Pathoma Chapter 8 Cardio
Terms in this set (118)
Chest pain that arises with exertion or emotional stress. Lasts less than 20 minutes and radiates to left arm or jaw. Presents with diaphoresis and shortness of breath.
What types of ischemic heart disease are reversible?
What types are irreversible?
stable angina, unstable angina, prinzmetal angina
What would an ECG show with stable angina?
ST segment depression (subendocardial ischemia)
How is stable angina relieved?
Rest and nitroglycerin
Chest pain that occurs at rest
What is the cause of unstable angina?
Rupture of atherosclerotic plaque with thrombosis and
of a coronary artery
Tx for unstable angina?
Vasospasm of coronary artery leading to episodic chest pain unrelated to exertion.
What would an ECG show with Prinzmetal angina?
ST segment elevation bc of transmural ischemia
Severe, crushing chest pain lasting greater than 20 minutes that radiates to left arm or jaw; presents with diaphoresis and dyspnea. Symptoms NOT relieved by nitroglycerin.
What generally causes MI?
rupture of atherosclerotic plaque with thrombus and
occlusion of coronary artery
MI usually involves which part of the heart?
3 most commonly involved arteries in MI.
Left descending artery, right coronary artery, left circumflex artery
What would an ECG show with early myocardial infarction?
ST segment depression
What would an ECG show with a late, transmural myocardial infarction?
ST segment elevation
Most sensitive and specific marker for detecting MI.
When can Troponin I be detected and when do levels return to normal?
Rises 2-4 hours after infarction, returns to normal by 7-10 days
Which marker is useful for detecting reinfarction days after MI?
When can CK-MB be detected and when do levels return to normal?
Rises 4-6 hours after infarction, returns to normal by 72 hours
How is MI treated pharmalogically?
- limit thrombosis
- minimize ischemia
- prevent vasospasm (selective for veins), lowering preload so decrease stress, dilates coronary aa
- induces bradycardia, dec work of heart, dec risk of arrythmia
- dec L ventricular dilation, block constriction of arterioles -> dec work, prevent inc of blood volume
How is MI treated surgically?
Fibrinolysis or angioplasty- opens blocked vessels
< 4 hour changes in MI: gross, microscopic, and complications?
none; none; cardiogenic shock (massive infarction), CHF and arrhythmia
2-24 hour changes in MI: gross, microscopic, and complications?
dark discolorization; coagulative necrosis; arrhythmia
1-3 day changes in MI: gross, microscopic, and complications?
yellow pallor; neutrophils; fibrinous pericarditis-presents as chest pain with friction rub
4-7 day changes in MI: gross, microscopic, and complications?
yellow pallor; macrophages; rupture of ventricular free wall (leads to cardiac tamponade), IV septum (leads to shunt), or papillary muscle (leads to Mitral insufficiency)
1-3 weeks changes in MI:gross, microscopic, and complications?
red border emerges as granulation tissue enters from edge of infarct; granulation tissue with plump fibroblasts, collagen and blood vessels; N/A
1 month changes in MI:gross, microscopic, and complications?
white scar; fibrosis; aneurism, mural thrombus or dressler syndrome
What is dressler syndrome?
autoantibodies against pericardium 6-8 weeks post-MI
What is sudden cardiac death?
What are the symptoms?
What causes it?
-unexpected death due to cardiac disease
-occurs w/o symptoms or <1 hour after symptoms arise
-1st: acute ischemia 2nd: mitral valve prolapse, cardiomyopathy and cocaine abuse
What is chronic ischemic heart disease?
poor myocardial function due to chronic ischemic damage (with or w/o infarction); progresses to CHF
List causes of left-sided heart failure.
dilated cardiomyopathy (4 chanber dilatation, cant contract as well)
restrictive cardiomyopathy (cant fill the heart approprately)
Describe the consequences of left-sided failure.
Pulmonary edema with dyspnea, PND, orthopnea, and crackles;
heart failure cells
(hemosiderin laden macrophages)
Decreased forward perfusion (activation of renin-angiotensin system)
What is the main treatment for left sided congestive heart failure?
List causes of right-sided heart failure.
Most commonly due to
; also, left-to-right shunt and chronic lung disease (cor pulmonale)
Describe clinical features of right sided heart failure.
JVD, painful Hepatosplenomegaly (could lead to cardiac cirrhosis- nutmeg liver), dependent pitting edema
What is the most common congenital heart defect?
What condition is VSD associated with?
Fetal alcohol syndrome
and maternal diabetes
Describe the shunting situation with VSD.
At first, blood from left ventricle will enter the lower pressure system of the right ventricle so you have a left to right shunt. Eventually, the excess blood in the right ventricle will cause pulmonary hypertension to the extent that blood from the right ventricle will enter the relatively lower pressure systemic circuit by entering the left ventricle. This results in cyanosis.
Large ventricular septal defects can lead to what? What is that?
Eisenmenger syndrome; the reversal of a left to right shunt to a right to left shunt due to eventual pHTN
What are some consequences of Eisenmenger syndrome?
Right ventricular hypertrophy, polycythemia and clubbing
What are the two types of ASD?
Ostium secundum (most common) Ostium primum (associated with Down syndrome)
Left to right shunt with a
split S2 on auscultation; paradoxical emboli are important complication
Condition associated with patent ductus arteriosis.
Asymptomatic at birth with holosystolic 'machine like' murmur; Eisenmenger syndrome results in lower extremity cyanosis
What is the treatment for PDA and how does it work?
Indomethacin; decreases PGE which would keep the PDA open
What are the 4 problems associated with tetralogy of Fallot?
Stenosis of RV outflow tract, right ventricular hypertrophy, VSD, aorta that overrides the VSD
Early cyanosis; patients learn to squat to relieve cyanotic spells. See "boot shaped" heart on X-ray.
Tetralogy of Fallot
What condition is associated with transposition of the great vessels?
What is transposition of the great vessels?
When the pulmonary artery arises from the LV and the aorta arises from the RV
How do you treat transposition of great vessels?
Give PGE to keep the ductus arteriosis open until you can surgically fix the problem
What is the problem in truncus arteriosus?
The truncus fails to divide into the aorta and pulmonary vessels; single large vessel arising from both ventricles --> early cyanosis
Describe findings of tricuspid atresia.
Tricuspid valve orifice fails to develop. Right ventricle is hypoplastic. Associated with ASD resulting in right-to-left shunt--> early cyanosis
Describe the difference between the infantile and adult forms of coarctation of the aorta.
Infantile form: coarctation lies distal to aortic arch, but proximal to PDA. Adult form: not associated with PDA, coarctation lies distal to aortic arch.
How does infantile form of coarctation of the aorta present?
Lower extremity cyanosis
What condition(s) is/are associated with infantile form of coarctation of the aorta?
PDA and Turner syndrome
How does adult form of coarctation of the aorta present?
Upper extremity hypertension and lower extremity hypotension
What condition is associated with adult form of coarctation of the aorta?
What is a consequence that develops due to adult form of coarctation of the aorta?
Collateral circulation develops across intercostal arteries. Engorged arteries cause
notching of ribs
Acute rheumatic fever preferentially affects which part of the heart?
Mitral valve, leading to mitral valve regurgitation
acute rheumatic fever:
caused by what process?
Criteria for diagnosis?
-caused by molecular mimicry, bacterial M protein resembles human tissue
What are the Jones' criteria?
Joint problems (migratory polyarthritis), heart problems (pancarditis), nodules in the skin, erythema marginatum (rash), chorea
What is a histological finding of myocarditis?
Aschoff body with caterpillar cells
What is an Aschoff body?
Focus of chronic inflammation with giant cells and fibrinoid material along with Anitschkow cells (caterpillar cells)
What is the most common cause of death within the acute phase of rheumatic fever?
What type of microorganism is associated with acute rheumatic fever?
Group A B-hemolytic streptococci
Chronic disease caused by repeat occurance of rheumatic fever affects which valves?
sometimes aortic-> fusion of comissures
What is a complication of chronic rheumatic fever infections?
Endocarditis leading to valve stenosis
What gross findings are characteristic of valvular stenosis caused by rheumatic fever?
Scarring of the valves which causes fusion of the commisures; fish mouth opening of the valve
What is usually the cause of aortic stenosis?
Fibrosis and calcification from "wear and tear" (which is made worse by less cusps)
What condition increases the risk and hastens disease onset for aortic stenosis?
Bicuspid aortic valve
Systolic ejection click followed by a crescendo-decrescendo murmur
Complications of aortic stenosis?
Treatment of aortic stenosis?
valve replacement after onset of complications
What is aortic regurgitation?
backflow of blood from aorta into L ventricle during diastole
Most common cause of aortic regurgitation
Aortic root dilation (eg. syphilitic aneurysm)
Early blowing diastolic murmur
Bounding pulses, pulsating nail bed, and head bobbing (
Aortic regurg results in what 2 findings due to volume overload?
LV dilation and eccentric hypertropy
Tx of aortic regurgitation?
valve replacement once LV dysfunction develops
Mid-systolic click followed by murmur
Mitral valve prolapse
What causes mitral valve prolapse?
ballooning of mitral valve into L atrium during systole
-due to myxoid degeneration (accumulation of ground substance) of the valve (often seen in Marfan's and Ehlers-Danlos)
Tx of mitral prolapse?
What is mitral regurg?
reflux of blood from L ventricle into L atrium during systole
Causes of mitral regurgitation?
Complication of MVP, LV dilation (L sided heart failure), infective endocarditis, acute rheumatic heart disease, and papillary muscle rupture after MI
Holosystolic "blowing" murmur that gets louder with squatting or expiration
Opening snap followed by diastolic rumble
What often causes mitral stenosis?
narrowing of mitral valve orifice, usually due to chronic rheumatic valve disease
What are the clinical features of mitral stenosis?
vol overload of L atrium -> dilation ->
1.pulm congestion with edema and alv hemorrhage
2. pulm HTN ->R sided heart failure
3. A fib with associated risk for mural thrombi
Most common overall cause of bacterial endocarditis; results in small vegetations that do not destroy valve
Strep viridans, only infects previously damaged valves
Most common cause of bacterial endocarditis in IV drug-abusers; results in large vegetations that destroy the valve
Staph aureus-> acute endocarditis
Most common cause of bacterial endocarditis on
Most common cause of bacterial endocarditis in patients with
underlying colorectal carcinoma
Which organisms should you suspect if patient has endocarditis with *negative blood cultures?
Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella; (HACEK)
Clinical features of endocarditis.
murmur (due to vegetations),
Janeway lesions (painless on hands and feet)
Osler nodes (painful- fingers and toes)
anemia of chronic disease
splinter hemorrhages of nail beds
clubbing of nails
What are lab findings of bacterial endocarditis?
Which conditions are associated with nonbacterial thrombotic endocarditis?
Hypercoagulable state or underlying adenocarcinoma
Where do nonbacterial thrombotic endocarditis infections usually arise?
On mitral valve along lines of closure; results in regurgitation
Sterile vegetations present on surface
undersurface of mitral valve causing mitral regurgitation
Which condition is associated with Libman-Sacks endocarditis?
What is the most common form of cardiomyopathy?
Dilated cardiomyopathy (dilation of all four chambers)
What complications arise from dilated cardiomyopathy?
Systolic dysfunction leading to biventricular CHF; mitral and tricuspid valve regurgitation and arrhythmia
What are some causes of dilated cardiomyopathy?
Genetic mutation, myocarditis (coxsackie A or B), alcohol abuse, drugs (doxorubicin), and pregnancy
Tx of dilated cardiomyopathy?
What causes the hypertrophy of the left ventricle in hypertrophic cardiomyopathy?
Genetic mutations in
proteins (most commonly AD)-
Beta myosin heavy chain
Diastolic disorder causing decreased cardiac output; sudden death due to ventricular arrhythmias in young athletes; syncope with exercise
What would you see on biopsy of hypertrophic cardiomyopathy?
Myofiber hypertrophy with disarray
What causes restrictive cardiomyopathy?
Decreased compliance of ventricular endomyocardium:
endocardial fibroelastosis (in children-dense layer of elastic tissue in endocardium),
Loeffler syndrome (eosinophilic infiltrate with inflammation resulting in fibrosis)
Patient presents with CHF, low-voltage EKG, and diminished QRS amplitudes
Most common primary cardiac tumor in adults; benign
proliferation with a gelatinous appearance due to abundant ground substance
Where would you find a myxoma?
Pedunculated mass in the left atrium
What does a myxoma cause?
Syncope due to obstruction of mitral valve
Most common primary cardiac tumor in children; benign hamartoma of cardiac muscle
What condition is rhabdomyoma associated with?
Where does a rhabdomyoma usually arise?
In the ventricle
What are common matastases to the heart?
Breast and lung cancer, melanoma, and lymphoma
Which part of the heart is most commonly involved in metastasis?
Pericardium, resulting in a pericardial effusion