Cardiac Pathology
The most important histologic features of the myocardium in HCM are ?
(1) extensive myocyte hypertrophy to a degree unusual in other conditions, with transverse myocyte diameters frequently more than 40 um (normal approximately 15 um) (2) haphazard disarray of bundles of myocytes, individual myocytes, and contractile elements in sarcomeres within cells (myofiber disarray) (3) interstitial and replacement fibrosis.
A 55-year-old hypertensive man develops sudden onset of excruciating pain beginning in the anterior chest, and then radiating to the back. Over the next 2 hours, the pain moves downward toward the abdomen. Which of the following is the most likely diagnosis? (A) Aortic dissection (B) Aortic valve stenosis (C) Atherosclerotic aneurysm (D) Myocardial infarction (E) Syphilitic aneurysm
(A) Aortic dissection This patient has an aortic dissection (formerly called dissecting aneurysm), a potentially fatal condition that is too often confused clinically with myocardial infarction. *The most important clinical clue is that the pain shifts with time*. Noninvasive techniques, such as transesophageal echocardiography, CT, and MRI, are increasingly useful in making this diagnosis. Myocardial infarction (choice D) is the major diagnosis most often confused with this patient's condition. The movement of the pain is the major clinical tip-off suggesting that this is not the correct answer.
AV Fistula
* * * * * * *
Aortic Aneurysm
* * * * * * * *
Aortic Dissection
* *Occurs in two groups of patients; hypertensive men, age 60-80 (3:1 M:F) or a younger patient with a connective tissue disorder (Marfan's/Ehler Danlos) *Most common cause of death in Marfan's Syndrome * * * *Aortic regurgitation is present in >50% of cases ( *The initiating event in an aortic dissection is a tear in the intimal lining of the aorta *Blood can pass proximally or distally *Most common cause of death is rupture of the dissection into the pericardial (tamponade = MC), pleural, or peritoneal cavities *
Scarring of aortic valves => fusion of commisures => fishmouth
****
Name 6 Risk Factors for the Development of Aortic Dissection
*Hypertension (most common) *Connective Tissue Disorders (Marfan's, Ehlers Danlos, Copper Deficiency) **Bicuspid Aortic Valve* *Turner's Syndrome *Trauma *Vasculitis *Coarctation of the Aorta
Describe the Clinical Presentation of Aortic Dissection
*Sudden onset of excruciating, "tearing" anterior chest pain *Radiating to the back, between the scapula **Pain moves downward as the dissection progresses* **Interarm blood pressure differential greater than 20 mm Hg is highly suggestive* *Signs of Aortic Regurgitation (Diastolic Murmur) *Neurological deficits are present in 20% of patients (syncope/altered mental status) due to dissection into carotid artery **Many patients have sense of impending doom*
A 22-year-old man who is a professional cyclist undergoes extensive physiologic testing as part of his training regimen. His resting pulse is 33/min , and blood pressure is 110/62 mm Hg. Echocardiography shows dilated ventricles with normal function and a left ventricular ejection fraction of 75%. Which of the following best describes the findings in this patient? A) Congestive cardiomyopathy B) Diastolic dysfunction C) Eccentric hypertrophy D) Hypertrophic cardiomopathy E) Increased myocardial stiffness
C) Eccentric hypertrophy
A 61-year-old male visits the emergency with complaints of acute and severe chest pain. After initial investigations, an MRI is performed and it reveals a widened descending thoracic aorta with a "double barrel." His electrocardiogram is within normal limits. The single most important risk factor for this patient's condition is which of the following? A. Spirochetal infection B. Smoking C. Hypertension D. Diabetes mellitus E. Limited physical activity
C. Hypertension
What is coarctation of the aorta? What are the two common forms?
Coarctation of the aorta is aortic narrowing near the insertion of the ductus arteriosus classically divided into infantile and adult forms.
Tricuspid Atresia
Complete absence of the tricuspid valve Leads to a hypoplastic/absent RV Usually associated with an ASD ASD allows RA -> LA -> LV -> Systemic circulation for blood to be able to reach the lungs, a VSD or patent ductus arteriosus must be present
Aortic Dissection is associated with which mineral deficiency?
Copper Due to weak collagen without copper-dependent enzymatic cross-linking
Digeorge Syndrome is associated with which congenital heart defects?
particularly conotruncal malformations (interrupted aortic arch (50%), persistent truncus arteriosus (34%), tetralogy of Fallot, and ventricular septal defect) TA > TOF
What are two complications of reperfusion of infarcted myocytes?
1) Reperfusion injury 2) Contraction band necrosis Contraction bands are intensely eosinophilic transverse bands composed of closely packed hypercontracted sarcomeres. They are most likely produced by exaggerated contraction of myofibrils at the instant perfusion is reestablished, at which time they are exposed to a high concentration of calcium ions from the plasma. In other words, they represent hypercontraction due to massive calcium influx
Rheumatic Fever
1)A sequela of pharyngeal streptococcal infection caused by Group A, Beta-hemalytic S. pyogenes pharyngitis 2) An autoimmune disease caused by cross-reactions between Strep M protein antigens and the antigens on joint and heart tissue 3) Rheumatic fever is a systemic immune process may or may not lead to RHD 4) RHD is a valvular abnormality secondary to rheumatic fever most often manifesting as mitral stenosis 5) Rheumatic heart disease oftentimes produces a pancarditis that can result in pericarditis, myocarditis and endocarditis. 5) Penicillin V is indicated for treatment of acute rheumatic fever 6) The main cause of death in the acute stage of rheumatic heart disease is heart failure from the myocarditis
A 15-year-old girl presents with four days of malaise, painful joints, nodular swelling over her elbows, low-grade fever, and a rash on her chest and left shoulder. Two weeks ago, she complained of a sore throat that gradually improved but was not worked up. She was seen for a follow-up approximately one week later. At this visit her cardiac exam was notable for a late diastolic murmur heard best at the apex in the left lateral decubitus position with no radiation. Which of the following is the best step in the management of this patient? 1. Penicillin therapy 2. NSAIDS for symptomatic relief 3. Aortic valve replacement 4. Mitral valve repair 5. Reassurance that this is a benign murmur and send home
1. Penicillin therapy The patient in this vignette most likely has rheumatic heart disease. Patients with mitral valve disease as a result of rheumatic fever should receive chronic penicillin therapy to reduce the risk of recurrent Group A strep pharyngitis and progression of rheumatic heart disease. Rheumatic fever is an autoimmune disease sequelae of untreated pharyngeal streptococcal infection which is caused by cross-reactions between streptococcal antigens and antigens on joint and heart tissue. Rheumatic fever does not always lead to rheumatic heart disease (RHD), but when it occurs it is more likely to involve left-sided heart valves, particularly the mitral valve. Mitral stenosis is the most common presentation of RHD. RHD usually only occurs after multiple attacks but may occasionally occur after a single case of acute rheumatic fever, as in this case.
Rheumatic fever typically develops ____ to ____ weeks after a throat infection
2-4 weeks
Cardiac cells can withstand ischemic conditions for approx ____ minutes before cellular death occurs.
20 minutes
Free wall rupture may occur at almost any time after MI but is most frequent approximately ____ to ____ days after onset
3-7
A 67-year-old man presents to the emergency room with chest pain. He reports that the pain is severe and describes it as a ripping pain that radiates to his interscapular region. He also reports shortness of breath. He has a long history of hypertension and is a 20-pack-year smoker. His pulse is 101/min, blood pressure is 155/85 mmHg in one arm and 180/110 mmHg in the other, respirations are 21/min, and O2 saturation 99% on room air. Physical examination is notable for a high-pitched blowing diastolic murmur that is best heard on the left sternal border. A chest radiograph is obtained (Figure A). Which of the follow represents the next best step in management for this patient? 1. Perform a CT scan of the chest 2. Perform transesophageal echocardiography 3. Begin treatment with IV metoprolol and IV sodium nitroprusside 4. Begin treatment with IV hydralazine and IV furosemide 5. Perform an EKG
3. Begin treatment with IV metoprolol and IV sodium nitroprusside A widened mediastinum is concerning for aortic injury such as dissection. The information given of hypertension, tearing chest pain, and a chest radiograph demonstrating a widened mediastinum is more than enough information to begin treating the patient with the appropriate medications (metoprolol and nitroprusside) rather than to continue confirming the diagnosis. Diagnosis of aortic dissection relies on imaging since the classic clinical findings are often not apparent. The best initial test is a chest radiograph. On chest radiograph, patients present with a widened mediastinum which may measure greater than 8 cm on anterior-posterior view. Transesophageal echocadiogram has a high sensitivity and specificity and is preferred in an unstable patient since it can be performed at the bedside. The most accurate test is a CT scan. CT scan and MRI are both very sensitive and specific but MRI is often not ideal due to the long testing time. Dissections may be classified into those affecting the ascending aorta (type A) and those affecting the descending aorta (type B). Note that in this vignette, the patient has developed aortic valve insufficiency secondary to the dissection.
Aerobic Training is associated with __________________ (Pressure/Volume) Overload Hypertrophy Anaerobic Training is associated with __________________ (Pressure/Volume) Overload Hypertrophy
Aerobic: Volume Overload Anaerobic: Pressure Overload
A 30-month-old female is brought to your office by her mother who is concerned about her daughter's irritability and the bluish tinge of her torso. A quick perusal of her chart reveals a documented 3/6 harsh, systolic ejection murmur heard best at the upper left sternal border. During the interview the mother abruptly interjects to draw your attention to the child who is in mild distress and sitting with her knees drawn to her chest in the corner. Auscultation of the upper left sternal border reveals her murmur has increased to a 4/6. What is the most likely diagnosis? 1. Atrial septal defect 2. Ventricular septal defect 3. Tetralogy of Fallot 4. Transposition of the great arteries 5. Patent ductus arteriosus
3. Tetralogy of Fallot Squatting in an attempt to relieve distress is most commonly seen with Tetralogy of Fallot. The primary features of Tetralogy of Fallot follow the mnemonic PROV: P) Pulmonary stenosis, R) Right ventricular hypertrophy, O) Overriding aorta, and V) Ventricular septal defect. The pulmonary stenosis can be thought of as a right ventricular outflow obstruction, and thus in the presence of a VSD, blood is preferentially shunted from the right to the left heart. In bypassing the lungs, this deoxygenated blood causes cyanosis. During "Tet spells", shunting is exaggerated and causes distress, which the child learns to remedy by squatting. Squatting increases the peripheral vascular resistance, mitigating the pressure differential between the left and right outflow tracts, thereby increasing the blood flow through the pulmonary artery. While this decreases the shunting and improves the oxygen saturation of the systemic blood, the increased volume of blood through the stenotic pulmonary artery increases the intensity of the murmur. Saenz et al. describe the signs and symptoms that should raise suspicion for congenital heart disease: difficulty feeding, feeding lasting longer than 30 minutes, tachypnea, sweating, subcostral retractions, and cyanosis. They further specifically describe the clinical presentation of a "Tet spell" as characterized by hyperpnea, irritability, cyanosis, and decreased murmur intensity. During the spell itself, there is increased shunting hence the cyanosis and diminished murmur. While squatting is effective at immediately diminishing the cyanosis, most children with Tetralogy will eventually undergo a multi-stage surgical repair by the age of four.
A 25-year-old male presents for a new primary-care visit. He has never been seen by a physician and reports that he has been in good health. You note a very tall, very thin male whose arm span is greater than his height. The patient reports that his father had a similar build but passed away suddenly in his 40s. You suspect a genetic disorder characterized by a defect in fibrillin-1. What is the histopathology of the most common large-artery complication of this disease? 1. Focal granulomatous inflammation with mural lymphocytes, macrophages, giant cells 2. Eosinophilic vasculitis 3. Predominant neutrophilic infiltration with fibrinoid necrosis 4. Fibrinoid necrosis of blood vessel walls, endothelial swelling, and neutrophilic infiltrate in skin lesions 5. Cystic medial degeneration
5. Cystic medial degeneration This individual likely has Marfan syndrome. The large-artery complication associated with this condition is aortic dissection resulting from cystic medial degeneration. The development of aortic dissection and aneurysm often involves cystic medial degeneration, characterized by myxomatous changes in the media of large arteries. The elastic tissue of the media becomes fragmented, with separation of the components and filling in of amorphous extracellular matrix. Individuals with Marfan syndrome are at risk for this due to the autosomal dominant defect in fibrillin-1, a component of the extracellular matrix.
Stable Angina (angina upon exertion) occurs when atherosclerosis of coronary arteries exceeds ______ % Unstable angina (angina during rest) occurs when atherosclerosis of coronary arteries exceeds ______ %
70% (<70% is usually asymptomatic, even with exertion) 90%
What is a "Double Barrel" Aorta
A "double barreled" aorta occurs when a dissection progresses forward, then spontaneously reconnects to the aorta at the distal part of the dissection. These patients are considered at less of a risk for tears of the adventitia and subsequent fatal hemorrhages/tamponade Overtime, these false channels may become endothelialized and can be recognized as chronic dissections
Ischemic Heart Disease/ Coronary Artery Disease
A group of diseases that includes stable/unstable angina, myocardial infarction, and sudden coronary death. Most common cause of CAD = Atherosclerosis of the coronary arteries
What is thought to be the primary event that leads to an aortic dissection?
A tear in the tunica intima *However in very rare cases, a dissection may be caused by hemorrhage of the vaso vasorum of the media and no intimal tear may be present
Markers of a prior group A B-hemolytic strep infection?
ASO or Anti-DNase B titer
What is the early valvular complication of rheumatic heart disease? What is the late valvular complication of rheumatic heart disease?
Acute: Mitral valve regurgitation Chronic: Mitral stenosis. Note that rheumatic heart disease is virtually the only cause of mitral stenosis.
What heart defect is associated with the adult form of coarctation of the aorta?
Adult coarctation of the aorta is commonly associated with a bicuspid aortic valve.
What is the classical x-ray finding in a patient with coarctation of the aorta?
Adult coarctation of the aorta leads to increased collateral circulation over the intercostal arteries, these enlarged arteries cause progressive "notching of ribs" on x-ray.
Describe the pericarditis that is often seen in Rheumatic Heart Disease
Also seen during the acute stage of the disease is a prominent pericarditis, characterized by tenacious deposits of fibrin that resemble the shaggy irregular surfaces of two slices of buttered bread that have been pulled apart- the so called bread-and-butter appearance.
Prognosis of Heart Failure
Although the outlook depends to some extent on the underlying cause of the problem, heart failure carries a very poor prognosis: approximately 50% of patients with severe heart failure will die within 2 years. Many patients die suddenly, often due to malignant ventricular arrhythmias or myocardial infarction.
A 57-year-old man presents to the emergency department with tearing chest pain that radiates to his back. CT angiography reveals the presence of two aortic lumens separated by an intimal flap. What is the most likely diagnosis?
Aortic Dissection
What are the three layers of the aorta?
As with all other arteries, the aorta is made up of three layers, the intima, the media, and the adventitia.
What are the characteristic heart sounds associated with an atrial septal defect?
Atrial septal defect is characterized by a loud S1 with a wide, fixed split S2 that is best heard at the upper left sternal border.
A 61-year-old woman with a long history of poorly controlled hypertension suddenly has excruciating anterior upper sternal pain radiating to the neck and back. On admission to the emergency department, her blood pressure is 210/110 mm Hg. Fifteen minutes later, while lying down, it is 110/64 mm Hg. Transesophageal echocardiography shows aortic insufficiency, a suggestion of a double lumen of the ascending aorta, and a pericardial effusion. She dies suddenly while awaiting an operation. Which of the following is the most likely cause of death? A. Acute myocardial infarct B. Acute hemopericardium C. Cerebral infarct D. Congestive heart failure E. Massive retroperitoneal hemorrhage
B. Acute hemopericardium But why?
A 56-year-old male presents with the sudden onset of excruciating pain. He describes the pain as beginning in the anterior chest, radiating to the back, and then moving downward into the abdomen. His blood pressure is found to be 160/115. Your differential diagnosis includes myocardial infarction; however, no changes are seen on ECG, and you consider this to be less of a possibility. You obtain an x-ray of this patient's abdomen and discover a "double-barrel" aorta. This abnormality most likely results from? A. A microbial infection B. Loss of elastic tissue in the media C. A congenital defect in the wall of the aorta D. Atherosclerosis of the abdominal aorta E. Abnormal collagen synthesis
B. Loss of elastic tissue in the media Cystic Medial Degeneration/Necrosis
What is the medical treatment for Aortic Dissection?
Beta Blocker (often labetalol) to reduce blood pressure followed by a Vasodilator (i.e Nitroprusside) Vasodilator MUST follow the Beta Blocker, otherwise it will cause reflex tachycardia
How are Beta Blockers helpful in treating HCM?
Beta blockers improve LV filling by prolonging the diastolic filling period and reduce obstruction of the outflow tract due to a negative inotropic effect
What is the most frequent preexistent histologically detectable lesion present in Aortic Dissection?
Cystic Medial Degeneration/Necrosis
Cystic Medial Degeneration/Necrosis
Cystic medial necrosis or degeneration is a disorder of large arteries, in particular the aorta, where there is a focal degeneration of the elastic tissue and the muscle in the media, with the presence of mucoid material. The pink elastic fibers should be in parallel arrays but notice how they are interrupted by masses of basophilic blue mucoid material Commonly seen with Ehler Danlos/Marfan's, HTN, Pregnancy
A 28-year-old man who had rheumatic fever as a child comes to the physician's office because of fatigue and dyspnea for the past 4 months. An early diastolic sound followed by a low-pitched rumbling decrescendo diastolic murmur is present 4 cm left of the sternal border in the fourth intercostal space and is heard best with the patient in the left lateral decubitus position. Which of the following valve defects is most likely in this patient? (A) Aortic regurgitation (B) Aortic stenosis (C) Mitral regurgitation (D) Mitral stenosis (E) Pulmonic regurgitation (F) Pulmonic stenosis (G) Tricuspid regurgitation (H) Tricuspid stenosis
D ******* AIDS is an ASS (Aortic Insufficiency = DiaStolic murmur) = Mitral Stenosis (Aortic Stenosis = Systolic murmur) = Mitral Insufficiency and do the opposite for mitral stenosis & mitral insufficiency. in RHD, the valve MOST commonly involved is mitral and it causes INSUFFICIENCY, so systolic murmur. but in this CASE they mention mitral stenosis, which can happen, so it is Diastolic murmur) also, if u read the case again, the sound is at 4cm LEFT to the sternal border at the 4TH ICS (almost reaching the where the apex sound will be most heard). at the 4th ICS we only here tricuspid and mitral sounds (not aortic or pulmonary, which are at the 2nd ICS) i hope that was helpful.
What type of murmur could be present in a patient with an Aortic Dissection, Systolic or Diastolic?
Diastolic Aortic Regurgitatio****** Explain better
A 68 year old male suffers a myocardial infarction. Six weeks later he begins to have sharp substernal chest pains radiating to his left neck worse with laying flat and better while sitting up and leaning forward. His electrocardiogram is below. Which of the following is his likely diagnosis? A) Ventricular free wall rupture B) Acute mitral valve regurgitation C) Dressler's syndrome D) Left ventricular aneurysm E) Aortic dissection
Dressler's syndrome is an autoimmune pericarditis what occurs weeks to months after myocardial infarction. The typical ECG changes of pericarditis occur (diffuse ST segment elevation in a concave upward shape with PR depression). Symptoms of pericarditis include sharp chest pain worse with laying flay and better with leaning forward and pain that radiates to the left trapizius muscle. Dressler's syndrome is thought to be due to antibodies produced against an unknown myocyte protein. Those antibodies crossreact with pericardial antigens resulting in inflammation and pericarditis. The physical exam findings of pericarditis include a pericardial friction rub, however it is not always present. Treatment includes NSAIDs such as ibuprofen and if needed corticosteroids. Avoiding anticoagulation is recommended due to the risk of spontaneous hemorrhage into the pericardium in Dressler's syndrome resulting in cardiac tamponade. Ventricular free wall rupture (A) occurs as a complication of myocardial infarction that occurs within a few days of infarction and results in cardiac tamponade which can be fatal. Acute mitral valve regurgitation (B) is a complication of an inferior wall myocardial infarction due to papillary muscle dysfunction or rupture which also occurs a few days after MI. Left ventricular aneurysm (D) takes weeks to develop, usually after an anterior wall myocardial infarction and does result in ST segement elevation on the ECG in leads V1 - V3 (not diffuse like in pericarditis). Left ventricular aneurysms cause heart failure, ventricular arrhythmias, and increase the risk of rupture, but do not cause chest pains. Aortic dissection (E) is not a complication of myocardial infarction, but can actually result in infarction due to concomitant dissection of a coronary artery.
A 1-month-old girl undergoes cardiac catheterization for evaluation of a congenital cardiac disorder. She is adequately sedated and remains stable throughout the procedure. Her levels of oxygen saturation in various locations in and around the heart are shown. Location Oxygen Saturation Superior vena cava 71% Right atrium 80% Right ventricle 80% Pulmonary artery 98% Which of the following congenital heart defects is most likely in this patient? A. Aortic insufficiency B. Aortic stenosis C. Atrial septal defect D. Pulmonic stenosis E. Transposition of the great arteries F. Tricuspid insufficiency G. Ventricular septal defect
E The patient had a O2 step up between RV and PA and this can be only explained by TGA (transposition of great vessels) Differential diagnosis for this case is mainly PDA and TGA TGA means that the freat vessels (PA and Aorta) have exchanged position meaning that now the PA comes out of the LV and Aorta comes out of the RV If this case is complete, the baby will die on birth because the right side and the left side became completely separated circles When O2 saturation on a right sided chamber or vessel is increased compared to it's proximal chamber --> O2 step up --> defect with a left to right shunt Examples: if RA > IVC or SVC --> ASD (ie oxygenated blood is coming from the LA to the RA increasing its O2 saturation more than the IVC) Similarly if RV> RA --> VSD (oxygenated blood from LV to RV) If PA> RV --> PDA (oxygenated blood from aorta to PA) In this question the step up happened in the PA however PDA is not an option in the answers so that leads to thinking about another congenital anomaly defect which is (as described before) the TGA In TGA the PA is carrying blood from the LV BACK AGAIN TO THE LUNG --> BLOOD STAYS IN A CLOSED CIRCUIT AND IS ALWAYS HIGHLY OXYGENATED So the only reasonable answer is TGA
Eisenmenger's syndrome
Eisenmenger's syndrome describes a condition in which a left-to-right shunt caused by a congenital heart defec REVERSES to become a right-to-left shunt in the presence of progressive pulmonary hypertension secondary to increased pulmonary circulation. Usually develops before puberty but can occur in late adolescence or early adulthood
Agents such as nitrate, ACE inhibitors, nifedipine-type calcium antagonists are often used to reduce pre-or afterload when treating HOCM (hypertrophic obstructive cardiomyopathy) T/F?
F! Agents to reduce pre- or afterload (such as nitrate, ACE inhibitors, nifedipine-type calcium antagonists) are contraindicated with HOCM due to possible AGGRAVATION of the outflow tract obstruction. In an underfilled left ventricle there is less separation between the mitral valve and interventricular septum—thus resulting in a GREATER degree of obstruction since the LVOT orifice is already narrowed prior to onset of systole. (decreasing preload => increasing obstruction)
Myocardial infarction usually involves the right ventricle T/F?
F! MIs usually involve the Left Ventricle RV and both aria are usually spared
Most Myocardial infarctions are subendocardial T/F?
F! Majority of MIs are transmural Transmural infarctions are usually due to complete occlusion of a coronary artery while subendocardial infarctions are usually not due to complete occlusion. Subendocardial infarctions is often seen in shock or due to hypotension
The main cause of death in the acute stage of rheumatic heart disease is ?
Heart failure from the myocarditis
Why do patients with Aortic Dissection have Blood Pressure Variation Between Arms?
If the dissection extends to the left subclavian or brachiocephalic artery, blood in the dissected wall obstructs the artery and hence reduces blood pressure in the involved arm. Blockage of Brachiocephalic Artery => less BP in Right Arm Blockage of L. Subclavian Artery => less BP in Left Arm
Name and describe 2 important histological findings in rheumatic heart disease myocarditis.
Important histological findings in rheumatic heart disease myocarditis include: Aschoff bodies, which are granulomas with giant cells. Anitschkow cells, which are enlarged macrophages with a ribbon-like nucleus. Anitschkow cells are also referred to as "caterpillar cells" and are pathognomonic for rheumatic heart disease.
What pharmacologic therapy can be administered to close a patent ductus arteriosus?
Indomethacin Patent ductus arteriosus can be treated pharmacologically with COX inhibitors, such as NSAIDs (e.g., indomethacin), or may require invasive procedures in refractory cases.
Separating the false lumen from the true lumen in an aortic dissection, is a layer of intimal tissue known as the?
Intimal Flap FIND A PIC
Aortic Dissection and Transverse Myelitis
Involvement of the spinal arteries can cause transverse myelitis ****???
Most common artery involved in Myocardial infarction?
LAD
What systemic symptoms often accompany Eisenmenger's syndrome?
Late cyanosis with clubbing and polycythemia often accompany Eisenmenger's syndrome.
Most common cause of Left Sided Heart Failure Most common cause of Right Sided Heart Failure Most common reason for developing CHF after you have a normal heart?
Left: Chronic Hypertension, Coronary Artery Disease (both listed as mcc) Right: Left sided Heart Failure Ischemia (Kaplan video) Chagas disease is most common reason worldwide? Another source says dilated cardiomyopathy is most common reason worldwide
In decreasing order of frequency, the heart valves that are commonly affected in Rheumatic Heart Disease include:
Mitral > Aortic > Tricuspid RheuMATic
Which part of the myocardium is most susceptible to ischemia? Which part of the myocardium is least susceptible to ischemia?
Most: Subendocardial region Least: Subepicardial region
How many hours post onset can myocardial infarction be appreciated by the naked eye?
Until about 8-12 hours of onset when the infarcted area may look pale or has a blotchy appearance due to both pallor and congestion
The normal mitral valve annulus has a cross-sectional area of about _______ cm2, and signs and symptoms of mitral stenosis only occur when this is reduced to _____ cm2 or less.
Normal: 5 cm2 Mitral Stenosis: < 1 cm2
Aortic dissections in older adults (40-60 years of age) are most commonly due to what risk factor? younger adults?
Older adults: Hypertension Younger adults: Connective Tissue Disorders (Marfan's/Ehler Danlos)
What congenital infection is associated with PDA?
Patent ductus arteriosus is often associated with congenital rubella.
What is the embryonic pathogenesis of persistent truncus arteriosus?
Persistent truncus arteriosus is caused by abnormal neural crest cell migration, leading to incomplete fusion of the AP septum and failure of the truncus arteriosus to divide.
Pressure overload hypertrophy is characterized by the addition of new sarcomeres arranged in ________________ (parallel/series) Volume overload hypertrophy is characterized by the addition of new sarcomeres arranged in ________________ (parallel/series)
Pressure Overload : New Sarcomeres in Parallel Volume Overload: New Sarcomeres in Series
Transposition of the Great Vessels
Pulmonary artery arises from LV and Aorta arises from RV Associated with Maternal Diabetes presents with EARLY cyanosis pulmonary and systemic circuits do not mix Creation of shunt after birth is REQUIRED for survival PGE can be administered to maintain PDA until definitive surgical repair is performed
What is the most common congenital heart defect?
VSD
What is the most common cause of death in patients with aortic dissection?
Rupture through the adventitia into the pericardial sac causing cardiac tamponade, or into the Pleural or peritoneal cavities leading to massive hemorrhage (most sources say that out of these three possibilities, cardiac tamponade is the most common)
Persistent Truncus Arteriosus
SINGLE large vessel Failure of truncus to divide presents with EARLY cyanosis due to deoxygenated blood from RV mixing with oxygenated blood from LV before pulmonary and aortic circulations separate
How does Subendocardial Ischemia present on EKG? How does Transmural Ischemia present on EKG?
Subendocardial: ST-segment depression Transmural: ST-segment elevation
RHD usually only occurs after multiple attacks but may occasionally occur after a single case of acute rheumatic fever T/F?
T
Unstable angina occurs at rest while stable angina occurs upon exertion/stress T/F?
T
Mechanism of Persistent Truncus Arteriosus
The embryological structure known as the truncus arteriosus fails to properly divide into the pulmonary trunk and aorta. This results in one arterial trunk arising from the heart and providing mixed blood to the coronary arteries, pulmonary arteries, and systemic circulation => Early cyanosis
Within the heart, where do the majority of ventricular septal defects occur?
The majority of ventricular septal defects occur in the membranous interventricular septum.
What are the most common etiologies of Eisenmenger's Syndrome?
The most common etiologies of Eisenmenger syndrome include undetected (and thus uncorrected) PDA, VSD, and ASD
Where can the murmur associated with a PDA be best auscultated?
The murmur associated with patent ductus arteriosus can best be heard over the left infraclavicular region.
MAKE MORE FLASHCARDS ABOUT CARDIOMYOPATHIES
WHEN YOU GET TIME
What is the classical description of the appearance of the stenotic mitral valve in rheumatic heart disease?
The stenotic mitral valve in rheumatic heart disease has 'fish-mouth' appearance. Thickening and fusion of the chordae tendineae and cusps may also be seen.
Congenital heart defects and associations
Transposition of the Great Vessels: Maternal Diabetes Patent Ductus Arteriosus: Congenital Rubella Digeorge Syndrome: TA > TOF
In patients presenting 2 to 3 days after the onset of symptoms of suspected myocardial infarction, ________ may provide diagnostic help due to the prolonged elevation of these proteins.
Troponin
The most sensitive and specific test for myocardial damage?
Troponin Test
The The Stanford Classification divides aortic dissections into two types. What are they? Which one is more common? Which one is worse?
Type A: Involves either both the ascending and descending aorta or just the ascending aorta only Type B: Involves the descending aorta and/or aortic arch. No ascending aorta involvement *(distal to the left subclavian artery)* Type A is more common and is the most dangerous FIND A PIC
How does the treatment of Stanford Type A Aortic Dissection differ from that of Type B?
Type A: Surgical management is superior to medical management Type B: Medical management is preferred over surgical
Of the three variants, stable angina, Prinzmetal angina, and unstable angina, _______ is the most threatening as a frequent harbinger of MI
Unstable angina is the most threatening Unstable angina is most often due to a rupture of an atherosclerotic plaque with thrombus formation and INCOMPLETE occlusion of coronary artery Although the ischemia that occurs in unstable angina falls precariously close to inducing clinically detectable infarction, unstable angina is often the prodrome of subsequent acute MI. Thus this syndrome is sometimes referred to as preinfarction angina, and in the spectrum of IHD, unstable angina lies intermediate between stable angina on the one hand and MI on the other.
What is a characteristic finding on chest x-ray in patients with aortic dissection?
Widening of the Mediastinum
When is a patient who just suffered an acute MI, most at risk of developing an arrythmia?
Within the first 24 hours
Angina
a condition of episodes of severe chest pain due to inadequate blood flow to the myocardium (either atherosclerosis or vasospasm) REVERSIBLE and NO MYOCYTE NECROSIS
Anitschkow cells
enlarged macrophages with ovoid wavy rod like nuclei (caterpillar cells)
