CV-Cardiovascular Disease and Pathology

What is cystic medial degeneration?

"Degenerative changes" due to any etiology are collectively called cystic medial degeneration which is nonspecific and can be seen in a variety of settings, including Marfan syndrome and scurvy.

Describe the appearance of hyperplastic arteriolosclerosis.

"Onion-skin lesions" with concentric, laminated thickening of the vessel walls leading to luminal narrowing.

What is a fusiform aneurysm?

"Spindle-shaped" aneurysms are variable in both their diameter and length; their diameters can extend up to 20 cm (8 in). They often involve large portions of the ascending and transverse aortic arch, the abdominal aorta, or less frequently the iliac arteries.

Give the risk of rupture associated to abdominal aortic aneurysm size (4).

- < 4 cm: close to 0% -4-5 cm: 1% per year -5-6 cm: 11% per year - > 6 cm: 25% per year

What is the mortality associated with elective surgical repair of an aneurysm (3)?

-3-5% for thoracic aneurysms, depending on whether endovascular stent graft is possible or if cardiopulmonary bypass is needed -1-2% for abdominal aortic aneurysms at high-volume institutions -Long term outcomes are still being defined

What is the diameter of the normal aorta at its origin, in the ascending, descending and abdominal aortas?

-3cm -3.8 to 4.5cm -2 to 2.5cm -About 2.5cm

What are the causes of atheroemboli (2)?

-50% of cases are spontaneous -50% are caused by intra-arterial procedures, such as cardiac catheterization

What are the most common locations of aortic dissections (3)?

-65% ascending thoracic aorta -20% descending thoracic aorta -5% abdominal aorta

What are the blood pressure goals for patients with diabetes or renal disease that also have peripheral artery disease and what medications are indicated in these patients?

-< 140/90 or < 130/80 -Beta blockers and ACE inhibitors

What is pentoxifylline and what are the advantages of using it to treat peripheral artery disease?

-A substituted xanthine derivative, is thought to improve the deformability of red and white blood cells -It may help prevent claudication in some

List the two types of angiotensin production or recetor blockers.

-ACE inhibitors -Angiotensin II receptor blockers

Which medications can be used as adjunctive therapy for all acute coronary syndrome (2)?

-ACE inhibitors -Statins

What are the contraindications of bile binding resins (2)?

-Absolute: dysbetalipoproteinemia or TG > 400 -Relative: TG > 200

What are the contraindications of ezetimibe (2)?

-Absolute: dysbetalipoproteinemia or TG > 400 -Relative: TG > 200

What are the kinetics of fibrates (6)?

-Absorbed quantitatively -Cross placenta -Bind to plasma proteins -Enterohepatic circulation -Half-life of 1.5 hours -Mostly eliminated unchanged in the urine

What are the toxicities of sodium nitroprusside (6)?

-Accumulation of cyanide -Metabolic acidosis -Arrhythmias -Excessive hypotension -Death -Thiocyanate poisoning (weakness, disorientation, psychosis, muscle spasm and convulsions) with long term use

What are the consequences of platelet activation and aggregation (2)?

-Activation of the coagulation cascade -Vasoconstriction

What is the result of a rupture of the interventricular septum and how common is this complication?

-Acute left to right shunt and congestive heart failure -1-3% of cases

How does acute arterial occlusion present?

-Acute limb ischemia causing pain, paresthesias and motor weakness distal to the occlusion -Loss of pulses, pallor, cool skin, cyanosis, positive Buerger's sign

What symptoms of atherosclerosis and ischemic heart disease can manifest during dynamic changes in the coronary arteries (3)?

-Acute plaque changes -Coronary artery thrombosis -Coronary artery vasospasm

Give a differential diagnosis for nonatherosclerotic causes of acute coronary syndrome (8).

-Acute vasculitis (especially polyarteritis nodosa) -Coronary emboli from endocarditis, artificial valves -Congenital anomalies of the coronary arteries -Coronary trauma or aneurysm -Spontaneous coronary artery dissection -Severe coronary artery spasm (e.g., cocaine- or meth-induced) -Increased blood viscosity (e.g., polycythemia vera) -Significantly increased myocardial oxygen demand (e.g., severe aortic stenosis)

List the miscellaneous anti-arrhythmic agents (3).

-Adenosine -Digoxin -MgCl

What is the general treatment approach for all patients with acute coronary syndrome (4)?

-Admit to intensive care; include continuous ECG monitoring for arrhythmias -Initially maintain at bedrest to minimize myocardial oxygen demand -Deliver oxygen (through nasal cannulaor face mask) to improve oxygen supply -Give analgesia such as morphine to reduce pain and anxiety, thereby reducing the catecholamine response

List the high yield facts about Takasuya arteritis (3).

-Affects aorta and its branches -Known as the "pulseless disease" -Generally affects younger women

List the high yield facts about giant cell arteritis (2).

-Affects medium to large arteries, especially cranial vessels -65% of patients are women over 50

List the high yield facts about thromboangiitis obliterans (4)

-Affects small arteries, especially distal arteries of the extremities -Uncommon -Affects younger men -Strongly correlated with smoking

When are myoglobin levels typically elevated (4)?

-After strenuous exercise -With renal failure -In muscular dystrophy -After IM injections.

What factors are used to calculate a thrombolysis in MI score (6)?

-Age greater than 65 years old -Greater than 3 risk factors for CAD -Proven prior coronary stenosis of > 50% -Greater than 2 anginal episodes in prior 24 hours -Use of aspirin in prior 7 days (implying resistance to effect) -Elevated serum troponin or CK-MB

What are the causes of aortic stenosis?

-Aging -In the 1-2% of the population born with an abnormal aortic valve, there is increased risk of degenerative changes -Rheumatic fever

What are the features common to all lipoproteins (3)?

-All lipids are transported bound to protein -Lipids and proteins interact non-covalently -All lipoproteins are mixed pseudomicelles with phospholipids, cholesterol and free fatty acids in the shell, triglycerides and cholesteryl esters in the core

What are the causes of pulmonic stenosis (2)?

-Almost always due to congenital valve deformity (e.g., Tetralogy of Fallot) -Another rare cause is carcinoid syndrome

What are the other effects quinidine has (2)?

-Alpha receptor blockade (reflex tachycardia) -Anti muscarinic effects

List the class III potassium channel blockers (5).

-Amiodarone -Bretylium -Sotolol -Ibutilide -Dofetilide

What are the important pathologies of the aorta (2)?

-Aneurysm -Dissection

What are the major presenting symptoms of aortic stenosis?

-Angina -Syncope -Congestive heart failure may appear after many asymptomatic years of slowly progressive aortic stenosis

What are the syndromes associated with atheroscleorsis and ischemic heart disease (4)?

-Angina pectoris, table or unstable -Acute myocardial infarction -Sudden cardiac death -Chronic ischemic heart disease with congestive heart failure

Give the mean survival time of aortic stenosis based on presenting symptoms.

-Angina: 5 years -Syncope: 3 years -Congestive heart failure: 2 years -Atrial fibrillation: 6 months

What are the current classifications of vasculitis with anti-neutrophil cytoplasmic antibodies (2)?

-Anti-proteinase-3 (PR3-ANCA), previously c-ANCA -Anti-myeloperoxidase (MPO-ANCA), previously p-ANCA

Describe how hypersensitivity to a drug can contribute to immune complex associated vasculitis (5).

-Antibodies directed against drug-modified proteins or foreign molecules lead to the formation of immune complexes -The drug may bind to serum proteins (e.g. penicillin) -The drug itself may be a foreign protein (e.g. streptokinase) -Manifestations vary in severity and location; most frequently seen in the skin -Resolution, when the drug is discontinued

What are anti-endothelial cell antibodies and which condition are they implicated in?

-Antibodies to endothelial cells may predispose to vasculitis -Kawasaki disease

Describe the pathogenesis of immune complex associated vasculitis (4)?

-Antibody and complement are typically detected in vasculitic lesions -Antigens responsible for the deposition cannot usually be determined -Antigen-antibody complexes may form elsewhere and then deposit in a particular vascular bed or form in situ from the seeding of antigen in a vessel wall followed by antibody binding -Antigen-antibody deposits may be scarce; the immune complexes may have been cleared by the time the tissue diagnosis is made, or other mechanisms may apply in "pauci-immune" cases

How is variant angina treated (2)?

-Any known risk factors are treated -The mainstays of medical therapy are nitrates and calcium channel blockers

List the nitrates and nitrites (4).

-Anyl nitrite -Nitroglycerin -Isosorbide dinitrate -Isosorbide mononitrate

What are the causes of aortic root dilation (4)?

-Aortic aneurysm (due to inflammation, hypertension, connective tissue disease) -Aortic dissection -Annuloaortic ectasia (a dilatation or an enlargement of the ascending aorta, the aortic annulus and/or a loss of function of the aorta secondary to connective tissue disease) -Syphilis

List the aortic valve diseases (2).

-Aortic stenosis -Aortic regurgitation

Which valvular diseases cause systolic murmurs (4)?

-Aortic stenosis -Pulmonic stenosis -Mitral regurgitation -Tricuspid regurgitation

Which proteins are known to assist in the transfer of cholesterol out of cells onto HDL (2)?

-Apo A1 -ATP binding cassette proteins (ABCs)which are present in peripheral cells, especially macrophages

It is possible to have both DVT and superficial thrombophlebitis. If DVT is suspected, what further tests must be done?

-Appropriate labs -Doppler ultrasound

What is the prognosis for peripheral artery disease/coronary artery disease (3)?

-Approximately 30-50% of patients with symptomatic PAD have evidence of coronary artery disease based on clinical presentation and electrocardiogram -Over 50% have significant coronary artery disease by coronary angiography -Patients with PAD have a 15-30% 5-year mortality rate and a two- to sixfold increased risk of death from coronary heart disease

What are the goals in the treatment of aortic dissection (3)?

-Arrest progression of the dissecting channel -Reduction of systolic blood pressure to between 100 to 120 mmHg -Decrease left ventricle contraction to shear wall stress

What are the toxicities of bepridil (3)?

-Arrhythmias (Torsades de Pointes) -Dizziness -Nausea

What are the two classes of vasodilating drugs (2)?

-Arteriolar dilators -Both arteriolar and venule dilators

Give a brief description of Kawasaki disease (3).

-Arteritis with mucocutaneous lymph node syndrome -Usually occurs in children -Coronary arteries can be involved with aneurysm formation and/or thrombosis

Describe the late phase of chronic aortic regurgitation (4).

-As aortic regurgitation progresses, left ventricle enlargement surpasses preload reserve on the Frank-Starling curve with the ejection fraction falling to normal and then subnormal levels -Also note that the left ventricle myocardium has been remodeling through the years, eventually resulting in systolic dysfunction leading to increased LA pressure which results in increased pulmonary vascular pressures -Eventually, the left ventricle reaches its maximal diameter and diastolic pressure begins to rise -Increasing left ventricle end-diastolic pressure may also lower coronary perfusion gradients

List the proteins commonly found in myocardial tissue (5).

-Aspartate Aminotransferase (AST) -Lactate Dehydrogenase (LDH) -Myoglobin -Creatine Kinase MB (CKMB) -Troponin I and Troponin T

Which medications are part of anti-thrombotic therapy (4)?

-Aspirin -ADP inhibitor -Heparin -IV glycoprotein IIb/IIIa inhibitors

Which pharmalogical agents are used to prevent recurrence of stable angina and progression to acute coronary syndrome (6)?

-Aspirin (to block platelet activation) or clopidogrel -Sublingual nitroglycerin (as needed to relieve symptoms) -Beta-blocker (to reduce oxygen demand by inhibiting increases in heart rate, arterial pressure and myocardial contractility), has been shown to improve life expectancy following acute MI -Calcium antagonists (to reduce myocardial oxygen demand, contractility, and arterial pressure) -Lipid lowering agent (to reduce LDL < 100 mg/dL) -ACE-I are advocated by most cardiologists

What does the standard post-MI discharge therapy include (6)?

-Aspirin (with the addition of clopidogrel for 9-12 months if indicated) -A beta-blocker -An ACE inhibitor or ARB, especially if left ventricle dysfunction is present -A statin to achieve a long-term LDL < 100 mg/dL -Rigorous attention to other factors: smoking, hypertension, diabetes, weight -A formal exercise rehabilitation program often speeds convalescence (Goal: 30 minutes of moderate aerobic exercise 5-7 days per week)

How can you distinguish the different ANCA associated disorders associated with small vessel vasculitis (5)?

-Assess vessels for granuloma -If there are no granulomas, it is microscopic polyanginitis and most patients will be positive for anti-MPO -If there are granulomas, assess patients for signs of asthma and eosinophilia -If eosinophilia and asthma are not present it is Wegener granulomatosis and 95% of patients will be anti-PR3 positive -If asthmas and eosinophilia are present, then it is Churg-Strauss syndrome and less than 50% of patients will be anti-MPO positive

What clinical presentation is associated with a diagnosis of pneumonia (2)?

-Associated symptoms (cough, sputum) -Abnormal chest x-ray

What are the contributing factors in the development of aortic aneurysms (5)?

-Atherosclerosis -Hypertension -Trauma -Vasculitis -Infections

What pathologies are associated causes of aneurysms (4)?

-Atherosclerosis -Polygenetic potential -Cystic medial necrosis -Inflammation

What are the primary contributors to the development of a descending or thoracic aneurysm (5)?

-Atherosclerosis -Smoking -Dyslipidemia -Male gender -Advanced age

What are some examples of true aneurysms (4)?

-Atherosclerotic -Syphilitic -Congenital vascular aneurysms -Ventricular aneurysms that follow transmural myocardial infarctions

Describe how atherosclerosis contributes to the development of an abdominal aortic aneurysm (3).

-Atherosclerotic plaque in the intima compresses the underlying media and compromises nutrient and waste diffusion from the vascular lumen into the arterial wall -Media undergoes degeneration and necrosis resulting in arterial wall weakness and consequent thinning -The major cause of aneurysm formation is the production of MMPS by inflammatory cells

Describe the pathogenesis of ischemia (3).

-Atherosclerotic thickening of the intima increases the distance that oxygen and nutrients must diffuse -Systemic hypertension causes narrowing of vasa vasorum (e.g., in the aorta) and leads to outer medial ischemia -Smooth muscle cell loss or change in synthetic phenotype

Which statins have the longest half-life (2)?

-Atorvastatin: 14 hours -Rosuvastatin: 19 hours

Which statin reduces triglycerides by the most (1)?

-Atorvastatin: 29%

Which statins reduce LDL by the most (2)?

-Atorvastatin: 60% -Rosuvastatin: 63%

What other pathologies are associated with a thromboembolism (5)?

-Atrial fibrillation -Mitral stenosis -Dilated cardiomyopathy -MI -Endocarditis

What are the three kinds of apoproteins contained within VLDL?

-B100 -Cs -E

What is the time frame for total creatine kinase levels during an MI?

-Begins to rise 2-4 hours after MI -Peaks at 24 hours -Returns to normal within 72 hours

What is the time frame for creatine kinase MB levels during an MI?

-Begins to rise 2-4 hours after the MI -Peaks at 18 hours -Disappears within 48 hours

List the long-acting ACE inhibitors (7).

-Benazepril -Fosinopril -Moexipril -Perindopril -Quinapril -Ramipril -Trandolapril

List the nondihydropiridine calcium channel blockers (3).

-Bepridil -Dilitiazem -Verapamil

What therapy is used for symptom control of mitral stenosis (5)?

-Beta blockers -Nondihydropiridine calcium channel blockers -Digoxin for rate control of atrial fibrillation -Cardio-version for new onset of atrial fibrillation and heart failure -Diuretics for heart failure

Which medications are indicated for aortic dissection (2)?

-Beta blockers -Vasodilators (sodium nitroprusside)

What are the drugs associated with pulmonary fibrosis (3)?

-Bleomycin -Amiodarone -Bulsulfan

Where is creatine kinase concentrated (3)?

-Brain -Myocardium -Skeletal muscle

What are the toxicities of carvedilol (7)?

-Bronchoconstriction -Orthostatic hypotension -Dizziness -Fatigue -Weight gain -Bradycardia -Heart block

What are the toxicities of non-specific beta blockers (11).

-Bronchoconstriction (avoid with asthma or COPD) -Bradycardia -Negative inotropy (avoid with CHF), -Hypotension -Arrhythmias -Sedation and depression -Reduce recovery from hypoglycemia (problem with diabetics) -Withdrawal may occur (taper dose) -Impotence -Negative GI effects -Altered lipid panels (inc VLDL and dec. HDL)

What are the side effects of the class 1C sodium channel blockers (5)?

-CAST study demonstrates increased mortality -Dizziness -Blurred vision -Headache -Nausea

What conditions should you be cautious of when prescribing beta blockers (9)?

-CHF -Asthma -COPD -Diabetes -Heart conduction abnormalities -MAO inhibitors -Elderly -Patients with depression -PVD

Which creatine kinase dimers are concentrated in the myocardium? Which is more specific to myocardium?

-CKMM and CKMB -CKMB

What are the different classes of sympathoplegic agents (6)?

-CNS acting -Ganglion blockers -Adrenergic nerve blockers -Alpha blockers -Mixed alpha and beta blockers -Beta blockers

What are the toxicities of methyldopa (3)?

-CNS: sedation, mental lassitude and impaired mental concentration, nightmares, depression, vertigo and extrapyrimidal effects -Lactation -Positive Coombs test

List the ACE inhibitors (10).

-Captopril -Enalapril -Lisinopril -Benazepril -Fosinopril -Moexipril -Perindopril -Quinapril -Ramipril -Trandolapril

What complications do 80-90% of hospitalized patients experience (5)?

-Cardiac arrhythmia (75-95%) -Left ventricular failure with pulmonary edema (60%) -Cardiogenic shock (10%) -Thromboembolism (15-50%) -Rupture of cardiac free wall, septum or papillary muscle (4-8%)

What additional tests can be done to diagnose chronic stable angina?

-Cardiac imaging -Coronary arteriography/angiographycatheterization

What are the common clinical manifestation of aortic dissection (6)?

-Cardiac tamponade -Aortic insufficiency -Retrograde dissection into the aortic root causes disruption of the aortic valve -Extension into the coronary arteries results in AMI -Extension into the great arteries of the neck or renal, mesenteric, or iliac arteries causes critical vascular obstruction and ischemia -Compression of spinal arteries may cause transverse myelitis

What are the side effects of quinidine (3)?

-Cardiac: arrhythmias -Noncardiac: nausea, vomiting, diarrhea, cinchonism, displaces digoxin from tissue binding sites, thrombocytopenia, hepatitis and angioneurotic edema -Two times more likely to maintain normal sinus rhythm, also two times more likely to cause death

What changes would you see in an ECG of an anterior MI, and what most likely caused it?

-Changes in any of the precodial leads -Occlusion of the left anterior descending artery

What ECG changes are seen in an anterior MI and what is usually its cause (2)?

-Changes in any of the precordial leads -Caused by an occlusion of the left anterior descending artery

What ECG changes are seen in a lateral wall MI and what is usually its cause (2)?

-Changes in leads I, aVL, V5 and V6 -Caused by an occlusion of the circumflex artery

What changes would you see in an ECG of a lateral wall MI, and what most likely caused it?

-Changes in leads I, aVL, V5 and V6 -Occlusion of the circumflex artery

What ECG changes are seen in an inferior MI and what is usually its cause (2)?

-Changes in leads II, III and aVF -Occlusion of the right coronary artery or its descending branch

What changes would you see in an ECG of an inferior MI, and what most likely caused it?

-Changes in leads II, III and aVF -Occlusion of the right coronary artery or its descending branch

What ECG changes are seen in an posterior MI and what is usually its cause

-Changes indicated by looking for reciprocal changes in the anterior leads, especially V1 -Caused by occlusion of the right coronary artery (and therefore is often accompanied by an inferior MI)

What changes would you see in an ECG of a posterior MI, and what most likely caused it?

-Changes indicated by looking for reciprocal changes in the anterior leads, especially V1 -Occlusion of the right coronary artery (and therefore is often accompanied by an inferior MI).

What are the signs and symptoms of an acute MI (6)?

-Characteristic substernal pain or pressure in up to 75% of patients, along with dyspnea. (Levine's sign: clenched fist over chest) -Sympathetic effect -Parasympathetic effect -Inflammatory response -Cardiac findings -Other

Describe Monckeberg medial sclerosis (4).

-Characterized by calcific deposits in muscular arteries in persons typically older than age 50 -Deposits may undergo metaplastic change into bone -Lesions do not narrow the vessel lumen -Usually not clinically significant

An aneurysm should be included on your differential for what types of pain (7)?

-Chest -Back -Abdominal -Buttock -Groin -Testicular -Leg

What are the symptoms of chronic stable angina (10)?

-Chest heaviness -Pressure -Squeezing -Dyspnea -Choking -Indigestion -Rarely outright pain -May indicate Levine's sign (clenched fist over chest). -Typically lasts 2-5 min, crescendo-decrescendo pattern -May radiate to left shoulder, both arms, back, jaw

List the bile binding resins (3).

-Cholestyramine -Colestipol -Colesevelam

List the ischemic syndromes (3).

-Chronic stable angina -Variant angina -Silent angina

List the lipoproteins in order from least dense to most dense and give their composition.

-Chylomicron: 86% triglyceride, 2% protein -VLDL: 55% triglyceride, 9% protein -LDL: 8% triglyceride, 25% protein -HDL: <5% triglyceride, 45% protein

What are the four major classes of lipoproteins?

-Chylomicrons -VLDL -LDL -HDL

What is the etiology of a mycotic abdominal aortic aneurysm (2)?

-Circulating microorganisms lodge in the aortic wall and cause inflammation -Bacteremia from a primary Salmonella gastroenteritis is a common cause

Describe a concentric atheroma (2).

-Circumferential, mostly collagenous fibrotic plaque and medial fibrosis -Drug therapy is ineffective

How can a distinction between acute coronary syndromes that cause ST elevation and those that do not be made (3)?

-Clinical presentation -ECG findings -Serum biochemical markers for myocardial damage

What are the findings of a physical examination of a patient with advanced aortic stenosis (3)?

-Coarse late-peaking crescendo-decrescendo systolic ejection murmur -Weakened and delayed upstroke of the carotid artery pulsations due to the obstructed left ventricle outflow -May have an S4 (atrial kick into the stiff left ventricle)

Morphologic features of MI, microscopic changes: 24-72 hours

-Complete coagulation necrosis of myofibers -Heavy neutrophil infiltrate with fragmentation of neutrophil nuclei

What are the causes of acute ischemic heart disease (4).

-Complications in atheromatous plaques -Thrombus formation is usually the main cause -75% of cases are the result of fissures in the plaque and bleeding into the body of the plaque with ballooning of the lumen -25% of cases are due to superficial ulceration of endothelium over a plaque

How can venous stasis dermatitis be prevented (2)?

-Compression stockings -Weight loss

What are the causes of aortic valve leaflet abnormalities (3)?

-Congenital (bicuspid valve) -Endocarditis -Rheumatic fever

What are the causes of arteriovenous fistulas

-Congenital areteriovenous malformation - AVM - most common -Rupture of an arterial aneurysm into an adjacent vein -Penetrating injuries that pierce arteries and veins -Inflammatory necrosis of adjacent vessels -Iatrogenic, created to provide vascular access for chronic hemodialysis

List the congenital abnormalities of the vessels (3).

-Congenital weakness of the vessel walls -Arteriovenous fistulas -Fibromuscular dysplasia

Morphologic features of MI, microscopic changes: 18-24 hours

-Continuing coagulation necrosis (nuclear pyknosis, karyorrhexis, karyolysis, cytoplasmic eosinophilia) -Contraction band necrosis (reperfusion injury) at the periphery -Neutrophil infiltrate

What factors influence coronary blood flow (7).

-Coronary perfusion pressure -Coronary vascular resistance -External compression -Intrinsic regulation -Local metabolites -Endothelial factors -Neural innervation

What are the signs and symptoms associated with pneumonia (2)?

-Cough, sputum, etc -Abnormal chest x-ray

What is the immediate damage to the heart generated by MI (3)?

-Decrease in contractility -Electrical instability -Tissue necrosis

Which downstream complications of MI lead to congestive heart failure (3)?

-Decrease in contractility -Mitral regurgitation -Ventricular septal defect

What are the complications of dysfunctional endothelium (2)?

-Decrease in vasodilator effect -Decrease in antithrombotic effect

Collectively, what are all the contributing factors of atherosclerosis that result in coronary thrombosis (5)?

-Decrease in vessel lumen diameter -Activation of the coagulation cascade -Platelet activation and aggregation -Vasoconstriction -Decrease in antithrombotic effect

What cardiac effects do beta blockers produce (3)?

-Decrease phase 4 spontaneous depolarization -Prolong AV conduction -Decrease heart rate and contractility

What cardiac effects do the calcium channel blockers produce (2)?

-Decrease phase 4 spontaneous depolarization -Slow conduction in cells dependent on calcium current (SA and AV nodes)

Pulmonary congestion can result from which two complications of myocardial ischemia?

-Decreased systolic function -Decreased diastolic compliance

List the complications that can occur due to myocardial ischemia (4).

-Decreased systolic function -Decreased diastolic compliance -Papillary muscle dysfunction -Increased sympathetic tone

Describe the characteristics of secondary varicose veins (2).

-Deep veins are affected -Caused by abnormalities such as venous occlusion

Give a brief description of Marfan syndrome and how it contributes to the aneurysm formation.

-Defective synthesis of the scaffolding protein fibrillin leads to aberrant TGF-β activity and progressive weakening of elastic tissue -Progressive dilation of aorta due to remodeling of the poor quality of the elastin in the media

What is the treatment goal and treatment for severe aortic regurgitation with preserved left ventricle function?

-Delaying the need for surgery -Afterload reducing vasodilators (calcium channel blockers, ACE-I's)

How is inflammation involved in the pathogenesis of aneurysms (4)?

-Destructive proteolytic enzymes are produced by inflammatory cells -Macrophages produce MMPs in atherosclerotic plaque or in vasculitis -MMPs degrade components of the ECM in the arterial wall (collagens, elastin, proteoglycans, laminin, fibronectin) -Decreased release of tissue inhibitor of metalloproteinase (TIMP) expression contributes to the overall ECM degradation

Once you determine the most isoelectric lead, what are your next steps (3)?

-Determine the vector of the isoelectric lead -Determine the vector of the perpendicular lead -Determine whether the vector is moving toward or away from the lead's positive pole, indicated by the direction of the arrowhead

Describe the signs associated with increased sympathetic tone (3).

-Diaphoresis -Tachycardia -Elevated blood pressure

What sympathetic effects are part of the signs and symptoms of acute MI (3)?

-Diaphoresis -Tacycardia -Cool and clammy skin with pallor due to vasoconstriction

List the agents that are both arteriolar and venule dilators (4).

-Diazoxide -Fenoldopam -Calcium channel blockers -Sodium nitroprusside

Give an overview of triglyceride digestion and absorption (5).

-Dietary triglycerides are emulsified with lecithin in the intestinal lumen -Pancreatic lipase (zymogen) is activated by cofactor colipase -The lipase-colipse hydrolyzes the emulsified triglycerides to beta-monoglyceride and two free fatty acids -The beta-monoglyceride is amphipathic and enters the shell of a pseudomicelle -When the pseudomicelle comes in close proximity with the intestinal villi, the beta-monoglyceride is absorbed

What are the therapeutic uses of MgCl (3)?

-Digitalis-induced arrhythmias -Torsades de pointes -Acute MI

What are the two different classes of calcium channel blockers?

-Dihydropriridines -Nondihydropriridines

What hemodynamic effects does fenoldopam produce (2)?

-Dilation of peripheral arteries -Renal vasodilation via dopamine receptor activation (protective)

List the class IV calcium channel blockers (3)

-Dilitiazem -Verapamil -Bepridil

How does an abdominal aortic aneurysm affect the renal and superior or inferior mesenteric arteries (2)?

-Direct pressure -Narrowing or occlusion of vascular ostia by mural thrombi

What are the different classes of hypertension drugs (4)?

-Diuretics -Sympathoplegic agents -Angiotensin production or receptor blockers -Direct vasodilators

What therapy is used for symptom control of mitral regurgitation (2)?

-Diuretics for heart failure -Vasodilators for acute mitral regurgitation

What are the toxicities of felodipine (2)?

-Dizziness -Headache

Which drug was developed as a substitute for amiodarone and what modification were made to the structure?

-Dronedarone -Iodines removed and modified to avoid thyroxine metabolic issues

What is the proposed mechanism for vasculitis with anti-neutrophil cytoplasmic antibodies (ANCAs) (5)?

-Drugs or cross-reactive microbial antigens induce ANCAs -Alternatively, PMN surface expression or release of PR3 and MPO in the setting of an infection incites ANCA formation in a susceptible host -Subsequent infection, endotoxin exposure, or other inflammatory stimuli elicit cytokines, e.g. TNF, that cause surface expression of PR3 and MPO on PMNs and other cells -ANCAs react with cytokine-activated cells and either cause direct injury to endothelial cells or induce further activation in neutrophils -ANCA-activated PMNs degranulate and cause further injury by releasing ROS reactive oxygen, which causes endothelial cell damage and leads to tissue injury indirectly

Describe the early phase of chronic aortic regurgitation (3).

-During the early phases of chronic aortic regugitation, the left ventricle ejection fraction is normal or even increased (due to the increased preload and the Frank-Starling mechanism), patients may remain asymptomatic during this period -The left ventricle adapts over time, because the main problem is volume overload, left ventricle dilation predominates, and hypertrophy is a lesser process -As the left ventricle continues to dilate to accommodate the large regurgitant volume, aortic diastolic pressure drops substantially, which then can cause decreased coronary artery perfusion pressure -Therefore, stroke volume increases, producing a high systolic arterial pressure, and aortic diastolic pressure drops, producing an increased or widened pulse pressure

What are the symptoms of pulmonary fibrosis (5)?

-Dyspnea -Dry cough -Fatigue -Unexplained weight loss -Aching muscles and joints

What is the clinical presentation of congestive heart failure due to left ventricle dysfunction?

-Dyspnea -Fatigue -Weakness (Fatigue and weakness are consequences of inadequate cardiac output)

What are the major presenting symptoms of aortic regurgitation (4)?

-Dyspnea upon exertion -Fatigue -Decreased exercise tolerance -Sometimes the patient will be aware of feeling uncomfortably strong, forceful heartbeats

What are the test results seen in a prolonged ischemia (2)?

-ECG: ST elevation (Q waves later) -Serum biomarkers: positive

Morphologic features of MI, microscopic changes: 4-12 hours

-Early coagulation necrosis -Increased eosinophilia of myofibrils -Edema -Occasional neutrophils -Minimal hemorrhage

What are the two types of atheromas?

-Eccentric -Concentric

What are the signs of aortic dissection (5)?

-Elevated BP. -Different systolic blood pressure in arms if a subclavian artery has occluded -Neurologic deficits if dissection extends to carotids -Early diastolic murmur if aortic regurgitation occurs -Signs of cardiac tamponade if leakage into the pericardial sac

What are the direct consequences of backward flow of blood into the left atrium?

-Elevation of left atrium volume and pressure -Reduction of forward cardiac output -Volume related stress on the left ventricle

What are the conservative treatments for varicose veins (3)?

-Elevation of the legs -Avoiding prolonged standing -Compression stockings

What are the signs and symptoms of a thoracic aortic aneurysm (9)?

-Encroachment on mediastinal structures -Respiratory difficulties due to encroachment on the lungs and airways -Difficulty in swallowing due to compression of the esophagus -Persistent cough due to irritation of or pressure on the recurrent laryngeal nerves -Pain caused by erosion of bone (i.e., ribs and vertebral bodies) -Aortic valve dilation with valvular insufficiency -Narrowing of the coronary ostia causing myocardial ischemia -Rupture -Most patients with syphilitic aneurysms die of heart failure due to aortic valve incompetence

Describe the healing stage of vascular response to injury (4).

-Endothelial cells migrating from adjacent uninjured areas and circulating precursors originating in bone marrow fill areas of denudation -Medial smooth muscle cells or smooth muscle precursor cells migrate into the intima, proliferate, and synthesize ECM (analogous to fibroblasts filling in a wound) -Results in the formation of a neointima -Healing results in permanent intimal thickening

Give a brief description of Churg-Strauss syndrome (4).

-Eosinophil-rich granulomatous inflammation involving the respiratory tract -Necrotizing vasculitis affecting small vessels -Associated with asthma and blood eosinophilia -Associated with MPO-ANCAs

What are the clinical findings of superficial thrombophlebitis (3)?

-Erythema -Tenderness -Edema in skin overlying affected vein

List the class II antiarrhythmics, the beta blockers (4).

-Esmolol -Metoprolol -Pindolol -Propanolol

What are the toxicities of diazoxide (3)?

-Excessive hypotension -Reflex sympathomimetic response -Inhibits pancreatic insulin release

What labs should be done when evaluating a patient who may have stable angina (3)?

-Fasting lipid panel -Serum glucose/HgbA1c -Renal function

What are the toxicities of beta blockers (5)?

-Fatigue -Inability to perform exercise -Impotence -Erectile dysfunction -Depression

What are the most common arteries involved in the pathogenesis of peripheral artery disease and what is the pain associated with each artery (3)?

-Femoral and popliteal: 80-90% of patients, pain in the calf -Tibial and popliteal: 40-50% of patients, pain in the calf -Abdominal aorta and iliac: 30% of patients, pain in the buttock, hip, thigh or calf

What are the kinetics of sodium nitroprusside (4)?

-Ferrous iron core that is complexed with CN- and NO -Metabolism releases CN- -CN- is further metabolized by rhodanase/sulfur donor (co-administration of sodium thiosulfates helps prevent CN- poisoning) to thiocyanate -IV

What are the constitutional signs of vasculitis (4)?

-Fever -Malaise -Myalgias -Arthralgias

Describe an eccentric atheroma (3).

-Fibrolipid plaque on one side on one side of the vessel with corresponding medial fibrosis -Normal intima and media on the opposite side of he plaque -Vasodilators are effective for treatment

Morphologic features of MI, macroscopic changes: 7-8 weeks

-Firm -Gray

List the Class 1C sodium channel blockers (2).

-Flecainide -Propafenone

Recap: List the most common amphipathic lipids (3).

-Free fatty acids -Phospholipids -Cholesterol

Summary of Apo proteins: AII

-Function unknown -Makes HDLs less capable of picking up excess cholesterol in periphery -May inhibit interaction of HDLwith ABC-1, LCAT and hepatic lipase

What are the two different kinds of true aneurysms?

-Fusiform -Saccular

What are the signs and symptoms associated with acute cholecystitis (2)?

-Gallbladder spasm affecting the right upper quadrant and may refer to right scapula -Characteristic abdominal ultrasound

What clinical presentation is associated with a diagnosis of cholecystitis (2)?

-Gallbladder spasm affecting the right upper quadrant and may refer to the right scapula -Characteristic abdominal ultrasound

What are the kinetics of amyl nitrite (3)?

-Gas, inhaled -Very fast acting -Short action of duration, 3 to 4 minutes

What are the toxicities of bile binding resins (4)?

-Gastrointestinal: constipation, bloating, heartburn, diarrhea, steatorrhea -Liver: aminotransferase elevation, -Metabolic system: increase serum triglycerides by 10% -Electrolytes: hyperchloremic acidosis in children and patients with renal failure

Which conditions are associated with large vessel vasculitis (2)?

-Giant cell (temporal)arteritis -Takayasu arteritis

What are the kinetics of hydralazine (4)?

-Good oral absorption -Rapid first pass metabolism (acetylation) -Short half life (hours) but prolonged effects -Tachyphlaxis

Give a brief description of giant cell (temporal) arteritis (4).

-Granulomatous inflammation -Frequently involves the temporal artery -Usually occurs in patients older than age 50 -Associated with polymyalgia rheumatica.

Give a brief description of Takayasu arteritis (2).

-Granulomatous inflammation -Usually occurs in patients younger than age 50

Give a brief description of Wegener granulomatosis (3).

-Granulomatous inflammation involving the respiratory tract -Necrotizing vasculitis affecting small vessels, including glomerular and pulmonary vessels -Associated with PR3-ANCAs

List the sympathoplegic adrenergic nerve blockers (3).

-Guanethidine -Guanadrel -Reserpine

What are the toxicities of nimodipine (2)?

-Headache -Diarrhea

What are the toxicities of isradipine (2)?

-Headache -Fatigue

What are the toxicities of hydralazine (7)?

-Headache -Nausea -Anorexia -Palpitations -Sweating and flushing -Reflex tachycardia -Slow acetylators: arthralgia, myalgia, skin rashes and fever resembling Lupus erythematosus.

What are the toxicities of amlodipine (2)?

-Headache -Peripheral edema

What are the contraindications of calcium channel blockers

-Heart failure -Bradycardia -AV node block -Long QT interval (bepridil)

Summary of Apo proteins: E

-Help IDL interact with LDL-receptors in liver (clears IDL). -Help chylo remnants interact with LRP (LDL-receptor related protein receptors).

Describe the process of vasculogenesis (3).

-Hemangioblast angiogenic precursors migrate to the sites of vascularization and differentiate into endothelial cells -Primary growth factors involved: isoforms of vascular endothelial growth factor (VEGF) -Stabilization of newly formed tubes requires recruitment of pericytes and smooth muscle cells; angiopoietin 1 binding to endothelial cell Tie2 receptors is required

List the non-ANCA associated small vessel vasculitides (3).

-Henoch-Schonlein purpura -Cryoglobulinemia -Other, e.g. vasculitis associated with inflammatory bowel disease

What are the toxicities of labetalol (4)?

-Hepatic necrosis -Bronchospasm -Priapism -Similar to other blockers

What are the kinetics of captopril (5)?

-High and rapid oral bioavailability -Conjugated in the liver -50% excreted in the kidneys -Administered 2-3 times daily with meals -Start at lose dose and adjust for desired blood pressure

What clinical presentation is associated with a diagnosis of exacerbation of asthma or COPD (5)?

-History -Dyspnea -Wheezing -Pulse oximetry -ABGs

What are the signs and symptoms associated with exacerbation of asthma or COPD (5)?

-History -Dyspnea -Wheezing -Pulse oximetry -Abnormal arterial blood gases

In which patients is fibrinolytic therapy contraindicated (5)?

-History of CV hemorrhage -Recent stroke -Blood pressure greater than 180/110 -Active internal bleeding -Dissecting aortic aneurysm

What are the anatomic variants of arteriolosclerosis (2)?

-Hyaline -Hyperplastic

Compare the causes of hyaline arteriolosclerosis versus hyperplastic arteriolosclerosis.

-Hyaline arteriolosclerosis results from plasma protein leakage into the vascular wall -Hyperplastic arteriolosclerosis results proliferation of intimal smooth muscle and reduplication of basement membranes

List the arteriolar dilators (2).

-Hydralazine -Minoxidil

What are the clinical uses of ezetimibe (2)?

-Hypercholesterolemia -Hyperlipoproteinemia

What are the clinical uses of the bile binding resins (2)?

-Hypercholesterolemia -Hyperlipoproteinemia

Clinical uses of statins (4).

-Hypercholesterolemia -Hyperlipoproteinemia -Ischemic stroke prophylaxis -Reduction of LDL levels needed

Major risk factors for atherosclerosis and ischemic heart disease: Potentially controllable risks (5).

-Hyperlipidemia -Hypertension -Diabetes mellitus -Cigarette smoking -Inflammation (C reactive protein)

Which pathologic processes fall under the category of malignant hypertension (2).

-Hyperplastic arteriolosclerosis -Fibrinoid necrosis in the renal arteriolar wall

What are the clinical uses of felodipine (3)?

-Hypertension -Raynaud's phenomenon -Congestive heart failure

What are the therapeutic uses of angiotensin II receptor blockers?

-Hypertension with elevated renin levels -CHF -Diabetic nephropathy

What are the therapeutic uses of ACE inhibitors (4)?

-Hypertension with elevated renin levels -CHF -Diabetic nephropathy -Enalapril IV for malignant hypertension

What are the clinical uses of fibrates (3)?

-Hypertriglyceridemia -Combined lipoproteinemia -Adjunctive therapy for hypercholsterolemia

What are the clinical uses of niacin (3)?

-Hypertriglyceridemia -Combined lipoproteinemia -Adjunctive therapy for hypercholsterolemia

What are the toxicities of diuretics (5)?

-Hypokalemia -Impaired glucose tolerance -Increase in serum lipids -Increase in uric acid levels -Hypercalcemia

What are the toxicities of dilitiazem (4)?

-Hypotension -Dizziness -Flushing -Bradycardia

What are the toxicities of nifedipine (5)?

-Hypotension -Dizziness -Nausea -Constipation -Dependent edema

What are the toxicities of nisoldipine (5)?

-Hypotension -Dizziness -Nausea -Constipation -Dependent edema

What are the toxicities of verapamil (4)?

-Hypotension -Myocardial depression -Constipation -Dependent edema

Once its triglyceride is transferred to HDL, it is no longer a good substrate for lipoprotein lipase. What are the two possible fates of IDL?

-IDL is taken up by the liver through the binding of proteins E and B100 to LDL receptors in the liver; and undergoes hepatic endocytosis to form another VLDL -IDL loses its Cs and Es proteins and is converted to LDL vis the decrease of its triglyceride content by hepatic lipase

List the ECG leads associated with the inferior region of the heart (3).

-II -III -aVF

What are the kinetics of nifedipine (5)?

-IV -Low oral bioavailability -High first pass effect -High plasma protein binding -Fast onset of action

What are the kinetics of adenosine (2)?

-IV bolus -Half-life of 10 seconds

Which drugs are used to treat mitral regurgitation (2)?

-IV diuretics -Vasodilators (IV sodium nitroprusside)

Which medications are part of anti-ischemic therapy (3)?

-IV nitrates -Beta blockers -Calcium channel blockers

What are the kinetics of bretylium (2)?

-IV only -Excreted unchanged in urine

What are the kinetics of lidocaine (2)?

-IV only -Prominant first pass metabolism

What are the causes of acute mitral regurgitation (2)?

-Idiopathic rupture of the chordae tendineae -Papillary muscle dysfunction secondary to MI

How can you distinguish the different non-ANCA associated disorders associated with small vessel vasculitis (4)?

-If there are IgA immune deposits present , then it is Henoch-Schonlein purpura -If there are no IgA immune deposits present, asses if serum cryoglobulin is present -If serum crypglobulin is not present, it is some other non-ANCA vasculitis -If serum crypglobulin is present, it is cryoglobulinemia

What is the etiology of atherosclerosis and ischemic heart disease (3)?

-Imbalance between myocardial oxygen demand and blood supply -Manifestation of coronary atherosclerosis -Probably begins in childhood or early in adulthood

How are vasculitides classified by etiology (4)?

-Immune complex mediated vasculitis -Infectious vasculitis -Noninfectious vasculitis -Physical and chemical injury

The pathophysiology of peripheral artery disease is also similar to that of coronary artery disease. Explain how (4).

-In general, ischemia is induced by exercise and improved or relieved by rest -Pain at rest signifies severe disease -Over time, leg muscle fibers degenerate and atrophy -As the disease progresses, blood flow is so impaired that even resting metabolic requirements are not met, so ischemia is prolonged, and tissue necrosis and gangrene may occur.

What are the kinetics of amiodarone (2)?

-Incomplete oral -Long half-life

What are the specific treatments indicated for peripheral artery disease (3)?

-Increase in exercise -Cilostazol -Pentoxifylline

Describe the cycle of cardiogenic shock.

-Increase in ischemia -Decrease in contractility -Hypotension -Decrease in coronary perfusion pressure -Increase in ischemia etc

What are the long term adaptive changes that evolve with use of diuretics (4)?

-Increase in plasma renin activity (ACEI or ARB combo is useful) -Cardiac output and plasma volume return to near pretreatment levels -Decrease vessel stiffness -Residual decrease in blood pressure may last up to a year

Summarize chronic mitral regurgitation

-Increased left atrium size and compliance -More normal left atrium and pulmonary venous pressures -Low forward cardiac output

How do ischemia and infarction affect the compartment which contains myocardial tissue proteins (2)?

-Increased permeability of the cell membrane -Leakage of contents depending on size and solubility

How does aortic stenosis cause angina (2)?

-Increases myocardial oxygen demand: hypertrophied muscle and increased wall stress -Decreases myocardial oxygen supply: elevated left ventricle diastolic pressure reduces the coronary perfusion pressure gradient

Major risk factors for atherosclerosis and ischemic heart disease: Non-modifiable constitutional risks (4).

-Increasing age -Male gender -Family history -Genetic abnnormalities

What are the infrequent pathologies associated with the development of an aneurysm (3)?

-Infection -Takayasu arteritis -Giant cell arteritis

What are the four major regions of infarction?

-Inferior MI -Lateral wall MI -Anterior MI -Posterior MI

What are the four major regions of myocardial infarction?

-Inferior MI -Lateral wall MI -Anterior MI -Posterior MI

What differential diagnosis can you derive from a left axis deviation (3)?

-Inferior wall MI -Left anterior fascicular block -Left ventricular hypertrophy (sometimes)

List the factors that cause aneurysms due to altered balance of collagen degradation and synthesis (2).

-Inflammation -Genetic predisposition

MOA of statins (3).

-Inhibits Hmg CoA reductase -Reduces synthesis of liver cholesterol -Upregulation of LDL receptors in the liver

What cardiac effects are produced by adenosine (2)?

-Inhibits calcium flux -Increases potassium conductance

What are the toxicities of ACE inhibitors (5)?

-Initial dose-induced severe hypotension when hypovolemic (diuretic, salt restricted diets and GI fluid loss) -Renal failure, dry cough and angiodema (bradykinin and substance P) -Hyperkalemia when renal insufficiency or diabetes is present -Contraindicated with pregnancy (fetal hypotension, malformations and death) -Drug interactions: hyperkalemia especially with potassium sparing diuretics, NSAIDS may impair hypotensive effects (blocks bradykinin and prostaglandin mediated vasodilation)

What are the cosmetic treatments for varicose veins (3)?

-Injecting sclerotic agents into small veins -Laser therapy -Larger veins can be treated with radiofrequency ablation and vein ligation or removal

What are the second line pharmacological agents that are given to patients who can't exercise as a stress test? How do they work?

-Inotrope dobutamine -Increases heart rate and contractility

What are the three layers of the arterial wall?

-Intima -Media -Adventitia

What are the stages of vascular response to injury (3)?

-Intimal thickening -Endothelial cell loss or dysfunction -Healing

What are the consequences of a plaque rupture (4)?

-Intraplaque hemorrhage -Release of tissue factor -Exposure of subendothelial collagen -Turbulent blood flow

What physical and chemical injuries can cause vasculitis (3)?

-Irradiation -Mechanical trauma -Toxins

Describe how acute ischemic heart disease can insidious (2).

-It can occur in a low grade stenosis without any previous symptoms -The initial manifestation of coronary artery disease may be sudden cardiac death with no history of angina with exertion

What is ciilstazol and what are the advantages of using it to treat peripheral artery disease?

-It is a selective phosphodiesterase inhibitor; it has vasodilator and platelet-inhibiting properties -It has been shown to improve exercise capacity in patients with peripheral artery disease

What is the prevalence/incidence of atherosclerosis (3)?

-It is the single most common cause of death in the developed world -Accounts for one third of all deaths in the US and Europe -Average annual rate: 7 per 1000 in men at ages 35-44; 68 per 1000 in men at ages 85-94; women have comparable rates occurring 10 years later

What are the causes of tricuspid regurgitation (3)?

-It is usually secondary to right ventricle enlargement -Rheumatic fever is often implicated -A very rare cause is carcinoid syndrome

Can angina be treated with medication and what are the consequences of prolonged angina?

-It may be modifiable by drugs -Long periods of impaired flow may result in the development of diffuse myocardial fibrosis

What are the side effects of morphine administration to an MI patient and how can they be treated (2)?

-It may reduce sympathetically mediated arteriolar and venous constriction, and the resulting venous pooling may reduce cardiac output and arterial pressure; these hemodynamic disturbances usually respond promptly to elevation of the legs, but in some patients volume expansion with intravenous saline is required; the patient may experience diaphoresis and nausea, but these events usually pass and are replaced by a feeling of well-being associated with the relief of pain -It also has a vagotonic effect and may cause bradycardia or advanced degrees of heart block, particularly in patients with inferior infarction; these side effects usually respond to atropine.

Morphologic features of MI, microscopic changes: 1-2 hours

-LM: Few wavy myofibers at the margin of the infarct -EM: Irreversible changes with sarcolemmal disruption and electron dense mitochondrial depositions

Morphologic features of MI, microscopic changes: 0-30 min

-LM: No change -EM: Reversible changes with mitochondrial swelling and relaxation of myofibrils

List the mixed alpha and beta blockers (2).

-Labetalol -Carvedilol

What are the consequences associated with arteriovenous fistulas?

-Large fistulas become clinically significant by shunting blood from the arterial to the venous circulations and may result in high-output cardiac failure -An important cause of intracerebral hemorrhage

What are the side effects of the class 1B sodium channel blockers (2)?

-Least toxic for cardiac arrhythmias -CNS: drowsiness, slurred speech, paresthesia, agitation, confusion and convulsions

What are the three proteins that HDL binds from the plasma?

-Lecithin-Cholesterol Acyl Transferase -Cholesterol ExchangeTransfer Protein -Phospholipid Transfer Protein

Which three proteins are necessary to HDL3 to HDL2?

-Lecithin-cholesterol acyl transferase -Phospholipid Transfer Protein -Cholesterol Exchange/Transfer Protein

What mitral regurgitation findings will be present on an ECG (2)?

-Left atrium enlargement -Left ventricle hypertrophy

What are the toxicities of reserpine (3)?

-Less postural hypotension -CNS: sedation, mental lassitude, nightmares, severe mental depression, extrapyramical effects (Parkinson's like) -GI: diarrhea, GI cramps; do not give to patient with a history of peptic ulcer

List the Class 1B sodium channel blockers (3).

-Lidocaine -Mexiletine -Tocainide

What are the kinetics of clonidine, guanabenz and guanfacine (4)?

-Lipid soluble and rapidly enters the brain -Good oral bioavailability -Short half-life -Multiple daily dosing or transdermal patch for weekly dosing

What are the toxicities of statins (5)?

-Liver: elevated aminotransferase -Muscle: elevated creatinine kinase, myopathy, rhabdomylosis -Neuropathy -Hypersensitivity -Drug interactions with CYP inhibitors and inducers

What are the treatments available for superficial thrombophlebitis (4)?

-Local heat -Continued ambulation -Compression -Acetasalicylic acid or NSAIDs

What are the signs of an atheroembolism (5)?

-Localized cyanosis -Necrosis -Livedo reticularis -Kidney failure -Intestinal ischemia

What are the therapeutic uses of sotolol (2)?

-Long term therapy to decrease rate of sudden death via MI -For sustained ventricular tachycardia

What are the kinetics of diazoxide (3)?

-Long-acting parenteral drug -Metabolized in the liver -Excreted by the kidneys

What are the clinical uses of oral/transdermal nitroglycerin, isosorbide dinitrate and isosorbide mononitrate (2)?

-Longer term maintenance of stable angina -Can also be used for vasospastic and unstable angina

List the angiotensin II receptor blockers (7).

-Losartan -Valsartan -Candesartan -Eprosartan -Irbesartan -Omlisartan -Telmisartan

What are common signs of peripheral artery disease (4)?

-Loss of pulses distal to the stenosis and slow capillary refill -Increased turbulence at the stenosis causes bruits -Distal limbs may have muscle atrophy, pallor, cynosis, alopecia, cool and shiny skin, ulcers, necrosis -Positive Buerger's sign

List the statins (6).

-Lovastatin -Pravastatin -Simvastatin -Atorvastatin -Fluvastatin -Rosuvastatin

What are the kinetics of methyl dopa (5)?

-Low oral bioavailabiltiy (high first pass metabolism via conjugation reactions in gut) -Enters brain via active transport -4-6 hours before metabolites build up enough to produce effects -2/3 is excreted unchanged by the kidney -1-2g daily (divided dose).

What is plaque composed of (4)?

-Macrophages -Muscle cells -Lipids -Collagen

Morphologic features of MI, microscopic changes: 4-7 days

-Macrophages appear -Early disintegration and phagocytosis of necrotic myofibers -Loss of integrity of cardiac wall (danger of rupture) -Granulation tissue visible

Summary of Apo proteins: B48

-Made in intestinal epithelium -Found in chylos -Chylos cannot be secreted from intestine without B48 -Required for assembly of chylomicron

Summary of Apo proteins: B100

-Made in liver -Found in VLDL, IDL, and LDL -Very large, M.W. = 250,000 -Interacts with specific LDL receptors in liver and peripheral tissues -95% of LDL protein is in B100; required for assembly of VLDL.

What are the common differences among lipoproteins (3)?

-Major contents of the hydrophobic (combinations of triglycerides and cholesteryl esters) -Types of associated apoproteins -Type of lipid carried: exogenous (dietary) or endogenous (made in the liver)

What is vasculitis with anti-neutrophil cytoplasmic antibodies (ANCAs)?

-Many patients with vasculitis have circulating heterogeneous autoantibodies ANCAs directed against constituents (mainly enzymes) of neutrophil primary granules, monocyte lysosomes, and endothelial cells -Previously classified according to their intracellular distribution, either cytoplasmic (c-ANCA) or perinuclear (p-ANCA) -Current classification is based on their target antigens

What connective tissue disorders increase the risk of mitral regurgitation (2)?

-Marfan syndrome -Ehler Danlos syndrome

List the disorders that cause aneurysms due to poor intrinsic quality of the vascular wall connective tissue (4).

-Marfan syndrome -Loeys-Dietz syndrome -Ehlers Danlos syndrome -Vitamin C deficiency

Morphologic features of MI, microscopic changes: 10 days

-Maximal phagocytosis -Prominent granulation tissue in peripheral areas

Morphologic features of MI, macroscopic changes: 10 days

-Maximally yellow -Soft, shrunken -Granulation tissue visible as a purple border at the periphery of the infarct

What are two common stressors on the normal aorta?

-Mechanical trauma induced by continuous high pulsatile pressure and shear stress -With aging comes stiffening of the vasculature tissues and increased arterial pressure

Who should be screened for aneurysms (2)?

-Men ages 65 to 75 years old who have ever smoked -Patients with a strong family history of abdominal aortic aneurysm.

List the sympathoplegic CNS acting agents (4).

-Methyldopa -Clonidine -Guanabenz -Guanfacine

List the beta1 specific blockers (5).

-Metoprolol -Esmolol -Atenolol -Betaxolol -Bisprolol

What are two common amphipathic associations?

-Micelles -Bilayers

What are the therapeutic uses of non-specific beta blockers (3)?

-Mild to moderate hypertension -In combination with vasodilators to prevent reflex tachycardia for severe hypertension -Improves mortality rates in post MI patients

What is the prognosis of aortic stenosis (2)?

-Mild, asymptomatic AS: very slow progression, with ~20% of patients progressing to severe or very severe in 20 years -Natural history of severe, symptomatic uncorrected AS: one-year survival is ~ 57%

What are the adverse effects of calcium channel blockers (8)?

-Misdiagnosis of ventricular tachycardia for supraventricular tachycardia -Hypotension -Ventricular fibrillation -AV block -Constipation -Lassitude -Nervousness -Peripheral edema

List the mitral valve diseases (3).

-Mitral stenosis -Mitral regurgitation -Mitral valve prolapse

Which valvular diseases cause diastolic murmurs (4)?

-Mitral stenosis -Tricuspid stenosis -Aortic regurgitation -Pulmonic regurgitation

What are the morphologic features of chronic ischemic heart disease (6)?

-Moderate to severe atherosclerosis -Cardiomegaly with dilation of all chambers -Myocardial fibrosis with varying atrophy and hypertrophy of remaining muscle fibers -Myocytolysis in the subendocardial region -Endocardial fibrosis -Endocardial mural thrombi can be common

Which patients are more likely to develop an abdominal aortic aneurysm (3)?

-More frequent in men and in smokers -Rarely develops before age 50 -Other factors must contribute since the incidence is is less than 5% in men older than 60 years of age despite almost universal abdominal aortic atherosclerosis in that population

What are the side effects of procainamide (6)?

-More pronounced SA and AV block -Lupus erythematosus-like syndrome -Arrhythmias -CNS effects -Ganglion blockade (hypotension) -Agranulocytosis (0.2%)

What is the etiology of thoracic aortic aneurysms (4)?

-Most commonly associated with hypertension -Marfan syndrome -Loeys-Dietz syndromes -Syphilis (historically)

Morphologic features of MI, microscopic changes: 4 weeks

-Most necrotic tissue has been cleared away -Maturing granulation tissue with fewer capillaries and more collagen

Physical exam findings of patients with valvular disease: Aortic regurgitation.

-Murmur: Blowing diastolic -S1: Soft -S2: Normal -Other findings: Wide pulse pressure; systolic hypertension, hyperdynamic circulation -Maneuvers: Murmur increased with handgrip or squatting

Physical exam findings of patients with valvular disease: Mitral stenosis.

-Murmur: Diastolic rumble -S1: Loud -S2: Normal -Other findings: Opening snap may be present -Maneuvers: Murmur increased with brief exercise

Physical exam findings of patients with valvular disease: Mitral regurgitation.

-Murmur: Holosystolic -S1: Soft -S2: Normal or split -Other findings: S3 may be present, carotid upstrokes brisk -Maneuvers: Murmur louder with Valsalva maneuver

Physical exam findings of patients with valvular disease: Mitral valve prolapse.

-Murmur: Mid to late systolic -S1: Normal -S2: Normal -Other findings: Mid-systolic click -Maneuvers: Murmur increased with standing

Physical exam findings of patients with valvular disease: Aortic stenosis.

-Murmur: Mid to late systolic; may be soft or absent if severe -S1: Normal -S2: Single or paradoxically split -Other findings: Carotid upstrokes diminished and delayed; S3 or S4 may be present -Maneuvers: Murmur softer with Valsalva maneuver

Give a brief description of Loeys-Dietz syndrome and how it contributes to aneurysm formation.

-Mutations in TGF-β receptors lead to abnormalities in elastin and collagen I and III -Even small aneurysms can rupture easily

Which infections are associated with the development of aortic aneurysms (4)?

-Mycotic aneurysms due to a septic embolus -Extension of an adjacent suppurative process -Circulating organisms can directly infect the arterial wall -Tertiary syphilis

Give a chest pain differential diagnosis (12).

-Myocardial infarction -Pericarditis -Aortic dissection -Pulmonary embolism -Pneumonia -Pneumothorax -Esophageal spasm -Acute cholecystitis -Acute pancreatitis -Exacerbation of COPD or asthma -Costochondritis -Panic attack

What are the causes of chronic mitral regurgitation (5)?

-Myxomatous degeneration of the mitral valve -Rheumatic fever -Infective endocarditis -Calcification of the mitral annulus associated with hypertension, diabetes mellitus and renal disease -Hypertrophic cardiomyopathy

What are the three different types of calcium channels?

-N -T -L

Give the two mechanisms through which vascular pathology results in disease.

-Narrowing (stenosis) or complete obstruction of vessel lumens, either progressively (e.g., by atherosclerosis) or precipitously (e.g., by thrombosis or embolism) -Weakening of vessel walls, leading to dilation or rupture

What parasympathetic (vagal) effects are part of the signs and symptoms of acute MI (3)?

-Nausea -Vomting -Weakness

Give a brief description of microscopic polyanginitis (4)

-Necrotizing small-vessel vasculitis with few or no immune deposits -Necrotizing arteritis of small and medium-sized arteries can occur -Necrotizing glomerulonephritis and pulmonary capillaritis are common -Associated with MPO-ANCAs

List the dihydropiridine calcium channel blockers (7).

-Nifedipine -Amlodipine -Felodipine -Isradipine -Nicardipine -Nimodipine -Nisoldipine

Which drug combination is indicated in unstable angina (4)?

-Nitrates -Beta blockers -Anti-platelet therapy -Anti-thrombin therapy (especially in ICU)

Which drug combination is indicated in vasospastic angina (2)?

-Nitrates -Calcium channel blockers

Which of the classes of angina agents are used to increase coronary flow (2)?

-Nitrates and nitrites -Calcium channel blockers

What are the different classes of drugs used to treat angina (3)?

-Nitrates and nitrites -Calcium channel blockers -Beta blockers

Which of the classes of angina agents are used to decrease heart work (3)?

-Nitrates and nitrites -Calcium channel blockers -Beta blockers

What cardiac effects do the class 1C sodium channel blockers produce (3)?

-No effect on the action potential duration -Slows phase 0 depolarization -Decreases conduction velocity

What are the consequences of developing venous stasis dermatitis (4)?

-Non-pitting (brawny) edema -Long-term fibrotic changes -Changes in the color and texture of the skin -Red, pruritic patches of stasis dermatitis precede ulceration

List the types of beta blockers used to treat hypertension (3).

-Non-specific beta blockers -Beta1 specific blockers -Partial agonists

Summarize acute mitral regurgitation (4).

-Normal left atrium size and compliance -High left atrium pressure -High pulmonary venous pressure -Pulmonary congestion and edema

Describe the pathological process of an aortic aneurysm due to a tertiary syphilis (4).

-Now a rare cause of aortic aneurysms -The obliterative endarteritis characteristic of late-stage syphilis has a predilection for small vessels, including vasa vasorum of the thoracic aorta -Ischemic injury of the aortic media leads to weakening and aneurysmal dilation, which sometimes involves the aortic valve annulus

List the types of patients who experience arterial dissection (4).

-Occurs most of often in hypertensive men, aged 40 to 60 years (>90% of cases) -Younger patients have systemic or localized abnormalities of connective tissue affecting the aorta (e.g., Marfan syndrome) -Iatrogenic (e.g., complicating arterial cannulations during diagnostic catheterization or cardiopulmonary bypass) -During or after pregnancy

What are the causes and complications of arterial dissection?

-Often aneurysmal but not always -May rupture

What are the kinetics of quinidine (3)?

-Oral -Liver metabolized -Some urinary excretion

What are the kinetics of the class 1C sodium channel blockers (2)?

-Oral -Long half-life

What are the kinetics of sotolol (2)?

-Oral -Unchanged via kidneys

What are the kinetics of amlodipine (2)?

-Oral -Very long half-life

What are the kinetics of disopyramide (2)?

-Oral -50% excreted unchanged in the kidney

What are the kinetics of procainamide (4)?

-Oral -Active metabolite -Excreted in kidneys (caution with renal failure) -Short half-life

What are the kinetics of angiotensin II receptor blockers (3)?

-Oral active agent -Active metabolites -Once daily dosing

What are the kinetics of isosorbide dinitrate (2)?

-Oral and sublingual -Long acting

What are the kinetics of the calcium channel blockers (2)?

-Oral bioavailability is 20% -Metabolized in the liver

What are the kinetics of reserpine (3)?

-Oral daily dosing -Kinetics unclear -Readily enters the CNS

What are the kinetics of minoxidil (4)?

-Oral preparations only -Well absorbed in GI tract -Metabolized via conjugation in liver -Short half life with long lasting hypotensive effects (active metabolite = minoxidil sulfate)

What are the toxicities of alpha receptor blockers (6)?

-Orthostatic hypotension -First dose syncope -Palpitations -Blurred vision -Priapism -GI upset

What are the toxicities of the nitrates and nitires?

-Orthostatic hypotension -Tachycardia -Throbbing head ache -Tolerance and dependence

What makes up myocardial oxygen supply (2)?

-Oxygen content -Coronary blood flow

What are the signs and symptoms associated with pericaditis (2)?

-Pain changes with position -Friction rub

What clinical presentation is associated with a diagnosis of pericarditis (2)?

-Pain changes with position -Friction rub

What are the signs and symptoms associated with acute pancreatitis (2)?

-Pancreatic enzymes may migrate to thorax -A significant hemoperitoneum may put pressure on the diaphragm

What complications of MI involve the papillary muscle (2)?

-Papillary dysfunction (common) -Rupture (1%)

What are the complications of cardiac tissue necrosis (4)?

-Papillary muscle infarction/ischemia -Ventricular septal defect -Ventricular rupture -Pericardial inflammation (pericarditis)

What health risks is the oxidation of Apo1 protein associated with?

-Patients at high cardiac risk have high levels of myleoperoxidase in circulation -The enzyme is apparently released by inflamed coronary arteries -Further, individuals with high levels of myeloperoxidase-modified apo-A1 had a 16 fold higher risk of heart disease.

Give a differential diagnosis for chest pain (10).

-Percarditis -Aortic dissection -Pulmonary embolism -Pneumonia -Pneumothorax -Esophageal spasm -Acute cholecystitis -Exacerbation of asthma or COPD -Costochondritis -Panic attack

What are the consequences associated with a rupture due to an aortic dissection (3)?

-Pericardial tamponade -Hemomediastinum -Hemothorax (usually left-sided)

Which two complications of cardiac tissue necrosis can lead to cardiac tamponade?

-Pericarditis -Ventricular rupture

What is Dressler syndrome and how is it treated?

-Pericarditis that occurs weeks after MI -Usually responds well to NSAIDs

What are the important pathologies associated with occlusive arterial disease (3)?

-Peripheral arterial disease (PAD) due to atherosclerosis -Acute arterial occlusion (thrombo- or atheroembolism) -Vasculitic syndromes

What are the toxicities of nicardipine (3)?

-Peripheral edema -Dizziness -Fatigue

List the alpha blocker (4).

-Phentolamine -Prazosin -Terazosin -Doxazosin

List the partial beta agonists (3).

-Pindolol -Acebutolol -Penbutolol

How does atherosclerosis contribute to thrombus formation (2)?

-Plaque rupture, which exposes the circulating blood elements to thrombogenic substances -Endothelial dysfunction with the loss of normal protective antithrombotic and vasodilatory properties

Which conditions are associated with medium vessel vasculitis (2)?

-Polyarteritis nodosa -Kawasaki

What are some examples of false aneurysms (2)?

-Post-MI ventricular rupture that is contained by a pericardial adhesions -Leak at the sutured junction of a vascular graft with a natural artery

What are the toxicities of guanethidine and guanadrel (6)?

-Postural hypotension -Hypotension following exercise -Prevents perfusion to organs -Retrograde ejaculation -Diarrhea -Drug interactions: TCA and cocaine block uptake, reduce effects and can precipitate withdrawal when removed suddenly; cold medications when used with guanethidine can cause hypertension

What are the side effects of bretylium (2)?

-Postural hypotension -Torsades de Pointes

Which statins increase HDL by the most (2)?

-Pravastatin: 12% -Simvastatin: 12%

What are the two major causes of a plaque rupture?

-Presence of inflammatory chemical factors, which destabilize the plaque -Unusual physical stresses, such as increased blood turbulence and pressure

What are the clinical consequences of having an abdominal aortic aneurysm (5)?

-Presents as a pulsatile abdominal mass that simulates a tumor -Rupture into the peritoneal cavity or retroperitoneal tissues with massive, potentially fatal hemorrhage -Obstruction of a branch vessel resulting in ischemic injury of downstream tissues, e.g. iliac (leg), renal (kidney), mesenteric (gastrointestinal tract), or vertebral (spinal cord) arteries -Emboli from atheroma or mural thrombus -Impingement on an adjacent structure, e.g., compression of a ureter or erosion of vertebrae

What are the inherited causes of mitral valve prolapse?

-Primary autosomal dominant disorder -Inherited connective tissue disorders (Marfan and Ehler Danlos) -Inherited myxomatous degeneration of the mitral valve

What is the treatment strategy for tricuspid regurgitation (3)?

-Primary treatment is to focus on the conditions responsible for right ventricle hypertrophy -Diuretic therapy -Surgery is indicated for severe cases.

Which vessels does giant cell arteritis most commonly affect?

-Principally affects the arteries in the head, especially the temporal arteries -Less commonly affected: the vertebral and ophthalmic arteries and aorta

What cardiac effects do potassium channel blockers produce (2)?

-Prolongs action potential duration -Increased refractory period (increased QT interval)

What are the physical exam findings when examining a patient with tricuspid regurgitation?

-Prominant v waves -Pulsatile liver

What are the signs and symptoms associated with pulmonary embolism (2)?

-Pronounced dyspnea -Venous thrombosis risk factors

What clinical presentation is associated with a diagnosis of pulmonary embolism (2)?

-Pronounced dyspnea -Venous thrombosis risk factors

List the non-specific beta blockers (3).

-Propanolol -Cartelol -Nadolol

List the beta blockers used to treat angina (4).

-Propanolol (nonspecific) -Metoprolol (beta1) -Nadolol (nonspecific) -Atenolol (beta1)

What are the side effects of amiodarone (7)?

-Pulmonary fibrosis -Liver toxicity -Hypothyroidism -Photosensitivity -Neuropathy -Blue skin -Corneal discoloration

What other signs and symptoms can present with an acute MI (3)?

-Pulmonary rales if congestive heart failure is present -JVP if a right ventricular MI has occurred -Pansystolic murmur if mitral regurgitation occurs

List the pulmonic valve diseases (2).

-Pulmonic stenosis -Pulmonic regurgitation

What ECG changes are indicative of MI (5)?

-Q waves -ST segment abnormalities -T wave inversion -Arrhythmias -Conduction disturbances

List the Class 1A sodium channel blockers (3).

-Quinidine -Procainamide -Disopyrimide

The physical examination of a patient with mitral regurgitation may also reveal signs of left or right congestive heart failure, what are they (5)?

-Rales -Crackles -Lower extremity edema -Hepatomegaly -Increased JVP

Which drugs are most commonly used in fibrinolytic therapy (3)?

-Recombinant tissue-type plasminogen activator (tPA) -Reteplase (rPA) -Tenecteplase (TNK-tPA)

What are the two surgical options for treating chronic mitral regurgitation and what are their mortality rates (2)?

-Reconstruction of the native valve, 2-4% operative mortality (preferred) -Mitral valve replacement, 5-7% mortality

What are the potential complications that can result from MI (7)?

-Recurrent ischemia -Arrhythmias -Congestive heart failure -Cardiogenic stock -Papillary muscle dysfunction -Ventricular free wall rupture -Acute pericarditis and Dressler syndrome

What is advantageous about treatment with beta blockers and what is the goal when using them?

-Reduce sympathetic drive and reduce the risk of progression from angina to MI -Administer to achieve a heart rate of less than 70 bpm

What are the clinicopathologic consequences of atherosclerosis and ischemic heart disease (4)?

-Reduction of blood flow through arteries -Predisposition to thrombosis -Bleeding into plaque -Weakening of vessel wall and aneurysm formation

What are the toxicities of fenoldopam (4)?

-Reflex sympathomimetic effects -Headache -Flushing -Hypokalemia

What are the therapeutic uses of the class 1C sodium channel blockers (2)?

-Refractory ventricular arrhythmias -Some supreventricular arrhythmias

What are the contraindications of niacin (2)?

-Relative: acanthosis nigricans, diabetes, peptic ulcer disease, GI ulcers -Absolute: chronic liver disease and gout

What indicates successful reperfusion (3)?

-Relief of pain -Normalization of the ST segment -Earlier-than-usual peaking of troponin and CK-MB

Which vessels is fibromuscular dysplasia most common in (4)?

-Renal (renovascular hypertension) -Carotid -Splanchnic -Vertebral

Summary of Apo proteins: A1

-Required for assembly of HDL -Activating cofactor of LCAT (Lecithin Cholesterol Acyl Transferase) - -Found on chylomicrons and HDL -Required to pick up cholesterol from cell membranes (possibly binds to ABC-1 shuttle protein.)

What tests are used to diagnose chronic stable angina (2)?

-Resting ECG: Usually normal if there is no angina at the time of the test, look for evidence of old myocardial injury (Q waves) -Stress testing: Treadmill stress testing (TMST) is the most widely used test for both the diagnosis of ischemic heart disease and estimating its prognosis, TMST tries to induce ischemia and reproduce the patient's symptoms

What are the signs and symptoms associated with esophageal spasm (2)?

-Retrosternal pain that waxes and wanes -Relieved by GI cocktail

What clinical presentation is associated with a diagnosis of esophageal spasm (2)?

-Retrosternal pain that waxes and wanes -Relieved by GI cocktail

What are the toxicities of ezetimibe (2)?

-Reversible, impaired hepatic function -Myositis (rare)

What are the chief ECG characteristics of right ventricular hypertrophy?

-Right axis deviation (RAD) -In lead V1, the R-wave is larger than the S-wave

What differential diagnosis can you derive from a right axis deviation

-Right ventricular hypertrophy -Acute right heart strain (e.g. massive pulmonary embolism) -Left posterior fascicular block

What are the general treatment options for peripheral artery disease (2)?

-Risk reduction: smoking, blood pressure, lipids, diabetes -Anti-platelet therapy

What are the complications of aortic dissection (3)?

-Rupture (up to 90% mortality) -Occlusion of the aortic branch vessels -Distortion of aortic annulus

What is a ventricular free wall rupture, when does it typically occur after MI and what further complication can develop from it?

-Rupture through necrotic tissue -About two weeks -Fatal cardiac tamponade

Describe acute plaque changes that can occur in atherosclerosis and ischemic heart disease (2).

-Rupture, fissuring and ulceration with exposure of the ECM to blood (highly thrombogenic) -Hemorrhage into the amorphous core of plaque with expansion of plaque volume and further narrowing of vessel lumen

What cardiac findings are typical signs of an acute MI (2)?

-S4 (and S3 if congestive heart failure is also present) -Friction rub if pericarditis is present

What kind of ECG results can be seen when assessing a partially occlusive thrombus (3)?

-ST segment depression -And/or T wave inversion -Normal ECG

What kind of ECG results can be seen when assessing for transient ischemia (3)?

-ST segment depression -And/or T wave inversion -Normal ECG

What is a reciprocal change on an ECG and how significant is it in diagnosing MI?

-ST segment depression in leads remote from the site of an acute infarct -It is a highly sensitive indicator of acute myocardial infarction, reciprocal changes are seen in up to 70% of inferior and 30% of anterior infarctions; absence does not rule out infarction

What are the side effects of adenosine (4)?

-Safe -Flushing -Shortness of breath -Hypotension

What are the features of the synthetic phenotype of ischemia (4)?

-Scarring -Loss of elastic fibers -Inadequate ECM synthesis -Production of increased amounts of amorphous ground substance (glycosaminoglycans)

What are the uncertain or non-quantified risk factors for atherosclerosis and ischemic heart disease (8)?

-Sedentary lifestyle -Obesity -Stress -Post menopausal estrogen deficiency -Lipoprotein a -High serum homocysteine -Trans fat intake -Chlamydia pneumoniae infection

Give an overview of the pathogenesis of atherosclerosis and ischemic heart disease (5).

-Severe and chronic atherosclerosis -Disease of the intima of the coronaty arteries -Plaques -Critical stenosis -Onset of symptoms also depends on dynamic changes in the coronary arteries

What are the therapeutic uses of hydralazine (2)?

-Severe hypertension (in combo) -Preeclampsia/eclampsia of pregnancy

What are the therapeutic uses of loop diuretics (2)?

-Severe hypertension when used in combination with sympathoplegic or vasodilatory agents (similar effects as thiazides, but more powerful effect) -Hypertensive emergencies with left side ventricular failure

What symptoms are present at the onset of MI (5)?

-Severe, crushing substernal pain which may radiate to the jaw, epigastrium, shoulder or left arm -Long episodes of angina not relieved by nitroglycerin (50% of patients) -Dyspnea -Diaphoresis -Rapid, weak pulse

What are the signs and symptoms associated with pneumothorax (2)?

-Sharp, unilateral pleuritic pain -Abnormal chest x-ray

What clinical presentation is associated with a diagnosis of pneumpthorax (2)?

-Sharp, unilateral pleuritic pain -Abnormal chest x-ray

What cardiac effects do class 1B sodium channel blockers produce (3)?

-Shorten action potential -Shorten phase 3 repolarization -Decrease slope of repolarization

What are the toxicities of clonidine, guanabenz and guanfacine (2)?

-Similar CNS effects as methyldopa -Dry mouth

What are the side effects of disopyramide (3)?

-Similar to quinidine -Antimuscarinic effects: dry mouth, urinary retention, blurred vision, constipation and increased glaucoma symptoms -Increases digoxin toxicity

Which factors determine the amount of blood from aortic regurgitation that is added to stroke volume?

-Size of the regurgitant aortic orifice -The pressure gradient across the aortic valve during diastole -The duration of diastole

What are the toxicities of fibrates (7)?

-Skin rash -GI tract: stomach upset, abdominal pain -GU tract: erectile dysfunction -Muscles: myositis with imapired renal function, rhabdomyolysis when combined with statins -Increases anticoagulant effect -Liver: increased serum aminotrasnferase -Increased risk gallstones

What is the MOA of non-specific beta blockers (6)?

-Slow heart rate and reduce contractile force -Inhibit rennin release from kidney -Reduce aqueous humor secretion -Bronchoconstriction -Inhibit hepatic glycogenolysis -Anesthetic properties

What are the kinetics of oral or ointment nitroglycerin (4)?

-Slow release buccal and slow release transdermal are both long acting -Last for hours -High capacity hepatic reduction -Low bioavailability

What are the different types of coronary thrombi (3)?

-Small thrombus (non flow limiting) -Partially occlusive thrombus -Occlusive thrombus

List the risk factors that are treated for to prevent or treat chronic stable angina (5).

-Smoking cessation -Treatment of hypertension -Optimize weight and exercise -Treatment of diabetes -Reduce stress

What pathologic processes of hyperplastic ateriolosclerosis contribute to the luminal narrowing (2)?

-Smooth muscle cell proliferation -Thickened, reduplicated basement membranes

What are the four different types of drugs used to treat arrhythmias?

-Sodium channel blockers, Class 1 -Sympathetic blockade, Class II -Potassium Channel Blockers, Class III -Calcium channel blockers, Class IV

What are the causes of superficial thrombophlebitis (2)?

-Spontaneous -Iatrogenic

What types of angina are considered to be transient angina (2)?

-Stable -Unstable Pectoris angina

What are the clinical uses of beta blockers (4)?

-Stable and unstable angina -Reduce death due to MI -Hypertension -Good as combination therapy to reduce reflex tachycardia

What are the clinical uses of amlodipine (2)?

-Stable and vasospastic angina -Hypertension

What are the clinical uses of verapamil (5)?

-Stable and vasospastic angina -Hypertension -Arrhythmias -Migraine -Supraventricular arrhythmia

What are the clinical uses of nifedipine (5)?

-Stable and vasospastic angina -Hypertension -Migraine -Cardiomyopathy -Raynaud's phenomenon

What are the clinical uses of dilitiazem (4)?

-Stable and vasospastic angina -Hypertension -Raynaud's phenomenon -Supraventricular arrhythmia

What are the clinical uses of nicardipine (3)?

-Stable and vasospastic angina -Raynaud's phenomenon -Congestive heart failure

What are the clinical uses of bepridil (2)?

-Stable and vasospastic angina -Supraventricular arrhythmia

Aside from inflammation and unusual physical stress, what are other triggers of acute coronary syndrome (2)?

-Strenuous physical activity and emotional stress -Acute MI occurring in early morning hours

Describe the two types of cardiac imaging thata re used to diagnose chronic stable angina.

-Stress myocardial perfusion: uses contrast enhanced imaging done before and after exercise to visually detect areas of ischemia in the myocardium -2-dimensional stress echocardiography can assess both global and regional wall motion abnormalities of the left ventricle as well as its ejection fraction (LVEF)

What information is derived from doppler echocardiogram when diagnosing mitral regurgitation (2)?

-Structural causes -Grade of severity

What are the clinical uses of nimodipine (2)?

-Subarachnoid hemorrhage -Migraine

What are the classical clinical symptoms of aortic dissection (3)?

-Sudden onset of excruciating pain, usually beginning in the anterior chest, radiating to the back between the scapulae -Pain moves downward as the dissection progresses -Symptoms can be confused with myocardial infarction

Describe the characteristics of primary varicose veins (2).

-Superficial veins are affected -Caused by pregnancy, obesity and prolonged standing

What other effects do class 1B sodium channel blockers produce (2)?

-Suppress arrhythmias produced by abnormal automaticity -Abolish ventricular reentry

When is surgery indicated for peripheral artery disease and what type of surgery is preferred?

-Surgery is indicated when medical therapy has failed or severe limb ischemia is present -Percutaneous transluminal angioplasty is preferred over open surgery due to lower rates of short term mortality and complications

What are the toxicities of mecamylamine?

-Sympathoplgia: orthostatic hypotension and sexual dysfunction -Parasympathoplagia: constipation, urinary retention, precipitation of glaucoma, blurred vision and dry mouth

Give some examples of immune complex associated vasculitis (4).

-Systemic lupus erythematosus -Polyarteritis nodosa (PAN) -Hypersensitivity vasculitis -Vasculitis secondary to viral infections

What cardiac effects are produced if the right ventricle is damaged (2)?

-Systolic and diastolic dysfunction -Increased pressure in the inferior vena cava, producing JVP

What are the toxicities of minoxidil (7)?

-Tachycardia -Palpitaions -Angina -Edema (without diuretics and beta blockers) -Headache -Sweating -Hypertrichosis

Acute arterial occlusion can also be due to vasculitic syndromes, list them (4).

-Takasuya arteritis (rare) -Giant cell arteritis -Thromboangiitis obliterans (Beurger disease) -Raynaud's Phenomenon (common)

What are the signs and symptoms associated with aortic dissection (4)?

-Tearing -Ripping pain that migrates -Asymmetry of arm blood pressures -Widened mediastinum on chest x-ray

What clinical presentation is associated with a diagnosis of aortic dissection (3)?

-Tearing, ripping pain that migrates -Asymmetry of arm blood pressures -Widened mediastinum on chest x-ray

Describe the pathophysiology of mitral stenosis

-The development of stenosis introduces a degree of obstruction to blood flow through the thickened, stiff valve -Left atrium pressures increase and impaired filling of the left ventricle contributes to decreased stroke volume and cardiac output -As left atrium pressure increases, so do pulmonary and capillary pressures, which can induce transudation of of plasma into the lung interstitium and alveoli

What are the three proteins that HDL2 interacts with in the liver?

-The liver's SR-B1 receptors (scavenger receptors) -Hepatic lipase -HDL receptors

Describe the process of diagnostic imaging for diagnosing an aortic dissection (3).

-The preliminary imaging choice is a chest x-ray -If the patient is hemodynamically stable, CT angiography with 3D reconstruction is warranted -If the patient is not hemodynamically stable, echocardiogram

List the factors that determine the severity and impact on cardiac output of mitral regurgitation (5).

-The size of the mitral orifice during mitral regurgitation -Systolic pressure gradient between the left atrium and left ventricle -Systemic vascular resistance opposing forward left ventricle blood flow -Left atrium compliance -Duration of regurgitation with each systolic contraction

What is atypical chest pain or atypical angina and what kind of patients are most likely to experience it?

-The sympathetic and parasympathetic effects of MI -Predominantly women

Describe the development of atrial fibrillation in chronic mitral regurgitation.

-There is inadequate forward cardiac output because the compliant left atrium becomes a preferred low-pressure "sink" -The more blood that flows into the left atrium, the more dilated and compliant it becomes -Forward cardiac output declines over time, and as the left atrium continues to dilate, the risk of atrial fibrillation increases

How do you diagnose left ventricular hypertrophy on a 12 lead ECG?

-There should be increased R-wave amplitude in leads overlying the left ventricle, and -There should be increased S-wave amplitude in leads overlying the right ventricle. -Finally, the R-wave amplitude in lead V5 or V6 plus the S-wave amplitude in V1 or V2 > 35 mm.

Why are thiazides the diuretics of choice (2)?

-They are half the cost of ACE or ARBs and are included on most insurance formularies -Several large randomized trials demonstrate a reduction in cerebrovascular events, coronary heart disease and stroke as well as cardiovascular mortality

What is the clinical relevance of class 1A sodium channel blockers (2)?

-They block cells that are more frequently depolarizing: Tachycardic-cells when Na+ channels are open -Allow for preferential blockade of abnormally fast beating cells over cells in a more normal rhythm

What are the therapeutic uses of thiazides (2)?

-They can be used alone for mild to moderate hypertension (can lower BP by 10-15 mmHg) -Used for severe hypertension when used in combination with sympathoplegic or vasodilatory agents (reduces the compensatory effect of these agents)

What are the therapeutic uses of potassium sparing diuretics (3)?

-They can be used alone for mild to moderate hypertension (can lower BP by 10-15 mmHg) -Used for severe hypertension when used in combination with sympathoplegic or vasodilatory agents (reduces the compensatory effect of these agents) -Effects are more pronounced when patient is on digoxin

What cardiac effects do class 1A sodium channel blockers produce (4)?

-They decrease the phase 0 depolarizing slope, prolonging the action potential -They have some potassium channel blocking activity -Decreases phase 4 spontaneous depolarization -Preferential for ectopic arrhythmias and ventricular arrhythmias produced by increased automaticity and reentry

What is the mechanism of action of calcium channel blockers and when are they indicated?

-They exert anti-ischemic effects by decreasing heart rate and contractility, and promoting vasodilation -They are indicated when ischemia persists despite beta blocker and nitrate therapy and should not be used in those with left ventricle failure

List the different classes of diuretics (3).

-Thiazides -Loop diuretics -Potassium sparing

What are the aortic aneurysm take home points?

-This chronic disease is often asymptomatic but must be considered in the pain differential -The greater the diameter, the greater the risk of death from rupture or dissection -Key management: beta-blockers and sometimes surgery

What are the take home points of aortic dissection (3)?

-Though aneurysms of the thoracic aorta are not as common as abdominal aortic aneurysms, they carry a higher risk of dissection and rupture -Severe chest pain with dyspnea and other symptoms requires emergent assessment -CT angiography is the preferred emergency imaging for diagnosis; however, if the patient is hemodynamically unstable, echocardiography is used

What is the purpose of combination therapy when using thiazides (2)?

-To reduce the amount and subsequent toxicity of other drugs -To reduce compensatory reflex mechanisms of other drugs

What are the two types of ischemia that can result from an occlusive thrombus?

-Transient -Prolonged

What are the potential clinical outcomes of myocardial ischemia (4)?

-Transient ischemia -Prolonged ischemia -Arrhythmias -Cardiomegaly and heart failure

What is the follow up protocol after seeing a patient with chronic stable angina (2)?

-Treadmill stress test for any clinical changes -Follow up every 6 to 12 months depending on the case

How is silent angina treated (2)?

-Treat risk factors, particularly lipids and blood pressure -The use of aspirin, statins, and beta blockers have been shown to reduce events and improve outcomes in asymptomatic as well as symptomatic patients with ischemia and proven CAD

List the trisupid valve diseases (2).

-Tricuspid stenosis -Tricuspid regurgitation

Recap: List the totally hydrophobic lipids (2).

-Triglycerides -Cholesteryl esters

List the cardiac specific troponins (3).

-Troponin C -Troponin I -Troponin T

Which isoforms of tropnin are found in cardiac muscle (2)?

-Troponin T -Troponin I

Which type of aortic dissection is most common, least common?

-Two thirds are type A -One third are type B

Which acute coronary syndromes result from a partial vessel occlusion (2)?

-Unstable angina -Non-ST elevation MI

List the acute coronary syndromes (3).

-Unstable angina -Non-ST elevation MI -ST elevation MI

What are borderline values of troponin (0.06 - 1.49 ng/mL) associated with other than MI (3)?

-Unstable angina -Other heart disorders -Chronic kidney failure

Which acute coronary syndromes result from a partial occlusion (2)?

-Unstable angina (UA) -Non-ST-segment elevation myocardial infarction (NSTEMI), also known as "non-Q-wave MI" or non-transmural MI or subendocardial MI

Describe the morphological changes to the vessels as a result of unstable angina or non-ST elevation MI and an ST elevation MI.

-Unstable angina or non-ST elevation MI: Plaque rupture, platelet aggregation, non-occlusive thrombus formation and unopposed vasoconstriction -ST elevation MI: Occlusive thrombus formation

What are the clinical outcomes of aortic dissection (3)?

-Used to be fatal, but now 65-75% of patients survive due to rapid diagnosis, intensive anti-hypertensive therapy, and surgery involving plication of the aortic wall -The most common cause of death is rupture of the dissection outward into the pericardial, pleural, or peritoneal cavities

What are the therapeutic uses of labetalol and carvedilol (2)?

-Useful to treat hypertension produced by pheochromocytomas -Hypertensive emergencies (IV Labetolol)

What are the major presenting symptoms of mitral valve prolapse (3)?

-Usually asymptomatic -Chest pain -Palpitations (usually due to premature atrial or ventricular contractions)

Describe the morphology of an abdominal aortic aneurysm (6).

-Usually below the renal arteries and above the bifurcation of the common iliac arteries -Saccular or fusiform, up to 15 cm in diameter, and up to 25 cm in length -Intimal surface typically shows severe complicated atherosclerosis with destruction and thinning of the underlying aortic media -Frequently contains a laminated, poorly organized mural thrombus, which may partially or completely fill the dilated segment -Renal and superior or inferior mesenteric arteries may be affected -Often accompanied by smaller aneurysms of the iliac arteries

When is coronary arteriography/angiographycatheterization indicated when diagnosing angina (3)?

-Usually indicated for patients with acute myocardial infarction or unstable angina -Consider in stable angina if medical treatment does not control symptoms or in those who have ventricular dysfunction -Take age, occupation, other factors into consideration

Which precordial leads overlie the right ventricle (2)?

-V1 -V2

Which precordial leads overlie the left ventricle (2)?

-V5 -V6

List the ECG leads associated with the anterolateral region of the heart (3).

-V5 and V6 -1 -aVL

What are the causes of aortic regurgitation (2)?

-Valve leaflet abnormalities -Dilation of aortic root

What are the kinetics of guanethidine (3)?

-Variable bioavailability -Half is cleared through the kidneys -Large volume of distribution due to accumulation in the nerves and thus a long half-life, 5 days

What are the important pathologies associated with venous disease (2)?

-Varicose veins and sequelae -Venous thrombosis is covered in Respiratory

What are the first line pharmacological agents that are given to patients who can't exercise as a stress test? How do they work?

-Vasodilators: Adenosine or dipyridamole (persantine) -They induce healthy myocardium to "steal" blood from the diseased areas, inducing transient ischemia

List the high yield facts about Raynaud's phenomenon (2).

-Vasoplastic disease -Either rpimary or secondary form

What are the contraindications of beta blocker therapy (5)?

-Vasospastic angina -Severe bradycardia -Sick sinus syndrome -Severe left ventricle failure -Caution with asthmatics

Which maladies are considered to comprise venous disease (2)?

-Venous insufficiency -Venous stasis dermatitis

Which complications arise from a decrease in heart contractility (3)?

-Ventricular thrombus -Cardiogenic shock -Congestive heart failure

How can vasculitides be classified (6)?

-Vessel size -Immune complexes -Specific autoantibodies -Granuloma formation -Specific organ -Population demographics

What makes up myocardial oxygen demand (3)?

-Wall stress -Heart rate -Contractility

What is the historical treatment of mitral regurgitation (2)?

-Warfarin for atrial fibrillation and thromboembolism -Vasodilators for hypertension

What is the historical treatment of mitral stenosis (2)?

-Warfarin for atrial fibrillation or thromboembolism -Penicillin for rheumatic fever prophylaxis

What are the toxicities of niacin (8)?

-Warm flushes -Skin rashes -GI upset -Elevated liver transferase -Hepatotoxicity -Carbohydrate intolerance -Hyperuricemia -Supraventricular arrhythmias

Which conditions are associated with small vessel vasculitis (3)?

-Wegener -Churg-Strauss -Microscopic polyangitis

What signs of aortic regurgitation are found upon physical examination (4)?

-Widened pulse pressure (SBP - DBP > 40 mmHg) may produce bounding pulses -PMI: may be diffuse or hyperdynamic and is often displaced inferiorly and toward the axilla -Murmur described as a "blowing" diastolic decrescendo sound -May hear Austin-Flint murmur

When is treatment for an arrhythmia indicated (3)?

-With decreased cardiac output (severe bradycardia, ventricular fibrillation) -Arrhythmias that are likely to precipitate more serious arrhythmias (atrial flutter → ventricular arrhythmia) -Precipitate an embolism (chronic atrial fibrillation)

When can acute pericarditis occur and how common is it?

-Within 2 to 4 days of a transmural MI -15% of cases

What are the aggravating and alleviating factors of chronic stable angina?

-Worsened by activity -Relieved by rest or sublingual nitroglycerin

Give two tests for arachnodactyly.

-Wrist sign: positive if the distal phalanges of the first and fifth digits of one hand overlap when wrapped around the opposite wrist -Thumb sign: positive if the thumb, when completely opposed within the clenched hand, projects beyond the ulnar border.

How are the Angiotensin Receptor Blockers Named?

-sartan. Examples are Losartaran, Azilsartan, etc. Similar Toxicities and Contraindications as ACE Inhibitors.

What is the reference range for troponin?

0-0.05ng/mL.

How is endogenous cholesterol synthesized?

1) 3 molecules of acetyl CoA combine to form B-hydroxy-B-methyl-glutaryl CoA (HMG CoA) 2) HMG CoA is double reduced to mevalonic acid by HMG CoA reductase (rate limiting step) 3) Mevalonic acid goes through several more reactions to form cholesterol

What are some common substituents of phosphotidic acid? (4)

1) Choline 2) Serine 3) Ethanolamine 4) Inositol

What are the four major categories of lipoproteins, from lowest to highest density?

1) Chylomicrons 2) VLDL 3) LDL 4) HDL

What drug classes are recommended for hypertension in the presence of heart failure? (5)

1) Diuretics 2) Beta blockers (BB) 3) ACE inhibitors (ACEI) 4) Angiotension receptor blocker (ARB) 5) Aldosterone antagonist (Aldo ANT)

What are three common amphipathic lipids?

1) Free fatty acids 2) Phospholipids 3) Cholesterol

How are Re-Entry Currents fixed?

1) Increase refractory period preventing reentry (bidirectional block) 2) Decrease the # of available unblocked channels preventing propagation

What are the three forms of HDL?

1) Nascent (pre-beta HDL) 2) Alpha HDL3 3) Alpha HDL2

What are the three proteins that help to break down and recycle HDL?

1) SR-B1 receptors in liver uptake cholesterol and CE 2) Hepatic lipase hydrolyzes TG and PL, destabilizing all apoproteins but A1 (converts back to nascent HDL) 3) HDL receptors in liver can endocytose the entire HDL

What are two common totally hydrophobic lipids?

1) Triglycerides 2) Cholesterol esters

How do Re-Entrant Currents Arise?

1)Must be obstacle to prevent homogenous conduction. 2) Unidirectional blocks only 3) Conduction time must exceed refractory period of obstacle area to allow reentrant conductance

What three things are true of all Lipoproteins?

1. All transport Lipids. 2. All are Mixed-Pseudomicelles. 3. All are formed of non-covalent interactions between lipid and proteins.

Give five possible Molecular markers of a Myocardial Infarction.

1. Aspartate Aminotransferase (AST) 2. Lactate Dehydrogenase (LDH) 3. Myoglobin 4. Creatine Kinase MB (CKMB) 5. Troponin I and Troponin T

What are the options for Pharmacological Treatment of Stable Angina?

1. Aspirin or Clopidogrel for Antiplatelet. 2. Sublingual Nitroglycerin for Symptoms 3. Beta-Blocker 4. Calcium Channel Blockers 5. Lipid Lowering Agents 6. Ace Inhibitors

Give Four Steps in Infectious Endocarditis Pathogenesis?

1. Survive Host Defense. 2. Adhere to Nonbacterial Thrombotic Vegetation (via platelets and Fibrin) or Directly to Valve (S. Aureus) 3. Multiply on Valve Surface. 4. Promote further Vegetation Formation.

What three things vary between Lipoproteins?

1. Whether they are TG or CE rich. 2. Types of Apoproteins. 3. Carrying Endogenous or Exogenous Lipids.

How common is a circumferential acute myocardial infarction?

10% of cases.

How common are Varicose Veins?

10-20% of the population, more Women.

What percentage of hospitalized patients do not experience any complications?

10-20%.

Class of Disopyramide?

1A Beta Blocker.

Class of Procainamide?

1A Beta Blocker.

Class of Quinidine?

1A Beta Blocker.

Class of Lidocaine?

1B Beta Blocker.

Class of Phenytoin?

1B Beta Blocker.

Class of Mexiletine?

1B Beta Blocker. A Lidocaine Analog with less 1st pass metabolism, so taken Orally.

Class of Flecainide?

1C Beta Blocker.

Class of Propafenone?

1C Beta Blocker.

Contrast ATP production with or without Oxygen.

2 ATP per glucose without Oxygen, 36 per Glucose Aerobically.

What is the general treatment for Bacterial Infectious Endocarditis?

2 Antibiotics for Several Weeks, because it is hard to clear the vegetation. Most common Combinations are: Penicillin + Gentamicin: for Streptococci & Enterococci Nafcillin + Gentamicin: for Staphylococci Vancomycin + Gentamicin: for MRSA (methicillin-resistant S.aureus) Surgery Required for Fungal Endocarditis or in other cases if the Drugs dont work.

What is Systemic Inflammatory Response Syndrome?

2 or more of the Following: 1) Fever 2) Tachycardia 3) Rapid Breathing 4) High White Cell Count It is a nonspecific diagnosis with Many Causes.

By how much can weight loss reduce blood pressure?

2-3 mmHg.

What percent of CV Events happent o people without any modifiable Risk Factors?

20%.

How wide is the Aorta?

3 cm at the Origin, about 4.5 cm along the Ascending Aorta and 2.5 cm in the descending Thoracic Aorta and Abdominal Aorta. Larger values can be sign of Aneurysm.

How is Blood Culturing done if Endocarditis is suspected?

3 sets of Cultures, preferably from different sites over 24-48 hours. A negative culture does not mean no Endocarditis. Perhaps Antibiotics were recently administered, for example.

When can hospitalized MI patients be safely discharged?

5 to 6 days after an acute MI or sooner if aggressive reperfusion therapies were undertaken and complications did not occur.

Define High Grade Stenosis.

50% Occulusion of a Coronary Artery. This is present almost always with Stable Angina.

Where is Cholesterol Made?

50% in the Liver, 35% in the Skin, 15% in the Intestine.

How common is sudden cardiac death?

50% of patients.

What is a normal JVP?

6 to 8 cm H2O.

What levels are HDL are risky and which are protective?

60 and above is considered protective, less than 40 is considered a Risk Factor.

By how much can a reduction in sodium intake reduce blood pressure?

7 mmHg.

Who is most likely to experience a sudden cardiac event?

70% to 90% of sudden cardiac events occur in men.

What are the primary Arteries involved in PAD?

90% Popliteal and Femoral, 50% Tibial and Popliteal, 30% Iliac and Abdominal Aorta.

How common is a regional acute myocardial infarction?

90% of cases.

How much Stenosis is needed to see via imaging?

90%. However, during Stress imaging Atherosclerotic vessels will fail to Dilate normally and as low as 50% Stenosis can be seen.

What Heart Sound is heard in Aortic Regurgitation?

A "blowing" diastolic decrescendo sound.

What is an Arteriovenous Fistula?

A 'shortcut' between an Artery and its vein that bypasses Capillaries. They can be caused by Ruptured Aneurysms, Inflammatory Necrosis, or Congenital Diseases.

How Much does a CT Cost?

A CT cost $2,000.

How Much does a Chest X-Ray Cost?

A Chest X-Ray costs $100.

What is Nifedipine?

A Dihydropyridine Calcium Channel Blocker. Remember that the Dihydropyridines selectively block Calcium Channels on Vascular Smooth Muscle, causing Dilation.

What is Abciximab?

A Fibronectin Receptor Monoclonal Antibody, used to prevent Clots.

What is Migratory Polyarthritis?

A Major Criteria of Rheumatic Fever, involving inflammation in the Large Joints, but not the small ones. Do not treat with Aspirin, because it will get better so fast you won't know if it was Rheumatic Fever.

What is a Mixed Micelle?

A Micelle formed of multiple types of Amphipathic molecules.

What is a Pseudomicelle?

A Micelle with a nonpolar substance dissolved in the center.

What Heart Sound is heard in Mitral Valve Prolapse?

A Mid-Systolic Click and Late Systolic Murmur that gets louder until it ends at S2. It is best heard at the Apex.

What is Asymptomatic, aka Silent, Ischemia?

A Painless event of Ischemia which could actually even be an MI. Best detected on Treadmill Stress Test.

What class of drug is Ezetimibe?

A Sterol Absorbtion Inhibitor. These drugs basically do nothing, according to studies.

What is Aortic Stenosis and how does it Present?

A Stiffening of the Aortic Valve which reduces its Orifice Area by 50% and Impairs blood flow through the Valve during Systole. It presents with Angina, Syncope, CHF, and LV and LA Hypertrophy. It can lead to Atrial Fibrillation.

What is ABC1?

A Transporter that moves Cholesterol out into the Blood for transport. This is impaired in Tangier's Disease, causing low HDL because it cannot really be made.

What is superficial thrombophlebitis?

A benign disorder due to inflammation or thrombosis of a superficial vein.

What happens during percutaneous coronary intervention?

A cardiologist feeds a deflated balloon or other device on a catheter from the inguinal femoral artery or radial artery up through blood vessels until they reach the site of blockage in the heart. X-ray imaging is used to guide the catheter threading. At the blockage, the balloon is inflated to open the artery, allowing blood to flow. A stent is often placed at the site of blockage to permanently open the artery.

What is Hypertrophic Obstructive Cardiomyopathy?

A cause of Sudden Death characterized by Asymmetrical thickening of the Septal wall without thickening of the Free Ventricle Wall.

What is venous insufficiency?

A chronic disorder, usually due to elevated leg vein pressure from varicose veins.

What is a chylomicron remnant?

A chylomicron with a depleted triglyceride core.

What is Mitral Valve Prolapse?

A common and usually asymptomatic condition consisting of billowing of the mitral leaflets into the LA during ventricular systole.

What is mitral valve prolapse?

A common and usually asymptomatic condition which consists of the billowing of the mitral leaflets into the left atrium during ventricular systole.

What is livedo reticularis?

A common skin finding consisting of a mottled reticulated vascular pattern that appears like a lace-like purplish discoloration of the skin. The discoloration is caused by swelling of the venules owing to obstruction of capillaries by thrombi.

What is Thromboangiitis Obliterans?

A completely preventable disease caused by smoking. It causes thrombosis in Small and Medium Arteries, presenting as Necrosis of Fingers and Toes. Histologically resembles polyarteritis nodosa or microscopic polyangiitis, but in addition has Granulomas and Eosinophils. The only cure is to stop smoking, or it will spread to Nerves and Veins.

How do arrhythmias result from MI?

A conduction system injury can lead to ventricular fibrillation, sinus bradycardia, sinus tachycardia and conduction blocks.

What is a Judkins Catheter?

A coronary Catheter that has a Right or Left bend. Judkins Left is for Ascending Aorta, Pigtail is for piercing the Aortic Valve.

What is the downstream effect of niacin treatment?

A decrease in VLDL production.

What is a consequence of an intraplaque hemorrhage?

A decrease in vessel lumen diameter.

What is a false aneurysm?

A defect in the vascular wall which leads to an extravascular hematoma that freely communicates with the intravascular space ("pulsating hematoma") .

What is an Aschoff Body?

A finding of Rheumatic Heart Disease.

What does the ischemic response look like on an ECG when it is elicited by a stress test?

A flat or downsloping depression of the ST segment greater than 0.1mV below baseline (0.1 mV = 1 vertical box).

Which type of true aneurysm is most common?

A fusiform aneurysm, involving the entire circumference.

What is Vasculitis?

A general term for inflammation of Blood Vessels. There are more than 20 types. Categories include Immune-Complex Mediated Vasculitis, Infectious, and Traumatic.

What is Ehler-Danlos syndrome?

A heterogeneous group of inherited connective-tissue disorders characterized by joint hypermobility, cutaneous fragility, and hyperextensibility. Type IV is associated with arterial rupture and visceral perforation, with possible life-threatening consequences.

What is an amphipathic lipid?

A lipid that has one hydrophobic and one hydrophilic region (eg fatty acids)

What is an amphipathic lipid?

A lipid which has one region which is hydrophobic and one region which is hydrophilic.

What is an aneurysm?

A localized congenital or acquired abnormal dilation of a blood vessel or the heart. Rupture has catastrophic consequences.

What is the Austin-Flint murmur?

A low-frequency, mid-diastolic rumble thought to represent turbulent blood flow across the mitral valve during diastole.

What is myoglobin?

A low-molecular weight protein found in both cardiac and skeletal muscle.

What is a mixed micelle?

A micelle that has more than one type of amphipathic molecule.

What is a pseudomicelle?

A micelle with a nonpolar substance dissolved in the center

What is a pseudomicelle?

A micelle with a nonpolar substance dissolved in the center region of the micelle.

The presence of abdominal aortic aneurysm is indicative of what other conditions?

A person with AAA is very likely to have atherosclerosis in other vessels and has an increased risk of IHD and stroke.

Who is Dr Forssmann?

A pioneer who threaded a Catheter into his own heart in 1929. This is the Xray he took.

What is Amlodipine?

A popular Hypertension and Angina Medication, the only Dihydropyridine used for Angina.

How does an Aortic Aneurysm Present?

A pulsatile mass in upper abdomen. Pain, can be referred quite far. Ultrasound is a cheap screen, should be used in older people who have smoked as a regular standard or care.

What does Percutaneous mean?

A puncture rather than incision. The groin, over the Femoral Artery, is the site of most Percutaneous Coronary Intervention.

What is tricuspid stenosis?

A rare disease that is usually due to rheumatic fever. It often is present along with mitral stenosis. It has a very similar murmur consisting of an opening snap and diastolic rumble.

What is the result of the lysis of the thrombus or collateral blood flow during a regional acute myocardial infarction?

A regional subendocardial infarction.

Does a regional acute myocardial infarction lead to reversible or irreversible damage?

A severe ischemia caused by coronary artery occlusion and lasting at least 20 to 40 minutes causes irreversible injury and death of cardiac myocytes.

What is a micelle?

A simple, spherical association. In a polar environment, the hydrophobic tails of the lipid compounds are in contact in the center of the sphere and the polar groups face outward toward the surface.

What is the mean ORS axis?

A single vector summarizes all of the instantaneous vectors of ventricular depolarization. The direction of this summation vector is the axis of ventricular depolarization.

What are the potential outcomes of the formation of an intracoronary thrombus?

A small, non-occlusive thrombus may be lysed by natural mechanisms or may be incorporated into the original plaque, forming a more substantial plaque. Deeper plaque rupture may cause greater exposure of subendothelial collagen and tissue factor, forming a larger thrombus that occludes most or all of the vessel's lumen.

What is Obstructive Shock?

A subset of Cardiogenic Shock, Obstructive Shock is a form of shock associated with physical Obstruction of the Great Vessels or the heart itself. Pulmonary embolism and cardiac tamponade are considered forms of obstructive shock.

What is the best approach to increasing exercise in a patient with peripheral artery disease?

A supervised walking program.

What is Shock?

A syndrome of Inadequate Tissue Perfusion, causing Cellular Dysfunction. This leads to Cell Injury and the Release of Inflammatory Mediators.

What is Rheumatic Fever?

A systemic CHildhood disease that follows a Group A Beta-Hemolytic Streptococcal Infection of the Pharynx. It can spread to the rest of the body.

How does aortic stenosis develop?

A thickened, stiff aortic valve is usually the result of age-related degenerative calcific changes, especially in patients who present with aortic stenosis after the age of 65. These changes cause impaired blood flow through the valve during systole.

What is clopidogrel?

A thienopyridine class inhibitor of P2Y12 ADP platelet receptors.

What is the result of complete, persistent occlusion in a regional acute myocardial infarction?

A transmural infarction.

What QRS morphology is characteristic of a right bundle branch block?

A typical diagnostic shape in the right ventricle leads, V1 and V2, known as RR' or rabbit ears. The first R wave is typically smaller in amplitude than the R'.

What value is considered indicative of am MI?

A value greater than 0.09ng/mL is suggestive of an MI when at least one of the following is also present: -Ischemic symptoms -ECG changes indicative of ischemia -Coronary intervention

What is lipoprotein a?

A variant of LDL.

What is giant cell arteritis?

A vascular syndrome that affects predominantly cranial arteries.

What is a rare cause of a thromboembolism?

A venous clot that has navigated through an atrial septal defect, also known as a paradoxical embolism.

What is Monckeberg Medial Sclerosis.

A very apparent Arteriosclerosis that is thick with Calcium, which can be seen on X-ray. Seen here in the Popliteal Artery on the right.

What is the hallmark sign of aortic regurgitation?

A widened pulse pressure.

What is Striae Palmaris?

A yellowing of the palms caused by Cholesterol Deposits. It is seen in FH type 3.

What is the Function of APO A1 and APO A2?

A1 activates LCAT and is a cofactor for ABC-1, which transfers Cholesterol into the Blood from Intestinal Epithelium. A2 inhibits both LCAT and ABC1.

What drug classes are NOT recommended for hypertension in pregnant women?

ACEI and ARB

What drug classes are recommended for hypertension in the presence of chronic kidney disease? (2)

ACEI, ARB

What is Vasculitis with Antineutrophil Cytoplasmic Antibodies?

ANCAs are circulating antibodies that attack enzymes of Neutrophils and Endothelial Cells. c-ANCA is cytoplasmic, p-ANCA is perinuclear.

How can a large Cardiac Silhoutte be Misdiagnosed?

AP Xray, poor inspiration, Rotated Patient, Supine Film.

Give an Overview of how VLDL is made by the Liver.

APO B100 is made by Rough ER, goes to Golgi and Exocytosed.

HDL Contributes two proteins to Nascent Chylomicrons to make them Mature. Name them.

APO E and APO CII.

What is the Defining Lipoprotein of HDL?

APO-A. It also carries APO CII and E.

What drug classes are NOT recommended for hypertension in the presence of high coronary disease risk? (2)

ARB, Aldo ANT

What transporter can pump excess cholesterol out of the epithelial cell?

ATP Binding Cassete Protein 1 (ABC-1 protein)

What Biochemical Changes occur within minutes of an Infarct?

ATP is reduced while Lactate is increased. Irreversible damage begins after about 30 minutes.

What are the constellation of Lupus Symptoms?

Abdominal pain, fever, chills, arthralgia or arthritis, myalgia, pericarditis, pleuritis, and/or skin rash

What is abnormal Posturing?

Abnormal posturing is an involuntary flexion or extension of the arms and legs, indicating severe brain injury.

Describe the pathogenesis of coronary thrombosis.

Abnormalities associated with atherosclerotic lesions overwhelm the mechanisms of normal hemostasis and result in thrombosis and vessel occlusion. These abnormalities stimulate excess clot formation, disable the normal clotting factors and minimize vasodilation.

What are Varicose Veins?

Abnormally dilates, tortuous veins produced by increased Lumenal pressure and loss of wall tension and incompetence of Valves. Obesity increases the risk, as does standing long periods.

Newly synthesized chylomicrons contain which apoproteins?

Abo-B48 is made first, then AI, AII and lipids are added

What Percent Stenosis can you have in an Artery while still being capable of Maximum Coronary Blood Flow?

About 40%.

What is the best indication of Good Prognosis in Acute Rheumatic Fever in children?

Absence of Carditis. 30% die within 10 years if it is present.

What are Relative and Absolute Contraindications for Niacin?

Absolute: Chronic Liver Disease, Acanthosis Nigricans, Hyperuricemia. Relative: Insulin Sensitivity Reduction,

What is Variant, aka Prinzmetal Angina?

Accounting for 2-3% of Angina Pectoris, it is caused by defective NO production yielding a Dysfunctional Epithelium, causing Focal Coronary Artery Vasospasm.

What is Cardiac Tamponade?

Accumulation of Pericardial fluid under Pressure. The Pericardial sac thickens and loses Elasticity.

ABBEAM is mnemonic for the Beta-1 Specific Blockers. Name them.

Acebutolol, Betaxolol, Bisoprolol, Esmolol, Atenolol, Metaprolol.

Which Beta Blockers have Intrinsic Sympathetic Activity?

Acebutolol, Pindolol, Penbutolol, and Labetalol.

Describe how Contraction Bands are Formed.

Actin and Myosin require ATP, therefore Oxygen, in order to separate and relax the muscle. Contraction bands are local areas of ATP shortage and Hypoxia.

Summary of Apo proteins: CII

Activating cofactor for lipoprotein lipase.

What is a consequence of the release of tissue factor?

Activation of the coagulation cascade.

What is an absolute contraindication of statins?

Active or chronic liver disease.

What produces chronic stable angina?

Activity increases oxygen demand, which may not be adequately met in areas of myocardium supplied by arteries with stenotic lesions.

What happens to blood lipids in Liver Disease?

Acute Hepatitis increases VLDL.

Contrast Acute and Subacute Infections Endocarditis.

Acute Infective Endocarditis is caused by infection of a previously normal heart valve by a highly virulent organism. It is difficult to cure with antibiotics and usually require surgery, and Death within days to weeks ensues in many patients with acute IE, despite treatment. Subacute Infective Endocarditis is caused by organisms of lower virulence. These are insidious infections of deformed valves that are less destructive. The disease may pursue a protracted course of weeks to months, and cures are often produced with antibiotics

Compare the Bugs in Native Valve Infective Endocarditis, Both Acute and Subacute. Native valve means not a Prosthetic Valve.

Acute Infective Endocarditis occurs to healthy Valves, so the Bug must be able to attach, so Staphylococcus Aureus is the guy in 60% of cases. Others include Pneumococci, Streptococci and Gram(-) rods. For SubAcute IE, Alpha Hemolytic Streptococci account for 60%. Others include Enterococci, Fastidious Gram - rods, and Coagulase - Staphylococci.

What is Wegener's Granolumatosis?

Acute Necrotizing Granulomas of the Respiratory Tract, affecting small to medium vessels. It is similar to Microscopic Polyangiitis but with Respiratory involvement. c-ANCAs involved 95%, good marker. Good response to Immunosuppressive therapy.

When are ACE Inhibitors Contraindicated?

Acute Renal Failure, Pregnancy.

Which of the following valvular disorders would cause the greatest increase in left ventricle pressure during diastole?

Acute aortic regurgitation.

What are the clinical indications for esmolol?

Acute arrhythmias during surgery or emergencies.

What is Acute Arterial Occlusion?

Acute limb ischemia causing Pain, Paresthesias, & motor weakness Distal to the occlusion. Presentation similar to PAD with positive Beurger's Sign, loss of pulses, Cyanosis.

Which is worse, Acute or Subacute Endocarditis?

Acute will kill you in a few weeks. It has more fever and occurs 1/3 of the time. It is largely based on the Organism.

What is ACAT?

Acyl-Cholesterol-Acyl-Transferase is the Enzyme that attaches a fatty Acid to Cholesterol to Form Cholesterol Esters. It is found in the Epithelial Cells of the Intestine.

How is a Catalase Test Performed?

Add a drop of Catalase and see what happens.

MoA of Adenosine?

Adenosine Receptor Antagonist.

Give Characteristics of Pseudomonas Aeruginosa.

Aerobic Gram Negative Rod, pigmented. Not native flora but very common. Often Causes IE in IV drug users or in Nosocomial Infections.

What is Churg-Strauss Syndrome?

Affecting only small vessels, this is a rare Allergic Granulomatosis. Associated with asthma, allergic rhinitis, lung infiltrates, peripheral blood hypereosinophilia, and extravascular necrotizing granulomas. It often involves the heart, which is the primary cause of Mortality.

What is Polyarteritis Nodosa?

Affecting only the small and Medium Arteries, 30% of these patients have Chronic Hepatitis B and the Hep B surface Antigen is responsible for it. It is seen as Segmental Trasnmural Necrotizing Inflammation of Small and Medium Arteries. Can lead to Aneurysm, formation of Scars (nodes) in the vascular wall.

What is the purpose of the hepatic lipase?

After the cholesterol is depleted from HDL, hepatic lipase hydrolyzes its triglycerides. This rearrangement of lipid content destabilizes the apoproteins and the HDL loses all apoproteins but AI. It has now been converted back to the smaller pre-beta HDL. Pre-beta HDL begins the cycle all over again, picking up more cholesterol from cholesterol-laden cells.

What are Signs and Symptoms of Acute MI? Note that it can be quite Variable.

Again, can be quite Variable, especially in Women. Instead of pain it could be 'Elephant on the Chest' Pressure or referred Pain to Jaw, Arm, Shoulders.

Give the Four Non-Modifiable Risk Factors for Atherosclerosis.

Age, Gender, Family History, Genetics.

How are aneurysms greater than 5cm managed?

Aggressively, usually by surgical bypass involving prosthetic grafts. Endoluminal stent grafts (expandable wire frames covered by a cloth sleeve) are used in selected patients.

What are the Basics of treating Shock, as characterized by the Mnemonic ABCs? (D,E)

Airway, Breathing, Circulation. (Drugs: Aspirin, Nitroglycerin, Morphine, Inotropics)(Evaluation:Chest Xray, Blood Culture)

What drug classes are NOT recommended for hypertension in the presence of diabetes?

Aldo ANT

How are lipids transported in plasma?

All except beta-ketoacids MUST be bound to protein. Short chains (<12C) bound to albumind, longer chains in lipoprotein shell.

What is the source of endogenously made cholesterol?

All the carbons that make up cholesterol come from acetyl CoA.

What is the MOA of clonidine, guanabenz and guanfacine?

Alpha 2 receptor agonists.

How can Viridans Streptococcus be identified?

Alpha-hemolytic, Optochin resistant, Bile resistant, Lack capsule and Lancefield antigens, Low virulence.

What is Marantic Endocarditis?

Also known as Non-Bacterial Thrombotic Endocarditis, it is the deposition of small sterile vegetations on valve leaflets.

What is Takayasu Arteritis?

Also known as Pulseless Disease, it is a Vasculitis that involves extensive Intimal Fibrosis.

What does an Aortic or Mitral Valve Replacement look like?

Also visible on PA Xray, looking like near perfect Circles.

Give a brief description of vitamin C deficiency.

Altered collagen cross-linking.

What is Einthoven's Triangle?

Although Electrodes are placed far from the heart during 3-Lead EKG, each electrode corresponds to the tips of an imaginary equilateral triangle that surrounds the heart. The body is a good conductor which allows this approximation.

What is Trandolapril?

An Ace Inhibitor. Remember these are very useful for reducing Vascular Remodeling.

Define Acute Coronary Syndrome.

An Acute expression of Ischemic Heart Disease, implying a lack of Oxygen to the Myocardium and associated with some general symptoms.

What is a True Aneurysm?

An Aneurysm that involves all three layers of the Vessel.

What is a False Aneurysm?

An Aneurysm that only involves that Adventitia. Can be called an Extravascular Hematoma or Pulsating Hematoma.

What Heart Sounds are heard in Mitral Regurgitation?

An Apical Holosystolic Murmur that radiates to the (Left) Axilla.

Describe the Pathology of FH Type 3, Dysbetalipoproteinemia.

An Apo-E Mutation affects the binding of LDL and reduces the ability to remove IDL. IDL, TG, and CE elevated. Xanthomas may be seen.

What will an ECG of a patient with aortic stenosis reveal?

An ECG of a patient with advanced aortic stenosis may reveal left ventricle hypertrophy.

What Heart Sounds are associated with Early Aortic Stenosis?

An Early Systolic ejection Murmur.

How Much does an MRI Cost?

An MRI costs $3,000.

What heart sound is heard with left ventricular systolic failure?

An S3 or ventricular gallop.

What heart sound is produced by a stiffened ventricle (diastolic dysfunction)?

An S4 or atrial gallop will be heard if the left atrium is vigorously contracting against a very stiffened ventricle.

What is a hemothorax?

An accumulation of blood in the pleural space.

What is the Structure of Amiodarone?

An analog of Thyroid Hormone.

What is the most common physical exam finding in a patient with mitral regurgitation?

An apical holosystolic (pansystolic) murmur that radiates to the axilla.

How does a CT capture the Heart in the same phase of contraction as it scans?

An attached EKG monitors so that the pictures are taken at exactly the same time during EKG, so should be same part of Heart contraction.

What imaging modality can be used to visualize mitral valve prolapse?

An echocardiogram demonstrates posterior displacement of one or both mitral leaflets into the left atrium during systole.

What is hemomediastinum?

An effusion of blood into the mediastinum.

What is Lipoprotein Lipase?

An enzyme that cleaves all three of the 'Legs' off fatty acids.

What is Coenzyme Q10, also called Ubiquinone?

An enzyme that is supposedly used up faster while taking Statins because HMG-CoA is used to make it, though no one has ever found that. It is a ETC protein that helps make ATP. If it is truly reduced it can cause problems, and it helps in CHF.

What is myxomatous degeneration?

An idiopathic degenerative process that can lead to mitral valve prolapse or mitral regurgitation.

What is Marfan syndrome?

An inherited connective-tissue disorder transmitted as an autosomal dominant trait. Consists of mutations in the fibrillin-1 (FBN1) gene on chromosome 15, which encodes for the glycoprotein fibrillin. Fibrillin is a major building block of microfibrils, which constitute the structural components of the suspensory ligament of the lens and serve as substrates for elastin in the aorta and other connective tissues.

What is heparin?

An injectable anticoagulant (IV or SQ) with rapid action. It is used to prevent or stabilize clots but is not an effective thrombolytic.

What is a complication of the development of fibromuscular dysplasia?

Aneurysms may develop in adjacent vessel segments with attenuated media leading to rupture.

What is the single most frequent symptom of Intermittent Myocardial Ischemia?

Angina Pectoris.

What are Compelling Indications that favor Calcium Channel Blockers?

Angina, SVT, Diabetes, and in African Americans. Note some similarities to Beta Blocker Compelling Indications, except diabetes.

What is a bizarre side-effect that can occurewhen taking an ACE inhibitor?

Angioedema (of the tongue).

What is the Gold Standard of diagnosing Coronary Atherosclerosis?

Angiogram.

How Much does Angiography Cost?

Angiography costs $5,000-$15,000.

What is the best, cheap screen for PAD?

Ankle Brachial Test, ideally with a doppler. Normal is greater than 1, less than 0.9 is PAD.

What Labs can help identify the Rheumatic Fever?

Anti-Streptolysin O (ASO) Titer is positive in 85% of RF. Adding Anti-DNAase B or Anti-Hyaluronidase to ASO increases sensitivity to 90%.

Describe the Pathogenesis of Rheumatic Fever.

Antibodies to Group A Streptococcus, based on Molecular Mimicry, attack the HEart Valves, Subcutaneous tissue, Tendons and Joints and the Basal Ganglia of the brain.

Describe how a viral infection can contribute to immune complex associated vasculitis.

Antibodies to viral proteins forms immune complexes that can be found in the serum and the vascular lesions.

What are ANCAs?

Antineutrophil Cytoplasmic Antibodies are circulating antibodies that attack enzymes of Neutrophils and Endothelial Cells. They stimulate these cells to release Cytokines and ROS.

What are Ticlopidine and Clopidogrel?

Antiplatelet medicines that act by Antagonizing Adenosine Diphosphate.

What is the Treatment for PAD?

Antiplatelet therapy, such as Aspirin. Increased exercise, preferably a supervised walking program. Cilostazol and Pentoxifylline can help with Claudication. No need to memorize.

What is the primary goal of treatment for unstable angina or non-ST elevation MI?

Antithrombotic therapy aimed at stabilizing the underlying coronary thrombus and anti-ischemic medication to improve the balance between myocardial oxygen supply and demand.

What is a lipid?

Any biochemical species which is hydrophobic or which has substantial regions of hydrophobicity.

What is the general definition of a lipid?

Any molecule that is hydrophobic or has regions of substantial hydrophobicity

Which vessels are affected by large vessel vasculitis?

Aorta and large branches to extremities, head, and neck.

What is Marfan Syndrome, and how does it relate to Aneurysm?

Aortic Dissection and Dilation are the main causes of death in Marfan's, with life expectancy of 30-40 years. It is a Fibrillin problem with the gene FBN-1, with characteristic Arachnodactyly.

What is Aortic Regurgitation?

Aortic Regurgitation occurs when there has been damage to the aortic leaflets or there has been significant aortic dilation, allowing abnormal regurgitation of blood from the aorta into the LV during diastole.

What condition causes the Largest and Heaviest Heart?

Aortic Stenosis, even more so with Mitral Regurgitation. Hypertension alone would not account for a heart near 850g (as an example).

What is the major cause of mortality and morbidity in Marfan syndrome patients?

Aortic dilatation and dissection, with an average life expectancy of 40 to 40 years.

A 69-year old male is evaluated in the ER for chest pain and dyspnea. He is diagnosed with an ascending aorta dissection and is admitted to the hospital. During the night he develops significantly worsened dyspnea, and a chest x-ray shows the new development of bilateral pulmonary edema. Physical exam reveals a new heart sound described as a "blowing" decrescendo diastolic murmur. Which of the following has most likely occurred?

Aortic regurgitation.

What is the consequence of the distortion of the aortic annulus due to an aortic dissection?

Aortic regurgitation.

A 55-year old woman is referred for evaluation of angina. Her history also includes occasional lightheadedness with exertion. There is a coarse crescendo-decrescendo systolic murmur that is loudest at the base of the heart. She has weakened and delayed carotid artery upstrokes. There are also rales auscultated at the bases of both lungs. Which diagnosis is most consistent with this clinical picture?

Aortic stenosis

What in the HDL is an activator of Lecithin-cholesterol acyl transferase?

Apo A1.

What receptor allows cells to uptake LDL when cholesterol is needed?

Apo B100 receptor

What protein does lipoprotein lipase interact with on chylomicrons? What does this allow?

Apo C II - this interaction allows the lipoprotein lipase to hydrolyze the TG content of the chylomicron (but NOT the CE)

How is IDL taken up by the liver?

Apo C is lost; Apo E/B100 have a high affinity for liver LDL receptors

Which apoprotein is a cofactor for lipoprotein lipase?

Apo CII

Which apoprotein is an inhibitor of lipoprotein lipase?

Apo CIII

What kept the E apoprotein from binding liver receptors before the chylomicron became a remnant?

Apo CIII apoproteins (prior to their removal).

How is lipoprotein lipase regulated?

Apo CIII is an inhibitor of lipoprotein lipase. Thus, the ratio of Apo CII to Apo CIII controls the level of activity of lipoprotein lipase.

Apo-E3 is the most common variant of Apo-E found in people. What are the other two and what risks or Benefits do they incur?

Apo E2 carriers must eat right and exercise, and Respond poorly to Statins. It makes Type 3 FH much worse. Apo E4 carriers respond well to Statins and not so well to diet and exercise. Alcohol should be avoided, and Alzheimers risk doubled.

What rare mutation can lead to a low HDL?

Apo-A1 Deficiency. It can be bad enough to have essentially zero HDL. Apo-A1 Milano is low HDL but it works super well so they're ok.

What is lipoprotein (a)?

Apolipoprotein (a) resembles plasminogen and is linked to the apo B100 of LDL. The combination is called lipoprotein (a). High levels of Lp(a) are linked to heart disease.

Marfan syndrome can be difficult to diagnose, what is one significant sign of Marfan syndrome?

Arachnodactyly.

What are reciprocal Changes on 12-Lead ECG?

Areas of ST depression that occur while ST is elevated elsewhere. Yellow is Elevation, Blue is Reciprocal Changes (Depressions) in the picture.

What complications arise form electrical instability in the heart (1)?

Arrhythmias.

What does a Normal Pulmonary Angiogram look like? (Also called an Arteriogram)

Arteries up to 50% filled with Iodine Contrast. Injection was recent, so only Arteries are visible. Later veins will be also.

Define Arteriolosclerosis, and contrast Hyaline and Hyperplastic varieties.

ArterioLOsclerosis means narrowing of the small resistance Arteries, making this important in Hypertension. Hyaline is caused by leaking of Pink colored Plasma Proteins leaking out of Endothelial cells. It is seen here and there in Elderly people but widespread in Hypertension. Hyperplastic is Muscle Cell Proliferation in response to very high Blood Pressure, like over 240 systolic.

Which vessels are affected by small vessel vasculitis?

Arterioles, venules, capillaries, and occasionally small arteries.

How does HDL start out?

As pre-beta or "lipid free" HDL, in which It is organized as a flat discoidal phospholipid bilayer surrounded by apo-AI.

How does aortic stenosis cause congestive heart failure?

As the stenosis progresses, the left ventricle becomes less able to cope with the gradually increasing afterload. Left ventricle diastolic volume and pressure increases leading to increased left atrium pressure which leads to increased pulmonary venous pressure which results in pulmonary alveolar congestion.

How do you distinguish between acute coronary syndrome?

Assessment of the ECG and serum biomarkers.

In what group of pts should beta blockers be avoided? (3)

Asthma, reactive airway disease, second or third degree heart block

Where do primary arterial thrombi develop?

At sites of endothelial damage or compromise.

How is HMG CoA reductase activity regulated?

At the gene level by phosphorylation. When cholesterol is in excess in the liver and/or bile acids in the intestine, the activity of this enzyme is decreased.

What is the most common condition associated with the development of an abdominal aortic aneurysm?

Atherosclerosis.

What is the most common etiology of an abdominal aortic aneurysm?

Atherosclerosis.

What is the most frequent and clinically important pattern of arteriosclerosis?

Atherosclerosis.

Give some contributing Etiologies to Aneurysm.

Atherosclerosis. Polygenetic Potential. Cystic Medial Necrosis. Syndromes: Marfan and Ehlers-Danlos. Inflammation.

How is the presence of coronary atherosclerosis measured?

Atherosclerotic plaques become progressively calcified over time, and coronary calcification in general increases with age. Thus, methods for detecting coronary calcium have been developed.

Which Statins have the longest half-life?

Atorvastatin and Rosuvastatin. These are also the most efficacious at lowering LDL.

Which statin is not absorbed when taken with food?

Atorvastatin.

What are the contraindications of beta blockers?

Avoid in Wolf-Parkinson-White type arrhythmia.

What type of apoproteins are found in VLDL?

B100, C and E

Which VLDL apoprotein is similar to B48?

B100, which is required for organization and secretion of the VLDL.

What is the only apoprotein retained by LDL as it is modified from IDL?

B100.

What drug classes are recommended for hypertension post-myocardial infarction? (3)

BB, ACEI, Aldo ANT

What drug classes are NOT recommended for hypertension and recurrent stroked prevention? (4)

BB, ARB, CCB, Aldo ANT

What are some Risk Factors for Infective Endocarditis?

Bacteremia is the major predisposing factor Valvular lesions Mitral prolapse Bicuspid aortic valve Calcified aortic valve Prosthetic valve Diabetes Intravenous drug abuse

How are lipoproteins classified?

Based on their density.

How is it that Partial LCAT deficiency is worse that full LCAT knockout.

Because Partial Knockout only affects HDL, the good one that removes Cholesterol. The LDL still functions to provide Cholesterol, so this is worse than full knockout which impairs both Delivery and Removal of Cholesterol.

How does aortic stenosis lead to left heart hypertrophy?

Because aortic stenosis develops over years, the left ventricle compensates by undergoing concentric hypertrophy secondary to generating high systolic pressure. The hypertrophy somewhat reduces ventricular wall stress but also reduces compliance so that increasing diastolic left ventricle pressure leads to left atrium hypertrophy due to increased (diastolic) pressure needed to fill the stiff left ventricle.

Wwhy is "lipid free" HDL the most abundant species of HDL in the extravascular space?

Because of its relatively small size.

Which Calcium Channel Blockers work on both heart and Vasculature?

Bepridil, Diltiazem, and Verapamil.

What is the best way to test for silent angina?

Best detection is with TMST, followed by imaging to visualize wall motion, LVEF, etc.

What is the mechanism of action of esmolol?

Beta 1 receptor antagonist.

What is the mechanism of action of metoprolol?

Beta 1 receptor blocker.

What is the Treatment for Aortic Dissection?

Beta Blockers and Sodium Nitroprusside, a Vasodilator. Goal is to reduce SBP to 120. Surgery not very helpful, only indicated if the Aortic Diameter greater than 6 cm.

What is the best Pharmacology to treat Aortic Aneurysm?

Beta Blockers, and surgery in cases where the Aneurysm is growing faster than .6-.8 cm per year diameter.

What are Arrhythmia Drugs Class II?

Beta Blockers.

What hemodynamic effects do non-specific beta blockers produce?

Beta receptor blockade reduces blood pressure via a decrease in cardiac output and a decrease in beta-receptor stimulated increases in renin production.

Once absorbed, how are beta-monoglycerides and fatty acids inserted into chylomicrons?

Beta-monoglyceride + 2 FA-SCoA converted by fatty acyl transferases -> regenerated TG -> inserted to core of new chylomicron by Microsomal Lipid Transfer Protein (MLTP) in SER lumen

What are the clinical indications for pindolol?

Better for someone with cardiac failure.

What is the advantage of triglycerides being hydrophobic?

Better storage, as they do not hold water like carbohydrates

Where does the normal QRS axis fall on the heart?

Between aVL (-30 degrees) and aVF (90 degrees).

What are mixed bilayers? Give an example.

Bilayers which contain more than one type of compound, for example, a cell membrane which is comprised of the amphipathic molecules phospholipids, sphingolipids and cholesterol.

Class of Cholestyramine.

Bile-Acid Binding Resin.

Class of Colesevelam.

Bile-Acid Binding Resin.

Class of Colestipol.

Bile-Acid Binding Resin.

What is the mechanism of action of adenosine?

Binds adenosine receptor.

What is the role of the apo A1 protein?

Binds to peripheral cell membranes and interacts with their ABC-1 proteins that facilitate cholesterol transfer into the HDL

Once inside the cell, what is the fate of LDL?

Binds with lysosome and release CE which is converted to free cholesterol by cholesterol ester deacylase

Contrast Mechanical and Biological Valve.

Biological last only about 10 years but require less anticoagulation. They are also silent.

What is Atheroembolism?

Bits of cholesterol that occlude small blood vessels, leading to Livedo Reticularis, shown.

What is an atheroembolism?

Bits of cholesterol, platelet clots and fibrin migrate distally and occlude small arteries in the muscle and skin.

What drugs are associated with Pulmonary Fibrosis?

Bleomycin, Amiodarone, Busulfan.

When are Class 1A Arrhythmia Drugs used?

Block cells that are more frequently depolarizing. Allows for preferential blockade of abnormally fast beating cells over cells in a more normal rhythm.

What is the mechanism of action of amiodarone?

Blockade of calcium, sodium and potassium channels as well as blocking beta receptors.

What is the MOA of mecamylamine?

Blocks nicotinic receptor in autonimc ganglia, thus preventing neurotransmission.

What is the mechanism of action of bretylium?

Blocks potassium channels.

What is the mechanism of action of sotolol?

Blocks rectifier potassium current and also beta receptors.

What is an arterial dissection?

Blood enters the arterial wall itself as a hematoma dissecting between its layers.

What is important to note about B48 and B100?

Both B100 and B48 are encoded by the same gene. The mRNA is edited in the intestine to make the smaller protein.

When managing common types of Angina, is the goal Mainly to decrease Myocyte Oxygen Consumption or to Vasodilate the Arteries?

Both, but Oxygen Consumption is often all we can do because the vessels can be so occluded.

Is VLDL associated with Elevated CE or TG?

Both. LDL carries CE to Tissues, HDL carries CE to Liver.

What do Ace Inhibitors have to do with Bradykinin?

Bradykinin is the substrate of ACE, so it builds when patients are on ACE Inhibitors. It can lead to coughs and angiodema.

Define LDL

Breakdown of VLDL via IDL, enriched in CE, only coated in apo B100. Taken up by liver and cholesterol used to make bile acids (about 60%)

What does a Thoracic Aortic Aneurysm look like on CT Angiogram?

Bulging out into the right is the Aneurysm.

Describe non-specific cholesterol intake.

Bulk endo-cytosis by endothelial cells of fluid occurs at all times. The higher the concentration of LDL in the blood the more cholesterol that will be nonspecifically taken up at any one time. By transcytosis the LDL is deposited in the subendothelial space.

What are Esophageal Varices?

Bumpy projections made from varicose type veins in the Esophagus. Often caused by Portal Hypertension. Also called Esophageal Hemorrhoids.

How is HDL3 converted to HDL2?

By LCAT, PLTP, and CETP. LCAT removes cholesterol from the outer shell of the HDL, PLTP transfers more phospholipid and possibly cholesterol to shell. CETP exchanges CE for TG, allowing the excess CE to be returned to the liver and LDL for redistribution.

How is the Cartesian Coordinate plane for 3-Lead EKG derived?

By Rearranging the legs of Einthoven's Triangle, moving them because they are vectors.

How are endogenous TGs transferred to the tissues?

By VLDL

Other than B100 receptor binding, how can cholesterol be taken up into cell?

By continuous bulk endocytosis by endolthelial cells - the higher LDL is in the blood, the more will be taken up - LDL is deposited in subendothelial space

How is lipoprotein lipase regulated, especially in adipose tissue?

By insulin, and the ratio of Apo CII to Apo CIII

How is pre-beta / nascent HDL converted to alpha HDL?

By picking up cholesterol and interacting with the triglyceride rich lipoproteins, thereby picking up Apo AII, Apo C and Apo E. Also binds LCAT, CETP and PLTP from plasma to the HDL surface.

How do tissues pick up cholesterol?

By putting out B100 receptors, which bind LDL

What is the fate of the chylomicron remnant once it has lost most of its lipids?

C proteins transferred back to HDL. E proteins can now bind to LRP receptors in liver and facilitate endocytosis.

When is Coronary Artery Bypass Grat indicated?

CABG is used often for Left Main Coronary Artery Stenosis, or if complications occur with Percutaneous intervention such as Stent Failure.

What is the Primary issues with elevated Cholesterol versus elevated Triglycerides?

CE causes Atheroscelerosis, shrinking the Lumen of blood vessels. TG alone does not cause those plaques, and in fact is mainly very hard on your Pancreas.

What is the fate of a VLDL once it has become an IDL? What protein faciliates this?

CE from HDL is transferred to IDL, and IDL TGs are transferred to HDL. This is facilitated by cholesterol exchange transfer protein (CETP)

When are Calcium Channel Blockers used cautiously?

CHF, 2nd and 3rd degree Heart Block.

Which used to be the best marker of MI, until Troponins?

CKMB, Creatine Kinase MB.

Inflammation is bad. Does it predispose a patient to Atherosclerosis? Support your answer.

CRP is an inflammatory marker made by the Liver, and its Chronic Elevation is a significant Risk Factor for Atherosclerosis. It does so by activating complement, increasing the Adhesiveness of the Endothelium for Leukocytes. Statins reduce CRP independently of their LDL effects.

What type of Imaging can confirm Aortic Dissection?

CT Angiography with 3d reconstruction if tolerable, otherwise MRI. It is also visible on Chest-Xray, large on shown here.

What is the preferred method for assessing an aneurysm in an urgent situation, if the patient is clinically stable?

CT.

What drug class is NOT recommended for hypertension in the presence of heart failure?

Calcium channel blockers (CCB)

What is a potential favorable effect of beta blockers? (5)

Can be useful in tx of atrial tachyarrythmia/fibrilliation, migraine, thyrotoxicosis, essential tremor, perioperative hypertension

What is a potential favorable effect of calcium channel blockers?

Can tx Reynaud's syndrome and certain arrhythmias

Although Fungal Endocarditis is rare, which are the most common Fungal variants that cause it.

Candida spp. - yeast, part of normal flora. Aspergillus spp. - mold, ubiquitous in nature.

Some people are allergic to Iodine. What is an alternative Contrast possibility?

Carbon Dioxide.

How does Aortic Stenosis cause Exertional Syncope?

Cardiac Output cannot increase normally during exercise, so instead unusual Syncopes are seen.

What are the general Consequences of Mitral Regurgitation?

Cardiac Output is directly reduced, because some blood goes backward to the Left Atrium and thus less into the Aorta. This leads to Increased Left Atrial Volume and Pressure. The 'extra' blood that returned to the Atrium enters the Left Ventricle, increasing Initial volume and forcing the Ventricle to work harder to increase Stroke Volume.

Give some causes for Pulsus Paradoxis.

Cardiac tamponade Acute or chromic airway disease Constrictive pericarditis Restrictive cardiomyopathy Pulmonary embolism Right ventricular infarction Circulatory shock

What is Cardiogenic Shock?

Cardiogenic shock is when the heart has been damaged so much that it is unable to supply enough blood to the organs of the body.

Which are the Major Jones Criteria for Rheumatic Fever (2 gives a diagnosis).

Carditis, Migratory Polyarthritis, Sydenham's Chorea, Subcutaneous Nodules, Erythema Marginatum.

What is the pregnancy category for niacin?

Category C.

What is the pregnancy category of bile binding resins?

Category C.

What is the pregnancy category of ezetimibe?

Category C.

What is the pregnancy category of fibrates?

Category C.

What category are statins for pregnant patients?

Category X.

Which types of Infectious Endocarditis are commonly caused by Staph. Epidermidis?

Catheter & prosthetic devise infections IE in IV drug users and prosthetic valve IE. It is the most common cause of Subacute IE, and their Virulence Factor is Biofilms.

Occlusion of the left circumflex artery:

Causes a lateral MI.

Occlusion of the left coronary artery:

Causes a massive antero-lateral MI.

Occlusion of the right coronary artery:

Causes a posterior inferior MI.

Occlusion of the left anterior descending artery:

Causes an antero-septal MI.

What are the characteristics of inflammatory aortic aneurysms?

Characterized by dense periaortic fibrosis and abundant lymphoplasmacytic inflammation with many macrophages and often giant cells.

What labs are called for if Chronic Stable Angina is diagnosed?

Check fasting Lipid Panel, serum Glucose/HgbA1c, Renal Function, Resting ECG.

How does Acute Pericarditis Present?

Chest Pain, retrosternal radiating to the Trapezius, ST Elevation in more than one region, Leaning forward reduces pain and increased Chest Pain when lying down. Other symptoms include a Pericardial Friction Rub, Fever, Odynophagia (Painful swallowing), Splinted Breathing, Intermittent Dysrhythmias.

What is variant angina?

Chest pain that occurs during activity or at rest.

What demographic is at risk for group A Beta-Hemolytic Streptococcus infection of the Pharynx?

Children 5-15. If treated with Penicillin or Erythromycin you will not get Rheumatic Fever later in life. Otherwise, you have about 0.5% chance of getting RF later. It accounts for 25% of Cardiac Admissions in some countries.

How is cholesterol inserted into a chylomicron?

Cholesterol converted by acyl cholesterol acyl transferase (ACAT) -> cholesterol ester -> inserted to chylomicron by Microsomal Lipid Transfer Protein (MLTP)

Describe how a breakdown product of VLDL is modified to form LDL.

Cholesterol ester transferred from HDL to IDL via a cholesterol exchange transfer protein until it is mostly cholesterol ester with very little triglyceride. The triglyceride content is depleted by hepatic lipase.

Why must cholesterol be carried in the core of lipoproteins?

Cholesterol is only very weakly amphipathic - if too much is inserted in the shell of a lipoprotein or micelle, the structure can come out of solution

Give three examples of Bile-Acid Binding Resins.

Cholestyramine, Colestipol, Colesevelam.

What can cause Acute Mitral Regurgitation?

Chordae Tendinae Rupture, Papillary Muscle Dysfunction secondary to MI. Fenfluramine and Phentermine have also been indicated.

Contrast the Effects of Chronic and Acute Mitral Regurgitation.

Chronic MR can present as weakness with exertion. It can lead to LV Failure or RV failure. Acute MR can cause Pulmonary Edema and so presents as Dyspnea.

What Disorders fall under the Category of more Chronic Ischemic Syndromes? (versus Acute)

Chronic Stable Angina, Variant Angina, Silent Ischemia.

What are the therapeutic uses of mexiletine (1)?

Chronic treatment of ventricular arrhythmias.

What is giant cell (temporal) arteritis?

Chronic, granulomatous inflammation of large to small-sized arteries.

Which condition is anti-myeloperoxidase (MPO-ANCA) most commonly associated with?

Churg-Strauss and microscopic polyangiitis.

Which lipoproteins are rich in TG?

Chylomicrons and VLDL

Describe the features of chylomicrons.

Chylomicrons are made in the intestine and carry dietary lipids.

How does the electrophoresis pattern of fed plasma differ from fasting plasma?

Chylomicrons present at origin and VLDL present between LDL and HDL

Which lipoprotein transports dietary lipids?

Chylomicrons.

What is the Lipoprotein Carrier of Dietary Triglycerides?

Chylomicrons. These should not be present in fasting blood.

Describe how systemic lupus erythematosus can contribute to immune complex associated vasculitis.

Circulating DNA-anti-DNA complexes may be present, but the sensitivity and specificity are low.

Class of Tocainide?

Class 1B Beta Blocker.

Which drugs increase the QT interval?

Class 3 Potassium Blockers, 1A Sodium Blockers, and Amiodarone. These reduce Potassium Conductance.

Contrast Class 1A, 1B, and 1C Beta Blockers.

Class A increase APD by blocking Potassium Channels. Class B decrease APD, and class C have no effect on it.

What is the prognosis for aortic regurgitation?

Clinical progression in chronic aortic regurgitation is very slow, so asymptomatic patients are monitored periodically, which includes regular assessment of left ventricle function.

What Heart Sounds are associated with Advanced Aortic Stenosis?

Coarse late-peaking crescendo-decrescendo systolic ejection murmur, and may have S4.

Strokes are a common consequence of Hypertension. What effects can these have besides death?

Cognition impairment in the elderly.

Which Bile Acid is more specific with less side effects?

Colesevelam.

What is Fibromuscular Dysplasia?

Common in Renal Arteries, it is a Focal irregular Thickening of the walls of medium and large muscular arteries, a combination of irregular Medial and Intimal Hyperplasia and Fibrosis . Dysplasia is basically a Misnomer as no cancer is involved, but rather narrow Renal arteries that activate the Renin pathway.

What is Infective Endocarditis?

Commonly Bacterial infection resulting in vegetations: Masses of dead cells, clots and organisms .

How is a Stress Test interpreted?

Compare Rest and Peak images. Normal- no defects/ stays same for both acquisitions Ischemia- no activity in stress/ with redistribution at rest Infarction- a defect in the same place in both

How does critical stenosis result in angina pectoris?

Compensatory coronary dilation is not enough to meet a moderately increased demand.

Are triglycerides hydrophobic or hydrophilic?

Completely hydrophobic; the long hydrocarbon chain shield the ester group

What is the structure of creatine kinase?

Composed of two dimers, "M" and "B."

What is a Berry Aneurysm?

Congenital Weakness of Cerebral Vessel walls create expansions that may rupture.

What is a complication of ventricular septal defect?

Congestive heart failure.

What is the best approach to have when treating an aortic dissection?

Conservative, unless the risks of the surgery are reasonable for a given patient.

What effect do calcium channel blockers have on the gut?

Constipation.

What is Constrictive Pericarditis?

Constrictive pericarditis is due to a thickened, fibrotic pericardium that forms a non-compliant shell around the heart. This shell prevents the heart from expanding when blood enters it. This limits Diastolic Expansion.

About 12 Hours into an Infarct, Neutrophil Migration becomes prominent. What does this look like on a Microscope?

Contraction bands are pink Streaks that are unusually large.

What is the Gold Standard to diagnose PAD?

Contrast Angiography. MR Angiography not too bad either.

What is the gold standard of diagnostic imaging for peripheral artery disease?

Contrast angiography.

What is the fate of endogenously synthesized cholesterol?

Converted to CE and packaged by liver in VLDL

What is the MOA of methyldopa?

Converted to an active product which behaves as an a2 receptor agonist.

What is vasculogenesis?

De novo formation of blood vessels during embryogenesis.

What is the treatment rationale for stable angina?

Decrease heart work through the peripheral resistance, ventricular volume and/or cardiac output.

What reflex does the treatment of high blood pressure induce?

Decreased blood flow leads to sodium and water retention.

What is the MOA of niacin?

Decreases free fatty acid mobilization to the liver and increases VLDL clearance via lipoprotein lipase activation.

Give a brief description of Ehlers Danlos syndrome.

Defective type III collagen synthesis.

Describe the Pathology of Type I Hyperlipoproteinemia.

Deficiency in LPL leads to way too many Chylomicrons. Triglycerides in blood will be high, up to 2500. Acute Pancreatitis is a very large risk for these people, more so than MI.

What does MI look like after years?

Dense collagenous scar.

What are the toxicities of the calcium channel blockers

Depending on class: Reflex tachycardia, constipation, headache, hyperkalemia, edema, heart block and liver dysfunction Depending on onset of action: Fast onset Ca++-channel blockers are associated with ↑ MI's and death vigorous sympathetic response to sudden drop of blood pressure. Slow release formulations may be better

What are the claudication symptoms that can experienced with peripheral artery disease?

Depending on the artery affected, the patient will have buttock, thigh or calf discomfort precipitated by walking and relieved by rest.

How is the procedure for a patient with acute arterial occlusion chosen (3)?

Depends on -Severity of the ischemia -Extent and location of the thrombus -General medical condition of the patient

What is a phospholipid or substituted phosphotidic acid?

Derivatives of a 1,2-diacyl glycerol in which the remaining hydroxyl group is esterified with phosphoric acid, making the molecule amphipathic.

What is chronic ischemic heart disease?

Development of congestive heart failure based on long term progressive ischemic myocardial injury.

What are compelling indications for ACE inhibitors?

Diabetes, CHF, post-MI.

What is the Classic Diabetic Nephropathy?

Diabetic Kidneys have both Afferent and Efferent Hyaline Arteriolosclerosis. In Hypertension only Afferent tend to be affected.

What clinical presentation is associated with a diagnosis of panic attack (1)?

Diagnosis of last resort; must rule-out other diagnoses with testing.

Which lipids do chylomicrons transport?

Dietary triglycerides and cholesterol.

How does Thoracic Aortic Aneurysm Present?

Difficulty swallowing and breathing, persistant cough from pressure on Recurrent Laryngeal Nerves.

What EKG changes can be seen in Pericarditis?

Diffuse ST Segment Elevation(except aVR and V1), PR segment Depression, Decreased QRS Voltage.

What are fusiform aneurysms?

Diffuse, circumferential dilation of a long vascular segment They vary in diameter (up to 20 cm) and in length and may involve extensive portions of the aortic arch, abdominal aorta, or iliac arteries.

When is Magnesium used for Arrhythmia?

Digitalis induced Arrhythmias, and in Acute MI.

What is the Differential for Cardiomegaly on Chest X-Ray?

Dilatation (stretching, as in Aneurysm), Hypertrophy, Pericardial Effusion.

What are the hemodynamic effects diazoxide produces?

Dilates both arteries and veins.

What hemodynamic effects does sodium nitroprusside produce?

Dilates both arteries and veins.

What hemodynamic effects do the arteriolar dilators produce?

Dilation of arteriolar resistance vessels leads to a decrease in peripheral vascular resistance.

What hemodynamic effects do prazosin, etc produce?

Dilation of both resistance and capacitance blood vessels. Blood pressure is reduced more in an upright posture than a supine posture.

What is infectious vasculitis?

Direct invasion of vascular walls by pathogens.

Is arterial dissection common is patients with syphilis?

Dissection is unusual in the presence of substantial medial scarring such as syphilis, presumably because the medial fibrosis inhibits propagation of the dissecting hematoma.

What drug classes are recommended for hypertension and recurrent stroked prevention? (2)

Diuretic, ACEI

What drug classes are NOT recommended for hypertension post-myocardial infarction? (3)

Diuretic, ARB, CCB

What drug classes are recommended for hypertension in the presence of diabetes? (5)

Diuretic, BB, ACEI, ARB, CCB

What drug classes are recommended for hypertension in the presence of high coronary disease risk? (4)

Diuretic, BB, ACEI, CCB

What drug classes are NOT recommended for hypertension in the presence of chronic kidney disease? (4)

Diuretic, BB, CC, Aldo ANT

What therapy is used for symptom control of aortic regurgitation (1)?

Diuretics and vasodilators for heart failure.

What therapy is used for symptom control of aortic stenosis (1)?

Diuretics for heart failure.

What Imaging Techniques are used to Diagnose Mitral Regurgitation, and really most other Valvular diseases?

Doppler Echo by far first choice. You can also use Chest X-ray and ECG to see Hypertrophy. This ECG shows LVH.

What is the best imaging modality for visualizing aortic regurgitation?

Doppler echocardiogram which can determine the degree and cause of the regurgitation.

What is the best imaging modality for assesisng the aortic valve and left ventricle wall?

Doppler echocardiogram.

What is the best imaging modality when evaluating tricuspid regurgitation?

Doppler echocardiogram.

What is Dressler's Syndrome?

Dressler's syndrome is a secondary form of Pericarditis that occurs in the setting of injury to the Heart or the Pericardium (the outer lining of the heart). It consists of a triad of features, Fever, Pleuritic Pain and Pericardial Effusion, and is treated with NSAIDS.

Side Effects of Lidocaine?

Drowsiness, Slurred Speech, Confusion, Arrhythmias. Lidocaine is given IV and can reach the brain.

Contrast Bare Metal Stents and Drug Eluding Stents?

Drug Eluding Stents are coated with Steroids which decrease the intimal Hyperplasia, but they tend to thrombose a few years later. You must be on Plavix and Aspirin for at least a year if not life. Bare Metal Stents require anticoagulation for only 3 Months, but they have a higher rate of complications.

What are the therapeutic uses of adenosine (1)?

Drug of choice for paroxysmal supraventricular tachycardia.

What are the therapeutic uses of digoxin (1)?

Drug of choice for supraventricular type arrhythmias.

What are the therapeutic uses of lidocaine (1)?

Drug of choice for ventricular arrhythmias, especially post-MI.

What are the beneficial drug interactions calcium channel blockers have?

Drug transport systems (responsible for resistance to chemotherapy of cancer) are inhibited by verapamil in isolated cells.

Which Arrhythmia Drugs are for Rhythm Control?

Drugs that alter Sodium and Potassium Channel Conduction, eg the Blockers.

How does lipoprotein a contribute to the persistance of wounds?

Due to its similarity to plasminogen, Lp(a) competes with plasminogen for tissue plasminogen activators. This helps clots to persist. The clot may be the trigger for a heart attack or may contribute to the gradual thickening of the artery wall that precedes the heart attack. The Lp(a) also competes with plasminogen for binding sites on fibrin, making it more difficult for the enzyme precursor to find its normal substrate fibrin.

Give the relative sizes of Lipoproteins.

During Electrophoresis, generally the small Lipoproteins move furthest, although VLDL moves farther than LDL.

How is mitral valve prolapse usually identified?

During cardiac auscultation during a routine physical examination.

Describe the pathophysiology of mitral regurgitation.

During systole, a portion of the left ventricle stroke volume is ejected backward into the left atrium, reducing the cardiac output through the aorta.

Describe the signs associated with decreased systolic function.

Dyskinetic apical impulse.

What are the signs and symptoms of Pulmonary Fibrosis?

Dyspnea, Dry Cough, Aching Muscles, Fatigue, Weight Loss.

How Does Aortic Regurgitation Present?

Dyspnea, and the Patient may be aware of Pounding, intense heartbeats.

What is the major presenting symptom of pulmonary hypertension?

Dyspnea.

Contrast Dystrophic Calcification with Metastatic Calcification.

Dystrophic occurs without Hypercalcemia, and in only one or a few places. Metastatic is widespread, resulting from Hypercalcemia. Complex Plaque shown with Dystrophic Calcification.

Which is the most sensitive MI lab test. Least?

EKG and ECHO need 10 grams infarct to see Q-Waves.

What is the most common complication of fibronlytic therapy?

Each stimulates the natural fibrinolytic system but is not specific, so bleeding is the most common complication, though the newer agents have slightly lower risk of bleeding.

When do most Heart Attacks occur?

Early Morning. Perhaps caused by the Stress of getting to work.

Compare the Bugs in Prosthetic Valve Infective Endocarditis, Both Early and Late.

Early is less than 3 months, caused by Staphylococci (55% of cases), Gram(-) rods, Fungi (candida). These are often Nosocomial. Late is caused by Alpha-hemolytic streptococci, Enterococci or Staphylococci.

What does the literature say about surgery for type B aortic dissections?

Early surgery does not improve outcomes. Actuarial survival rate of medically managed patients was 98.4% at 1 month and 93.5% at 8 years. CONCLUSIONS: Medical treatment of type B acute aortic dissection produced good results. Surgical intervention for type B dissection should be done when the maximum aortic diameter exceeds 60 mm.

Contrast Eccentric and Concentric Atheroma.

Eccentric Atheromas respond well to Vasodilators, because the Fibrous Plaque is only on one side of the vessel. Concentric Atheromas surround the whole vessel and do not respond to Drug Therapy well.

How Much does a Cardiac Ultrasound Cost? (also called Echocardiography)

Echocardiography costs $1,000.

Why does the heart quickly compensate when atrial fibrillation develops secondary to aortic stenosis?

Effective stroke volume is lost.

How does Constrictive Pericarditis Present?

Effort dyspnea Fatigue Abdominal swelling and discomfort Orthopnea (Shortness of Breath when lying Flat) Cough.

What is meant by Carditis as a general Term?

Either Pericarditis, Cardiomegaly, Right or Left Sided Heart Failure, Mitral or Aortic Regurgitation. (For RF the Mitral Valve is indicated 60% of the time, usually Stenosis)

How does Giant-Cell Arteritis Present?

Elderly Patient, Intense headache or pain on facial artery with thick, cord-like Temporal Artery. Ocular Symptoms (Blindess, etc) can occur rapidly and must be treated rapidly.

What are the effects of Amiodarone?

Elements of Class I, II, III, and IV drugs. Most Pronounced: Prolongation of action potential duration and Refractory period.

What Physical Findings are found in Cardiac Tamponade?

Elevated systemic venous pressure 100% Paradoxical pulse 98% Respiratory rate>20/min 80% Heart rate > 100/min 77% Diminished heart sounds 34% Pericardial friction rub 29% Rapidly declining blood pressure 25%

What is a positive Buerger's Sign?

Elevation of the Extremity causes pallor or cyanosis, and restoring to dependent position results in color changing to red.

What is a positive Buerger's sign?

Elevation of the extremity causes pallor or cyanosis, and restoring to dependent position results in color changing to red.

What complication results from a ventricular thrombus?

Embolism.

How is dietary TG absorbed into the intestinal epithelium?

Emulsified with lecithin (phosphatidyl choline) -> hydrolyzed by pancreatic lipase + intestinal colipase -> beta-monoglyceride + 2 free fatty acids form a pseudomicelle with bile acids, phospholipids and fat soluble vitamins, reaches villi -> beta-monoglyceride (2-MG) and FA absorbed into epithelium

Which Organism is most often responsible for Infective Endocarditis in patients with Healthy vs Diseased Valves?

Endocarditis of abnormal valves is caused most commonly (50% to 60% of cases) by Streptococcus viridans, which is part of the normal flora of the oral cavity. In contrast, more virulent S. aureus organisms commonly found on the skin can infect either healthy or deformed valves and are responsible for 10% to 20% of cases overall; S. aureus is the major offender in intravenous drug abusers with IE.

What is the mechanism of action of ibutlide?

Enhances inward sodium conductance and inhibits Ikr (rapid delayed rectifier potassium current).

What is the key factor in formation of alpha HDL3?

Enrichment of the HDL core with CE by LCAT bound to surface (activated by apo A1), using lecithin (phosphatidyl choline) from HDL or a nearby lipoprotein OR free cholesterol from the HDL shell

What is stable angina?

Episodic chest pain during and after increased demand for myocardial work.

Which drugs have serious interactions with nitrates and nitrites?

Erectile dysfunction drugs like sildenafil, tadalafil, and vardenafil, which are cGMP specific phosphodiesterase inhibitors. Concurrent use can produce excessive hypotension.

How can High Triglycerides be visualized?

Eruptive Xanthomas are blisters full of TGs, and you can also see Lipemia Retinalis, fat overgrowing the Retina on a Fundus exam.

What is the interval for follow up if the abdominal aorta is between 4cm and 4.5cm?

Every six months.

What is the interval for follow up if the abdominal aorta is between 3cm and 4cm?

Every year.

Describe the Timeline of MI.

Evolving 6 h Acute 6 h-7 days Healing 7-28 days Healed 29 days and beyond

Give Side effects of Flecainide.

Exacerbation of the arrhythmia Induce life-threatening ventricular tachycardia CAST study demonstrates increases mortality 2X, so not a very good drug. Dizziness, blurred vision, headache, and nausea

Summarize cholesterol exchange transfer protein (CETP)

Exchanges CE in core of HDL for TG in core of TGRLPs.

What is the function of cholesterol exchange transfer protein?

Exchanges cholesterol ester in core of HDL for triglyceride in core of TGRLPs.

What is the function of cholesterol exchange/transfer protein is the conversion of HDL3 to HDL2?

Exchanges the accumulating cholesterol esters in the core of the HDL for triglycerides in the core of the TGRLPs.

What are the two types of lipids in the body?

Exogenous (dietary) vs endogenous (made in liver)

Where is lipoprotein lipase located?

Extruded from luminal face of capillary endothelium in peripheral tissues when TG are needed

Summarize phospholipid transfer protein PLTP

Facilitates one-way transfer of phospholipid and some cholesterol from the shell of TGRLPs to the shell of shrinking HDLs. Also transfers PL and cholesterol from HDLs to shrinking chylos and VLDLs. (Maintains proper shell : core ratios.)

What is a consequence of genetic defects in B100 receptors?

Familial hypercholesterolemia

What is the consequence of genetic defects in the B100 receptors?

Familial hypercholesterolemia. The lack of one gene (or both genes) for B100 receptors increases the circulating level of LDL and therefore the nonspecific deposition of cholesterol. Homozygotes die early in life. Genetic defects of B100 have a similar effect.

What are the kinetics of nicardipine (1)?

Fast onset.

What are the Toxicites of ACE Inhibitors?

Fatigue, Impotence, Forgetfulness, Hyperkalemia. These are much more mild than other hypertensive medicines. A positive effect is to reduce Vascular Remodeling. Check Potassium levels before beginning treatment.

What enzyme converts absorbed cholesterol to cholesterol ester?

Fatty acyl cholesterol acyl transferase.

Which weight loss drug can cause mitral regurgitation?

Fen-phen, the weight loss drug combination of femfluramine and phentermine which also promoted aortic regurgitation and tricuspid valve disease. Was withdrawn in 1997.

What are three examples of Fibrate drugs?

Fenofibrate, Clofibrate, Gemfibrozil.

Which fibrate has a very long half-life?

Fenofibrate.

Class of Clofibrate?

Fibrate to lower Triglyceride.

Class of Fenofibrate?

Fibrate to lower Triglyceride.

Class of Gemfibrozil?

Fibrate to lower Triglyceride.

What class of drugs stimulates lipoprotein lipase activity?

Fibrates

What class of drugs treat high Triglycerides?

Fibrates.

Which class of drugs stimulates lipoprotein lipase activity?

Fibrates.

How can hyperplastic arteriolosclerosis damage the kidney in particular?

Fibrinoid deposits and vessel wall necrosis (necrotizing arteriolitis) in extreme cases are seen particularly in the kidney.

Morphologic features of MI, microscopic changes: 7-8 weeks

Fibrosis.

Describe the general events that occur as the Depolarization signal moves through the heart.

First the Septum depolarizes as shown, then the Apex and Base.

What is unstable angina?

Fissuring of plaques may cause sudden onset of angina that increases in severity and frequency.

What does the mnemonic 'My Niece Likes to FIGHT' mean?

Flushing, Itching, GI Upset, Hepatic Problems and Hyperuricemia, Tachyarrythmias. These are Niacin (niece) side effects.

What is fibromuscular dysplasia?

Focal irregular thickening of the walls of medium and large muscular arteries.

When is an ADP inhibitor prescribed for acute coronary syndrome?

For additional platelet inhibition or when aspirin is contraindicated.

How is cholesterol absorbed into the intestinal epithelium?

Forms micelles with bile acids, reaches villi -> cholesterol transporters (eg Nieman-Pick NPC1L1) brings cholesterol into cell.

Summary of Apo proteins: C1

Function unknown.

Give the 2 Types of True Aneurysms.

Fusiform Aneurysm expand on Both Sides, Saccular Aneurysms Expand only on one side. True Aneurysm means all three layers expand.

What does the Mnemonic 'The PHENOmenal GEMstone hurts!' mean?

Gallstones Elevated liver enzymes Enhanced action of oral anticoagulants (Warfarin) Myositis or even rhabdoMyolosis. These are Gemfibrozil side effects.

Give causes for Hypovolemic Shock.

Gastroenteritis, Burns, Trauma, Surgery.

What is vasculitis?

General term for vessel wall inflammation. There are more than 20 forms identified.

What is arteriosclerosis?

Generic term reflecting arterial wall thickening and loss of elasticity; hardening of the arteries.

What are the genetic predispositions that contribute to aneurysm formation?

Genetic polymorphisms of MMP and/or TIMP.

What is the most significant independent Risk Factor for Atherosclerosis?

Genetics, aka Family History.

What are the two types of Large-Vessel Vasculitis?

Giant-Cell Arteritis, and Takayasu Arteritis.

What are glycerol derived lipids?

Glycerol is a three carbon compound with a hydroxyl group attached to each carbon. Each hydroxyl group is capable of forming an ester bond with the carboxylic acid of a fatty acid.

In what group of pts should thiazides be avoided? (2)

Gout or hyponatremia

Give general Characteristics of Bartonella quintana.

Gram Negative Coccobacillus. Carried by Lice, seen in the Homeless.

Give some Characteristics of Staphylococci.

Gram Positivem, Arranged in Clusters, Catalase Positive. Gram stain shown.

What are Nutritionally Variant Streptococci?

Gram positive Cocci that are similar to Viridans Streptococci, but they require Pyridoxal or Cysteine to grow on Blood Agar. It is difficult to treat.

Give General Characteristics of Enterococcus Faecalis.

Gram positive Cocci, Single cells or very short chains, Catalase Negative, and grow in 6.5% NaCl. These are nosocomially acquired (although Normal Flora), and more often cause Subacute Infectious Endocarditis, affecting abnormal or damaged Heart Valves. Their Virulence factors are Biofilms and Cytolysin.

What type of Cells form Recanalizations in Plaques?

Granulomatous Tissue.

What type of tissue dominates MI after about a week to two weeks?

Granulomatous Tissue.

What is Giant-Cell Arteritis?

Granulomatous inflammation; frequently involves the temporal artery. Usually occurs in patients older than age 50. It is the most common Vasculitis in Elderly people. Steroids are used to treat, because Opthalmic artery involvement can cause blindness. Healing can lead to scarring, thickening the Intima. Inflammatory Infiltrate contains mostly T-Cells and Macrophages.

Which are the most Important cause of Viral Myocarditis?

Group A and B Coxsackieviruses, particulary B3, and Echoviruses.

What are tropnins?

Groups of proteins found in human skeletal and cardiac muscle.

What is the purpose of the liver's SR-B1 receptors?

HDL can directly deliver cholesterol to tissues where cholesterol is needed.

Describe the first type of HDL formed.

HDL3 is the smallest of all the HDLs and is therefore the most numersous. It is also capable of picking up excess free cholesterol from peripheral cell membranes, but it does so more slowly and less avidly than the pre-beta HDL.

Which lipoprotein picks up excess cholesterol and returns lipids to the liver?

HDLs.

What is the regulatory step of cholesterol synthesis?

HMG CoA is double reduced to mevalonic acid by HMG CoA reductase.

Give the three types of Drugs used to Treat High Cholesterol.

HMG-CoA Reductase Inhibitors, Bile-Acid binding Resins, and Sterol Absorbtion Inhibitors.

What does the Mnemonic HACEK stand for, Normal Mouth Flora.

Haemophilus Aphrophilus, Actinobacillus Actinomycetemcomitans, Cardiobacterium Hominis, Eikenella Corrodens, Kingella Kingae. These cause 5% of Subacute IE, and are called Fastidious Organisms because 5-10% Carbon Dioxide to grow.

What is the Half Life and Toxicity of Adenosine?

Half life 10 seconds. Given via rapid IV in gradually increased doses. Transient Asystole may occur, and Flushing, Shortness of Breath.

How are the AVL AVR and AVF axes derived?

Halfway between the 3 main axes. AVF perpendicular to Lead I. Note that no new electrodes needed to get these.

What is arteriolosclerosis?

Hardening of small arteries and arterioles, and may cause downstream ischemic injury.

What cardiac effects does amiodarone produce?

Has class I, II, III and IV activity and was randomly put in this group, many effects that lead to decrease in arrhythmias (increases QT interval).

What are Toxicities of Calcium Channel Blockers?

Headache (as with all vasodilators), Reflex Tachycardia, Constipation, Hyperkalemia, Edema, Heart Block, Liver Dysfunction. Slow release are better to avoid possible MI.

What Toxicities are associated with Hydralazine?

Headache, nausea, Lupus like symptoms.

What can be determined by using Ultrasound in the Femoral Area and Compressing?

Healthy vessels will be properly Compressed, but not Atherosclerotic Vessels.

What are the Toxicities of Beta Blockers?

Heart Failure, Fatigue, Bronchospasm, GI issues. Increased TG and decreased HDL. Withdrawal effects and exercise intolerence. Caution in CHF, Asthma, COPD, Diabetes, Depression or with MAO inhibitors

What is the best treatment for DCM? (Dilated Cardiac Myopathy)

Heart Transplant.

Where are T-type calcium channels found?

Heart and neurons.

Summarize the E apoproteins

Help IDL interact with LDL-receptors in liver (clears IDL); Help chylo remnants interact with LRP (LDL-receptor related protein receptors).

Which drug is the first line of treatment for acute arterial occlusion?

Heparin is given IV to limit propagation of the clot.

What is the fate of a chylomicron once 50-90% of its TGs have been removed?

Hepatocytes interact with apo E protein and endocytose the remnant (including the CE remaining after TG removal).

What is the main effect of CETP deficiency? Explain.

High HDL cholesterol will occur, as it can no longer be transferred off HDL.

Which treatment are lipoprotein a levels responsive to?

High levels of niacin, which tends not to be tolerated well.

Describe the classic murmur associated with mitral regurgitation.

High-pitched, blowing holosystolic (pansystolic) murmur beginning with S1 and extending to S2. The intensity usually is constant throughout systolic ejection, often radiating to the axilla.

Describe the appearance of hyaline arteriolosclerosis.

Homogeneous, pink hyaline thickening with associated luminal narrowing.

Besides the Coxsackieviruses and Echoviruses, what are some other Viral Causes of Myocarditis?

Human herpes virus-6 (normally a pediatric pathogen; "roseola") Adenovirus (now considered less common) HIV Cytomegalovirus (rare) Influenza (rare) Epstein-Barr virus (rare) Hepatitis C virus (rare, mostly in Japan) Parvovirus B19 (controversial; may be a bystander in monocytes infiltrating heart tissue)

Where do fatty acids for endogenous TG synthesis come from?

Hydrolysis of adipose TG

In what group of patients should aldosterone antagonists and potassium-sparing diuretics be avoided?

Hyperkalemic pts

Give the Five Modifiable Risk Factors for Atherosclerosis.

Hyperlipidemia, Hypertension, Cigarettes, Diabetes, Inflammation.

What is often present in End-Stage Kidney Disease?

Hyperplastic Arteriolosclerosis, including reduplication of the Basement Membrane. 30% of patients also develop tumors, particularly Renal Cell Carcinoma, or perhaps Adenoma.

What effect does hypertension have on the vasculature?

Hypertension accelerates atherogenesis and causes degenerative changes in the walls of large and medium arteries.

Give Risk Factors for Aortic Dissection?

Hypertension, above 65 years of Age.

What are the clinical uses of isradipine (1)?

Hypertension.

What are the clinical uses of nisoldipine (1)?

Hypertension.

What is the most common condition associated with the development of aneurysms of the ascending aorta?

Hypertension.

Which condition is common to both anatomic variants of arteriolosclerosis?

Hypertension.

What are the therapeutic uses of phentolamine?

Hypertensive emergencies with adrenergic crises.

When is Diazoxide used?

Hypertensive emergencies, parenterally. The other Vasodilators can be given orally for non-emergencies.

What are the therapeutic uses of fenoldopam?

Hypertensive emergencies.

What is the unusual toxicity associated with minoxidil?

Hypertrichosis.

How does Aortic Stenosis cause Angina?

Hypertrophied, hard working Myocytes demand more Oxygen, especially during Exercise.

Phase 4 is the gradual slope in Cardiac Conducting Cells that leads to an Impulse. What drugs Steepen the slope, increasing Heart Rate?

Hypokalemia, B-adrenergic receptor stimulation, Positive chronotropic drugs, Fiber Stretch, Acidosis.

What are the Toxicities of Thiazides? mnemonic HyperGLUC.

Hypokalemia, Impaired glucose tolerance, Increase in serum lipids, Increase uric acid levels, Hypercalcemia.

Contrast Hypoxic and Ischemic Shock.

Hypoxic is a bit more rare, characterized by only too little Oxygen. Ischemia is too little Oxygen as well as too little Glucose.

How is IDL converted LDL?

IDL loses Apo C and Apo E. Hepatic lipase reduces TG content. Cholesterol exchange transfer protein (CEPT) enriches the IDL with CE, transforming to LDL. This forces the remaining B100 into a conformation that can interact with LDL receptors in liver and periphery.

What is Isosorbide Dinitrate?

ISDN is a Nitrate, meaning it contributes an NO group. Others in this group are Nitroglycerin and Nitroprusside.

What is Senile Calcific Aortic Stenosis?

IT is the most Common Calcific Valve Disease. Not much Lipid, plaque, or Cellular Proliferation.

When is Bacterial Endocarditis often seen?

IV Drug users.

Define Crystalloid Volume Replacement.

IV Fluids which contain blood proteins to keep fluid in the vessels.

What are the therapeutic uses of beta1 specific blockers?

IV for hypertensive emergency with MI or unstable angina.

What are the kinetics of fenoldopam?

IV infusion.

What are the kinetics of mecamylamine?

IV.

What do you do if the axis is not normal?

Identify the most isoelectric lead.

Define critical stenosis.

If 75% or more of the lumen is occluded.

Give an example of an underlying cause that presents with a good prognosis.

If caused by rheumatic fever, there may be a slow progression with a 15-year survival of 70%.

What happens to blood lipids in Type 1 Diabetes?

If controlled, Lipids will often be normal.

When are Nitrates contraindicated?

If intracranial pressure is elevated.

How does lipoprotein a contribute to the atherosclerotic plaque build-up?

If oxidized (much like oxidized LDL), it is engulfed by macrophages and promotes foam cell formation, an important contributing factor to plaque formation.

How can we diagnose Cardiomegaly via Chest XRay?

If the Cardiac Silhouette is greater than 1/2 the Lateral Width of the Chest space on a PA Xray, Not AP. Calipers help.

When should Surgery be considered in Aortic Regurgitation?

If the Ejection fraction is reduced to less than 50%, then LV function is impaired and Surgery should be considered. Other major symptoms can also prompt Surgery.

How can Stable Angina progress to unstable Angina?

If the Plaque ruptures and a clot forms, occluding a narrowed Artery.

What information can be gleaned from calculating the axis by inspecting leads I and aVF?

If the QRS complex is predominantly positive in both leads I and aVF, then the QRS axis must lie between 0 degrees and +90 degrees, which is part of the region defined as normal axis.

How can creatine kinase levels be used to rule out MI?

If there is no rise in creatine kinase and creatine kinase MB levels in the first 48 hours after the onset of chest pain, an MI is excluded.

When should patients with UA/NSTEMI have urgent Percutaneous Coronary Intervention?

If they have a thrombolysis in MI score greater than 3.

What is the Alternative to a Treadmill Stress Test if, for example, the patient cannot exercise?

Imaging and Pharmacological Intervention.

When is diagnostic imaging indicated for peripheral artery disease?

Imaging is generally done by the vascular surgeon at the time that revascularization is being considered (in the event the patient fails medical therapy or has more profound ischemic changes).

How is Acute Arterial Occlusion treated?

Immediate IV Heparin, followed by surgery in some cases or more medicine. Diagnostic Angiography is the best to diagnose.

What are the clinical uses of amyl nitrite and sublingual nitroglycerin?

Immediate relief from symptoms of stable, variant and unstable angina.

What is the interval for follow up if the abdominal aorta is greater than 4.5cm?

Immediately refer to a vascular surgeon.

Why is it critically important to distinguish between infectious and immunological mechanisms of vasculitis?

Immunosuppressive therapy is appropriate for immune- mediated vasculitis but can worsen infectious vasculitis.

What is claudication?

Impairment in walking.

What is the incidence of a silent MI?

In 20-30% of cases an MI presents without associated chest pain. Often occurs in diabetics, hypertensive patients and the elderly.

HDL is pretty awesome. What are four Nifty functions it serves?

In addition to acting as a reservoir for Apoliproteins (CII and E), It acts in Uptake , Esterification , and Reverse Transport of Cholesterol. In other words, it Removes Cholesterol from the Arteries and returns them to the Liver or to VLDL.

Why are troponins useful for making an early or late acute MI diagnosis?

In an acute MI, troponin levels begin to rise 3 hours after the onset of MI symptoms and persist for 7 to 14 days.

Summarize the C apoproteins

In general, block interaction of E-apoproteins with receptors in liver. C1 function unknown.

What is the most important factor to weigh when deciding on a treatment for acute coronary syndrome?

In order to begin the best therapy, the most important distinction to make is between acute coronary syndrome that causes ST segment elevation (STEMI) from the acute syndromes that do not (NSTEMI).

Where are aortic aneurysms most likely to occur?

In the abdominal aorta.

Where are triglycerides (TG) and cholesterol esters (CE) synthesized and inserted into chylomicrons?

In the intestinal epithelial cell (Lumen of smooth ER and Golgi)

Where is HDLs synthesized?

In the liver and intestine.

How are beta blockers generally metabolized?

In the liver, doses should be calculated based on hepatic function.

Where are VLDLs synthesized? What is their function?

In the liver. Carries exogenous AND endogenous TG and CE. TG can be removed by LPL in tissues, similar to a chylomicron.

Where are VLDLs made?

In the liver. The liver is the major site of endogenous lipid production, including triglycerides and cholesterol esters.

Where and how are triglycerides synthesized?

In the liver; three fatty acids are transferred to glycerol

How are lipids from VLDL absrobed by the tissues?

In the same manner as dietary lipids carried by chylomicrons. The CII apoprotein again acts as a cofactor for lipoprotein lipase (LPL) in the periphery. The triglyceride is similarly hydrolyzed to free fatty acids and glycerol and is absorbed by the various tissues.

Where are aortic dissections most likely to occur?

In the thoracic aorta.

MoA of Digoxin?

Increase Vagal tone.

Give three ways to Cause Vasodilation in Smooth Muscle Cells.

Increase cGMP (Nitrates), Reduce Calcium Influx (CCB), Opening Potassium Channels (Minoxidil and Nicorandil)

What is the treatment rationale for variant angina?

Increase coronary blood flow through the redistribution of coronary flow and/or vasodilation, diastolic interval.

What happens to blood lipids in Hypothyroidism?

Increased LDL and TG also if obese. Correcting Thyroid problem will help.

What is Venous Stasis Dermatitis?

Increased Venous pressure allows fibrous proteins to leak out, creating a non-pitting 'Brawny' Edema and changing skin Color and Texture. Zinc is very helpful to clean this up.

What is the MOA of sodium nitroprusside?

Induces nitrous oxide release and activation of guanylyl cyclase.

What is Infective Phlebitis?

Infection of a Vein Lumen.

What is Infective Endarteritis?

Infection of an Artery.

How can Myocarditis be seen Histologically?

Inflammatory Infiltrate of Myocardium are Diagnostic for Myocarditis. DCM creates Autoantibodies to Cardiac Antigens.

What is Myocarditis?

Inflammatory of the Myocardium, Characterized histologically as lymphocytic infiltration of the myocardium, with Myocytolysis (muscle cell death) also seen. 60% is Viral.

Contrast Inflammatory and Mycotic Abdominal Aortic Anuerysms.

Inflammatory, uncertain etiology. Mycotic AAA is caused by circulating Microorganisms, such as Salmonella gastroenteritis, lodge in the Aortic wall and cause inflammation.

What is the mechanism of action of MgCl?

Influences sodium pump and other ion channels.

Summary of Apo proteins: CIII

Inhibitor of lipoprotein lipase / blocks binding of E to receptors.

What other effects does bretylium produce (1)?

Inhibits catecholamine release.

What is the mechanism of action of aspirin?

Inhibits platelet aggregation, it is effective across the entire spectrum of acute coronary syndromes.

How does a Myocardial Stress Test work?

Inject Radionuclides at Rest and then at Peak of exercise.

What causes the subjective feeling of dyspnea during an MI?

Injury to the left ventricle can cause a systolic dysfunction as well as a diastolic dysfunction, both of which ultimately increase pressure in the pulmonary veins. The resultant pulmonary congestion influences shallow, rapid breathing.

Where is the chylomicron made?

Inside the lumen of the smooth endoplasmic reticulum.

Why is the systolic murmur produced by tricuspid regurgitation heard better during inspiration?

Inspiration decreases intrathoracic pressure and increases return of blood to the heart from the peripheral veins.

Which calcium channel blocker interferes with pancreatic insulin secretion?

Insulin secretion is inhibited by high concentrations of verapamil.

What hormone regulates the synthesis of lipoprotein lipase, especially in the adipose tissue?

Insulin.

What is a true aneurysm?

Intact attenuated arterial wall or thinned ventricular wall of the heart bulges outwards.

What is IDL?

Intermediate Density Lipoprotein. VLDL Remnants give rise to IDL, which 'decides' to become LDL or to be recycled.

What is the name for a VLDL with 50-90% of its TG removed?

Intermediate density lipoprotein (IDL)

What is the name for a VLDL remnant?

Intermediate density lipoprotein, in which the triglyceride of the orignial VLDL has been reduced.

What is Claudication?

Intermittent Leg Pain Precipitated by walking and Relieved by rest.

Contrast IMA vs SVG as conduits for Bypass.

Internal Mammary Artery has better patency requiring fewer future procedures, but a more difficult surgery because it is smaller and more delicate. It looks a bit burned as Anterior Intercostals have been Cauterized and Transversus Thoracis cut.

What does a Normal Pulmonary Venogram look like?

Iodine has had time to perfuse Veins as well as Arteries, so much less in Arteries and we mostly see Veins.

List the factors that cause aneurysms due to loss of smooth muscle cells or inappropriate synthesis of non-collagenous or non-elastic extracellular matrix (1).

Ischemia.

What is the Mechanism of Fibrate drugs?

It affects DNA Transcriptional Regulators. Particularly, LPL production is increased, increasing shuttling of Fatty Acids into tissues. It also decreases Apo C3 synthesis, and increases Apo A1 and A2 synthesis. This means less VLDL secretion and increased oxidation of Fatty acids.

Define Hyperhomocystinemia and relate it to Atherosclerosis.

It can be caused by low Folate and B12, and this metric has a strong correlation with Atherosclerosis.

What causes coronary artery vasospasm?

It can be induced by the release of vasoplastic mediators such as thromboxane A2 from platelet aggregates.

What can happen to Oxidized LDL?

It can be phagocytosed by Foam Cells in the blood vessel epithelium, forming Atherosclerotic Plaque. LDL that is not oxidized is Benign.

What effects can Infectious Endocarditis have on the Brain?

It can cause cerebral Abscesses.

Myoglobin is not a very good test to prove an MI just happened. What is it good for?

It can rule out that an MI happened if it is negative.

How common is variant or prinzmetal angina?

It causes 2 to 3% of angina pectoris. The median age group is 51 to 57.

What is the mechanism for Niacin?

It causes a decrease of Mobilization of Free Fatty Acids from Adipose tissue. It is caused by a reduction in Adenylyl Cyclase from G proteins in Adipocytes.

What hemodynamic effects does methyldopa produce?

It causes a reduction in vasomotor center mediated sympathetic outflow and sensitizes the baroreceptor reflex to elevated blood pressure.

What are the toxicities of Niacin?

It causes immediate Redness of face and skin, called flushing caused by Prostaglandins released from Langerhans cells. Some say that indicates the drug is working. COX inhibitors can reduce this effect. Also GI Distress, Hepatotoxicity, Supraventricular Arrythmias, blurred Vision, Hypotension.

Describe the composition of a newly formed chylomicron.

It contains mostly triglycerides with some cholesterol esters. It only contains one major apoprotein, B48.

What is the MOA of Nitroprusside?

It decomposes to NO which increases cGMP and directly dilates veins and arteries.

What influences the form an acute coronary syndrome will take?

It depends on the degree of coronary obstruction and associated ischemia.

Can the pain of an MI be relieved by anything?

It does not wane with rest, and the response to sublingual nitroglycerin is variable.

What is the function of phospholipid transfer protein?

It facilitates one-way transfer of phospholipid and some cholesterol from the shell of TGRLPs to the shell of shrinking HDLs. Also transfers PL and cholesterol from HDLs to shrinking chylos and VLDLs. (Maintains proper shell : core ratios.)

How is cholesterol absorbed?

It forms micelles with bile acids so it can penetrate the watery unstirred layer next to the intestinal villi. Cholesterol is absorbed through protein transporters.

What is peripheral arterial disease?

It generally refers to atherosclerotic disease of pelvic and lower extremity arteries. The upper extremities can be affected, but it is not common.

What is the fate of the chylomicron remnant?

It gives its C apoproteins back to HDLs in the circulation. The E apoprotein recognizes specific receptors in the liver, the LRP receptors (LDL-receptor-related protein receptors). The E receptor (LRP receptor) binds the remnant to the liver where it undergoes endocytosis.

What is a characteristic of "lipid free" HDL?

It has a high capacity for picking up excess cholesterol from tissues.

What is important to know about the kinetics of esmolol?

It has a short duration.

What is Streptococci Bovis?

It has the same Characteristics as Enterococcus Faecalis, except it cannot grow in 6.5% NaCl. In other words, a Gram positive Cocci, short chains, Catalase Negative, and grow in 6.5% NaCl.

What is the mechanism of action of bepridil?

It has the same MOA as nifedipine, but with more cardio effects. It also blocks sodium and potassium channels.

What is the mechanism of action of dilitiazem and verapamil?

It has the same MOA as nifedipine, but with more cardio effects. These include decrease in contractility, conduction velocity and heart rate.

What is the MOA of Diazoxide?

It increases Potassium Conductance.

What is the MOA of diazoxide?

It increases potassium conductance preventing smooth muscle contraction.

What does it mean when a limb lead has an isoelectric QRS complex?

It indicates that the mean electrical axis of the ventricles is perpendicular to that lead.

By what mechanism does Diabetes Mellitus increase Atherosclerosis risk?

It induces Hypercholesterolemia and Advanced Glycation End Products (AGEs) damage vasculature.

What is the Function of APO-CIII?

It inhibits LPL.

What is the MOA of ezetimibe?

It inhibits NPC1L1 transport protein, which leads to the prevention of cholesterol absorption.

Orlistat is a Anti-obesity drug. How does it work?

It inhibits intestinal Lipase, sending more Lipids to the Feces.

What is a subendocardial infarction?

It involves a small area in the subendocardial wall of the left ventricle, ventricular septum, or papillary muscles.

What defines a regional acute myocardial infarction?

It involves one segment of the ventricular wall.

What defines a circumferential acute myocardial infarction?

It involves the subendocardial zone of the ventricle.

What is the MOA of reserpine?

It irreversibly blocks the uptake of amines into synaptic vesicles, resulting in the depletion of neurotransmitters.

What is Critical Stenosis?

It is 75% Occlusion of Coronary Arteries, making compensatory reflexes insufficient and leading to Angina Pectoris.

Define Complex Plaque.

It is Atherosclerosis where Calcification, Thrombosis, or Hemorrhage are also present.

Give some characteristics of Staphylococcus Epidermidis.

It is Coagulase Negative, Mannitol Negative, and causes no Hemolysis. They are also Catalase Negative It is part of Normal Flora.

Describe the Duke Criteria for Infectious Endocarditis.

It is Highly sensitive but not specific, so 10% of those diagnosed will not have it. Must have two Major or 1 Major and 3 Minor Criteria.

Define Primary or Essential Hypertension.

It is Hypertension that is not caused by anything else, or has unknown cause. This tends to increase with age and Pharmacology works well to treat it.

What is NSTEMI?

It is Non-ST Segment Elevation Myocardial Infarction. It is caused Not by a full Occlusive Thrombus but from a Mural Thrombus with potential to Embolize.

What is a Tendon Xanthoma?

It is a Cholesterol Deposit on Tendons that occur in 75% of people with Familial Hyperlipidemias.

What is NPC1?

It is a Cholesterol Transporter that moves Cholesterol from the Intestine to the Epithelial Cell. This Transporter is Impaired in Type 1 Niemann Pick. Type 2 is NPC2.

What is the MOA of fenoldopam?

It is a D1 receptor agonist.

What is PCSK9?

It is a Proteolytic Enzyme that destroys old LDL receptors. With too much of these, you get decreased receptors and similar phenotype to FH. The opposite is true, also. These people have low LDL their whole life and very low CHD risk.

What are the effects of Digoxin?

It is a Sodium Potassium ATPase Inhibitor, particularly in the Vagal Neuron. It mimics Vagal effects: Hyperpolarization, Shortening of Atrial Action Potential, Increase in AV node refraction.

What shuttle is inhibited by Ezitimibe?

It is a Sterol Absorbtion Inhibitor that affects NPC1.

What is a Superficial Thrombophlebitis?

It is a Thrombosis and Inflammation of Superficial Veins which presents as a painful induration with erythema. It is a contrast to DVT.

What is apo CII apoprotein?

It is a co-factor for lipoprotein lipase.

What is the Function of APO CII?

It is a cofactor that Activates LPL, allowing cleaving of Triglycerides from the Chylomicron to provide energy to Peripheral Tissue. Its Absence or Malfunction leads to Buildup of Chylomicrons, causing Hyperlipidemia. LPL deficiency would be very similar.

Describe the Pathology of Hyperproteinemia Type 2B, Familial Combined Hyperlipidemia?

It is a common disorder where TG, VLDL, and LDL are elevated. HDL is low. You do not see the Xanthomas and other strong signs of FH. It is called Bouncing Lipid because by fixing one you tend to see another thing rise. It is caused by VLDL overproduction, genetically.

When is chest pain used to diagnose panic attacks?

It is a diagnosis of last resort, you must rule out other diagnoses with testing.

What is a Cystic Medial Necrosis, also known as Familial Aortic Dissection?

It is a genetic breakdown of Collagen, Elastin, and Smooth Muscle that predisposes to Aneurysm and Dissection of the Aorta particularly.

Describe ventricular arrhythmia as a complication of MI.

It is a late complication of a large transmural MI. It is caused by bulging of non-contractile myocardium during systole. Mural thrombi are often associated but do not lead to rupture. Stroke volume decreases or the rest of the heart may become hyperkinetic, then fail.

What is an aneurysm?

It is a localized, blood-filled balloon-like bulge in the wall of a blood vessel.

What are the kinetics of lisinopril?

It is a lysine derivative of enalapril.

What is MPO?

It is a lysosomal granule constituent normally involved in generating oxygen free radicals. MPO-ANCAs can be induced by a variety of therapeutic agents (e.g. propylthiouracil).

Define Microalbuminuria and relate it to Atherosclerosis.

It is a marker of Kidney Damage in Diabetes, and is somewhat predictive of Atherosclerosis in Non-Diabetics.

What is Lipoprotein A?

It is a modified LDL with a very very long Apolipoprotein, that confers 10 times the CHD risk of LDL itself.

What is Lp(a)

It is a molecule with properties of clotting factors that is found in some Atheromas and makes them much worse. It is a risk factor for MI.

Define Hyperlipidemia Type 2A, also called Familial Hyperlipidemia.

It is a mutation in the LDL-receptor. This will increase LDL only in the blood. Both types of Type 2 Hyperlipidemias lead to increased Cholesterol Synthesis by the Liver, because cells feel deprived of Cholesterol.

Define Hyperlipidemia Type 2B, also called Familial Combined Hyperlipidemia.

It is a mutation or deficiency in LDL receptors with Increased APO B48. This results in increased LDL, VLDL, and Triglycerides. Both types of Type 2 Hyperlipidemias lead to increased Cholesterol Synthesis by the Liver, because cells feel deprived of Cholesterol.

What is PR3?

It is a neutrophil azurophilic granule constituent and shares homology with many microbial peptides; this may explain how PR3-ANCAs develop.

What is the MOA of phentolamine?

It is a non-selective alpha1 and alpha2 receptor blocker.

Describe the Patholgy of Type IV Hyperlipoproteinemia.

It is a relatively common disease where the Liver produces more VLDL and reduced removal of it, particularly in people with Diabetes and Obesity. VLDL is increased in this Disorder.

What is a berry aneurysm?

It is a sac-like outpouching in a cerebral blood vessel, which can seem berry-shaped, hence the name. Once a berry aneurysm has formed it is likely to rupture, causing a stroke. Thus they are serious medical emergencies, and should be treated as soon as possible.

What is cardiogenic shock and how is it treated?

It is a self-perpetuating problem of underperfusion. It is treated with dobutamine or an intra-aortic balloon pump.

What is a False or Pseudo Aneurysm?

It is a swelling clot in the Adventitia of the vessel, with a hole leading to the Lumen.

What is Rheumatic Fever?

It is a systemic inflammatory disease, a sequela of group A streptococcus (S. pyogenes) infection. Due to cross reactivity between M protein and antigens of heart or joint tissue leads to autoimmune response, and to Rheumatic Heart Disease if occuring Chronically.

What does a Subcostal Echocardiogram (Ultrasound) look like? (In this case with Pericardial Effusion)

It is a view from the bottom of the Sternum looking up.

What is the most common cause of Mitral Stenosis?

It is almost always caused by Rheumatic Fever. It can lead to A fib.

What is the most common cause of regional acute myocardial infarction?

It is almost nearly always caused by thrombus formation on an atheromatous plaque.

What is Hyperlipidemia Type 3, also known as Family Dysbetalipoproteinemia.

It is an Apo-E Deficiency or Mutation. It leads to increased IDL.

What is Ehlers-Danlos Syndrome?

It is an Autosomal Dominant genetic disorder that leads to defective Collagen Synthesis. It is a Risk Factor for Aortic and other Aneurysms.

What is CETP? (Cholesterol Exchange Transfer Protein)

It is an Enzyme that transfers Cholesterol Esters from HDL to VLDL.

What is Hyperlipidemia Type 1, also known as Hyperlipoproteinemia?

It is an LPL or APO-CII Deficiency or Mutation. It leads to increased Chylomicrons only.

Give the background of aortic dissection.

It is an acute, life threatening event which results from the unzipping of the intimal layer, causing bleeding into the lumen. It usually starts with a tear in the intimal layer, sometimes from a bleed within the medial layer.

What is LCAT? (Lecithin Cholesterol Acyl Transferase)

It is an enzyme that Esterifies Cholesterol inside HDL after receiving Cholesterol from Cell Membranes. It is also in LDL, where it serves to Deesterify Cholesterol for delivery to cell.

What is functional capacity?

It is an estimate of what the patient's heart will allow the patient to do. It is not based on measurements of structural lesions of the heart.

Define acute coronary disease.

It is an expression of ischemic heart disease, which implies a lack of oxygen sent to the myocardium, causing an imbalance between oxygen supply and demand which often triggers characteristic symptoms.

What is Pulmonary Capillary Wedge Pressure?

It is an indirect marker for Left Atrial Pressure. The pressure is measured by wedging a pulmonary catheter with an inflated balloon into a small pulmonary arterial branch.

What is Giant Cell Arteritis?

It is an inflammatory disease of blood vessels most commonly involving large and medium Arteries of the head.

What is Takayasu arteritis?

It is an uncommon, chronic inflammatory disorder of unknown etiology affecting the aorta and its major branches. It predominantly affects women ages 15 to 25, with a female-to-male ratio of 9:1.

What is Aortic Dissection?

It is an unzipping of the Aortic Intima, creating a second space within the vessel and reducing systemic blood flow.

What other event is associated with variant angina?

It is associated with coronary artery spasm which may occur in the normal portion of the coronary artery.

What is the cause of a circumferential acute myocardial infarction?

It is caused by general hypoperfusion of the main coronary arteries. It is usually due to a hypotensive episode which critically reduces blood flow in the arteries already affected by high grade stenosis.

What is the c wave?

It is caused either by transmission of the carotid arterial impulse through the external and internal jugular veins or by the bulging of the tricuspid valve into the right atrium in early systole.

How common is mitral regurgitation?

It is clinically significant in about 2% of the population.

What happens to pre-Beta HDL?

It is converted to alpha HDL by picking up cholesterol and by interacting with the triglyceride-rich lipoproteins (TGRLP), VLDL, IDL, chylomicrons and chylomicron remnants. From the TGRLPs the HDL picks up other apo-proteins, Apo AII, the apo C's and apo-E.

How is it decided whether there is a need for surgery when an aneurysm has occurred?

It is decided on a case by case basis. In the case of abdominal aortic aneurysms, when the aneurysm is greater than 4.5cm, surgery is considered.

What causes variant angina?

It is due to a focal coronary artery vasospasm, usually at the site of a non-obstructive plaque which is thought to be caused by defective or decreased nitric oxide production and/or other factors (increased sympathetic tone) associated with dysfunctional endothelium.

What is the Primary Raynaud Phenomenon?

It is exaggerated Vasoconstriction responses of Digital vessels. Can present as Cyanosis or pallor of the extremities, with Red White or Blue color changes.

When and where is lipoprotein lipase expressed?

It is extruded from the luminal face of the capillary endothelium surrounding various peripheral tissues (mostly skeletal and cardiac muscle and adipose), if they are in need of triglycerides.

What is the a wave?

It is generated by atrial contraction, which actively fills the right ventricle in end-diastole. Normally the crests of the a and v waves are approximately equal in amplitude.

Why is unstable angina concerning?

It is high risk for subsequent total thrombotic occlusion. A significant number of patients will progress to myocardial infarction or may die from the secondary development of a ventricular arrhythmia.

Describe the pathology of peripheral artery disease.

It is identical to coronary artery disease. 50% of patients with peripheral artery disease also have clinically significant coronary artery disease.

When is surgery indicated for aortic stenosis?

It is indicated when those with severe aortic stenosis develop symptoms or when there is progressive left ventricle dysfunction

How does HDL2 compare to HDL3?

It is larger and enriched in triglycerides relative to HDL3. HDL2 has a very poor ability to pick up cholesterol from the periphery.

What is a stable plaque?

It is marked by a thick fibrous cap and small lipid core.

Choosing between ACE inhibitors: What are the advantages of using a combination?

It is more effective than using a monotherapy of either drug. However, long term adverse effects are less clear.

Fibromuscular dysplasia is most commonly seen in which patients?

It is most frequently found in young women.

Once cholesterol is synthesized in the liver what is its fate?

It is packaged as cholesterol ester in the core of a VLDL.

What is Pulsus Paradoxis?

It is present in Cardiac Tamponade and not in Tension Pneumothorax. It is a drop in Systolic Pressure during Inspiration. In other words, as you are testing BP you notice the pulse disappears with Inspiration at the high levels of pressure.

What does it mean if angina cannot be relieved with rest or nitroglycerin?

It is probably not stable angina, begin to suspect other problems such as acute coronary syndrome, dissecting aneurysm, pericarditis, respiratory or GI focus.

What is carcinoid syndrome?

It is produced by a type of gastrointestinal tumor that releases serotonin metabolites that are thought to promote endocardial plaques on the right side of the heart.

What is the fate of excess cholesterol?

It is pumped out of the cell and back into the intestinal lumen by the ABC-1 transporter protein.

How serious is papillary muscle dysfunction?

It is rapidly fatal if the muscle ruptures.

What happens once beta-monoglyceride is absorbed?

It is reconverted to triglyceride. The triglyceride, with the help of a microsomal lipid transfer protein is inserted into a growing chylomicron.

Describe the pathogenesis of peripheral artery disease.

It is related to the development of atherosclerotic plaques. They form preferentially at arterial branch points and sites of increased turbulence. There is an increased risk of peripheral artery disease with diabetes and age (most patients are over 70).

What causes Renin release and what are its effects?

It is released in response to Hypotension or Sympathetic Stimulation via Beta-1 at the Kidneys.

Can variant angina be treated with medication?

It is responsive to vasodilators.

Why is lysolecithen bound to albumin?

It is strongly disruptive of cell membranse.

What is the fate of 60% of LDL?

It is taken up by the liver, which uses its cholesterol to make bile acids.

What is Dilated Cardiomyopathy?

It is the Chronic Stage of Myocarditis, which is basically an Acute Syndrome. 30% of Myocarditis will progress to Dilated Cardiomyopathy (DCM)

What is Seldinger Technique?

It is the General way lines are inserted into Arteries or Veins. First a needle goes in, and then a guide wire through the needle. Lastly, a Catheter is fed around the guide wire and you are all set.

What is HMG-CoA?

It is the Precursor to Cholesterol. It is converted to Mevalonic Acid by HMG CoA Reductase. This is the Regulatory Step of Cholesterol Production, and Cholesterol itself inhibits HMG CoA Reductase.

Define Vascular Pedicle.

It is the area with the Aortic Arch and Pulmonary Trunk. It is enlarged at Stage 1 CHF, so is an early sign.

Which patients does giant cell arteritis most commonly affect?

It is the most common form of vasculitis among elderly individuals in the United States and Europe. Rare before the age of 50.

What lab tests confirm that you are looking at Staphylococcus Aureus?

It is the only Infectious Bacteria that is Coagulase Positive. It also demonstrates Beta-Hemolysis. It grows on Mannitol (Mannitol Positive) and turns it Yellow. it is also Salt-Tolerant.

What is special about Staph Aureus in the Heart?

It is the only Microorganism that colonizes the Endocardium.

What is Special about Nimodipine?

It is the only Vasodilator that Targets Cerebral Blood Vessels, used to prevent Ischemia during Cerebral Hemorrage.

What is 2-MonoacylGlyceride?

It is the product of Lipid Digestion by Lipase and Colipase in the intestine, and it is able to cross the Apical Membrane to enter the body along with the 2 cleaved Fatty Acid CoAs. It is then converted back to Triglyceride via Fatty Acyl CoA Transferase.

What is the Penumbra of MI?

It is the progression of Cell Death from inside to out.

What happens to the chylomicron remnant once it enters the liver?

It is totally disassembled and the triglycerides and cholesterol esters are repackaged in another lipoprotein called the VLDL, or very low density lipoprotein.

When is Digoxin Administerd?

It is used in A Fib and A Flutter.

Describe the clinical course of mitral valve prolapse.

It is usually benign, though it uncommonly leads to a gradual progression of mitral regurgitation.

What are the causes of mitral valve prolapse?

It is usually inherited.

What is the turnover of chylomicrons?

It is very fast, their half-life is less than a half hour.

What is important about the Structure of Statins?

It looks like HMG-CoA but with a large Side group, making it a good competitive inhibitor of that Enzyme.

What hemodynamic effects does reserpine produce?

It lowers blood pressure via the inhibition of norepinephrine release from sympathetic nerves.

Why can't nitrates be given to patients who have taken the phosphodiesterase-5 inhibitor sildenafil for erectile dysfunction within the preceding 24 hours?

It may potentiate the hypotensive effects of nitrates.

What will a chest x-ray of a patient with aortic stenosis reveal?

It may reveal left ventricle hypertrophy.

What signs of aortic regurgitation are seen on an ECG?

It may show left ventricle enlargement depending on the degree of hypertrophy.

What is Polygenic Hypercholesterolemia?

It means defective Apo-B1000, with decreased affinity for the LDL receptors.

Ventricular Aneurysm is a possible complication of MI. What does this mean and what does it look like?

It means the Ventricle has stretched, reducing functional contraction area. It is visible as a bulge on Chest Xray.

What is the presentation of mitral valve prolapse that is heard during cradiac auscultation?

It most typically presents with a mid-systolic click and late systolic murmur loudest at the cardiac apex.

What is variant angina?

It occurs at rest and may awaken the patient from sleep.

How common is mitral valve prolapse?

It occurs in about 2% of the population, it is more common in women than in men.

When does aortic regurgitation present?

It occurs when there has been damage to the aortic leaflets or there has been significant aortic dilation, allowing abnormal regurgitation of blood from the aorta into the left ventricle during diastole.

What changes does tricuspid stenosis introduce into the JVP graph?

It produces prominant a waves in the jugular veins that are two times the amplitude of the v waves.

When is Adenosine Used?

It promptly converts Paroxysmal Super Ventricular Tachycardia to normal Sinus Rhythm.

Give 2 effects of Adenosine in the Conducting Cardiac Cells.

It reduces heartbeat by increasing Potassium Conductance and reducing Calcium Influx.

Verapamil, a Non- DHP CCB, has some positive and negative effects. Name on of each.

It reduces platelet Aggregation, but also reduces Insulin secretion.

Why is anti-platelet therapy indicated for peripheral artery disease?

It reduces the risk of adverse coronary events in patients with peripheral atherosclerosis. Clopidogrel can be used as an alternative.

What is the y descent?

It represents the abrupt termination of the downstroke of the v wave during early diastole after the tricuspid valve opens and the right ventricle begins to fill passively. Normally the y descent is neither as brisk nor as deep as the x descent.

Give a general description of the pain experienced during an MI.

It resembles anginal discomfort qualitatively but is usually more severe, is rapid in onset and often briskly crescendos. It lasts longer, and may radiate more widely. Patients may deny pain but instead report pressure, "like an elephant on my chest."

What happens to Glycerol after LPL cleaves off all the Fatty Acids?

It return to the liver to be recycled.

How does endothelial cell loss or dysfunction lead to the thickening of the intima?

It stimulates smooth muscle cell growth and ECM synthesis causing thickening of the intima.

Which is better, Rate Control or Rhythm Control?

It's pretty much a toss-up.

Class of Diltiazem?

L Type Calcium Channel Blocker, so Class IV.

Class of Verapamil?

L Type Calcium Channel Blocker, so Class IV.

What are Arrhythmia Drugs Class IV?

L Type Calcium Channel Blockers.

Describe the mechanism by which HDL3 is formed.

LCAT enriches the core of the HDL in with cholesterol esters. This enzyme utilizes as substrates lecithine) from the phospholipid shell of the HDL or a nearby TG-rich lipoprotein, and free cholesterol from the shell of the HDL3. LCAT removes the fatty acid in the 2 or beta position of lecithin and esterifies it to the hydroxyl group of cholesterol forming cholesteryl ester and lysolecithin. The cholesterol ester is transferred to the core of the pre-beta HDL plumping it up. The HDL is now an HDL3

Which lipoproteins are rich in CE?

LDL and HDL

What is the difference between IDL and LDL?

LDL has APO B100, but not APO CII and APO E. IDL has both. The two extra Apoproteins are given back to HDL where they came from to convert IDL to LDL.

Which kind of receptors are recognized by apoprotein B100?

LDL receptors in the liver and peripheral tissue.

On which three Lipoproteins can APO B100 be found?

LDL, IDL, VLDL.

Which lipoprotein delivers cholesterol to the periphery?

LDLs.

Which is better, to have 100 mg/dL of Large LDL particles or small ones?

Large. Small ones means there are more of them, up to 70% difference. Apo-B100 and LDL ratio can be used to see how big they are because one Apo-B100 per LDL.

What are the characteristics of alpha HDL2?

Larger than HDL3, more TG enriched, more apo AII, lower affinity for free peripheral cholesterol

Why do people with Pericarditis prefer to lean forward?

Laying down pushes the heart against the more inflamed areas. Nearly all Pericarditis occurs in the Posterior and Lateral areas, so ECG changes are rarely seen in aVR and V1.

The three Leads on a 3 Lead arrangement refer to the Voltage Difference between 2 of the 3 total Electrodes. Define Lead 1,2,and 3.

Lead I is LA-RA. Lead II is LL-RA. Lead III is LL-LA.

Which enzyme that HDL binds is necessary to produce HDL3?

Lecithin-cholesterol acyl transferase. The enzyme enriches the core of the HDL in CE.

What are the Consequences of Mitral Stenosis?

Left Atrial Pressure increases, which can lead to increased Pulmonary Pressure. The stretching of the Left Atrium can disrupt Conduction Bundles, causing Arrythmias, typically Atrial Fibrillation. The Left Ventricle filling is also impaired.

What does an enlarged Vascular Pedicle look like in Stage 1 CHF?

Left Normal. Right Enlarged.

What mitral regurgitation signs can be found on a chest x-ray?

Left atrium and left ventricle enlargement in chronic mitral regurgitation.

How does left atrium enlargement contribute to the development of atrial fibrillation?

Left atrium dilation stretches the atrial conduction fibers and may disrupt the integrity of the cardiac conduction system.

What signs of aortic regurgitation are seen on a chest x-ray?

Left ventricle enlargement.

How does aortic stenosis cause syncope?

Left ventricle hypertrophy creates a pressure sufficient to produce a normal cardiac output at rest, but because the stenotic aortic orifice is fixed, the output cannot increase with exertion. This decreases cerebral perfusion, causing dizziness and possibly syncope.

Contrast Dronedarone and Amiodarone?

Less Iodine, less Thyroid Issues and no Pulmonary Fibrosis. However, possible increase of Heart Attack and Stroke.

What does an Ischemic Stress Test look like?

Less perfusion at Rest.

What is the Normal Range for Troponin I, and what are significant levels?

Less than .05ng/mL is normal. Greater than that is suspicious and greater than 2.0 ng/mL indicates Significant Myocardial Injury. Unchanged CK-MB (a Creatinine Kinase) or Troponin over 2 days means no MI.

What is the ankle-brachial index which indicates a diagnosis of peripheral artery disease?

Less than 0.9.

How many patients with peripheral artery disease are actually symptomatic?

Less than 50%!

What is the half life of a chylomicron?

Less than one hour

What complication related to MI accounts for the most deaths prior to hospitalization?

Lethal arrhythmia.

What are the therapeutic uses of bretylium (1)?

Life-threatening ventricular arrhythmias when lidocaine and cardioconversion have failed.

Which treatments are used for both High Cholesterol and High Triglycerides?

Lifestyle Counseling and Niacin. Niacin can raise HDL.

What is the fate of cholesterol converted to cholesterol ester?

Like triglyceride, it is inserted into the core of a growing chylomicron in the lumen of the smooth endoplasmic reticulum using a microsomal lipid transfer protein.

What is the result of an occlusion of the iliac, subclavian or brachiocephalic artery due to an aortic dissection?

Limb ischemia.

Which screening exam can provide additional information to the the results of the ankle-brachial reflex and has the possibility of localizing the lesion of peripheral artery disease?

Limb segmental systolic pressure measurements and pulse volume recordings.

How is Viral Myocarditis Treated?

Limit Physical Activity, and No Corticosteroids. Other Immunosuppression may help, and also Interferon B may have benefits. Treat similarly to CHF with Beta Blockers, Diuretics, ACEI and ARBS.

What is Xanthelasma?

Lipid Deposits near and around the Eyes.

What enzyme allows tissues to remove triglycerides from lipoproteins for energy?

Lipoprotein lipase

How do tissues in need of fatty acids extract them from the chylomicron?

Lipoprotein lipase and apoprotein CII hydrolyze the triglyceride in the core of the chylomicron to free fatty acids and glycerol which are then absorbed by the tissue.

What are the kinetics of ezetimibe?

Long half-life, excreted in the feces.

Why are calcium channel blockers used as second line agents and not first line agents?

Long term benefits are questionable due to the increased incidence of MIs.

How does Peripheral Artery Disease present?

Loss of pulses in the extremities, Bruits, Positive Buerger's Sign.

How is Secondary Prevention of Rheumatic Fever achieved?

Low does of antibiotics like Penicillin, Erythromycin.

What causes stable angina?

Low flow in atherosclerotic coronary arteries. Usually, there is at least one coronary artery that is more than 50% stenotic.

What is the end result of fibromuscular dysplasia?

Luminal stenosis.

Explain the Mnemonic, It's not HIPP to have Lupus.

Lupus like symptoms can be induced by Hydralazine, INH, Procainamide, Phenytoin.

What is the unusual toxicity associated with hydralazine?

Lupus like symptoms.

Some Drugs and Procedures can induce Iatrogenic Pericarditis. Which ones?

Lupus-Like Syndromes (Hydralazine, Procainamide, Diphenylhydantoin). Anticoagulants (particulary Unfractionated Heparin), Radiation Therapy. Methysergide (Migraine medicine), Cyclosporine (prevent organ reduction), Minoxidil (not topical), Streptokinase (Thrombolytic Drug), Cardiac Surgery or Procedures.

Macrophages are important actors in the development of Atheromas. Explain.

Macrophages gorge themselves on the Fat in Atheromatic Plaques, becoming Foam Cells and dying in the process, secreting Cholesterol which forms Crystals. Other Macrophages cannibalize their dead comrades, growing the plaque further in an Inflammatory Cycle. They also secrete Cytokines that induce Fibrin Formation to start the 'repair process', forming dangerous clots that can become Thrombi.

Which vessels are affected by medium vessel vasculitis?

Main visceral arteries and their branches.

What are the therapeutic uses of mecamylamine (3)?

Mainly its historical uses, but it is currently used to manage: -Hypertensive crisis -Acute aortic dissection -Induce controlled hypotension for neurosurgery

How does Wegener's Granulomatosis present?

Males more than females, About age 40. Persistant Pneumonitis with Cavitary Infiltrates. Often with Renal Disease and Ulcerations of the Nasopharynx. If untreated, 80% fatality in one year.

What are some causes of Cardiac Tamponade? (anything that causes pericardial effusion)

Malignant tumor Idiopathic pericarditis Uremia Bacterial infections Anticoagulant therapy Dissecting aneurysm Diagnostic procedures Tuberculosis Postpericardiotomy Trauma Connective tissue disease Cardiac Tamponade is one of the Biggest Dangers of Pericarditis.

What is a vulnerable plaque?

Marked by a thin fibrous cap, rich lipid core, extensive macrophage infiltrate and a paucity of smooth muscle cells.

What is Angioedema?

Massive Swelling of vascular organs. Can be life-threatening.

Aneurysms are caused by production of MMPS. What are these?

Matrix Metalloproteinases, capable of degrading all kinds of extracellular matrix proteins.

What are the negative consequences of AAA?

May Rupture into the peritoneal cavity or retroperitoneal tissues with massive, potentially fatal hemorrhage. Obstruction of a branch vessel resulting in ischemic injury of downstream. Emboli from atheroma or mural thrombus. Impingement on an adjacent structure, e.g., compression of a ureter or erosion of vertebrae.

What is the possible physiologic role of low levels of Lp(a)? What is the result of high levels?

May provide cholesterol for wound healing; high levels help clots to persist

What is a potential favorable effect of alpha-blockers?

May tx prostatism

How do Physical Exams fit into Endocarditis?

Maybe no Physical findings, but you must check them regularly to make sure they dont occur.

Murmurs heard in patients with pulmonic stenosis can very, how are they graded?

Measurement of the peak systolic pressure gradient at the pulmonic valve helps determine severity: < 40 mmHg→ mild 40-80 mmHg → moderate > 80 mmHg → severe

Which ankle-brachial measurements are most useful?

Measurements done before and after exercise (5 minutes on a treadmill) are most useful. Even if the ABI is normal at rest, the value after exercise may drop, indicating PAD risk.

List the ganglion blockers (1).

Mecamylamine.

Which patients are most likely to experience an aortic dissection?

Men in their sixth or seventh decade. Two thirds of aortic dissection patients have hypertension.

Define Metabolic Syndrome and relate it to Atherosclerosis.

Metabolic Syndrome is characterized by Insulin Resistance, Hypertension, and central Obesity. It is a risk factor for Atherosclerosis.

What drug classes are recommended for hypertension in pregnant women?

Methyldopa, BB, vasodilators

Contrast Micelles with Liposomes.

Micelles have only a single layer, while Liposomes are formed of a bilayer membrane.

How is Infectious Endocarditis diagnosed?

Microorganisms, demonstrated by culture or histologic examination, in a vegetation, embolus from a vegetation, or intracardiac abscess Also histologic confirmation of active endocarditis in vegetation or intracardiac abscess.

What protein loads lipid into the B100 protein to make VLDL? What VLDL proteins interact with lipoprotein lipase?

Microsomal lipid transfer protein (MLTP) and Apo CII

What protein is required to load lipids onto B100?

Microsomal lipid transfer protein.

Give some signs or Sequelae of Rheumatic Fever.

Migratory Polyarthritis. Pancarditis, including Endocarditis, Myocarditis, and Pericarditis. Erythema Marginatum and Sydenham's Chorea are rarer Syndromes.

What inflammatory response is indicative of an acute MI?

Mild fever.

What are the therapeutic uses of calcium channel blockers?

Mild to moderate hypertension, especially in the elderly.

What are the therapeutic uses of prazosin, etc?

Mild to moderate hypertension.

What are the therapeutic uses of clonidine, guanabenz and guanfacine?

Mild to moderately severe hypertension.

What are the therapeutic uses of methyldopa?

Mild to moderately severe hypertension.

Ischemia of the papillary muscles can lead to a High Pitched, Blowing Holosystolic Murmur. What are you hearing?

Mitral Regurgitation.

What are the major presenting symptoms of chronic mitral regurgitation (3)?

Mitral regurgitation can decrease cardiac output, causing: -Weakness and fatigue, especially with exertion -Left ventricle failure causes dyspnea -Right ventricle failure causes peripheral edema

Describe the signs associated with papillary muscle dysfunction.

Mitral regurgitation.

What is a complication of papillary muscle infarction/ischemia?

Mitral regurgitation.

What other valvular disease sometimes accompanies mitral valve prolapse?

Mitral regurgitation.

What are serum lipoproteins?

Mixed pseudomicelles with phospholipids, free fatty acids and cholesterol in their shell, triglyerides and/or cholesterol esters in core, and non-covalently associated apoproteins.

What are the glycerol-derived lipids?

Mono-, di-, and tri-acyl glycerols

How is IDL converted to LDL?

More CE added to core, loss of all apoproteins except apo B100.

Where are there more Angiotensin II receptors, on the efferent or afferent side of the Glomerulus?

More on the efferent side, so pressure increases in the Glomerulus as ATII increases. This is why ACE Inhibitors should not be used in Renal Failure, as you will not be able to achieve optimal filtration pressure.

Describe the pathogenesis of acute coronary syndrome.

More than 90% of acute coronary syndromes result from a disruption of an atherosclerotic plaque with subsequent platelet aggregation and formation of a intracoronary thrombus.

What is a mixed micelle?

More than one type of amphipathic molecule

How much do abdominal aortic aneurysms grow per year?

Most aneurysms expand at a rate of 0.2 to 0.3 cm/yr, but 20% expand more rapidly.

What is the most common complication that causes sudden death in patients with myocardial ischemia?

Most patients who die of coronary artery disease do so as a result of ischemia induced ventricular tachyarrhythmia.

What is the typical clinical presentation of an aneurysm?

Most people are asymptomatic, but early signs can include noting a pulsatile mass (e.g. upper abdomen) or problems due to compression of adjacent structures (cough, hoarseness [recurrent laryngeal nerve], nonspecific GI symptoms).

Which bugs are responsible for Infective Endocarditis?

Mostly Gram Positive Cocci.

How does Infectious Endocarditis present in IV drug users?

Mostly Staph Aureus, Right Sided Endocarditis involving the Tricuspid valve presenting without a murmur. This is because they shoot up into the Vein. This leads to Septic Pulmonary Embolism in 75% of people. Blood Cultures are usually Positive, so this is a good test.

How is acute arterial occlusion diagnosed?

Mostly through clinical presentation and confirmed by angiography. Assessment is usually done by a vascular specialist.

What does MI look like 24-72 Hours in?

Mottling with yellow-tan infarct center.

How does Viral Myocarditis present?

Much like MI: Patients typically present with shortness of breath, chest pain, EKG abnormalities, and fever. All typically have a history of upper respiratory or GI tract infection in the previous 1-2 weeks. Some pts may present with no prior symptoms or even as sudden death.

What are the Toxicities of Statins?

Muscle Soreness. Rare Liver toxicities, monitor glucose, Hypersensitivity reactions.

What is the most important aspect of treatment of acute arterial occlusion?

Must be treated immediately, time is of the essence. Extensive, irreversible damage occurs within six hours.

Loeys-Dietz Syndrome can predispose a patient to Aneurysm. What is it?

Mutations in TGF-β receptors lead to abnormalities in Elastin and Collagen, so even small aneurysms can rupture easily.

Stains can cause Myalgia, Myopathy, and Rhabdomylosis. Compare these.

Myalgia is simply muscle pain, Myopathy is pain with increased Creatinine Kinase. Rhabdomylosis has CK 50 times normal indicating real damage.

What protein can decrease the ability of Apo A1 to pick up cholesterol, and increase the risk of heart disease?

Myeloperoxidase (MPO)

What is the result of an occlusion of the coronary artery due to an aortic dissection?

Myocardial infarction.

What is the role of myoglobin in the diagnosis of MI?

Myoglobin levels peak between 1 to 4 hours after an acute MI, but it cannot be used alone to diagnose MI. However, it can be useful in conjunction with other markers for AMI diagnosis, to prove the effectiveness of thrombolytic therapy and most importantly, if it is not present, then AMI is ruled-out.

Is Unstable Angina more closely related to STEMI or NSTEMI?

NSTEMI. These both result from Partial Occlusion of Coronary Arteries rather than Full Occlusion which gives STEMI.

Which beta blocker's half-life is dependent on renal function?

Nadolol, it is excreted unchanged.

Describe severe and chronic atherosclerosis.

Narrowing of the lumen of one or more coronary arteries.

Give a brief description of polyarteritis nodosa.

Necrotizing inflammation typically involving renal arteries but sparing pulmonary vessels.

Where are N-type calcium channels found?

Neurons.

How does Infectious Endocarditis Present?

New regurgitant Murmurs, cardiac Abcesses, Heart Block. Fever 80-90% Chills/sweats 40-75% Heart murmur 80-90% CHF 30-40% Worsened murmur 10-40% Arterial emboli 20-50% Neurologic changes 20-40% Spenomegaly 15-50% Peripheral signs 2-15%

What is angiogenesis?

New vessel formation in the mature organism.

What drug inhibits adipose tissue lipolysis? What is its effect?

Niacin (nicotinic acid); decrease in liver TG synthesis and therefore VLDL production

What is an inhibitor of adipose tissue lipolysis?

Niacin or nicotinic acid.

What is the only treatment for Lp(a) problems?

Niacin.

What are the other effects prcainamide has (1)?

Nicotinic receptor blockade (hypotension).

Which CCB has the fastest onset?

Nifedipine and Nicardipine. These are basically less safe because they can cause Sudden MI. Slow is better.

Which calcium channel blocker has been shown in some studies to reduce left ventricle enlargement, increase left ventricle ejection fraction and delay the need for surgery in hypertensive patients with severe aortic regurgitation who have normal left ventricle contractile function?

Nifedipine.

Which calcium channel blocker has a preferential effect on cerebral vessels?

Nimodipine has a high lipid solubility and preferentially binds to the alpha-1 subunit of the calcium channels on cerebral vasculature. It also reduces the consequences of subarachnoidal hemorrhage by relieving consequent vasospasm.

What effect do nitrates have on hemoglobin?

Nitrite reacts with (ferrous) hemoglobin to produce (ferric) methemoglobin. Large amounts of nitrates and nitrites (polluted water, cured meat) may lead to hypoxia and death in children. However, nitrite-induced methemoglobin has high affinity for cyanide and may remove CN- from cytochromes, making nitrates a therpeutic possibility for cyanide poisoning.

What is the interval for follow up if the abdominal aorta is less than 3cm?

No further testing needed.

Objective assessment of function capacity class 1.

No objective evidence of cardiovascular disease.

What is the historical treatment of aortic stenosis (1)?

No proven therapy.

Can mitral valve prolapse be detected by a chest x-ray or ECG?

No, chest x-ray and ECG are usually normal.

If flow is completely stopped to an Artery for a while, is it a good idea to open it up?

No, clotted blood will go everywhere. This is a CT Angiogram. ICA on Patient Left has no flow, ICA on Patient Right has a Stint.

Is Niacin a synthetic chemical?

No, it is Vitamin B3, at much higher levels than in Vitamins.

Is the balloon in the balloon catheter filled with air?

No, it is usually filled with Contrast Medium so we can see it inflate.

Can you use Beta blockers in Prinzmetal Angina?

No, it will Block Beta but leave Alpha, so constriction can occur.

Up to 30% of those with elevated troponin levels will have a normal creatine kinase MB, does this rule out a diagnosis of acute MI?

No, normal creatine kinase MB levels do not discount the elevated troponin levels.

Does the absence of arachnodactyly rule out a diagnosis of Marfan syndrome?

No.

When assessing a partially occlusive thrombus, what is the most likely diagnosis when serum biomarkers are positive?

Non-ST elevation MI.

When assessing for transient ischemia, what is the most likely diagnosis when serum biomarkers are positive?

Non-ST elevation MI.

What are Echoviruses and Coxsackieviruses?

Non-enveloped ssRNA viruses, members of the Enterovirus genera, in the Picornavirus family.

What type of calcium channel blockers comprise the class IV anti-arrhythmics?

Nondihydropiridine calcium channel blockers.

Morphologic features of MI, macroscopic changes: 0-30 min

None.

What drugs help with Chronic Bradycardias?

None. Give him a pacemaker. Epinephrine and Dopamine can be used acutely.

What other effects does sotolol produce (1)?

Nonspecific beta blocker.

What is the mechanism of action of propanolol?

Nonspecific beta receptor blocker.

FH Homozygotes are exceedingly rare, One in a Million. Are Heterozygotes?

Nope, 1 in 500.

How sensitive are troponin levels for detecting an MI?

Normal (reference) levels are virtually zero. After an MI, levels rise to greater than 20 times the reference range. Even very small degrees of necrosis can be detected.

How is Aortic Stenosis Graded?

Normal Aortic Orifice Area is 3-4 Square Centimeters. Mild AS is less than 2, Moderate is less than 1.5, and Severe AS is less than 1 Square Centimeters.

Give the grades of aortic stenosis based on the aorta's cross-sectional area.

Normal aortic valve cross-sectional area is 3-4 cm2. -Mild AS: area is < 2 cm2 -Moderate AS: area is 1.0-1.5 cm2 -Severe AS: area is < 1.0 cm 2

Toxicity of Amiodarone?

Not always good long term: Pulmonary Fibrosis, Liver Tox, Hyper or Hypothyroidism, Blue Skin and Yellow Cornea (from Iodine accumulation), Photosensitivty and CNS effects. It does reduce Mortality though?

Nitrosamines, formed from Nitrates and Amines, are Carcinogenic. Are Nitrates Carcinogenic?

Not at Therapeutic Doses.

Is Primary Pulmonary Hypertension Common?

Not at all. It is seen often in Women, and often caused by Myointimal Smooth Muscle Cell Proliferation in Medium-Size Arteries, causing high Blood Pressure in Pulmonary Arteries.

How helpful is a 12 lead ECG in diagnosing an aortic dissection?

Not very, it is usually within normal limits or has non-specific abnormalities.

Morphologic features of MI, macroscopic changes: 1-2 hours

Not visible, but can be shown by nitro-blue-tetrazolium (NBT); infarcted area does not stain blue.

Morphologic features of MI, macroscopic changes: 4-12 hours

Not visible, but can be shown by nitro-blue-tetrazolium (NBT); infarcted area does not stain blue.

What does a normal, medium sized artery look like?

Note the INTIMA,IEL, MEDIA, EEL, ADVENTITIA.

What does Chronic Pulmonary Congestion from Chronic Heart Failure look like?

Note the high amounts of Iron from blood congestion.

Give the Compositions of the Various Lipoproteins.

Note the main difference between HDL and LDL is that HDL has more protein and less Cholesterol.

How Much does Nuclear Medical Imaging Cost?

Nuclear Medical Imaging costs $2,000.

Objective assessment of function capacity class 2.

Objective evidence of minimal cardiovascular disease.

Objective assessment of function capacity class 3.

Objective evidence of moderately severe cardiovascular disease.

Objective assessment of function capacity class 4.

Objective evidence of severe cardiovascular disease.

What is the most common cause of myocardial ischemia?

Obstructive atherosclerotic disease of the epicardial coronary arteries.

When does hyperplastic arteriolosclerosis present?

Occurs in severe (malignant) hypertension of a blood pressure greater than 240/120 mmHg.

What is a false aneurysm?

Occurs when only the adventitia balloons out after an intimal rupture. Can occur at sites of infection or trauma.

What is Polyarteritis Nodosa?

Often caused by underlying Hepatitis B, this Vasculitis is attributable to Hep B surface Antigen.

Can Steroids reduce HDL?

Oh yeah. They look healthy, but they have heart attacks young.

Why is most of the absorbed cholesterol converted to its totally hydrophobic form, cholesterol ester?

Once absorbed, cholesterol will become part of a lipoprotein. But because cholesterol is only weakly amphipathic, if too much is inserted into the shell of the lipoprotein, the lipoprotein can come out of solution. Therefore, most of the absorbed cholesterol is converted to its totally hydrophobic form, cholesterol ester.

What is the protocol for diagnosing an acute MI using cardiac biochemical markers?

One approach is to measure cardiac troponin, CK-MB, and myoglobin levels on admission, then serial troponin every 8 hrs until peak levels are reached (or 24 hrs). If myoglobin is negative, likelihood of AMI is virtually zero. [CKMB and troponin negative as well!] If myoglobin is positive, continue serial testing of troponin.

Where are the electrodes placed in a Standard 3 Lead EKG?

One on each arm and one on the Left Leg.

What significance does lipoprotein a have for an individual's health?

One's concentration of Lp(a) is an inherited trait and does not respond to variation in diet, exercise or pharmaceutical intervention. From the Framingham study, a high level of Lp(a) has been cited as one of the most prevalent genetic risks for heart disease. It further noted that a given amount of Lp(a) in the blood confers as much added risk as does 10 times as much LDL.

What are the kinetics of nimodipine (1)?

Onset unknown.

What are the kinetics of nisoldipine (1)?

Onset unknown.

Which state of the sodium channel does lidocaine prefer to bind to?

Open/activated.

What is the mortality of abdominal aortic aneurysms?

Operative mortality for unruptured AAAs is approximately 5%; emergency surgery after rupture has a mortality rate of > 50%.

Inhaled and Sublingual Nitrates have the Shortest Half life. Which have the longest?

Oral, Transdermal, or Buccal.

Which clinical situation are arteriolar dilators best used in?

Oral, long-term outpatient hypertension treatment.

What are the kinetics of bile binding resins?

Oral, taken with meals.

What are the kinetics of dofetilide (1)?

Oral.

What are the kinetics of ibutelide (1)?

Oral.

What are the kinetics of isosorbide mononitrate (1)?

Oral.

What are the kinetics of mexiletine (1)?

Oral.

What are the kinetics of niacin?

Oral.

What are the kinetics of tocainide (1)?

Oral.

What is the Pharmacokinetics of Gemfibrozil?

Orally taken, well absorbed.

What is the result of an occlusion of the splanchnic artery due to an aortic dissection?

Organ infarction.

Why has it become popular to use biochemical markers to diagnose cardiac infarction?

Over the past 20 years, sensitive and specific lab tests for serum cardiac markers have identified an additional 33% of patients who would not have fulfilled criteria for acute MI in the past. The resting ECG can miss up to 50% of acute MI.

How does venous insufficiency lead to venous stasis dermatitis?

Over time, there is an increased venous hydrostatic pressure leading to an increase in the permeability of the dermal capillaries. This increased permeability enables macromolecules, such as fibrinogen, to leak out into the pericapillary tissue.

Which wave represents atrial depolarization?

P waves.

Give the Stages of CHF and how they appear on Chest Xray.

PCWP is Pulmonary Capillary Wedge Pressure.

What specific Receptor do Fibrates target?

PPAR-alpha. Peroxisome Proliferator-Activated Receptor-Alpha. These may raise LDL, a negative consequence.

What part of the EKG is affected by Rate Control Drugs?

PR interval, indicating the passage of the current through the AV Node.

What is a sign of unstable angina?

Pain at rest.

What clinical presentation is associated with a diagnosis of costochondritis (1)?

Pain is reproduced by palpating chest wall in a low-risk patient.

What are the signs and symptoms associated with costochondritis (1)?

Pain is reproduced by palpating the chest wall in a low risk patient.

What is silent angina?

Painless episodes of ischemia, occurring in patients who have angina and in those who do not. Painless infarction is also possible.

Morphologic features of MI, macroscopic changes: 4-7 days

Pale center with hyperemic border.

What does MI look like from 12-24 Hrs in?

Pale myocardium with dark mottling.

Morphologic features of MI, macroscopic changes: 18-24 hours

Pale with blotchy discoloration.

Morphologic features of MI, macroscopic changes: 24-72 hours

Pallor.

How is Infectious Endocarditis treated?

Parenteral Antibiotics trying to reach super high concentrations to get it into the vegetation(Vancomycin or Gentamycin). Surgery if Organisms are resistant or it is spreading.

Which clinical situation are arteriolar and venule dilators best used in?

Parenteral treatment for hypertensive emergencies.

What are the clinical uses of sodium nitroprusside?

Parenteral treatment of hypertensive emergencies.

What are the therapeutic uses of diazoxide?

Parenteral treatment of hypertensive emergencies.

What is the mechanism of action of pindolol?

Partial beta agonist.

How successful was dronedarome as a substitute for amiodarone?

Partially successful, no reports of pulmonary fibrosis, but severe liver toxicity has been reported.

Define Amphipathic?

Partly Hydrophobic, Partly Hydrophobic.

What kind of ECG morphology indicates a prior MI?

Pathologic Q waves.

Which patients are IV glycoprotein IIb/IIIa inhibitors most beneficial for?

Patients who receive angioplasty.

Describe successful administration of fibrinolytic therapy.

Patients who receive therapy within 2 hours of the onset of symptoms have half the mortality rate of those who receive it after 6 hrs of symptoms.

Functional capacity class 1.

Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain.

Functional capacity class 4.

Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

Functional capacity class 3.

Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

Functional capacity class 2.

Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

Contrast PCI and CABG.

Percutaneous Coronary Intervention is a shorter and more painless procedure. However, it requires more frequent procedures such as Angiogram and second PCI.

Contrast PCI and CABG. (pronounced Cabbage I guess)

Percutaneous Coronary Intervention is the insertion of a Stint into an Atherosclerotic Coronary Artery. Coronary Artery Bypass Graft is using another vessel to give perfusion to the Distal Vessal beyond the Clot.

What is PTCA?

Percutaneous Translumenal Coronary Angioplasty. It can be with a Stent or a Balloon.

What is Acute Hemorrhagic Pericarditis?

Pericardial Exudate contains blood. Often caused by Tumors.

How can you differentiate a Pericarditis Friction Rub from a Pleural Friction Rub?

Pericarditis rubs follow the rhythm of the Heart rather than the rhythm of the Lungs.

What is Rheumatic Heart Disease?

Permanent damage to heart valves caused by repeated attacks of Rheumatic Fever.

How is Persistant Rheumatic Fever diagnosed?

Persistant Valve Lesions.

What are some Pathological Effects of Infective Endocarditis?

Persistent Bacteremia leading to release of Cytokines inducing Fever and Sweat. Tissue damage including Valvular Insufficiency, Myocardial Abscesses, distant infections. Possible embolism of Vegetation, possible Autoimmune complications.

How are patients who are unable to exercise stress tested?

Pharmacologic interventions plus nuclear imaging or echocardiography can reveal areas of impaired myocardial perfusion.

What molecule forms the core of most Amphipathic Glycerol-based molecules?

Phosphatidic Acid, which can be substituted with Choline, Inisitol, Etc.

What are Sildenafil, Tadalafil, and Vardenafil?

Phosphodiesterase Inhibitors that prevent the breakdown of cGMP. They are Erectile dysfunction medicines that interact with Nitrates because we get massive cGMP and over-relaxation of Smooth Muscle.

What becomes of the chell of the chylomicron as its triglycerides are extracted?

Phospholipid Transfer Protein (on circulating HDLs) transfers phospholipid from the shell of the chylomicron to the shell of an HDL.

What happens to chylomicrons as TG is hydrolyzed in the core?

Phospholipids transfered from chylomicron to shell of an HDL by Phospholipid Transfer Protein on HDLs

What three molecules are typically found in animal cell membranes?

Phospholipids, sphingolipids, and cholesterol forming "mixed bilayers"

What is the speculated purpose of lipoprotein a?

Physiologically low levels of Lp(a) assist with the healing of blood vessel wounds by providing cholesterol needed for the proliferation of the cells involved in wound healing. Lp(a) binds well to partially degraded clots, but less strongly to intact fibrin. Therefore, when the clot begins to dissolve, the Lp(a) would bind and support the proliferation of inflammatory cells and fibroblasts.

How can you use the Amplitude in each lead to calculate the direction and strength of the Electrical Vector?

Pick 2, chart them on their axes. Draw a perpendicular and draw a vector from the origin to their intersection.

Once new chylomicrons reach the lymphatic vessel, how do they mature?

Pick up apoproteins C and E from HDLs, then empty into thoracic duct

What is the function of HDL?

Picks up excess cholesterol from peripheral tissues and returns it to liver for repackaging or excretion

What causes hyaline arteriolosclerosis?

Plasma protein leakage across injured endothelial cells and increased smooth muscle ACM in response to chronic hemodynamic stress.

Which other protein does apolipoprotein a resemble?

Plasminogen, though it lacks three of the four folded "kringle" domains of plasminogen. The fourth kringle domain is repeated more than 30 times in apolipoprotein (a). Eighty percent of apoprotein (a)'s amino acids coincide with those of plasminogen.

Which process of hemostasis do the exposure of subendothelial collagen and turbulent blood flow contribute to?

Platelet activation and aggregation.

What effect do nitrates have on platelets?

Platelet aggregation is reduced by NO-induced cGMP, but there is no survival benefit in myocardial infarction.

What are the two types of Medium vessel Vasculitis?

Polyarteritis Nodosa and Kawasaki Arteritis.

What are the Major Duke Criteria of Infectious Endocarditis?

Positive blood culture in at least 1 out of 3 cultures. New Valvular regurgitation or Echo showing vegetation. Trans-Esophageal Echo is much better at detecting Vegetation.

What does an abnormal R wave progression seen with ST segment downsloping/depression indicate?

Posterior MI.

Class of Bretylium?

Potassium Channel Blocker, so Class III.

Class of Ibutilide?

Potassium Channel Blocker, so Class III.

Class of Sotalol?

Potassium Channel Blocker, so Class III.

Class of Amiodarone?

Potassium Channel Blocker.

Class of Dofetilide.

Potassium Channel Blocker.

Class of Dronedarone?

Potassium Channel Blocker.

What are Arrhythmia Drugs Class III?

Potassium Channel Blockers, which Prolong Action Potential Depolarization (APD) which increases QT.

What is the mechanism of action of dofetilide?

Potent lkr blocker.

Which Statins are the best at raising HDL?

Pravastatin and Simvastatin.

What is nascent HDL?

Pre-beta or nascent HDL is newly synthesized in the liver. Flat and discoid phospholipid bilayer surrounded by apo A1. High capacity to pick up cholesterol.

What are the Contraindications of Statins?

Pregnant women or likely to be pregnant (fetal Malformation), small children. Relative contraindications.

What is the purpose of assessing a patient's functional capacity?

Primarily the classification guides physical activity activity recommendations, but it can also help determine when surgical treatment is necessary to improve quality-of-life.

Despite the advantages of percutaneous coronary therapy, why is fibrinolytic therapy still the standard treatment for ST elevation MI?

Primary PCI is limited to centers that are very experienced in coronary angioplasty and are equipped to perform it on an emergency basis. Since the majority of U.S. hospitals do not meet these criteria, the use of thrombolytic therapy remains the widespread standard.

Differentiate between Primary and Secondary Varicose Veins?

Primary causes are Prolonged Standing, Pregnancy, Obesity, only affecting Superficial veins. Secondary causes are Venous Occlusion, etc.

What kind of emotional response is associated with the pain of an MI?

Profound feelings of doom.

What ECG abnormality is often seen in Acute Rheumatic Fever?

Prolonged PR interval, indicative of an AV Block. This is a sign of Carditis generally also.

What are the other effects disopyramide has (1)?

Pronounced anti muscarinic effects.

What other effects do the class 1C sodium channel blockers produce?

Propafenone has weak beta blocking activity.

What are predisposing Risk Factors for Infectious Endocarditis?

Prosthetic heart valves Intravenous drug use Valvular damage from a previous endocarditis Congenital cardiac defects Degenerative heart disease; such as calcific valvular disease Mitral valve prolapse - most common in young adults Rheumatic heart disease

What happens to blood lipids in AIDS?

Protease Inhibitors can cause Metabolic Syndrome with increased TG and insulin resistance that can become Type 2 Diabetes.

What kind of Virulence Factors does Staphylococcus Aureus have?

Protein A - inhibits Phagocytosis Fibrinogen-binding protein - Clumping Factor Coagulases - convert fibrinogen to a fibrin clot Cytotoxic toxins - pore-forming toxins It can also develop Antibiotic Resistance.

Which type of aortic dissections are most dangerous?

Proximal dissections.

What are the major presenting symptoms of acute mitral regurgitation (1)?

Pulmonary edema causes dyspnea.

What additional side effect does tocainide have?

Pulmonary fibrosis.

How serious of a medical condition is pulmonic regurgitation?

Pulmonic regurgitation is usually of little hemodynamic significance; right heart failure is a consequence of pulmonary hypertension rather than of pulmonic regurgitation

Give common complications of Angiography and their Rates.

Puncture Site Hematoma-5%. Contrast Agent Toxicities to kidney and Liver. Catheter Related Dissection or Embolism-less than .05%.

Why are Q waves no longer used to distinguish between types of MI?

Q waves, unlike ST changes and biochemical markers, may take hours or longer to develop and cannot be used to make early therapeutic decisions.

What does ST Elevation give rise to in the Long Run?

Q-Waves. These are deep spikes of the normally short Q area.

Describe an indeterminate axis deviation.

QRS is: -Downward in lead I -Downward in lead aVF

Describe a right axis deviation.

QRS is: -Downward in lead I -Upward in lead aVF

Describe a left axis deviation.

QRS is: -Upright in lead I -Downward in lead aVF

Explain the Mnemonic Queen Proclaims Diso pyramids.

Quinidine, Procainamide, and Disopyramide are 1A Beta Blockers.

What cardiac dysfunction produces rales?

Rales may be present at the lung bases depending on the degree of pulmonary congestion or edema.

Describe the signs associated with pulmonary congestion.

Rales.

Who is at risk for Viral Myocarditis?

Rapid and Fatal in Children, though overall Mortality less than 1%.

Phase 4 is the gradual slope in Cardiac Conducting Cells that leads to an Impulse. What drugs Lessen the slope, decreasing Heart Rate?

Rate Control Drugs: B-blockers, Na+ and Ca++ channel blockers. Vagal discharge, as by Massage.

What are the therapeutic uses of dilitiazem (1)?

Rate conrol for: reentrant supraventricular tachycardia.

What are the therapeutic uses of propanolol (3)?

Rate control for: -Atrial fibrillation -Atrial flutter -AV nodal reentry

What are the therapeutic uses of dofetilide (2)?

Rate control for: -Atrial flutter -AV nodal reentry

What are the therapeutic uses of verapamil (2)?

Rate control for: -Atrial flutter -AV nodal reentry

Which type of therapy is safer, rate control or rhythm control?

Rate control, CAST determined that rhythm control is associated with higher incidences of mortality.

What are the therapeutic uses of esmolol, metoprolol and pindolol (1)?

Rate control: supraventricular arrhythmias.

Summarize the interaction of apo CII and apo CIII

Ratio CII / CIII regulates activity of lipoprotein lipase

What is Raynaud's Syndrome?

Raynaud's phenomenon is an exaggeration of vasomotor responses to cold or emotional stress. More specifically, it is a Hyperactivation of the sympathetic nervous system causing Extreme Vasoconstriction of the Peripheral Blood Vessels, leading to Tissue Hypoxia.

When is Arrhthmia Pharmacology Indicated?

Reduced Cardiac Output, Arrhythmias that can progress (Atrial Fib--> V Fib), or Arrhythmias that can precipitate an Embolism (Chronic A Fib)

What is systolic dysfunction?

Reduced contractility.

What causes angina ischemia in late phase chronic aortic regurgitation?

Reduced coronary perfusion gradients.

What are the clinical indications for propanolol?

Reduces mortality rate post-MI, reduces incidence of MI induced arrhythmias.

The National Cholesterol Education Program Adult Treatment Panel considers peripheral artery disease to be a coronary heart disease equivalent, what is their recommendation?

Reducing LDL cholesterol to < 100 mg/dL.

List some Possible Mechanisms that Ace Inhibitors use.

Reduction in left ventricular hypertrophy Vascular hypertrophy Progression in atherosclerosis Plaque rupture Thrombosis More favorable O2 supply/demand ratio Reduction in sympathetic activity

Calcium Channel Blockers are Rate Control Drugs. Which Specific Heart Rhythms can be treated with these?

Reentrant SVT, A Fib and A Flutter.

90% of Infarcts are Regional. What does this mean in comparison to Circumferential Infarct?

Regional Infarcts generally involve Thrombi blocking a region, Circumferential often involve Hypotensive episodes that reduces blood flow to the ventricle, making it evenly necrotic all around. Both begin at the Subendocardial Level, and Regional Infarcts can give rise to Transmural Infarct.

Where can the pain of infarction be referred to?

Regions of the C7-T4 dermatomes, including the neck, jaw, shoulders and arms.

Give Side Effects of Sotalol.

Remember that it is both a Beta Blocker and Potassium channel Blocker. Good for Sustained V-Tach. Can cause Torsades de Point, as does anything that increases QT interval. Generally safer than alternatives.

What is arteriogenesis?

Remodeling of existing arteries in response to chronic changes in pressure or flow. It results from an interplay of endothelial cell and smooth muscle cell derived factors.

What is the function of lecithin-cholesterol acyl transferase is the conversion of HDL3 to HDL2?

Removes cholesterol from the outer shell of the HDL.

What is the result of an occlusion of renal artery due to an aortic dissection?

Renal failure.

Summarize apoprotein A1

Required for assembly of HDL; activating cofactor of LCAT (Lecithin Cholesterol Acyl Transferase); found on chylomicrons and HDL; also required to pick up cholesterol from cell membranes (possibly binds to ABC-1 shuttle protein.)

What are the therapeutic uses of ibutilide (1)?

Restore sinus rhythm in atrial fibrillation and flutter.

What is the clinical use of dronedarone?

Restores sinus rhythm in atrial fibrillation.

Compare Restrictive Cardiomyopathy with Constrictive Pericarditis.

Restrictive Cardiomyopathy and Constrictive Pericarditis both lead to Diastolic Filling problems, but Restrictive is based on Rigid Myocytes and Constrictive is based on Rigid Pericardial Sac.

How can you tell Cardiomegaly on a Lateral Chest X-Ray?

RetroSternal Space is occluded, it also stretches farther posterior than normal.

What does definitive treatment of acute arterial occlusion involve?

Revascularization, either by surgical thromboembolectomy or chemical thrombolysis.

What kind of transport of HDL involved in?

Reverse cholesterol transport. The movement of cholesterol from areas of excess in the peripheral tissues back to the liver or to areas of cholesterol need

What is the mechanism of action of digoxin?

Reversibly Inhibits Na+/K+ ATPase.

When do you often see Calcified valves as a Primary Condition?

Rheumatic Heart Disease.

Which are the most efficacious Statins in terms of lowering LDL?

Rosuvastatin and Atorvastatin.

How is Myocarditis diagnoses?

Rule out other things, then do Biopsy as Gold Standard. Lymphocytosis and Cardiac Myocyte Necrosis support the Diagnosis. Blood Cultures rule out Bacteria, PCR helps identify Virus,.

What is the most Common Pathology of ACS? (MI and unstable Angina)

Rupture of Atherosclerotic Plaque.

Which complication is common to 10% of hospitalized patients dying of MI?

Rupture of the infarcted myocardium.

What causes cardiac tamponade?

Rupture through the epicardium.

What are the common Causative organisms in Infectious Endocarditis related to IV drug use.

S. aureus (most common) coagulase (-) Staphylococci. less common: streptococci, enterococci, gram(-) rods, fungi.

What is the Technical name for a Ventricular Gallop?

S3. Sounds like a running horse, 2 fast beats during the Second heart sound. This indicates a Failing Left Ventricle.

Describe the signs associated with decreased diastolic compliance.

S4.

What is the Technical Name for an Atrial Gallop?

S4. Sounds like a running horse, 2 fast beats during the First heart sound. This is caused by a Stiff Ventricular wall, into which the Atrium is slamming.

What is the most likely diagnosis with prolonged ischemia?

ST elevation MI.

Which acute coronary syndromes result from a complete vessel occlusion (1)?

ST elevation MI.

What kind of ECG morphology indicates an acute MI?

ST elevations or depressions.

What is STEMI?

ST-Elevated Myocardial Infarction. It results from Occlusive Thrombi. The ST segment on the EKG is quite literally elevated above the normal Zero value that it should be at.

Which acute coronary syndrome results from a complete occlusion (1)?

ST-segment elevation myocardial infarction (STEMI), also known as a "Q-wave MI" or transmural MI.

Contrast the two types of True Aneurysms, Saccular and Fusiform.

Saccular Aneurysms are Spherical outpouchings involving only a portion of the vessel wall. Fusiform Aneurysm are Diffuse, Circumferential dilations of a long vascular segment up to 20 cm in length May involve extensive portions of the aortic arch, abdominal aorta, or iliac arteries.

Choosing between ACE inhibitors and angiotenson II receptor blockers: In what ways are they equivalent (3)?

Same efficacy in -Treating essential hypertension -Treating proteinuria of chronic renal disease -Treating congestive heart failre

What are signs on the Microscope of Old MI, more than 8 weeks?

Scar Tissue formation at advanced stage.

What are the therapeutic uses of class 1A sodium channel blockers (3)?

Second/third line drugs (toxicity) for all types of arrhythmias: -Atrial fibrillation -Atrial flutter -Ventricular tachycardia

What is Erythema Marginatum?

Seen in less than 10% of Rheumatic Fever, it is a classic sign and strong indicator of the Disease. It is described as the presence of pink rings on the trunk and inner surfaces of the limbs which come and go for as long as several months

What events cause the Q, R, and S peaks?

Septal, Apex, and Base Depolarization. The vectors that point Left, Septal and Base, register as negative voltages on EKG.

What is Septic Shock?

Septic shock is a medical condition as a result of severe infection and sepsis, though the microbe may be systemic or localized to a particular site. It can cause multiple organ dysfunction syndrome, bringing in Elements of Other types of Shock.

What are the advantages of percutaneous coronary intervention?

Several clinical trials have shown achievement of optimal flow in > 95% of patients (compared to 70-80% with fibrinolytics). PCI also has few contraindications.

What are the therapeutic uses of minoxidil?

Severe hypertension (must be used in combination with beta blocker to reduce reflex sympathomimetic effects and loop diuretics to prevent sodium and water retention).

What are bilayers?

Sheets formed by a double layer of molecules with the nonpolar regions of the lipids in the center and the polar portions facing both aqueous surfaces.

What are the kinetics of sublingual nitroglycerin (1)?

Short acting, 30 minutes.

Describe the Short Term and Long Term effects of Thiazides.

Short term they lower Blood Pressure and Plasma Volume. Long Term they decrease vessel stiffness, but reflexive plasma Renin Activity can be problematic.

Choosing between ACE inhibitors: In what ways are ACE inhibitors disadvantageous (2)?

Side effects: -Three times more likely to develop a chronic cough -Use is more often withdrawn in patients

What does a troponin value of greater than 2ng/mL mean?

Significant myocardial infarction.

What hemodynamic effects do angiotensin II receptor blockers produce?

Similar effects as ACE inhibitors, but produce a more pronounced blockade and have no effect on bradykinin pathways.

What hemodynamic effects do potassium sparing diuretics produce?

Similar effects as thiazides, but with less potassium wasting.

What hemodynamic effects do labetalol and carvedilol produce?

Similar effects to propanolol on cardiac output and renal renin release, but also prevents alpha receptor mediated vasoconstriction.

What hemodynamic effects do loop diuretics produce?

Similar effects to thiazides, but more pronounced.

What are the toxicities of angiotensin II receptor blockers?

Similar to ACE inhibitors, except cough and angiodema are not present (AT1 antagonist don't effect bradykinin cascade).

What is Postpericardiotomy Syndrome?

Similar to Dressler's Syndrome, 10-40% of patients following Cardiac Operations develop Chest pain, fever, increased sedimentation rate, pericardial effusion, occas. Pulmonary infiltrates.

What hemodynamic effects do clonidine, guanabenz and guanfacine produce?

Similar to methy dopa, plus decreased renal vascular resistance.

What are the kinetics of bepridil?

Similar to nifedipine, but medium onset.

What are the kinetics of dilitiazem and verapamil?

Similar to nifedipine, rapid IV onset and fast to medium oral onset.

What are the toxicities of beta1 specific blockers?

Similar to propanolol with reduced lung effects.

What are the toxicities of partial beta agonists?

Similar to propranolol, but because they are partial agonists they produce less bradyarrhythmias and bronchoconstriction.

What are the therapeutic uses of partial beta agonists?

Similar to propranolol, but may be better for patients with depressed cardiac function or lung disease.

How are Chest Lead Electrodes arranged?

Six of them wrap around the side of the body to add dimension.

What aspect of an abdominal aortic aneurysm is related to its risk of rupture?

Size.

Why can't physicians rely on a single creatine kinase MB measurement for an MI diagnosis?

Skeletal muscle contains some creatine kinase MB, so it is best to compare the relative measurements of serial values.

Why don't calcium channel blockers have any effect on skeletal muscle?

Skeletal muscle contraction does not require transmembrane calcium influx, intracellular calcium pools are utilized.

What are the Toxicities of Gemfibrozil?

Skin Rash, Gi upset, Erectile Dysfunction, Myositis that impairs Renal Function (Rhabdomyalosys if combined with Statin, Liver damage.

What are the kinetics of isradipine (1)?

Slow onset.

What are the kinetics of felodipine (1)?

Slowest onset.

What is a potential favorable effect of thiazides?

Slows demineralization in osteoporosis

What type of vessels are most commonly affected by vasculitis?

Small vessels, from arterioles to capillaries to venules. Several of the vasculitides tend to affect only vessels of a particular size or particular vessel beds.

What are arteriovenous fistulas?

Small, direct connections between arteries and veins.

What are the characteristics of alpha HDL3?

Smallest alpha HDL, most numerous, picks up excess cholesterol but not as well as nascent HDL due to interfering presence of apo AII.

What Lifestyle Changes are advised in Stable Angina?

Smoking cessation. Treatment of hypertension. Optimize weight & exercise. Treatment of diabetes. Reduce stress.

Which environmental factor is most strongly related to peripheral artery disease?

Smoking, in contrast to coronary disease, prolonged smoking cessation did not appear to eliminate this risk completely.

Give an Overview of Chylomicron Production in the Intestinal Epithelium.

Smooth ER contributes Triglycerides, Rough ER contributes APO-B48. These go to Golgi, and emerge as Nascent Chylomicrons that undergo Exocytosis.

Where are L-type calcium channels found?

Smooth muscle and they are the prevalent type in the heart.

What are Arrhythmia Drugs Class I?

Sodium Channel Blockers.

What Ion Channels are used in Contracting Cardiac Cells?

Sodium Channels, L type Calcium, Potassium.

What Ion Channels Are used in Conducting Cardiac Cells?

Sodium Funny Currents, T Type Calcium, L Type Calcium, and Potassium Channels.

What Cell Membrane component is the most rapidly affected by Ischemia or Shock?

Sodium Potassium ATPase and other simlary pumps fail, often causing cell swelling and failure of Electrical Cells.

What effect do Ace Inhibitors have on Potassium?

Sodium Potassium Shuttling is reduced in the Collecting Duct, so we retain more Potassium while getting rid of more Sodium.

What hemodynamic effects do thiazides produce?

Sodium stays on the lumenal side of the distal tubule, water follows the sodium, thus increasing the excretion of water and sodium. The net result is a reduction in total body water volume and therefore blood pressure. Additionally, sodium may play a role in increasing the stiffness of vessels and neural activity.

What other effects do beta blockers produce (1)?

Some anesthetic effects.

Can Constrictive Pericarditis be seen on XRay?

Somewhat, the calcification can be seen on the lateral X-ray.

How is the treadmill stress test performed?

Speed and incline of treadmill are gradually increased while symptoms, ECG changes and blood pressure are monitored. The test is stopped if the patient has chest discomfort, shortness of breathe, dizziness or severe fatigue, or if there are abnormalities in the ECG or in blood pressure.

What are saccular aneurysms?

Spherical outpouchings involving only a portion of the vessel wall. They vary from 5 to 20 cm in diameter and often contain thrombus.

Explain the Mnemonic, 'The K STAYs.'

Spirinolactone, Triamterene, Amiloride are the Potassium-Sparing Diuretics. Thiazides waste Potassium so it is nice to include these in a Combo.

What are ordered amphipathic lipids?

Spontaneous arrangements of amphipathic lipids in an energetically favorable conformation in aqueous environment

Contrast Stable and Unstable Angina.

Stable Angina increases with exercise but then goes away. Unstable, or Crescendo Angina, never goes away. Variable, or Prinzmetal Angina, often occurs at rest eg at night during sleep.

Compare Vulnerable and Stable Plaque Histologically.

Stable Plaque has much less inflammatory cells, correlating with a lower CRP.

What is the mechanism of action of the nondihydropiridine calcium channel blockers?

State dependent blockade of open and inactive calcium channels.

What class of drugs targets HMG CoA reductase?

Statins

Which class of drugs targets HMG CoA reductase?

Statins.

What are the Toxicities of Bile Binding Resins?

Steatorrhea, Bloating, Heartburn, Increased Serum Triglycerides so Absolutely Contraindicated if TG more than 400. Hyperchloremic Acidosis in children and Renal Failure.

How is Rheumatic Fever treated?

Step I - primary prevention and treatment, meaning eradication of streptococci with penicillin or Erythromycin Step II - anti-inflammatory treatment (aspirin and/or steroids) Step III - supportive management & management of complications Step IV - secondary prevention

What three things does Cholesterol make?

Steroids, Bile Salts, and Membranes.

What can be seen as the earliest sign of Ischemia, within a few hours?

Stiff, wavy myocardial Fibers. The rest is normal.

What is the result of an occlusion of the carotid artery due to an aortic dissection?

Stroke.

What is Mitral Regurgitation?

Structural Defects in the Mitral Valve prevent its Closure during Systole, leaking blood back into the Left Atrium. It is often Benign, depending on Severity.

What is the Initiating Event in Acute MI?

Sudden Plaque Disruption.

How does Aortic Dissection present?

Sudden, severe chest Pain, with a tearing or ripping quality. Type A between scapulae, Type B can be in Abdomen anywhere. Pain can radiate. Elevated BP.

What is the number one symptom of aortic dissection?

Sudden, severe chest pain with a tearing or ripping quality. Located in the anterior chest with type A, between the scapulae with type B. The pain can radiate anywhere in the thorax or abdomen.

What is pericardial tamponade?

Sufficient blood in the space between the muscle and pericardium to compress the heart.

How does a mycotic abdominal aortic aneurysm lead to dilation and rupture of the aorta?

Suppuration destroys the media.

What is the treatment of choice for tricuspid stenosis?

Surgery is usually required, whether valvuloplasty or valve replacement.

What is the treatment for severe aortic regurgitation (symptomatic or asymptomatic) with impaired left ventricle function?

Surgery should be offered. Without surgery, death occurs within 4 years of the development of angina, and within 2 years of the development of heart failure symptoms.

What does the literature say about surgery for type A aortic dissections?

Surgical treatment of type A acute aortic dissection remains a challenge, especially in elderly patients or in patients with a critical preoperative status. Overall mortality rate was 19.8% with an exponential increase with age (50% over 80 years).

Does raising HDL help?

Surprisingly no. The underlying cause must be addressed. The HDL that is added often doesn't work.

What is Sydenham's Chorea?

Sydenham's Chorea is a disease characterized by rapid, uncoordinated jerking movements affecting primarily the face, feet and hands. It is a Major Criteria for Rheumatic Fever.

What hemodynamic effects does mecamylamine produce?

Sympathetic neurons dominate control of the vasculature. Therefore a ganglion blockade prevents sympathetic mediated increases in vascular resistance, which leads to a reduction in blood pressure. It also can increase pooling of blood in capacitance vessels.

What are the added benefits of combined treatment with diuretics and sympathoplegics or vasodilators?

Sympathoplegics and vasodilators reduce vascular responsoveness, which allows blood pressure to be greatly influenced by volume changes.

Which other drug classes are used in combination with diuretics to treat severe hypertension?

Sympathoplegics or vasodilators.

When is valvuloplasty indicated for pulmonic stenosis?

Symptoms usually develop at pressures greater than 40 mmHg, at which point valvuloplasty is indicated.

What would a tissue need cholesterol for?

Synthesis of: -Cell membrane -Bile acids -Steroid hormones

Contrast Systolic and Diastolic Dysfunctions.

Systolic Dysfunctions are caused by reduced Contractility, Diastolic Dysfunction is caused by

Why is an acute MI more likely to occur in the early hours of the morning?

Systolic blood pressure, blood viscosity and plasma epinephrine levels tend to be most elevated at that time of day, and these factors subject vulnerable plaques to rupture.

How does congestive heart failure develop after MI?

Systolic dysfunction from impaired contractility and diastolic dysfunction from myocardial stiffness leads to heart failure.

What kind of ECG morphology indicates ischemia?

T wave inversions.

What happens to blood lipids when drinking Alcohol?

TG synthesis increased in liver --> increased VLDL. Can stack with FH.

What is Wolfe Parkinson White Syndrome?

THe bundle of Kent, a shortcut between the Atrium and Ventricle that shouldn't be there, allows a second connection. Do not use Rate Control or you will block the AV Node and increase Current through the Shortcut.

What are Vasculitic Syndromes that can cause Occlusive Arterial Disease?

Takayasu Arteritis, Giant Cell Arteritis, Thromboangiitis Obliterans, and Raynaud's Syndrome.

How does a doctor decide whether to use drugs to treat high LDL?

Take the target LDL and add 30. If higher than that use drugs. (Target is 160 if low risk, 100 if High risk) This number is also the Non-HDL goal for high TG treatment. If lower than that but still above the target use Lifestyle Counseling.

List the ECG leads associated with the posterior region of the heart.

Tall R waves in V1-V2.

What do genetic mutations in ABC proteins result in?

Tangier's disease. Affected individuals have low levels of HDL and cholesterol accumulates, promoting atherosclerosis and killing nerve cells throughout the body.

When assessing a small thrombus, what do normal ECG results tell you?

That healing and plaque enlargement are underway.

Which Calcium Channel Blockers work only on the Vasculature?

The 'dipines': Amlodipine, Felodipine, Isradipine, Nifedipine, and Nisoldipine. These are also called the Dihydropyridines.

How is a newly formed chylomicron organized?

The B48 is made first and then the lipids are added to it. If it is absent, the lipoprotein cannot assemble.

Describe the Progression of Atherosclerosis from Endothelial Dysfunction to Advanced Lesion.

The Intermediate stages are Fatty Streak and Fibrous Plaque. Notice the first Foam Cell is formed from T-cells and Macrophages that turn eventually to a plaque and then become Necrotic.

Which is the important Calcium Channel we target with Angina?

The L-Type Calcium Channel that is Prevalent on Cardiac Muscle and the only type found in Smooth Muscle. Dihydropyridines focus on this channel.

In FH Type 2A, what is the Pathophysiology?

The Liver receptors are Defective, and LDL cannot be taken into the Liver.

What is the Official Definition of Mitral Stenosis?

The Mitral Valve Orifice, Normally 4-6 Square Centimeters, shrinks to less than 2.

What enzymes does the Pancreas contribute to Lipid Digestion?

The Pancreas makes and secretes Bicarbonate, Lipase, and Colipase.

What is the most common location for aortic aneurysms?

The abdominal aorta followed by the thoracic aorta.

The amount of IDLs that follow either path is equal, what shifts this equilibrium?

The amount of LDL receptors that the liver has. If the liver is deficient in LDL receptors more IDLs will be made into LDLs.

What is the best screening test for peripheral artery disease?

The ankle-brachial index, which compares the ratio of blood pressure in the ankles to the arms with manometry and doppler to detect blood flow. Normal is less than or equal to 1.

What are the anti-thrombotic and anti-ischemic medications used for ST elevation MI (3)?

The approach is very similar to that described for UA and NSTEMI: -Antiplatelet therapy with aspirin and/or an ADP inhibitor such as clopidogrel (Plavix) -IV unfractionated heparin for 1-2 days after tPA, rPA or TNK-tPA to maintain coronary vessel patency . -Beta-blockers and nitrates are also given

On a vector arrow, which side corresponds to the Positive Extracellular region?

The arrow head.

Review: Where is IDL made?

The blood.

Review: Where is LDL made?

The blood.

Once in the lymphatic system, how does the chylomicron mature?

The chylomicron picks up other apoproteins (Cs and E) from HDLs circulating there.

Describe the path of circulation of a chylomicron.

The chylomicrons are so large they must be secreted into the lymphatic system draining the gut (and then via the thoracic duct into the blood via the left subclavian vein).

What are the alternative pharmacologic regimens for reperfusion therapy?

The combination of an intravenous glycoprotein IIb/IIIa inhibitor with a reduced dose of a fibrinolytic agent.

How does Rate Control Work?

The current Must pass through the AV node to get through to the ventricles. This means you would not use Rate control for Ventricular Arrhythmias.

What pathology is aortic dissection related to?

The degeneration of arterial integrity secondary to aortic aneurysm expansion.

What is cystic medial necrosis?

The degeneration of the media of the vessel, it usually occurs in the ascending thoracic aorta and is associated with aging,W Marfan syndrome and Ehler-Danlos syndrome.

What is pulse pressure?

The difference between arterial systolic and diastolic pressures.

Define State-Dependent Binding for Arrhythmia Drugs?

The drugs only bind Open Receptors. This is good because it is more likely to target receptors that are open at the wrong time. Some drugs will also bind in the inactive state, but the Closed state can in fact kick off the drug.

Apo1 can be oxidized by myleoperoxidase, how does this effect the function of the enzyme?

The enzyme catalyzes the addition of nitro- and chloro- groups to tyrosine residues on the protein. Oxidation of the protein decreases the ability of HDL to pick up excess cholesterol.

Pateints may be discharged as early as 5 days after an Acute MI. What is the most important factor to predict a longer stay?

The extent of dysfunction in the Ventricular Wall.

What is the most important predictor of post-MI outcome?

The extent of left ventricle dysfunction.

What is the aortic annulus?

The fibrous rings surrounding the arterial orifices that serve for the attachment of the great vessels and semilunar valves.

What do we see Morphologically During Infective Endocarditis?

The hallmark of IE are the vegetations containing fibrin, inflammatory cells, and bacteria or other organisms on the heart valves The aortic and mitral valves are the most common sites of infection, the valves of the right heart (in intravenous drug abusers). Vegetations sometimes erode into the underlying myocardium and produce an abscess (ring abscess). Emboli may be shed from the vegetations at any time; because the embolic fragments may contain large numbers of virulent organisms, abscesses often develop at the sites where the emboli lodge, leading to sequelae such as septic infarcts or mycotic aneurysms.

How does a regional acute myocardial infarction occur?

The infarct typically begins in the subendocardial region, which is the less well perfused region of the ventricular wall. The zone of necrosis extends outward and reaches full size in three to six hours.

What is Cephalization?

The initial phase of cardiogenic pulmonary edema is manifested as redistribution of the pulmonary veins. This is know as cephalization because the pulmonary veins of the superior zone dilate due to increased pressure.

What happens in an aortic dissection?

The intimal layer of the aortic wall tears, separating (dissecting) and causing a new, false channel to form within the artery wall. This can continue to expand, causing excruciating pain & pressure, and robs the distal arterial system of blood.

What is an isoelectric lead?

The lead in which the QRS complex's upward deflection from baseline is equal to the downward deflection.

How does a stiff left ventricle affect stroke volume?

The left atrium eventually may constitute about 25% of the stroke volume. Normally, the contribution of the left atrium to stroke volume is very small.

How can acute mitral regurgitation result in a medical emergency?

The left atrium is relatively stiff and so left atrium pressure increases substantially, transmitting increased pressure into the pulmonary circulation. This can result in overt pulmonary edema which is a medical emergency.

Why is there less of an impact on the pulmonary circulation with chronic mitral regurgitation?

The left atrium undergoes a gradual compensatory dilation and increased compliance. The compensatory changes allow a larger left atrium volume without a substantial increase in pressure.

How does the left ventricle compensate for mitral regurgitation?

The left ventricle accommodates the increased volume load with a compensatory increase in the stroke volume.

How does acute aortic regurgitation lead to a surgical emergency?

The left ventricle pressure will substantially increase with the increased volume. The pressure transmits to the left atrium and pulmonary circulation leading to pulmonary edema and dyspnea. Surgical valve replacement is required.

What constitutes the variant of LDL?

The linkage of B100 and apoprotein in one position in LDL.

What is another common ordered amphipathic lipid?

The lipid bilayer

Review: Where is VLDL made?

The liver.

What is the simplest ordered amphipathic lipid?

The micelle (hydrophobic tails in, hydrophilic heads out)

How do triglycerides contribute to the solidity of fat?

The more saturated the fatty acids making up the triglyceride, the more solid the fat.

What is pulmonic regurgitation?

The most common acquired abnormality affecting the pulmonary valve is regurgitation secondary to dilation of the pulmonic valve ring by severe pulmonary hypertension.

Describe the murmur heard in patients with pulmonic regurgitation.

The murmur is a high-pitched, blowing, decrescendo diastolic murmur, virtually indistinguishable from aortic regurgitation.

What happens during Chronic Ischemic Heart Disease?

The muscle cells Hypertrophy.

When do hemodynamic changes resulting form mitral stenosis become apparent?

The normal cross-sectional area of the mitral valve orifice is 4-6 cm2; when the area is reduced to < 2 cm2, hemodynamic changes become clinically apparent.

What is the treatment for aortic stenosis?

The only effective treatment for advanced aortic stenosis is surgical replacement of the valve.

Describe the pathophysiology of aortic regurgitation.

The pathophysiology of aortic regurgitation is very similar to that of mitral regurgitation. The blood regurgitating from the aorta during diastole is added to the normal amount of blood from the left atrium, forcing the left ventricle to increase stroke volume.

Give an example of a clinical presentation of critical ischemia of the foot.

The patient had a sudden onset of foot discomfort, with coldness and loss of sensation in the toes and the dorsum of the foot. He had previously suffered from intermittent claudication and has evidence of chronic ischemia, including absence of hair and thinness of the skin. Arteriography is necessary to define the nature of the lesion.

What are the consequences of the changes induced in the left atrium due to mitral stenosis?

The patient is at risk for developing: -Pulmonary hypertension -Congestive heart failure -Left atrium enlargement

How does the phosphoric acid of the phosphatidic acid influence its chemical properties?

The phosphoric acid is negatively charged and thus forms a polar end of the molecule. The entire molecule becomes amphipathic.

Describe how phospholipids are even more amphipathic than phosphatidic acids.

The phosphoric acid moiety of phosphatidic acid can be further esterified with another charged molecule containing a hydroxyl group.

Type 1 and 5 HyperLipoproteinemia both come with highly increased Chylomicrons. How can this be visualized?

The plasma gets milky and creamy.

Describe the transfer that occurs between IDL and HDL and what is the protein involved in this transfer?

The plasma protein, cholesterol exchange transfer protein, transfers cholesterol ester to IDL from HDL and moves IDL's triglyceride to the HDL.

How common is recurrent ischemia after an MI?

The post-infarction angina rate is 20-30%.

Describe the epidemiology of aortic dilatation in Marfan syndrome patients.

The prevalence of aortic dilatation in Marfan syndrome is 70-80%. It manifests at an early age and tends to be more common in men than women. A diastolic murmur over the aortic valve may be present.

What are the kinetics of enalapril?

The prodrug is converted to the active enalaprilat.

How is the prognosis of mitral regurgitation determined?

The prognosis depends on the underlying cause

What happens during a circumferential acute myocardial infarction?

The region at the end of the perfusion zone undergoes necrosis.

Describe the volume related stressors on the left ventricle due to mitral stenosis.

The regurgitated volume returns to the left ventricle in diastole along with the normal pulmonary venous return. To eject this increased volume, the left ventricle stroke volume must rise.

What role does inflammation play in the development of an aneurysm?

The size of an aneurysm is correlated with IL-6 and CRP levels.

Describe the murmur produced by tricuspid regurgitation.

The systolic murmur is typically a high-pitched, blowing, holosystolic, nonradiating murmur best heard at the lower left sternal border. It becomes louder on inspiration.

How is cholesterol absorbed by tissues specifically where its needed?

The tissue expresses B100 receptors on its surface. LDL-B100 binds to the receptor and undergoes endocytosis. Fusion with lysosomes release cholesterol esters which are the converted to free cholesterol by lysosomal cholesterol ester deacylase. As the need for cholesterol decreases, the tissue expresses fewer receptors.

Wwhat determines the density of a lipoprotein?

The triglyceride content. The higher the triglyceride content, the lower the density.

What determines the clinical features of the different forms of vasculitis?

The vascular bed affected (e.g., central nervous system vs. heart vs. small bowel).

What is the advantage of Color Flow Ultrasound?

The velocity of blood flow can be measured. Branching vessels can be compared to determine relative cross-sectional Area and so Stenosis Percent can be estimated.

What morphology is characteristic of a left bundle block?

The wide QRS complex assumes a characteristic broad, deep S-wave opposite the left ventricle (right ventricular leads - V1 and V2). Delayed depolarization of the left ventricle causes a marked prolongation in the rise of the R waves in V5 and V6, causing either broadened or notched shapes.

How can you tell a patient has moderate to severe Chronic Limb Ischemia?

The wrinkles and gangrenous nails give it away.

What is the most common body part for patients to experience pain with peripheral artery disease?

Their calf.

Describe, Alpha Beta Nomenclature for Triglycerides.

There is an Alpha, Beta, then Alpha 1. This is because you can count from either end.

Why is the total hydrophobicity of triglycerides so advantageous?

There is negligible interaction with water which makes triglycerides an excellent energy storage form since it does not hold water with it the way carbohydrates do.

What happens if Myocarditis is not cleared?

There is no Latent phase for the Picornaviruses responsible for Myocarditis. The presence of viral RNA in biopsy specimens in stages of the disease after acute infection indicates a worse clinical outcome. A lack of improvement or even deterioration in LVEF is seen in patients with viral persistence. The lack of spontaneous IFN-β production is associated with enterovirus persistence. This is an Antiviral Cytokine.

How is Rheumatic Fever Diagnosed?

There is no Single Gold Standard Test, but rather a constellation of signs and symptoms. The Jones Criteria says you must have 2 Major Criteria of the Disease, or 1 Major and 2 Minor.

What do Petechial Hemorrhages look like on the Microscope?

These Petechial Myocardial and Epicardial Hemorrhages indicate death by Asphyxiation.

What are Eptifibitide and Tirofiban?

These are Antiplatelet drugs of the glycoprotein IIb/IIIa inhibitor class.

What is Acute Fibrinous and Serofibrinous Pericarditis?

These are the most common type of Pericarditis, composed of serous fluid and Fibrinous Exudate. It is often caused by Acute MI or Dressler's Syndrome.

How many legs does Intestinal Lipase cleave from Triglycerides, with the help of Colipase?

These two enzymes cleave two legs off of Triglycerides, forming 2- Monoacyl GLyceride, 2-MG.

How do Class 1B Arrhythmia Drugs affect Ventricular Arrhythmias?

They Prevent Focal Points that are beating essentially on their own. It is attracted to their open channels and binds preferentially, leaving AV node as pacemaker.

How do strenuous physical activity and emotional stress trigger acute coronary syndrome?

They activate the sympathetic nervous system, increasing blood pressure, heart rate and the force of ventricular contractions all of which can rupture the plaque.

How common are varicose veins?

They affect 10 to 20% of the population. They are more common in women than in men.

How are the ACE Inhibitors named?

They all end in Pril. Examples Captopril, Enalopril, etc.

How are statins excreted?

They are 90% secreted via the feces.

What are Hydralazine, Minoxidil, and Calcium Channel Blockers?

They are Arteriole Dilators.

Give general Characteristics of Viridans Streptococcus.

They are Gram Positive, occurring in Chains. They are Catalase Negative. Their major virulence factor is Biofilms.

What are Sodium Nitroprusside and Diazoxide?

They are Vasodilators, meaning they dilate both Venous and Arterial blood vessels.

What is the MOA of fibrates?

They are a ligand for a nuclear transcription factor, peroxisome proliferator-activated receptor-alpha (PPAR-α). Transcriptionally up-regulate LPL, apoA-I and II, and down-regulate apoCIII (inhibitor of lipolysis).

Describe the wrist-test for Marfan's Syndrome?

They are able to wrap their Spider Fingers a long way around the wrist.

What are the contraindications of fibrates?

They are absolutely contraindicated in kidney, liver or biliary disease.

What class of Drug are Prasozin, Terazosin, and Doxazosin and when are they indicated?

They are alpha-receptor blockers, used when BPH is a compelling indication for Hypertension. Toxicities include sleepiness and Orthostatic Hypotension.

What is the MOA of prazosin, etc?

They are alpha1 receptor blockers.

What is special about Labetolol and Carvedilol?

They are also Alpha blockers in addition to Beta Blockers.

What are phosphatidic acids?

They are derivatives of a 1,2-diacyl glycerol in which the remaining hydroxyl group has esterified with phosphoric acid.

LDL receptors are made in Tissue Cells. What is special about their manufacture?

They are generally recycled if they are still functional.

Describe the features of LDLs.

They are made from VLDL and IDL and deliver cholesteryl esters to tissues needing cholesterol and which therefore express B-100 receptors.

What is the advantage of measuring troponin levels over creatine kinase levels?

They are more specific than creatine kinase levels and remain elevated for 4 to 7 days.

What is the mechanism of action of the nitrates and nitrites?

They are nitric oxide donors. When nitric oxide is released, guanylate cyclase is stimulated leading to cGMP induced smooth muscle relaxation via dephosphorylation/inactivation of myosin light chain. Vasodilation of large veins and arteries reduces myocardial oxygen demand.

What is the MOA of labetalol and carvedilol?

They are racemic mixtures with both alpha and beta blocking activity.

What is the source of the fatty acids used by the liver to synthesize triglycerides?

They are released through the hydrolysis of triglycerides in the adipose tissue.

What is a saccular aneurysm?

They are spherical in shape and involve only a portion of the vessel wall; they vary in size from 5 to 20 cm (8 in) in diameter, and are often filled, either partially or fully, by thrombus.

What is most notable about the fibrates?

They are the most effective triglyceride lowering drugs.

What are Kerley B Lines and what do they look like?

They are thin linear pulmonary opacities caused by fluid or cellular infiltration into the interstitium of the lungs. I don't really see them.

What is an important feature of triglycerides?

They are totally hydrophobic.

When are Beta Blockers used in Hypertension?

They are very good post MI, and they are also good in combinations with Thiazides and Vasodilators to reduce the reflexive sympathetics. It can also help in compelling indications like Angina, tremors, Hyperthyroidism, and SVT, as you can kill two birds with one stone.

What is the MOA of angiotensin II receptor blockers?

They block angiotensin II receptors.

What is the MOA of guanethidine and guanadrel?

They block the release of norepinephrine by replacing norepinephrine in synaptic vesicles and acting as a false transmitter.

What role do chylomicrons and VLDLs share?

They both deliver triglycerides to tissue via interaction with lipoprotein lipase.

What complication can result from mural thrombi developing on the endocardial surface?

They can break off and lead to infarcts in the brain, kidney, etc.

What is the purpose of HDL receptors?

They can initiate uptake of the whole HDL by endocytosis by the liver.

How do amphipathic lipids behave in an aqueous environment?

They can spontaneously assume energetically favorable associations in which the hydrophobic portions of a number of molecules can become closely associated. The associations depend on the temperature and composition of lipids in the solution.

What is the purpose of lipoproteins?

They carry hydrophobic lipids (triglycerides and cholesteryl esters) in the blood in a water soluble form.

What affect do Renin-Secreting Tumors or Obstruction of Renal Arteries have on Blood Pressure?

They cause dysfunction of the Renin-Angiotensin-Aldosterone pathway, causing hypertension. The obstructed arteries feel like a drop in blood pressure to the Kidneys.

What is the mechanism of action of class 1A sodium channel blockers?

They create a high affinity blockade for activated (open) sodium channels as well as potassium channels. They also create an anti-muscarinic receptor blockade.

What is the mechanism of action of the class 1B sodium channel blockers?

They create a high affinity blockade for activated and inactivated sodium channels.

What is the mechanism of action of the class 1C sodium channel blockers?

They create a high affinity blockade for activated and inactivated sodium channels.

What is the mechanism of action of the beta blockers?

They decrease heart rate and contractility as well as blood pressure. They decrease myocardial demand for oxygen during exercise and rest.

What is the MOA of the calcium channel blockers?

They decrease intracellular calcium concentrations in smooth muscle and cardiac muscle, decreasing calcium mediated contraction and decreasing heart rate.

Why are Dihydropyridines not the best CCBs for Angina?

They do not target Cardiac Smooth Muscle. Remember that Vasodilation of Arteries can lead to Shunting of blood away from occluded Arteries.

What is a transmural infarction?

They extend through the whole thickness of the heart muscle and are usually a result of complete occlusion of the area's blood supply.

What is the mechanism of action of the dihydropiridine calcium channel blockers?

They form a blockade of open calcium channels located on smooth muscle cells reducing calcium mediated excitation contraction coupling. They have vascular versus cardiac selectivity and they reduce myocardial oxygen requirement.

What is the MOA of bile binding resins

They form insoluble complexes with bile acids and salts, preventing reabsorption of bile acids and cholesterol.

Where do most Angiograms Begin?

They go into the Femoral Triangle, into the Femoral Artery or Vein. It could also be Subclavian Vein. Not the Subclavian Artery, because you cant stop its bleeding.

What is the clinical relevance of class 1B sodium channel blockers?

They increase diastole.

What is the Mechanism of Bile-Binding Resins?

They indiscriminately reduce absorbtion, preventing reabsorbtion of Bile Acid from intestines. This can affect Vitamin Absorbtion.

What do Statins do?

They inhibit HMG-CoA Reductase, the regulatory enzyme in Cholesterol Synthesis in the Liver.

What is the MOA of thiazides?

They inhibit NaCl transport in the distal convoluted tubule preventing sodium reabsorption.

What is the MOA of the ACE inhibitors?

They inhibit angiotensin converting enzyme, thus preventing angiotensin 1 from being converted to angiotensin II. They also inhibit the breakdown of bradykinin.

What is the MOA of Thiazide Diuretics?

They inhibit the Na+/Cl- Cotransporter in the Distal Convoluted Tubule.

What is the MOA of loop diuretics?

They inhibit the Na-K-Cl exchanger in the thick ascending limb of the loop of henle.

What is the MOA of potassium sparing diuretics?

They inhibit the aldosterone receptor and thus blocks an aldosterone mediated increase in sodium pump uptake of sodium from the lumen into the blood.

What is the consequence of having a congenital weakness of the vessel walls?

They lead to berry aneurysms in cerebral vessels (particularly in the circle of Willis at the base of brain), which may rupture and cause fatal intracerebral hemorrhage.

Why are ACE inhibitors used as adjunctive therapy for acute coronary syndrome?

They limit adverse ventricular remodeling and reduce the incidence of heart failure, recurrent ischemic events and mortality following an MI. Their benefit is additive to that of aspirin and beta-blockers.

What hemodynamic effects do guanethidine and guanadrel produce?

They lower blood pressure via the inhibition of norepinephrine release from sympathetic nerves.

What enzymes does the Gallbladder contribute to Lipid Digestion?

They make and secrete Bile Salts, which help form the ring of the Micelle.

How do Nitrates Work?

They mostly decrease Oxygen Demand in the heart by Dilating the Veins and reducing preload, making the heart work less. They also Dilate arteries but this is less Important.

What are the hemodynamic effects ACE inhibitors produce?

They prevent angiotensin II mediated vasoconstriction, aldosterone release, synaptic nerve activation and arginine vasopressin release. They also prevent the breakdown of vasodilator, bradykinin. The net effect is decreased peripheral vascular resistance without reflex effects.

What is the mechanism of action of nitrates?

They provide venodilation and reduce preload, lowering myocardial oxygen demand and reducing angina.

Why are statins used as adjunctive therapy for acute coronary syndrome?

They reduce mortality rates. Their benefit may extend beyond lipid lowering, they can potentially improve endothelial dysfunction, inhibit platelet aggregation and impair thrombus formation. LDL levels should be measured as early as possible during hospitalization and treatment begun accordingly.

Why are diuretics used to treat mitral regurgitation?

They reduce pulmonary edema.

Why are vasodilators used to treat mitral regurgitation?

They reduce resistance to forward flow and augment forward cardiac output.

What are the x and x' descents?

They reflect movement of the lower portion of the right atrium toward the right ventricle during the final phases of ventricular systole.

What is the function of tropnins?

They regulate calcium mediated muscle contraction.

What happens to the Baroreceptors over time?

They seem to lose function over time, losing homeostatic control and leading to increased Blood Pressure.

Which important test must be done especially for patients who did not receive percutaneous coronary intervention to evaluate their post-MI outcome?

They should receive exercise treadmill stress testing. Typically a low-level TMST is done prior to hospital discharge with a more rigorous one 4-6 weeks later. Abnormalities may trigger a referral for cardiac catheterization to define coronary anatomy.

What is the MOA of Calcium Channel Blockers?

They slow the heart rate by their affect on Cardiac Muscle. In smooth muscle, Calcium channel blocks reduces smooth muscle contraction, relaxing and vasodilating the vessels.

Stage 1 Hypertension is SBP above 140 or DBP above 90. What is the recommended treatment?

Thiazide and Lifestyle Modification.

Stage 2 Hypertension is SBP above 160 or DBP above 100. What is the recommended treatment?

Thiazide plus other drugs, such as ARB, BB, AceI. Also Lifestyle Modification.

What does Pericardial Effusion look like on Chest Xray?

This is a Rounded, Waterbottle shape that will cahnge when drained. The heart is larger in basically all directions, unlike in LVH etc.

What is Hypovolemic Shock?

This is a Shock caused by Low Blood Volume. This decreases Preload, reducing Cardiac Output and Oxygen Delivery.

What is Microscopic Polyangiitis?

This is also called Hypersensitivity Vasculitis, and affects only small vessels. Lesions are all the same 'Age', unlike in PAN. 90% of patients have Necrotizing Glomerulonephritis, and Pulmonary Capillaritis is also common. These can be caused by Penicillin etc Hypersensitivity.

What is Takayasu's Arteritis?

This is also called Pulseless disease, this disorder commonly affects the Aortic Arch and looks histologically the same as Giant-Cell Arteritis, including Giant Cells. It can cause Ocular Disturbances also.

What are the Consequences of Acute Mitral Regurgitation? Contrast these With Chronic MR.

This is worse in some sense than Chronic MR because there is no time to Compensate. The Left Atrium does not have time to 'Stretch' as it would in the long run, so pressure is transferred to lungs causing Overt Pulmonary Edema. In Chronic, the LA grows in size instead of increasing pressure so much, so we do not see as Severe Pulmonary Edema but instead other Sequelae like Atrial Fibrillation.

What is Chronic Adhesive Mediastinopericarditis?

This often follows Infectious Pericarditis, or Surgery or Radiation. The pericardial Sac is Obliterated, with Systolic Retraction of the Rib cage and Diaphragm. This increase Cardiac Work load leading to LVH and LV Dilation.

Contrast Vulnerable and Stable Plaque.

This refers to the thickness of the Endothelium and Fibrous cap. Stable means a thick cap that makes it difficult to release to the blood.

What is the RetroSternal Clear Space?

This space is occluded in Cardiomegaly.

How is blood concentration of Lp(a) determined?

This trait is inherited and does not respond to diet, exercise or most drugs (may respond to niacin)

How does the body respond to Acute Serous Pericarditis?

This type of Pericarditis is generally non-infectious, so it presents with Sterile Serous Effusion. Histologically, Lymphocytes dominate the immune response.

Which is worse, an Abdominal or Thoracic Aortic Aneurysm?

Thoracic is worse because there is more pressure being nearer the heart.

What molecules are needed to Synthesize HMG-CoA?

Three Acetyl-SCoA are needed.

What is the troponin complex?

Three subunits that regulate the calcium mediated contractile process of striated muscle.

How many different classes of sodium channel blockers are there?

Three: 1A, 1B and 1C.

What is the number one cause of acute arterial occlusion?

Thromboembolism, particularly emboli from the heart due to intracardiac stasis of blood flow.

What is the #1 cause of Acute Arterial Occlusion?

Thromboembolism. These are often seen in MI, Atrial Fibrillation, MItral Stenosis, Endocarditis, as blood flow slows. An atrial Septal defect can allow clots to enter arterial flow, paradoxical embolisms.

What agent is used for chemical thrombolysis?

Tissue plasminogen activator.

What is the goal of thrombolytic (fibrinolytic) therapy?

To accelerate lysis of the intracoronary thrombus.

What is the goal of medical treatment for mitral regurgitation?

To augment forward cardiac output while reducing regurgitation into the left atrium and decreasing pulmonary congestion.

Why is the importance of determining the mean QRS axis?

To generate a differential diagnosis.

What is the goal of surgical treatment of chronic mitral regurgitation?

To prevent the development of left ventricle failure.

What is the focus of acute treatment of ST elevation MI?

To quickly salvage jeopardized myocardium by restoring blood flow through the occluded coronary artery. This requires reperfusion therapy: fibrinolytic drugs or percutaneous coronary intervention (PCI).

What are the side effects of dofetilide (1)?

Torsades de Pointes.

What are the side effects of ibutilide (1)?

Torsades de Pointes.

What are the side effects of sotolol (1)?

Torsades de Pointes.

How can chronic mitral regurgitation develop into heart failure?

Total cardiac output remains relatively steady for several years via the Frank-Starling mechanism, though eventually systolic function deteriorates, resulting in decreased total cardiac output and heart failure.

What is a consequence of prolonged ischemia?

Total or subtotal coronary occlusion can lead to myocardial necrosis.

What is TAVR?

Transcatheter Aortic Valve Replacement is a technique to replace the Aortic Valve without stopping the heart. It carries risk of Vasuclar Complications and is reserved for those too sick for Open Heart Surgery. It uses a Compressible Valve sort of like a stent.

What is the function of phospholipid transfer protein is the conversion of HDL3 to HDL2?

Transfers more phospholipid (and possibly cholesterol) to the outer shell to take the place of cholesterol.

What is chronic stable angina?

Transient episodes of chest discomfort due to ischemic heart disease, typically occurs during activity.

Define Transmural as it relates to IHD.

Transmural means the Necrosis goes from the Endocardium through the Wall and also affects the Epicardium. It is caused by fully Occlusive Thrombosis.

What is a TMST?

Treadmill Stress Test. Stable Angina is reproduced in the lab via a treadmill, while EKG is attached. This test is indicated for Stable Angina if the Patient can Exercise and has a normal ECG.

What treatments are indicated for mitral valve prolapse?

Treatment is not indicated unless mitral regurgitation is present, and even most of those cases will not require treatment.

What is the typical clinical presentation of tricuspid stenosis (3)?

Tricuspid stenosis creates an obstruction that can cause: -Neck vein distention -Abdominal distention -Hepatomegaly

Which isoform of troponin is exclusive to cardiac muscle?

Troponin I.

What is the Gold Standard of Laboratory Diagnosis of MI?

Troponins. TnI, TnT, TnC. Levels detectable after 3 Hours and peak at 18 Hours. Detectable up to 2 weeks. Higher Troponin is more Mortality (graph).

What is the fate of IDL?

Two possible fates: endocytosed by hepatocytes for reconstruction or conversion to LDL

Differentiate Type A and B Aortic Dissection. What fraction is which?

Type A involves the Ascending Aorta, can affect the valves and is more dangerous. 2/3 are type A.

What is the difference between type A and type B aortic dissections?

Type A involves the ascending aorta, type B does not.

How does Poltarteritis Nodosa present?

Typically a young Adult, and with varied symptoms. Commonly Fever, Weight Loss, Malaise. Abdominal Pain and Bloody Stool occur because of Vascular Lesions. Morbidity often caused when Renal Artery is involved, leading to Rapid Hypertension. Treat with Corticosteroid and Cyclophosphamide to reduce inflammation.

What method is best used for screening for aneurysms?

Ultrasound.

What is the etiology of an inflammatory abdominal aortic aneurysm?

Uncertain.

What is the MOA of the arteriolar dilators?

Unclear, they may increase potassium conductance preventing smooth muscle contraction.

What causes fibromuscular dysplasia?

Unknown cause, probably developmental; first-degree relatives of affected individuals have an increased incidence.

What disorders fall under the Category of Acute Coronary Syndrome?

Unstable Angina, MI.

When assessing a partially occlusive thrombus, what is the most likely diagnosis when serum biomarkers are negative?

Unstable angina.

When assessing for transient ischemia, what is the most likely diagnosis when serum biomarkers are negative?

Unstable angina.

How often is an MI diagnosis made in retrospect?

Up to 25% of patients are asymptomatic during an MI, and the diagnosis is made after the fact.

Describe how polyarteritis nodosa (PAN) can contribute to immune complex associated vasculitis.

Up to 30% of patients with PAN have an underlying hepatitis B infection that produces a vasculitis attributable to complexes of hepatitis B surface antigen (HBsAg) and anti-HbsAg.

What are the two possible fates of an IDL?

Uptake by liver or conversion to LDL (about 50/50 split)

When is invasive management of acute coronary syndrome indicated?

Urgent cardiac catheterization and coronary revascularization are reserved for patients with high-risk features, such as those with ST-segment abnormalities, elevated serum markers, and multiple cardiac risk factors.

What are the clinical indications for metoprolol?

Use if afraid of bronchospasm.

List the ECG leads associated with the anteroseptal region of the heart

V1-V2.

List the ECG leads associated with the anterior region of the heart.

V1-V6.

List the ECG leads associated with the anteroapical region of the heart

V3-V4.

What is the difference between VLDL and IDL?

VLDL eventually becomes IDL after LPL cleaves most of its Fatty Acids. The Apoproteins are the same for Both: APO B100, APO CII, and APO E.

What is LDL a breakdown product of?

VLDL through IDL.

What is the Lipoprotein Carrier of Liver-produced Trigylcerides?

VLDL.

Describe the features of VLDLs.

VLDLs are made in the liver and carry endogenous lipids.

Which lipoprotein transports endogenously made lipids?

VLDLs.

What cardiac effects are produced by digoxin (3)?

Vagotic effects: -Hyperpolarization -Shortening of atrial action potentials -Increases in AV nodal refractoriness

Describe the morphological changes to the vessels as a result of variant angina and chronic stable angina (ischemic syndromes).

Variant angina: intense vasospasm due to endothelial dysfunction Chronic stable angina: lumen narrowed by plaque

What is Caput Medusae?

Varicose enlargement of periumbilical veins of the abdominal wall due to Portal Hypertension.

Which cells constitute the greatest combined cell mass in the body?

Vascular Endothelium cells. Injury to these from a variety of Sources causes Atherosclerosis.

What are Thallium 201 and Technetium 99 Used to see?

Vascular Perfusion. They go where the blood goes.

What is Immune-Complex Mediated Vasculitis?

Vascular inflammation from Antigen-Antibody Complexes. These may form elsewhere but bind the vessel wall. Examples are Systemic Lupus Erythematosus, Polyarteritis Nodosa, and Hypersensitivity Vasculitis.q

What is Secondary Raynaud Phenomenon?

Vascular insufficiency of the extremities secondary to arterial changes. Caused by other diseases including SLE, scleroderma, Buerger disease, or Atherosclerosis

What is noninfectious vasculitis?

Vasculitis caused by immune complexes generated by infection or cross-reactivity.

Contrast Angiogenesis with Vasculogenesis and with Arteriogenesis.

Vasculogenesis is the original development of blood vessels in an infant. Angiogenesis is new vessel formation occurring in Mature organisms, and Arteriogenesis is Remodeling of the existing Arteries in response to pressure changes.

What is a result of the decrease in vasodilator effect?

Vasoconstriction.

What other effects do calcium channel blockers produce (1)?

Vasodilation.

What is the historical treatment of aortic regurgitation (1)?

Vasodilators for hypertension.

What is infective Endocarditis?

Vegetation adhering to Valves at areas that were previously injured. It sheds bacteria etc, creating bacteremia and a persistant challenge to the Immune System. Without proper treatment you will die, though it is faster in some people (Fulminant) and slower in others (Indolent).

When are Class 2A Arrhythmia drugs used?

Ventricular Arrhythmias, including during MI.

What are the therapeutic uses of tocainide (1)?

Ventricular tachy-arrhythmias.

What are the detrimental drug interactions calcium channel blockers have

Verapamil increases digoxin levels.

Which calcium channel blocker has a beneficial effect on platelet aggregation?

Verapamil reduces platelet aggregation and may be beneficial in atherosclerosis.

What is Libman-Sacks Endocarditis?

Verrucous vegetation on Aortic Valve Leaflets. This is seen only in SLE (Lupus).

Half life of Amiodarone?

Very long, weeks. Orally taken so, nice.

What are the therapeutic uses of amiodarone (2)?

Very popular because of effectiveness and survival rates: -Supraventricular and ventricular tachy-arrhythmia -Paroxysmal atrial fibrillation

In addition to hypertension, in which other patients is hyaline arteiolosclerosis seen (3)?

Vessels of normo- or hypertensive elderly persons also frequently show hyaline arteriosclerosis, but in hypertension it is more generalized and severe -In nephrosclerosis due to chronic hypertension the arteriolar narrowing of hyaline arteriosclerosis causes diffuse impairment of renal blood supply and glomerular scarring -Diabetic microangiopathy has similar lesions

How are TGs and CEs transported from the intestine?

Via chylomicrons transported in lymph (too large to secrete directly into blood)

What are some of the Causes of Pericarditis?

Viral Idiopathic, which tends to be Acute. Bacterial takes longer to manifest. Can be a Malignancy, can sometimes see on ECHOcardiogram. Tuberculosis. Dressler's Syndrome.

How does Myocarditis travel to the heart?

Viral replication occurs mostly in Lymph nodes, then travels to the heart and replicates there.

Morphologic features of MI, macroscopic changes: 4 weeks

Visible scarring.

What is diastolic dysfunction?

Wall stiffness.

What are we looking for in a Treadmill Stress Test, and when must it be stopped?

We are looking for an Ischemic Response, visualized by ST depression in more than one Lead. We stop if the patient feels dizzy, short of breath, or pain.

Why would the height of a wave be different at different EKG leads?

We only see the vector component in one axis. The stronger the signal, the more it is in line with that axis. If the vector was going left in this case we would see a negative Voltage on the EKG.

Consider the Spectrum of Selectivity for Calcium Channel Blockers. Which target Cardiac Muscle, which target Smooth Muscle?

We want to Target Cardiac Muscle in Angina, Vascular Smooth Muscle in Hypertension.

Which condition is anti-proteinase-3 (PR3-ANCA) most commonly associated with?

Wegener granulomatosis.

What are the Three types of Small-Vessel Vasculitis?

Wegener, Churg-Strauss, and Microscopic Polyangiitis.

When does cardiogenic shock occur?

When 40% of the left ventricle is involved.

How can atherosclerosis result in myocardial ischemia?

When a stenosis reduces the cross-sectional area by ~75%, a full response in flow to meet increased myocardial demand is not possible. When the luminal area is reduced by > 80%, blood flow at rest may be reduced, and further minor decreases in the stenotic orifice can reduce coronary flow dramatically.

When are calcium channel blockers used in combination with or as a substitute for beta blockers?

When initial treatment with beta blockers is unsuccessful, the side effects of beta blockers are unacceptable or when treating specific arrhythmias.

Describe the (Vicious) Shock Cycle.

When the body realizes it has not enough oxygen, the Heart must work harder and this causes further increased Oxygen Demand.

When should surgery to repair an abdominal aortic aneurysm be considered in men?

When the diameter of the aneurysm reaches a maximal diameter of 5.5cm. Surgery also should be considered when the aneurysm expands by more than 0.6 to 0.8 cm per year.

What is a true aneurysm?

When the diameter of the localized area has increased by at least 50% and involves all three layers.

What causes dyspnea in late phase chronic aortic regurgitation?

When the left ventricle reaches its maximal diameter and diastolic pressure rises.

When aortic stenosis become a problem?

When the valve orifice is less than 50% of its normal size, significant elevation of left ventricle pressure is needed to push blood into the aorta.

What is mitral regurgitation?

When there is a backward flow of blood. This occurs when this one way valve has structural defects that prevent complete closure during systole.

What determines the site of a regional myocardial infarction?

Which vessel is involved.

What will history and a physical exam reveal about a patient with chronic stable angina?

With the exception of a high likelihood of hypertension, the exam may be completely normal.

Contrast Beating Heart surgery and Cardiac Arrest surgery.

With the heart stopped, it is easier to make stitches etc. With the heart not stopped it is a more difficult surgery with a faster recovery, although enthusiasm may be waning.

Secondary Hypertension is caused by other conditions. What does this mean for treatment?

Without treating the underlying cause, the patient will likely not be as responsive to drugs. These are generally structural or hormonal abnormalities, and are distinct from the Compelling Indications such as Diabetes and Renal Failure.

What are the contraindications for calcium channel blockers (1)?

Wolf-Parkinson-White type arrhythmias.

Why should caution be used with potential female MI patients?

Women more often have an "atypical presentation" which includes tiredness, vague epigastric pain mistaken for GI symptoms, back pain and dyspnea.

In what group of pts should ACE inhibitors be avoided? (2)

Women who are pregnant or likely to become so (along with ARBs), angioedema

Tangier disease is a Deficiency of ABC1 transporter. What are the signs and symptoms.

Yellow Tonsils, low HDL.

Can Atherosclerosis be Visualized in the Aorta without a microscope?

Yep.

Is CHF with Pulmonary Edema a possible complication of MI?

Yes it is.

Can Tuberculosis cause Pericarditis?

Yes, 1-2% of patients with Pulmonary TB get this.

Does size matter in AAA?

Yes, Risk is Directly related to size: <4 cm: close to 0% 4-5 cm: 1% per year to for AAAs between 5-6 cm: 11% per year >6 cm: 25% per year

Can Alopecia (Assymetric Hair Loss) be a sign of Peripheral Arterial Disease?

Yes, an early sign of Ischemia.

Do patients develop Tolerance for Nitrates?

Yes, and there is cross-Tolerance. Ace Inhibitors can prevent Tolerance.

Can Ankle-Brachial Index help localize PAD?

Yes, but it is a more complex procedure.

Can nitrates Help with Cyanide Poisoning?

Yes, displacing the Cyanide.

Do Nitrates cause reflexive responses?

Yes, increase in Heart Rate and Contractility.

Do genes play a role in the development of varicose veins?

Yes, there is a genetic predisposition.

Besides Opportunistic Infection and Neoplasm, can AIDS cause pericarditis?

Yes, via Lymphoma, Kaposi's Sarcoma, Mycobacterium tuberculosis, Mycobacterium avium intracellulare, Non specific pericarditis, HSV type 2, Cytomegalovirus, Crytpococcus neoformans, and Nocardia asteroides

Is smoking Associated with PAD?

Yes, you are at risk if you have Ever smoked.

Are Roth Spots seen in Endocarditis?

Yes.

Can a Papillary Muscle Rupture as a complication of MI?

Yes.

Is Acute Fibrinous Pericarditis a possible complication of MI?

Yes.

Is Janeway's Lesion seen in Endocarditis?

Yes.

Is Mural Thrombosis, with possible Embolism, a possible complication of MI?

Yes.

Is Osler's node seen in SubAcute Endocarditis?

Yes.

Is Rupture of Myocardium with Hemopericardium and Cardiac Tamponade a possible complication of MI?

Yes.

Is Septic Emboli seen in Acute Infectious Endocarditis?

Yes.

Is a patint with PAD likely to have CAD?

Yes: 50% of patients with Peripheral Arterial Disease also have Coronary Arterial Disease.

Why can ARterial Dilation be a problem for treating Angina?

You can Vasodilate other Arteries, reducing pressure to the relatively non-responsive Occluded Artery. This is called Steele Shunting.

What happens to blood lipids in Type 2 Diabetes?

You see moderate elevation of TG, VLDL, and low HDL. LDL is normal levels, but small and dense version called pattern B. (Pattern A is fluffy and works much better) This cannot be corrected by treating the Diabetes alone.

What is the advantage and disadvantage of a Stent vs a Balloon?

You will need to take anticoagulants for the rest of your life, so you must be able to take them. The stent is very helpful in large artery occlusions.

How does Thromboangiitis Obliterans present?

Young people with Claudication, Cold Sensitivity of the Raynaud type in hands, Pain in the instep during exercise.

What is Dr. Troll's rule of ECG?

aVR is nearly completely worthless.

Summarize apoprotein CII

activating cofactor for lipoprotein lipase

Contrast cytoplasmic ANCA and perinuclear ANCA.

c-ANCA seen in Wegener Granulomatosis, p-ANCA seen in Churg-Strauss and microscopic Polyangiitis.

Summarize apoprotein AII

function unknown; makes HDLs less capable of picking up excess cholesterol in periphery. (May inhibit interaction of HDLwith ABC-1, LCAT and hepatic lipase.)

Summarize apoprotein CIII

inhibitor of lipoprotein lipase / blocks binding of E to receptors

What is Thromboangiitis obliterans, also known as Buerger's Disease?

is a Recurring Progressive Inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet. It is strongly associated with use of tobacco products

Summarize apoprotein B48

made in intestinal epithelium, found in chylos; chylos cannot be secreted from intestine without B48; required for assembly of chylomicron

Summarize apoprotein B100

made in liver, found in VLDL, IDL, and LDL; very large, M.W. = 250,000; interacts with specific LDL receptors in liver and peripheral tissues; 95% of LDL protein is in B100; required for assembly of VLDL.

What is the v wave?

reflects the passive increase in pressure and volume of the right atrium as it fills in late systole and early diastole. Normally the crests of the a and v waves are approximately equal in amplitude.

What Valvular Abnormalities can lead to Subacute Infective Endocarditis?

rheumatic heart disease, mitral valve prolapse, degenerative calcific valvular stenosis, bicuspid aortic valve artificial (prosthetic) valves, congenital defects.

Give the Pathway by which Beta Blockers affect Calcium Channels.

sympathetic --> norepinephrine --> BR-->Adenylyl Cyclase -->cAMP -->PKA -->phosphorylates Ca++ channels. So Beta Blockers affect the heart in that case much like Calcium Channel Blockers.