Flashcards in Chapter 11 - Heart Disorders Deck (274):
How does wall stress affect gene expression in the heart?
Wall stress increases gene-controlled sarcomere duplication
What is afterload?
Afterload: resistance ventricle contracts against to eject blood in systole
What is the effect of increased afterload on sarcomeres and muscle?
↑Afterload: sarcomeres duplicate parallel to long axis; muscle is thicker
Increased afterload results in what type of hypertrophy?
↑Afterload: concentric ventricular hypertrophy
What are the causes of concentric LVH?
Concentric LVH: essential HTN, AV stenosis, hypertrophic cardiomyopathy
What are the causes of concentric RVH?
Concentric RVH: PH, PV stenosis
What is preload?
Preload: volume of blood ventricle must expel during systole
How does increased preload affect sarcomeres and muscle fibers?
↑Preload: sarcomeres duplicate in series; muscle fibers longer/wider
Increased preload causes what type of hypertrophy?
↑Preload causes eccentric ventricular hypertrophy
What are the causes of eccentric LVH?
Eccentric LVH: MV/AV regurgitation; left-to-right shunt
What are the causes of eccentric RVH?
Eccentric RVH: TV/PV regurgitation
What are the consequences of ventricular hypertrophy?
Consequences: heart failure, S4, angina (subendocardial ischemia)
What does the S4 heart sound indicate?
S4: blood entering noncompliant ventricle (concentric/eccentric hypertrophy)
What does the S3 heart sound indicate?
S3: blood entering volume overloaded ventricle
What is the most common cause of hospital admission for persons >65 years old?
CHF: MCC hospital admission for persons >65 years old
What are the types of heart failure?
Types heart failure: left/right, biventricular, high output
Where does blood back up into in LHF?
LHF: blood backs up into lungs
Where does blood back up into in RHF?
RHF: blood backs up into venous system
What type of edema is caused by LHF?
LHF → pulmonary edema
What is the most common type of LHF? What is the pathogenesis of LHF?
SHF: MC type LHF; ↓ventricular contraction
What are the causes of SHF? Which cause is the most common?
SHF: ischemia MCC; myocarditis, post-MI, dilated cardiomyopathy
What is DHF?
DHF: noncompliant LV (stiff ventricle) with impaired relaxation; ↑LVEDP
What is the most common cause of DHF?
DHF: MCC essential HTN
How is the EF affected in SHF?
How is the EF affected in DHF?
DHF: normal EF at rest
What are the microscopic findings of LHF?
LHF: heart failure cells; alveolar macrophages with hemosiderin
What is dyspnea?
Dyspnea: cannot take full inspiration
How do the pulmonary capillary HP and OP compare in pulmonary edema?
Pulmonary edema: pulmonary capillary HP > OP
What causes cardiac asthma?
Cardiac asthma: peribronchiolar edema
What is a physical exam finding in LHF?
LHF: bibasilar inspiratory crackles (edema)
What are the chest radiograph findings in LHF?
LHF X-ray: bat-wing configuration, fluffy alveolar infiltrate, Kerley lines, air bronchograms
What is the first cardiac sign of LHF?
S3: first cardiac sign LHF
What type of regurgitant murmur may be present in LHF?
LHF: functional MV regurgitation
What is the cause of PND/orthopnea?
PND/orthopnea: ↑venous return to right side of heart at night → failed left heart → pulmonary edema
Describe how pillows relieve orthopnea.
Pillow orthopnea: pillows ↑gravitational effect → ↓venous return to right heart
What is BNP useful in?
BNP: useful in confirming/excluding LHF; predicting survival
How is ANP affected in LHF?
ANP: ↑with left atrial dilatation in LHF
How is the venous HP affected in RHF?
RHF → ↑venous hydrostatic pressure
What is the most common cause of RHF?
MCC RHF: ↑afterload from LHF
What are the causes of decreased RV contraction in RHF?
RHF: ↓RV contraction; e.g., myocarditis, RV infarction
What are the causes of a noncompliant RV in RHF?
RHF: RV noncompliant; e.g., restrictive cardiomyopathy, concentric RVH
What are the causes of increased RV preload in RHF?
RHF: ↑RV preload; e.g., valvular regurgitation; left-to-right shunt
What are the clinical findings in RHF?
RHF: prominence internal jugular veins; function TV regurgitation
RHF: S3/S4 heart sounds
RHF: painful hepatomegaly; centrilobular hemorrhagic necrosis
RHF: dependent pitting edema, ascites, cyanotic mucous membranes
What is the nonpharmacologic therapy for CHF?
Restrict sodium & water
What are two pharmacologic treatments for CHF? How do they work?
ACE inhibitor: ↓afterload, ↓preload
β-Blocker: ↓myocardial O2 consumption; ↓heart rate
Describe the pathogenesis and causes of high-output heart failure.
HOF: ↑SV; e.g., hyperthyroidism
HOF: ↓blood viscosity; e.g., severe anemia
HOF: vasodilation PVRs; e.g., septic shock, thiamine deficiency
HOF: arteriovenous fistula
What is ischemic heart disease?
IHD: imbalance in demand of O2 and supply
When do coronary arteries normally fill?
Coronary arteries: fill in diastole
How does tachycardia affect diastole and the filling of coronary arteries?
Tachycardia: ↓diastole and filling of coronary arteries
What is the distribution of the LAD?
LAD: anterior portion LV; anterior IVS; apex
What is the most common site of coronary artery thrombosis?
LAD: MC site coronary artery thrombosis
What is the distribution of the RCA?
RCA: posterior LV; posterior IVS; RV; posteromedial papillary muscle; SA/AV nodes
What is the distribution of the left circumflex coronary artery?
Left circumflex: lateral wall LV
IHD is a major cause of what in the U.S.?
IHD: major cause of death in U.S.
What is the most common manifestation of coronary artery disease?
Angina pectoris: MC manifestation coronary artery disease
What is the most important risk factor for angina pectoris?
Angina pectoris: age most important risk factor
Which gender is more affected by angina pectoris?
Angina: males > females
What is the most common variant of angina?
Chronic (stable) angina: MC type of angina
What is the most common cause of stable angina?
Stable angina: MCC fixed atherosclerotic coronary artery disease
What are other causes of stable angina?
Stable angina: AV stenosis/HTN with concentric LVH
Describe the pathogenesis of stable angina.
Pathogenesis: subendocardial ischemia; ↓coronary artery blood flow/concentric hypertrophy
What is a clinical finding of stable angina?
Exercise-induced substernal chest pain; relieved by rest/nitroglycerin
How does subendocardial ischemia appear on a stress test?
Subendocardial ischemia: ST-segment depression on stress test
What is Prinzmetal angina?
Prinzmetal angina: vasospasm with transmural ischemia/ST-segment elevation
What is unstable angina?
Unstable angina: angina at rest; multivessel disease; disrupted plaques
What is the treatment for Prinzmetal variant angina?
Prinzmetal variant angina: calcium channel blockers vasodilate coronary arteries
What is CIHD?
CIHD: muscle replaced by noncontractile fibrous tissue; progressive CHF
What is sudden cardiac death? What is its most important risk factor?
SCD: unexpected death within 1 hour after symptoms; IHD most important
What is a NSTEMI?
NSTEMI = non-ST elevation myocardial infarction
What is the most common cause of SCD in children?
SCD in children: AV stenosis MCC
Describe the pathogenesis of SCD in adults.
SCD: coronary artery thrombosis not usually present; ventricular arrhythmia
What is the most common cause of death in adults in the U.S.?
AMI: MCC death in adults in U.S.
Describe the pathogenesis of developing an AMI.
Rupture of disrupted plaque → platelet thrombus → AMI
Describe the coronary arteries in a cocaine-induced AMI.
Cocaine: AMI with normal coronary arteries
What is a STEMI?
STEMI = ST wave elevation myocardial infarction; Q waves
What is the effect of early reperfusion following AMI?
Early reperfusion (<3 hr): ↑short- and long-term survival
What is reperfusion injury?
Reperfusion injury: ischemic myocardial cells not already irreversibly damaged become so after reperfusion
Reperfusion injury: previously ischemic cells become irreversibly damaged
What is reversible after reperfusion?
Myocardial stunning after reperfusion is reversible
Describe the mechanism of irreversible myocardial injury.
Irreversible injury: superoxide FRs
Neutrophils contribute to irreversible myocardial injury
When does coagulation necrosis occur following an AMI?
AMI: coagulation necrosis within 24 hours
What period following an AMI is the risk for rupture the greatest?
AMI: heart softest 3–7 days; danger of rupture
What are the clinical findings of an AMI?
AMI: retrosternal pain >30 minutes, radiation to left inner arm/shoulder, diaphoresis
What are the nerves to the heart?
Nerves to heart: T1–T5
Inner arm pain is in the distribution of which nerve?
Inner arm pain: T1 distribution
The epigastrium is in which nerve distribution?
Epigastrium radiation: T4–T5 distribution
How does the early mortality rate of a STEMI compare to that of an NSTEMI?
STEMI: ↑early mortality rate
Having an NSTEMI increases the risk of what?
NSTEMI: ↑risk for SCD
What is the most common arrhythmia post-STEMI?
Ventricular premature contractions MC arrhythmia
What is the most common cause of death in a STEMI?
Ventricular fibrillation: MCC death in STEMI
When is myocardial rupture most common post-AMI?
Myocardial rupture: MC at 3–7 days
What is posteromedial papillary muscle rupture associated with? How does it present?
Posteromedial papillary muscle rupture: RCA thrombosis; MV regurgitation
What is the most common cause of an IVS rupture? What does it produce?
IVS rupture: left-to-right shunt; LAD thrombosis MCC
There is danger of what with a mural thrombus?
Mural thrombus: danger of embolization
Describe the characteristics of fibrinous pericarditis following STEMI AMI.
Fibrinous pericarditis: early (acute inflammation); late complication (autoimmune)
Describe the characteristics of ventricular aneurysm following STEMI AMI.
Ventricular aneurysm: precordial bulge with systole; CHF MCC death
What is a right ventricular AMI associated with? What are its clinical findings?
RV AMI: RCA thrombosis; hypotension, RHF, preserved LV function
How is reinfarction of the heart defined?
Reinfarction: reappearance of CK-MB after 3 days
What are the cardiac troponins tested for in an AMI? Can they be used to diagnose reinfarction?
cTnI, cTnT: cannot diagnose reinfarction
What is the gold standard for diagnosis of an AMI?
cTnI, cTnT: gold standard for diagnosis of AMI
What are the ECG findings in a STEMI?
ECG findings in STEMI: inverted T waves, elevated ST segments, Q waves
What do inverted T waves correlate with in an AMI?
Inverted T waves: correlates with ischemia at periphery of infarct
What does ST elevation correlate with in an AMI?
ST elevation: correlates with injured myocardial cells surrounding area of necrosis
What do new Q waves correlate with in an AMI?
Q waves: correlates with area of coagulation necrosis
Describe the role of the chorionic villus in the fetal circulation.
Chorionic villus: primary site O2 exchange; vessels become umbilical vein
Describe the role of the umbilical vein in the fetal circulation.
Umbilical vein: highest PO2 in fetal circulation
What keeps the ductus arteriosus open?
Ductus arteriosus kept open by PGE2, a vasodilator synthesized by placenta
Which two structures are patent in the fetal circulation but not the adult circulation?
Fetal circulation: foramen ovale and ductus arteriosus are patent
The presence of a single umbilical artery increases the risk for what?
Single umbilical artery: ↑risk congenital abnormalities
What are the changes in the fetal circulation at birth?
Ductus arteriosus becomes ligamentum arteriosum after birth
Newborn: foramen ovale and ductus arteriosus are closed
What type of heart disease is the most common in children?
CHD MC heart disease in children
Which are the most common causes of congenital heart disease?
Genetic-environmental causes MCC CHD
How does the risk for CHD change with maternal age?
CHD: ↑risk with ↑maternal age
What are the maternal risk factors for CHD?
Previous child with CHD; poorly controlled DM
Alcohol; congenital infections (rubella)
Aspirin, diphenylhydantoin, SLE
Describe the spectrum of CHD.
CHD: valvular disorders, shunts (acyanotic, cyanotic)
What are the systemic complications of CHD?
Complications: 2° polycythemia, clubbing, infective endocarditis, metastatic abscesses
What are the types of shunts in CHD?
CHD shunts: left-to-right; right-to-left (often cyanotic)
Describe the effect of left-to-right shunts on SaO2.
Left-to-right shunts: step up of SaO2 in right heart
Describe the effect of right-to-left shunts on SaO2.
Right-to-left shunts: step down of SaO2 in left heart
What is shunt reversal due to in left-to-right shunts?
Shunt reversal due to PH and RVH
What is there danger of if a left-to-right shunt is uncorrected?
Left-to-right shunts: danger of shunt reversal if uncorrected
What is the most common type of CHD?
VSD: MC CHD
Which type of VSD is most common?
VSD MC a defect in membranous portion of IVS
What are the associations of VSD with other congenital heart diseases?
VSD associations: cri du chat syndrome, fetal alcohol syndrome
How is the SaO2 affected in a patient with a VSD?
VSD: step up SaO2 in RV and PA
What percentage of VSDs spontaneously close?
VSD: ~50% spontaneously close
What is the most common CHD in adults?
ASD: MC CHD in adults
What is the most common cause of ASD?
ASD: MCC patent foramen ovale
What are the associations of ASD with other CHDs?
ASD associations: fetal alcohol syndrome, Down syndrome (primum type)
What is the physical exam finding of ASD?
ASD: wide and fixed split of S2 very characteristic
ASD is associated with which type of embolism?
ASD: paradoxical embolism (venous clot in system circulation)
How is the SaO2 affected in a patient with an ASD?
ASD: step up SaO2 in RA, RV, PA
What are the associations of PDAs?
PDA associations: congenital rubella, RDS, transposition
What is the physical exam finding of a PDA? How is the SaO2 affected in a patient with a PDA?
PDA: continuous machinery murmur; step up SaO2 in PA
What is the physical exam finding of a shunt reversal in PDA?
Reversal of shunt in PDA: differential cyanosis (pink on top, blue on bottom)
What is the treatment for a PDA?
PDA: closed with indomethacin
What is the most common cyanosis CHD after one year of age?
Tetralogy of Fallot: MC cyanotic CHD after age 1 year
What are the defects in tetralogy of Fallot?
VSD, infundibular pulmonic stenosis, dextrorotation of aorta, RVH
What does the degree of PV stenosis correlate with in tetralogy of Fallot?
Degree of PV stenosis correlates with presence or absence of cyanosis
What is the effect of severe PV stenosis in tetralogy of Fallot?
Severe PV stenosis → cyanosis; mild PV stenosis → no cyanosis
How is the SaO2 affected in patients with tetralogy of Fallot?
Step down in SaO2 in LV and Ao
What are the cardioprotective shunts in tetralogy of Fallot?
Cardioprotective shunts in tetralogy: ASD, PDA
What are tet spells? Describe the mechanism of compensation.
Tet spells (hypoxemic episode): squatting ↑PVR → reverses shunt → ↑PaO2
What is transposition of the great arteries?
Transposition: abnormal formation of truncal and aortopulmonary septa
What are the defects of complete transposition?
Transposition: Ao empties RV; PA empties LV; atria normal
What are the cardioprotective shunts in transposition?
Cardioprotective shunts: ASD, VSD, PDA
Describe the characteristics of infantile coarctation.
Infantile coarctation: preductal; constriction proximal to ligamentum arteriosum; associated with Turner syndrome
Describe the characteristics of adult coarctation.
Adult coarctation: constriction distal to ligamentum arteriosum
What is commonly present in patients with an adult coarctation?
Adult coarctation: bicuspid AV commonly present
What are the clinical findings and possible complications proximal to the coarctation in adult coarctation?
↑Upper extremity systolic blood pressure (SBP); ↑cerebral blood flow (risk for berry aneurysms)
What are the clinical findings and possible complications distal to the coarctation in adult coarctation?
Disparity between upper/lower extremity blood pressure >10 mm Hg
Leg claudication: pain in calf/buttocks when walking
HTN due to activation of RAA system from ↓renal blood flow
Describe the collateral circulation that develops in coarctation.
Coarctation collaterals: anterior ICAs → posterior ICAs → Ao; superior epigastric artery → inferior epigastric artery → external iliac artery
What causes rib notching?
Rib notching from enlarged ICAs
Acute rheumatic fever only occurs after what?
Acute RF: only after group A streptococcal pharyngitis
Describe the pathogenesis of RF.
Type II HSR (most common); cell-mediated immunity type IV HSR
M protein antibodies cross-react with human tissue (mimicry)
What is the most common initial presentation of RF?
Migratory polyarthritis MC initial presentation
What types of carditis may be present in acute RF?
Carditis: pericarditis, myocarditis, endocarditis (valves)
What is the most common cause of death in acute RF?
Myocarditis MCC death in acute RF
Describe the characteristics of endocarditis in RF.
Endocarditis: MV most often involved, followed by AV; sterile vegetations
How does valvular disease differ between acute RF and chronic RF?
MV regurgitation in acute RF; MV stenosis in chronic RF
The subcutaneous nodules in RF are comparable to those in what disease?
Subcutaneous nodules similar to rheumatoid arthritis nodules
Describe the physical exam findings in erythema marginatum.
Erythema marginatum: circular or C-shaped areas of erythema around normal skin
Describe the characteristics of Sydenham chorea in acute RF.
Sydenham chorea: late manifestation; reversible
How is acute RF diagnosed?
Acute RF: diagnose with revised Jones criteria
What are the major criteria of the revised Jones criteria?
Acute RF: carditis, arthritis, chorea, erythema marginatum, subcutaneous nodules
What are the lab findings and ECG finding of acute RF?
Acute RF: carditis, arthritis, chorea, erythema marginatum, subcutaneous nodules
What is the most common cause of MV stenosis?
MV stenosis: MCC is recurrent RF
What are the effects on the LA caused by MV stenosis?
MV stenosis: LA dilated/hypertrophied
What are the pulmonary clinical findings in MV stenosis?
Dyspnea; rust-colored sputum from pulmonary congestion
Pulmonary venous hypertension → RVH → RHF
What are the cardiovascular clinical findings in MV stenosis?
Atrial fibrillation: common in MV stenosis; danger thrombus formation/embolization
MV stenosis: opening snap followed by an early to middiastolic rumble
What are the gastrointestinal clinical findings in MV stenosis?
Dysphagia for solids from LA dilation
What is MV regurgitation?
MV regurgitation: retrograde blood flow into LA during systole
What is the most common cause of mitral valve regurgitation?
MVP: MCC of MV regurgitation
What is the effect of MV regurgitation on cardiac output and the LA?
MV regurgitation: ↓cardiac output; LA dilated/hypertrophied
What is the effect of MV regurgitation on the pulmonary vein, right ventricle, and right side of the heart?
Pulmonary venous hypertension → RVH → RHF
How do the stroke volume and cardiac output change in chronic compensated mitral regurgitation?
Normalization of stroke volume/cardiac output in chronic compensated mitral regurgitation
What is the effect of MV regurgitation on the left ventricle?
Eccentric LVH due to ↑LV volume
What are the clinical findings of MV regurgitation?
Pansystolic murmur; S3/S4; no ↑intensity with deep held inspiration
MVP is associated with what syndromes?
MVP: association with Marfan, Ehlers-Danlos, Klinefelter syndromes
Describe the pathophysiology of MVP.
Bulging anterior and/or posterior leaflets into LA during systole
MVP: myxomatous degeneration; excess dermatan sulfate in MV
What are the clinical findings of MVP?
MVP: systolic click followed by murmur; most patients are asymptomatic
What does preload alter in MVP?
Preload alters click and murmur relationship to S1/S2
What is the effect of decreasing preload on MVP? List three causes of decreased preload.
↓Preload (anxiety, standing, Valsalva) click/murmur closer to S1
What is the effect of increasing preload on MVP? List three causes of increased preload.
↑Preload (reclining, squatting, sustained hand grip) click/murmur closer to S2
What is the treatment for symptomatic MVP?
Symptomatic MVP: β-blockers
What is the most common valve lesion in Western countries?
AV stenosis is MC valve lesion in Western countries
What is the most common cause of stenosis in patients >60 years old?
Calcific AV stenosis: MCC of stenosis in patients >60 years old
What is a major cause of stenosis <30 years old?
Congenital AV stenosis major cause of stenosis <30 years old
How does obstruction to LV outflow tract in AV stenosis affect the left ventricle?
Obstruction to LV outflow tract → concentric LVH
Describe the physical exam findings of AV stenosis.
Harsh systolic ejection murmur with radiation into neck; S4 heart sound
What changes the murmur intensity in AV stenosis?
Changing preload changes murmur intensity
How does the murmur intensity of AV stenosis change with preload?
↓Murmur intensity with ↓preload; ↑murmur intensity with ↑preload
What is the most common valvular lesion causing syncope/angina with exercise?
MC valvular lesion causing syncope/angina with exercise
What is the most common cause of microangiopathic hemolytic anemia with schistocytes and hemoglobinuria?
MCC microangiopathic hemolytic anemia with schistocytes and hemoglobinuria
What is the most common cause of AV regurgitation?
Isolated AV root dilation MCC AV regurgitation
What are the other causes of AV regurgitation?
Chronic RF, syphilitic aortitis, infective endocarditis, aortic dissection, coarctation
How are LVEDP, SBP, pulse pressure and cardiac output affected in acute AV regurgitation?
Acute AV regurgitation: ↑LVEDP, ↓SBP, normal/↓pulse pressure, ↓cardiac output
How are LVEDP, SBP, DBP, pulse pressure and cardiac output affected in chronic AV regurgitation?
Chronic AV regurgitation: normal LVEDP, ↑SBP, ↓DBP, ↑pulse pressure, normal cardiac output
How does AV regurgitation affect the left ventricle?
AV regurgitation: eccentric LVH
What are the clinical findings of AV regurgitation?
Early diastolic murmur; S3, S4; no ↑intensity with inspiration
Wide pulse pressure → bounding pulses, head nodding, pulsating nail bed
Austin Flint murmur: sign for AV replacement
What is the most common cause of TV regurgitation in adults?
TV regurgitation: functional (stretching of ring), MCC in adults
What is the most common cause of TV regurgitation in adolescents/young adults?
Adolescents/young adults: CHD MCC
What is the most common cause of TV regurgitation in IVDA?
IVDA: infective endocarditis of valve MCC
Describe the pathophysiology of TV regurgitation.
Retrograde blood flow into RA during systole
RA dilatation/hypertrophy; eccentric RVH; ↑pressure in venous system
What are the clinical findings of TV regurgitation?
Pulsating liver; ascites; ↑portal vein pressure
Giant c-v wave; pansystolic murmur + S3/S4 that ↑in intensity with deep held inspiration
What is PV stenosis associated with?
PV stenosis: CHD, carcinoid heart disease
What is the most common cause of PV regurgitation?
PV regurgitation: MCC stretching of ring from PH
Describe the characteristics of carcinoid heart disease.
Must be liver metastasis to produce carcinoid heart disease; serotonin causes valve fibrosis
Carcinoid heart disease: PV stenosis, TV regurgitation
IE is most frequent at what age?
IE most frequent at age 45–65 years
What is the most common cause of IE?
Acute IE: Staphylococcus aureus MCC
What is the most common cause of IVDA IE?
IVDA IE: Staphylococcus aureus MCC
What is the most common cause of subacute IE?
Subacute endocarditis: viridans Streptococcus MCC
What are the most common overall pathogens causing IE?
Viridans group of Streptococcus: overall MCC IE
What is the most common cause of early IE associated with prosthetic heart valves?
Prosthetic valve IE early: Staphylococcus epidermidis (coagulase negative) MCC
What are the causes of late IE associated with prosthetic heart valves?
Prosthetic valve IE late: Staphylococcus aureus, enterococci, group D streptococci
What is the most common cause of nosocomial IE in patients with intravenous catheters?
Nosocomial IE intravenous catheters: Staphylococcus aureus MCC
What is the most common cause of nosocomial IE in patients with indwelling urinary catheters?
Nosocomial IE indwelling urinary catheters: enterococci MCC
What is the cause of IE associated with ulcerative bowel lesions?
IE associated with ulcerative bowel lesions: Streptococcus bovis
What is the most common valve involved in IE?
MC valve involved in IE: MV
What are the valvular lesions in IVDA IE?
IVDA IE: TV regurgitation/AV regurgitation
What do the viridans group of streptococci infect in IE?
Viridans group of streptococci infect previously damaged valves
What does Staphylococcus aureus infect in IE?
Staphylococcus aureus infects normal or damaged valves
What type of murmurs are the most common in IE?
Regurgitant murmurs MC in IE
What is the most consistent sign in IE?
Fever is most consistent sign in IE
What are the immunocomplex signs in IE?
Immunocomplex signs: glomerulonephritis (nephritic), Roth spot in eyes
What are the microembolization signs in IE?
Microembolization signs: splinter hemorrhages, Janeway lesions (painless), Osler nodes (painful), infarctions
What are the other clinical findings in IE?
Changing heart murmurs, splenomegaly (only subacute)
What are the lab findings in IE?
Positive blood culture majority of cases
Describe the characteristics of Libman-Sacks endocarditis.
Libman-Sacks endocarditis: associated with SLE; MV regurgitation
Describe the characteristics of NBTE.
NBTE: sterile vegetations MV; paraneoplastic syndrome; mucin-producing tumors
Myocarditis is a major cause of sudden death in what age group worldwide?
Major cause sudden death in adults <40 years old
What is the most common cause of acute myocarditis in the U.S.?
Viruses: MCC acute myocarditis U.S.
What is the most common cause of myocarditis leading to CHF in Central/South America?
Chagas disease: MCC myocarditis leading to CHF in Central/South America
What type of RF is an etiology of myocarditis?
Myocarditis in acute RF
Which toxins are etiologies of myocarditis?
Toxins: diphtheria, carbon monoxide, black widow and scorpion venoms
Which drugs are etiologies of myocarditis?
Drugs: doxorubicin, daunorubicin, cocaine, alcohol
Which systemic and collagen vascular diseases are etiologies of myocarditis?
SLE, systemic sclerosis, Kawasaki disease, radiation, sarcoidosis
Describe the pathology of myocarditis.
Myocarditis: global enlargement of heart; dilation of all chambers
What are the clinical findings of myocarditis?
Myocarditis: fever, dyspnea, chest pain
Myocarditis: arrhythmias, pericarditis, biventricular CHF, MV regurgitation
What are the lab findings in myocarditis?
Myocarditis: ↑CK-MB, troponin I/T
Describe the etiology of most cases of pericarditis.
Pericarditis: most cases are idiopathic
What are the clinical findings in pericarditis?
Precordial friction rub; pain relieved by leaning forward; worse when leaning back
A young woman with pericarditis and effusion most likely has what?
Young woman with pericarditis and effusion most likely has SLE
What is the physical exam findings of a pericardial effusion? How is the cardiac output affected?
Effusion: muffled heart sounds
Effusion: ↓cardiac output; neck vein distention with inspiration
Effusion: hypotension with pulsus paradoxus on inspiration
What is the pericardial effusion triad?
Effusion triad: muffled heart sounds, neck distention on inspiration, pulsus paradoxus on inspiration
What are the chest x-ray findings of pericardial effusion?
Effusion: chest X-ray shows water bottle configuration of heart silhouette
What is the most common cause of constrictive pericarditis worldwide?
Constrictive pericarditis: TB MCC worldwide
Most cases of constrictive pericarditis are due to what in the U.S.?
Constrictive pericarditis U.S.: idiopathic or post open heart surgery
Describe the pathophysiology of constrictive pericarditis.
Constrictive pericarditis: incomplete filling of chambers; pericardial knock
What are the findings of constrictive pericarditis on chest x-ray?
Constrictive pericarditis: calcification pericardium on x-ray
What are the types of cardiomyopathy?
Cardiomyopathies: dilated, hypertrophic, restrictive
What is the most common cardiomyopathy in young people?
Dilated: MC cardiomyopathy
What is the most common known cause of dilated cardiomyopathy?
Dilated: myocarditis MC known cause
What are the other causes of cardiomyopathy?
Dilated: alcohol—direct toxic effect; thiamine deficiency (↓ATP)
Dilated: drugs—doxorubicin, daunorubicin, cocaine
Dilated: postpartum, organic solvents, acromegaly, myxedema heart
Describe the pathophysiology of dilated cardiomyopathy.
Dilated: global enlargement of heart
What are the clinical findings in dilated cardiomyopathy?
Dilated: signs/symptoms biventricular failure
Dilated: narrow pulse pressure; arrhythmias
How is dilated cardiomyopathy diagnosed?
Dilated: echocardiography—EF <40%
What is the most common cause of sudden death in young athletes?
HCM: MCC sudden death in young athletes
What is the most common type of HCM? Describe its characteristics.
Familial type HCM: AD with complete penetrance; MC type
Who is affected by the sporadic type of HCM?
Sporadic type HCM: elderly population
Describe the pathophysiology of HCM.
HCM: obstruction outflow tract below AV
HCM: aberrant myofibers in conduction system cause fatal arrhythmia, sudden death
HCM: noncompliant LV—diastolic dysfunction
What are the clinical findings in HCM?
HCM: palpable double apical impulse
How do preload changes in HCM compare to preload changes in AV stenosis?
HCM: preload changes are opposite those for AV stenosis
What are the clinical findings when exercising in HCM? These findings also occur in what condition?
HCM: angina/syncope with exercise similar to AV stenosis
What is the cause of sudden death in HCM?
HCM: sudden death due to ventricular tachycardia/fibrillation
What is the treatment for HCM?
HCM: treat with β-blockers
Which is the least common cardiomyopathy?
Restrictive: least common cardiomyopathy
What is the most common cause of restrictive cardiomyopathy?
Restrictive: amyloidosis MCC
Describe the pathophysiology of restrictive cardiomyopathy.
Restrictive: ↓ventricular compliance; biventricular heart failure
What are the ECG findings of restrictive cardiomyopathy?
Restrictive: characteristic low voltage ECG
Describe the epidemiology of heart tumors.
Heart tumors: metastasis > primary tumors
Where is the most common site for metastasis in the heart?
Pericardium MC site for metastasis
What is the most common adult primary tumor of the heart? Where in the heart is its most common site?
Cardiac myxoma: MC adult primary tumor; MC in LA
What are the complications of cardiac myxoma?
Myxoma: embolization; syncopal episodes