Term
| Pulmonary HTN defined as... |
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Definition
|
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Term
| O2 delivery = cardiac output x ..... |
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Definition
|
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Term
| O2 delivery to the tissues per minute = |
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Definition
| 1 L (because cardiac output = 5 L/min) |
|
|
Term
|
Definition
A wave = atrial contraction
C wave = isovolumic contraction of ventricles
V wave = filling of atria |
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Term
| which abnormal heart sound can be heard in atrial systole? |
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Definition
|
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Term
|
Definition
| MITRAL STENOSIS (diastolic sound) |
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Term
| Ejection click heard in... |
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Definition
| AORTIC STENOSIS (systolic sound) |
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Term
|
Definition
| MYOCARDIAL RELAXATION (diastole is an active process) |
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Term
| What does systolic failure do to the Pressure Volume Loop? |
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Definition
| SHIFT TO THE RIGHT - at a higher starting point due to ventricular dilation (i.e. increase in EDV) |
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Term
| What happens to EDV in systolic heart failure? |
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Definition
| It increases - due to heart essentially being volume overloaded, causes dilation of failed ventricle |
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Term
| What happens to the Pressure Volume Loop in diastolic failure? |
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Definition
| The bottom line moves upwards - same volume, higher pressures (Have higher systolic and diastolic pressures for a given volume) - greater after load for a given preload |
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Term
| Why is there an increased DIASTOLIC Pressure across the SL valves? |
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Definition
| Due to COMPETENT VALVES - should prevent back flow of blood |
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Term
| What happens to diastolic pressure in the great vessels in semilunar incompetency? |
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Definition
| it decreases (normally have diastolic increase across SL valves when they are competent, prevent any back flow) |
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Term
| What happens to pulse pressure if vasodilated? in shock? |
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Definition
HIGHER PP - wider gap because lower diastolic BP
SHOCK = LOWER PP |
|
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Term
| what does the dicrotic notch represent? |
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Definition
| Closing of the aortic valve, in aortic pressure curve |
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Term
|
Definition
| Diastolic P + 1/3(pulse pressure) |
|
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Term
| What happens to pulse pressure when the aorta stenoses? |
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Definition
| WIDENS, due to increased systolic BP |
|
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Term
| 2 things that can cause widening of the pulse pressure? |
|
Definition
Aortic Stenosis
Vasodilation of aorta |
|
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Term
|
Definition
Failure
Isufficiency (mitral/tri)
Pregnancy
Pericarditis
Youth |
|
|
Term
|
Definition
HTN
Ischemia/Infarct
Tamponade
Stenosis |
|
|
Term
| Compliance on the pressure volume loop is? |
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Definition
|
|
Term
| Intrinsic automaticity of SA node = |
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Definition
110-115 bpm
But with vagal tone, down to 60-80 |
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Term
| Atropine classified as a __________ antagonist |
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Definition
| Muscarinic receptor antagonist |
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Term
| What is the Bowditch/Treppe Phenomenon? |
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Definition
| force-frequency relationship of heart; increase in HR, increases force of contraction of heart (increased intracellular Ca2+) |
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Term
| How does your body compensate for Bowditch/Treppe phenomenon? |
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Definition
| Decreased preload because of decreased diastolic filling time |
|
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Term
| What effect does the Treppe phenomenon have on diastolic filling? |
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Definition
Shortens it
Treppe = force-frequency relationship of the heart; increased force with increased frequency |
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Term
| Factors affecting preload... |
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Definition
Total blood volume, venous tone, ventricular compliance
Afterload
Atrial contractility
Intrathoracic pressure |
|
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Term
|
Definition
| Pressure x Radius/2xWallThickness |
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Term
| What happens to the shape of the ventricle when it contracts? |
|
Definition
|
|
Term
| Which ventricle has a higher after load? |
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Definition
| LV - even though it has thicker wall |
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Term
| How can we alter after load with therapy (IABP) |
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Definition
| IABP - blows up during diastole; decreases LV after load by increasing diastolic BP |
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|
Term
| Pulmonary embolism can increase after load in ....... |
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Definition
|
|
Term
| ACUTE vs. CHRONIC compensation for increased afterload |
|
Definition
ACUTELY - LV dilation to accomodate
Chronically - hypertrophy to thicken wall, reduces perfusion and compliance |
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Term
|
Definition
Delta V over delta P (change in volume over change in pressure)
Compliance is the SLOPE of the pressure volume curve |
|
|
Term
| Change in volume over change in pressure = |
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Definition
|
|
Term
| Decrease in compliance of the ventricle can predispose to ________ heart failure |
|
Definition
DIASTOLIC - because decreased compliance = harden to fill
Have higher end diastolic pressure for a given end diastolic volume |
|
|
Term
| How do you plot a compliance curve? |
|
Definition
| Change in volume over change in pressure |
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|
Term
| What happens to the compliance curve in aortic stenosis vs. aortic regurgitation? |
|
Definition
Aortic stenosis - increased pressure, pressure overload hypertrophies ventricle, shifts curve upwards (higher pressure for any volume)
Aortic insuffi - volume overload; dilation, have higher volumes, dilation shifts curve to the right |
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|
Term
| What happens to ventricular compliance during dilation (e.g. due to aortic regurg)? |
|
Definition
|
|
Term
| What happens to ejection fraction in diastolic HF? |
|
Definition
| It is preserved (stays the same) |
|
|
Term
| Comparison of diastolic vs. systolic heart failure: |
|
Definition
Diastolic - normal EF, EDV; increased relative wall thickness of LV
Systolic - reduced EF, decreased wall thickness, increased EDV |
|
|
Term
| Difference in EDV in diastolic vs. systolic heart failure? |
|
Definition
Diastolic - normal EDV
Systolic - increased EDV |
|
|
Term
| How does resistance compare in parallel vs. series wiring of BVs? |
|
Definition
| Lower overall resistance in parallel circulation |
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|
Term
| Increased cGMP levels lead to? |
|
Definition
Vasodilation (usually mediated by NO)
Low cGMP = vasoconstriction |
|
|
Term
| Increased cAMP and IP3 in vascular smooth muscle lead to? |
|
Definition
|
|
Term
| Acute regulation of vascular tone? |
|
Definition
Baroreceptor reflex - barorecpetors in carotid and aortic arches
Respond to increased/decreased stretch |
|
|
Term
| CN mediation of aortic vs. carotid baroreceptors |
|
Definition
Aortic = CN X
Carotid = glossopharyngeal (CN IX) |
|
|
Term
| Most powerful endogenous vasoconstrictor |
|
Definition
|
|
Term
| What is the function of Atrial Natriuretic Peptide |
|
Definition
REDUCES BLOOD VOLUME; released when increased stretch is sensed in atria
Increased GFR, decreased Na+ reabsorption to lose more water and Na+ |
|
|
Term
| Difference between Autoregulation vs. Active and Reactive Hyperemia? |
|
Definition
Autoregulation - blood flow is INDEPENDENT of changes in blood pressure (i.e. neural flow)
Active - blood flow increased in order to meet needs of increased metabolic rate (e.g. exercise)
Reactive - after occlusion is released, flow increases PAST point of control (i.e. reperfusion injury) |
|
|
Term
| Amount of reactive hyperemia is proportional to... |
|
Definition
| METABOLIC DEBT (how long occlusion was present for) |
|
|
Term
| Name the phases of the cardiac AP? |
|
Definition
phase 0 = rapid depol
phase 1 = early repol
phase 2 = plateau
phase 3 = late repol
phase 4 = resting membrane potential |
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|
Term
| How can you tell which atrium is enlarged if P wave is biphasic? |
|
Definition
1st wave = RA
2nd wave = LA |
|
|
Term
| QT duration longer in males or females? |
|
Definition
| Females - 460 msec vs. only 440 in males; yeah we win again |
|
|
Term
| ST depression on ECG may represent |
|
Definition
Subendocardial ischemia
May be present w/ inverted T wave |
|
|
Term
| LV hypertrophy vs. RV hypertrophy on ECG? |
|
Definition
LV = increased voltage in V4-V6
RV = increased voltage V1-3 |
|
|
Term
|
Definition
Increased aldosterone secretion
Vasoconstriction
Mediate ventricular remodeling in heart
Contribute to protein leak in kidneys |
|
|
Term
| Which part of the RAA system mediates ventricular remodelling? |
|
Definition
|
|
Term
| Indications for ACEI therapy? |
|
Definition
HTN
Post-MI
Heart failure
Diabetic nephropathy |
|
|
Term
| Why is ACEI therapy beneficial for all stages of heart failure? |
|
Definition
| BLOCK ventricular remodelling (via anti-ANGII) in all stages of heart failure associated with decompensation (i.e. prevent concentric hypertrophy) |
|
|
Term
| Contraindications for ACEI? |
|
Definition
PREGNANCY****(in all trimesters)
Hyperkalemia - impairs K+ excretion
Renal disease
Hypotension |
|
|
Term
| Pregnancy is an important contraindication for ______ |
|
Definition
|
|
Term
| Bradykinin mediated adverse effects of ACEI |
|
Definition
|
|
Term
| What happens to K+ levels when taking ACEI? |
|
Definition
| Increase - impaired K+ excretion due to decreased GFR |
|
|
Term
"sartan" drugs are ________
"pril" drugs are _________ |
|
Definition
|
|
Term
| Evidence for combining ACEI and ARBs in treatment? |
|
Definition
| NO EVIDENCE - may lead to adverse effects |
|
|
Term
| Spironolactone is classified as a __________ |
|
Definition
| K+ sparing diuretic and Aldosterone Antagonist |
|
|
Term
| Example of aldosterone antagonist _________ |
|
Definition
| Spironolactone (K+ sparing diuretic) |
|
|
Term
| Spironolactone improves ____________ in patients with NYHA class III/IV |
|
Definition
|
|
Term
| What are two contraindications present for all of ACEIs, ARBs, Spironolactone? |
|
Definition
Hyper-K+
Renal dysfunction |
|
|
Term
| Which drug is gynecomastia a side effect in? |
|
Definition
|
|
Term
| 2 mechanisms of action of Digoxin? |
|
Definition
Inhibit Na+/K+ ATPase - leads to Ca2+ exchange into cell; positive inotrope - good for heart failure treatment
Indirect vagal effect - rate control for arrhythmia; only good for patients with low resting sympathetic tone |
|
|
Term
| Which cardiac drug has a very small therapeutic window + long half life? |
|
Definition
DIGOXIN
Half life = 36 hours |
|
|
Term
| Main drug interaction of digoxin? |
|
Definition
| AMIODARONE (Class III Antiarrhythmic) |
|
|
Term
| Drug toxicity of digitalis is predisposed with..... |
|
Definition
|
|
Term
| Low Mg2+ and K+ can predispose to toxicity of which drug? |
|
Definition
|
|
Term
| Which syndrome is digoxin contraindicated in? |
|
Definition
|
|
Term
| How can nitrates make myocardial O2 demand higher? |
|
Definition
| Reflex tachycardia from the drop in BP |
|
|
Term
| How do you avoid a nitrate tolerance |
|
Definition
| Chronic therapy requires nitrate-free interval of 8-10 hours |
|
|
Term
| What are the effects of CCB's - 3 different locations? |
|
Definition
Vascular muscle = vasodilation
Cardiac muscle = decreased contractility
Conduction tissue = slowed conduction |
|
|
Term
| Effects of DHP CCB's vs. nDHP CCBs |
|
Definition
DHP = pine drugs; vascular selectivity
nDHP = diltiazem, verapamil; cardiac selectivity + conduction selectivity |
|
|
Term
| 1st line therapy vs. 2nd line therapy for angina? |
|
Definition
|
|
Term
|
Definition
| Arterial vasodilator; increased CO because of decreased after load |
|
|
Term
| What is 3rd line heart failure treatment for those not tolerating ACEIs and ARBs? |
|
Definition
|
|
Term
| B1 vs. B2 receptor effects? |
|
Definition
B1 = cardiac contractility; HR + conduction
B2 = vascular; vasodilation, bronchodilation |
|
|
Term
| Cardiac vs. vascular/bronchial location of B1 vs. B2 |
|
Definition
B1 = cardiac; affects heart
B2 = vascular + bronchial (dilates both) |
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|
Term
| Which B blocker receptor subtype is cardioselective? |
|
Definition
|
|
Term
| Example of a cardioselective B-blocker? |
|
Definition
| METOPROLOL (B1 selectivity) |
|
|
Term
| What is used to treat Prinzmetal's Angina? |
|
Definition
CCBs
NOT B-BLOCKERS -- because Prinzmetal's is due to vasospasm |
|
|
Term
|
Definition
|
|
Term
| Example of a non-selective B-blocker |
|
Definition
|
|
Term
| E.g. of 3rd gen B-blocker |
|
Definition
| Cardevilol (combined B and alpha blocking effects) |
|
|
Term
| What does L atrial enlargement look like on a CXR? |
|
Definition
|
|
Term
| SPECT is used to measure? |
|
Definition
Fixed vs. reversible perfusion defects
Fixed defect (at rest and exercise) = infarct
Reversible defect = ischemia |
|
|
Term
| Which abnormal heart sound is ABSENT in A FIB? |
|
Definition
| S4 - S4 is due to atrial contraction against a stiff ventricle; so no atrial contraction is no S4 |
|
|
Term
| Bicuspid aortic valve murmur? |
|
Definition
Blowing systolic murmur, ejection click
Crescendo-decrescendo |
|
|
Term
| Most common cause of aortic stenosis? |
|
Definition
| Calcification of aortic valve |
|
|
Term
| Murmur of aortic stenosis? |
|
Definition
Harsh, high frequency, late-peaking systolic murmur
Crescendo-decrescendo |
|
|
Term
| For aortic stenosis, what quality suggests severity of the stenosis? |
|
Definition
the TIMING OF IT (NOT THE INTENSITY)
Later is worse |
|
|
Term
| Pulsus parvus and tardis present in which valvular defect? |
|
Definition
| aortic stenosis (late peaking and weak carotid pulse) |
|
|
Term
| Thirds rule of bicuspid aortic valve? |
|
Definition
1/3 nothing
1/3 progress to AR
1/3 progress to AS |
|
|
Term
| Symptoms of aortic stenosis and their survival? |
|
Definition
Angina - 50% survival at 5 yrs
Syncope - 50% survival at 3 yrs
Dyspnea - 50% survival at 2 yrs |
|
|
Term
| Outcome in patients with aortic stenosis but no symptoms? |
|
Definition
|
|
Term
| Intervention in aortic stenosis? |
|
Definition
ONLY TREAT if symptomatic (if asymptomatic, no treatment necessary)
If symptomatic, replace valve |
|
|
Term
| Lifespan of mechanical vs. bioprosthetic valve? |
|
Definition
Mechanical - lasts longer, need lifelong anticoagulation
Bioprosthetic - 10 yr life span; no anti-coag needed |
|
|
Term
| 4 components of mitral valve ? |
|
Definition
| Annulus, leaflets, chordae, papillary muscles |
|
|
Term
| Most common cause of mitral regurgitation? |
|
Definition
| MYXOMATOUS MITRAL VALVE DISEASE (prolapse) |
|
|
Term
| Key feature of mitral prolapse? |
|
Definition
| chordae thin and leaflets thicken - billow back into L atrium |
|
|
Term
| Why is loud P2 common in mitral regurgitation? |
|
Definition
|
|
Term
| What does mitral regurgitation management depend on? |
|
Definition
LV EF (ejection fraction)
Have HIGH survival if LVEF >60%, if <50% then survival decreases (30% 10 yr survival) |
|
|
Term
| Surgery for mitral regurgitation when? |
|
Definition
Symptomatic + LVEF <60%
Symptoms = signs of L heart failure |
|
|
Term
| 99% of cases of mitral stenosis caused by |
|
Definition
| Rheumatic valvular disease (group A strep) |
|
|
Term
| Main symptom of mitral valve stenosis? |
|
Definition
|
|
Term
| Most common symptom of mitral stenosis? |
|
Definition
| Exertional dyspnea - due to fluid backup into lungs |
|
|
Term
| Which arrhythmia is present in almost all mitral stenosis patients? |
|
Definition
|
|
Term
| Severity of stenosis in mitral vs. aortic stenosis dependent on? |
|
Definition
Mitral = duration of murmur
Aortic stenosis = timing of murmur |
|
|
Term
| 2 problems that can lead to aortic regurgitation? |
|
Definition
Dilation of the aortic root (where leaflets sit) - usually ROOT ENLARGEMENT
Leaflet problem -> USUALLY CALCIFIC DEGENERATION |
|
|
Term
| Marfan's syndrome can predispose to? |
|
Definition
|
|
Term
| What happens to pulse pressure in aortic regurgitation? |
|
Definition
| WIDENS (lack of valve competency) |
|
|
Term
| What is the management in asymptomatic with aortic regurgitation? |
|
Definition
| Endocarditis prophylaxis THAT'S IT |
|
|
Term
Most common acute cause of endocarditis?
Subacute cause? |
|
Definition
Staph aureus
Strep viridans |
|
|
Term
| Peripheral stigmata of endocarditis? |
|
Definition
Janeway lesions
Osler notes
Splinter hemorrhage
Finger clubbing
Roth spots |
|
|
Term
| Congenital lesions that are cyanotic with increased pulmonary flow? |
|
Definition
d-Transposition of Great Vessels
Total Anomalous Pulmonary Drainage
Truncus Arteriosus |
|
|
Term
| Cyanotic lesion with NORMAL pulmonary flow? |
|
Definition
|
|
Term
| Causes of grey heart disease? |
|
Definition
Grey = LVOT + shock
Coarctation of Aorta
Critical Stenosis of Aorta
Hypoplastic L Heart Syndrome |
|
|
Term
| Valve repair restores life expectancy! |
|
Definition
KNOW THIS
Guess what. Valve repair restores life expectancy. |
|
|
Term
| Outcomes with valve repair are excellent! |
|
Definition
KNOW THIS.
GUESS WHAT. Outcomes with valve repair are excellent. |
|
|
Term
| Why doesn't coarctation present immediately at birth? |
|
Definition
Because ductus arteriosus is still open
GIVE PROSTAGLANDINS |
|
|
Term
| Prostaglandins keep ductus arteriosus open in which condition? |
|
Definition
|
|
Term
| Symptoms for aortic stenosis? |
|
Definition
ASD - angina, syncope, dyspnea
50% survival = 5 yrs, 3, yrs, 2 yrs |
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|
