Cardio Flashcards
Cardiac Causes of Clubbing
- Atrial Myxoma
- Bacterial Infective Endocarditis
- Congenital Cyanotic Heart Disease
Causes of collapsing pulse
- AR
- Thyrotoxicosis
- Pregnancy
- Anaemia
Causes of absent radial pulse
- Dead
- Trauma
- Thrombosis or embolism
- Coarctation of the aorta
- Takayasu’s Arteritis
Causes of impalpable apex beat
- COPD
- Obesity
- Pericardial effusion
- Dextrocardia
What are the features of Pulmonary HTN
- ↑JVP
- Left parasternal heave
- Loud P2 + PSM of TR
- Pulsatile hepatomegaly
- Ascites and peripheral oedema
What are the four heart sounds
- S1: mitral valve closure
- S2: aortic valve closure
- S3: rapid ventricular filling of dilated left ventricle
- S4: atrial contraction against stiff ventricle
What investigations would you want to do at the end of a cardio examination?
- ECG
- Blood
- FBC: anaemia exacerbates cardiac symptoms
- U+E: renovascular disease
- NT-proBNP: heart failure
- Fasting lipids and glucose: cardiac risk
- Trops
- Imaging
- CXR
- Echo
- Cardiac catheterisation
Features of Aortic Stenosis
- Crescendo decrescendo ESM
- Right 2nd ICS
- Radiates to carotids
- Sitting forward in end-expiration
- May be an ejection click in bicuspid valve disease
Features of severe disease:
- Low-volume pulse
- Slow-rising (anacrotic)
- Narrow pulse pressure (<30mmHg)
- Aortic thrill
- Heaving apex
- Reversed splitting of S2
- Soft aortic component of S2
- 4th HS
- Pulmonary HTN
Ddx of AS
- Aortic sclerosis: no radiation, normal pulse character
- MR
- HOCM:
- valsalva ↑s murmur
- squatting ↓s murmur
- Right-sided: PS
- Supra-valvular aortic stenosis (William’s syndrome)
Causes of AS
Common:
- Age-related senile calcification
- Bicuspid aortic valve and other congenital causes
- Rheumatic heart disease
Rare:
- Infective endocarditis
- Hyperuricaemia
- Alkaptonuria
- Paget’s disease
Rx of AS
Clinical signs of severe MR
- LVF
- AF
- Soft first HS
- 3rd and 4th HS
- Displaced apex beat
- Precordial thrill
- Mid-diastolic flow murmur
- Widely split second HS
Murmur in MR
Blowing PSM
Apex
Left lateral position in end-expiration
Radiates to the axilla
DDx for MR
Right-sided: TR
AS
VSD
Causes of MR
Chronic:
- Functional: LV dilatation (e.g. 2O to HTN or idiopathic)
- Annular calcification → contraction
- Rheumatic heart disease
- Mitral valve prolapse
- Connective tissue disorders: Marfan’s, Ehler’s danlos, osteogenesis imperfecta
- Cardiomyopathies
- SLE (Libman-Sachs endocarditis)
- Papillary muscle dysfunction (ischaemia)
Acute
- Rupture of chordae tendinae
- Infective endocarditis
- Trauma
What might you see on ECG and CXR for a patient with MR?
ECG
- AF
- P mitrale (LA hypertrophy)
CXR:
- LA (double right heart border) and LV hypertrophy
- Splaying of the carina (LA dilatation)
- Left atrial appendage
- Mitral valve calcification
- Pulmonary oedema
Echo features for severe MR
Jet width >0.6cm
Systolic pulmonary flow reversal
Regurgitant volume >60ml
Specific Mx of MR
AF: rate control and anticoagulation
Emboli: anticoagulant
↓ afterload
ACEi or β-B (esp. carvedilol)
Diuretics
Valve replacement
Murmur in AR
High-pitched early diastolic murmur
LLSE (3rd left IC parasternal)
Sitting forward in end-expiration
Additional Murmurs:
Ejection systolic flow murmur
Austin-Flint murmur (rumbling MDM @ apex secondary to regurgitant jet fluttering the anterior mitral valve)
Signs of AR
Eponymous Signs
Quincke’s: capillary pulsation in nail beds
Corrigan’s: visible vigorous carotid pulsation
De Musset’s: head nodding
Traube’s: pistol-shot sound over femorals
Duroziez’s
Systolic murmur over the femoral artery ̄c proximal compression.
Diastolic murmur ̄c distal compression
Mueller’s: systolic pulsations of the uvula
Rosenbach’s: systolic pulsations of the liver
Causes of AR
Chronic
- Bicuspid aortic valve
- HTN
- Rheumatic heart disease
- Autoimmune: Ank spond, RA, SLE
- Connective tissue: Marfan’s, Ehler’s Danlos
- Aortitis: Takayasu, syphilis, Reiter’s syndrome
- Perimembranous VSD
Acute
- IE
- Type A Aortic dissection
Indications of valve replacement for AR
Symptomatic: NYHA >2
LV dysfunction
Pulse pressure >100mmHg
ECG changes: T inversion in lateral leads
LV enlargement on CXR or EF <50%
Mitral Stenosis Murmur
Opening snap
Rumbling MDM
Apex - tapping apex
Left lateral position in end-expiration
With the Bell
Radiates to the axilla
Loud first HS
Pre-systolic accentuation if pt. in sinus rhythm
Atrial contraction
Graham Steell murmur (EDM secondary to PR)
ECG Features of Mitral Stenosis
P-mitrale
AF
Criteria for Rheumatic Fever
Revised Duckket Jones Criteria
2 major criteria, or
1 major + 2 minor
Major Criteria
Pancarditis
Arthritis
Subcut nodules
Erythema marginatum
Sydenham’s chorea
Minor criteria
Fever
Raised ↑ESR or ↑CRP
Arthralgia
Prolonged PR interval
Prev rheumatic fever
Rx of Rheumatic Fever
Bed rest until CRP normal for 2wks
Benpen 0.6-1.2mg IM for 10 days
Analgesia for carditis/arthritis: aspirin / NSAIDs
Add oral pred if: CCF, cardiomegaly, 3rd degree block
Chorea: Haldol or diazepam
Secondary prophylaxis (Pen V 250mg/ 12h PO for 5-10 years)
Most likely valves to be affected by Rheumatic Heart Disease
Mitral (70%)
Aortic (40%)
Tricuspid (10%)
Pulmonary (2%)
Common acute IE organisms
- S. aureus
- S. epidermidis
Most common organisms for Bacterial Endocarditis
S aureus now
S. viridans (previously)
S. epidermidis (Valvular in the first two months)
S. bovis (do colonoscopy for colonic neoplasm)
Clinical features of subacute endocarditis
Hands
Clubbing
Splinters
Janeway lesions
Oslers nodes
Other
- Fever
- Roth spots
- Splenomegaly
- Haematuria
Criteria for diagnosing Endocarditis
Rx of endocarditis
Depends on the organism and type of valve:
- Strep viridans or bovis = Benpen + gent (+/- vancomycin)
- Staph = flucloxacillin
- Staph on mechanical valve = Flucloxacillin + rifampicin + low-dose gentamicin
What are the different types of heart valves for replacement?
Xenograft:
- Porcine
Homograft:
- Cadaveric
- Ross procedure → using pulmonary valve
Mechanical:
- Ball and cage: e.g. Starr-Edwards
- Tilting disc: e.g. Bjork-Shiley
- Bileaflet: e.g. St. Jude
Which patients would you consider a biological valve in?
Older patients
Women of child-bearing age
Bleeding risk: e.g. peptic ulcer, frequent falls
Complications of a valve prosthesis
FIBAT
- Failure
- Infective endocarditis
- Bleeding: minor – 7%/yr, major – 3%/yr
- Anaemia: warfarin and haemolysis
- Thromboembolism: 1-2% per annum despite warfarin
The differentials for a Irregularly Irregular Pulse. How would you distinguish them from each other?
AF
Multiple ventricular ectopics
Clinical Distinction
- Exercise pt.
- AF: pulse stays irregularly irregular
- VE: ↑ HR → regular pulse
- ↓ diastole time closes window for ectopics
What is the CHA2-DS2-VAS Score?
Determines necessity of anticoagulation in AF
Dabigatran may be cost-effective alternative to warfarin
ECG of a patient with a pacemaker
- Pacing spikes
- May be absent if pt. producing adequate intrinsic rhythm
- Evidence of ischaemia
What are some indications for pacing?
- Complete AV block
- Mobitz Type 2
- Symptomatic bradycardia: e.g. sick sinus syndrome
- Drug-resistant tachyarrhythmias
- Biventricular pacing in chronic heart failure
What are some common complications of a pacemaker?
- Insertion
- Bleeding
- Arrhythmia
- Post Insertion
- Erosion
- Lead migration
- Pocket infection
- Malfunction
Causes of LHF
- IHD
- Idiopathic dilated cardiomyopathy
- Systemic HTN
- Mitral and aortic valve disease
Signs of LHF
- Cold peripheries ± cyanosis
- Often in AF
- Cardiomegaly ̄c displaced apex
- S3 + tachycardia = gallop rhythm
- Wheeze (cardiac asthma)
- Bibasal creps
Causes of RHF
- LVF
- Cor pulmonale
- Tricuspid and pulmonary valve disease
Signs of RHF
↑JVP + jugular venous distension
Tender smooth hepatomegaly (may be pulsatile)
Pitting oedema
Ascites
Causes of a displaced apex beat
- idiopathic
- cardiomyopathy
- congestive cardiac failure
- aortic regurgitation
- mitral regurgitation
- ventricular septal defect
Features of TR
- Loudest in the tricupsid region
- Louder on inspiration
- Pansystolic murmur
- Raised JVP
- Palpable liver
Presenting
O/E of the hands: pulse … , I would like the BP
O/E of the head and neck … the JVP was not raised and there were no signs of carotid bruits
O/E of the chest … both heart sounds were audible with no additional sounds, the apex was not displaced
In addition … the lung bases were clear and there was no peripheral or sacral oedema
What is a Graham Steele Murmur?
Soft, blowing, decrescendo early diastolic murmur of pulmonary incompetence caused by pulmonary hypertension
How do you classify severity of AS?
- Valve area <1cm squared
- Transaortic pressure gradient >40mmHg
- Dyspnoea has worst prognosis
Complications of AS?
- LVF
- Sudden death
- Pulmonary HTN
- Arrhythmia
- Heart block
- Infective endocarditis
- Systemic embolic complications
- Haemolytic anaemia
- Heyde’s syndrome (iron deficiency anaemia)
What might you see on ECG of a patient with AS?
- LVH
- LV strain
- P mitrale (left atrial hypertrophy)
- LAD
- LBBB/1st degree heart block
Causes of mitral stenosis?
- Rheumatic fever (most common)
- Congenital mitral stenosis
- Rheumatoid arthritis
- SLE
- Carcinoid syndrome
Features of severe mitral stenosis?
- Early opening snap
- Increasing length of murmur
- Pulmonary HTN
- Graham Steele murmur
- Low pulse pressure
Differential dx for malar flush?
- Mitral stenosis
- Hypothyroidism
- Carcinoid
- SLE
- Systemic sclerosis
- Polycythaemia
How to differentiate between MR and TR clinically?
- Location of murmur
- Pulse may be jerky in MR
- Systolic ‘v’ waves in JVP for TR
- Pulsatile hepatomegaly for TR
- Thrill is apical in MR and parasternal in TR
Complications of MI?
- Death
- Arrhythmia
- Rupture (free ventricular wall/ ventricular septum/ papillary muscles)
- Tamponade
- Heart failure (acute or chronic)
- Valve disease
- Aneurysm of ventricle
- Dressler’s syndrome
- thromboEmbolism (mural thrombus)
- Recurrence/ mitral Regurgitation
Indications for PCI
Poor response to medical Rx
Refractory angina but not suitable for CABG
