Chapter 27 Disorders of Cardiac Function Part A

Which of the following condition will result in pathological changes arising from pulseless electrical activity A. pericardial effusion B. Cardiac tamponade C. Pericarditis

C pericarditis

Describe idiopathic dilated cardiomyopathy

a transverse section of enlarged heart reveals dilation of both ventricles, and although the ventricular wall appears to be thin there is considerable hypertrophy

What is the ECG change for zone of necrosis

abnormal Q

This represents the spectrum of ischemic coronary disease ranging from unstable angina through myocardial infarction

acute coronary syndrome (ACS)

______ is a group of conditions due to decreased blood flow in the coronary arteries such that part of the _____ is unable to function properly or dies

acute coronary syndrome (ACS), heart muscle

What is the pathogenesis of pericardial effusion

acute or chronic accumulation of fluid

_____ is the force or load against which the heart has to contract to eject blood out of the aorta

after load

What is pleuritic pain with pericarditis

aggravated by inspiration and coughing

______ is chest pain or discomfort when your heart muscle does not get enough oxygen rich blood such as with CAD

angina

What is the atypical chest pain in women relieved by

antacids

Gross pathology of rheumatic heart disease causes

aortic stenosis which causes fused aortic valve leaflets from above

Which area is affected by left anterior descending coronary artery obstruction

area below left ventricle

_____ and other ______ can be used for treatment of pericarditis

aspirin, NSAIDs

What is the most common cause of coronary artery disease

atherosclerosis

_______ refers to the build up of fats, cholesterol, and other substances in an on your artery walls which can constrict blood flow

atherosclerosis

What are the causes of stable angina

atherosclerosis > ischemia

Less blood in chronic ischemia heart disease is due to _____ and _____

atherosclerosis and vasospasm

What ECG changes is seen with necrosis

depressed Q, elevated ST segment

What ECG changes do we see with ischemia

depressed T wave

This is the leading indication for heart transplantation and is many times genetic

dilated cardiomyopathy

A person with hypertrophic cardiomyopathy is prone to ______, and may suffer _______

heart failure, sudden death during exertion

What is the most common cause of cardiac death in young athletes

hypertrophic cardiomyopathy

Decreased tissue perfusion is related to ________ secondary to the presence of _________ within the coronary arteries

inadequate blood flow, plaques

_______ is a valve that is unable to close completely

incompetent or regurgitant valve

How do we compensate for mitral valve regurgitation

increase heart rate

What is the treatment for acute MI

increase myocardial oxygen supply to promote vasodilation

What is the pain like in NSTEMI

increase onset, intensity, and duration than angina

What happens since the right ventricle cannot accept enough blood in pericardial effusion

increased venous pressure because of back up and jugular distension

_____ can lead to irreversible cellular damage & muscle death or necrosis

infarction

What is myocarditis

inflammation of the myocardium, causing the wall of the heart to become thick and swollen

The treatment for pericarditis is medication that address ______, alleviate _______, and stop _______

inflammation, pain, inflammatory process

Pericardial effusion in the pericardial cavity is usually a result of ______ or ______, ______, and ______

inflammatory, infectious process, trauma, cardiac surgery

During _____, venous flow into the right side of the heart _______, causing the ________ to bulge into the left ventricle.

inspiration, increases, inter-ventricular septum

______ can lead to reversible cellular damage

ischemia

______ is not severe enough to cause sufficient MI damage, but does cause acute decrease in blood flow in unstable angina

ischemia

What happens with a NSTEMI

ischemia is severe enough to cause sufficient myocardial damage

Which artery is known as the "widow maker"

left anterior descending artery

Where is the acute myocardial infarction pain for women

left chest, abdomen, back, or arm (not mid chest)

Describe the pathogenesis of STEMI

lipid accumulation and platelet attraction (extensice)

Describe the pathogenesis of non-STEMI

lipid accumulation, small thrombus, and lots of platelets attraction

What is the etiology and clinical manifestations of pericarditis

long-term inflammation from mediastinal radiation, cardiac surgery, or infection

______ is genetic and more common in females

mitral valve prolapse

Describe the chest pain in STEMI

more prolonged that angina

What do we hear with a stethoscope with valve regurgitation

murmur of blood leaking back through when it should be close

What is heard with arterial stenosis

murmur of blood shooting through narrow opening when valve is open

What is dilated cardiomyopathy

muscle fibers in the heart have been stretched too far and the heart chambers are enlarged continuously (don't expand and relax)

A myocardial infarction that is "tomb stoning" is associated with extensive _______, reduced ________, and serious ______ and poor _______

myocardial damage, left ventricle function, hospital complications, prognosis

Coronary heart disease can result in ______

myocardial infarctions

Acute ST Elevation Myocardial Infarction (STEMI) is associated with _______

myocardial necrosis

______ is the amount of oxygen the heart requires to maintain optimal function

myocardial oxygen demand

_____ is the amount of oxygen supplied to the heart by the blood vessels which is controlled by the coronary arteries

myocardial oxygen supply

In the precordial area with pericarditis the pain can radiate to ______, _______, ______, or _______

neck, back (trapezius muscle), abdomen, or side

______/______ can be done to resolve cardiac tamponade and pericardial effusion

needle aspiration and pericardiocentesis

What are the ECG patterns of NSTEMI

non-ST elevation or T-wave inversion

_____ involves myocardial perfusion imaging, infarct imaging, radionuclide angiocardiography, and positron emission tomography

nuclear cardiovascular imaging methods

This is an "incompetent" valve

regurgitation

This is when blood leaks back through valve because it is not closed all the way

regurgitation

Chest pain in women is not relieved by ______ and _______

rest and NTG

STEMI is not relieved by ______, ______, or _____

rest, nitroglycerin, morfinsulfate

Inflammation of pericardium may _____ heart movement

restrict

What does a CABG involve

revascularization of the affected myocardium

What is the primary cause of valve stenosis

rheumatic fever and also calcification

This can also not accept enough blood in pericardial effusion

right ventricle

In constrictive pericarditis ______ contracts and interferes with ______ and, and ______ becomes fixed

scar tissue, diastolic filling, cardiac reserve

What causes the chest pain (and fever) with pericarditis

secondary to inflammation (secondary to pericarditis)

A new onset unstable angina is more _______ with ______ pain, and is more ______ than previously experienced unstable angina

severe, worsening, prolonged

The chest pain felt with pericarditis is _____ and ______

sharp and abrupt onset

Chest pain in women is ______, _______, _________, very _________, and unrelated to ________

sharp, fleeting, repetitive, very prolonged, and exercise

What is possible with pericardial effusion

shock

Which area is affected by left circumflex coronary artery obstruction

side of left ventricle

________ occurs in the absence of anginal pain and is caused by impaired blood flow

silent myocardial ischemia

What decreases the chest pain of pericarditis

sitting and leaning forward

Describe the pathogenesis of unstable angina (slide 61)

small lipid accumulation and small thrombus

Which area is affected by right coronary artery obstruction (slide 38)

space between right and left ventricles

Which type of angina is brought by exercise or stress

stable

_____ this is in which signs and symptoms don't vary, they don't get worse with decreased blood flow to the heart (CAD)

stable angina

What happens with stable angina and (CAD)

stable fixed atherosclerotic plaque doesn't progressively get bigger after a certain point and the symptoms of angina do not get progressively worse

Unstable angina has prolonged ______ and it not relieved by ______

symptoms, meds

Describe mammary artery bypass graft

the mammary artery is anastomosed to the descending branch of the left coronary artery, bypassing the obstructing lesion

Describe the saphenous vein bypass graft

the vein segment of the saphenous vein is sutured to the ascending aorta and the right coronary artery at a point distal to the occluding lesion

What happens with acute pericarditis

the viral/ bacterial infection causes an inflammatory process that results in vasodilation, increase capillary permeability, and increase in wbcs (inflammatory response) causing exudate (fluid) to accumulate in the pericardial cavity causing pericardial effusion

Describe the pathogenesis of CAD

there is an imbalance between oxygen supply and oxygen demand needs, which threatens the myocardial function because of decreased oxygen

Describe hypertrophic cardiomyopathy

there is disproportionate thickening of inter-ventricular septum causes intermittent left ventricular outflow obstruction

What happens as a result of streptococcus antibodies attack glycoproteins in the heart

-the endocardium is thickened and has an overlying vegetation -vegetation of valves (aortic valve cusps) -evidence of left ventricle hypertrophy

What results from the imbalance of oxygen supply and demand of the heart

decreased tissue perfusion

Less than 5 years after an acute myocardial infarction more women than men will suffer from ______, or _____

heart failure, stroke

What are the ECG changes with pericarditis

wide spread ST-segment (ST elevation) and PR depression segment

The symptoms of STEMI for ______ are usually atypical

women

Who has atypical chest pain with a myocardial infarction

women

Less than one year after an acute myocardial infarction more _____ will die compared to ______

women, men

How do you rule out an MI

you monitor troponin I levels, check at 4, 8, and 8 hours following the onset of signs and symptoms and two negative results suggests no myocardial infarction

When listening with stethoscope to someone with pericarditis it sounds ______ and ______ due to

"leathery", "scratchy", rubbing and friction between the inflamed pericardial surfaces

What are the serum cardiac markers for an acute MI

(proteins released from necrotic heart cells) -myoglobin, creatine kinase, troponin

What do women usually experience with a STEMI

-GI distress, nausea, vomiting (pain severity and vagal stimulation) -Tachycardia -anxiety, restlessness, and feeling of impending doom

What are the procedures for treatment of acute MI

-Percutaneous Coronary Intervention (PCI) - non - surgical: stent -Coronary Angioplasty (balloon-expandable stent insertion)

Secondary cardio myopathies are associated with/ may be linked to

-alcohol or other drugs, catecholamines (pheochromocytoma), diphtheria, beriberi (thiamine defiency), and various chemicals

Ischemia may cause:

-angina -heart attack -cardiac arrhythmias -conduction deficits -heart failure -sudden death

What are the aortic valve disorders

-aortic valve stenosis -aortic valve regurgitation

What would be looked for in a chest x-ray for pericarditis

-cardiomegaly (enlarged heart) -clear lungs (no pneumonia -- clear lung fields)

What are the signs and symptoms of acute myocardial infarction

-chest discomfort -arm or back discomfort -neck or jaw discomfort -trouble breathing with or without chest discomfort -feeling light headed or breaking into a cold sweat -feeling sick or discomfort in your stomach

What are the manifestations of acute myocardial infarction

-chest pain (angina) -severe, crushing, or like "heart burn" -"gas" -heavy or mild pressure -viselike, constricted -referred pain

What laboratory result can be indicative of pericarditis

-elevated sedimentation rate and a C-reactive protein (inflammatory markers) -high wbc count (suggestive of infection)

Map the flow of blood through the heart

-enters through the superior and inferior vena cava into the right atrium -pass through tricuspid valve into the right ventricle -pass through the pulmonary valve and blood leaves the heart via pulmonary arteries -goes to lungs to get oxygenated -blood comes back to the heart through the pulmonary veins and enters the left atrium -goes through the mitral valve to enter the left ventricle -blood then goes through the aortic valve to enter the aorta and leave the heart via the aorta

What are the coronary artery disease (CAD) risk factors

-history of heart disease -high cholesterol and high levels of triglycerides -hypetension -cigarette smoking -diabetes -men age 45 yrs older, women 55 and older -family history of heart disease -obesity

Why is silent myocardial ischemia asymptomatic

-history of myocardial infarct and continue to have silent ischemia -people with angina continue to have silent ischemia

What are the functions of the pericardium

-isolates the heart from other thoracic structures -maintains its position in the thorax -prevents it from overfilling -contributes to the coupling of the distensibility between the two ventricles during diastole; they both fill equally

What are the mitral valve disorders

-mitral valve stenosis -mitral valve regurgitation -mitral valve prolapse

What is the sympathetic nervous system response to acute myocardial infarction

-tachycardia -anxiety, restlessness, feeling of impeding doom -may be precipitated by activity or emotions -GI distress, nausea, vomiting -hypotension and shock: weakness in arms and legs

What are the two broad disorders of CAD

1. Acute coronary syndrome 2. Chronic ischemia heart disease

What are the components of the classical triad for pericarditis

1. Chest pain 2. ECG changes 3. Pericardial friction rub (a heart sound)

What are the primary cardiomyopathies

1. Hypertrophic cardiomyopathy 2. Dilated cardiomyopathy 3. Myocarditis

What are the mechanical complications of a myocardial infarct

1. Papillary muscle rupture (making for heart murmur) 2. Interventricular septum rupture 3. Rupture of the free wall of the left ventricle with pseudoaneurysm formation

What are the two types of valve defects

1. Stenosis 2. Regurgitation

What are the diseases under the heart disease "umbrella"

1. coronary artery disease 2. arrhythmias 3. congenital heart defects, valve disorders

Pericardial effusion is the accumulation of fluid in the pericardial space exceeding the typical ____ to ____ cc

15 to 50

What is the duration of stable angina

3-5 minutes

Manifestation of acute myocardial infarction are virtually silent until artery is approximately _____ percent blocked by plaque

40%

troponin I has a ____% sensitivity and _____% specificty for _____ hours following signs and symptoms

90, 95, 8

Which of the following may result in the development of a cardiomyopathy A. Valvular stenosis B. Valvular regurgitation C. MI D. Ischemia E. All the above F. None of the above

E

____ evaluates changes in the pattern or orientation of wave forms

ECG

Unstable angina may or may not have _______

ECG changes

This an an infection of the inner heart surfaces, and characterized by the invasion of heart valves

Endocarditis Disorders

Describe coronary angioplasty

Insertion of a guide catheter with a collapsed ballon-expandable stent mounted over a guide wire into a coronary artery, advancement of guide wire across the coronary lesion, positioning of the ballon expandable stent across the lesion, ballon inflation with deployment of the stent is expanded, the ballon system is removed

Describe silent myocardial ischemia

MI without anginal pain; reason unclear (may have differences in pain threshold, also see with Diabetics with neuropathy)

What is the acute treatment for acute MI

MONA Morphine oxygen nitroglycerine aspirin (to prevent clots)

What does NSTEMI stand for

Non-ST Elevation myocardial infarction

What do elders experience with a STEMI

SOB more frequently than chest pain

What are the ECG changes for acute MI

ST segment elevation

What is the ECG change for zone of injury

ST-segment depression or elevation

With this there is complete narrowing of the lumen

STEMI

silent ______ compromises a significant proportion of all ______ in older adults, and they are painless

STEMI, STEMI

What is the ECG changes for zone of ischemia

T wave inversion

What ECG changes are seen in acute coronary syndrome

T-wave inversion, ST segment elevation (or depression); abnormal Q wave

How is stable angina typically relieved

Upon relief of precipitating factors/ rest

What is valve prolapse

Valve everts and blood flows the wrong direction.

What is another name for the mitral valve

bicuspid valve

When placing a stent in the left anterior descending coronary artery what happens

blood supply to the front wall of the heart is restored to normal

What do the alterations in hemodynamic function of aortic valve stenosis, mitral valve stenosis, mitral valve regurgitation, and aortic valve regurgitation cause

blood to be back up into the left ventricle making for hypertrophied heart muscle that can lead to heart failure

Pericardial effusion affects _____; symptoms of ________

cardiac function, cardiac compression

There are no changes of _______ in unstable angina

cardiac markers

_______ looks at serum cardiac markers in acute coronary syndromes

cardiac panel

Pericardial effusion can cause ______

cardiac tamponade

Pericardial effusion can lead to

cardiac tamponade

Rapid accumulation of exudate compresses the heart causing _______

cardiac tamponade

This is slow or rapid compression of the heart due to accumulation of fluid, pus, or blood in the pericardial sac

cardiac tamponade

In _______, the fluid in the pericardial sac produces further compression of the left ventricle, causing an exaggeration of the normal inspiratory decrease in ______ and _______

cardiac tamponade, stroke volume, systolic blood pressure

_______ are disorders of heart muscle

cardiomyopathies

Describe endocarditis from rheumatic fever (rheumatic heart disease)

caused by streptococcus infection indirectly; antibodies to Strep attack glycoproteins of the heart, skin and joint

What are the cause of valve regurgitations

causes range from rheumatic fever, endocarditis, and congenital defects

What happens with variant angina

chest pain occurring almost exclusively at rest, related to coronary artery spasm with subsequent myocardial ischemia

_______ is the inability of coronary arteries to supply blood to meet metabolic demands of heart

chronic ischemic heart disease

_____________, ____________, ____________, are involved in chronic ischemic heart disease

chronic stable angina, silet myocardial ischemia, variant or vasospastic angina

Pain with stable angina maintains a ______ threshold in severity

constant

This is a consequence of pericarditis

constrictive pericarditis

What does CABG stand for

coronary artery bypass graft

_______ is the most common type of heart disease >370,000 deaths a year

coronary heart disease

During inspiration the inter-ventricular septum bulges into the left ventricle producing a _______________, with a subsequent ____________

decrease left ventricular volume, decrease in stroke volume output

What is the overall feeling of STEMI

discomfort

_____ involves m-mode, two-dimensional, Doppler, and esophaheal

echocardiogram

What ECG changes do we see with injury

elevated ST wave

There is a higher O2 demand with ______ and _____

exercise and cold

_____ is a motorized treadmill and bicycle ergometer

exercise stress testing

What are the precipitating factors of stable angina

exertion, stress

Fluid in pericardial cavity restricts heart ______, causing the _____ to not be able to accept enough blood, this causes a _______ of cardiac output, and a _____ blood pressure

expansion, left ventricle, decrease, increase

_____, _____,_____, or ______ constricts the heart in pericardial effusion

exudate, fluid, pus, or blood

What happens with constrictive pericarditis

fibrous, calcified scar tissue develops between the visceral and parietal layers of the serous pericardium

Pericardial friction rub is the result of _______ between inflamed layers of the pericardium when the heart moves within the ________

friction, pericardial sac

Cardiomyopathies can be ______, _______, ______

genetic, acquired, mixed (both)

What happens with valve stenosis

harder to force blood through the valve

This is leading cause of death in the United States (30% of deaths worldwide)

heart disease

Describe pulsus paradoxus

on inhaling, right ventricles fills with blood, because heart cannot expand fully when the right ventricle is filled, the left ventricle is compressed and cannot accept much blood. On the next heart beat, the left ventricle does not send out much blood causing the systolic blood pressure to decrease

This remains the same with chronic stable angina

onset, duration, intensity

What increases the chest pain of pericarditis

orthopnea (SOB when lying down)

Cells that have hypertrophied need more ______ and perform less ______

oxygen, efficiently

What is unusual with chronic stable angina

pain at rest

Describe chronic stable angina

pain usually when heart's oxygen demand increases; fixed coronary obstruction

Describe variant/vasospastic angina

pain when coronary arteries spasm (cause not understood)

With unstable angina there is ______ at rest and with _______, lasting 20 minutes if untreated with _______

pain, minimal exertion, NTG

Women tend to have _______ without chest pain during acute myocardial infarction

palpations

This is attached to the great vessels and is the outer fibrous layer of the heart

parietal pericardium

What is variant/ vasospastic angina also known as

parinzmetal's

Medications for chronic stable angina can be timed to provide ______

peak effect

The two layers of the pericardium are separated by the ________, with _____ ml of serous fluid

pericardial cavity, 50

Pericarditis leads to _______ that is life threatening

pericardial effusion

The complication of pericarditis is

pericardial effusion

This is LIFE THREATENING

pericardial effusion

This is the accumulation of fluid in the pericardial cavity

pericardial effusion

What is the most common finding of pericarditis

pericardial friction rub (a heart sound)

This is an acute inflammatory process of the pericardium and it can be acute, chronic, or constrictive

pericarditis

Differentiate pericarditis from MI

pericarditis is the inflammation of the pericardium and MI is the death of heart tissue as a result of ischemia (decreased blood flow)

This is a double layered serous membrane

pericardium

What is the treatment for the blockage of the left anterior descending artery

placing a stent to facilitate blood flow

_____ is the initial stretching of cardiac myocytes prior to contraction, related to ventricular filling

pre load

Stable angina pain has a ______ pattern

predictable

_____ and ______ may be the result of broken chordinae tendineae

prolapse and regurgitation

Chest pain in unstable angina is more _______ than angina and have no ________

prolonged, predictable pattern

This is a diagnostic feature in tamponade

pulsus paradoxus

_______ is the term used to describe an exaggerated blood pressure variation with the respiratory cycle....This hemodynamic effect of a large pericardial effusion causing cardiac tamponade is referred to as

pulsus paradoxus, pulsus paradoxus

The key to fixing the widow maker is to fix it

quick and properly

What happens with plaques in regards to acute coronary syndrome

there is plaque disruption and platelets aggregate to the plaque which then can lead to a big thrombus by attracting more platelets making for larger disruption of blood flow to the heart (unstable angina)

Where does pain from angina radiate

to the neck, shoulders, inner aspect of arms, center of back

"______" is ST elevation, and depressed Q wave

tomb stoning

In variant angina there are ______ ECG changes

transient

What are the proteins released from necrotic heart cells

troponin I and T (only in cardiac muscle), myoglobin, creatine kinase (CK-MB)

_____ and _____ are preferred as they have the highest _____ and _______ for the diagnosis of acute myocardial infarction

troponin I, T, sensitivity, specificity

What are the elevated cardiac markers in NSTEMI

troponins, creatine kinase (CK-MB) myoglobin

True or False: mitral (bicuspid) valve regurgitation results in diminished stroke volume

true: if the mitral valve does not close as it should, a portion of the stroke volume leaks back into left atrium, decreasing the amount of blood that is ejected during the beat

Why is silent myocardial ischemia painless

unknown

What does idiopathic mean

unknown cause

This is not relieved by rest or NTG/MS

unstable angina

What do we treat as an emergency because it could be a sign of impeding myocardial infarction

unstable angina

What is progressive, crescendo angina, pre-infarction angina

unstable angina

Acute ischemia heart diseases range from ________ to _______

unstable ischemia, acute MI

Describe valve regurgitation

valve is not closing completely

Describe valve stenosis

valve will not open all the way; flaps thicken or fuse

This usually occurs during rest

variant/vasospastic angina

What effect does NTG have

vasodilating

What is the most common cause of acute pericarditis

viral and bacterial infections

Myocarditis is usually associated with

viral infections

This adheres to the epicardium and is the thin inner layer on the outside the heart

visceral pericardium

Defects in contractile proteins of the heart makes cells _____, cells will then ____ to do the same amount of work as normal cells in hypertrophic cardiomyopathy

weak, hypertrophy