Flashcards in Congenital heart defects Deck (216):
ASD/VSD/endocardial cushion defect
Coarctation of the aorta (infantile, pre-ductal)
--Weak connective tissue (fibrillin)
--So aorta dilates and the media of the vessel splits because of weakness in the wall!
Transposition of Great vessels
Smooth L and R ventricles
Trabeculated L and R atria
Left horn of sinus venosus
Right horn of sinus venosus
Smooth part of right atrium
Right common cardinal vein and right anterior cardinal vein
Smooth L and R ventricles
Trabeculated L and R atria
L horn of sinus venosus
Smooth part of right atrium
R horn of sinus venosus
R common cardinal and R anterior cardinal veins
erythopoiesis occurs in yolk sac during which weeks?
Erythropoiesis of the liver?
Eryropoiesis of the spleen?
Erythropoiesis of the bone marrow?
22 weeks to adult
Major source of RBC at 25 weeks
Major source of RBCs at birth
Major source of RBC at 7 weeks
Which organs make RBCs at 25 weeks?
Liver, spleen and bone
Which organs make RBCs at 32 weeks?
Liver and bone
medial umbilical ligaments
MEDIAN umbilical ligament
what conditions have pulsus paradoxus as a finding?
What are the sx of a cardiac tamponade?
1. mechanism: blood accumulates in pericardial sac
signs/symptoms: pulsus paradoxus (systolic blood pressure decreases > 10 mmHg during inspiration)
signs/symptoms: triad of hypotension, increased JVP, muffled heart sounds
Causes of serous pericardidits
What else can cause an aortic dissection aside from marfans?
bicuspid aortic valve and hypertension
--Presents as sudden chest pain radiating to the back
What are the class IA antiarrythmics?
How do class IA antiarrythmics work?
INCREASE AP duration and increase QT interval
What do you use Class IA for?
re-entrant/ectopic supraventricular tachycardia
What are the side effects in general of class IA?
thrombocytopenia, Torsades from long QT
What is the side effect of quinidine?
What is the side effect of procainamide?
What is the side effect of disopyramide?
What are the class IB antiarrhythmics?
How do class IB work?
Decrease AP duration
When do you use class IB?
Post MI Ventricular Arrhythmias
Also in DIGOXIN toxicity
What is the side effect of class IB?
What are the class IC drugs?
How does class IC work?
No effect on AP duration
When do you use class IC?
As a last resort for ventricular tachycardias-->VF and SVT
When is class IC contraindicated?
post-MI or pts with structural heart disease
Toxicity of class IC?
What are the class II antiarrhythmics?
How do beta blockers work as an antiarrhytmic?
Decrease SA and AV nodal activity by decreasing cAMP and Ca currents
When would you use a beta blocker?
ALSO Afib and Aflutter
What are the side effects of beta blockers?
3. Metoprolol causes dyslipidemia
Who is contraindicated for a beta blocker?
1.ASTHMATICS--do not use a nonselective beta blocker
2. Also, MASKS hypoglycemia signs! Be careful with DIABETICS
3. Propranolol worsens prinzmetal's angina
What are the class III antiarrhythmics?
K+ channel blockers
How do class III drugs work?
Increase AP duration and QT and ERP
When do you use Class III
As a last resort
What are the toxicities of class III?
Amiodarone: pulmonary fibrosis, Thyroid issues, hepatotoxicity, photodermatitis
What do you need to get labs on before giving amiodarone?
LFTs and PFTs and TFTs!!
Name the class III antiarrhythmics
What are the class IV drugs?
calcium channel blockers verapamil and diltiazem
When do you use class IV drug?
SVT (nodal arrhtymias)
What are the side effects of class IV drugs?
Constipation, flushing, edema, CV effects
What are other antiarrhythmics?
What is the drug of choice in SVT?
How does adenosine work?
Increase K efflux out of cell, hyperpolarizing it and decreasing calcium influx
What are adenosine side effects
flushing, hypotension, chest pain.
effects blocked by theophylline and caffeine
When do you use mg?
torsade de pointes and digoxin toxicity
How can you treat digoxin toxicity?
Magnesium or Class IB antiarrhythmics (Lidocaine, tocainamide, Mexiletine)
What do veno/vasodilators do to preload and afterload?
Venodilators decrease preload
Vasodilators decrease afterload
Does viscosity of blood increase or decrease in anemia?
--Fewer RBCs, more water in the blood
JVP A wave
JVP c wave
JVP x descent
JVP v wave
Increased right atrial pressure with filling
JVP y descent
Flow of blood from RA to RV
When do you see wide splitting?
When do you see paradoxical splitting?
Which sound comes first in physiologically split S2?
A2 then P2 (aortic then pulmonic)
Most murmurs increase with hand grip. What are the exceptions?
AS and HOCM
Most murmurs decrease with valsalva (decrease venous return). What are the exceptions?
MVP and HOCM murmurs increase
What will rapid squatting do? Which murmurs are affected?
Rapid squatting increases venous return. After some time, afterload increases too
--MVP and HOCM murmurs decrease
How do you increase MVP and HOCM murmurs?
How do you decrease MVP and HOCM murmurs?
What do you hear at the aortic area?
What do you hear at the left sternal border?
What do you hear at the pulmonic area?
Pulmonic stenosus, PDA
What do you hear at the tricuspid area?
VSD, ASD, Tricuspid regurg/stenosis
What do you hear at the mitral area?
Mitral regurg and stenosis
You hear a holosystolic high pitched murmur at the apex which radiates to the axilla
Holosystolic high pitched murmur at tricuspid area extending to right sternal border
Symptoms of aortic stenosis
SAD: syncope, angina, dyspnea on exertion
Holosystolic harsh sounding murmur at tricuspid area
Midsystolic click folowed by crescendo murmur. Heard best over apex
Blowing diastolic decrescendo murmur
What are the other signs of aortic regurg?
bounding pulses and head bobbing
You hear an opening snap in diastole followed by a rumbling diastolic murmur
What is a common cause of PDA?
What are the causes of sensorineural deafness with congenital torsades?
Jervell and lange-nielsen syndrome
How does ANP work its magic?
Decreases Na resorption
Constricts efferent renal arterioles
Dilates afferent arterioles
What's the difference between peripheral and central chemoreceptors?
Peripheral receptors respond to O2 < 60, but central chemoreceptors do not
What factors are important for autoreguation of the heart?
CO2 all dilate the heart's vessels.
You see a cyanotic baby with a boot shaped heart
tetralogy of fallot
How do pts with Tetralogy of fallot alleviate their symptoms?
By squatting to increase PVR and decrease Right to Left shunting (cyanosis)
What causes adult type coarcatation of aorta?
Bicuspid aortic valve. Will present with HTN in upper extremities, weak pulses, and notching of the ribs.
onion skinning arteriolosclerosis
How does PDA present as?
Cyanosis in the lower extremities
EKG shows I and aVL Q waves
Lateral wall infarction
When are you at greatest risk for ventricular aneurysm formation?
1 week post MI
When ar eyou at greatest risk for ventricular free wall rupture?
What are the causes of dilated cardiomyopathy?
How do you treat dilated vs hypertrophic cardiomyopathy?
Dilated: ACE, diuretics, transplant
Hypertrophic: Beta blocker, NON DIHYDROPYRIDINE calcium channel blocker
You see endomyocardial fibrosis with a prominent eosinophilic infiltrate
Loffler's syndrome, a type of restrictive cardiomyopathy
What are the main causes of restrictive (fibrotic) cardiomyopathy?
sarcoidosis, hemachromatosis, loffler's,
Which drugs reduce mortality in CHF?
Beta blocker, ACEI, and spironolactone. Sometimes hydralazine
everything else is symptomatic, including other diuretics.
Right heart failure resulting in hepatomegaly
What are the symptoms of rheumatic fever?
Which valves are most often affected in rheumatic fever?
Mitral>aortic>>tricuspid (high pressure valves)
Histological findings of rheumatic fever
Schoff bodies and anitschkow's cells with ASO titer elevation.
What type of hypersensitivity is rheumatic fever?
Type II hypersensitivity with antibodies to M protein
Symptoms of pericarditis
Sharp pleuritic pain relieved by sitting up and leaning forward with a friction rub. Widespread ST elevation
What are the symptoms of cardiac tamponade
Hypotension, diminished heart sounds, friction rub
treebark aorta and calcifications of the aortic root
syphilitic heart disease
Increase in JVP on inspiration instead of a decrease. Seen in constrictive pericarditis, cardiac tamponade
What is the most common heart tumor?
In children: rhabdomyoma
In adult: myxoma
Resistance equals to
Delta P/Q (flow)
=(8n x l)/(pi*r^4)
benign capillary hemangioma of infancy that regresses at age 5-8
Benign capillary hemangioma of the elderly that does not regress
cavernous lymphangioma of neck
What is cystic hygroma associated with?
Polypoid capillary hemangioma that ulcerates and bleeds. Associated with trauma/pregnancy
Benign painful red-blue tumor under finger nails. FROM SMOOTH MUSCLE CELLS!!
Benign capillary skin papules caused by cartonella henselae
What pts often get bacillary angiomatosis?
Blood vessel malignancy
What is angiosarcoma associated w/
breast cancer and hodgkins pts getting chemo
Lymphatic malignancy associated with persistent lymphedema
port wine stain
Intracerebral AVM (leptomeningeal angiomatosis)
Why don't we use dihydropyridines (end in -dine) to treat angina?
do not treat angina because their powerful systemic vasodilator and pressure lowering effects can lead to reflex cardiac stimulation= increase myocardial oxygen demand.
Which are the non dihydropyridine CCBs to treat angina? they have stronger selectivity for the heart muscle
(V for ventricle)
Less of a systemic vasodilatory effect. These work more strongly on the HEART
First line anti-HTN therapy for diabetics
ACEI or ARBS, then everything else.
Which CCBs work stronger on the vascular smooth muscle?
amlodipine=nifedipine > diltiazem>verapamil
How does hydralazine work?
Increase cGMP=smooth muscle relaxation. Vasodilation of arterioles more than veins
Uses of hydralazine?
severe HTN, CHF
In which population is hydralazine first line?
Pregnancy! with methyldopa
What is hydralazine frequently prescribed with?
Beta blocker to prevent reflex tachycardia
Direct release of CO causing increase in cGMP. Mostly a vasodilator
toxicity of nitroprusside?
Dopamine D1 agonist used for vasodilation to treat malignant hypertension
How does nitroglycerin work?
Dilates veins >> arteries, decreasing preload
What are the problems with using nitrates?
Increase in contractility and heart rate from reflex response
How do you solve the problem with nitrates?
Co-prescribe with beta blockers
Side effects of HMG-CoA reductase
Hepatotoxicity and rhabdomyolysis
effect of niacin
--minor effect on triglycerides
How does niacin work?
Inhibits lipolysis in adipose tissue
Reduces VLDL secretion
Side effects of niacin?
How do you prevent flushing from niacin?
What are the effects of bile acid resins?
How does ezetimibe work?
Decreases cholesterol reabsorption at the small intestine brush border
What are the side effects of ezetimibe?
What are the side effects of fibrates?
myositis, hepatotoxicity, gallstones
How do fibrates work?
upregulate LPL to increase triglyceride clearance
What are the side effects of cardiac glycosides?
cholinergic toxicity + blurry yellow vision
EKG changes, with arrhythmias
Who is at risk for digoxin toxicity?
What is the antidote for digoxin tox?
Treatment for malignant hypertension
Nitroprusside or fenoldopam which are both VASOdilators
Does prinzmetal's angina cause ST elevation or depression?
You see wavy bands on biopsy of a pt's heart: How long has it been since infarct?
You see a hyperemic border to a yellow section of heart. How long has it been since MI?
You see contraction bands on a heart. How long has it been?
The infarcted heart tissue looks yellow
1-7 days (from WBC migration)
What are the four modifiable risk factors for atherosclerosis?
Who do you see kaposi's sarcoma in?
Elderly european males
Do kaposi's lesions blanch?
No, a tumor of endothelial cells, not vascular lesions
Angiosarcoma of the liver is associated with
Major side effect of ACE inhibitors
angioedema, with swelling of face can cause difficulty breathing.
-->From increased bradykinin levels
-->ACE usually breaks down bradykinin
Which drugs reduce VLDL?
fibrates and nicotinic acid
Venous return fxn of
-->starling curve stays the same if the above do
CO fxn of
SV x HR
Abrupt standing maneuver is similar to
valsalva-ing (decrease Venous Return)
passive leg raise maneuver is similar to
Squatting (increase preload)
Severity of mitral regurg determined by
Most common cause of cor pulmonale
In 20-40 year old woman, can also be idiopathic pulmonary hypertension
Common cause of sudden cardiac death in a young healthy person
Wolff Parkinson White syndrome
Worrisome complication after coronary angioplasty
Causes of restrictive cardiomyopathy
vasodilation that decreases PVR--> should reduce most murmurs
Systolic ejection murmur accentuated by standing
Hypertrophic obstructive cardiomyopathy
(standing decreases VR, should decrease most murmurs EXCEPT MVP and HOCM)
Late diastolic decrescendo murmur decreased by amyl nitrite
Late diastolic murmur eliminated by atrial fibrillation
Smokers < 35 presenting with claudication with cold sensitivity and ulcerations.
Granulomatous inflammation of the media
The five cyanotic heart disease are caused by a problem with
neural crest cell migration
digoxin effect on Afib
increases parasympathetic tone, decreasing AV nodal conduction
transient monocular vision loss from an embolus to the ophthalmic artery lasting a few seconds
Which classes of antiarrhythmic class I have strong/weak sodium channel binding strength?
1C>1A>1B. Thus, 1C can promote arrhythmias. High use dependence, which means slow dissociation allows blocking effect to accumulate with time.
1B dissociates from sodium quickly, less likely for this effect to occur
GI pain, bleeding
Coronary sinus lies within
Persistent low flow causes chronic reversible loss of contractile functioning
Brief ischemia causing a short trem reversible loss in contractility
Signs of digoxin toxicity
-color vision alterations, GI sx and Neuro Sx
Cause of varicose veins
impairment of venous valves and reflux of venous blood. Causes superficial venous thrombosis. Most commonly will cause ulcers over the medial malleolus
What does a HOCM murmur sound like
systolic ejection murmur
Most common site of injury of aorta in MVA
Aortic arch. heart and aorta decerate at different rates
DiGeorge heart abnormality
Tetralogy of fallot
Interrupted aortic arch (extreme coarctation dx at birth)
Friederich ataxia heart abnormality
Marfan heart abnormality
mitral valve prolapse
cystic medial necrosis
Tuberous sclerosus heart abnormalities
rhabdomyomas causing valvular obstruction
Turner syndrome heart abnormalities
bicuspid aortic valve
weight loss, fatigue
-mid diastolic rumble at apex
atrial myxoma, most common cardiac neoplasm
scattered cells in a mucopolysaccharide stroma
QRS interval prelongation
bundle branch block
absent P waves
Only P waves
Class 1C mechanism antiarrhyth
Inhibit sodium channels in phase 0
--Use dependence--effect stronger with increased heart rate