PROCESSES AND PATHWAYS

Male patient usually has a coronary disease at fifty five years old and above

When does a male patient usually develop a coronary disease?

After menstruation, at the start of menopause, one should count fifteen years

What time frame after menopause begins marks when women may already be at risk for coronary artery disease (CAD)?

Cardiovascular events happen in a male less than fifty five years old or in female less than sixty five years old

What is the age criterion for defining premature coronary disease?

Seventy five percent

What approximate percentage of a cardiac problem diagnosis is comprised by the cardiovascular history?

Chest pain on exertion that is relieved by rest

What is the description of typical angina, which is highly specific to coronary artery disease?

Chest pain at rest or chest heaviness

What type of chest pain could be just atypical?

When accompanied by diaphoresis, especially if the patient also exhibits hypotension

What circumstance increases the specificity of atypical chest pain for coronary artery disease (CAD)?

Left sided congestive heart failure

What is the more common type of congestive heart failure (CHF)?

Progression of left sided congestive heart failure

What is the most common cause of right sided congestive heart failure (RHF)?

Congested left side of the heart leads to backflow to pulmonary vein, which increases blood in the lungs, pooling backward to the pulmonary artery, pooling blood in the right ventricle, causing congestion of the lungs and liver, leading to hepatomegaly, ascites, and edema of the lower extremities

What is the progression of symptoms for congestive heart failure from the left side to the right side?

Exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea

What is the sequence of symptoms for left sided congestive heart failure (LHF)?

Hepatomegaly, ascites, edema

What is the sequence of symptoms for right sided congestive heart failure (RHF)?

Exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, ascites, edema, and hepatosplenomegaly

What is the sequence of symptoms for combined left and right sided congestive heart failure?

The patient will eventually regain consciousness

What happens if syncope is due to an arrhythmia and the patient is reclined?

Ventricular tachycardia which leads to cardiac arrest

What type of arrhythmia can cause consciousness to be totally lost?

Septic emboli

What are Janeway lesions a form of, typically found in the palms and soles of infective endocarditis (IE) patients, and are not painful?

Immunologic reactions

What are Osler’s Nodes, typically situated towards the tip of the fingers, and are painful?

Swelling and redness of the lower extremities

What is the presentation of phlebitis (vein inflammation)?

Inspiratory decline in systolic pressure greater than ten millimeters of mercury

What is the threshold for a decline in systolic pressure during inspiration that is considered pulsus paradoxus?

Negative intrathoracic pressure creates a vacuum effect which causes increased systemic venous return to the right side of the heart, which leads to more blood returning to the right ventricle, shifting the interventricular septum towards the left ventricle, resulting in less volume in the left ventricle, thus decreasing stroke volume and cardiac output

What is the mechanism of pulsus paradoxus?

Hypotension, muffled heart sounds, distended neck veins

What are the three components of Beck's triad?

Impaired diastolic filling on the left side of the heart leads to decreased stroke volume and decreased cardiac output, resulting in a decrease in blood pressure

What is the mechanism that causes hypotension in cardiac tamponade?

Increased fluid around the pericardium surrounds the heart, muffling the soundwaves

What is the cause of muffled heart sounds in cardiac tamponade?

Elevation of venous pressures because the right side of the heart is unable to fill with blood

What is the effect of cardiac tamponade on the right side of the heart, leading to distended neck veins?

Blood from the ventricles leave the heart, making room for right atrial filling, which causes the jugular venous pressure to decrease

What is the mechanism that causes the prominent X descent in cardiac tamponade?

The equalization of diastolic filling pressure across the chambers, which removes the pressure gradient across the right atrium and right ventricle

What is the mechanism that causes the absent Y descent in cardiac tamponade?

The walls on the right atrium and the right ventricle are thinner compared to the left ventricle, so the high pressure outside overpowers the intracavitary pressures, leading to collapse and inability to fill

What causes right atrial and right ventricular collapse in cardiac tamponade?

Healing of acute fibrinous or serofibrinous pericarditis, or resorption of a chronic pericardial effusion

What is the pathogenesis of constrictive pericarditis?

Obliteration of the pericardial cavity with granulation tissue formation, which contracts and forms a firm scar encasing the heart

What is the key initial step in the pathogenesis of constrictive pericarditis?

Thickened, scarred, inelastic, and often calcified noncompliant pericardium limits diastolic filling of the ventricles

What is the primary pathophysiological issue in constrictive pericarditis?

Negative intrathoracic pressure is not transmitted to the heart because of the rigid, calcified, thickened pericardium, so there is still increased venous return but the right ventricle is noncompliant, leading to increased right atrial pressure

What is the mechanism that causes Kussmaul's sign (increase in jugular venous pressure upon inspiration) in constrictive pericarditis?

Pressure difference between the atrium and ventricle causes a rapid filling phase

What causes a rapid Y descent in constrictive pericarditis and restrictive cardiomyopathy?

The atrium contracts over a closed tricuspid valve

What produces a cannon A wave in complete heart block, due to simultaneous atrial and ventricular contraction?

Blood backflows from the right ventricle to the right atrium due to tricuspid valve incompetence

What is the mechanism that produces a tall V wave in tricuspid regurgitation?

The tricuspid valve will not open or will have difficulty in opening

What is the mechanism that produces a giant A wave in tricuspid stenosis, by generating very high atrial pressure when the atrium contracts?

A vascular communication between the pulmonary artery and aorta that persists after birth

What is the definition of patent ductus arteriosus (PDA)?

The pressures on the right side of the heart are lower than the pressures on the left side of the heart

What is the relationship between right and left side heart pressures that drives blood flow from left to right in defects with openings between heart chambers?

Left to right shunting of blood

What is the hemodynamic mechanism in ventricular septal defect, patent ductus arteriosus, and atrial septal defect that causes volume overload on the heart and the lungs?

When the blood that should be going out of the left side of the heart returns back to the right side of the heart

What is the mechanism that causes the right side of the heart to become overworked and enlarged in congestive heart failure due to a shunt?

Volume overload of the left ventricle

What is the hemodynamic consequence of a moderate-sized ventricular septal defect (VSD)?

Volume overload of the left ventricle and pressure overload of the right ventricle

What are the hemodynamic consequences of a large-sized ventricular septal defect (VSD)?

When the pressure of the lungs is higher than the left, high enough to equal systemic blood pressure

When can the shunt reverse from left to right to right to left in VSD, leading to Eisenmenger syndrome?

Pressure overload of the right ventricle

What is the hemodynamic consequence of pulmonary stenosis (PS)?

Pressure overload of the left ventricle

What is the hemodynamic consequence of aortic stenosis (AS)?

Pressure overload of the left ventricle

What is the hemodynamic consequence of coarctation of the aorta (CoA)?

Increases flow in the right side, behaving like an atrial septal defect

What is the hemodynamic consequence of partial anomalous pulmonary venous return (PAPVR)?

Volume loading of the right side

What is the hemodynamic consequence of atrial septal defect (ASD)?

The pulmonary valve closes with delay because of the volume overload on the right side of the heart

What is the cause of the split second heart sound in an atrial septal defect (ASD)?

Systole is the phase of contraction, and diastole is the phase of relaxation

What are the two phases of the cardiac cycle?

Atrial contraction to fill the right ventricle

What event does the A wave of the jugular venous pulse represent?

Ventricular systole causes the bulging of the tricuspid valve

What event does the C wave of the jugular venous pulse represent?

Atrial venous filling

What event does the V wave of the jugular venous pulse represent?

Atrial relaxation

What event does the X descent of the jugular venous pulse represent?

Ventricular filling (rapid filling phase)

What event does the Y descent of the jugular venous pulse represent?

Closure of the mitral and tricuspid valves

What event produces the S one heart sound (lub)?

Closure of the aortic and pulmonary valves

What event produces the S two heart sound (dub)?

Left sided valves close earlier than right sided valves

What is the relationship between valve closures due to pressure difference?

After the aortic and pulmonic valves close

When does ventricular filling/relaxation occur in the cardiac cycle?

Closure of the aortic and pulmonic valves will be caused by the blood that was ejected being sucked back by the left ventricle

What is the suctioning effect mechanism that causes the S two heart sound (dub)?

Diastole (S two to S one) is longer compared to systole (S one to S two)

What is the relative duration of systole and diastole in the cardiac cycle?

The atrium contracts

What physiological event characterizes atrial systole?

Increases in ventricular volume, atrial pressure (a wave), and ventricular pressure

What three pressure and volume changes occur during atrial systole?

The ventricles contract but the valves are closed, and the ventricular volume does not change

What three events define isovolumetric contraction?

The aortic semilunar valve opens when left ventricular pressure exceeds aortic pressure

What event happens at the end of isovolumetric contraction?

Ventricular pressure reaches its peak

What is the peak pressure event that occurs during the ejection phase?

The aortic valve closes

What event, which produces the S two heart sound, marks the end of the ejection phase and the start of isovolumetric relaxation?

The mitral valve opens when the ventricular pressure drops below the atrial pressure

What event happens at the end of isovolumetric relaxation?

The volume will increase in the ventricles as they fill, and the atrial pressure reduces as they empty (y descent)

What is the volume and pressure change in the heart chambers during the filling phase?

The atria contract against a ventricle that is stiff and not very compliant

What pathological condition causes the fourth heart sound (S four) to be heard?

The left ventricle and ascending aorta are severely hypoplastic and cannot support systemic circulation

What is the cause of Hypoplastic Left Heart Syndrome (HLHS)?

Increases systemic vascular resistance, reducing the right to left shunt

What is the physiological mechanism of squatting in Tetralogy of Fallot (TOF) that improves oxygenation?

One defect or association of defects allows the mixture of oxygenated and de-saturated blood to reach the systemic circulation

What is the unifying mechanism in cyanotic heart disease?

When the pressure of the lungs is higher than the left, high enough to equal systemic blood pressure

When can the shunt reverse from left to right to right to left, resulting in Eisenmenger syndrome?

The oxygenated blood from the lungs via the pulmonary vein did not end up on the left side of the heart

What is the mechanism of cyanosis in Total Anomalous Pulmonary Venous Return (TAPVR)?

Oxygenated blood is stuck on the left side and venous blood is stuck on the right side to the aorta, requiring holes in the heart for survival

What is the mechanism of cyanosis in Transposition of the Great Arteries (TGA)?

Less than one hundred fifty millimeters of mercury (torr) after ten minutes of one hundred percent FiO two

What is the PaO two level that suggests a positive Hyperoxia test for intracardiac right to left shunting?

Greater than one hundred fifty millimeters of mercury (mmHg) after ten minutes of one hundred percent FiO two

What PaO two level suggests a negative Hyperoxia test, indicative of a pulmonary disease that is responsive to oxygen?

The patient will eventually regain consciousness

What happens when a syncope attack is due to arrhythmia and the patient is reclined?

Increased volume inside the heart at diastole

What is preload (End-Diastolic Volume)?

Resistance that ventricles must overcome to circulate blood during systole

What is afterload?

How hard the myocardium contracts for a given preload

What is contractility?

Coronary Artery Disease, Hypertension, Diabetes Mellitus, Valvular heart disease

What are some common final pathways of chronic cardiovascular diseases that lead to heart failure (HF)?

Impaired ability of the left ventricle to fill with or eject blood

What is the structural or functional impairment in heart failure?

Chronic hemodynamic stimuli (pressure and/or volume overload), mechanical stress/stretch, production of circulating neurohormones and inflammatory cytokines, and oxidative stress

What are the remodeling stimuli in heart failure (HF)?

Increase in myocardial muscle mass to reduce stress caused by high pressure

What is the mechanism of concentric hypertrophy in heart failure?

Increase in left ventricular cavitary size or volume in response to volume overload

What is the mechanism of eccentric hypertrophy in heart failure?

Production of myocyte hypertrophy and interstitial fibrosis

What is the change that occurs at the cellular level during ventricular remodeling?

Alteration in calcium handling and cytoskeletal function (weakening of sarcomeres)

What is the change that occurs at the protein level during ventricular remodeling?

Re-expression of fetal genes

What is the change that occurs at the molecular level during ventricular remodeling?

Progressive loss of myocytes due to maladaptation of myocytes to pressure or volume overload

What is the mechanism of cell loss in heart failure pathogenesis?

Left ventricular dilatation plus increased afterload leads to decreased stroke volume and heart failure

What is the mechanism by which ventricular remodeling leads to impairment of pump action?

Neurohormonal activation (sympathetic nervous system and renin angiotensin aldosterone system) and vasodilatory hormones

What are the two main compensatory mechanisms to maintain blood pressure when left ventricular pump action is impaired in heart failure?

Increased heart rate, increased blood pressure, increased cardiac contractility, and sodium and water retention

What are the overall effects of neurohormonal activation (sympathetic nervous system and renin angiotensin aldosterone system) in heart failure?

They are designed to augment preload to maintain cardiac output

What is the goal of neurohormonal activation responses in heart failure?

Excessive vasoconstriction, volume retention, electrolyte and renal abnormalities, and arrhythmia

What complications result if neurohormonal activation remains unchecked or sustained in heart failure?

Decreased cardiac output through baroreceptor dysfunction leads to decreased afferent parasympathetic tone and increased efferent sympathetic tone

What is the initial chain of events in neurohormonal activation in heart failure?

Sodium plus water reabsorption, vasoconstriction, and myocyte hypertrophy

What are the three effects of RAAS activation in heart failure?

Vasodilation, decreased sodium plus water reabsorption, decreased renin plus aldosterone release, and decreased baroreceptor modulation

What are the effects of vasodilatory hormones (ANP, BNP, PGE one, PGI two, Bradykinin, Adrenomedullin, Nitric oxide) in heart failure?

Reduced cardiac output decreases renal perfusion, activating neurohormonal pathways that worsen fluid retention and heart failure symptoms

What is the mechanism of cardiorenal interaction involving reduced cardiac output?

Congestion from heart failure can cause renal dysfunction, which further impairs fluid balance

What is the mechanism of cardiorenal interaction involving congestion?