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Bootcamp.com Cardiology.pdf

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OUTLINE 1. Embryologic Derivatives 2. Truncus Arteriosus ● A. Physiologic ● B. Persistent Truncus Arteriosus ● C. Transposition of Great Vessels 3. Atrial Septation ● A. Mechanism ● B. Patent Foramen Ovale ● C. Atrial Septal Defect 4. Aortic Arch Derivatives and Pharyngeal Arches Cardiology: Embryology
Bootcamp.com Cardiology: Embryology • Sinus venosus à Coronary sinus, posterior portion of right atrium • Common cardinal veins à Superior vena cava • Umbilical vein à Ligamentum teres hepatis • Vitelline veins à Portal circulation and mesenteric veins • Truncus arteriosus à Ascending aorta and pulmonary trunk • Left and right dorsal aorta à Descending aorta • Primitive ventricle à Trabeculated portion of right and left ventricle • Primitive atria à Trabeculated portion of right and left atria • Bulbus cordis à Smooth portion of the right and left ventricle • Endocardial cushions à Valves and membranous portion of ventricular septum https://commons.wikimedia.org/wiki/File:2037_Embryonic_Development_of_Heart.jpg Heart begins beating during Week 4
Bootcamp.com Cardiology: Embryology • Physiologic: • Neural crest cell migration • Aorta and pulmonary artery partitioned and undergo spiral formation à aorticopulmonary septum constructed • Persistent Truncus Arteriosus: • Partial (incomplete) aorticopulmonary septum formation • Mixing of deoxygenated and oxygenated blood • Classic Association: DiGeorge Syndrome • Transposition of Great Vessels: • Failed spiraling of aorticopulmonary septum à reversal of pulmonary artery and aorta • Two parallel circuits • Right ventricle à Aorta • Left ventricle à Pulmonary artery • Classic Association: Mothers with diabetes https://commons.wikimedia.org/wiki/File:Truncus_arteriosus.jpg https://commons.wikimedia.org/wiki/File:D-tga-575px.jpg
Bootcamp.com Cardiology: Embryology • Step 1: Septum Primum Forms • Forms inferiorly from superior primitive atrium • Foramen primum: opening b/w septum primum + AV cushions • Step 2: Foramen and Septum Secundum Form • Foramen Secundum: Forms within septum primum • Septum Secundum: Superior and inferior segment • Step 3: Foramen Ovale Closes • Foramen Ovale: Formed by area between septum primum and secundum • ↓ pulmonary vascular resistance, ↑ LAP, ↓ RAP • Patent Foramen Ovale: • Incomplete joining of septum primum and septum secundum • Most patients are asymptomatic • Cryptogenic cerebrovascular accident, paradoxical embolism • Atrial Septal Defect: • Secundum-type is most common and tend to be isolated • Primum-type generally associated with additional heart defects • Cryptogenic cerebrovascular accident, paradoxical embolism Ventricular Septal Defects most commonly occur due to defects in the membranous portion of the interventricular septum
Bootcamp.com Cardiology: Embryology • First Arch: Maxillary Artery • Second Arch: Hyoid and Stapedial Arteries • Third Arch: Common Carotid and Proximal Internal Carotid Arteries • Left Fourth Arch: Aortic Arch • Classic Pathology: Coarctation of the aorta • Right Fourth Arch: Proximal Right Subclavian Artery • Left Sixth Arch: Ductus Arteriosus and Proximal Pulmonary Arteries • Classic Pathology: Patent ductus arteriosus • Right Sixth Arch: Proximal Pulmonary Arteries https://commons.wikimedia.org/wiki/File:Gray473.png
Bootcamp.com Cardiology: Embryology Pharyngeal Arches Segment Vascular Supply Cranial Nerve Important Muscles Cartilage Classic Pathology First- Mandibular Arch Maxillary Artery V2 and V3 -Muscles of mastication -Anterior belly of digastric -Tensor tympani, tensor veli palatini Meckel’s Cartilage à Mandible, maxilla Zygomatic bone Malleus and incus Treacher Collins Syndrome Pierre Robin Syndrome Second- Hyoid Arch Hyoid and Stapedial Arteries VII -Muscles of facial expression -Posterior belly of digastric -Stylohyoid, stapedius Reichert’s Cartilage à Stapes, styloid process Stylohyoid ligament Lesser horn of hyoid Congenital Pharyngocutaneou s Fistula Third Common Carotid and Proximal Internal Carotid Arteries CN IX -Stylopharyngeus à Greater horn of hyoid Fourth Aortic Arch (L) R Subclavian (R) CN X: Superior Laryngeal Nerve -Cricothyroid -Palatopharyngeus -Levator veli palatini Superior thyroid cartilage Coarctation of Aorta Sixth Ductus Arteriosus (L) L Pulmonary Artery (L) R Pulmonary Artery (R) CN X: Recurrent Laryngeal Branch Intrinsic muscles of larynx (except Cricothyroid) Inferior thyroid cartilage Arytenoid, corniculate, and cuneiform cartilage Patent Ductus Arteriosus https://commons.wikimedia.org/wiki/File:Kiemenbogen.jpg Pharyngeal Pouches Pharyngeal Grooves 1st: Eustachian tube, tympanic cavity, mastoid air cells 1st: External auditory meatus, auditory canal, outer tympanic membrane 2nd: Epithelial lining of palatine tonsils 2nd – 4th: Obliterated in utero 3rd: Dorsal à Inferior parathyroid glands 3rd: Ventral à Thymus 4th: Dorsal à Superior parathyroid glands 4th: Ventral à Parafollicular (C cells) of thyroid
≣ Item 1 of 1 Question ID: 0030 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 57-year-old male with a past medical history of hypertension presents to his primary care physician for hoarseness and dyspnea that has been progressively worsening over the past two months. He has a chronic smoking history ”for as long as he can remember”. He also states that he has been having double vision when leaning forward. During physical examination, auscultation reveals mild end-expiratory wheezing bilaterally over the lung fields. Heart sounds are normal with a regular rhythm. Radial pulses are 2+ and symmetric bilaterally. No thyromegaly is present. Diffuse venous distention is observed in the neck and chest wall. Edema is present diffusely throughout the upper extremities. Fundoscopic examination reveals papilledema bilaterally. Chest radiography is performed. A suspicious mass is identified and highlighted on the imaging study below. Which embryologic derivatives are most closely associated with the structured compressed in this patient? ⚪ A. Truncus arteriosus ⚪ B. Cardinal veins ⚪ C. Endocardial cushions ⚪ D. Right sixth pharyngeal arch ⚪ E. Left fourth pharyngeal arch https://commons.wikimedia.org/wiki/File:SVCCXR.PNG
OUTLINE 1. General Anatomical Overview ● A. Cardiac Atria ● B. Cardiac Ventricles 2. Cardiac Silhouette: Chest Radiography ● A. Cardiac Atria ● B. Cardiac Ventricles 3. Axial Imaging: CT and MRI ● A. Ascending and Descending Aorta ● B. Pulmonary Trunk ● C. Cardiac Atria and Ventricles 4. Penetrating Cardiac Injury 5. Cardiac Conduction Anatomy ● A. Sinoatrial Node ● B. Atrioventricular Node 6. Radiofrequency Ablation Targets ● A. Atrial Fibrillation Foci ● B. Atrial Flutter Foci 7. Coronary Artery Anatomy ● A. Right Coronary Arteries ● B. Left Coronary Arteries ● C. Dominant Coronary Artery Circulation 8. Coronary Sinus 9. Cardiac Catheterization ● A. Swan-Ganz Catheter ● B. Coronary Angiography, Percutaneous Coronary Intervention ● C. Trans-Septal Left Atrial Catheterization Cardiology: Anatomy
Bootcamp.com Cardiology: Anatomy • Right Atrium: • Right heart border • Right Ventricle: • Anterior and inferior heart border • Left Atrium: • Posterior border of heart (also minor component of left ventricle) • Clinical Correlation: Enlargement leads to cardiovascular dysphagia • Clinical Correlation: Transesophageal echocardiography • Left Ventricle: • Left heart border (also minor component of left atrial appendage) https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg
Bootcamp.com Cardiology: Anatomy • Right Atrium: • Right heart border • Right Ventricle: • Anterior and inferior heart border • Left Atrium: • Posterior border of heart (also minor component of left ventricle) • Clinical Correlation: Enlargement leads to cardiovascular dysphagia • Clinical Correlation: Transesophageal echocardiography • Left Ventricle: • Left heart border (also minor component of left atrial appendage) https://commons.wikimedia.org/wiki/File:X-ray_of_cardiac_silhouettes.jpg
Bootcamp.com Cardiology: Anatomy • Ascending aorta • Descending aorta • Pulmonary trunk • Atria and Ventricles https://commons.wikimedia.org/wiki/File:SADDLE_PE.JPG https://commons.wikimedia.org/wiki/File:Cardiac_mri_slice_bionerd.jpg
Bootcamp.com Cardiology: Anatomy • Mid-Left Sternal Border 3rd-4th Intercostal Space: • Right ventricle susceptible to injury • Left Sternal Border to Mid-Clavicular Line 5th Intercostal Space: • Medial à Left ventricle and left lung susceptible to injury • Lateral à Left lung primarily susceptible to injury https://commons.wikimedia.org/wiki/File:Surface_projections_of_the_organs_of_the_trunk.png
Bootcamp.com Cardiology: Anatomy • Sinoatrial Node: • Contains specialized pacemaker cells • Location: Right atrium along roof (proximity to opening of SVC) • Atrioventricular Node: • Delayed conduction between atria and ventricle • Location: Right atrium along interatrial septum (proximity to tricuspid valve and coronary sinus) • Bundle of His • Purkinje Fibers https://commons.wikimedia.org/wiki/File:ConductionsystemoftheheartwithouttheHeart-en.svg https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg
Bootcamp.com Cardiology: Anatomy • Atrial Fibrillation Foci: • Left atrial myocardium • Pulmonary vein ostia within left atrium • Atrial Flutter Foci: • Area between tricuspid valve and IVC https://commons.wikimedia.org/wiki/File:ConductionsystemoftheheartwithouttheHeart-en.svg https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg
Bootcamp.com Cardiology: Anatomy • Right Coronary Artery (RCA): • Majority of right-side of heart • Sinoatrial node • Left Coronary Artery (LCA): • Majority of left-side of heart • Two major branches: • Left Anterior Descending Artery (LAD)à Anterior 2/3 of interventricular septum, anterolateral papillary muscle, anterior left ventricle • Left Circumflex Artery (LCX) à Posterolateral LA and LV, anterolateral papillary muscle • Posterior Descending Artery (PDA): • ~85% R-dominant, 8% L-dominant, 7% co-dominant • Primarily inferior borders of heart • Posterior 1/3 of interventricular septum • Posteromedial papillary muscle
Bootcamp.com Cardiology: Anatomy • All coronary veins drain into the coronary sinus • Location: Left posterior atrioventricular groove • Drains directly into the right atrium • Embryologic derivative: Sinus venosus • Clinical Correlation: Biventricular pacemaker lead placement into LV • Clinical Correlation: Dilated in pulmonary hypertension https://commons.wikimedia.org/wiki/File:Gray491.png https://commons.wikimedia.org/wiki/File:PPM.png
Bootcamp.com Cardiology: Anatomy • Swan-Ganz Catheter (Pulmonary Artery Catheter): • Venous catheter • Use: Measures right-sided pressures • Pulmonary capillary wedge pressure: Surrogate marker for left atrial pressure • Coronary Angiography, Percutaneous Coronary Intervention (PCI) • Arterial catheter • Use: Visualize atherosclerotic lesions and stenosis of coronary vessels • Trans-Septal Left Atrial Catheterization • Venous catheter • Use: Direct measurement of left atrial pressure and/or ablation of pathogenic foci https://commons.wikimedia.org/wiki/File:Pulmonary_artery_catheter_english.JPG https://commons.wikimedia.org/wiki/File:Coronary_Angiography.png
≣ Item 1 of 1 Question ID: 0031 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 25-year-old female presents to the emergency room with dyspnea and palpitations. She states that she believes she may be having a panic-attack. She reports that she was walking her dog when suddenly she began to feel lightheaded and short of breath. She denies any family history of heart disease. Telemetry monitoring reveals an irregularly irregular heart rate of 134/min. Blood pressure is 138/54, respiratory rate is 14/min, blood glucose is 84 mg/dL. Fine tremors are observed in the distal phalanges. Electrocardiogram is performed and shown. Initial labs reveal a significantly decreased thyroid-stimulating hormone level. Which of the following locations is likely a source of aberrant electrical foci contributing to this patient’s symptoms? ⚪ A. Cavotricuspid isthmus of right atrium ⚪ B. Superior subendocardial right atrium ⚪ C. Membranous portion of interventricular septum ⚪ D. Left posterior atrioventricular groove ⚪ E. Pulmonary vein ostia of left atrium ⚪ F. Pulmonary artery root of right ventricle https://commons.wikimedia.org/wiki/File:ECG_Atrial_Fibrillation.jpg
OUTLINE 1. Aorta ● A. Vascular Structures and Branches ● B. Ligamentum Arteriosum ● C. Key Landmarks of the Aorta 2. Subclavian Steal Syndrome 3. Venous Drainage Obstruction ● A. Superior Vena Cava Syndrome ● B. Brachiocephalic Vein Obstruction ● C. Subclavian and/or Axillary Vein Obstruction 4. Coronary Bypass Grafting ● A. Internal Thoracic Artery ● B. Great Saphenous Vein 4. Femoral Access ● A. NAVEL ● B. Femoral Arterial Access ● C. Femoral Venous Access 6. Inferior Vena Cava ● A. Key Landmarks of the Inferior Vena Cava ● B. Inferior Vena Cava Filter Cardiology: Vascular System
Bootcamp.com Cardiology: Vascular System • Vascular Structures: • Coronary Arteries • Brachiocephalic trunk • Subclavian arteries • Common carotid arteries • Ligamentum Arteriosum: • Remnant of ductus arteriosus • Key Landmarks: • T12: Descending aorta traverses' diaphragm via aortic hiatus • T12: Celiac trunk • L1: Superior mesenteric artery origin • L3: Inferior mesenteric artery origin • L1-L2: Right and left renal arteries origin • L2: Gonadal arteries origin • L4: Bifurcation into common iliac arteries (at navel) https://commons.wikimedia.org/wiki/File:Aorta_branches.svg
Bootcamp.com Cardiology: Vascular System • Etiology: Atherosclerosis, Takayasu arteritis, previous thoracic (aortic) surgery • Pathophysiology: • Subclavian stenosis à contralateral vertebral artery steal phenomena • Presentation: • Ipsilateral limb ischemia • Asymmetric BP between upper extremities • Dizziness, diplopia, syncope • Worsening of symptoms during activity of affected limb • Imaging: • Reduced contrast uptake in areas distal to stenosis and ipsilateral vertebral artery https://commons.wikimedia.org/wiki/File:The_promixal_part_of_left_subclavian_is_blocked_on_left_side_so_no_flow_in_vertebra l_and_to_left_arm-blood_from_right_vertebral_enters_left_vertebral_and_flows_back_to_supply_left_arm_2013-07-05_17-11.jpg https://commons.wikimedia.org/wiki/File:Angiogram_of_Left_Subclavian_Steal_Syndrome.PNG
Bootcamp.com Cardiology: Vascular System • Superior Vena Cava Syndrome • Etiology: Mass lesion (malignancy) or thrombosis (venous catheter) • Edema à bilateral face, bilateral upper extremities • Jugular venous distention • Headache, ↑ intracranial pressure • Brachiocephalic Venous Obstruction • Etiology: Pancoast tumor or thrombosis (venous catheter) • Edema à Unilateral face, unilateral upper extremity • Subclavian and/or Axillary Venous Obstruction • Edema à Unilateral upper extremity • No facial involvement • Inferior Vena Cava Compression • Supine hypotensive syndrome (3rd trimester) Edema à Bilateral lower extremities Fetal hypoxia à improves with repositioning https://commons.wikimedia.org/wiki/File:2132_Thoracic_Abdominal_Veins.jpg Azygos Vein Right-sided vein Connects SVC and IVC Alternative pathway for blood to return to right atrium
Bootcamp.com Cardiology: Vascular System • Internal Thoracic (Mammary) Artery • Great Saphenous Vein • Medial foot, medial malleolus, medial leg and thigh • Joins femoral vein https://upload.wikimedia.org/wikipedia/commons/c/c8/2136ab_Lower_Limb_Veins_Anterior_Posterior.jpg https://commons.wikimedia.org/wiki/File:Gray522.png
Bootcamp.com Cardiology: Vascular System • NAVEL (lateral to medial) • Femoral Nerve • Femoral Artery • Femora Vein • Empty • Lymphatics • Femoral Arterial Access • At the site of femoral pulsation below inguinal ligament • Coronary angiography, PCI • Clinical Correlate: If access above inguinal ligament à ↑ risk of retroperitoneal hemorrhage • Femoral Venous Access • Medial to the site of femoral pulsation below inguinal ligament • Swan-Ganz catheter • Trans-septal left atrial catheterization https://commons.wikimedia.org/wiki/File:Gray545.png
Bootcamp.com Cardiology: Vascular System • Key Landmarks: • T8: Traverses diaphragm • L5: Formed by right and left iliac veins • Inferior Vena Cava Filter • Indication: Failure or contraindication to anticoagulation in the setting of a lower extremity deep venous thrombosis https://commons.wikimedia.org/wiki/File:3D_Medical_Animation_Inferior_Vena_Filter.jpg https://radiopaedia.org/cases/normal-ct-abdomen?lang=us
≣ Item 1 of 1 Question ID: 0032 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com ⚪ A. Right vertebral artery ⚪ B. Left subclavian artery ⚪ C. Left internal carotid artery ⚪ D. Left axillary artery ⚪ E. Grafted internal thoracic artery A 67-year-old left-handed male is brought to the emergency room by paramedics for 9/10 acute onset chest pain that began during a game a of ping-pong at his senior living facility. The patient states that he has been noncompliant with his statin medication and has not been consistent in checking his blood pressure at home. He reports having chest pain over the past week worsened with rapid left arm movement. His medical history is significant for a myocardial infarction secondary to significant stenosis of the left anterior descending and circumflex arteries and had previously undergone a coronary artery bypass grafting procedure. Physical exam reveals a cool left extremity with a 1+ left radial pulse. The right upper extremity is normal in color with a systolic blood pressure 30 mmHg greater than the left. Cardiovascular surgery is emergently consulted, and a percutaneous revascularization is performed. Retrograde transport of blood through which of the following arteries most likely contributed to this patient’s presentation?
OUTLINE 1. Stroke Volume ● A. End-Diastolic Volume ● B. End-Systolic Volume ● C. Ejection Fraction 2. Stroke Volume Variables ● A. Preload ● B. Afterload ● C. Contractility 3. Heart Rate 4. Frank-Starling Mechanism ● A. Principle and Mechanism ● B. Frank-Starling Curve 6. Cardiac Output ● A. Fick-Principle 7. Mean Arterial Pressure ● A. Total Peripheral Resistance ● B. Pulse Pressure 8. Coronary Blood Flow and Autoregulation Cardiology: Cardiac Parameters of Physiologic Function
Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • End-Diastolic Volume: ~ Preload • End-Systolic Volume: ~ 1/Contractility • Stroke Volume (SV) = End-diastolic volume (EDV) – End-systolic volume (ESV) • Ejection Fraction (EF) = SV / EDV
Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Preload: • ↑ Venous return à ↑ EDV ~ ↑ Preload à ↑ Stroke volume, ↑ Contractility • Afterload: • ↑ TPR ~ ↑ Afterload à ↑ ESV à ↓ Stroke volume • Preload compensates in healthy hearts • Afterload has a more dominant effect in heart failure • Law of LaPlace: Wall stress = !"#$$%"# & '()*%$ +(,, -.*/01#$$ = +(,, -#1$*21 +(,, -.*/01#$$ • Contractility • ↑ SNS activity à ↑ Contractility à ↓ ESV à ↑ Stroke volume SV = EDV - ESV
Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Physiologic Mechanism: ↓ Vagal tone à SA Node à ↑ HR • Coronary Perfusion: • Left ventricular myocardial perfusion occurs primarily during diastole • Tachycardia: • Elevated heart rate • ↑ HR à ↓ time of diastole à ↓ ventricular myocardial perfusion, ↓ diastolic filling time à ↓ CO CO = HR x SV Maximal HR = 220 bpm – Age (in years)
Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Principle: • ↑ Preload à ↑ Contractility à ↑ SV • Mechanism: • ↑ Venous return • ↑ EDV ~ ↑ Preload • ↑ Myocyte stretch prior to contraction • ↑ Sarcomere length (↑ active tension and velocity of fiber shortening) • Frank-Starling Curve: • X-axis: LVEDP (preload, LVEDV, fiber length) • Y-axis: Stroke Volume • Slope of curve: Defined by afterload and contractility • Point along curve: Defined by venous return (preload) SV = EDV - ESV
Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Cardiac Output = HR x SV • Fick Principle à Cardiac Output = Rate of O2 consumption / Arteriovenous O2 difference
Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Total Peripheral Resistance (TPR) = Determined by state of arteriolar resistance • Pulse Pressure (PP) = Systolic pressure – Diastolic pressure • Mean Arterial Pressure (MAP) = CO x Total peripheral resistance (TPR) • Mean Arterial Pressure (MAP) = 1/3 systolic pressure + 2/3 diastolic pressure • Mean Arterial Pressure (MAP) = 1/3 PP + Diastolic Pressure
Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Left Ventricular Coronary Blood Flow: ↑ Ventricular diastole • Oxygen Extraction: • Significant in myocardial tissues • Coronary sinus à ↑↑↑ deoxygenation • ↑ O2 demand à coronary vasodilation (nitric oxide, adenosine)
≣ Item 1 of 1 Question ID: 0033 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 57-year-old male presents to the emergency department for a dry cough and dyspnea. He states that over the past seven years he has experienced mild shortness of breath with continued physical exertion, however, over the past week he has suddenly become short of breath at rest. He has a past medical history of poorly controlled hypertension and hyperlipidemia. The patient also admits to a 30-year smoking history. He is afebrile, blood pressure is 102/64, heart rate is 102/min, oxygen saturation is 92% on room air. Auscultation of the heart reveals an S3 heart sound and a faint systolic decrescendo murmur in the axillary region. Lung auscultation is significant for diffuse crackles. There is dullness to percussion over the lung fields. Chest radiography is shown. Which of the following is most consistent with this patient’s presentation? ⚪ A. Elevated systolic aortic pressures ⚪ B. Elevated pulmonary capillary wedge pressure ⚪ C. Depressed left atrial pressure ⚪ D. Depressed pulmonary venous pressure ⚪ E. Unchanged left ventricular diastolic volume https://commons.wikimedia.org/wiki/File:Pulmonary_oedema.jpg
OUTLINE 1. Cardiac Function Curves 2. Venous Return Curves 3. Combined Cardiac Function and Venous Return Curves ● A. Steady State ● B. Specific Pathologic Processes Cardiology: Cardiac Function and Venous Return Curve Physiology
Bootcamp.com Cardiology: Cardiac Function and Venous Return Curve Physiology • Cardiac Function Curve: • X-axis: Right atrial pressure (independent variable) • Y-axis: Cardiac output (dependent variable) • Slope of curve: Defined by contractility, afterload, and heart rate
Bootcamp.com • Venous Return Curve: • X-axis: Right atrial pressure (dependent variable) • Y-axis: Cardiac output (independent variable) • Slope of curve: Defined by total peripheral resistance • X and Y intercept: Defined by venous compliance and total blood volume Cardiology: Cardiac Function and Venous Return Curve Physiology
Bootcamp.com • Intersection: • Steady state operating target for right atrial pressure and cardiac output • Variables: • Slope of Cardiac Function Curve à Contractility, Heart rate, Afterload • Slope of Venous Return Curveà TPR • X-intercept of Venous Return Curve (Pm) à Total blood volume, Venous compliance Cardiology: Cardiac Function and Venous Return Curve Physiology
Bootcamp.com • Acute Hemorrhage: Disruption: ↓ blood volume • Cardiac Function Curve: No change • Venous Return Curve: X-intercept shifts left • Steady State: Shifted downward and to the left • Intravenous Fluids: Disruption: ↑ blood volume • Cardiac Function Curve: No change • Venous Return Curve: X-intercept shifts right • Steady State: Shifted upward and to the right • Chronic Systolic Heart Failure: Disruption: ↓ contractility, Chronic à Compensation • Cardiac Function Curve: ↓ slope • Venous Return Curve: Slope decreases, X-intercept shifts right • Steady State: Shifted downward and to the right • Digoxin: Disruption: ↑ contractility • Cardiac Function Curve: ↑ slope • Venous Return Curve: Slope unchanged, X-intercept unchanged • Steady State: Shifted upward and to the left • Phenylephrine: Disruption: ↑ TPR (!1-agonist) • Cardiac Function Curve: ↓ slope • Venous Return Curve: ↓ slope , X-intercept unchanged (usually) • Steady State: Shifted downward • Hydralazine: Disruption: ↓ TPR • Cardiac Function Curve: ↑ slope • Venous Return Curve: ↑ slope , X-intercept unchanged (usually) • Steady State: Shifted upward Slope of Cardiac Function Curve à Contractility, Heart rate, Afterload Slope of Venous Return Curveà TPR X-intercept of Venous Return Curve (Pm) à Total blood volume, Venous compliance Cardiology: Cardiac Function and Venous Return Curve Physiology
≣ Item 1 of 1 Question ID: 0034 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪✪ Bootcamp.com A 67-year-old male with a chronic smoking history presents to the emergency department by paramedics with hypotension refractory to intravenous fluids following an episode of syncope at home. His daughter reports he suddenly loss consciousness while watching television. Vitals are significant for a blood pressure of 88/28 mmHg, heart rate of 124/min, and respiratory rate of 18/min. Imaging reveals findings consistent with an aortocaval fistula. Surgery is emergently performed. Which of the following new steady states are most representative of the acute pathophysiology observed in this patient prior to surgical intervention? ⚪ A. ⚪ B. ⚪ C. ⚪ D. ⚪ E. Cardiac Output Venous Return Right Atrial Pressure (E.) Prior to aortocaval fistula A. B. C. D. E.
OUTLINE 1. Basic Principles ● A. Key Principles ● B. Phases 2. Determinants ● A. Preload ● B. Contractility ● C. Afterload 3. Valvular Disease ● A. Aortic Regurgitation ● B. Aortic Stenosis ● C. Mitral Regurgitation ● D. Mitral Stenosis 4. Advanced Pathophysiology ● A. Exercise ● B. Arteriovenous Fistula ● C. Systolic Heart Failure ● D. Diastolic Heart Failure Cardiology: Pressure Volume Loops
Bootcamp.com Cardiology: Pressure Volume Loops • Key Principles: • All valves are closed during isovolumetric phases (vertical lines) • Width of the pressure volume loop ~ Stroke Volume • Area of pressure volume loop ~ Ventricular Stroke Work • Ventricular compliance makes up the base of the loop • Phases: • Isovolumetric contraction • Left ventricular ejection • Isovolumetric relaxation • Ventricular filling
Bootcamp.com Cardiology: Pressure Volume Loops • Preload: • ↑ à EDV shifts right • ↓ à EDV shifts left • Contractility: • ↑ à ESV shifts left • ↓ à ESV shifts right • Afterload: • ↑ à ESV shifts right • ↑ à ↑ LVP isovolumetric contraction • ↓ à ESV shifts left • ↓ à ↓ LVP isovolumetric contraction https://commons.wikimedia.org/wiki/File:Cardiac_cycle_(pressure_volume_loop).svg
Bootcamp.com Cardiology: Pressure Volume Loops • Hemorrhagic Shock: • ↓ Total blood volumeà ↓ Preload • Intravenous Fluids: • ↑ Total blood volumeà ↑ Preload • Nitroglycerin: • Venodilator (primary)à ↓ Preload • Vasodilator (secondary)à ↓ Afterload • Sodium Nitroprusside: • Vasodilator (primary)à ↓ Afterload, ↓ TPR (↓ DBP) • Venodilator (primary) à ↓ Preload
Bootcamp.com Cardiology: Pressure Volume Loops • Digoxin, Dobutamine: • Inotropic agentà ↑ Contractility • Slight increases in ventricular afterload are possible https://en.wikipedia.org/wiki/Press ure%E2%80%93volume_loop_ana lysis_in_cardiology#/media/File:En d_Systolic_Pressure_Volume_Rel ationship.jpg
Bootcamp.com Cardiology: Pressure Volume Loops • Phenylephrine: • !1-agonist à ↑ Afterload, ↑ TPR (↑ DBP) • Hydralazine: • Vasodilatorà ↓ Afterload, ↓ TPR (↓ DBP)
Bootcamp.com Cardiology: Pressure Volume Loops • Aortic Regurgitation: • Retrograde flow of oxygenated blood into LV à ↑ Preload • Loss of isovolumetric phases • Aortic Stenosis: • Stenosis distal to left ventricle à ↑ Afterload • Chronic: ↓ Ventricular compliance (Diastolic heart failure) • Mitral Regurgitation: • Retrograde flow of oxygenated blood into LA à ↑ Preload • Loss of isovolumetric phases • Mitral Stenosis: • Stenosis proximal to left ventricle à ↓ Preload https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Aortic_stenosis.jpg https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Aortic_regurgitation.jpg https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Mitral_regurgitation.jpg https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Mitral_stenosis.jpg
Bootcamp.com Cardiology: Pressure Volume Loops • Exercise: • Venoconstriction, muscle and respiratory pumps à ↑ Preload • Sympathetic stimulation to heart à ↑ Contractility • Muscle vasodilation < ventricular afterload à ↑ Afterload (↓ DBP) • Arteriovenous Fistula: • Low resistance fistulaà ↓ Afterload • High flow of blood through fistula à ↑ Venous return, ↑ Preload • If fistula is large à hypotension à ↑ Contractility, heart rate à High-output cardiac failure • Systolic Heart Failure • Principal determinant: ↓ Contractility • Chronic à ↓↓↓ Contractility, ↑ Preload, ↓ Afterload • Diastolic Heart Failure • Principal determinant: ↓ Ventricular compliance • Chronic: ↓ Preload, variable changes in contractility and afterload • Key point: Decrease in stroke volume and compliance
≣ Item 1 of 1 Question ID: 0035 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 57-year-old male with presents to an urgent care clinic with a numbness of his right foot and shortness of breath. He states that he had three fall episodes over the past month because “he can’t feel the floor”. He denies any dizziness and reports that he has not been seen by a physician in over twenty years. Physical examination reveals a left internuclear ophthalmoplegia. The pupils accommodate but are not reactive to direct or indirect light stimulation. Locally destructive ulcerative lesions are present diffusely throughout the face and upper back. Cardiovascular examination demonstrates a high-pitched diastolic murmur most prominent at the left fourth intercostal space along the left sternal border. Pulses are notable for a rapid upstroke and downstroke. Reflexes are 1+ at L4 and C5 bilaterally. Sensory ataxia is also present. A biopsy of the skin lesions is taken revealing a monocytic infiltrate. The patient is referred for a lumbar puncture. Which of the following best demonstrates the time along the left ventricular pressure-volume loop that this patient’s heart murmur will be most prominent? ⚪ A. Distance between A to B ⚪ B. Distance between B to C ⚪ C. Distance between C to D ⚪ D. Distance between D to A ⚪ E. Point D https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_diagram
OUTLINE 1. Endothelial Regulated Vasodilation ● A. Mechanism of Action 2. Excitation-Contraction Coupling ● A. Cardiac Myocyte ● B. Vascular Smooth Muscle ● C. Skeletal Muscle 3. G-Protein Coupled Receptor Vasoconstriction Pathway ● A. Gq Pathway 4. Pharmacologic Targets ● A. !1 agonists ● B. Nonhydropyridine Calcium Channel Blockers ● C. Dihydropyridine Calcium Channel Blockers ● D. Phosphodiesterase-3 Inhibitors ● E. Additional Vasodilatory Drugs Cardiology: Vasodilation and Vasoconstriction
Bootcamp.com Cardiology: Vasodilation and Vasoconstriction • Endothelial Cell: • Acetylcholine, bradykinin, and shear stress forces à ↑ cytosolic [Ca2+ ] • Nitric oxide Synthase stimulated by ↑ [Ca2+ ] • L-Arginine + O2 à Nitric oxide + Citrulline • Nitric oxide diffuses freely among cells • Vascular Smooth Muscle: • Nitric oxide causes increased conversion of GTP à cGMP • cGMP à activation of PKG à ↓ cytosolic [Ca2+ ] • Relaxation of vascular smooth muscle
Bootcamp.com • Cardiac Myocytes • Depolarization of cell membrane by action potential • L-type calcium channel: influx of calcium ions from extracellular • Calcium-induced calcium release: incoming calcium ions bind to ryanodine receptor • Ryanodine receptor: influx of calcium ions from SR • Calcium ions bind to troponin-C • Conformational change allows actin to interact with myosin head • SERCA: Sequesters intracellular calcium into SR via ATP à relaxation • Smooth Muscle: • Depolarization of cell membrane by action potential • L-type calcium channel: influx of calcium ions from extracellular • Calcium induced calcium release • Calcium ions bind to calmodulin • Conformation change in myosin light chain kinase (MLCK) • Phosphorylates myosin light chain (MLC) à contraction • Myosin light chain phosphatase dephosphorylates MLC à relaxation • Skeletal Muscle (Major Differences from Cardiac Myocytes): • Pathway stimulated by acetylcholine (not automaticity) • Mechanical coupling of LTCC with RyR https://upload.wikimedia.org/wikipedia/commons/1/10/Cardiac_calcium_cycling_and_excitation-contraction_coupling.png Cardiology: Vasodilation and Vasoconstriction
Bootcamp.com • Gq-GPCR Mechanism: • Present on arterioles (↑ afterload) and veins (↑ preload) • Gq protein à ↑ Phospholipase C (PLC) • PIP2 à ↑ inositol triphosphate (IP3) + Diacylglycerol (DAG) • IP3 à ↑ cytosolic [Ca2+ ] (from ER) • DAG à Protein Kinase C (PKC) à ↑ cytosolic [Ca2+ ] (from extracellular space) Cardiology: Vasodilation and Vasoconstriction
Bootcamp.com • !1-agonists • Activation of Gq-GPCR pathway • Primary effect: Vasoconstriction • Drugs: Phenylephrine (selective), norepinephrine (nonselective) • Nondihydropyridine Calcium Channel Blockers: • Inhibition of L-type calcium channels • Greater effect on calcium-induced calcium release • Primary effect: ↓ Contractility, bradycardia, AV block • Drugs: Verapamil, diltiazem • Dihydropyridine Calcium Channel Blockers: • Inhibition of L-type calcium channels • Greater effect on calcium-induced calcium release • Primary effect: Vasodilation • Drugs: Nifedipine, nicardipine, felodipine, amlodipine (arterial > venous) • Phosphodiesterase-3 (PDE-3) Inhibitor: • PDE-3 à Inhibition of cAMP degradation (myocytes) and ↑ SR calcium uptake (vascular) • Primary effect: ↑ Contractility, vasodilation • Drugs: Milrinone, Cilostazol, Dipyridamole • Additional Vasodilatory Drugs: • Nitric oxide (venous > arterial) • Hydralazine, minoxidil (arterial > venous) • Nitroprusside (arterial = venous) • Sildenafil (PDE-5 inhibitor) à (pulmonary and corpus cavernosum) https://upload.wikimedia.org/wikipedia/commons/1/10/Cardiac_calcium_cycling_and_excitation-contraction_coupling.png Cardiology: Vasodilation and Vasoconstriction
≣ Item 1 of 1 Question ID: 0036 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 77-year-old male is brought to the emergency department from his living facility with lethargy. Vital signs reveal a blood pressure of 58/20 mmHg, heart rate 122 beats/min, respiratory rate 20 breaths/min, oxygen saturation 91% on room air, and a temperature of 103.3F (39.6C). Initial labs reveal a lactate of 9.0 and white blood cell count of 18,000/mm3. He is aggressively fluid resuscitated and started on slow intravenous phenylephrine injection for blood pressure support. Which of the following cellular changes are most likely to occur due to the direct effects of the medication given? ⚪ A. Increased inhibition of adenylyl cyclase ⚪ B. Decreased intracellular concentrations of L-arginine ⚪ C. Decreased cyclic AMP degradation ⚪ D. Increased myosin light chain phosphatase activity ⚪ E. Decreased degradation of adenosine ⚪ F. Increased intracellular concentrations of inositol triphosphate
OUTLINE 1. Vessel Compliance ● A. Key Principles 2. Blood Flow ● A. Poiseuille Equation ● B. Resistance 3. Sensory Receptors of the Vasculature ● A. Carotid Sinus and Aortic Arch Baroceptors ● B. Carotid Sinus Massage ● C. Carotid Sinus Hypersensitivity ● D. Carotid and Aortic Body Chemoreceptors Cardiology: Pressure and Flow Physiology
Bootcamp.com Cardiology: Pressure and Flow Physiology • Vessel Compliance: • Compliance = ∆Volume / ∆Pressure • Elastance = ∆Pressure / ∆Volume • ↑ Compliance à Veins • ↓ Compliance à Arterioles
Bootcamp.com Cardiology: Pressure and Flow Physiology • Poiseuille Equation: • Flow (Q) = !" #!$ 8%& r4π • Q = Flow • P = Pressure at point in blood vessel • ! = viscosity of blood within blood vessel • l = length of blood vessel • r = radius of blood vessel • Capillaries have greatest total cross-sectional area à lowest blood velocity • Resistance: • R ∝ %& '! • R = Resistance • Arterioles are the primary regulator of total peripheral resistance • Series: Total Resistance = RT = R1 + R2 + …Rn • Parallel: Total Resistance = 1/%T = 1/%1 + 1/%2 + … 1/%n
Bootcamp.com • Carotid Sinus and Aortic Arch Baroceptors: • ↑ stretch (↑ BP) à ↑ afferent ↑ efferent PNS firing à ↑ parasympathetic response à vasodilation, ↓ HR, ↓ contractility • ↓ stretch (↓ BP) à ↓ afferent ↓ efferent PNS firing à ↓ parasympathetic response à vasoconstriction, ↑ HR, ↑ contractility • Carotid Sinus Massage: • ↑ afferent ↑ efferent PNS firing à ↑ parasympathetic response à vasodilation, ↓ HR, ↓ contractility • Stable narrow complex tachycardia à Vagal maneuver • Carotid Sinus Hypersensitivity: • Develops severe hypotension and/or bradycardia after carotid sinus stimulation • “Tight shirt collar” • Presyncopal/syncopal event • Carotid and Aortic Body Chemoreceptors: • Effective at responding to chronic hypoxia (as opposed to central chemoreceptors) • ↓ O2 (↑ CO2, ↓ pH) à ↑ sympathetic response à ↑ respiratory rate Cardiology: Pressure and Flow Physiology
≣ Item 1 of 1 Question ID: 0036 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪ Bootcamp.com A 78-year-old female with a past medical history of dyslipidemia, hypertension, and type 2 diabetes mellitus is evaluated at an acute rehabilitation facility for dizziness during therapy. She denies any shortness of breath, vision changes, or chest pain. The patient has a history of C3-C5 laminectomy for severe spinal stenosis. Vital signs are shown below. Auscultation of the heart reveals a regular rate and rhythm with no murmurs or abnormal heart sounds. The lungs are clear to auscultation. Which of the following undiagnosed conditions best describes a possible cause of this patient’s presentation? Temperature: 97.8F (36.6C) Blood pressure when lying supine: 144/88 mmHg Heart rate when lying supine: 102/min Respiratory rate when lying supine: 12/min Blood pressure when standing: 110/56 Heart rate when standing: 112/min Respiratory rate when standing: 14/min ⚪ A. Carotid sinus hypersensitivity ⚪ B. Autonomic neuropathy ⚪ C. Neurogenic shock ⚪ D. Constrictive pericarditis ⚪ E. Hypertrophic cardiomyopathy
OUTLINE 1. Auscultation ● A. Aortic Area ● B. Pulmonic Area ● C. Mitral Area ● D. Tricuspid Area ● E. Erb’s Point 2. Heart Sounds ● A. S1 ● B. S2 ● C. Physiologic Splitting of S2 ● D. Pathologic Splitting of S2 ● E. S3 ● F. S4 3. Cardiac Cycle ● A. Isovolumetric Contraction ● B. Ejection ● C. Isovolumetric Relaxation ● D. Ventricular Filling ● E. Atrial Systole 4. Jugular Venous Waveform ● A. A-wave ● B. C-wave ● C. X-descent ● D. V-wave ● E. Y-descent Cardiology: Cardiac Cycle 5. Classic Disorders ● A. Aortic Stenosis ● B. Aortic Regurgitation ● C. Mitral Stenosis ● D. Mitral Regurgitation ● E. Constrictive Pericarditis ● F. Cardiac Tamponade ● G. Atrial Fibrillation ● H. AV-dissociation
Bootcamp.com Cardiology: Cardiac Cycle • Aortic Area: • 2nd R parasternal ICS • Pulmonic Area: • 2nd L parasternal ICS • Tricuspid Area: • 4th L parasternal ICS • Mitral Area: • 5th L mid-clavicular line ICS • Erb’s Point • 3rd L parasternal ICS https://en.wikipedia.org/wiki/Heart_sounds#/media/File:Gray1216_modern_locations.svg
Bootcamp.com Cardiology: Cardiac Cycle • S1: • Produced by: Closure of tricuspid and mitral valves • Best heard: Cardiac apex Accentuation: Left lateral decubitus position in expiration • S2: • Produced by: Closure of the pulmonary (P2) and aortic valve (A2) • Best heard: P2 à 2nd L parasternal ICS A2 à 2nd R parasternal ICS • Physiologic S2 Splitting: • Narrowing à Expiration • Widening à Inspiration • Pathologic S2 Splitting: • Wide Fixed à Atrial septal defect • Wide à Pulmonary stenosis, Right bundle branch block • Paradoxical à Severe aortic stenosis, Left bundle branch block
Bootcamp.com Cardiology: Cardiac Cycle • S3: • Produced by: Rapid passive ventricular filling (↑ left ventricular volumes) • Best heard: Cardiac apex (bell) Accentuation: Left lateral decubitus position in expiration • Timing: Early diastole, after S2 (gallop) • Physiologic: Young and fit, pregnancy • Pathologic: Heart failure (systolic), mitral regurgitation, aortic regurgitation • S4: • Produced by: Atrial kick (↑ left ventricular pressures) • Best heard: Cardiac apex (bell) Accentuation: Left lateral decubitus position in expiration • Timing: Late diastole, before S1 • Physiologic: Elderly • Pathologic: Heart failure (diastolic), chronic hypertension, aortic stenosis
Bootcamp.com Cardiology: Cardiac Cycle • Isovolumetric Contraction: • Begins after closing of mitral valve (S1) • Highest oxygen consumption • QRS complex on ECG à ventricular depolarization • Ejection: • Begins after opening of the aortic valve • Rapid Ejection: Rising LVP, ↓↓ LV volume • Reduced Ejection: Decreasing LVP https://commons.wikimedia.org/wiki/File:Wiggers_Diagram.svg
Bootcamp.com Cardiology: Cardiac Cycle • Isovolumetric Relaxation: • Begins after closing of aortic valve (S2) • Dicrotic notch • Coronary blood flow peaks • Ventricular Filling: • Begins after opening of the mitral valve • Rapid Fillin • S3: Rapid filling into volume overload LV • Reduced Filling • Atrial Systole: • At conclusion of diastole • S4: Atrial kick into “stiff” ventricle https://commons.wikimedia.org/wiki/File:Wiggers_Diagram.svg
Bootcamp.com Cardiology: Cardiac Cycle • A-wave: • Atrial systole (P wave) • C-wave: • Ventricular contraction • Tricuspid valve protrudes into atrium • X-descent: • Atrial relaxation • V-wave: • Atrial filling à tricuspid valve “back-pressure” • Y-descent: • Ventricular filling • Classic Disorders: • Atrial fibrillation: Absent A-waves (absent P-waves on ECG) • Tricuspid (or Mitral) regurgitation: ↑ V-wave > A-wave • Tamponade: Blunting of Y-descent • Constrictive pericarditis: Increased Y-descent • Atrial contraction against closed tricuspid: “Cannon” A-waves https://commons.wikimedia.org/wiki/File:Wiggers_diagram_with_jugular_venous_waveform.png
Bootcamp.com Cardiology: Cardiac Cycle • Aortic Stenosis: • LVP >> Aortic pressure • Aortic Regurgitation: • ↑ Aortic pressure during systole • ↓ Aortic pressure at the end of diastole • ↑ Pulse pressure (SBP - DBP) • Loss of dicrotic notch • Mitral Stenosis: • LAP > LVP during diastole • Mitral Regurgitation: • Tall V-wave (similar to tricuspid regurgitation) https://commons.wikimedia.org/wiki/File:Wiggers_diagram_with_jugular_venous_waveform.png
≣ Item 1 of 1 Question ID: 0038 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 56-year-old male with a past medical history of alcohol use and withdrawal seizures is brought to the emergency department from a homeless shelter with acute onset confusion, ataxia, and agitation. He is unable to recall the time of his last drink. Blood pressure is 168/68, heart rate is 126/min, respiratory rate is 16/min. On physical examination he appears to have diffuse muscular atrophy and peripheral edema in the distal lower extremities. The patient also appears tremulous and has visible nystagmus on testing of the extraocular muscles. An electrocardiogram is performed showing sinus tachycardia with no evidence of ST-segment elevation or depression. Chest radiography is shown below. Which of the following additional examination findings would be most expected in this patient? ⚪ A. Wide-fixed splitting of S1 heart sounds ⚪ B. Wide-fixed splitting of S2 heart sounds ⚪ C. Prominent S3 heart sound ⚪ D. Prominent S4 heart sound ⚪ E. Paradoxical splitting of S2 heart sounds https://upload.wikimedia.org/wikipedia/commons/7/75/Pulmonary_oedema.jpg
OUTLINE 1. Regulation ● A. Renin ● B. Angiotensin Converting Enzyme ● C. Angiotensin II ● D. Natriuretic Peptides 2. Direct Pharmacologic Targets ● A. Angiotensin Converting Enzyme Inhibitors ● B. Angiotensin Receptor Blockers ● C. Direct Renin Inhibitors ● D. Neprilysin Inhibitors ● E. β1-antagonism Cardiology: Renin- Angiotensin- Aldosterone System
Bootcamp.com Cardiology: RAAS • Renin • Location: Juxtaglomerular apparatus • Stimulus: ↑↑ Renin: β1 stimulation, ↓ pressure in renal artery, ↓ Na to distal tubules (kidney) • Function: Converts Angiotensinogen to Angiotensin I • Angiotensin Converting Enzyme (ACE) • Location: Lungs (primarily) • Function: Angiotensin I converted to Angiotensin II (ATII) by ACE https://en.wikipedia.org/wiki/Juxtaglomerular_apparatus#/media/File:Renal_corpuscle-en.svg
Bootcamp.com Cardiology: RAAS • Actions Angiotensin II: • ↑ Vasoconstriction (↑ TPR) • ↑ Norepinephrine release and availability • ↑ Na reabsorption, ↑ blood volume • Stimulates aldosterone release from zona glomerulosa • Stimulates vasopressin (ADH) release from posterior pituitary https://commons.wikimedia.org/wiki/File:Renin-angiotensin-aldosterone_system.svg
Bootcamp.com Cardiology: RAAS • Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP) • Location: Myocardium • Stimulus: ↑ Atrial and ventricular pressures • Function: ↑ Vasodilation, ↑ Diuresis, inhibition of aldosterone and renin release • Attempts to compensate (temporarily) for ATII in heart failure • Molecular Mechanism: • ↑ cGMP à stimulates vasodilation and diuresis https://commons.wikimedia.org/wiki/File:Renin-angiotensin-aldosterone_system.svg
Bootcamp.com Cardiology: RAAS • ACE Inhibitors (Lisinopril, Captopril, Enalapril, -pril) • Inhibition of ACE à ↑ angiotensin I and renin, ↓ angiotensin II • Use: Hypertension, Nephroprotective effects (Diabetes), Cardioprotective effects (Heart failure) • Adverse Effect: Dry cough, hyperkalemia, angioedema • Angiotensin Receptor Blockers (ARBs) (Valsartan, Losartan, -sartan) • Receptor blockade of angiotensin II type 1 receptor • Use: Hypertension, Nephroprotective effects (Diabetes), Cardioprotective effects (Heart failure) • Direct Renin Inhibitors (Aliskiren) • Inhibition of conversion of angiotensinogen to angiotensin I • Use: Hypertension (not first line) • Neprilysin Inhibitors (Sacubitril) • Neprilysin inactivates ANP, BNP and AT-II • Use: Heart failure when combined with angiotensin-II receptor inhibitor • Selective β1-blockers (Metoprolol, Nebivolol, Esmolol, Atenolol) • Antagonism of β1 receptors at juxtaglomerular apparatus • Use: Coronary artery disease, cardiac arrhythmias (and many more) • Adverse Effect: Bradycardia, bradyarrhythmia (AV nodal block) https://commons.wikimedia.org/wiki/File:Renin-angiotensin-aldosterone_system.svg
≣ Item 1 of 1 Question ID: 0039 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 68-year-old female with a past medical history of osteoarthritis and hyperthyroidism presents to the emergency department with shortness of breath. She states that she has been having palpitations for the past two hours. She reports running out of her thyroid medication five weeks prior and has not yet refilled her prescription. She is later diagnosed with new onset atrial fibrillation with rapid ventricular response. She is initiated on metoprolol for rate control. Which of the following primary changes in chemical mediators will likely occur due to the initiation of this medication? Renin Angiotensin I Angiotensin II Aldosterone ⚪ A. ↑ ↑ ↑ ↑ ⚪ B. ↑ ↑ ↑ ↓ ⚪ C. ↑ ↑ ↓ ↓ ⚪ D. ↑ ↓ ↓ ↓ ⚪ E. ↓ ↓ ↓ ↓
OUTLINE 1. ● A. ● B. ● C. ● D. ● ● ● ● ● 2. ● A. ● B. Cardiology: Exercise Physiology . ● A. ● B.
Bootcamp.com Cardiology: Exercise Physiology • ↑ Preload • Venoconstriction à ↑ Venous return à ↑ LVEDV • Vasoconstriction of splanchnic vessels • Vasodilation at skeletal muscle à ↓ SVR (↓ DBP) à ↓ Afterload • ↑ Contractility • ↓ Afterload • Can be variable depending on dynamic vs static, muscle groups recruited, intensity, ect. • ↑ Heart Rate • ↑ Sympathetic tone (↓ Vagal tone) • ↓ Coronary Perfusion • ↓ Time spent in diastole at high heart rates • ↑ Minute Ventilation • ↑ O2 demand à ↑ RR, ↑TV à ↑ O2 consumption and CO2 production • ↑ Temperature • ↓ Arterial pH • ↑ Lactic acidosis
Bootcamp.com Cardiology: Exercise Physiology • Fick Principle à Cardiac Output = Rate of O2 consumption / Arteriovenous O2 difference • VO2 = Rate of oxygen consumption • Oxygen Extraction Efficiency: • PaO2 relatively normal • PaCO2 relatively normal • Venous O2 decreased • Venous CO2 increased
Bootcamp.com Cardiology: Exercise • General Rules: • Max HR = 220 - Age • Early exercise à HR and SV responsible for ↑ CO • Intense exercise à HR primarily responsible for ↑ CO • Athletic Cardiovascular Physiology: • Max HR not affected by athletic ability • Stroke volume primarily responsible for ↑↑ CO • ↑ VO2 maximum • ↑ RBC mass and plasma volume à ↑ O2 carrying capacity • ↑ Efficiency of skeletal muscle oxygen extraction • ↑ Vascularization of skeletal muscle • ↓ resting heart rate
≣ Item 1 of 1 Question ID: 0040 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 26-year-old female professional cyclist is training for a 143- km bicycle-road race. She is seen by her primary care physician one week prior to the event for a check-up. Vital signs are shown below. Her physical examination is unremarkable. Temperature: 97.2F (36.2C) Blood pressure: 110/62 mmHg Heart rate: 52/min Respiratory rate: 10/min Oxygen saturation: 100% on room air Which of the following is most consistent with the hemoglobin-oxygen dissociation curve of the patient during the upcoming cycling event, assuming the blue curve (A.) is consistent with her baseline at rest? ⚪ A ⚪ B. ⚪ C. ⚪ D. ⚪ E. Hemoglobin O 2 Saturation (%) Arterial Partial Pressure of O2 (mmHg)
OUTLINE 1. ● A. ● B. ● C. ● D. ● E. 2. ● A. ● B. 3. ● A. ● B. ● Cardiology: Cardiac Conductive Physiology . ● A. ● B. ● ●
Bootcamp.com Cardiology: Cardiac Conductive Physiology • Sinoatrial (SA) Node • Site of electrical impulse generation • Pacer rate of 60-100 per minute • Supplied by RCA • Atrioventricular (AV) Node • Delays conduction from SA node • Pacer rate of 45-55 per minute • Supplied by PDA (usually RCA) • Bundle of His • Prevents retrograde electrical conduction • Right Bundle à Right ventricle • Left Bundle à Left ventricle (anterior and posterior) • Purkinje Fibers • Transmits conduction across ventricles https://en.wikipedia.org/wiki/Purkinje_fibers#/media/File:ConductionsystemoftheheartwithouttheHeart-en.svg Cardiac Conduction Velocity Purkinje > Atrial myocytes > Ventricular myocytes > AV node
Bootcamp.com Cardiology: Cardiac Conductive Physiology • Pacemaker Cells • Exhibit automaticity (spontaneous depolarization) • Absence of Phase 1 and 2 • Phase 4 is a slow depolarization phase • Phase 4: Pacemaker Potential • Begins with: ↑ Permeability of inward Na+ (If) current à Slow, spontaneous depolarization • Then: ↑ Permeability T-type and L-type Ca2+ current à Further depolarization • Phase 0: Action Potential Depolarization • Begins when threshold is reached • Na+ current and T-type calcium current decreases • Increased L-type Ca2+ current à Action potential depolarization • Phase 3: Action Potential Repolarization • Outward K+ current à Hyperpolarization • Inward L-type Ca2+ current decreases (inactivation) https://commons.wikimedia.org/wiki/File:2020_SA_Node_Tracing.jpg
Bootcamp.com Cardiology: Cardiac Conductive Physiology • Non-Pacemaker Cells • Do not exhibit automaticity • Phases 0-4 are present • Phase 4 is a resting potential phase (approximates equilibrium potential of potassium) • Phase 4: Resting Membrane Potential • ↑ Permeability of outward K+ current • Fast Na+ channels and L-type Ca2+ channels are closed • Phase 0: Action Potential Depolarization • Begins with depolarization from action potential at adjacent cell • ↑ Permeability of inward fast Na+ current • ↓ Permeability of outward K+ current • Phase 1: Early Repolarization • Transient ↑ permeability of outward K+ current • Rapid closure of fast Na+ channels (inactivation) • Phase 2: Plateau Phase • L-type Ca2+ channels are open and balance K+ efflux • Phase 3: Late Repolarization • Various K+ channels open à ↑↑ permeability outward K+ current • Inactivation of L-type Ca2+ channels https://en.wikipedia.org/wiki/Ventricular_action_potential#/media/File:Action_potential_ventr_myocyte.gif
Bootcamp.com Cardiology: Cardiac Conductive Physiology • Sympathetic Stimulation Effects on Pacemaker Potentials • β1 stimulation à ↑ cAMP à ↑ permeability of inward calcium current à ↑ HR • Parasympathetic Stimulation Effects on Pacemaker Potentials • M2 stimulation à ↓ cAMP à ↓ permeability of inward calcium current à ↓ HR • Sodium Channelopathy: • Impairment of inward fast Na+ current (Phase 0) • Brugada Syndrome: AD, ECG: ST-elevation in V1-V3, pseudo-RBBB • QT Interval Prolongation • Delayed ventricular repolarization • Impairment of voltage-gated potassium channels à delayed rectifier potassium current • May lead to torsade de pointes (“twisting of the peaks”), ventricular tachycardia à sudden cardiac death • Romano-Ward Syndrome: AD, no associated sensorineural hearing loss • Jervell and Lange-Nielsen Syndrome: AR, associated congenital bilateral sensorineural hearing loss • Drug Induced: *see table below* Class Classic Drug Other Drugs/Effects A Antiarrhythmics Quinidine Disopyramide, procainamide, sotalol, dofetilide B Antibiotics Macrolides Fluoroquinolones C Antipsychotics Haloperidol Ziprasidone D Antidepressants Tricyclic antidepressants Methadone E Antiemetics/Electrolytes Ondansetron Hypocalcemia, hypokalemia, hypomagnesemia F Antifungals Azoles https://www.wikidata.org/wiki/Q1625433#/media/File:Tosadesdepointes.jpg https://en.wikipedia.org/wiki/Long_QT_syndrome#/media/File:Long_QT_syndrome_type_1.jpg
≣ Item 1 of 1 Question ID: 0041 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 14-year-old male with a past medical history of mild intermittent asthma presents to the emergency department with a productive cough and mild shortness of breath that started before going to school this morning. His mother reports that he has been nauseous this morning and hasn’t eaten his breakfast. She also states that he has a family history of “bad luck with the heart” on his father’s side. His father is deceased from unknown cause of sudden cardiac death at age 38. The patient is up to date with vaccinations. Vitals are stable and he is saturating 99% on room air. Mild end-expiratory wheezing is auscultated. Laboratory workup is unrevealing. The patient is given a single dose of azithromycin and ondansetron. He is monitored in the emergency room. The patient’s respiratory symptoms improve, and he is prescribed a short-acting inhaled beta-agonist on discharge. Four hours later, the patient returns to the emergency room with his mother for acute worsening of shortness of breath. Electrocardiogram findings from lead II are shown below. Which of the following most likely explains the cause of this patient’s return to the emergency department? ⚪ A. Decreased inward calcium current in pacemaker cells ⚪ B. Decreased inward calcium current in cardiomyocytes ⚪ C. Decreased inward sodium current in cardiomyocytes ⚪ D. Decreased outward potassium current in cardiomyocytes ⚪ E. Increased outward potassium current in pacemaker cells https://commons.wikimedia.org/wiki/File:De-Acquired_longQT_(CardioNetworks_ECGpedia).jpg
OUTLINE 1. ● A. ● B. ● C. ● D. 2. ● A. ● B. ● ● Cardiology: Antiarrhythmics ● A. ● ● . . ● A. ● ● ●
Bootcamp.com Cardiology: Antiarrhythmics Overview • Class I • Three subclasses: Class IA, IB, IC • Blockade of fast Na+ channels • Class II • β-blockers • Delayed atrial ➔ ventricular depolarization • Class III • Blockade of potassium channels • Class IV • Calcium channel blockers • Delayed atrial ➔ ventricular depolarization https://en.wikipedia.org/wiki/Antiarrhythmic_agent#/media/File:Cardiac_action_potential.png
Bootcamp.com Cardiology: Antiarrhythmics • Class IA • Quinidine, Procainamide, Disopyramide • Mechanism: Moderate blockade of fast Na+ channels (Non-pacemaker) • ↑ Action potential duration, ↓ Diastole • Widening of QRS, QT prolongation • Quinidine à Cinchonism • Drug-Induced Lupus à Procainamide • Class IB • Lidocaine, Mexiletine, Phenytoin • Mechanism: Weak blockade of fast Na+ channels (Non-pacemaker) • ↓ Action potential duration, ↑ Diastole • QRS prolongation, shortened QT interval • ↑↑ Efficacy on ischemic Purkinje and ventricular myocardial cells • Class IC • Flecainide, Propafenone • Mechanism: Strong blockade of fast Na+ channels • • • QRS prolongation, no significant change in QT (Exceptions exist) • Flecainide à ↑ Action potential duration • Contraindicated in ischemic heart disease (Proarrhythmic) • • • https://commons.wikimedia.org/wiki/File:Action_potential_Class_Ib.svg https://commons.wikimedia.org/wiki/File:Action_potential_class_Ia.svg https://commons.wikimedia.org/wiki/File:Action_potential_class_Ic.svg
Bootcamp.com Cardiology: Antiarrhythmics • Class II • Metoprolol, Esmolol, Propranolol, Atenolol, Carvedilol • Mechanism: Inhibition of cAMP à ↓ intracellular Ca2+ • Prolonged Phase 4 (Pacemaker) • PR prolongation
Bootcamp.com Cardiology: Antiarrhythmics • Class III • Sotalol, Ibutilide, Dofetilide • Mechanism: Inhibition of K+ channels (delayed rectifier potassium current) • ↑ Action potential duration • QT prolongation à torsades de pointes • Sotalol prolongs PR interval; Ibutilide and Dofetilide do not
Bootcamp.com Cardiology: Antiarrhythmics • Class IV • Verapamil, Diltiazem • Mechanism: Inhibition of L-type Ca2+ channels (Pacemaker) • Prolonged Phase 0 and Phase 4 (Pacemaker) • PR prolongation
Bootcamp.com Cardiology: Antiarrhythmics • Adenosine • Mechanism: Inhibition of L-type Ca2+ channels, ↑ K+ conductance • Prolonged Phase 4 (Pacemaker) • Classic use: Paroxysmal supraventricular tachycardia • Adverse effects: Sense of impending doom, flushing, chest pain • Digoxin • Mechanism: Inhibition of Na+/K+ ATPase à ↑ intracellular Ca2+ • Adverse effects: Blurry, yellow discoloration to vision • Magnesium • Mechanism: ↓ intracellular Ca2+ • Classic use: Torsades, digoxin toxicity • Ivabradine • Mechanism: Inhibition of Na+ slow (funny) channels • Prolonged Phase 4 (Pacemaker) • Adverse effects: Visual luminous phenomenon (↑ visual brightness)
≣ Item 1 of 1 Question ID: 0043 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 38-year-old male with a past medical history of hypertension, mild intermittent asthma, and a recent diagnosis of pre-excitation cardiac conduction abnormalities, presents to his primary care physician for a fixed erythematous rash over the malar eminences with sparing of the nasolabial folds. He reports that the rash started after a long afternoon at the beach. He denies any pruritis or drainage from the lesion. He also reports feeling a dull, soreness in the deltoid region bilaterally. On physical exam multiple painless ulcers are noted along the oral mucosa. After a thorough review of the patient’s medications, a laboratory workup is performed and shown below. Leukocyte count: 10,800/mm3 Hemoglobin: 13.7 g/dL Platelet count: 165,000/mm3 Sodium: 136 mEq/L Potassium: 4.4 mEq/L Chloride: 102 mEq/L Creatinine: 1.6 mg/dL Antinuclear (ANA) antibody: Positive for elevation in ANA titer Anti-double-stranded DNA antibody: Negative Antihistone antibody: Positive Anti-smith antibody: Negative Anti-Ro antibody: Negative ⚪ A. Increased potassium conductance ⚪ B. Decreased action potential duration ⚪ C. Increased action potential duration ⚪ D. Increased vagal nerve output to the atrioventricular node ⚪ E. Inhibition of L-type calcium channel conductance Which of the following changes to the electrical conductivity is most likely occurring in ventricular cardiomyocytes as a result of iatrogenic causes in this patient?
OUTLINE 1. Atrial Fibrillation ● A. Pathophysiology ● B. Presentation ● C. Precipitating Factors ● D. Complications ● E. Rate Control ● F. Rhythm Control ● G. Catheter Ablation ● H. Anticoagulation ● I. Hemodynamics in Heart Failure ● J. Jugular Venous Pressure Tracing ● K. ECG Findings 2. Atrial Flutter ● A. Pathophysiology ● B. Presentation ● C. Precipitating Factors ● D. Management ● E. ECG Findings 3. Sick Sinus Syndrome ● A. Pathophysiology ● B. Presentation ● C. Association ● D. Management Cardiology: Atrial Arrhythmias
Bootcamp.com Cardiology: Atrial Arrhythmias • Pathophysiology: • Automatic foci in vicinity of pulmonary veins à structural fibrotic remodeling of atria à ↑ risk of occurrence • Rapid uncoordinated atrial contractions à AV node intermittently refractory à Rapid ventricular response • Presentation: • Irregularly irregular rhythm, absence of P waves • Palpitations • Tachycardia • Shortness of breath, dizziness, palpitations • Precipitating Factors: • Cardiovascular disease (Coronary artery disease, hypertension, heart failure) • Hyperthyroidism • Mitral stenosis • ↑ Sympathetic tone (cocaine, amphetamines, EtOH) • Complications: • Embolic phenomena à left atrial appendage • Pulmonary edema • Ventricular tachycardia https://commons.wikimedia.org/wiki/File:Heart_conduct_atrialfib.gif https://commons.wikimedia.org/wiki/File:Heart_conduct_sinus.gif https://commons.wikimedia.org/wiki/File:Afib_ecg.jpg
Bootcamp.com • Rate Control: • β-blockers and CCBs: Preferred first-line • Digoxin: Second-line, useful in systolic dysfunction • Rhythm Control: • Class IC Antiarrhythmics (Flecainide, propafenone) • Class III Antiarrhythmics (Ibutilide, sotalol) • Amiodarone • Catheter Ablation: • Symptomatic paroxysmal atrial fibrillation à ablation at pulmonary vein ostia (left atrium) • Persistent atrial fibrillation with RVR à ablation can be at other sites like AV node (right atrium) • Amiodarone • Anticoagulation • Hemodynamics in Heart Failure • Left atrial dilatation • ↓ LV Preload à ↓ CO • ↑ PCWP • Pulmonary edema • Jugular Venous Pressure Tracing • Loss of a waves https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg Cardiology: Atrial Arrhythmias
Bootcamp.com https://commons.wikimedia.org/wiki/File:ECG_Atrial_Fibrillation.jpg Absence of P waves Irregularly irregular (varying R-R intervals) Narrow QRS complexes Cardiology: Atrial Arrhythmias
Bootcamp.com • Pathophysiology: • Re-entry circuit in right atrium (most common) • Presentation: • Sawtooth appearance of P waves • Generally, regular rhythm (exceptions exist) • 2:1 conduction is most common • Tachycardia is common • Shortness of breath, dizziness, palpitations • Precipitating Factors: • Similar to atrial fibrillation • Management: • Rhythm control, rate control • Catheter ablation of re-entrant circuit (right atrium) https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg Cardiology: Atrial Arrhythmias
Bootcamp.com • Pathophysiology: • Fibrosis and degeneration of the SA node (usually age-related) • Iatrogenic (β-blockers, CCBs, Digoxin) • Presentation: • Bradycardia, delayed P waves, dropped P waves • Junctional escape beats • Syncope, fatigue, shortness of breath • HR doesn’t increase as expected with exercise • Tachycardia-Bradycardia Syndrome • Association: • Elderly • Management: • Iatrogenic: Stop offending medications as necessary • Asymptomatic: Conservative • Acute (Unstable) Symptomatic: Atropine à Temporary cardiac pacing • Long Term (Stable) Symptomatic: Permeant Pacemaker placement, selective β-blockers Cardiology: Atrial Arrhythmias https://commons.wikimedia.org/wiki/File:Brady-tachy_syndrome_AV-junctional_rhythm.png
≣ Item 1 of 1 Question ID: 0043 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 46-year-old male with a past medical history of cocaine and alcohol use presents to the emergency room for palpitations. He states that he went out on a “binge” prior to arrival. His last drink was reported to have been five minutes prior to walking into the emergency department. An ECG strip is shown below. Which of the following is most likely directly related to the heart rate observed in this patient? ⚪ A. Accessory pathway bypassing the atrioventricular node ⚪ B. Pacing initiation triggered at the atrioventricular node ⚪ C. Complete conduction through the atrioventricular node ⚪ D. Intermittent conduction through the atrioventricular node ⚪ E. Negligible conduction through the atrioventricular node https://commons.wikimedia.org/wiki/File:Atrial_Fibrillation_in_two_leads.jpg
OUTLINE 1. Supraventricular Tachycardia ● A. Pathophysiology ● B. Presentation ● C. ECG Findings ● D. Management 2. Wolff-Parkinson-White Syndrome ● A. Pathophysiology ● B. ECG in Sinus WPW ● C. ECG in AVRT WPW ● D. Presentation ● E. Management ● F. Complications 3. Torsades De Pointes ● A. Pathophysiology ● B. Causes ● C. ECG Findings ● D. Management ● E. Complications 4. Monomorphic Ventricular Tachycardia ● A. Pathophysiology ● B. Causes ● C. ECG Findings 5. Ventricular Fibrillation ● A. Pathophysiology ● B. Causes ● C. ECG Findings Cardiology: Ventricular Arrhythmias and Pre-Excitation Syndromes
Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Re-entrant pathway within the AV node, accessory pathway, or SA node • Most common = Atrioventricular nodal re-entrant tachycardia (AVNRT) • Second most common = Atrioventricular re-entrant tachycardia (AVRT) • Presentation: • Young patient, no significant cardiac history • Abrupt onset, chest pain, dyspnea, palpitations • ECG Findings: • Narrow QRS (< 3 little boxes) tachycardia • Heart rate usually >150 beats per minute • P wave may be buried within the QRS complex • Management (Stable): • Vagal maneuvers (Carotid sinus massage) • Adenosine • CCBs, β-blockers • Management (Unstable): • Electrical cardioversion (Immediate) • Catheter ablation of re-entry pathway (Definitive) https://commons.wikimedia.org/wiki/File:SVT_Lead_II-2.JPG SVT AVRT AVNRT Atrial T.
Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Sinus: Accessory pathway (Bundle of Kent) à bypass AV node (anterograde through bundle of Kent) • Orthodromic AVRT: Re-entrant circuit (anterograde through AV node, retrograde through bundle of Kent) • Antidromic AVRT: Re-entrant circuit (anterograde through bundle of Kent, retrograde through AV node) • ECG in Sinus WPW: • Shortened PR interval • Early, “slurred” upstroke of QRS (delta wave) • Wide QRS • ECG in AVRT WPW: • Narrow QRS • P wave follows QRS (usually) • Presentation: • Sinus: Generally asymptomatic • AVRT: Generally symptomatic • Management (Stable): • Procainamide à ideal for antidromic AVRT • Adenosine, CCB à ideal for orthodromic AVRT • Management (Unstable): • Electrical cardioversion • Catheter ablation (definitive) • Complications: • AV nodal blocking agents and vagal maneuvers à ventricular tachycardia or ventricular fibrillation (unrestricted transmission) https://commons.wikimedia.org/wiki/File:SVT_Lead_II-2.JPG
Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Prolonged action potential in cardiomyocytes à Prolonged QT interval à ↑ risk of TdP • Causes: • Congenital Long QT Syndrome (usually younger patient) • ECG Findings: • Polymorphic ventricular tachycardia (“twisting of the peaks” pattern) • Irregularly irregular rhythm • Sinusoidal change in amplitude of QRS complexes • Management: • Intravenous magnesium • Avoid QT-prolonging medications during acute TdP • Complication: • Ventricular fibrillation or sudden cardiac death Class Classic Drug Other Drugs/Effects A Antiarrhythmics Quinidine Disopyramide, procainamide, sotalol, dofetilide B Antibiotics Macrolides Fluoroquinolones C Antipsychotics Haloperidol Ziprasidone D Antidepressants Tricyclic antidepressants Methadone E Antiemetics/Electrolytes Ondansetron Hypocalcemia, hypokalemia, hypomagnesemia F Antifungals Azoles https://commons.wikimedia.org/wiki/File:Tosadesdepointes.jpg
Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Aberrant ventricular foci • Intraventricular re-entry circuit • Causes: • Ischemic and/or structural heart disease • Complication of acute MI • Electrolyte disturbances (hypokalemia, hypomagnesemia) • Acidosis, hypoxemia • ECG Findings: • Wide QRS (≥3 little boxes) monomorphic tachycardia • Typically, regular rhythm • Poorly discernible P or T waves at high rates • Heart rates of 100-300 beats per minute • Pathophysiology: • Uncoordinated ventricular depolarization • Causes: Similar to Ventricular Tachycardia • Association: Cardiac arrest • ECG Findings: • Wide QRS (≥3 little boxes) tachycardia • Heart rates of 100-300 beats per minute • Complication: • Sudden cardiac death (rapid) https://commons.wikimedia.org/wiki/File:Lead_II_rhythm_ventricular_tachycardia_Vtach_VT_(cropped).JPG https://commons.wikimedia.org/wiki/File:Ventricular_fibrillation.png Ventricular arrhythmias are common in the first 24-48 hours after MI
≣ Item 1 of 1 Question ID: 0043 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪✪ Bootcamp.com A 28-year-old female with a past medical history of alcohol use presents to the emergency department with palpitations and tremors. She denies any chest pain or nausea. The patient states that she recently started using cocaine approximately two months prior. ECG reveals an irregularly irregular rhythm with an erratic baseline, absent P-waves, and an approximate heart rate of 140/min. An intravenous drug is administered. The patient reports becoming very anxious after the drug is given. A cardiac monitoring rhythm strip taken after the patient received the intravenous drug is also shown. The patient subsequently loses consciousness and acute resuscitative measures are initiated. Which of the following intravenous medications were most likely given to this patient? ⚪ A. Diltiazem ⚪ B. Procainamide ⚪ C. Quinidine ⚪ D. Amiodarone ⚪ E. Ibutilide https://commons.wikimedia.org/wiki/File:Ventricular_fibrillation.png
OUTLINE 1. Atrioventricular Blocks ● A. First Degree ● B. Second Degree, Mobitz Type I (Wenckebach) ● C. Second Degree, Mobitz Type II ● D. Third Degree 2. Bundle Branch Blocks ● A. Right Bundle Branch Blocks ● B. Left Bundle Branch Blocks 3. Cardiac Conduction Blood Supply ● A. Right Coronary Artery ● B. Left Anterior Descending Artery Cardiology: Conduction Blocks
Bootcamp.com Cardiology: Conduction Blocks • First Degree: • PR interval >5 little boxes (200ms) • Unchanged P-P intervals • Regular rhythm • Low risk block à Generally conservative management • Second Degree, Mobitz Type I (Wenckebach): • Progressive lengthening of PR interval until QRS is dropped • Regularly irregular rhythm • Low risk block à Generally conservative management • Second Degree, Mobitz Type II: • Intermittent non-conducted P-waves à dropped QRS • Unchanged P-P intervals • Regularly irregular rhythm • Medium-High risk block à Review medications, pacemaker • Third Degree: • Complete AV dissociation (between QRS and P waves) • High risk block à Review medications, pacemaker High Yield Causes: Ischemic heart disease Hyperkalemia Lyme Disease Endocarditis/ARF Iatrogenic AV Nodal Blocking Agents Calcium Channel Blockers β-blockers Adenosine Digoxin Asymptomatic Symptomatic https://en.wikipedia.org/wiki/Heart_block
Bootcamp.com Cardiology: Atrioventricular Blocks • Right Bundle Branch Block (RBBB): • Classic causes: Pulmonary embolus, right heart strain, ischemic heart disease • Pseudo-RBBB in Brugada (with ST-elevation in V1-V3) • ”M” shape, “rabbit ears” (Focus on V1) • Slurring of S-wave (Focus on V6) • Left Bundle Branch Block (LBBB): • Classic causes: AS, AR, Lyme disease, dilated cardiomyopathy, ischemic heart disease • Lack of R waves (Focus on V1) • Notched R waves (Focus on V6) https://commons.wikimedia.org/wiki/File:ConductionsystemoftheheartwithouttheHeart-en.svg https://commons.wikimedia.org/wiki/File:Cardiogram_indicating_right_bundle_branch_block.jpg https://commons.wikimedia.org/wiki/File:Right_bundle_branch_block_ECG_characteristics.svg https://commons.wikimedia.org/wiki/File:Left_bundle_branch_block_ECG_characteristics.svg
Bootcamp.com Cardiology: Atrioventricular Blocks • Right Coronary Artery: • SA node • AV node (usually) • Bundle of His (major) • Proximal right bundle branch • Left Anterior Descending Artery: • Bundle of His (minor) • Complete left bundle branch • Distal right bundle branch
≣ Item 1 of 1 Question ID: 0045 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪✪ Bootcamp.com A 14-year-old male presents to his pediatrician with his father for shortness of breath and fatigue. He has no significant past medical history although his father has a history of asthma. His father denies any family history of heart disease or sudden cardiac death. The patient states that he has felt “winded” with activity over the past week. According to his father, the shortness of breath became particularly bothersome during football practice. The patient also reports a mild erythematous rash on his forearm that had resolved within three days. The rash was first noticed two weeks earlier when on a hiking trip with family. The patient denies any chest pain, nausea, and diarrhea. Vital signs are shown below. An ECG performed in-office is also shown. ⚪ A. Inhaled short-acting β-agonist ⚪ B. Transient hyperpolarization of cardiac nodal cells ⚪ C. Inhibition of Na+/K+ ATPase in myocardial cells ⚪ D. Inhibition of cardiac L-type calcium channels ⚪ E. Irreversible inhibition of bacterial cell wall synthesis https://commons.wikimedia.org/wiki/File:Complete_A-V_block_with_resulting_junctional_escape.png Temperature: 99.7F (37.6C) Heart rate: 30/min Blood pressure: 74/44 Respiratory rate: 18/min Oxygen saturation: 94% on room air A drug with which mechanism of action would most likely improve this patient’s condition?
OUTLINE 1. Heart Failure Overview ● A. Heart Failure Variants of Disease ● B. Heart Failure Location (Left vs Right) ● C. Heart Failure Presentation 2. Systolic Heart Failure ● A. Causes ● B. Pathophysiology 3. Diastolic Heart Failure ● A. Causes ● B. Pathophysiology 4. High and Low Output Heart Failure ● A. Classic Causes 5. Pharmacologic Targets ● A. ACE Inhibitors, ARBs ● B. Mineralocorticoid Receptor Antagonists ● C. β-blockers ● D. Neprilysin Inhibitors ● E. Loop Diuretics ● F. Thiazine Diuretics ● G. Digoxin Cardiology: Heart Failure
Bootcamp.com Cardiology: Heart Failure • Systolic: • Heart failure with reduced ejection fraction (HFrEF) • Principal determinant: ↓ Contractility à ↑↑↑ Volume • Diastolic: • Heart failure with preserved ejection fraction (HFpEF) • Principal determinant: ↑↑↑ Pressure à ↓ Compliance • High-Output • Low-Output https://en.wikipedia.org/wiki/Heart_block Heart Failure Variant Heart Failure Location • Left: • ↑ LAP (PCWP) • Pulmonary edema • Pleural effusion • Functional mitral valve regurgitation • Right: • MCC à Left heart failure • If not from left heart failure, unlikely pulmonary edema • Hypoxic pulmonary vasoconstriction (Pulmonary HTN) • Left parasternal lift • Jugular venous distention • Peripheral edema • Hepatomegaly (Nutmeg liver) • Ascites • Functional tricuspid valve regurgitation
Bootcamp.com Cardiology: Heart Failure • Subjective: • Dyspnea with activity (or at rest in severe stages) • Orthopnea • Paroxysmal nocturnal dyspnea • Objective • Jugular venous distention • Pulmonary crackles • Reduced Lung Sounds • Shifted PMI (LVH) • Left parasternal lift (RVH) • S3 heart sound • S4 heart sound à classic for diastolic HF • ↑↑↑ BNP https://commons.wikimedia.org/wiki/File:Normal_posteroanterior_(PA)_chest_radiograph_(X-ray).jpg https://commons.wikimedia.org/wiki/File:Pulmonaryedema09.JPG https://commons.wikimedia.org/wiki/File:Combinpedal.jpg
Bootcamp.com Cardiology: Heart Failure • Overview: • Heart failure with reduced ejection fraction (HFrEF) • Principal determinant: ↓ Contractility à ↑↑↑ Volume • Causes: • Ischemic heart disease • Viral myocarditis • Chronic Alcohol Use • Pathophysiology: • ↓ Contractility (↓ EF) à ↓ CO à ↑ LVEDP • Eccentric hypertrophy: ↑ Contractile proteins added in series • ↑ Compliance, ↓ CO, ↓ EF https://en.wikipedia.org/wiki/Heart_block
Bootcamp.com Cardiology: Heart Failure • Overview: • Heart failure with preserved ejection fraction (HFpEF) • Principal determinant: ↑↑↑ Pressure à ↓ Compliance • Causes: • Prolonged hypertension • Aortic stenosis • Infiltrative disorders • Pathophysiology: • ↑ LVP à ↑ Contractility • Concentric hypertrophy: ↑ Contractile proteins added in parallel • ↓ Compliance, ↓ CO, normal EF • Additional Clinical Features: • S4 (due to stiff ventricle) https://en.wikipedia.org/wiki/Heart_block
Bootcamp.com Cardiology: Heart Failure • Classic Causes: • Thiamine deficiency • Severe anemia • Hyperthyroidism • Arteriovenous fistula https://en.wikipedia.org/wiki/Heart_block • Classic Cause: • Cardiogenic shock
Bootcamp.com Cardiology: Heart Failure • ACE Inhibitors (Lisinopril, Captopril, Enalapril, -pril) • Inhibition of ACE à ↓ angiotensin II • Adverse Effect: Dry cough, hyperkalemia, angioedema • Angiotensin Receptor Blockers (ARBs) (Valsartan, Losartan, -sartan) • Receptor blockade of angiotensin II type 1 receptor • Mineralocorticoid receptor Antagonists (Spironolactone, Eplerenone) • β-blockers (Metoprolol, Carvedilol) • Neprilysin Inhibitors (Sacubitril): • Neprilysin is a metalloproteinase that inactivates ANP, BNP, and AT-II • ↑ ANP, ↑ BNP, ↑ AT-II • Used with angiotensin-II receptor blocker • Loop Diuretic (Furosemide): • Inhibition of Na/K/Cl transporter in ascending limb of loop of Henle • Primary use: Fluid retention and pulmonary edema • Thiazide Diuretic (Metolazone): • Inhibition of Na/Cl transporter in distal tubule • Potentiation of loop diuretic effect • Digoxin: • Inhibition of Na+/K+-ATPase in myocytes • ↑ Vagal activity to nodal cells • ↑ intracellular calcium concentration in ventricular myocytes • Toxicity: Disturbed color perception, GI symptoms, arrhythmias • Precipitated by hypokalemia https://en.wikipedia.org/wiki/Heart_block
≣ Item 1 of 1 Question ID: 0046 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 57-year-old obese female with a past medical history of type II diabetes mellitus, dyslipidemia, chronic hypertension, and coronary artery bypass grafting performed 7 years earlier presents to the emergency department for shortness of breath. She denies any tobacco use and states that she has a glass of wine on rare occasion. She states that she was having difficulty sleeping through the night because she is running to the bathroom every few hours to void. She reports throwing away her ”water pills” last week due to frustration. Blood pressure is 164/88mmHg, heart rate 88/min, respiratory rate 14/min, saturating 94% on 2 liters of oxygen by nasal cannula. Physical exam reveals diffuse crackles bilaterally in the lung fields, an S3 heart sound, and 2+ pitting edema in the bilateral lower extremities. Chest X-ray is shown below. ECG reveals a normal sinus rhythm with mild left ventricular hypertrophy. Thyroid stimulating hormone levels are within normal limits. B-type natriuretic peptide level is significantly elevated. Patient had an echocardiogram performed three months earlier revealing a left ventricular ejection fraction of 30%. ⚪ A. Depressed pulmonary capillary wedge pressure ⚪ B. Depressed central venous pressure ⚪ C. Elevated cardiac index ⚪ D. Increased urinary potassium excretion ⚪ E. Significantly decreased serum levels of vitamin B1 Which of the following findings are most consistent with this patient’s acute presentation? https://radiopaedia.org/articles/heart-failure-summary?lang=us
OUTLINE 1. Cardiomyopathy Overview ● A. Major Types of Cardiomyopathy ● B. Cardiac Myocyte Histology 2. Dilated Cardiomyopathy ● A. Pathophysiology ● B. Systolic Heart Failure ● B. Other Classic Causes 3. Restrictive Cardiomyopathy ● A. Pathophysiology ● B. Infiltrative Disease ● C. Diastolic Heart Failure 4. Hypertrophic Obstructive Cardiomyopathy ● A. Pathophysiology ● B. Classic Causes ● C. Histopathology ● D. Management 5. Viral Myocarditis 6. Chagas Disease 7. Takotsubo Cardiomyopathy 8. Amyloid Cardiomyopathy 9. Aging of Cardiomyocytes 10. Other Causes of Cardiomyopathy Cardiology: Cardiomyopathy
Bootcamp.com Cardiology: Cardiomyopathy • Dilated Cardiomyopathy: • Association with Systolic HF • Restrictive Cardiomyopathy: • Association with Diastolic HF • Hypertrophic Obstructive Cardiomyopathy • Normal contractility • ↓ Ventricular cavity size • Impaired diastolic function • Septal hypertrophy • Histology of Cardiomyocytes: • Central appearing nuclei • Striation's present • Branching cardiomyocytes https://commons.wikimedia.org/wiki/File:414c_Cardiacmuscle.jpg https://commons.wikimedia.org/wiki/File:Blausen_0470_HeartWall.png https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png
Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology Systolic Heart Failure: • Eccentric hypertrophy • ↑ Contractile proteins added in series • ↑ LV mass, ↑ LV cavity, ↓ LV EF, Normal LV relaxation • Highest Yield Causes: • Systolic heart failure • Viral myocarditis • Chaga’s Disease • Takotsubo • Additional Causes: • Familial (AD, truncating mutation of TTN gene) • Pregnancy • Anthracyclines (doxorubicin) • Excess alcohol use • Selenium deficiency https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png
Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology Diastolic Heart Failure: • Concentric hypertrophy • ↑ Contractile proteins added in parallel • ↑ LV mass, ↓ LV cavity, Normal/↓ LV EF, ↓ LV relaxation • Pathophysiology Restrictive Cardiomyopathy: • Stiffened ventricular walls, not typically thickened (exceptions exist: Amyloidosis) • Normal LV mass, Normal or ↓ LV cavity, Normal LV EF, ↓ LV relaxation • Highest Yield Causes: • Diastolic heart failure à Prolonged hypertension, Aortic stenosis • Infiltrative disorders à Amyloidosis, hemochromatosis, sarcoidosis • Radiation-induced • Infiltrative Disease Considerations: • Variable ventricular wall thickness (vs hypertensive secondary cause) • Prominent y-descent • Conduction abnormalities https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png
Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Genetic mutations of cardiac sarcomere à • β-myosin heavy chain and myosin-binding protein C • Autosomal dominant (most cases) • Dynamic LV outflow tract obstruction (↑ LV septal thickness) • ↑ LV mass, ↓ LV cavity, Normal/↑ LV EF, ↓ LV relaxation • Classic Case: • Generally asymptomatic until strenuous exercise • Sudden cardiac death, young patient • Systolic crescendo-decrescendo murmur at LLSB +/- holosystolic murmur at apex • Valsalva à ↓ LV blood volume à Worsen obstruction à ↑ ejection murmur • Passive leg raise à ↑ LV blood volume à Improve obstruction à ↓ ejection murmur • S4 heart sound • Histopathology: • Myofibrillary disarray and interstitial fibrosis • Mitral Valve: • Anterior mitral leaflet in closer proximity to aortic valve • Distorted mitral valve à ejection against valve à functional mitral regurgitation • Management: • Avoid dehydration and strenuous exercise • β-blockers https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png https://commons.wikimedia.org/wiki/File:HCM%EF%BC%BFHE.jpg
Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Direct viral-induced cytotoxic effect to myocardial cells • Dilated cardiomyopathy (usually) • Etiology: • Coxsackievirus • Adenovirus • Influenza virus • Classic Case: • Young patient + viral prodrome • Histopathology: • Irregular banding patterns, less nuclei observed • Inflammatory infiltration with lymphocytes • Primary Cardiomyopathy Subtype: • Dilated cardiomyopathy https://en.wikipedia.org/wiki/Heart_block
Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Direct parasitic-induced cytotoxic effects • Etiology: • Trypanosoma cruzi (Reduviid family) • Classic Case: • Central and South America • Histopathology: • Protozoa peripheral to myocytes • Inflammatory infiltration with lymphocytes • Primary Cardiomyopathy Subtype: • Localized apical wall thinning and/or aneurysm • ↑ risk of mural thrombus and/or emboli • Dilated cardiomyopathy • Other Features: • Megaesophagus • Megacolon https://en.wikipedia.org/wiki/Heart_block https://www.wikidoc.org/index.php/File:Heart_in_Chagas_disease_4.jpg
Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Catecholamine surge à impaired kinetic activity of left ventricle • Etiology: • Emotional stress is classic • Classic Case: • Death of a loved one • Postmenopausal female • Primary Cardiomyopathy Subtype: • Ballooning of left ventricle • Dilated cardiomyopathy https://en.wikipedia.org/wiki/Heart_block
Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • ↑ Extracellular deposition of amyloidogenic proteins • Transthyretin (ATTR) • Light chain (AL) • Histopathology: • Pink amorphous material surrounding cardiomyocytes • Apple-green birefringence with polarized light and Congo red stain • Primary Cardiomyopathy Subtype: • Restrictive cardiomyopathy (Ventricular wall thickening) • Other Features of Amyloidosis: • Nephrotic syndrome • Hepatomegaly https://commons.wikimedia.org/wiki/File:Cardiac_amyloidosis_high_mag_he.jpg https://www.flickr.com/photos/euthman/377559955/ licensed under CC BY-SA 2.0
Bootcamp.com Cardiology: Cardiomyopathy • Gross Anatomical Changes: • Sigmoidal shape of ventricular septum • Histopathology: • Myofibrillary disarray and interstitial fibrosis • ↑ Lipofuscin pigment • ↑ Connective tissue https://commons.wikimedia.org/wiki/File:Cardiac_myocyte_showing_lipofuscin_pigment.jpg
Bootcamp.com Cardiology: Cardiomyopathy • Hemochromatosis: • ↑ Extracellular deposition of iron • Prussian blue stain (stains iron blue-black) • Peripartum/Postpartum: • Dysfunctional angiogenic growth factors • Third trimester peripartum female – postpartum female • Anthracycline-Induced • Anthracyclines: Daunorubicin, doxorubicin • Binds with topoisomerase II à cleaves DNA in cancer cells • ↑ with cumulative dose • Prevent with dexrazoxane • Trastuzumab-Cardiotoxicity • Monoclonal antibody binding to human epidermal growth factor receptor-2 (HER2) • Does not change with cumulative dose • Tends to be reversible
≣ Item 1 of 1 Question ID: 0047 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 17-year-old male presents to the emergency room for 8/10 chest pain that began during a soccer practice a few hours earlier. He states that he has experienced chest discomfort and shortness of breath in the past with sports activity and had previously been diagnosed with asthma 3 years earlier. He states that he finds little improvement in his symptoms when using his albuterol inhaler. He denies any other past medical or surgical history. He states that his father and first cousin are both deceased from “heart problems” in their early thirties. He states that he vapes occasionally and denies any other substance use. Blood pressure is 108/58 mmHg, heart rate is 76/min and regular, oxygen saturation is 99% on room air. The point of maximal impulse appears to be modestly shifted laterally beyond the midclavicular line. A 2/6 crescendo-decrescendo systolic murmur is auscultated at the lower left sternal border. The murmur is accentuated with standing. Pulmonary auscultation reveals clear lung sounds bilaterally with no wheezing observed. ECG reveals a regular rhythm with left axis deviation and deep Q waves in leads I, II, III, aVF and V5-V6 are observed. A transthoracic echocardiogram and cardiac MRI are performed. The patient is subsequently prescribed a medication and restricted from further sports activity on discharge. Which of the following mechanisms of action would most likely be consistent with the medication given? ⚪ A. Activation of β1-receptors in myocardial cells ⚪ B. Activation of guanylyl cyclase at venous and coronary vessels ⚪ C. Inhibition of Na+/K+ ATPase in myocardial cells ⚪ D. Inhibition of phosphodiesterase-5 enzymes in vascular smooth muscle ⚪ E. Inhibition of Na+/K+/Cl- co-transporters in the loop of Henle ⚪ F. Non-selective inhibition of β-receptors systemically
OUTLINE 1. Anatomical Considerations ● A. Aorta ● B. Vessel Wall Layers 2. Aortic Dissection ● A. Pathophysiology ● B. Etiology ● C. Presentation ● D. Stanford Classification ● E. Complications ● F. Imaging ● G. Management 3. Aortic Aneurysm ● A. Thoracic vs Abdominal ● B. Pathophysiology ● C. Risk Factors ● D. Presentation ● E. Preventative Management 4. Cardiac Considerations of Marfan Syndrome ● A. Pathophysiology ● B. Cystic Medial Degeneration ● C. Mitral Valve Prolapse ● D. Other Findings 5. Aortic Coarctation ● A. Pathophysiology ● B. Associations ● C. Presentation ● D. Management Cardiology: Aortic Disease
Bootcamp.com Cardiology: Aortic Disease • Aorta: • Ascending: Proximal to brachiocephalic artery • Arch of aorta: Between ascending and descending • Descending: Distal to left subclavian artery • Vessel Wall Layers: • Luminal: Tunica intima • Middle: Tunica media • Peripheral: Tunica adventitia (externa) https://radiopaedia.org/cases/normal-cta-chest https://commons.wikimedia.org/wiki/File:Gray506.svg Aortic Isthmus: -Traumatic aortic rupture -Coarctation
Bootcamp.com Cardiology: Aortic Disease • Pathophysiology: • Tear through intima and media à propagation of dissection through media • Etiology: • Acquired: Hypertension (#1), trauma, aortic vasculitis • Connective Tissue Disease: Marfan syndrome, Ehlers-Danlos syndrome • Structural Disease: Coarctation of aorta, Bicuspid aortic valve • Presentation: • Severe, acute “tearing” retrosternal chest +/- radiating back pain • Asymmetric blood pressure and pulse discrepancies • Stanford A: • Location: Ascending aorta and/or descending aorta • Classic origin: Sinotubular junction • Surgical management (usually) • Stanford B: • Location: Descending aorta • Classic origin: Left subclavian artery • Medical management (usually) • Complications: • Aortic rupture • Aortic regurgitation • Cardiac tamponade • Ischemia https://commons.wikimedia.org/wiki/File:Aortic_dissection_types.jpg https://commons.wikimedia.org/wiki/File:Aortic_dissection_(1)_Victoria_blue-HE.jpg
Bootcamp.com Cardiology: Aortic Disease • Imaging: • CXR: Widened mediastinum • CT Angiography (Gold standard): Intimal flap • Transesophageal echocardiogram (TEE) for unstable or renal insufficiency • Management: • Stanford A à Surgery • Stanford B à β-blocker then vasodilator https://commons.wikimedia.org/wiki/File:AoDiss_ChestXRay.jpg https://commons.wikimedia.org/wiki/File:Descending_(Type_B_Stanford)_Aortic_Dissection.PNG https://commons.wikimedia.org/wiki/File:DissectionCT.png
Bootcamp.com Cardiology: Aortic Disease • Pathophysiology: • Transmural inflammation à dilation of intima, media, and adventitia • General Risk Factors: • Smoking • Atherosclerosis • Old age • Connective tissue disease • Tertiary Syphilis • Classic Presentation: • Generally asymptomatic until rupture • Presentation in Rupture: • Acute onset, severe tearing/ripping abdominal/back pain • Severe chest/abdominal pain • Hypotension • Preventative: • Abdominal ultrasound screening in men aged 65-75 who have ever smoked (USPSTF) Aortic Aneurysms Thoracic Abdominal Primary Risk Factor Hypertension Smoking Additional Important Risk Factors Tertiary syphilis Bicuspid aortic valve Connective tissue disease Atherosclerosis Classic Symptoms Chest pain Mid (thoracic) back pain Hoarseness Dysphagia Low back pain Abdominal bruit Pulsatile abdominal mass Other CXR: Widened mediastinum Ascending aorta (classic location) Abdominal U/S Infrarenal (classic location) https://commons.wikimedia.org/wiki/File:AneurysmT.PNG https://commons.wikimedia.org/wiki/File:Thoracic_Aortic_Aneurysm.png
Bootcamp.com Cardiology: Aortic Disease • Pathophysiology: • Defect in fibrillin-1 • Autosomal dominant • Cystic Medial Degeneration of Aorta: • Aortic aneurysmà Aortic root dilation (thoracic) à Aortic regurgitation and/or dissection • Aortic dissection à most common cause of death • Histopathology: Amorphous extracellular deposition into medial wall • Mitral Valve Prolapse: • Mid-systolic click at apex • Other Findings: • Tall stature, long extremities • Joint hypermobility • Ectopia lentis, upward lens dislocation • Pectus deformity à carinatum, excavatum • Kyphosis, scoliosis • Arachnodactyly https://www.researchgate.net/figure/Pathologic-finding-of-excised-aortic-tissue-A-cystic-medial-necrosis-which-is- defined_fig4_221683474 https://creativecommons.org/licenses/by-nc/3.0/
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Bootcamp.com Cardiology.pdf

  • 1.
  • 2.
  • 3. OUTLINE 1. Embryologic Derivatives 2. Truncus Arteriosus ● A. Physiologic ● B. Persistent Truncus Arteriosus ● C. Transposition of Great Vessels 3. Atrial Septation ● A. Mechanism ● B. Patent Foramen Ovale ● C. Atrial Septal Defect 4. Aortic Arch Derivatives and Pharyngeal Arches Cardiology: Embryology
  • 4. Bootcamp.com Cardiology: Embryology • Sinus venosus à Coronary sinus, posterior portion of right atrium • Common cardinal veins à Superior vena cava • Umbilical vein à Ligamentum teres hepatis • Vitelline veins à Portal circulation and mesenteric veins • Truncus arteriosus à Ascending aorta and pulmonary trunk • Left and right dorsal aorta à Descending aorta • Primitive ventricle à Trabeculated portion of right and left ventricle • Primitive atria à Trabeculated portion of right and left atria • Bulbus cordis à Smooth portion of the right and left ventricle • Endocardial cushions à Valves and membranous portion of ventricular septum https://commons.wikimedia.org/wiki/File:2037_Embryonic_Development_of_Heart.jpg Heart begins beating during Week 4
  • 5. Bootcamp.com Cardiology: Embryology • Physiologic: • Neural crest cell migration • Aorta and pulmonary artery partitioned and undergo spiral formation à aorticopulmonary septum constructed • Persistent Truncus Arteriosus: • Partial (incomplete) aorticopulmonary septum formation • Mixing of deoxygenated and oxygenated blood • Classic Association: DiGeorge Syndrome • Transposition of Great Vessels: • Failed spiraling of aorticopulmonary septum à reversal of pulmonary artery and aorta • Two parallel circuits • Right ventricle à Aorta • Left ventricle à Pulmonary artery • Classic Association: Mothers with diabetes https://commons.wikimedia.org/wiki/File:Truncus_arteriosus.jpg https://commons.wikimedia.org/wiki/File:D-tga-575px.jpg
  • 6. Bootcamp.com Cardiology: Embryology • Step 1: Septum Primum Forms • Forms inferiorly from superior primitive atrium • Foramen primum: opening b/w septum primum + AV cushions • Step 2: Foramen and Septum Secundum Form • Foramen Secundum: Forms within septum primum • Septum Secundum: Superior and inferior segment • Step 3: Foramen Ovale Closes • Foramen Ovale: Formed by area between septum primum and secundum • ↓ pulmonary vascular resistance, ↑ LAP, ↓ RAP • Patent Foramen Ovale: • Incomplete joining of septum primum and septum secundum • Most patients are asymptomatic • Cryptogenic cerebrovascular accident, paradoxical embolism • Atrial Septal Defect: • Secundum-type is most common and tend to be isolated • Primum-type generally associated with additional heart defects • Cryptogenic cerebrovascular accident, paradoxical embolism Ventricular Septal Defects most commonly occur due to defects in the membranous portion of the interventricular septum
  • 7. Bootcamp.com Cardiology: Embryology • First Arch: Maxillary Artery • Second Arch: Hyoid and Stapedial Arteries • Third Arch: Common Carotid and Proximal Internal Carotid Arteries • Left Fourth Arch: Aortic Arch • Classic Pathology: Coarctation of the aorta • Right Fourth Arch: Proximal Right Subclavian Artery • Left Sixth Arch: Ductus Arteriosus and Proximal Pulmonary Arteries • Classic Pathology: Patent ductus arteriosus • Right Sixth Arch: Proximal Pulmonary Arteries https://commons.wikimedia.org/wiki/File:Gray473.png
  • 8. Bootcamp.com Cardiology: Embryology Pharyngeal Arches Segment Vascular Supply Cranial Nerve Important Muscles Cartilage Classic Pathology First- Mandibular Arch Maxillary Artery V2 and V3 -Muscles of mastication -Anterior belly of digastric -Tensor tympani, tensor veli palatini Meckel’s Cartilage à Mandible, maxilla Zygomatic bone Malleus and incus Treacher Collins Syndrome Pierre Robin Syndrome Second- Hyoid Arch Hyoid and Stapedial Arteries VII -Muscles of facial expression -Posterior belly of digastric -Stylohyoid, stapedius Reichert’s Cartilage à Stapes, styloid process Stylohyoid ligament Lesser horn of hyoid Congenital Pharyngocutaneou s Fistula Third Common Carotid and Proximal Internal Carotid Arteries CN IX -Stylopharyngeus à Greater horn of hyoid Fourth Aortic Arch (L) R Subclavian (R) CN X: Superior Laryngeal Nerve -Cricothyroid -Palatopharyngeus -Levator veli palatini Superior thyroid cartilage Coarctation of Aorta Sixth Ductus Arteriosus (L) L Pulmonary Artery (L) R Pulmonary Artery (R) CN X: Recurrent Laryngeal Branch Intrinsic muscles of larynx (except Cricothyroid) Inferior thyroid cartilage Arytenoid, corniculate, and cuneiform cartilage Patent Ductus Arteriosus https://commons.wikimedia.org/wiki/File:Kiemenbogen.jpg Pharyngeal Pouches Pharyngeal Grooves 1st: Eustachian tube, tympanic cavity, mastoid air cells 1st: External auditory meatus, auditory canal, outer tympanic membrane 2nd: Epithelial lining of palatine tonsils 2nd – 4th: Obliterated in utero 3rd: Dorsal à Inferior parathyroid glands 3rd: Ventral à Thymus 4th: Dorsal à Superior parathyroid glands 4th: Ventral à Parafollicular (C cells) of thyroid
  • 9. ≣ Item 1 of 1 Question ID: 0030 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 57-year-old male with a past medical history of hypertension presents to his primary care physician for hoarseness and dyspnea that has been progressively worsening over the past two months. He has a chronic smoking history ”for as long as he can remember”. He also states that he has been having double vision when leaning forward. During physical examination, auscultation reveals mild end-expiratory wheezing bilaterally over the lung fields. Heart sounds are normal with a regular rhythm. Radial pulses are 2+ and symmetric bilaterally. No thyromegaly is present. Diffuse venous distention is observed in the neck and chest wall. Edema is present diffusely throughout the upper extremities. Fundoscopic examination reveals papilledema bilaterally. Chest radiography is performed. A suspicious mass is identified and highlighted on the imaging study below. Which embryologic derivatives are most closely associated with the structured compressed in this patient? ⚪ A. Truncus arteriosus ⚪ B. Cardinal veins ⚪ C. Endocardial cushions ⚪ D. Right sixth pharyngeal arch ⚪ E. Left fourth pharyngeal arch https://commons.wikimedia.org/wiki/File:SVCCXR.PNG
  • 10. OUTLINE 1. General Anatomical Overview ● A. Cardiac Atria ● B. Cardiac Ventricles 2. Cardiac Silhouette: Chest Radiography ● A. Cardiac Atria ● B. Cardiac Ventricles 3. Axial Imaging: CT and MRI ● A. Ascending and Descending Aorta ● B. Pulmonary Trunk ● C. Cardiac Atria and Ventricles 4. Penetrating Cardiac Injury 5. Cardiac Conduction Anatomy ● A. Sinoatrial Node ● B. Atrioventricular Node 6. Radiofrequency Ablation Targets ● A. Atrial Fibrillation Foci ● B. Atrial Flutter Foci 7. Coronary Artery Anatomy ● A. Right Coronary Arteries ● B. Left Coronary Arteries ● C. Dominant Coronary Artery Circulation 8. Coronary Sinus 9. Cardiac Catheterization ● A. Swan-Ganz Catheter ● B. Coronary Angiography, Percutaneous Coronary Intervention ● C. Trans-Septal Left Atrial Catheterization Cardiology: Anatomy
  • 11. Bootcamp.com Cardiology: Anatomy • Right Atrium: • Right heart border • Right Ventricle: • Anterior and inferior heart border • Left Atrium: • Posterior border of heart (also minor component of left ventricle) • Clinical Correlation: Enlargement leads to cardiovascular dysphagia • Clinical Correlation: Transesophageal echocardiography • Left Ventricle: • Left heart border (also minor component of left atrial appendage) https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg
  • 12. Bootcamp.com Cardiology: Anatomy • Right Atrium: • Right heart border • Right Ventricle: • Anterior and inferior heart border • Left Atrium: • Posterior border of heart (also minor component of left ventricle) • Clinical Correlation: Enlargement leads to cardiovascular dysphagia • Clinical Correlation: Transesophageal echocardiography • Left Ventricle: • Left heart border (also minor component of left atrial appendage) https://commons.wikimedia.org/wiki/File:X-ray_of_cardiac_silhouettes.jpg
  • 13. Bootcamp.com Cardiology: Anatomy • Ascending aorta • Descending aorta • Pulmonary trunk • Atria and Ventricles https://commons.wikimedia.org/wiki/File:SADDLE_PE.JPG https://commons.wikimedia.org/wiki/File:Cardiac_mri_slice_bionerd.jpg
  • 14. Bootcamp.com Cardiology: Anatomy • Mid-Left Sternal Border 3rd-4th Intercostal Space: • Right ventricle susceptible to injury • Left Sternal Border to Mid-Clavicular Line 5th Intercostal Space: • Medial à Left ventricle and left lung susceptible to injury • Lateral à Left lung primarily susceptible to injury https://commons.wikimedia.org/wiki/File:Surface_projections_of_the_organs_of_the_trunk.png
  • 15. Bootcamp.com Cardiology: Anatomy • Sinoatrial Node: • Contains specialized pacemaker cells • Location: Right atrium along roof (proximity to opening of SVC) • Atrioventricular Node: • Delayed conduction between atria and ventricle • Location: Right atrium along interatrial septum (proximity to tricuspid valve and coronary sinus) • Bundle of His • Purkinje Fibers https://commons.wikimedia.org/wiki/File:ConductionsystemoftheheartwithouttheHeart-en.svg https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg
  • 16. Bootcamp.com Cardiology: Anatomy • Atrial Fibrillation Foci: • Left atrial myocardium • Pulmonary vein ostia within left atrium • Atrial Flutter Foci: • Area between tricuspid valve and IVC https://commons.wikimedia.org/wiki/File:ConductionsystemoftheheartwithouttheHeart-en.svg https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg
  • 17. Bootcamp.com Cardiology: Anatomy • Right Coronary Artery (RCA): • Majority of right-side of heart • Sinoatrial node • Left Coronary Artery (LCA): • Majority of left-side of heart • Two major branches: • Left Anterior Descending Artery (LAD)à Anterior 2/3 of interventricular septum, anterolateral papillary muscle, anterior left ventricle • Left Circumflex Artery (LCX) à Posterolateral LA and LV, anterolateral papillary muscle • Posterior Descending Artery (PDA): • ~85% R-dominant, 8% L-dominant, 7% co-dominant • Primarily inferior borders of heart • Posterior 1/3 of interventricular septum • Posteromedial papillary muscle
  • 18. Bootcamp.com Cardiology: Anatomy • All coronary veins drain into the coronary sinus • Location: Left posterior atrioventricular groove • Drains directly into the right atrium • Embryologic derivative: Sinus venosus • Clinical Correlation: Biventricular pacemaker lead placement into LV • Clinical Correlation: Dilated in pulmonary hypertension https://commons.wikimedia.org/wiki/File:Gray491.png https://commons.wikimedia.org/wiki/File:PPM.png
  • 19. Bootcamp.com Cardiology: Anatomy • Swan-Ganz Catheter (Pulmonary Artery Catheter): • Venous catheter • Use: Measures right-sided pressures • Pulmonary capillary wedge pressure: Surrogate marker for left atrial pressure • Coronary Angiography, Percutaneous Coronary Intervention (PCI) • Arterial catheter • Use: Visualize atherosclerotic lesions and stenosis of coronary vessels • Trans-Septal Left Atrial Catheterization • Venous catheter • Use: Direct measurement of left atrial pressure and/or ablation of pathogenic foci https://commons.wikimedia.org/wiki/File:Pulmonary_artery_catheter_english.JPG https://commons.wikimedia.org/wiki/File:Coronary_Angiography.png
  • 20. ≣ Item 1 of 1 Question ID: 0031 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 25-year-old female presents to the emergency room with dyspnea and palpitations. She states that she believes she may be having a panic-attack. She reports that she was walking her dog when suddenly she began to feel lightheaded and short of breath. She denies any family history of heart disease. Telemetry monitoring reveals an irregularly irregular heart rate of 134/min. Blood pressure is 138/54, respiratory rate is 14/min, blood glucose is 84 mg/dL. Fine tremors are observed in the distal phalanges. Electrocardiogram is performed and shown. Initial labs reveal a significantly decreased thyroid-stimulating hormone level. Which of the following locations is likely a source of aberrant electrical foci contributing to this patient’s symptoms? ⚪ A. Cavotricuspid isthmus of right atrium ⚪ B. Superior subendocardial right atrium ⚪ C. Membranous portion of interventricular septum ⚪ D. Left posterior atrioventricular groove ⚪ E. Pulmonary vein ostia of left atrium ⚪ F. Pulmonary artery root of right ventricle https://commons.wikimedia.org/wiki/File:ECG_Atrial_Fibrillation.jpg
  • 21. OUTLINE 1. Aorta ● A. Vascular Structures and Branches ● B. Ligamentum Arteriosum ● C. Key Landmarks of the Aorta 2. Subclavian Steal Syndrome 3. Venous Drainage Obstruction ● A. Superior Vena Cava Syndrome ● B. Brachiocephalic Vein Obstruction ● C. Subclavian and/or Axillary Vein Obstruction 4. Coronary Bypass Grafting ● A. Internal Thoracic Artery ● B. Great Saphenous Vein 4. Femoral Access ● A. NAVEL ● B. Femoral Arterial Access ● C. Femoral Venous Access 6. Inferior Vena Cava ● A. Key Landmarks of the Inferior Vena Cava ● B. Inferior Vena Cava Filter Cardiology: Vascular System
  • 22. Bootcamp.com Cardiology: Vascular System • Vascular Structures: • Coronary Arteries • Brachiocephalic trunk • Subclavian arteries • Common carotid arteries • Ligamentum Arteriosum: • Remnant of ductus arteriosus • Key Landmarks: • T12: Descending aorta traverses' diaphragm via aortic hiatus • T12: Celiac trunk • L1: Superior mesenteric artery origin • L3: Inferior mesenteric artery origin • L1-L2: Right and left renal arteries origin • L2: Gonadal arteries origin • L4: Bifurcation into common iliac arteries (at navel) https://commons.wikimedia.org/wiki/File:Aorta_branches.svg
  • 23. Bootcamp.com Cardiology: Vascular System • Etiology: Atherosclerosis, Takayasu arteritis, previous thoracic (aortic) surgery • Pathophysiology: • Subclavian stenosis à contralateral vertebral artery steal phenomena • Presentation: • Ipsilateral limb ischemia • Asymmetric BP between upper extremities • Dizziness, diplopia, syncope • Worsening of symptoms during activity of affected limb • Imaging: • Reduced contrast uptake in areas distal to stenosis and ipsilateral vertebral artery https://commons.wikimedia.org/wiki/File:The_promixal_part_of_left_subclavian_is_blocked_on_left_side_so_no_flow_in_vertebra l_and_to_left_arm-blood_from_right_vertebral_enters_left_vertebral_and_flows_back_to_supply_left_arm_2013-07-05_17-11.jpg https://commons.wikimedia.org/wiki/File:Angiogram_of_Left_Subclavian_Steal_Syndrome.PNG
  • 24. Bootcamp.com Cardiology: Vascular System • Superior Vena Cava Syndrome • Etiology: Mass lesion (malignancy) or thrombosis (venous catheter) • Edema à bilateral face, bilateral upper extremities • Jugular venous distention • Headache, ↑ intracranial pressure • Brachiocephalic Venous Obstruction • Etiology: Pancoast tumor or thrombosis (venous catheter) • Edema à Unilateral face, unilateral upper extremity • Subclavian and/or Axillary Venous Obstruction • Edema à Unilateral upper extremity • No facial involvement • Inferior Vena Cava Compression • Supine hypotensive syndrome (3rd trimester) Edema à Bilateral lower extremities Fetal hypoxia à improves with repositioning https://commons.wikimedia.org/wiki/File:2132_Thoracic_Abdominal_Veins.jpg Azygos Vein Right-sided vein Connects SVC and IVC Alternative pathway for blood to return to right atrium
  • 25. Bootcamp.com Cardiology: Vascular System • Internal Thoracic (Mammary) Artery • Great Saphenous Vein • Medial foot, medial malleolus, medial leg and thigh • Joins femoral vein https://upload.wikimedia.org/wikipedia/commons/c/c8/2136ab_Lower_Limb_Veins_Anterior_Posterior.jpg https://commons.wikimedia.org/wiki/File:Gray522.png
  • 26. Bootcamp.com Cardiology: Vascular System • NAVEL (lateral to medial) • Femoral Nerve • Femoral Artery • Femora Vein • Empty • Lymphatics • Femoral Arterial Access • At the site of femoral pulsation below inguinal ligament • Coronary angiography, PCI • Clinical Correlate: If access above inguinal ligament à ↑ risk of retroperitoneal hemorrhage • Femoral Venous Access • Medial to the site of femoral pulsation below inguinal ligament • Swan-Ganz catheter • Trans-septal left atrial catheterization https://commons.wikimedia.org/wiki/File:Gray545.png
  • 27. Bootcamp.com Cardiology: Vascular System • Key Landmarks: • T8: Traverses diaphragm • L5: Formed by right and left iliac veins • Inferior Vena Cava Filter • Indication: Failure or contraindication to anticoagulation in the setting of a lower extremity deep venous thrombosis https://commons.wikimedia.org/wiki/File:3D_Medical_Animation_Inferior_Vena_Filter.jpg https://radiopaedia.org/cases/normal-ct-abdomen?lang=us
  • 28. ≣ Item 1 of 1 Question ID: 0032 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com ⚪ A. Right vertebral artery ⚪ B. Left subclavian artery ⚪ C. Left internal carotid artery ⚪ D. Left axillary artery ⚪ E. Grafted internal thoracic artery A 67-year-old left-handed male is brought to the emergency room by paramedics for 9/10 acute onset chest pain that began during a game a of ping-pong at his senior living facility. The patient states that he has been noncompliant with his statin medication and has not been consistent in checking his blood pressure at home. He reports having chest pain over the past week worsened with rapid left arm movement. His medical history is significant for a myocardial infarction secondary to significant stenosis of the left anterior descending and circumflex arteries and had previously undergone a coronary artery bypass grafting procedure. Physical exam reveals a cool left extremity with a 1+ left radial pulse. The right upper extremity is normal in color with a systolic blood pressure 30 mmHg greater than the left. Cardiovascular surgery is emergently consulted, and a percutaneous revascularization is performed. Retrograde transport of blood through which of the following arteries most likely contributed to this patient’s presentation?
  • 29. OUTLINE 1. Stroke Volume ● A. End-Diastolic Volume ● B. End-Systolic Volume ● C. Ejection Fraction 2. Stroke Volume Variables ● A. Preload ● B. Afterload ● C. Contractility 3. Heart Rate 4. Frank-Starling Mechanism ● A. Principle and Mechanism ● B. Frank-Starling Curve 6. Cardiac Output ● A. Fick-Principle 7. Mean Arterial Pressure ● A. Total Peripheral Resistance ● B. Pulse Pressure 8. Coronary Blood Flow and Autoregulation Cardiology: Cardiac Parameters of Physiologic Function
  • 30. Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • End-Diastolic Volume: ~ Preload • End-Systolic Volume: ~ 1/Contractility • Stroke Volume (SV) = End-diastolic volume (EDV) – End-systolic volume (ESV) • Ejection Fraction (EF) = SV / EDV
  • 31. Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Preload: • ↑ Venous return à ↑ EDV ~ ↑ Preload à ↑ Stroke volume, ↑ Contractility • Afterload: • ↑ TPR ~ ↑ Afterload à ↑ ESV à ↓ Stroke volume • Preload compensates in healthy hearts • Afterload has a more dominant effect in heart failure • Law of LaPlace: Wall stress = !"#$$%"# & '()*%$ +(,, -.*/01#$$ = +(,, -#1$*21 +(,, -.*/01#$$ • Contractility • ↑ SNS activity à ↑ Contractility à ↓ ESV à ↑ Stroke volume SV = EDV - ESV
  • 32. Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Physiologic Mechanism: ↓ Vagal tone à SA Node à ↑ HR • Coronary Perfusion: • Left ventricular myocardial perfusion occurs primarily during diastole • Tachycardia: • Elevated heart rate • ↑ HR à ↓ time of diastole à ↓ ventricular myocardial perfusion, ↓ diastolic filling time à ↓ CO CO = HR x SV Maximal HR = 220 bpm – Age (in years)
  • 33. Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Principle: • ↑ Preload à ↑ Contractility à ↑ SV • Mechanism: • ↑ Venous return • ↑ EDV ~ ↑ Preload • ↑ Myocyte stretch prior to contraction • ↑ Sarcomere length (↑ active tension and velocity of fiber shortening) • Frank-Starling Curve: • X-axis: LVEDP (preload, LVEDV, fiber length) • Y-axis: Stroke Volume • Slope of curve: Defined by afterload and contractility • Point along curve: Defined by venous return (preload) SV = EDV - ESV
  • 34. Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Cardiac Output = HR x SV • Fick Principle à Cardiac Output = Rate of O2 consumption / Arteriovenous O2 difference
  • 35. Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Total Peripheral Resistance (TPR) = Determined by state of arteriolar resistance • Pulse Pressure (PP) = Systolic pressure – Diastolic pressure • Mean Arterial Pressure (MAP) = CO x Total peripheral resistance (TPR) • Mean Arterial Pressure (MAP) = 1/3 systolic pressure + 2/3 diastolic pressure • Mean Arterial Pressure (MAP) = 1/3 PP + Diastolic Pressure
  • 36. Bootcamp.com Cardiology: Cardiac Parameters of Physiologic Function • Left Ventricular Coronary Blood Flow: ↑ Ventricular diastole • Oxygen Extraction: • Significant in myocardial tissues • Coronary sinus à ↑↑↑ deoxygenation • ↑ O2 demand à coronary vasodilation (nitric oxide, adenosine)
  • 37. ≣ Item 1 of 1 Question ID: 0033 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 57-year-old male presents to the emergency department for a dry cough and dyspnea. He states that over the past seven years he has experienced mild shortness of breath with continued physical exertion, however, over the past week he has suddenly become short of breath at rest. He has a past medical history of poorly controlled hypertension and hyperlipidemia. The patient also admits to a 30-year smoking history. He is afebrile, blood pressure is 102/64, heart rate is 102/min, oxygen saturation is 92% on room air. Auscultation of the heart reveals an S3 heart sound and a faint systolic decrescendo murmur in the axillary region. Lung auscultation is significant for diffuse crackles. There is dullness to percussion over the lung fields. Chest radiography is shown. Which of the following is most consistent with this patient’s presentation? ⚪ A. Elevated systolic aortic pressures ⚪ B. Elevated pulmonary capillary wedge pressure ⚪ C. Depressed left atrial pressure ⚪ D. Depressed pulmonary venous pressure ⚪ E. Unchanged left ventricular diastolic volume https://commons.wikimedia.org/wiki/File:Pulmonary_oedema.jpg
  • 38. OUTLINE 1. Cardiac Function Curves 2. Venous Return Curves 3. Combined Cardiac Function and Venous Return Curves ● A. Steady State ● B. Specific Pathologic Processes Cardiology: Cardiac Function and Venous Return Curve Physiology
  • 39. Bootcamp.com Cardiology: Cardiac Function and Venous Return Curve Physiology • Cardiac Function Curve: • X-axis: Right atrial pressure (independent variable) • Y-axis: Cardiac output (dependent variable) • Slope of curve: Defined by contractility, afterload, and heart rate
  • 40. Bootcamp.com • Venous Return Curve: • X-axis: Right atrial pressure (dependent variable) • Y-axis: Cardiac output (independent variable) • Slope of curve: Defined by total peripheral resistance • X and Y intercept: Defined by venous compliance and total blood volume Cardiology: Cardiac Function and Venous Return Curve Physiology
  • 41. Bootcamp.com • Intersection: • Steady state operating target for right atrial pressure and cardiac output • Variables: • Slope of Cardiac Function Curve à Contractility, Heart rate, Afterload • Slope of Venous Return Curveà TPR • X-intercept of Venous Return Curve (Pm) à Total blood volume, Venous compliance Cardiology: Cardiac Function and Venous Return Curve Physiology
  • 42. Bootcamp.com • Acute Hemorrhage: Disruption: ↓ blood volume • Cardiac Function Curve: No change • Venous Return Curve: X-intercept shifts left • Steady State: Shifted downward and to the left • Intravenous Fluids: Disruption: ↑ blood volume • Cardiac Function Curve: No change • Venous Return Curve: X-intercept shifts right • Steady State: Shifted upward and to the right • Chronic Systolic Heart Failure: Disruption: ↓ contractility, Chronic à Compensation • Cardiac Function Curve: ↓ slope • Venous Return Curve: Slope decreases, X-intercept shifts right • Steady State: Shifted downward and to the right • Digoxin: Disruption: ↑ contractility • Cardiac Function Curve: ↑ slope • Venous Return Curve: Slope unchanged, X-intercept unchanged • Steady State: Shifted upward and to the left • Phenylephrine: Disruption: ↑ TPR (!1-agonist) • Cardiac Function Curve: ↓ slope • Venous Return Curve: ↓ slope , X-intercept unchanged (usually) • Steady State: Shifted downward • Hydralazine: Disruption: ↓ TPR • Cardiac Function Curve: ↑ slope • Venous Return Curve: ↑ slope , X-intercept unchanged (usually) • Steady State: Shifted upward Slope of Cardiac Function Curve à Contractility, Heart rate, Afterload Slope of Venous Return Curveà TPR X-intercept of Venous Return Curve (Pm) à Total blood volume, Venous compliance Cardiology: Cardiac Function and Venous Return Curve Physiology
  • 43. ≣ Item 1 of 1 Question ID: 0034 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪✪ Bootcamp.com A 67-year-old male with a chronic smoking history presents to the emergency department by paramedics with hypotension refractory to intravenous fluids following an episode of syncope at home. His daughter reports he suddenly loss consciousness while watching television. Vitals are significant for a blood pressure of 88/28 mmHg, heart rate of 124/min, and respiratory rate of 18/min. Imaging reveals findings consistent with an aortocaval fistula. Surgery is emergently performed. Which of the following new steady states are most representative of the acute pathophysiology observed in this patient prior to surgical intervention? ⚪ A. ⚪ B. ⚪ C. ⚪ D. ⚪ E. Cardiac Output Venous Return Right Atrial Pressure (E.) Prior to aortocaval fistula A. B. C. D. E.
  • 44. OUTLINE 1. Basic Principles ● A. Key Principles ● B. Phases 2. Determinants ● A. Preload ● B. Contractility ● C. Afterload 3. Valvular Disease ● A. Aortic Regurgitation ● B. Aortic Stenosis ● C. Mitral Regurgitation ● D. Mitral Stenosis 4. Advanced Pathophysiology ● A. Exercise ● B. Arteriovenous Fistula ● C. Systolic Heart Failure ● D. Diastolic Heart Failure Cardiology: Pressure Volume Loops
  • 45. Bootcamp.com Cardiology: Pressure Volume Loops • Key Principles: • All valves are closed during isovolumetric phases (vertical lines) • Width of the pressure volume loop ~ Stroke Volume • Area of pressure volume loop ~ Ventricular Stroke Work • Ventricular compliance makes up the base of the loop • Phases: • Isovolumetric contraction • Left ventricular ejection • Isovolumetric relaxation • Ventricular filling
  • 46. Bootcamp.com Cardiology: Pressure Volume Loops • Preload: • ↑ à EDV shifts right • ↓ à EDV shifts left • Contractility: • ↑ à ESV shifts left • ↓ à ESV shifts right • Afterload: • ↑ à ESV shifts right • ↑ à ↑ LVP isovolumetric contraction • ↓ à ESV shifts left • ↓ à ↓ LVP isovolumetric contraction https://commons.wikimedia.org/wiki/File:Cardiac_cycle_(pressure_volume_loop).svg
  • 47. Bootcamp.com Cardiology: Pressure Volume Loops • Hemorrhagic Shock: • ↓ Total blood volumeà ↓ Preload • Intravenous Fluids: • ↑ Total blood volumeà ↑ Preload • Nitroglycerin: • Venodilator (primary)à ↓ Preload • Vasodilator (secondary)à ↓ Afterload • Sodium Nitroprusside: • Vasodilator (primary)à ↓ Afterload, ↓ TPR (↓ DBP) • Venodilator (primary) à ↓ Preload
  • 48. Bootcamp.com Cardiology: Pressure Volume Loops • Digoxin, Dobutamine: • Inotropic agentà ↑ Contractility • Slight increases in ventricular afterload are possible https://en.wikipedia.org/wiki/Press ure%E2%80%93volume_loop_ana lysis_in_cardiology#/media/File:En d_Systolic_Pressure_Volume_Rel ationship.jpg
  • 49. Bootcamp.com Cardiology: Pressure Volume Loops • Phenylephrine: • !1-agonist à ↑ Afterload, ↑ TPR (↑ DBP) • Hydralazine: • Vasodilatorà ↓ Afterload, ↓ TPR (↓ DBP)
  • 50. Bootcamp.com Cardiology: Pressure Volume Loops • Aortic Regurgitation: • Retrograde flow of oxygenated blood into LV à ↑ Preload • Loss of isovolumetric phases • Aortic Stenosis: • Stenosis distal to left ventricle à ↑ Afterload • Chronic: ↓ Ventricular compliance (Diastolic heart failure) • Mitral Regurgitation: • Retrograde flow of oxygenated blood into LA à ↑ Preload • Loss of isovolumetric phases • Mitral Stenosis: • Stenosis proximal to left ventricle à ↓ Preload https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Aortic_stenosis.jpg https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Aortic_regurgitation.jpg https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Mitral_regurgitation.jpg https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_loop_analysis_in_cardiology#/media/ File:Mitral_stenosis.jpg
  • 51. Bootcamp.com Cardiology: Pressure Volume Loops • Exercise: • Venoconstriction, muscle and respiratory pumps à ↑ Preload • Sympathetic stimulation to heart à ↑ Contractility • Muscle vasodilation < ventricular afterload à ↑ Afterload (↓ DBP) • Arteriovenous Fistula: • Low resistance fistulaà ↓ Afterload • High flow of blood through fistula à ↑ Venous return, ↑ Preload • If fistula is large à hypotension à ↑ Contractility, heart rate à High-output cardiac failure • Systolic Heart Failure • Principal determinant: ↓ Contractility • Chronic à ↓↓↓ Contractility, ↑ Preload, ↓ Afterload • Diastolic Heart Failure • Principal determinant: ↓ Ventricular compliance • Chronic: ↓ Preload, variable changes in contractility and afterload • Key point: Decrease in stroke volume and compliance
  • 52. ≣ Item 1 of 1 Question ID: 0035 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 57-year-old male with presents to an urgent care clinic with a numbness of his right foot and shortness of breath. He states that he had three fall episodes over the past month because “he can’t feel the floor”. He denies any dizziness and reports that he has not been seen by a physician in over twenty years. Physical examination reveals a left internuclear ophthalmoplegia. The pupils accommodate but are not reactive to direct or indirect light stimulation. Locally destructive ulcerative lesions are present diffusely throughout the face and upper back. Cardiovascular examination demonstrates a high-pitched diastolic murmur most prominent at the left fourth intercostal space along the left sternal border. Pulses are notable for a rapid upstroke and downstroke. Reflexes are 1+ at L4 and C5 bilaterally. Sensory ataxia is also present. A biopsy of the skin lesions is taken revealing a monocytic infiltrate. The patient is referred for a lumbar puncture. Which of the following best demonstrates the time along the left ventricular pressure-volume loop that this patient’s heart murmur will be most prominent? ⚪ A. Distance between A to B ⚪ B. Distance between B to C ⚪ C. Distance between C to D ⚪ D. Distance between D to A ⚪ E. Point D https://en.wikipedia.org/wiki/Pressure%E2%80%93volume_diagram
  • 53. OUTLINE 1. Endothelial Regulated Vasodilation ● A. Mechanism of Action 2. Excitation-Contraction Coupling ● A. Cardiac Myocyte ● B. Vascular Smooth Muscle ● C. Skeletal Muscle 3. G-Protein Coupled Receptor Vasoconstriction Pathway ● A. Gq Pathway 4. Pharmacologic Targets ● A. !1 agonists ● B. Nonhydropyridine Calcium Channel Blockers ● C. Dihydropyridine Calcium Channel Blockers ● D. Phosphodiesterase-3 Inhibitors ● E. Additional Vasodilatory Drugs Cardiology: Vasodilation and Vasoconstriction
  • 54. Bootcamp.com Cardiology: Vasodilation and Vasoconstriction • Endothelial Cell: • Acetylcholine, bradykinin, and shear stress forces à ↑ cytosolic [Ca2+ ] • Nitric oxide Synthase stimulated by ↑ [Ca2+ ] • L-Arginine + O2 à Nitric oxide + Citrulline • Nitric oxide diffuses freely among cells • Vascular Smooth Muscle: • Nitric oxide causes increased conversion of GTP à cGMP • cGMP à activation of PKG à ↓ cytosolic [Ca2+ ] • Relaxation of vascular smooth muscle
  • 55. Bootcamp.com • Cardiac Myocytes • Depolarization of cell membrane by action potential • L-type calcium channel: influx of calcium ions from extracellular • Calcium-induced calcium release: incoming calcium ions bind to ryanodine receptor • Ryanodine receptor: influx of calcium ions from SR • Calcium ions bind to troponin-C • Conformational change allows actin to interact with myosin head • SERCA: Sequesters intracellular calcium into SR via ATP à relaxation • Smooth Muscle: • Depolarization of cell membrane by action potential • L-type calcium channel: influx of calcium ions from extracellular • Calcium induced calcium release • Calcium ions bind to calmodulin • Conformation change in myosin light chain kinase (MLCK) • Phosphorylates myosin light chain (MLC) à contraction • Myosin light chain phosphatase dephosphorylates MLC à relaxation • Skeletal Muscle (Major Differences from Cardiac Myocytes): • Pathway stimulated by acetylcholine (not automaticity) • Mechanical coupling of LTCC with RyR https://upload.wikimedia.org/wikipedia/commons/1/10/Cardiac_calcium_cycling_and_excitation-contraction_coupling.png Cardiology: Vasodilation and Vasoconstriction
  • 56. Bootcamp.com • Gq-GPCR Mechanism: • Present on arterioles (↑ afterload) and veins (↑ preload) • Gq protein à ↑ Phospholipase C (PLC) • PIP2 à ↑ inositol triphosphate (IP3) + Diacylglycerol (DAG) • IP3 à ↑ cytosolic [Ca2+ ] (from ER) • DAG à Protein Kinase C (PKC) à ↑ cytosolic [Ca2+ ] (from extracellular space) Cardiology: Vasodilation and Vasoconstriction
  • 57. Bootcamp.com • !1-agonists • Activation of Gq-GPCR pathway • Primary effect: Vasoconstriction • Drugs: Phenylephrine (selective), norepinephrine (nonselective) • Nondihydropyridine Calcium Channel Blockers: • Inhibition of L-type calcium channels • Greater effect on calcium-induced calcium release • Primary effect: ↓ Contractility, bradycardia, AV block • Drugs: Verapamil, diltiazem • Dihydropyridine Calcium Channel Blockers: • Inhibition of L-type calcium channels • Greater effect on calcium-induced calcium release • Primary effect: Vasodilation • Drugs: Nifedipine, nicardipine, felodipine, amlodipine (arterial > venous) • Phosphodiesterase-3 (PDE-3) Inhibitor: • PDE-3 à Inhibition of cAMP degradation (myocytes) and ↑ SR calcium uptake (vascular) • Primary effect: ↑ Contractility, vasodilation • Drugs: Milrinone, Cilostazol, Dipyridamole • Additional Vasodilatory Drugs: • Nitric oxide (venous > arterial) • Hydralazine, minoxidil (arterial > venous) • Nitroprusside (arterial = venous) • Sildenafil (PDE-5 inhibitor) à (pulmonary and corpus cavernosum) https://upload.wikimedia.org/wikipedia/commons/1/10/Cardiac_calcium_cycling_and_excitation-contraction_coupling.png Cardiology: Vasodilation and Vasoconstriction
  • 58. ≣ Item 1 of 1 Question ID: 0036 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 77-year-old male is brought to the emergency department from his living facility with lethargy. Vital signs reveal a blood pressure of 58/20 mmHg, heart rate 122 beats/min, respiratory rate 20 breaths/min, oxygen saturation 91% on room air, and a temperature of 103.3F (39.6C). Initial labs reveal a lactate of 9.0 and white blood cell count of 18,000/mm3. He is aggressively fluid resuscitated and started on slow intravenous phenylephrine injection for blood pressure support. Which of the following cellular changes are most likely to occur due to the direct effects of the medication given? ⚪ A. Increased inhibition of adenylyl cyclase ⚪ B. Decreased intracellular concentrations of L-arginine ⚪ C. Decreased cyclic AMP degradation ⚪ D. Increased myosin light chain phosphatase activity ⚪ E. Decreased degradation of adenosine ⚪ F. Increased intracellular concentrations of inositol triphosphate
  • 59. OUTLINE 1. Vessel Compliance ● A. Key Principles 2. Blood Flow ● A. Poiseuille Equation ● B. Resistance 3. Sensory Receptors of the Vasculature ● A. Carotid Sinus and Aortic Arch Baroceptors ● B. Carotid Sinus Massage ● C. Carotid Sinus Hypersensitivity ● D. Carotid and Aortic Body Chemoreceptors Cardiology: Pressure and Flow Physiology
  • 60. Bootcamp.com Cardiology: Pressure and Flow Physiology • Vessel Compliance: • Compliance = ∆Volume / ∆Pressure • Elastance = ∆Pressure / ∆Volume • ↑ Compliance à Veins • ↓ Compliance à Arterioles
  • 61. Bootcamp.com Cardiology: Pressure and Flow Physiology • Poiseuille Equation: • Flow (Q) = !" #!$ 8%& r4π • Q = Flow • P = Pressure at point in blood vessel • ! = viscosity of blood within blood vessel • l = length of blood vessel • r = radius of blood vessel • Capillaries have greatest total cross-sectional area à lowest blood velocity • Resistance: • R ∝ %& '! • R = Resistance • Arterioles are the primary regulator of total peripheral resistance • Series: Total Resistance = RT = R1 + R2 + …Rn • Parallel: Total Resistance = 1/%T = 1/%1 + 1/%2 + … 1/%n
  • 62. Bootcamp.com • Carotid Sinus and Aortic Arch Baroceptors: • ↑ stretch (↑ BP) à ↑ afferent ↑ efferent PNS firing à ↑ parasympathetic response à vasodilation, ↓ HR, ↓ contractility • ↓ stretch (↓ BP) à ↓ afferent ↓ efferent PNS firing à ↓ parasympathetic response à vasoconstriction, ↑ HR, ↑ contractility • Carotid Sinus Massage: • ↑ afferent ↑ efferent PNS firing à ↑ parasympathetic response à vasodilation, ↓ HR, ↓ contractility • Stable narrow complex tachycardia à Vagal maneuver • Carotid Sinus Hypersensitivity: • Develops severe hypotension and/or bradycardia after carotid sinus stimulation • “Tight shirt collar” • Presyncopal/syncopal event • Carotid and Aortic Body Chemoreceptors: • Effective at responding to chronic hypoxia (as opposed to central chemoreceptors) • ↓ O2 (↑ CO2, ↓ pH) à ↑ sympathetic response à ↑ respiratory rate Cardiology: Pressure and Flow Physiology
  • 63. ≣ Item 1 of 1 Question ID: 0036 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪ Bootcamp.com A 78-year-old female with a past medical history of dyslipidemia, hypertension, and type 2 diabetes mellitus is evaluated at an acute rehabilitation facility for dizziness during therapy. She denies any shortness of breath, vision changes, or chest pain. The patient has a history of C3-C5 laminectomy for severe spinal stenosis. Vital signs are shown below. Auscultation of the heart reveals a regular rate and rhythm with no murmurs or abnormal heart sounds. The lungs are clear to auscultation. Which of the following undiagnosed conditions best describes a possible cause of this patient’s presentation? Temperature: 97.8F (36.6C) Blood pressure when lying supine: 144/88 mmHg Heart rate when lying supine: 102/min Respiratory rate when lying supine: 12/min Blood pressure when standing: 110/56 Heart rate when standing: 112/min Respiratory rate when standing: 14/min ⚪ A. Carotid sinus hypersensitivity ⚪ B. Autonomic neuropathy ⚪ C. Neurogenic shock ⚪ D. Constrictive pericarditis ⚪ E. Hypertrophic cardiomyopathy
  • 64. OUTLINE 1. Auscultation ● A. Aortic Area ● B. Pulmonic Area ● C. Mitral Area ● D. Tricuspid Area ● E. Erb’s Point 2. Heart Sounds ● A. S1 ● B. S2 ● C. Physiologic Splitting of S2 ● D. Pathologic Splitting of S2 ● E. S3 ● F. S4 3. Cardiac Cycle ● A. Isovolumetric Contraction ● B. Ejection ● C. Isovolumetric Relaxation ● D. Ventricular Filling ● E. Atrial Systole 4. Jugular Venous Waveform ● A. A-wave ● B. C-wave ● C. X-descent ● D. V-wave ● E. Y-descent Cardiology: Cardiac Cycle 5. Classic Disorders ● A. Aortic Stenosis ● B. Aortic Regurgitation ● C. Mitral Stenosis ● D. Mitral Regurgitation ● E. Constrictive Pericarditis ● F. Cardiac Tamponade ● G. Atrial Fibrillation ● H. AV-dissociation
  • 65. Bootcamp.com Cardiology: Cardiac Cycle • Aortic Area: • 2nd R parasternal ICS • Pulmonic Area: • 2nd L parasternal ICS • Tricuspid Area: • 4th L parasternal ICS • Mitral Area: • 5th L mid-clavicular line ICS • Erb’s Point • 3rd L parasternal ICS https://en.wikipedia.org/wiki/Heart_sounds#/media/File:Gray1216_modern_locations.svg
  • 66. Bootcamp.com Cardiology: Cardiac Cycle • S1: • Produced by: Closure of tricuspid and mitral valves • Best heard: Cardiac apex Accentuation: Left lateral decubitus position in expiration • S2: • Produced by: Closure of the pulmonary (P2) and aortic valve (A2) • Best heard: P2 à 2nd L parasternal ICS A2 à 2nd R parasternal ICS • Physiologic S2 Splitting: • Narrowing à Expiration • Widening à Inspiration • Pathologic S2 Splitting: • Wide Fixed à Atrial septal defect • Wide à Pulmonary stenosis, Right bundle branch block • Paradoxical à Severe aortic stenosis, Left bundle branch block
  • 67. Bootcamp.com Cardiology: Cardiac Cycle • S3: • Produced by: Rapid passive ventricular filling (↑ left ventricular volumes) • Best heard: Cardiac apex (bell) Accentuation: Left lateral decubitus position in expiration • Timing: Early diastole, after S2 (gallop) • Physiologic: Young and fit, pregnancy • Pathologic: Heart failure (systolic), mitral regurgitation, aortic regurgitation • S4: • Produced by: Atrial kick (↑ left ventricular pressures) • Best heard: Cardiac apex (bell) Accentuation: Left lateral decubitus position in expiration • Timing: Late diastole, before S1 • Physiologic: Elderly • Pathologic: Heart failure (diastolic), chronic hypertension, aortic stenosis
  • 68. Bootcamp.com Cardiology: Cardiac Cycle • Isovolumetric Contraction: • Begins after closing of mitral valve (S1) • Highest oxygen consumption • QRS complex on ECG à ventricular depolarization • Ejection: • Begins after opening of the aortic valve • Rapid Ejection: Rising LVP, ↓↓ LV volume • Reduced Ejection: Decreasing LVP https://commons.wikimedia.org/wiki/File:Wiggers_Diagram.svg
  • 69. Bootcamp.com Cardiology: Cardiac Cycle • Isovolumetric Relaxation: • Begins after closing of aortic valve (S2) • Dicrotic notch • Coronary blood flow peaks • Ventricular Filling: • Begins after opening of the mitral valve • Rapid Fillin • S3: Rapid filling into volume overload LV • Reduced Filling • Atrial Systole: • At conclusion of diastole • S4: Atrial kick into “stiff” ventricle https://commons.wikimedia.org/wiki/File:Wiggers_Diagram.svg
  • 70. Bootcamp.com Cardiology: Cardiac Cycle • A-wave: • Atrial systole (P wave) • C-wave: • Ventricular contraction • Tricuspid valve protrudes into atrium • X-descent: • Atrial relaxation • V-wave: • Atrial filling à tricuspid valve “back-pressure” • Y-descent: • Ventricular filling • Classic Disorders: • Atrial fibrillation: Absent A-waves (absent P-waves on ECG) • Tricuspid (or Mitral) regurgitation: ↑ V-wave > A-wave • Tamponade: Blunting of Y-descent • Constrictive pericarditis: Increased Y-descent • Atrial contraction against closed tricuspid: “Cannon” A-waves https://commons.wikimedia.org/wiki/File:Wiggers_diagram_with_jugular_venous_waveform.png
  • 71. Bootcamp.com Cardiology: Cardiac Cycle • Aortic Stenosis: • LVP >> Aortic pressure • Aortic Regurgitation: • ↑ Aortic pressure during systole • ↓ Aortic pressure at the end of diastole • ↑ Pulse pressure (SBP - DBP) • Loss of dicrotic notch • Mitral Stenosis: • LAP > LVP during diastole • Mitral Regurgitation: • Tall V-wave (similar to tricuspid regurgitation) https://commons.wikimedia.org/wiki/File:Wiggers_diagram_with_jugular_venous_waveform.png
  • 72. ≣ Item 1 of 1 Question ID: 0038 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 56-year-old male with a past medical history of alcohol use and withdrawal seizures is brought to the emergency department from a homeless shelter with acute onset confusion, ataxia, and agitation. He is unable to recall the time of his last drink. Blood pressure is 168/68, heart rate is 126/min, respiratory rate is 16/min. On physical examination he appears to have diffuse muscular atrophy and peripheral edema in the distal lower extremities. The patient also appears tremulous and has visible nystagmus on testing of the extraocular muscles. An electrocardiogram is performed showing sinus tachycardia with no evidence of ST-segment elevation or depression. Chest radiography is shown below. Which of the following additional examination findings would be most expected in this patient? ⚪ A. Wide-fixed splitting of S1 heart sounds ⚪ B. Wide-fixed splitting of S2 heart sounds ⚪ C. Prominent S3 heart sound ⚪ D. Prominent S4 heart sound ⚪ E. Paradoxical splitting of S2 heart sounds https://upload.wikimedia.org/wikipedia/commons/7/75/Pulmonary_oedema.jpg
  • 73. OUTLINE 1. Regulation ● A. Renin ● B. Angiotensin Converting Enzyme ● C. Angiotensin II ● D. Natriuretic Peptides 2. Direct Pharmacologic Targets ● A. Angiotensin Converting Enzyme Inhibitors ● B. Angiotensin Receptor Blockers ● C. Direct Renin Inhibitors ● D. Neprilysin Inhibitors ● E. β1-antagonism Cardiology: Renin- Angiotensin- Aldosterone System
  • 74. Bootcamp.com Cardiology: RAAS • Renin • Location: Juxtaglomerular apparatus • Stimulus: ↑↑ Renin: β1 stimulation, ↓ pressure in renal artery, ↓ Na to distal tubules (kidney) • Function: Converts Angiotensinogen to Angiotensin I • Angiotensin Converting Enzyme (ACE) • Location: Lungs (primarily) • Function: Angiotensin I converted to Angiotensin II (ATII) by ACE https://en.wikipedia.org/wiki/Juxtaglomerular_apparatus#/media/File:Renal_corpuscle-en.svg
  • 75. Bootcamp.com Cardiology: RAAS • Actions Angiotensin II: • ↑ Vasoconstriction (↑ TPR) • ↑ Norepinephrine release and availability • ↑ Na reabsorption, ↑ blood volume • Stimulates aldosterone release from zona glomerulosa • Stimulates vasopressin (ADH) release from posterior pituitary https://commons.wikimedia.org/wiki/File:Renin-angiotensin-aldosterone_system.svg
  • 76. Bootcamp.com Cardiology: RAAS • Atrial Natriuretic Peptide (ANP) and Brain Natriuretic Peptide (BNP) • Location: Myocardium • Stimulus: ↑ Atrial and ventricular pressures • Function: ↑ Vasodilation, ↑ Diuresis, inhibition of aldosterone and renin release • Attempts to compensate (temporarily) for ATII in heart failure • Molecular Mechanism: • ↑ cGMP à stimulates vasodilation and diuresis https://commons.wikimedia.org/wiki/File:Renin-angiotensin-aldosterone_system.svg
  • 77. Bootcamp.com Cardiology: RAAS • ACE Inhibitors (Lisinopril, Captopril, Enalapril, -pril) • Inhibition of ACE à ↑ angiotensin I and renin, ↓ angiotensin II • Use: Hypertension, Nephroprotective effects (Diabetes), Cardioprotective effects (Heart failure) • Adverse Effect: Dry cough, hyperkalemia, angioedema • Angiotensin Receptor Blockers (ARBs) (Valsartan, Losartan, -sartan) • Receptor blockade of angiotensin II type 1 receptor • Use: Hypertension, Nephroprotective effects (Diabetes), Cardioprotective effects (Heart failure) • Direct Renin Inhibitors (Aliskiren) • Inhibition of conversion of angiotensinogen to angiotensin I • Use: Hypertension (not first line) • Neprilysin Inhibitors (Sacubitril) • Neprilysin inactivates ANP, BNP and AT-II • Use: Heart failure when combined with angiotensin-II receptor inhibitor • Selective β1-blockers (Metoprolol, Nebivolol, Esmolol, Atenolol) • Antagonism of β1 receptors at juxtaglomerular apparatus • Use: Coronary artery disease, cardiac arrhythmias (and many more) • Adverse Effect: Bradycardia, bradyarrhythmia (AV nodal block) https://commons.wikimedia.org/wiki/File:Renin-angiotensin-aldosterone_system.svg
  • 78. ≣ Item 1 of 1 Question ID: 0039 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 68-year-old female with a past medical history of osteoarthritis and hyperthyroidism presents to the emergency department with shortness of breath. She states that she has been having palpitations for the past two hours. She reports running out of her thyroid medication five weeks prior and has not yet refilled her prescription. She is later diagnosed with new onset atrial fibrillation with rapid ventricular response. She is initiated on metoprolol for rate control. Which of the following primary changes in chemical mediators will likely occur due to the initiation of this medication? Renin Angiotensin I Angiotensin II Aldosterone ⚪ A. ↑ ↑ ↑ ↑ ⚪ B. ↑ ↑ ↑ ↓ ⚪ C. ↑ ↑ ↓ ↓ ⚪ D. ↑ ↓ ↓ ↓ ⚪ E. ↓ ↓ ↓ ↓
  • 79. OUTLINE 1. ● A. ● B. ● C. ● D. ● ● ● ● ● 2. ● A. ● B. Cardiology: Exercise Physiology . ● A. ● B.
  • 80. Bootcamp.com Cardiology: Exercise Physiology • ↑ Preload • Venoconstriction à ↑ Venous return à ↑ LVEDV • Vasoconstriction of splanchnic vessels • Vasodilation at skeletal muscle à ↓ SVR (↓ DBP) à ↓ Afterload • ↑ Contractility • ↓ Afterload • Can be variable depending on dynamic vs static, muscle groups recruited, intensity, ect. • ↑ Heart Rate • ↑ Sympathetic tone (↓ Vagal tone) • ↓ Coronary Perfusion • ↓ Time spent in diastole at high heart rates • ↑ Minute Ventilation • ↑ O2 demand à ↑ RR, ↑TV à ↑ O2 consumption and CO2 production • ↑ Temperature • ↓ Arterial pH • ↑ Lactic acidosis
  • 81. Bootcamp.com Cardiology: Exercise Physiology • Fick Principle à Cardiac Output = Rate of O2 consumption / Arteriovenous O2 difference • VO2 = Rate of oxygen consumption • Oxygen Extraction Efficiency: • PaO2 relatively normal • PaCO2 relatively normal • Venous O2 decreased • Venous CO2 increased
  • 82. Bootcamp.com Cardiology: Exercise • General Rules: • Max HR = 220 - Age • Early exercise à HR and SV responsible for ↑ CO • Intense exercise à HR primarily responsible for ↑ CO • Athletic Cardiovascular Physiology: • Max HR not affected by athletic ability • Stroke volume primarily responsible for ↑↑ CO • ↑ VO2 maximum • ↑ RBC mass and plasma volume à ↑ O2 carrying capacity • ↑ Efficiency of skeletal muscle oxygen extraction • ↑ Vascularization of skeletal muscle • ↓ resting heart rate
  • 83. ≣ Item 1 of 1 Question ID: 0040 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 26-year-old female professional cyclist is training for a 143- km bicycle-road race. She is seen by her primary care physician one week prior to the event for a check-up. Vital signs are shown below. Her physical examination is unremarkable. Temperature: 97.2F (36.2C) Blood pressure: 110/62 mmHg Heart rate: 52/min Respiratory rate: 10/min Oxygen saturation: 100% on room air Which of the following is most consistent with the hemoglobin-oxygen dissociation curve of the patient during the upcoming cycling event, assuming the blue curve (A.) is consistent with her baseline at rest? ⚪ A ⚪ B. ⚪ C. ⚪ D. ⚪ E. Hemoglobin O 2 Saturation (%) Arterial Partial Pressure of O2 (mmHg)
  • 84. OUTLINE 1. ● A. ● B. ● C. ● D. ● E. 2. ● A. ● B. 3. ● A. ● B. ● Cardiology: Cardiac Conductive Physiology . ● A. ● B. ● ●
  • 85. Bootcamp.com Cardiology: Cardiac Conductive Physiology • Sinoatrial (SA) Node • Site of electrical impulse generation • Pacer rate of 60-100 per minute • Supplied by RCA • Atrioventricular (AV) Node • Delays conduction from SA node • Pacer rate of 45-55 per minute • Supplied by PDA (usually RCA) • Bundle of His • Prevents retrograde electrical conduction • Right Bundle à Right ventricle • Left Bundle à Left ventricle (anterior and posterior) • Purkinje Fibers • Transmits conduction across ventricles https://en.wikipedia.org/wiki/Purkinje_fibers#/media/File:ConductionsystemoftheheartwithouttheHeart-en.svg Cardiac Conduction Velocity Purkinje > Atrial myocytes > Ventricular myocytes > AV node
  • 86. Bootcamp.com Cardiology: Cardiac Conductive Physiology • Pacemaker Cells • Exhibit automaticity (spontaneous depolarization) • Absence of Phase 1 and 2 • Phase 4 is a slow depolarization phase • Phase 4: Pacemaker Potential • Begins with: ↑ Permeability of inward Na+ (If) current à Slow, spontaneous depolarization • Then: ↑ Permeability T-type and L-type Ca2+ current à Further depolarization • Phase 0: Action Potential Depolarization • Begins when threshold is reached • Na+ current and T-type calcium current decreases • Increased L-type Ca2+ current à Action potential depolarization • Phase 3: Action Potential Repolarization • Outward K+ current à Hyperpolarization • Inward L-type Ca2+ current decreases (inactivation) https://commons.wikimedia.org/wiki/File:2020_SA_Node_Tracing.jpg
  • 87. Bootcamp.com Cardiology: Cardiac Conductive Physiology • Non-Pacemaker Cells • Do not exhibit automaticity • Phases 0-4 are present • Phase 4 is a resting potential phase (approximates equilibrium potential of potassium) • Phase 4: Resting Membrane Potential • ↑ Permeability of outward K+ current • Fast Na+ channels and L-type Ca2+ channels are closed • Phase 0: Action Potential Depolarization • Begins with depolarization from action potential at adjacent cell • ↑ Permeability of inward fast Na+ current • ↓ Permeability of outward K+ current • Phase 1: Early Repolarization • Transient ↑ permeability of outward K+ current • Rapid closure of fast Na+ channels (inactivation) • Phase 2: Plateau Phase • L-type Ca2+ channels are open and balance K+ efflux • Phase 3: Late Repolarization • Various K+ channels open à ↑↑ permeability outward K+ current • Inactivation of L-type Ca2+ channels https://en.wikipedia.org/wiki/Ventricular_action_potential#/media/File:Action_potential_ventr_myocyte.gif
  • 88. Bootcamp.com Cardiology: Cardiac Conductive Physiology • Sympathetic Stimulation Effects on Pacemaker Potentials • β1 stimulation à ↑ cAMP à ↑ permeability of inward calcium current à ↑ HR • Parasympathetic Stimulation Effects on Pacemaker Potentials • M2 stimulation à ↓ cAMP à ↓ permeability of inward calcium current à ↓ HR • Sodium Channelopathy: • Impairment of inward fast Na+ current (Phase 0) • Brugada Syndrome: AD, ECG: ST-elevation in V1-V3, pseudo-RBBB • QT Interval Prolongation • Delayed ventricular repolarization • Impairment of voltage-gated potassium channels à delayed rectifier potassium current • May lead to torsade de pointes (“twisting of the peaks”), ventricular tachycardia à sudden cardiac death • Romano-Ward Syndrome: AD, no associated sensorineural hearing loss • Jervell and Lange-Nielsen Syndrome: AR, associated congenital bilateral sensorineural hearing loss • Drug Induced: *see table below* Class Classic Drug Other Drugs/Effects A Antiarrhythmics Quinidine Disopyramide, procainamide, sotalol, dofetilide B Antibiotics Macrolides Fluoroquinolones C Antipsychotics Haloperidol Ziprasidone D Antidepressants Tricyclic antidepressants Methadone E Antiemetics/Electrolytes Ondansetron Hypocalcemia, hypokalemia, hypomagnesemia F Antifungals Azoles https://www.wikidata.org/wiki/Q1625433#/media/File:Tosadesdepointes.jpg https://en.wikipedia.org/wiki/Long_QT_syndrome#/media/File:Long_QT_syndrome_type_1.jpg
  • 89. ≣ Item 1 of 1 Question ID: 0041 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 14-year-old male with a past medical history of mild intermittent asthma presents to the emergency department with a productive cough and mild shortness of breath that started before going to school this morning. His mother reports that he has been nauseous this morning and hasn’t eaten his breakfast. She also states that he has a family history of “bad luck with the heart” on his father’s side. His father is deceased from unknown cause of sudden cardiac death at age 38. The patient is up to date with vaccinations. Vitals are stable and he is saturating 99% on room air. Mild end-expiratory wheezing is auscultated. Laboratory workup is unrevealing. The patient is given a single dose of azithromycin and ondansetron. He is monitored in the emergency room. The patient’s respiratory symptoms improve, and he is prescribed a short-acting inhaled beta-agonist on discharge. Four hours later, the patient returns to the emergency room with his mother for acute worsening of shortness of breath. Electrocardiogram findings from lead II are shown below. Which of the following most likely explains the cause of this patient’s return to the emergency department? ⚪ A. Decreased inward calcium current in pacemaker cells ⚪ B. Decreased inward calcium current in cardiomyocytes ⚪ C. Decreased inward sodium current in cardiomyocytes ⚪ D. Decreased outward potassium current in cardiomyocytes ⚪ E. Increased outward potassium current in pacemaker cells https://commons.wikimedia.org/wiki/File:De-Acquired_longQT_(CardioNetworks_ECGpedia).jpg
  • 90. OUTLINE 1. ● A. ● B. ● C. ● D. 2. ● A. ● B. ● ● Cardiology: Antiarrhythmics ● A. ● ● . . ● A. ● ● ●
  • 91. Bootcamp.com Cardiology: Antiarrhythmics Overview • Class I • Three subclasses: Class IA, IB, IC • Blockade of fast Na+ channels • Class II • β-blockers • Delayed atrial ➔ ventricular depolarization • Class III • Blockade of potassium channels • Class IV • Calcium channel blockers • Delayed atrial ➔ ventricular depolarization https://en.wikipedia.org/wiki/Antiarrhythmic_agent#/media/File:Cardiac_action_potential.png
  • 92. Bootcamp.com Cardiology: Antiarrhythmics • Class IA • Quinidine, Procainamide, Disopyramide • Mechanism: Moderate blockade of fast Na+ channels (Non-pacemaker) • ↑ Action potential duration, ↓ Diastole • Widening of QRS, QT prolongation • Quinidine à Cinchonism • Drug-Induced Lupus à Procainamide • Class IB • Lidocaine, Mexiletine, Phenytoin • Mechanism: Weak blockade of fast Na+ channels (Non-pacemaker) • ↓ Action potential duration, ↑ Diastole • QRS prolongation, shortened QT interval • ↑↑ Efficacy on ischemic Purkinje and ventricular myocardial cells • Class IC • Flecainide, Propafenone • Mechanism: Strong blockade of fast Na+ channels • • • QRS prolongation, no significant change in QT (Exceptions exist) • Flecainide à ↑ Action potential duration • Contraindicated in ischemic heart disease (Proarrhythmic) • • • https://commons.wikimedia.org/wiki/File:Action_potential_Class_Ib.svg https://commons.wikimedia.org/wiki/File:Action_potential_class_Ia.svg https://commons.wikimedia.org/wiki/File:Action_potential_class_Ic.svg
  • 93. Bootcamp.com Cardiology: Antiarrhythmics • Class II • Metoprolol, Esmolol, Propranolol, Atenolol, Carvedilol • Mechanism: Inhibition of cAMP à ↓ intracellular Ca2+ • Prolonged Phase 4 (Pacemaker) • PR prolongation
  • 94. Bootcamp.com Cardiology: Antiarrhythmics • Class III • Sotalol, Ibutilide, Dofetilide • Mechanism: Inhibition of K+ channels (delayed rectifier potassium current) • ↑ Action potential duration • QT prolongation à torsades de pointes • Sotalol prolongs PR interval; Ibutilide and Dofetilide do not
  • 95. Bootcamp.com Cardiology: Antiarrhythmics • Class IV • Verapamil, Diltiazem • Mechanism: Inhibition of L-type Ca2+ channels (Pacemaker) • Prolonged Phase 0 and Phase 4 (Pacemaker) • PR prolongation
  • 96. Bootcamp.com Cardiology: Antiarrhythmics • Adenosine • Mechanism: Inhibition of L-type Ca2+ channels, ↑ K+ conductance • Prolonged Phase 4 (Pacemaker) • Classic use: Paroxysmal supraventricular tachycardia • Adverse effects: Sense of impending doom, flushing, chest pain • Digoxin • Mechanism: Inhibition of Na+/K+ ATPase à ↑ intracellular Ca2+ • Adverse effects: Blurry, yellow discoloration to vision • Magnesium • Mechanism: ↓ intracellular Ca2+ • Classic use: Torsades, digoxin toxicity • Ivabradine • Mechanism: Inhibition of Na+ slow (funny) channels • Prolonged Phase 4 (Pacemaker) • Adverse effects: Visual luminous phenomenon (↑ visual brightness)
  • 97.
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  • 99. ≣ Item 1 of 1 Question ID: 0043 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 38-year-old male with a past medical history of hypertension, mild intermittent asthma, and a recent diagnosis of pre-excitation cardiac conduction abnormalities, presents to his primary care physician for a fixed erythematous rash over the malar eminences with sparing of the nasolabial folds. He reports that the rash started after a long afternoon at the beach. He denies any pruritis or drainage from the lesion. He also reports feeling a dull, soreness in the deltoid region bilaterally. On physical exam multiple painless ulcers are noted along the oral mucosa. After a thorough review of the patient’s medications, a laboratory workup is performed and shown below. Leukocyte count: 10,800/mm3 Hemoglobin: 13.7 g/dL Platelet count: 165,000/mm3 Sodium: 136 mEq/L Potassium: 4.4 mEq/L Chloride: 102 mEq/L Creatinine: 1.6 mg/dL Antinuclear (ANA) antibody: Positive for elevation in ANA titer Anti-double-stranded DNA antibody: Negative Antihistone antibody: Positive Anti-smith antibody: Negative Anti-Ro antibody: Negative ⚪ A. Increased potassium conductance ⚪ B. Decreased action potential duration ⚪ C. Increased action potential duration ⚪ D. Increased vagal nerve output to the atrioventricular node ⚪ E. Inhibition of L-type calcium channel conductance Which of the following changes to the electrical conductivity is most likely occurring in ventricular cardiomyocytes as a result of iatrogenic causes in this patient?
  • 100. OUTLINE 1. Atrial Fibrillation ● A. Pathophysiology ● B. Presentation ● C. Precipitating Factors ● D. Complications ● E. Rate Control ● F. Rhythm Control ● G. Catheter Ablation ● H. Anticoagulation ● I. Hemodynamics in Heart Failure ● J. Jugular Venous Pressure Tracing ● K. ECG Findings 2. Atrial Flutter ● A. Pathophysiology ● B. Presentation ● C. Precipitating Factors ● D. Management ● E. ECG Findings 3. Sick Sinus Syndrome ● A. Pathophysiology ● B. Presentation ● C. Association ● D. Management Cardiology: Atrial Arrhythmias
  • 101. Bootcamp.com Cardiology: Atrial Arrhythmias • Pathophysiology: • Automatic foci in vicinity of pulmonary veins à structural fibrotic remodeling of atria à ↑ risk of occurrence • Rapid uncoordinated atrial contractions à AV node intermittently refractory à Rapid ventricular response • Presentation: • Irregularly irregular rhythm, absence of P waves • Palpitations • Tachycardia • Shortness of breath, dizziness, palpitations • Precipitating Factors: • Cardiovascular disease (Coronary artery disease, hypertension, heart failure) • Hyperthyroidism • Mitral stenosis • ↑ Sympathetic tone (cocaine, amphetamines, EtOH) • Complications: • Embolic phenomena à left atrial appendage • Pulmonary edema • Ventricular tachycardia https://commons.wikimedia.org/wiki/File:Heart_conduct_atrialfib.gif https://commons.wikimedia.org/wiki/File:Heart_conduct_sinus.gif https://commons.wikimedia.org/wiki/File:Afib_ecg.jpg
  • 102. Bootcamp.com • Rate Control: • β-blockers and CCBs: Preferred first-line • Digoxin: Second-line, useful in systolic dysfunction • Rhythm Control: • Class IC Antiarrhythmics (Flecainide, propafenone) • Class III Antiarrhythmics (Ibutilide, sotalol) • Amiodarone • Catheter Ablation: • Symptomatic paroxysmal atrial fibrillation à ablation at pulmonary vein ostia (left atrium) • Persistent atrial fibrillation with RVR à ablation can be at other sites like AV node (right atrium) • Amiodarone • Anticoagulation • Hemodynamics in Heart Failure • Left atrial dilatation • ↓ LV Preload à ↓ CO • ↑ PCWP • Pulmonary edema • Jugular Venous Pressure Tracing • Loss of a waves https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg Cardiology: Atrial Arrhythmias
  • 103. Bootcamp.com https://commons.wikimedia.org/wiki/File:ECG_Atrial_Fibrillation.jpg Absence of P waves Irregularly irregular (varying R-R intervals) Narrow QRS complexes Cardiology: Atrial Arrhythmias
  • 104. Bootcamp.com • Pathophysiology: • Re-entry circuit in right atrium (most common) • Presentation: • Sawtooth appearance of P waves • Generally, regular rhythm (exceptions exist) • 2:1 conduction is most common • Tachycardia is common • Shortness of breath, dizziness, palpitations • Precipitating Factors: • Similar to atrial fibrillation • Management: • Rhythm control, rate control • Catheter ablation of re-entrant circuit (right atrium) https://commons.wikimedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).svg Cardiology: Atrial Arrhythmias
  • 105. Bootcamp.com • Pathophysiology: • Fibrosis and degeneration of the SA node (usually age-related) • Iatrogenic (β-blockers, CCBs, Digoxin) • Presentation: • Bradycardia, delayed P waves, dropped P waves • Junctional escape beats • Syncope, fatigue, shortness of breath • HR doesn’t increase as expected with exercise • Tachycardia-Bradycardia Syndrome • Association: • Elderly • Management: • Iatrogenic: Stop offending medications as necessary • Asymptomatic: Conservative • Acute (Unstable) Symptomatic: Atropine à Temporary cardiac pacing • Long Term (Stable) Symptomatic: Permeant Pacemaker placement, selective β-blockers Cardiology: Atrial Arrhythmias https://commons.wikimedia.org/wiki/File:Brady-tachy_syndrome_AV-junctional_rhythm.png
  • 106. ≣ Item 1 of 1 Question ID: 0043 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 46-year-old male with a past medical history of cocaine and alcohol use presents to the emergency room for palpitations. He states that he went out on a “binge” prior to arrival. His last drink was reported to have been five minutes prior to walking into the emergency department. An ECG strip is shown below. Which of the following is most likely directly related to the heart rate observed in this patient? ⚪ A. Accessory pathway bypassing the atrioventricular node ⚪ B. Pacing initiation triggered at the atrioventricular node ⚪ C. Complete conduction through the atrioventricular node ⚪ D. Intermittent conduction through the atrioventricular node ⚪ E. Negligible conduction through the atrioventricular node https://commons.wikimedia.org/wiki/File:Atrial_Fibrillation_in_two_leads.jpg
  • 107. OUTLINE 1. Supraventricular Tachycardia ● A. Pathophysiology ● B. Presentation ● C. ECG Findings ● D. Management 2. Wolff-Parkinson-White Syndrome ● A. Pathophysiology ● B. ECG in Sinus WPW ● C. ECG in AVRT WPW ● D. Presentation ● E. Management ● F. Complications 3. Torsades De Pointes ● A. Pathophysiology ● B. Causes ● C. ECG Findings ● D. Management ● E. Complications 4. Monomorphic Ventricular Tachycardia ● A. Pathophysiology ● B. Causes ● C. ECG Findings 5. Ventricular Fibrillation ● A. Pathophysiology ● B. Causes ● C. ECG Findings Cardiology: Ventricular Arrhythmias and Pre-Excitation Syndromes
  • 108. Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Re-entrant pathway within the AV node, accessory pathway, or SA node • Most common = Atrioventricular nodal re-entrant tachycardia (AVNRT) • Second most common = Atrioventricular re-entrant tachycardia (AVRT) • Presentation: • Young patient, no significant cardiac history • Abrupt onset, chest pain, dyspnea, palpitations • ECG Findings: • Narrow QRS (< 3 little boxes) tachycardia • Heart rate usually >150 beats per minute • P wave may be buried within the QRS complex • Management (Stable): • Vagal maneuvers (Carotid sinus massage) • Adenosine • CCBs, β-blockers • Management (Unstable): • Electrical cardioversion (Immediate) • Catheter ablation of re-entry pathway (Definitive) https://commons.wikimedia.org/wiki/File:SVT_Lead_II-2.JPG SVT AVRT AVNRT Atrial T.
  • 109. Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Sinus: Accessory pathway (Bundle of Kent) à bypass AV node (anterograde through bundle of Kent) • Orthodromic AVRT: Re-entrant circuit (anterograde through AV node, retrograde through bundle of Kent) • Antidromic AVRT: Re-entrant circuit (anterograde through bundle of Kent, retrograde through AV node) • ECG in Sinus WPW: • Shortened PR interval • Early, “slurred” upstroke of QRS (delta wave) • Wide QRS • ECG in AVRT WPW: • Narrow QRS • P wave follows QRS (usually) • Presentation: • Sinus: Generally asymptomatic • AVRT: Generally symptomatic • Management (Stable): • Procainamide à ideal for antidromic AVRT • Adenosine, CCB à ideal for orthodromic AVRT • Management (Unstable): • Electrical cardioversion • Catheter ablation (definitive) • Complications: • AV nodal blocking agents and vagal maneuvers à ventricular tachycardia or ventricular fibrillation (unrestricted transmission) https://commons.wikimedia.org/wiki/File:SVT_Lead_II-2.JPG
  • 110. Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Prolonged action potential in cardiomyocytes à Prolonged QT interval à ↑ risk of TdP • Causes: • Congenital Long QT Syndrome (usually younger patient) • ECG Findings: • Polymorphic ventricular tachycardia (“twisting of the peaks” pattern) • Irregularly irregular rhythm • Sinusoidal change in amplitude of QRS complexes • Management: • Intravenous magnesium • Avoid QT-prolonging medications during acute TdP • Complication: • Ventricular fibrillation or sudden cardiac death Class Classic Drug Other Drugs/Effects A Antiarrhythmics Quinidine Disopyramide, procainamide, sotalol, dofetilide B Antibiotics Macrolides Fluoroquinolones C Antipsychotics Haloperidol Ziprasidone D Antidepressants Tricyclic antidepressants Methadone E Antiemetics/Electrolytes Ondansetron Hypocalcemia, hypokalemia, hypomagnesemia F Antifungals Azoles https://commons.wikimedia.org/wiki/File:Tosadesdepointes.jpg
  • 111. Bootcamp.com Cardiology: Ventricular Arrhythmias • Pathophysiology: • Aberrant ventricular foci • Intraventricular re-entry circuit • Causes: • Ischemic and/or structural heart disease • Complication of acute MI • Electrolyte disturbances (hypokalemia, hypomagnesemia) • Acidosis, hypoxemia • ECG Findings: • Wide QRS (≥3 little boxes) monomorphic tachycardia • Typically, regular rhythm • Poorly discernible P or T waves at high rates • Heart rates of 100-300 beats per minute • Pathophysiology: • Uncoordinated ventricular depolarization • Causes: Similar to Ventricular Tachycardia • Association: Cardiac arrest • ECG Findings: • Wide QRS (≥3 little boxes) tachycardia • Heart rates of 100-300 beats per minute • Complication: • Sudden cardiac death (rapid) https://commons.wikimedia.org/wiki/File:Lead_II_rhythm_ventricular_tachycardia_Vtach_VT_(cropped).JPG https://commons.wikimedia.org/wiki/File:Ventricular_fibrillation.png Ventricular arrhythmias are common in the first 24-48 hours after MI
  • 112. ≣ Item 1 of 1 Question ID: 0043 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪✪ Bootcamp.com A 28-year-old female with a past medical history of alcohol use presents to the emergency department with palpitations and tremors. She denies any chest pain or nausea. The patient states that she recently started using cocaine approximately two months prior. ECG reveals an irregularly irregular rhythm with an erratic baseline, absent P-waves, and an approximate heart rate of 140/min. An intravenous drug is administered. The patient reports becoming very anxious after the drug is given. A cardiac monitoring rhythm strip taken after the patient received the intravenous drug is also shown. The patient subsequently loses consciousness and acute resuscitative measures are initiated. Which of the following intravenous medications were most likely given to this patient? ⚪ A. Diltiazem ⚪ B. Procainamide ⚪ C. Quinidine ⚪ D. Amiodarone ⚪ E. Ibutilide https://commons.wikimedia.org/wiki/File:Ventricular_fibrillation.png
  • 113. OUTLINE 1. Atrioventricular Blocks ● A. First Degree ● B. Second Degree, Mobitz Type I (Wenckebach) ● C. Second Degree, Mobitz Type II ● D. Third Degree 2. Bundle Branch Blocks ● A. Right Bundle Branch Blocks ● B. Left Bundle Branch Blocks 3. Cardiac Conduction Blood Supply ● A. Right Coronary Artery ● B. Left Anterior Descending Artery Cardiology: Conduction Blocks
  • 114. Bootcamp.com Cardiology: Conduction Blocks • First Degree: • PR interval >5 little boxes (200ms) • Unchanged P-P intervals • Regular rhythm • Low risk block à Generally conservative management • Second Degree, Mobitz Type I (Wenckebach): • Progressive lengthening of PR interval until QRS is dropped • Regularly irregular rhythm • Low risk block à Generally conservative management • Second Degree, Mobitz Type II: • Intermittent non-conducted P-waves à dropped QRS • Unchanged P-P intervals • Regularly irregular rhythm • Medium-High risk block à Review medications, pacemaker • Third Degree: • Complete AV dissociation (between QRS and P waves) • High risk block à Review medications, pacemaker High Yield Causes: Ischemic heart disease Hyperkalemia Lyme Disease Endocarditis/ARF Iatrogenic AV Nodal Blocking Agents Calcium Channel Blockers β-blockers Adenosine Digoxin Asymptomatic Symptomatic https://en.wikipedia.org/wiki/Heart_block
  • 115. Bootcamp.com Cardiology: Atrioventricular Blocks • Right Bundle Branch Block (RBBB): • Classic causes: Pulmonary embolus, right heart strain, ischemic heart disease • Pseudo-RBBB in Brugada (with ST-elevation in V1-V3) • ”M” shape, “rabbit ears” (Focus on V1) • Slurring of S-wave (Focus on V6) • Left Bundle Branch Block (LBBB): • Classic causes: AS, AR, Lyme disease, dilated cardiomyopathy, ischemic heart disease • Lack of R waves (Focus on V1) • Notched R waves (Focus on V6) https://commons.wikimedia.org/wiki/File:ConductionsystemoftheheartwithouttheHeart-en.svg https://commons.wikimedia.org/wiki/File:Cardiogram_indicating_right_bundle_branch_block.jpg https://commons.wikimedia.org/wiki/File:Right_bundle_branch_block_ECG_characteristics.svg https://commons.wikimedia.org/wiki/File:Left_bundle_branch_block_ECG_characteristics.svg
  • 116. Bootcamp.com Cardiology: Atrioventricular Blocks • Right Coronary Artery: • SA node • AV node (usually) • Bundle of His (major) • Proximal right bundle branch • Left Anterior Descending Artery: • Bundle of His (minor) • Complete left bundle branch • Distal right bundle branch
  • 117. ≣ Item 1 of 1 Question ID: 0045 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪✪ Bootcamp.com A 14-year-old male presents to his pediatrician with his father for shortness of breath and fatigue. He has no significant past medical history although his father has a history of asthma. His father denies any family history of heart disease or sudden cardiac death. The patient states that he has felt “winded” with activity over the past week. According to his father, the shortness of breath became particularly bothersome during football practice. The patient also reports a mild erythematous rash on his forearm that had resolved within three days. The rash was first noticed two weeks earlier when on a hiking trip with family. The patient denies any chest pain, nausea, and diarrhea. Vital signs are shown below. An ECG performed in-office is also shown. ⚪ A. Inhaled short-acting β-agonist ⚪ B. Transient hyperpolarization of cardiac nodal cells ⚪ C. Inhibition of Na+/K+ ATPase in myocardial cells ⚪ D. Inhibition of cardiac L-type calcium channels ⚪ E. Irreversible inhibition of bacterial cell wall synthesis https://commons.wikimedia.org/wiki/File:Complete_A-V_block_with_resulting_junctional_escape.png Temperature: 99.7F (37.6C) Heart rate: 30/min Blood pressure: 74/44 Respiratory rate: 18/min Oxygen saturation: 94% on room air A drug with which mechanism of action would most likely improve this patient’s condition?
  • 118. OUTLINE 1. Heart Failure Overview ● A. Heart Failure Variants of Disease ● B. Heart Failure Location (Left vs Right) ● C. Heart Failure Presentation 2. Systolic Heart Failure ● A. Causes ● B. Pathophysiology 3. Diastolic Heart Failure ● A. Causes ● B. Pathophysiology 4. High and Low Output Heart Failure ● A. Classic Causes 5. Pharmacologic Targets ● A. ACE Inhibitors, ARBs ● B. Mineralocorticoid Receptor Antagonists ● C. β-blockers ● D. Neprilysin Inhibitors ● E. Loop Diuretics ● F. Thiazine Diuretics ● G. Digoxin Cardiology: Heart Failure
  • 119. Bootcamp.com Cardiology: Heart Failure • Systolic: • Heart failure with reduced ejection fraction (HFrEF) • Principal determinant: ↓ Contractility à ↑↑↑ Volume • Diastolic: • Heart failure with preserved ejection fraction (HFpEF) • Principal determinant: ↑↑↑ Pressure à ↓ Compliance • High-Output • Low-Output https://en.wikipedia.org/wiki/Heart_block Heart Failure Variant Heart Failure Location • Left: • ↑ LAP (PCWP) • Pulmonary edema • Pleural effusion • Functional mitral valve regurgitation • Right: • MCC à Left heart failure • If not from left heart failure, unlikely pulmonary edema • Hypoxic pulmonary vasoconstriction (Pulmonary HTN) • Left parasternal lift • Jugular venous distention • Peripheral edema • Hepatomegaly (Nutmeg liver) • Ascites • Functional tricuspid valve regurgitation
  • 120. Bootcamp.com Cardiology: Heart Failure • Subjective: • Dyspnea with activity (or at rest in severe stages) • Orthopnea • Paroxysmal nocturnal dyspnea • Objective • Jugular venous distention • Pulmonary crackles • Reduced Lung Sounds • Shifted PMI (LVH) • Left parasternal lift (RVH) • S3 heart sound • S4 heart sound à classic for diastolic HF • ↑↑↑ BNP https://commons.wikimedia.org/wiki/File:Normal_posteroanterior_(PA)_chest_radiograph_(X-ray).jpg https://commons.wikimedia.org/wiki/File:Pulmonaryedema09.JPG https://commons.wikimedia.org/wiki/File:Combinpedal.jpg
  • 121. Bootcamp.com Cardiology: Heart Failure • Overview: • Heart failure with reduced ejection fraction (HFrEF) • Principal determinant: ↓ Contractility à ↑↑↑ Volume • Causes: • Ischemic heart disease • Viral myocarditis • Chronic Alcohol Use • Pathophysiology: • ↓ Contractility (↓ EF) à ↓ CO à ↑ LVEDP • Eccentric hypertrophy: ↑ Contractile proteins added in series • ↑ Compliance, ↓ CO, ↓ EF https://en.wikipedia.org/wiki/Heart_block
  • 122. Bootcamp.com Cardiology: Heart Failure • Overview: • Heart failure with preserved ejection fraction (HFpEF) • Principal determinant: ↑↑↑ Pressure à ↓ Compliance • Causes: • Prolonged hypertension • Aortic stenosis • Infiltrative disorders • Pathophysiology: • ↑ LVP à ↑ Contractility • Concentric hypertrophy: ↑ Contractile proteins added in parallel • ↓ Compliance, ↓ CO, normal EF • Additional Clinical Features: • S4 (due to stiff ventricle) https://en.wikipedia.org/wiki/Heart_block
  • 123. Bootcamp.com Cardiology: Heart Failure • Classic Causes: • Thiamine deficiency • Severe anemia • Hyperthyroidism • Arteriovenous fistula https://en.wikipedia.org/wiki/Heart_block • Classic Cause: • Cardiogenic shock
  • 124. Bootcamp.com Cardiology: Heart Failure • ACE Inhibitors (Lisinopril, Captopril, Enalapril, -pril) • Inhibition of ACE à ↓ angiotensin II • Adverse Effect: Dry cough, hyperkalemia, angioedema • Angiotensin Receptor Blockers (ARBs) (Valsartan, Losartan, -sartan) • Receptor blockade of angiotensin II type 1 receptor • Mineralocorticoid receptor Antagonists (Spironolactone, Eplerenone) • β-blockers (Metoprolol, Carvedilol) • Neprilysin Inhibitors (Sacubitril): • Neprilysin is a metalloproteinase that inactivates ANP, BNP, and AT-II • ↑ ANP, ↑ BNP, ↑ AT-II • Used with angiotensin-II receptor blocker • Loop Diuretic (Furosemide): • Inhibition of Na/K/Cl transporter in ascending limb of loop of Henle • Primary use: Fluid retention and pulmonary edema • Thiazide Diuretic (Metolazone): • Inhibition of Na/Cl transporter in distal tubule • Potentiation of loop diuretic effect • Digoxin: • Inhibition of Na+/K+-ATPase in myocytes • ↑ Vagal activity to nodal cells • ↑ intracellular calcium concentration in ventricular myocytes • Toxicity: Disturbed color perception, GI symptoms, arrhythmias • Precipitated by hypokalemia https://en.wikipedia.org/wiki/Heart_block
  • 125. ≣ Item 1 of 1 Question ID: 0046 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪ Bootcamp.com A 57-year-old obese female with a past medical history of type II diabetes mellitus, dyslipidemia, chronic hypertension, and coronary artery bypass grafting performed 7 years earlier presents to the emergency department for shortness of breath. She denies any tobacco use and states that she has a glass of wine on rare occasion. She states that she was having difficulty sleeping through the night because she is running to the bathroom every few hours to void. She reports throwing away her ”water pills” last week due to frustration. Blood pressure is 164/88mmHg, heart rate 88/min, respiratory rate 14/min, saturating 94% on 2 liters of oxygen by nasal cannula. Physical exam reveals diffuse crackles bilaterally in the lung fields, an S3 heart sound, and 2+ pitting edema in the bilateral lower extremities. Chest X-ray is shown below. ECG reveals a normal sinus rhythm with mild left ventricular hypertrophy. Thyroid stimulating hormone levels are within normal limits. B-type natriuretic peptide level is significantly elevated. Patient had an echocardiogram performed three months earlier revealing a left ventricular ejection fraction of 30%. ⚪ A. Depressed pulmonary capillary wedge pressure ⚪ B. Depressed central venous pressure ⚪ C. Elevated cardiac index ⚪ D. Increased urinary potassium excretion ⚪ E. Significantly decreased serum levels of vitamin B1 Which of the following findings are most consistent with this patient’s acute presentation? https://radiopaedia.org/articles/heart-failure-summary?lang=us
  • 126. OUTLINE 1. Cardiomyopathy Overview ● A. Major Types of Cardiomyopathy ● B. Cardiac Myocyte Histology 2. Dilated Cardiomyopathy ● A. Pathophysiology ● B. Systolic Heart Failure ● B. Other Classic Causes 3. Restrictive Cardiomyopathy ● A. Pathophysiology ● B. Infiltrative Disease ● C. Diastolic Heart Failure 4. Hypertrophic Obstructive Cardiomyopathy ● A. Pathophysiology ● B. Classic Causes ● C. Histopathology ● D. Management 5. Viral Myocarditis 6. Chagas Disease 7. Takotsubo Cardiomyopathy 8. Amyloid Cardiomyopathy 9. Aging of Cardiomyocytes 10. Other Causes of Cardiomyopathy Cardiology: Cardiomyopathy
  • 127. Bootcamp.com Cardiology: Cardiomyopathy • Dilated Cardiomyopathy: • Association with Systolic HF • Restrictive Cardiomyopathy: • Association with Diastolic HF • Hypertrophic Obstructive Cardiomyopathy • Normal contractility • ↓ Ventricular cavity size • Impaired diastolic function • Septal hypertrophy • Histology of Cardiomyocytes: • Central appearing nuclei • Striation's present • Branching cardiomyocytes https://commons.wikimedia.org/wiki/File:414c_Cardiacmuscle.jpg https://commons.wikimedia.org/wiki/File:Blausen_0470_HeartWall.png https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png
  • 128. Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology Systolic Heart Failure: • Eccentric hypertrophy • ↑ Contractile proteins added in series • ↑ LV mass, ↑ LV cavity, ↓ LV EF, Normal LV relaxation • Highest Yield Causes: • Systolic heart failure • Viral myocarditis • Chaga’s Disease • Takotsubo • Additional Causes: • Familial (AD, truncating mutation of TTN gene) • Pregnancy • Anthracyclines (doxorubicin) • Excess alcohol use • Selenium deficiency https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png
  • 129. Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology Diastolic Heart Failure: • Concentric hypertrophy • ↑ Contractile proteins added in parallel • ↑ LV mass, ↓ LV cavity, Normal/↓ LV EF, ↓ LV relaxation • Pathophysiology Restrictive Cardiomyopathy: • Stiffened ventricular walls, not typically thickened (exceptions exist: Amyloidosis) • Normal LV mass, Normal or ↓ LV cavity, Normal LV EF, ↓ LV relaxation • Highest Yield Causes: • Diastolic heart failure à Prolonged hypertension, Aortic stenosis • Infiltrative disorders à Amyloidosis, hemochromatosis, sarcoidosis • Radiation-induced • Infiltrative Disease Considerations: • Variable ventricular wall thickness (vs hypertensive secondary cause) • Prominent y-descent • Conduction abnormalities https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png
  • 130. Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Genetic mutations of cardiac sarcomere à • β-myosin heavy chain and myosin-binding protein C • Autosomal dominant (most cases) • Dynamic LV outflow tract obstruction (↑ LV septal thickness) • ↑ LV mass, ↓ LV cavity, Normal/↑ LV EF, ↓ LV relaxation • Classic Case: • Generally asymptomatic until strenuous exercise • Sudden cardiac death, young patient • Systolic crescendo-decrescendo murmur at LLSB +/- holosystolic murmur at apex • Valsalva à ↓ LV blood volume à Worsen obstruction à ↑ ejection murmur • Passive leg raise à ↑ LV blood volume à Improve obstruction à ↓ ejection murmur • S4 heart sound • Histopathology: • Myofibrillary disarray and interstitial fibrosis • Mitral Valve: • Anterior mitral leaflet in closer proximity to aortic valve • Distorted mitral valve à ejection against valve à functional mitral regurgitation • Management: • Avoid dehydration and strenuous exercise • β-blockers https://commons.wikimedia.org/wiki/File:Tipet_e_kardiomiopative.png https://commons.wikimedia.org/wiki/File:HCM%EF%BC%BFHE.jpg
  • 131. Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Direct viral-induced cytotoxic effect to myocardial cells • Dilated cardiomyopathy (usually) • Etiology: • Coxsackievirus • Adenovirus • Influenza virus • Classic Case: • Young patient + viral prodrome • Histopathology: • Irregular banding patterns, less nuclei observed • Inflammatory infiltration with lymphocytes • Primary Cardiomyopathy Subtype: • Dilated cardiomyopathy https://en.wikipedia.org/wiki/Heart_block
  • 132. Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Direct parasitic-induced cytotoxic effects • Etiology: • Trypanosoma cruzi (Reduviid family) • Classic Case: • Central and South America • Histopathology: • Protozoa peripheral to myocytes • Inflammatory infiltration with lymphocytes • Primary Cardiomyopathy Subtype: • Localized apical wall thinning and/or aneurysm • ↑ risk of mural thrombus and/or emboli • Dilated cardiomyopathy • Other Features: • Megaesophagus • Megacolon https://en.wikipedia.org/wiki/Heart_block https://www.wikidoc.org/index.php/File:Heart_in_Chagas_disease_4.jpg
  • 133. Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • Catecholamine surge à impaired kinetic activity of left ventricle • Etiology: • Emotional stress is classic • Classic Case: • Death of a loved one • Postmenopausal female • Primary Cardiomyopathy Subtype: • Ballooning of left ventricle • Dilated cardiomyopathy https://en.wikipedia.org/wiki/Heart_block
  • 134. Bootcamp.com Cardiology: Cardiomyopathy • Pathophysiology: • ↑ Extracellular deposition of amyloidogenic proteins • Transthyretin (ATTR) • Light chain (AL) • Histopathology: • Pink amorphous material surrounding cardiomyocytes • Apple-green birefringence with polarized light and Congo red stain • Primary Cardiomyopathy Subtype: • Restrictive cardiomyopathy (Ventricular wall thickening) • Other Features of Amyloidosis: • Nephrotic syndrome • Hepatomegaly https://commons.wikimedia.org/wiki/File:Cardiac_amyloidosis_high_mag_he.jpg https://www.flickr.com/photos/euthman/377559955/ licensed under CC BY-SA 2.0
  • 135. Bootcamp.com Cardiology: Cardiomyopathy • Gross Anatomical Changes: • Sigmoidal shape of ventricular septum • Histopathology: • Myofibrillary disarray and interstitial fibrosis • ↑ Lipofuscin pigment • ↑ Connective tissue https://commons.wikimedia.org/wiki/File:Cardiac_myocyte_showing_lipofuscin_pigment.jpg
  • 136. Bootcamp.com Cardiology: Cardiomyopathy • Hemochromatosis: • ↑ Extracellular deposition of iron • Prussian blue stain (stains iron blue-black) • Peripartum/Postpartum: • Dysfunctional angiogenic growth factors • Third trimester peripartum female – postpartum female • Anthracycline-Induced • Anthracyclines: Daunorubicin, doxorubicin • Binds with topoisomerase II à cleaves DNA in cancer cells • ↑ with cumulative dose • Prevent with dexrazoxane • Trastuzumab-Cardiotoxicity • Monoclonal antibody binding to human epidermal growth factor receptor-2 (HER2) • Does not change with cumulative dose • Tends to be reversible
  • 137. ≣ Item 1 of 1 Question ID: 0047 ◽"Mark ⟽ ⟾ Previous Next Test Your Knowledge Difficulty: ✪✪✪ Bootcamp.com A 17-year-old male presents to the emergency room for 8/10 chest pain that began during a soccer practice a few hours earlier. He states that he has experienced chest discomfort and shortness of breath in the past with sports activity and had previously been diagnosed with asthma 3 years earlier. He states that he finds little improvement in his symptoms when using his albuterol inhaler. He denies any other past medical or surgical history. He states that his father and first cousin are both deceased from “heart problems” in their early thirties. He states that he vapes occasionally and denies any other substance use. Blood pressure is 108/58 mmHg, heart rate is 76/min and regular, oxygen saturation is 99% on room air. The point of maximal impulse appears to be modestly shifted laterally beyond the midclavicular line. A 2/6 crescendo-decrescendo systolic murmur is auscultated at the lower left sternal border. The murmur is accentuated with standing. Pulmonary auscultation reveals clear lung sounds bilaterally with no wheezing observed. ECG reveals a regular rhythm with left axis deviation and deep Q waves in leads I, II, III, aVF and V5-V6 are observed. A transthoracic echocardiogram and cardiac MRI are performed. The patient is subsequently prescribed a medication and restricted from further sports activity on discharge. Which of the following mechanisms of action would most likely be consistent with the medication given? ⚪ A. Activation of β1-receptors in myocardial cells ⚪ B. Activation of guanylyl cyclase at venous and coronary vessels ⚪ C. Inhibition of Na+/K+ ATPase in myocardial cells ⚪ D. Inhibition of phosphodiesterase-5 enzymes in vascular smooth muscle ⚪ E. Inhibition of Na+/K+/Cl- co-transporters in the loop of Henle ⚪ F. Non-selective inhibition of β-receptors systemically
  • 138. OUTLINE 1. Anatomical Considerations ● A. Aorta ● B. Vessel Wall Layers 2. Aortic Dissection ● A. Pathophysiology ● B. Etiology ● C. Presentation ● D. Stanford Classification ● E. Complications ● F. Imaging ● G. Management 3. Aortic Aneurysm ● A. Thoracic vs Abdominal ● B. Pathophysiology ● C. Risk Factors ● D. Presentation ● E. Preventative Management 4. Cardiac Considerations of Marfan Syndrome ● A. Pathophysiology ● B. Cystic Medial Degeneration ● C. Mitral Valve Prolapse ● D. Other Findings 5. Aortic Coarctation ● A. Pathophysiology ● B. Associations ● C. Presentation ● D. Management Cardiology: Aortic Disease
  • 139. Bootcamp.com Cardiology: Aortic Disease • Aorta: • Ascending: Proximal to brachiocephalic artery • Arch of aorta: Between ascending and descending • Descending: Distal to left subclavian artery • Vessel Wall Layers: • Luminal: Tunica intima • Middle: Tunica media • Peripheral: Tunica adventitia (externa) https://radiopaedia.org/cases/normal-cta-chest https://commons.wikimedia.org/wiki/File:Gray506.svg Aortic Isthmus: -Traumatic aortic rupture -Coarctation
  • 140. Bootcamp.com Cardiology: Aortic Disease • Pathophysiology: • Tear through intima and media à propagation of dissection through media • Etiology: • Acquired: Hypertension (#1), trauma, aortic vasculitis • Connective Tissue Disease: Marfan syndrome, Ehlers-Danlos syndrome • Structural Disease: Coarctation of aorta, Bicuspid aortic valve • Presentation: • Severe, acute “tearing” retrosternal chest +/- radiating back pain • Asymmetric blood pressure and pulse discrepancies • Stanford A: • Location: Ascending aorta and/or descending aorta • Classic origin: Sinotubular junction • Surgical management (usually) • Stanford B: • Location: Descending aorta • Classic origin: Left subclavian artery • Medical management (usually) • Complications: • Aortic rupture • Aortic regurgitation • Cardiac tamponade • Ischemia https://commons.wikimedia.org/wiki/File:Aortic_dissection_types.jpg https://commons.wikimedia.org/wiki/File:Aortic_dissection_(1)_Victoria_blue-HE.jpg
  • 141. Bootcamp.com Cardiology: Aortic Disease • Imaging: • CXR: Widened mediastinum • CT Angiography (Gold standard): Intimal flap • Transesophageal echocardiogram (TEE) for unstable or renal insufficiency • Management: • Stanford A à Surgery • Stanford B à β-blocker then vasodilator https://commons.wikimedia.org/wiki/File:AoDiss_ChestXRay.jpg https://commons.wikimedia.org/wiki/File:Descending_(Type_B_Stanford)_Aortic_Dissection.PNG https://commons.wikimedia.org/wiki/File:DissectionCT.png
  • 142. Bootcamp.com Cardiology: Aortic Disease • Pathophysiology: • Transmural inflammation à dilation of intima, media, and adventitia • General Risk Factors: • Smoking • Atherosclerosis • Old age • Connective tissue disease • Tertiary Syphilis • Classic Presentation: • Generally asymptomatic until rupture • Presentation in Rupture: • Acute onset, severe tearing/ripping abdominal/back pain • Severe chest/abdominal pain • Hypotension • Preventative: • Abdominal ultrasound screening in men aged 65-75 who have ever smoked (USPSTF) Aortic Aneurysms Thoracic Abdominal Primary Risk Factor Hypertension Smoking Additional Important Risk Factors Tertiary syphilis Bicuspid aortic valve Connective tissue disease Atherosclerosis Classic Symptoms Chest pain Mid (thoracic) back pain Hoarseness Dysphagia Low back pain Abdominal bruit Pulsatile abdominal mass Other CXR: Widened mediastinum Ascending aorta (classic location) Abdominal U/S Infrarenal (classic location) https://commons.wikimedia.org/wiki/File:AneurysmT.PNG https://commons.wikimedia.org/wiki/File:Thoracic_Aortic_Aneurysm.png
  • 143. Bootcamp.com Cardiology: Aortic Disease • Pathophysiology: • Defect in fibrillin-1 • Autosomal dominant • Cystic Medial Degeneration of Aorta: • Aortic aneurysmà Aortic root dilation (thoracic) à Aortic regurgitation and/or dissection • Aortic dissection à most common cause of death • Histopathology: Amorphous extracellular deposition into medial wall • Mitral Valve Prolapse: • Mid-systolic click at apex • Other Findings: • Tall stature, long extremities • Joint hypermobility • Ectopia lentis, upward lens dislocation • Pectus deformity à carinatum, excavatum • Kyphosis, scoliosis • Arachnodactyly https://www.researchgate.net/figure/Pathologic-finding-of-excised-aortic-tissue-A-cystic-medial-necrosis-which-is- defined_fig4_221683474 https://creativecommons.org/licenses/by-nc/3.0/