Cardiologyslides

Cardiac Anatomy
Jason Ryan, MD, MPH

The Heart
Chambers
SVC PVs
PA
LA
RA
Aorta
IVC LV
RV
The Heart
Valves
PV
AV
TV
MV
Anterior-Posterior Structures
Right Ventricle → Anterior
Left atrium → Posterior

Coronary Arteries 90% Right dominant
10% Left dominant
Heart drains to coronary sinus
CS → Right atrium
Left Main
RCA LCX
LAD
PDA
Coronary Artery Territories
• Anterior wall, anterior septum, apex → LAD
• Lateral wall → LCX
• Inferior wall, inferior septum → PDA
• RCA 90% of the time
• 10% of people “left dominant” - LCX supplies PDA
• Occlusion occurs LAD>RCA>LCX
Mitral Valve
• Two papillary muscles
• Anterolateral (AL)
• Posteromedial (PM)
• AL has dual blood supply
• LAD/LCX
AL • PM →single blood supply
• RCA (or LCX)
PM • Inferior infarction can
lead to rupture of PM pap
• Severe mitral regurgitation
• Acute heart failure
Cardiac Electrical System
SA/AV node
Usually supplied
by RCA
SA
AV LBB
His
SA Node – Right atrial wall Purkinje
AV Node –Interatrial Septum Fibers
HIS – Interventricular septum RBB
Cardiac Physiology
Jason Ryan, MD, MPH
Heart Volumes
ESV
EDV
End diastolic Volume End systolic Volume

Filling completed Emptying completed
Contraction beginning Relaxation beginning
Important Terms
• Stroke Volume (SV) = EDV - ESV
• Ejection Fraction (EF) = SV / EDV
• Cardiac Output (CO) = SV * HR
Important Terms
• Venous Return (VR)
• Blood returned to left ventricle
• Should be equal to the cardiac output
• Total peripheral resistance
• Resistance to blood flow from peripheral structures
• Vasoconstriction → ↑ TPR
• Vasodilation → ↓ TRP
Blood Pressure Terms
• Systolic Blood Pressure (SBP)
• Largely determined by cardiac output
• Diastolic Blood Pressure (DBP)
• Largely determined by TRP
• Pulse pressure
• SBP – DBP
• Proportional to SV
Blood Pressure Terms
• Mean arterial pressure (MAP)
• DBP + 1/3 (SBP – DBP)
• Example: SBP 120/80
• MAP = 80 + 1/3 (40) = 93.3
Cardiac Output
• Very important physiology parameter
• Must rise to meet demands
• More cardiac output = more work/O2
• CO = HR x SV
• More beats per minute = more work
• More volume per beat = more work
Cardiac Output
Determinants
1. Preload
2. Afterload
3. Contractility
4. Heart rate
Preload
• Amount of blood loaded into left ventricle
• Also how much stretch is on fibers prior to contraction
• Some books say “length” instead of “stretch”
• More preload = more cardiac output
• More preload = more work the heart must do
• ↑O2 required
To INCREASE Preload
1. Add volume (blood, IVF)
2. Slow heart rate → more filling → more volume
3. Constrict veins
• Veins force blood into heart
• Veins hold LARGE blood volume
• Response to blood loss → venous constriction
• Sympathetic stimulation → α1 receptors in veins
To DECREASE Preload
1. Remove volume (bleeding, dehydration)
2. Raise heart rate (opposite mechanism above)
3. Pool blood in veins
• Mechanism of action of nitrates
• Relieve angina
• Lower preload → less work for heart
Preload
Important Terms
• LVEDV
• Volume of blood in the left ventricle when filled
• LVEDP
• Pressure in the left ventricle when filled
Afterload
• Forces resisting flow out of left ventricle
• Heart must squeeze to increase pressure
• Needs to open aortic valve → push blood into aorta
• This is harder to do if:
• Blood pressure is high
• Aortic valve is stiff
• Something in the way: HCM, sub-aortic membrane
To INCREASE Afterload
1. Raise mean blood pressure
2. Obstruct outflow of left ventricle
• Aortic stenosis, HCM
To DECREASE Afterload
1. Lower the mean blood pressure
2. Treat aortic valve disease, HCM
• More afterload = more work
• More oxygen required
Contractility
• How hard the heart muscle squeezes
• Ejection fraction = index of contractility
• Major regulator: sympathetic nervous system
• Also increases heart rate
To INCREASE Contractility
• Sympathetic nervous system activity
• Sympathetic innervation to heart
• Circulating catecholamines (epinephrine, norepinephrine)
• ↑ calcium release from sarcoplasmic reticulum
• Triggers: stress, exercise
• Sympathomimetic drugs
• Dopamine, dobutamine, epinephrine, norepinephrine
• Digoxin
• Inhibits Na-K pump → ↑ calcium in myocytes
To DECREASE Contractility
• Sympathetic system blocking drugs
• Beta blockers
• Calcium channel blockers
• Verapamil, diltiazem
• Less calcium for muscle contraction
• Heart failure
• Disease of myocytes
Heart Rate
• Increases cardiac output under physiologic conditions
• Mainly regulated by sympathetic nervous system
• Also increased by sympathomimetic drugs
• Decreased by beta blockers and calcium blockers
Heart Rate
• ↑ HR = ↓ stroke volume (less filling time)
Stroke Volume
Heart Rate
Heart Rate
• ↑HR = ↑ cardiac output
CO = SV * HR
Cardiac Output
Heart Rate
Heart Rate
• Sympathetic nervous system: ↑HR and ↑contractility
• Stroke volume rises with increased HR
Stroke Volume
Heart Rate
Heart Rate
• At pathologic heart rates ↑ HR = ↓ CO
• High heart rate with arrhythmia can lead to ↓CO
CO = SV * HR
Cardiac Output
Heart Rate
Work of the heart
Myocardial O2 demand
• Preload (LVEDV/P)
• Afterload (MAP)
• Contractility (EF)
• Heart Rate
Hearts starved for O2 → Reduce O2 demand

Low output → Need to increase work
Cardiovascular
Response to
Exercise
Jason Ryan, MD, MPH
Response to Exercise
• Body’s overall goal:
• Maximize perfusion skeletal muscles and heart
• Minimize perfusion all other areas
• Initiator: Muscle hypoxia
• Mediator: Sympathetic nervous system
• Process begins with muscle contraction
• ATP consumed → oxygen consumed (need more ATP)
• Result: Local hypoxia in muscle tissue
• Vasodilation occurs
• Multiple mediators released into plasma
• Adenosine generated from ATP consumption
• Lactate
• Carbon dioxide, potassium
• Lowers total peripheral resistance (TPR)
• Sympathetic nervous system activated
• ↑contractility (stroke volume)
• ↑HR
• Net result: ↑ cardiac output
• Results in ↑ systolic blood pressure (SBP)
• Vasoconstriction in some areas (gut, skin)
• Redistributes blood to important areas (i.e. heart/muscles)
Blood Pressure Summary
• SBP rises
• More CO = more blood in arteries = more pressure
• Primary determinant systolic BP = cardiac output
• DBP decreases slightly or stays normal
• Local dilation of skeletal muscles
• Primary determinant diastolic BP = peripheral resistance
• Pulse pressure increases
• TPR goes down
Ejection Fraction
EDV - ESV
EF =
• LVEF increases EDV
• More vigorous contraction
• Major impact: ESV decreases
• EDV effects minor/variable
• More preload but less filling time at fast heart rates
Coronary Perfusion
• Fast HR shortens diastole

• LESS coronary filling time
• Coronary vasodilation → increased blood flow
• Only way to get more oxygen
• Cannot extract more O2
• Cardiac tissue extracts maximum oxygen from RBCs
• Cannot extract more to meet increased demand
Preload
• Preload rises with exercise

• Sympathetic stimulation → venous contraction
• Increases preload/EDV
• Contributes to rise in cardiac output
• Along with increased heart rate and contractility
Lusitropy
• Lusitropy = myocardial relaxation
• Opposite of contractility
• Increased with exercise
• Contributes to increased preload → ↑ cardiac output
Lusitropy
• Key regulatory protein: Phospholamban
• Inhibitor: sarcoplasmic reticulum Ca2+-ATPase (SERCA)
• Phosphorylated via beta adrenergic stimulation
• Stops inhibiting SERCA
• Result: SERCA takes up calcium → relaxation
SERCA
Sarco/endoplasmic reticulum Ca2+-ATPase
• Sympathetic stimulation → phosphorylates PLB

• Inactivates PLB (relieves inhibitory effect)
• Allows SERCA to uptake more calcium
Beta
Adrenergic
P Stimulation
SERCA PLB
Sarcoplasmic Ca++
Reticulum
Exercise Begins
Muscle Hypoxia
Vasodilation ↓TPR
(Afterload)
Sympathetic ↓/- DBP

Activation
Heart Peripheral
Vessels
↑ Contractility ↑ HR ↑ Lusitropy Venous Arteriole

Constriction Constriction
↓ESV ↑ CO
↑Preload
↑EDV
↑EF ↑SBP
Blood Flow
Mechanics
Jason Ryan, MD, MPH
Flow Equations
Ohm’s Law V = I R
For fluids: ΔP = Q X R
CO = Q for body
TPR = total peripheral resistance
ΔP = CO * TPR
Flow Equations
Velocity
Area
Velocity * Area = Flow

(m/s) * (m2) = (m3/s)
Resistance and Compliance
Resistance = resistance to flow

Compliance = distensability of vessels
Stiff Vessels Stretchy Vessels

↑ resistance ↓ resistance
↓ compliance ↑ compliance
High resistance = low compliance (vice versa)

Pulse Pressure
• Systolic BP – diastolic BP
• Normal = 120 – 80 = 40mmHg
• Older patients = ↑ pulse pressure
• Hypertensive patients = ↑ pulse pressure
• Related to vessel compliance
• ↓ compliance = ↑ pulse pressure
Pulse Pressure
• Compliance = Δ volume / Δ pressure
• Stiff vessel → ↓ compliance → ↑ pulse pressure
• Small change in volume for given pressure applied to walls
• Stretchy vessel → ↑ compliance → ↓ pulse pressure
• Large change in volume for given pressure applied to walls
C = ΔV / ΔP
ΔP = ΔV / C
Pulse Pressure
• Pulse pressure varies with vessel compliance
• Stiff vessels → ↓ compliance
Distensible Stiff
Vessel Vessel
120/80 170/100
Flow Equation
Total Peripheral Resistance
ΔP = CO * TPR
↑ resistance = ↑ pressure to maintain flow

↑ pressure = ↑ cardiac work
• Easy to push blood out of heart → less O2 required
• Resistance to flow → more work for heart
• What resists forward flow out of heart?
1. Types of vessels (i.e. pipes/tubes)
2. Thickness of blood (viscosity)
Types of Vessels
• Aorta: SBP 100mmHg
• Large arteries: Falls few mmHg
• Small arteries: 10-20mmHg
• Arterioles: 35mmHg
• Capillaries: 25mmHg
Types of Vessels
• Arterioles = “resistance vessels”
• Major determinant of total peripheral resistance
• Large pressure drop
• Vasoconstriction = ↑ TPR
• Vasodilation = ↓ TPR
Viscosity
• Thickness of blood
• Low viscosity
• Anemia
• High viscosity
• Polycythemia
• Multiple myeloma
• Spherocytosis
Poiseuille's Law
• ΔP= QXR
8 η (viscosity) L (length)
ΔP
R =
Q = Π r (radius) 4
Changes in radius → large change in resistance

Series and Parallel Circuits
Human organs arranged in parallel

Resistances add up differently in series than in parallel
1 1 1
= + Rtotal = R1 + R2
Rtotal R1 R2
Parallel Series
Series and Parallel Circuits
For two resistances (2 and 2), what is total R?
1 1 1
= + Rtotal = R1 + R2
Rtotal R1 R2
Rtotal = 2 + 2 = 4
1 1
1
=
Rtotal 2 + 2
Rtotal = 1
Flow Equation ΔP = Q * R
• Used to calculate resistance, CO, or ΔP

• Often applied to body and lungs
• For both systems Q = Cardiac Output (CO)
Flow Equation ΔP = Q * R
• Body
• ΔP = Arterial pressure – right atrial pressure
• R = Total peripheral resistance (TPR)
• R = Systemic vascular resistance (SVR)
• Lungs
• ΔP = Pulmonary artery pressure – left atrial pressure
• R = Pulmonary vascular resistance (PVR)
Mean Arterial Pressure
• Diastolic plus 1/3 (Systolic – Diastolic)
• Total body
• Arterial blood pressure = 120/80 mmHg
• Mean arterial pressure = 80 + 1/3 (40) = 93 mmHg
• Lungs
• Pulmonary artery pressure = 40/20 mmHg
• Mean pulmonary artery pressure = 20 + 1/3 (20) = 27 mmHg
Total Body
ΔP = CO * TPR
• R = TPR
• ΔP = MAP – RAP
• MAP = mean arterial pressure
• RAP = right atrial pressure
• CO of 5L/min; BP 155/80 (MAP 105), RA 5
TPR = ΔP = MAP – RAP = 105 – 5 = 20

CO 5 5
Lungs
ΔP = CO * TPR
• R = PVR
• ΔP = PA – LAP
• PA = mean pulmonary artery pressure
• LAP = left atrial pressure
• CO of 5L/min; PA 40/10 (MAP 20), LA 5
PVR = ΔP = PA – LAP = 20 – 5 = 3
CO 5 5
Lung and Body Flow Variables
Lung Body
Flow CO CO
Resistance PVR TPR
Start Pressure PA AoP
End Pressure LA RA
ΔP PA – LA Ao - RA
Velocity and Area
• Flow = Velocity * Area
• Changes as blood moves through vessels
• Aorta → arterioles → capillaries → veins
• Cardiac output moves through system (same flow)
• Different vessels → different area, velocity
• Area ↑↑, velocity ↓↓
Velocity
Area
Flow = Velocity * Area

(m3/s) = (m/s) * (m2)
Flow Properties of
Blood Vessels
Property Highest Lowest
Flow -- --
Area Capillaries Large arteries
Velocity Large Arteries Capillaries
Resistance Arterioles Veins
ΔP Arterioles Veins
Flow = Vel * Area

ΔP= QXR
Law of Laplace
• Wall tension or wall stress
• Applies to vessels and cardiac chambers
• ↑ tension → ↑ O2 demand → ischemia/angina
P*r
Tension α
2h
Wall Tension
• Afterload: Increases pressure in left ventricle
• Hypertension, aortic stenosis
• Will increase wall tension
• “Pressure overload”
P*r
Tension α
2h
Wall Tension
• Preload: Increases radius of left ventricle
• Chronic valvular disease (aortic/mitral regurgitation)
• Will increase wall tension
• “Volume overload”
P*r
Tension α
2h
Wall Tension
• Hypertrophy: Compensatory mechanism
• Will decrease wall tension
• Force distributed over more mass
• Occurs with chronic pressure/volume overload
P*r
Tension α
2h
Eccentric Hypertrophy
• Longer myocytes
• Sarcomeres added in series
• Left ventricular mass increased
• Wall thickness NOT increased
Normal
LV Size Dilated LV Increased myocyte size
Sarcomeres in series
Normal wall thickness
Eccentric Hypertrophy
• Volume overload of left ventricle
• Aortic regurgitation
• Mitral regurgitation
• Cardiomyopathy
• Ischemic and non-ischemic
Concentric Hypertrophy
• Pressure overload
• Chronic ↑↑ pressure in ventricle
• Sarcomeres added in parallel
• Left ventricular mass increased
• Wall thickness increased
Normal
↓ LV Size Increased myocyte size
LV Size Sarcomeres in parallel
Increased wall thickness
• Classic causes: Hypertension, Aortic stenosis
• Both raise pressure in LV cavity
• Decreased compliance (stiff ventricle)
• Often seen in diastolic heart failure
Regulation of
Blood Pressure
Jason Ryan, MD, MPH
Blood Pressure
• Required for perfusion of tissues
• Varies with sodium/water intake
• Regulated by nervous system
Baroreceptors
• Blood pressure sensors via stretch
• Signal central nervous system (brain)
• Response via autonomic nervous system
• Sympathetic and parasympathetic
• Modify:
• Heart rate/contractility
• Arterial tone (vasoconstriction)
• Venous tone (more tone = more preload to ventricle)
• Renal renin release
Baroreceptors
• Aortic arch and carotid sinus
• Quick response to changes in blood pressure
• Rapid response via autonomic nervous system
• Kidneys (renin release)
Baroreceptors
• Aortic arch
• Senses elevated blood pressure
• Poor sensing of low blood pressure Carotid
Sinus
• Carotid sinus
• Most important baroreceptor
• Modifies signals over wider range of blood pressure
• Senses low and high blood pressure
Aortic
Arch
Blood Pressure Control
Sympathetic
Parasympathetic
Aortic Arch
CN X (Vagus) Veins/Arteries
a e Constrict/Dilate
Blood Pressure Brain
a e
Heart
Carotid sinus ↑↓HR
CN IX (GP)
Afferent = Arrive at the brain

Efferent = Exit the brain
Nucleus Solitarius
High Blood Pressure
Sympathetic
Parasympathetic
Aortic Arch
CN X (Vagus) Veins Dilate
a e Arteries Dilate
↑ Blood Pressure Brain
a e
Heart
Carotid sinus
↓ HR/Contractility
CN IX (GP)
↓ Salt/Water
Kidney Retention
Hemorrhage
Sympathetic
Parasympathetic
Aortic Arch
CN X (Vagus) Veins Constrict
a e Arteries Constrict
↓ Blood Pressure Brain
a e
Heart
Carotid sinus
↑ HR/Contractility
CN IX (GP)
↑ Salt/Water
Kidney Retention
Carotid Massage
Sympathetic
Syncope while shaving Parasympathetic
or buttoning shirt
Aortic Arch
CN X (Vagus) Veins Dilate
a e Arteries Dilate
a e
Heart
Carotid sinus ↓ HR
CN IX (GP)
Tricks carotid sinus into thinking ↑ BP

Result: ↓ HR, Vasodilation, ↓ BP
Carotid Occlusion
Sympathetic
Parasympathetic
Aortic Arch
a e
Heart
Carotid sinus ↑HR
CN IX (GP)
Tricks carotid sinus into thinking ↓ BP

Result is ↑HR, Vasoconstriction, ↑BP
Severing CN IX
Sympathetic
Parasympathetic
Aortic Arch
a e
Heart
Carotid sinus ↑HR
CN IX (GP)
Tricks brain into thinking ↓ BP

Result is ↑ HR, Vasoconstriction, ↑BP
Severing CN X
Sympathetic
Parasympathetic
Aortic Arch
CN X (Vagus) Veins --
a e Arteries --
a e
Heart
Carotid sinus ↑HR
CN IX (GP)
Vagotomy
Unopposed Sympathetic Cardiac Stimulation
Result is ↑ HR
Summary of Techniques
Technique Interpretation Result
Carotid Massage ↑BP ↓HR,↓BP

Carotid Occlusion ↓BP ↑HR, ↑BP
Sever CN IX ↓BP ↑HR, ↑BP
Sever CN X -- ↑HR
Coronary Blood Flow
120
Aortic
Pressure 80
Coronary
Flow
Time(s)
• In tachycardia, less time in diastole → less flow

Regional Blood Flow
• Epicardium → site of coronary arteries

• Subendocardium receives smallest amount blood flow
Organ Circulation
Organ Key Features
Lung 100% of Cardiac Output
Liver Largest Systemic Blood Flow
Kidneys Highest blood flow by weight
Largest Δ02 (80%)
Heart
↑ demand vasodilation
Autoregulation
• Some tissue beds maintain constant blood flow
• ↑ BP → ↑ flow → vasoconstriction → ↓ flow (normal)
• Use local metabolites to sense blood pressure
Autoregulation
Organ Key Control Variables
Heart CO2, Adenosine, NO
Brain CO2, pH
Kidneys BP and NaCl feedback
Lungs Hypoxia → Vasoconstriction
Skeletal Muscle Lactate, adenosine, K+
Skin Sympathetic stimulation
Kidney, brain, heart: Excellent autoregulation systems

Skin: Poor autoregulatory capacity
Capillary Fluid Exchange
• Two forces drive fluid into or out of capillaries
• Hydrostatic pressure (P)
• Molecules against capillaries walls
• Pushes fluid out
• Oncotic pressure (∏)
• Solutes (albumin) drawing fluid into capillaries
Capillary
Pc ∏c
Interstitial
Space
Pi ∏i
• Hydrostatic pressure – fluid PUSHING against walls
• High pressure drives fluid TOWARD low pressure
• Oncotic pressure –solutes PULLING fluid in
• High pressure draws fluid AWAY from low pressure
Pc ∏c
Pi ∏i
Net Pressure (NP) = (Pc –Pi) + (∏i - ∏c)
Flow = (NP) Kf
• Hydrostatic pressure – fluid PUSHING against walls
• High pressure drives fluid TOWARD low pressure
• Oncotic pressure –solutes PULLING fluid in
• High pressure draws fluid AWAY from low pressure
Pc (100) ∏c (50)
Pi (50) ∏i (30)
Net Pressure (NP) = 50 - 20
= 30
Flow = (NP) Kf
Edema
• Excess fluid movement out of capillaries
• Tissue swelling
• Lungs: Pulmonary edema
• Systemic capillaries: Lower extremity edema
James Heilman, MD
Edema Net Pressure (NP) = (Pc –Pi) + (∏i - ∏c)
Capillary
Pc ∏c
Interstitial
Space
Pi ∏i
↑ capillary pressure, ↑ Pc (heart failure)

↓ plasma proteins, ↓ ∏c (nephrotic syndrome, liver failure)
↑ capillary permeability, ↑Kf (toxins, infections, burns)
↑ interstitial osmotic pressure, ↑ ∏i (lymphatic blockage)
3rd Spacing
• Intracellular fluid – 1st space
• About 2/3 body fluid
• Extracellular fluid – 2nd space
• About 1/3 body fluid
• Third spacing - fluid where it should NOT be
• Pleural effusions
• Ascites
• Cerebral edema
• Low intravascular volume/High total volume
• Occurs post-op, sepsis
Pressure Volume
Loops
Jason Ryan, MD, MPH
LV Pressure
PV Loops
LV Vol
Time
LV Pressure
LV Vol
LV Pressure
PV Loops
LV Vol
Time
LV Pressure
LV Vol
PV Loops
ESPVR
LV Pressure
LV Pressure
LV Vol
EDPVR
Time LV Vol
PV Loops
S2
LV Pressure
A A
LV Pressure
M A
LV Vol
M
A M M
S1
Time LV Vol
Systole
LV Pressure
EDP
Diastole
LV Vol
ESV EDV
Afterload
Stroke Volume
Preload
PV Loop Parameters
• Changes in preload
• Changes in afterload
• Changes in contractility
• Changes in compliance
• In reality, these are inter-related
• Example: ↑ preload → ↑ contractility (Frank-Starling)
Preload Changes
Increase ↑ EDV
↑ SV
↑ EF (slightly)
SV = EDV - ESV
EF = EDV - ESV
EDV
Preload Changes
Decrease ↓ EDV
↓ SV
↓ EF (slightly)
SV = EDV - ESV
EF = EDV - ESV
EDV
Afterload Changes
Increase
↑ ESV
↓ SV
↓EF
EF = EDV - ESV
EDV
Afterload Changes
Decrease
↓ ESV
↑SV
↑EF
EF = EDV - ESV
EDV
Contractility Changes
Decrease
ESPVR
↑ ESV
↓ SV
↓ EF
EF = EDV - ESV
EDV
Contractility Changes
Increase
↓ ESV
↑ SV
↑ EF
EF = EDV - ESV
EDV
Compliance Changes
Decreased Compliance
↓EDV
↑ EDP
EDPVR
Work of the Heart
More area = More work
Commonly Tested PV Loops
• Aortic Stenosis
• Mitral Regurgitation
• Aortic Regurgitation
• Mitral Stenosis
Aortic Stenosis
LV Pressure
LV Vol
Mitral Regurgitation
Isovolumic Contraction Disrupted
LV Pressure
LV Vol
Aortic Regurgitation
Isovolumic Relaxation Disrupted
LV Pressure
LV Vol
Mitral Stenosis
Ventricle can’t fill properly
LV Pressure
LV Vol
Wiggers’ Diagram
Jason Ryan, MD, MPH
Wiggers’ Diagram
Aorta
LV
LA
LV Volume
S1
Heart Sounds
S2
Venous Pressure
EKG
Left Ventricular Volume
Aorta
LV
LA
Wiggers’ Diagram
Aorta
LV
LA
LV Volume
S1
Heart Sounds
S2
Venous Pressure
EKG
Normal Heart Diseased Heart
Aortic Stenosis
Mitral Stenosis
Venous Pressure
Tracings
Jason Ryan, MD, MPH
Venous Pressure
a v
c
x y
Venous Pressure
Atrial relaxation
TV opens
Atrial contraction Pressure Falls
Pressure goes up a
c v
TV closes
Venous filling
Pressure rises
a wave = Atrial contraction

v wave = Venous filling
c wave = triCuspid valve
x descent = atrial relaXation
y descent = emptYing of the atrium
Venous Pressure
Tricuspid valve
TV Closes
TV Closes TV Opens
a a
v
c c
x x
y
No RV filling RV filling
RV Contraction RV Relaxation
Wiggers’ Diagram
Aorta
LV
LA
LV Volume
S1
Heart Sounds
a S2
Venous Pressure c
x v y
EKG
Classic Findings
• Large a wave
• Cannon a wave
• Absent a waves
• Large v waves
Large a wave
Tricuspid stenosis
a v
c
x y
Cannon a wave
AV dissociation
a v
c
x y
Absent a wave
Atrial fibrillation
a v
c
x y
Giant v wave
Tricuspid regurgitation
a v
c
x y
High Yield Findings
• Large a wave (increased atrial contraction pressure)
• Tricuspid stenosis
• Right heart failure/Pulmonary hypertension
• Cannon a wave (atria against closed tricuspid valve)
• Complete heart block
• PAC/PVC
• Ventricular tachycardia
• Absent a wave (no organized atrial contraction)
• Atrial fibrillation
• Giant V waves
• Tricuspid regurgitation
Left Atrial Pressure
a v
c
x y
Starling Curves
Jason Ryan, MD, MPH
Frank-Starling Curve
Stroke
Volume
Preload (LVEDP, LVEDV)

Left and Right Shifts
↑ Contractility
↓ Peripheral Resistance (afterload)
Normal
Stroke ↓ Contractility
Volume ↑ Peripheral Resistance (afterload)
Preload (LVEDP, LVEDV)

Left and Right Shifts
• Contractility
• Increase: Exercise, inotropes
• Decrease: Myocardial infarction, heart failure
• Peripheral resistance:
• Total peripheral resistance (TPR)
• Systemic vascular resistance (SVR)
• Increase: Vasopressors
• Decrease: Vasodilators, sepsis
Venous Return Curve
Right Atrial
Pressure
Venous Return
or
Cardiac Output
Right Atrial Pressure
Venous Return Curve
Venous Return
or
Cardiac Output
Mean Systemic Filling Pressure
(MSFP)
Pressure if heart stops

Venous Return Curve
Left and Right Shifts Volume
Venous Tone
↑ Blood Volume
Venous constriction (↑ tone)
Venous Return
or
Cardiac Output
Normal
↓ Blood Volume
Venous dilation (↓ tone)

Venous Return Curve
Changes in Slope
↓ Total peripheral resistance
Venous Return
or
Cardiac Output
Normal
↑ Total peripheral resistance
TPR change shifts curve right/left

No change in MSFP
Result: change in slope of Venous Return curve
Combined Curves
Starling and Venous Return
CO
or
VR

or
Preload
Heart Failure
↓contractility
↑ TPR
CO ↑ Fluid volume
or
VR

or
Preload
* Black = normal
Hemorrhage
Blood loss
↑ TPR
↑ Contractility
CO
or
VR

or
Preload
* Black = normal
Exercise
• Decreased afterload (TPR)
• Venous contraction
• Increased contractility
• Net result = increased CO
AV Fistulas
• Decreased afterload (TPR)
• Venous contraction
• Net result = increased CO
Vasopressors
• Increased afterload (TPR)
• Alters VR and Starling Curves
• Net result = decreased CO
Combined Curves
Starling and Venous Return
For a patient on
A
15
CO 10
B starling curve A
or with a MSFP of 10
VR 5 C
what is the cardiac
output?
10 12 14

* Black = normal
Atherosclerosis
Jason Ryan, MD, MPH
Vocabulary
• Arteriosclerosis
• Hardening of arteries
• Hyaline
• Hyperplastic
• Atherosclerosis
• Form of arteriosclerosis
• Most common type
Atherosclerosis
• Plaque accumulation in arterial walls
• Chronic inflammatory process
• Involves macrophages, T-cells
• Accumulation of lipoproteins especially LDL
• Underlying cause of many diseases
• Myocardial infarction
• Stroke
• Peripheral vascular disease
A. Rad et al./Wikipedia
Nephron/Wikipedia
OpenStax College/Wikipedia
Arterial Structure
• Intima
• Single layer of endothelial cells
• Basement membrane
• Media
• Smooth muscle cells
• Elastin
• Adventicia Bruce Blaus/Wikipedia
• Connective tissue
• Vasa vasorum (blood supply to artery wall)
• Nerve fibers
Type of Arteries
• Elastic
• Large amounts of elastin in media layer
• Expansion in systole, contraction in diastole
• Aorta, carotid arteries, iliac arteries
• Muscular
• Layers of smooth muscle cells
• Vasoconstriction/vasodilation to modify blood flow
• Arterioles: smallest muscular vessels (most flow resistance)
Atherosclerosis
• Large elastic arteries
• Aorta, carotid arteries, iliac arteries
• Medium-sized muscular arteries
• Coronary, popliteal
Luke Guthman/Wikipedia
Atherosclerosis
Pathogenesis
• Endothelial injury or dysfunction

• Details incompletely understood
• Believed to be related to risk factors
• Cigarette smoke
• High blood pressure
• High cholesterol
Atherosclerosis
Pathogenesis
• Branch points and vessel origins (ostia)

• Common sites of plaque
• Turbulent flow → endothelial stress
Atherosclerosis
Pathogenesis
• Lipids
• LDL accumulation in intima
• Oxidized by free radicals
• Oxidized LDL scavenged by macrophages
• Cannot be degraded
• Macrophages become foam cells
Public Domain
Atherosclerosis
Pathogenesis
• Chronic inflammation
• LDL oxidized from free radicals
• Damages endothelium, smooth muscle
• Macrophages release cytokines
Atherosclerosis
Pathogenesis
• Smooth muscle cells proliferate in intima

• Lay down extracellular matrix
• Key growth factor: PDFG
• Platelet-derived growth factor
OpenStax College/Wikipedia
Atheroma Growth
• Fatty streaks
• Macrophages filled with lipids
• Form line (steak) along vessel lumen
• Do not impair blood flow
• Can be seen in children, adolescents
• Not all progress
Npatchett/Wikipedia
Atheroma Growth
• Atherosclerotic plaques
• Intima thickens
• Lipids accumulate
• Usually patchy along vessel wall
• Rarely involve entire vessel wall
• Usually eccentric
Npatchett/Wikipedia
Normal Fatty Fi brofatty Adva nced/vu I nera ble
vessel streak plaq ue plaq ue
N patchett/Wikipedia
Locations
• Abdominal aorta (large vessel)
• Coronary arteries
• Popliteal arteries
• Internal carotid
• Circle of Willis
Public Domain
Atherosclerosis Complications
• Ischemia
• Plaque rupture
• Exposes thrombogenic substances
• Clot formation
• May cause acute vessel closure (STEMI)
• Thrombus may embolize (stroke from carotid plaque)
Atherosclerosis Complications
• Hemorrhage into plaque
• Lesions: proliferating small vessels (“neovascularization”)
• Contained rupture may suddenly expand lesion
• Aneurysm
• Lesions may damage underlying media
• Plaque associated with abdominal aortic aneurysms
Public Domain
Dystrophic Calcification
• Commonly seen in atheroma
• Result of chronic inflammation
• Basis for “coronary CT scans”
Infarction
• Area of ischemic necrosis
• Two types: white and red
• White infarcts
• Occlusion of arterial supply to a solid organ
• Common in heart, kidneys, spleen
• Limited blood seepage from healthy tissue
• Tissue becomes pale (white)
White Infarct
Renal Infarction
Ryan Johnson/Flikr
Red Infarcts
Hemorrhagic Infarct
• Blood enters ischemic tissue

• Blockage of venous drainage
• Testicular torsion
• Tissues with dual circulation
• Blood flow from 2nd supply floods ischemic area
• Classic location: Lung (diffuse blood supply)
• Small intestine
• Flow re-established to necrotic area
• Angioplasty restores flow in coronary artery
Red Infarct
Lung Infarction
Yale Rosen/Wikipedia
Cardiac Ischemia
Jason Ryan, MD, MPH
Cardiac Ischemia
• Caused by coronary atherosclerosis
• O2 SUPPLY << O2 DEMAND = ISCHEMIA
• Typical symptoms
• Chest pain (angina)
• Dyspnea
• Diaphoresis
Freestocks.org
Stable Angina
• Stable atherosclerotic plaque
• No plaque ulceration
• No thrombus
• Must occlude ~75% of lumen to cause symptoms
NO SYMPTOMS
SYMPTOMS WITH EXERTION

(EXERTIONAL ANGINA)
Acute Coronary Syndromes
• Plaque rupture → thrombus formation
• Subtotal occlusion
• Unstable angina
• Non-ST elevation myocardial infarction
• Total occlusion (100%)
• ST-elevation myocardial infarction (STEMI)
Subtotal Occlusion Total Occlusion

Sudden Death
• Common complication of CAD
• Plaque rupture → arrhythmias
• CAD is most common cause of sudden death adults
• Younger patients: Hypertrophic cardiomyopathy (HCM)
Risk Factors
• Major risk is prior coronary disease
• Coronary risk equivalents
• Diabetes
• Peripheral artery disease
• Chronic kidney disease
Risk Factors
• Hypertension
• Hyperlipidemia
• Family History (1° relative, M<50, F<60)
• Smoking
• Obesity, sedentary lifestyle
Extent of Ischemia
• Transmural ischemia
• Occurs with complete 100% flow obstruction (STEMI)
• Subendocardial ischemia
• Occurs with flow obstruction but some distal blood flow
• Stable angina, unstable angina, NSTEMI
Subendocardial Ischemia Transmural Ischemia

Subendocardial Ischemia
Subtotal Occlusion
Limited distal flow

Transmural Ischemia
Transmural Ischemia
Complete Occlusion
Ischemic EKG changes
ST depressions
T wave inversions
• Many causes other than CAD

• Raised ICP
• Cerebral T waves
• Resolving pericarditis
• Bundle branch blocks
• Ventricular hypertrophy
T wave inversions
ST Elevations
Seen only with transmural ischemia

Evolution of EKG changes
STEMI
Normal Acute Hours 1-2 Days 3-7 Days > 7 Days
Q wave
Hyperacute T waves
• Seen in transmural ischemia
• Early sign of ischemia
• Seen before ST elevations
Poor R Wave Progression
• R wave increases (progresses) in size V1-V6
• Normally R>S waves seen by lead V3
• Poor progression seen in anterior ischemia
• Acute or prior infarction
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Terminology
• Revascularization
• Angioplasty
• Coronary stenting
• Coronary bypass surgery
Revascularization
Coronary angiogram: Before Coronary angiogram: After

Coronary Stents
• Angioplasty: Reshape vessel
• Balloon angioplasty: Balloon inflation to open vessel
• Percutaneous Coronary Intervention (PCI)
• Stent placement
• About 600,000 stents/year implanted US
Exp 111w.fod S'lont Balloon
Wikipedia/Public Domain
CABG
Coronary Artery Bypass Surgery
• “Bypass Surgery”
• Left Internal Mammary Artery (LIMA) Graft
• Saphenous (leg) Vein Grafts
• Radial (arm) Artery Grafts
Patrick J. Lynch/Wikipedia
Patrick J. Lynch/Wikipedia
Revascularization
Major Indications
• Angina
• Myocardial infarction
• Systolic dysfunction
• Hibernating myocardium
Ischemic Pathologic Changes
Myocardium
• Zero to 4 hrs
• No changes!
• 4 – 12 hrs
• Gross: Mottled
• Micro: Necrosis, edema, hemorrhage
• 12-24 hrs
• Gross: Hyperemia
• Micro: Surrounding tissue inflammation
• 5 – 10 days
• Gross: Central yellowing
• Micro: Granulation tissue
• 7 weeks
• Gross: Gray-white scar
• Micro: Scar
Complications of Ischemia
• First 4 days
• Arrhythmia
• 5 – 10 days
• Free wall rupture
• Tamponade
• Papillary muscle rupture
• VSD (septal rupture)
• Weeks later
• Dressler’s syndrome
• Aneurysm
• LV Thrombus/CVA
Cause of Death
0 – 4 days after MI
Cause of Death
5-10 days after MI
• Free wall rupture

• Usually fatal – sudden death
• May lead to tamponade
• Papillary muscle rupture
• Acute mitral regurgitation (holosystolic murmur)
• Heart failure, respiratory distress
• More common inferior MIs
• Septal rupture – VSD
• Loud, holosystolic murmur (thrill)
• Hypotension, right heart failure (↑ JVP, edema)
Ventricular Aneurysm
Weeks after MI
• More common anterior infarction

• Risk of thrombus → stroke, peripheral embolism
Patrick J. Lynch, medical illustrator/Wikipedia

Ventricular Pseudoaneurysm
• Rupture contained by pericardium/scar tissue
• Not a true aneurysm
• No endocardium or myocardium
• May rupture
• Presents as chest pain or dyspnea
• Often seen in the inferior wall
• Occurs earlier (<2 weeks) than true aneurysm
Dressler’s Syndrome
Weeks to months after MI
• Form of pericarditis
• Chest pain
• Friction rub
• Immune-mediated (details not known)
• Treatment: NSAIDs or steroids
Fibrinous Pericarditis
• Occurs days after MI
• Sometimes called “post-MI” pericarditis
• Not autoimmune
• Extension of myocardial inflammation
• Dressler’s occurs weeks after MI
• Sometimes called “post cardiac injury” pericarditis
• Rarely life-threatening
Secondary Prevention
• Any CAD → ↑ risk of recurrent events
• STEMI, NSTEMI, stable angina
• Preventative therapy used to lower risk
• Even in asymptomatic patients
Secondary Prevention
• Several proven therapies for risk reduction
• Aspirin
• Statins
• Atorvastatin, Rosuvastatin
• Beta blockers
• Used in patients with prior infarction (STEMI/NSTEMI)
Ragesoss/Wikipedia
Stent Complications
Restenosis
• Slow, steady growth of scar tissue over stent
• “Neo-intimal hyperplasia”
• Re-occlusion of vessel
• Rarely life-threatening
• Slow, steady return of angina
• Most stents coated “drug eluting stents”
• Metal stent covered with polymer
• Polymer impregnated with drug to prevent tissue growth
• Sirolimus
Stent Complications
Thrombosis
• Acute closure of stent
• Same as STEMI: life-threatening event
• Dual anti-platelet therapy for prevention
• Associated with missed medication doses
Stent Thrombosis Prevention
• “Dual antiplatelet therapy”
• Typically one year of:
• Aspirin
• Clopidogrel, Prasugrel or Ticagrelor
• After one year, stent metal no longer exposed to blood
• “Endothelialization”
• Risk of thrombosis is lower (but not zero)
• Most patients take aspirin only
ST-Elevation
Myocardial
Infarction (STEMI)
Jason Ryan, MD, MPH
STEMI
• Atherosclerotic plaque rupture
• Thrombus formation
• Complete (100%) vessel occlusion
• Ischemic chest pain
• ST-elevations on ECG
STEMI
Transmural Ischemia
Complete Occlusion
ST-elevation Myocardial Infarction

Ulcerated Plaque – Thrombus
Complete occlusion
No distal blood flow
STEMI
STEMI
Leads go together
ST Elevations - Anterior
Leads go together
ST Elevations - Anterior
Leads go together
ST Elevations - Lateral
Leads go together
ST Elevations - Lateral
Leads go together
ST Elevations - Inferior
Leads go together
ST Elevations - Inferior
Coronary Artery Territories
• Left anterior descending artery
• Anterior → V1-V4
• Left circumflex artery
• Lateral → I, L, V5, V6
• Posterior descending artery
• Inferior → II, III, F
• Branch of right coronary artery 90%
• LCX 10%
Special Complications
Inferior MI
• Right ventricular infarction

• Loss of right ventricular contractility
• Elevated jugular venous pressure
• Decreased preload to left ventricle → hypotension
• Diagnosis: Right sided chest leads
Jmarchn/Wikipedia
Special Complications
Inferior MI
• Sinus bradycardia and heart block

• Vagal stimulation from inferior wall ischemia
Left Main Occlusion
Posterior Myocardial Infarction
STEMI
Special Subtypes
• Left main
• ST-elevation aVR
• Diffuse ST depressions
• Posterior
• Anterior ST depressions with standard leads
• ST-elevation in posterior leads (V7-V9)
Treatment of STEMI
• “Time is muscle”
• Coronary artery occluded by thrombus
• Longer occlusion → more muscle dies
• More likely the patient may die
• More heart failure symptoms n=1791
• More future hospitalization for heart disease
• Medical emergency
Treatment of STEMI
• Main objective is to open the artery
• “Revascularization”
• Option 1: Emergency angioplasty
• Mechanical opening of artery
• Should be done <90min
• Option 2: Thrombolysis
• Lysis of thrombus with drug
• Should be done <30min
• “Door to balloon” or “door to needle”
Treatment of STEMI
• Time matters
• Medical therapy is supportive
• Given while working to open artery
• Remember: this is a thrombotic problem
• Aspirin to inhibit platelet aggregation
• Heparin to inhibit clot formation
• This is also an ischemic problem
• Beta blockers to reduce O2 demand
• Nitrates to reduce O2 demand
Cautions
• Beta blockers
• Inferior MI stimulates vagal nerve
• Bradycardia and AV block can develop
• Nitrates
• Occlusion of RCA can cause RV infarct
• RV infarction → ↓ preload
• Nitrates ↓ preload→ hypotension
Other STEMI Treatments
• Clopidogrel
• ADP receptor blocker
• Inhibits platelets
• Eptifibatide
• IIB/IIIA receptor blocker
• Inhibits platelets
• Bivalirudin
• Direct thrombin inhibitor
• Inhibits clot formation
Typical STEMI Course
• Arrival in ER with chest pain 5:42pm
• EKG done 5:50pm
• STEMI identified
• Cardiac cath lab activated for emergent angioplasty
• Meds given in ER
• Aspirin
• Metoprolol
• Nitro drip
• Heparin bolus
• Transport to cath lab 6:15pm
• Artery opened with balloon 6:42pm
• DTB time 60 minutes (ideal <90min)
Typical STEMI Course
• Arrival in ER with chest pain 5:42pm
• EKG done 5:54pm
• STEMI identified
• Meds given in ER
• Aspirin
• Metoprolol
• Nitro drip
• Heparin bolus
• tPA given based on weight 6:07pm
• IV push
• Door to needle time 25min (ideal <30)
NSTEMI and
Unstable Angina
Jason Ryan, MD, MPH
NSTEMI
Non-ST-Elevation Myocardial Infarction

• Subtotal (<100%) vessel occlusion
Subtotal Occlusion
Limited distal flow

NSTEMI
ECG Changes
• ST depressions
• T-wave inversions
Cardiac Biomarkers
• Biomarkers spill into blood with cardiac injury
• Most common marker used: Troponin I or T
• Increase 2-4 hours after MI
• Stay elevated for weeks
• CK-MB also used
• Increase 4-6 hours after MI
• Normalize within 2-3 days
Cardiac Biomarkers
• Several types of CK
• MM – Skeletal muscle
• MB – Cardiac
• BB – Brain
• Most tissues have some of all three
• Ratio of MB to total CK can be used in ischemia
• Helpful when total CK also up due to muscle damage
Cardiac Biomarkers
• Some AST found in cardiac cells
• Abdominal pain with isolated ↑ AST could be MI
Bodyparts3D/Wikimedia Commons
Treatment of NSTEMI
• Thrombotic and ischemic syndrome (like STEMI)
• Unlike STEMI: No “ticking clock”
• Subtotal occlusion
• Some blood flow to distal myocardium
• No emergency angioplasty
• No benefit to thrombolysis
• Aspirin
• Beta blocker
• Heparin
• Angioplasty (non-emergent)
Typical NSTEMI Course
• Presents to ER with chest pain
• Biomarkers elevated
• Medical Therapy
• Aspirin
• Metoprolol
• Heparin drip
• Admitted to cardiac floor
• Hospital day 2 → angiography
• 90% blockage of LAD → Stent
Unstable Angina
• Subtotal (<100%) vessel occlusion
• Normal biomarkers
Unstable Angina
• Diagnosis largely based on patient history
• Chest pain increasing in frequency/intensity
• Chest pain at rest
• ECG may show ST depressions or T wave inversions
• Treatment is same as for NSTEMI
• Condition often called “UA/NSTEMI”
Stable Angina
Jason Ryan, MD, MPH
Stable Angina
• Ischemic chest pain with exertion
• Relieved by rest
• Stable pattern over time
• Stable coronary atherosclerotic plaque
• No plaque rupture/thrombus
Stable Angina
• Symptoms generally absent until ~75% occlusion
• Distal arteriolar dilation → normal flow if <75%
Stable Angina
• Diagnosis: cardiac stress test
• Increases demand for O2
Stable Angina
• NOT a thrombotic problem
• No role for heparin or antithrombotic drugs
• In US usually treated with revascularization
• Most common indication PCI, CABG is stable angina
• Recent clinical trials suggest medical therapy may work just as
well as PCI/CABG in some patients
Stable Angina: Typical Case
• 65-year old man with chest pain while walking
• Relieved with rest
• Presents to ED
• EKG normal
• Biomarkers normal
• Stress test
• Walks on treadmill→ chest pain, EKG changes
• Cardiac catheterization performed
• 90% LAD artery blockage
• Stent placed → angina resolved
Medical Therapy for Ischemia
O2 Demand
O2 Supply
↓O2 Demand
↑O2 Supply ↓ Heart rate
Dilate coronary arteries ↓ Contractility
Increase diastole ↓ Afterload
↓ Preload
Nitrates
• Converted to nitric oxide → vasodilation
• Predominant mechanism is venous dilation
• Bigger veins hold more blood
• Takes blood away from left ventricle
• Lowers preload (LVEDV)
• Also arterial vasodilation (art<< veins)
• Increase coronary perfusion
• Some peripheral vasodilation
Nitroglycerine
Nitrates
• ↓ preload → ↓ cardiac output
• Sympathetic nervous system activation
• Increased heart rate/contractility
• Increases O2 demand
• Opposite of what we want to do for angina
Nitrates
• Rare patients with complex CAD → angina
• In most patients, preload reducing effects dominate
• Nitrates alone often improve angina
• Co-administer beta-blocker or Ca channel blocker
• Blunts “reflex” effect
Nitrates
Forms
• Nitroglycerin Tablets/Spray
• Rapid action ~5 minutes
• Take during angina attack, before exercise
• Isosorbide Dinitrate
• Effects last ~6hrs
• Isosorbide Mononitrate
• Once daily drug
• Topical Nitroglycerin
• Topical cream, patches
Nitrates
Adverse Effects
• Headache (meningeal vasodilation)

• Flushing
• Hypotension
• Angina
• Reflex sympathetic activation
phee/Pixabay/Public Domain
Nitrate Tolerance
• Drug stops working after frequent use
• Avoid continuous us for more than 24 hours
• Does not occur with daily isosorbide mononitrate
Jpeterson101/Wikipedia
Nitrate Withdrawal
• Nitrate withdrawal (rebound) after discontinuation
• Occurs when using large doses of long-acting nitrates
• Angina frequency will increase
Freestocks.org
Monday Disease
• Workers in nitroglycerin manufacturing facilities
• Regular exposure to NTG in the workplace
• Leads to the development of tolerance
• Over the weekend workers lose the tolerance
• "Monday morning headache" phenomenon
• Re-exposed on Monday
• Prominent vasodilation
• Tachycardia, dizziness, and a headache
Beta Blockers
• Slow heart rate and decrease contractility
• Increase preload (LVEDV)
• Slower heart rate = more filling time
• Increase O2 demand
• Blunts some beneficial effect
• Reduced blood pressure (↓ afterload)
• Net effect = less O2 demand
Beta Blockers
• For angina, generally use cardioselective (β1) drugs
• Metoprolol, atenolol
• Some beta blockers are partial agonists
• Pindolol, Acebutolol
• Don’t use in angina
Calcium Channel Blockers
• Three major classes of calcium antagonists
• dihydropyridines (nifedipine)
• phenylalkylamines (verapamil)
• benzothiazepines (diltiazem)
• Vasodilators and negative inotropes
• Nifedipine: vasodilator
• Lower blood pressure
• Reduce afterload
• Dilate coronary arteries
• May cause reflex tachycardia
• Verapamil/diltiazem: negative inotropes
• Similar to beta blockers
• Reduced heart rate/contractility
• Can precipitate acute heart failure if LVEF very low
Antianginal Therapy
Nitrates/Beta Blockers
Nitrates +
Nitrates Beta blockers
Beta blockers
Supply
Coronary vasodilation Increase -- Increase
Duration diastole ↓ reflex Increase --
Demand
Preload Decrease Increase Decrease
Afterload Decrease Decrease Decrease
Contractility ↑ reflex Decrease --/↓
Heart Rate ↑ reflex Decrease --/↓
Antianginal Therapy
Verapamil Diltiazem Nifedipine

Supply
Coronary vasodilation -- -- Increase
Duration diastole Increase Increase ↓ reflex
Demand
Preload Increase Increase --
Afterload Decrease Decrease Decrease
Contractility Decrease Decrease ↑ reflex
Heart Rate Decrease Decrease ↑ reflex
Ranolazine
• Inhibits late sodium current
• Reduces calcium overload → high wall tension
• Reduces wall tension and O2 demand
Late Na influx
Na Na Ca
Ranolazine
• Constipation, dizziness, headache
• QT prolongation (blockade of K channels)
Prolong QT
Variant (Prinzmetal) Angina
• Ischemia from vasospasm
• Not caused by atherosclerotic narrowing
• Often artery is “clean” with no stenosis
• May also occur near sites of mild atherosclerosis
• Spontaneous episodes of angina
• Transient myocardial ischemia
• ST-segment elevation on ECG
• Episodes usually at rest
• Midnight to early morning
• Sometimes symptoms improve with exertion
• Associated with smoking
Diagnosis
• Usually based on history

• Intracoronary ergonovine
• Acts on smooth muscle serotonergic (5-HT2) receptors
• Can be administered during angiography
• Vasospasm visualized on angiogram
• Intracoronary acetylcholine
• Acts on endothelial muscarinic receptors
• Healthy endothelium → vasodilation via nitric oxide
• Endothelial dysfunction → vasoconstriction
• Vasospasm visualized on angiogram
Treatment
• Quit smoking
• Calcium channel blockers, nitrates
• Vasodilators
• Dilate coronary arteries, oppose spasm
• Avoid propranolol
• Non selective blocker
• Can cause unopposed alpha stimulation
• Symptoms may worsen
Pixabay/Public Domain
Coronary Steal
• Mechanism of angina
• Induced by drugs
• Blood flow increased to healthy vessels
• Blood flow decreased in stenotic vessels
• Blood “stolen” from diseased coronary vessels
Coronary Steal
• Stenotic vessels
• Significant (>75%) narrowing
• Arterioles maximally dilated to maintain flow
• Normal vessels
• No or minimal narrowing
• Arterioles NOT maximally dilated
Coronary Steal
• Vasodilator administered
• Stenotic vessels → no response
• Arterioles already maximally dilated
• Normal vessels → vasodilation
• Flow increases to normal vessels
• Flow decreases to abnormal vessels
• Results: ischemia due to coronary steal
Coronary Steal
• Rarely seen with nitrates, nifedipine
• Key principle for chemical stress tests
• Adenosine, persantine, regadenoson
• Potent, short-acting vasodilators
• Brief ↓ in blood flow to stenotic vessels → ischemia
• Nuclear tracers can detect ↓ blood flow
EKG Basics
Jason Ryan, MD, MPH
SA
AV
HIS
Bundle
Bundle
Branches
Purkinje
Fibers
AV Node
HIS Bundle
Bundle Branches
Purkinje Fibers
R
SA
AV
T HIS
P
Bundle
Q Bundle
S Branches
Atrial Ventricular
Depolarization Depolarization Purkinje
Fibers
EKG
EKG Electrical Activity
SA
AV LBB
His
Purkinje
RBB Fibers
I
AVR V1 V2 V3 V4 V5 V6
AVL
II III AVF
EKG
EKGs
Key Principles
• #1: Waves represent repolarization/depolarization

• #2: EKGs have 12 leads
• Each lead watches the same thing
• Each lead watches from different vantage point
• Electrical activity toward lead = upward deflection
• Electrical activity away from lead = negative deflection
Pacemakers
• SA node is dominant pacemaker of the heart
• Other pacemakers exist but are slower
• If SA node fails, others takeover
• SA node (60-100 bpm)
• AV node (40-60 bpm)
• HIS (25-40 bpm)
• Bundle branches (25-40 bpm)
• Purkinje fibers (25–40 bpm)
Conduction Velocities
• SLOWEST conduction is through AV node
• Very important so ventricle has time to fill
• Purkinje fibers → fastest conduction
• Purkinje > Atria > Vent > AV node
Determining Heart Rate
• 3 – 5 big boxes
between QRS
complex
300 150 100 75 60 50

QRS Axis
SA
AV LBB
His
Purkinje
RBB Fibers
QRS Axis
-90o
+180o 0o
Normal QRS Axis
-30 and +90 degrees
+90o
QRS Axis
Left Axis Deviation
-90o LBBB
Ventricular Rhythm
+180o 0o
Normal QRS Axis
-30 and +90 degrees
+90o
QRS Axis
Left Axis Deviation
-90o LBBB
Ventricular Rhythm
Right Axis Deviation

RBBB
RVH
+180o 0o
Normal QRS Axis
-30 and +90 degrees
+90o
Determining Axis
-90o
(-)
LAD
Lead F (+)
Lead I (-) (+)
+180o 0o
Normal Axis
RAD
-30 to +90
+90o
Axis Quick Method
• First, glance at aVr.
• It should be negative
• If upright, suspect limb lead reversal
Normal
Axis Quick Method
• If leads I and II are both positive, axis is normal
Lead I
Axis 0 to 90°
Lead II
Axis Quick Method
• For left axis deviation:
• All you need is lead II
Lead I
Axis -30 to -90°
Lead II
Axis 0 to -30°
Lead II Physiologic
Left Axis
Axis Quick Method
• For right axis deviation:
• All you need is lead I
• Negative = RAD
Lead I
Axis 90 to 180°
Lead II
Axis Quick Method
• Look at aVr: Make sure its negative
• Look at I, II: If both positive, axis is normal
• If II is negative: LAD
• If I is negative: RAD
Normal Phys Left Left Right
Lead I
Lead II
PR Interval
Normal PR
120-200ms
Prolonged PR
1° AV block
Short PR - WPW
QRS Interval
Normal QRS
<120ms
Right Bundle
Branch Block
Left Bundle
Branch Block
Qt Interval
Normal Qt
Short Qt: Hypercalcemia
Prolonged Qt
Hypocalcemia
Drugs
LQTS
Calcium
Myocyte Action Potential
Phase 1
IK+ (out) Phase 2
ICa+ (in) & IK+ (out)
0mv
Phase 3
Phase 0 IK+ (out)
INa+ (in)
-85mv
Phase 4
Torsade de Pointes
• Feared outcome of Qt prolongation
• Results in cardiac arrest
• Antiarrhythmic drugs
• Hypokalemia, hypomagnesemia
• Rarely from hypocalcemia
Congenital Long Qt Syndrome
• Rare genetic disorder
• Abnormal K/Na channels
Na
Prolonged QT
Congenital Long Qt Syndrome
• Family history of sudden death (torsades)
• Classic scenario: Young patient recurrent “seizures”
• EKG shows long Qt interval
• Jervell and Lange-Nielsen Syndrome
• Norway and Sweden
• Congenital deafness
Acquired Long Qt Syndrome
• Levofloxacin (antibiotic)
• Haldol (antipsychotic)
• Many other drugs
• Congenital LQTS: need to avoid these drugs
T waves
Peaked T waves
↑K
Early ischemia
(hyperacute)
U waves
Origin unclear
T U
May represent
repolarization of
Purkinje fibers
T U
Can be normal but
also seen in
hypokalemia
High Yield EKGs
Jason Ryan, MD, MPH
EKGs You Should Know
1. Sinus rhythm
2. Atrial Fibrillation/Flutter
3. Ischemia: ST elevations, ST depressions
4. Left bundle branch block
5. Right bundle branch block
6. PAC/PVC
7. 1st, 2nd, 3rd degree AV block
8. Ventricular tachycardia
9. Ventricular fibrillation/Torsades
Step 1: Find the p waves
• Are p waves present?
Sinus p waves
• Originate in sinus node
• Upright in leads II, III, F
Step 2: Regular or Irregular
• Distance between QRS complexes (R-R intervals)
Regular
Irregular
Steps 1 & 2
• P waves present, regular rhythm
• Sinus rhythm
• Rare: atrial tachycardia, atrial rhythm
• No p waves, irregular rhythm
• Atrial fibrillation – irregularly irregular
• Atrial flutter with variable block
Steps 1 & 2
• P waves present, irregular rhythm
• Sinus rhythm with PACs
• Multifocal atrial tachycardia
• Sinus with AV block
• No p waves, regular rhythm
• Hidden p waves: retrograde
• Supraventricular tachycardias (SVTs)
• Ventricular tachycardia
Step 3: Wide or narrow
• Narrow QRS (<120ms; 3 small boxes)
• His-Purkinje system works
• No bundle branch blocks present
• Wide QRS
• Most likely a bundle branch block
• Ventricular rhythm (i.e. tachycardia)
QRS Interval
Normal QRS
Right Bundle
Branch Block
Left Bundle
Branch Block
Step 4: Check the intervals
• PR (normal <210ms; ~5 small boxes; ~1 big box)
• Prolonged in AV block
• Lengthens with vagal tone, drugs
• Shortens with sympathetic tone
• QT (normal <1/2 R-R interval)
• Prolonged with ↓ Ca (tetany; numbness; spasms)
• Prolonged by antiarrhythmic drugs
• Shortened with ↑ Ca (confusion, constipation)
Step 5: ST segments
• T wave abnormalities
• Inverted: ischemia
• Peaked: Early ischemia, hyperkalemia (↑K)
• Flat/U waves: Hypokalemia (↓K)
• ST Depression
• Subendocardial ischemia
• ST Elevation
Normal Sinus Rhythm
Right Bundle Branch Block
Left Bundle Branch Block
Atrial Fibrillation
Atrial Flutter
Ventricular Tachycardia
Torsades de pointes
• ↑ risk with prolonged Qt interval
• Congenital long Qt syndrome
• Antibiotics (erythromycin, quiniolones)
• Hypokalemia
• Hypomagnesemia
• Rarely hypocalcemia
PAC and PVC
Cardiac Action
Potentials
Jason Ryan, MD, MPH
Cardiac Action Potential
• Changes in membrane voltage of cell
• Transmit electrical signals through heart
• Triggers contraction of myocytes
Atrial/ventricular myocytes
Phase 1
IK+ (out) Phase 2
0mv
Phase 3
Phase 0 IK+ (out)
INa+ (in)
-85mv
Phase 4
Phase 4
• Resting potential: about −85mV
• Constant outward leak of K+
• “Inward rectifier channels”
• Na+ and Ca2+ channels are closed
Phase 4 Phase 4
Phase 0 Phase 0
• Nearby myocyte raise membrane potential

• Gap junctions
• Rising potential opens “Fast” Na+ channels
• Threshold potential reached (about -70mV)
• Large Na+ current → rapid depolarization
• Membrane potential overshoots (>0mV)
• Fast Na+ channels close
• Class I antiarrhythmic drugs: block Na channels
Phase 1
• Membrane potential is positive
• K+ channels open
• Outward flow of K+ returns membrane to ~0 mV
Phase 1
Phase 2
• L-type Ca2+ channels open → inward Ca2+ current
• Contraction trigger: excitation-contraction coupling
• K+ leaks out (down concentration gradient)
• Delayed rectifier K+ channels
• Balanced flow in/out = plateau of membrane charge
• Verapamil/Diltiazem = block L-type Ca channels
Phase 2
Phase 3
• Ca2+ channels inactivated
• Persistent outflow of K+
• Resting potential back to −85 mV
• Class III antiarrhythmic drugs: block K channels
Phase 3
Skeletal Muscle
• No plateau (phase 2)
• No gap junctions
• Each cell has its own NMJ
Na+ K+
Refractory Period
• Phase 0 until next possible depolarization
• Determines how fast myocyte can conduct
• Many antiarrhythmic drugs prolong refractory period
Refractory Period
• Similar AP in HIS, bundle branches, Purkinje fibers

Pacemaker Action Potential
SA node, AV node
0mv
Phase 0
Phase 3
ICa
Threshold IK
-40mv
Phase 4
-85mv If (Na)
SA node, AV node
• Funny current (pacemaker current)

• Spontaneous flow of Na+
• About −40 mV: threshold potential
• L-type Ca2+ channels open → depolarize cell
• Delayed rectifier K+ channels open
• Return cell to −60 mV
SA node, AV node
• Automaticity
• Do not require stimulation to initiate action potential
• Capable of self-initiated depolarization
• No fast Na+ channel activity
• Fewer inward rectifier K+ channels
• Membrane potential never lower than −60 mV
• Fast Na+ channels need −85 mV to function
SA node, AV node
• Any drug that slows this AP may cause two effects:

• Slower heart rate (sinus node)
• Slower AV conduction (AV node)
0mv
Phase 0
ICa
Threshold
-40mv
-85mv
SA node, AV node
• Two key drug classes that affect pacemaker AP

• Calcium channel blockers (Verapamil/Diltiazem)
• Beta blockers
0mv
Phase 0
ICa
Threshold
-40mv
-85mv
SA node, AV node
• Verapamil/Diltiazem = block L-type Ca channels

• Slow rate of sinus depolarization (slow heart rate)
• Slow AV node conduction
0mv
Phase 0
ICa
Threshold
-40mv
-85mv
Beta Blockers
• Modify slope of phase 4
• Less slope → longer to reach threshold → ↓ HR
Beta Blocker
Normal
Slower phase 4
(less slope)
Beta Blockers
• Also prolong repolarization
Beta Blocker
Normal
Slower repolarization
(slows conduction)
Slope of Phase 4
Sinus Node
• Changes in slope modify heart rate
• Decrease slope (slower rise)
• Parasympathetic NS, beta blockers, adenosine
• Increased slope (faster rise)
• Sympathetic NS, sympathomimetic drugs
Phase 4
Pacemakers
• Many cardiac cells capable of automaticity
• SA node normally dominates
• Fastest rise in phase 4
• Controls other pacemaker cells
• Pacemakers: SA Node > AV Node > Bundle of HIS
• HIS (25-40 bpm)
AV and
Bundle Branch Blocks
Jason Ryan, MD, MPH
AV Node
HIS Bundle
Bundle Branches
Purkinje Fibers
R
SA
AV
T HIS
P
Bundle
Q Bundle
S Branches
Atrial Ventricular
Depolarization Depolarization Purkinje
Fibers
AV Blocks
• Slowed or blocked conduction atria → ventricles
• Can cause prolonged PR interval
• Can cause non-conducted p wave
Non-conducted P wave
Prolonged PR Interval
AV Blocks
Symptoms
• Often incidentally noted on EKG

• Especially milder forms with few/no non-conducted p waves
• Can cause bradycardia
• Occurs when many or all p waves not conducted
• Fatigue, dizziness, syncope
• Symptomatic AV block often treated with a pacemaker
AV Blocks
Anatomy
• Caused by disease in AV conduction system

• AV node → HIS → Bundle Branches → Purkinje fibers
• Divided into two causes
• AV node disease
• HIS-Purkinje disease
AV Blocks
Anatomy
• AV node disease
• Usually less dangerous
• Conduction improves with exertion (sympathetic activity)
• HIS-Purkinje disease
• More dangerous
• Usually does not improve with exertion
• Often progresses to complete heart block
• Often requires a pacemaker
AV Blocks
Four Types
• Type 1
• Prolongation of PR interval only
• All p waves conducted
• Type II
• Some p waves conducted
• Some p waves NOT conducted
• Two sub-types: Mobitz I and Mobitz II
• Type III
• No impulse conduction from atria to ventricles
1st degree AV Block
Prolonged PR (normal <200ms)

Block usually in AV Node
Beta blockers
Calcium channel blockers
Well-trained athletes
2 degree AVB
nd
Mobitz I/Wenckebach

Progressive PR prolongation
Grouped Beating
RR intervals NOT regular
Similar causes as 1st degree AV block
2 degree AVB
nd
Mobitz I/Wenckebach

Progressive PR prolongation
Grouped Beating
RR intervals NOT regular
Similar causes as 1st degree AV block
2 degree AVB
nd
Mobitz II
Block usually in the HIS-Purkinje System

Often seen with bundle branch block
Usually symptomatic
Dizziness, syncope
3rd degree AVB

Regular RR intervals excludes Wenckebach
3rd degree AVB

Regular RR intervals excludes Wenckebach
Lyme Disease
• Spirochete infection with Borrelia burgdorferi
• Stage 2: Lyme carditis
• Varying degrees of AV block
• 1st, 2nd, 3rd
• AV block improves with antibiotics
Image courtesy of Wikipedia/Public Domain

Vocabulary
• Complete heart block
• Impulses cannot be transmitted from atria to ventricle
• AV dissociation
• Atria and ventricular depolarization uncoupled (“dissociated”)
• Can be cased by complete heart block
• Also occurs if ventricular rate > sinus rate (no heart block)
• Seen in ventricular tachycardia and other rhythms
Escape Rhythm
• SA node: Dominant (fastest) pacemaker
• Heart block: SA cannot send impulses to ventricles
• Other pacemakers exist but are slower
• HIS (25-40 bpm)
• Bundle branches (25-40 bpm)
• Purkinje fibers (25–40 bpm)
Escape Rhythm
• Heart block: lower pacemaker depolarizes ventricles
• “Escape rhythm”
• Rate of lower pacemaker determines symptoms
• Very slow: dizziness, syncope, hypotension
• Less slow: fatigue, exercise intolerance
Sites of AV Block
Disorder Common Site of Block

1st Degree AV node
Mobitz I AV Node
Mobitz II His-Purkinje System
3rd degree (Complete) His-Purkinje System
Causes of Heart Block
• Drugs
• Beta blockers, calcium channel blockers
• Digoxin
• High vagal tone
• Athletes
• Fibrosis and sclerosis of conduction system
Pacemaker
• Treatment for “high grade” AV block
• Usually 3rd degree or Mobitz II
• Often in patients with symptoms (syncope, dizziness)
• Both bundle branches blocked
• Results in AV block
• Form of HIS-Purkinje system disease
• ONE bundle branch blocked
• Does not cause AV block
• Normal PR interval
• QRS will be prolonged
Right Bundle Branch Block
Left Bundle Branch Block
A. Rad/Wikipedia
• Symptoms: None
• Identified incidentally on ECG
• May progress to AV block (need for pacemaker)
• Interfere with detection of ischemia
• ST elevations, T-wave inversions can be normal
Causes
• Often caused by slowly progressive fibrosis/sclerosis

• More common in older patients
• Can result from “structural heart disease”
• LBBB: Prior MI, cardiomyopathy
• RBBB: Right heart failure
Atrial Fibrillation
and Flutter
Jason Ryan, MD, MPH
Atrial Fibrillation
• Cardiac arrhythmia
• Results in an irregularly, irregular pulse
• Can cause palpitations, fatigue, dyspnea
• Diagnosis: EKG
Atrial Fibrillation
J. Heuser/Wikipedia
Atrial Fibrillation
Atrial Fibrillation
Atrial Fibrillation
SA
AV LBB
His
Purkinje
RBB Fibers
Atrial Fibrillation
Terminology
• Paroxysmal
• Comes and goes; spontaneous conversion to sinus rhythm
• Persistent
• Lasts days/weeks; often requires cardioversion
• Permanent
Atrial Fibrillation
Symptoms
• Wide spectrum of symptoms
Asymptomatic Palpitations, Dyspnea, Fatigue

Heart Rate <100bpm Heart Rate >100bpm
Cardiomyopathy
• Caused by untreated, rapid atrial fibrillation
• “Tachycardia-induced cardiomyopathy”
• ↓ LVEF
• Systolic heart failure
Heart Rate
• AV node refractory period determines heart rate
• Young, healthy patients → rapid heart rate
• Older patients → slower heart rate
• Atrial rate in fibrillation: 300-500bpm
• Ventricular rate: 70-180bpm
Preload
• Atrial fibrillation eliminates ventricular pre-filling
• “Loss of atrial kick”
• Decreases preload
• Can lead to low cardiac output and hypotension
• Especially in “preload dependent” patients
• Aortic stenosis
• LVH or diastolic heart failure (stiff ventricle)
Atrial Fibrillation
Thrombus in Left Atrial Appendage
Atrial Fibrillation
Cardiac Embolism
• Brain (stroke)
• Gut (mesenteric ischemia)
• Spleen
ConstructionDealMkting
Valvular Atrial Fibrillation
• Associated with rheumatic heart disease
• Usually mitral stenosis
• Often refractory to treatment
• VERY high risk of thrombus
• Non-valvular: not associated with rheumatic disease
Atrial Fibrillation
Risk Factors
• Age
• ~10% of patients >80
• <1% of patients <55
• More common in women
• Most common associated disorders: HTN, CAD
• Anything that dilates the atria → atrial fibrillation
• Heart failure
• Valvular disease
• Key diagnostic test: Echocardiogram
Hyperthyroidism
• Commonly leads to atrial fibrillation
• Reversible with therapy for thyroid disease
• Atrial fibrillation therapies less effective
• Key diagnostic test: TSH
Atrial Fibrillation
Triggers
• Often no trigger identified

• Binge drinking (“holiday heart”)
• Increased catecholamines
• Infection
• Surgery
• Pain
Atrial Fibrillation
Treatment
• Heart Rate
• “Rate control”
• Ideally <110bpm
• Heart Rhythm
• “Rhythm control”
• Restoration of sinus rhythm
• Anticoagulation
Rate Control
Beta Blockers
Digoxin
Rate Control
• Use drugs that slow AV node conduction
• Beta blockers
• Usually β1 selective agents
• Metoprolol, Atenolol
• Verapamil, Diltiazem
• Digoxin
• Increases parasympathetic tone to heart
Rhythm Control
• Goal: restore sinus rhythm
Cardioversion
Cardioversion
• Electrical
• Deliver “synchronized” shock at time of QRS
• Administer anesthesia
• Deliver electrical shock to chest
• All myocytes depolarize
• Usually sinus node first to repolarize/depolarize
Pollo/Wikipedia
Cardioversion
• Chemical
• Administration of antiarrhythmic medication
• Often Ibutilide (class III antiarrhythmic)
• Less commonly used due to drug toxicity
Cardioversion
• Spontaneous
• Often occurs after hours/days
Cardioversion
Risk of Stroke
• Chemical/electrical cardioversion may cause stroke

• 48hours required for thrombus formation
• Symptoms <48hours: cardioversion safe
• Symptoms >48hours (or unsure)
• Anti-coagulation 3 weeks → cardioversion
• Transesophageal echocardiogram to exclude thrombus
• Exception: Hypotension/shock
• Emergent cardioversion performed
Rhythm Control
• Antiarrhythmic medications
• Administered before/after cardioversion
• Class I drugs
• Flecainide, propafenone
• Class III drugs
• Amiodarone, sotalol, dofetilide
Anticoagulation
• Warfarin
• Requires regular INR monitoring
• Goal INR usually 2-3
• Rivaroxaban, Apixaban
• Factor X inhibitors
• Dabigatran
• Direct thrombin inhibitor
• Aspirin
• Less effective
• Only used if risk of stroke is very low
• Less risk of bleeding
Anticoagulation
• Whether atrial fibrillation persists or sinus rhythm
restored anticoagulation MUST be administered
• Studies show similar stroke risk for rate control
versus rhythm control
Stroke Risk
• CHADS Score
• CHF (1 point)
• HTN (1 point)
• Age >75yrs (1 point)
• Diabetes (1 point)
• Stroke (2 points)
• Score >2 = Warfarin or other anticoagulant
• Score 0 -1 = Aspirin
Stroke Risk
• CHADS VASC Score
• CHF (1point)
• HTN (1pont)
• Diabetes (1point)
• Stroke (2points)
• Female (1point)
• Age 65-75 (1point)
• Age >75yrs (2points)
• Vascular disease (1point)
• Score >2 = Warfarin or other anticoagulant
• Score 0 -1 = Aspirin
Atrial Fibrillation
Summary
New Onset
Atrial Fibrillation
Unstable Patient
Emergent Cardioversion
Echocardiogram
TSH
Rate Control Anticoagulation Rhythm Control

Beta Blockers Aspirin Cardioversion
Calcium Blockers Warfarin Antiarrhythmic drugs
Digoxin Other drugs
Pulmonary Vein Isolation
Surgical Therapy for Atrial Fibrillation
Pulmonary Vein Isolation
Surgical Therapy for Atrial Fibrillation
Atrial Flutter
Atrial Flutter
Atrial Flutter
Symptoms
• Generally the same as atrial fibrillation

• May be asymptomatic
• Palpitations, dyspnea, fatigue
Atrial Flutter
Treatment
• Generally the same as atrial fibrillation

• Rate or rhythm control
• Rate-slowing drugs
• Cardioversion
• Anticoagulation based on stroke risk
Atrial Flutter Ablation
AVNRT
Jason Ryan, MD, MPH
PSVT
Paroxysmal Supraventricular Tachycardia
• Intermittent tachycardia (HR > 100bpm)

• Sudden onset/offset
• Contrast with sinus tachycardia
• Electrical activity originates above ventricle
• “Supraventricular”
• Contrast with ventricular tachycardia
• Produces narrow QRS complex (<120ms)
PSVT
Paroxysmal Supraventricular Tachycardia
• Often causes sudden-onset palpitations

• Chest discomfort
• Rarely syncope
AVNRT
Atrioventricular nodal reentrant tachycardia
• Most common cause of PSVT

• More common in young women
• Mean age onset: 32 years old
• Requires dual AV nodal pathways
Normal Conduction
SA
AV LBB
His
Purkinje
RBB Fibers
Dual Pathways
Sinus Rhythm
Slow Fast
Conduction Conduction
Short RP Long RP
HIS
Dual Pathways
PAC
Slow Fast
Conduction Conduction
Short RP Long RP
HIS
Retrograde P Waves
AVNRT
• Recurrent episodes of palpitations
• Many episodes spontaneously resolve
• ↓ conduction in AV node breaks arrhythmia
• Will halt conduction is slow pathway
• Carotid massage
• Vagal maneuvers
• Adenosine
Carotid Massage
• Examiner presses on neck near carotid sinus
• Stretch of baroreceptors
• CNS response as if high blood pressure
• Increased vagal tone
• ↓ AV node conduction
Vagal Maneuvers
• Valsalva
• Patient bears down as if moving bowels
• Increased thoracic pressure
• Aortic pressure rises → ↓ heart rate and AV conduction
• Breath holding
• Coughing
• Deep respirations
• Gagging
• Swallowing
AVNRT
Chronic Treatment
• Many patients need no therapy

• Beta blockers, Verapamil/Diltiazem
• Slow conduction in slow pathway
• Surgical ablation of slow pathway
Wolff-Parkinson
White
Jason Ryan, MD, MPH
WPW Syndrome
Wolff-Parkinson White Syndrome
• Cardiac electrical disorder

• “Accessory atrioventricular pathway”
• Conducts impulses from atria to ventricles
• Bypasses AV node
• “Bundle of Kent”
• Causes “pre-excitation”
• Ventricular depolarization before AV nodal impulse
• May lead to arrhythmias
EKG in WPW
Short PR
Delta Wave
WPW EKG
Cardiac Electrical System
SA
AV LBB
His
Purkinje
Fibers
RBB
AVRT
AV Re-entrant Tachycardia
Orthodromic Antidromic
Bypass Tract Consequences
• Most patients asymptomatic
• EKG with delta wave only
• Called WPW “pattern”
• Some have tachycardias
• Presents as palpitations
• Called WPW syndrome
• AVRT (anti or orthodromic)
• Rarely causes syncope or sudden death
• Treatment: Ablation of accessory pathway
Atrial Fibrillation in WPW
• Atrial fibrillation can be life threatening
• Atrial depolarization rate 300-500/min
• AV node conducts <200/min
• Impulses may conduct rapidly over bypass tract
Wide complex, irregular, tachycardic

Atrial Fibrillation in WPW
• Slowing AV node conduction is dangerous
• Allows more impulses over bypass tract
• Usual atrial fibrillation therapies contraindicated
• Beta blockers
• Digoxin
• Adenosine
• Acute treatment: Cardioversion or antiarrhythmics
• Ibutilide, procainamide
• Slow conduction in bypass tract
Antiarrhythmic
Drugs
Jason Ryan, MD, MPH
Vaughan Williams
Class I Class II
Quinidine
Procainamide Ia
Lidocaine Beta Blockers

Mexiletine Ib
Flecainide
Propafenone Ic
Class III Class IV

Amiodarone
Sotalol Ca-channel Blockers
Dofetilide (Verapamil/Diltiazem)
Ibutilide
Use of Antiarrhythmic Drugs
• Drugs used to “suppress” arrhythmias
• Prevent formation of aberrant impulses
• Most also cause arrhythmias
• Can lead to cardiac arrest and death
• Used in dangerous arrhythmias
• Also used in recurrent symptomatic arrhythmias
Use of Antiarrhythmic Drugs
• Persistent/recurrent ventricular tachycardia
• Recurrent atrial fibrillation
Rapid Atrial Fibrillation

Mechanisms
• All drugs slow cardiac electrical activity
• Class I drugs → Block Na channel
• Class III drugs → Block K channels
• Class II, IV: Slow sinus and AV node conduction
Class I, III BB, CCB

(Class II, IV)
Phase 1
IK+ (out) Phase 2
0mv
Phase 3
Phase 0 IK+ (out)
INa+ (in)
-85mv
Phase 4
Na Channel Blockade
Slow Phase 0
Q S
Prolong QRS
K Channel Blockade
Prolonged Repolarization
Prolong QT
0mv
ERP
-85mv
AP
Class I drugs
• Block sodium channels → prolong QRS
• Some also affect K+ channels → prolong Qt
• Can prolong action potential duration
• Can prolong effective refractory period
Class I drugs
Effects on Resting Action Potential
Ia Ib Ic
↑QRS ↑QT +/-QRS ↓ QT ↑ QRS +/-QT
↑AP ↑ERP ↓AP ↓ ERP +/-AP

Class Ia Drugs
Quinidine, procainamide
• Prolong QRS
• Can also prolong Qt (↓K+ outflow)
• Quinidine
• Oral drug
• Can decrease recurrence rate of atrial fibrillation
• Associated with increased mortality
• Procainamide
• Intravenous drug
• Slows conduction in accessory pathways (WPW)
• Used in arrhythmias associated with bypass tracts
Procainamide
• Associated with drug-induced lupus
• Classic drugs: INH, hydralazine, procainamide
• Often rash, arthritis, anemia
• Antinuclear antibody (ANA) can be positive
• Key features: anti-histone antibodies
• Resolves on stopping the drug
Class Ib Drugs
Lidocaine, Mexiletine
• Little/no effect on QRS at normal HR

• Slight decrease in Qt interval (minimal)
• Least effect on action potential of class 1 drugs
Class Ib Drugs
• Most Na channel binding in depolarized state

• Ischemia → more depolarized myocytes
• Effective drugs in ischemic arrhythmias
Most Na channel block here

(depolarized state)
0mv
ERP
-85mv
Phase 4
Class Ib Drugs
• Drug rapidly unbinds

• Slow heart rates: little drug effect by next heart beat
• More effective in fast heart rates
• Less time to unbind before Na channels open again
• Main use: ischemic ventricular tachycardia
• Fast heart rates
• Depolarized Na channels
Class Ib Drugs
• Lidocaine also a local anesthetic

• Na channel nerve block
• May cause CNS stimulation
• Tremor, agitation
• Tremor in patient on Mexiletine = toxicity
• Cardiovascular side effects
• From excessive block of Na channels
• Bradycardia, heart block, hypotension
Class Ic Drugs
Flecainide, Propafenone
• Block open Na channels

• Very slow unbinding
• Result: QRS can markedly prolong
• Limited use due to concern of toxicity
• Especially proarrhythmic effects
CAST Trial
The Cardiac Arrhythmia Suppression Trial
• Landmark clinical trial of antiarrhythmic drugs

• Tested the suppression hypothesis
• Suppression of arrhythmias with drugs is a good thing
• Patients with asymptomatic arrhythmias after MI
• Encainide and flecainide administered
• Patients taking drugs had less arrhythmias
• Also: 3.6-fold increased risk of arrhythmic death
• Result: Major ↓ antiarrhythmic drugs
• Now used only with compelling indication
Class Ic Drugs
Flecainide, Propafenone
• Only used in patients with structurally normal hearts

• Effective in reducing recurrence of atrial fibrillation
• Must monitor for QRS prolongation
• Prolonged QRS → Risk of cardiac arrest
Use Dependence
• Na channels fluctuate between 3 different states
• Resting, Open and Inactivated
• Drugs bind more in certain states
• Class I drugs bind best in open/inactivate states
• States when Na channel is in “use”
• These drug exhibit “use dependence”
Inactive
Open
Resting
Use Dependence
3 Seconds
Bradycardia
Na Channels Na Channels
Open/Inactive 3 Seconds Resting
Tachycardia
Use Dependence
• Use dependent drugs: more binding fast heart rates
• All class I drugs have some use dependence
• Seen most frequently IC drugs
• Practical implication:
• Flecainide and propafenone (IC drugs)
• Marked use dependence
• Toxicity (QRS prolongation) at high heart rates
• Stress testing often done to screen for toxicity
Class III drugs
Amiodarone, Sotalol, Dofetilide, Ibutilide
Delayed Repolarization
K+ Channel Blockade
+/-QRS ↑QT
↑AP ↑ERP
Torsade de Pointes IA
• Feared outcome of Qt prolongation

• Results in cardiac arrest
• Class IA, III drugs prolong Qt III
Amiodarone
• Class III drug
• K channel blocker: Prolongs Qt interval
• Lowest incidence TDP of all class IIIs
• Also has class I, II, and IV effects
• Class I: Prolongs QRS
• Class II, IV: Slow HR, delay AV conduction
• Very effective drug
• Suppresses atrial fibrillation
• Suppresses ventricular tachycardia
Amiodarone
• Highly lipid soluble
• Accumulates in liver, lungs, skin, other tissues
• Half-life about 58 days
• Once steady state reached, very long washout
• Safe in renal disease (biliary excretion)
Amiodarone
• Many potential side effects related to accumulation
• Less likely at lower dosages
• Risk accumulates over time
• Young patients on indefinite therapy at greatest risk
• Often used in older patients
Amiodarone
Side Effects
• Hyper and hypothyroidism

• Contains iodine
• Increased LFTs
• Usually asymptomatic and mild
• Drug stopped if elevation is marked
• Skin sensitivity to sun
• Patients easily sunburn
Amiodarone
Side Effects
• Blue-gray discoloration
• Less common skin reaction
• “Blue man syndrome”
• Most prominent on face
• Corneal deposits
• Secretion of amiodarone by lacrimal glands
• Accumulation on corneal surface
• Appearance of “cat whiskers” on cornea
• Does not usually cause vision problems
• See in many patients on chronic therapy
Amiodarone
Side Effects
• Pulmonary fibrosis
• Most common cause of death from amiodarone
• Foamy macrophages seen in air spaces
• Filled with amiodarone and phospholipids
• “Honeycombing” pattern on chest x-ray
Amiodarone
Side Effects
• When starting amiodarone

• Chest X-ray
• Pulmonary function tests (PFTs)
• Thyroid function tests (TFTs)
• Liver function tests (LFTs)
Sotalol and Dofetilide
• Both drugs block K channels (class III)
• Can prolong Qt interval → torsade de pointes
• Practical consideration:
• Patients often admitted to hospital to start therapy
• Rhythm monitored on telemetry
• Qt segment checked by EKG each day
• Sotalol: Also has beta blocking properties
• Can be used in patients with cardiomyopathy
• “Reverse use dependence”
Reverse Use Dependence
• K channels also fluctuate between 3 different states
• Class III drugs bind best in resting state
• These drug exhibit “reverse use dependence”
Reverse Use Dependence
3 Seconds
Bradycardia K Channels
K Channels Open/Inactive
Resting 3 Seconds
Tachycardia
• Reverse use dependence: more binding slow rates
• Practical implication:
• Bradycardia in patient on sotalol/dofetilide
• Qt interval may prolong
• Increased risk of torsade de pointes
• Commonly used in patients with atrial fibrillation
• Typical case
• Recurrent episodes symptomatic atrial fibrillation
• Sotalol/Dofetilide started
• Cardioversion to restore sinus rhythm
• Sinus rhythm persists on therapy
• Other antiarrhythmic also used in this manner
• Amiodarone
• Propafenone
• Flecainide
Ibutilide
• Intravenous drug
• Half life of 2 to 12 hours
• Used for “chemical cardioversion”
Cardioversion
• Termination of arrhythmias
• Often atrial fibrillation or flutter
Ibutilide
Chemical Cardioversion
Electrical Cardioversion No sedation
Requires sedation May cause Torsade
Beta Blockers
Class II Antiarrhythmics
• Main effect: Pacemaker cells (SA and AV node)

• Decrease slope of phase 4
• Prolong repolarization (phase 3)
0mv
Phase 0
Phase 3
ICa
Threshold IK
-40mv
Phase 4
-85mv If (Na)
Beta Blockers
Class II Antiarrhythmics
↓HR
↓Cond Velocity
↑PR Interval
Verapamil and Diltiazem
• Block calcium channels

• Slow heart rate
0mv
Phase 0
Phase 3
ICa
Threshold IK
-40mv
Phase 4
-85mv If (Na)
Verapamil and Diltiazem
Normal ↓HR
Ca Blocker ↓Cond Velocity
↑PR Interval
Decreased Slope
Slower Rise
AV Block
• Beta blockers/Ca channel blockers → ↓ AV conduction
Type 1 AV block
Wenckebach (Mobitz I)
Atrial Fibrillation
• Beta blockers and CCBs commonly used
• Control ventricular rate
Atrial Fibrillation with rapid ventricular response
Rate controlled with beta blocker or CCB

Sudden Cardiac Death
• Increased risk among systolic heart failure patients
• Lower rates among patients on beta blockers
• Improved mortality
Ventricular Fibrillation
Adenosine
• Nucleoside base
• Used to make ATP
• Receptors in many locations (purinergic receptors)
• AV nodal tissue
• Vascular smooth muscle
Adenosine
Triphosphate
Adenosine
• AV nodal cells:
• Activates K+ channels
• Drives K+ out of cells
• Hyperpolarizes cells: Takes longer to depolarize
• Also blocks Ca influx
• Result: Slowing of conduction through AV node
Adenosine
• Short half life
• Given IV for acute therapy of SVT
• Slows AV node conduction
Narrow Complex
Originates above HIS bundle
Adenosine
• Most common SVT: AVNRT
• AV node reentrant tachycardia
• Slow and fast circuits in AV node → arrhythmia
• Adenosine slows AV node conduction
• Arrhythmia with terminate
Adenosine
Adenosine
• Effects blocked by theophylline and caffeine
• Block adenosine receptors
Adenosine Caffeine Theophylline

Adenosine
• Also a vasodilator
• Causes skin flushing, hypotension
• Some patients also develop dyspnea, chest pain
• Effects quickly resolve
• Must warn patients before administration for SVT
Jorge González/Flikr
Magnesium
• Acute management of torsade de pointes
• Mg blocks influx of Ca into cells
• Ca influx leads to early afterdepolarizations
Phase 1
IK+ (out) Phase 2
0mv 0mv
Phase 3
Phase 0 IK+ (out)
INa+ (in)
ERP
-85mv
Phase 4
Atropine
• Muscarinic receptor antagonist
• Parasympathetic block → ↑ HR and AV conduction
• Used in bradycardia → ↑ heart rate
• Also speeds conduction through AV node
• Useful for bradycardia especially from AV block
Atropine
Before Atropine
After Atropine
Atropine
• May side effects related to muscarinic block
• Toxicity:
• Dry mouth
• Constipation
• Urinary retention
• Confusion (elderly)
Digoxin
• Two cardiac effects
• #1: Increases contractility
• Used in systolic heart failure with ↓ LVEF
• #2: Slows AV node conduction
• Used in atrial fibrillation to slow ventricular rate
Digoxin
Increased Contractility
• Inhibits Na-K-ATPase
DIGOXIN
X K+
2 1
Ca+ Na+ ATP

Digoxin → Na trapped inside of cell
Less Na exchange for Ca (pump 2)
Result: More Ca inside of cell
Digoxin
AV Nodal Slowing
• Suppresses AV node conduction

• Increased vagal (parasympathetic) tone
• Separate effect from blockade of Na-K-ATPase
• Can be used to ↓ heart rate in rapid atrial fibrillation
• Continued atrial fibrillation
• Fewer impulses to ventricle → slower heart rate
• Effects similar to BB and CCB in AV node
Digoxin Toxicity
• Renal clearance
• Risk of toxicity in patients with chronic kidney disease
• Hypokalemia promotes toxicity
• Caused by many diuretics, especially loop diuretics
• Digoxin patient on furosemide → toxicity
• Levels often need to be monitored
Digoxin Toxicity
• Gastrointestinal
• Anorexia, nausea, vomiting, abdominal pain
• Neurologic
• Lethargy, fatigue
• Delirium, confusion, disorientation
• Weakness
• Visual changes
• Alterations in color vision, scotomas, blindness
• Cardiac arrhythmias
Digoxin Toxicity
Cardiac Toxicity
• More Na inside of cell

• ↑ resting potential atrial/ventricular cells
• Increased automaticity
• Dig toxic rhythms:
• Extra beats: atrial, junctional, ventricular
• Evidence of AV node block
Digoxin Toxicity
Treatment
• Digibind
• Digoxin antigen binding fragments (Fab)
• Produced in animals (sheep)
• Dig bound to albumin (hapten) → antibodies
• Antibody converted to fragments
• Corrects hyperkalemia, symptoms
Heart Murmurs
Jason Ryan, MD, MPH
Heart Murmurs
• Cardiac sound heard with stethoscope
• Caused by turbulent blood flow
• May be normal or pathologic
Laminar vs. Turbulent Flow
Laminar Flow = Quiet(er)
Turbulent Flow = Loud

High Flow Rates
Narrow Flow Areas
Murmurs
Grading
• I - barely audible on listening carefully

• II - faint but easily audible
• III - loud and easily audible, no thrill
• IV - loud murmur with a thrill
• V –heard with scope barely touching chest
• VI - audible with scope not touching the chest
Murmurs
Other Descriptors
Systole Diastole Systole
S1 S2 S1 S2
Holosystolic
Pansystolic Crescendo Decrescendo Crescendo-
decrescendo
Murmurs
Location LUSB
Pulmonic Murmurs
RUSB PDA
Aortic Stenosis
A P
LSB
Aortic Regurg T Apex
M Mitral Murmurs
HCM
LLSB
Tricuspid Murmurs
VSD
Murmurs
Location
• Point of maximal impulse (apical impulse)

• Left 5th intercostal space
• Mid-clavicular line
• Lateral shift = Enlarged heart
• Hyperdynamic
Base
Apex
Innocent/Functional Murmurs
• Caused by normal flow of blood
• Common in children
• Also young, thin patients
• Generally soft murmurs
• No signs/symptoms of heart disease
• Stills murmur
• Pulmonic flow murmur
• Venous hum
Systolic Murmurs
• Occur when heart contracts/squeezes
• Between S1-S2
• Aortic stenosis
• Pulmonic stenosis
• Hypertrophic cardiomyopathy
• Ventricular septal defect (VSD)
Diastolic Murmurs
• Occur when heart relaxes/fills
• Between S2-S1
• Mitral stenosis
• Pulmonic regurgitation
Aortic Stenosis
Murmur
• Systolic crescendo-decrescendo murmur

• Also called an “ejection murmur”
S1 S2
Aortic Stenosis
Severe Disease Findings
• Late-peaking murmur
• Slow flow across stenotic valve
• Soft/quiet S2
• Stiff valve can’t slam shut
• Pulsus parvus et tardus
• Weak and small carotid pulses
• Delayed carotid upstroke
HCM
Hypertrophic Cardiomyopathy
• Same murmur as aortic stenosis

• Differentiated by maneuvers
• Valsalva
• Decreases venous return/preload
• Increase HCM murmur
• Decrease AS murmur
HCM
Murmur
• Decrescendo, blowing diastolic murmur
S1 S2
• Holosystolic murmur heard best at the apex
• 5th intercostal space, mid-clavicular line
S1 S2
Holosystolic
(Pansystolic)
Mitral Stenosis
• Diastolic rumbling murmur
• Preceded by opening snap
Systole Diastole Systole Diastole
Diastolic Rumble
S1 S2 OS (Murmur)
Mitral Stenosis
• No left sided S3, S4 in mitral stenosis
• Time to opening snap associated with severity
• High left atrial pressure in severe disease
• Higher left atrial pressure → ↓ time to opening snap
• Short time to opening snap seen in severe disease
Tricuspid/Pulmonic Disease
• Valve lesions sound like left sided-counterparts
• Heard in different locations
• Left upper sternal border
• Pulmonic stenosis/regurgitation
• Left lower sternal border
• Tricuspid stenosis/regurgitation
Carvallo’s Sign
• Most right sided murmurs louder with inspiration
• Inspiration draws blood volume to lungs
• Louder right sided murmurs
• Softer left sided murmurs
• rIght sided murmurs increase with Inspiration
• lEft sided murmurs increase with Exhalation
VSD
Ventricular Septal Defect
• Holosystolic murmur similar to MR

• Small VSD → more turbulence → loud murmur
3 Causes Holosytolic Murmurs

Tricuspid Regurgitation
VSD
S1 S2
Holosystolic
(Pansystolic)
PDA
Patent Ductus Arteriosus
• Continuous, “machine-like” murmur
S1 S2 S1 S2
Maneuvers
• Performed at bedside with patient
• May increase or decrease murmur
• Used to make diagnosis
Davidjr74/Wikipedia
Maneuvers
Preload/Venous Return
• Increase preload/venous return

• Leg raise – blood falls back toward heart
• Squatting – blood in legs forced back toward heart
• Decrease preload/venous return
• Valsalva- ↑ intra-thoracic pressure→ vein compression →↓ VR
• Standing – Blood falls toward feet, away from heart
• Most murmurs INCREASE with more preload except:
• HCM
• MVP
Valsalva Maneuver
• Bear down as if moving bowels
• Phase I (few seconds)
• ↑ thoracic pressure
• ↓ venous return (compression of veins → ↑RA pressure)
• Transient rise in aortic pressure (compression)
• ↓ heart rate and AV node conduction (baroreceptors)
• Phase II
• ↓ preload → ↓ cardiac output
• ↑ heart rate and AV node conduction (baroreceptors)
Maneuvers
Afterload
• Increase Afterload
• Hand grip - clench fist
• Decrease Afterload
• Amyl Nitrate - vasodilator
Amyl Nitrate
Maneuvers
Afterload
• Backward Valve Disorders

• AR, MR, VSD
• Louder with more afterload
• More force pushing blood backward
• Forward Valve Disorders
• MS, AS
• Softer with more afterload
• Less pressure difference moving blood forward
• MVP, HCM
• Softer
• Increased LV cavity size
Clues to Diagnosis
• Young female, otherwise healthy → MVP
• Healthy, young athlete, syncope → HCM
• Immigrant or pregnant → Mitral stenosis
• IV drug abuser → Tricuspid regurgitation
• Turner Syndrome or Aortic Coarctation
• Bicuspid AV
• Early stenosis
• Marfan → MVP
Summary
Commonly Tested Murmurs
S1 S2 S1 S2
AS/HCM
MR/VSD
AR
MS
PDA
Heart Sounds
Jason Ryan, MD, MPH
The Cardiac Cycle
Aorta
LV
LA
LV Volume
S1
Heart Sounds
S2
Venous Pressure
EKG
S1 and S2
• Normal heart sounds
• Each has two components
• One from left sided valves (aortic, mitral)
• One from right sided valves (tricuspid, pulmonic)
• S1 usually “single”
• Two components close together
• Cannot distinguish separate sounds
• S2 can be “split”
• Two components far enough apart to be audible
S1 and S2
• S1
• Mitral and tricuspid valves close
• S2
• Aortic and pulmonary valves close
MV TV AV PV MV TV AV PV
S1 S2 S1 S2
Physiologic S2 splitting
S1 S2
Exhalation
MV TV AV PV
S1 S2
Inspiration
MV TV AV PV
Increased venous return delays P2 by 40-60ms

Single to split with inspiration
Persistent S2 splitting
RBBB or Pulmonary Hypertension
S1 S2
Exhalation
PeRsistent = Right sided delay
MV TV AV PV
S1 S2
Inspiration
AV PV
MV TV
Delayed PV closure even during exhalation
Fixed S2 splitting
Atrial septal defect
S1 S2 Atrial Septal Defect
Fixed split S2
Systolic Ejection Murmur LSB
Exhalation
MV TV AV PV
S1 S2
Inspiration
AV PV
MV TV
Flow across ASD → increased right sided flow

Paradoxical S2 splitting
Delayed closure of aortic valve
S1 S2
Exhalation
MV TV PV AV
S1 S2
Inspiration
MV TV PV AV
Paradoxical Splitting
• Electrical causes → delayed LV activation
• LBBB
• RV pacing
• Mechanical causes → delayed LV outflow
• LV systolic failure
• Aortic stenosis
ParodoxicaL = Left sided delay

Summary of S2 Splitting
• Physiologic = normal respiratory variation
• PeRsistent = RBBB, pulmonary HTN
• Fixed = Atrial septal defect
• ParadoxicaL = LBBB, cardiomyopathy
Cardiac Phonography
S1, S2
Fixed Split S2
Loud P2
• Loud pulmonic component of S2
• Pulmonary hypertension
• Forceful closure of pulmonary valve
• Normally P2 not heard at apex
• If you hear it here, it’s “loud”
S3 and S4
• Pathologic/abnormal heart sounds
• Occur in diastole during filling of left ventricle
• Low-pitched sounds heard best with bell
• S3: Early filling sound
• S4: Late filling sound
S1 S2
S4 S1 S2 S3
Tama988/Wikipedia
S3
• Commonly seen in acute heart failure
• High LA pressure → rapid early filling of LV → S3
• Associated with ↑ LAP & ↑LVEDP
• “Pushers” → push blood into LV
• Very specific sign of high left atrial pressure
• May be heard in normal hearts
• Young patients (<30), pregnant women
• These patients are “suckers”
• Vigorous LV relaxation lowers pressure rapidly
S3
• Low frequency best heard with bell
• Louder in left lateral decubitus position
• Loudest at apex
Rama/Wikipedia
S4
• Heard in patients with stiff left ventricle
• Long-standing hypertension
• Diastolic heart failure
• Rapid late filling of LV due to atrial kick
• Not heard in atrial fibrillation
Atrial Fibrillation
Right Sided S3 & S4
• Both sounds can occur in right ventricle
• Same mechanisms as left sounds
• Right heart failure → right sided S3
• Right ventricular hypertrophy → right sided S4
Systolic Clicks
Click Click
S1 S2 S1 S2
Ejection Click Non-Ejection Click

Early in systole Late in systole
BEFORE carotid pulse AFTER carotid pulse
Bicuspid Aortic Valve Mitral Valve Prolapse
Mitral Valve Prolapse
• Billowing of mitral valve leaflets above annulus
• Common cause of mitral regurgitation
• Causes a systolic click
• Don’t confuse with opening snap of mitral stenosis
Mitral Valve Disorders

Proclick
Stenosnap Normal
MVP
Mitral Valve Prolapse
Systole
Diastole
Click
S1 Murmur S2
Heart Failure Basics
Jason Ryan, MD, MPH
Heart Failure
• Impaired ability of the heart to pump blood
• Hallmark: Low cardiac output
↓ CO
Heart Failure
Tank
H20
Tank
Pump
Heart Failure
Tank
H20
Tank
Pump
Heart Failure
Tank
H20
Tank
Pump
Heart Failure
Tank
H20
Tank
Heart
Heart Failure
Tank
Blood
Tank
Heart
Heart Failure
Tank
Blood
Tank
Heart
Heart Failure
Lungs
&
Veins
Heart
Heart Failure
Pathophysiology
• “Failing” chambers → Increased pressures

• Pressures rise in cardiac chambers
Heart Failure
Pathophysiology
• Left ventricular failure → ↑ LV pressure

• LV systolic pressure: depends on contractility (can be low)
• LVEDP = always high in left heart failure
• Hallmark of left heart failure
• Less blood pumped out → more left behind → more pressure
• Stiff ventricle (diastolic HF) → high pressure
Heart Failure
Pathophysiology
• ↑ LVEDP → ↑ LA pressure
• ↑ pulmonary capillary pressure
• Dyspnea
• Pulmonary edema
Aorta
LV
LA
Heart Failure
Pathophysiology
↑Pc
Heart Failure
Pathophysiology
• ↑ pulmonary capillary pressure → ↑ PA pressure

• ↑ PA pressure → ↑ RV pressure
• ↑ RV pressure → ↑ RA pressure
• Right atrial pressure = central venous pressure
• High pressure in venous system
• ↑ jugular venous pressure (neck veins)
• Capillary leak → pitting edema
Heart Failure
Signs/Symptoms
• Physiologic effects of lying flat (supine)

• Increased venous return
• Redistribution of blood volume
• From lower extremities and splanchnic beds to lungs
• Little effect in normal individuals
• Impaired ventricle cannot tolerate changes
• Worsens pulmonary congestion and breathing
Heart Failure
Signs/Symptoms
• Left heart failure

• Dyspnea especially on exertion
• Paroxysmal nocturnal dyspnea (wake up SOB)
• Orthopnea (can’t breathe lying flat)
• Right heart failure
• Increased jugular venous pressure
• Lower extremity edema
• Liver congestion (rarely can cause cirrhosis)
• “Backward failure”
Heart Failure
Right Heart Failure
• Most common cause R heart failure: Left heart failure

• Occasionally right heart failure occurs in isolation
• Normal left atrial pressure
• High pulmonary artery, right ventricular, right atrial pressure
• Usually secondary to a lung process
• COPD
. • This is often called “cor pulmonale”
Heart Failure
Signs/Symptoms
• Low flow signs/symptoms (“forward failure”)

• Loss of appetite
• Weight loss (cachexia)
• Confusion
• Cool extremities
• “Narrow pulse pressure”
• Seen only with very low cardiac output (systolic HF)
• Not seen in diastolic heart failure
Heart Failure
Lung Findings
• Classic finding is rales

• Fluid filled alveoli “pop” open with inspiration
• Chest X-ray shows congestion
• Lungs/CXR can be clear in chronic heart failure
• ↑lymphatic drainage
Heart Failure
Lung Findings
• Heart failure cells

• Hemosiderin (iron) laden macrophages
• Brown pigment in macrophages
Zorkun/Wikipedia
Heart Failure
Signs/Symptoms
• Elevated jugular venous pressure (normal 6-8cmH2O)
• Look for height of double bounce (cause by a and v waves)
Heart Failure
Hepatojugular Reflux
• Pressure on abdomen raises JVP 1-3cm normally

• With failing RV, increase is greater
Heart Failure
Signs/Symptoms
• Lower extremity pitting edema

• Increased capillary hydrostatic pressure
• Fluid leak from capillaries → tissues
• Gravity pulls fluid to lower extremities
↑Pc
James Heilman, MD
Heart Failure
Abnormal Heart Sounds
• S3 (associated with high left atrial pressure)

• S4 (associated with stiff left ventricle)
• Displaced apical impulse – enlarged heart
S1 S2
S4 S1 S2 S3
Heart Failure
Pathophysiology
• All forms of heart failure lead to ↓ cardiac output

• Activates two physiologic systems
• Activation of sympathetic nervous system
• Activation of renin-angiotensin-aldosterone system
• All RAAS hormone levels will rise
• Both systems lead to two key effects:
• Increased peripheral vascular resistance (vasoconstriction)
• Retention of sodium/water (kidneys)
Heart Failure
• Cardiac output falls → vasoconstriction

• Angiotensin II, sympathetic nervous system
• TPR always high
• Blood pressure often high but may be low
• Depends on combined changes CO and TPR
BP = CO X TPR
Heart Failure
Sodium/Water Retention
↓ cardiac
output
↓ Effective Circulating
Volume
↑ RAAS ↑ SNS ↑ ADH
↑ Na/H2O
↑ Total Body
Water
Heart Failure
Other Hormones
• ANP (Atrial natriuretic peptide)

• Atrial stretch (pressure/volume) → ANP release
• Vasodilator (↓TPR)
• Constricts renal efferents/dilates afferents
• ↑ diuresis
• Opposite effects of RAAS system
Afferent Efferent
Heart Failure
Other Hormones
• ANP released by atrial myocytes

• BNP (brain natriuretic peptide): Ventricles
• Both rise with volume/pressure overload
• Both counter effects of RAAS system
• BNP sometimes used for diagnosis in dyspnea
• High levels suggest heart failure
• Low levels suggest other causes of dyspnea
ANP/BNP
RAAS
Nesiritide
• Recombinant BNP
• Vasodilation
• ↓ afterload, ↑CO
• Failed to show benefit in clinical trials
Heart Failure
Diagnosis
• Most common: typical signs/symptoms

• Elevated BNP level
• Heart catheterization
• Increased LVEDP = left heart congestion/failure
• Increased RA, RVEDP = right heart congestion/failure
BruceBlaus
Systolic and Diastolic
Heart Failure
Jason Ryan, MD, MPH
Heart Failure
Systolic Heart Failure Diastolic Heart Failure
Ejection fraction is reduced EF is normal (55-65%)

Heart Failure
• Same congestive signs/symptoms

• Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
• Rales, ↑ JVP, pitting edema
• Exception: Low flow symptoms in systolic only
• Cool extremities
• Cachexia
• Confusion
Dilated Cardiomyopathy
• Systolic heart failure with LV cavity dilation
• “Eccentric” hypertrophy
• Volume overload (chronic retention of fluid in cavity)
• Longer myocytes
• Sarcomeres added in series
Normal
LV Size Dilated LV Increased myocyte size
Sarcomeres in series
Normal wall thickness
• Pressure overload
• Chronic ↑↑ pressure in ventricle: HTN, Aortic stenosis
• Decreased compliance (stiff ventricle)
• Often seen in diastolic heart failure
Normal
↓ LV Size Increased myocyte size
LV Size Sarcomeres in parallel
Increased wall thickness
LV Pressure
LV Pressure
LV Vol LV Vol
Systolic Heart Failure Diastolic Heart Failure

↓ Contractility ↓ LV Compliance
↓ Lusitropy
Systolic Heart Failure
• ↓ Cardiac output
• Problem in SYSTOLE
• Can’t get blood out
LV Pressure
• ↓ Stroke volume
• SV = EDV – ESV
• ↑ ↑ ESV (↓ contractility)
• ↑ EDV (↑ESV + VR)
• ↑ LVEDP
LV Vol

↓ Contractility
Normal
Stroke ↓ Contractility
Volume
Preload (LVEDV)
Diastolic Heart Failure
• ↓ Cardiac output
• Problem in DIASTOLE
• Can’t get blood in
LV Pressure
• Small ↓ stroke volume
• ↓ EDV (↓ filling)
• ↑↑ LVEDP (stiff ventricle)
LV Vol
↓ LV Compliance
↓ Lusitropy
Systolic vs. Diastolic
Normal Systolic/Dilated Diastolic

EDV 100 200 90
ESV 40 160 40
SV/CO 60 40 50
EF % 60 20 56
• Most common cause: Myocardial infarction
• Myocytes replaced by scar tissue
• “Ischemic” cardiomyopathy
• Many causes of “non-ischemic” cardiomyopathy
• About 50% idiopathic
• Many other causes: viral, familial, peri-partum, chemotherapy
toxicity, HIV, alcoholic, sarcoidosis, tachycardia-mediated
• Exact cause unknown
• Many cases have concentric hypertrophy
• Many associated conditions
• Age, diabetes, hypertension
• Terms:
• Heart failure preserved EF
• HFpEF
• Diastolic dysfunction
Nonischemic Cardiomyopathy
Viral
• May follow upper respiratory infection

• Many associated viruses
• Coxsackie
• Influenza, adenovirus, others
• Virus enters myocytes
• Causes myocarditis → cardiomyopathy
• Myocarditis phase may go undiagnosed Pixabay/Public Domain
• No specific therapy for virus

Peri-partum
• Late in pregnancy or early post-pregnancy

• Exact cause unknown (likely multifactorial)
• Women often advised to avoid future pregnancy
Øyvind Holmstad/Wikipedia
Chemotherapy
• Usually after treatment with anthracyclines

• Antitumor antibiotics
• Doxorubicin and daunorubicin
Daunorubicin Doxorubicin
(Adriamycin)
Familial
• Mutations
• Often sarcomere proteins
• Beta myosin heavy chain
• Alpha myosin heavy chain
• Troponin
• Many autosomal dominant
• X-linked, autosomal recessive also described
Tachycardia-mediated
• Constant, rapid heart rate for weeks/months

• Leads to depression of LV systolic function
• Reversible with slower heart rate
Takotsubo/Apical ballooning
• Stress-induced cardiomyopathy
• Occurs after severe emotional distress
• Markedly reduced LVEF
• Increase CK, MB, Troponin; EKG changes
• Looks like anterior MI (but no coronary disease)
• Usually recovers 4-6 weeks
Jheuser/Wikipedia
Alcohol
• Chronic consumption can cause cardiomyopathy
• Believed to be due to toxic metabolites
• Can recover with cessation of alcohol
High Output Heart Failure
• Heart in overdrive
• Severe anemia
• Thyroid disease
John Liu/Flikr
• Thiamine (B1) vitamin deficiency (beriberi)
• A-V fistulas (post-surgical)
• Exact mechanism unclear
• Decreased LV filling time
• Defining characteristic: HIGH cardiac output
• Heart failure symptoms in absence of low output
• ↑JVP, pulmonary edema
Restrictive
Cardiomyopathy
Jason Ryan, MD, MPH
Restrictive Heart Disease
• Something “infiltrates” the myocardium
• Granulomas (Sarcoid)
• Amyloid protein (Amyloidosis)
• Heart cannot relax and fill
• SEVERE diastolic dysfunction
MarkBuckawicki/Wikipedia
• LVEF = normal
• Left ventricular volume = normal (not dilated)
• Restricted filling = ↑ atrial pressure
• Dilated left and right atria
• Classic imaging findings:
• Normal left ventricular function/size
• Bi-atrial enlargement
Clinical Features
• Dyspnea
• Prominent right heart failure
• Markedly elevated jugular venous pressure
• Liver congestion
• May lead to cirrhosis (“nutmeg liver”)
David Monniaux/Wikipedia
Classic signs
• Kussmaul’s sign
• Inspiration causes rise in JVP
Rhythm Disturbances
• Myocardial infiltration may disrupt electrical activity

• Arrhythmias (sudden death)
• AV block
Ventricular Tachycardia 3rd Degree Heart Block

Major Causes
• Amyloidosis
• Amyloid protein deposits in heart
• Various forms (primary, secondary, etc.)
Ed Uthman, MD
Classic signs
• Can see thickened myocardium

• Low voltage on EKG
• Classic finding in amyloidosis and Fabry’s disease
Major Causes
• Sarcoidosis
• Granuloma formation
• Usually involves lungs
• Extra-pulmonary organs include heart
Major Causes
• Fabry disease
• Lysosomal storage disease
• Deficiency of α-galactosidase A
• Accumulation of ceramide trihexoside
Mediran/Wikipedia
Major Causes
• Hemochromatosis
• Iron excess
• Commonly causes dilated cardiomyopathy
• Rarely may cause restrictive
Tomihahndorf
Major Causes
• Post-radiation
• Acutely: May cause inflammation
• Fibroblast recruitment
• Extra-cellar matrix deposition
• Collagens and fibronectin
Dina Wakulchik/Wikipedia
Major Causes
• Pericarditis may occur acutely after therapy

• Long term effects
• Pericardial disease
• Coronary artery disease
• Valvular disease
• Conduction abnormalities
• Restrictive cardiomyopathy
• Fibrous tissue accumulation
Major Causes
• Loeffler’s syndrome
• Hypereosinophilic syndrome
• High eosinophil count
• Eosinophilic infiltration of organs Bobjgalindo/Wikipedia
• Skin (eczema)
• Lungs (fibrosis)
Major Causes
• Primary HES
• Neoplastic disorder
• Stem cell, myeloid, or eosinophilic neoplasm
• Secondary HES Bobjgalindo/Wikipedia
• Reactive process
• Eosinophilic overproduction due to cytokines
• Occurs in parasitic infections (ascaris lumbricoides)
• Some tumors/lymphomas
• Idiopathic HES
Major Causes
• Eosinophilic infiltration of myocardium

• Common mode of death
• Acute phase
• Myocarditis (often asymptomatic) Bobjgalindo/Wikipedia
• Chronic phase
• Endomyocardial fibrosis and myocyte death
• Can see restrictive heart disease
• Thrombus formation common (embolic stroke)
Major Causes
• Endocardial fibroelastosis
• Endocardial thickening (innermost myocardium)
• Infants in first year of life
• Thick myocardium
• Proliferation of fibrous (collagen) and elastic fibers
Avsar Aras
Acute Heart Failure
Jason Ryan, MD, MPH
Heart Failure
Acute vs. Chronic
Acute Chronic
• Congested/Swollen • Euvolemic
• Pulmonary Edema • Clear lungs
• Pitting Edema • No pitting edema
• ↑JVP • JVP flat
Acute Exacerbations
Causes
• #1: Dietary indiscretion

• High salt intake
• #2: Poor medication compliance
LukeB20161933/Wikipedia Pixabay/Public Domain

Dietary Indiscretion
↑Na Intake
Plasma Na = 140meq/L
↑Plasma
Osmolarity
↑ADH
↑Free Water ↑Volume
Normal ↓RAAS
Plasma [Na] ↓ADH
↑Urine
Output
Acute Exacerbations
Causes
• Infection/trauma/surgery
• Ischemia (rare)
• Decreased cardiac output
• NSAIDs
• Inhibit cyclooxygenase (COX) → ↓ prostaglandins
• Prostaglandins maintain renal perfusion
• Result: Less renal perfusion → salt/water retention
Acute Heart Failure Therapy
• Often treated in the hospital
• Goal: Symptom relief
• Contrast with chronic HF: reduce mortality/hospitalizations
• Often same therapies for diastolic versus systolic
Loop Diuretics
Na
2Cl
Ascending Limb
Loop Diuretics
Loop Diuretics
Furosemide, Bumetanide, Torsemide, Ethacrynic Acid
• Inhibit Na-K-Cl pump in ascending loop of Henle

• Result in salt-water excretion
• Relieve congestion
• IV better than PO (gut is swollen)
• Key side effects
• Hypokalemia
• Volume depletion (Renal failure; hypotension)
• Sulfonamide drugs: allergy (except ethacrynic acid)
Metolazone
• Thiazide-like diuretic
• Inhibits Na-Cl reabsorption distal tubule
• Gives loop diuretics a “kick”
• Vigorous diuresis
• Side effects: additional fluid, K+ loss
Nitrates
• Predominant mechanism is venous dilation
• Bigger veins hold more blood
• Takes blood away from left ventricle
• Lowers LVEDV (preload), LA pressure
• Less pulmonary edema → improved dyspnea
Nitrates
• Side effects
• Headache (meningeal vasodilation)
• Flushing
• Hypotension
Vasodilators
“Afterload reduction”
• ACE inhibitors
• Hydralazine
• Cause peripheral vasodilation
• Reduced afterload → increased cardiac output
Nitrates plus Hydralazine
• Combination therapy for acute and chronic HF
• Studied in systolic heart failure
• Reduction in preload (nitrates) and afterload (hydralazine)
• Acute therapy: Improves symptoms
• Chronic therapy: Lowers mortality in some studies
• Largely replaced by ACE inhibitors
• Some studies suggested benefit in black patients
Inotropes
• Increase contractility
• Only for systolic heart failure
• No role in diastolic heart failure (normal contractility)
• All activate β1 pathways in myocytes
• Increased HR and contractility
• Can also active β2 pathways in smooth muscle
• Vasodilation → hypotension
Inotropes
Milrinone
• Phosphodiesterase 3 inhibitor
• PD3 breaks down cAMP in myocyctes
• Inhibition → ↑cAMP → contraction
• Vascular smooth muscle ↑cAMP (β2) → dilation
• ↑Inotropy
• ↑Vasodilation
• Hypotension
β1
Contraction cAMP
PD3 AMP
Myocyte
Inotropes
Dobutamine
• Mostly beta-1 agonist

• Increases heart rate and contractility
• Weak beta-2 agonist
• Vasodilation
• ↑Inotropy
• ↑Vasodilation
• Hypotension
• Similar effects to milrinone β1
Contraction cAMP
PD3 AMP
Myocyte
Inotropes
Dopamine
• Does not cross blood brain barrier (no CNS effects)

• Peripheral effects highly dependent on dose
• Low dose: dopamine agonist
• Vasodilation in kidneys
• Medium dose: beta-1 agonist
• Increased heart rate and contractility
• High dose: alpha agonist
• Vasoconstriction
Inotropes
Epinephrine
• Also dose dependent effects

• Low dose: beta-1 and beta-2 agonist
• Increased heart rate & contractility, vasodilation
• High dose: alpha agonist
• Vasoconstriction
Inotrope Risks
• Numerous registries and clinical trials demonstrate
increased mortality with routine use of inotropes
• Dangerous drugs used in very sick patients under
monitored conditions
A Typical Acute
Heart Failure Course
• ER presentation:
• Dyspnea, edema, sleeping in chair
• Admitted to hospital
• Nitro drip to relieve dyspnea
• IV Furosemide to remove fluid
• Hospital Day 2
• Weight down 4kg, feels better
• Nitro drip stopped
• Changed to oral furosemide
• Hospital Day 3: Discharge
A More Complex
• ER presentation:
• Dyspnea, edema, sleeping in chair
• Known LVEF 10%
• Admitted to hospital
• Nitro drip to relieve dyspnea
• IV Furosemide to remove fluid
• Hospital Day 2
• Poor urine output, Cool extremities, Cr rises 1.1→1.4
• Dobutamine drip started
A More Complex
• Hospital Day 3-5
• Good urine output
• Weight loss 4kg
• Breathing improves
• Hospital Day 6
• Dobutamine stopped
• Furosemide drip stopped
• Hospital Day 7
• Oral furosemide given
• Hospital Day 8: Discharge
Heart Failure Readmission
• Recurrence of HF after discharge common
• Post-discharge follow-up VERY important
• “Readmissions” a focus of public health policy
• High risk of readmission within 30 days
• Highest risk category among Medicare population
Acute Heart Failure
• Most patients require chronic, daily diuretic
• Helps to maintain euvolemic status
• Often oral furosemide or other loop diuretic
• Some patients require daily long acting nitrate
• Often oral isosorbide mononitrate
Acute Heart Failure
• Rare patients: continued treatment for low output
• Systolic heart failure only
• Chronic, IV infusion inotrope (i.e. “home dobutamine”)
• Left ventricular assist device (LVAD)
• Heart transplant
Digoxin
• Only available oral inotrope
• “Dig and diuretic” once the mainstay of HF treatment
• What changed?
• Digoxin shown to have no mortality benefit
• Digoxin not effective for diastolic heart failure
• About 50% of all cases
• Digoxin carries significant risk of side effects
Digoxin Mechanism
Two important cardiac effects
• #1: Inhibits Na-K-ATPase pump

• More Na in cell → more Ca++ in cell
• More Ca++ → more contractility
• #2 Suppresses AV node conduction (parasympathetic)
• Can be used to slow heart rate in rapid atrial fibrillation
Digoxin
Benefits in Heart Failure
• Useful for systolic HF patients

• Symptoms despite maximal therapy on other drugs
• i.e. persistent dyspnea despite good volume status
• Can be administered for acute heart failure
• Can be administered long term to maintain CO
Digoxin
Benefits in Heart Failure
• Increased cardiac output

• Improved symptoms and quality of life
• No established mortality benefit
Chronic Heart
Failure
Jason Ryan, MD, MPH
Heart Failure Treatment
Pathway
Acute
Heart Failure Symptom Relief
Loop diuretics
Nitroglycerine
Rx Inotropes
Diastolic Chronic Systolic

Heart Failure Heart Failure Heart Failure
Chronic Heart Failure
• LOTS of therapies for systolic heart failure
• Drugs: ACE-inhibitors, beta blockers, aldosterone antagonists
• Defibrillators
• Bi-ventricular pacemakers
• NO direct therapies for diastolic heart failure
• Guidelines recommendations: treat HTN, diabetes, A. fib
• Mainstay of therapy: monitor for symptoms, diuretics
• Chronic over-activation of two physiologic systems
• Renin-angiotensin-aldosterone system
• Sympathetic nervous system (β1 stimulation)
• Blockade → ↓ mortality and disease progression
Renin-Angiotensin System
Angiotensinogen ARBs
Sympathetic System
+ Renin
Renal Na/Cl resorption
AI A2
+ ACE
Arteriolar vasoconstriction
ACE Inhibitors Adrenal aldosterone secretion
Net Result Pituitary ADH secretion

↑Salt/Water Retention
↑Preload
↑TPR
↑Afterload
RAAS Drugs
• ACE Inhibitors
• Captopril, Enalapril, Lisinopril, Ramipril
• Block conversion AI → AII
• Angiotensin Receptor Blockers (ARBs)
• Candesartan, Irbesartan, Valsartan
• Directly block AII receptor
• Both classes: ↓ morality, ↓ hospitalizations
• Side effects
• Hyperkalemia (↓aldosterone)
• Renal failure (↓GFR)
ACE Inhibitors
Unique Side Effects
• Due to increased bradykinin

• Dry Cough
• Occurs in ~10% of patients
• Angioedema
• Swelling of face, tongue
• Can be life-threatening
Bradykinin
Bradykinin Cough AI
Vasodilation
X X
ACE Inhibitors
Inactive A2
Metabolites
Beta Blockers
• Once contraindicated in systolic heart failure
• Negative inotropes
• Not used in acute heart failure
• May worsen cardiac output and symptoms
Beta Blockers
• Three agents beneficial in chronic systolic HF failure
• Metoprolol (β1)
• Carvedilol (β1β2α1)
• Bisoproplol (β1)
• ↓ morality, ↓ hospitalizations
Aldosterone Antagonists
Sympathetic System
Renal Na/Cl resorption

A2
X Spironolactone
Arteriolar vasoconstriction Eplerenone
Adrenal aldosterone secretion
Pituitary ADH secretion

Spironolactone, Eplerenone
Potassium-sparing diuretics
• ↑Na/H2O excretion (diuretics)

• “Spare” potassium
• Unlike other diuretics, do not increase K+ excretion
• HYPERkalemia is side effect
• Reduced mortality
• Reduced hospitalization rate
Spironolactone, Eplerenone
Potassium-sparing diuretics
• Similar structure to testosterone

• Blocks testosterone effects
• Gynecomastia in men
• Eplerenone: No gynecomastia
• Derivative of progesterone
• Activates progesterone receptors Eplerenone
• Amenorrhea in women
Testosterone Progesterone
Spironolactone
Neprilysin Inhibitors
Sacubitril
• Neprilysin: Degrades atrial/brain natriuretic peptide

• Inhibition → ↑ANP/BNP
• Antagonists to RAAS system
• Vasodilatation
• Natriuresis (sodium excretion)
• Diuresis (water excretion)
• Reduced sympathetic tone
ANP/BNP
RAAS
Sacubitril
• Entresto: oral combination sacubitril/valsartan

• Valsartan: angiotensin receptor blocker (ARB)
• ↓ morality
• ↓ hospitalizations
ANP/BNP
RAAS
Side Effects
• Studied in combination with valsartan

• Many side effects similar to ARBs
• Hypotension
• Hyperkalemia
• Angioedema
• Rare, feared adverse effect
• Neprilysin also degrades bradykinin (like ACE)
• Angioedema may occur
• Cannot be given together with ACE inhibitors
Ivabradine
• Selective sinus node inhibitor
• Elevated HR → worse prognosis
• Slows heart rate without ↓ contractility
• Inhibits SA pacemaker “funny current” (If)
• Used in patients on max-dose beta blocker with ↑HR
• Limited evidence of ↓ morality and ↓hospitalizations
Chronic Systolic Heart Failure
Drug Therapy
• ACE inhibitors/ARB
• Beta Blockers
• Aldosterone antagonists
• Neprilysin inhibitors
• Ivabradine
ICD
Implantable Cardiac Defibrillator
• Annual risk SCD >20% some studies

• Most due to ventricular tachycardia
ICD
Implantable Cardiac Defibrillator
• Improve mortality in appropriate patients

• Implantation carries some risk:
• Bleeding, infection
• Inappropriate shocks
Biventricular Pacemakers
Cardiac Resynchronization Therapy (CRT), BiV pacer
Out of Synch After Pacemaker

Heart Failure Treatment
Pathway
Acute
Heart Failure
Lasix
Rx Nitroglycerine
Inotropes
Chronic
Heart Failure
Diastolic Systolic
Heart Failure Heart Failure
No specific therapy Drugs
ICD
Bi-V Pacer
Cardiac
Embryology
Jason Ryan, MD, MPH
Primitive Heart
22 days
Sinus
Venosus
Primitive Heart
22 days
Aorta
Pulmonary Artery
Smooth
LV/RV
Trabeculated
LV/RV
Trabeculated Atria
Sinus
Venosus
Right Atrium
Coronary Sinus
OpenStax Colleg/Wikipedia
Sinus Venosus
Right Left
Horn Horn
Smooth Coronary Sinus

Right Atrium
(sinus venarum)
Cardinal Veins
• Form SVC/IVC (not from heart tube)
• Connect to right atrium
• Superior vena cava
• R common cardinal vein and R anterior cardinal vein
• Inferior vena cava
• Posterior veins
Adult Heart
Patrick J. Lynch, medical illustrator/Wikipedia

Primitive Heart
Cardiac Looping
• Heart tube “loops” at about 4 weeks gestation
• Establishes left-right orientation in chest
• Requires cilia and dynein
• Dextrocardia (heart on the right side of body)
• Seen in in Kartagener syndrome
• Part of primary ciliary dyskinesia
Nevit/Wikipedia
Ventricular Septum Formation
AP
Aorticopulmonary
Twist
Septum Membranous
Septum
Forms
Muscular AP Fuses Endocardial Cushions

Ventricular Muscular Septum Separate R/L atria
Septum R/L ventricle
Ventricular Septum Pathology
• Membranous VSD (most common type)
• Muscular VSD
Endocardial Cushions
• Contribute to several cardiac structures
• Atrial septum
• Ventricular septum
• AV valves (mitral/tricuspid)
• Semilunar valves (aortic/pulmonic)
• Endocardial cushion defects
• Atrioventricular canal defects
• Atrioventricular septal defects
• ASD, VSD, Valvular malformations Endocardial Cushions
Separate R/L atria
• Common in Down syndrome
R/L ventricle
Aorticopulmonary septum
Spiral Septum
• Formed from neural crest cells

• Migrate to truncal and bulbar ridges
• Separates aorta and pulmonary arteries
• Fuses with interventricular septum
Aorticopulmonary septum
Spiral Septum
• Abnormal formation → congenital pathology

• Transposition of great vessels
• Failure to spiral
• Tetralogy of Fallot
• Skewed septum development
• Persistent truncus arteriosus
• Partial/incomplete septum development
Atrial Septum
Septum Septum Foramen
Primum Primum Secundum
RA LA
Foramen
Primum
Endocardial
Future Cushion Future
Ventricles Ventricles
Atrial Septum
Septum primum fuses
Endocardial cushion Septum secundum grows
RA Remaining
Opening
Foramen LA Foramen
Secundum Ovale
Future
Future
Ventricles
Ventricles
PFO
Patent Foramen Ovale
• Found in ~25% adults

• Failure of foramen ovale to close after birth
• Septum primum/secundum fail to fuse
RA
LA
Fetal Circulation
• High resistance to flow in lungs
• Oxygenated blood umbilical veins
• About 80% saturated (30mmHg O2)
• Travels directly to right atrium
• Bypasses liver via ductus venosus
• Bypasses lungs via foramen ovale BruceBlaus/Wikipedia
• Some blood gets to RV (SVC)

• Bypasses lungs via ductus arteriosus
• Left pulmonary artery to aorta
Changes at Birth
• Pulmonary resistance falls
• More blood to left atrium
• LA pressure > RA pressure
BruceBlaus/Wikipedia
• Foramen ovale closes (fossa ovalis)
• Ductus arteriosus closes
• In utero: ↓ O2, ↑ prostaglandins maintain patency
• Birth: ↑ O2, ↓ prostaglandins (loss of placenta)
PVR RA LA
In Utero ↑ ↑ ↓
Birth ↓ ↓ ↑
Changes at Birth
• Placenta has low resistance to flow
• In utero: helps keep LA pressure low
• At birth: increase in peripheral resistance
• Rise in systemic blood pressure
• Rise in left ventricular pressure
• Contributes to rise in LA pressure
Shunts
Jason Ryan, MD, MPH
Shunts
LA RA
LV RV
Ao PA
Shunts
• Left side pressures >> Right side pressures
• LA ~10mmHg >> RA ~6mmHg
• LV ~120/10 >> RV ~24/6
• Ao ~ 120/80 >> PA ~24/12
• Left to right connection → Left to right flow
• VSD (LV→RV)
• ASD (LA→RA)
• PDA (Aorta → Left pulm artery)
Shunts
• At birth:
• Left to right flow → volume overload of right heart
• Blood flow to lungs unimpaired → no cyanosis
• YEARS later (untreated)
• Pulmonary vessels become stiff/thick
• Right ventricle hypertrophies
• Right sided pressures rise
• Shunt reverses (now R → L)
• Cyanosis occurs (Eisenmenger syndrome)
• “Blue kids” not “blue babies”
VSD
• Most common congenital anomaly

• Communication LV/RV
• Harsh, holosystolic murmur
• Tricuspid area (LLSB)
VSD
• Characterized in many ways

• Size
• Location
• Associated defects
VSD
• Small VSD
• Tiny hole → resists flow across defect (“restrictive”)
• Lots of turbulence → loud murmur
• Small shunt (small volume of flow across defect)
• Large VSD
• Large hole (“non-restrictive”)
• Significant shunting
• Often closed surgically
ASD
Atrial Septal Defect
• Communication between left/right atrium

• Adds volume to RA/RV
• Delays closure of pulmonic valve
• Wide, fixed splitting of S2
• Increased flow across PV/TV
• Systolic ejection murmur
• Rarely a mid-diastolic murmur
ASD
• Oxygenated blood LA → RA
• ↑ O2 saturation in RA, RV, PA
• “Shunt run”
• Series of blood samples
• SVC = 65%
• IVC = 65%
• RA = 75%
• RV = 75% “Step up”
• PA = 75%
ASD
• Secundum type is most common

• Defects at site of foramen ovale/ostium secundum
• Poor growth of secundum septum
• Or excessive absorption of primum septum
• Located mid-septum
• Often isolated defect
Foramen
Ovale
R
Septum secundum
Septum primum
L
ASD
Septum Primum
Foramen Septum Secundum Excessive
Ovale Too Short Reabsorption
R R R
L L L
Septum secundum
Septum primum
ASD
ASD
• Primum type
• Defect at site of ostium primum
• Failure of primum septum to fuse with endocardial cushions
• Located near AV valves; often occurs with other defects
• Seen in endocardial cushion defects (Down syndrome)
Primitive Primitive
Atria Atria
fusion
Septum primum
Ventricle Endocardial cushion Ventricle
ASD
PDA
• Ductus arteriosus shunts blood in utero

• Left pulmonary artery → aorta
• Closes close after birth
• “Functional” closure 18 to 24 hours (smooth muscle)
• “Anatomic” occlusion over next few days/weeks
• Becomes ligamentum arteriosum
• Patency maintained by prostaglandin E2
• Major source in utero is placenta
PDA
• Rarely remains patent (3 to 8 per 10,000 births)

• Associated with congenital rubella syndrome
• ToRCHeS infection
• Mother: Rash, fever, lymphadenopathy
• Baby: Deafness, cataracts, cardiac disease
• PDA common
• Rare in developed countries (vaccination)
• Consider in infants whose mothers are immigrants
PDA
• Continuous, machine-like murmur

• Widened pulse pressure
• Loss of volume in arterial tree through PDA
• Low diastolic pressure → Increased pulse pressure
• Differential cyanosis
• Occurs when shunt reverses R → L
• Blue toes, normal fingers
Alprostadil
• Prostaglandin E1
• Maintains patency of ductus arteriosus
• Key effect: delivers blood to lungs
• Useful when poor RV → PA blood flow
• Pulmonary atresia
Indomethacin
• NSAID
• Inhibits cyclooxygenase
• Decreases prostaglandin formation
• Can be used to close PDA
Qp:Qs
• Qp = Pulmonary blood flow
• Qs = Systemic blood flow
• Qp:Qs should be 1:1
• In shunts, Qp:Qs may be > 1:1
• 1.5:1, 2:1, 3:1, etc.
Eisenmenger’s Syndrome
• Uncorrected ASD/VSD/PDA
• Right heart chronically overloaded
• RV Hypertrophy
• Shunt reverses right → left
• Cyanosis
• Clubbing
• Polycythemia (very high Hct)
Fetal Alcohol Syndrome
• Caused by prenatal exposure to alcohol (teratogen)
• Characteristic facial features
• Impaired neurologic function
• Congenital heart defects
• Atrial septal defect
• Ventricular septal defect
Teresa Kellerman/Wikipedia
PFO
Patent Foramen Ovale
• Found in ~25% adults

• Failure of foramen ovale to close after birth
• Can lead to stroke in patients with DVT/PE
Cyanotic
Congenital Heart
Disease
Jason Ryan, MD, MPH
Cyanosis
• Central cyanosis • Peripheral cyanosis
• Cardiac output normal • Low blood flow
• Blood is flowing • Severe heart failure
• Not enough O2 • Cold extremities
• Lips
• Nail beds
• Conjunctivae
• Warm extremities
WaltFletcher/Wikipedia
Blue Babies
• Central cyanosis early in life
• Blood not going through lungs after birth
• Truncus arteriosus
• Tricuspid atresia
• Total anomalous pulmonary venous return
Tetralogy of Fallot
• Constellation of four abnormalities
• Ventricular septal defect (VSD)
• Rightward deviation of aortic valve (“overriding aorta”)
• Subpulmonary stenosis
• Right ventricular hypertrophy
Infundibulum
Conus Arteriosus
• “Funnel” leading to pulmonic valve

• Develops from bulbus cordis
• Smooth, muscular structure at RV outflow to PA
Infundibulum
Conus Arteriosus
• Septum displaced (moves toward RV) in TOF

• Causes “overriding aorta”
• 5-95% of aorta may lie over RV
• Causes VSD
• Usually large (“non-restrictive”)
Infundibulum
Conus Arteriosus
• “Infundibular stenosis”
• Subpulmonary stenosis
• RV outflow tract obstruction
• Abnormal pulmonary valve
• Rarely main cause of obstruction
• Flow obstruction → RVH
Tetralogy of Fallot
Physiology
• High resistance to flow RV → pulmonary artery

• RV outflow pulmonic stenosis
• Diverts blood across VSD to left ventricle
• Severity of flow obstruction determines symptoms
• Severe obstruction: severe cyanosis
• Mild obstruction: less shunting (“pink” tets)
Tetralogy of Fallot
Physiology
• Poor blood flow RV → lungs

• Left to right shunts beneficial
• Bring back to pulmonary artery
• Diverts blood to lungs
• Improves oxygenation
• Patent ductus arteriosus
• Aortopulmonary collateral arteries
• Surgical shunt
Tetralogy of Fallot
Murmur

• Crescendo-decrescendo
S1 S2
• RV outflow and pulmonic stenosis
• Heard best at left sternal border
• Single S2
• S2 = closure of aortic and pulmonic valves
• TOF: Diseased pulmonic valve → no sound
• VSD murmur (holosystolic) not typically heard
• Large VSD → no murmur
Tetralogy of Fallot
X-ray
Tetralogy of Fallot
Other Features
• Squatting improves symptoms

• Increased afterload/TPR (resists flow out of LV)
• Pressure rises in the aorta/left ventricle
• Less blood shunted RV → LV via VSD
• More blood to lungs
Sherif Salama/Flikr
Tetralogy of Fallot
Other Features
• “Tet spells”
• Sudden cyanosis often when agitated
• Severe/complete RVOT obstruction
• O2, knees to chest, beta blockers (propranolol)
Truncus Arteriosus
• Common arterial trunk → Mixing of blood
• Failure of neural crest cells to drive formation
of aorticopulmonary septum
• Almost always has VSD
Transposition of Great Vessels
• Normal heart:
• Aorta is posterior and to right of pulmonary artery
Kshafer/WikiDoc
• D-transposition (most common type):
• Aorta forms anterior and rightward of pulmonary artery
• Aorta arises from right ventricle
• Pulmonary artery from left ventricle
Kshafer/WikiDoc
• RV → Aorta → body → RA → RV
• LV → Pulmonary artery → LA → LV
• Two completely separate circuits
• NOT compatible with life unless shunt present
• Usually PDA or VSD
No
No
Body
Lungs
L-TGA
L-Transposition of the Great Arteries
• “Double switch”: Aorta/PA and LA/RA

• “Congenitally corrected TGA”
• Venous blood → RA → LV → PA → Lungs
• Lungs → PV → LA → RV → Aorta
• Two circuits not separated
• Wrong connections (RV-Aorta, LV-PA)
• Eventually right ventricle fails
Maternal Diabetes
• Infants at increased risk congenital anomalies
• Common congenital heart defects
• Tricuspid atresia
• VSD
• PDA
Tricuspid Atresia
• Abnormal AV valves from endocardial cushions
• No tricuspid valve
• No blood RA → RV
LA
ASD
RA
LV
RV VSD
Tricuspid Atresia
• All cases have R→L shunt
• Always seen with ASD
• Allows blood flow to LA
• All cases have L→R shunt LA
• Allows blood flow to lungs ASD
• LV→ RV via VSD RA
LV
• Ao → PA via PDA
RV VSD
TAPVR
Total Anomalous Pulmonary Venous Return
• Normal: pulmonary veins drain to left atrium

• TAPVR: pulmonary veins drain to venous system
• Innominate (brachiocephalic) veins → SVC
• Coronary sinus
• Portal vein
TAPVR
Total Anomalous Pulmonary Venous Return
• RV → Lungs → Pulm Veins → RA → RV

• RA and RV dilate
• Must have a right to left shunt
• ASD (most common)
• PDA
• Mixed (low O2) blood to body
Ebstein’s Anomaly
• Apical displacement of TV → small RV
• “Atrialization” of RV tissue
• Severe tricuspid regurgitation
• Can lead to right heart failure
Wikipedia Commons
Ebstein’s Anomaly
• Right to left shunting and cyanosis if ASD
• High RA pressure
• Associated with WPW
• Electrical bypass tract often present
• Delta wave on EKG
Maternal Lithium
• Teratogen
• Completely equilibrates across the placenta
• Teratogenic effects primarily involve heart
• Ebstein’s anomaly most common
Pulmonary Atresia
• Failure of pulmonic valve orifice to develop
• No flow from RV to lungs
• In utero blood bypasses lungs (normal development)
• At birth: No blood flow to lungs through PV
• PVR should fall but does not
• Often co-exists with VSD for outflow of RV
• Similar to a severe form of Tetralogy of Fallot
• Survival depends on ductus arteriosus
• Alprostadil given to keep DA open
Pulmonary Atresia
No VSD VSD
CDC/Public Domain
Alprostadil
• Prostaglandin E1
• Maintains patency of ductus arteriosus
• Key effect: delivers blood to lungs
• Useful when poor RV → PA blood flow
• Pulmonary atresia
Conotruncal Heart Defects
• Outflow tract anomalies
• Trunk = Truncus arteriosus
• Conus = Conus arteriosus
• Transposition of the great arteries
• 22q deletion syndromes
• DiGeorge syndrome (Thymic Aplasia)
• Immunodeficiency, hypocalcemia
• Conotruncal anomalies
Coarctation
of the Aorta
Jason Ryan, MD, MPH
Coarctation of the Aorta
Left
BC Carotid Subclavian
Artery
• Congenital disorder
• Usually involves thoracic aorta distal to subclavian
• Near insertion of ductus arteriosus
• “Juxtaductal” aorta
• Subtypes based on location of ductus arteriosus
• High resistance to flow in aorta
Ductus
Arteriosus
Ductus
Arteriosus
Pre-ductal Coarctation Post-ductal Coarctation

Ductus Arteriosus
• Shunts blood in utero
• Left pulmonary artery → aorta
• Patency maintained by ↓O2 and ↑ prostaglandins
• At birth: ↑O2 and ↓ prostaglandins
• “Functional” closure 18 to 24 hours after birth
• Smooth muscle constriction
• “Anatomic” occlusion over next few days/weeks
• Becomes ligamentum arteriosum
Preductal or Infantile
• Ductus arteriosus supplies lower extremities

• Poor development of collateral vessels
• At birth ductus arteriosus open (not closed yet)

• Deoxygenated blood to lower extremity
• Lower extremity cyanosis may occur
• Ductus closure → symptoms may develop

• All flow through aorta with severe narrowing
• Abrupt increase afterload
• Rise in LVEDP
• Acute heart failure
• LV can dilate → fail → shock
• All caused by closure of DA
• Key associations: Turner syndrome (45, XO)

• Short stature, webbed neck
• 5-10% have coarctation of the aorta
Johannes Nielsen/Wikipedia
Postductal or Adult type
• Ductus arteriosus does not supply lower extremities

• Collaterals develop
• May go undetected until adulthood
• Lower extremities → low blood pressure
• ↑ Renin release
• Salt/water retention
• Vasoconstriction (AII)
• Weak pulses (“brachio-femoral delay”)
• Upper extremities and head → high blood pressure
• Secondary hypertension
• Key association: bicuspid aortic valve
• Found in up to 60% of coarctation cases
Patrick J. Lynch, medical illustrator

• Key association: intracranial aneurysms
• Occur in about 10% of patients with coarctation
Signs/Symptoms
• Only sign may be hypertension in arms

• Murmur over back between scapula
• Weak femoral pulses
• Pain with walking (claudication)
Signs/Symptoms
• Rib notching
• High pressure above coarctation
• Intercostals enlarge to carry blood around obstruction
• Bulge into ribs
• “Rib notching” seen on chest x-ray
WikiRadiography
Signs/Symptoms
• 3-sign
• Bulge before and after coarctation
• “3 sign” on chest x-ray
WikiRadiography
Physiology
• Autoregulation maintains regional blood flow

• Normal upper/lower perfusion despite high/low pressures
• Upper extremities
• High blood pressure → high flow
• Arterioles constrict to limit flow to normal level
• Local effect – not mediated by sympathetic/parasympathetic
• Resistance to flow is high (Q = Δ P / R )
• Lower extremities
• Low blood pressure
• Arterioles dilate to increase flow to normal level (Q = Δ P / R )
• Result is normal (“compensated”) flow
Complications
• Heart failure
• Pressure overload of left ventricle
• Aortic rupture/dissection
• Endocarditis/endarteritis
• High-low pressure across narrowing
• Endothelial injury
• Low pressure distal to narrowing
• Bacteria may attach more easily
Hypertension
Jason Ryan, MD, MPH
Hypertension
• Blood pressure >140/90
• Need more than one measurement
Etiology
• Most (90%) is primary (“essential”) HTN
• Cause not clear
• Remainder (10%) secondary
Hypertension
Risk Factors
• Family history
• African-American race
• High salt intake
• Alcohol
• Obesity
• Physical inactivity
Sodium Intake
↑ Na
↑ Posm Wikipedia/Public Domain
↑ ADH
↑ H2O ↑ ECV ↑ BP
[Na] = 140meq/L
Hypertension
Associations
• Stroke
• Heart disease
• MI
• Heart failure
• Renal failure
• Aortic aneurysm
• Aortic dissection
Hypertension Effects
• Atherosclerosis – lipid/fibrous plaques in vessels
• Arteriosclerosis – thickening of artery wall
• Response to chronic hypertension
• Hyaline arteriosclerosis
• Thickening of small arteries
• Seen with aging
• Also common with diabetes
Nephron/Wikipedia
• Hyperplastic arteriosclerosis
• Arteries look like “onion skin”
• Occurs when hypertension is severe (usually DBP>120)
• “Malignant” hypertension
• Retinal hemorrhages, exudates, or papilledema
Pacolarosa/Wikipedia
Arteriolar Rarefaction
• Loss of arterioles
• Arterioles close off and get resorbed
Hypertension Effects C = ΔV / ΔP
• Pulse pressure may increase

• Example: Normal 120/80; HTN 170/100 ΔP = ΔV / C
• Stiff arteries → ↓compliance
Distensible Stiff
Vessel Vessel
120/80 170/100
• Afterload on heart is increased
• Left ventricle: concentric hypertrophy
• Large voltage on EKG
• Displaced apical impulse
• S4
Hypertensive Urgency
• Severe hypertension without end-organ damage
• No agreed upon BP value
• Usually >180/120
Hypertensive Emergency
• Also no definite value
• BP usually >180/120
• Patient longstanding HTN, stops meds
• Neurologic impairment
• Retinal hemorrhages, encephalopathy
• Renal impairment
• Acute renal failure
• Hematuria, proteinuria
• Cardiac ischemia
• Associated with MAHA
• Endothelial injury → thrombus formation
• Improved with BP control
Databese Center for Life Science (DBCLS)

Malignant Hypertension
• Historical term
• Most cases hypertension: “benign”
• Modestly elevated blood pressure
• Stable over years
• “Malignant hypertension”
• Rare form, often fatal
• Severe elevation of blood pressure (diastolic >120mmHg)
• Rapidly progressive over 1 to 2 years
• Renal failure, retinal hemorrhages, ischemia
Secondary
Hypertension
Jason Ryan, MD, MPH
Etiology
• Most (90%) is primary (“essential”) HTN
• Cause not clear
• Remainder (10%) secondary
Blood Pressure
Determinants
• Cardiac output
• Increased with renal salt/water retention
• Total peripheral resistance
• Key vessels: arterioles
• Increased by vasoconstrictors (i.e. catecholamines)
• Increased by sympathetic nervous system
BP = CO X TPR
Chronic Kidney Disease
• Over 80% of patients have hypertension
• Multiple causes:
• Sodium retention
• Increased renin-angiotensin-aldosterone activity
• Increased sympathetic nervous system activity
Anna Frodesiak/Wikipedia
Obstructive Sleep Apnea
• Sleep-related breathing disorder
• Apnea during sleep
• Often associated with hypertension
• Treatment may reduce BP
PruebasBMA /Wikipedia
NSAIDs
Ibuprofen, naproxen, indomethacin, ketorolac, diclofenac
• Nonsteroidal anti-inflammatory drugs

• Inhibit cyclooxygenase in kidneys
• Decrease synthesis of prostaglandins
• PGE-2: Renal vasodilator
Madhero88 /Wikipedia
NSAIDs
Ibuprofen, naproxen, indomethacin, ketorolac, diclofenac
• ↓ Na/Water excretion
• May cause hypertension
• May exacerbate heart failure
Vasoconstriction
↓RBF
↓GFR
Oral Contraceptive Pills
OCPs
• Estrogen and progesterone analogs

• Cause mild increase in blood pressure
Ceridwen/Wikipedia
Pseudoephedrine
• Nasal decongestant
• Alpha-1 agonist
• Vasoconstriction → ↓ nasal blood flow
Epinephrine Pseudoephedrine
Cyclosporine & Tacrolimus
• Immunosuppressants
• Calcineurin inhibitors
• Renal vasoconstriction → salt/water retention
• Diltiazem: drug of choice
• Impairs metabolism (↑ drug levels)
• Treats HTN and allows lower dose cyclosporine to be used
Primary Aldosteronism
• Excessive levels of aldosterone secretion
• Not due to increased activity of RAAS system
• Adrenal adenoma (Conn’s syndrome)
• Bilateral idiopathic adrenal hyperplasia
Wikipedia /Public Domain

• ↑Na reabsorption distal nephron
• ↑ECV → ↑CO → Hypertension
• ↑K excretion → hypokalemia
Aldosterone Escape
• Excess aldosterone does not lead to volume overload
• Usually no pitting edema, rales, increased JVP
• Na/Fluid retention → hypertension
• Compensatory mechanisms activated
• Increased ANP
• Increased sodium and free water excretion
• Result: diuresis → normal volume status
• Clinical features
• Resistant hypertension
• Hypokalemia
• Normal volume status on physical exam
• Diagnosis
• Renin-independent aldosterone section
• Low plasma renin activity
• High aldosterone levels
• Drugs of choice: Spironolactone/Eplerenone
• Aldosterone antagonists
Liddle’s Syndrome
• Genetic disorder
• Increased activity of ENaC
• Similar clinical syndrome to hyperaldosteronism
• Hypertension
• Hypokalemia
• Aldosterone levels low
Collecting Duct
Lumen (Urine) Principal Cell Interstitium/Blood
Na+
Na+
Aldosterone ATP
+
Aldosterone
K
K+
H2O
Intercalated Cell
Aldosterone
Cl-
H+
Pheochromocytoma
• Catecholamine-secreting tumor
• Epinephrine, norepinephrine, dopamine
• Usually arises from adrenal gland
• Triad: Palpitations, headache, episodic sweating
• PHEochromocytoma
• Most patient have hypertension
• Diagnosis: Catecholamines breakdown products
• Metanephrines
• Vanillylmandelic acid (VMA)
Cushing’s Syndrome
• Excess cortisol
• Often from steroid administration
• Other causes
• Cushing’s Disease (pituitary oversecretes ACTH)
• Tumors (i.e. small cell lung cancer secretes ACTH)
• Adrenal tumor secretes cortisol
• Cortisol → hypertension
• Increased vascular sensitivity to adrenergic agonists
Renal Artery Stenosis
• Vascular disease of renal arteries
• Decreased blood flow to kidneys
• Key exam finding: renal bruit
Kidney
• Increased renin, salt-water retention → HTN
• Often unilateral stenosis
• Normal kidney compensates
• Results: No signs of volume overload
↑RAAS
↑ BP
Euvolemia
↑Renin ↓Renin
↑ Na ↓Na
Stenotic Normal
Angiotensin II
• Normal GFR depends on angiotensin II

• AII → efferent arteriole vasoconstriction
• Maintains GFR
• ACE inhibitors can precipitate renal failure
Fibromuscular Dysplasia
• Vascular disease → obstruction to flow
• Common among women
• Often occurs in 40s-50s
• Non-atherosclerotic, non-inflammatory
• Often involves medial layer fibroplasia
• Stenosis and aneurysms of vessels (“string of beads”)
• Most common in renal and carotid arteries
• Can lead to renal artery stenosis
Left
BC Carotid Subclavian
Artery
ADPKD
Autosomal dominant polycystic kidney disease
• Genetic disorder
• Mutations of PKD1 or PKD2
• Presents in adulthood with HTN and renal cysts
• Increased RAAS activity
Antihypertensives
Jason Ryan, MD, MPH
BP = CO X TPR
Heart Rate Circulating Vascular Tone
Contractility Volume
Beta Receptors
• β1 receptors in heart, kidneys
• Increase heart rate and contractility
• Stimulate renin release
• Blockade → ↓ CO, ↓ ECV → ↓ BP
• β2 receptors
• Dilate blood vessels (muscle, liver)
• Bronchodilate
• Blockade does not lead to lower blood pressure
Beta Blockers
β1-selective antagonists
• Atenolol, Metoprolol, Esmolol

• Used for hypertension
• Blockade → ↓ CO, ↓ ECV → ↓ BP
• Metoprolol: Systolic heart failure
• Blocks sympathetic stimulation of heart
• Reduces mortality
Beta Blockers
β1β2 (nonselective) antagonists
• Propranolol, Timolol, Nadolol

• Can be used for hypertension
• Nadolol, Propranolol: Used in portal hypertension
• Beta 1 blockade: ↓ CO, ↓ ECV → ↓ BP
• Beta 2 blockade: ↓ portal blood flow
• Timolol: Used in glaucoma
• Beta 1 and Beta 2 → aqueous humor production
Beta Blockers
β1β2α1
• Carvedilol, Labetalol
• Labetalol: Hypertensive Emergency
• Rapid reduction in blood pressure
• Carvedilol: Systolic heart failure
• Blocks sympathetic stimulation of heart
• Reduces mortality
Beta Blockers
Partial Agonists
• Pindolol: β1β2 (nonselective)

• Acebutolol: β1-selective
• “Intrinsic sympathomimetic activity”
• Beta agonist when sympathetic activity is low
• Beta blocker when sympathetic activity is high
• Can cause angina through beta 1 activation
• Special pharmacologic properties
Beta Blockers
Side effects
• Fatigue, erectile dysfunction, depression

• More common with older beta blockers (propranolol)
• Hyperlipidemia
• Mild increase in triglycerides
• Mild decrease in HDL
• Effect varies with different beta blockers
Beta Blockers
Side effects
• Caution in diabetes
Victor/Flikr
• Blockade of epinephrine effects
• Epinephrine raises glucose levels
• Blockade → hypoglycemia
• Blockade of hypoglycemia symptoms
• ↓ glucose → sweating/tachycardia
• Symptoms “masked” by beta blockers
Beta Blockers
Side effects
• Caution in asthma/COPD
• β2 receptors: bronchodilators
• β2 blockade may cause a flare
• β1 blockers (“cardioselective”) often used
• Decompensated heart failure
• β1 blockers lower cardiac output → worsening of symptoms
• Commonly used in compensated heart failure
• Mortality benefit
Beta Blockers
Overdose
• Depression of myocardial contractility → shock

• Bradycardia/AV block
Beta Blockers
Overdose
• Treatment: Glucagon
• Activates adenyl cyclase at different site from beta receptors
• ↑ cAMP → ↑ intracellular Ca
• Increased contraction and heart rate
Glucagon
β1 AC
AMP cAMP
α1 Blockers
Tamsulosin, Alfuzosin, Doxazosin, Terazosin
• α1 receptors in periphery: vasoconstrict

• Blockade → vasodilation → ↓ TPR → ↓ BP
• Used in benign prostatic hypertrophy
• Relax smooth muscle of bladder/prostate
• Increase urine flow
• Common side effect: Postural hypotension
• Tamsulosin: “Uroselective”
• Less hypotension effect
Alpha 2 Receptors
α2 receptors in CNS
Presynaptic receptor
Feedback to nerve when NE released
Activation leads to ↓NE release
Neuron
α2
NE Norepinephrine
Vascular
Smooth Muscle
Clonidine
α2 agonist
• Old, rarely used hypertension drug

• Key side effect: Rebound hypertension
• Abrupt cessation of drug (usually at high dose)
• Severe hypertension (SBP>200; DBP>120)
• Symptoms of high BP and sympathetic over-activity
• Nervousness, sweating, headache, chest pain
• Also causes sedation
Methyldopa
α2 agonist
• Drug of choice in pregnancy

• Also causes sedation
• Key side effect (rare): Hemolytic anemia
RBC
• Three major classes of calcium antagonists
• dihydropyridines (nifedipine)
• phenylalkylamines (verapamil)
• benzothiazepines (diltiazem)
• Vasodilators and negative chronotropes/inotropes
• Vascular smooth muscle effects
• Nifedipine>Diltiazem>Verapamil
• Heart rate/contractility effects
• Verapamil>Diltiazem>Nifedipine
• Dihydropyridines (nifedipine) → vasodilators
• Main effect: ↓TPR
• Non-dihydropyridines (Verapamil, diltiazem)
• Similar to β1 blockers
• Main effects: ↓HR; ↓ contractility
Dihydropyridines (nifedipine)

• Flushing, headache, hypotension
• Peripheral vasodilation
• Key side effect: edema
• Increased capillary hydrostatic pressure
• Pre-capillary arteriolar vasodilation
James Heilman, MD/Wikipedia

Dihydropyridines (nifedipine)
Pre- Capillary
Arteriole Capillary
100 50
Systemic
50
Pre-Capillary
Arteriole Capillary
80 60 60
Systemic
Verapamil, diltiazem

• Also used in heart disease
• Arrhythmias (atrial fibrillation)
• Stable angina (lower oxygen demand)
• Potential side effect: Negative inotropes
• Can precipitate heart failure
Other Side Effects
• Constipation
• Most commonly with verapamil
Elya/Wikipedia
Other Side Effects
• Hyperprolactinemia
• Seen with verapamil
• Blocks calcium channels CNS → ↓ dopamine release
• Causes hypogonadism
• Men: ↓ libido, impotence
• Pre-menopausal women: irregular menses, galactorrhea
Other Side Effects
• Gingival hyperplasia
• Seen in all types CCB
• Also with phenytoin, cyclosporine
Lesion/Wikipedia
Angiotensin II
Angiotensinogen
Sympathetic System
+ Renin
Renal Na/Cl reabsorption
AI A2
+ ACE
Adrenal aldosterone secretion

Net Result
↑Preload
↑Afterload
↑BP
Angiotensin II Inhibition
Angiotensinogen ARBs
Sympathetic System
+ Renin
Renal Na/Cl reabsorption
AI A2
Aliskiren + ACE
X
ACE Inhibitors Adrenal aldosterone secretion

Net Result
↑Preload
↑Afterload
↑BP
AII Drugs
• ACE Inhibitors
• Captopril, Enalapril, Lisinopril, Ramipril
• Angiotensin Receptor Blockers (ARBs)
• Candesartan, Irbesartan, Valsartan
• Side effects
• Hyperkalemia (↓aldosterone)
• Renal failure (↓GFR)
Bradykinin
Bradykinin Cough AI
Vasodilation
X X
ACE Inhibitors
Inactive A2
Metabolites
ACE Inhibitors
Unique Side Effects
• Due to increased bradykinin

• Dry Cough
• Occurs in ~10% of patients
• Angioedema
• Swelling of face, tongue
• Can be life-threatening
Aliskiren
• Direct renin inhibitor
• Reduces angiotensin I levels (unique effect)
Angiotensinogen
+ Renin
AI A2
+ ACE
Diuretics
• Loop diuretics
• Furosemide, bumetanide, torsemide, ethacrynic acid
• Thiazide diuretics
• Hydrochlorothiazide; chlorthalidone; metolazone
• Potassium sparing diuretics
• Spironolactone, Eplerenone, Triamterene, Amiloride
Hydralazine
• Direct arteriolar vasodilator
• Rarely used for hypertension
• Combined with nitrates for heart failure
• Safe in pregnancy
• Causes drug-induced lupus
Drug-induced Lupus
• Syndrome similar to lupus
• Often rash, arthritis, low blood cell counts
• Milder than SLE
• Usually no associated renal failure/CNS disease
• Key finding: anti-histone antibodies
• Three drugs
• Hydralazine
• Procainamide
• Isoniazid
• Unique drugs used for therapy
• Intravenous, rapid acting
• Lowering BP too fast can cause ischemia
• Autoregulation of vascular beds → vasoconstriction
KOMUNews/Flikr
• Nitroprusside
• Short acting drug
• ↑ intracellular cGMP
• ↑ nitric oxide release Sodium Nitroprusside
• Venous and arteriolar vasodilation
• ↓ preload (VR); ↓ afterload
• Cyanide toxicity with prolonged use
• Multiple cyanide groups per molecule
• Inhibits electron transport
• Toxic levels with prolonged infusions
• Fenoldopam
• D1 agonist
• Arteriolar vasodilation
• Increased urinary sodium/water excretion
• Maintains renal perfusion while vasodilating
• Labetalol
• β1 and α1 Blocker
• Esmolol
• Rapid acting intravenous β1 blocker
• Nicardipine, Clevidipine
• Intravenous dihydropyridine calcium channel blocker
Orthostatic Hypotension
Postural Hypotension; Orthostasis
• ↓blood pressure due to gravity with standing

• Compensation from sympathetic nervous system
• Increased VR, CO, HR, TPR
• Impaired with low volume, low TPR, blunted ANS
• Severe ↓BP (>20mmHg) = orthostatic hypotension
• Dizziness, syncope
• Common etiologies:
• Hypovolemia
• Hypertensive medications
Orthostatic Hypotension
Postural Hypotension; Orthostasis
• Alpha-1 blockers
• ACE-inhibitors
• Especially in patients on diuretics
• Volume depletion → ↑RAAS
• “First dose hypotension”
Reflex Tachycardia
• Vasodilation → ↓BP → ↑SNS
• Reflex response: ↑ HR
• Can be caused by vasodilators
• Hydralazine
• Alpha-1 blockers
• Dihydropyridine calcium channel blockers
• Nitroglycerine
• May exacerbate chronic stable angina
• Drugs may be co-administered with β blocker
Choosing Drugs
• Diabetes
• ACE inhibitors: Protective of kidneys
• Beta blockers can lower glucose and mask hypoglycemia
• HCTZ can increase glucose
• Systolic Heart Failure
• ACEi, beta blockers, aldosterone blockers: mortality benefit
• Calcium channel blockers → ↓ contractility
Choosing Drugs
• Hypertension in Pregnancy
• Methyldopa
• Beta blockers, nifedipine, hydralazine
• Avoid: ACE inhibitors, ARBs, direct renin inhibitors
• Associated with congenital malformations
• Significant renal failure or ↑K
• Avoid: ACE-inhibitors, ARBs (↓AII, ↓aldsoterone)
• Avoid: Potassium sparing diuretics (↑ K)
• Avoid: Other diuretics (↓ECV → ↓GFR)
• Calcium blockers, beta blockers usually ok
Valve Disease
Jason Ryan, MD, MPH
Heart Valves
Pulmonic
Aortic
Tricuspid
Mitral
Valve Disease
• Stenosis
• Stiffening/thickening of valve leaflets
• Obstruction to forward blood flow
• Regurgitation
• Malcoaptation of valve leaflets
• Leakage of blood flow backwards across valve
Valve Lesions - Systole
• Occur when heart contracts/squeezes
• Aortic stenosis
• Pulmonic stenosis
Valve Lesions - Diastole
• Occur when heart relaxes/fills
• Mitral stenosis
• Pulmonic regurgitation
Valve Disorders
Treatments
• Only severe valvular lesions treated

• Mostly surgical diseases
• Surgical repair
• Often done for mitral valve prolapse → mitral regurgitation
• Valve replacement
• Bioprosthetic (pig or cow)
• Mechanical (requires life-long anticoagulation)
• Valvuloplasty (stenotic lesions)
Stenotic Valve Disorders
• Stiff valve
• “Gradient” across valve
• High pressure upstream
• Lower pressure downstream
Rheumatic Fever
• Occurs weeks after streptococcal pharyngitis
• Common in children
• Autoimmune: type II hypersensitivity reaction
• Antibodies to bacterial M proteins cross-react
Rheumatic Fever
• Jones criteria
• Joints: Polyarthritis (>5 joints)
• ♥: Carditis (valvulitis, myocarditis, pericarditis)
• Nodules (subcutaneous)
• Erythema marginatum (rash on trunk)
• Sydenham chorea (jerking movement disorder)
Rheumatic Heart Disease
• Damage to heart valves by rheumatic fever
• Mitral valve most commonly involved
• Often presents years after acute rheumatic fever
• Many patients do not recall acute symptoms
• Common in developing countries
• Limited access to medical care for pharyngitis
• Often seen in immigrants to US
Carcinoid Heart Disease
• Caused by carcinoid tumors of intestines
• Secrete serotonin
• Fibrous deposits tricuspid/pulmonic valves
• Leads to stenosis and regurgitation
• Serotonin inactivated by lungs
• Left sided lesions rare
Aortic Stenosis
Pathophysiology
• Stiff aortic valve

• Systolic problem
• Increased afterload
Aortic Stenosis
Hemodynamics
• LV pressure systolic >> aortic pressure

• LVSP = 160mmHg (normal = 120)
• SBP = 120mmHg (normal = 120)
• Gradient = 40mmHg
• ↑ LVEDP due to ↑ afterload
Normal Aortic Stenosis

Aortic Stenosis
Clinical features
• Systolic crescendo-decrescendo murmur

• Syncope: failure to ↑CO due to ↑ afterload
• Angina: ↑ LVEDP → ↓ coronary blood flow
• Left heart failure: ↑ LVEDP
Aortic Stenosis
Causes
• Senile aortic stenosis

• “Wear and tear”
• Collagen breakdown
• Calcium deposition
• Bicuspid aortic valve
Patrick J. Lynch, medical illustrator
• Rarely rheumatic heart disease
CDC/Public Domain
Supravalvular Aortic Stenosis
• Narrowing of ascending aorta above aortic valve
• Seen in Williams syndrome
• Genetic deletion syndrome
Mitral Stenosis
Pathophysiology
• Stiff mitral valve

• Diastolic problem
• LA pressure >> LV diastolic pressure
• Left atrial pressure 20mmHg (normal = 10)
• LVEDP 5mmHg (normal = 10)
• Gradient = 15mmHg
• Decreased preload
Mitral Stenosis
Clinical features
• Caused by rheumatic fever

• Most common symptom: dyspnea
• ↑ LA pressure → pulmonary congestion
• Murmur: diastolic rumble with opening snap
Tricuspid Stenosis
• Very rare valve disorder
• Diastolic murmur at left lower sternal border
• Caused by rheumatic fever (with mitral disease)
• Tricuspid regurgitation more common
• Carcinoid heart disease
Pulmonic Stenosis
• Congenital defect in children
• Fused commissures with thickened leaflets
• Carcinoid heart disease
Regurgitant Lesions
• Acute and chronic forms
• Acute regurgitation (often from endocarditis)
• May cause shock
• Chronic regurgitation
• No shock
• Leads to chronic heart failure
• Sympathetic activation only if severe heart failure
Pathophysiology
• Blood leaks across aortic valve

• Diastolic problem
• Increased preload, stroke volume
• More stroke volume → aorta → ↓ compliance (stiffening)
• Blowing diastolic murmur
Causes
• Dilated aortic root → leaflets pull apart

• Often from HTN or other aortic aneurysm
• Rarely from tertiary syphilis (aortitis)
• Turner syndrome
• Coarctation of the aorta
• Endocarditis
• Rheumatic heart disease
• Almost always with mitral disease
Clinical features
• Leaking blood back into LV causes low diastolic BP

• 120/80 (normal) → 120/40
• Low diastolic pressure
• Wide pulse pressure
• High cardiac output with low diastolic pressure
• Wide pulse pressure symptoms
• “Water hammer” pulses
• Head bobbing
• Many, many others (mostly historical)
Pathophysiology
• Blood leaks across mitral valve

• Increased LA volume → Starling mechanism
• Increased left ventricular filling from LA
• Increased preload, stroke volume
• Reduced afterload
Causes
• Primary MR caused by mitral valve prolapse

• Also called degenerative or myxomatous
• Billowing of mitral valve leaflets above annulus
• Common cause of mitral regurgitation
• Causes a systolic click
• Don’t confuse with opening snap of mitral stenosis
Secondary causes
• Ischemia → damage to papillary muscle

• Left ventricular dilation
• Dilated cardiomyopathy
• Leaflets pulled apart
• “Functional” MR
Causes
• Endocarditis
• Rheumatic heart disease
• Congenital
• Cleft mitral valve
• Endocardial cushion defect
• Down syndrome
Clinical Features
• Holosystolic murmur at apex
S1 S2
Afterload Reduction
Aortic and Mitral Regurgitation
• In theory, ↓ afterload can improve forward flow

• For severe, acute regurgitation this helps
• For chronic disease, clinical trials with mixed results
• In general, these are surgical diseases
• Common test scenario “Best medical option?”
Tricuspid Regurgitation
• Small amount of TR normal (“physiologic TR”)
• Holosystolic murmur at left sternal border
• Pathologic causes
• Functional TR from RV enlargement
• Endocarditis - classically IV drug users
• Carcinoid
• Ebstein’s anomaly
Pulmonic Regurgitation
• Most common cause: repaired Tetralogy of Fallot
• Repair of RVOT obstruction damages valve
• Endocarditis (rare)
• Rheumatic heart disease (rare)
Tetralogy of Fallot
Shock
Jason Ryan, MD, MPH
Shock
• Life-threatening fall in blood pressure
• Poor tissue perfusion
• Low cardiac output
• Loss of contractility
• Low intravascular volume
BP = CO X TPR
Types of Shock
• Cardiogenic
• Cardiac disorder → fall in cardiac output
• Hypovolemic
• Fall in intravascular volume → fall in cardiac output
• Hemorrhage
• Distributive
• Septic, anaphylactic
• Obstructive
Types of Shock
• Different treatments for different types of shock
• Often can determine type from history
• Myocardial infarction → cardiogenic shock
• Massive bleeding → hypovolemic shock
• Shock of unclear etiology: Swan-Ganz catheter
Swan-Ganz Catheter
Pulmonary artery catheter
Pulmonary Capillary Wedge Pressure

PCWP
“Wedge Pressure”
Equal to LA pressure
Swan-Ganz Data
• RA Pressure (Normal ~ 5mmHg)
• RV Pressure (20/5)
• PA Pressure (20/10)
• PCWP Pressure (10)
• Mixed venous O2 sat
• Oxygen concentration after all veins mix
Fick Equation
Oxygen Consumed = O2 Out Lungs – O2 In Lungs
= CO (Art O2 – Ven O2)
Cardiac Output = O2 Consumption

(Art O2 – Ven O2)
O2 Consumption α body size

Arterial O2 Content = O2 sat on finger probe
Venous O2 Content = O2 from Swan-Ganz
Swan-Ganz catheter gives cardiac output

Flow Equation
• Used to determine systemic vascular resistance
ΔP = CO * SVR
MAP – RAP = CO * SVR
SVR = MAP – RAP

CO
Swan-Ganz Catheter gives SVR

Swan-Ganz Data
• Direct
• RA Pressure (Normal ~ 5mmHg)
• RV Pressure (20/5)
• PA Pressure (20/10)
• PCWP Pressure (10)
• Mixed venous O2 sat
• Calculated
• Cardiac output
• Systemic Vascular Resistance
Hemodynamic of Shock
• Four major classes of shock
• All have different hemodynamics from Swan
• Swan can be used to determine etiology of shock
• Cardiogenic
• Hypovolemic
• Distributive
• Obstructive
Cardiogenic Shock
• Hallmark is low cardiac output
• High cardiac pressures
• High SVR (sympathetic response)
• Classic cause: large myocardial infarction
• Also seen in advanced heart failure (depressed LVEF)
Hypovolemic Shock
• Poor fluid intake
• High fever, insensible losses
• Hemorrhage
• Low cardiac pressures
• High SVR (sympathetic response)
Distributive Shock
• Hallmark is low SVR
• Diffuse vasodilation and/or endothelial dysfunction
• Sepsis (most common)
• Anaphylaxis
• Neurogenic
• Cardiac output classically high (variable)
• Cardiac pressures variable
Type of Shock
Cardiogenic Hypovolemic Distributive
Blood Pressure ↓ ↓ ↓
HR ↑ ↑ ↑
RA Pressure ↑ ↓ ↓/-
RV Pressure ↑ ↓ ↓/-
PCWP ↑ ↓ ↓/-
Cardiac Output ↓ ↓ ↑
SVR ↑ ↑ ↓
Major Shock Types
SVR
Low
High
Distributive
Pressures
High Low
Cardiogenic Hypovolemic
Physical Exam
• Cold skin → high SVR and low CO
• Cardiogenic
• Hypovolemic
• Warm skin → low SVR and high CO
• Distributive
• Jugular venous pressure → high RA pressure
• Pulmonary rales → high LA pressure
Obstructive Shock
• Obstruction to blood flow from heart
• Low cardiac output despite normal contractility
• Tamponade
• Tension pneumothorax
• Massive pulmonary embolism
• High SVR
Treatment of Shock
• Cardiogenic: inotropes
• Milrinone, Dobutamine
• Hypovolemic: volume
• Blood transfusions, IV fluids
• Distributive: vasopressors
• Phenylephrine, epinephrine, norepinephrine
• Obstructive: resolve obstruction
• Treat tamponade, embolism, tension pneumothorax
Swan in Valve Disease
RA (5) 15
RV (20/5) 45/15
PA (20/10) 45/30
PCWP (10) 30
LV (120/10) 120/5
Ao (120/80) 120/80
Mitral Stenosis
RA (5) 5
RV (20/5) 20/5
PA (20/10) 20/10
PCWP (10) 10
LV (120/10) 150/10
Ao (120/80) 120/80
Aortic Stenosis
RA (5) 15
RV (20/5) 45/15
PA (20/10) 45/30
PCWP (10) 30
LV (120/10) 120/30
Ao (120/80) 120/40
Left Atrial Pressure
a v
c
x y
Giant V waves
• Seen in mitral regurgitation in PCPW tracing
• Similar to giant V waves in tricuspid regurgitation
• Seen in venous pressure tracing
a v
c
Pericardial Disease
Jason Ryan MD, MPH
Pericardium
• Three layers
• Fibrous pericardium
• Serous pericardium
• Parietal layer Blausen Medical Communications, Inc.
• Visceral layer
• Pericardial cavity between serous layers
• Innervated by phrenic nerve
• Pericarditis → referred pain to the shoulder
Pericardial Diseases
• Pericarditis
• Tamponade
• Constrictive pericarditis
Blausen Medical Communications, Inc.

Pericarditis
• Most common pericardial disorder
• Inflammation of the pericardium
• Immune-mediated (details not known)
• May recur after treatment
Pericarditis
Clinical Features
• Chest pain
• Sharp
• Worse with deep breath (pleuritic)
• Worse lying flat (supine)
• Better sitting up/leaning forward
• Fever
• Leukocytosis
• Elevated ESR
Pericarditis
EKG Findings
Pericarditis
EKG Findings
ST Elevation
PR Depression
Pericarditis
Diffuse ST elevation
PR depression
Pericarditis
EKG
• Technically, 4 stages of EKG changes

• Stage 1: diffuse ST elevations, PR depressions
• Stage 2 (~1 week later): Normal
• Stage 3: T wave inversions
• Stage 4: Normal
Pericarditis
Physical Exam
• Pericardial friction rub

• Scratchy sound
• Systole and diastole
Pericarditis
Etiology
• Usually idiopathic
• Viral
• Classic cause is Coxsackievirus
• Often follows viral upper respiratory infection (URI)
• Bacterial
• Spread of pneumonia
• Complication of surgery
• Tuberculosis
• Fungal
Pericarditis
Etiology
• Uremic (renal failure)

• Post-myocardial infarction
• Fibrinous (days after MI)
• Dressler’s syndrome (weeks after MI)
• Autoimmune disease (RA, Lupus)
Pericarditis
Treatment
• NSAIDs
• Steroids
• Colchicine
• Inhibits WBCs via complex mechanism
• Useful in gout and familial Mediterranean fever
• Added to NSAIDs to lower risk of recurrence
Myopericarditis
• Myocarditis = inflammation of myocardium
• Similar presentation to ischemia
• Chest pain
• EKG changes
• Increased CK-MB, Troponin
Tamponade
• Accumulation of pericardial fluid
• High pericardial pressure
• Filling restriction of cardiac chambers
• Amount of fluid variable
• Acute accumulation (bleeding): small amount of fluid
• Chronic accumulation (cancer): large amount of fluid
Tamponade
Water Bottle Sign
Tamponade
Causes
• Cancer metastases to pericardium

• Uremia
• Pericarditis
• Trauma
• Treatment: Drainage of effusion
Tamponade
Clinical features
• Distant heart sounds

• Dyspnea
• High left atrial pressure
• Pulmonary edema
• Elevated jugular venous pressure
Tamponade
Clinical features
• Beck’s Triad
• Distant heart sounds
• Elevated JVP
• Hypotension
• Seen in rapidly-developing traumatic effusions
• Severe impairment LV function → low cardiac output
• Slower effusions: Pericardium stretches/dilates
Pulsus Paradoxus
• Classic finding in tamponade
• Systolic BP always falls slightly on inspiration
• Exaggerated fall (>10mmHg) = pulsus paradoxus
• Severe fall = pulse disappears
Public Domain
Pulsus Paradoxus
Inspiration
↑ VR
↑ RV Size
Septum bulges
↓ LV Size
↓ CO
Pulsus Paradoxus
• Also seen in asthma and COPD
• Inspiration: ↓ left sided flow
• Caused by pulmonary pressure fluctuation
• Exaggerated in lung disease
• Normal lungs: 0 to -5mmHg
• Lung disease: Change up to 40mmHg
• Large drop in left sided flow → pulsus paradoxus
Pulsus Paradoxus
Measurement Technique
• Raise cuff pressure until no sounds heard

• NORMAL respirations
• Slowly lower cuff pressure
• First point (P1): intermittent sounds
• Second point (P2): constant sounds
• Pulsus = P1 – P2
Tamponade
EKG
• Sinus tachycardia
• Low voltage – EKG sees less electricity due to effusion
Electrical Alternans
Tamponade
Prominent x descent, Blunted y descent
a
v
a
c v
Blunted y descent
Prominent x descent Poor RV filling
↓ RA pressure in diastole
during RV contraction a
in systole
v
Equalization of Pressures
• Occurs when cardiac chambers cannot relax
• Pressure in RA, RV, LA, LV falls but then abruptly stops
• Seen in tamponade and pericardial constriction
Parameter Normal Tamponade

RA mean 5 20
RV Pressure 20/5 44/20
PCPW Pressure 10 20
Constrictive Pericarditis
www.learningradiology.com, courtesy of Dr. William Herring, MD, FACR. Used with permission.
• Fibrous, calcified scar in pericardium
• Loss of elasticity: stiff, thickened, sticky
• Can result from many pericardial disease processes
• Pericarditis
• Radiation to chest
• Heart surgery
Clinical Features
• Dyspnea
• Markedly elevated jugular venous pressure
• Liver congestion
• May lead to cirrhosis (“nutmeg liver”)
David Monniaux/Wikipedia
Other Features
• Pulsus paradoxus uncommon (~20%)

• High RA, RVEDP, PCPW pressures
• Equalization of pressures
• Pericardial knock
S1 S2
Pericardial
Knock
Kussmaul’s Sign
ac v
• Inspiration → ↑ VR → slight fall in mean JVP

• Kussmaul’s sign = ↑ JVP with inspiration
• Ventricle cannot accept ↑VR
• Constrictive pericarditis
• RV myocardial infarction
• Not seen in tamponade
Pulsus and Kussmaul’s
• Pulsus paradoxus: classic sign of tamponade
• Pulsus in tamPonade
• Kussmaul’s sign: classic sign of constriction
• Also seen in restrictive heart disease
• Kussmaul’s in Konstriction/Restriction
Tamponade Constriction Restrictive

Pulsus Yes No No
Kussmaul’s No Yes Yes
Rapid/prominent y descent
a
c v
Rapid y descent
Rapid filling of RV
Abrupt stop in filling
Myocardium adherent to pericardium

In diastole: rapid relaxation and suction of RA volume
Venous Pressure Findings
Tamponade Constriction
x descent Rapid --
y descent Absent Rapid
Dip and Plateau
Square Root Sign
Right Ventricular Pressure

Rapid filling, abrupt stop
Dip &
Normal Plateau
Constrictive
Pericarditis
Constriction and Restriction
• Constrictive pericarditis/Restrictive heart disease
• Many common features
• Kussmaul’s sign
• Rapid y descent
• Dip and plateau
Aortic Dissection
Jason Ryan, MD, MPH
Aortic Dissection
CT Angiogram
* Images courtesy Dr. James Heilman and Wikipedia; used with permission
Aortic Dissection Adventicia
• Three layers to aorta Media

Intima
• Intima
• Media
• Adventicia
• Dissection → tear in intima
• Blood “dissects” intima and media
Com Carotid
Propagation Brachiocephalic
Subclavian
• Blood enters dissection plane

• Spreads proximal, distal
• Can disrupt flow to vessels
Diaphragm
Illiacs
Types
• Type A
• Involves ascending aorta and/or arch
• Treated surgically
• Type B
• Descending aorta
• Can be treated medically
• Control hypertension/symptoms
• Surgical mortality high
Symptoms
• “Tearing” chest pain radiating to back
Other symptoms
• Propagation to aortic root
• Pericardial effusion/tamponade
• Myocardial ischemia (obstruction RCA origin)
• Propagation to aortic arch
• Stroke (carotids)
• Horner’s syndrome
• Vocal cord paralysis
Recurrent Laryngeal Nerve
• Branch of vagus nerve
• Supplies larynx and voice box
• Compression:
• Aortic dissection
• Massive left atrial enlargement
Other findings
• Blood pressure differential between arms
• Widened mediastinum on chest x-ray
JHeuser /Wikipedia
Diagnosis
• Suggested by history, exam, chest x-ray
• Definitive diagnosis
• CT scan
• MRI
• Transesophageal echocardiogram (TEE)
• D-dimer
• Sensitive but not specific
• Normal value makes aortic dissection unlikely
Risk Factors
General Principles
• Medial layer of aorta

• Tensile strength and elasticity
• Key proteins: collagen and elastin
• Weakness of medial layer → dissection/aneurysms
• Common aneurysm feature: medial damage/destruction
• Vasa vasorum
• Network of small vessels primarily in adventitial layer
• Supplies blood to medial layer in thick vessels (i.e. aorta)
• Thickening (HTN) → weakening of medial layer
Risk Factors
General Principles
• Requires tension on wall

• Common in proximal aorta (near aortic valve)
• High tension from blood moving out of heart
• Worsened by hypertension
• Requires weakness of media layer
• Also caused by hypertension
• Seen in collagen disorders (genetic)
Risk Factors
General Principles
• Cystic medial necrosis

• Development of cysts and necrosis in medial layer
• Occurs to mild degree with aging
• More rapid with:
• Marfan syndrome
• Common in ascending thoracic aneurysms
Risk Factors
Aortic Dissection
• Aortic damage
• HTN - #1 risk factor
• Atherosclerosis
• Thoracic aneurysm
• Abnormal collagen
• Marfan Syndrome
• Ehlers-Danlos
• Others
• Turner Syndrome (bicuspid, coarctation)
• Tertiary syphilis: Aortitis
Aortic Aneurysms
• Dilation/bulge of aorta
• More than 1.5x normal
• Involves all three 3 layers
• Thoracic (TAAs)
• Abdominal (AAAs)
Thoracic Aortic Aneurysms
• Important risk factor for dissection
• Usually occur in proximal/ascending aorta
• Usually seen in association with another disorder
• Marfan, Turner, Bicuspid aortic valve, Syphilis
• Family history of aneurysm important
• May be associated with atherosclerosis
• More common in descending aorta
• Occur in association with atherosclerosis risk factors
• HTN, smoking, high cholesterol
Thoracic Aortic Aneurysms
Symptoms
• Most are asymptomatic

• Can cause aortic regurgitation
• Surgery if size >5.0cm
Abdominal Aortic Aneurysms
• More common than thoracic aneurysms
• Classically taught as a disease of atherosclerosis
• Infrarenal aorta most affected by atherosclerosis
• Also most common site of AAA
• Current research suggests many factors
• Genetic, environmental, hemodynamic, immunologic
Risk Factors
• Smoking: strongest association with AAA

• Males: 10x more common men vs. women
• Age
• Rare before 55
• As high as 5% in men >65
• HTN, hyperlipidemia
• Most are asymptomatic
• Some detected on physical exam
• Pulsatile mass from xiphoid to umbilicus
• Natural history is enlargement → rupture
• Followed with ultrasound or CT scan
• Surgery if >5.0cm
Aortic Rupture
• Usually from trauma
• Most common site is isthmus
Isthmus
Cardiac Tumors
Jason Ryan, MD, MPH
Cardiac Tumors
• Myxoma
• Most common 1° cardiac tumor
• Rhabdomyomas
• Most common 1° cardiac tumor children
• Metastatic tumors
• Most common cardiac tumor overall
Myxoma
Myxoma
• Common in the left atrium (80%)
• Usually attached to atrial septum
• Often at the border of fossa ovalis
• Benign (do not metastasize)
Myxoma
• Mesenchymal cells (undifferentiated cells)
• Endothelial cells
• Thrombus/clot
• Mucopolysaccharides
Myxoma
• Often cause systemic symptoms
• “B symptoms”
• Fevers, chills, sweats
• Can embolize → stroke
ConstructionDealMkting
Myxoma
• May disrupt mitral valve function
• Regurgitation
• Heart failure
• Can sit in mitral valve
• “Ball in valve”
• Mitral stenosis symptoms
• Syncope or sudden death
• Auscultation: Diastolic “tumor plop”
Cardiac Rhabdomyomas
• Tumors of muscle cells
• Benign (do not metastasize)
• Usually children (most <1year)
• Sometimes detected prenatal
• Tumor embedded in ventricular wall
• Most regress spontaneously
• Rare symptoms from obstruction of blood flow
Public Domain
Cardiac Rhabdomyomas
• Associated with tuberous sclerosis (90%)
• Autosomal dominant genetic syndrome
• Mutation in TSC1 or TSC2 gene
• TSC1: Hamartin
• TSC2: Tuberin
• Mutations → widespread tumor formation
Tuberous Sclerosis
• Involves MULTIPLE organ systems
• Numerous hamartomas and other neoplasms
• Seizures – most common presenting feature
• “Ash leaf spots”: Pale, hypopigmented skin lesions
• Facial skin spots (angiofibromas)
• Mental retardation
Tuberous Sclerosis
Herbert L. Fred, MD and Hendrik A. van Dijk

Tuberous Sclerosis
Mohd Hanafi
Hypertrophic
Cardiomyopathy
Jason Ryan, MD, MPH
Names
• Hypertrophic cardiomyopathy (HCM)

• Hypertrophic obstructive cardiomyopathy (HOCM)
• Idiopathic hypertrophic subaortic stenosis (IHSS)
HCM
• Genetic disorder caused by gene mutations
• About 50% cases familial (50% sporadic)
• Autosomal dominant
• Variable expression
• Significant variation in severity of symptoms
• Many variations in location/severity of hypertrophy
Morphologic Variants
Zorkun/Wikipedia
HCM
• Often single-point missense mutations
• Point mutation → altered amino acid in protein
• 15+ genes with 1500+ mutations identified
• Often involve genes for cardiac sarcomere proteins
• Beta-myosin heavy chain (40% cases)
• Myosin binding protein (40% cases)
HCM
Histology
• Myocyte disarray (excessive branching)

• Hypertrophy
• Interstitial fibrosis
Zorkun/Wikipedia
Myokard/Wikipeedia
HCM
Clinical Features
• Many patients asymptomatic

• Heart failure
• Impaired emptying due to LVOT obstruction
• Chest pain (angina)
• Increased O2 demand
HCM
Clinical Features
• Sudden cardiac death

• Abnormal myocytes → ventricular arrhythmias
• Most common cause SCD in young patients
• Syncope
• Arrhythmias may lead to syncope
• Thickened myocardium → LVOT obstruction
HCM
Clinical Features
• Problem #1: Arrhythmia problem

• Thick myocardium vulnerable to arrhythmias
• Most serious is ventricular tachycardia → sudden death
• Exercise (catecholamines) increase risk SCD
• Sudden death in athletes
• Defibrillators for high risk patients
• Avoidance of exercise
HCM
Clinical Features
• Problem #2: Outflow obstruction problem

• Thickened myocardium obstructs blood leaving LV
• Same physics and symptoms as aortic stenosis
• Heart failure, chest pain, exercise-induced syncope
• Treated with surgery
• Beta blockers (↓ contractility)
• Ca blockers (verapamil)
HCM
Clinical Features
• #3: Mitral valve problem

• High velocity in LVOT tugs mitral valve chords and leaflets
• Causes systolic anterior motion (SAM) of mitral valve
• Over time this leads to mitral regurgitation
HCM
Clinical Features

• Caused by outflow tract obstruction
• Sounds just like AS unless you do maneuvers
• Lots of associated abnormal heart sounds
• S4
• Holosystolic murmur of MR
• Paradoxical split S2
S1 S2
HCM
Maneuvers
• For any HCM maneuver, think about size of LV

• ↑ LV size → ↓ murmur
• ↓ LV size → ↑ murmur
HCM
Maneuvers
• Valsalva
• Patient bears down as if having a bowel movement
• Or blows out against closed glottis
• Increase thoracic pressure → compression of veins → ↓ VR
• Less VR → Less preload → Smaller LV cavity
• Obstructing septum moves further into the outflow tract
• Murmur INCREASES in intensity
HCM
Maneuvers
• Squatting
• Forces blood volume stored in legs to return to heart
• Preload rises → size of LV increases → less obstruction
• Murmur DECREASES in intensity
Wikipedia
HCM
Other maneuvers
• Raising the legs

• Increases venous return
• More VR → More preload → Bigger LV cavity
• This moves the obstructing septum out of the way
• Murmur DECREASES in intensity
• Standing
• Opposite mechanism of leg raise
• Murmur INCREASES in intensity
Aortic Stenosis
• Both HCM and AS cause a systolic ejection murmur
• Less effect of maneuvers on aortic stenosis
• Fixed obstruction
• Opposite effects of maneuvers in aortic stenosis
• Less preload → less flow → quieter AS murmur
HCM
Maneuver Summary
• Valsalva → INCREASE
• Standing → INCREASE
• Squatting → DECREASE
• Leg Raise → DECREASE
HCM
Associations
• Maternal diabetes
• Infants: transient hypertrophic cardiomyopathy
• Usually thickening of interventricular septum
• May have small LV chamber → obstruction in newborn
• Resolves by a few months of age
HCM
Associations
• Friedreich Ataxia
• Autosomal recessive CNS disease
• Trinucleotide repeat disorder
• Spinocerebellar symptoms
• Often have concentric left ventricular hypertrophy
• Also septal hypertrophy
Cardiac Hypertrophy
Other Causes
• Hypertension
• Valve disease
• Athlete’s heart
Pixabay
Cardiac Hypertrophy
Rare Pathologic Causes
• Fabry Disease
• Lysosomal storage disease
• Deficiency of α-galactosidase A
• Neuropathy, skin lesions, lack of sweat
• Left ventricular hypertrophy
Cardiac Hypertrophy
Rare Pathologic Causes
• Pompe Disease
• Glycogen storage disease (develops in infancy)
• Acid alpha-glucosidase deficiency
• Enlarged muscles, hypotonia
• Cardiac enlargement
Endocarditis
Jason Ryan, MD, MPH
Endocarditis
• Inflammation of endocardium of heart
• Usually involves cardiac valves
• Often causes new regurgitation murmur
• Consequence of bacteremia
Endocarditis
Echocardiogram
General Symptoms
• Fever
• Chills
• Sweats
• Petechiae
• Small vessel inflammation
• Leakage of blood
James Heilman, MD
Regurgitant Valve Disease
Embolic Symptoms
• Brain (stroke)
• Spinal cord (paralysis)
• Eye (blindness)
• Legs (ischemia)
• Splenic or renal infarction
• Pulmonary embolism (tricuspid)
• Coronary artery (acute myocardial infarction)
Endocarditis Stigmata
• Physical exam findings in endocarditis
• Caused by septic emboli and immune complexes
• Very rare in modern era
Endocarditis Stigmata
• Roth spots
• Retinal lesions
• Red with pale center
• Osler nodes
• Painful bumps on pads of fingers and toes
• Janeway lesions
• Nontender red macules on palms and soles
• Splinter hemorrhages
• Reddish-brown lines under fingernails
Diagnosis
• Major Duke Criteria
• Positive blood cultures
• Vegetation on echocardiogram
• Minor Criteria
• Fever
• Risk factors
• Roth spots, Osler nodes, Janeway lesions, splinters
• 2 major, 1 major 3 minor, or 5 minor
Microbiology
• Staphylococcus aureus
• Viridans streptococcus
• Streptococcus Bovis
• Enterococcus
• Staphylococcus epidermidis
• Culture negative endocarditis
• Libman-Sacks
Joydeep/Wikipedia
Staph Aureus
• Gram positive cocci
• Catalase positive
• Coagulase positive
• May infect tricuspid valve in IV drug users
Iqbal Osman/Flikr
Staph Aureus
• Causes acute endocarditis
• Rapid, severe infection
• Symptoms occur over days
• Can occur in patients with normal heart valves
• No pre-disposing valvular heart condition
Viridans Streptococcus
• Group of gram positive cocci
• S. mitis, S. mutans, S. sanguinis
• Catalase negative
• Mouth flora
• Endocarditis may occur after dental procedure
• Low virulence bacteria
• Often affect damaged valves
• Bacteria synthesize dextran
• Dextran adheres to fibrin
• Fibrin found with endothelial damage
• Classic predisposing condition: mitral valve prolapse
• Causes subacute endocarditis
• Less severe symptoms
• Symptoms occur over days to weeks
Streptococcus Bovis
• Lancefield group D
• Normal gut bacteria
• Associated with colon cancer
• All subtypes associated with cancer
• Strongest association: S. gallolyticus (S. bovis type 1)
Enterococcus Endocarditis
• Lancefield group D
• Normal gut bacteria
• Usually a subacute endocarditis course
• Commonly occurs in older men
• Associated with manipulation of GI/GU tract
• Abdominal surgery
• Urinary catheter
• TURP for treatment of BPH
Prosthetic Valve Endocarditis
• Occurs with mechanical or biologic valves
• Rarely cured with antibiotics
• Usually requires repeat valve surgery
• Similar bacteria to native valve endocarditis
• Staphylococcus epidermidis
• Rarely cause endocarditis except in prosthetic valves
Stif Komar/Wikipedia
Staphylococcus Epidermidis
• Catalase positive
• Coagulase negative (unlike S. Aureus)
• Most common coagulase negative staphylococcus
• Normal skin flora
• Low virulence
• Commonly cause infection of prosthetic material
• Cardiac valves
• Intravascular catheters
• Prosthetic joints
Culture Negative Endocarditis
• Evidence of endocarditis with sterile blood cultures
• Caused by rare bacteria difficult to culture
• Coxiella burnetii
• Bartonella
Y tambe/Wikipedia
Coxiella Burnetii
• Zoonotic bacteria (transferred from animals)
• Obligate intracellular bacteria
• Found in farm animals
• Cattle, sheep and goats
• Abortions in farm animals: Coxiella placenta infection
• Humans inhale aerosolized bacteria from animals
• Causes Q fever
Coxiella Burnetii
• Acute Q fever
• Flu-like illness
• May present as pneumonia
• More than half of cases: no symptoms
• Chronic Q fever
• Most common manifestation is endocarditis
Bartonella
• Bartonella quintana
• Small, gram-negative rod
• Transmitted by lice
• Patients with poor hygiene
• Bartonella henselae BruceBlaus/Wikipedia
• Found in cats
• Causes cat scratch fever
Inge Wallumrød/Pexels.com
NBTE
Non-bacterial, thrombotic endocarditis
• Libman-Sacks Endocarditis or Marantic endocarditis

• Lesions on valves that look like endocarditis
• Found on both sides of valve
• Mitral valve most common
• Formed by thrombus, immune complexes
• Seen in hypercoagulable states
• Advanced malignancy
• Systemic lupus erythematosus
NBTE
Non-bacterial, thrombotic endocarditis
• Often asymptomatic identified at autopsy

• Rarely cause regurgitation or murmurs
• Thrombus easily dislodges → embolization
• Most patients asymptomatic until embolism occurs
• May embolize to spleen, kidney, skin, extremities
• May cause stroke
• Can cause myocardial infarction
Bacterial Endocarditis
Treatment
• Several weeks appropriate antibiotics

• Broad spectrum antibiotics initially
• Drug therapy changes when bacteria identified
• Valve surgery sometimes required
• Large vegetation
• Severe valve disease → heart failure
Bacterial Endocarditis
Complications
• May form abscess beneath valve annulus

• Persistent fever, bacteremia often indicates abscess
• Aortic valve abscess can lead to heart block
• AV node dysfunction
Prophylaxis
• Primary prevention for bacterial endocarditis
• Done before high-risk medical procedures
• Antibiotics given to some high-risk patients
• New guidelines restrict to highest risk circumstances
Scotth23/Pixabay
Prophylaxis
Conditions Procedures
Prosthetic valves
Dental work
Prior endocarditis
Respiratory procedures
Cyanotic congenital heart disease
Skin surgery
Heart transplants
Amoxicillin
Clindamycin

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Cardiac Anatomy

Jason Ryan, MD, MPH

Right Ventricle → Anterior

Left atrium → Posterior

End diastolic Volume End systolic Volume

Hearts starved for O2 → Reduce O2 demand

• Fast HR shortens diastole

• Preload rises with exercise

• Sympathetic stimulation → phosphorylates PLB

Sympathetic ↓/- DBP

↑ Contractility ↑ HR ↑ Lusitropy Venous Arteriole

Velocity * Area = Flow

Resistance = resistance to flow

Stiff Vessels Stretchy Vessels

High resistance = low compliance (vice versa)

↑ resistance = ↑ pressure to maintain flow

Changes in radius → large change in resistance

Human organs arranged in parallel

For two resistances (2 and 2), what is total R?

• Used to calculate resistance, CO, or ΔP

TPR = ΔP = MAP – RAP = 105 – 5 = 20

Flow = Velocity * Area

Flow = Vel * Area

Afferent = Arrive at the brain

Tricks carotid sinus into thinking ↑ BP

Tricks carotid sinus into thinking ↓ BP

Tricks brain into thinking ↓ BP

Carotid Massage ↑BP ↓HR,↓BP

• In tachycardia, less time in diastole → less flow

• Epicardium → site of coronary arteries

Kidney, brain, heart: Excellent autoregulation systems

↑ capillary pressure, ↑ Pc (heart failure)

a wave = Atrial contraction

Preload (LVEDP, LVEDV)

Preload (LVEDP, LVEDV)

Right Atrial Pressure

Right Atrial Pressure

↑ Total peripheral resistance

Right Atrial Pressure

TPR change shifts curve right/left

Right Atrial Pressure

Right Atrial Pressure

Right Atrial Pressure

Right Atrial Pressure

• Endothelial injury or dysfunction

• Branch points and vessel origins (ostia)

• Smooth muscle cells proliferate in intima

• Blood enters ischemic tissue

SYMPTOMS WITH EXERTION

Subtotal Occlusion Total Occlusion

Subendocardial Ischemia Transmural Ischemia

Limited distal flow

• Many causes other than CAD

Seen only with transmural ischemia

Normal Acute Hours 1-2 Days 3-7 Days > 7 Days

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Coronary angiogram: Before Coronary angiogram: After

• Free wall rupture

• More common anterior infarction