Heart

Question 1

Where does coronary circulation begin?

Answer 1

Sinus of valsalva, where the RCA and LCA arise.

Question 2

What are the coronary arteries?

Answer 2

Left main branches into LAD and LCX
RCA- usu goes to PDA (90% are right-dom)
but PDA can also come from LCX

Question 3

What do the LAD and LCX supply?

Answer 3

LAD- anterior of LV, apex, IV septum, and the part of the RV that borders the IV septum
LCX is in groove that separates LA and LV, gives of marginal branches that supply LV.

Question 4

What do RCA and PDA supply?

Answer 4

RCA is between RA and RV- supplies lateral portion of RV

PDA supplies AV node.

Question 5

What are the Ao and mitral valves and where are they located?

Answer 5

Aortic valve- bt LV and Ao. 3 leaflets, 3 sinuses (one for RCA, one for LCA, on non-coronary sinus)
Mitral valve- bt LA and LV. 2 leaflets (anterior goes farther across the valve). Chordae tendenae attach leaflets to papillary muscles in LV.

Question 6

What is the most common cause of mortality in the US?

Answer 6

Atherosclerosis of coronary arteries.

Question 7

When does coronary artery stenosis become hemodynamically significant?

Answer 7

When the lumen decreases to 75% of the native area.

Question 8

HPE for ischemic heart dz

Answer 8

Substernal chest pain/prs that radiates down arms, to jaw, teeth, back.
Usually happens during activity/emotional stress.
Evidence of PVD- diminished pulses,
Signs of ventricular failure- cardiomegaly, congestive heart failure, S3 or S4, MR murmur

Question 9

Stable vs unstable angina

Answer 9

Stable- pain is reproducible and resolves with rest
Unstable- pain occurs at rest, does not improve with rest, is new and severe, is progressive. Suggests impending infarct.

Question 10

Dx Eval for ischemic heart dz

Answer 10

EKG- signs of ischemia or old infarct
CXR- enlarged heart, pulm congestion
Exercise stress test- tells if myocardium is at risk
Nuclear med scans (thallium)- use to localize ischemic areas
Echo- myocardial fn and valve fn
Angiography- gold standard. shows lesions in coronary arteries.

Question 11

RX for ischemic heart dz- who gets surgery?

Answer 11

Surgery for severe dz of LM or severe dz in the 3 mjr coronary arteries. Do coronary bypass.

Question 12

What vessels are used during coronary bypass?

Answer 12

IMA (preferred)

Saphenous vein

Question 13

Causes of Ao Stenosis (AS)

Answer 13

Bicuspid valve- px’s by 70yo.
Rheumatic fever- causes fusion and calcification
Degenerative stenosis- causes calcification.
Unicuspid valve (px’s early in life)

Question 14

What is the physiologic response to AS?

Answer 14

LVH- this preserves stroke volume and cardiac output.

But, LVH and the increasing resistance of the valve result in decreased CO, pulm HTN, and myocardial ischemia

Question 15

HPE

Answer 15

Pts have angina, syncope, dyspnea (dyspnea means it’s bad)
Hear a mid-systolic ejection murmur
Cardiomegaly, signs of CHF
Pulsus tardus et parvus

Question 16

What is pulsus tardus et parvus

Answer 16

delayed/diminished pulse at the carotid

Question 17

Dx eval for AS

Answer 17

Echo or cardiac catheterization

Question 18

What extent of AS signifies severe dz? (in cm)

Answer 18

Normal Ao valve area is 3-4 cm.

<1cm means severe dz.

Question 19

Rx for AS

Answer 19

If sxtic- valve replacement.

If asxtic- operate if there is progressive cardiomegaly. (surg >med rx)

Question 20

Causes of Ao Insufficiency (AI)

Answer 20

rheum fever
CT disorders- marfan's, ehlers-danlos
endocarditis
Ao dissection
trauma

Question 21

What happens when there is AI?

Answer 21

Incompetent valve causes decreased CO, so there is LV dilation.
Larger LV means greater wall stress, so myocardial O2 demand is increased.

Question 22

HPE of AI

Answer 22

Angina sx, dyspnea
Crescendo-decrescendo diastolic murmur
Wide pulse prs, water-hammer
PMI displaced/diffuse

Question 23

Dx eval for AI

Answer 23

Echo

Question 24

Rx for AI

Answer 24

If sxtic- valve replacement surg

Question 25

Causes of mitral stenosis (MS)

Answer 25

rheumatic heart dz malignant carcinoid SLE

Question 26

What is rheumatic heart dz?

Answer 26

Occurs after gp A strep pharyngitis. Causes pancarditis, which makes valve leaflets fibrose and fuse into fishmouth. See aschoff nodules.

Question 27

Pathophysiology of MS

Answer 27

fibrosis/fusion of valve leaflets causes less blood flow through valve Increased LA prs cause LA hypertrophy, this causes Afib or pulm HTN P-HTN can cause RVH and r-sided HF

Question 28

HPE of MS

Answer 28

``` Dyspnea, fatigue Sometimes hemoptysis from the P-HTN Cachexia, sx of CHF pulm rales, tachypnea JVD peripehral edema ascities sternal heave of RVH Opening snap followed by low rumbling murmor Decreased splitting of S2 (pulm part louder) Afib ```

Question 29

Dx eval for MS

Answer 29

CXR- cardiomegaly, LA hypertrophy, pulm edema EKG- afib, LA hypertrophy (broad, notched P-waves), R axis dev (for RVH) Echo Cardiac cath- shows prs gradient across valves, so can calculate area of opening

Question 30

Rx for MS

Answer 30

valvulotomy or valve replacement

Question 31

Cause of mitral regurg (MR)

Answer 31

Rheumatic fever | idopathic calcification a/w HTN, DM, AS, renal failure

Question 32

What happens when there is MR? (pathophys)

Answer 32

LV dilation to preserve CO A lot is ejected retrograde- so increased cardiac work, increased LA volume, incrsd pulm venous prs Can lead to LA enlargement and Afib and/or pulm HTN (which can lead to RV failure)

Question 33

HPE of MR

Answer 33

``` Dyspnea, orthopnea, fatigue Cachexia Irreg pulse w rapid upstroke, waves Pulm rales Sternal heave. Holosystolic murmur radiating to axilla/back PMI displaced ```

Question 34

Dx eval for MR

Answer 34

CXR- cardiomeg and pulm edema EKG- LVH or both LVH and RVH; LA enlargement, P mitrale (broad, notched p waves) Echo Cardiac cath- shows pulm prs and CO

Question 35

Rx for MR

Answer 35

Reduce afterload! - ACE inhib, nitroglycerin, diuretics | Surg if CHF interferes w live, if there is worsened P-HTN or LV dilation, or if Afib

Question 36

Rx if there is life-threatening MR from endocarditis, ischemia, trauma

Answer 36

Aggressive afterload reduction Balloon pump Abx if needed Try to convert emergency into elective procedure

Question 37

mid-systolic ejection murmur

Answer 37

Ao stenosis

Question 38

crescendo-decrescendo diastolic murmur

Answer 38

Ao insufficiency

Question 39

opening snap, then low rumbling murmur

Answer 39

Mitral stenosis

Question 40

holosystolic murmur radiating to axilla or back

Answer 40

mitral regurg