep!
26
What is the Fick equation?
CO = VO2/(Ca-Cv)
CO=cardiac output
Ca = arterial O2 concentration
Cv = venous O2 concentration
27
Is increase in arterial O2 content a factor in the increase in muscle oxygen extraciton during exercize?
No
28
How does the heart meet increased oxygen demand during exercize?
Increased coronary blood flow.
| O2 extraction is already high at rest, so it doesn't increase by much during exercize
29
What is the Frank-Starling law?
Stroke volume increases in response to an increase in the volume of blood filling the heart (end diastolic volume) when all other factors are constant
Why? Increased stretching of ventricular wall causes cardiac muscle to contract more forecefuly
Why? Because when muscle fibers stretch , calcium sensitivity increases
30
What is the Frank-Starling curve?
Ventricular end-diastolic pressure vs. stroke colume
The more the LV is filled, the more it will contract
31
What measureable thing is elevated in myocyte necrosis?
Troponin enzymes (I and T)
Begin 3-12 hours after injury and peak 18-24 hours after necrosis begins
32
What does LDL bind to in the intima, resulting in entrapment?
ECM proteoglycans
33
What are dietary fats called when they are in the lymphatic system?
Chylomicrons
34
What is the main difference in composition between LDL and HDL cholesterol?
HDL has more protein and LDL has more lipid
35
What are apolipoproteins?
Proteins that bind lipids to carry them through the lymphatics and blood stream
36
Which apoplipoprotein is highly correlated with HDL cholesterol? non-HDL cholesterol?
Apolipoprotein A
| Apolipoprotein B
37
What does apoplipoprotein C do?
It enhances the interactions of chylomicrons with lipoprotein lipases that hydrolize the triglycerides in them to free fatty acids
38
What are the 5 clnical indications of metabolic syndrome?
```
Large abdominal circumference
Triglycerides >150 mg/dL
Reduced HDL
BP > 130/85
Glycemia >100
```
39
What 3 things does insulin do?
It mostly promotes caloric storage
Protein metabolism: increased AA transport, decreased proteolysis, increased protein synthesis
Carbohydrate metabolism: decreased glycogenolysis, gluconeogenesis, increased glucose transport, glycogen synthesis, glucose oxidation
Fat metabolism: decreased lipolysis, VLDL secretion, muscle lipoprotein lipase . Increased lipogenesis, apoB degradation, adipose tissue LPL
40
What is the best treatment for metabolic syndrome?
Lifestyle change
Genetics play a very small role and environment is the biggest factor
41
What are the 3 risk factors for peripheral artery disease?
Diabetes
Smoking
Lipids
In order - diabetes is largest
42
What are the 2 symptoms of peripheral artery disease?
Claudication caused by reversible muscle ischemia
| Ischemic rest pain/ischemic ulcers
43
How do you diagnose peripheral artery disease?
Ankle-brachial index
Abnormal if ankle systolic BP/arm systolic BP >0.9
44
Aortic aneurysm involves which layers of the blood vessel?
All 3
45
What are the 2 'shapes' of aneurysm?
Fusiform - entire circumference
| Saccular - evagination of a segment of the circumference
46
What does risk of aneurysm rupture correlate with?
Size
47
At what fetal day does the heart begin to beat?
22 or 23
48
In the end of the 5th week, 2 masses appear in the truncus of the developing heart:
Dextrosuperior -> aortic cusp
| Sinistroinferior truncal swellings -> anterior pulmonary cusp
49
What are the 3 major layers of the heart?
Epicardium - connective tissue and fat
Myocardium - cardiac myocytes
Endocardium - ECs
50
What encloses the heart? What are its material properties?
Pericardium
Is noncompliant
51
What are the 4 valves?
Tricuspid - right AV
Pulmonic
Mitral - left AV
Aortic
52
The SA node's intrinsic activity is ___________bpm
100
53
What does the His-Purkinje system do?
Conduct rapid depolarization to trigger coordinated ventricular contraction
54
What are the 3 layers of an artery?
Adventitia
Media
Intima
55
What is the definition of microcirculation?
The vasculature from the first-order arterioles to the venules
56
Which valves have chordae tendinae?
AV valves
The semilunar valves don't have them!
57
How does the time to repolarization of cardiac muscle differ from skeletal muscle? Why?
It is much longer in order to prevent tetanus
58
What is the molecular structure of myosin?
2 heavy chains, 4 light chains
59
Why is blood flow fastest in the aorta?
Because its cross-sectional area is smallest
60
Flow equation
Q = dP/R where R is resistance
| Analogous to V=IR
61
What is the ratio between flow and resistance?
F=r^r
62
Equation for mean arterial pressure
Diastolic P + 1/3(systolic P - diastolic P)
63
Equation for vessel compliance
C = dV/dP
64
How many liters of blood do we have?
5
65
For the left ventricle, preload is equal to ________
| Afterload is equal to________
End diastolic volume
| Aortic pressure
66
What is the bainbridge reflex?
A way (in addition to starling's law) in which increased venous return causes increased cardiac output
Increased venous return stretches sinus node -> HR increase
67
What is the pulse pressure?
Systolic-diastolic pressure
68
Inotropy is also called ______________
Lusitropy is ________
Contractility
Rate of myocardial relaxation
69
How does cardiac ATPase compare to that of skeletal and smooth muscle?
It is slower than skeletal muscle but faster than smooth muscle
70
Cardiac muscle cells are connected by _________________
Intercalated discs
71
What are the 5 steps of the cardiac muscle contraction-relaxation cycle
1. Action potential leads to calcium release
2. Calcium binds to troponin C
3. Troponin complex undergoes structural change, moving tropomyosin out of the way
4. Myosin binds actin and the crossbridge moves
5. Calcium is released and tropomyosin reblocks the binding site, causing relaxation
72
Thick filaments are ______________ and thin filaments are ______________
Myosin
| Actin + troponin + tropomyosin
73
______________ blocks binding sites on actin
Tropomyosin
74
What does troponin do?
When bound by calcium, displaces tropoyosin, freeing up binding sites on actin
75
Calcium in cardiac cells is stored in the ______________
Sarcoplasmic reticulum
76
What does titin do? (2)
It helps tether myosin to the Z line of the sarcomere
Also forms an elastic spring, and is responsible for much of the passive elastic properties of the cell/heart
77
How is a GPCR (G protein-coupled receptor) deactivated?
Autodephosphorylation of GTP to GDP allows subunits to rebind
78
What are the 5 steps of vascular smooth muscle cell activation?
1. Calcium enters cytoplasm (from SR and through channels)
2. Calcium binds calmodulin
3. Ca-CaM binds to myosin light chain kinase and activates
4. Activated MLCK phosphoylates the light chain of myosin, so cross bridge cycling can occur
5. Contraction is halted by dephosphoylation of myosin light chain by myosin light chain phosphatase
79
What does cAMP do to vascular smooth muscle?
Relaxes
80
Where are the arterial baroreceptors (2)?
Aortic arch
Carotid sinus
81
What is the set point for the baroreceptor reflex?
~100mmHg
82
What does endothelin do? What enzyme makes it?
Vasoconstrict
| Endothelin converting enzyme
83
What 3 things stimulate renin release?
Sympathetic stimulation of juxtaglomerular cells
Decreased blood pressure in renal artery
Decreased Na+ reabsorption in the kidney
84
What does renin do?
Cleaves angiotensinogen to angiotensin I
85
What cleaves angiotensin I to angiotensin II?
ACE
86
What are the 5 effects of angiotensin II?
Systemic vasoconstriction via binding to GPCRs on vascular SMCs
Stimulates sympathetic activity
Stimulates aldosterone release from adrenal cortex
Stimulates release of endothelin from vascular endothelium
Stimulates ADH release from pituitary
87
What does aldosterone do?
Promotes reabsotpion of Na+ and water in kidney collectin ducts
88
What does ADH do? (2)
Increases water reabsorption in kidneys
| Vasoconstriction
89
Timothy syndrome is a defect in which channel? What ECG finding does this result in?
L-type calcium
| Long QT
90
What ECG finding does Brugada syndrome result in?
Short QT
| Sodium-channel mutation
91
What is the behavior of the funny current channel?
Permeable to Na+ below -30 mV and K+ above this
92
What are the phases and ion activity of a fast cardiac action potential? Draw!
```
0 - rise
1 - partial repolarization
2 - plateau
3 - repolarization
4 - resting
```
93
What are the phases and ion activity of a slow cardiac action potential? Draw!
0 - ast fdepolarizaton
3 - repolarization
4 - resting (but really slowly depolarization)
94
What cause phase 0 of the fast action potential?
Influx of Na+ through voltage-activated channels
95
What causes phase 1 of the fast action potential?
Inactivation of sodium current and activation of transient potassium current
96
What causes phase 2 of the action fast potential?
Voltage-activated L-type calcium channels
Delayed rectifier potassium channels
Calcium influx is balanced by potassium eflux
97
What causes phase 3 of the fast action potential?
Calcium channel inactivation
| Delayed rectifier potassium channels
98
What are the only drugs that have been demonstrated to reduce the incidence of sudden cardiac death?
Beta blockers!
99
How do defective potassium channels cause long QT?
There are fewer of them (b/c misfolded proteins aren't let out and about), reducing current amplitude, delaying repolarization
100
How do defective sodium channels cause long QT?
They don't completely inactivate so there is still sodium flowing during phase 2, prolonging it
101
What causes early vs. late afterdepolarizations?
Early - reactivation of Ca2+ channels in response to elevated Ca2+ in the prolonged QT
Delayed - Elevated Ca2+ from the Na/Ca exchanger (NCX)
102
What are the 3 degrees of conduction block?
1 - long PR interval
2 - some P waves are not followed by QRS
3 - complete block. No relationship between timing of P and QRS
103
What are the 2 requirements for re-entrant arrhythmias?
Unidirectional conduction block in a functional circuit
Conduction time > refractory period
104
What is the principle of use-dependence in anti arrhythmics?
Blocking agents can more easily inactivate active channels (because they physically slip in there) so they tend to preferentially work on overactive regions of the heart or ones with abnormal resting potentials
105
What are the 2 ways class I antiarrhythmic drugs can suppress re-entrant arrhythmias?
Slowing conduction velocity (by slowing current)
Prolonging refractory period
106
Which neurotransmitter is released by the preganglionic sympathetic neurons? Postganglionic sympathetic neurons?
Acetylcholine
| Norepinephrine
107
What transmitter is released by post and preganglionic parasympathetic neurons?
Acetylcholine
108
What are the 2 types of cholinergic receptors? Where are they located? What type of receptor are they?
Nicotinic. Cell body of postganglionic neurons. Na/K ion channel.
Muscarinic. Effector cells. G protein-coupled.
109
What is the problem in diastolic vs. systolic heart failure?
What does diastolic heart failure results in? Systolic heart failure? (in terms of heart size)
Filling. Hypertrophy
| Squeeze. Dilation
110
What is the suffix for ACE inhibitors?
What is the suffix for angiotensin receptor blockers?
What is the suffix for aldosterone receptor blockers?
What is the suffix for beta-blockers?
- pril
- sartan
- one
- olol
111
Which way does electrical signal flow through the atrial septum?
L to R
112
Draw cardiac output diagram
:)
113
Draw pressure volume loops for normal, increased preload, increased inotropy, increased afterload
:)
114
Draw His bundle conduction system through the ventricles
:)
115
What are the 3 troponin isoforms?
C - calcium-binding
I - inhibits myosin ATPase
T - tropomyosin-binding
116
What are the 2 titin isoforms? How do their material properties differ?
N2B
| N2BA, which is less stiff
117
Where do slow action potentials occur?
SA and AV node
118
How do action potentials of endocardial and epicardial cells compare?
Endocardial cells depolarize slightly before and their repolarization is longer
119
Draw an EKG and explain the parts
:)
120
In which leads is the QRS upright?
Left-sided leads
It is downwards in right-sided leads
121
What are the effects of R, L, and L fascle bundle blocks?
R - wide QRS with delayed RV conduction
L - wide QRS with delayed LV conduction
Fasicle - QRS is not widened, but direction of depolarizaiton altered (frontal plane mean axis is altered)
122
What happens in Finnish familial arrhythmia?
Mutant K+ channel is not properly upregulating during increased sympathetic activity. There is not enough repolarizing K+ current to match the increased depolarizing Ca2+ current
This prolongs phase 2 triggering afterdepolarizations
123
Which channel is responsible for early afterdepolarizaitons? Delayed afterdepolarizaitons?
Late-calcium
| NCX
124
What are the 4 classes of antiarrhythmics?
I - block voltage-gated Na+ channels
II - beta-blockers
III - prolong fast response phase 2 by delaying repolarization
IV - block voltage-gated Ca2+ channels
125
What are the 3 subclasses of class I antiarrhythmics? Draw their voltage charts. What are examples of each.
:)
1a: quinidine, procainamide, disopyramide
1b: lidocaine, tocainide, mexeletine, phenytoin (lettuce, tomato, mayo, pickles)
1c: propafenone, flecainide, ecainide
126
What is measurement of conduction velocity used as a surrogate for?
Current density
127
Which 3 currents do class II/beta blockers reduces?
Funny
Long-type Ca2+
K+
128
What 2 effects do beta blockers have on the slow response?
Decreased phase 4 slope -> decreased firing rate
Prolonged repolarizaiton -> increased refractory period
129
What channel is responsible for Ca2+ influx out of the SR? What opens it?
RyR (ryanodine receptor)
Ca2+
130
Does skeletal muscle contraction require entry of external calcium?
No, only cardiac muscle does
Calcium does the same thing in both cell types though. It binds to troponin on thin filaments and activates contraction.
131
What 3 channels remove calcium from the cytosol?
SERCA - puts into SR
NCx - puts outside
PMCA - puts outside
In order of importance
132
What is the ratio for NCX?
3 Na for 1 Ca
It can actually run in either direction (calcium into cell during depolarization and out of the cell upon repolarization.)
133
What happens in catecholaminergic polymorphic ventricular tachycardia?
What ion channel is it a defect in?
ECG abnormalities upon exercize
Mutations in RyR2, which allows Ca2+ to leak out of the SR during resting phase
134
What role does GTP play in G-proteins?
The activated subunits bind GTP and the inactivated subunits bind GDP
135
The main target of G-proteins is _______
cAMP
136
The main target of cAMP is _______
PKA
Activated by cAMP binding
137
What does the sympathetic nervous system do to the L-type calcium channel?
L-type Ca2+ - slowed inactivation -> increased inotropy (contractility)
138
What does the sympathetic nervous system do to troponin?
Troponin I - causes increased ca dissociation -> increased lusitropy (relaxation)
139
What does the sympathetic nervous system to do phospholamban?
Inhibits, so it doesn't inhibit SERCA
- > faster resetting of Ca2+ levels in SR
- > increases inotropy (increased SR load), lusitropy (faster removal of Ca2+)
140
How is the HCN (funny current) channel activated?
cAMP directly
| Most other ones are phosphorylated by PKA
141
What 4 channels do the sympathetic and parasympathetic nervous systems act on to increase/decrease HR?
HCN
L-type Ca2+
RyR
NCX
Sympathetic - more cAMP by Gs
Parasympathetic - less cAMP by Gi
142
What is the primary mechanism for parasympathetic control of heart rate?
The gamma G-protein subunit activates GIRK (G protein inward rectifier K channel), hyperpolarizing the cell
143
Do smooth muscle cells have sarcomeres, troponin, or tropomyosin?
No
144
How does sympathetic stimulation cause vasoconstriction?
NE activates AARs (alpha adrenergic receptors) on vascular SMCs
AARs are coupled to Gq (G-quirky.)
Increased IP3
Increases Ca2+ release from SR
145
Where in the brain is the cardiovascular control center?
Medulla
146
What is the primary mechanism by which blood flow in capillaries is matched to metabolic demand?
Vasoactive metabolites produced by metabolically active tissue act on receptors on VSMCs
147
What is the myogenic response?
A feedback mechanism of VSMCs to maintain constant flow even with changes in pressure
Stretching causes vasoconstriction
148
What are the 2 Mobitz types of 2nd degree AV blocks?
1 - PR lengthens until a P does not conduct
| 2 - PR interval is constant
149
What is the ECG difference between atrial flutter and fibrillation?
flutter has P waves but fibrillaiton does not
150
What causes a junctional rhythm? What does the ECG look like?
Where the AV node causes most of the heart's beating
P waves are in the wrong place
151
What does a premature ventricular contraction or ventricular tachycardia look like?
Wide, abnormal QRS
| No P wave
152
What are the ECG effects of hyper and hypocalcermia?
Shortens QT interval
Lengthens QT interval
153
What are 3 ECG effects of hypokalemia?
Lengthened QT interval
Prominent U waves
T waves may be inverted
154
What does the ECG reveal in acute pericarditis?
DIffuse ST elevation
155
What is the drug of choice for acute pericarditis? What are 2 alternatives??
Ibuprofen
Aspirin, colchicine (for preventing recurrent pericarditis)
156
What are 5 causes of pericardial iffusion?
```
Pericarditis
Metastatic malignancy
Uremia
Autoimmune disease
Hypothyroidism
```
157
What is the distinguishing symptomatic feature of pericardial pain vs. acute coronary pain?
It is aggravated by deep breathing and relieved by sitting up/postural changes
158
What are 3 important effects of quinidine not related to Na+ channel block?
Blocks K+ channels real well -> prolongs AP duration
Vagal inhibitor
Alpha-adrenergic receptor antagonist
159
What is cor pulmonale?
When primary lung disease causes right heart failure
160
Is the autonomic nervous system part of the central or peripheral nervous system?
The peripheral
161
How does the speed and specificity of the autonomic and somatic motor systems compare?
The autonomic system is slower and has diffuse projections
162
What are 2 important inputs to the autonomic nervous system?
Nucleus of the solitary tract
| Hypothalamus
163
Comparing the sympathetic and parasympathetic systems,
Where do neurons originate?
Where are the ganglia located?
Which has the larger ratio of pre to post ganglionic neurons?
Sympathetic: Thoracic and lumbar spinal cord, near spinal cord (sympathetic chain), less (1:10 ratio)
Parasympathetic: brainstem and sacral spinal cord, near target organs, more (1:3 ratio)
164
What does the subfornical organ do in terms of the CV system?
Detects low blood pressure
| Causes release of vasopressin in posterior pituitary
165
What does vasopressin do? (2)
Vasoconstriction
| Increase water retention in kidneys
166
What is the positive feedback input to the subfornical organ?
Angiotensin II activates neurons in the subfornical organ
167
Calcium is sequestered in the SR by binding to _______
Calsequestrin
168
What does phospholambin do?
Inhibits the SERCA calcium pump
169
How are cardiac output and peripheral vascular resistance altered durig weight training?
Peripheral resistance is increased
| CO stays the same
170
How do the ATPase levels and myosin isotype ratio change with pathological hypertrophy? With physiological hypertrophy?
Decrease in ATPase and increase in BB MHC
Increase in ATPase and aa MHC
171
What is orthopnea?
Immediate shortness of breath when lying flat due to blood pooling in the legs in heart failure
172
What is pulse pressure like in heart failure with low flow?
It is low due to low output
173
What are the 3 waves of jugular venous pressure? Draw
A - atrial contraction
C - closing of tricuspid valve in early systole
V - movement of right ventricle annulus and tricuspid valve backwards at the end of systole
174
What causes S3?
When does it occur?
What sound does it make?
Rapid expansion of ventricular walls in early diastole
Dilated heart
'kentucky'
175
What causes S4?
| What sound does it make?
Atria contracting against a stiff LV
'tennessee'
176
What 4 things cause B-type natriuretic peptide release?
Ventricular stretch (primary)
Secondary:
Hyperadrenergic state
RAAS activation
Ischemia
177
What 2 tests are there for B-type natriuretic peptide level?
BNP
| NT-proBNP, N-terminalbreakdown product of BNP (much higher)
178
What is the diagnostic use of BNP (B-type natriuretic peptide)
Negatively predictive - a low BNP makes HF unlikely as the cause of symptoms
179
What are the 2 groups of diuretics?
```
Loop directics (usually sulpha drugs)
Thiazide diuretics (use to augment loop diuretics)
```
180
What are 3 loop diuretics we care about?
Furosemide (most commonly used)
Bumetanide
Torsemide
181
What are 3 ACE inhibitors we care about? What is ther dosing schedule?
Lisonipril - qd (most commonly used)
Enaliapril - bid
Captopril- tid
182
What are 3 angiotensin receptor blockers? What is their dosing regimen?
When do you use them?
Valsartan BID
Candesartan QD
Losartan QD
'The valiant knight Candy loses'
Use when patients develop cough to ACE inhibitors - they have been shown to be equivalent in studies
183
What are the 2 mineralocorticoid receptor antagonists?
| What are 2 side effects?
Spironolacetone
Eplerenone
Hyperkalemia
Gynecomastia (spironolactone only)
184
What are the 2 side effects of beta-blockers?
Negative inotropy: fluid retention, hypotension, decreased CO
Bronchoconstriction
185
The combination of which 3 drug classes decrases remodeling in heart failure?
Ace inhibitors/angiotensin receptor blockers (add first)
Beta blockers (add second)
Aldosterone receptor blockade
186
What other drug class do you give for African Americans with heart failure in addition to the 3?
Arterial vasodilation antihypertensives: hydralazine/isosorbide dinitrate
187
What is the clinical indication for cardiac resynchronization therapy (biventricular pacemakers)
Bundle branch block -> QRS >150 ms
188
What are 3 positive inotropic agents, how are they administered, and how do they work?
Digoxin (PO) - K/Na exchange
Dobutamine (IV) - beta agonist
Milrinone (IV) - phosphodiesterase inhibitor, similar effect as above
189
ACE inhibitors also act on______, causing ______
Kinin II -> increase in bradykinin (which is protective!)
Cough (a pulmonary irritant)
190
6 side effects of ACE inhibitors
```
Cough
Hyperkalemia (becaus angiotensin II gets rid of potassium)
Angioedema
Renal dysfunction
Neutropenia
Hypotension
```
191
What are the side effects of angiotensin inhibitors?
Less angioedema, cough than ACE inhibitors
```
Also hyperkalemia
Uricosuric effects (can make gout worse)
```
192
What are the only 3 beta blockers that have been shown to reduce mortality?
Bisoprolol BID
Carvedilol BID
Metroprolol succinate QD
193
HFpEF is also known as _______ heart failure
Diastolic
194
What are the unipolar limb leads of the EKG?
aVR - to right arm
aVF - to left foot
aVL - left arm
AV = augmented vector
195
What are the bipolar limb leads of the EKG?
In an equilateral triangle of each arm and left leg
I points straight across from right arm to left arm
II is from right arm to left leg
III is from left arm to left leg
196
What defines Q, R, and S waves?
Q is downward deflection
R is upward deflection
S is downward deflection following an upwards one
197
What are the grid lines on the EKG?
.1 mV / .5 mV
| 0.04s/0.2s
198
What are the steps for analyzing an EKG?
```
Voltage
Rhythm
Rate
Intervals
Mean QRS axis
P wave abnormalities
QRS abnormalities
ST abnormalities
```
199
What are 5 class III antiarrhythmic drugs?
```
Ibutlide
Dofetilide
Amiodarone
Sotalol (also a beta-blocker)
Bretylium
```
200
What are 2 class IV antiarrhythmic drugs?
Verapamil
| Diltiazem
201
Does OTC cough medication work on kinin cough?
No, because it is a different mechanism
202
What are 5 drugs that interact with ACE inibitors?
Lithium and other salt substitutes
NSAIDS
Loop diuretics
K+ sparing diuretics (because can cause hyperkalemia)
203
What happens to receptor selectivity as beta blocker dose increases?
Selectivity decreases (for either beta1/beta2/alpha1). For heart, I think we want beta receptors
204
Which organ metabolizes beta blockers?
The liver, so don't use in liver failure
205
What blood pressure defines hypertension?
>140/90
206
Which type of heart failure can lead to liver congestion?
Right heart
207
What is myxomatous degeneration?
Pathological weakening of connective tissue (usually used in context of mitral valve prolapse)
208
Rheumatic fever is when antibodies form against ______ of which bacteria?
What does this cross-react with?
M protein
Group A strep (GAS)
Glycoproteins
209
What is the Jones Criteria for rheumatic fever?
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Joints
O - myocarditis
Nodules, subcutaneous
Erythema merginatum
Syndenham chorea
```
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Minor:
CRP increased
Arthralgia
Fever
Elevated ESR
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Prolonged PR
Anamnesis of rheumatism
Leukocytosis
210
What are Aschoff bodies?
Collectionsof mononuclear cells in the myocardium during carditis
211
Which valves are usually affected in endocarditis? (2)
Mitral (65-75%)
| Aortic (25%)
212
What is a sterile/marantic/non=bacterial vegetation from?
Thrombus on valve
213
Which is the most common primary tumor of the heart in teens and adults? Where is it located?
Cardiac myxoma
| LA >> RA > other sites
214
Mutations to which 3 proteins are present in 70-80% of hypertrophic cardiomyopathies?
Myocin-binding protein C
Beta-myosin heavy chain
Cardiac troponin T
215
Mutations to which 4 proteins are oten found in dilated cardiomyopathy?
Desmin
Dystrophin
Sarcoglycans
Lamin
216
How much of hypertrophic cardiomyopathy is due to genetics?
All of it
217
What structural change occurs in hypertrohic cardiomyopathy?
Thickened interventricular septum bulges into the LV outflow tract during early systole -> outflow obstruction
218
What is Sq? What is S2?
Closeure of the AV valves
| Closure of the semilunar valves
219
What causes the vast majority of mitral stenosis?
Rheumatic (80-99%)`
| Second most is calcific (3%)
220
How is a tricuspid regurgitation murmur affected by breathing?
It becomes louder during inspiruation
221
What happens to the jugular during tricuspid regurgitation (2)?
Jugular venous distension
| Systolic V wave
222
What is the most common cause of tricuspid regurgitation?
From RV pressure/volume overload
223
What is the most common congenital cardiac defect?
Bicuspid aortic valve
| Like 1% of people
224
When do you treatbicuspid aortic valve?
When symptoms begin. Otherwise, you die pretty quickly
225
Should you use ACE inhibitors and angiotensin II receptor blockers at the same time?
No. THere is no added benefit
226
What are 2 aldosterone antagonists we care about?
```
Spironolactone
Eplerenone (use if edocrine side effects occur with spinonolactone)
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227
Digoxin works via the _______
Neurohormonal modulator
228
How is digoxin excreted?
How long does it take to reach steady state?
What is its volume of distribution?
Renally
7-10 days
5-7 L (so, blood volume)
229
What disease is digoxin used to manage?
HFrEF (heart failure with reduced ejection fraction)
It reduces hospitalizations
Does not benefit HFpEF
230
What 5 drug classes are indicate careful digoxin dosing? (a 50% dicrease in dosing)
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Antiarrhytymics
Antifungals
Calcium channel blockers (particularly verapamil)
Quinine
Macrolides
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231
Digoxin toxicity can cause changes to which 3 ions?
Hypokalemia
Hypercalcemia
Hypomagnesemia
232
What are the 2 drugs to increase inotropy?
Dobutamine - Beta1 agonist, slight peripheral vasodilation
Milrinone - phosphodiesterase inhibitor (something about heart disease), increases myocyte Ca2+ utulization, moderate peripheral vasodilation
233
What does dopamine administration do to the heart
Stimulates adrenergic receptors
| Releases norepinephrine form nerve terminals (not sure what this does)
234
What is the difference between pericardial effuson and tamponade?
Tamponade is a worse effusion, where there is a decrease in blood output to the body
235
What is the clinical presentation of pericardial effusion with tamponade (3)?
Decreased RV diastolic filling during inspiration
Distended neck veins
Inspiratory decrease in arterial pressure (paradoxical pulse) - because RV filling squishes LV filling
236
What happens to the IVC during tamponade?
It doesn't have the normal 50% reduction during inspiration. It remains dilated.
237
What are 2 EKG findings in cardiac tamponade?
Sinus tachycardia
Low voltage
Electrical alternans (alternating QRS height that reflects swinging of heart in pericardium(
238
What happens to RV and LV diastolic pressures during constrictive pericarditis?
They become equal
Both become elevated and equal because heart filling is restricted
239
How do you calculate heart rate from an EKG?
300/# heavy lines between QRS
1500/# small lines between QRS
240
Which 2 leads monitor the RV?
| Which 2 leads monitor the LV?
V1,V2
| V5,V6
241
What causes ST depression?
Ischemia due to sudden high oxygen demand that can't be met (coronary blood flow can't be increased)
242
What cause T wave inversion?
Ischemia due to acute coronary artery obstruction during low oxygen demand (coronary blood flow suddenly is lessened)
243
What EKG findings do transmural infarcts produce?
What about subendocardial infarcts?
Q waves - a negative deflection in leads over the infarcted myocardium
ST depression
244
What is heart failure?
When the heart can't pump enough blood forward to meet the demands of the body (forward), or can only do so if cardiac filling pressures are super high (backward failure)
245
What is chronotropic incompetence?
An inability of the heart to regulate its rate appropriately in response to physiologic stress
246
What are 2 indications for teatment of bradyarrhythmias?
When the patient is symptomatic
| When the rhythm is below the AV node
247
Which of the AV blocks are infranodal?
2 and 3 (idk why...)
248
How you distinguish single and multifocal atrial tachycardia?
3+ p-wave morphologies
249
When do you cardiovert people?
If a rhythm is hemodynamically unstable (syncope, confusion, end organs aren't perfused)
250
What does adenosine do for arrhythmias?
It temporarily blocks the AV node
251
What is the pathophysiology of Atrioventricular nodal reentrant tachycardia
fast and slow pathway through AV node
A properly timed extra beat can go down the slow and up the fast pathway
Atria and ventricles depolarize simultaneously
252
What does the EKG look like in atrioventricular reentrant tachycardia?
Shortened P-R interval
Slurred QRS with delta wave
Because, there is no pause between atrial and ventricular contraction
253
What is a nonpharmacologic maneuver for atrial tachycardias?
Vagal maneuvers - slow AV conduction
254
What are the 5 C's of atrial fibrillation management??
```
reverse Cause
Control rate
antiCoagulate
Control rhythm (consider)
Catheter ablation (consider)
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255
What 2 drug types are used for rhythm control in supraventricular tachycardia?
CLass 1C agents
| CLass III agents
256
What 4 medication classes are for ventricular tachyarrhythmmias?
Beta blockers, calcium channel blockers, class iC, class III
257
Nearly all diruretic agents exert their effects ath the_____ surface of renal tubule cells
Luminal (urine)
258
Na+ is the major extracellular cation and its movement between compartments is controlled by regulated active transport via _________ activity at the ______ surface
Na/K ATPase
Interstitial (blood)
259
What does acetazolamide do?
ReInhibits carbonic anhydrase, resulting in retention of HCO3- in urine and mild alkaline diuresis (so... we don't really use it as a diuretic)
260
Draw the sites of diuretic action
:)
261
What is the range (in degrees) of the normal QRS axis?
-30-+90
262
What does the P-wave look like in RA and LA enlargement? Draw!
mrr
263
What 2 drugs are for ventricular arhythmias?
Beta-blockers - proven benefit
| Amiodarone - maybe benefit
264
What is a disadvantage of Angiotensin II receptor antagonists compared to ACEIs?
They don't have bradykinin actions
265
How does serum K+ affect condctance?
Low - decreased conductance despite increased electrochemical gradient
High - increased conductance despite decreased electrochemical gradient
266
How does QT length affect risk of torsades?
QT prolongation increases risk of torsades and this further increases with low K+
267
What loop diuretic substitute can be used if there is a sulfa sallergy?
Ethacrynic acid
268
How does the AHA organize cardiomyopathies?
Genetic
Acquired
Mixed
269
Sarcomeres are added in _____________ in eccentric hypertrophy
Series
270
What is outflow tract obstruction? What condition is it often seen in?
Mitral valve in mid-systole covers outflow tract to the aortic valve
Hypertrophic cardiomyopathy
271
What are the murmur characteristics in hypertrophic cardiomyopathy?
Systolic
| Louder with standing/valsalva (increases LV volume) and softer with squatting
272
What is restrictive cardiomyopathy?
Decreased ventricular volumes with normal ventricular wall thickness
273
How does digoxin slow the AV node?
Increasing vagal tone, probably via the neurohormonal modulator
274
What drug is good to combine angiotensin 1 receptor blockers with?
Neprilysin inhibitor
275
Are there any diuretics that inhibit Na/K ATPase?
No! They just decrease Na+ reabsorption at vairous sites in the nephron
276
What EKG change is evident in hyperkalemia?
Peaked T waves
277
What happens to the pacemaker rate in n hyperkalemia? Action potential duration? Conduction rate?
HR slows
AP is shorter
Conduction rate is slower
278
How do loop diuretics work?
They inhibit NaCl transport via the Na/K/2Cl transporter
279
What happens to blood pH with loop diuretics
Hypokalemic metabolic alkalosis because more Na+ is absorbed at the collecting tubule, resulting in more K+ and H+ excretion
280
Draw effect of diuretic agents on plasma electrolytes
Mrr
281
How do thiazide diuretics work?
They inhibit the Na/Cl cotransporter
282
What do thiazides do to serum calcium levels?
The increase reabsorption (ice cream fall out of slide)
283
What are 5 side effects of thiazides?
```
Hypokalemia
Hyperglycemia
Hyperuricemia (gout!)
Hyperlipidemia
Allergy - sulfa
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284
Which 2 diuretic classes increase K+?
ACE inhibitors
| Aldosterone receptor inibitors
285
What are the 2 ways K+-sparing diuretics work?
Competitive antagonist at aldosterone receptor (spironolactone/eplerenone)
Direct block of Na+ channels (triamterene/amiloride) - not used in HF
286
How does spironolactone help in heart failure besides being a diuretic?
Blocks aldosterone receptors in heart, reducing remodeling
287
Which 3 drugs can you use on stable ventricultachyarrhythmias (like after shock)
Amiodarone
Lidocaine
Procainamaide
288
What is a dyhydropyridine we care about?
Nifedipine
289
How does adenosine work?
Agonist at A1 receptor ast AV node
It hyperpolarizes by increasing K current and reduces phase 0 Ca current, thereby inhibiting AV node and increasing its refractory period
290
How do you treat bradyarrhythmias?
Pacemaker if symptomatic
| Very limited role for medications
291
What 3 drugs can increase vagal tone, reducing AV block?
Dopamine
Epinephrine
Atropine
Only for short term
Long-term pharmacotherapy is not possible and requires pacemaker
292
Which potassim state can cause early afterdepolarizastions?
Hypokalemia
293
Which drug is a parasympathomimetic?
Digoxin
294
Does the aortic of pulmonic valve close first?
Aortic
295
When is S2 1 sound? When is it 2 sounds?
Expiration
| Inspiration (A2 P2)
296
WHEN are S3 and S4 heard in the heart cycle?
S3 - diastole systole
| S4 - late diastole
297
PHosphorylation of troponin I weiincreases ______
LUsitropy/relaxation
