Cardio Flashcards
📌 How do you manage a patient with chest pain?
✅ History (SOCRATES), ECG, Troponins, CXR, D-dimer if PE suspected
✅ MONAC (Morphine, Oxygen, Nitrates, Aspirin, Clopidogrel) if ACS suspected
✅ Consider PE workup, GI causes, musculoskeletal pain if non-cardiac
📌 When to surgically replace an aortic valve?
✅ Severe Symptomatic AS
✅ Severe AS with LVEF <50%
✅ Very Severe AS with Peak Gradient >60mmHg
✅ Severe AS requiring other cardiac surgery (e.g., CABG)
📌 Bilateral Apical Thoracotomy Scars, Pansystolic Murmur (MR/TR) - Differentials
✅ Previous Lung Surgery (Lung Volume Reduction, Transplant)
✅ Severe MR (Mitral Regurgitation)
✅ Severe TR (Tricuspid Regurgitation)
📌 Bilateral Apical Thoracotomy Scars, Pansystolic Murmur (MR/TR) - Investigations
✅ ECG (Ischaemia, AF, LVH)
✅ Echocardiogram (MR/TR Severity, Pulmonary HTN, LV Function)
✅ CXR (Previous surgical clips, Pulmonary congestion)
📌 Bilateral Apical Thoracotomy Scars, Pansystolic Murmur (MR/TR) - Management
✅ Diuretics if Fluid Overload
✅ Mitral/Tricuspid Valve Repair or Replacement if Severe Symptoms
📌 Aortic Stenosis Patient with Previous CABG Scars - Differentials
✅ Post-CABG Severe AS
✅ Degenerated Bioprosthetic Valve
✅ Concomitant CAD with AS
📌 Aortic Stenosis Patient with Previous CABG Scars - Investigations
✅ ECG, Echocardiography, Coronary Angiography, BNP, CT Aortogram if TAVI planned
📌 Aortic Stenosis Causes
✅ Calcific AS (Degenerative)
✅ Bicuspid Aortic Valve
✅ Rheumatic Heart Disease
📌 Aortic Stenosis - Symptoms
✅ Dyspnoea, Syncope, Angina, Sudden Death
📌 Aortic Stenosis - When Would You Surgically Replace the Valves?
✅ Severe AS with Symptoms, LVEF <50%, or Concomitant Surgery
📌 List as Many Causes as You Can for Midline Sternotomy
✅ CABG, Valve Surgery (Aortic/Mitral), Congenital Repairs, Heart Transplantation
📌 AS - Next Steps and Management
✅ Conservative: Monitor mild AS, BP control
✅ Medical: Diuretics for HF symptoms
✅ Surgical: AVR/TAVI if severe symptomatic AS
📌 AS - Investigations & Diagnostic Criteria
✅ Echocardiography (Valve Area <1 cm², Gradient >40 mmHg)
✅ ECG, BNP, Coronary Angiography if needed
📌 Potential Operations via Midline Sternotomy
✅ CABG, AVR, MVR, Heart Transplantation, Aortic Surgery
📌 Differentials of a Systolic Murmur
✅ Aortic Stenosis, Mitral Regurgitation, Tricuspid Regurgitation, VSD
📌 AS - Management (Specifically Surgical)
✅ SAVR or TAVI based on patient’s risk profile
📌 AF and MR - Role of DOACs in This Patient
✅ DOACs NOT used in Valvular AF (Warfarin required in MS/Mechanical Valves)
📌 Metallic Valve Replacements - Why Choose Metallic vs Biological?
✅ Mechanical (Durable, Requires Warfarin) vs Bioprosthetic (Less Durable, No Anticoagulation)
📌 Midline Sternotomy, Loud S1, Clicking - How Would You Like to Complete Your Examination?
✅ Check for Prosthetic Valve Sounds, Murmurs, Signs of HF
📌 Midline Sternotomy, Loud S1, Clicking - Top Differentials
✅ Prosthetic Valve, Congenital Repair, Rheumatic Heart Disease
📌 Midline Sternotomy, Loud S1, Clicking - If Suspecting Infective Endocarditis, How Would You Investigate?
✅ Blood Cultures (3 Sets), Echocardiogram (TTE + TOE), Duke’s Criteria
📌 Metallic Valves - S1/S2/Aortic/Mitral? - What Investigations?
✅ Echocardiography (TOE Best for Prosthetic Valves), INR Monitoring, ECG, CXR
📌 Metallic Valves - S1/S2/Aortic/Mitral? - What Drugs Might the Patient Be On?
✅ Warfarin (Mechanical Valves), Beta-Blockers, Diuretics, ACE Inhibitors
📌 Systolic Murmur & Pedal Oedema - Differentials
✅ Aortic Stenosis, Mitral Regurgitation, VSD, Prosthetic Valve Dysfunction
📌 Which of These (AS, MR, VSD) is Ejection Systolic?
✅ Aortic Stenosis = Ejection Systolic Murmur
📌 Systolic Murmur & Pedal Oedema - Investigations
✅ ECG, Echocardiography, BNP, CXR, Cardiac Catheterisation
📌 How Would You Manage AS: Conservative, Medical & Surgical?
✅ Monitor mild AS, Diuretics for HF symptoms, AVR/TAVI if severe symptomatic AS
📌 Indications for Valve Replacement (NICE Guidelines)
✅ Severe Symptomatic AS, LVEF <50%, Peak Gradient >60mmHg
📌 Complications of CABG Surgery
✅ Early (Bleeding, MI, Stroke, AF) vs Late (Graft Failure, HF Progression)
📌 Secondary Prevention Post-CABG
✅ DAPT (Aspirin + Clopidogrel), Statins, Beta-Blockers, ACE Inhibitors, Lifestyle Changes
📌 Valve Replacement in a 20-Year-Old (Murmur & CABG from the Leg) - What Type of Valve Would He Get?
✅ Mechanical (For Young, Durable, Requires Warfarin) vs Bioprosthetic (For Elderly, No Anticoagulation, Less Durable)
📌 Three Scenarios Around a Patient Presenting with Heart Failure & How to Manage Each
✅ Acute HF (IV Diuretics, CPAP, Nitrates), Chronic HF (ACEI, Beta-Blockers, CRT Consideration)
What are the main differentials for infective endocarditis?
Sepsis, autoimmune disease (SLE, vasculitis), atrial myxoma, metastatic cancer.
What are the classic signs and symptoms of infective endocarditis?
Fever, new murmur, Janeway lesions, Osler nodes, Roth spots, splinter hemorrhages.
What are the most common causes of infective endocarditis?
Staphylococcus aureus (acute), Streptococcus viridans (subacute), Enterococcus, HACEK organisms.
What are the key risk factors for developing infective endocarditis?
Prosthetic valves, congenital heart disease, rheumatic heart disease, IVDU, poor dental hygiene.
What investigations would you order to diagnose infective endocarditis?
Blood cultures (3 sets), TTE (TOE if needed), FBC, CRP, urine dipstick, Duke’s criteria.
What is the initial management for infective endocarditis?
Empirical IV antibiotics (Vancomycin + Gentamicin), fluids, monitor for embolic complications.
What are the indications for surgery in infective endocarditis?
Severe valve dysfunction, large vegetations, persistent bacteraemia, abscess formation, prosthetic valve IE.
How do you prevent infective endocarditis in at-risk patients?
Good dental hygiene, antibiotic prophylaxis (high-risk patients only per NICE), aseptic technique.
When is prosthetic valve replacement indicated?
Severe symptomatic valve disease, severe valve dysfunction with LV dysfunction, prosthetic valve IE.
What are the two main types of prosthetic valves used for valve replacement?
Mechanical valves (longer lasting, requires warfarin), bioprosthetic valves (shorter lifespan, no warfarin).
How do you decide between mechanical and biological valves?
Mechanical for <65 years (lifelong warfarin), bioprosthetic for >70 years or pregnancy considerations.
What is the management of a patient with a prosthetic valve replacement?
Anticoagulation (mechanical), echocardiographic monitoring, endocarditis prophylaxis.
What are the complications associated with prosthetic valve replacement?
Thromboembolism, endocarditis, haemolysis, paravalvular leak, valve degeneration.
How would you manage a young patient (<50 years) requiring valve replacement?
Mechanical valve preferred (<50 years), lifelong warfarin, bioprosthetic if high bleeding risk.
How do you monitor a patient after prosthetic valve replacement?
Regular INR monitoring (mechanical), annual echo for mechanical, bioprosthetic monitoring.
What are the key differential diagnoses for AR?
Aortic stenosis, mitral regurgitation, infective endocarditis, aortic dissection.
How would you differentiate AR from mitral regurgitation on clinical examination?
AR: early diastolic murmur, wide pulse pressure. MR: pansystolic murmur, radiates to axilla.
What features distinguish AR from aortic stenosis?
AR: wide pulse pressure, collapsing pulse. AS: slow-rising pulse, ejection systolic murmur.
How does pulmonary hypertension present similarly to AR?
Dyspnoea, fatigue, peripheral murmur may mimic AR but has a loud P2, RV heave.
Why is infective endocarditis an important differential for AR?
IE can cause acute AR with rapid deterioration, fever, embolic signs.
What are the common symptoms of AR?
Dyspnoea, fatigue, palpitations, angina, peripheral signs of hyperdynamic circulation.
Why do patients with AR experience dyspnoea?
LV overload, pulmonary congestion, increased work of breathing.
What causes palpitations in AR?
Hyperdynamic circulation, LV enlargement, wide pulse pressure.
How does AR lead to heart failure?
Chronic volume overload leads to LV dilatation, increased LVEDP, heart failure.
What are the characteristic peripheral signs of AR?
Corrigan’s pulse, Quincke’s sign, de Musset’s sign, Traube’s sign.
Describe the murmur of AR and where it is best heard.
Early diastolic murmur, best heard left sternal edge, sitting forward, expiration.
What is Hill’s sign, and what does it indicate?
Hill’s sign: popliteal BP > 20 mmHg higher than brachial BP, indicates severe AR.
What are the most common causes of AR?
Bicuspid aortic valve, rheumatic heart disease, Marfan, hypertension, endocarditis.
How does a bicuspid aortic valve lead to AR?
Congenital BAV degenerates early, aortic root dilates, valve malcoaptation.
Which connective tissue disorders are associated with AR?
Marfan, Ehlers-Danlos, Loeys-Dietz, Turner syndrome.
Why is hypertension a risk factor for AR?
Hypertension causes aortic root dilatation, widening valve annulus, increasing AR.
What is the role of infective endocarditis in causing AR?
Endocarditis damages valve leaflets, causes acute AR, abscess formation.
How does aortic dissection result in AR?
Aortic dissection disrupts valve attachment, acute AR, cardiogenic shock.
What is the relationship between syphilis and AR?
Tertiary syphilis weakens aortic wall, aneurysms, chronic AR.
What are the key risk factors for developing AR?
Bicuspid valve, hypertension, Marfan, endocarditis, aortic dissection.
How does age influence the risk of AR?
Young: congenital causes. Elderly: degenerative valve disease, hypertension.
Why are patients with Marfan syndrome at increased risk of AR?
Marfan: weak aortic wall, aortic root dilatation, dissection risk.
What congenital conditions predispose to AR?
Bicuspid valve, Marfan, Loeys-Dietz, Turner, repaired Tetralogy of Fallot.
How does poorly controlled hypertension contribute to AR?
Hypertension accelerates aortic dilatation, worsening AR.
What is the gold standard investigation for AR?
Gold standard: Transthoracic Echo (TTE), TOE if unclear.
How does echocardiography help in assessing AR severity?
TTE assesses severity: regurgitant volume, LV dilatation, Doppler assessment.
What findings on ECG might be seen in AR?
LVH, left axis deviation, atrial fibrillation in late-stage AR.
What changes might be seen on a chest X-ray in AR?
Cardiomegaly, prominent aortic knuckle, pulmonary oedema.
When would you perform a CT or MRI scan in a patient with AR?
MRI/CT if aortic dissection or aneurysm suspected, unclear echo findings.
How do BNP levels assist in the assessment of AR?
BNP elevated in AR with LV dysfunction, predicts disease progression.
Why are blood cultures necessary in some cases of AR?
Blood cultures for IE suspicion, persistent fever, embolic signs.
How would you manage a patient with mild AR?
Monitor with regular echocardiography, control BP, ACE inhibitors/ARBs.
What are the indications for surgical intervention in AR?
Severe symptomatic AR, LV dysfunction (EF <50%), progressive LV dilatation.
When is aortic valve replacement (AVR) indicated?
Severe symptomatic AR, EF <50%, progressive LV dilatation, aneurysm >5.5 cm.
What medications are used in AR, and what is their role?
ACE inhibitors/ARBs (reduce afterload), beta-blockers (only for aneurysms).
Why are beta-blockers used cautiously in AR?
Beta-blockers prolong diastole, increasing regurgitant volume, worsen severe AR.
What is the role of afterload-reducing agents in AR?
ACE inhibitors/ARBs reduce afterload, decrease regurgitant volume.
How does the presence of left ventricular dysfunction change management?
Severe LV dysfunction warrants early surgery, requires HF medications.
What factors influence the choice between a mechanical and bioprosthetic valve in AR?
Mechanical preferred if young, bioprosthetic if high bleeding risk, pregnancy.
What follow-up is required for a patient with AR?
Mild AR: echo every 2-3 years, BP control, avoid heavy weightlifting.
What is the long-term prognosis of untreated AR?
Untreated AR: progressive LV dysfunction, heart failure, sudden death.
What lifestyle modifications are recommended for patients with AR?
Lifestyle: avoid heavy lifting, control BP, maintain dental hygiene.
When should a patient with AR be referred to cardiology?
Refer if severe AR, LV dysfunction, progressive symptoms, aneurysm >4.5 cm.
How does the presence of an aortic aneurysm affect management?
Aneurysm >5.5 cm requires surgery, earlier if Marfan (>4.5 cm).
What complications can arise if AR is left untreated?
Complications: HF, arrhythmias, sudden death, aortic dissection, IE.
