Bradyarrhythmias less than 50/min suggest a disorder of what part of the heart?
Bradyarrhythmias less than 50/min suggest an SA node disorder. SA node dysfunction may worsen with cardioactive drugs, such as cardiac glycosides, β-adrenergic blockers, calcium channel blockers, and amiodarone.
A 66-year-old man has had cough and worsening shortness of breath for 3 years. On examination, there is dullness to percussion at both lung bases and poorly audible breath sounds. On physical examination, pulse is 77/min and BP is 110/80 mm Hg. He does not have anginal pain. His liver span is increased to 14 cm. He has pitting edema to his knees. Jugular venous distention is noted to the angle of the jaw at 45-degree elevation of his head while lying down. What is most likely causing his heart disease?
Smoking These findings are consistent with right-sided congestive heart failure leading to peripheral edema, body cavity effusions (pleural effusions in this case), passive congestion of the liver, and jugular venous distension. Pure right-sided failure is less common than left-sided failure, and the former most often follows pulmonary disease (cor pulmonale). Chronic obstructive pulmonary disease (COPD) is more common than restrictive lung disease, and smoking leads to COPD.
A 62-year-old woman has had increasing dyspnea for the past 2 years. She now awakens at night with air hunger and cough productive of frothy sputum. On examination, she has rales in all lung fields. Her point of maximal impulse is strong and displaced laterally. Echocardiography shows a decreased ejection fraction of 30% with concentric increase in left ventricular wall size. The valves appear normal. What underlying diseases does she have?
HTN Left-sided congestive heart failure leads to pulmonary congestion and edema. Systemic hypertension is common and leads to pressure load with predominantly concentric left ventricular hypertrophy with systolic dysfunction.
A 41-year-old woman has been awakened at night with “air hunger” for the past year. She notes sleeping better while sitting up in bed. Her serum B-type natriuretic peptide is >400 pg/mL (very high). What cardiac disease best explains her condition?
Rheumatic valvulitis Paroxysmal nocturnal dyspnea is a feature of left-sided congestive heart failure, and rheumatic heart disease most often involves the mitral, aortic, or both valves, and left-sided valvular disease leads to pulmonary edema.
An infant born at term is noted to have cyanosis during the first week of life. On examination a heart murmur is auscultated. Abnormal findings with echocardiography include an overriding aorta, ventricular septal defect, right ventricular thickening, and pulmonic stenosis involving the fetal heart. This infant is most likely to have an inherited mutation involving which gene?
NOTCH2 There are a number of mutations in genes linked to congenital heart disease that encode proteins in transcription or signaling pathways. The NOTCH pathway plays a role in modulation of vascular development, including cardiac outflow tracts. NOTCH2 mutations are associated with tetralogy of Fallot, as in this infant.
KCNQ1 mutations may be seen with what cardiac disease?
KCNQ1 mutations may be seen with long QT syndrome
Following an uncomplicated pregnancy, a term infant appears normal at birth, but at 1 day of life the infant develops respiratory distress. On physical examination the infant has tachypnea, tachycardia, and cyanosis. There is an S1 ejection click and a split S2 with prominent P sound. A radiograph shows normal heart size but prominent hilar vascular markings. Echocardiography shows a small left atrium, large right atrium, normally sized ventricles, widely patent foramen ovale, and normally positioned aorta and pulmonary trunk. What type of congenital heart disease does this infant most likely have?
Total anomalous pulmonary venous connection This shunt results from abnormal confluence of pulmonary veins leading to the right atrium (or systemic veins), and not the left. Obstruction is often present, as in this case, with pulmonary congestion. Deoxygenated systemic and oxygenated pulmonary venous blood mix in the right atrium.
T/F: Coarctation of the aorta is associated with cyanosis.
Uncorrected VSD carries what complication?
A 3-year-old child is developing normally. Physical examination reveals a low-pitched cardiac murmur. An echocardiogram shows the presence of an ostium secundum, with a 1-cm defect. What abnormality is most likely to be found in this child?
Left to right shunt A persistent ostium secundum is the most common form of atrial septal defect. Because atrial pressures are low, the amount of shunting from the left atrium to the right atrium is small, and this lesion may remain asymptomatic for many years. Eventually, pulmonary hypertension can occur, with reversal of the shunt.
Cyanosis is a feature of what pathological cardiac shunt?
Right to left
What kind of shunt is PDA?
Although often not causing a large shunt defect, a patent ductus arteriosus can produce a significant murmur and predispose to infection. This left-to-right shunt may eventually result in pulmonary hypertension.
A 5-year-old girl who is below the 5th percentile for height and weight for age has exhibited easily fatigability since infancy. On physical examination, she appears cyanotic. Her temperature is 37° C, pulse is 82/min, respirations are 16/min, and blood pressure is 105/65 mm Hg. Pulse oximetry shows decreased oxygen saturation. One month later, she has fever and obtundation. A cerebral CT scan shows a right parietal, ring-enhancing, 3-cm lesion. What congenital heart diseases is the most likely diagnosis?
Truncus arteriosus Cyanosis at this early age suggests a right-to-left shunt. Truncus arteriosus, transposition of the great arteries, and tetralogy of Fallot are the most common causes of cyanotic congenital heart disease.
A 15-year-old boy complains of pain in his legs when he runs more than 300 m. Physical examination shows temperature, 36.8° C; pulse, 76/min; respirations, 22/min; and blood pressure, 165/90 mm Hg. The radial pulses are 4+, and the dorsalis pedis pulses are 1+. Arterial blood gas measurement shows a normal oxygen saturation level. What congenital cardiovascular anomaly is most likely to be present in this patient?
Coarctation of the aorta In children and adults, the coarctation is typically postductal, and collateral branches from the proximal aorta supply the lower extremities, leading to the large pulse differential between upper and lower extremities. Collaterals often involve intercostal arteries whose enlargement produces “rib notching” on chest radiographs. Diminished renal blood flow below the coarctation increases renin production and promotes hypertension.
Transposition of the great arteries results in:
Transposition of the great arteries results in a right-to-left shunt with cyanosis.
What is truncus arteriosus?
Truncus arteriosus is an anomalous, incomplete separation of the pulmonic and aortic trunks.
T/F: Atherosclerosis is accelerated with diabetes mellitus.
The cystic medial necrosis that occurs in Marfan syndrome most often involves what section of the aorta?
The cystic medial necrosis that occurs in Marfan syndrome most often involves the ascending aorta and predisposes to dissection that could involve coronary arteries, although with external compression.
Calcific aortic stenosis leads to what cardiac pathology?
Calcific aortic stenosis leads to left-sided congestive heart failure (CHF), and the extra workload of the left ventricle may cause angina pectoris.
Aschoff bodies are found in what diagnosis?
Rheumatic myocarditis is characterized by minimal myocardial necrosis with foci of granulomatous inflammation (Aschoff bodies).
Hemorrhage and contraction bands in necrotic myocardial fibers are most likely to be seen with infarction in what clinical setting?
Thrombolytic therapy Reperfusion of an ischemic myocardium by spontaneous or therapeutic thrombolysis changes the morphologic features of the affected area. Reflow of blood into vasculature injured during the period of ischemia leads to mitochondrial dysfunction, followed by leakage of blood into the tissues (hemorrhage).
CK activity does what after an MI?
CK activity begins to increase 2 to 4 hours after an MI, peaks at about 24 to 48 hours, and returns to normal within 72 hours. Total CK activity is a sensitive marker for myocardial injury in the first 24 to 48 hours.
When do tropinin I levels rise after MI?
Troponin I levels begin to increase at about the same time as CK and CK-MB, but remain elevated for 7 to 10 days.
When do CK-MB levels rise after MI?
2-4 hours Specific, but not very sensitive
Hereditary hemochromatosis may result in what cardiac pathology?
Hereditary hemochromatosis may result in an infiltrative (dilated) cardiomyopathy with iron overload, more typically by the fifth decade.
What is an atrial myxoma?
An atrial myxoma is the most common primary cardiac neoplasm, but it is rare and is not related to ischemic heart disease.
What is the most common cause of constrictive pericarditis?
Constrictive pericarditis follows a previous suppurative or tuberculous pericarditis.
An elevated serum B-type natriuretic peptide (which is measured instead of atrial natriuretic peptide) is consistent with ________
An elevated serum B-type natriuretic peptide (which is measured instead of atrial natriuretic peptide) is consistent with heart failure.
Amiodarone is used to treat ____________
Amiodarone is used to treat intractable arrhythmias.
Left ventricular failure leads to ______
Left ventricular failure leads to pulmonary edema.
What kind of heart disease leads to endocardial and valvular collagenous thickening?
Carcinoid heart disease leads to endocardial and valvular collagenous thickening. release of active tumor products –> flushing, wheezing, skin lesions, diarrhea
PDA causes what kind of heart murmur?
A patent ductus arteriosus causes a shrill systolic murmur.
What is the cause of heart failure in rheumatic heart disease?
Myocarditis leads to dilation of the ventricle so severe that the mitral valve becomes incompetent.
A 10-year-old girl develops subcutaneous nodules over the skin of her arms and torso 3 weeks after a bout of acute pharyngitis. She manifests choreiform movements and begins to complain of pain in her knees and hips, particularly with movement. A friction rub is heard on auscultation of her chest. An abnormality detected by which serum laboratory finding is most characteristic of the disease affecting this girl?
anti–streptolysin O (ASO) titer Acute rheumatic fever can involve any or all layers of the heart. Because rheumatic fever follows group A streptococcal infections, the antihyaluronidase, anti-DNase, and anti–streptolysin O (ASO) titers are often elevated.
A 26-year-old woman has had a fever for 5 days. On physical examination, her temperature is 38.2° C, pulse is 100/min, respirations are 19/min, and blood pressure is 90/60 mm Hg. A cardiac murmur is heard on auscultation. Her sensorium is clouded, but there are no focal neurologic deficits. Laboratory findings include hemoglobin, 13.1 g/dL; platelet count, 233,300/mm3; and WBC count, 19,200/mm3. Blood cultures are positive for gram-positive bacteria. Urinalysis shows hematuria. An echocardiogram shows a 1.5-cm vegetation on the mitral valve. What condition is this patient most likely to develop?
Cerebral arterial mycotic aneurysm She developed bacterial septicemia followed by infective endocarditis of the mitral valve. Thus she has a high risk for developing complications of infective endocarditis. Such valvular vegetations are destructive of the valve. The impaired functioning of the mitral valve (most likely regurgitation) would give rise to left atrial dilation and left ventricular failure with pulmonary edema. Septic emboli from the mitral valve vegetation could reach the systemic circulation and give rise to abscesses. Infection of an arterial wall can weaken the wall, resulting in aneurysm formation and the potential for rupture.
Coxsackievirus B and Trypanosoma cruzi are causes of what kind of cardiac complication?
Coxsackievirus B and Trypanosoma cruzi are causes of myocarditis.
A 71-year-old woman has had a 10-kg weight loss accompanied by severe nausea and vomiting of blood for the past 8 months. On physical examination, she is afebrile. Laboratory studies show hemoglobin, 8.4 g/dL; platelet count, 227,100/mm3; and WBC count, 6180/mm3. Biopsy specimens obtained by upper gastrointestinal endoscopy show adenocarcinoma of the stomach. CT scan of the abdomen shows multiple hepatic masses. CT scan of the head shows a cystic area in the right frontal lobe. Her condition is stable until 2 weeks later, when she develops severe dyspnea. A chest CT scan shows areas of decreased pulmonary arterial attenuation. What cardiac lesion is most likely to be present in this woman?
Nonbacterial thrombotic endocarditis So-called marantic vegetations may occur on any cardiac valve, but tend to be small and do not damage the valves. They have a tendency to embolize, however. They can occur with hypercoagulable states that accompany certain malignancies, especially mucin-secreting adenocarcinomas.
A 41-year-old woman has had increasing dyspnea for the past week. On physical examination, temperature is 37.3° C, pulse is 85/min, respirations are 20/min, and blood pressure is 150/95 mm Hg. There is dullness to percussion over the lung bases. A chest radiograph shows large bilateral pleural effusions and a normal heart size. Laboratory findings include serum creatinine, 3.1 mg/dL; urea nitrogen, 29 mg/dL; troponin I, 0.1 ng/mL; WBC count, 3760/mm3; hemoglobin, 11.7 g/dL; and positive ANA and anti–double-stranded DNA antibody test results. What cardiac lesion is most likely to be present in this patient?
Libman-Sacks endocarditis Libman-Sacks endocarditis is an uncommon complication of systemic lupus erythematosus (SLE) that has minimal clinical significance because the small vegetations, although they spread over valves and endocardium, are unlikely to embolize or cause functional flow problems.
A 50-year-old man with a history of infective endocarditis has increasing fatigue. He receives a bileaflet tilting disk mechanical mitral valve prosthesis. After surgery, he is stable, and an echocardiogram shows no abnormal valvular or ventricular function. What pharmacologic agent should he receive regularly after this surgical procedure?
Warfarin Anticoagulant therapy is necessary for patients with mechanical prostheses to prevent potential thrombotic complications.
A 25-year-old man suffers a sudden cardiac arrest. He is resuscitated. On examination his vital signs are normal. Echocardiography shows that the left ventricle is normal but there is marked thinning with dilation of the right ventricle. MR imaging of his chest shows extensive fibrofatty replacement of the myocardium, but no inflammation. What is the most likely cause for his findings?
Cardiomyopathy Arrhythmogenic right ventricular cardiomyopathy (arrhythmogenic right ventricular dysplasia) is most likely an autosomal dominant inherited condition with abnormal desmosomal adhesion proteins in myocytes.
Ventricular fibrosis with ventricular wall thinning can be caused by what infection?
A 10-year-old girl who is normally developed has chronic progressive exercise intolerance. On physical examination, temperature is 37.1° C, pulse is 70/min, respirations are 14/min, and blood pressure is 100/60 mm Hg. A chest radiograph shows cardiomegaly and mild pulmonary edema. An echocardiogram shows severe left ventricular hypertrophy and a prominent interventricular septum. The right ventricle is slightly thickened. During systole, the anterior leaflet of the mitral valve moves into the outflow tract of the left ventricle. The ejection fraction is abnormally high, and the ventricular volume and cardiac output are both low. What is the most likely cause of the cardiac abnormalities in this patient?
Beta-myosin heavy chain mutation Hypertrophic cardiomyopathy is familial in >70% of cases and is usually transmitted as an autosomal dominant trait. The mutations affect genes that encode proteins of cardiac contractile elements. The most common mutation in the inherited forms affects the β-myosin heavy chain.
_________ is the most common cause of sudden unexplained death in young athletes.
Hypertrophic cardiomyopathy is the most common cause of sudden unexplained death in young athletes.
A 33-year-old woman from Victoria, British Columbia, goes to the physician because of increasingly severe dyspnea, orthopnea, and swelling of the legs for the past 2 weeks. She has no previous history of serious illness or surgery. On physical examination, her temperature is 37.8° C, pulse is 83/min, respirations are 20/min, and blood pressure is 100/60 mm Hg. An ECG shows episodes of ventricular tachycardia. An echocardiogram shows right and left ventricular dilation, but no valvular deformities. An endomyocardial biopsy shows focal myocyte necrosis and lymphocytic infiltrate. What organism most likely caused the infection?
Coxsackie A virus Focal myocardial necrosis with a lymphocytic infiltrate is consistent with viral myocarditis. This is uncommon, and many cases may be asymptomatic. In North America, most cases are caused by coxsackieviruses A and B. This illness may often be self-limited. Less often, it ends in sudden death or progresses to chronic heart failure.
_________ may cause myocarditis with mixed inflammatory cell infiltrates in immunocompromised patients.
Toxoplasma gondii may cause myocarditis with mixed inflammatory cell infiltrates in immunocompromised patients.
A 48-year-old, previously healthy woman reports having suddenly lost consciousness four times in the past 6 months. In three instances, she was unconsciousness for only a few minutes. After the fourth episode 1 month ago, she was unconscious for 6 hours and had weakness in her right arm and difficulty speaking. On physical examination, she is afebrile, and her blood pressure is normal. No murmurs are auscultated. She has good carotid pulses with no bruits. What cardiac lesion is most likely to be present in this woman?
Left atrial myxoma Atrial myxoma is the most common primary cardiac neoplasm. On the left side of the heart, it can produce a ball-valve effect that intermittently occludes the mitral valve, leading to syncopal episodes and possible strokes from embolization to cerebral arteries.
A 45-year-old man receives a cardiac allograft for dilated cardiomyopathy. He has no problems with rejection, but 5 years later he has worsening exercise tolerance with increasing dyspnea and peripheral edema. Echocardiography shows a reduced ejection fraction of 35%. What pathologic abnormalities has he most likely developed in the allograft?
Coronary arteriopathy Nearly every allograft develops some degree of arteriopathy within 10 years, and half of patients have significant arteriopathy by 5 years following transplantation. Unlike atherosclerosis, the smaller coronary artery branches are preferentially affected, but the result is the same: ischemic damage.
When is fibrinous pericarditis seen?
2-10 weeks after a transmural MI
What is Dressler dyndrome?
Postmyocardial infarction syndrome; delayed form of pericarditis that develops 2-10 weeks postMI; pain appears anginal
What is the diagnosis? Right ventricular hypertrophy and dilation secondary to pulmonary hypertension; often arises from COPD
Cor pulmonale (Pulmonary stenosis is a rare cause of cor pulmonale)
Does dilated cardiomyopathy feature hypertension as a symptom?
What is the diagnosis? Nonbacterial vegetations on the undersurface of the mitral valve; Fibrinoid necrosis of small vessels; Focal degeneration of interstitial tissue
Libman-Sacks endocarditis; Associated with SLE ANA+ anti-DS-DNA+
Name the diagnosis: Sterile vegetations or normal cardiac valves; associated with cancer or other wasting disease; increased blood coagulability and immune complex deposition are suggested for pathogenesis
Anitschkow cells are plump macrophages seen in what dx?
Rheumatic heart disease (beta hemolytic, group A streptococcus) Anitschkow cells are part of the Aschoff bodies lesions