Cardio Flashcards
Early diastolic murmur
Aortic regurgitation -
Early diastolic murmur (best heard at left sternal edge, with patient sat forward and breath held in expiration). Look for: pulse large volume and collapsing, de Musset's sign (head nodding), Corrigan's sign (visible carotid pulsations), displaced forceful apex beat. Also: check BP (wide pulse pressure). Look for hyperdynamic circulation: Traube's sign 'pistol shot femorals' Quincke's sign of nail bed capillary pulsations, Duroziez's sign of a to-and-fro murmur. Causes: Rheumatic fever, hypertension, atherosclerosis, endocarditis, bicuspid aortic valve. Also associated with: Marfan's syndrome, ankylosing spondylitis, rheumatoid arthritis, syphilis.
Congenital pulmonary valve disease
Downs (trisomy 21)
Noonan (short stature, micrognatia, wideey spaces eyes, ears back)
Turner (X chromosome, short stature and reporuductive failure)
Causes of mitral regurgitation
Degenerative (age related) Underlying MVP - note connective Tissue Disorders IE Rheumatic Fever MI (papillary muscle rupture)
Investiagations to request: mitral regurgitation
ECG, Fundoscopy, Urine dipstick
Bloods - inflammatory markers, FBC (anaemia), U&E
Echo - pulmonary htn, concommitant lesions, ejection fraction
Complications of aortic stenosis
Endocraditis - splinters, ON (finger pulp), JL (palm), Roth spots (retina), temperature, splenomegaly, haematuria
LVD - displaced apex beat, bibasal crackles
Concution problems
DDx ESM
HOCM VSD PS Aortic sclerosis Aortic flow - high output states
Causes of AS
Biscuspid AV (congenital) Aquired (age, rheumatic)
Severity of AS
ASD Angina - 5 Syncope - 3 Dyspnoea - 2 50% mortality
Dukes Criteria for IE
Major –> Typical organism on 2 blood cultures, Echo evidence of IE
Minor –> Pyrexia, echo suggestive, predisposition (e.e.g prosthetic valve), embolic phenomena, vasculitic phenomena (ESR, CRP), atypical organism on blood culture
2 major or 1 major and 2 minor or 5 minor
Management of AS
Asymptomatic - none, good dental health, regular review of symptoms and echo findings to assess gradient and LVF
Surgical - AVR +/- CABG (operative 3-5% mortality
Percutaneous - baloon aortic valvuloplasty or TAVI
NNT for TAVI 5 at 1 year
Investigating ESG
ECG - LVH, conduction defect (e.g. 1*HB)
CXR - ?valvular calcification, ?cardiomegaly
Echo - mean gradient 40mmHg, valve area <1.0 severe
Angiography - ?extent of co-existing CAD
AR eponymous signs
deMussets - head bobbing Corrigans - visible carotid pulsations Quicke's - nail bed pulsation Durosier's - diastolic murmur proximal to femoral artery compression Traube's - pistol shot femoral
DDx aortic regurg
Valve leaflet - endocarditis (acute), rheumatic fever (chroinc)
Aortic root - dissection/trauma (acute), dilatation due to marfans and hypertension, aortitis (ank spond, syphilis, vasculitis
Causes of a collapsing pulse
AR Prednancy PDA Pagets Anaemia Thyrotoxicosis
Investigating AR
ECG - lateral TWi
CXR - cardiomegaly, widened mediastinum
TTE/TOE - severity, LVEF and dimentions, root size, jet width
Cardiac catheterisation - grade severity and check coronary patency
Managing AR
1 Medical - ACE-i and ARBs (reduce afterload)
Regular review - symptoms, echo: LVEF, LV dimentions and degree of AR
Surgery (acute) - dissection, aortic root abscess or endocarditis
Surgery (chronic) - wide pulse pressure >100mgHg, ECG changes on ETT, LV enlargement >5.5 cm systolic diameter, or EF <50%
Ideally aim to replace valve prior to LVD and dilatation
Asymptomatic with EF>50% - 1% mortality and 5 years
Symptomatic of all three criteria - 65% mortality at 3 years
Mitral stenosis on examination
Malar flush, irregular pulse (AF), tapping apex beat, left parasternal heave if PTH ir enlarged left atrium
Loud 1st heart sounds
Opening snap followed by mid diastolic murmur best heart in apex left lateral in expiration with bell.
Haemodynamic - ?PHT, functional TR, RV heave, loud P2
Embolic complications - stroke risk high if MS + AF
Causes and DDx of mitral stenosis
Congenital (rare), acuired - rheumatic heart disease, senile degeneration, large mitral leaflet vegetation from endocarditis
DDx - left atrial myxoma, austin flint murmur
Investigating mitral stenosis
ECG - p mitrale and AF
CXR - enlarged left atirum calcified valve, pulmonary oedema
TTE/TOE - valve area (<1cm severe, cusp mobility, calcification and left atrial thrombus, RVF
Rheumatic Fever
Group A beta haemolytic streptococcus (e.g. strep pyogenes) + immunological cross reactivity with valve tissues
Duckett-Jones criteria - proven B haemolytic strep by throat swab or ASOT
Major - chorea, erythema marginatum, S/C nodules, polyarthritis, carditis
Minor - raised ESR, raised WCC, arthralgia, previous rheumatic fever, pyrexia, prolonger PR interval
Treatment - rest, high dose aspirin and penicillin
Prophylaxis - primary prevention - penV 10 days
Managing mitral stenosis
Medical - AF rate control and anticoagulation, diuretics
Mitral valvuloplasty - if pliable, non calcified and minimal regurgitation and no left atrial thrombus
Surgery - closed mitral valvotoomy (without open heart) or open valvotomy (on bypass) or valve replacement
Prognosis - latent asymptomatic phase 15-20 years, NYHA > 2 = 50% mortality at 5 years
Causes of mitral regurgitation
Acute –> Bacterial endocarditis or chordae/papillae rupture
Chronic –> Degenerative, rheumatic, CTD, fibrosis (pergolide), functional (dilated LV), calcification, infiltration (amyloid), fibrosis
Investigating MR
ECG - p mitrale, atrial fibrillation, previous infarctions
CXR - cardiomegaly, LA enlargement, pulmonary oedema
Echo
Severity (size/density or MR jet, LV dilation and reduced EF
Cause (prolapse, vegetation, ruptured papillae, fibrotic restriction, infarction
Managing mitral regurgitation
Medical - anticoagulation for AF, diuretic, B blocker and ACEi
Percutaneous - mitral clip device for palliation
Surgical - valve repair (preferable) with annuloplasty or replacement
Aim to operate when symptomatic, prior to severe LV dilation and dysfunction
Often asymptomatic for >10 years
25% mortality at 5 years if symptomatic
Mitral valve prolapse
5% in young tall women
Associated with CTD (e.g. marfan’s, HOCM)
Often asymptomatic but may present with chest pain, syncope, palpitations
Small risk emboli and endocarditis
Mid systolic ejection click + pan systolic murmur
Murmur accenuated by standing from squatting position or during valsalva
Tricuspid reguargitation
Raised JVP with giant CV waves, thrill left sternal edge
PSM loudest on inspiration
Pulsatile liver, ascites, peripheral oedema,
Pulmonary HTN - RV heave, loud P2
Other valve lesions = rheumatic mitral stenosis
DDx tricuspid regurgitation
Congenital - Ebsteins anomaly (atrialisation of the RV and TR
Acuired - endocarditis, chronic - functions, rheumatic, carcinoid
Investigating and managing tricuspid incompetence
ECG - p pulmonale and RVH
CXR - double right heart border (enlarged RA)
TTE - TR jet, RV dilation
Management
Medial - diuretics, B blocker, ACEi, support stocking for oedema
Surgical - valve repair (annuloplasty) if medical treatment fails
Pulmonary stenosis
Raised JVP with giant A waves, left parasternal heave, thrill in pulmonary area, ESM loudest in inspiration, widely split S2
RVF
Carcinoid Syndrome
Neuroendocrine tumour - secreting 5HT3 Primary gut, mets in liver Diarrhoea, wheeze and flushing Right sided heart fibrosis and TR +/- PS Treated with octreotide or surgical resection
Managing pulmonary stenosis
Valvotomy if gradient >70mmHg or RVF
Percutaneous pulmonary valve implantation
Surgical repair / replacement
Prosthetic valves - scars
Midline sternotomy - CABG, AVR, MVR
Lateral thoracotomy - MVR, mitral valvotomy, coarctation repair, BT shunt
Subclavicular - PPM
ACF / wrist - angiography
Aortic valve replacement
Metallic click insead of 2
May be opening click and ESM
Bioprosthetic valve has normal heart sounds
Abnormal findings - AR
Mitral valve replacement
Mettalic 1st heart sounds. Opening click in early diastole
Abnormal - MR
Choice of valve replacement and complications
Metal - durable, but needs anticoagulation, young / co-existing AF
Porcine - no warfarin, less durable, elderly / at risk haemorrhage
Operative mortality 3-5%
Thromboembolus - 1-2% VTE despite warfarin
Bleeding - fatal 0.6, major 3% minor 7% annual
Bioprosthetics dysfunctions
Haemolysis
IE
AF
ICD guidelines
Primary prevention
MI >4/52 ago (NYHA 120 ms
or
Familial condition with high risk - LQTS, Brugada, HCM
Secondary prevention
Cardiac arrest 2* to VT or VF
Haemodynamically compromising VT
VT with LVEF <35%
+ Cardiac resynchronisation therapy
Atrial Septal Defect
Fixed split S2 which does not change with respiratory. Pulmonary ESM and mid distolid flow murmur with large left to right shunts
Consider PHT - RV heave and loud P2 + cyanosis and clubbing (Eisenmenger’s R–>L shunt)
Types of
