M2 Cardiology Key Facts - Week 3

Question 1

Shock - Definition

Answer 1

Low tissue perfusion leads to cellular hypoxia and energy defect - usually with hypotension - compensation can delay hypotension onset.

Question 2

Two Major Class of Shock (3 Types Each)

Answer 2

Low CO Shock - Cardiogenic, Obstructive, Hypovolemic

Disruptive - Low Resistance Shock - Sepsis, Neurogenesis, Anaphalaxis

Question 3

Two Major Compensation Mechanisms for low CO Shock

Answer 3

Baroreceptors - Detect low BP - Decrease signal, decreases their parasymp stimulation + symp inhibition - Symp. Dominates - Increases CO and Vasoconstriction

RAAS - Low Kidney Perfusion - Activates Renin - AI - AII - Aldosterone - Vasoconstriction + Fluid Retention

Question 4

Responses to Low CO Shock (Universal) - 3

Answer 4

1) Increased Vasoconstriction - Cold/Clammy
2) Metabolic Acidosis
3) Tachypnea

Question 5

Cardiogenic Shock - Causes (4) + Major Signs/Symptoms (3)

Answer 5

Causes

1) #1 = Acute MI > 40% of Ventricle
2) Cardiomyopathy
3) Valve Disease
4) CHF

Major Symptoms - Pump Failure = Pulm. Overload

1) Pulm. Congestion with Rales/Wheezes + S3 and maybe S4
2) If RCA MI - Mitral Regurgitation
3) Cold/Clammy
4) JVD

Question 6

Hypovolemic Shock - Causes (3) + Major Signs/Symptoms (3)

Answer 6

Causes - Loss of Volume/Plasma

1) Trauma/Surgery
2) GI Fluid Loss - Choleara
3) Plasma Loss via Burn Injury

Major Symptoms - Decreased Preload

1) Weak Thready Pulse + Narrow Pulse Pressure + Tachycardia
2) Weak/Cold/Clammy

Question 7

Obstructive Shock - Causes (2) + Major Signs/Symptoms (3)

Answer 7

Causes - Restricted Venous Return

1) Cardiac Tamponade
2) Pneumothorax

Major Symptoms - Decreased Preload
Tamponade (4)
Becks Triad = Hypotension + Muffled Heart Sounds + JVD
Pneumothorax (2)
Trachea deviated to opposite side of pneumothorax + JVD + Absent breathe sounds

Question 8

Hypovolemic vs. Cardiogenic Shock

Answer 8

Both Low CO - Hypovolemia has no lung/JVD Signs

Question 9

Septic vs. Hypovolemic Shock

Answer 9

Septic has normal skin color because there is no vasoconstriction

Question 10

Neurogenic Shock vs. Anaphylactic Shock

Answer 10

Neurogenic - Loss of Symp. Tone after SCI

Anaphylactic - Histime and Prsotagladin Vasodilation

Question 11

Septic Shock - Causes (2) + Major Signs/Symptoms (3)

Answer 11

Causes 
Bacteria signals (LPS etc.) induce massive vasodilation via NO with inability for CO to compensate 

Major Symptoms

1) Hypotension less responsive to vasopressors (NE is best)
2) Reduced peripheral oxygen extraction
3) Not Cold/Clammy

Question 12

Hypovolemic Shock vs. Obstructive

Answer 12

Obstructive with JVD vs. No JVD in Hypovolemic

Question 13

Infectious Endocarditis - Common Causes (3)

Answer 13

1) 80% = Staph or Strep
2) Strep Viridans = Most Common Sub-Acute Cause
3) Staph Aureus = Most Common Acute Cause - IV Drug Users + Tricuspid

Question 14

S. Aureus Endocarditis - 3 Keys

Answer 14

1) Acute Onset
2) IV Drug User
3) Tricuspid Involvement

Question 15

Common Valves Infected by Endocarditis (3)

Answer 15

All Regurgitationn Murmurs

1) Aortic - 60%
2) Mitral - 35%
3) Tricuspid (S. Aureus IV Drug User)

Question 16

S. Viridans Endocarditis - 2 Keys

Answer 16

1) Sub-Acute (Most Common)

2) Requires predisposed valve (e.g. via Rheumatic Fever or Artificial Valve)

Question 17

Major Endocarditis Findings (6)

Answer 17

1) New Regurgitation Murmur
2) Unremitting Fever
3) Nail Bed Splinter
4) Roth Spot (Eye)
5) Janeway Lesions - Painless - Palm/Sole
6) Osler Nodes - Painful Fingertip Nodules

Question 18

Olser Nodes vs. Janeway Lesions

Answer 18

Painful Fingertip Nodules vs. Painless on Palm

Question 19

Peripheral Arterial Occlusive Disease - Basics and Comparison to CAD

Answer 19

Intermittent Claudication - Stable Angina
Rest Pain - Unstable Angina
Ischemic Limb - NSTEMI/STEMI

Question 20

Peripheral Arterial Occlusive Disease - Most Common Causes (2) + Most Common Symptom (1)

Answer 20

Causes - Atherosclerosis + Emboli

Finding - Poor Healing Wounds (Low O2 Perfusion

Question 21

Key for Intermittent Claudication (3) vs. Spinal Stenosis (3)

Answer 21

IC = Reproducible + No Discomfort when standing + relieved by rest
Spinal Stenosis - Variable + Discomfort with standing + Relieved when flexing the spine via sitting

Question 22

Intermittent Claudication Pain + Associated Vessel (2)

Answer 22

Calf Pain - Superficial Femoral = Most Common

Thigh + Buttock with Erectile Dysfunction - Aortoiliac Area

Question 23

Acute Limb Ischemia - 5 P’s

Answer 23

1) Pain
2) Pulseless
3) Paresthesias
4) Paralysis
5) Poiklytothermia (Feels Cold)

Most Common Cause = Emboli
Most Common Location = Femoral Artery Bifurcation

Question 24

Major Symptoms of Claudication (6)

Answer 24

1) Bruits (Renal, Femoral, Illiac
2) Decreased Distal Pulse
3) Decreased ABI (Ankle-Brachial Index) - Normal > 1 because of gravity
4) Atrophy of Calf Muscle
5) Thin Shinny Skin
6) Depedent Rubor - Redness that goes away on knee lifting

Question 25

3 Major Class of Heart Failure

Answer 25

Systolic - Reduced EF - Increased Afterload or Decreased Contractility Diastolic - Preserve EF - Decreased Preload /Impaired Filling Right Heart Failure

Question 26

Systolic Heart Failure Causes (5)

Answer 26

Reduced Contractility 1) MI/Ischemia 2) Chronic Valve Overload Valve Disease (Regurgitation) - Aortic or Mitral 3) Dilated Cardiomyopathy Increased Afterload Chronic HTN Aortic Stenosis

Question 27

Diastolic Heart Failure Causes (4)

Answer 27

Reduced Filling 1) LVH - Stiff LV 2) Restrictive Cardiomyopathy 3) Cardiac Tamponade 4) Pericardial Constriction

Question 28

Right Heart Failure Causes (4)

Answer 28

#1 = Left HF ``` Isolated Right HF - Pulm. Issue COPD Chronic Chroncitis Smoking Primary Pulm. HTN (PE + Right MI) ```

Question 29

Compensation for CHF - Low Perfusion Pressure Response (4)

Answer 29

1) Increase RAAS - Volume Overload + Cardiac Remodeling 2) Increase Contracility (Symp. via Baroreceptors) 3) Increase ADH All good at first but make it worse later - Volume Overload + high SVR

Question 30

Symptoms of Left Heart Failure (3)

Answer 30

1) Dyspnea (Pulm. Congestion) 2) Orthopnea/PND 3) Fatigue (Low Perfusion

Question 31

Symptoms of Right Heart Failure (2)

Answer 31

1) Peripherial Edema | 2) Right Upper Quadrant Pain

Question 32

Exam Findings in Left Heart Failure (5)

Answer 32

1) Symp Stim - Diaphoresis + Tachycardia + Tachypnea 2) Pulmonary Rales 3) S3 Sound - Abnormal Filling of a Dilated Chamber (Systolic Failure) 4) S4 Sound - Forceful contraction against a stiff LV (Diastolic Failure) 5) Elevated BNP Peptide

Question 33

Exam Findings In Right Heart Failure (6)

Answer 33

1) Peripherial Edema 2) Ascities 3) JVD 4) Hepatomegaly 5) Palpable Parasternal RV Heave 6) Right S3/4 with Tricuspid Regurgitation

Question 34

Key Pearl - Dilated (2) vs. Hypertrophic (3) vs. Restrictive (3) Cardiomyopathy

Answer 34

Dilated 1) Problem with Preload 2) Linked with Mitral/Tricuspid Regurgitation Hypertrophic 1) Problem with Afterload 2) Key pathology = disarray of myofibers on histopathology 3) Can cause functional aortic stenosis + LV septum enlargement Restrictive 1) Problem with Expansion 2) ECG with diminished QRS = Key Finding 3) FIbrosis of Endocardium

Question 35

Pathophysiology - Dilated (3) vs. Hypertrophic (2) vs. Restrictive (2) Cardiomyopathy

Answer 35

Dilated 1) Systolic Dysfunction of ventricles bilateraly leading to CHF 2) Eccentric - Myocytes added in series 3) Loss of Ejection Fraction - Systolic Failure Hypertrophic 1) Diastolic Dysfunction - Impaired relaxation leads to low filling volume due to high compliance 2) Concentric - Myocytes added in parallel Restrictive 1) Stiff LV with impaired relaxation and filling 2) Preserved Ejection Fraction - Diastolic Failure

Question 36

Common Causes - Dilated (5) vs. Hypertrophic (2) vs. Restrictive (3) Cardiomyopathy

Answer 36

Dilated 1) Alcohol 2) Coxsackie A + B 3) Cocaine 4) Pregnancy 5) Genetics (Beri-Beri) Hypertrophic 1) Genetics 2) High Afterload (HTN/Aortic Stenosis Restrictive 1) Amyloidosis 2) Hematochromatosis 3) Scleroderma

Question 37

Major Symptoms - Dilated (4) vs. Hypertrophic (3) vs. Restrictive (2) Cardiomyopathy

Answer 37

Dilated 1) Left HF - Dyspnea + Orthopnea + PND Hypertrophic 1) Like Angina - Dyspnea on Exertion + Syncope Restrictive 1) Dyspnea on Exertion + Fatigue

Question 38

Major Exam Findings - Dilated (4) vs. Hypertrophic (3) vs. Restrictive (2) Cardiomyopathy

Answer 38

Dilated 1) Pulmonary Crackles/Weeze 2) S3/4 3) Right Heart Signs - JVD + Peripheral Edema Hypertrophic 1) S4 + Systolic Murmur (if Aortic Stenosis Present) 2) Possibly Mitral Regurgitation Restrictive 1) Mostly Right Side Signs - JVD + Hepatomegaly

Question 39

3 Major Disorders Linked to Congenital Heart Defects

Answer 39

VSD - Fetal Alcohol Syndrome ASD - Osium Primum = Down's Syndrome Coartaction of the Aorta - Turner's Syndrome

Question 40

ASD - Key Associations (3)

Answer 40

1) Murmur - Fixed Split S2 - LA/RA Balance Pressures 2) Primum Associated with Downs + Valve Disease 3) Secondum = More Common

Question 41

VSD - Key Associations (3)

Answer 41

1) Murmur - LLSB = Holosystolic 2) Associated with Fetal Alcohol Syndrome 3) Early VSD Closing = Stem Cells

Question 42

Tetraology of Fallot - Key Associations (4)

Answer 42

1) Cynosis development based on degree of pulmonic stenosis 2) - 4 Components - VSD + Overriding Aorta + Pulmonic Stenosis + RV Hypertrophy 3) Boot Shaped Heart on CXR 4) Mid-pitched coarse systolic murmur LUSB Radiating to the Chest

Question 43

Small Slit Left Heart - Syndrome + Pathology

Answer 43

Hypoplastic Left Heart Syndrome PFO Shunts the blood back and PDA keeps you alive (basically blood goes from pulm circulation back to RA from LA and then into circulation via PDA

Question 44

PDA - Key Features

Answer 44

1) Continuous Machine Like Murmur 2) Increases Risk of Infection 3) Closed by Prostaglandin Drop + High O2 at Birth - Kept open by prostaglandin inhibitor indomethacin

Question 45

Bicuspid Aortic Valve - Associated Predispositions (2) + Associated Pathology (5)

Answer 45

Syndromes that Predispose to Bicuspid Marfan Ehler-Danlos ``` Assocaited Pathology Aortic Regurgitation Aortic Stenosis Aortic Endocarditis AAA Aortic Dissection ```

Question 46

Aortic Dissection - Risk Factors (7)

Answer 46

1) Smoking 2) Hylaine Atherosclerosis of Vaso Vasorum 3) Pregnancy 4) Cocaine 5) Chronic HTN 6) Marfan 7) Ehlers-Danlos

Question 47

Aortic Dissection - Classifications (2) + Second Most Common Site

Answer 47

1) - Sanford A - Ascending Aorta Involved 2) - Sanford B - No Ascending Aorta Involved Second Most Common Site - Distal to Left-Subclavain - Trauma = Ligamentum Arteriosus Tear

Question 48

Aortic Dissection - Exam Findings (2) + Secondary Pathology (3)

Answer 48

Findings 1) HTN + Murmur/Aortic Regurgitation 2) Perfusion Deficit Secondary Pathology 1) Cardiac Tamponade 2) MI 3) Renal Artery Occlusion

Question 49

Thoracic Aortic Aneurysm - Congenital Causes (3) + Acquired Causes (2)

Answer 49

Congenital 1) Marfan 2) Ehlers-Danlos 3) Bicuspid Aortic Valve Acquired 1) Smoking 2) Tertiary Syphilis (Endartaritis) 3)

Question 50

Thoracic Aortic Aneurysm - Major Complications (3)

Answer 50

1) Dilated Root 2) Aortic Regurgitation 3) Mediastinum Compress

Question 51

Abdominal Aortic Aneurysm Rupture Symptoms

Answer 51

Beck's Triad 1) Flank Pain 2) Hypotension 3) Pulsatile Mass (Still) 4) Shock - More likely in the setting of acute abdominal pain vs. sepsis

Question 52

Acute Pericarditis - Causes (7)

Answer 52

1) Cocksackie 2) Enterovirus 3) MI (Acute + Autoimmune) 4) Trauma 5) TB 6) Procainamide 7) Hydralazine

Question 53

Acute Pericarditis - Signs/Symptoms (3)

Answer 53

1) Pericardial Pain - Worse on inspiration - better leaning forward/expiration 2) Pericardial Friction Rub 3) ECG Changes - Diffuse ST Elevation

Question 54

Acute Pericardial Effusion - Causes (3)

Answer 54

Trauma, Acute MI with Rupture, Aortic Dissection

Question 55

Acute Pericardial Effusion - Findings (6)

Answer 55

1) Soft Heart Sounds 2) Reduced Intensity of Pericardial Rub 3) ECG - Electric Alterans - QRS with alternating amplitudes 4) Dysphagia 5) Dyspnia 6) Hoarseness

Question 56

Cardiac Tamponade - Signs + Symptoms (6)

Answer 56

Beck's Triad 1) Hypotension 2) Muffled Heart Sounds 3) Elevated JVP 4) Pulsus Paradoxus 5) Pulm. Rales 6) Less y Ascent on JVP Tracing

Question 57

Constrictive Pericarditis - Signs + Symptoms (5)

Answer 57

1) Pericardial Knock 2) Reduced CO (Hypotension) 3) Right HF Mimic - Hepatosplenomegaly + Ascities much worse than expected based on peripherial edema 4) Kausmall's Sign - Elevated JVP on Inspirtation (normall not the case) 5) Exaggerated y wave on JVP