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Flashcard 150919457

Tags
#2015 #book-2 #cfa #cfa-level-1 #economics #schweser
Question
In the [...] run, if price is less than ATC, the firm has economic losses and will minimize losses in the [...] run by going out of business and reducing ongoing losses to zero.
Answer
long

statusnot learnedmeasured difficulty37% [default]last interval [days]               
repetition number in this series0memorised on               scheduled repetition               
scheduled repetition interval               last repetition or drill

Parent (intermediate) annotation

Open it
In the long run, if price is less than ATC, the firm has economic losses and will minimize losses in the long run by going out of business and reducing ongoing losses to zero.</

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Annotation 1343213407500

ARIA is a developing standard that lets you supply extra information for screen readers through attributes on any HTML element.
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Annotation 1343214456076

role attribute, which indicates the purpose of a given element.
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Annotation 1343233068300

Contractility “ the inherent capacity of the myocardium to contract independently of changes in preload or afterload” Preload “the load present within the heart before contraction has started (i.e. at the end of diastole)” Afterload “the systolic load on the heart after it has started to contract; the sum of arterial blood pressure, aortic compliance, and obstructive lesions”
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Annotation 1343234641164

Frank-Starling Mechanism “Increasing left ventricular preload will be matched by increases in stroke volume”
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Annotation 1343236476172

Pathology of Aortic stenosis:
-congenital bicuspid valve
-degenerative (Ca & fibrosis restricts valve opening)
  • calcific (wear & tear)
  • ​rheumatic
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Annotation 1343238049036

Pathophysiology
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Annotation 1343240146188

Pressure Hypertrophy 13 Left ventricular pressure overload induces genes that promote concentric hypertrophy Concentric hypertrophy increases contractile force while normalizing wall stress… … but ultimately results in a “musclebound” heart that does not fill normally (diastolic dysfunction) and is unable to increase stroke volume in response to demand Critical aortic stenosis = fixed cardiac output
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Annotation 1343242243340

Progression of aortic stenosis:
-50% reduction in valve orifice results in minimal pressure gradient
-Increments beyond this produce exponential increases in gradient
-Progression is variable between individuals
-Careful, frequent follow-up is important
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Annotation 1343243816204

Angina Pectoris Syncope (especially effort-related syncope) Dyspnea (heart failure) 16
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Annotation 1343245389068

Angina Pectoris 17 ↑Demand -left ventricular hypertrophy -myocardial O2 uptake - wall stress
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Annotation 1343246961932

Syncope:
-Classically exertional
---Cardiac output is fixed and cannot rise with exercise
---Vasodilation occurs during exercise → Blood pressure & cerebral perfusion fall

-May also be from arrhythmia
---Tachycardia (ventricular or atrial)
---Bradycardia (heart block)
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Annotation 1343248534796

Dyspnea Left ventricular hypertrophy diastolic dysfunction Progressive left ventricular dilation and contractile failure systolic dysfunction Signs and symptoms of heart failure (dyspnea on exertion, orthopnea, edema, pleural effusions)
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Annotation 1343250107660

Sudden Death ~0.3% per year in the asymptomatic patient Mechanism = malignant tachy- or bradyarrhythmia
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Annotation 1343251680524

Long asymptomatic “latent” period Onset of symptoms indicates a poor prognosis unless treated
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Annotation 1343253253388

Possibile “Gallivardin’s dissociation
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Annotation 1343254826252

AORTIC STENOSIS: SEVERITY
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Annotation 1343256399116

A common congenital heart lesion ~1.5% of males, ~0.8% of females Prone to both aortic stenosis and regurgitation Associated with ascending aortic aneurysm, and a risk factor for aortic dissection Rarely associated with aortic coarctation (whereas the majority of instances of coarctation are associated with bicuspid aortic valves) At risk for aortic valve endocarditis 25
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Annotation 1343257971980

Diagnosis ECG LA enlargement, LV hypertrophy Chest X-ray post stenotic aortic dilation, Ca ++ • Echocardiogram • Thickening and restricted motion of leaflets • Gradient and valve area can be calculated • Cardiac catheterization • Gradient across valve and valve area • Stress testing • For prognosis
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Annotation 1343259544844

-Medical therapy for Aortic stenosis is basically non-existent
-Mechanical problem = mechanical treatment
-Afterload-reducing drugs are contraindicated
---BP = CO x resistance (by reducing resistance, BP will shoot down b/c CO can't increase to compensate)
-Mild to moderate asymptomatic aortic stenosis:
---Close follow up: history, exam, echocardiogram
---Warn re: endocarditis risk
---Treat associated atherosclerotic risk factors
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Annotation 1343261117708

Why is aortic stenosis important? Common Major clinical implications Highly morbid once symptomatic Treatable
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Annotation 1343262690572

Common Errors Failure to distinguish aortic sclerosis from stenosis Failure to diagnose and / or investigate Failure to act once symptoms arise Prescription of afterload-reducing drugs Abrupt reduction in preload / afterload (e.g. upon induction of a general anesthetic)
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Annotation 1343264263436

aortic regurg:
Etiology Diseased valve cusps calcific degeneration, bicuspid, rheumatic Diseased aortic root hypertension with annulo-aortic ectasia, hereditary aortopathies, connective-tissue disorders, Marfan syndrome, syphilis Acute pathologies aortic dissection, trauma, endocarditis, prosthetic valve failure
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Annotation 1343267147020

aortic regurg:
Pathophysiology - Acute Acute volume overload results in markedly elevated filling pressure The left ventricle does not have time to enlarge and accommodate Stroke volume rises modestly, inadequate to compensate for the regurgitant volume High left ventricular filling pressure is transmitted back to the left atrium, resulting in pulmonary congestion Forward cardiac output falls
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Annotation 1343269768460

Pathophysiology - Chronic With time, genes are activated allowing increases in both left ventricular cavitary dimensions and wall thickness – described as eccentric hypertrophy or “cor bovinum” A very large total stroke volume allows forward output to remain normal; clinical features of wide pulse pressure are present The dilated ventricle accommodates larger volumes at a lower filling pressures, and pulmonary congestion is generally absent Ejection fraction remains normal during this phase May remain compensated for decades
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Annotation 1343271341324

Chronic severe aortic regurgitation will eventually result in left ventricular fibrosis and systolic dysfunction

As the ventricle dilates further, wall tension and filling pressure rise

Ejection fraction falls, reducing stroke volume and forward output

Irreversible structural changes may occur prior to the development of symptoms
-one of the insidious features of regurgitation is that by the time sx's occur, you're already in big trouble
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Annotation 1343272914188

Natural History
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Annotation 1343275011340

Natural History Asymptomatic phase may last decades Adverse ventricular remodeling is often asymptomatic (initially) Symptoms associated with reduced left ventricular ejection fraction Exercise intolerance Dyspnea on exertion Angina (rare) Sudden death (rare)
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Annotation 1343277108492

Palpitations – due to hyperdynamic stroke volume, heart interactions with the chest wall, and possibly extrasystoles Heart failure – dyspnea on exertion, orthopnea, peripheral edema, fatigue Angina Pectoris, Syncope (rare in isolated aortic regurgitation) 38
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Annotation 1343278681356

Hyperdynamic precordium May radiate widely in a “sash” from R base to apex Associated with cardiomegaly and S 3 Multiple peripheral findings of large stroke volume
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Annotation 1343280254220

Diagnostic Tests ECG - almost always shows LVH Chest x-ray - cardiomegaly Echocardiogram Cardiac catheterization
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Annotation 1343281827084

Medical Management Surveillance Echocardiography follow LV size and function every few years if AR is mild, every 6-12 months if severe Avoid bradycardia – (prolonged diastole worsens regurgitation) Vigilance against endocarditis Diuretics - furosemide (Lasix) Vasodilators - nifedipine, ACE-inhibitors, hydralazine controversial - may reduce slope of decline in left ventricular function
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Annotation 1343283924236

ndications for Surgical Management Definite Symptomatic with normal ejection fraction Symptomatic or asymptomatic with mildly decreased ejection fraction Very Probable Asymptomatic with normal ejection fraction but severe left ventricular dilation Probable Severe left ventricular systolic dysfunction
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Annotation 1343285759244

Common Errors Failure to monitor for asymptomatic but irreversible adverse left ventricular remodeling Over-reliance on medications once symptoms or adverse remodeling occur
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Annotation 1343287332108

Valve Surgery bioprosthetic valve mechanical valve
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Annotation 1343288904972

Surgical Risks Peri-operative mortality ~ 2-4% for aortic valve replacement Mortality rate increases with: Age Poor left ventricular systolic function Associated valve disease Associated coronary artery disease Post-op prognosis fairly good Mechanical valve structural failure is rare Tissue valves eventually deteriorate
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Annotation 1343290477836

Percutaneous Valve Intervention Balloon aortic valvuloplasty and trans-catheter aortic valve implantation
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Annotation 1343292050700

Late Complications Systemic thromboembolism - 1- 2%/year (Less frequent in bioprosthetic valves) Mechanical valve thrombosis - 0.5%/year usually from inadequate anti-coagulation can be treated with thrombolysis or surgery Heart block Prosthetic valve endocarditis - 0.5- 1.0%/year
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Annotation 1343293623564

Aortic stenosis → pressure overload
--“Concentric hypertrophy”
--Operate for symptoms

Aortic regurgitation → volume overload
--“Eccentric hypertrophy”
--Operate for adverse ventricular remodeling
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Annotation 1343295196428

Etiology Almost always rheumatic (immunologic sequelae of Group A Streptococcal pharyngitis) Rheumatic fever usually occurs in childhood / adolescence Murmur appears ~ 20 years later Many don’t recall childhood illness Rheumatic valve disease is more common and progresses more rapidly in developing countries
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Annotation 1343296769292

Etiology of mitral stenosis

Rare causes: Calcified mitral annulus, Atrial myxoma, Endocarditis, Carcinoid valvulopathy, Congenital
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Annotation 1343298342156

Pathology – Rheumatic Mitral Stenosis Fibrotic, rigid mitral leaflets Fused valve commissures Short, thick, fused chordae tendinae Calcification of leaflets Aschoff nodules on histology
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Annotation 1343299915020

Pathophysiology Obstruction to mitral inflow accentuates the pressure gradient from left atrium to left ventricle during diastole, resulting in elevated left atrial pressure Left atrial pressure overload causes: Pulmonary hypertension and interstitial / alveolar pulmonary edema due to back-transmission of pressure Left atrial dilation, resulting in 1. blood stasis and propensity for thromboembolism, and 2. risk of atrial fibrillation
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Annotation 1343301487884

Now, all the people who visit your page get the enhanced experience with the pop up microformat button, no matter what browser they use.
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Annotation 1343302536460

The second most popular microformat is hCalendar, a simple way of marking up events.
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Annotation 1343304109324

Pathophysiology of mitral stenosis:

-A pulmonary capillary wedge pressure of 25mmHg causes transudation of fluid into alveoli, resulting in dyspnea

-Increases in pulmonary venous and capillary pressures raise pulmonary artery systolic pressure (pulm HTN)
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Annotation 1343305682188

pulmonary hypertension right ventricular dilation tricuspid regurgitation ↑ pulmonary capillary wedge pressure R
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Annotation 1343307255052

Severity Mild Moderate Severe Mean Gradient <5 mmHg 5-10 mmHg >10 mmHg Valve Area >1.5 cm 2 1.0-1.5 cm 2 <1.0 cm 2 Symptoms with vigorous exertion with activity with minimal activity * Gradients depend on diastolic filling time and cardiac output * Loss of atrial contraction e.g. in atrial fibrillation often results in marked worsening of symptoms
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Annotation 1343308827916

Complications of mitral stenosis:

-Pulmonary edema & hemoptysis
-Atrial fibrillation and cardioembolism
-Right heart failure
-Endocarditis
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Flashcard 1343310400780

Question
The second most popular microformat is [...]
Answer
hCalendar, a simple way of marking up events.

statusnot learnedmeasured difficulty37% [default]last interval [days]               
repetition number in this series0memorised on               scheduled repetition               
scheduled repetition interval               last repetition or drill

Parent (intermediate) annotation

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The second most popular microformat is hCalendar, a simple way of marking up events.

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Annotation 1343311711500

Signs of pulmonary hypertension may coexist Inconspicuous LV apex Augmented S 1
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Flashcard 1343313022220

Question
The second most popular microformat is hCalendar, a simple way of marking up [...]
Answer
events.

statusnot learnedmeasured difficulty37% [default]last interval [days]               
repetition number in this series0memorised on               scheduled repetition               
scheduled repetition interval               last repetition or drill

Parent (intermediate) annotation

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The second most popular microformat is hCalendar, a simple way of marking up events.

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Annotation 1343314857228

ECG
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Flashcard 1343316430092

Question
What is microdata?
Answer
Microdata is a third take at solving the challenge of semantic markup.

statusnot learnedmeasured difficulty37% [default]last interval [days]               
repetition number in this series0memorised on               scheduled repetition               
scheduled repetition interval               last repetition or drill

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Annotation 1343317478668

CXR Splayed carina Straight left heart border (pulmonary artery dilation and enlarged left atrial appendage) Pulmonary venous congestion
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Annotation 1343319313676

Medical Therapies Reduce pulmonary congestion diuretics, e.g. furosemide Prevent / treat atrial fibrillation anti-arrhythmics, e.g. amiodarone Prevent embolism anticoagulation, e.g. coumadin Prevent / treat endocarditis oral hygiene early recognition & treatment
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Annotation 1343321410828

New York Heart Association (NYHA) functional class:

I - no limitation
II - slight limitation, symptoms with ordinary activity
III - marked limitation, symptoms with less than ordinary activity
IV - symptoms at rest or any activity
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Annotation 1343324818700

Indications for Intervention in mitral stenosis:

-Definite
---NYHA III-IV & valve area < 1.5 cm^2

-Very Probable
---Severe mitral stenosis (< 1.0 cm^2 ) & severe pulmonary hypertension (pulmonary artery pressure > 60-80 mmHg) & NYHA I-II

-Probable
---Asymptomatic patients with moderate or worse mitral stenosis (< 1.5 cm^2 ) with new onset atrial fibrillation
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Annotation 1343327177996

Percutaneous Balloon Valvuloplasty
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Annotation 1343328750860

Surgery for Mitral Stenosis

-Mechanical vs. bioprosthetic valves
---durability vs. anti-coagulation

-Mechanical valve thromboembolic complication rate ~ 3%/year

- ~30% of bioprosthetic mitral valves fail at 10 years

-mitral prostheses tend to last less than aortic ones b/c thrombotic rate is higher
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Annotation 1343331372300

Etiology of mitral regurg:

-Leaflets/chordae
---Myxomatous (becomes progressively floppy), Rheumatic, Endocarditis (gets chewed up), Congenital

-Annulus
---Left ventricular dilation (cardiomyopathy)

-Papillary muscles
---Ischemia or infarction
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Annotation 1343333207308

Pathophysiology of chronic mitral regurg

-A state of left ventricular and left atrial volume overload

-Left ventricular systolic function may remain normal for years until fibrosis and progressive dilation herald a decline in ejection fraction

-The low-pressure left atrial “outlet” is a form of afterload reduction - and may mask clinical deterioration
---Left ventricular ejection fraction may be normal despite impaired contractile function
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Annotation 1343335042316

Pathophysiology of chronic mitral regurg:

-Reduced left ventricular ejection fraction in mitral regurgitation is serious... and indicates a poor prognosis regardless of treatment!

-When ejection fraction declines, diastolic filling pressures, left atrial & pulmonary pressures rise, Causing the left ventricle to dilate, increasing afterload further... creating more mitral regurgitation
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Annotation 1343337139468

Pathophysiology (acute) Sudden volume overload Left ventricle and left atrium are not ready (no dilation, no hypertrophy) ↑ preload, ↓ afterload ↑ contractility (Frank-Starling mechanism, sympathetic activation) ↓ forward cardiac output, ↑ pulmonary capillary wedge pressure pulmonary edema, shock
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Annotation 1343340285196

Acute vs. Chronic mitral regurgitation
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Annotation 1343341858060

Clinical Features of mitral regurg:
-Fatigue
-Exertional dyspnea
-Orthopnea
-Edema
-Paroxysmal nocturnal dyspnea
-Palpitations
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Annotation 1343344217356

Murmur PANsystolic - from S 1 to beyond S 2 • High gradient, high pitch • If severe, associated with S 3 and diastolic flow rumble Elevated left atrial pressure Cardiac apex is dilated and displaced May feel a thrill Lungs may be wet
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Annotation 1343346052364

Diagnosis ECG Left atrial enlargement, left ventricular hypertrophy +/- atrial arrhythmias CXR Cardiomegaly, atrial dilation, pulmonary venous congestion Echocardiography Cardiac catheterization
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Annotation 1343347887372

Medical Therapy of mitral regurg:

-Treat the underlying cause (if possible)
-Afterload reduction e.g. ACE inhibitors
---however, little if any benefit in delaying surgery (fundamental rx is surgery)
-Preload reduction: diuretics & nitrates
-Endocarditis recognition and treatment
-Anti-arrhythmics and anti-coagulants (for complications)
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Annotation 1343349722380

Surgical Therapy (mitral regurg)

-Valve repair:
---for myxomatous degeneration / prolapse; less successful in other etiologies
---good outcomes in selected patients
---preferable

-Valve replacement: Mechanical vs. bioprosthetic
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Annotation 1343351295244

Indications for Surgery Definite Acute symptomatic mitral regurgitation NYHA II-IV & normal ventricular function Symptomatic or not with left ventricular systolic dysfunction Surgery is relatively contraindicated in the context of severe ventricular dysfunction
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Annotation 1343353654540

Surgical Outcomes Operative mortality ~ 6% Repair associated with: Better long-term survival Greater freedom from thromboembolism Less risk of bleeding Less risk of endocarditis Long-term outcomes are related to underlying cause
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Annotation 1343355751692

Mitral stenosis → Lt ventricular underfilling, pulm edema
-Balloon or surgery for symptoms

Mitral regurgitation → Left ventricular volume overload
-Operate for adverse ventricular remodeling or symptoms
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Annotation 1343357586700

Transient Bacteremia (exposure) + Predisposing Cardiac Lesion (diathesis) (abn leaky flow, turbulent flow, etc) = Infective Endocarditis
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Annotation 1343359159564

Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival & nailbed hemorrhages, Janeway lesions (painless, on hands and feet) Immunological phenomena: glomerulonephritis, Roth spots (retinal infarcts), positive rheumatoid factor, Osler’s nodes (painful, on hands and feet),
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Annotation 1343360732428

Modified Duke Criteria for Endocarditis Major Criteria Positive blood cultures with typical organism Evidence of endocardial involvement (by echocardiography) Minor Criteria Predisposition Fever Vascular phenomena Immunologic phenomena Microbiological evidence
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Annotation 1343362305292

Treatment of Endocarditis:

-Targeted parenteral animicrobial therapy
---Narrow-spectrum, intensive, synergistic
---Depends on culture and sensitivity!
-Eliminate portal of entry (if possible)
-Valve surgery
---For hemodynamic compromise
---For recurrent embolism
---For large and highly mobile vegetations
---For prosthetic valve endocarditis
---For fungal endocarditis
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Annotation 1343364402444

Common Errors Failure to recognize asymptomatic left ventricular dysfunction in the context of mitral regurgitation Failure to anticoagulate for atrial fibrillation in the context of rheumatic mitral stenosis Failure to provide bridging anticoagulation for mechanical valvular prostheses Failure to recognize and treat infective endocarditis
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Annotation 1343366237452

Choosing Wisely It is cost-ineffective, unwarranted, and / or inadvisable to perform routine echocardiography in: Asymptomatic patients with innocent murmurs Asymptomatic patients with mild aortic stenosis more often than every 3-5 years Asymptomatic patients with mild mitral regurgitation and normal ventricular size and function
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Annotation 1343368858892

Aortic stenosis → pressure overload “Concentric hypertrophy” Operate for symptoms Aortic regurgitation → volume overload “Eccentric hypertrophy” Operate for adverse ventricular remodeling
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Annotation 1343370431756

Mitral stenosis → Balloon or surgery for symptoms Mitral regurgitation → Left ventricular volume overload Operate for adverse ventricular remodeling or symptoms
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Annotation 1343375150348

Cardiac Valve Surgery Durability v.s. thromboembolic risk Replacing one disease with another Endocarditis Clinical manifestations and diagnostic criteria Exposure + Diathesis model Prophylaxis guidelines
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Article 1343376985356

History of the United States
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History of the United States From Wikipedia, the free encyclopedia "American history" redirects here. For the history of the continents, see History of the Americas. Part of a series on the History of the United States Timeline[hide] Prehistory Pre-Colonial Colonial period 1776–1789 1789–1849 1849–1865 1865–1918 1918–1945 1945–1964 1964–1980 1980–1991 1991– present By ethnicity[show] By topic[show] United States portal v t e The date of the start of the history of the United States is a subject of debate among historians. Older textbooks start with the arrival of Christopher Columbus in 3 August 1492 and emphasize the European background, or they start around 1600 and emphasize the American frontier. In recent decades American schools and universities typically have shifted back in time to include more on the colonial period and much more on the prehistory of the Native peoples. [1] [2] Indigenous people lived in what is now the United State