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USMLE Step 1-2015 > Cards > Flashcards

Flashcards in Cards Deck (165):
1

Patient with TIA/stroke in setting of thromboembolic disease (DVT) should be suspicious for what?

Paradoxical embolism

2

VSD most commonly occurs where?

membranous septum

3

3 main conotruncal abnormalities

Transposition of great vessels, TOF, persistent truncus arteriosus

4

Valves are formed from what structures?

Endocardial cushions

5

Anlantois-->Urachus

Median umbilical ligament

6

Ductus arteriosus

Ligamentum arteriousm

7

Ductus venosus

Ligamentum venosum

8

Foramen ovale

Fossa ovalis

9

Notochord

Nucleus pulposus

10

Umbilical arteries

Medial umbilical ligaments

11

Umbilical vein

Ligamentum teres hepatis (contained in falicform ligament)

12

What closes PDA?

Indomethacin (decrease prostaglandin)

13

Supplies posterior 1/3 of interventricular septum, posterior walls of ventricles, and posteromedial papillary muscle

Posterior descending/interventricular artery (PDA)

14

Supplies anterior 2/3 of interventricular septum, anterolateral papillary muscle, and anterior surface of left ventricle. Inferior wall of LV forms diaphragmatic heart surface

Left anterior descending (LAD)

15

Supplies lateral and posterior walls of left ventricle, anterolateral papillary muscle

Left circumflex coronary artery (LCX)

16

supplies right ventricle

Right (acute) marginal artery

17

What usually supplies SA/ AV node

Ricght coronary artery

18

Right dominant circulation

85% of individuals (PDA arises from RCA)

19

Left dominant ciruclation

8% individuals (PDA arises from LCX)

20

Codominant circulation

7% individuals (PDA arises from both LCX and RCA)

21

Where does coronary artery occlusion most commonly occur?

LAD

22

Two most important factors involved in coronary blood flow autoregulation and what do they regulate

NO-regulates large coronary artery + Pre-arteriolar vessels
Adenosine-regulates small coronary arteriolar vessels

23

Enlargement of what part of the heart can cause dysphagia/hoarseness?

Left atrium

24

Most coronary venous blood drains into

Coronary sinus of right atrium

25

Where does desceining aorta lie in regard to esophagus and left atrium?

Posterior to both allowing visualization of descending aorta via transesophageal echocardiography

26

3 specific factors differentiating heart ciruclation from blood flow provided to skeletal muscle and viscera

1) Heart muscle perfused during diastole consuming only 5% of CO
2) Myocardial oxygen req is very high (resting 75-80% and while at work around 90% and this extraction does not occur at this level anywhere else in body)
3) coronary flow regulated by metabolic factors (adenosine causes vasodilation and decreased vascular resistance)

27

Most common cause of early cyanosis

TOF

28

What other congenital heart anomaly do patients with persistent truncus arteriosus have?

VSD

29

Most common congenital cardiac defect?

VSD

30

How is ASD different than patent foramen ovale?

ASD has septae missing tissue while PDA has tissue that is unfused

31

What does tricuspid atresia require for viability?

Both ASD and VSD

32

Most important prognostic factor in TOF?

Pulmonic stenosis

33

What is the consequence of PDA?

Late cyanosis in lower extremities (differential cyanosis) and not upper extremities because PDA after major branches of aorta that feed the upper extremities. Due to late on set reversal of shunt flow from left to right to right to left.

34

Alcohol rexposure in utero (fetal alcohol syndrome)

VSD (important cause), PDA, ASD , TOF

35

Congenital rubella

PDA

36

Down syndrome

AV septal defect (endocardial cushion defect), VSD ASD (ostium primum ASD)

37

Infant of diabetic mother

Trasposition of great vessels

38

Marfan syndrome

MVP, thoracic aortic aneurysm and dissection

39

Prenatal lithium exposure

Ebstein anomaly

40

Turner syndrome

Bicuspid aortic valve, coarctation of aorta

41

Williams syndrome

Supravalvular aortic stenosis

42

22q 11 syndromes

Truncus arteriosus, TOF

43

Fredreich ataxia

Hypertrophic cardiomyopathy

44

Tuberous sclerosus

Valvular obstruction due to cardiac rhabdomyomas

45

Most common heart tumor

Metastasis from breast, lung, melanoma, lymphoma

46

Most frequent cardiac tumor in children

Rhabdomyomas (associated with tuberous sclerosis)

47

Most frequent cardiac tumor in adults

Myxomas

48

Growth factor avidly produced by myxomas?

VEGF

49

Fick principle

CO=rate of O2 consumption/arterial O2-venous O2 content

50

Mean arterial pressure

CO*TPR or 2/3 SBP*1/3DBP

51

Pulse pressure

Systolic pressure-diastolic pressure

52

2 variables pulse pressure is related to

Directly related to SV and inversely related to capacitance

53

Contractility is a function of what?

intracellular calcium

54

La place law

radius*pressure/2*wall thickness

55

4 factors that require increase myocardial oxygen demand

Increase contractility, increase afterload, increase heart rate, increase diameter of ventricle

56

What accounts for most TPR an what accounts for most blood storage capacity?

TPR, Veins

57

Resistance equation

Driving pressure(delta p)/flow (q)-->8nl/pir^4

58

Volumetric flow rate (Q)

flow velocity (v) * cross-sectional area (A)

59

What period of cardiac cycle is the period of highest O2 consumption

Isovolumetric contraction

60

JVP absent in atrial fibrillation

a wave

61

JVP absent in tricuspid regurgitation

x descent

62

a wave

right atrial contraction

63

c wave

RV contraction (closed tricuspid valve bulging into atrium)

64

x descent

right atrial relaxation and downward displacement of closed tricuspid valve during ventricular contraction

65

v wave

increase right atrial pressure due to filling agains closed tricuspid valve

66

y descent

RA emptying into RV

67

murmur best heard at aortic area

systolic murmur (aortic stenosis, flow murmur, aortic valve sclerosis)

68

murmur best heard at left sternal border

diastolic murmur (AR/PR) systolic murmur (hypertrophic cardiomyopathy)

69

murmur best heard at left infraclavicular region

Continuous murmur (patent ductus arteriosus)

70

murmur best heard at pulmonic area

systolic ejection murmur (pulmonic stenosis, flow murmur (eg. physiologic murmur))

71

murmur best heard at tricuspid area

pansystolic murmur (triscuspid regurgitation, VSD) diastolic murmur (tricuspid stenosis, ASD)

72

murmur best heard at mitral area

systolic murmur (mitral regurg) diastolic murmur (mitral stenosis)

73

Bedside maneuver: Inspiration
Effect:

Increase intensity of right heart sounds

74

Hand grip

Increase afterload
Increase intensity of MR, AR, VSD
Decrease intensity of HOCM
MVP: later onset of click/murmur

75

Valsalva, standing up

(decrease preload)
decrease intensity of most murmurs (including AS)
increase intensity of HOCM
MVP" earlier onset of click/murmur

76

Rapid squatting

increase preload
increase intensity of AS murmur
decrease intensity of HOCM
MVP: later onset of click/murmur

77

Speed of conduction

Purkinje>atria>ventricles>AV node

78

Pacemeakers

SA>AV>Bundle of his/purkinje/ventricles

79

Normal length of PR interval

80

Normal length of QRS complex

81

QT interval

ventricular depolarization, mechanical contraction of ventricles, ventricular repolarization

82

PR interval

From start of atrial depolarization to start of ventricular depolarization

83

T wave

ventricular repolarization. inversion may indicate recent mi

84

J point

Point in between QRS complex and start of ST segment

85

ST segment

isoelectric, ventricles depolarized

86

presence of U wave is caused by what?

hypokalemia, bradycardia

87

Drug induced causes of Torsades

AntiArrhythmics
AntiBiotics
AntiCychotics
AntiDepressants
AntiEmetics

88

Inheritance of Romano ward an jervell lange nielsen and brugada syndrome

Auto dominant and auto recessive and auto dominant

89

Triad of WPW

Prolonged QRS, Shorter PR interval, Delta wave

90

What regulates number of atrial impulses that can reach ventricle and determines ventricular contraction rate in afib?

AV node refractory period

91

Afib treatment for chronic Afib (>48 hours)

Antithrombotic therapy (eg warfarin), rate control (b blocker, non-dihydropyridine Ca2+ channel blocker, digoxin), rhythm control (class IC or III antiarrhythmics)

92

AFib treatment for new afib (

Cardioversion (used for new and not old afibb becuase cardioverision can dislodge possible clot)

93

Where to right/left leads in pacemakers get in the heart

Right is simple from left subclavian to SVC while left is more difficult because it goes through coronary sinus on atrioventricular groove of right atrium

94

1st degree AV block

PR interval >200 msec. Each PR interval is equal

95

Difference btwn 2nd degree Type I and Type II av block

Type I- progressive lengthening of PR interval until beat is "dropped" (P wave not followed by QRS complex)
Type II-Dropped beats are not preceeded by change in PR interal (P wave not followed by QRS complex)

96

Treatment of 1st, 2nd, 3rd AV block

1st-none
2nd type I-none type II-pacemaker
3rd degee-pacemaker

97

Disease that can cause 3rd degree av block

lyme disease

98

What is recombinant form of BNP for heart failure?

Nesiritide

99

Aortic arch receptor transmits through what?

Vagus nerve to solitary nucleus of medulla (responds to increase in BP)

100

Carotid sinus transmits through what?

Glossopharyngeal nerve to solitary nucleus of medulla (responds to decrease and increase in BP)

101

Method by which carotid massage decreases HR

Increase AV node refractory period

102

Triad of cushing reaction

hypertension, bradycardia, and respiratory depression

103

Describe cushing rxn.

Increase in ICP-->arteriole constriction-->cerebral ischemia-->increased pCO2+decrease pH-->increased perfusion pressure (hypertension)-->increased stretch of carotid sinus-->peripheral reflex baroreceptor induced bradycardia

104

Central vs peripheral chemoreceptor response

Central-Paco2, hypercapnia
Peripheral-PaO2, hypoxemia

105

What can be used to treat paroxysmal supraventricular tachycardia in patients with no other history of heart disease?

Carotid massage (slows conduction through AV node and increase node refractory period sotpping reentrant tachycardia)

106

What is unique about vasculature in lungs compared to other organs in setting of hypoxia

Lung hypoxia causes vasoconstriction so that only well ventilated areas are perfused. In other organs, hypoxia causes vasodilation

107

Autoregulation of skeletal muscle

Exercise: lactate, adenosine, H+, K+, CO2
At rest: Sympathetic tone (alpha1 vasoconstriction, b2 vasodilation)

108

Autoregulation of heart

local metabolites: adenosine, NO, CO2, decreased o2

109

Autoregulation of brain

CO2( decrease pH)-->potent cerebral vasodilator

110

equation for net fluix movement Jv

Kf[(Pc-Pi)-c(pi(c)-piIi)]

111

4 factors causing edema with excess fluid outflow into interstitium commonly caused by:

Increase capillary pressure (increase Pc)
Decreased plasma proteins (decrease pi(C))
Increased capillary permeability (increased kf)
increased interstitial fluid colloid osmotic pressure (increase pi (i).)

112

4 types of xanthomas?

Eruptive xanthoma-abruptly with plasma triglyceride or lipid increase
Tendinous xanthoma
Xanthalesma-eyelid or periorbital
Plane anthomas-appear as linear lesions in skin folds associated with primary biliary cirrhosis

113

In what conditions is hyaline arteriolosclerosis found?

Essential hypertension or diabetes mellitus

114

In what conditions is hyperplastic arteriolosclerosis found?

Severe hypertension

115

Differentse bewtween arteriolosclerosis and monckeberg (medial calcific sclerosis)

Arteriolosclerosis decreases vessel caliber and produce end organ ischemia. Monckeberg is not clinically significant because does not affect luminal caliber and blood flow

116

Vessels that arteriolosclerosis and monckeberg calcific sclerosis affect

Arteriolosclerosis-small arteries and arterioles
Monckeberg-medium sized arteries

117

Pathophys of monckeberg (medial calcific sclerosis)

Calcification of internal elastic lamina (ie media of arteries). INTIMA NOT INVOLVED

118

Varicose veins blood flow

From deep veins to superficial veins due to increased pressure in superificial veins causing them to dilate restricting venous outflow

119

What is more common in varicose veins? thromboembolism or venous stasis?

Venous stasis that can cause ulcers common in the medial malleolus

120

What can happen to skin in chronic venous insufficiency?

Stasis dermatitis with erythema and scaling and perogressive dermal fibrosis and hyperpigmentation.

121

4 modifiable risk factors for atherosclerosis

HTN, diabetes, hyperlipidemia, smoking

122

What is most responsible for producing intimal response in atherosclerosis?

SMC

123

SMC migration involves what growth factors

FGF, PDGF, TGFB

124

Main determinant onf whether or not a coronary artery plaque will cause ischemic myocardial injury?

RAT at which it occludes involved artery

125

AAA is associated with what risk factor?

Atherosclerosis

126

TAA associated with what risk factor?

Cystic medial degeneration

127

What changes are seen with cystic medial degeneration?

Myxomatous changes

128

Most common site of injury in blunt aortic rupture (traumatic aortic rupture most commonly in MVC)

Aortic isthmus

129

Single most important risk foctor for development of intimal tears

HTN

130

Common location of atheroscleorisis?

AA>coronary>popliteal>carotid

131

EKG for stable, unstable, prinzmetal angina

ST sement depression, st segment depression, st segment elevation

132

What test is most sensitive for coronary artery vasospasm?

Ergonovine test by stimulating alpha-adrenergic/serotonergic receptors

133

What is the mechanism behind pharmacologic stress tests?

coronary steal syndrome

134

What determines likelinhood of plaque rupture?

plaque stability rather than size where activated macrophages in the atheroma contribute to collagen degradation by secreting metalloproteinases contributing to collagen degradation

135

Most common cause of sudden cardiac death

v fib

136

Explain CAD induced SCD

Acute plaque-->acute myocardial ischemia-->electrical instability in heart-->potentially lead to vfib

137

Leads with st elevations or Q waves
V1-V2

Anteroseptal (LAD)

138

V3-V4

anteroapical (disatl LAD)

139

V5-V6

Anterolateral (LAD or LCX)

140

I, aVL

Lateral (LCX)

141

InFerior (RCA)

II, III, aVF

142

Gold standard for MI in first 6 hours

ECG

143

Most sensitive and specific marker for MI (gold standard)

Troponin I (rise after 4 hours after infarction and increased for 7-10 days)

144

Useful marker for detecting reinfarction that occurs days afterinitial MI

CKMB (because rises 6-12 hours after and levels return to normal within 48 hours)

145

Risk of complications and time frame
0-4 hours, 4-24 hours, 1-3 days, 3-14 days, 2weeks- 2 months

0-24 hours (arrhythmia, cardiogenic shock , heart failure)
1-3 days (Fibrinous pericarditis)
3-14 days (Ventricular pseudoaneurysm (risk of rupture), free wall rupture-->tamponade, papillary muscle rupture-->mitral regur, iv septal rupture-->VSD)
2 weeks-2 months (Dressler syntrome, HF, arrhythmias, true ventricular aneurysm)

146

valvular disorder in HOCM

May see mitral regurg due to impaired mitral valve closure

147

Cause of LV outflow obstruction in obstructive HOCM

anterior displacement of mitral valve leaflet toward hypertrophied interventricular septum

148

3 places where you see eccentric hypertrophy

1) aortic/mitral regurg
2) MI
3) dilated cardiomyopathy

149

3 places where you see concentric hypertrophy

1) chronic htn
2) aortic stenosis
3) HOCM

150

Mainstay treatment of CHF

ACE inhibitor

151

drugs that decrease mortality in CHF

ACE inhibitors or ARBs, b blockers, and spironolactone

152

drugs that are used for symptomatic relief in CHF

thiazide or loop diuretics

153

drugs that improve both symptoms and mortality in select patients

Hydralazine with nitrate therapy

154

Difference in EF, EDV and contractility and compliance in systolic vs diastolic dysfunction

Systolic-decreased contractility, decreased EF, increased EF
Diastolic-decreased compliance, same EF, same EDV, increased LV EDP

155

First sign of shock

tachycardia

156

CVP, CO, SVR or Hypovolemic, cardiogenic, obstructive, and distributive shock

Hypovolemic: decreased CVP, decreased CO, increased SVR
Cardiogenic/obstructive: increased cvp, decreased co, increased SVR
Distributive: decreased CVP, increased CO, decreased SVR

157

tricuspid valve endocarditis associated with what 3 bugs in IV drug abuse

candida, s auereus, pseudomonas

158

Negative culture and bacterial endocarditits

Coxiella burnetii, bartonella, HACEK

159

2 manifestations of syphillitic heart disease

Aneurysm of ascending aorta or aortic arch, or aortic insufficiency (aortic regurg)

160

Does verapamil work on skeletal muscle?

no. no significant flux of calcium across l-type calcium channels in skeletal muscle, but significant flux in cardiac and smc.

161

How is ca2+ efflux established prior to myocyte relaxation?

ca2+ atpase (active transport to sequester calcium within sr to reistablish ion gradient) and Na+/ca2+ exchanger.

162

what type of channels cause automaticity in cardiac nodal cells?

If channels

163

What increases slope of phase 4 in SA node and determines HR

Catecholamines

164

What decreases slope of phase 4 in SA node and decreases HR

Ach/adenosine

165

Bacillary angiomatosis vs Kaposi sarcoma differnces

Mistaken for each other frequently but bacillary angiomatosis has neutrophils infiltrate while kaposi sarcoma has lympocytic infiltrate