for BOD
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| Left Anterior Descending Artery Supplies... | Anterior Wall & Some Septal Wall
(Has "Diagonal Branches")
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| Left Circumflex Artery Supplies... | Lateral Wall
(Has "Marginal Branches")
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| Right Coronary Artery Supplies... | Inferior Wall
(Usually PDA off of it, which Supplies Infra-Septal and Inferior Wall)
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| 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
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| 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).
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| Beta Receptors | Iso > Epi > NE.
Cardiostimulation, Bronchodilation, Vasodilation, Metabolic Acidosis. Gs --> Adenylyl Cyclase --> cAMP --> PKA --> Ca from SR --> Contractility
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| Epinepherine | Alpha Receptors: Vasoconstriction
Beta Receptors: Vasodilation
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| Norepinepherine | Alpha Receptors (Mostly): Vasoconstriction
Beta-1 Receptors (Cardiac): Cardiostimulation
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| Ispopreternol | Beta Receptors: Vasodilation and cardiostimulation
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| Ergotoxin | Blocks NE's Vasoconstriction (alpha)
Blocks Epi's Vasoconstriction (alpha)
Does NOT block Epi's Vasodlation (Beta)
Alpha Blocker (The First!)
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| Dichloroisopreternol | Beta Blocker (The first!)
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| 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)
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| 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)
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| Blood Vessels | Alpha-1 & Alpha-2 (Constrict to ^^BP).
Beta-2 (Dilate in Skeletal muscle arterioles)
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| Bronchi | Alpha-1 (Constrict).
Beta-2 (Relaxes)
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| Heart | Beta-1 & Beta-2 (increase HR, increase contractility). Target for beta-blockers!
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| Nerve Endings | Alpha-2 (neg feedback to lower NE Release).
Beta-1 & Beta-2 (on nerve endings. Increase NE Release)
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| Mast Cells | Beta-2 (less histamine release)
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| Second Messengers for Alpha-1, Alpha-2, Beta-1, Beta-2 Receptors | A1 (IP3 + DAG). A2 (less cAMP). B1+B2 (more cAMP).
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| Ritodrine | B2 agonist. Delays uterine contraction att erm.
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| Salbutamol | B2 agonist. For asthma
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| Methoxamine & ****PHENYLEPHRINE***** | A1 agonist (vasoconstriction)
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| Alpha-Methylnorepinepherine & Clonidine | Alpha-2 agonist (neg feedback to stop vasoconstriction)
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| Butoxamine | B2 antagonist
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| Labetolol & Metoprolol | B1 antagonist
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| ***Propanolol*** | B1 & B2 antagonist
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| Yohimbine | A2 antagonist
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| Prazosin | A1 antagonist (for HTN)
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| ***Phentolamine*** | Short-acting A1/A2 antagonist (for shock)
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| ***Phenoxybenzamine*** | Long-Acting A1 & A2 antagonist (for shock)
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| 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.
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| Platelet Aggregation | Expose subendothelial Matrix. Thromboxane A2 + ADP recruit + activate platelets to form plug).
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| 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).
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| Endothelial Cell Drug Targets (ANti-Clotting) |
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| ***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)
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| ***Clopidogrel*** (Plavix) | P2Y12 Antagonist. Prodrug (CYP2C19 activates). (Omeprazole is a CYP2C19 inhibitor). Used to prevent occlusion after stunting coronary vessels.
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| ***Prasugrel*** (Effient) | P2Y12 antagonist. Prodrug. MOre potent than plavix, more bleeding. Does not use CYP2C19, but DOES use Cyp3A5 + 2B6.
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| Ticagrelol (Brilanta) | Direct (no CYP450) reversible inhibitor of P2Y12
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| Abciximab, Tirofiban, Eptifibatide, Lamifiban | GPIIb/IIIa antagonist (block receptor). Inhibit platelet aggregation BUT risk intrinsic platelet activation & thrmbocytopenia (low platelet count). Used, bu limited.
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| Anticoagulants (note, different from antiplatet, these are anti-clotting) | Normally: tissue injury --> TF expressed, Phospholipid complex forms, Activates thrombin, Fibrin polymerization and clot formation
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| Pro-coagulation from Thrombin (IIa) | ADP, TXA2, Va, VIIa, XIa, TAFI (thrombin-activated thrombolysis inhibitor)
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| Anti-coagulation from Thrombin (IIa) | Prostocyclin, NO, tPA, Protein C+S (activate by IIa will inactivate Va, VIIIa)
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| Heparin (Anticoagulant) | Inactivates ACTIVE clotting factors oof INTRINSIC pathway. WOrks by accelerating ATIII 1000x
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| 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.
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| 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.
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| 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).
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| 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.
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| 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
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| 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
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| Virchow's Triad | 1. Hypercoaguability 2. Hemodynamic Changes (stasis/turbulence) 3. Endothelial cell injury/Dysfunction.......THROMBUS!!!
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| Risk Factors (For Pretty much Everything) | Male, Old, Smoker, HTN, Dislipidemia, Atherosclerosis, Family History
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| 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)
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| Vasculitis | High ESR, High CRP, GIant cell arteritis, Sup temporal artery, common in elderly, often unilateral. Can go blind. Multinucleited giant cells.
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| Large Vessel Vasculitis | Giant cell arteritis if >50 YO, Takayasu if < 50 YO
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| Medium Vessel Vasculitis | Polyarteritis Nodosa (w/o MCLN)
Lawasaki (w/ MCLN)
(MCLN = mucocutaneous lymph node syndrome)
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| Small Vessel Vasculitis | Many! Immune complexes in vessels or paucity of vasc IgG
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| ST Depression | More global ischemia, cormobidities, coronary disease, hypertension, hyperlipidemia. A chronic thing.
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| Angina: General Treatment Strategies | 1. Nitrates 2. Calcium Channel BLockers 3. Beta Blockers
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| 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
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| 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).
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| Beta Blockers | Less contractility, less renin/angiotensein so lowers BP, anti-arrhythmic, less exercise tachycardia
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| 1st Generation (Blanket) Beta Blockers | ***Propanolol*** (etc)
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| 2nd Generation (B1) Beta Blockers (Cardioselective) | Atenolol, ***Metoprolol*** etc
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| 3rd Generation (Vasodilating) Beta Blockers | Pindolol, ***Carvedilol*** etc
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| Mixed alpha/beta blocers | Labetalol
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| 9 min half life beta blocker | Esmolol (to lower BP in ER)
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| 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
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| Takyatsu Arteritis | Involves aortic arch and branches by granuloomatous arterities. Thickened intima. Female. Patients < 50
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| 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
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| Kawasaki Disease | Kids <4 yo, most common acquired heart disease in children. smooth muscle in arterial wall. Arteritis associated w/ MLNS
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| Wegener Granulomatosis | Granulomatous inflam. Resp tract, kidney , sinus, nasal mucosas. Necrotizing glomeruonephritis common. C-ANCA (anti-neutrophil cytoplasmic antibiodies) Low Ig.
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| Churg-Strauss Syndrome | Eosinophilia, Asthma, Granulomas. Glomerunophritis. p-ENCA
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| Microscopic Polyangitis/arteritis | Lesions of the same age. Nec glomeruonephritis common. Pulm capillaries involved. C-ANCA. Leads to hemorrhage.
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| Granulmoatous Vasculitis (Temporal Arteritis) | Intima Prolif, breaks in elastic stain. Biopsy need not be (+), elevated SED rate and CRP
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| Buerger Disease | Thromboangitis obliterans (in extremeties. Ven thromboses. With Tobacco!)
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| Rheumatic Fever | Pharyngitis, Skin absess (impetigo), group A strep pharyngitis precedes it. Antigen-mimic (M protein). Give prophylatic penicillin
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| 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
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| 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)
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| Fibrous Pericarditis | Stiff, can't contract. TB, fungal, pericarditis, tumor, radiation, no-resolving fibrillin. Fibroblastic prolif. Create brididges pericardium to epicardium. KUSMALL sign: JVD
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| 4 Factors Influencing Cardiac Performance | 1. Preload (venous return) 2. Afterload (TPR) 3. Cotnractility 4. HR
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| Digitalis, Digoxin (longer), OUabain (shorter) | More contractility vía more intracellular sodium (inhibit the na/k atpase. Stops calcium extrusion. so more pumping.
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| DAD | Delayed after depolarization...more contractility, V. tach (toxicity of digitalis).
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| Beta Blockers in CHF | Metoprolol - B1 selective
Carvedilol - Non selective
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| Systolic HF | "Fat and Short" P(V) curve
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| Diastolic HF | "Tall and Skinny" P(V) Curve
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| FACES | Heart failure symptoms: Fatigue, Angina, Congestion (Chest), Edema, SOB
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| NYHA Classification | I: Mid II Mild (slight limitation III Moderate (marekd limitation) IV: severe
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| ACC/AHA Classification: | A: High risk B: Asymptomatic LV dysfunction C: Past/current HF Sx D: End Stage HF
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| EAD (early after depolarizations) | Phase 2: prolonged or Phase 3 prolonged. Can mediate torsade de Pointes (polymorphic VT)
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| 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.
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| 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).
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| 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.
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| Class 3 Anti-Arrhythmics | K Blockers (slow depolarization)
Amioderone, Sotalol, Bretylium. Prolong repolarization (may see EADs). Also photosensitivity with AMiderone.
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| 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.
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| Automaticity Arrhythmia? | Use Beta Blocker, Calcium Channel Blocker
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| Triggered Arrhythmia (EADs/DAD's)? | Use Beta blockers, Calcium Channel Blockers
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| Conduction (reentry) Arrythmias? | Sodium and Calcium blockers.
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| Imaging | X-ray, Cath, Nuclear, Echo, CTA, MR
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