Pathophys Exam 3

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Pathophys Exam 3
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2010-12-08 17:04:42
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  1. Tunica media
    smooth muscle layer that plays the biggest role in blood pressure regulation
  2. Tunica externa
    composed of collagen
  3. BP =
    CO X Peripheral Vascular Resistance
  4. CO =
    stroke volume x heart rate
  5. Amount the left ventricle pumps out over one minute
    cardiac output
  6. Short term regulation of blood pressure
    • minutes to hours
    • autonomic nervous system
    • humoral mechanisms
  7. Long term regulation of blood pressure
    • daily, weekly, monthly
    • kidney role in regulating fluid
  8. acts on aldosterone (sodium/water retention) which increases CO
    aldosterone antagonists
  9. acts on kidney/intestin reabsorption of sodium and water which increases CO
    diuretics
  10. Vasopressin
    • increases CO
    • increases PVR
  11. acts to counteract Sympathetic discharge which causes increased CO
    central alpha 2 agonists
  12. Actos on vascular smooth muscle vasoconstriction
    • calcium channel blockers
    • vasodilators
  13. Acts on heart contractility
    • beta adrenergic blockers
    • non-DHP CCBs
  14. How does lisinopril lower BP?
    decreases PVR
  15. Autonomic Nervous system regulation of BP mechanisms
    • baroreceptors
    • chemoreceptors
    • external stimuli
  16. Humoral mechanisms for regulating BP
    • vasopressin (ADH)
    • Renin-angiotensin-aldosterone system
  17. Risky amount of salt for developing HTN
    2.4 g/day or 6 g/day NaCL
  18. Causes of secondary HTN
    • sleep apnea
    • aldosteronism
    • chronic kidney disease
    • renal artery stenosis/aortic stenosis
    • pheochromocytoma/intracranial tumor
    • cushing's syndrome/thyroid/parathyroid
  19. Drugs that can induce HTN
    • NSAIDS
    • Cocaine
    • Amphetamine
    • Oral contraceptives
    • Glucocorticoids/cyclosporin/tacrolimus
    • EPO
  20. Pseudoresistance
    blood pressure elevated secondary to medication or white coat syndrome
  21. Top concerns with HTN
    • target organ damage
    • mainly CV, stroke and kidney failure
  22. Orthostatic hypotension
    • baroreceptor response isn't working properly
    • decrease in bp when switching to upright position
  23. Diagnosis of orthostatic hypotn
    • systolic drop >20mmHG within 3 min of standing
    • diastolic drop >10mmHg within 3 min of standing
  24. Symptoms of orthostatic hypotension
    • dizziness
    • blurred vision
    • palpitations presyncope
  25. most common risk factor for orthostatic hypotension
    age
  26. Arterial disorder
    • decreased blood flow to tissues
    • impared oxygen and nutrient delivery
  27. Venous disorder
    • interference with outflow of blood
    • interference with removal of waste
  28. Adverse events upon endothelial damage to arteries
    • plasma and wbc are drawn to the area
    • they uptake cholesterol and transition to foam cells
    • fibrous cap forms
    • necrotic core forms
    • leads to vessel occlusion
  29. Atherosclerosis of primary arteries
    hardening of the arteries
  30. Thrombosis leads to
    • (plaque formed in arteries)
    • Coronary Heart disease
    • ischemic heart disease
    • stroke
    • peripheral artery disease
    • aneurysms
  31. Risk factors for thrombosis
    • Hyperlipidemia
    • age/family history
    • male
    • cigarettes
    • HTN, DM
    • elevated inflamatory markers (c-reactive protein)
  32. Lipoproteins
    • carry cholesterol
    • carry triglycerides
  33. Chylomycrons
    • 80-90% triglycerides
    • cary triglycerides in the blood
  34. VLDL
    • 55-65% triglycerides
    • released from liver
  35. LDL
    50% cholesterol
  36. HDL
    50% protein
  37. Primary Hyperlipidemia
    • increased sensitivity to dietary cholesterol
    • lack of or defective LDL receptors
    • Cellular defects in use of cholesterol
    • altered synthesis of apoproteins
  38. Secondary hyperlipidemia
    • due to lifestyle
    • obesity
    • high calorie diet
    • DM
  39. Clinical presentation of primary HLD
    • Familial: LDL 250-1000 mg/dl
    • MI very early in life
  40. Clinical presentation of secondary HLD
    coronary artery disease
  41. optimal LDL levels
    <100 mg/dl
  42. optimal total cholesterol
    <200 mg/dl
  43. optimal HDL cholesterol
    between 40 and 60 mg/dl
  44. Ischemia
    reductino in arterial flow resulting in insufficient oxygenation to meet needs
  45. Infarction
    are of ischemic necrosis resulting from occlusion of arterial supply or venous drainage
  46. Management of HLD
    • increase physical activity
    • smoking cessation
    • diet modification/weight loss
    • medication
    • increase HDL
  47. Peripheral artery disease
    • usually in lower extremities
    • gradula vessel occlusion
    • impairs circulation
  48. Risk factors for peripheral artery disease
    • male
    • increasing age
    • atherosclerosis
    • cigarettes
    • DM
  49. Clinical presentations of PAD
    • painful walking (claudication)
    • aches, numbness
    • muscular atrophy
    • weak pulse, cool temp, blanching when leg raised
    • deep red color when leg lowered
  50. Visual Diagnosis of PAD
    • brittle toenails
    • Hairloss
    • pallor
    • coolness
    • atrophy
  51. Palpable diagnosis of PAD
    pedal pulses
  52. Other exams to test for PAD
    • ankle-brachial index
    • ultrasound
    • MRI, CT
  53. Management of PAD
    • adjust risk factors
    • medications
    • surgery
  54. Aneurysm
    • localized dilation of blood vessel
    • occurs in arteries and veins
    • most common in aorta
  55. Risk factors for aneurysm
    • atherosclerosis
    • HTN
    • congenital defects
    • trauma/surgery
    • infection
    • pregnancy
  56. Clinical presentation of aneurysm
    • asymptomatic
    • substernal, back or neck pain
    • dyspnea, stridor, cough
    • hoarsness
    • edema
    • pulsating mass
  57. Risk factors for varicose veins
    • standing
    • blockage of veins
    • pregnancy
  58. 3 components of pathophysiology of a thrombosis
    • endothelial injury
    • hypercoaguable state
    • circulatory stasis
  59. when a thrombus breaks off and moves it is called an
    embolus
  60. Clinical presentation of DVT
    • deep leg pain
    • calf tenderness
    • erythema (red and warm)
    • edema
    • homans' sign
  61. assesment for a DVT
    • venous duplex (look at blood flow)
    • d-dimer (test for remnants of clots in blood)
  62. Pulmonary embolism
    blood borne substance lodged in the pulmonary artery
  63. PE can cause
    • obstruction of pulmonary circulation
    • reflex bronchoconstriction
    • infarction is uncommon (ischemia)
  64. Major problem with PE
    lack of gas exchange
  65. Assesment for pulmonary embolism
    • d-dimer
    • CT scan of lungs
    • Lung scan
  66. Complications of PE
    • pulmonary hypertension
    • right heart failure
    • extension of clot
    • mortality rate >30%
  67. Cardiac conduction system
    • sinoatrial node
    • atrioventricular node
    • bundle of his
    • purkinje fibers
  68. SA node
    • pacemaker of heart
    • 60-100 bpm
  69. AV node
    • only connection between atria and ventricle
    • 40-60 bpm
  70. Bundle of His
    • predisposed to dmg due to calcification or infection
    • blood supply is from main coronary arteries
  71. Purkinje fibers
    15-40 bpm rate of firing
  72. Resting phase
    selectivley permeable to K+
  73. Repolarization
    pumps Na+ out using ATPase (digoxin action)
  74. 5 phases of cardiac AP
    • depolarization
    • repolarization
    • plateu
    • rapid repolarization
    • resting
  75. Plateu phase of cardiac AP
    • only in cardiac cells
    • allows for 3-15x longer contraction
  76. Fast response APs in the heart
    • atria
    • ventricles
    • PK fibers
  77. slow resonse AP
    • SA node
    • AV node
  78. absolute refractory period
    cannot be stimulated
  79. relative refractory period
    • below threshold
    • respond to greater than normal stimulus
  80. P wave
    depolarization of atria
  81. QRS complex
    ventricular depolarization
  82. T wave
    ventricular repolarization
  83. Causes of cardiac arrhythmias
    • myocardial injury
    • congenetal defects
    • fluid or e- imbalance
    • medications
  84. for mechanisms contributing to arrhythmias
    • automaticity
    • excitability
    • conductivity
    • refractoriness
  85. Tachyarrhythmia
    • result of reentry
    • electric current feeds back and initiates a new current
  86. Sinus bradycardia
    • slow heartrate <60 bpm
    • vagal stimulation (coughing or bearing down)
    • may pass out
  87. Sinus tachycardia
    HR >100 bpm
  88. Sinus arrest
    • SA node fails
    • AV node has to take over but is slower
  89. supraventricular arrhythmia
    • premature atrial contraction
    • causes a pause in the SA node
  90. Paroxysmal supraventricular tachycardia
    • Rapid HR
    • caused by abnormal reentry
  91. Atrial flutter
    • supraventricular arrhythmia
    • extopic tachycardia (reentry loop)
    • saw tooth ECG
  92. Atypical flutter
    reentry because of L atria
  93. typical flutter
    caused by dmg to R atria
  94. Atrial fibrillation
    • most common chronic arrhythmia
    • reentry circuits constatly arrising in the atria
    • 400-600 atrial beats
    • 80-180 ventricle beats
  95. Paroxysmal A fib
    • recurrent episodes that self terminate
    • lasts less than a 24hrs - 1 week
  96. Persistent A fib
    • reccurrent episodes that last for more than 1 week
    • stop only with treatment
  97. permanent A fib
    ongoing long-term episode
  98. Atrial fibrillation assesment
    • No identifiable P wave
    • loss of atrial kick causes ventricles to depolarize irregular too
  99. A. Fib lowers CO by
    10-20%
  100. Complications of A. Fib.
    • Hypotension
    • loss of CO
    • fatigue
    • syncope
    • thrombus/risk of stroke
  101. Treatments for A. FIb
    • anticoagulation
    • shock therapy (after anti coag unless onset is known to be current)
  102. Rate control
    decrease heart rate to 60-100 bpm
  103. Rhythm control
    convert to normal sinus rhythm with medication
  104. Ventricle arrhythmias
    • premature ventricular contractions
    • ventricular tachycardia
    • torsades de pointes
    • ventricular flutter/fibrillation
    • more serius than atrial
  105. Premature ventricular contractions
    • "skipped beat"
    • may lead to v fib
    • no real P wave
  106. causes of premature ventricular contractions
    • e- imbalance
    • infection
    • premature ventricular contraction
  107. Ventricular tachycardia
    • life threatening
    • 70-250 bpm
    • increased automaticity in the ventricles
    • CO is non existant
    • more than 30 sec needs intervention
  108. Torsades de Pointes
    • prolonged QT interval
    • unstable
    • usually caused by medications
  109. Ventricular flutter/fibrillation
    • fatal rhythm
    • no cardiac output
    • no identifiable waves
  110. complications of ventricular arrhythmias
    • rapid heart beat
    • dizziness
    • Sob
    • loss of pusle
    • death
  111. Atrioventricular conduction disorders
    • first, second and thrid degree blocks
    • secong degree has 2 types
  112. First degree AV block
    • prolonged PR interval
    • delay in SA and or AV node
  113. Second degree AV block type I
    • wenkelback or mobitz
    • progessive lengthening of PR interval until a beat is skipped
    • usually occurs with right side MI
  114. Type 2 second degree AV block
    • Mobitz II
    • dropped ventricular contraction
    • PR with no QRS when there should be
    • inferior wall MI ischemia
    • can quickly lead to third degree
  115. Third degree AV block
    • complete heart block
    • independent atrial and ventrical rates
    • fainting spells
    • usually caused by MI or ischemia
    • decreased CO
  116. Pharmacologic treatments for arrhythmias
    • sodium channel blockers
    • beta blockers
    • potassium channel blockers
    • calcium channel blockers
  117. Pacemaker used for
    • sinus bradycardia
    • pace atria, ventricle or both
  118. cardioversion
    • direct current
    • syncronized during refractory period
    • planned procedure
  119. defibrillation
    • no synchronizing
    • goal is to stop miss firing
  120. alblation
    • go through vein and use radio frequency to detect beat and counteract it
    • cardiac cath lab procedure
  121. surgery
    coronary artery bypass
  122. Pericarditis
    • inflammation of the pericardium
    • acute < 2 weeks
  123. causes of pericarditis
    • infections
    • ischemia
    • physical damage
  124. signs and symptoms of pericarditis
    • chest pain
    • pericardial friction rub
    • ECG changes
  125. Treatment of pericarditis
    • NSAIDS
    • colchicine
  126. Pericardial Effusion
    • caused by pericarditis
    • accumulation of fluid in the pericardial cavity
  127. causes of pericardial effusion
    • neoplasms
    • surgery/trauma
    • MI
  128. signs and symptoms
    • small = none
    • large = heart failure symptoms
    • shortness of breath
    • edema
  129. Diagnosis of pericardial effusion
    echocardiogram
  130. Echocardiogram examins
    • ejection fraction
    • pericardial disease
    • valvular dysfunction
  131. TTE echo
    • probe is external
    • 1st line choice
  132. TEE echo
    • invasive procedure
    • tube sent through esophagus
    • closer to the heart
    • used if TTE is negative
  133. Cardiac Tamponade
    • life threatening form of pericardial effusion
    • compression of heart chambers
  134. signs and symptoms of cardiac tamponade
    • pulsus paradoxus
    • tachycardia
    • distant heart sounds
  135. treatment of cardiac tamponade
    • pericardiocentesis
    • pericardial window
  136. Infective endocarditis
    • infection on the inner serface of the heart
    • colonization of heart valves leading to destruction
  137. Signs and symptoms of infective endocarditis
    • fever, high wbc, + blood culture
    • new or changed heart murmur
    • evidence of embolic complication
  138. Osler nodes
    • painful and raised
    • sign of infective endocarditis
  139. Janeway lesions
    • thrombolic
    • not raised or painful
    • sign of infective endocarditis
  140. Major risk factors for infective endocarditis
    • mitral valve prolapse
    • prosthetic heart valves
    • IVDU
  141. valve patients have this bacteria
    staph epi
  142. IVDU have this bacteria
    staph aureus
  143. other bacteria that can cause endocarditis
    streptococci and enterococci
  144. Diagnosis of infective endocarditis
    • echocardiogram (TTE then TEE)
    • Blood culture
    • modified duke criteria
  145. Treatment of infective endocarditis
    • long term antibiotics
    • surgery
  146. Major signs of infective endocarditis
    • + blood culture
    • positive TTE or TEE
  147. Minor criteria for infective endocarditis
    • high risk patient
    • + blood culture
    • fever
    • vascular phenom (stroke, janeway...)
    • immunologic phenom
  148. Definite diagnosis via modified duke criteria
    • 2 major
    • 1 major + 2 minor
    • 5 minor
  149. Possible diagnosis of infective endocarditis
    • 1 major and 1 minor
    • 3 minor
  150. Pulmonary valvle
    right ventricle to pulmonary artery
  151. Tricuspid valve
    right atrium to right ventricle
  152. mitral valvle
    left atrium to left ventricle (oxy)
  153. aortic valve
    left ventricle to aorta (oxy)
  154. most commonly effected with valvular heart disease
    • left heart
    • higher pressure
  155. Stenosis
    • opening problem
    • narrowing of valve
    • sx with exercise
  156. Refurgitant valvular heart disease
    • closing problem
    • valve permits backflow
  157. signs and symptoms of mitral valve stenosis
    • pulmonary congestion
    • left atria enlargement (may cause Afib)
    • decreased cardiac output
    • paroxismal nocturnal dyspnia
    • palpitations
    • chestpain
    • diastolic murmur
  158. Mitral valve regurgitation
    • pulmonary congestion
    • left atria and ventricle enlargement (may start afib)
    • decreased CO
    • mild case no symptoms, major case = shock
    • holosystolic murmur (high pitch)
  159. Mitral valve prolapse
    • risk for endocarditis
    • more common in women
    • mid systolic clicks
  160. aortic valve stenosis
    • LV enlargement of muslce
    • decreased CO
    • angina, syncope, HF
    • loud systolic ejection murmur or split S2
    • no medical therapy
  161. Aortic valve regurgitation
    • LV enlargement
    • increase CO at first but then falls (frank starling)
    • sever cases = HF, PND, orthopnea
    • water hammer pulse
    • high pitched diastolic blowing murmur
  162. Treatment for valvular heart diseases
    • routine checks
    • surgery
    • medications
    • repair or replace valve
    • long term anticoag

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