Congenital Heart Path
Comp?
COMP = Infective Endocarditis
Aortitis (Vasa Vasorum destruction)
Etiology?
ET:
- 3ry Syphilis
Transposition of the Great Arteries
Mech, Imaging (CLUE)?
MECH:
Failure of fetal AP Septum to SPIRAL (during septation of TA).
IMAGING (Echo) = “Aorta ant to Pulm art”
Preductal Coarctation of the Aorta
Seen In?
SEEN IN:
- Turner’s Sx
Bicuspid Aortic Valve
Seen In (2), Comp?
SEEN IN:
- Turner Sx
- Adult / Postductal Coarctation of Aorta
COMP:
- Aortic dissection
Aortic Aneurysm
Etiology, Causes by Location (3)?
ET = atrophy + weakening of vessel wall (comp of Ath plaque).
CAUSES:
- Marfan Sx (Ascending Aorta)
- Tertiary Syphilis (Arch of Aorta)
- Atherosclerosis (Descending + Ab Aorta)
Aortic Dissection
Causes (3), Pres (2), Imaging (CXR)?
CAUSES:
- Pregnancy (double plasma vol -> weakening of aorta)
- Ehler-Danlos (collagen defect)
- Marfan (fibrillin defect = weakened elasticity of aorta)
PRES:
- “Tearing pain radiating to back”
- Diminished left pulse vs right
CXR: Widening of aortic knob.
Ruptured Abdominal Aortic Aneurysm
Pres (Triad)?
PRES:
- Sudden-onset severe L flank pain (aorta is retroperitoneal)
- Hypotension
- Pulsatile mass
Deep Venous Thrombosis (DVT)
Etiology (Virchow’s Triad), Pres (1 sign), Comp,
Prevention / RX?
Virchow’s Triad:
1. Stasis
2. Endothelial damage (b/c exposed collagen triggers
Clotting Cascade)
3. Hypercoagulability
Pulmonary embolus.
PRES:
- Homan’s Sign: Dorsiflexion of foot -> tender calf muscle
PREV + RX:
- Heparin (short-term prevention + acute management)
- Warfarin (long-term prevention)
Peripheral Vascular Disease
Etiology?
ET:
- Atherosclerotic plaques in Lower Extremity art ->
Impaired bl flow + Ischemia
Vasculites
Def’n, HS Type, Mech (location in vessel + 4 types of changes), Comp?
Group of disorders that DESTROY BL VESSELS by infl.
Both arteries + veins affected = ‘Arteritis’ + ‘Phlebitis’.
Type 3 HS.
MECH: Changes occur in WALLS of vessels and include:
- Thickening
- Narrowing
- Scarring
- Weakening
COMP:
- Coronary art vasospasm
Temporal (Giant Cell) Arteritis
Vessel, Pres (Epi + Triad), Comp (2)?
Temporal art. (Incl its branches, eg opthalmic art)
Granulomatous vasculitis.
PRES: Elderly Females
- Unilateral headache (Temporal art)
- Visual disturbances on same side as headache (Opthalmic art)
- Jaw claudication / pain (Temporal art)
COMP:
- Polymyalgia Rheumatica
- Irreversible ipsilateral Blindness (due to thrombosis / occlusion of Opthalmic art)
Takayasu’s Arteritis (“Pulseless Dz”)
Vessel, Pres (Epi)?
Aortic Arch. (Incl its branch points)
PRES: Young, Far-Eastern woman
Polyarteritis Nodosa
Mech of Vasculitis, Path (2), RX (2)?
THINK: p-anca, hepBsag, kidney, heart + infarct
Fibrinoid + necrotizing vasculitis. IC-mediated.
Involving multiple organs, however SPARING the LUNGS.
PATH:
- Multiple aneurysms
- Constrictions / spasms
RX: ** Fatal if not treated **
- Cyclophosphamide
- Corticosteroids
Kawasaki Dz
Vessel, Pres (Epi + 3), Comp?
Coronary art.
PRES: Asian Children
- Mucocutaneous infl
- Desquamation of skin
- Lymphadenopathy
COMP = MI!
Buerger Disease (Thromboangitis Obliterans)
Location Affected, Mech of Vasculitis, Causes, Pres (2 Epi + 1)?
Digits (fingers + toes).
Acute Infl -> Autoinfarction / Autoamputation / Gangrene.
CAUSES:
- Smoking
PRES: Males, Heavy Smokers
- Raynaud’s Phenomenon
Microscopic Polyangitis
Locations Affected (3), Mech of Vasculitis, Ab, RX (2)?
- Skin (palpable purpura)
- Lungs
- Kidneys (pauci-immune glomerulonephritis / RPGN)
Necrotizing vasculitis.
AB:
- p-ANCA: correlate with disease activity
RX:
- Corticosteroids
- Cyclophosphamide
Wegener Granulomatosis (Granulomatosis with Polyangitis)
Mech of Vasculitis (2), Pres (4 Locations), Ab, RX?
Granulomatous infl + Necrotizing vasculitis.
PRES:
- Nose:
- “Saddle nose” deformity
- Chronic Sinusitis
- Ears:
- Mastoiditis
- Otitis Media
- Lung: Nodular masses. URIs (-> cough, hemoptysis, dyspnea).
- Kidneys:
- Hematuria
- RBC Casts
AB:
- c-ANCA / PR3-ANCA
RX = Cyclophosphamide
Churg-Strauss Sx
Mech of Vasculitis, Ab (2)?
Granulomatous vasculitis with EOSINOPHILS. Involving multiple organs.
AB:
- MPO-ANCA / p-ANCA
- IgE ↑
Angina
Path, Pres, 2 Subtypes?
PATH: Atherosclerotic plaque in Coronary art -> Impaired bl flow -> Ischemia.
PRES = Chest pain on exertion
Stable Angina (chest pain with moderate exertion) ; Unstable Angina (chest pain with minimal exertion)
Acute MI #1
Def’n, Mech (2)?
Necrosis of cardiac myocytes, usually in ventricles.
MECH:
- THROMBUS (group of platelets bound together with fibrin)
- Coronary art vasospasm
Acute MI #2
Classic Pres (5)?
PRES: - SUBSTERNAL "crushing chest pain" lasting > 20 mins and "radiating to L arm and/or jaw" - Dyspnea - Diaphoresis - Fatigue - Nausea + Vomiting
** NOT relieved by Nitro **
Acute MI #3
Cardiac Enzymes↑(6), Dx (1 + 2 special circumstances)?
ENZ:
- AST ** Nonspecific **
- CKMB (EARLY: rises after 6 hrs, peaks at 24 hrs, lasts for 48 h)
- Myoglobin (EARLY) ** Nonspecific **
- LD1 > LD2 = ‘LDH Flip’ (18 hrs, peaks at 3 days, lasts for 7 days)
- LD1 + LD5 (MI compounded with LIVER CONGESTION)
- Troponin I (EARLY: rises after 4 hrs, peaks at 24 hrs, lasts for 7 days)
DX:
- EKG (however only 80% sensitivity): ST elevation + new q wave
- Dx of p/t that comes in 2-3 days after symptoms: ‘LDH Flip’
- Dx of Reinfarction: CK-MB (b/c levels return to normal after 48 h)
Acute MI #4
General Comp + their Conseq (11, incl 3 ruptures)?
COMP: ALL can result in Hypotension
- Reperfusion injury
- Bradycardia / Tachycardia (RV inf wall MI)
- Arrhythima (common in 1st few days) ->
- Embolus (from mural thrombus)
- Ventricular Aneurysm (“systolic bulge of pericardium”)
- Cardiogenic Shock
- LHF (incl Pulm Edema)
- Dressler’s Sx
- Post-Infarct Fibrinous Pericarditis
- Extension of Infarct / Reinfarction
- Ruptures: ** Heart softest = greatest chance of rupture b/w 3-7 days (-> hemopericardium) **
- Ventricular wall -> Cardiac Tamponade
(Several days after. “Sudden loss of pulse”.)
- Septum / Valve -> “New onset of murmur (M.R)” +
“Pulm congestion” +
VSD (Step-Up in O2 Sat from R.A to R.V)
- Papillary muscle -> Mitral Regurg
Acute MI #5- Bradycardia COMP
2 Types?
- Sinus Bradycardia (ischemia of SA node)
- 3rd Degree / Complete AV Block (“cannon A waves”)
LAD MI
Infarct Type, Pres (3), Comp?
Pale Infarct.
PRES:
- ‘Classic’ MI Pres
- Heart Block (most of conduction bundles in Ant 2/3 of IV septum = supplied by LAD)
- Mural thrombi
COMP:
- Rupture -> Hemopericardium (Day 3 or 4- “chest pain, muffled heart sounds, neck vein distension”)
RCA MI
Path / Pres (2)?
PRES:
- AV Node dysfunction -> Sinus Bradycardia + Atypical chest pain (eg epigastric pain, mimics GERD)
- Posteromedial papillary muscle dysfunction -> Mitral Regurg that arises b/w days 3-7
Post-Infarction Fibrinous Pericarditis
Etiology, Pres (2, based on timing), RX?
ET: Transmural infarct
PRES: “3-component Friction Rub” that can occur 2 times post-MI:
1) 1st week: Chest pain- relieved when leaning fwd / worse when leaning back
2) 6 wks: Fever + Muscle aches/pains (Dressler’s Sx: auto-ab against pericardial tis)
RX: NSAIDs
Coronary art Vasospasm
Causes (4)?
CAUSES:
- Cocaine use
- Emboli
- Variant / Prinzmetal Angina
- Vasculites
Dilated / Congestive Cardiomyopathy
Def’n, Etiologies (9: “ABCCCDD” + 2), Mech (3 steps),
Pres, Findings (1 + Imaging),
Comp (2)?
Dilation of all 4 heart chambers. Effusions at both lung bases.
ET:
- Alcohol abuse
- Wet Beriberi
- Chagas dz
- Coxsackie B virus Myocarditis
- Cocaine abuse
- Doxorubicin toxicity
- Duchenne Muscular Dystrophy
- Hemochromatosis
- Peripartum Cardiomyopathy (6 wks postpartum)
MECH = ECCENTRIC hypertrophy (sarcomeres added in series) ->
Ventricles unable to pump ->
SYSTOLIC dysfunction.
PRES = HF
FINDINGS:
- S3
- “Balloon” appearance of heart on CXR / Dilated heart on U/S
COMP:
- Mitral / Tricuspid Regurg
- Arrhythmia
Hypertrophic Cardiomyopathy
Location, Mech (5 steps), Inher, Genetics, Pres (3), Findings (2)?
LV
MECH:
CONCENTRIC hypertrophy (sarcomeres added in parallel) ->
Hypertrophied IV SEPTUM ->
Outflow obstruction thr Mitral valve + Altered conduction bundles ->
Ventricles unable to fill + Conduction defects ->
DIASTOLIC dysfunction + Conduction defects.
AD. 60-70% cases familial.
β-myosin heavy chain mutation in sarcomere proteins.
PRES:
- Conduction defects
- Sudden death in young athletes (due to ventricular arrhythmia)
- Dyspnea
- Syncope (esp with exercise)
FINDINGS: * Normal-sized heart *
- S4 + Aortic Regurg
- Apical impulses
Restrictive / Obliterative Cardiomyopathy
Etiologies (6), Pres, EKG (2)?
ET: “oses”
- Amyloidosis
- Sarcoidosis
- Post-Radiation fibrosis
- Endocardial Fibroelastosis (fibrosis in endocardium of “young child”)
- Hemochromatosis
- Loffler’s Sx (fibrosis with prominent “eosinophilic infiltrate”)
PRES = LHF
EKG:
- Low-Voltage EKG
- ↓QRS amplitude
Cardiac Dilation
Cause?
CAUSE =↑Ventricular EDV
Shock
3 Types + Causes of each, Conseq of all (2)?
CARDIOGENIC Shock: Loss of myocardial CONTRACTILITY -> HF.
HYPOVOLEMIC Shock: Hypovolemia due to BL LOSS.
SEPTIC Shock: Loss of VASCULAR TONE due to infl / infection.
CONSEQ:
- Hypotension
- ↓organ perfusion
Dyspnea on Exertion
Cause?
CAUSE = Failure of CO to↑during exercise
Congestive Heart Failure (CHF)
Def’n, Mech (Starling’s Law + 1), Pres (3), Comp?
Failure of heart to pump out enough blood.
MECH:
Starling’s Law: Force of CONTRACTION directly proportional to length of muscle fiber up until a certain limit.
Beyond this limit muscles undergo dilatation and failure.
-↑venous pressure
PRES:
- Dyspnea
- Fatigue
- S3
COMP:
- 2ry Hyperaldosteronism
Systolic CHF
Def’n, Causes?
Low EF heart failure.
CAUSES:
- IHD / MI
Diastolic CHF
Def’n, Causes, Findings?
Normal EF,↓ventricular Compliance heart failure.
CAUSES:
- Long-standing Htn
FINDINGS:
- S4
↑Venous Pressure
Conseq (4), Seen In?
CONSEQ: -↑CENTRAL venous pressure ->↑resistance to portal flow -> Hepatomegaly / Nutmeg Liver -↑PULM venous pressure -> Pulm Edema - Peripheral Edema - Jugular Venous Distention (JVD)
SEEN IN:
- HF
Orthopnea + Paroxysmal Nocturnal Dyspnea
Def’n, Mech, Seen In?
Shortness of breath when supine / Breathless awakening from sleep.
MECH:
Pulm vascular congestion EXACERBATED by↑venous return
(due to redistribution of blood from ‘immediate gravity effect’).
SEEN IN:
- LHF
LHF
Mech (3), Path (2), Causes (2 general), Pres (2)?
MECH:
- ↑Preload
- ↑Afterload
- ↓Contractility (multiple infarcts -> fibrous tis)
PATH: Clinical features due to↓forward perfusion:
- > pulmonary congestion
- > ↓bl flow to kidneys -> Activation of RAA Sys -> Fluid retention
CAUSES:
- Htn / Ischemia / MI
- Cardiomyopathy (Dilated or Restrictive)
PRES:
- Pulm Edema
- > Dyspnea
- > PND + Pillow Orthopnea
- > Bilat basal crackles
- > Blood-tinged frothy sputum (chronic LHF)
- ‘Pulsus Alternans’
RHF
Mech, Causes (3), Pres (5)?
MECH: RH can’t get bl thr the pulm vessels.
CAUSES:
- LHF
- L-to-R shunt
- Cor Pulmonale
PRES:
- JVD
- Ascites
- Hepatomegaly (painful) + ‘Nutmeg Liver’
- Pitting Edema of lower ext
- ‘Pulsus Paradoxus’
High-Output HF
Mech, Causes (3)?
MECH: ↑Venous Return -> Heart gives up.
CAUSES: (ALL↑Venous Return)
- ↓TPR - Vasodilation of peripheral arterioles - Septic Shock - Thiamine def - Hydralazine - ↑Sym activity /↑Contractility - Hyperthyroidism / Graves - AV Fistula
Bacterial Endocarditis
Def’n, Causes / Assoc (4),
H-S Type, Pres (4)?
Mitral valve w big bulky vegetations + ruptured chordae tendinae.
CAUSES / ASSOC:
- IV drug abuse (Tricuspid Valve)
- Sequela of dental procedures (Strep viridans)
- Prosthetic heart valves (Staph epidermidis)
- Patients with underlying Colorectal Carcinoma (Strep bovis)
Type III H-S (IC vasculitis).
PRES:
- Fever
- Glomerulonephritis
- Roth Spots (Eye)
- “Splinter hemorrhages in fingernails”:
- Painless = Janeway Lesion
- Painful = Osler Nodes
Libman-Sacks Endocarditis
Def’n, Ab, Seen In?
WART-like sterile vegetations on both sides of heart valve.
AB:
- ANA
SEEN IN:
- SLE
Acute Rheumatic Fever
MC Valve Involved, Path, Pres (Jones Criteria: 6)?
Mitral Valve > Aortic Valve
PATH: Post-Pharyngitis. Culture NEGATIVE (immunologic mech) = sterile vegetations.
PRES: Jones Criteria:
- Young person, post-pharyngitis
- Polyarthritis + Nodules on joint surfaces
- Erythema Marginatum
- Rales in lungs + Dyspnea
- Mitral Regurg murmur + Friction Rub + Endocarditis and Myocarditis
- Syndham’s Chorea (LATE)
Constrictive Pericarditis
Causes (3), Assoc, Pres, Comp
CAUSES:
- Coxsackie virus
- Previous cardiac surgery (U.S)
- TB (3rd World)
ASSOC:
- Lupus
PRES:
- Pericardial Knock on inspiration
COMP:
- Cardiac Tamponade
Cardiac Tamponade
Cause, Assoc, Pres (Beck Triad), ECHO (2), RX?
CAUSE: Pericarditis -> Pericardial Effusion
ASSOC:
- Lupus
PRES: Beck Triad
- Hypotension +…
- Pulsus Paradoxus: radial pulse↓on inspiration
- Distended neck veins (Kussmaul’s Sign)
- Muffled heart sounds
ECHO:
- Pericardial fluid accumulation
- Collapse of R.A
RX: Pericardiocentesis
Myxomas
Def’n, Location, Pres (Epi + 1)?
Benign mesenchymal cardiac tumor. “Ball-valve obstruction” in L.A.
90% occur in Atria (MC = L.A).
PRES: MC 1ry cardiac tumor in Adults
- Syncope (due to obstruction of mitral valve)
COMP:
- Embolization (soft tumors w small pieces inside them)
Rhabdomyomas
Def’n, Location, Assoc, Pres (Epi)?
Benign HAMARTOMA of cardiac muscle.
Usually occur in Ventricles.
ASSOC:
- Tuberous Sclerosis
PRES: MC 1ry cardiac tumor in Children
Carcinoid Heart Dz
Def’n (incl Location + Mech), Causes, Pres (2: valvular)?
R-sided valvular fibrosis due to↑COLLAGEN.
CAUSES:
- Carcinoid Tumor / Carcinoid Sx
PRES:
- Tricuspid regurg
- Pulm Valve stenosis
Sturge-Weber Dz
Def’n, Pres (CLUE + 4)?
Congenital vascular disorder that affects small / capillary-sized vessels.
PRES:
- “Port-Wine stain”: trigeminal nerve distribution
- IPSILATERAL leptomeningeal angiomas (= AV malformation on same side of brain)
- Slight mental retardation
- Seizures
- Early-Onset Glaucoma
Strawberry vs Cherry Hemangioma
Def’n of both, Differences (3)?
Benign capillary hemangiomas.
- Age of Onset: Infancy (first few wks of life) vs Elderly
- Course + Regression: Grows rapidly + regresses spontaneously vs
NO regression - Frequency: 1/200 births vs↑Freq with age
Pyogenic Granuloma
Def’n, Assoc (2)?
Polypoid capillary hemangioma that can ulcerate + bleed.
ASSOC:
- Pregnancy
- Trauma
Lymphangiosarcoma
Def’n?
Lymphatic malignancy associated with persistent lymphedema
eg post-radical mastectomy
Cystic Hygroma
Def’n, Assoc?
Cavernous lymphangioma of neck.
ASSOC:
- Turner Sx
Torsades de Pointes
Def’n, Causes (2 + 2), Pres on EKG, RX?
V-Tach that can progress to V-Fib.
CAUSES:
- Anything that prolongs QT interval:
- Congenital Long QT Sx
- Drugs (Antiarrhythmics- Class IA + Class III)
- ↓Ca
- ↓Mg
PRES ON EKG:
- “Shifting” sinusoidal waveforms
RX:
- Mg Sulfate
Pulsus Paradoxus
Def’n, Seen In (4)?
Exaggerated drop ( > 10 mmHg) in SYS bp during INSP.
SEEN IN:
- Cardiac Tamponade
- Constrictive Pericarditis
- Asthma (severe) / COPD
- Hypovolemic Shock