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269 Cards in this Set
- Front
- Back
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What provides a smooth surface for blood to flow against?
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Endothelium of BV
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What is the BV endothelium called?
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the Intima
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What is in the adventitia around the arteries?
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CT, Nerves, small arterioles
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Do BV get all of their nutrients from the blood they carry?
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No, they need additional capillaries to provide their own blood supply
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What are the elastic arteries often called?
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Large arteries
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What are two examples of medium BV?
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Coronary and renal arteries
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Can different types of arteries be susceptible to different types of dx?
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Yes
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Compare arteries to veins
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Veins have greater diameter, larger lumens, thinner walls. Only some veins have smooth muscle
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If the CV system is in a hypertensive state, what will present first?
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enlarged veins before enlarged arteries
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What does the weaker nature of veins leave them prone to?
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irregular dilation compression and inflammation
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What do venous valves do?
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Fxn as check valves to prevent backflow of blood
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What is the diameter of a normal capillary?
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~ 1 RBC in diameter
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How thick are capillaries?
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Single endothelial cell
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How much capillary surface area is there in 1 cubic inch of tissue?
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20 sq ft
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Are capillaries how pressure or low? Fast or slow blood flow?
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low pressure; slow blood flow
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What are fxn's of the endothelium?
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permeability, vessel repair, coagulation/clotting, regulates inflammation/cell growth, oxidizes LDL, modulates blood flow
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Where is the BV endothelium found?
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Throughout the entire vascular system
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What role do cytokines play with BV endothelium?
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mediate inflammation
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What role do growth factors play with BV endothelium?
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regulate growth
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What is the only vein that has oxygenated blood?
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Pulmonary artery
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Where is the tricuspid valve?
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Right atrium --> Right ventricle
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Where is the mitral valve?
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Left atrium --> Left ventricle
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What is the sinus rhythm?
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the rhythm of a normal heart
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Define tachycardia
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>100 BPM
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Define bradycardia
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<100 BPM, rare compared to tachycardia
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What is the coronary artery most commonly affected in MI?
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left anterior descending artery
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What does the SA node control?
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electrical impulse that coordinates contraction of the heart
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What can cause tachycardia?
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fever, sickness, weakness
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What is the cutoff for reduced risk of MI with regards to resting heart rate?
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70 BPM
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What is systole?
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contraction/emptying blood form the heart
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Do the left and right sides of the heart contract simultaneously?
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Yes
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What two structures receive blood from the heart?
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pulmonary artery, aorta
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What is the first heart sound?
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when the tricuspid and mitral valves close at the beginning of heart contraction cycle
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What valves are closed as blood is exiting the heart?
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mitral and tricuspid valve "MT"
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What is the first heart sounds also called?
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S1
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What is diastole?
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relaxation/filling of heart with blood
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What valves are closed during diastole?
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pulmonary and aortic valves
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What causes the second heart sound?
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Closing of pulmonary and aortic valves
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What is the second heart sound also called?
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S2
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What is cardiac preload?
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How much blood is present in the ventricle at the end of diastole (how 'full' the heart is)
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What is the Frank-Starling relationship?
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the elastic stretching of the ventricle due to blood filling it
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What is afterload?
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The force that resists blood flow through the body
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What is the main cause of afterload?
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arterial pressure
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What is a high afterload?
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A less elastic arterial system, greater resistance to blood flow
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What is contractility also called?
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Inotropy
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What is contractility?
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The ability of the heart muscle to change shape independent of preload/afterload
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What can decrease contractility?
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beta blockers
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What controls contractility?
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calcium levels and Beta-1 sympathetic system
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How much blood per minute can a normal heart move?
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5-6L
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What do calcium channel blockers do in the heart?
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Works on the inner walls of cells, decreases contractility by keeping Ca++ in the cell
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What is cardiac index?
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cardiac output divided by body surface area
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What is a normal cardiac index?
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2.6-4.2 L/min/m^2
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What is a sinus (general definition)
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Any opening/hollowing/cavity
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Can the sinoatrial (SA) node regulate the heart beat?
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yes, 60-100 bpm
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Can the AV node regulate heart beat?
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Yes, it tends to only 40-60 bpm, tends to be overruled by faster beating SA node
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What is fibrillation?
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irregular contraction of heart muscle
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Where does the contraction impulse go from the AV node?
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into the bundle of His --> divides into R and L branches --> purkinje fibers in ventricle wall
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What does the sympathetic system innervate in the heart?
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atria and ventricles
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How does the sympathetic system affect cardiac output?
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increases calcium, which increases contractility --> greater output
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What does the parasympathetic system innervate?
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atria via the vagus nerve, little effect on ventricles
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What does parasympathetic system do to cardiac output?
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decrease
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What maintains the resting membrane potential of nerve fibers?
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Na/K ATP pump maintains depolarized (more negative) intracellular state
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What leaks faster, Na or K?
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K leaks out faster than Na leaks in, so it will always be negative inside of cell
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What is open when a cell is depolarizing?
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Na+ gates
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What is open when a cell is repolarizing?
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K+ gates
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What is faster, cardiac or regular neural AP's?
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systemic neural AP's
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Does the SA node spontaneously depolarize?
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yes
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What causes the SA node to spontaneously depolarize?
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natural leakiness to Na+ and Ca++
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What are the types of Ca++ channels in the heart?
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L and T channels
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What Ca++ channel type is affected stronger by cardiac drugs?
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L channels
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What stays depolarized longer, SA node or cardiac muscle?
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cardiac muscle
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What causes slow repolarization of cardiac muscle?
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Ca++ channels that are slow to close
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When can cardiac muscle repolarize?
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once K+ and Ca++ channels are closed
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What opens first in cardiac muscle depolarization?
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Na+ gates first, Ca++ second
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Compare cardiac and skeletal muscle
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cardiac cells are smaller than skeletal, cardiac cells are connected via gap jxn's, all cardiac muscle cells share neural stimulation --> firing at the same time
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How many syncytia are found in the heart?
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two
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Where are the syncytia found in the heart?
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atrial and ventricular
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What is the term for blocks of cardiac cells that fire together due to gap jxn's?
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syncytia
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Do ions move easier in cardiac or skeletal muscle?
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cardiac muscle
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What can induce Ca++ release in a cardiac muscle cell?
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Initial Ca++ entering cell causes sarcoplasmic reticulum and mitochondria to release Ca++
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If Ca++ cannot leave cardiac muscle, what happens?
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Muscle cannot relax
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What is seen in the unbound [Ca++] when contractility is increased?
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[Ca++] is high
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Do Ca++ channel blockers completely stop Ca++ flow?
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No, it only restricts it
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How is Ca++ removed from the cell?
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Sodium/Calcium exchange, calcium is taken up by the sarcoplasmic reticulum and mitochondria
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What is the prevalence of CVD death in the US?
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34%
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How much does CVD depress life expectancy?
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7 years
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At what ages does cancer overtake CVD for #1 cause of death?
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75
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What ratio of pt's wil present with some form of CVD?
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1 in 3
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Are males or females more likely to die from CVD?
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Both are equally likely, CVD is the # killer of both sexes
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Where do women present with heart dx s/sx?
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jaw and back more likely
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Which arm is more likely to present pain during a cardiac event?
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left arm, but both can present it
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What is syncope?
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a short term loss of consciousness
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What are the most important s/sx of heart dx?
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jaw, back, dyspnea, nausea and vomiting (n&V)
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What ocular findings increase risk of CVD?
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ARMD, retinopathy (diabetic or non)
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What is the increased prevalence of CVD in ARMD?
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2x higher death rate from CVD
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What is the increased prevalence of CVD in retinopathy?
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2-6x higher chance of heart dx
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What can CVD cause in the eye?
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TIA, central retinal vein occlusion (CRVO), ocular ischemic syndrome (carotid blockage)
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Name two CV meds than can cause adverse ocular rxns
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warfarin, amiodarone
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What ocular med can cause stroke?
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lucentis
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What can require AB prophylaxis?
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some optometric procedures if the pt also has CVD
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What is a typical biochemical sign of MI
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serum enzyme levels increase
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What is CK-MB?
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creatine phosphokinase - myocardial band
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What is the onset of increased CK-MB?
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2-6 hr
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What can cause LDH-1 serum levels to increase?
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death of RBC's
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What is the peak of CK-MB serum levels
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12-24 hrs
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When is CK-MB back to normal after MI
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3 days
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What is the onset of increased LDH-1 after MI?
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24-72 hr
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When I the peak of LDH-1 levels after MI?
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2-5 days
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When does LDH-1 drop back to normal after a MI?
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14 days
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When does troponin I increase after MI?
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4-6 hrs
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What is the peak of troponin I levels after MI?
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10-24 hrs
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When does troponin I levels return to normal after a MI?
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10-15 days
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How many waves are in a normal ECG
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5 waves (deflections)
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What is the 'P' wave in an ECG?
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atrial cell depolarization
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What is the 'QRS' wave in an ECG?
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ventricle depolarization
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What is the 'T' wave in an ECG?
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ventricular repolarization
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What is the PR interval?
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measure of AV conduction time
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What is cardiac catheterization?
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insertion of a thin flexible tube into a vein (often femoral) or artery, which is guided into the heart
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What can cardiac catheterization detect?
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BP and patterns of blood flow; cardiac output in general
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How is angiography contrast introduced?
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cardiac catheterization
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What image is taken in contrast angiography?
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x-ray
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What is monitored in a cardiac stress test?
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ECG, BP, pulse rate
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What changes during cardiac ischemia during a stress test?
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ECG
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What is echocardiography?
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ultrasound scan of the heart, measures structure and movement of heart
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What is a MUGA scan?
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Multiple gated acquisition scan
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What is measured in a MUGA scan?
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left ventricular wall motion and ventricle ability to eject blood
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What is the stress thallium test commonly known as?
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DIP-thal test
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What is administered in the DIP-thal test
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Thallium 201 is injected into the vein
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What does the DIP-thal test measure?
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How much thallium is taken up by myocardial tissues, dead tissues absorbs it poorly
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What is a cold spot?
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a region of dead or scarred heart tissue of compromised fxn
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What are the visual side effects of Na/K pump inhibition?
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blurred vision, altered color perception (blue tinged), haloes on dark objects
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When are visual side effects of Na/K pump inhibition most common?
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overdose of related drugs
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What is the mechanism of Verapamil?
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slows heart rate by interfering with SA and AV repolarization
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What cardiac meds interfere with the ANS?
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beta blockers
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What do Beta blockers inhibit?
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epinephrine activity
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What drug can slow conduction time and should not be used in severe heart block pt's?
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beta blockers
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What do beta blockers do to heart activity?
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decrease heart rate, decrease contractility
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What is a retinal macro aneurysm?
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HTN causes outpouching of BV in the eye
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What can cause retinal emboli?
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HTN
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what can increase the risk for diabetic retinopathy?
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HTN
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What can incrase the risk for ARMD?
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HTN
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What % of US population with HTN, is unaware they have HTN?
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20%
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What % of US population with HTN is controlling it well?
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48%
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What % of HTN cases are in 3-18 yo?
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3.60%
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What % of caucasians have HTN?
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28%
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What % of african americans have HTN?
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41%
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What are major risk due to HTN?
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stroke, heart failure, kidney failure
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What is the second most common cause of preventable death in the US?
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HTN (smoking is #1, but falling; obesity is rising as well)
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What is JNC 7?
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Joint Council: A group that creates guidelines for care and have highlighted HTN as a focal point of medicine across disciplines
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What are HTN risk factors that are not pt controllable??
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Family history, gender, age, menopause
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What are HTN risk factors that are pt controllable?
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obesity, dyslipidemia, alcohol abuse, sedentary lifestyle, smoking, lack of sleep, low Vit D may be involved, medication, DM
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What can cause BP to change through the course of a day?
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Morning/Evening, level of anxiety, recent activity, caffeine intake
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What is the minimum standard before diagnosing HTN?
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must average 2 or more properly performed BP reading
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Describe a properly performed BP reading
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pt must be seated, must average 2 different readings on EACH of TWO different office visits
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What is normal BP?
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<120/<80
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What is Pre HTN BP?
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120-139/80-89
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What is HTN Stg 1 BP?
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140-159/90-99
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What is HTN Stg 2 BP?
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>160/>100
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When should BP be rechecked in 2 years?
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<120/<80
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When should BP be rechecked in 1 year w/ lifestyle modification discussion?
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120-139/80-89
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When should BP be referred to PCP within 1 mo?
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160-179/100-109
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When should BP be referred to PCP within 1 week?
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180-219/110-119
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When should BP be referred to PCP within a few hours to 1-2 days?
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>220/>120; 1-2 days if no end organ effects; Refer within a few hours if end organ effects are present
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What are end organ effects for the heart?
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Risk of CVD doubles for EACH increment of 20/10 mmHg above 115/75 mmHg
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What CV risk increase with HTN?
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atherosclerosis, coronary artery dx, heart failure, left ventricular hypertrophy, MI
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What is more important for diagnosing HTN, systolic or diastolic BP?
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systolic > 140 mmHg in individuals over 50 is the most important benchmark
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What ethnicity has a greater risk for HTN related mortality?
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african descent
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If BP is >160 mmHg, what is the risk of stroke?
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4x greater than with normal BP
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What neurological disorder increases in prevalence with HTN?
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alzheimer's dx
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What % of HTn related deaths are from CVA's?
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10-15%
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Having high BP in their 50's increases the chance of what dx later in life?
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alzheimer's dx
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What is an end organ effect of the kidney?
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atherosclerosis, of renal arteries --> ischemia; nephrosclerosis
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What is an end organ effect of the eye?
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retinopathy, swelling of ONH
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How many s/sx of end organ effects must a pt present to be diagnosed with an end organ effect?
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just one
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What is an end organ effect of the CV system?
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Peripheral artery dx
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For a pt under 18, to what increment should their age be defined?
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1/4 year
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Is a child's height taken into account for BP measurement?
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yes
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What is a child's height used to calculate for BP readings?
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height percentile for their age
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What percentile is Pre-HTN in a minor?
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<90th percentile, >95th percentile OR BP >120/>80 mmHg
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What percentile is HTN Stg 1 in a minor?
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>95th percentile --> 5 mm above the 99th percentil
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What percentile is HTN stg 2 in a minor?
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>5mmHg above the 99th percentile
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What influences peripheral CV resistance?
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tunic media in arterioles --> vessel size, elasticity Alpha-1 increases vasocontriction in sympathetic stimulation; blood viscosity
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What factors affect cardiac output related to HTN?
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blood volume: renin increases from Beta-1 symp. Stimulation --> higher BP; Beta-1 increases heart rate
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When are medications prescribed for minors with HTN?
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only when compelling indications are present, OR they are HTN Stg 2
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How often should a minor's BP be rechecked if pre-HTN?
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Every 6 months
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How often should a minor's BP b rechecked if HTN Stg 1?
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1-2 weeks, if shows up high in 2 subsequent visits, refert within 1 mo to PCP
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How often should a minor's BP be rechecked if HTN Stg 2?
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Refer within 1 week or immediately if symptoms
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When should weight-management counseling be discussed with a minor?
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If at Pre-HTN stage or higher
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What CV parameters are use in feedback regulation?
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baroreceptors in carotid sinus (these are fast almost immediate); juxtaglomelular cells in kidney are slower acting (20 min); serum osmolarity, if [Na+] is high body retains water to lower it; increased CO2 and H+ --> body assumes inadequate tissue perfusion --> increases sympathetic brain STEM activity
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What is the cause of primary HTN?
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idopathic
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What % of HTN is primary?
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70-95%
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What are the physiologic abnormalities in primary HTN?
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persisten elevated cardiac output, abnormal peripheral resistance
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What is impaired natriuresis?
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elevated BP --> does not cause natriuresis as it does in normals --> BP does not lower properly
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What is baroreceptor resetting?
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In HTN, the baroreceptors maintain a set point that is too high, so the feedback loop does not damp BP properly
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Can renin-angiotensin-aldosterone system abnormalities cause HTN?
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yes
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What is secondary HTN?
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HTN that presents as a s/sx of another dx
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What can renal dx do to BP?
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raise it due to reduced salt excretion, altered renin-angiotensin-aldosterone activity
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What can an adrenal or pituitary tumor do to BP?
|
Elevated it
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What can thyroid dx do to BP?
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elevate it
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What can sleep apnea and sleep deprivation do to BP?
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elevated it
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What are considerations for how to treat HTN?
|
level of BP elevation, what risk factors are present, any comorbities? (diabetes, renal dx), any organ or CV dx? Ethnicity
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What is the goal of HTN treatment?
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Reduce CVD, morbidity and mortality
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What is the target BP for HTN tx?
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<140/90 mmHg. If diabetic/renal dx is present, target is <130/80
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What reduction in stroke can be realized due to HTN tx?
|
35-40%
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What reduction in MI can be realized due to HTN tx?
|
20-25%
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What reduction in heart failure can be realized due to HTN tx?
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>50%
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What are nonpharmacological measures to reduce HTN?
|
pt education, cease smoking, Na intake <2.3 g/d (6g NaCl), Maintain 90 mmol/d of K+, Maintain proper Ca++, Mg+, and Vit , weight reduction and exercise, limit EtOH
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What does reducing EtOH cause endocrine wise?
|
reduced catecholamine release
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What is very bad habit for maintaining proper BP?
|
binge drinking
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What is the level of BP reduction that can bee seen through 'dark chocolate tx'?
|
5.2 mmHg systolic, 1.8 mmHg diastolic
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ACE inhibitors and CCB are being studied for what purpose?
|
HTN tx, reducing morbidity and mortality
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What is the mechanism of diuretics?
|
decreased Na+ reabsorption in kidneys
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What is the result of diuretic use?
|
increased urine output --> decreased blood volume
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How does the body resist diuretic effectiveness?
|
it can reset the feedback loop to maintain the higher HTN
|
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Can diuretics reduce peripheral resistance?
|
yes, via relaxing arteriolar smooth muscle
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What is a good drug to pair with a diuretic for HTN tx?
|
beta-blockers
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What ethnicity responds very well to diuretics for HTN tx?
|
black
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What are thiazide diuretics?
|
decrease Na+ reabsorption in the short term, increased vasodilation in the long term
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What is the time course for maximum effect in thiazide diuretics?
|
1-3 weeks
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What are the adverse effects of diuretics?
|
hypokalemia --> arrythmia, hyperuricemia (70%), volume depletion, hypercalcemia; hyperglycemia (10%)
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What is the CI for thiazide diuretics?
|
diabetes
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What is the mechanism of loop diuretics?
|
inhibit re abosorption of ions in the loop of Henle
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What is the most efficacious of all diuretics?
|
loop diuretics
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Are loop diuretics long or short acting?
|
Short, must be taken 2x /day
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What is more potent, bumetanide or furosemide?
|
bemtanide, though furosemide more commonly prescribed. Loop diuretic.
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What are the adverse effects of loop diuretics?
|
Permanent ototoxicity, hyperuricemia, acute hypovolemia --> shock, arrythmia, K+ depletion
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What are K+ sparing diuretics?
|
inhibit Na reabsorption and K+ secretion, prevent aldosterone from binding and working
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Name a K+ sparing diuretic
|
spironolactone
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What are adverse side effects of K+ sparing diuretics?
|
gynecomastia in males, menstrual irregularity in females, therefore better as only a short term tx.
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Where are Beta blockers most effective?
|
In young and/or caucasian pt
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How do Beta blockers reduce HTN?
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decrease cardiac output, decrease sympathetic outflow to decrease renin release
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What is the time course of beta blockers for treating HTN?
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may take several weeks for maximum effect
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What are Beta blocker CI's?
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sinus bradycardia, asthma, greater than 1st degree heart block, PAD ( non selective blockers). Diabetics that use insulin (non-selective blockers) --> masks s/sx of low insulin
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Redo slide 38!!
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Redo slide 38!!
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Name 3 non-selective beta blockers
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propranolol, timolol nadolol
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Name 3 Beta 1 selective beta blockers
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atenolol, metoprolol, nebivolol
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Name an alpha and beta blocker
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labetalol
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What are ACE inhibitors?
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block angiotensin 1 --> angiotensin 2 pathway, reduce aldosterone, prevent bradykinin inactivation --> vasodilation
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What are adverse side effects of ACE inhibitors?
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dry cough, rashes, fever, hyperkalemia, altered taste
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What is a CI for ACE inhibitors?
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pregnancy
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What is the suffix for ACE inhibitors?
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"-epril"
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What is the DOC for DM htn?
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ACE inhibitors
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What drug is administered by MD for close observation?
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ACE inhibitors, may cause syncope or angioedema
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What are ARB's?
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angiotensin II antagonists
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How do ARB's work?
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inhibit angiotensin II from binding to receptor, blocks aldosterone secretion
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Do ARB's influence bradykinins?
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no
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What is a CI for ARB's?
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pregnancy
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What are adverse effects of ARB's?
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less dry cough
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Redo slide 45, ask about what drug she highlighted
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see other side
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What is the mechanism of Ca++ channel blockers?
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modulates smooth muscle Ca++ release --> reduces muscle tone, vasodilation
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Can Ca++ channel blockers reduce PR?
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yes, cause vasodilation
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What is the time course for Ca++ channel blockers?
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short duration, must be used tid for good control
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What are adverse effects of Ca++ channel blockers?
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constipation, dizziness, HA, fatigue
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What are CI for Ca++ channel blockers?
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heart failure, topical Beta blockers --> hypotension, bradycardia, AV block
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Why are 2nd gen Ca++ channel blockers more effective?
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relisten to lecture!
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What are renin inhibitors?
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1st new class of HTN drugs in 10 yrs
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How do renin inhibitors work?
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inhibits renin from producing angiotensin II
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What are the advantage of renin inhibitors?
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taken qd
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What are the SE of renin inhibitors?
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diarrhea, HA, cold symptoms
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What are the disadvantages of combo drugs?
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Cost!!
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What drugs were abandoned due to major CVD risk?
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alpha blockers for HTN tx
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What is Clonidine?
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a CNS drug that treats HTN
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What is Clonidine's mechanism for HTN?
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sympathetic vasomotor center
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What is a good drug for treating HTN if kidney ex is present?
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clonidine, it acts on the CNS instead of the kidneys
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What is catapres?
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clonidine patch
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