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Cardiology Pathology

for BOD

Left Anterior Descending Artery Supplies... Anterior Wall & Some Septal Wall (Has "Diagonal Branches")
Left Circumflex Artery Supplies... Lateral Wall (Has "Marginal Branches")
Right Coronary Artery Supplies... Inferior Wall (Usually PDA off of it, which Supplies Infra-Septal and Inferior Wall)
Heart Blocks (1st, 2nd, 3rd Degree) 1st Degree: Consistent PR delay (>200 ms), No Skipped Beats. 2nd Degree: Increasingly lengthen PR w/ occasional PVC. 3rd Degree: Junctional (narrow) escape rhythm with complete AV. block
Alpha Receptors Epi > NE (no isopreternol). Vasoconstriction, Mydriasis, Splenic Contraction. Gq --> PL-C --> DAG + IP3. DAG--> PKC + MAPK (Vasoconstrict, ^BP). IP3 --> Ca from SR (^ Cardiocontractility).
Beta Receptors Iso > Epi > NE. Cardiostimulation, Bronchodilation, Vasodilation, Metabolic Acidosis. Gs --> Adenylyl Cyclase --> cAMP --> PKA --> Ca from SR --> Contractility
Epinepherine Alpha Receptors: Vasoconstriction Beta Receptors: Vasodilation
Norepinepherine Alpha Receptors (Mostly): Vasoconstriction Beta-1 Receptors (Cardiac): Cardiostimulation
Ispopreternol Beta Receptors: Vasodilation and cardiostimulation
Ergotoxin Blocks NE's Vasoconstriction (alpha) Blocks Epi's Vasoconstriction (alpha) Does NOT block Epi's Vasodlation (Beta) Alpha Blocker (The First!)
Dichloroisopreternol Beta Blocker (The first!)
Dopamine Inotropine (Similar to NE) Increase force of contraction Vasodilates renal arteries (but alpha effects & vasoconstriction at high doses) Indicated for shock with oliguria (increase CO via Beta Receptors & Increase renal blood flow via DA-ergic effects)
Dobutamine (+) isomer: Beta-1 Agonist + Alpha-1 Antagonist (-) isomer: Alpha-1 agonist For: Short term for CHF, MI (increase CO, SV w/o HR increase)
Blood Vessels Alpha-1 & Alpha-2 (Constrict to ^^BP). Beta-2 (Dilate in Skeletal muscle arterioles)
Bronchi Alpha-1 (Constrict). Beta-2 (Relaxes)
Heart Beta-1 & Beta-2 (increase HR, increase contractility). Target for beta-blockers!
Nerve Endings Alpha-2 (neg feedback to lower NE Release). Beta-1 & Beta-2 (on nerve endings. Increase NE Release)
Mast Cells Beta-2 (less histamine release)
Second Messengers for Alpha-1, Alpha-2, Beta-1, Beta-2 Receptors A1 (IP3 + DAG). A2 (less cAMP). B1+B2 (more cAMP).
Ritodrine B2 agonist. Delays uterine contraction att erm.
Salbutamol B2 agonist. For asthma
Methoxamine & ****PHENYLEPHRINE***** A1 agonist (vasoconstriction)
Alpha-Methylnorepinepherine & Clonidine Alpha-2 agonist (neg feedback to stop vasoconstriction)
Butoxamine B2 antagonist
Labetolol & Metoprolol B1 antagonist
***Propanolol*** B1 & B2 antagonist
Yohimbine A2 antagonist
Prazosin A1 antagonist (for HTN)
***Phentolamine*** Short-acting A1/A2 antagonist (for shock)
***Phenoxybenzamine*** Long-Acting A1 & A2 antagonist (for shock)
Cocaine Sympathomimetic. Blocks NET (more NE in synapse). Increase O2 demand (A + B adrenergic effect) w/ less O2 delivery. Result: ischemia, infarction, arrhythmia. Chronic: dilated or hypertrophic cardiomyopathy, atherosclerosis, myocarditis, necrosis.
Platelet Aggregation Expose subendothelial Matrix. Thromboxane A2 + ADP recruit + activate platelets to form plug).
Anti-Platelet Drug Targets Platelet Surface ADP Receptor P2Y12 (CLOPIDOGREL & PRASUGREL) & GPIIB/IIIa Receptors (ABCIXIMAB). Platelete dense granules: ThrombaxaneA2 (ASPIRIN via Cyclooxygenase inhibition. Irreversible) & ADP (CLOPIDOGREL + PRASUGREL).
Endothelial Cell Drug Targets (ANti-Clotting)
***Aspirin*** (Acetyl Salicyclic Acid) Acetylates serine in COX-1. Irreversible inhibition. (Cannot become TxA2 which normally causes vasoconstriction and platelet agg). Toxicities: GI discomfort, bleeding, antiinflamm, Hypercapnia, Glucose intolerance, poison (reps alk, met acidosis, RD)
***Clopidogrel*** (Plavix) P2Y12 Antagonist. Prodrug (CYP2C19 activates). (Omeprazole is a CYP2C19 inhibitor). Used to prevent occlusion after stunting coronary vessels.
***Prasugrel*** (Effient) P2Y12 antagonist. Prodrug. MOre potent than plavix, more bleeding. Does not use CYP2C19, but DOES use Cyp3A5 + 2B6.
Ticagrelol (Brilanta) Direct (no CYP450) reversible inhibitor of P2Y12
Abciximab, Tirofiban, Eptifibatide, Lamifiban GPIIb/IIIa antagonist (block receptor). Inhibit platelet aggregation BUT risk intrinsic platelet activation & thrmbocytopenia (low platelet count). Used, bu limited.
Anticoagulants (note, different from antiplatet, these are anti-clotting) Normally: tissue injury --> TF expressed, Phospholipid complex forms, Activates thrombin, Fibrin polymerization and clot formation
Pro-coagulation from Thrombin (IIa) ADP, TXA2, Va, VIIa, XIa, TAFI (thrombin-activated thrombolysis inhibitor)
Anti-coagulation from Thrombin (IIa) Prostocyclin, NO, tPA, Protein C+S (activate by IIa will inactivate Va, VIIIa)
Heparin (Anticoagulant) Inactivates ACTIVE clotting factors oof INTRINSIC pathway. WOrks by accelerating ATIII 1000x
HIT Heparin-Induced Thrombocytopenia: combo of bleeding AND thrombosis (30% mortality): activated platelets, removed by spleen macrophages (thrombocytopenia). Plaetelets also procoaglunant (thrombosis). Treat with thrombin inhibitors.
LMWH (***enoxaprin*** dalteparin, ___parin) Low molecular weight heparin: more predictable effects, can give subQ, more bioavailable, longer half life, less HIT, less osteoporosis. does NOT inhibit IIa.
Thrombin Inhibitors (***Hirudin (leech derivative), Lepirudin, Argatroban, Bivalirdivin, **Rivaroxaban***(oral), ***Apixaban*** (oral) Use for HIT (inactivates soluble and clot-bound IIa. WOrks if ATIII is deficient).
Warfarin Oral anticoag. Inhibits FORMATION of active (acts @ IX, X, II). Prevents gamma carboxylation by inhib. vit K epoxide reductase. Takes ~1 week to kick in (circ clotting factors long 1/2 life). Monitor INR (2-3). CYP2C9. More vit K may lower INR. Teratogen.
Fibrinolysis (tPA, streptokinase, Reteplase, Tenecteplase) tPA from endothelial cells, activates plasmin to degrade clot (more D-dimer in blood). Give for acute MI, thrombotic stroke, arterial thromboses, PE, DVTs, occlude catheters and shunts. Bleeding risk! Streptokinase: risk allergic rxn. Not fibrin-specific
Rose Criteria (is pain cardiac?) 1. Substernal Chest Pain 2. Temporal Relation to Stimulus (Exercise/Stress) 3. Relieved with discontinuation of stimulus 4. Relieved with Nitrates
Virchow's Triad 1. Hypercoaguability 2. Hemodynamic Changes (stasis/turbulence) 3. Endothelial cell injury/Dysfunction.......THROMBUS!!!
Risk Factors (For Pretty much Everything) Male, Old, Smoker, HTN, Dislipidemia, Atherosclerosis, Family History
AAA (Abdominal Aortic Aneurism) Saccular (one side) + Fusiform (all the way around. True (ALL layers) vs. False (Confined by adventitia but can still easily rupture)
Vasculitis High ESR, High CRP, GIant cell arteritis, Sup temporal artery, common in elderly, often unilateral. Can go blind. Multinucleited giant cells.
Large Vessel Vasculitis Giant cell arteritis if >50 YO, Takayasu if < 50 YO
Medium Vessel Vasculitis Polyarteritis Nodosa (w/o MCLN) Lawasaki (w/ MCLN) (MCLN = mucocutaneous lymph node syndrome)
Small Vessel Vasculitis Many! Immune complexes in vessels or paucity of vasc IgG
ST Depression More global ischemia, cormobidities, coronary disease, hypertension, hyperlipidemia. A chronic thing.
Angina: General Treatment Strategies 1. Nitrates 2. Calcium Channel BLockers 3. Beta Blockers
Nitrates (Glyceryl Trinitrate/Nitroglycerine) Venous capicitanse (more preload, less O2 demand). Release NO in vasc smooth muscle cells. Kidney excretion. Relzx blood vessel. Dosage! (vein-->arteries). Met by mito lad dehy. NO --> cGMP --> relax smooth muscle
Calcium Channel Blockers ***Verapamil***, ***NIfedipine***, Dilitiazem Inhibit calcium entry. Verapiml + Dilitiazem suppress conduction (@ nodes) so less HR, more vasodilation, less contractility. Nifedipine, Nicardapine, Minodipine do NOT have effect on Conduction (vasodilator, less contractility).
Beta Blockers Less contractility, less renin/angiotensein so lowers BP, anti-arrhythmic, less exercise tachycardia
1st Generation (Blanket) Beta Blockers ***Propanolol*** (etc)
2nd Generation (B1) Beta Blockers (Cardioselective) Atenolol, ***Metoprolol*** etc
3rd Generation (Vasodilating) Beta Blockers Pindolol, ***Carvedilol*** etc
Mixed alpha/beta blocers Labetalol
9 min half life beta blocker Esmolol (to lower BP in ER)
Giant Cell Temporal Vasculitis Large Vessel. Granulomatous vasculitis of aorta and extra cranial branches of carotid. Patients >50. May lead to blindness. Associated w/ polymyalgia rheumatica
Takyatsu Arteritis Involves aortic arch and branches by granuloomatous arterities. Thickened intima. Female. Patients < 50
Polyarteritis Nodosa Lesions of dif ages. 30% associated w/ HepB. Necrotizing inflammation w/o glomerulnephritis. Nodules on arterial wall, skin, viscera. Immune complex disease. Fibrinoid necrosis
Kawasaki Disease Kids <4 yo, most common acquired heart disease in children. smooth muscle in arterial wall. Arteritis associated w/ MLNS
Wegener Granulomatosis Granulomatous inflam. Resp tract, kidney , sinus, nasal mucosas. Necrotizing glomeruonephritis common. C-ANCA (anti-neutrophil cytoplasmic antibiodies) Low Ig.
Churg-Strauss Syndrome Eosinophilia, Asthma, Granulomas. Glomerunophritis. p-ENCA
Microscopic Polyangitis/arteritis Lesions of the same age. Nec glomeruonephritis common. Pulm capillaries involved. C-ANCA. Leads to hemorrhage.
Granulmoatous Vasculitis (Temporal Arteritis) Intima Prolif, breaks in elastic stain. Biopsy need not be (+), elevated SED rate and CRP
Buerger Disease Thromboangitis obliterans (in extremeties. Ven thromboses. With Tobacco!)
Rheumatic Fever Pharyngitis, Skin absess (impetigo), group A strep pharyngitis precedes it. Antigen-mimic (M protein). Give prophylatic penicillin
Jones Criteria 2 Major or 1 Major + 2 Minor. Required: Evidence of Strep. Major: Carditis, Polyarteritis, Chorea, Erythema Marginatum, SubQ nodules. Minor: Fever, Arthralgia, Previous Rheum fever/heart disease, ESR up, CRP up, leukocytosis, PR interval up (heart blo
Fibrinous Pericarditis From: End Stage Renal Disease, MI, Dressler's Syndrome (after MI), Radiation Pericarditis, Virus, Trauma, Drugs. UREMIA. "Bread & Butter." See fat, organization, fibrin (pink/amorphous)
Fibrous Pericarditis Stiff, can't contract. TB, fungal, pericarditis, tumor, radiation, no-resolving fibrillin. Fibroblastic prolif. Create brididges pericardium to epicardium. KUSMALL sign: JVD
4 Factors Influencing Cardiac Performance 1. Preload (venous return) 2. Afterload (TPR) 3. Cotnractility 4. HR
Digitalis, Digoxin (longer), OUabain (shorter) More contractility vía more intracellular sodium (inhibit the na/k atpase. Stops calcium extrusion. so more pumping.
DAD Delayed after depolarization...more contractility, V. tach (toxicity of digitalis).
Beta Blockers in CHF Metoprolol - B1 selective Carvedilol - Non selective
Systolic HF "Fat and Short" P(V) curve
Diastolic HF "Tall and Skinny" P(V) Curve
FACES Heart failure symptoms: Fatigue, Angina, Congestion (Chest), Edema, SOB
NYHA Classification I: Mid II Mild (slight limitation III Moderate (marekd limitation) IV: severe
ACC/AHA Classification: A: High risk B: Asymptomatic LV dysfunction C: Past/current HF Sx D: End Stage HF
EAD (early after depolarizations) Phase 2: prolonged or Phase 3 prolonged. Can mediate torsade de Pointes (polymorphic VT)
DAD (delayed after depolarization) Impaired calcium handling (Na/Ca exchanger up, then depolarizing current). Occurs w/ digitalis and idiopathic c VTs. Sensitive to adenosine, Calcium channel blockers, beta blockade.
Class 1 Anti-Arrhythmics Block Entry of Na (Phase 0). 1b (RAPID i.e. LIDOCAINE). 1a (med ie QUINIDINE). 1c (longer ie econide and flecanide).
Class 2 Anti-Arrhythmics Beta Blockers -Main effect on L-type calcium channels and If phase 4 in nodal cells. PROPANOLOL: anti-arrhythmic, inhibits exercise tachycardia, alleviates angina, lowers renin. Use for increased sympathetic activity.
Class 3 Anti-Arrhythmics K Blockers (slow depolarization) Amioderone, Sotalol, Bretylium. Prolong repolarization (may see EADs). Also photosensitivity with AMiderone.
Class 4 Anti-Arrhythmics Ca Channel Blockers. 4a: L-type Ca block. Shorten repolarization (verapamil, dilitiazem). Depress phase 0 in SA cells, shorten plateau. 4B: K channel openers (ADENOSINE). SLOWING of AV conduction. DO NOT USE IN ASTHMA. for paroxysmal supra vent. tach.
Automaticity Arrhythmia? Use Beta Blocker, Calcium Channel Blocker
Triggered Arrhythmia (EADs/DAD's)? Use Beta blockers, Calcium Channel Blockers
Conduction (reentry) Arrythmias? Sodium and Calcium blockers.
Imaging X-ray, Cath, Nuclear, Echo, CTA, MR
Created by: JuliaR10