CLIN PATH: EXAM #1 (CARDIO 1.C VALVES/CAD)

Aortic stenosis and mitral regurgitation are what kind of murmur?

Systolic murmur

Aortic regurgitation and mitral stenosis are what kind of murmur?

Diastolic murmur

Stenosis of valves develops _________________ whereas Regurgitation can either be chronic or acute

slowly over time

Stenosis of valves develops slowly over time whereas Regurgitation can ___________________.

either be chronic or acute

What are the 3 cardinal symptoms of Aortic Stenosis?

1. Chest Pain (5 yrs)

2. Syncope (3 yrs)

3. Heart Failure (2 yrs)

PE findings of this valvular heart disease include palpation of carotid upstroke reveals pulsus parvus (decreased) and pulsus tardus (late) relative to apical impulse?

Aortic Stenosis

Auscultation of this valvular heart disease reveals a midsystolic murmur, loudest at base of the heart and often with radiation to sternal notch and neck?

Aortic Stenosis

Depending on cause of this valvular heart disease, a crisp, high pitched aortic systolic click can be heard just after S1, a soft or absent S2, especially as disease progresses, and S4 can also be present?

Aortic Stenosis

A 20 y/o M presents to your clinic with findings of unicuspid, bicuspid, or tricuspid with partially fused leaflets. Abnormal flow --> fibrosis and calcification. What type of Aortic Stenosis do they have?

A. Congenital

B. Rheumatic

C. Degenerative

Congenital

A 50 y/o F presents to clinic with pathological findings including Tissue inflammation --> adhesion and fusing of commissures. PMx includes a feverish childhood disease. What type of Aortic Stenosis do they have?

A. Congenital

B. Rheumatic

C. Degenerative

Rheumatic

A 78 y/o F presents to clinic with pathological findings including Leaflets inflexible --> calcium deposits at bases. Leaflet tips remain relatively normal. PMx includes DM and HLD. What type of Aortic Stenosis do they have?

A. Congenital

B. Rheumatic

C. Degenerative

Degenerative

Systolic gradient between LV and Aorta can exceed ___________.

150 mmHg

Cardinal features of __________________ include left ventricular hypertrophy and systolic ejection murmur.

Aortic Stenosis

You suspect your pt has Aortic Stenosis. What description would you expect to see on the ECHO report?

"concentric hypertrophy"

Angina Pectoris, Syncope, and HF are 3 symptoms of which valvular heart disease?

Aortic Stenosis

You Dx your pt with Aortic Stenosis. Due to decreased cerebral perfusion from fixed obstruction, what symptoms might they experience?

Syncope

________________ are common in Aortic Stenosis which can cause syncope.

Ventricular arrythmias

How would you discriminate between HOCM and Aortic Stenosis?

Valsalva maneuver = HOCM would make murmur louder & AS would make it quieter

In _______________, compensatory mechanisms have no time to be activated, so SOB, pulmonary edema, and hypotension—often with cardiovascular collapse—occur suddenly.

A. Acute Aortic Regurgitation

B. Chronic Aortic Regurgitation

Acute Aortic Regurgitation

In _________________, there is a long latent period during which the patient remains asymptomatic as the heart responds to the volume load.

A. Acute Aortic Regurgitation

B. Chronic Aortic Regurgitation

Chronic Aortic Regurgitation

Your pt presents with pounding pulses, an apical impulse hyperdynamic and displaced laterally, and 3 murmurs may be heard. What valvular cardiac disease do you suspect?

Chronic Aortic Regurgitation

You auscultate your pt's heart and hear a Diastolic rumble (Austin Flint murmur). What valvular cardiac disease do you suspect?

Chronic Aortic Regurgitation

You observe the following upon PE:

- Peripheral signs are absent

- LV impulse is normal

Auscultation:

- Diastolic murmur is much softer

- Austin Flint murmur, if present, is short

- First heart sound will be soft and sometimes absent

What valvular cardiac disease do you suspect?

Acute Aortic Regurgitation

Aortic Regurgitation places a volume load on the LV, because during diastole blood enters the ventricle both from the _______________________.

left atrium and from the aorta

You suspect your pt has Aortic Regurgitation. What description would you expect to see on the ECHO report?

"eccentric hypertrophy"

Aortic Regurgitation leads to decreased SV. This means less blood is going out to the body which results in a decrease diastole. (Less blood out means less blood in.) What happens to the Aortic pulse pressure?

Aortic pulse pressure is widened

Cardinal features of ______________ include: Large hypertrophied left ventricle; large aorta; increased SV; wide pulse pressure; diastolic murmur.

Aortic Regurgitation

In Acute Aortic Regurgitation, what SOB related disease develops because the ventricle doesn't have time to compensate?

Pulmonary Edema

Your pt presents to clinic with dyspnea, fatigue, hemoptysis, and tachycardia. What valvular heart disease do you suspect?

Mitral Stenosis

Your pt presents to clinic with transient numbness or weakness of extremities, sudden loss of vision, and difficulty with coordination. This is a neurologic sign of what valvular heart disease?

Mitral Stenosis

Your pt has a late low-pitched diastolic rumble and upon auscultating the lungs, you hear rales. This is a characteristic of what valvular heart disease?

Mitral Stenosis

What valvular heart disease results in elevated left atrial pressure, left atrial hypertrophy, opening snap, and a diastolic murmur?

Mitral Stenosis

What is the most common type of Mitral Stenosis and involves narrowing results from fusion and thickening of commissures, cusps, and chordae tendinae?

A. Rheumatic

B. Calcific

Rheumatic

What type of Mitral Stenosis usually causes MR, but can cause MS in some cases?

A. Rheumatic

B. Calcific

Calcific

What type of Mitral Stenosis usually presents during infancy or childhood?

A. Congenital

B. Collagen-Vascular disorder

Congenital

What type of Mitral Stenosis is associated with SLE or RA (rare)?

A. Congenital

B. Collagen-Vascular disorder

Collagen-Vascular disorder

The main pathophysiologic abnormality in ______________ is elevated pulmonary venous pressure and elevated right-sided pressures (pulmonary artery, right ventricle, and right atrium)

A. Mitral Stenosis

B. Mitral Regurgitation

Mitral Stenosis

Pt presents to clinic with SOB, hemoptysis, orthopnea, palpitations, and neurologic symptoms. What valvular heart disease do you suspect?

Mitral Stenosis

Mitral Stenosis leads to increased LA size and predisposes patients with MS to atrial arrhythmias, due to chaotic atrial activity. What symptom does this present as?

Palpitations

In Mitral Stenosis, reduced outflow leads to dilation of LA and stasis of blood flow. Thrombus in LA is seen on ECHO in approx. 20% of patients with prevalence increasing with age, AF, severity of stenosis, and any reduction in CO. What symptom does this present as?

Neurologic

Mitral Stenosis leads to LA enlargement and can also impinge on what nerve resulting in hoarseness (Ortner Syndrome)?

Recurrent laryngeal nerve

Your pt c/o dyspnea, easy fatigability, and palpitations. Upon PE, you hear a holosystolic high-pitched regurgitant murmur. What valvular heart disease do you suspect?

Mitral Regurgitation

What is the most common cause of Mitral Regurgitation?

MVP (mitral valve prolapse)

In coronary artery disease, obstruction of the circumflex coronary artery can lead to ischemia or rupture of the papillary muscles. What valvular heart disease would you suspect if this occurred?

A. Acute Mitral Regurgitation

B. Chronic Mitral Regurgitation

Acute Mitral Regurgitation

Ruptured chordae tendinae, Ruptured or dysfunctional papillary muscles, and Perforated Leaflet are all types of what valvular heart disease?

Acute Mitral Regurgitation

Inflammatory, Infection, Degenerative, and Rupture of dysfunction of chordae tendinae or papillary muscles are all types of what valvular heart disease?

A. Acute Mitral Regurgitation

B. Chronic Mitral Regurgitation

Chronic Mitral Regurgitation

In Chronic Mitral Regurgitation, what would you see that does NOT occur in Acute Mitral Regurgitation?

Atrial and Ventrical chamber enlargement and hypertrophy

Cardinal features of this valvular heart disease include:

- Systolic backflow into left atrium

- Left atrial enlargement

- Left ventricular enlargement (hypertrophy in acute lesions)

Mitral Regurgitation

You auscultate a holosystolic murmur. What valvular cardiac disease do you suspect?

Mitral Regurgitation

Pt presents to clinic with symptoms of pulmonary edema, fatigue, and palpitations. What valvular cardiac disease do you suspect?

Mitral Regurgitation

Rapid elevation of pulmonary capillary pressure in Acute Mitral Regurgitation leads to the sudden onset of what disease manifested by SOB, orthopnea, and paroxysmal nocturnal dyspnea?

Pulmonary Edema

In Mitral Regurgitation, this symptom develops due to decreased forward blood flow to peripheral tissues.

Fatigue

In Mitral Regurgitation, LA enlargement leads to atrial arrythmias (AF) causing what symptom?

Palpitations

A 74 y/o M presents to your clinic with syncope. You perform an echocardiogram. What do you expect to see?

A. Bicuspid Aortic Valve

B. Adhesion and fusing of commissures

C. Calcified Aortic Valve

Calcified Aortic Valve

What is one of the hemodynamic changes the heart undergoes due to Aortic Stenosis?

A. Shift contractility curve to left

B. Decrease preload

C. Shift compliance curve to right

Shift contractility curve to left

What kind of changes would you see on an ECHO in patients with Chronic Aortic Regurgitation?

A. Concentric Hypertrophy

B. Essentric Hypertrophy

C. Low Ventricular Volumes

Essentric Hypertrophy

What type of murmur is associated with Aortic Regurgitation?

A. Crescendo-Decrescendo Systolic

B. Austin Flint Murmur

C. Late low pitched diastolic rumble

D. Holosystolic high pitched murmur

Austin Flint Murmur

Which valvular abnormality may present with hoarseness?

A. AS

B. AR

C. MS

D. MR

MS

Which of the following is an example of an acute cause of Mitral Regurgitation?

A. Rheumatic Heart Disease

B. Infective Endocarditis

C. Ruptured Papillary Muscle

D. Calcification of Mitral Leaflet

Ruptured Papillary Muscle

What is the most common symptom associated with CAD?

Dull chest pain that often radiates down arm or to jaw

Coronary Artery Disease ______________________.

A. worsens with a deep breath

B. does not worsen with a deep breath

does not worsen with a deep breath

If pain only occurs with exertion and is stable over a period of time = __________________.

A. STABLE ANGINA

B. UNSTABLE ANGINA

STABLE ANGINA

If pain occurs at rest = ___________________

A. STABLE ANGINA

B. UNSTABLE ANGINA

UNSTABLE ANGINA

If CP persists without interruption for prolonged periods and irreversible myocyte damage has occurred = __________________

A. Unstable Angina

B. Myocardial Infarction

Myocardial Infarction

What is the most common cause of CAD?

A. Atherosclerosis

B. Spasm

Atherosclerosis

What type of CAD causes Coronary artery vasospasm d/t histamine/serotonin/catecholamine mediated vasoconstriction, and is not exertion related?

A. Atherosclerosis

B. Spasm

Spasm

Which type of CAD is rare and can occur from vegetation in patients with endocarditis?

A. Atherosclerosis

B. Emboli

Emboli

This type of coronary artery abnormalities are present in 1-2% of the population. However, only a small fraction of these abnormalities cause symptomatic ischemia.

A. Emboli

B. Congenital

Congenital

Cellular ischemia occurs when there is either increased demand for oxygen relative to maximal arterial supply or an absolute reduction in oxygen supply. Which one are most clinical cases due to?

Decreased oxygen supply

What popular street drug increases oxygen demand (by inhibiting reuptake of norepinephrine at adrenergic nerve endings in the heart) and can reduce oxygen supply by causing vasospasm?

Cocaine

What remains the predominant cause of angina and myocardial infarction?

Atherosclerosis of large coronary arteries

Atherosclerosis is found mainly in areas exposed to __________________________ such as bending points and bifurcations and are thought to arise from isolated macrophage foam cell migration into areas of minimal chronic intimal injury.

increased shear stresses

In patients with ______________, fixed narrowing of one or several coronary arteries is usually present.

A. STABLE ANGINA

B. UNSTABLE ANGINA

STABLE ANGINA

In patients with __________________, fissuring of the atherosclerotic plaque can lead to platelet accumulation and transient episodes of thrombotic occlusion, usually lasting 10–20 minutes.

A. STABLE ANGINA

B. UNSTABLE ANGINA

UNSTABLE ANGINA

In _____________________, deep arterial injury from plaque rupture may cause formation of a relatively fixed and persistent thrombus.

Myocardial Infarction

Plaque composition mediated by inflammation has an important role in clinical presentation of what CAD?

Myocardial Infarction

The heart receives its energy primarily from?

ATP generated by oxidative phosphorylation of free fatty acids

How long does it take after coronary artery occlusion before myocardial oxygen tension in the affected cells falls essentially to zero?

60 seconds

After 60 seconds of coronary artery occlusion, cardiac stores of high-energy phosphates are rapidly depleted, and the cells shift rapidly to _________________ with consequent lactic acid production

anaerobic metabolism

Once cardiac cells shift to anaerobic metabolism, dysfunction of myocardial relaxation and contraction occurs within ____________, even before depletion of high-energy phosphates occurs.

seconds

After coronary artery occlusion occurs, If perfusion is not restored within _______________, an irreversible stage of injury characterized by diffuse mitochondrial swelling, damage to the cell membrane, and marked depletion of glycogen begin.

40-60 minutes

With prolonged episodes of ischemia—up to 1 hour—it may take up to 1 month to restore ventricular function. What is this known as?

"stunned" myocardium

Clinical manifestations for this disease include Chest Pain, 4th heart sound/SOB, Shock, Bradycardia or Tachycardia, and N/V?

Myocardial Infarction

In patients with CAD, 70–80% of episodes of ischemia are actually ________________.

asymptomatic

Dysfunction of afferent nerves, transient reduced perfusion, and differing pain thresholds among patients account for the large proportion of what?

Asymptomatic episodes of CAD

What is d/t diastolic and systolic dysfunction of the ischemic myocardium (heart failure symptoms)?

A. 4th Heart Sound and SOB

B. Shock

4th Heart Sound and SOB

Obstruction of the __________________________ will usually present as severe cardiac failure, often with associated hypotension (shock)

A. CX and CAD

B. LM or the proximal LAD

LM or the proximal LAD

If necrosis of the septum occurs from ________________ occlusion, myocardial rupture with the formation of an interventricular septal defect can occur

A. CAD artery

B. LAD artery

LAD artery

Rupture of the anterior or lateral free walls from occlusion of the LAD or CX leads to what two very bad things?

A. severe MR and shock

B. pericardial effusion and tamponade

pericardial effusion and tamponade

Cx occlusion may result in ischemia and dysfunction or overt rupture of the papillary muscles leads to what two very bad things?

A. severe MR and shock

B. pericardial effusion and tamponade

severe MR and shock

Inferior Wall Myocardial Infarction (IWMI) usually arise from occlusion of the what artery?

RCA

Which nodal conduction dysfunction does not occur because that area receives blood from both the right and the left coronary arteries?

A. SA

B. AV

SA

AV nodal conduction abnormalities can occur because of reflex activation of the ___________ nerve, which richly innervates the AV node.

vagus

What symptom occurs d/t activation of the vagus nerve in the setting of an inferior wall myocardial infarction?

A. Nausea/Vomiting

B. Tachycardia

Nausea/Vomiting

Levels of catecholamines are usually raised in patients with myocardial infarction which maintains SV but leads to what?

Tachycardia

At what percent occlusion will a patient with CAD feel pain at rest?

A. 50%

B. 70%

C. 90%

90%

A 54 y/o F presents with CP. She states she had it a few days ago when she was walking around the park. When she sat down, the pain went away. How would you classify this CP?

A. UNSTABLE ANGINA

B. STABLE ANGINA

C. MYOCARDIAL INFARCTION

STABLE ANGINA

Severe chest pain that has a sharp retrosternal onset with radiation to back and worse with deep inspiration or coughing is the clinical presentation of what disease?

Pericarditis

Pt presents to clinic with chest pain that is worse when he lays down and improved when he sits up and leans forward. What disease is this characteristic of?

Pericarditis

Upon physical exam, you auscultate the heart and hear a high pitched squeaking sound. What disease is this characteristic of?

Pericarditis