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444 Cards in this Set

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S1 corresponds to _____ on EKG
QRS complex indicating ventricular depolarization (ventricular contraction- marks beginning of systole)
S2 corresponds to _____ on EKG
S2 follows T wave- marks beginning of diastole
Physiologic split accentuation:
Inspiration/ expiration?
Inspiration.

^
I = | (arrow up) accentuation
A2 accentuation observed in ____
systemic hypertension
P2 accentuation observed in ____
pulmonary hypertension
S3 heart sound: Associated conditions?
Indicates increased/rapid ventricular filling in diastole.

Normal finding in children and adulthood.

Abnormal in adults>40yrs: indicates regurgitation
1st sign of congestive heart failure?
s3 heart sound
S3: location best heard in?
Best heard over apex in left lateral decubitus position.
S4? associated conditions
Due to increased resistance to filling.

Indicates LVH.
Volume ovreload.
AV murmurs: radiation location?
Neck(aortic stenosis)
Aortic stenosis murmurs: radiation to?
Neck
Mitral regurg murmurs: radiation to?
Axilla
Change in abnormal heart sounds and murmurs with inspiration/expiration?
Increase in intensity of murmurs/abnormal sounds with inspiration: RIGHT sided murmurs

No change in intensity of LEFT sided murmurs with inspiration/expiration
MCC of continuous murmur (thru systole and diastole)
Cervical venous hum (innocent murmur)
Continuous murmurs: associated conditions?
PDA
Cervical venous hum
Innocent murmurs?
Occur in children between age 3-7yrs.
Grade 2 systolic murmurs.
JVP:waves?
+ve: acv
-ve: xy
a wave: atrial contraction
c wave: TV bulging during systole
x wave: TV downward displacement during systole
v wave: RA filling
y wave: RA emptying (without contracting)

**refer show-me(ipad)
Types of hypertrophy
Concentric
Eccentric
Sequence of events leading to concentric hypertrophy
Increased afterload/resistance-->increased wall stress-->alteration in gene expression-->duplication of sarcomeres in PARALLEL---->LVH
LVH: causes
1. Essential HTN
2. Aortic stenosis
3. Hypertrophic cardiomyopathy
Eccentric hypertrophy: sequence of events?
Preload(increased volume)--> Increased length of sarcomere-->frank-starling law--> sarcomere duplicate in series--->eccentric hypertrophy--> dilation
Eccentric hypertrophy- causes?
1. Volume overload from regurgitation
2. Left to right shunting of blood
Ventricular hypertrophy: effects?
Heart failure
Angina
S4 heart sound
S4 heart sound due to?
Blood filling non compliant ventricle
MC hospital admission dx in elderly pts?
Heart failure
Heart failure types?
1. Right sided
2. Left sided
3. Biventricular
4. High output
LHF: classification?
1. Systolic dysfunction(contraction)
2. Diastolic dysfunction(compliance)
Causes of systolic dysfunction?
1. Ischemia from CAD
2. Post-MI
3. Myocardial fibrosis
4. Myocarditis
5. Dilated cardiomyopathy
Causes of diastolic dysfunction?
1. MCC: Concentric LVH(due to essential hypertension)
2. Glycogen storage
3. Amyloid deposition
4. AR/MR
Effect of systolic dysfunction on EF?
Effect of diastolic dysfunction on EF?
Systolic dysfunction: Reduced EF
Diastolic dysfunction: Normal or Elevated EF
Heart failure:
Gross and Microscopic features?
Gross:
Lungs are heavy and congested
Contain pink frothy exudate

Microscopic: Alveolar macrophages contain hemosiderin ("Heart failure cells)
Effect of heart failure on LVEDP and LVEDP
Both elevated
Effects of heart failure?
1. Pulmonary edema
2. Left sided S3
3. Functional MR
4. PND
5. Increased BNP
Dyspnea due to heart failure: reason?
INTERSTITIAL FLUID accumuating---> stimulating juxtacapillary I receptors innervated by VAGUS
Sequence of events leading to Pulmonary edema?
Increased LVEDV-->increased hydrostatic pressure in LV-->LA-->Pulm veins-->Pulm cappillaries--> over-riding of oncotic pressure-->Transudation into interstitial spaces-->(dyspnea)--->into alveolar spaces-->pulmonary edema
Kerley's lines in CXR due to?
SEPTAL edema
Wheezing in CHF due to?
PERIBRONCHIOLAR edema
Bibasilar crackles in CHF due to?
Air expanding alveoli filled with fluid.
CXR findings in CHF?
1. Kerley lines
2. Upper lobe congestion
3. Perihilar congestion-
"Batwing configuration"
PND cause?
Due to elimination of effect of gravity while supine--> fluid moves back into vascular compartment --> increases venous return --> back pressure in lungs --> pulmonary edema
Brain natriuretic peptide: site of secretion?
Ventricles
Brain natriuretic peptide: clinical use?
Prognostic, diagnostic, predictive value.
RHF: causes?
1. RVH(non compliance)
2. Right ventricular infarction(decreased contraction)
3. Increased afterload:
LVH
Pulmonary hypertension
4. Increased preload:
TR
left->right shunt
RHF: clinical effects?
1. TV regurgitation
2. JVD
3. Hepatomegaly(painful)
4. Ascites
5. Peripheral edema
6. Cyanosis

7. S3 and S4 heart sounds
CHF: drugs used for rx?
1. ACE inhibitors: reduce preload and afterload
2. Diuretics; Reduce preload
3. Digitalis: positive inotropic agent
4. B- blockers:
Reduce oxygen consumption +
Increases diastolic filling time+
Reduce sympathetic tone
5. Hydralazine: Reduce afterload
+ reduce pulmonary pressures
6.
CHF: Non pharmacologic method?
Salt restriction<2g/day
Water restriction< 2l/day
CHF + HTN
CCB
B blockers
ACEI
High output failure: associated conditions?
1. Anemia
2. Beriberi
3. AV malformations-
1. Paget's disease - Mosaic bone
2.
4. Hyperthyroidism
Coronary circulation and distribution
LAD: (MCC for CA thrombosis)
1. Anterior portion left ventricle
2. Anterior 2/3rds of interventricular septum

Right coronary artery:
1. Right ventricle
2. Posterior 1/3rd of interventricular septum
3. Postero-inferior portion of left ventricle
4. SA node
5. AV node
6. Posteroinferior papillary muscle

Left circumflex artery:
Lateral surface of left ventricle.
Types of ischemic heart disease?
1. Angina
2. MI
3. Sudden cardiac death
4. Chronic ischemic heart disease
Risk factors: ischemic heart disease.
1. Age>45yrs- m
Age>55yrs- f
2. Smoking
3. Hypertension
4. HDL<40
5. LDL> 160
6. DM
7. Family history of premature CAD/stroke
MCC type of ischemic heart disease?
Chronic stable angina
Stable angina: causes?
1. Atherosclerotic heart disease
2. LVH (HTN and AS)
3. Hypertrophic cardiomyopathy
4. Cocaine induced vasospasm
Stable angina: pathogenesis?
Subendocardial ischemia
Stable angina: Clinical findings?
1. Chest pain- exercise induced- 30 seconds to 30 minutes. radiation left arm/jaw
2. SOB/diaphoresis- sympathetic signs
3. Relieved by nitroglycerine
4. ST segment depression>1mm
Prinzmetal angina: Pathogenesis?
Intermittent vasospasm
1. Thromboxane A2
2. Endothelin
Prinzmetal angina:
Stress test findings on EKG?
ST segment elevation
Unstable angina: Pathogenesis?
1. Severe multivessel atherosclerotic disease

2. Disrupted plaques- with/without platelet thrombi.
Unstable angina: clinical findings?
Frequent bouts of chest pain with/without exertion.
May progress to MI
Angina: Rx- drugs?
Stable angina:
Nitrates
B blockers
Ca channel blockers

Prinzmetal's angina:
CCBs

Unstable angina:
Heparin + Aspirin

Statins
Folate
Revascularization procedures?
1. PTCA
2. Balloon angioplasty w/wo stents
3.
Restenosis more common in:
1. Balloon angioplasty
2. Stents?
Balloon angioplasty
Prevention of complications(thrombi related) following revascularization procedures?
Abciximab- IIb- IIIa receptor blocker

**refer show me (ipad)
CABG: indication?
Symptomatic three vessel disease
Left main CAD
CABG: Grafts used?
Internal mammary artery grafts

Saphenous vein grafts
Chronic ischemic heart disease: Pathogenesis?
Long term ischemic damage to myocytes-->replacement of myocytes with scar tissue(non contractile)
Chronic ischemic heart disease: clinical findings?
1. Biventricular failure
2. Angina
3. Dilated cardiomyopathy
Sudden cardiac death?
Risk factors?
Unexpected death within one hour of onset of symptoms.

1. Obesity
2. Glucose intolerance
3. HTN
4. Smoking
5. Recent non-Q wave myocardial infarction
Sudden cardiac death: peak time of occurance(during a typical day)
Morning hours- hypercoagulability max
Sudden cardiac death: pathogenesis?
1. Ventricular fibrillation
2. Absence of detectable thrombus
3. Disrupted Fibrous plaques
4. Severe atherosclerosis
Sudden cardiac death: diagnosis?
Dx of exclusion:
R/o following:
1. MVP
2. Calcified AS
3. Hypertrophic cardiomyopathy
4. Cocaine use
5. Conduction defect abnormalities (?)
Sudden cardiac death: diagnosis?
Dx of exclusion:
R/o following:
1. MVP
2. Calcified AS
3. Hypertrophic cardiomyopathy
4. Cocaine use
5. Conduction defect abnormalities (?)
MI: Causes/associated conditions?
1. Atherosclerotic
2. Vasculitis-
(Kawasaki)
(PAN)
3. Embolization
(Plaques in aorta/CA)
4. Thrombosis synrdomes
(Polycythemia)
(A/thrombin III deficiency)
5. Cocaine use
6. Dissection: aortic
MI: Causes/associated conditions?
1. Atherosclerotic
2. Vasculitis-
(Kawasaki)
(PAN)
3. Embolization
(Plaques in aorta/CA)
4. Thrombosis synrdomes
(Polycythemia)
(A/thrombin III deficiency)
5. Cocaine use
6. Dissection: aortic
Types of MI?
Transmural- Q wave
(Full thickness)

Subendocardial- Non Q waves
(Inner 1/3rd)

Non Q has lesser mortality
Types of MI?
Transmural- Q wave
(Full thickness)

Subendocardial- Non Q waves
(Inner 1/3rd)

Non Q has lesser mortality
Reperfusion injury:
significance?
Improves long and short term prognosis
Damaged myocytes removed by reperfusion
Limits size of infarct

(Injured cells consume sources denying healthy cells their needs)
Reperfusion injury:
significance?
Improves long and short term prognosis
Damaged myocytes removed by reperfusion
Limits size of infarct

(Injured cells consume sources denying healthy cells their needs)
Reperfusion: Histologic findings?
1. Contraction band necrosis
2. Hypercontraction of dying cells- influx of Ca into cytosol
Reperfusion: Histologic findings?
1. Contraction band necrosis
2. Hypercontraction of dying cells- influx of Ca into cytosol
MI: Gross/ microscopic findings ?
1st 24 hrs:
Gross: No changes
Micro:
1. Coagulation necrosis
2. Neutrophils enter infarction area

1-3days:
Gross: Pale area of infarct
Micro:
1. Neutrophils(max in no) lyse dead cells
2. Myocyte striations/nuclei disappear

3-7 days:
Gross: Granulation tissue appears at the edge of infarct
Micro: Macrophages remove debris

7-10 days:
Gross: Yellow area of necrosed infarct
Micro: Granulation tissue and collagen -well formed

2 months:
Infarcted tissue replaced by white patchy non contractile tissue
MI: Gross/ microscopic findings ?
1st 24 hrs:
Gross: No changes
Micro:
1. Coagulation necrosis
2. Neutrophils enter infarction area

1-3days:
Gross: Pale area of infarct
Micro:
1. Neutrophils(max in no) lyse dead cells
2. Myocyte striations/nuclei disappear

3-7 days:
Gross: Granulation tissue appears at the edge of infarct
Micro: Macrophages remove debris

7-10 days:
Gross: Yellow area of necrosed infarct
Micro: Granulation tissue and collagen -well formed

2 months:
Infarcted tissue replaced by white patchy non contractile tissue
MI: clinical presentation
1. Severe chest pain>30 minutes
2. No relief on nitroglycerine
3. Radiates down shoulder/jaw/neck
4. Associated with sympathetic signs

Silent AMI:
elderly and DM
MI: clinical presentation
1. Severe chest pain>30 minutes
2. No relief on nitroglycerine
3. Radiates down shoulder/jaw/neck
4. Associated with sympathetic signs

Silent AMI:
elderly and DM
MI: complications?
1. Cardiogenic shock
2. CHF
3. Rupture
4. Ventricular aneurysm
5. Mural thrombus
6. Arrhythmias

6. Fibrinous pericarditis
MI: complications?
1. Cardiogenic shock
2. CHF
3. Rupture
4. Ventricular aneurysm
5. Mural thrombus
6. Arrhythmias

6. Fibrinous pericarditis
MC arrhythmias in MI?
Ventricular premature contractions?
MC arrhythmias in MI?
Ventricular premature contractions?
MCC death in MI?
Ventricular fibrillation
MCC death in MI?
Ventricular fibrillation
2MI: Rupture- time of occurence?
3-7 days after MI
22Effect of anterior wall rupture?
2Causes cardiac tamponade.
Anterior wall rupture: associated with____?
LAD coronary artery
Posteromedial papillary muscle rupture associated with?
RCA thrombosis.
(inferior AMIs)
MI associated with mitral valve dysfunction: Commonly affected vessel?
RCA
Interventricular septal rupture associated with_____?
effect?
LAD

Effect:
left to right shunt causing RHF.
Mural thrombus associated with_____CA?
Complication?
LAD

Complication: embolization
Fibrinous pericarditis: associated with Q wave/non-Q wave MI?
Day of occurence after MI?
Clinical effects?
Q wave MI

3-7 days later

Clinical effects:
1. Chest pain on leaning backwards
Relieved on leaning forwards
Percardial friction rub
Ventricular aneurysm: time of occurence after MI?
Develops within 1st 48 hrs.
Recognized after 4-8 weeks.
Ventricular aneurysm: Clinical presentation?
Complications?
Anterior bulge observed during systole-->
Blood enters aneurysm causing anterior chest wall movements.

Complications:

1. CHF due to lack of contractile tissue

2. Danger of embolization

3. Rupture
CK-MB:
Duration?
Appears in 4-8 hrs
Peaks at 24 hrs(1 day)
Disappears by 2-3 days

**MB= 48yrs
CK-MB: significance?
CK-MB elevation after 3rd day indicates re-infarction
Trp I and T: duration?
Appears in 3-12 hrs
Peaks in 24 hrs
Disappears in 7-10 days

**TT no 14
LDH: duration and measurement in MI?
Normally LDH2>LDH1

In AMI-
"LDH flip": LDH1>LDH2
Appears in 10 hrs
Reaches max in 24 hrs
Disappears in 7 days
EKG changes and corelationships?
Inverted T cells:
Ischemic area at infarct periphery

Elevated ST segment:
Injured myocardial cells

New Q waves:
Coagulation necrosis

Elevated ST segment
New Q waves
EKG patterns in AMI?
Q waves in:
Anterior wall infarction (LAD): V1-V4
Anterolateral ( LAD ):
V1-V4, I and aVL
Anteroseptal: V1-V2
Lateral(Circumflex): I, aVL
Right Inferior (RCA): II, III and aVF
Posterior (Post descending): V6 + R>S in I
Fetal circulation?
Chorionic villus(prim site for gas exchange)-->umbilical veins--->
1. IVC-->RA--> LA(thru foramen ovale)--> RV-->aorta
OR
2. SVC-->RA-->RV--> Pulm trunk-->PDA-->Aorta
(Fetal pulm arteries are constricted + hypertrophie so do not allow blood to enter)
Aorta--> Umbilical arteries(2)
Vessels with maximum O2 concentration in fetal circulation?
Umbilical veins
Vessels with minimum O2 concentration in fetal circulation?
Umbilical arteries
Changes in fetal circulation post birth?
1. Anatomic closure of PDA in 2weeks-2 months.

2. Gas exchange in lungs initiates due to increased pO2

3. Foramen ovale closes in 24 hrs
Autoimmune pericarditis: Time period of development post MI?
Cause?
Clinical findings?
1. Time period: Post 6-8wks

2. Due to Autoantibodies.

3. Fever and precordial friction rub.
Risk factors for Congenital heart diseases?
1. Previous child with CHD
2. Down syndrome/other trisomies
3. Maternal- Age
4. Maternal- DM
5. Maternal- Alcohol
6. Maternal- Infections(rubella)
Congenital heart diseases: systemic complications?
1. Secondary polycythemia
(reduced PaO2)
2. Infective endocarditis
3. Metastatic abscess
O2 saturation shunts
Left--> right: Step UP
Right --> left Step DOWN
Left--> Right shunts: complications?
1. Pulmonary HTN
2. RVH
3. LVH
4. Shunt reversal
"Eisenmengerization"

Cyanosis and clubbing
MC congenital HD?
Ventricular septal defect
VSD: associated conditions?
1. Corrected transposition
2. Fallot's quad
3. Cri du chat
4. Fetal alcohol syndrome
VSD: associated complication?
Infectious endocarditis
VSD: fate?
Spontaneous closure in 1/2 cases
MC adult Congenital HD?
ASD
VSD: clinical finding?(murmur)
Pansystolic murmur
ASD: clinical associations?
Down's syndrome
Fetal alcohol syndrome
Paradoxical embolus
ASD: types
Septum primum type
Septum secondum
MC type of ASD?
Septum primum type
Murmur in ASD?
Abnormal heart sound?
SaO2: increased/decreased?
Midsystolic in upper left sternal border
Fixed S2 split
SaO2: increased in right atrium/ventricles
PDA: associations?
1. Congenital rubella syndrome
2. Down's syndrome
3. RDS (decreased PaO2)
4. Transposition- complete
PDA: effects?
1. Continuous machinery murmur
2. Right to left shunt due to Pulm HTN--> Deox blood shunts into aorta (below subclavian)--> differential cyanosis
3. Increased SaO2 in pulmonary artery
Left--> Right shunts?
1. ASD
2. VSD
3. PDA
Right--> left shunts?
1. Fallot's
2. Transposition
Fallot's Quad?
1. VSD
2. PS
3. Aortic dextrorotation
4. RVH
ToF: onset of cyanosis: time frame?
After 3 months
ToF: associated murmur?
Systolic murmur along left sternal border.
ToF: decisive factor for cyanosis?
PS severity.
Tet spells?
Hypoxic spells in ToF: due to increase in hypoxemia and cyanosis

Squatting increases resistance--> increases left sided pressure--> reverses shunt temporarily
Coarctation of aorta: site?
Constriction site: Between subclavian artery and ductus arteriosus
Coarctation associated with?
Turner's syndrome
Coarctation of aorta: Clinical findings?
1. Hypertension in UL
2. Hypotension in LL
3. Dilation of aorta and aortic rings--> dissection
4. Increased cerebral blood flow--> berry aneurysm
5. Claudication in LL
6. RAA activation--> hypertension
7. Collateral circulation-
anterior IC(internal mammary) and posterior IC vessels ( Aorta) : NOTCHING OF RIBS
Superior- inferior epigastric artery
8. Bicuspid aortic valve.
9. Systolic murmurs
Rheumatic fever: Site of primary infection?
Pharynx(pharyngitis)
RF: Type of autoimmune reaction?
Pathogenesis?
Type II
Type IV

"Molecular mimicry"
Group A strept infection--> immune reaction--> AB cross react against human tissue
Difference between RF starins of grp B strept and Nephrogenic strains?
Nephrogenic strains lack M proteins
Earliest clinical presentation of RF?
Migratory polyarthritis
Migratory polyarthritis:
Sites?
Damage mediated:
Permanent/ temporary?
Knees
Ankles
Wrists

Damage- temp
MCC of death in RF?
Myocarditis
(pancarditis)
RF Myocarditis: microscopic finding?
Aschoff bodies:
Central area of fibrinoid necrosis surrounded by Anitschkow cells: reactive histiocytes
RF endocarditis: MC valves involved?
Gross?
#1 MV: MR
#2 AV: AR

Gross: Sterile Verucoid vegetation along lines of closure of valves.

Recurrent MV/AV infection-->
MV/AV stenosis
RF endocarditis: embolism common / uncommon?
uncommon
Subcut nodules: site of development?
Extensor surfaces of arms/legs
Erythema marginatum?
Evanescent redness that develops around normal skin
Latest manifestation of RF?
Sydhenam's chorea
Sydhenam's chores?
Reversible, rapid involuntary movement
RF: Dx?
One major+ 2 minor+ antecedent proof of streptococcal infection

Major:
1. Migratory polyarthritis
2. Carditis
3. Erythema marginatum
4. Sydhenam's chorea
5. Subcutaneous nodules

Minor:
1. Fever
2. Arthralgia
3. Previous RF
4. Increased APR: ESR/CRP/Neutrophilic leukocytosis
5. Prolonged PR
RF: Lab tests?
1. ASO titres >400 Todd units
2. A/DNAse B titres
3. Throat cultures
RF: rx?
Penicillin
Aspirin
Corticosteroids if murmur present
Mitral stenosis: Etiology? Pathogenesis?
Etiology: RF
Pathophys: Narrowing of mitral orifice--> Left atrial dilation and hypertrophy
Mitral stenosis: Complications/Clinical effects?
1. Atrial fibrillation
2. Pulmonary hypertension
3. Dysphagia for solid foods
4. Opening snap with mid-diastolic rumble
5. Dyspnea/hemoptysis
6. Systemic embolization from A-fib
Mitral regurgitation: Causes/ Associated conditions?
1. Mitral Valve prolapse:(Marfan's, ED syndrome)
2. Infective endocarditis
3. Rupture of papillary muscles
4. Libman sack endocarditis
Most frequent valvular lesion?
Mitral valve prolapse
Mitral valve regurg: Pathophysiology?
Clinical findings?
Dilated and hypertrophied left atrium from
Volume overload.
Clinically:
Dyspnea
Inspiratory crackles
Cough(LVH)

PANSYSTOLIC MURMURS
Mitral valve prolapse: Associated conditions
Marfan's syndrome
Ehlers Danlos sydrome
MVP: Pathophysiology?
Bulging of leaflets into left atrium during systole.
Mainly due to redundancy of valve tissue from myxomatous degeneration from excess production of dermatan sulfate.
Mitral valve prolapse: associated murmur?
Mid-systolic click.
(sudden restrain of chordae tendinae) followed by mid systolic murmur.
Effect of preload alteration on mitral valve prolapse murmurs?
Effect:
Increased preload causes sound to move closer to S2
(squatting/sustained hand grip, reclining) squatting increases peripheral resistance and impedes emptying.


Decreased preload causes sound to mover closer to S1.
(anxiety, standing, valsalva maneuver)

Clinical findings?
1. Palpitations
2. Chest pain
3. Chordae rupute
Mitral valve prolapse: rx?
B-blockers- less force of contraction therefore less traction and damage to MV
Mitral stenosis: Etiology? Pathogenesis?
Etiology: RF
Pathophys: Narrowing of mitral orifice--> Left atrial dilation and hypertrophy
Mitral stenosis: Complications/Clinical effects?
1. Atrial fibrillation
2. Pulmonary hypertension
3. Dysphagia for solid foods
4. Opening snap with mid-diastolic rumble
5. Dyspnea/hemoptysis
6. Systemic embolization from A-fib
Mitral regurgitation: Causes/ Associated conditions?
1. Mitral Valve prolapse:(Marfan's, ED syndrome)
2. Infective endocarditis
3. Rupture of papillary muscles
4. Libman sack endocarditis
Most frequent valvular lesion?
Mitral valve prolapse
Mitral valve regurg: Pathophysiology?
Clinical findings?
Dilated and hypertrophied left atrium from
Volume overload.
Clinically:
Dyspnea
Inspiratory crackles
Cough(LVH)

PANSYSTOLIC MURMURS
Mitral valve prolapse: Associated conditions
Marfan's syndrome
Ehlers Danlos sydrome
MVP: Pathophysiology?
Bulging of leaflets into left atrium during systole.
Mainly due to redundancy of valve tissue from myxomatous degeneration from excess production of dermatan sulfate.
Mitral valve prolapse: associated murmur?
Mid-systolic click.
(sudden restrain of chordae tendinae) followed by mid systolic murmur.
Effect of preload alteration on mitral valve prolapse murmurs?
Effect:
Increased preload causes sound to move closer to S2
(squatting/sustained hand grip, reclining) squatting increases peripheral resistance and impedes emptying.


Decreased preload causes sound to mover closer to S1.
(anxiety, standing, valsalva maneuver)

Clinical findings?
1. Palpitations
2. Chest pain
3. Chordae rupute
Mitral valve prolapse: rx?
B-blockers- less force of contraction therefore less traction and damage to MV
Aortic valve: area of the valve?
3 cm^2
Aortic valve stenosis: definition?
Area of AV< 1cm^2
Aortic valve stenosis: area below which pt presents clinically?
0.5 cm^2
Aortic stenosis: causes?
1. Bicuspid aortic valve--> calcification
2. Age related degeneration >60 yrs
3. Rheumatic fever
4. Congenital aortic stenosis < 30 yrs
Aortic stenosis: Pathophysiology/clinical effects?
Concentric LVH d/t increased afterload
Angina
Syncope on exertion
Palpitations
S4 heart sound
Systolic murmur
Hemolytic anemia- schistocytes

Stenotic valve reduces blood flow --> decreased coronary and central perfusion--> angina/syncope

LVH also contributes to angina
Aortic stenosis: effects of preload/afterload on murmurs?
Murmur intensity
Increases with increased preload
Aortic regurgitation: Causes?
1. Aortic root dilation(marfan's)
2. Syphilitic aortitis
3. Ankylosing spondylitis aortitis
4. Aortic dissection
5. Aortic coarctation
6. Infectious endocarditis
7. RF
8. Takayasu's arteritis
9. Long standing HTN
Aortic regurgitation: Clinical findings?
1. Early diastolic murmur
2. S3 and S4
3. Increased systolic pressure
4. Decreased diastolic pressure
5. Widened pulse pressure
(signs of widened pulse pressure)
6. Austin Flint murmur
Austin Flint murmur?
Observed in AI.
Regur jet hit MV and produces noise
Widened pulse pressure signs?
1. Watson's water hammer pulse
2. Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
low diastolic and increased pulse pressure
3. De Musset's sign (head nodding in time with the heart beat)
3. Quincke's sign (pulsation of the capillary bed in the nail; named for Heinrich Quincke)
4. Traube's sign (a 'pistol shot' systolic sound heard over the femoral artery; named for Ludwig Traube)
5. Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethescope)
Tricuspid regurgitation: causes?
1. Functional:
1. RVH
(Pulm HTN
RV infarction
Dilated cardiomyopathy)
2. Congenital malformation
3. Infective endocarditis
4. Carcinoid heart diseases
Tricuspid regurgitation: causes?
1. Functional:
1. RVH
(Pulm HTN
RV infarction
Dilated cardiomyopathy)
2. Congenital malformation
3. Infective endocarditis
4. Carcinoid heart diseases
Tricuspid regurgitation: causes?
1. Functional:
1. RVH
(Pulm HTN
RV infarction
Dilated cardiomyopathy)
2. Congenital malformation
3. Infective endocarditis
4. Carcinoid heart diseases
Tricuspid regurgitation: clinical findings?
1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation
3. RHF
4. Pulsating liver
5. Giant c and v wave on JVP
Tricuspid regurgitation: clinical findings?
1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation
3. RHF
4. Pulsating liver
5. Giant c and v wave on JVP
Tricuspid regurgitation: causes?
1. Functional:
1. RVH
(Pulm HTN
RV infarction
Dilated cardiomyopathy)
2. Congenital malformation
3. Infective endocarditis
4. Carcinoid heart diseases
Pulmonic stenosis: disease association?
Murmur?
Dz assoc: Carcinoid heart disease.

Murmur: Ejection systolic murmur
(RVH)
Pulmonic stenosis: disease association?
Murmur?
Dz assoc: Carcinoid heart disease.

Murmur: Ejection systolic murmur
(RVH)
Tricuspid regurgitation: causes?
1. Functional:
1. RVH
(Pulm HTN
RV infarction
Dilated cardiomyopathy)
2. Congenital malformation
3. Infective endocarditis
4. Carcinoid heart diseases
Pulmonic valve regurg: disease cause/assoc?
Pulm HTN
Diastolic murmur
Tricuspid regurgitation: clinical findings?
1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation
3. RHF
4. Pulsating liver
5. Giant c and v wave on JVP
Tricuspid regurgitation: clinical findings?
1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation
3. RHF
4. Pulsating liver
5. Giant c and v wave on JVP
Tricuspid regurgitation: clinical findings?
1. Pansystolic murmur. S3 and S4
2. Right atrial hypertrophy and dilation
3. RHF
4. Pulsating liver
5. Giant c and v wave on JVP
Pulmonic valve regurg: disease cause/assoc?
Pulm HTN
Diastolic murmur
Carcinoid heart disease: Associated valvular heart lesions
TI
PS

"TIPS"
Pulmonic stenosis: disease association?
Murmur?
Dz assoc: Carcinoid heart disease.

Murmur: Ejection systolic murmur
(RVH)
Pulmonic stenosis: disease association?
Murmur?
Dz assoc: Carcinoid heart disease.

Murmur: Ejection systolic murmur
(RVH)
Carcinoid heart disease: Associated valvular heart lesions
TI
PS

"TIPS"
Pulmonic stenosis: disease association?
Murmur?
Dz assoc: Carcinoid heart disease.

Murmur: Ejection systolic murmur
(RVH)
Austin flint murmur: significance?
Indicates Aortic valve replacement necessary.
Pulmonic valve regurg: disease cause/assoc?
Pulm HTN
Diastolic murmur
Infectious endocarditis: risk factors?
IVDA
IV caths
Poor dental hygiene
Aortic stenosis
Mitral valve prolapse
Prosthetic valves
Hemodialysis
DM
HIV
Congenital heart diseases
Pulmonic valve regurg: disease cause/assoc?
Pulm HTN
Diastolic murmur
Austin flint murmur: significance?
Indicates Aortic valve replacement necessary.
Infectious endocarditis: risk factors?
IVDA
IV caths
Poor dental hygiene
Aortic stenosis
Mitral valve prolapse
Prosthetic valves
Hemodialysis
DM
HIV
Congenital heart diseases
Infectious endocarditis: associated pathogens?
Strept viridans
Strept bovis

Staph aureus
Staph epidermidis
Pulmonic valve regurg: disease cause/assoc?
Pulm HTN
Diastolic murmur
Carcinoid heart disease: Associated valvular heart lesions
TI
PS

"TIPS"
Carcinoid heart disease: Associated valvular heart lesions
TI
PS

"TIPS"
Infectious endocarditis: associated pathogens?
Strept viridans
Strept bovis

Staph aureus
Staph epidermidis
Austin flint murmur: significance?
Indicates Aortic valve replacement necessary.
Infectious endocarditis: risk factors?
IVDA
IV caths
Poor dental hygiene
Aortic stenosis
Mitral valve prolapse
Prosthetic valves
Hemodialysis
DM
HIV
Congenital heart diseases
Carcinoid heart disease: Associated valvular heart lesions
TI
PS

"TIPS"
MCC of infectious endocarditis?
Strept viridans
Infectious endocarditis: associated pathogens?
Strept viridans
Strept bovis

Staph aureus
Staph epidermidis
MCC of Infectious endocarditis in IVDS?
Prognosis?
Staph aureus
High mortality
MCC of infectious endocarditis?
Strept viridans
Austin flint murmur: significance?
Indicates Aortic valve replacement necessary.
Austin flint murmur: significance?
Indicates Aortic valve replacement necessary.
Infectious endocarditis: risk factors?
IVDA
IV caths
Poor dental hygiene
Aortic stenosis
Mitral valve prolapse
Prosthetic valves
Hemodialysis
DM
HIV
Congenital heart diseases
MCC of Infectious endocarditis in IVDS?
Prognosis?
Staph aureus
High mortality
Infectious endocarditis: associated pathogens?
Strept viridans
Strept bovis

Staph aureus
Staph epidermidis
MCC of infectious endocarditis?
Strept viridans
Infectious endocarditis: risk factors?
IVDA
IV caths
Poor dental hygiene
Aortic stenosis
Mitral valve prolapse
Prosthetic valves
Hemodialysis
DM
HIV
Congenital heart diseases
MCC of infectious endocarditis?
Strept viridans
MCC of Infectious endocarditis in IVDA?
Prognosis?
Staph aureus
High mortality
MCC of Infectious endocarditis in IVDS?
Prognosis?
Staph aureus
High mortality
Infectious endocarditis: associated pathogens?
Strept viridans
Strept bovis

Staph aureus
Staph epidermidis
MCC of infectious endocarditis?
Strept viridans
MCC of Infectious endocarditis in IVDA?
Prognosis?
Staph aureus
High mortality
infective endocarditis: valves involved : left side/ right side?
left sided valves generally involved
Right sided valve involvement associated with?
Infective endocarditis
MC valve involved in infective endocarditis?
Mitral valve
MC valves involved in Infective endocarditis due to IVDA?
Tricuspid and aortic valves.
Infective endocarditis: Pathogenesis?
Turbulent blood flow--> damage of valve--> adherence of fibrin platelet--> trapping of bacteria and fungi--> proliferation--> fibrin deposited to encase vegetation
Previously damaged valves are infected by
?
Strept viridans
MCC of infective endocarditis in colorectal ca/ ulcerative colitis?
Strept bovis
MCC of infective endocarditis after prosthetic valve insertion?
Time frame of occurence?
Staph epidermidis
After 2 months
Previously normal valve involvement in infectious endocarditis: associated organism?
Staph aureus
Infective endocarditis: pathology?
Vegetations damage valve leaflets and chordae tendinae--> regurgitation
Infective endocarditis: Clinical finding?
1. Fever
2. Immune complex vasculitis:
a. Osler's nodes: Painful nodules reddish, on palms and soles- immune complex deposits
b. Glomerulonephritis
c. Roth spots-(retinal white spot surrounded by irregular red hemorrhagic area)

3. Microembolization findings:
i. Splinter hemorrhages in nail bed
ii. Janeway's lesion: painless lesions on palms and feet. Microabscess of DERMIS does NOT involve epidermis
iii. Mucosal petechiae
iv. Infarctions(micro?)- digits and brain
4. Splenomegaly
5. Hematuria + RBC cast
Osler's nodes vs Janeway lesions?
Similarities:
Erythematous
Occur on palms and feet
Macules or papules

Differences:
Osler's nodes- painful
Janeway lesions- painless

Osler's nodes- immune complex
Janeway nodes: septic emboli
Osler's nodes: associated diseases?
1. SLE
2. Marantic endocarditis
3. Disseminated Gonococcal infection
4. Infected arterial catheter
Osler's nodes are indicative of :
Subacute/ acute bacterial endocarditis?
Subacute bacterial endocarditis
Infective endocarditis: lab findings?
1. Positive blood cultures: serial +ve cultures required for Dx.
2. Neutrophilic leukocytosis
3. Monocytic leukocytosis
4. Anemia of chronic disease
5. Transesophageal echocardiography: for detecting vegetations
Infective endocarditis:
Neutrophilic leukocytosis indicates:
Acute/ Subacute IE?

Monocytic leukocytosis indicates:
Acute/subacute IE?
Neutrophilic: Acute IE
Monocytic: Subacute IE
Libman sack endocarditis: associated dz?
Pathology?
SLE
Sterile vegetations over Mitral valve and chordae--> regurg
Marantic endocarditis
Associated condition?
Pathogenesis?
Complication?
Associated condition: Paraneoplastic syndrome

Pathogenesis: Mucin secreting tumor--> procoagulant effect

Complication:
1. Embolization
2. Secondary infection
Major cause of sudden death in adults?
Myocarditis
Myocarditis: Etiology?
1. Coxsackie virus
2. Chagas' disease: Trypanosoma cruzi
3. Lyme disease
4. ARF
5. Drugs- dauxorubicin, daunorubicin, cocaine
6. SLE
7. Systemic sclerosis
8. Sarcoidosis
9. Diphtheria
10. CO
Myocarditis: pathology?
1. Enlargement and dilation of heart
2. Lymphocytic inflitration(coxsackie v)
3. Focal areas of necrosis
(coxsackie v)
Myocarditis: clinical picture?
Fever
Chest pain
Pericardial friction rub
MV regurgitation
Myocarditis: lab findings?
CK-MB
Trop I and T

Detection of antibodies
Pericarditis: MCC?
Coxsackie
Pericarditis: Pathology?
1. Fibrinous type of exudate
(with effusion)
2. Scar tissue with dystrophic calcification
Pericarditis: Clinical findings?
1. Tachycardia
2. Fever
3. Precordial chest pain- relived on leaning forwards
4. Pericardial friction rub
5. Sr CK-MB- normal
6. Trop I and T increased
7. Pericardial effusion
8.Muffled heart sounds(effusion)
9. Drop in systolic blood pressure by 10mm on inspiration
10. Neck vein distention on inspiration
Hypotension/pulsus paradoxus associated with pericardial effusion? reason?
10mm drop in systolic BP: due to
increased pressure of blood in rt ventricle-->
displaces septum to left -->
Decrease in left ventricle volume-->
Decreased BP
Pericardial effusion: Neck vein distension on inspiration?
Due to decreased blood entering right side of heart-->
blood refluxes back into jugular vein
aka "Kussmaul sign"
Pericardial effusion: CXR?
CXR:
"Water-bottle" configuration
Pericardial calcification (constrictive pericarditis)
Constrictive pericarditis: Etiology?
1. Tb
2. Scarring from prior open heart sx
3. Pericardial calcification
Constrictive pericarditis: pathophysiology?
Incomplete filling of cardiac chamber
Pericardial knock:
Associated condition?
Reason?
Condition: Constrictive pericarditis
Ventricles hitting the thickened pericardium
Cardiomyopathy: primarily involves:
Endocardium
Pericardium
Myocardium?
Myocardium
Cardiomyopathy: types?
Dilated
Hypertrophic
Restrictive
MC cardiomyopathy?
Dilated cardiomyopathy
Dilated cardiomyopathy: Etiology?
1. Idiopathic
2. Genetic
3. Myocarditis

4. Drugs
Daunorubicin
Dauxorubicin
Cocaine
Alcohol- thiamine deficiency

5. Post partum

6. Organic solvents
"glue sniffers' heart

7. Acromegaly
8. Myxedema
Dilated cardiomyopathy:
Clinical findings?
1. Dilated chambers
2. MR, TR
3. Reduced pulse pressure
4. Reduced EF<40%
5. S3 and S4
6. Echocardiography- poor contractility
7. Arrhythmias
Dilated cardiomyopathy: Rx?
Cardiac transplantation
MCC of dilated cardiomyopathy?
Myocarditis
MCC of sudden cardiac death?
Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathy: types/forms?
Familial
Sporadic
Hypertrophic cardiomypathy: familial form: inheritance pattern?
AD
Hypertrophic cardiomypathy: Genetic defect?
Chromosome 14 affected:
Mis-sense mutation in atleast 1/10 genes
: code for cardiac sarcomeres

Mutation in myosin heavy chain
Hypertrophic cardiomypathy: Pathophysiology?
1. Hypertrophy of myocardium
2. Disproportionate hypertrophy of Interventricular septum
3. IVS hypertrophy obstructs outflow tracts
(Obstruction BELOW aortic valve level)
4. Abberant myofibrils present--> Conduction defects
5. Non compliant left ventricle
Hypertrophic cardiomypathy:
Clinical findings?
1. Systolic ejection murmur
2. Palpable double apical impulse
3. Murmur intensity increases with decreased preload(worsens obstruction)
vice versa
Increased preload-->opens obstruction--> opens outflow tract
4. Angina/syncope with excercise.
Hypertrophic cardiomypathy: Rx?
Avoid exercise
Avoid drugs that decreased preload (diurectics)/
increase force of contraction(digitalis)

b-blockers-
Decrease contractility
Improves diastole--> increase preload
Implantable cardio-defibrillator
Screen relatives with Echo
Restrictive cardiomyopathy: Causes?
1. Amyloidosis
2. Myocardial fibrosis(post sx)
3. Radiation
4. Pompe's dz
5. Hemochromatosis
6. Endocardial fibroelastosis
7. Systemic sclerosis
Restrictive cardiomyopathy: pathophysiology? clinical findings?
Decreased ventricular compliance
Diastolic dysfunction
progressive LHF and RHF
EKG- ST-wave changes
MC tumor of heart?
Metastasis
MC site for metastsis?
Pericardium
Primary cardiac tumors?
Cardiac myxoma
Rhabdomyoma
MC prim adult heart tumor?
Cardiac myxoma
Cardiac myxoma: benign/malignant?
benign
Cardiac myxoma: type of tumor? mc site?
Mesenchymal tumor
site: left atrium
Cardiac myxoma: presentation similar to____ valvular defect?
why?
Ball valve effect blocks mitral valve orifice-->prevents diastolic filling of heart

simulates MS
Cardiac myxoma: Clinical findings?
Fever fatigue malaise
Cardiac myxoma: complication?
dx?
Embolization
Syncope

dx: transesophageal ultrasound
(viewing left atrium)
MC primary tumor in infants and children?
Rhabdomyoma
Rhabdomyoma: dz association?
Tuberous sclerosis
Rhabdomyoma: type of tumor?
Hamartoma: Non neoplastic
TG transporters in blood?
Chylomicrons
VLDL

(major component= TGs)

Diet: Chylomicrons
Liver: VLDL
Lipoprotein composition?
1. Proteins
2. TG
3. Cholesterol
4. Phospholipids
Chylomicron synthesis requires_____apolipoprotein
apoB48
Source of apoCII and apo E?
HDL
Chylomicrons: function?
Source of FAs and glycerollo
Chylomicrons: hydrolysis/metab?
Hydrolysed by capillary LPLase--> chylomicron remnant--> taken up by liver (receptors for apoE)
VLDLs require ____apoprotein for assembly.
apoB100
VLDL: function?
Source of FAs and glycerol for synthesis of triglycerides.
VLDL: hydrolysis/metab?
VLDL(Capillary LPL)--> IDL -->LDL

IDL--> removed by liver(receptors to apo E)
Cholesterol ester transport protein: fn?
Transfers CH from HDL to VLDL
Transfers TG from VLDL to HDL

Increase in VLDL causes decrease in HDL
VLDL and chylomicrons location in plasma?
VLDL: infranate
Chylomicrons: supranate
TG levels: optimal levels?
<150mg/dl
LDL: function?
Transport if CHOLESTEROL in blood
LDL: source?
VLDL--> IDL--> LDL
(by capillary LPL)
LDL: calculation?
LDL= Sr cholesterol- HDL- TG/5
Cholesterol fn?
A= Adrenal cortex hormones
B= Bile
C= Cell membrane
D= Vit D
LDL: optimal levels?
<100 mg/dl
LDL measured during fasting: reason?
Chylomicrons post food consumption falsely lowers calculated LDL.
LDL: risk for coronary heart disease when LDL level are ____.
> 190mg/dl
Cholesterol lowering therapy?
Subdivide-

1. Patients with known coronary artery disease
Hmg CoA reductase inhibitors:
target < 100mg/dl

2. Patients without known coronary artery disease.

a. With risk factor: 0-1
<160mg/dl
b. with risk factors:2+
<130mg/dl

Risk factors:
1. Male>45
Females>55
2. Hypertension
3. Family history of CAD
4. HDL<40
5. LDL>160mg/dl
6. Cigarette smoking
HDL increased with?
Exercise
Wine
Estrogen
HDL: synthesis site?
1. Iiver
2. Small intestines
HDL: function?
Source for apolipoprotein.
Removes CH from periphery
HDL: optimal levels?
suboptimal?
Optimal: HDL>60

Suboptimal:
HDL<40
Lipoprotein disorders
Types I-V
Abetalipoprotinemia


****refer show-me(ipad)
Type I hypercholesterolemia: Inheritance pattern?
Pathogenesis?
Autosomal recessive

LPL deficiency
ApoCII deficiency
Type I hypercholesterolemia: Clinical findings?
1. Chylomicrons increased
2. VLDL increased
3. Acute pancreatitis

(Rupture of pancreatic vessels filled with chylomicrons)
Type I hypercholesterolemia:
lab findings?
1. TG>1000mg/dl
2. Turbid supranate
3. Clear infranate
4. Cholesterol levels NOT increased
Type II hypercholesterolemia:
Inheritance pattern(familial)?
Other causes?
Inheritance: AD

Causes:
Hypothyroidism
(Nephrotuc syndrome, extrahepatic cholestasis)
Type II hypercholesterolemia: Pathogenesis?
LDL receptor deficiency
Type II hypercholesterolemia:
Clinical findings?
1. Premature coronary artery disease
2. Tendon xanthoma
3. Xanthelasma
Polygenic hypecholesterolemia?
Type IIa
Multifactorial inheritance
Normal sr. TG
Increased sr CH
Familial combined hypercholesterolemia?
Type IIb
AD
Increased sr. TG
Increased sr. CH
Familial combined hypercholesterolemia: associated condition?(IIB)
Metabolic syndrome
Type III hyperlipoprotenemia: Inheritance pattern?
Pathogenesis?
AD
Pathogenesis: Deficiency of apoE--> decreased uptake of IDL and chylomicron remnants
Type III hypercholesterolemia: Inheritance pattern?
pathogenesis?
Inheritance pattern: AD

Pathogenesis:
Deficiency of apoE-->
decreased liver uptake of chylomicron remnants
Type III hypercholesterolemia:
Clinical findings?
Palmar crease xanthoma

Increased risk for:
CAD
Peripheral vascular disease
Type III hypercholesterolemia:
lab findings/Dx?
CH and TGs increased
LDL--normal

Lipoprotein electrophoresis and apoE gene identification
Type IV hyperlipoproteinemia:
Inheritance pattern?
Pathogenesis?
AR
Increased synthesis and reduced catabolism of VLDL
Type IV hypercholesterolemia:
Acquired causes?
1. Excess alcohol
2. OC pills
3. DM
4. Thiazides, B blockers
5. CRF

Thiazides, b blockers- inhibit LPL
Disorders(hypercholesterlemias) associated with PVDs?
Type III, IV
Type V hypercholesterolemia?
(Hyperchylomicronemia syndrome)
Clinical findings?
Increased VLDLs + chylomicrons pptd by exacerbation (MC= DKA, alcohol)

Clinical findings:
1. Xanthomas
2. Acute pancreatitis
3. Lipemia retinalis
4. Dyspnea (hypoxemia)
5. Hepatosplenomegaly
6. Increased serum TG>1000mg/dl
7. Normal sr CH and LDL
Abetalipoproteinemia?
Deficient apoB48 and apoB100
Decrease in CH and TG
Abetalipoproteinemia?
Clinical findings?
Malabsorption: Chylomicrons accumulate in villi--> prevent absorption of micelles

Ataxia
Hemolytic anemia
Acanthocytes--from vit E deficiency
Abetalipoproteinemia: Rx?
Vit E
Arteriosclerosis: Types?
1. Medial calicification
2. Atherosclerosis
3. Arteriolosclerosis
Medial calcification: pathogenesis?
Effect?
Dystrophic calcification in muscular arteries

Effect: none
Endothelial cell injury: causes?
HTN
LDL
Homocysteine
Tobacco
Atherosclerosis: pathogenesis?
Damage to endothelium--> platelet and macrophage activation-->release of cytokines--> smooth muscle proliferation--> migration to tunica intima--> CH enters sm cells-->foam cells--> SM release cytokines--> form extracellular matrix(proteoglycans, elastina and collagen)
-->fibrous plaque
Fibrous plaque composition?
Components:
Fibrous cap: made of
i. Smooth muscles
ii. Foam cells
iii. Inflammatory cells
iv. Extracellular matrix

Necrotic center:
Cellular debris
CH crystals
Foam cells
Increased CRP indicates?
Disrupted plaques
Plaque sequaleae?
1. Disrupted
2. Calcified
3. Ulcerated
Atherosclerosis: Sites?
#1. Abdominal aorta
#2. Coronary artery
#3. Popliteal artery
#4. Carotid artery
Atherosclerosis: Complications
1. Vessel weakness-> (aneurysm)
2. Thrombosis (MI)
3. HTN (Renal artery atherosclerosed)
4. Cerebral atrophy (Circle of Willis)
5. PVDs- claudications/ gangrene
Arteriolosclerosis:
Types?
Pathogenesis?
Types:
Hyaline arteriolosclerosis
Hyperplastic arteriolosclerosis

Pathogenesis:
Hyaline: Due to protein deposition in the vessel wall
HTN--> forces protein into the vessel wall
DM--> enzymatic glycozylation of BM--> increased permeability--> protein deposition in the vessel wall

Hyperplastic:
Severe/malignant hypertension
Smooth muscle hyperplasia and BM duplication


**** "ONION SKIN APPEARANCE" ****
Vessel aneurysm: types?
1. Abdominal aneurysm
2. Mycotic aneurysm
3. Syphilitic aneurysm
4. Berry aneurysm
5. Aortic dissection
Abdominal aorta aneuryms: location?
Predisposing factor?
Location: Located below renal artery orificae.
Predisposing factor: Atherosclerosis
(no vasa vasorum, increased stress, connective tissue structure defect)
Aortic aneurysm rupture: Clinical findings?
TRIAD:
1. Left flank pain
2. Hypotension
3. Pulsatile mass
Mycotic aneurym:
Causes?
Clinical findings?
Causes:
Aspergillus
Candida
Mucor
("ACM")

Bacterial:
Pseudomonas aeruginosa
Salmonella
Bacteroides fragilis

Clinical findings:
Rupture-->hemorrhage
Thrombosis-->infarction
Berry aneurysm:
Site?
Cause?
Effect?
clinical findings?
Site: Junction of
ACA-ACA: 40%
PCA-MCA: 20%
PCA-PCA:4%

Cause:
Lack internal elastic lamina and smooth muscle

Clinical findings:
1. nuchal rigidity
2. Occipital headache
3. "Worst headache of life"
Syphilitic aneurysm:
Affecting Stage of syphilis ?
Complication of tertiary syphilis
Causative organism: T.Pallidum
Syphilitic aneurysm: Pathogenesis?
"End arteritis obliterans"
"Plasma cell infiltrate in vessel wall"
Vessel ischemia of medial tissue-->dilation of aorta and aortic valve ring
Syphilitic aneurysm: clinical findings?
1. Aortic valve regurgitation
2. Brassy cough(recurrent laryngeal nerve compression)
Aortic dissection: MC group affected?
Men
40-60yrs with
HTN
Aortic dissection: associated connective tissue disorder?
Marfan's syndrome
Ehlers Danlos syndrome
Aortic dissection: Pathogenesis?
**Tunica Media**
"Cystic medial degeneration"
1. Elastic tissue fragmentation
2. Matrix material collection
Risk factors for cystic medial degeneration?
Wall stress:
1. HTN
2. Pregnancy
3. Coarctation

Connective tissue disorders:
Marfan's
EDS
Intimal tear: site?
1. Within 10cm of aortic valve
2. Blood dissects areas of weakness
Aortic dissection: clinical findings?
Severe retrosternal pain
AR
Loss of UL pulse (compression of subclavian)
Rupture-->pericardial/pleural/peritoneal cavity
Varicose veins: sites?
Causes?
1. Saphenous vein (MC site)
2. Distal esophagus (portal htn)
3. Anorectal region
4 Left scrotal sac

Pregnancy
Obesity
Prolonged standing
OC PILLS
Secondary TO DVT

INCOMPETENCE OF PERFORATOR VESSELS
Superficial varicosities: causes?
1. Pregnancy
2. Prolonged standing
3. Obesity
4. OC pills
5. Age
5. Familial tendency
6. DVT
Superficial varicosities: rx?
Compression stockings
Sclerotherapy
Ligation and stripping
Laser/diathermy obliteration
Phlebothrombosis?
Causes?
1. Thrombosis without inflammation
2. Causes:
1. Stasis of blood
2. Hypercoaugulability
Phlebothrombosis: MC site?
Other sites?
#1. Deep vein of calf

Others:
Portal vein
Hepatic vein
Dural venous sinuses
DVT: clinical findings?
1. Swelling
2. Pain on dorsiflexing foot(Homan's sign)
3. Pitting edema
4. Stasis dermatitis: Orange discoloration + Ischemic ulcers
Stasis dermatits?
Orange discoloration: from hemosiderin
Ischemic ulcers: reduced O2 perfusion
DVT: dx? rx?
Ultrasound + d-dimer assay

Rx:
1. Low molecular weight heparin
2. Compression stockings
Thrombophlebitis?
Pain and tenderness along superficial vein.
Thrombophlebitis: disease associations/causes?
1. IV venous cannulation
2. Staph aureus infection
3. Ca-head of pancreas- "Superficial migratory thrombophlebitis" (Trosseau sign)
Trosseau sign?
Trosseau's sign of latent tetany:
Blood pressure cuff around arm compresses the brachial artery--> tetany of hand (Main de accoucher)

Trosseau's sign of malignancy:
Microvesicals released from malignant cells contain procoagulant factors---> spontaneous formation and resolution of clots (migratory)
Thrombophlebitis: Clinical findings?
1. Tender palpable cord
2. Erythema and edema of overlying skin
Thrombophlebitis:
1. Warm moist compresses
2. NSAIDs
SVC syndrome: Causes?
Extrinsic SVC compression (primary lung ca): Small cell ca of lungs
SVC syndrome: findings?
1. Retinal cell hemorrhage
2. Stroke
SVC syndrome: rx?
Stent - bypass(?)
Radiation
Thoracic outlet syndrome
Cervical rib
Spastic ant scalene
Thoracic outlet syndrome: clinical findings?
Brachial plexus
Subclavian artery and vein

Vascular and nerve root signs. (Tingling etc)
Adson's test: loss of radial pulse when the person looks to the side and inspires
Acute lymphangitis: Causative agent?
Strept Pneumoniae
Turner's syndrome: webbed neck due to?
Dilatation of lymphatic vessels
Vascular Tumors:
Angiomyolipoma
Angiosarcoma
Bacillary angiomatosis
Capillary hemangioma
Cavernous hemangioma
Angiomyolipoma: disease association?
Tuberous sclerosis
Kidney hamartoma: Muscle, fat and blood vessel (components)
Angiosarcoma: site/risk factors?
site: Liver
Risk factors:
1. Polyvinyl chloride
2. Arsenic
3. Thorium dioxide
Bacillary angiomatosis: causative agent?
Bartonella henselae involves skin and visceral organs
(in HIV infection- simulates kaposi's sarcoma)
Capillary hemangioma?
Facial lesion- regresses with age
Cavernous hemangioma?
Benign liver and spleen tumor.
Hereditary telengectasia?
Dilated vessel on skin and mucos membranes---> GIT and mouth---
> epistaxis/other bleeds--> fe deficiency anemia
Spider telengectasia?
AV fistula
associated with pregnancy/ cirrhosis
(hyperestrenism)
Sturge weber syndrome?
Nevus flamues. Birth mark along the distribution of opthalmic division of trigeminal nerve.

Ipsilateral malformation of meningeal vessels (over
Von Hippel Lindau syndrome
1. Cavernus hemangiomas in cerebellum/retina
2. Renal angioma
3. RCC
4. Pheochromocytoma
ANCA: effect?
types?
Release of enzymes from neutrophils.---> free radicals--->vessel damage

c-ANCA: ABs against proteinase 3 in cytoplasmic granules(Wegner's granulomatosis)

p-ANCA: AB against myeloperoxidase
(Microscopic polyangiitis
Churg-Strauss syndrome)
Small vessel vasculitis? clinical findings?
Henoch-schonlein purpura,
Microscopic polyangiitis

"Palpable purpura"
Hemorrhagic, raised, PAINFUL skin lesion.

****Refer show me (ipad) for all vasculitides
Medium vessel vasculitis?
Clinical findings?
Muscular artery involvement
(PAN, Kawasaki)
Clinical finding:
1. Thrombosis/Infarction
2. Aneurysm
Large vessel vasculitis?
Elastic artery vasculitis
Takayasu arteritis, Giant cell arteritis(temporal)
Takayasu arteritis: Vasculitis type?
Clinical features?
Populations affected?
Rx?
"PULSELESS DISEASE"

1. Granulomatous large vessel arteritis.
2. Absent upper extremity pulses
3. Discrepancy in BP between arms > 10mm
4. Visual defects
5. Stroke.

(Imagine Takayasu:
Japanese zen grand master- blind, handicap, with weak pulse(apparently absent) from transcendental meditation)

Population : Young ASIAN women and children

Rx: Corticosteroids
Giant cell(temporal) arteritis
1. Involves superficial temporal and ophthalmic arteries.

Temporal headache
Jaw claudication(pain while chewing)
Blindness on ipsilateral side

"Polymyalgia rheumatica"
(muscle and joint pain: normal sr. creatine kinase)
Increased ESR
Rx: corticosteroids
Hereditary telengectasia?
Dilated vessel on skin and mucos membranes---> GIT and mouth---
> epistaxis/other bleeds--> fe deficiency anemia
Spider telengectasia?
AV fistula
associated with pregnancy/ cirrhosis
(hyperestrenism)
Sturge weber syndrome?
Nevus flamues. Birth mark along the distribution of opthalmic division of trigeminal nerve.

Ipsilateral malformation of meningeal vessels (over
Von Hippel Lindau syndrome
1. Cavernus hemangiomas in cerebellum/retina
2. Renal angioma
3. RCC
4. Pheochromocytoma
ANCA: effect?
types?
Release of enzymes from neutrophils.---> free radicals--->vessel damage

c-ANCA: ABs against proteinase 3 in cytoplasmic granules(Wegner's granulomatosis)

p-ANCA: AB against myeloperoxidase
(PAN
Microscopic polyangiitis
Churg-Strauss syndrome)
Small vessel vasculitis? clinical findings?
Henoch-schonlein purpura,
Microscopic polyangiitis

"Palpable purpura"
Hemorrhagic, raised, PAINFUL skin lesion.

****Refer show me (ipad) for all vasculitides
Medium vessel vasculitis?
Clinical findings?
Muscular artery involvement
(PAN, Kawasaki)
Clinical finding:
1. Thrombosis/Infarction
2. Aneurysm
Large vessel vasculitis?
Elastic artery vasculitis
Takayasu arteritis, Giant cell arteritis(temporal)
Takayasu arteritis: Vasculitis type?
Clinical features?
Populations affected?
Rx?
"PULSELESS DISEASE"

1. Granulomatous large vessel arteritis.
2. Absent upper extremity pulses
3. Discrepancy in BP between arms > 10mm
4. Visual defects
5. Stroke.

(Imagine Takayasu:
Japanese zen grand master- blind, handicap, with weak pulse(apparently absent) from transcendental meditation)

Population : Young ASIAN women and children

Rx: Corticosteroids
Giant cell(temporal) arteritis
1. Involves superficial temporal and ophthalmic arteries.

Temporal headache
Jaw claudication(pain while chewing)
Blindness on ipsilateral side

"Polymyalgia rheumatica"
(muscle and joint pain: normal sr. creatine kinase)
Increased ESR
Rx: corticosteroids
Polyarteritis nodosa?
Common arteries involved?
Disease association?
Clinical effects?
Medium(muscular) vessel vasculitis

Renal
Coronary
Mesenteric

Disease association:
1. HbsAg
2. pANCA

Clinical effects:
1. Kidney infarction: increased BUN: Creat
2. Heart: Acute MI
3. Bowels: Diarrhea
4. Skin: Livedoreticularis
5. Testicular pain
6. Diastolic HTN

**Renal>heart>liver>GI**
Polyarteritis nodosa: Ix?
Ix:
1. Biopsy
2. Angiography
Kawasaki disease?
Necrotizing medium(muscular) vessels
MCC of MI in children?
Kawasaki disease
Kawasaki disease: clinical features?
1. Fever
2. Erythema + Edema of hands and feet
3. Cervical adenopathy
4. Desquamating rash
5. Oral erythema/cracking of lips
6. ABNORMAL EKG
7. Strawberry tongue
8. Conjunctivitis

In Children:
Skin rash + Abnormal EKG
(EKG shows acute MI)

Risk for CORONARY ANEURYSM
Kawasaki disease: rx?
Rx:
IVIG
Aspirin
(NO Corticosteroids- danger of vessel rupture)
Thromboangiitis obliterans?
"Digital vessels thrombosis"
"Neutrophilic vasculitis"
Raynaud's phenomenon
Extremities involved
Intermittent claudication

Microabscess formation/
Segmental thrombosis-->
Gangrene
Ulceration
SMOKERS

Ulceration
Gangrene
Thromboangiitis obliterans:
Pathology
"Digital vessels thrombosis"
"Neutrophilic vasculitis"

Raynaud's phenomenon
Intermittent claudication
(extremities)
Microabscess formation/
Segmental thrombosis-->
Gangrene
Ulceration
Thromboangiitis obliterans:
rx?
Smoking cessation
IV iloprost(vasodilator)
Raynaud's disease?
Small vessel vasculitis
Raynaud's disease:
Vessels affected?
sites affected?
Small sized vessels
Sites:
Fingers
Toes
Tip of nose
Ears
Raynaud's disease:
clinical finding?
White-->Blue-->Red

Chronic conditions: ulceration and gangrene
atrophy of skin
Raynaud's phenomenon
Observed secondary to:
*SLE
*Systemic sclerosis
*CREST syndrome
Buerger's disease
Atherosclerosis

*Important associations with secondary raynaud's
Raynaud's phenomenon: pathology?
Digital ulceration
Gangrene

1. VESSEL FIBROSIS
2. DYSTROPHIC CALCIFICATION
Raynaud's phenomenon: rx?
1. Avoid cold temperatures
2. Calcium channel blockers
Wegner's granulomatosis
"Necrotizing granulomas":
Respiratory tracts-
Upper:
Saddle nose deformity
Chronic sinusitis
Tracheal collapse

Lower respiratory tract:
Cavitating nodular lesion

Necrotizing vasculitis in lungs
Kidneys: Crescentic glomerulonephritis
c-ANCA
Wegener's granulomatosis: Associated AB?
Rx?
c-ANCA
Rx: corticosteroids+cyclophosphamide


3Cs:
c-ANCA
Corticosteroids
Cyclophosphamide

c-ANCA: Wegner's
p-ANCA: PAN, Churge strauss
Microscopic polyangiitis?
pANCA+ glomerulonephritis+ Palpable purpura

ppt by drug(penicillin), infections, immune disorders
Churg-Strauss: type of vasculitis?
Small vessel vasculitis

Skin+lungs+heart

(Allergic granulomatosis + angiitis)
Allergic rhinitis+ asthma+
pANCA+ eosinohilia
Henoch schonlein purpura?
Type of autoimmune disorder?
Type III disorder

Follows URTI---> AB against Strept pharyngeal infection
--> immune COMPLEX formation--> Immune COMPLEX reaction

Palpable purpura-
Buttocks
Lower extremities

Polyathritis
Nephropathy
GI bleed


Immune complexes in Henoch Schonlein purpura?
IgA-anti-IgA immune complexes
pANCA +ve vasculitides
1. PAN
2. Microangiopathic polyangiitis
3. Churge Strauss syndrome
Henoch Schonlein purpura: Rx?
Self resolves after 4 months

When are corticosteroids indicated?
Severe GI or renal disease
Cryoglobulinemia: disease associations?
HCV
Type I MPGN
Multiple myeloma
pANCA +ve vasculitides
1. PAN
2. Microangiopathic polyangiitis
3. Churge Strauss syndrome
Cryoglobulinemia:
Vessel affected?
pathology?
Vessel affected- small vessels

Due to cryoglobins- precipitate when exposed to cold temperature.

Raynaud's phenomenon
Palpable purpura
Glomerulonephritis
Arthritis
Abdominal pain
Infectious vasculitis?
Causative agents?
Small vessel vasculitis

Causative agents:
Rickettsia rickettsiae
Neisseria meningitis
Henoch Schonlein purpura: Rx?
Self resolves after 4 months

When are corticosteroids indicated?
Severe GI or renal disease
Essential hypertension: primary proposed mechanism?
Reduced sodium excretion
Cryoglobulinemia: disease associations?
HCV
Type I MPGN
Multiple myeloma
Renovascular hypertension?
Renal artery affected by:
1. Atherosclerotic plaque
2. Fibromuscular hyperplasia

-->

Decreased renal blood flow

-->

Activates renin-angiotensin system

-->

Plasma renin
Cryoglobulinemia:
Vessel affected?
pathology?
Vessel affected- small vessels

Due to cryoglobins- precipitate when exposed to cold temperature.

Raynaud's phenomenon
Palpable purpura
Glomerulonephritis
Arthritis
Abdominal pain
Renovascular hypertension: clinical findings?
1. Severe uncontrolled hypertension
2. Increased plasma renin in involved kidney
3. Decreased plasma renin in uninvolved kidney
4. Epigastric bruit
5. Angiography:
i. Atrophy of involved kidney
ii. Beaded appearance in fibromuscular hyperplasia
Infectious vasculitis?
Causative agents?
Small vessel vasculitis

Causative agents:
Rickettsia rickettsiae
Neisseria meningitis
Essential hypertension: primary proposed mechanism?
Reduced sodium excretion
Renovascular hypertension?
Renal artery affected by:
1. Atherosclerotic plaque
2. Fibromuscular hyperplasia

-->

Decreased renal blood flow

-->

Activates renin-angiotensin system

-->

Plasma renin
Renovascular hypertension: clinical findings?
1. Severe uncontrolled hypertension
2. Increased plasma renin in involved kidney
3. Decreased plasma renin in uninvolved kidney
4. Epigastric bruit
5. Angiography:
i. Atrophy of involved kidney
ii. Beaded appearance in fibromuscular hyperplasia