Cardio 1/19/06

Front 1

What vessels determines the blood pressure and blood flow?

Size?

Back 1

Arterioloar resistance arteries

Under 200 micrometers

Front 2

Describe the sequence or atrial depolarization leading to ventricular activation & repolarization

Back 2

SA Node -> AV Node -> Bundle of His -> Bundle branches -> Purkinje fibers

Front 3

Five factors that regulate CV mechanics

Back 3

1)prelaod
2)afterload
3)HR
4)contractility
5)lusitorpy (distensibility)

Front 4

Preload is directly estimated by?

indirectly by? clinically by?

Back 4

directly: EDV

indirectly: EDP

clinically:
1)Neck veins (jugular venous distenstion)
2)Hepatojugualr reflux
3)Pulmonary capillary wedge pressure (PCWP - mean fluid pressue of lungs as a representation of filling pressue of L Ventricle)
4)Ultrasound (ECHO)

Front 5

Most common cause of CHF is _____ dysfunction, reflected by abnormally high _____ ?

Back 5

Diastolic

Diastolic pressures

Front 6

Afterload is determined by what 4 factors?

Back 6

1)aortic valve
2)left ventricular outflow tract
3)blood mass & viscosity
4)preload

Front 7

Thickening of the muscle below the aortic valve increasing afterload called?

Back 7

Hypertrophic obstructive cardiomyopathy

Front 8

Examples of events that can v lusitropy & contractility?

Back 8

hyptertrophy, fibrosis, ischemia & distension

Front 9

5 ways to ^ mycocardial O2 supply?

Back 9

1)Heart rate
2)SV
3)O2 extraction
4)Redistribution of bloodflow
5)Anaerobic metabolism

Front 10

Major mechanism by which most individuals ^ CO in response to ^ demand or exercise?

What is the max?

Controlled by?

Back 10

^ Heart rate

200 minus age

Autonomic nervous system (withdrawal of PARASYM tone)

Front 11

Stroke Volume ^ due to what 2 factors?

Back 11

1)Skeletal muscle contracting,compressing veins in lower extremities
2)^ Sympathetic component of venous constriction

Front 12

Which muscles can ^ O2 extraction? By how much?

Which muscles cannot ^ O2 extraction?

Back 12

Skeletal Muscles; A-V O2 difference at rest = 20% (from 95% to 75%), exercise = 60% (95% to 35%)

Myocardial cells (95% to 20% O2 saturation...even at rest fully extracts O2 from available blood supply)

Front 13

People with lesss than ___ O2 saturation at rest are in big trouble? Example?

Back 13

50%

CHF - 40% Hb saturation at rest (normal is 75%)

Front 14

Which cells can use anaerobic metabolism when needed? Which cant?

Back 14

Skeletal muscles can use anaerobic metabolism

Anaerobic energy usage,
normal = 5% heart failure = 30%

Myocardial cells cant...

Front 15

What nervous tone predomindates most of our conscious state

Back 15

Parasympathetic

Front 16

Most common arrhythmia?

Back 16

Atrial fibrillation - loss of AV synchrony

incurable & irreversible :(

Front 17

4 major determinants of myocardial O2 consumption

Back 17

1)Myocardial mass
2)Wall stress
3)Inotropic state (contractility)
4)Heart rate

Front 18

Coronary flow reserve can ^ resting flow rate by how much? Necessary b/c?

Low velocity flow during?
High velocity flow during?

Back 18

4-5 times value at rest

myocardial cells cant ^ O2 extraction

Low v flow - systole
High v flow - diastole

Front 19

Coronary blood flow is determined by?

Back 19

pressure gradient difference between the aorta and the left ventricular pressure in DIASTOLE

Front 20

Vasoconstriction in epicardial conduit vessels treated by?

resistance vessels treated by?

Back 20

Nitroglycerin

agetns other than nitroglycerin

Front 21

It is necessary to V the diameter of an epicardial coronary vessel by ____ to cause signficant decrease in resting coronary blood flow?

Back 21

60-70% (2/3rds)

Front 22

Coronary blood flow varies with ____ & ____ of the obstruction?

Back 22

length & character

Front 23

Tachycardia predisposes to mycardial ischemia b/c of what 2 reasons?

Major therapy?

Back 23

1) ^ myocardial O2 consumption

2) V myocardial O2 supply (v duration of diasole)


Beta blockers

Front 24

Narrowing of valves called?

Regurgitant valves called?

Back 24

Stenosis

Insufficient/Incompetant

Front 25

In systole hear murmur over A/V valves?

over M/T valves?

Back 25

A/V stenosis

M/T regurge

Front 26

In diastole hear murmur over A/V valves?

over M/T valves?

Back 26

A/V regurge

M/T stenosis

Front 27

Incompetent valve heart response?

Valve stenosis heart response?

Back 27

Dilation (eccentric hypertrophy) - deal w/ ^ volumes

^ wall thickness, v chamber volume (concentric hypertrophy) --> can lead to eccentric hypertorphy

When eccentric hypertophy from Aortic stenosis (AS), usually irreversible

Front 28

Aortic Stenosis (AS) more common in?....usually caused by?

Other causes of aortic stenosis (2)?

Back 28

Males

Valve degeneration (bicuspid aortic valve, instead of normal tricuspid)...esp b/w ages of 15-65


Rheumatic AS - adhesion & fusion

Senile AS - calicification (most common valve lesion leading to valve replacement)

Front 29

AS usually conpensated by?

Back 29

concentric ventricular hypertrophy (eventually leading to eccentric VH)

Front 30

With AS blood flow inadequate in what situation & where?

Hypertrophy also causes?

Back 30

Especially during exercise (v flow to SUBENDOCARDIUM)

v coronary artery flow from hypertrophy

Front 31

AS symptoms?

Back 31

1)angina (w/out coronary artery dz!)

2) syncope

3) shortness of breath (dyspnea)

Front 32

Physical Findings of AS (3)?

Back 32

1) Pulsus parvus et tardus (delayed and smaller, relative to conduction of heart)

2) Ejection murmur after ejection click, peaking at mid-systole w/ "muscial quality" (can ofen be transferred to the carotid a)

3) can have S4 (b/c of LV hypertrophy)

Front 33

Perferred technique of AS diagnosis?

Standard technique of AS diagnosis?

Back 33

ECHO - noninvasive, measure difference b/w pressure in ventilce and aorta

Catheterization - invasive, used to assess he severity of AS
-Done ONLY if discrepancy b/w physical exam & ECHO

Front 34

Coronary artery disease association w/ what % of AS?

Back 34

50% of patients

Front 35

AS symptom/severity correlation

Aortic valve area (AVA) severity scale?

Back 35

Angina - 5 years
Syncope - 3 years
CHF - 2 years

Severe - AVA < 1cm2
Critical - AVA , 0.7cm2

Front 36

3 major causes of Aortic Regurgiation (AR)

Back 36

1) Marfans

2) HTN

3) endocarditis

-as the aortic root dialates, takes leaflets with it

Front 37

AR pathophysiolgy?

Back 37

volume overload -> eccentric hypertrophy

- ^ LV chamber volume, v LV wall thickness

Front 38

Signs of AR (5)?

Back 38

1) De Mussett's sign - bobbing of head in synch with HR (b/c have to have sys BP high, dias BP low - BOUNCING PULSES)

2) Traube's sign - "pistol shot"-like sound heard over femoral artery

3) Austin-flint murmur - "blowing," decrescendo murmur after A2

4) S1 may be soft b/c mitral valve actually closes due to the aortic regurgitation

5)Diastolic thrill (signifies severe AR)

Front 39

Main predictor of development of symptoms for AR?

Back 39

Systolic dysfunction (esp @ rest)

Front 40

AR Treatment:

Nonsurgical txmt when? what?

Surgical txmt when? what?

Back 40

Nonsurgical - asymprtomaic patient w/ moderate AR and NO LV dilation; use Na Nitroprusside

Surgical - 1)patient symptomatic OR 2)asymptomatic w/ LV systolic dysfunction (Rule of 55 - if EF <55% or LV end-systolic diameter > 55mm)

Front 41

Mitral Stenosis (MS) due to?

Back 41

Rheumatic fever (almost always)

3rd world/rural phenomenon - BOARD

Front 42

Pathology/physiological signs of MS?

Back 42

Fusion of commisure and contracure of leaflet

^ LA pressure, ^ pulmonary pressure

Front 43

Natural History of MS?

Back 43

"The 10 year dz"

Rheumatic fever -> 10 years later get MS -> 10yl mild to moderate -> 10yl moderate to severe

Front 44

Symptoms of MS (4)?

Back 44

1) Dysnea on exertion

2) Atrial fibrillation

3) Hemoptysis

4) Systemic emboli

Front 45

Signs of MS (5)?

Back 45

1) Accentuated S1

2) Opening snap (timing = MS severity)

3) Decresendo diastolic "rumble" murmur

4) LA dialation & dilation of R-sided chambers (rise in pulmonary pressure)

5) Atrial fibrillation (P mitrale - huge P waves - double-hump)

Front 46

Severity of MS calculated by (2)? Correlates with?

Back 46

1) Mitral valve x-sectional area (<1.0 cm2 = severe)

2) LA/LV pressure gradient

Timing between the S2 and Opening Snap

Front 47

Tx pulmonary edema with?

" tachycardia with?

" atrial fibrillation with?

Surgery for MS patients?

Back 47

pulmonary edema - diuretics

tachycardia - beta blocker

atrial fib - anticoagulants

No, Surgery very rare

Front 48

Most common cause of Mitral Regurgitation (MR) is?

others?

Back 48

Heart failure - 2ary MR b/c of dilated LV

primary MR from alteration of leaflets (rheumatic fever, endocarditis, etc)

Front 49

Hallmark sign of MR is?

Back 49

Holosystolic, blowing murmur heard @ APEX

also, S3 & Diastolic rumble from blood into LV still full

Front 50

Signs of mitral valve prolapse?

Back 50

Midsystolic clicks

Front 51

Is surgery used for MR?

Back 51

YES, especially when show symptoms of heart failure (SoB, paroxysmal noturnal dyspnea, pulmonary edema, etc)

Front 52

Pulmonary Stenosis & Insufficiency mostly seen in?

Back 52

Pediatric patients

Front 53

Mechanical valves will last ____ but ____ ?

Back 53

Lifetime; anticoagulation therapy (warfarin) is essential

Used in young patients

Front 54

Bioprosthetic valves will last ____ but ____ ?

Back 54

10-15 years; no need for anticoagulation therapy

Used in Elderly and women of child-bearing age

Front 55

In Rheumatic fever (RF) caused by ____ with tissues by what mech?

Back 55

Cross reation of antibodies

Molecular mimicry

Front 56

Most common symptoms of RF (2)? Usually follows?

Back 56

following Strep pharygitis

1) Arthritis

2) Pan-carditis (involves epi, myo, & endo cardium

also..Syndenham chorea, Erythema marginatum (rash) & subcutaneous nodules

Front 57

Pathological sign of RF?

Back 57

Aschoff body - area of fibrinoid necdrosis surrounded by mononuclear cells in the HEART

Front 58

Most common involved valves with RF? Second?

Back 58

Mitral valve

Aortic valve

Front 59

Morphologic features of MS?

Back 59

1)Thickening and calcifications of valve leaflets

2)Fusion of commissures

3) Thickening and shortening of chordeae tendinae

Front 60

Response to MS in lungs?

Back 60

Reactive pulmonary hypertension - protective to pulmonary capillaries but causes increased pressure/failure in R side of heart

Front 61

Atrial response to MS?...consequence?

can lead to?

Back 61

Expansion of LA, relives pressure on lung, but also stretches CONDUCTION FIBERS causing ATRIAL FIBRILLATION

A-fib can lead to thrombi and embolism leading to embolic STROKES

Front 62

Anytime you have a valve abnormality you have an increased risk of ?

Back 62

Endocarditis

Front 63

Cardinal features (2) of MR?

Back 63

1) fatigue

2) weakness

A-fib also a major problem

Front 64

Mitral Vavlve Prolapse also called?

Causes?

Presents?

More common in men or women

Back 64

Myxomatouse mitral valve, Barlow's syndrome

MR

Usually asymprtomatic but sometimes atypical chest pain or MIDSYSTOLIC CLICK!

More common in women, but men more commonly have problems with it

Front 65

Acute AR causes?

Chronic AR causes?

Back 65

surgical emergency b/c of backpressure into lungs

Expanded ventricular volume (after initial hypertrophy)

Front 66

Hallmark of Chronic AR

Back 66

v diastolic LV pressure but ^ systolic...therefore ^^ PULSE PRESSURE

Front 67

What kind of endocarditis can affect normal valves?

What kind of endocarditis can affect abnormal valves only?

Back 67

Acute infective endocarditis - affect NORMAL valves only w/ hightly virulent orgnisms (ie Staph aureus)

Subacute infective endocarditis (ie viridans strept)

Front 68

What is the mortality rate for Acute infective endocarditis?

Back 68

100%!

Front 69

Left-sided embolism end up?

Right-sided embolism end up?

Back 69

Brain, spleen, and kidney

Lung IV drug use!! (BOARD)

Front 70

Complications of endocarditis (5)?

Back 70

1) Valve damage (cordae rupture)

2) Myocardial abscess (ring abscess)

3) Suppurative pericarditis

4) Embolism in coronary artery and other organs

5) Chronic - immune complex problems - glomerulonephritis, arthritis, vasculitis

Front 71

Small, sterile fibrin deposition along the line of valve closure caused by?

Back 71

Marantic (nonbacterial-bacterial) endocarditis

Front 72

Small, sterile fibrin deposition along both sides of the valves?

Back 72

Libman-Sacks endocarditis

occurs with LUPUS

Front 73

Tricuspid regurgition deadly?

Usually caused by?

Back 73

No, almost always functional

Carcinoid syndrome

Front 74

Congenital pulmonary stenosis primarily affects?

Usually caused by?

Back 74

Kids (Pediatric problem)

Carcinoid syndrome

Front 75

Most common cardiac defect is?

Usually found where?

Back 75

VSD

membranous septum

Front 76

What structure lies on the intraventricular sulcus?

Back 76

LAD artery

Front 77

Pulmonary arteris are ___ and to the ___ of the aorta

Back 77

Anterior and to the left

(cross right arm in front of left)

Front 78

What vessel carries oxygen from the placenta?

Shunted in the liver by?

Shunted in the heart intracardiacly by? extracardiacly by?

Back 78

Umbilical vein

Ductus venosus

Foravmen ovale

Ductus arteriosus

Front 79

Shunting of blood through the foramen ovele allows for?

Back 79

left side of heart and the aorta to grow

Front 80

T/F there is no blood in lungs of a fetus

Back 80

F, there is about 15%...not enough for L heart/aorta growth, but just enough to DEVELOP PULMONARY CIRCUIT

Front 81

Three elements needed for making the heart, functions?

Back 81

1) CARDIOGENIC MESENCHYME - strictly for heart, makes MYOCARDIUM & ENDOCARDIUM

2) PROEPICARDIAL ORGAN - multivesicular outcropping of mesothelial tissue near the liver, makes EPICARDIUM (makes coroary arterial supply)

3)NEURAL CREST CELLS - Aortic Arch and R/L ventricular outflow tracts; also makes all cranial/facial structures

Front 82

Example of disorder of Neural crest cells (NC cells) causes?

Back 82

DiGeorge syndrom - cardiac abnomalities

NC cells do not stay as epithelial cells but become actual mesenchyme

Front 83

Circulation developes when?

Back 83

4th Week of development

Front 84

Heart develops in?

Back 84

Pericardial sac

Front 85

Ventricular mass will become?

Bulbus cordis will become?

Back 85

L Ventricle

R Ventricle

Front 86

If R Ventricle does not rotate all the way around to get even development of both chambers then you end up with?

Back 86

Double inlet left ventricle

Front 87

Endocardial cushions made of 2 masses of mesenchyme that fuse in the middle forming what?

Failure to do this causes?

Most common defect of what syndrome?

Back 87

Mesenchymal bar

Atrio-venricular canal defect (common ventricle and big common atria)

Down's syndrome

Front 88

Initially heart tube folds to the left and heart tube rotates to the right called?

Back 88

Dextrocardia - SINUS INVERTUS

Levocardia is normal

Front 89

Sinus Invertus seen in what condition?

Back 89

Kartagener's syndrome - AD hereditary disorder
1)Sinus invertus
2)Bronchiectasis
3)Sinusitis

-problem with dynein arm of cilia?

Front 90

What cells are involved in the formation of outflow tracts?

Back 90

Neural crest cells

Front 91

atrial appendage bigger on R or L

Back 91

Right! (BROAD atrial appendage)

...b/c it receives blood from the placenta, IVC, SVC & coronary sinus while the L atrial appendage (NARROW connection) only has to get blood from LA to LV

Front 92

What separates the inflow and outflow valve in the RV?

Back 92

Conus

Front 93

Distinguishing morphology of RV (2)?

Back 93

1) Thick trabeculae

2) Separation of inflow and outflow (by CONUS)

Front 94

Distinguishing morphology of LV (2)?

Back 94

1) Trabulae are thin

2) Mitral and aortic valve touch each other in the FIBROUS CONTINUITY

(NOT THE THICKNESS OF VENTRICLES!)

Front 95

Most VSD found at?

Back 95

Membranous septum

-touches aortic valve, tricuspid valve & interatrial septum

-any VSD will allow either the mitral and tricuspid valves or the tricuspid and aortic valves to touch

Front 96

Features of the Tetralogy of Fallot

Back 96

1) Pulmonary stenosis

2) R Ventricular hypertrophy

3) Overriding Aorta

4) VSD


"PROVe you have Tetrology of Fallot!"

Front 97

Lungs are an outcropping of the ?

Back 97

Esophagus

Front 98

How many openings are incorporated into the superior posterior LA?

Back 98

4 openings

Front 99

If ou don't have enough blood flow to make the vessels of the brachiocephalic vein meet in the middle than you have ?

Significance?

Back 99

Persistent Left Superior Vena CAVA (PLSVC), which connects to the cornary sinus

99% of time PLSVC is an indication of other heart defects

Front 100

Describe paradoxic emboli in adults...caused by?

Back 100

Embolis from lefs that end up in head, spleen, kidney etc (instead of lungs)

Fossa ovalis (secundum type) defet

Front 101

Muscular septum is formed by?

Back 101

The carving of the verntricular chamber by APOPTOSIS (it does not "grow" from bottom)

Front 102

T/F Membranous septum is formed b/f the AV valve leaflets attach

Back 102

True!

Front 103

Most common heart defect in Trisomy 21 (Down's)?

Back 103

Atrioventricular septal defect

Front 104

T/F Kids die of their congenital heart disease?

Back 104

F, they die form the sequelae of the diseases (ie hypertension in lung/brain, etc)

Front 105

Papent Ductus Arteriosus (DA)is an embryonic remnant of the ?

DA closed by?

DA kept patent by? why use?

Back 105

LEFT SIXTH Aortic Arch

Indomethacin

Prostaglandins (ie PGE), used for patients with v coronary perfusion (hypoplastic LV, small aorta) or Transposition of Great Vessels

Front 106

LA pressure should not exceed ___ at the end of diastole

if higher, then ithe pressure causes ?

Back 106

10 - 12 mmHg at end of diastole

20-30 mmHg causes Shortness of Breath (SoB)

Front 107

Systole ends at about the end of the what part of EKG?

Back 107

T wave

Front 108

S1

Back 108

mitral valve closing

Front 109

S2

Back 109

aortic & pulmonic valves closing

A2 normally preceeds P2

Front 110

P2 further delayed (gains separation from A2) during

Back 110

inspiration

Front 111

Wide splitting - hear lengthened A2 & P2 separation during expiration, but still not as much as inspiration)

Back 111

1) R BBB

2) pulmonic stenosis

Front 112

Fixed splitting - A2 & P2 same separation during BOTH expiration and inspiration)

Back 112

1) A/S defect

Front 113

Paradoxical splitting - A2 & P2 separation during expiration ONLY

Back 113

1) L BBB

2) Advanced aortic stenosis

Front 114

Rumbling murmur achieved during mid-systole

Also hear?

Back 114

Aortic stenosis

Ejection click prior to murmur

Front 115

Holosytstolic (same throughout) murmur

Back 115

Mitral regurgitation

...or sometimes tricuspic regurge or V/S defect

Front 116

Late systolic murmur w/ mid-systolic click

Back 116

Mitral valve prolapse bitches!

Front 117

Delayed (mid) diastolic murmur?

Also hear?

Back 117

Mitral stenosis

Opening snap

Front 118

Early decrescendo diastolic murmur?

Back 118

Aortic regurgitation

Front 119

S4

sign of?

Back 119

Atrial contration ("kick")

Noncompliant Ventricle (ie vertricular hypertrophy)

Almost always with Systemic hyptertension

occurs immediately before S1

Front 120

S3

Back 120

High pressure in LV during diastole (giving extra sound)

associated with HEART FAILURE (CHF)

Harder to pick up than S4

Front 121

First beat of Carotid coincides with?

Back 121

S1

Front 122

Electrical axis usually between?

Back 122

-30 and +90 degrees (aVL & aVF)

Front 123

prolonged PR interval (over 200 milliseconds (5 blocks))

Back 123

1st degree AV block

Front 124

T wave is bifid (P wave hidden inside T wave)

Back 124

2nd degree AV block

-some P waves produce a QRS, some P waves dont

Front 125

P waves all over that dont proceed to QRS

Back 125

3rd degree AV block

Front 126

wide QRS (over 80 milliseconds (2 blocks))

Back 126

Bundle Branch Block (BBB)

LBBB if lack of Q in Lead 1, aVL, V5 or V6 & T wave is almost in QRS

RBBB if positive R' in V1 and V2

Front 127

1st sign after acute MI on EKG

Back 127

elevated ST segment