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An Atrial Septal Defect (ASD), one of the most common forms of congenital heart disease, arises from delayed closure of______Foramen ovaleASD can also be caused by inadequate development of the_________or Inadequate formation of________Septum Primum
&
Septum SecundumThe initial L to R shunt in ASD leads to overload and decreased compliance in the___________Right VentricleThe Right to left shunt (Eisenmengers) can be characterized as:A severe pulmonary vascular Dz leading to hypoxemia, cyanosis, and PHTNOver time, VSD leads to: (4 things)RV volume overload
Systolic dysfunction
HF symptoms
Pulmonary vasculature DzThe pulmonary vasculature Dz that occurs from prolonged VSD, is called_______. This Dz can has S&S of _____&______Eisenmenger Syndrome
Hypoxemia & CyanosisWhen is surgical correction indicated for for VSD patients?When they have CHF or Pulmonary vascular Dz (Eisenmenger- hypoxia/cyanosis)Patent ductus arteriosus (PDA) is characterized by a ___&___ overload with ______ dilation.Left atrium / Left Vent overload w/ Left vent dilationWhat type of murmur is characterized by PDA?Machine-like murmurEisenmenger Syndrome in PDA leads to low ___, which increases__________.Hgb
Bone marrow RBC productionIn PDA, what does Eisenmenger syndrome do to the viscosity of the blood?Hyperviscosity (from increase RBC production)The Eisenmenger syndrome in PDA has what S&S?Fatigue & Headaches
Stroke & Infarction
Pulmonary vessel ruptureIn children with Congenital Heart Dz, If the defect is LARGE, the Pt will display poor feeding, slow growth, and recurrent:Lower Respiratory InfectionsIn children with congenital heart Dz, if the defect is Moderate, the Pt will exhibit, Fatique, DOE, and _____PalpitationsIf _________ develops in congenital heart disease, Lower extremity cyanosis & clubbing will developEisenmenger syndromeThe most common abnormal aortic valve in Aortic Stenosis is _____The bicuspid valve (what the slides say but Aortic isnt a bicuspid valve)Aortic Stenosis is 4x more common in___MalesAortic Stenosis is characterized by the narrowing of_______, which causes an increase in__________ pressure, ultimately leading to _________ hypertrophyAortic orifice
Systolic aortic pressure
Left Vent hypertrophyThe narrowing of the aortic orifice in AS produce this heart sound:Systolic ejection murmurThe most common cause of cardiac cyanosis in neonates is:TOF - Tetralogy of Fallot (Blue baby)Accounting for 10% of congenital heart defects, TOF typically presents with these 4 lesions:VSD
Overriding Aorta
Pulmonary valve stenosis
Right Vent hypertrophyIn TOF, what is the Aorta "overriding" and where is it receiving blood fromAorta overrides the VSD & receives blood from BOTH LV and RVTetralogy of Fallot is characterized by a ______murmur caused by_______Systolic ejection murmur caused by the Stenosis of the Pulmonary valveThe increased pressure gradient produced in TOF is what leads to_____ (one of the 4 lesions)Right Vent HypertrophyIncreased Peripheral vascular resistance, CHRONIC hypoxemia, and cyanosis of the fingers/toes, earlobes, cheeks, and lips, and clubbing are all signs of:multiple heart defects: VSD, Pulmonary valve stenosis, Right Vent hypertrophy, and Overriding Aorta. (Tetralogy of Fallot - squatting blue smurfs)How does the shunt differ in TOF compared to the other congenital heart diseases?TOF is a Right to left shuntIn Tetralogy of Fallot, when the Right Ventrical contracts, describe the blood flow from here that leads to the cyanosis:RV contracts - some of the venous blood goes through Pulmonary valve but also goes through the Ventral septal defect into the left ventricle. This deoxygenated blood leads to cyanosisAortic coarctation is a congenital heart disease characterized as a _______ of the aorta distal to the origin of________constriction/narrowing
Left subclavian arteryAortic coarctation will also lead to a discrepancy in BP of the arms in legs. Why is this and where is BP at its highest?Due to the aortic narrowing, BP will be higher proximally (in the arms)What might be seen on an CXR of a Pt with Aortic coarctation? What causes this?Rib-notching - caused by the increased pressure in the intercostal arteriesChildren with this genetic disorder often have aortic coarctations (& Rib notching on CXR):Turner's Syndrome
(But what about it affecting males 2:1? Turners are missing all or part of their X)What happens inside the vessels that make it opportunistic for the pathogenesis of atherosclerosis to form (very first thing that happens. Before the build up of anything)An endothelial injury (metabolic or physical)This endothelial injury causes deposits of ___ & ___ to form.PLT and lipoproteinsDuring the endothelial repair, _________stimulates smooth muscle cell proliferation.
These smooth muscle cells eventually become____ (AKA____).PLT growth factor
Foam cells (Lipid-laden)(Along with PLT deposit, were deposits of lipoproteins)- The lipoproteins that deposit in the endothelial area during repair lead to an accumulation of ______ and other lipidsCholesterolWhen the foam cells, cholesterol, and other lipids begin to die, _____ are attracting to the area (clean-up). What happens to the cholesterol that cannot be removed?Macrophages clean up
Cholesterol crystallizes and deposits into the interstitium.After the macrophages have done their job, they become______? What is released as a result of this?Macrophages turn into foam cells, release cytokine -TNF which leads to more damageThe damage caused by the cytokines causes______of the cell wall and eventually leads to____Scarring (sclerosis) of the cell wall,
leads to arterial hardeningOver time, (at the site of initial injury) this will form: ______- a highly thrombogenic, protypical atherosclerosis lesion with a lipid rich center surrounded by collagenous fibersAtheromaThe soft core of the Atheroma is covered byA fibrous capWhen the fibrous cap ruptures, _____will formThrombusThe thrombus formed from the rupture of the fibrous cap in the arteries leads to _______ and subsequent _______complete occlusion and subsequent infarctionFixed splitting of S2 indicates:ASDWhat are the Non-modifiable risk factors associated with atherosclerosis?Age, gender (males - But what about Caitlyn Jenner?), and heredity (Fam Hx, M <55, F <65)A modifiable Risk factor of Atherosclerosis associated with Impaired endothelial function and Increased WBC adhesionDiabetes Mellitus (athero increases disposition and worsens the Dz)A modifiable risk factor of atherosclerosis through lipid accumulation of sub-endothelial spaces causing Increased LDL levelsA familial or secondary condition to obese Pt requiring a low saturated fat diet (Hyperlipidemia)How does Estrogen aid in the prevention of atherosclerosis?Estrogen is atheroprotective. Through mediation of lipids and lipoproteins it decreases athero progression, improves vasodilation, antioxidant and antiplatelet propertiesWho is more prone to aortic atherosclerosis and why?Males >50. Aorta becomes less elastic, more collegen = stiff aorta. Unable to adapt to pulse and blood pressure changes, resulting in HTN.If a male >50 with HTN, and atherosclerosis: what should you be concerned with in regards to aortic atherosclerosis?Aneurysm. Especially abdominal
Male smokers over 55 are most common AAA.A congenital or acquired weakness of an arterial wall, typically in males < 50, caused by a ballooning or outward rupture of a vessel.An increase of >1.5 times the normal width of an artery (Aneurysm)Once an aneurysm becomes >5cm, what is the gold standard for treatmentSurgical repairAn anuerysm is termed a TRUE aneurysm when:All 3 layers (Intima, Media, adventitia) are affected and usually >50% increase of original sizeMost common forms of True aneurysms are those that:affect the entire circumferential aortic dilation (Fusiform)An outpouching or partial involvement involving all 3 layers of a vessel is a ______aneurismSaccularA contained rupture within a vessel wall, not involving all 3 layers is, with a delayed or recurrent bleed is:A Highly unstable/prone to further rupture that must be monitored with high suspicion (Pulsatile hematoma/False or Pseudo-aneurysm)Pt normally presents with a "ripping'tearing" pain, and anterior chest pain between the scapulae. Pt may have uncontrolled HTN. CXR shows a wide mediastinum.A life threatening splitting of Intima from adventitia in the 2/3 ascending and 1/3 descending of the Aorta causing distal ischemia. (AORTIC DISSECTION)What 2 types of Pt are highly prone to Aortic Dissection?Marfan and Ehler Danlos SyndromWhat peripheral artery disease, related to aortic atherosclerosis, will lead to HTN and other subsequent conditions?Renal atherosclerosis causes Renal hypoperfusion and ischemia, leading to irreversible renal failure. Renin releases in response to the ischemia, and decreased urine output from the renal failure cause/further complicate HTNAn older Pt presents with GI symptoms such as malabsorption and constipation. Complains about having poor digestion and an increased intolerance to foods. What should you suspect?A chronic partial occlusion of the GI tract secondary to Intestinal atherosclerosisHow will Acute representation of Intestinal atherosclerosis differ from acute?Acute will usually be due to a massive infarction of a major artery with a thrombus or embolus.Pt complains of increasing pain in his legs during physical activity (intermittent claudication), especially when he walks long distances or runs. He gets relief soon after the end of exercise. You note under perfusion of his lower extremities. What do you suspect?Chronic ischemia secondary to a progressive narrowing of femoral/popliteal arteries as a result of Atherosclerosis.With the Pt, complaining of leg pain during exercise, what signs might point you to a sudden occlusion?Gangrene of affected tissuesPt complaining of intermittent claudication during exercise in his buttocks. Suspet what?Chronic ischemia secondary to progressive narrowing of iliac arteryPt complaining of intermittent claudication in mainly his thighs during exercise. Suspect what?Pt complaining of intermittent claudication in mainly his thighs during exercise. Suspect what?Chronic ischemial secondary to progressive narrowing of the femoral arteryPt complains of intermittent claudication in his calf muscles during exercise. Suspect what?Chronic ischemia secondary to progressive narrowing of SUPERFICIAL femoral arteryWhat is Leriche?
What is the Triad?Leriche- Atherosclerotic aorto-iliac occlusion
Triad- Buttock, thigh claudication
Erectile dysfunction
decreased pedal pulse (leg atrophy)Coronary Heart Dz presentation is dependent upon what 5 factors?Extent of occlusion
Speed of occlusion
Extent of atherosclerosis in other coronary areas
location of insult
Presence/absence of other diseases50% of all infarctions in CHD occur where?
what accounts for 15-20%?LAD (40% in RAD)
15-20% = Left circumflexThe infarction in CHD leads to Chronic________, as a result of Myocardial hypoperfusion. This Hypoperfusion & ischemia will evolve slowly into________.Chronic progressive ischemia
Pump failure (CHF)Pt suffering from Progressive ischemia are often asymptomatic or have _________Angina PectorisPt presents with chest pain and SOB when exercising, climbing stairs, or running. Symptoms do not present when at rest or functioning normally. What do you suspect?Myocardial ischemia secondary to a >75% occlusion of a cardiac artery causing decreased Perfusion.
(ANGINA PECTORIS)MI survivors will usually develop complications later in life such as: (5)LV failure leading to cardiogenic shock
Myocardium wall rupture
LV aneurysm
Non-contractile aneurysm (Thrombosis)
Embolus to distal sites_______-Most sensitive and specific cardiac markerTroponin ITroponin-I will stay elevated up to _______, and even longer if Pt has underlying______1 week
Longer if renal failureWhat is peak time for CK-MB?36-48 hoursMyoglobin-A will be elevated within 2 hours of_____cardiac necrosisWhat conditions may cause a "High output failure" form of CHF?Hyperparathyroidism
Pheochromocytoma
Severe Anemia4 Common causes of CHF:Systemic HTN
Mitral/Aortic Dz
Ischemic heart Dz (CAD)
CardiomyopathyPressure back up into the Pulmonary circulation is a result of:Left Vent failureLeft Vent failure causes pulmonary edema by:LV pump fails & EJ fraction decreases, L atria and pulmonary vessels increase in pressure. Alveolar capillaries fill with transudate.Name the symptoms common with left-sided heart failure:Dyspnea & Cough
Orthopnea
Paradoxysmal nocturnual dyspnea
Cardiomegaly
Tachycardia
S3 (blood against non-compliant vent)
RalesRight heart failure is usual due to:Left sided heart failureR heart failure is cause by L heart increasing the _______pressure, which causes_____ & R heart failurepulmonary vasculature
RV hypertrophyCor pulmonale is a chronic lung disease caused by severe______, typically leading to isolated_______Pulmonary HTN
Right sided heart failureMyocardial hypertophy and dilation are generally confined to which side of the heart?Right Vent and atria. Don't affect left sideIsolated right heart failure secondary to Primary pulmonic or tricuspid valve disease is generally caused by _______&______, resulting in right atrial pressure, ____ and ____Pulmonic stenosis & Tricuspid regurgitation
Peripheral/pedal edema
JVDA Pt with Cough/frothy sputum, orthopnea, or Paroxysmal nocturnal dyspnea is usually suffering from __________, as a result of _______ caused by______Pulmonary edema
Pulmonary congestion
Left side heart failureA Pt w/ Cyanosis and signs of hypoxia is usually suffering from an impaired______as a result of_____caused by______Impaired gas exchange
Pulmonary congestion
Left sided heart failureA Pt suffering from an increased intolerance to activity (exercise) could be suffering from a decreased_____secondary to _______decreased cardiac output
Left side heart failureA Pt presents with anorexia like symptoms, GI distress, and weight loss, despite normal diet. This could be caused by a congestion of_______ as a result of______secondary to______congestion of GI Tract
caused by peripheral tissue congestion
Right sided heart failure secondary to left sided heart failureWhat symptoms might you see in a Patient suffering from peripheral tissue congestion caused by ISOLATED right sided heart failure?Dependent edema and ascitesKidney response to decreased blood pressure:
They release_____
Renin combines with_____to make____, which then turns into______by ACE. AGII stimulates the release of_______from the Adrenal glands. Aldosterone promotes the increase of_____, which increases blood volume and pressure as a result.Renin
Angiotensinogen
AG-I
AGII
Aldosterone
Sodium resorptionWhat external physical exam is extremely important with HTN Pt & why?Opthalmic exam
HTN increased risk for retinal damages leading to blindnessHow does HTN affect retinal changes? What may be observed during the retinal exam?HTN causes arteriosclerosis of the arteriolar wall in the retina. During exam, AV nicking may be observed, or a "Copper wire arteriole".
-Optic Disc swelling
"macular star" around the retinaWhat is suspected in a Pt with Copper wire arterioles?arteriosclerosis of retinal vessels caused by HTN retinopathyMild signs of HTN retinopathy are often seen in normal people about ___% of the time in ages____3-14% >40yearsAdvanced retinopathy lesions will have many forms such as: (6)Microaneurysm
Blot/Flame hemorrhage
Cotton wool spots
Hard exudate
Optic disc swelling
Macular starExudative fluid in the pericardial sac is always associated with:PericarditisEpicardial inflammation (Pericarditis) is characterized by 3 stages:1. local vasodilation with cell-free, protein-poor transudate
2. increased vascular permeability with protein leakage
3. Exudate of neutrophils followed by mononuclear cellsSigns and Symptoms of Acute Pericarditis:Pleuritic chest pain
Fever
Pericardial friction rub
EKG abnormalitiesPleuritic chest pain, a sign of acute pericarditis is characterized by pain in the__________area, radiating to_________. This pain is usually aggravated by________. Pt will find positional comfort when____retrosternal/left precordial
left trapezius ridge
Non-exertional dyspnea (inspiration and coughing)
leaning forwardCommon to all Acute pericarditis cases is Serous Pericarditis- characterized as an early __________involving (2 cells). Serous Pericarditis is usually due to _______Inflammation response of lymphs and leukos
Due to viral infection (viral pericardits is usually in youn and healthy ppl)The most commonly observed pattern of pericarditis has a _________appearance with plasma and fibrinogen, causing more severe damage. This Pericarditis is called______exudate w/ rough & shaggy appearance
Serofibrionous Pericarditis (Bread and Butter)Pt with an early bacterial infection and/or Rheumatic fever will typically display these heart abnormalities:Thick exudate of pericardium leading to movement restriction, impaired diastolic filling, and scarring as a result of the SEROFIBRINOUS (bread and butter) Pericarditis.Suppurative Pericarditis is often associated with_______as a result of a ________from____ or ____Intense inflammatory response to a bacterial infection
Pus forming bacteria - Staph and StrepConstrictive pericarditis (late complicated form) will prevent diastolic dilation due to the________Fibrosis of the pericardial cavityNormal pericardial fluid is_____15-50 mlPericardial effusion w/increased cap permeability is assoc with:HypothyroidismPericardial effusion w/ increased capillary hydrostatic pressure is assoc with:Heart failureA decrese in plasma oncotic pressure w/pericardial effusion is assoc w/Nephrotic syndrom or cirrhosis______-A milky fluid consisting of lymph, emulsified fats, or fatty acids (with pericarditis or effusion) is usually due to a _______caused by_____Chylous effusion
from a lymph drainage obstruction
Caused by neoplasms or TBHallmark testing for Pericardial effusion is: (2)CXR w >250 ml volume & enlarged silhouette
Altered EKGA Pt with mild fever, SOB, and other signs of heart failure (i.e. chest pain, tachycardia, pulmonary edema). Lab tests may show a virus or parasite such as coxsakie or T. Cruzi. How is this virus manifesting these symptoms and causing Myocarditis?A T-lymph response to the virus that has released cytokines and TNF, causing further cell death and weakening the myocardiumIn order for Pyogenic bacteria to cause bacterial endocarditis, the following must occur: (4)Endocardial surface injury
Thrombus formation
Bacteria in circulation
Bacteria adherence to the endocardial surfaceBacterial lytic enzymes causing bacterial endocarditis cause destruction of ____tissue. How will this destruction of valvular connective tissue lead to further infections elsewhere? What external sign may be seen in later stages of Bacterial endocarditis?Valvular connective tissue
-The tissue deformities get replaced by fibrin and PLT thrombi
-Vegetations (warts) accumulate on top of this fibrin.
-over time, these break off as septic emboli, settling somewhere else, causing a new infection (micro abscess)
-Splinter hemorrages are the sign seen as a result of micro-emboli formationAs a result of the tissue build up on the valves in Bacterial endocarditis, a _____will form due to blood trying to flow over the deformed valve.Cardiac murmurThe deformed valves from bacterial endocarditis leads to______, which later can develop signs of_____. The valve most affected by this is the ______Valvular insufficiency (regurgitation)
Heart failure
Mitral valveWhat is the most prevalent complication to Rheumatic heart Dz?Vegetations on the valves leading to arterial emboli & Scarring of the valve leaflets/chordae causing stenosis or regurg. (ENDOCARDITIS)How will the most prevalent complication to Rheumatic heart Dz (Endocarditis) be observed on Pt presentation?The arterial emboli from vegetations will cause retinal & splinter hemorrhages
The Stenosis & Regurg will produce a murmurAnother common complication of Rheumatic heart diseases is Myocarditis. This complication will have a hallmark of_____- which are___________that destroy the Myocardium.Aschoff bodies - lymph/macrophage aggregatesWhile auscultating, you hear a scraping noise with each heartbeat. This sound is called_______, oftenly caused by _________ secondary to ________, and is another complication of Rheumatic Heart DiseasePericardial friction rub
Pericardial effusion
PericarditisRheumatic Fever is typically 2 weeks after a _____ infection, and considered a Type_____Rxn.Strep throat
Type II hypersensitivityRheumatic fever is diagnosed based on_______(S&S)Jones criteria (2 major, 1 minor)What causes Rheumatic fever?An Immune response to Strep Ag cross-reacts with Pt cells, causing damage in connective tissue, heart, joints, brain, etc.What type of prego-Pt would especially be at risk for developing Dilated Cardiomyopathy? What is it called?Pregnancy associated HTN w/volume overload, nutritional deficiency, and metabolic derangements (might have gestational diabetes) - PERIPARTUM cardiomyopathyMost common cause of Dilated Cardiomyopathy is:AlcoholWhat hereditary condition should you be aware concerning Dilated Cardiomyopathy?Hereditary hemochromatosis (causing iron overload)A Familial autosomal dominant Cardiomyopathy with abnormally thickened ventricular walls and abnormal diastolic relaxationHypertrophic CardiomyopathyWhat is the dangers of HCM? How will this present in young and old Patients?Then enlarged cardiac muscle cells and the partial obstruction of blood flow generally lead to ischemia during physical exertion
-May present as sudden death in younger Pt or HTN in older PtHow is the functional state of Restrictive Cardiomyopathy similar & confused with Constrictive Pericarditis or HCM?They will all have normal systolic functionRestrictive will be differentiated from HCM or Constrictive cardiomyopathy with the detection of__________causing________.
-Restrictive Cardiomyopathy will also have ______fibrosis.Myocardial infiltration of abnormal material causing amyloidosis
-Radiation fibrosis_____-Autoimmune disorder affecting small/medium sized arteries, causing local tissue damage from complement activation.PAN- Polyarteritis NodosaPolyarteritis nodosa causes local destruction of vessel walls, leading to ______ formation. PAN typically involves _______vessels but will spare the ______Microaneurysm
Renal/Visceral vessels
spares lungs70 year old Pt presenting with throbbing temporal unilateral headaches. His temples seem inflamed with erythema. Pt states that the temporal areas are tender to the touch and they are having visual disturbances. What are you suspecting?Luminal obliteration to the lateral temporals caused by an infiltration of macrophages & Giant cells into the medial layer of the arteries. (Giant Cell arteritis)Buergers Dz (Thromboangiitis Obliterans) is assoc. smokers. It is an___________Dz of the small and medium peripheral vessels. Over time, if a Pt continues to smoke, what happens to these vessels?Occlusive Inflammatory Dz
Obliteration of vessels, creating thrombii, leading to necrosis and amputationMost common people at risk for varicose veinsWomen over 50
Pregnant
prolonged standing
Family HxWhat causes Esophageal Varices?Often due to cirrhosis causing portal hypertension which increase pressure and dilate veins in the lower esophagusIn older populations, what conditions will cause complications w/hemorrhoidsDiverticulosis
Colon Cancer
AngiodysplasiaIn younger patients, what diseases cause complications with hemorrhoidsIBS & Meckel's diverticulumPathology of Varicose veinsVenous valves become incompetent and remain dilated and fail to close properly, causing a stagnant backpressure and retrograde flow leading to engorged veins
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