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154 Cards in this Set

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What supplies the apex and anterior interventricular septum?
Left anterior descending artery
comes off the anterior side of the circumflex artery
What supplies the posterior left ventricle?
Circumflex artery
What supplies the right ventricle?
Acute marginal artery
anterior branch coming off the RCA
What supplies the posterior septum/inferior left ventricle?
Posterior descending artery
Comes off the RCA posteriorly (80% of the time)

20% of the time (left dominant heart) the PD comes off the circumflex
What supplies the SA and AV nodes?
RCA
Where is the most common coronary artery occlusion and what does it supply?
LAD - the anterior interventricular septum
Which chamber is the most posteriorly oriented?
Left atrium
enlargement of this chamber can cause dysphagia and hoarseness
How do you calculate stroke volume?
SV = CO/HR = EDV - ESV
What is preload and what increases/decreases it?
Preload = ventricular EDV

inc. with exercise, fluid overload, sympathetics

dec. with venodilation (e.g. nitroglycerin)
What is afterload and what increases/decreases it?
Afterload = mean arterial pressure.

Inc. by increasing the PVR

Dec. with vasodilators (e.g. hydralazine)
What does digitalis do to the CHF starling curve?
shifts it left and up
How do you calculate ejection fraction?
(EDV-ESV)/EDV
Where is S1 loudest?
mitral area
What is S1?
mitral and tricuspid valve closure

begin systole
What is S2?
aortic and pulmonary valve closure
Where is S2 the loudest?
left sternal border
What is S3?
sound in early diastole during the rapid filling phase - so much blood is hitting the empty ventricle that it makes a noise

indicated inc. filling pressure and/or dilated ventricles
normal in children and pregnancy

"I-da-ho"
What is S4?
an "atrial kick" heard in late diastole (just before S1). the sound of left atria trying to push the last bit out against a stiff ventricle.

associated with ventricular hypertrophy
always pathologic

"A-la-ska"
What is the a wave?
inc. JVP from atrial contraction
What is the c wave?
inc. JVP from triscupid buldge into atria during systole
What is the v wave?
inc. JVP due to inc. right atrial pressure due to filling against a closed tricuspid
What is physiologic splitting?
normally heard in S2 during inspiration cuz aortic valve closes slightly before the pulmonic valve
What is fixed splitting and what is it a sign of?
It is when A2 comes more before P2 than it should and it stays like that whether you are inspiring or expiring
It is a sign of ASD
What is wide splitting a sign of?
pulmonic stenosis

right bundle branch block
What is paradoxical splitting a sign of?
aortic stenosis

left bundle branch block
What do you hear best on the left sternal border?
aortic regurgitation
pulmonic regurgitation
What are the systolic heart sounds?
aortic/pulmonic stenosis

mitral/tricuspid regurgitation
What are the diastolic heart sounds?
mitral/tricuspid regurgitation

aortic/pulmonic regurgitation
What is a holosystolic, high-pitched, blowing murmur?
mitral or tricuspid regurgitation
How is mitral reguritation heard best?
it is loudest at the apex and radiates to the axilla

enhanced by maneuvers that inc. TPR (like squatting and hand grip) or expiration
What tends to cause MR?
ischemic heart disease (e.g. ruptured cords)

mitral valve prolapse

LV dilation
Where/how is tricuspid regurgitation heard best?
loudest in tricuspid area with radiation to the right sternal border.

loudest on inspiration (inc. RA return)
What tends to cause TR?
RV dilation

endocarditis

Rheumatic fever
What kind of murmur is AS?
Crescendo-decrescendo systolic ejection murmur
Where is AS heard best?
left sternal border radiating to the carotids/apex
Which mumur is pulsus parvus et tardus associated with?
AS
What kind of murmur is a VSD?
holocystolic, harsh-sounding murmur
Where is VSD loudest?
tricuspid area
What kind of murmur is mitral valve prolapse?
late systolic crescendo with midsystolic click (due to sudden tensing of the chordae tendinae)
How/where is mitral valve prolapse heard best?
loudest at S2
enhanced by squattting/hand grip
What kind of murmur is AR?
immediate high-pitched "blowing" diastolic murmur.
What are the symptoms of AR?
wide pulse pressure

bounding pulses

head bobbing
What tends to cause AR?
aortic root dilation
bicuspid aortic valve
rheumatic fever
What tends to cause mitral valve prolapse?
myxomatous degeneration

rheumatic fever

chordae rupture
What kind of murmur is MS?
delayed rumbling late diastolic murmur following an opening snap (due to tensing of chordae tendinae)
What are the signs of MS?
LA>>LV during diastole

LA dilation (if it's chronic)

enhanced by expiration (inc. LA return)
What kind of murmur is a PDA?
continuous machine-like murmur loudest at S2
Which phase in pacemaker action potential determines HR?
slope of phase 4

Ifunny channels open more = inc. HR
P wave
atrial depolarization
PR interval
conduction through AV node
QRS complex
ventricular depolarization
QT interval
contraction of ventricles
T wave
ventricular repolarization
What does U wave on EKG indicate?
hypokalemia
What predisposes to torsades de pointes?
anything that prolongs the QT interval
Wolff-Parkinson-White syndrome findings
shortened PR

widened QRS

delta wave on ECG

may lead to SVT
Wollf-Parkinson-White pathophys
ventricular preexcitation

acccessory conduction pathway from atria to ventricle (bundle of kent) bypasses AV node and allows ventricles to depolarize earlier than normal

if reentry current ==> SVT
what are ECG findings for Afib?
Irregularly irregular rhythym

no discrete P wave in between irregularly placed QRS complex
what are ECG findings for Aftrial flutter?
a rapid succession of identical, back-tback atrial depolarization waves

sawtooth appearance
what are ECG findings for 1st degree AV block?
the PR interval is prolonged (>200msec)
benign
What are ECG findings for 2nd degree AV block?
progressive lengthening of the PR interval until a beat is "dropped" meaning there is a P wave that isn't followed by a QRS complex
usually asymptomatic

aka Mobitz type I (Wenckeback)
What are the ECG findings for 2nd degree heart block Mobtiz type II?
abrupt, nonconducted P waves show "dropped" beats that aren't preceded by lengthening PR intervals (as in type I). often found in a 2:1 P:QRS ratio
What are the ECG findings for 3rd degree heart block?
the atria and ventricles beat independently of one another.

both P waves and QRS complexes are present but they bear no relation to each other

atrial rate > ventricular rate
In pulmonary stenosis, what happens to pulmonary capillary wedge pressure?
It increases so that PCWP > LV
Which are the right-left-shut congenital heart diseases?
5 T's:
Tetralogy of Fallot
Transposition of the Great Vessells
Truncus arteriosus
Tricuspid atresia
Total anomalous pulmonary venous return
Which are the left-to-right shunts?
VSD
ASD
PDA
What is Eisenmenger's syndrome?
Uncorrected VSD, ASD PDA (L==>R shunt) becomes R==>L shunt causing late cyanosis in kids
occurs because the L->R shunt increases the work the RV has to do (inc. volume) so it hypertrophies. Eventually, this causes inc. right heart pressures that exceed those in the left heart
What are the pathologies in tetralogy of Fallot?
pulmonary stenosis
RVH
overriding aorta
VSD
What are the signs in tetralogy of Fallot?
squatting (inc. TPR ==> dec. R->L shunt across the VSD due to the stenotic pulm. valve)

boot-shaped heart

"cyanotic spells"
Infantile coarctation of the aorta
assoc. with turner's

narrowing is preductal

check femoral pulses
Adult coarctation of the aorta
stenosis is distal to the ligamentum arteriosum

notching of ribs

HTN in uppers, weak pulses in lowers

==> aortic regurg
Cardiac abnormalities associated with DiGeorge
truncus arteriousus

tetralogy of Fallot
Cardiac abnormalities associated with Down syndrome
ASD
VSD
AV septal defect

(endocardial cushion defect)
Cardiac abnormalities associated with congenital rubella
septal defects
PDA
pulmonary artery stenosis
Cardiac abnormalities associated with Turner syndrome
(preductal) coarctation of the aorta
Cardiac abnormalities associated with Marfan syndrome
aortic insufficiency (later)
Cardiac abnormalities associated with diabetic mother
transposition of the great vessels
Monckberg arteriosclerosis
calcification in the media of arteries (esp. radial and ulnar)

benign - doesn't obstruct blood flow
Arteriosclerosis
hyaline thickening of small arteries

due to essential hypertension, malignant HTN or diabetes

concentric intimal thickening ==> obstruction of blood flow
Where is the tear in an aortic dissection
longitudinal, intraluminal (within the tunic media)
How does angina present on ECG
ST depression
How does Prinzmetal's angina present on ECG?
ST elevation
Post-MI, when is the risk for arrythmia greatest?
2-4 days later
What are the signs of an MI on ECG
if transmural: ST elevations

if subendothelial: ST depressions

pathologic Q waves
What is CK-MB the best marker for?
reinfarction on top of acute MI
Q waves in V1-V4
anterior wall
LAD
Q waves in V1-V2
anteroseptal
LAD
Q waves in V4-V6
anterolateral wall
LCX
Q waves in I, aVL
lateral wall
LCX
Q waves in II, III, aVF
inferior wall
RCA
Post-MI complications (besides the obvious
mitral regurge
cardiac tamponade
VSD
aneursym
pericarditis
Dressler's syndrome
What is Dressler's syndrome?
auto-immune disorder resulting in fibrinous pericarditis several weeks post-MI
Common causes of dilated cardiomyopathy
alcoholism
Wet Beriberi
Coxsackie B virus myocarditis
chronic cocaine use
Chagas' disease
doxorubicin toxicity
hemochromatosis
peripartum cardiomyopathy
In which type of cardiomyopathy would you find an S3?
dilated
In which type of cardiomyopathy would you find an S4
hypertophic
what kind of murmur do you get with hypertrophic cardiomyopathy?
systolic murmur that gets louder with valsalva and squat==>stand
With which congenital disease is hypertrophic cardiomyopathy associated?
Friedreich's ataxia
What type of cardiac dysfunction ensues with restrictive cardiomyopathy?
diastolic dysfunction (heart can relax properly cuz it's all fibrotic/infiltrated)
What is the pathophys of PND/pulmonary edema in CHF patients
LV failure ==> inc. pulmonary venous pressure ==> distention and transudation of fluid
What is histologic evidence of CHF in the lungs?
hemosiderin-laden macrophages

due to mircohemorrhages from inc. pulmonary capillary pressure
What causes orthopnea in CHF patients?
Inc. venous return in supine position exacerbates pulmonary vascular congestion
What causes hepatomegaly in CHF patients?
inc. central venous pressure --> inc. resistance to portal flow
What causes ankle/sacral edema in CHF?
the long-standing pulmonary congestion from a failed LV leads to secondary failure of RV which backs up into the venous system causing inc. venous pressure and fluid transudation
What causes JVD in CHF?
the long-standing pulmonary congestion from a failed LV leads to secondary failure of RV which backs up into the venous system causing inc. venous pressure
What are the signs of bacterial endocarditis?
fever
Roth's spots (retinal hemorrhage)
Osler's nodes (lesions on fingers/toes)
Murmur (mitral regurge usually)
Janeway lesions (small red on palms/soles)
Anemia
Nail-bed hemorrhages
Emboli
Endocarditis in IV drug users
usually affects tricuspid valve

caused by S. aureus, Pseudomonas, Candida
Libman-Sacks endocarditis
SLE causes it:

sterile vegetations on both sides of the valve

usually benign but may lead to mitral regurge or stenosis
What are the histiologic/lab findings of rheumatic fever?
Aschoff bodies (granuloma with giant cells)

Anitschkow's cells (activated histocytes)

elevated ASO titers
What type of hypersensitivity reaction is rheumatic fever?
Type II immune-mediated.

antibodes are the M proteins produced by group A beta-hemolytic strep
What are the findings in cardiac tamponade?
hypotension
JVD
distant heart sounds
inc. HR
pulsus paradoxus
What is pulsus paradoxus?
aka kussmaul's sign

the pulse amplitude drops more than usual during inspiration
What can pulsus paradoxus be a finding in?
cardiac tamponade
asthma
sleep apnea
pericarditis
croup
What are the cardiac findings in tertiary syphillis
dilation of the aorta and valve ring
aneurysm of the ascending aorta
aortic valve regurgitation
calcification of the aortic arch ==> "tree bark" appearance of the aorta
What part of the vasculature does syphillis attack that causes the cardiac symptoms?
vasa vasorum of the aorta
What is the most common cardiac tumors in adults?
myxoma
what is the most common cardiac tumor in children?
rhabdomyomas
associated with tuberous sclerosis
Where are myxomas usually found?
left atrium
Wegner's granulomatosis causes what?
focal necrotizing vasculitis

necrotizing granulomas in the lung and upper airway

necrotizing glomerulonehpritis
Wegner's granulomatosis symptoms
hemoptysis
hematuria
perforation of nasal septum
chronic sinusitis
otitis media
mastoiditis
cough
dyspnea
Wegner's granulomatosis findings:
c-ANCA
CXR: large nodular densities
hematuria/red cell casts
Wegner's granulomatosis tx:
cyclophosphamide
corticosteroids
what is microscopic polyangitis?
like wegner's but without granulomas and p-ANCA (myeloperoxidase) instead of c-ANCA
What is Churg-Strass syndrome?
granulomatous vasculitis with eosinophilia
What are the symptoms/findings of Churg-Strass syndrome?
asthma
sinusitis
skin lesions
peripheral neuropathy (e.g. wrist/foot drop)
can also involve lungs, heart, GI, kidneys
p-ANCA +
What is Sturge-Weber disease?
congenital vascular disorder affecting capillaries mainly
What are the Sturge-Weber disease symptoms?
port-wine stain on face

ipsilateral leptomeningeal angiomatosis (intracerebral AVM)

seizures

early-onset glaucoma
what is Henoch-Schonlein purpura?
most common form of childhood systemic vasculitis (small vessels).
usually follows URI's.
IgA immune complexes
associated with IgA nephrompath
Henoch-Schonlein purpura symptoms
skin rash on buttocks and legs (palpable purpura)

arthralgia

intestinal hemorrhage

abdominal pain

melena
What is Buerger's disease?
thromboangitis obliterans
idiopathic, segmental thrombosing vasculitis of small and medium peripheral arteries and veins

smokers!!
Buerger's disease symptoms?
intermittent claudication
superficial nodular phlebitis
cold sensitivity (raynaud's)
serve pain in affected part
gangrene/auto-amputation of digits
What is Kawasaki disease?
acute, self-limiting necrotizing vasculitis in infants/children

association with Asian ethnicity

affects small/medium vessels
Kawasaki disease symptoms?
fever
conjunctivitis
changes in lips/oral muchosa (strawberry tongue)
lymphadenitis
desquamative skin rash
coronary aneurysm
What is Polyarteritis nodosa?
immune complex-mediated transmural vasculitis with fibrinoid necrosis

type III hypersensitivity

affects small/medium vessels
Polarteritis nodosa sx
fever
weight loss
malaise
abdominal pain
melena
headache
myalgia
HTN
neuro dysfunction
cutaneous eruptions
Polyarteritis nodosa findings
Hep B seropositivity
Multiple aneurysms and constrictions on arteriogram
Skin lesions are of different ages (unlike in HSP)
Typicall involves renal and visceral vessels, NOT pulm. vessels (like Wegners does)
p-ANCA usually
Polyarteritis nodosa tx
same as Wegner's:
corticosteroids
cyclophosphamide
What is Taayasu's arteritis?
aka "pulseless disease"

granulomatous thickening of aortic arch and/or prox. great vessels usually affecting young Asian women
Taayasu's arteritis sx?
fever
arthritis
night sweats
myalgia
skin nodules
ocular disturbances
weak pulses in upper extremities
What is temporal arteritis?
Most common vasculitis affecting medium and large arteriers, usually brances of the carotid.

Focal granulomatous inflammation, mainly in elderly females
temporal arteritis sx?
associated with inc. ESR

systemic involvement in half

polymyalgia rheumatica
strawberry hemangioma
benign capillary hemanioma of infacy. initially grows w/child then spontaneously regresses
cherry hemangioma
benign capillary hemanioma of elderly.

does not regress
pyogenic granuloma
polypoid capillary hemangioma that can ulcerate and bleed

assoc. with trauma and pregnancy
cystic hygroma
cavernous lymphangioma of the neck

assoc. w/Turner syndrome
Glomus tumor
benign, painful, red-blue tumor under fignernails.

Arises from modified SM cells of glomus body (thermal regulation)
Bacillary angiomatosis
Benign capillary skin papules found in AIDS patients

cause by Bartonella

ddx Kaposi's
Angiosarcoma
highly lethal malignancy of the liver.

vinyl cholride, arsening and thorotrast exposure
Lymphangiosarcoma
plympathic malignancy assoc. wither persistent lymphedema (e.g. post-radical mastectomy)
Temporal arteritis sx
unilateral headache
jaw claudication
impaired vision (occlusion of ophthalmic artery that may lead to irreversible blindness)
Hydralyzine MOA
inc. cGMP ==> smooth muscle relaxation

vasodilates arterioles > venuoles so dec. afterload
Hydralyzine clinical use
first line in HTN of preggers (along with methyl-dopa)

coadminister it with Beta-blocker to prevent reflex tachy
Hydralyzine toxicity
reflex tachy
fluid retention
nausea
headache
angion
lupus-like syndrome
Calcium-channel blockers MOA
block voltage-dependent L-type calcium channels of cardiac and smooth muscle, thereby reduce muscle contractility
Heart - verapimil > diltiazem > nifedipine

Vascular smooth muscle - nifedipine > diltiazem > verapimil
Calcium-channel blockers clinical use
HTN
angina (including Prinzmetal's)
arrhythmias (not nifedipine)
Raynaud's