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189 Cards in this Set
- Front
- Back
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Holosystolic murmur heard best at apex & radiates toward axilla?
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Mitral regurgitation
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What can mitral regurg be due to?
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Ischemic heart disease, MVP, LV dilation, hypertrophic cardiomyopathy, rheumatic heart disease
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What intensifies mitral regurg murmur
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Things that increase TPR -- squatting, hand grip, or LA return (expiration)
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Holosystolic murmur heard best at left lower sternal border & radiates to right sternal border
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Tricuspid regurg
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What increases tricuspid regurg murmur intensity?
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Things that inc blood in RA (inspiration)
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what causes tricuspid regurg?
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RV dilation, endocarditis, rheumatic fever
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systolic ejection murmur followed by an ejection click
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aortic stenosis
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Where does aortic stenosis radiate to?
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Carotids/apex
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What is pulsus parvus et tardus
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pulses weak compared to heart sounds, can lead to syncope
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what causes aortic stenosis
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Age related calcification, bicuspid aortic valve, syphillis, chronic rheumatic valvular disease
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Holosystolic harsh sounding murmur heard loudest at tricuspid area. Increased intensity with inspiration
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VSD (sounds identical to tricuspid regurg)
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Late systolic murmur with midsystolic click
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Mitral valve prolapse
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When is MVP heard loudest?
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S2
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Immediate high pitched blowing diastolic murmur
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aortic regurg
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This murmur causes widened pulse pressure when chronic, bounding pulses & head bobbing
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aortic regurg
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What causes aortic regurgitation?
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aortic root dilation, bicuspid aortic valve, rheumatic fever
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Murmur follows opening snap, late diastolic murmur
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mitral stenosis
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What murmur can result in LA dilation?
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Chronic mitral stenosis
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what causes mitral stenosis?
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secondary to rheumatic fever
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when is mitral stenosis heard best
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expiration (inc LA return)
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What causes continous machine like murmur
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PDA
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What causes wide/fixed splitting of S2
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ASD
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what causes a systolic ejection murmur accentuated by standing
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Hypertrophic cardiomyopathy
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Early diastolic Murmur decreased by amyl nitrite
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Aortic regurg
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Late diastolic murmur eliminated by atrial fibrillation
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Mitral or tricuspid stenosis
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ventricular preexcitation syndrome. Accessory pathway from atria to ventricle bypassing AV node
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Wolff-Parkinson-White syndrome
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What condition do you see a delta wave with?
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WPW
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WPW has a shortened what?
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PR interval
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How do you rx WPW?
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Procainamide, Amiodarone
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Irregularly irregular rhythm w/ NO discrete P waves
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A-fib
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How do a-fib lead to decreased preload --> hypotension --> acute HF
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loss of atrial kick
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Rx of a-fib?
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Beta block or nonDHP CCB & px for thromboembolism w/ warfarin
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Rx of rate control in chronic a-fib?
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Watch SVT & Rx w/ digoxin, bb, or CCB
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Rx of rhythm control in chronic a-fb
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Sotalol or amiodarone
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rapid succession of identical back-to-back atrial depolarization waves --> Sawtooth apperance
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A-flutter
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Rx for a-flutter
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Class Ia, Ic, or III antiarrythmics
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A fib or a flutter has absent P waves
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a-fib (a-flutter still has p waves)
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What is prolonged in 1st degree AV block & what can cause this?
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PR interval - Borrelial can cause AV nodal block
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What is Holiday heart syndrome (binge alcohol consumption)
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Atrial fib
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Progressive lengthening of PR interval until a beat is "dropped" (P wave w/ NO QRS) - usually asx
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2nd degree block - Mobitz Type I
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dropped beats that are NOT preceeded by change in length of PR interval
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Mobitz Type II block - tx w/ pacemaker
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Atria & ventricles beat completely independent of one another - both P & QRS are present but no relationship
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3rd degree heart block
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completely erratic rhythm w/ no identifiable waves
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V-fib
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failure of truncus arteriosus to divide into pulmonary trunk & aorta - mixing of blood
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persistent truncus arteriosus
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Absence of tricuspid valve & hypoplastic RV; must have ASD & VSD for viability
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Tricuspid atresia
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Rx for a-flutter
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Class Ia, Ic, or III antiarrythmics
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A fib or a flutter has absent P waves
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a-fib (a-flutter still has p waves)
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What is prolonged in 1st degree AV block & what can cause this?
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PR interval - Borrelial can cause AV nodal block
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What is Holiday heart syndrome (binge alcohol consumption)
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Atrial fib
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Progressive lengthening of PR interval until a beat is "dropped" (P wave w/ NO QRS) - usually asx
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2nd degree block - Mobitz Type I
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dropped beats that are NOT preceeded by change in length of PR interval
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Mobitz Type II block - tx w/ pacemaker
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Atria & ventricles beat completely independent of one another - both P & QRS are present but no relationship
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3rd degree heart block
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completely erratic rhythm w/ no identifiable waves
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V-fib
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failure of truncus arteriosus to divide into pulmonary trunk & aorta - mixing of blood
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persistent truncus arteriosus
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Absence of tricuspid valve & hypoplastic RV; must have ASD & VSD for viability
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Tricuspid atresia
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What cardiac abnormalities are assoc w/ Down syndrome
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ASD, VSD, AV septal defect (endocardial cushion defect)
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What cardiac abnormality is associated w/ congenital rubella
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Septal defects, PDA, pulmonary artery stenosis
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What cardiac abnormalities is assoc w/ turner's syndrome
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coarctation & bicuspid aortic valve
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what cardiac defect is assoc w/ an infant of diabetic mother
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transposition
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calcification in media of the arteries, especially radial or ulnar, usually benign; pipestem aa. - doesn't obstruct bloodflow & doesn't involve intima
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Monckeberg arteriolosclerosis
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Hyaline thickening of small aa in essential HTN or DM; hyperplastic onion skinning in malignant HTN
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Arteriolosclerosis
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Fibrous plaques and atheromas form in intima of aa.
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Atherosclerosis
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Aortic dissection is associated with
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Hypertension of cystic medial necrosis (marfan's)
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DOC for rx of aortic dissection
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BB to dec BP & dec slope of rise of BP
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what is the progression of atherosclerosis
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Endothelial cell injury --> exposure to subendothelial collangen --> + platelet adhesion & release of factors that + sm. muscle cell migration
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what factors + smooth muscle cell migration
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PDGF & TGFB
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What are the most common locations of atherosclerosis
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abdominal aorta > coronary aa > popliteal aa > carotid a
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what does stable angina show on ECG
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ST depression
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what does prinzmetal's angina show on ECG and how do you tx?
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DHP CCB (due to coronary vasospasm) & ST elevation on ECG
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what does unstable angina show on ECG
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ST depression
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What is the MOA fo ANP is the kidneys? adrenals? blood vessels?
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Kidneys - diuresis
Adrenals - blocks aldosterone secretion --> inc Na & h20 excretion Blood vessels - relaxes smooth muscle |
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Why does angina result?
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Imbalance between myocardial O2 demand & supply from coronary arteries
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Most common location for coronary artery occlusion
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LAD > RCA > Circumflex
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What does MI look like after first day?
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Nothing for first 2-4 hours
Contraction bands after 1-2 hours; early coag necrosis after 4 --> Release of contents of necrotic cells into bloodstream & beginning of neutrophil migration (measure cardiac enzymes); Grossly see dark mottling; pale w/ tetrazolium stain |
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what does MI look like after 2-4 days
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Grossly see hyperremia, microscopically see tissue surroudning infarct with acute inflammation, dilated vessels (hyperremia), neutrophil emigration, muscle shows extensive coagulative necrosis
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what does a MI look like 5-10 days after?
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Hyperemic border w/ central yellow brown softening grossly
Histologically outer zone (ingrowth of granulation tissue ) --> MOST PRONE TO RUPTURE --> CARDIAC TAMPONADE |
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what does MI look like 7 weeks post?>
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Grossly recanalized artery /grey white
Risk for ventricular aneurysm due to contracted scar (scar tissue starts to bulge w/ each contraction) Fibrosis w/ myocytes |
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Gold standard for dx of MI in 1st six hours
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ECG
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Rises after 4 hours & is elevated for 7-10 days
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cardiac troponin
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what type of infarct: increased necrosis, entire wall affected, ST ELEVATION on ECG
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STEMI (transmural infarct)
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what type of infarct: ischemic necrosis of <50% of ventricle wall, subendocardium vulnerable to ischemia, due to fewer collaterals, higher pressure, ST depression on ECG
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Subendocardial infarct
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what causes dilated (congestive) cardiomyopathy
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ABCD
Alcohol abuse wet BeriBeri chronic cocaine use Doxorubicin/Daunorubicin Hemochromatosis Peripartum cardiomyopathy |
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myocyte disarray; AD; a/w Friederich's ataxia
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Hypertrophic cardiomyopathy
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Rx for HCM
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BB or nonDHP CCB to dec O2 demand
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Eccentric hypertrophy
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DCM - sarcomeres added in series
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Concentric hypertrophy
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HCM - sarcomeres added in parallel
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Causes of restrictive/obliterative cardiomyopathy
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Sarcoidosis (granulomas)
Amyloidosis Postradiation fibrosis Endocardial fibroelastosis Loffler's syndrome Hemochromatosis |
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Endomyocardial fibrosis w/ a prominent eosinophilic infiltrate
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Loffler's syndrome
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Rx for acute exacerbation of CHF
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LMNOP
Loops Morphine Nitrates O2 Position & Pressor's |
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MCC of fatigue & new onset murmur in young adult? Rx?
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Bacterial Endocarditis
DOC - Vancomycin |
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Round white spots on retina surrounded by hemorrhage
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Roth's spots - BE
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Tender raised lesions on fingers or toes
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Osler's nodes BE
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Small erythematous lesions palms or soles
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Janeway lesions
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Splinter hemorrhages
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A/w BE
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Cause of acute bacterial endocarditis
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S. aureus - affects previously normal valves
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Cause of subacute BE
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S. viridans, s. epidermidis, enterococci, S. bovis (coon cancer)
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what causes culture negative endocarditis
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HACEK:
Haemophilus Actinobacillus Cardiobacterium Echinella Kinella |
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Characteristics of BE
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Bacteria FROM JANE
Fever Roth's spots Osler's nodes Murmur Janeway lesions Anemia Nail-bed hemorrhage Emboli |
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Most common valve affected in rheumatic heart disease
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Mitral >>aortic >>tricuspid
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Early lesion of rheumatic heart disease? Late lesion?
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Mitral valve prolapse
Mitral valve stenosis |
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Granuloma w/ giant cells in myocardium
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Aschoff bodies a/w rheumatic fever
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Activated histiocytes in myocardium
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Anitschkow's cells a/w rheumatic fever
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JONES Criteria for Rheumatic Fever
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J - Joints (migratory polyarthritis)
O- (shape of heart) - pancarditis N - Nodules -- Aschoff bodies E - Erythema Marginatum S - Syndenham's chorea (face, tongue, upper limb) |
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Interstitial myocardial granulomas - plump mass w/ abundant cytoplasm & central to round ovoid nuclei
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Aschoff body
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Hypotension, JVD, Muffled heart sounds, tachycardia, pulsus paradoxus
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Cardiac tamponade
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Causes of serous pericarditis
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SLE, RA, viral infection, uremia
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Causes of fibrinous pericarditis
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Uremia, MI (Dressler's), rheumatic fever
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ST elevation in ALL leads
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Pericarditis
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dilation of aorta & valve ring --> calcifcation of aortic root & ascending aortic arch
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Syphilitic heart disease
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Ball-valve obstruction in left atrium, a/w multiple syncopal episodes
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Myxoma - most common primary cardiac tumor in adults
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Tumor a/w tuberous sclerosis
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Rhabdomyomas
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Recurrent epistaxis, skin discolorations, mucosal telangiectasia & GI bleeds
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Hereditary hemorrhagic telangiectasia (Osler-Weber Rendu) (AD)
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Varicose veins predispose to what?
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Ulcerations & poor wound healing
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Rx of wegener's granulomatosis
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Cyclophosphamide & corticosteroids
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like wegener's but lacks granulomas p-ANCA
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Microscopic polyangiitis
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+ MPO-ANCA
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Pauci Immune crescentic glomerulopnephritis
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vasculitis a/w eosinophilia - asthma, sinusitis, skin lesions, & wrist/foot drops
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Churg strauss - p-ANCA
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Congenital vascular d/o + port-wine stain, intracerebral AVM, seizures, early-onset glaucoma
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Sturge-Weber disease
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What renal d/o is HSP a/w?
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IgA nephropathy
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Sx of Kawasaki disease?
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In young asian infant/kids
Fever, Conjunctivitis, changes in lips/oral mucosa (STRAWBERRY TONGUE), lymphaenitis, desquamative skin rash, CORONARY ANEURYSMS |
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Rx for kawasaki disease?
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Iv Ig & high dose aspirin to prevent coronary a. aneurysm rupture
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Transmural vasculitis + fibrinoid necrosis - fever, wt. loss, malaise, abdominal pain, melena, H/A, HTN, neuro dysfxn, cutaneous eruptions
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PAN
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PAN is a/w what 30% of time?
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HBV
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Rx for PAN
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cyclophosphamide & steroids (also for wegener's)
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Lesions of same age?
Lesions of different age? |
PAN
HSP |
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Pulseless diseasea- granlomatous thickening aortic arch
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Takayasu arteritis
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Asian females <40, what are the sx of this disease?
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takaysau - FAN MY SKIN On Wed
F- fever A- arthritis N - night sweats MY- myalgia SKIN - nodules O - ocular disturbances W- weak pulses in upper extremities |
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Focal granulomatous inflammation in elderly females w/ unilateral h/a & jaw claudication
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Temporal arteritis
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Polypoid capillary hemangioma that can ulcerate & bleed. A/w trauma & pregnancy
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Pyogenic granuloma
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cavernous lymphangioma of neck
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Cystic hygroma
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benign capillary skin papules in AIDS pt? What's causative agent?
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Bacillary angiomatosis - Bartonella henselae
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Lymph malignancy a/w persistent lymphedema like in post radical mastectomy
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Lymphoangiosarcoma
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What is the combo of drugs or tx for essential HTN
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Diuretics (HCTZ)
ACEI ARBs CCB |
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Drugs for CHF
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Diuretics (Loops)
ACEI/ARBs BB (dec mortality) K sparing diuretics (spirinolactone) |
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Drugs for DM at risk for heart disease
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ACEI/ARBs - protective against diabetic nephropathy
CCB Diuretics BB Alpha blockers |
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Drugs for HTN in pregnancy
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Hydralazine -- 1st line
Nifedipine Labetalol Methyldopa |
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MOA of Hydralazine
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Inc cGMP --> smooth muscle relax
aa >>> veins --> dec afterload REFLEX TACHY (dose w/ BB) |
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MOA of minoxidil
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K channel opener --> hyperpolarization --> relaxation smooth muscle
aa >> veins |
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Toxicity of minoxidil
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Hypertrichosis, pericardial effusion, reflex tach, angina, salt retention
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MOA of CCB
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blocks L-type Ca channels of cardiac (non-DHP) & smooth muscle (DHP) --> dec contractility
Vascular: nifedipine > diltiazem > verpamil Heart: verpamil >diltiazem >nifedipine |
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These toxicities are for what drug class - Cardiac depression, AV block, PERIPHERAL EDEMA, FLUSHING DIZZINESS, CONSTIPATION, gingival hyperplasia
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CCB
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Dilates veins >> arteries --> dec preload --> decrease myocardial O2 demand a/w reflex tach, hypotension, flushing, H/A
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Nitroglycerin, isosorbide dinitrate
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MOA of Nitroprusside & toxicity
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inc cGMP via direct release of NO
Can cause cyanide toxicity |
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MOA of fenoldopam
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D1 receptor agonist -- relaxes renal vascular smooth muscle (only HTN tx that increases renal blood flow)
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K channel opener, & can cause hyperglycemia b/c reduces insulin release
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Diazoxide
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what two combination of drugs decrease preload & decrease afterload in order to reduce myocardial O2 demand?
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BB + nitrates
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Inhibit cholesterol precurosr mevalonate
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HMG CoA reducatase inhbitors -STATINS
DEC LDL, inc HDL, dec TG |
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Hepatoxocity (inc LFT's), rhabdomyolysis, myositis, myalgias
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Statins
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Hyperglycemia, hyperuricemia (exacerbates gout)
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Niacin - also red flushed face
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Inhibits lipolysis in adipose tissue
Reduces hepatic VLDL secretion into circulation |
Niacin -- dec LDL, INC HDL (DOC), dec TG's
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Lipid lowering agents taht can precipitate cholesterol gall stones -- DON"T give together
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Bile acid resins & FIbrates
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Prevents intestinal reabsorption of bile acids; liver must use cholesterol to make more --> dec LDL, sl inc HDL
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Bile acid resins
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Cause a sl INC in TG's
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Bile acid resins
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Prevents cholesterol reabsorption at small intestine brush border
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Ezetimibe - just dec LDL, no other effects
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What lipid lowering agent inc plaque thickness in coronary aa.
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Ezetimibe
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Upregulates LPL --> inc TG clearance
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Fibrates (DOC)
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SE of fibrates
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Myositis
Hepatoxicity Cholesterol gallstones |
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What 2 drugs can cause increase in LFT's (lipid lowering agents)
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Statins & Fibrates
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Another way to lower triglycerides by supplementation?
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Omega 3 FA
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Uses for Digoxin
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CHF to inc contractility
Atrial fib for rate control - dec conduction @ AV node and depression of SA node |
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What is the toxicity due to - Change in color vision, N/V/D dec appetite
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Dig toxicity
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What do ECG changes in Dig toxicity look like?
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Inc PR, dec QT, scooping, T-wave inversion, arrhythmia, hyperkalemia
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What worsens Dig toxicity
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Renal failure (dec excretion), hypokalemia, quinidine (dec clearance)
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What are the sites of action for the IV class antiarrythmics?
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No Bad Boy Keeps Clean
I - Sodium blockers II - beta blockers III - K blockers IV - CCB |
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What drugs are in Class Ia?
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Police Dept Questioned
Procainamide Dispyramide Quinidine |
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What drugs are in Class IIb
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The Little Man
Tocainide Lidocaine Mexiletine |
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What drugs are in Class Ic
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For Pushing Ectasy
Fleicanide Encainide Propafenone |
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Use for procainamide?
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WPW (can cause drug induced lupus)
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Toxicity of quinidine
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cinchonism
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What is prolonged w/ class Ia drugs?
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QT interval --> risk for torsades
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Overall MOA of Class I Na channel blockers
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Slow or block conduction especially in depoalrized cells; dec slope of phase 4 depolarization & inc threshold for firing in abnormal pacemaker cells. STATE DEPENDENT
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Use of Class Ib antiarrhythmics
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Ventricular TACHYarrhytmias especially post MI & in dig induced tachyarrhythmias
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What class has no effect on AP duration & can only be used in patients w/o structural abnormalities?
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Class Ic - CI post MI b/c can be proarrhythmic
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Use for class Ic
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Last resort for refractory tachy, intractable SVT
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what class decreases AP duration
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IB
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this antiarrhythmic dec conduction through AV node --> inc PR interval by dec cAMP, dec Ca currents
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Beta blockers - suppress abnormal pacemakers by dec slope of phase 4.
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Shortest acting BB
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Esmolol
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Use for BB in rhythm control
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V-tach, SVT, slowing ventricular rate during A-fib & a-flutter
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What classes increase risk for torsades?
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Class Ia (quinidine) & Class III (sotalol)
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SE of amiodarone
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Check your LFT's, PFT's, & TFT's
Hepatoxic Hypo/hyperthyroidism Pulmonary fibrosis Corneal deposits, skin deposits (photodermatitis) Neuro effects Constipation |
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bretylium can cause what?
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new arrhytmia
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What drugs can you use to tx SVT?
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Ia, Ic
BB CCB (to prevent) Adenosine (Dx |
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Drugs to tx V-tach
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Ia
Ib** BB |
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Drugs to tx afib/flutter
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BB- rate control
Class III (amiodarone & sotalol) - rhythm control |
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Drugs to rx WPW
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Procainamide
Amiodarone |
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Drug used to tx dig arrhythmias?
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Brady - adenosine
Tachy - lidocaine |
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MOA of adenosine?
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Increases K out of cells --> hyperpolarizes cell + dec Ica
DOC dx of SVT (last 15 secs) |
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Toxicity of adenosine
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Flushing, hypotension, chest pain (effects blocked by theophylline)
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MOA of K in arrhythmia?
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depresses ectopic pacemakers in hypokalemia
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