Which artery supplies the SA and AV nodes?
Which artery supplies the inferior portion of the left ventricle and posterior septum?
Posterior descending (80% off the RCA, 20% off the circumflex)
Where does coronary artery occlusion occur most commonly?
What does the LAD supply?
apex and anterior interventricular septum
When do coronary arteries fill?
Where is the most posterior portion of the heart and what can it cause?
The LA, can cause dysphagia because of compression of the esophageal nerve or hoarseness by compressing the the recurrent laryngeal nerve
What supplies the posterior left ventricle?
stroke volume x HR =?
rate of 02 consumption/ arterial 02 - venous 02 ccontent=CO
CO x Total peripheral resistance
mean arterial pressure
2/3 diastolic + 1/3 systolic
systolic - diastolic
EDV - ESV
SV CAP means?
Stroke volume affected by contractility, afterload, and preload
How do catecholamines increase contractility?
Increasing activity of Ca pump in SR
What does increasing intracellular Ca do?
What happens with a decrease of extracellular Na
decrease in activity of Na/Ca exhanger and increase in contractility
How does digitatlis increase contractility?
Increase intracellular Na, resulting in increased Ca
How do beta blockers decrease contractility?
decrease in cAMP
Why is contractility decreased in heart failure?
How does acidosis affect contractility?
Do dihydropyridine or non-dihyrdropyridine Ca channel blockers decrease contractility
What cardiac change occurs in pregnancy?
What 4 things drive myocardial 02 demand?
inc afterload, inc contractility, inc heart rate, inc heart size (inc wall tension)
If HR is too fast (V tach) what happens during diastole?
filling is incomplete and CO falls
EDV is also known as
MAP is also known as
Afterload (proportional to peripheral resistance)
Which class of drugs decrease preload
Which class of drugs decreases afterload?
Exercise, overtransfusiion and excitiment causes and increase in...?
What does the starling curve show?
changes in CO as a function of preload
When does EF decrease
What is the formula for EF?
What is a normal EF
at least 55%
Given P = QR, what factors influence resistance?
proportional to viscosity and inversely proportional to the radius to the 4th power
Which vessels account for the most total peripheral resistance
Which lab value indicates blood viscosity?
In what disease states is blood viscosity increased?
polycythemia, hyperproteinemic states (multiple myeloma), hereditary spherocytosis
In the cardiac and vascular function curves, in what instance is the vascular curve shifted to the left?
In the cardiac and vascular function curves, in what instance is the vascular curve shifted to the right?
What is indicated when CO and venous return are equal?
The operating point of the heart
What causes the CO curve to shift upwards?
pos inotropy, exercise
what causes the CO curve to shift downwards?
neg inotropy, HF, narcotic overdose
In the cardiac cycle, which period has the highest 02 consumption?
On the cardiac cycle graph, on which corners do the opening and closing of the aortic and mitral valves occur?
lower right, MC, upper right, AO, upper right AC, lower left MO
What is the S1 sound?
mitral and tricuspid closure
What is the S2 sound?
Aortic and pulmonary closing
When and why is the S3 sound heard?
normal in children and pregs, assoc with inc filling pressures, early in diastole during rapid ventricular filling
When and why do you hear the S4 sound
late in diastole, high atrial pressure, pushing against a stiff LV wall, associated with ventricular hypertrophy
in the JVP, what is the a wave?
in the JVP, what is the c wave?
RV contraction (closed tricuspid valve bulding into atrium
in the JVP, what is the v wave?
inc RA pressure, due to filling against closed tricupsid valve
In normal S2 splitting, which valve closes first? What increases it?
the aortic before pulmonic, inspiration increases diff
What is the association with wide S2 splitting?
pulmonic stenosis and RBBB
What is association with fixed S2 splitting, does not increase with inspiration
What is associated with paradoxical spliting of S2
Aortic stenosis or LBBB
with what heart sounds do ASD usually present?
pulmonary flow murmur and diastolic rumble
Does blood flow across the actual ASD account for abnormal heart sounds? What is the reason?
No, no pressure gradient
Inspiration causes an increase in which sided heart sounds?
Expiration causes an increase in which sided heart sounds
What are the systolic heart sounds
aortic/pulmonic stenosis and mitral/tricuspid regurg
What are the diastolic heart sounds?
aortic/pulmonic regurg and mitral/tricuspid stenosis
Which murmur is characteristic of mitral/tricuspid regurg?
What are common causes of mitral regurg?
ischemic heart dz, mitral valve prolapse, LV dilation
What causes the murmur heard in MR to enhance?
inc TPR and LA return (expiration)
What causes the murmur heard in tricuspid regurg to enhance
in RA return (inspiration)
Which murmur is heard in aortic stenosis?
crescendo-decrescendo systolic ejection murmur following ejection click
What causes the ejection click in the Cres-decres murmur?
aburpt halting of valve leaflets
What is the characteristic pulse in aortic stenosis?
pulsus parvus and tardus, weak, can lead to syncope
What causes aortic stenosis
age related calcifications or bicuspid aortic valve
Which murmur is heard with VSD?
holosystolic, harsh sounding murmur, loudest over tricuspid area
Which murmur is heard with mitral prolapse?
late systolic crescendo murmur with a midsystolic click
what causes the midsystolic click
sudden tensing of chordae tendinae
What does mitral prolapse predeispose to?
What can cause mitral prolapse?
myxomatous degeneration, RF, chordae rupture
What murmur is heard with aortic regurg?
immediate high pitched blowing diasystolic murmur with a wide pulse pressure
What causes aortic regurg
aortic dilation, bicuspid aortic valve, RF,
Which class of drugs decrease the murmur heard in aortic regurg?
Which murmur do you hear in mitral stenosis?
late diastolic murmur following an opening snap
Chronic mitral stenosis can lead to what changes in size of the LA
Mitral stenosis is most often secondary to which condition?
What is the machine like murmur? What is the heart pathology and the predisposing causes
patent ductus arteriosus, congenital rubella or prematurity
When does extracellular calcium enter the cardiac muscle cells during contraction?
the plateau period
What stimulates release of calcium from the SR?
extracellular calcium, calcium induced calcium release
When during cardiac nodal cells depolarize?
How are cadiac myocytes eltrically coupled?
What happens in phase 0 of the cardiac ventricular action potential?
rapid upstroke, voltage gated Na channels open
What happends in phase 1 of the ventricular cardiac action potential?
initial repol, inactivation of of voltage gated Na channels, voltage gated K channels begin to open
What happens in phase 2 of the cardiac ventricular action potential?
plateau, influx of calcium through voltage gated ca channels, ca release from SR and contraction
What happens in phase 3 of the cardiac ventricular action potential?
rapid repol, massive K influx, opening of voltage gated slow K channels and closure of Ca channels
What happens in phase 4 of the cardiac ventricular action potential?
resting potential high K perm
Where are pacemaker cells?
SA and AV nodes
What channels do the the pacemaker cells lack?
fast volatge gated Na channels
What constitues the upstroke in pacemaker cells?
volatage gated Ca channels
What is the result of not have fast sodium channels in pacemaker cells?
slow conduction velocity, used by AV node prolongs transmission from atria to ventrical
Which channel accounts for automaticity of the SA and AV nodes?
If sodium channel
What is the effect on the slope of phase 4 in pacemaker cells by Ach or adenosine?
What is the effect on the slope of phase 4 in pacemaker cells by catecholamines and
increase, increase the chance the If are open
In an EKG, what is the p wave?
In an EKG, what is the PR interval?
conduction delay through AV node, nl < 200 msec
In an EKG, what is the QRS complex?
ventricular depolarization, nl < 120 msec
In an EKG, what is the QT interval?
mechanican contraction of the ventricles
In an EKG, what is the T wave?
What does T wave inversion indicated?
What masks atrial repolarization?
What does an isoelectric ST segment indicate?
ventricles are depolarized
What does the U wave indicated?
hypoK and bradycardia
What does prolonged QT predispose to?
torsades de pointes
What is the danger of torsades to pointes?
can progess to V fib
What other sign is often present with congenital long QT syndrome, why?
sensironeural deafness, defects in sodium and potassium channels, jervell and lange-neilsen syndrome
Rank the following by speed of conduction, av node, atria, purkinjee, ventricles
Rank the pacemakers cells
SA>AV>bundle of His>ventricles
delta wave on ECG, accesory conduction pathway from atria to ventricles, reentry leading to supraventricular tachycardia
Wolff-Parkinson white syndrome
Irregularly irregular ECG, no p waves: dx and treatment
A fib, beta block or ca channel block, warfarin, thromboembolism prophylaxis
atrial fiutter, identical back to back atrial depol's, convert to sinus, cal IA, IC or III antiarrhythmics
prolonged PR interval
1st degree AV blodck
progressive lengthening of PR until beat is dropped, a p wave not followed by QRS
2nd degree AV block, mobitz type 1
no change in PR interval followed by dropped beat
2nd degree AV block, mobitz type 2, may progess to 3rd degree block
no relation between p waves and QRS intervals, treatment and predisposing factor
3rd degree block, pacemaker, Lyme disease
What does the atria release in response to inc blood volume and atrial pressure
Which two mechanisms sense decrease MAP?
medullary vasomotor center senses baroreceptors and JGA
Which sympathetic receptors raise MAP
beta 1 inc HR and cont, alpha 1 venocxn, alpha 1 arteriolar vascxn
How does angiotensin II raise MAP
How does aldosterone raise MAP
inc blood volume
The aortic arch receptors transmit along which nerve?
vagus to medulla
The carotid sinus transmits along which nerve?
glossopharyngeal to soliary nucleus of medulla
decrease stretch in baroreceptors leads to what response?
increased efferent SANS and decreased efferent PANS
What do the carotid and aortic bodies respond to?
dec P02, inc PC02 and dec pH
Central chemoreceptors do not respond directly to which parameter?
What is the cushing triad?
HTN, bradycardia, and respiratory depression
What causes the cushing reflex and why
inc ICP, cerebral ischemia, inc SANS tone (HTN) and reflex bradycardia
Which organ gets the largest share of systemic cardiac output
Which organ has ht highest blood flow per gram of tissue
Which organ has the largest arteriovenous difference
Heart, 02 extraction is always around 100%
PCWP > LV diastolic pressure
PCWP is an estimate of
Left atrial pressure
What does hypoxia cause in the lung versus other tissues?
vasocxn, while other tissues it causes vasodilation
What does autoregulation do?
maintain blood flow to organ over wide range of perfussion pressures
What do the starling forces determine
fluid movement through capillaries
In terms of starling forces, why does heart failure cause edema?
increase in Pc
In terms of starling forces, why does nephrotic syndrome or liver failure cause edems
dec plasma proteins
Why is there edema after burns or during infection
inc Kf, capillary perm
what happens to capillaries in lymphatic blockage
inc interstitial osmotic pressure pulling fliud out of capillaries
What are the 5 T's of cyanoitc babies
tetralogy of fallot, transposition of great vessels, truncus arteriosus, tricuspid atresia, TAPVR
what does TAPVR stand for
total anomalous pulmonary trunk venous return
Right to left shunts are more common in babies or kids?
Left to right shunts are more common in babies or kids?
failure of truncus arteriosus to divide?
persistant truncus arteriosus
absecnce of tricuspid valve, hypoplastic RV
tricuspid atresia, requires ASD and VSD
pulmonary veins drain into right heart circulation (SVC, coronary sinus)
L to R shunt becomes R to L due to increase pulm pressures from original congenital heart defect
tetrology of fallot - pulmonary stenosis, RVH, overiding aorta, VSD
What causes the early cyanosis in Tet of Fallot?
R to L shunt caused by stenoic pulmonic valve
What is the classic X ray finding for tet of fallot?
boot shaped heart
What causes tet of fallot?
anterosuperior displacement of the infundibular septum
How does a patient with Tet of fallot learn to improve symptoms?
squat. Compression of femoral arteries, inc TPR, dec
What other congenital abnormality is necessary for life for a patient with transposition of the great vesses?
shunt, VSD, PDA or patent foramen ovale, due to failure of the aorticopulmonary septum to spiral
Weak pulses, notching of the ribs on xray, HTN in upper extremeties and weak peripheral pulses
adult type aortic coarctation
what is the difference between adult and infantile type aortic coarctation?
infantile is proximal to ductus arteriosus and adult is distal. Infantile IN and aDult is Distal to Ductus
What other syndrom is associated with infantile aortic coarctation
What is the difference between the fetal and neonatal direction of blood flow in a patent ductus arteriosus
fetal right to left, neonate left to right leading to RVH and failure
which medications are used to maintain patency or close the ductus arteriosus?
indomethacin closes, and pge keeps it open
congenital heart defect with 22q11
truncus, tet of fallot
congenital heart defect withdown syndrome
ASD, VSD, AV septal defect (endocardial cushion defect)
congenital heart defect with congenital rubella
septal defects, PDA, pulm art stenosis
congenital heart defect with turner's
coarcation of aorta
congenital heart defect with marfan's
aortic insuffic, late
congenital heart defect in an infant with a diabetic mother?
transposition of great vessels
What is the definition of HTN?
which ethnic groups have higher association with HTN?
black > white > asian
what percentage of HTN is secondary to renal disease?
What does HTN predispose to?
atherosclerosis, LVH, stroke, CHF, renal failure, retinopathy, aortic dissection
What are tendinous xanthoma, atheromas, and corneal arcus signs of?
Hyperplastic onion skinning
arteriolosclerosis in malignant hypertension
fibrous plaques and atheromas in intima of arteries
calcification in media of arteries esp radial and ulnar, does not obstruct blood flow, intima not involved
disease of elastic arteries and large and medium sized muscular arteries
What is the progression of atherosclerosis?
endothelial cell dysfxn, mac and LDL accum, foam cell, fatty streaks, smooth muscle cell migration, fibrous plaque, comlex atheromas
what are the complications of atherosclerosis?
aneurysms, ischemia, infarcts, peripheral vasc dz, thromboemboli
what are the four most common locations for atherosclerosis?
abdominal aorta>coronary artery>popliteal artery>carotid artery ACoPCa
tearing chest pain radiation to the back, associated with marfan
aortic disecction, intraluminal tear forming false lumen
retrosternal chest main with exertion, ST depression on ECG, likely due atherosclerosis
coronary artery spasm, ST elevation
thrombosis w/o necrosis, ST elevation, worsening chest pain at rest or with minimal exertion
What is the most common cause of MI
acute thrombosis of coronary artery
What is sudden cardiac death most commonly due to
v fib arrhythima
list the coronary vessels most likely to be occluded
LAD > RCA > circumflex
diaphoresis, N/V, severe retrosternal pain, pain in left arm/jaw, SOB, fatigue, adrenergic symptoms
What is the time frame for arrhythmia risk in the evolution of MI
the first 4 days
In an acute MI, are there any visible changes via LM in the first 2-4 hours
In the evolution of an MI, when the risk for free wall rupture, tamponade, papillary muscle rupture, or interventricular septal rupture the hightest? Why?
5-10 days, macs have degraded structural components
When do you see extensive coagulative necrosis in an MI
2-4 day, early coag necrosis on the first day
When is the scar completely formed in an MI?
Which enzyme rises after 4 hours and is elevated for 7 to 10 days after an MI?
What is the gold standard for dx of MI in the first 6 hours
Which enzymes are useful for diagnosing reinfarction
Which kind of infarct show ST elevation, and/or pathologic Q waves
What kind of infarct show ST depression
Which area of the endocardium is especially vulnerable to infarction? Why?
subendocardial, fewer collaterals and higher pressure
In an anterior wall infarct, which artery is effected and which leads show Q waves
LAD, V1 -V4
In an anteroseptal infarct, which artery is effected, and which leads show Q waves?
In an anterolateral infarct, which artery is effected and which leads show Q waves
In a lateral wall infarct, which artery is effected, and which leads show Q waves?
LCX, I, aVL
In an inferior wall infarct, which artery is affected and which leads show Q waves,
RCA, II, III, aVF
The 7 complications of MI
arrhythmia, LV failure and pulm edema, cardiogenic shock, free wall rupture, aneurysm, postinfarcation fibrinous pericarditis, dressler's
friction rub, 3-5 days post MI
postinfarction fibrinous pericarditis
fibrinous pericarditis several weeks post MI
S3, dilated heart on US, balloon appearance on CXR, eccentric hypertrophy
What are the different etiologies of dialted cardiomyopathy
EtOh, wet Beriberi, Coxsackie B, cocaine, chagas, doxorubicin, hemochromatosis, peripartum cardiomyopathy
How are the sarcomeres added in eccentric hypertrophy?
sudden death in young atheletes, S4, apical impulses, outflow obstruction
How are sarcomeres added in concentric hypertrophy?
Does eccentric hypertrophy or concentric hypertrophy cause systolic disfunction
eccentric, concentric hypertrophy causes diastolic disfunction
Restrictive cardiomyopathy causes
sarcoid, amyloid, postradiation fibrosis, endocardial fibroelastosis, Loffler, hemochromatosis
What kind of dysfunction ensues in restrictive cardiomyopathy
dyspnea, fatigue, edema and rales, multiple causes
The cause of dyspnea on exertion?
failure of LV to in CO during exercise
The cause of cardiac dilation?
greater ventricular EDV
The cause of pulmonary edema, paroxysmal nocturnal dyspnea?
LV failure, pulm venous distention transudation of fluid
When do you find hemosiderin laden macrophages in the lungs?
during HF from microhemorrhages from inc pulm cap pressure
what causes orthopnea?
inc venous return exaccerbates pulm vasc congestion
what causes hepatomegaly?
inc central venous pressure, inc resistance to portal flow
What causes ankle, sacral edema, jugular venous distention
RV failure, in venous pressure
What is the most common cause of right heart failure
left heart failure
What does FROM JANE stand for in bacterial endocarditis?
fever, roth's spots, osler's nodes, murmur, janeway lesions, anemia, nail-bed hemorrhages, emboli
Which valve is most commonly involved in bacterial endocarditis?
Which valve is commonly involved in bacterial endocarditis from IV drug use and which bacteria are most common?
tricuspid, don't tri drugs, S. aureus, pseudomonas, candida
bacterial endocarditis, previously normal valves, rapid onset, which bacteria?
smaller vegetations, congenitally abnormal or diseased valves, sequela of dental procedures. Insidious onset
Which bacteria causes endocarditis in the presence of colon cancer
which bacteria can cause endocarditis from prosthetic valves?
What are the complications from bacterial endocarditis?
chordae rupture, GN, suppurative pericarditis, emboli
wartiike, sterile vegetations occur on both sides of the valve, commonly causes mitral regurg. SLE causes it
Which bacteria causes rheumatic heart disease
group a beta hemolytic strep
what do patients die early from in rheumatic heart disease?
early deaths from myocarditis
which heart valves are afected most in rheumatic heart diseease
mitral>aortic>>tricuspid, high pressure valves affected most
what is the early and late lesion in rheumatic heart disease
mitral valve prolapse
What are aschoff bodies
granuloma with giant cells
what are anitschkow's cells
Do you see elevaged ASO titers in rheumatic heart disease
What does FEVERSS stand for in rheumatic heart disease
fever, erythema marginatum, valvular damage, ESR, red hot joints, subQ nodules, St. vitus dance (chorea)
Equilibration of diastolic pressures in all 4 chambers, decreased CO from compression of heart by fluid in pericardium
exaggerated decrease in pulse during inspiration.
kussmaul's sign, cardiac tamponade, pulsus paradoxus
clinical signs of cardiac tamponade
hypotension, inc venous pressure, distant heart sounds, inc HR, pulsus paradoxus
what conditions are associated with pulsus paradoxus
cardiac tamponade, asthma, obstructive sleep apnea, pericarditis and croup
disruption of the vasa vasorum of aorta, dilation of aorta and valve ring, tree bark appearance (calcifications on aortic root)
3rd degree syphillus, syphillit heart disease can lead to aortic valve incompetence
most common primary cardiac tumor in adults, ball-valve obstruction in left atrium
most common primary cardiac tumor in children, associated with tuberous sclerosis
most common heart tumor
metastasis from melanoma or lymphoma
dilated tortous veins due to chronically inc venous pressure, poor wound healing, varicose ulcers
varicose veins, thromboembolism rare
decrease blood flow to the skin due to arteriolar vasospasm in cold temp, emotional stress, also in SLE and CREST
necrotizing granulomas in lung and upper airways, nectrotizing GN, small vessel vasculitis
hemoptysis, hematuria, perforation of nasal septum, chronic sinusitis, otitis media, mastoiditis, cough dyspnea
serum marker for wegener's
cyclophosphamide and corticosteroids
microscopic polyangiitis, like wegener's without granulomas
Churg Strauss, presentation and test
granulomatous vasculitis with eosinophilia. Asthma, sinusitis, skin lesions and periphereal neuropathy (wrist/foot drop) heart, GI, kidneys
port wine stains on face, intracerebral AVM, siezures, early onset glaucoma, congenital
sturge weber, vasculitis of caps
skin rash on buttocks and legs, arthralgia, intestinal hemorrhage, abdominal pain, melena. Follows URI, IgA immune complex, most common childhood systemic vasculitis
segmental thrombosing vasculitis of small and medium vessels in smokers with intermittent claudication, superficial nodular phlebitis, raynaud's, gangrene and severe pain, autoamputation of digits is possible
acute, self limiting necrotizing vasculitis in children associated with fever, conjunctivitis, strawberry tongue, desquamatous skin rash, lymphadenitis, coronary sinus aneurysms. Seen in asians
immune mediated transmural vasculitis with fibrinoid necrosis, small and medium vessels, renal and viscera, not pulm arteries, hep B seropos in 30% of pts,
pulseless disease, granulomatous thickening of the aortic arch and/or proximal great vessels - elev ESR, asian females > 40
what does FAN MY SKIN On Wednesday stand for?
Fever, Arthritis, Night sweats, Myalgia, SKIN nodules, Ocular disturbances, Weak pulses in upper extremities
Unilateral headache, jaw claudication, impaired vision,
tempral arteritis, may cause irreversible blindness
Most common vasculitis affecting medium and large arteries
benign cap hemangioma of infancy, spont regresses
bening capillary hemangioma of elderly, does not regress
polypoid capillary hemangioma that can ulcerate and bleed
pyogenic granuloma, associated with trauma and pregnancy
cavernous lymphangioma of the neck, associated with turner's
benign, painful, red-blue tumor under fingernails from smooth muscle cells
benign capillary skin papules in AIDS patients mistaken for kaposi sarcoma, caused by bartonella henselae
highly lethal malignancy of the liver, associated with vinyl chloride, arsenic, and thorosrast exposure
lymphatic malignancy associated with persistant lymphadema, post radical mastectomy
endothelial malignancy of the skin assocated with HHV-8 and HIV