Cardio Flashcards
1
Q
Common causes of AS
A
- Bicuspid aortic valve (most common cause in the young)
- Degenerative calcification (most common cause in the elderly)
- RHD
- Congenital
- IE
2
Q
DDx of ESM
A
- AS
- HOCM
3
Q
Signs of severity of AS (11)
A
- Low volume pulse
- Slow-rising pulse
- Narrow pulse pressure
- Heaving apex
- Systolic thrill
- Reversed splitting of S2
- Soft or absent aortic component of S2
- S4
- Late systolic peaking of a long murmur
- Signs of pulmonary HTN
- Signs of pulmonary congestion (or cardiac failure)
4
Q
Complications of AS
A
- LVF
- Sudden death
- Pul HTN
- Arrhythmias (AF, VT)
- Heart block (calcification of the conduction system)
- IE
- Systemic embolic complications (disintegration of aortic valve apparatus)
- Haemolytic anaemia
- IDA (Heyde’s syndrome)
5
Q
ECG changes in AS
A
- LVH
- LV strain pattern
- Left atrial hypertrophy (bifid p waves in lead II)
- Left atrial dilatation (inverted of biphasic p waves in V1-V2)
- LAD
- Conduction abnormalities (LBBB, 1st degree Hb)
6
Q
CXR findings in AS
A
- Post-stenotic dilatation of proximal ascending aorta (marked in bicuspid AV)
- Rib notching (sign of coarctation of the aorta, frequently seen with bicuspid AV)
- Calcification of the AV
- Cardiomegaly (late stages)
- Pulmonary congestion
- Prominent pulmonary arteries (pul HTN)
7
Q
Causes of MS
A
- Rheumatic fever (most common)
- Degenerative
Rare:
- Congenital MS
- RA
- SLE
- Carcinoid syndrome
- Fabry’s disease
8
Q
DDx of mid-diastolic rumbling murmur
A
- L) atrial mass
- L) atrial thrombus
- Cor triatriatum
- Severe MR (increased forward flow across the MV)
9
Q
MS signs of severity (6)
A
- Early opening snap (lost with calcified leaflets)
- Increasing length of murmur
- Signs of pulmonary hypertension
- Signs of pulmonary congestion
- Graham-Steel murmur (pulmonary regurgitation)
- Low pulse pressure
- Apical thrill
Other key findings:
- AF (chronicity)
- Malar flush
- Tapping apex beat
- RV heave, loud P2
- Loud S1
- Diastolic rumble at apex
- Concomitant MR/AS/AR
- Soft S1/absent OS (MS/MR)
10
Q
Complications of MS
A
- LA enlargement
- AF
- LA thrombus for
- Pulmonary oedema
- R) HF
11
Q
ECG changes in MS
A
- AF
- L) atrial hypertrophy (bifid p waves in lead II) if in SR
- L) atrial dilatation (inverted or biphasic P waves in V1-V2) if in SR
12
Q
CXR findings in MS
A
- Double right heart border (left atrial enlargement)
- Splaying of the carina (dilated LA)
- Pulmonary congestion
- Prominent pulmonary arteries (pul HTN)
13
Q
Causes of Chronic MR (13)
A
- Rheumatic fever
- MVP
- IE
- LV dilatation (functional MR) - dilated annulus from DCM or pap muscle restriction from infarct/ischemia
- SAM (HCM, concentric LVH)
- Marfan’s syndrome
- Ehlers Danlos Syndrome
- RA
- SLE (Libman-Sachs Endocarditis)
- MAC
- Papillary muscle dysfunction (ischemia or degenerative diseases of the chordae)
- Cardiomyopathies (restrictive, hypertrophic, dilated)
- Osteogenesis imperfecta
- Pseudoxanthoma elasticum
14
Q
Causes of Acute MR (3)
A
- IE
- Rupture of chordae tendinae (IE, acute rheumatic fever, ischemia)
- Trauma
15
Q
Signs of severity of MR (9)
A
- Soft S1
- S3
- S4 (if in SR)
- Displaced apex beat (sign of LV enlargement), volume loaded
- Precordial thrill
- Mid-diastolic flow murmur
- Widely split S2
- Signs of pulmonary HTN
- Signs of pulmonary congestion
16
Q
S3 (lub de dub)
A
- turbulent flow in the ventricles - best heard at apex/LSE
- Due to rapid ventricular filling due to the increased blood volume in the LA due to the regurgitant volume in the previous cardiac cycle.
- normal in young patients (<40YO)
- older patients - HF - LV chordae are stiff and weak so reach their limit quicker than normal.
- MR, HF
17
Q
DDx of pansystolic murmur
A
- MR (apex)
- TR (LSE)
- VSD (LSE)
18
Q
ECG in MR
A
- AF
- LA hypertrophy (bifid P waves in lead II) if in SR
- LA dilatation (inverted or biphasic P waves in V1-V2) if in SR
19
Q
CXR in MR
A
- Double right heart border (LA enlargement)
- LA appendage
- Splaying of the carina (dilated of LA)
- Cardiomegaly
- Pulmonary congestion
- Prominent pulmonary arteries (pulmonary HTN)
20
Q
Causes of chronic AR
A
- Bicuspid aortic valve
- HTN
- Rheumatic fever
- Aortitis (syphilis, Takayasu’s arteritis, Ank Spond, Reiter’s syndrome, Psoriatic arthropathy)
- RA
- SLE
- CTD (Marfan’s syndrome, EDS, pseudoxanthoma elasticum, osteogenesis imperfecta)
- Perimembranous VSD
21
Q
Causes of acute AR
A
- Aortic dissection
- IE
- Ruptured sinus of Valsalva aneurysm
22
Q
Signs of severity of AR
A
- Wide pulse pressure
- Long duration of the decrescendo diastolic murmur
- S3
- Soft S2
- Austin Flint murmur
- Signs of Pulmonary HTN
- Signs of LVF
23
Q
Austin Flint Murmur
A
- Low frequency mid diastolic murmur heard at the apex caused by:
1) the aortic regurgitant jet impinging on the anterior mitral valve leaflet leading to functional MS
2) the LV diastolic pressure rising more rapidly than the LA pressure. - mimics MS - MS can be differentiated by the presence of an opening snap and loud S1. However, the S1 may be loud in AR (reflecting a hyperdynamic circulation), but it is not palpable (as it would be in MS, which would give a tapping apex beat).
24
Q
Corrigan’s sign
A
- visible carotid pulsations in the neck
25
Quinke's sign
- capillary pulsations in the fingernails
26
De Musset's sign
- head nodding with each heart beat
27
Muller's sign
- systolic pulsations of the uvula
28
Causes of collapsing/bounding pulse
- Anaemia
- Fever
- Pregnancy
- Thyrotoxicosis
- PDA
- AVF
- Severe bradycardia
- Severe MR
29
ECG of AR
- Usually no specific findings
| - LVH +/- strain pattern (esp if co-existant aortic stenosis)
30
CXR of AR
- Valvular calcification
- Cardiomegaly
- Pulmonary congestion
- Prominent pulmonary arteries (pulmonary HTN)
31
Anacrotic pulse
- slow volume, slow uptake - AS
32
Plateua pulse
- slow uptake - AS
33
Bisferien's pulse
- mixed AR and AS - collapsing and slow uptake
34
Collapsing (Corrigan's) pulse
- AR, PDA, Hyperdynamic circulation
35
Small volume pulse
- AS, tamponade
36
Alternans pulse
- Alternating strong and weak beats - LVF
37
Pressure loaded apex beat
- AS/HTN
38
Volume loaded apex beat
- MR/AR/DCM
39
Dyskinetic apex beat
- large area of impulse and not co-ordinated - LV failure eg., anterior infarct
40
Double impulse apex beat
- characteristic of HOCM
41
Tapping apex beat
- palpable S1 - early MS/TS
42
Causes of beat no palpable
- normal
- Emphysema
- Obesity
- Tamponade
- Dextrocardia
43
Right Ventricular Hypertrophy Criteria
Right axis deviation of +110° or more.
Dominant R wave in V1 (> 7mm tall or R/S ratio > 1).
Dominant S wave in V5 or V6 (> 7mm deep or R/S ratio < 1).
QRS duration < 120ms (i.e. changes not due to RBBB).
Right ventricular strain pattern with ST depression and T-wave inversion in V1-4.
44
RVH Causes
Pulmonary hypertension
Mitral stenosis
Pulmonary embolism
Chronic lung disease (cor pulmonale)
Congenital heart disease (e.g. Tetralogy of Fallot, pulmonary stenosis)
Arrhythmogenic right ventricular cardiomyopathy
45
RAD Criteria
QRS is POSITIVE (dominant R wave) in Lead II, Lead III and aVF
QRS is NEGATIVE (dominant S wave) in Lead I
46
RAD Causes
```
Left posterior fascicular block
Lateral myocardial infarction
Right ventricular hypertrophy
Acute lung disease (e.g. Pulmonary Embolus)
Chronic lung disease (e.g. COPD)
Ventricular ectopy
Hyperkalaemia
Sodium-channel blocker toxicity
WPW syndrome
Normal in children or thin adults with a horizontally positioned heart
```
47
LAD Criteria
QRS is POSITIVE (dominant R wave) in Lead I
| QRS is NEGATIVE (dominant S wave) in leads II, III and aVF
48
LAD Causes
```
Left anterior fascicular block
Left bundle branch block
Left ventricular hypertrophy
Inferior MI
Ventricular ectopy
Paced rhythm
Wolff-Parkinson White syndrome
```
49
LVH Criteria
Sokolov-Lyon criteria: S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm.
Limb Leads
R wave in lead I + S wave in lead III > 25 mm
R wave in aVL > 11 mm
R wave in aVF > 20 mm
S wave in aVR > 14 mm
Precordial Leads
R wave in V4, V5 or V6 > 26 mm
R wave in V5 or V6 plus S wave in V1 > 35 mm
Largest R wave plus largest S wave in precordial leads > 45 mm
Non Voltage Criteria:
Increased R wave peak time > 50 ms in leads V5 or V6
ST segment depression and T wave inversion in the left-sided leads: AKA the left ventricular ‘strain’ pattern
50
LVH Pathophys
The left ventricle hypertrophies in response to pressure overload secondary to conditions such as aortic stenosis and hypertension.
This results in increased R wave amplitude in the left-sided ECG leads (I, aVL and V4-6) and increased S wave depth in the right-sided leads (III, aVR, V1-3).
The thickened LV wall leads to prolonged depolarisation (increased R wave peak time) and delayed repolarisation (ST and T-wave abnormalities) in the lateral leads.
51
LVH Causes
```
Hypertension (most common cause)
Aortic stenosis
Aortic regurgitation
Mitral regurgitation
Coarctation of the aorta
Hypertrophic cardiomyopathy
```
52
Malar Flush Causes
- MS
- Hypothyroidism
- Cold weather
- Carcinoid syndrome
- SLE
- Systemic Sclerosis
- Irradiation
- Polycythaemia
Malar flush signifies a low cardiac output state with pulmonary HTN, often seen with patients with severe MS.
53
Common cardiac cases:
- MR (27%)
- AS (18%)
- AR (15%)
- HOCM (14%)
- Mixed mitral and Aortic Valve disease (13%)
- Pul HTN +/- TR (13%)
- Congenital Heart Disease (12%)
- VSD (11%)
- Mixed Aortic Valve Disease (10%)
- Prosthetic valve (7%)
- MVP (5%)
- MS (5%)
- Mixed MV disease (4%)
- PR (4%)
54
Pansystolic mumur ddx (3)
- MR
- TR
- VSD
55
Midsystolic murmur ddx (3)
- AS
- PS
- HOCM
56
Early systolic murmur ddx (2)
- VSD (small or large and pul HTN)
| - TR
57
Late systolic murmur ddx (2)
- MVP
| - Papillary muscle dysfunction
58
Early diastolic murmur ddx (2)
- AR
| - PR
59
Mid diastolic murmur ddx (4)
- MS
- TS
- Austin flint murmur of AR, Carey Combs of acute rheumatic fever
60
Pre-systolic murmur ddx (3)
- MS
- TS
- Atrial myxoma
61
Continuous murmur ddx (2)
- PDA
| - AVF
62
S4 (before S1) - Le lub dub
- high atrial pressure reflecting a non-compliant ventricle, e.g., AS, HTN, LVH
- always abnormal
- rare to hear
- stiff and hypertrophic LV
- turbulent flow from atria that is contracting against a non-compliant ventricle
63
10 questions of murmurs
1) Is it systolic or diastolic?
2) Description of murmur:
- if systolic: pan, ejection (harsh, musical), mid systolic
- if diastolic: early decrescendo, mid-diastolic/rumbling (?pre systolic accentuation if in SR)
3) Where is the murmur loudest & where does it radiate?
4) How loud is it? How long is it? Where is the peak?
5) How does the murmur change with respiration? Are any additional manoeuvres required? Valsalva, hand grip
6) How many murmurs? (listen in aortic area/LSE then out the axilla
7) Does S1, S2 or additional HS fit with out diagnosis/severity?
8) Do other findings fit or is there another lesion?
9) Are there additional OS, clicks?
10) How will you grade the severity clinically?
64
Loudness of murmurs (6)
1-2: soft
3-4: moderate
5: loud
6: very loud - can be heard even with stethoscope off the chest wall
65
MS - mid diastolic rumble, loud S1
- mid-diastolic murmur - sometimes louder just before systole.
- tapping apex beat
- opening snap better at base (like widely split S2)
- murmur best heard at apex with patient rolled on left side
- often VERY LOCALISED and DOES NOT RADIATE.
- accentuated by handgrip in mitral area
66
LSE - listen for:
- TR
- PR/PS (also in pulmonary areas
- AR (early diastolic decrescendo)
- HOCM (no radiation to neck, pulse - jerky, +/- MR)
- VSD
*Must listen in inspiration/expiration
67
Gallavardin Phenomenon
- dissociation between the noisy and musical components of the systolic murmur heard in aortic stenosis.
- the harsh noisy component is best heard at the aortic area radiating to the neck due to the high velocity jet in the ascending aorta.
- the musical high frequency component is best heard at the cardiac apex - can be confused with MR.
***However, the apical murmur of the Gallavardin phenomenon is ejection systolic and does not usually radiate to the L) axilla.
68
ASD
- soft ESM
| - Fixed splitting of S2
69
ESM of AS at aortic area
- if quiet but hear an ESM at LSE, think of HOCM.
70
Once cardiac auscultation completed:
* sit patient up:
- percuss and listen to lung bases
- look for sacral oedema
lie patient down:
- feel for liver edge - ? is it pulsatile
- spleen - ? IE
Ankles - gently
Pedal pulses!
71
Causes of TR
```
Usually secondary:
- Functional (RV dilatation), LV failure
- Pulmonary HTN
- PPM leads
Primary tricuspid pathology
- Endocarditis, carcinoid, trauma
- Congenital: ebstein, AV canal, repaired TGA
```
72
Key findings of TR
- JVP: prominent v waves
- RV heave
- Pansystolic murmur at LLSB loudest on inspiration (not always audible)
- Pulmonary HTN (loud P2, RV heave, fixed split S2)
73
TR signs of severity
- Pulsatile liver
- RV failure
- Cirrhosis (ascites)
74
Pul HTN causes (5)
Group 1 - primary PAH:
- scleroderma - hands/face
- ank spond - back
- idiopathic
Group 2 - LV failure
Group 3 - Lung disease - ILD/COPD --> resp exam
Group 4 - CTEPH
Group 5 - mixed/other: myeloprofilerative disorders, sickle cell, thalassaemia, sarcoid, thyrotoxicosis
75
HCM
- ESM max at Erb's point/Aortic region
- Increased with Valsalva (decrease pre-load)
- MR murmur due to SAM
- Pressure loaded apex beat
ECG:
- LVH by voltage
- Prominent septal S/Q waves
- Non-specific ant/inf TWI
- LA enlargement
76
VSD
- Harsh PSM +/- thrill at LLSB
- S3/S4
- Pulmonary HTN
77
ASD
- Fixed, split S2 @ RUSB
- DDx: S3, opening snap
- Pul HTN, RV failure, RV heave, TR
- Tricuspid flow murmur (mid diastolic rumble at LLSE)
- Echo: RV volume overload, TOE/CMR/gated cardiac CT to confirm
Indications for closure:
- unexplained stroke
- Qp:Qs > 2:1
- RV dilation/failure
- Caution with pul HTN (>5 wood units)
78
Austin Flint Murmur
Diastolic (MS) associated with severe AR - due to AR jet impingement on anterior mitral valve leaflet
79
Graham Steele Murmur
Early diastolic murmur of PR, heard at Erb's point
80
What to think of when you can't hear anything:
- MS - listen again at the apex with bell, in L) lateral with handgrip
- Pul HTN - Loud P2, RV heave, RV failure, associated conditions
- ASD - fixed, split S2
- HCM - pressure loaded apex beat, ESM at aortic area with Valsalva
- Dextrocardia - check other side
81
Parvus et tardus
Small volume, slow rising carotid pulse
82
Kussmaul's sign
JVP rise during inspiration (should fall with decreased intrathoracic pressure).
Signifies impaired RV filling (tamponade, RV failure, constriction)
83
Displaced Apex Beat suggests?
Dilated Cardiomyopathy
84
Pressure loaded apex beat
Slow ejection against increased afterload -- ‘forceful and sustained’
Well localised, non-displaced
Causes: AS, HTN, coarctation
85
Volume loaded apex beat
Rapid ejection of increased SV (increased preload) -- ‘Forceful but unsustained’
Diffuse impulse felt over a larger area
Causes: DCM, AR, MR, shunts
86
Iron targets in HF
- Ferritin >100, or between 100-299
AND
- T Sat >20%
*in order to alleviate heart failure symptoms, increase exercise capacity and improve QOL
87
MR Echocardiography (5)
- Thickened leaflets (rheumatic)
- Prolapsing leaflets
- LA size
- LV size and function
- Doppler detection of the regurgitant jet in the LA; colour mapping of jet size and detection of reversal of flow in the pulmonary veins
- Calcification of the mitral annulus - common in elderly
88
MR indications for surgery:
- severe, symptomatic MR
- asymptomatic severe MR + dilated LV (LVESD > 40mm), reduced LVEF (<60%) or pul HTN (PASP >50mmHg)
89
Cardiac Rehab (4)
- Safe exercise
- LOW
- Diet
- Smoking habits
90
Lifestyle modification CVD (4)
- LOW - BMI target 25 - Waist circum <94cm men, <80cm women
- Exercise - 30 mins moderate intensity (brisk walk) at least 5 days/week
- ETOH - 2x std drinks/day
- Salt restriction - decrease snacks
