What kind of sound does volume load on the ventricles cause?

Give examples of disorders:

S3= ventricular gallop

Normal in kids and pregnant people

Regurgitation (all 4)

L > R Shunts- ASD, VSD, patent ductus arteriosus

Dilated cardiomyopathy

What type of heart sound is created when an atrium contracts against a stiff ventricle (LVH)?

Associated disorders?

S4= atrial gallop

Hypertension- systemic and pulmonic

Acute MI

Hypertrophic and Dilated Cardiomyopathy

Stenosis- Aortic and pulmonic

What would cause a loud S1?

Soft S1?

Variable S1?

Mitral stenosis- valve is open when ventricle contracts

CHF- valve leaflets "float shut"

A fib- 3rd degree AV block

How do heart sounds change during expiration in a normal person?

Less splitting of S2= A2 and P2 are closer together

What causes wide splitting?

What causes paradoxical splitting?

Wide- mitral valve regurge (aortic closes early)

pulmonary HTN, pulmonary stenosis (pulmonic closes later)

Paradoxical- systemic arterial HTN, aortic stenosis (aortic closes later), tricuspid regurge (pulmonic closes early)

Systemic- loud A2

Pulmonic- loud P2

What would cause an ___ and where in the cardiac cycle would you hear it?

Ejection click?

Opening snap?

Pericardial knock?

EC- opening of aortic/pulmonic stenosis after S1

OS- opening of mitral/tricuspid stenosis after S2

PK- filling a thick ventricle- after S2- hear over apex

Right heart murmurs get louder during respiration whereas left heart murmurs don't change.

Also called Carvallo's sign

diamond shape (crescendo decrescendo)- Aortic stenosis

bow-tie (decrescendo crescendo)- Mitral stenosis

rectangular (holosystolic)- Mitral/Tricuspid regurge, VSD

--radiates to axilla

triangle (midsystolic)- mitral valve prolapse

All 3 have holosystolic murmur

Mitral- radiates to axilla

Tricuspid- louder on inspiration

VSD- thrill

early high-pitched blowing decrescendo- aortic/pulmonic regurge- short murmur is severe

mid-diastolic rumble- Austin Flint murmur- SEVERE Ao regurge- due to mitral valve partially closing

due to a continuous arteriovenous connection

arteriovenous fistula, PDA

Be specific:

Which artery supplies the anterior left ventrical?

Be specific:

Which artery supplies the posterior left ventricle?

Be specific:

Which artery supplies the posterior septum?

Right- RCA supplies PDA

Left- LCS supplies PDA

Which part of the heart would have the lowest % O2 saturation?

Coronary Sinus

Right Atrium

Left Atrium

Left Ventricle

Coronary Sinus- 30%

Right Atrium- 65-80%

Left Atrium- 95-100%

Left Ventricle- 95-100%

What should you see on an EKG if someone has subendocardial injury?

Q wave formation

Diminution of R wave

ST elevation

ST depression

Prolongued PR interval

Prolongued QRS duration

What should you see on an EKG if someone has a recent infarction in the lateral wall of the left ventricle?

a. Q wave formation and ST elevation in leads I, L

b. Diminution of R wave and ST elevation I, L

c. Q wave formation and ST depression V3, V4

d. Diminution of R wave and ST depression V3, V4

e. Prolongued PR interval

f. Prolongued QRS duration

LVH- leads I and L will show large R waves

QRS's will bump into eachother

Pick the 3 that are ABnormal and what could cause them?

Shortened QT with exertion

Variable PR interval

PR interval = .18

QRS = .18

QT = 2s

HR = 75

Variable PR interval- 3' AV block

QRS = .18- wide QRS can be due to v. tach

QT = 2s- prolongued QT is due to ion channels on myocytes functioning abrnormally

A patient comes in obtunded, hypotensive, cyanotic and elevated AST, ALT. The patient is found to have profound arterial vasodilation and low systemic vascular resistance, but normal intravascular volume.

How should you treat this patient?

What condition do they most likely have?

IV fluids and vasoconstrictors (vassopressin)

they have distributived shock due to sepsis

A person comes in with tachycardia, tachypnea, and decreased urine output. They have severely impaired systolic function. The intravascular volume and systemic vascular resistance are both elevated.

What treatments should they receive?

What condition do they most likely have?

Inotropic agents (Dopamine, Dobutamine) to increase contractility, and drugs for afterload reduction

Acute MI causing cardiogenic shock

1. decreased CO

2. pooling of blood in venous system

p45

Which is NOT a sign or symptom of Left Sided Heart Failure?

Rales

S3

Holosystolic Murmur

JVD

Orthopnea

JVD

p47

1. Ischemic heart disease

2. Systemic hypertension

3. Aortic/mitral valve diseases

4. Myocardial disease

Which 2 are NOT directly related to left heart failure?

Intersitial fibrosis in myocardium

LVH

Pedal edema

Cor pulmonale

Paroxysmal Nocturnal Dyspnea

Pedal edema

Cor pulmonale

Which would NOT appear in someone with ONLY Right Heart Failure eg obstructive lung disease or PE?

Holosystolic Murmur- increased w/ inspiration

Right ventricle dilation

Ascited

Anorexia

Dyspnea on exertion

What are the long term effects of the following maladaptice changes that occur in heart failure?

1. Salt and water retention

2. Vasoconstriction

3. Sympathetic stimulation

1. pulmonary and systemic venous congestion

2. pump dysfunction, increased cardiac energy expenditure

3. incr HR leads to increased energy expenditure

What's the difference between systolic and diastolic dysfunction?

Symptoms

Prognosis

Contractility

Systolic- worse prognosis and  more severe Sx- orthopnea, PND, ventricular remodeling

Diastolic- dyspnea on exertion, SOB

Which of the following does NOT cause aortic stenosis usually?

Hypertension

Rheumatic disease

Senile calcific

Bicuspid valve

Hypertension

p53

Bicuspid valve- congenital 

p54

stenosis- delayed, thrills

regurge- bounding carotids

What disorder causes an Austin Flint murmur?

what does an AF murmur sound like?

severe Aortic Regurge

mid-diastolic rumble

When do you replace a stenotic aortic valve?

When do you replace a valve causing aortic regurgitation?

1. severe (<1cm2) AND symptoms

symptoms include CHF-related, syncope, angina

1. severe AND symptoms

2. EF or LVESD <.55 / >5.5cm

Which of the following is NOT often caused by rheumatic disease?

Aortic Stenosis

Aortic Regurge

Mitral Stenosis

Mitral Regurge

Mitral valve prolapse

What usually causes it?

Which of the following valves should be replaced in asymptomatic patients? Assume they are all severe:

Aortic regurge- EF 50%

Mitral regurge- EF 60%

Aortic stenosis- EF 60%

Mitral stenosis- EF 50%

Aortic regurge- EF <55% needs to be replaced

Mitral regurge- EF <65% needs to be replaced

**stenotic valves are only replaced in symptomatic patients

Which valve abnormality results in:

LA dilation and RVH

LV dilation

LA and LV dilation

LV hypertrophy

MS- LA dilation and RVH

AR- LV dilation

MR- LA and LV dilation

AS- LV hypertrophy

Acute MR- nitroprusside or nitroG

Chronic MR- ACEi, dig, diuretics

What would cause a mid-systolic click and late-systolic murmur?

damage artery

use nephrotoxic dyes which destroys kidney

can cause arrhythmia

radiation causes cancer and funny looking babies

Coronary artery blockage

but does NOT tell time of blockage

What is likely to cause endocarditis in a kid?

Woman?

Old person?

Someone from a less-developed country?

What is most likely to cause R sided endocarditis?

What is most likely to lead to strep viridans assoc. endocarditis?

Congenital heart disease

Mitral valve prolapse

Calcified valves

Rheumatic valvular disease

IV Drug Use

Dental Work

Acute- high fever, die in days, caused by Staph usually

Subacute- vague symptoms, die in weeks, caused by Viridans usually, only occurs in abnormal valves

can result in incr. ESR, anemia, hypergammaglobulinemia, renal failure due to septic emboli

Which of the following is a small, painful lesion on fingers and toes?

Osler's nodes

Splinter hemorrhages

Janeway lesions

Petechia

Roth spots

Which of the following is a red/brown streaks in finger and toenail beds?

Osler's nodes

Splinter hemorrhages

Janeway lesions

Petechia

Roth spots

Which of the following is painless, blanching macules on palms and soles?

Osler's nodes

Splinter hemorrhages

Janeway lesions

Petechia

Roth spots

Which of the following is red, pinpoint lesions lesions on buccal mucosal and extremities?

Osler's nodes

Splinter hemorrhages

Janeway lesions

Petechia

Roth spots

Which of the following is oval, pale, retinal lesions near the optic disc?

Osler's nodes

Splinter hemorrhages

Janeway lesions

Petechia

Roth spots

Which should you use first to diagnose endocarditis?

Trans-thoracic echo or trans-esophageal echo

Why?

No- you must have 2 major OR 5 minor OR 1 major and 3 minor criteria. This patient only has 1 major and 2 minor.

Major 1. positive blood culture   2. echo

Minor- 1. heart disease or IVDU

2. Fever over 38/100.4F

3. Vascular problem- Janeways lesions, emboli

4. Immunologic problem- glomerulonephritis, Osler's nodes, Roth spots, rheumatoid factor

5. Other microbiologic evidence

MAIN reason- refractory CHF

or unresponsive to meds

or perivalvular or septal abscess

or multiple embolic events

Most serious-- Cardiac failure- usually L-sided endo.

Also septic embolism can deposit in brain, kidneys, pulmonary (R sided endocarditis)

HR

Contractility

Wall tension (determined by radius, pressure)

Name the 4 groups of drugs used to treat Stable Angina:

Which decrease HR and contractility?

B blockers and CCA (V/D) decr HR & contractility

Can also use DHPs and Nitroglycerin

What is the equation used to calculate LDL?

When would you NOT use this equation?

What is the patient's main goal if their TG >500?

LDL = Tc - HDL - TG/5

TG > 400

Decrease non-HDL cholesterol to <130 (or <100, depending)

STEMI- transmural occlusion

nonSTEMI- only subendocardial is necrosed

Thrombolytics are cheap and easy to administer, can cause intracranial bleeds

Primary PCI is expensive and requires highly trained personnel, safer

ABCS of post-MI

Aspirin

B blocker

aCe inhibitor

Statins

VSD

Aortic regurge

Papillary muscle rupture

Myocardial rupture

Cardiogenic shock

They won't change since congenital PS does NOT progress.

She will still have a longer, louder murmur (compared to people with mild PS)

And she may have showed up with cyanosis at birth

AS murmur is present at URSB while PS is only heard at ULSB.

AS is accompanied by thrills over the carotid.

AS progresses wheras PS does NOT

AS is worsened with exercise.

AS is more likely to occur in boys.

Kids with TOF might have clubbing, boot shaped heart, and a single S2.

How would you be able to tell that someone has coarctation of the aorta from exam and not a different type of CHD?

How would you treat someone with coarctation of the aorta?

they would have a higher BP in arms than legs

do surgery or else they die by age 35

do surgery or balloon angioplasty

How can you tell that someone has a small VSD compared to a large VSD?

When should you do surgery on someone with VSD?

small VSDs have murmurs that occur sooner and cause fewer symptoms, patient has a normal decrease in pulmonary vascular resistance

infant <6mo with CHF

older infant has pulmonary hypertension or symptoms

>2 years old with pulmonary flow/systemic flow is > 2:1

ASD

May have tricuspid atresia since it requires an ASD

A 8mo baby comes in with a systolic ejection murmur at ULSB, low mid-diastolic murmur at LLSB, widely split and fixed S2. Echo shows RVH and RAE. The parents want to know how you're going to treat this disorder.

What do you tell them?

baby has ASD

do surgery when child is 2-3 years old

CHF and endocarditis

Eisenmenger's syndrome and aneurysm also

Which of the following is NOT associated with TOF?

Clubbing

Holosystolic murmur

VSD

Right to left shunt

Pulmonary stenosis

Single S2

Holosystolic murmur

they have a SEM

Aortic Stenosis

Transposition of the Great Arteries

they have tricuspid atresia

1. PGE1 to maintain ductal patency

2. Create a Blalock Taussig shunt- where the subclavian is connected to the pulmonary artery

3. when the kid is 6-12mo then a Glenn shunt can be created- SC is connected to right PA

What is the major risk factor for abdominal aortic aneurysm?

What is the major risk factor for peripheral arterial disease?

atherosclerosis

smoking

What is the LaPlace Relation?

T= ?

Who should you screen for an abdominal aortic aneurysm?

82 year old female smoker

55 year old male with a family history for AAA

66 year old male smoker

aortic regurge

cardiac tamponade

MI

operate on Ascending aortic dissections= stanford classification A

surgery is necessary to prevent Aortic regurge, tamponade, MI

Bescending aortic dissections- just give them B blockers or CCA to control their hypertension

Ankle-Brachial Index

<.41 is severe PAD

What are the 2 main causes of acute peripheral arterial occlusion?

What ist he clinical presentation?

In-situ thrombosis and Embolism

5 P's and a C

Pain

Pallor

Paralysis

Paresthesia

Pulselessness

Coolness

A patient comes in with polymyalgia rheumatica and path shows lymphocytes and macrophages in their large arteries.

Which lab value should you most expect to see?

elevated CK-MB

elevated ESR

elevated lipids

elevated ESR

they have giant cell arteritis

Which 2 factors decrease during pregnancy and which 3 increase during preg?

SVR

PVR

HR

CO

Stroke work index

Venous pressure

Capillary wedge pressure

Colloid Oncotic Pressure

Incr- CO, HR

Decr- SVR, PVR, colloid oncotic pressure

Which of these are NORMAL during pregnancy?

Fatigue

Dyspnea which limits activity

Progressive orthopnea

Peripheral edema

Paroxysmal nocturnal dyspnea

Hemoptysis

Syncope

Systolic murmurs

Pulmonary rales

Fatigue

Peripheral edema

Syncope

Systolic murmurs

inadequate paravertebral perfusion and decreased atrial filling

-in preg. lecture

A pregnant woman comes in with an infection that has caused cardiac failure- how many months pregnant is she most likely to be?

1 month

8 months

8 months

2

Sys >160 OR Dia >100

Overweight

Sedentary

Eat too much salt

Drink too much

Diabetes

Low potassium in diet

Fat diabetic person sitting on a couch eating chips, drinking beer and NOT eating enough bananas.

Hyaline- arterioles get thick pink walls, plasma protein leakage, leads to complications in multiple organs

Hyperplastic- onion skinning (reduplicated basement membrane) around arterioles in malignant hypertension, can see necrotizing arteriolitis

3

1. narrowing

2. nicking

3. hemorrhage or exudates

4. papilledema- blurred disc edges

Which of the following is most associated with SYSTOLIC dysfunction?

Dilated Cardiomyopathy

Hypertrophic CM

Restrictive CM

Constrictive Pericarditis

Which one of the following does NOT usually caused dilated CM?

Alcohol

Radiation

Thiamine deficiency

Hyperthyroidism

Peripartum Inflammation

Radiation

**Alcohol is most common cause

Which one of the following is NOT associated with Kussmaul sign?

Dilated CM

Restrictive CM

Constrictive Pericarditis

Dilated CM

however, it does cause JVD with prominent V waves

look at maximal oxygen consumption

more likely to die soon if they can't increase their cardiac input during exertion

A patient has interstitial infiltrates with lymphocytes and patchy necrosis.  Their CXR shows Kerley B lines, EKG shows tachycardia, ectopy and antrial and ventricular hypertrophy.

What else are you most likely to find?

Myofiber disarray

Positive Congo Red stain

LVEF < .45

Cardiac tamponade

Chaga's

p173

Inherit a B myosin mutation

- gene encodes sarcomeric proteins

Fever (rheumatic)

Radiation

Uremia

SLE

Trauma

Ischemia (MI)

FRUSTI the fibrinous snowman has A Cute Pair o Cards

Acute pericarditis

p184

spontaneous phase 4 depolarization due to funny currents

p190

1. Unidirectional block

2. 2 separate pathways w/ different electrical behavior

3. 1 path with slow conduction

4. excitable gap

Early afterdepolarizations- phase 2 or 3- torsades

Delayed afterdepolarizations- phase 4- digitalis toxicity

Random note from review:

AV block can also be caused by Lyme disease and hypokalemia

What does this person have:

PR > .2 s

Bypass

AV node

Atrium

Ventricle

Acute- valsalva/carotid massage or adenosine

Chronic- B blockers or radiofrequency ablation

1. Delta wave at upstroke of QRS

2. Wide QRS

3. Short PR interval

4. SV tach

EAD in triggered activity

Polymorphic V tach causing long QT interval

elastic arteries

medium and large arterioles

Restrictive CM (and LVH)

Constrictive Pericarditis (no LVH)

Ischemic necrosis of 30% of the ventricle wall

shows as ST depression on EKG