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145 Cards in this Set

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What supplies inferior portion of LV
80%- PD arises from RCA, supplies posterior septum- right dominant
20%- PD aries from CFX
MC Coronary artery occlusion
LAD
Most posterior part of heart
LA
enlargement can cause compression of esophageal nerve- dysphagia or recurrent laryngeal nerve- hoarseness
Supplies RV
Acute marginal artery, off RCA
Supplies posterior LV
CFX
SA and AV nodes supplied by
RCA
Venodilators
ex nitroglycerin
dec preload
Vasodilators
ex hydAlAzine
dec Afterload (Arterial)
Digitalis
inc contractility of heart
inc intracellular Na which results i inc Ca
EF
SV/EDV= EDV-ESV / EDV
nmlly over 55%
Viscosity inc in
polycythemia, hyperproteinemic states- MM, hereditary spherocytosis
depends most on hct
Operating point of heart
CO = venous return
S2 splitting
aortic valve closes before pulmonic
inspiration inc this difference
Wide splitting
associated with pulmonic stenosis or RBBB
Fixed splitting
associated with ASD
Paradoxical splitting
associated with Aortic stenosis of LBBB
A2 delayed so P2 sound occurs first
on inspiration, P2 moves closer to A2
ASD murmur
presents with pulm flow murmur- inc flow through pulm valve, and diastolic rumble- inc flow across tricuspid
VSD murmur
pansystolic murmur heard in tricuspid area
Heard at left sternal border
Diastolic murmur- AR, PR
Systolic murmur- Hypertrophic cardiomyopathy
Hand grip
inc systemic vascular resistance
inc MR, VSD systolic murmurs
Valsalva
dec venous return
most murmurs dec instensity
INC MVP, hypertrophic cardiomyopathy murmurs
Rapid squatting
inc venous return, inc afterload
DEC MVP, hypertrophic cardiomyopathy murmurs
MVP murmur
dec preload causes click and murmur to move closer to S1 heart sound- anxiety, valsalva, standing
inc preload causes click and murmur to move closer to S2 heart sound- reclining, squatting, hand grip
Pulsus parvus et tardus
pulses weak compared to heart sounds
AS
cres decres systolic ejection murmur, radiates to carotids/apex
AR murmur
high pitched blowing diastolic murmur, wide pulse pressure, when chronic can present with bounding pulses and head bobbing
Congenital rubella
cataracts, deafness, PDA
Speed of conduction
Purkinje > atria > ventricles > AV node
Pacemakers
SA > AV > bundle of His/Purkinje/ventricles
AV node delay
100 ms delay, AV delay, allows time for ventricular filling
ECG
P wave- atrial depol
PR interval- conduction delay through AV node (nml < 200)
QRS complex- vent depol (nml < 120)
QT interval- mechanical contraction of ventricles
ST segment- isoelectric, ventricles depol
T wave- vent repol
T wave inversion
recent MI
Peaked T wave
hyperkalemia
U wave
hypokalemia, bradycardia
Torsades de points
v tch, shifting sinusoidal waveforms on ECG, can progress to v fi
anythng that prolongs QT interval can predispose to this
Congenital long QT syndromes
most often due to defects in cardiac Na or K channels
can present wiht severe congenital sensorineural deafness
Jervell and Lange-Nielsen syndrome
A fib
irregularly irregular, no P waves
tx beta blocker ca channel blocker, digoxin
prophylaxis against thromboembolism with warfarin
A flutter
sawtooth, flutter waves
use class IA, IC, III antiarrhythmics
1st degree AV block
prolonged PR interval >200 ms
asymptomatic
Mobitz type 1
2nd degree AV block
pregressive lengthening of PR interval until beat dropped- p wave with no qrs to follow
Mobitz type 2
2nd degree AV block
sporadic dropped beats
pathologic
may progress to 3rd degree
3rd degree AV block
atria and ventricles beat independently of each other
atrial rate is faster
tx with pacemaker
lyme dse can cause it
V fib
no identifiable waes
fatal arrhythmia without immediate CPR and defib
Atrial natriuretic peptide
released from atria in response to inc BV and atrial pressure
causes vasc relaxation, constricts efferent renal arterioles, dilates afferent arterioles- cGMP mediated, promotes diuresis, contributes to escape from aldosterone mechanism
Carotid massage
baroreceptor
inc pressure in carotid artery inc stretch, inc afferent baroreceptor firing, dec HR
Cushing rxn
ass with baroreceptors
hypertension, bradycardia, resp depression
Baroreceptors
respond to severe hemorrhage
hypotension causes vasoconstriction, inc HR, inc contractility, inc BP
Chemoreceptors
peripheral- respond to dec po2, inc pco2, dec pH of blood
central- respond to ph and pco2 of brain interstital fluid which is influenced by arterial CO2
Aortic arch receptors
transmits via vagus nerve to medulla
responds only to INC BP
Carotid sinus receptors
transmits via glossopharyngeal nerve to solitary nucleus of medulla
responds to INC AND DEC in BP
Largest AV O2 deff
Heart because extraction of O2 is always about 100%
inc O2 demand is met by inc coronary blood flow
Highest blood flow per gram tissue
Kidney
Largest share of systemic CO
Liver
PCWP
good approx of LA pressure
in MS, PCWP > LV diastolic pressure
Hypoxia in lungs causes
vasoconstriction
pulm vasc unique so that only well ventilated areas are perfused
Left to right shunts
late cyanosis, blue kids
VSD > ASD > PDA
Right to left shunts
early cyanosis, blue babies
TOF, Transposition of great vessels, Truncus arteriosus, Tricuspid atresia, Total anomalous pulm venous return (TAPVR)
Eisenmenger's syndrome
Uncorrected VSD, ASD, PDA
causes compensatory pulm vasc hypertrophy, results in pulm htn, shunt reverses to R to L!!
causing late cyanosis- clubbing and polycythemia
TOF
caused by anterosuperior displacement of infundibular septum
Pulm stenosis, RVH, overriding aorta, VSD
PROVe
Tet spells
cyanotic spells that TOF pts suffer from
squat to compress femoral aa, inc SVR, dec R to L shunt, directing more blood from RV to lungs
Transposition of great vessels
RV to aorta and LV to pulmonary trunk
not compatible with life unless there is a shunt to allow adequate mixing of blood- VSD, PDA, patent FO
due to failure of AP septum to spiral
Infantile coarctation of aorta
preductal- aortic stenosis proximal to insertion of ductus arteriosus
INfantile IN close to heart
Ass with Turners
Adult type coarct of aorta
aDult Distal to Ductus
postductal, ass with notching of ribs due to collateral circ
htn in upper limbs, weak pulses in lower extremities
Cardiac defect in infact of diabetic mother
Transposition of great vessels
Corneal arcus
lipid deposit in cornea, non specific- arcus senilis
Atherosclerosis
fibrous plaques and atheromas in intima of arteries
dse of elastic aa and large and med sized muscular aa
abd aorta > coronary artery > popliteal > carotid
Arteriolosclerosis
hyaline thickening of small aa in essential htn or dm
hyperplastic onion skinning in malignant htn
Monckeberg
calcificaiton in media of aa, esp radial or ulnar
benign pipestem aa, does not obstruct blood flow
AAA
ass with atherosclerosis
in male smokers > 50 yo
Throacic AA
ass with htn, cystic medial necrosis- Marfans
Tearing chest pain radiating to back
aortic dissection
mediastinal widening on chest x ray
Angina
CAD narrowing > 75%
stable- atherosclerosis, ST dep, retrosternal chest pain with exertion
prinzmetals- coronary artery spasm at rest, ST elevation
unstable/crescendo- chest pain at rest, ST dep
Coronary steal syndrome
vasodilator may aggravate ischemia by shunting blood from area of critical stenosis to area of higher perfusion
Coronary artery occlusion
LAD > RCA > CFX
Cardiac troponin I
RIses after 4 hrs and is elevated for 7-10 days, more specific than other protein markers
CK MB
In myocardium and also skeletal muscle
Useful in dx reinfarction on top of acute MI because only is elevated for 2-3 days after initial infarct, if elevated again means reinfarction
In first6 hours after mi what is test of choices
Ecg gold standard
St elevation- transmural
St depression- subendocardial
Q waves- transmural
Anterior wall mi
Lad, q waves in v1-4
Anteroseptal mi
Lad, qwaves in v1-2
Anterolateral mi
Lcx, q waves in v4-6
Lateral wall mi
Lcx, q waves in I, aVL
Inferior wall mi
Rca, q waves in II, III, aVF
Post infarction fibrinous pericarditis
Frictioj rub
3-5 days post MI
Dressler's syndrome
Autoimmune phenomenon resulting in fibrinous pericarditis several weeks post MI
Causes of dilated (congestive) cardiomyopathy
Chronic alcohol abuse, wet beriberi, coxsackie b virus myocarditis, chronic cocaine use, Chaga's disease, Doxorubicin toxicity, hemochromatosis, peri partum cardiomyopathy
S3, dilated heart on ultrasound, balloon appearance on chest X-ray
Eccentric hypertrophy- sarcomeres added in series, systolic dysfunction ensues
Hypertrophic cardiomyopathy
Hypertrophied IV septum, outflow tract obstruction, 50% familial AD, ass with Fredreichs ataxia, S4, diastolic dysfunction, concentric hypertrophy- sarcomeres added in parallel
Tx hypertrophic cardiomyopathy
Beta blocker or non dihydropyridine ca channel blocker- ex verapamil
Restrictive cardiomyopathy
Diastolic dysfunction ensues
Causes include sarcoidosis, amyloid, post radiation fibrosis
Lofflers syndrome
Endomyocardial fibrosis with prominent eosinophilia infiltrate
Causes restrictive cardiomyopathy
Right heart failure most often results from
Left heart failure
Isolated rhf most likely due to cor pulmonale
Tx chf
Ace inhibitors, beta blockers, angiotensin receptor blockers, spironolactone reduce mortality
Thiazides or loop diuretics used for symptomatic relief
Hemosiderin laden macrophages
Heart failure cells
In lungs, sign of pulmonary edema in lhf
Sign of right heart failure
Hepatomegaly- nutmeg liver, ankle, sacral edema, jugular venous dissension
Signs of left heart failure
Pulmonary edema, paroxysmal nostril dyspnea, orthopnea
Acute bacterial endocarditis
Staph aureus- high virulence
Large vegetarians on previously normal valve, rapid onset
Subacute bacterial endocarditis
Viridans strep- low virulence
Smaller vegetation on congenitally abnormal or diseased valves
Marantic/thrombotic endocarditis
Aseptic endocarditis, secondary to malignancy, hyper coag state or lupus
S Boris in colon ca
S epidermis in prosthetic valves
Aschoff bodies
Granulomas with giant cells
In rheumatic fever
Also ass with anitschkows cells- activated histiocytes
And elevated ASO titer
Rheumatic fever
Immune mediated, type II hs, antibodies to M protein
Fever, erythema marginatym, valvular damage- vegetation and fibrosis, inc ESR, Red hot joints- migratory polyarthritis, subq nodules, St Vitus' dance- chorea
Acute pericarditis
sharp pain worse with inspiration, better with sitting up and leaning forward
Pulsus paradoxus
dec in amplitude of systolic BP by 10 mm Hg during inspiration
seen in severe cardiac tamponade, asthma, obstructive sleep apnea, pericarditis and croup
Cardiac tamponade
compression of heart by fluid in pericardium, leading to dec CO
equilibration of diastolic pressures in all 4 chambers
hypotension, JVD, distant heart sounds, inc HR, pulsus paradoxus
Syphilitic heart dse
tertiary syphilis disrupts vasa vasorum of aorta, leads to dilation of aorta and valve ring, tree barking appearance- calcification
Kussmaul's sign
inc in jugular venous pressure on inspiration
sign of cardiac tumor causing obstruction
Varicous veins
dilated tortuous superficial veins due to chronically inc venous pressure
predispose to poor wound healing and varicose ulcers
Raynaud's dse
dec blood flow to skin due to arteriolar vasospasm, in response to cold temp or emotional stress
Raynaud's phenomenon
when secondary to mixed connective tissue disease, SLE, CREST syndrome
Wegener granulomatosis
c ANCA, focal necrotizing vasculitis, necrotizing granulomas in lung and upper airway, necrotizing glymerulonephritis
tx cyclophosphamide, corticosteroids
Churg Strauss syndrome
asthma, sinusitis, palpable purpura, wrist/foot drop, can also involve heart GI kidneys, p ANCA, granulomatous vasculitis with eosinophilia
Henoch Schonlein pupura
MC childhood systemic vasculitis
follows URIs, palpable purpura on buttocks/legs, arthralgia, GI sx, IgA immune complexes, ass with IgA nephopathy
Takayasus arteritis
large vessel vasculitis, pulseless dse, asian females < 40 yo, granulomatous thickening of aortic arch, prox great vessels
Polyarteritis nodosa
med vessel vasculitis, young adults, Hep B seropositive in 30% pts, immune complex med, involves renal and visceral vessels, NOT pulm aa
Kawasaki dse
asian children < 4yo, strawberry tongue, hand foot erythema, desquamation, tx IV immunoglobulin and aspirin
Glomus tumor
benign, painful red blue tumor under fingernails, arises from modified smooth muscle cells of glomus body
Bacillary angiomatosis
benign capillary skin papule in AIDS pts, caused by Bartonella henselae infxns, mistake for Kaposi's sarcome
Kaposi's sarcome
endothelial malignancy of skin associated with HHV 8 and HIV
Ca channel blockers on vascular smooth muscle
Nifedipine > diltiazem > verapamil
Ca Channel blockers on heart
Verapamil > diltiazem > nifedipine
Verapamil = Ventricle
Pindolol and acebutolol
partial beta agonists
contraindicated in angina
Niacin
inhibits lipolysis in adipose tissue
reduces hepatic VLDL secretion into circulation
inc HDL
SE hyperglycemia, hyperuricemia, red flushed face
Ezetimibe
cholesterol absorption blockers
prevent cholesterol reabsorption at small intestine brush border
dec LDL
Fibrates
Upregulate LPL, inc TG clearance
dec TG
SE myositis, hepatotox
Hydralazine
inc cGMP, smooth muscle relaxation, vasodilates arterioles>veins, dec afterload
1st line for htn in pregnancy with methyldopa
Malignant htn tx
Nitroprusside- inc cGMP via release of NO, can cause CN TOX
Fenoldopam- D1 receptor agonist, relaxes renal vasc smooth muscle
Diazoxide- K channel opener, can cause hyperglycemia
Nitrates- ntiroglycerin, isosorbide dinitrate
Vasodilate by releasing NO in smooth muscel, dilates veins > arteries, dec preload
aphrodisiac and erection enhancer
tx angina, pulmonary edema
relex tachy, flushing, HA, Monday disease in industrial exposure
DIgoxin
cardiac glycoside, direct inhib of Na K ATPase leads to indirect inhib of Na/Ca antiport
inc intracell Ca, Positive inotropy, stim vagus nerve
Digoxin in CHF tx
inc contractility
Digoxin in a fib tx
dec conduction at AV node and depression of SA node
Antidote for dig tox
slowly normalize K, lidocaine, cardiac pacer, anti dig Fab fragments, Mg2+
Nesiritide
recomb B type natriuretic peptide
inc cGMP and vasodilation
tx acute decompensated heart failure
Class IB antiarrhytmics
Lidocaine, Mexiletine, Tocainide, Phenytoin
Best Post MI and in dig induced arrhythmias
Dig tox
NVD blurry yellow vision
inc PR, dec QT, scooping, T wave inversion, arrhythmia, hyperkalemia
Class IC antiarrhythmics
Flecainide, propafenone
IC is Contraindicated Post MI
no effect on AP duration
refractory tachyarrhythmias
Amiodarone
K channel blocker- class III antiarrhythmic
inc AP duration, inc ERP, inc QT interval
need to check PFTs, LFTs, TFTs
tox- pulm fibrosis, hepatotox, hypo/hyperthyroidism, photodermatitis, blue gray skin deposits
Class IV antiarrhythmics
Verapamil, diltiazem, Ca channel blockers, dec conduction velocity, inc ERP, inc PR interval
used in prevention of nodal arrhythmias ex SVT
Adenosine
inc K out of cells, hyperpolarize cells and dec Ica, DOC in dx / abolishing SVT
very short ccting- 15 s
tox flushing hypotension chest pain
effects blocker by theophylline
Magnesium
effective in torsades de pointes and digoxin tox
Nicardipine
ca channel blocker
Used post SAH
Ticlopidine SE
neutropenia and TTP
bleeding
Cilostazol
phosphodiesterase inhibitor used for peripheral artery disease
inc cAMP, reversibly inhib platelet aggregation, vasodilator
tx pt with intermittent claudication from vascular dse with this
DOC for v fib in acute resuscitation
Amiodarone
structurally similar to thyroid hormone
SE hyper/hypothyroidism, pulm fibrosis, non sight threatening corneal deposits
can convert a fib with systolic dysfunction
Meds that have mortality benefit in CHF
beta blockers, ACE inhib, ARBs, spironolactone
implantable cardioverter defibrillator has benefit in ischemic cardiomyopathy with EF < 35%
Best initial therapy for MS
preload reduction with Na restriction and diuretic
most effective MS therapy- balloon valvuloplasty
Metal heart valve
maintain lifelong anticoag with warfarin
only pts in which you routinely maintain target INR above 2-3, target at least 2.5-3.5
Best medical therapy for pre eclampsia, eclampsia, torsade de pointes
Magnesium sulfate
prevents seizure in eclampsia
dec ACh in motor nerve terminals, slows SA node impulse formation rate and prolongs conduction time
reduces uterine contractility
Wolff Parkinson White syndrome
short PR interval
best tx with procainamide or amiodarone if SVT or VT develops