NLME CVS

National License: Infectious disease

PAGE 21NMLE step I

NL: Cardiology.. Encoded and printed by Waen32 and 248 MED34Proof and pictured by Waen32 MED34

Overview

mediastinum blood pool arterial venous system left ventricle (heart apex) cross section (chamber) (atrium) (ventricle) atrioventricular (AV) valve tricuspid valve mitral valve septum

Venous system superior vena cava inferior vena cava right atrium left atrium pulmonary vein Arterial system aorta left ventricle aortic valve

Coronary system right left coronary heart disease sudden death coronary heart disease emergency condition

Right coronary artery (RCA) right ventricle inferior wall left ventricle pacemaker SA node AV node RCA atherosclerosis MI right ventricular infarction right ventricle venous system engorged neck vein clear lung EKG ST elevation Lead II, III, aVF arrhythmia SA node AV node dysfunction ( AV block )

Left coronary artery anteroseptal wall (Lead V1, V2, V3, V4) left anterior descending artery (LAD) left circumflex coronary artery (LCX) lateral wall (V3,V4, V5, V6) ST elevation EKG lead occlusion lead

partial occlusion atherosclerosis collateral branch atherosclerosis anatomy coronary system collateral circulation

complete LAD occlusion acute left ventricular failure acute pulmonary edema acute left-side heart failure LV pressure LV LA crepitation right coronary lung clearHistology of the heart

Myocyte (branching) intercalated disk resistance (functional syncytium) cross section nucleus cytoplasm mitochondria

T system extracellular intracellular T system Z line intercalated disc catecholamine ANS cardiac plexus thoracic sympathetic ganglion 1 receptor HR contractility parasympathetic vagus nerve activity

Physiology

Cardiac cycle atrium ventricle atrium ventricle phase 2 phase (systole) phase (diastole) cardiac cycle ventricle

Atrial pressure venous wave Aortic pressure blood pressure ventricular pressure

conducting pathway SA node SVC AV (atrioventricular) node atrium ventricle AV node Bundle of His interventricular septum right left bundle branch ventricle purkinje fiber EKG wave

1 cardiac cycle = P wave + QRS complex + T wave

P wave represent atrial depolarization atrium P wave PR interval SA node ventricleQRS complex represent ventricle

T wave represent ventricular repolarization electrolyte potassium potassium T wave QT interval ventricular depolarization ventricular repolarization Plateau phase represent calcium influx calcium QT interval

EKG investigation EKG chest X-ray

SHAPE \* MERGEFORMAT


Clinical approach to chest pain

(Chest pain) skin ( breast ) musculoskeletal structure thoracic cavity great vessels aorta, SVC, IVC esophagus mediastinum cardiovascular disease non-cardiovascular disease

Cardiovascular disease

Chest pain cardiovascular disease coronary artery disease pain angina pectoris coronary artery disease pathology 2 chronic stable acute coronary syndrome

Acute coronary syndrome plaque rupture present 2 unstable angina acute myocardial infarction

Coronary artery disease risk factor plaque atherosclerosis risk factor coronary artery disease 60 acute coronary syndrome life-threatening condition

coronary artery aortic dissection aorta nerve fiber aortic dissection hypertension

Pericarditis pericardium fibrovascular structure chest pain sharping pain irritation pericardial friction rub

Non-cardiovascular disease

(pleuritis) pleural rubPulmonary embolism pulmonary infarction ischemic pain Skin pathology chest pain trauma Herpes zoster neuropathic pain dermatome vesicle Costochondritis muscle disease muscle sprain pericarditis pleuritis costochondritis (point of tenderness) GERD epigastrium sternum Coronary artery disease

Risk factors smoking, LDL- cholesterol , hypertension, obesity, impaired glucose tolerance atherosclerosis coronary artery coronary artery syndrome

Coronary artery disease coronary artery angina pectoris

Typical angina ischemic pain ATP pump - anaerobic respiration calcium influx phospholipase phospholipids arachidonic acid arachidonic pathway prostaglandins pain fiber visceral pain sympathetic fiber referred pain common () () exertion activity O2 supply ischemic pain ischemic pain sympathetic nerve sympathetic overactivity

pain typical angina nitroglycerin (Nitroglycerin nitric oxide vasodilatation )

Pathology coronary artery disease coronary artery atheroma plaque atheroma DM, smoking, hypertension, LDL

plaque stable fibrous cap lipid floor stable fibrous cap stable fibrous cap lipid floor LDL plaque rupture

Plaque 70% coronary diameter coronary artery syndrome angina pectoris stable plaque chronic stable angina

plaque rupture platelet coagulation clot clot (total occlusion) myocardial infarction transmural infarction EKG ST elevation Clot unstable angina MI acute coronary syndrome

Acute coronary syndrome acute chest pain sympathetic surge angina stable angina

Unstable angina myocardial infarction cardiac enzyme CK-MB troponin CK-MB troponin-T myocardial infarction 1 CK-MB troponin-T unstable angina

EKG ST elevation V2-V6 left coronary system (LAD LCX) acute myocardial infaction ventricle acute heart failure arrhythmia ( myocardium conducting system ) arrhythmia sudden death

Pathogenesis plaque rupture platelet coagulation antiplatelet anticoagulant aspirin block COX Thromboxane A2 platelet aggregation anticoagulant heparin factor X 2 forms conventional heparin Low molecular weight heparin (LMWH) conventional heparin bioavailability protein binding dose

total occlusion coronary artery reperfusion therapy (thrombolytic agent) streptokinase tPA

plaque stable ACE inhibitor statin groupRheumatic feverRheumatic Fever Rheumatic heart disease acute rheumatic fever rheumatism rheumatic heart disease

Rheumatic fever acute phase inflammatory process Beta hemolytic streptococcus group A multi-organ involvement rheumatism Beta hemolytic streptococcus group A 1. Upper respiratory tract infection pharyngitis complication acute rheumatic fever post-streptococcal glomerulonephritis strain 2. Skin infection complication post-streptococcal glomerulonephritis acute rheumatic feverRheumatic fever major criteria (carditis) (poly-migratory arthritis) (chorea) (erythema marginatum) (subcutaneous nodule)

Carditis 3 endocarditis valvular heart disease mitral stenosis myocarditis contractility present 2 heart failure arrhythmia pacemaker cell pericarditis chest pain sharping pain pancarditis


Polymigratory arthritis 3 synovial effusion arthritisChorea abnormal movement involuntary typical Huntingtons choreaErythema maginatum skin lesion


Subcutaneous nodule subcutaneous


minor criteria , , , PR prolong synovial effusion (arthralgia) investigate inflammatory marker CRP ESR PR interval AV node dysfunction

rheumatic fever 2 major criteria 1 major + 2 minor criteria Evidence Beta-hemolytic streptococcus group A throat swab culture primary inflammatory site antibody antistreptolysin O (ASO)

rheumatic fever 3-4 heart failure

Cardiac presentation acute rheumatic fever histopathology Aschoff body granuloma endocardium myocardium acute rheumatic fever

chronic inflammation scar complication valvular heart disease valve involvement mitral valve pathology mitral stenosis involve valve valvular heart disease acute rheumatic fever rheumatic heart disease

Valvular heart disease blood flow turbulent flow microinjury thrombus emboli arterial system embolic stroke acute arterial occlusion deep vein thrombosis emboli flow arterial system Bacterial endocarditis

bacteria endocardium valvular murmur bacterial infective endocarditis 2 virulence 1. Acute bacterial endocarditis Staphylococcus aureus virulence acute heart failure intravenous drug uses catheterization

2. Subacute bacterial endocarditis low virulence Streptococcus viridans, Beta hemolytic streptococcus group B Enterococci gradual heart failure heart failure progress rheumatic heart disease bacterimia injury bacteria immune bacteria rheumatic heart disease colonize bacteria scar colony bacteria vegetation endocardium

Clinical manifestation (splinter hemorrhage) Vegetation flow anurysm stroke glomerulonephritis splenic abscess


Endocardium structure high dose antibiotic IV form concentration antibiotic bactericidal acute rheumatic heart disease cloxacillin IV subacute rheumatic heart disease penicillin G gentamycin aminoglycoside Gram-positive bacteria synergistic penicillin G cell wall gentamycin 30S subunit ribosome Pericarditis

1. Acute pericarditis viral infection sharping chest pain pericardium pleura pleura irritate pericardium third space pericardium, peritoneum pleura fluid acute pericarditis pericardial friction rub pericardial effusion cardiac tamponade

2. Chronic pericarditis contraction constrictive pericarditis pressure engorged neck vein pulmonary artery cardiac output shock hypoperfusion

Fluid pericardial sac pericarditis trauma pericardial sac hemopericardium infiltrate pericardium lymphoma, lung cancer pericardium fluid rupture leak pericardial sac complication acute myocardial infarction myocardium complication hypertension aortic dissection fluid collection pericardial sac diastolic ventricular pressure cardiac output central venous pressure cardiac tamponade cardiac arrest cardiac tamponade distant heart sound heart sound , engorged neck vein, hypotension, Pulsus paradoxus systolic blood pressure 10 mmHg venous system pressure pericardial effusion pressure pressure interventricular septum shift cardiac output systolic blood pressure EKG QRS complex amplitude lead fluid collection electrical activity lead generalized low voltage generalized low voltage amplitude electrical alternans pericardial fluid anterior chest wall amplitude amplitude

Cardiac tamponade fluid inotrope dobutamine pericardiocentesis remove fluid pericardial space invasive procedure thoracotomy subxiphoid area 45 ( echo - -)

Heart failure

adequate tissue perfusion Low cardiac output pressure chamber

1. Left side heart failure pressure pressure pulmonary vein drain pulmonary vein pressure capillary interstitium fluid leak interstitium Starling gas exchange hypoxemia dyspnea on exertion paroxysmal nocturnal dyspnea (PND) Left side heart failure fluid collection pulmonary edema

paroxysmal nocturnal dyspnea venous return heart failure fine crepitation collapse fine crepitation 2. Right side heart failure pressure venous return inferior vena cava engorged neck vein generalized edema hydrostatic pressure transudate fluid leak interstitium pitting edema portal vein pressure congest liver hepatomegaly pleural effusion right side heart failure engorged neck vein, generalized edema, hepatomegaly ascites portal hypertension

Heart failure clinical syndrome pathology infective endocarditis, rheumatic heart disease myocardial infarction pathology endocardium murmur myocardium heart sound S3 S4 underlying disease cardiomyopathy pericardium right-sided heart failure Heart murmur

pressure atrium ventricle flow atrium ventricle ventricular volume ventricular pressure atrioventricular valve (mitral valve tricuspid valve) ventricular pressure pressure atrium pressure ventricle atrioventricular valve atrioventricular valve pressure gradient atrium ventricle heart sound 1 (S1) S1 mitral valve Mitral stenosis mitral valve ventricular pressure mitral valve S1 pressure gradient atrium ventricle Mitral regurgitation S1 mitral valve pressure gradient S1

ventricular pressure aortic valve flow aorta ventricular volume ventricular pressure aortic pressure ventricular pressure aortic valve heart sound 2 (S2) S2 aortic valve aortic stenosis, aortic regurgitation pulmonic valve aortic valve pressure pulmonic valve Atrial septal defect (ASD)

valve murmur ventricle S1 systolic phase murmur S1 systolic murmur

S3 gallop atrium flow ventricle normal heart sound abnormal heart sound S4 atrial contraction

Valvular lesion

1. Mitral stenosis mitral valve flow left atrium left ventricle left atrium left atrial hypertrophy pressure pulmonary vein pulmonary hypertension hydrostatic pressure (dyspnea on exertion) pressure right ventricle right ventricular hypertrophy S1 murmur diastolic rumbling murmur mitral valve diastolic phase bell left lateral decubitus mitral valve stethoscope RV heaving

2. Mitral regurgitation cusp infective endocarditis cusp left ventricular dilatation hypertension afterload mitral valve left ventricle left ventricular hypertrophy left atrial hypertrophy murmur pansystolic murmur murmur high pitch radiate axillary region mitral valve atrium systolic phase atrial pressure ventricular pressure pansystolic murmur S1 LV heaving3. Aortic stenosis 2 atherosclerosis calcification aortic valve aortic valve 2 cusps bicuspid aortic valve aortic stenosis aortic valve flow aorta syncope left ventricle systolic phase diastolic phase coronary perfusion left ventricle blood supply chest pain heart failure clinical triads aortic stenosis syncope, chest pain heart failure S2 murmur left ventricle systolic phase systolic ejection murmur turbulent flow pressure LV heaving pulse amplitude (pulsus et tardus)4. Aortic regurgitation aortic valve aortic valve S2 murmur diastolic blowing murmur flow (high pitch diaphragm aortic valve diaphragm) volume aorta aorta dilatation flow left ventricle left ventricular dilatation cycle stroke volume aorta left atrium high cardiac output pulse amplitude (bounding pulse)Vascular disease

3 tunica intima, tunica media tunica adventitia tunica adventitia supply vasa vasorum

Hypertension

BP = (SV X HR) X TPR blood pressure 1. Venous return RAAS Conns disease, Cushings syndrome, Hyperthyroidism, renal artery stenosis, glomerular disease, preductal coarctation2. Heart rate pheochromocytoma, caffeine, amphetamine, bronchodilator ventolin

3. Total peripheral resistance atherosclerosis

hypertension organ renal disease, endocrine disease vascular disease

Endocrine disease Cushings syndrome hypertension glucocorticoid mineralocorticoid receptor mineralocorticoid RAAS Conns syndrome RAAS , Hyperthyroidism sympathetic blood pressure Vascular disease Takayasus arthritis autoimmune disease Giant cell arthritis autoimmune disease involve ophthalmic branch blindness

Coarctation anatomical defect 2 types preductal coarctation blood flow renal blood flow RAAS blood flow blood flow pulse postductal coarctation hypertension

Hypertension complication Cerebral stroke, Coronary artery disease, Peripheral artery stenosis, Atherosclerosis, Hypertensive sclerosis glomerulus injuryTransient ischemic attack (TIA) stroke completely recover 24 muscle power imaging anatomy emboli thrombosis in situ Varicose vein vein valve gravity valve venous system rectal vein hemorrhoidElectrocardiogram ( Hard core MED32) 2 contractile myocardial cell (contractility) extracellular Ca2+ actin electrical system cell myocardial cell (automaticity) spontaneous depolarization spontaneous depolarization pacemaker cell

Electrical conducting system sinoatrial (SA) node internodal tract atrioventricular (AV) node Bundle of His ventricle purkinje fibers

Cardiac action potential

resting membrane potential K+ K+ efflux K+ influx K+ equilibrium -90 mV resting membrane potential maintain resting membrane potential ATPase Na+-K+ pump K+

Phase 0Upstroke Na+ fast channel (Na+ conductance )Phase 1Initial repolarization K+ Na+ conductance Phase 2Plateau phase Ca2+ K+ repolarize Phase 3Repolarization Ca2+ K+ Phase 4Resting state K+ equilibrium

Pacemaker action potential

Pacemaker action potential phase 1 2

Phase 0Upstroke Ca2+ slow channel membrane potential -50mV

Phase 3Repolarization K+ Phase 4Slow depolarization funny channel Na+ slow channel Ca2+ action potential pacemaker action potential phase 4

Conducting system pacemaker automaticity firing rate heart rate pacemaker cell SA node firing rate 60-100/min AV node firing rate 40-60/min ventricle firing rate 20-40/minAutonomic nervous system conducting system funny channel phase 4 pacemaker action potentialSympathetic Ca2+ conductance Ca2+ funny channel phase 4 threshold action potential Parasympathetic funny channel phase 4

Parasympathetic myocardium ACh muscarinic cholinergic receptors K+ conductance K+ cell membrane hyperpolarization membrane potential threshold

EKG vector vector electrode vector electrode

EKG paper

EKG sensitivity paper speed

Sensitivity EKG 10 MV/CM EKG sensitivity 5 MV/CM 2 2 sensitivity 20 MV/CM 2

Paper speed 25 mm/sec 50 mm/sec QRS complex 12.5 mm/sec narrow QRS tachycardia

1 = 25 1 1500 pulse rate pulse regular regular beat 10 QRS ( R wave) RR interval pulse rate = 1500 RR regular beat RR interval 15 pulse rate 1500 15 = 100 bpm

irregular beat QRS complex 30 ( 1 )

EKG leads

electrode EKG 12 leads EKG lead lead Limb lead (Lead I, II, III) Augmented lead (aVR, aVL, aVF) lead up-skirt Precordial lead (V1-V6)

Limb leads

Precordial (chest) leads

EKG lead vector electrode lead vector electrode lead vector electrode lead lead II, lead III, aVF vector lead 3 normal heart axis

Normal heart axis -30o 90o heart axis heart axis vector Lead I aVF Lead I aVF left axis deviation ( axis -30o ) lead I aVF right axis deviation (axis 90o) deviation ventricular hypertrophy( heart sound dextrocardia ?)

Lead II bundle branch conducting system EKG wave lead II

Rhythm (regular) (irregular) component EKG wave pattern 3 beats 3 beats regularly irregular pattern irregularly irregular

Normal rhythm

Irregular rhythm

Sinus bradycardia parasympathetic

Sinus tachycardia sympathetic

P wave 3x3

PR interval 3-5 (0.12-0.2 sec) PR prolong AV node AV block short PR automaticity ventricle premature ventricular contraction (PVC) Wolff-Parkinson-White syndrome Bundle of Kent accessory pathway ventricle delay AV node EKG triads short PR, QRS prolong, delta wave

P wave QRS complex P wave QRS complex QRS complex P wave

QRS complex 15 ( sensitivity ) 3 (0.06-0.10 sec) QRS complex hypertrophy QRS complex pathway QRS complex sensitivity dilate cardiomyopathy chest wall electrode pericardial effusion EKG signs of LV hypertrophy

1 EKG signs of LV hypertrophy

3

S wave V1 + R wave V5 V6 > 35 Right axis deviation

R wave V5 V6 > 27 R wave S wave V1 V2

R wave aVL > 11 Prominent S wave V5 V6

ST segment acute coronary syndrome ST segment elevate unstable angina Non-ST elevation MI ( cardiac biomarker ) ST elevation MI ST-elevation MI biconvex upward J point

T wave lead II 5 3-5 (0.10-0.25 sec) T wave 2/3 QRS complex hyperkalemia T wave U wave hypokalemiaU wave ventricle repolarization hypokalemia repolarize , cardiomyopathy hypertrophy repolarization

QT segment QRS complex T wave QT prolong side effect fluoroquinolone

Abnormal Electrocardiograpram

Myocardial infarction (acute myocardial infarction) coronary right coronary artery (RCA) acute inferior wall MI / posterior right ventricular MI left main coronary artery (sudden death) (massive infarction)

left anterior descending artery anterior wall infarction left circumflex artery lateral wall infarction 10% inferior wall posterior wall left ventricle

coronary artery injury 3 ECG 1. ischemia ECG T wave change ( inverted T wave)2. injury ECG ST change ST elevation transmural injury ST depression subendocardial injury

3. infarction ECG QRS change ( pathologic Q wave)

Arrhythmia

(disorder of impulse formation) (disorder of impulse conduction)

cell electrical conducting system automaticity spontaneous depolarization action potential partial depolarization depolarization ectopic impulse normal impulse depolarization phase 2 early depolarization phase 3 late depolarization trigger arrhythmia

Disorder of impulse conduction impulse pathway accessory pathway re-entry Re-entry track 2 track fast track slow track (trigger) fast track cycle

Arrhythmia heart rate rhythm regular irregular supraventricular ventricular QRS complex Sinus bradycardia sinus node sinus dysfunction hyperkalemia hypothyroid bradycardia low cardiac output dizziness syncope heart failure

Atrial flutter Saw-tooth wave HR 300 bpm amplitude duration EKG

Atrial fibrillation ectopic foci atrium atrium depolarization P wave baseline (f wave) ventricle ectopic foci ventricle

Atrial fibrillation most common type arrhythmia mitral stenosis left atrium ectopic foci totally irregular cardiac output beta blocker, calcium channel blocker, Digoxin AV node

atrial fibrillation sinus rhythm cardioversion 2 shock amiodaroneComplication atrial fibrillation turbulance flow clot emboli atrial occlution stroke anti-coagulant Warfarin

Ventricular tachycardia re-entry myocardial infarction 100-200 bpm, wide and bizarre QRS complex, ventricular fibrillation sudden death


Ventricular fibrillation ventricle depolarization repolarization ventricle cardiac output cardiac arrest

Torsades de pointes ventricular tachycardia potassium , hypomagnesemia, long QT side effect torsades de pointes

Supraventricular arrhythmia tachyarrhythmia QRS complex ectopic AV node ventricle QRS complex

AV block

AV node conducting velocity delay station venous filling time effective stroke volume delay SA ventricle cell ventricle impulse SA node heart block AV block 3 degree 1st degree PR prolong P wave QRS complex rhythm bradycardia

2nd degree: Mobitz type I (Wenckebach block) block AV node PR interval block P wave QRS complex

2nd degree: Mobitz type II block AV node PR interval block P wave QRS complex; P-P interval complete heart block

Advanced or High-degree AV block 2nd degree AV block Mobitz type I type II non-conducted P wave 3rd degree AV block atrium ventricle ventricle SA node AV dissociation (PP interval RR interval )

Antiarrhythmic agent

Antiarrhythmic drug 4 class Class I - Sodium-channel blockers Class Ia quinidine, procainamide, disopyramide Class Ib Lidocaine first drug of choice ventricular arrhythmia Class Ic flecainide

Class II Beta-blockers Propranolol Atenolol block beta1 receptor sinus node membrane potential stabilization Na-K pump phase 4 supraventricular tachycardia Class III - Potassium-channel blockers refractory period amiodarone broad antiarrhythmic drug AV node re-entrant rhythms Iodine thyroid thyroiditis (S/E porsus de quer) Class IV - Calcium-channel blockers Verapamil block cardiac myocyte supraventricular tachycardia

class V adenosine first drug of choice supraventricular tachycardia adenosine receptor AV node conduction side effect flushing

Digoxin cardiac glycoside Na-K pump cell membrane intracellular Na+ intracellular Ca2+ inotropic effect parasympathetic tone slow AV conduction atrial fibrillation heart block anorexia () gynecomastia toxicity Hypokalemia Practice

1. Structure

Myocardium

2. atrium wave

P wave3. Mitral valve

Rheumatic fever

4. skin manifestation cardiovascular system

erythema maginatum skin manifestation acute rheumatic fever


nodule subcutaneous nodule acute rheumatic fever


A B C A Splinter hemorrhage

B subconjunctivia hemorrhage

C Oslers node

clinical manifestation infective endocarditis7. CXR

left atrium left ventricle hypertrophy mitral stenosis

8. CXR

cardiomegaly pericardial effusion

After-repolarization funny channel

AV

SA

Bundle of His + Purkinje fiber

J point

NLME CVS

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