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HEARTS N STUFFZ
130
Medical
Professional
02/20/2014

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Term
Pulmonary HTN defined as...
Definition
Pressure >25 mm Hg
Term
O2 delivery = cardiac output x .....
Definition
pO2 of arterial blood
Term
O2 delivery to the tissues per minute =
Definition
1 L (because cardiac output = 5 L/min)
Term
CVP/JVP waveforms
Definition
A wave = atrial contraction
C wave = isovolumic contraction of ventricles
V wave = filling of atria
Term
which abnormal heart sound can be heard in atrial systole?
Definition
S4
Term
Opening snap heard in...
Definition
MITRAL STENOSIS (diastolic sound)
Term
Ejection click heard in...
Definition
AORTIC STENOSIS (systolic sound)
Term
Lusitropy is
Definition
MYOCARDIAL RELAXATION (diastole is an active process)
Term
What does systolic failure do to the Pressure Volume Loop?
Definition
SHIFT TO THE RIGHT - at a higher starting point due to ventricular dilation (i.e. increase in EDV)
Term
What happens to EDV in systolic heart failure?
Definition
It increases - due to heart essentially being volume overloaded, causes dilation of failed ventricle
Term
What happens to the Pressure Volume Loop in diastolic failure?
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
Term
Why is there an increased DIASTOLIC Pressure across the SL valves?
Definition
Due to COMPETENT VALVES - should prevent back flow of blood
Term
What happens to diastolic pressure in the great vessels in semilunar incompetency?
Definition
it decreases (normally have diastolic increase across SL valves when they are competent, prevent any back flow)
Term
What happens to pulse pressure if vasodilated? in shock?
Definition
HIGHER PP - wider gap because lower diastolic BP

SHOCK = LOWER PP
Term
what does the dicrotic notch represent?
Definition
Closing of the aortic valve, in aortic pressure curve
Term
MAP =
Definition
Diastolic P + 1/3(pulse pressure)
Term
What happens to pulse pressure when the aorta stenoses?
Definition
WIDENS, due to increased systolic BP
Term
2 things that can cause widening of the pulse pressure?
Definition
Aortic Stenosis

Vasodilation of aorta
Term
FIPPY - cause of S3
Definition
Failure
Isufficiency (mitral/tri)
Pregnancy
Pericarditis
Youth
Term
HITS - cause of S4
Definition
HTN
Ischemia/Infarct
Tamponade
Stenosis
Term
Compliance on the pressure volume loop is?
Definition
the bottom part
Term
Intrinsic automaticity of SA node =
Definition
110-115 bpm

But with vagal tone, down to 60-80
Term
Atropine classified as a __________ antagonist
Definition
Muscarinic receptor antagonist
Term
What is the Bowditch/Treppe Phenomenon?
Definition
force-frequency relationship of heart; increase in HR, increases force of contraction of heart (increased intracellular Ca2+)
Term
How does your body compensate for Bowditch/Treppe phenomenon?
Definition
Decreased preload because of decreased diastolic filling time
Term
What effect does the Treppe phenomenon have on diastolic filling?
Definition
Shortens it

Treppe = force-frequency relationship of the heart; increased force with increased frequency
Term
Factors affecting preload...
Definition
Total blood volume, venous tone, ventricular compliance
Afterload
Atrial contractility
Intrathoracic pressure
Term
LaPlace Law
Definition
Pressure x Radius/2xWallThickness
Term
What happens to the shape of the ventricle when it contracts?
Definition
Becomes more spherical
Term
Which ventricle has a higher after load?
Definition
LV - even though it has thicker wall
Term
How can we alter after load with therapy (IABP)
Definition
IABP - blows up during diastole; decreases LV after load by increasing diastolic BP
Term
Pulmonary embolism can increase after load in .......
Definition
RV
Term
ACUTE vs. CHRONIC compensation for increased afterload
Definition
ACUTELY - LV dilation to accomodate

Chronically - hypertrophy to thicken wall, reduces perfusion and compliance
Term
Compliance = ...
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 =
Definition
COMPLIANCE
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
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
Term
What happens to ventricular compliance during dilation (e.g. due to aortic regurg)?
Definition
INCREASES
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
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
Vasoconstriction
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
ANGII
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
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
4 effects of ANGII
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
ANG II
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
ACE inhibitors
Term
Bradykinin mediated adverse effects of ACEI
Definition
Cough
Angioedema
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
SARTAN = ARB

PRIL = ACEI
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
Morbidity/mortality
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
SPIRONOLACTONE
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
Low K+, Mg2+

High Ca2+
Term
Low Mg2+ and K+ can predispose to toxicity of which drug?
Definition
DIGOXIN
Term
Which syndrome is digoxin contraindicated in?
Definition
WPW Syndrome
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
1st = B-blocker
2nd = CCB
Term
What is Hydralazine?
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
Hydralazine + Nitrates
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)
Term
Which B blocker receptor subtype is cardioselective?
Definition
B1 - cardiac effects
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
AB CD rule is for...
Definition
HTN MANAGEMENT
Term
Example of a non-selective B-blocker
Definition
Propranolol
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
Double border on R side
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
GOOD
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
Due to pulmonary HTN
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
LA dilation
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
A FIB
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
Aortic Regurgitation
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
Tetralogy of Fallot
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
COARCTATION
Term
Symptoms for aortic stenosis?
Definition
ASD - angina, syncope, dyspnea

50% survival = 5 yrs, 3, yrs, 2 yrs
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