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CV HY Path

Day 7

QuestionAnswer
What are the symptoms of bacterial endocarditis? Fever (may be only initial symptom), Roth's spots, Osler's nodes (O for Ouch!), Murmur (new onset), Janeway lesions, Anemia, Nail bed hemorrhages (splinter hemorrhages), Emboli (FROM JANE)
Round white spots on retina surrounded by hemorrhage Roth's spots (rare finding in bacterial endocarditis)
Tender raised lesions on finger or toe pads Osler's nodes (finding in bacterial endocarditis); think O for Ouch!
Painless, small, erythematous lesions on palms or soles Janeway lesions (finding in bacterial endocarditis)
Which organisms cause culture negative endocarditis? HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
Bacterial endocarditis assoc'd with IV drug use involves which organisms? S. aureus, Pseudomonas, and Candida
What type hypersensitivity is bacterial endocarditis? Type 3 (circulating immune complexes can lead to glomerulonephritis)
Which organism is assoc'd with acute bacterial endocarditis? What type of valves does it preferentially affect? S aureus (high virulence) on normal valves; large vegetations
Which organism is assoc'd with subacute bacterial endocarditis? What type of valves does it preferentially affect? Viridans streptococci (low virulence) on diseased or prosthetic valves
How are valvular vegetations formed? Following bacterial binding, tissue factor expression results in platelet and fibrin deposition which forms the vegetation.
Which coagulase negative staph can cause bacterial endocarditis? Staph epidermidis
Which valve is most commonly affected with bacterial endocarditis? Mitral valve
Verrucous (wart-like), sterile vegetations occur on both sides of the valve; can be assoc'd with mitral regurgitation and Lupus Libman-Sacks endocarditis
What histologic finding is pathognomonic for rheumatic heart disease? Aschoff bodies (granuloma with giant cells); may also see Anitschkow's cells (activated histiocytes)
Infection with which organism may lead to the following symptoms in a patient: migrating polyarthritis, pancarditis, sub-q nodules, erythema marginatum (serpiginous skin rash), and Sydenham's chorea? Group A beta-hemolytic streptococci (strep pyogenes) causing pharyngitis; can result in immune mediated attack on heart valves
What type of hypersensitivity is Rheumatic heart disease? Type 2
Which valves are preferentially affected in rheumatic heart disease? Mitral> aortic >> tricuspid
What mitral valve changes are seen in rheumatic heart disease? Mitral valve prolapse: early Mitral valve stenosis: late
Pulsus paradoxus (>10mmHg difference between systolic and diastolic pulse on inspiration)and electrical alternans on EKG. Cardiac tamponade
Disruption of the vasa vasorum of the aorta with resultant dilation of the aorta and aortic valve ring Syphilitic heart disease. Syphilis-- the gift that keeps on giving!
Marfan patient who dies suddenly Mitral valve prolapse with conduction defects (NOT aortic dissection; you don't die immediately from aortic dissection)
Two valvular lesions associated with carcinoid syndrome. Tricuspid Insufficiency and Pulmonic Stenosis (TIPS)
Single most important risk factor for the development of intimal tears leading to aortic dissections. HTN
Sandpaper-like heart sounds, ST segment elevations in multiple leads Pericarditis
Name that sign! On inspiration, patient gets JVD. Kussmaul's sign; assoc'd with pericarditis
MC primary tumor in adults Myxoma (mostly in LA)
MC primary cardiac tumor in children Rhabdomyosarcoma (little rhascals like rhabdos); assoc'd with tuberous sclerosis
MC heart tumor Metastases; from melanoma and lymphoma
SVC-syndrome like symptoms on one side of the body (e.g., R sided face swelling, R arm swelling, engorgement of vv on R side of neck) Brachiocephalic v obstruction
Decreased blood flow to skin due to arteriolar vasospasm in response to cold temperature or emotional stress Raynaud's (disease if primary, phenomenon if secondary)
What is the treatment for Raynaud's? Aspirin, dihyropyridine CCB (nifedipine), and sildenafil (goal is to vasodilate)
Name 3 diseases assoc'd with Raynaud's phenomenon. SLE, CREST, and Buerger's
Vasculitides: Weak pulses in upper extremities Takyasu
Necrotizing granulomas of lung and necrotizing glomerulonephritis Wegener's
Vasculitides: Young male smokers Buerger's
Vasculitides: Young Asian women Takayasu; also Kawasaki
Vasculitides: Young asthmatic Churg-Strauss
Vasculitides: Infants and young children; involves coronary aa Kawasaki
MC vasculitis Giant cell/Temporal arteritis
Vasculitides: Assoc'd with Hep B infection Polyarteritis nodosa
Vasculitides: Occulsion of ophthalmic a can lead to blindness Giant cell/Temporal arteritis
Vasculitides: Perforation of nasal septum Wegener's
Unilateral headache with jaw claudication Giant cell/Temporal arteritis
How can you differentiate Wegener's from Goodpasture's? Wegener's granulomas can be found in the upper lung and upper airways
What is the treatment for Wegener's? Cyclophosphamides and corticosteroids (c-ANCA= C for cyclophosphamides and C for Corticosteroids)
What are the SE of cyclophosphamide toxicity? hemorrhagic cystitis and bladder cancer
What is the MCC of a saddle nose deformity in the US? Wegener's granulomatosis
c-ANCA produces which antibodies? Anti-neutrophil proteinase 3 antibodies
p-ANCA produces which antibodies? anti-neutrophil myeloperoxidase antibodies
Port wine stain on the face in the trigeminal n distribution (ophthalmic branch) Sturge Weber disease
Vascular malformation of the face and an arteriovenous malformation that predisposes to bleeding Sturge Weber disease
Lower extremity palpable purpura, arthritis in knees, abdominal pain, and recent URI. Self resolves Henoch Schonlein purpura
Mucocutaneous lymph node syndrome Kawasaki disease
Vasculitides: Like Wegener's but lacks granulomas. p-ANCA positive Microscopic polyangitis
Intermittent claudication in a heavy smoker Buerger's
Hypersensitivity to intradermal injections of tobacco extracts Buerger's
What is the treatment of choice for Buerger's disease? Smoking cessation
Peeling of fingertips and palms, strawberry tongue, and fever in an Asian child Kawasaki disease
What is the only time a child can be treated with high dose aspirin? Kawasaki disease; also use IV immunoglobulin to treat
Vasculitides: p-ANCA negative; generally affects renal and visceral vessels and spares the pulmonary aa; lesions are of different ages Polyarteritis nodosa
Vasculitides: Fever, malaise, weight loss, abdominal pain, and melena Polyarteritis nodosa
What is the treatment for polyarteritis nodosa? Corticosteroids and cyclophosphamide (same tx for Wegener's)
Young Asian woman without a pulse Takayasu's arteritis
Migratory thrombophlebitis Malignancy (always think malignancy when you see this)
L atrial tumor in adults that can cause syncopal episodes Myxoma
Muffled heart sounds with a knock Restrictive pericarditis
Muffled heart sounds with no knock Pericardial effusion
High output CHF with neuro symptoms Wet beri beri (thiamine/B1 deficiency)
R sided endocardial fibrosis with elevated plasma serotonin levels and elevated 5-hydroxyindoleatic acid (5HT metabolite) in the urine Carcinoid syndrome
Benign raised red lesion about the size of a mole in older patients Cherry hemangioma
Raised, red area present at birth, increases in size initially and then regresses over months to years Strawberry hemangioma
Lesion caused by lymphoangiogenic growth factors in an HIV infected patient Kaposi's sarcoma
Polypoid red lesion found in pregnancy or after trauma Pyogenic granuloma
Benign, painful red-blue tumor under fingernails Glomus tumor
Cavernous lymphangioma assoc'd with Turner's syndrome Cystic hygroma
Skin papule in AIDS patient caused by Bartonella Bacillary angiomatosis
Highly lethal malignancy of the liver assoc'd with vinyl chloride, arsenic, and thorotrast (VAT) Angiosarcoma
Lymphatic malignancy associated with persistent lymphedema (e.g., post-radial mastectomy) Lymphangiosarcoma
What is the treatment for bacillary angiomatosis? Sulfa drugs
What is the definition of HTN? >/= 140/90
What is the definition of pre-HTN? >/= 130/85
HTN can cause which heart sound? S4 (due to stiffened, hypertrophied LV)
Plaques in BV walls Atheromas
Plaques or nodules composed of lipid-laden histiocytes in the skin, especially the eyelids Xanthomas (called xanthelasmas in the eyelids)
Lipid deposit in the tendon, especially the Achilles tendon Tendinous xanthoma
Lipid deposit in cornea, nonspecific Corneal arcus (arcus senilis)
Calcification in the media of aa, esp radial or ulnar. Usually benign (does not obstruct blood flow and intima is not involved) Monckeberg (ONLY happens in the media; there's some Monkey business in the Media!)
Hyaline thickening of small aa in essential HTN or diabetes mellitus. Arteriosclerosis
Fibrous plaques and atheromas form in intima of aa Atherosclerosis
What is the management of an abdominal aortic aneurysm greater than 5cm? Surgery
What is the most important risk factor for heart disease? Age
What is the progression of atherosclerosis? Endothelial cell dysfunction--> macrophage and LDL accumulation --> foam cell formation--> fatty streaks--> smooth m cell migration (involves PDGF and TGF-beta)--> fibrous plaques--> complex atheroma; primarily mediated by sm m cells
What are the most common locations of atherosclerosis (in order)? Abdominal aorta > coronary a > popliteal a > carotid a
What determines the integrity of an atherosclerotic plaque? The fibrous cap (macrophages secrete metalloproteinases which can degrade the clot and lead to embolization)
One kidney much smaller than the other. Renal a stenosis
Abdominal aortic aneurysms are assoc'd with _______ while aortic dissection is assoc'd with ___________. Atherosclerosis; HTN (also cystic medial necrosis in Marfan's)
Mediastinal widening with double barrel aorta Aortic dissection
Tearing chest pain radiating to back Aortic dissection
When does angina become symptomatic? CAD narrowing >75%
ST depression= _________ ischemia subendocardial
ST elevation= __________ ischemia transmural (pathologic Q waves also point to transmural ischemia)
Stable (pain on exertion) angina and unstable (pain at rest) angina produce ST _____ on EKG depression
What substance can be injected to provoke vasospasms which aid in the diagnosis of Prinzmetal's angina? Ergonovine
Prinzmeta's angina (coronary vasospasms) produces ST ______ on EKG elevation
What is the most common cause of sudden cardiace death? Lethal arrhythmia (e.g., v fib)
What pulmonary process is analagous to the formation of an aneurysm? Bronchiectasis (weakening wall--> outpouching)
What is the most common site for an abdominal aorta? Below the renal aa (b/c there is no vasa vasorum at this point)
Sudden severe onset of L flank pain, hypotension, and pulsatile mass on PE Ruptured abdominal aorta
MCC of an aortic arch aneurysm Syphilis (affects vasa vasorum)
Evolution of MI: No visible change by light microscopy first 2-4 hours
Evolution of MI: Neutrophils and early coagulative necrosis 4 hours
Evolution of MI: Contraction bands 12-24 hours
Evolution of MI: Greatest risk for arrhytmias like V-fib 2-4 days
Evolution of MI: Acute inflammation; may develop pericarditis 2-4 days
Evolution of MI: Risk for free-wall rupture, cardiac tamponade, paipllary m rupture, iV septal rupture 5-10 days
Evolution of MI: Granulation tissue 5-10 days
Evolution of MI: Risk for ventricular aneurysm 7 weeks
Evolution of MI: Gray-white sar and recanalized a 7 weeks
Person comes in with pain, fever, m aches, and a pericardial friction rub (pain relieved by leaning forward) 7 weeks post-MI Dressler's syndrome (autoimmune pericarditis)
Reversible or irreversible? Vacuoles and phospholipids inside the mitochondria of the heart Irreversible damage; the cell will NOT recover =(
Reversible or irreversible? Mitochondrial swelling in cardiac myocytes Reversible damage (also myofibril relaxation, disaggregation of polysomes, disaggregation of granular and fibrillar elements, nuclear chromatin clumping, and loss of glycogen)
Name that heart attack marker!: non-specific, but elevated even earlier than troponin Myoglobin (elevated b/f 4 hours)
Gold standard diagnostic test for MI in the first 6 hours EKG
Name that heart attack marker!: rises after 4 hours and is elevated for 10 days; more specific than other protein markers; gold std Troponin
Name that heart attack marker!: Useful in diagnosing reinfarction on top of acute MI CK-MB
Name that heart attack marker!: non-specific; found in cardiac, liver, and skeltal m cells AST (not really useful)
EKG finding seen in an acute MI that correlates with areas of ischemia at the periphery of the infarct Inverted T wave
Stemi Q wave MI; transmural infarct with ST elevation on EKG (STEMI= ST Elevation MI)
Non-stemi Non-Q wave MI; subendocardial infarct with ST depression
Why should warfarin or heparin be given after an MI? To prevent an embolus from a potential mural thrombus
Patient with an MI who develops mitral regurg a few days later Papillary m rupture (risk is greatest 5-10 days post-MI)
S3, laterally displaced apical impuslse, problems with mutations in cardiac cytoskeletal proteins Dilated (congestive) cardiomyopathy
Hypertrophied IV septum is too close to mitral valve leaflet leading to outflow tract obstruction Hypertrophic cardiomyopathy
Sudden death in a young athlete Hypertrophic cardiomyopathy
Normal-sized heart, S4, apical impulses, and systolic murmur assoc'd with Friedrich's ataxia Hypertrophic cardiomyopathy
What is the treatment for hypertrophic cardiomyopathy? Beta blocker or non-dihydropyridine CCB (e.g., verapamil)
Cardiomyopathy seen in Loffler's syndrome Restrictive/obliterative cardiomyopathy (Loeffler's is endomyocardial fibrosis with a prominent eosinophilic infiltrate)
What disease presents with dilated cardiomyopathy with increased LV cavity size, and may present with signs and symptoms of CHF? Hemochromatosis
Patient with acute onset of heart failure after recent viral infection Dilated cardiomyopathy caused by a viral myocarditis
Hemosiderin containing alveolar macrophages (heart failure cells) indicate which findings in L sided heart failure? Pulmonary congestion and edema
What is the treatment for acute CHF exacerbation? Loop diuretics (furosemide), Morphine, Nitrates, Oxygen, Positioning or Pressors (LMNOP)
What leads to the formation of heart failure cells (hemosiderin-laden macrophages)? Microhemorrhages from increased pulmonary capillary pressure
Patient with PMH significant for HTN, hyperlipidemia, and CABG procedure presents with epigastric pain 30-60min after food intake. He has experienced some weight loss because of fear of postprandial pain. Chronic mesenteric ischemia: h/o cardiac disease suggests pt has atherosclerosis. intestinal hypoperfusion is v painful and is esp pronounced after eating meals when more blood is needed to digest an absorb nutrients
What is the differential for pulsus paradoxus? Cardiac tamponade, constrictive pericarditis, severe obstructive lung disease (e.g., asthma), and restrictive cardiomyopathy; caused by any disease that restricts the ability of the R side of the heart to expand into the pericardium during inspiration
Fever, bilateral conjunctivitis, lymphadenopathy, and cutaneous involvement (skin peeling off fingertips). Complication? Kawasaki disease; complication is coronary aneurysm
Patient with continuous machine like murmur best heard over the upper L sternal edge and a thrill felt on PE is scheduled for surgery. The derivative of which embryologic structure will be operated on? 6th aortic arch (pt has patent ductus arteriosus)
When cells in the heart, brain, or skeletal m are injured, which enzyme will be elevated in circulation? Creatine kinase
Differential cyanosis restricted to lower body in a child. PDA with late-onset reversal of shunt flow (from L-->R to R-->L)
Created by: sarah3148