Cardio Flashcards
What is Quincy’s sign?
Capillary beds in the fingers are pulsating because of aortic regurgitation which causes high sys and low Diastole.
Systolic ejection murmur with widely split second heart sound.
Atrial Septal Defect
Highly associated with Turner’s Syndrome.
Coarctation of the Aorta (females with only ONE X chromosome).
The pulmonary valve closes during
Diastole
“3” sign
Coarctation of the Aorta
What area of the ventricular septum is most likely to have a defect in VSD?
Membranous region
What causes the snap sound in mitral valve stenosis?
Higher pressure in the RA
What might you feel on the patient with pulmonary stenosis?
Palpable parasternal lift (because of right ventricular hypertrophy).
What might you see in an ECHO on a patient with Pulmonary Stenosis?
Doming or Dysplastic Valve.
Describe what goes on with the valve and blood during stenosis.
Pressure builds up, Ejection click, followed by turbulence (which gets louder, then quieter)…the CRESCENDO DE CRESCENDO murmur.
Common. Left to right shunt. Often involves a patent foramen oval.
Atrial Septal Defect
Failure of the ductus arteriosus to close after birth
Patent Ductus Arteriosus
What happens to the kidneys in coarctation of the aorta?
Blood reduced to kidneys>release Renin-Angiotensin-Aldosterone > causes water retention>leads to hypertension.
How does squatting help infants with Tetralogy of Fallot?
Increases aortic pressure, back flow to force left to right shunt to get more oxygenated blood and prevent deoxygenated blood to flow into LV.
Consider this when you see a young male with hypertension
Coarctation of the Aorta
What happens to blood with mitral valve regurgitation?
Blood leaks back into left atrium, pools, creates clots.
Where does the coarctation of the aorta occur in most infants?
AFTER the aortic arch ,BEFORE ductus arteriosus.
The only right sided ausculatory event that decreases with inspiration.
Pulmonary Stenosis (because of reduced flow of blood to lungs).
Continuous murmur heard superiority and midline in the back over the left anterior chest.
Coarctation of the Aorta
Harsh, Holosystolic murmor. Loudest along the left sternal border.
VSD
What are some risk factors for pulmonary stenosis?
Maternal Congenital Heart Disease. Maternal Gestational Diabetes. Congenital Rubella. Fetal alcohol syndrome. NOONAN SYNDROME. TETRALOGY OF FALLOT.
Boot shaped heart
Tetralogy of Fallot
When should you refer patients with pulmonary stenosis?
Peak Pulmonary valve gradient is GREATER THAN 60 mmHG.
(Patients w/ peak of 60 mmHg or mean of 40 mmH by echo/Doppelgänger should undergo intervention, regardless of symptoms).
What it’s he heart sound of Mitral Valve Stenosis
Snap Sound. Diastolic Rumble
What is an Epstein anomaly?
Leaflets are too low and located in the ventricle
Large pulmonary arteries. Increased pulmonary vascularity and enlarged RA and RV..BUT small aortic knob.
ASD
What is associated with Coarctation of the Aorta?
Turner’s Syndrome and Cerebral Berry Aneurysms.
What does the mitral valve do during diastole?
Opens and blood fills ventricle.
90% of ASD cases are due to…..
Optium Secundum
What are treatment options for Coarctation of the Aorta?
Balloon dilation to widen the aorta.
Surgical Removal of Coarctation.
What is myxomatous degeneration?
Weakened connective tissue, chordate tendinae and papillary muscles.
Eisenmenger syndrome
Pressure converting from left to right to right to left as left ventricle weakens.
How does Coarctation of the Aorta cause scalloping of the ribs?
UPSTREAM INCREASE PRESSURE, UNEVEN PRESSURE, causing REVERSED FLOW and PULSATING POSTERIOR INTERCOSTAL ARTERIES. (Where there is lower pressure). Ribs 3-9, mostly 3 & 4.
When the pulmonary valve doesn’t open all the way
Pulmonary stenosis
Most often due to pulmonary hypertension.
Tricuspid valve regurgitation
What happens to pressure in upper and lower extremities in coarctation of aorta?
Higher-upper extremities.
Lower-Lower extremities
You hear a CONTINUOUS MURMUR SUPERIORLY AND MIDLINE in the BACK and OVER LEFT ANTERIOR CHEST?
Coarctation of the Aorta
The pulmonary valve opens during…
Systole
Symptoms in spells, squatting.
Tet Spell-squatting helps kink the femoral arteries, increases vascular resistance-increases systemic pressure-pressure (Left>Right). Shunt REVERSES
Why is there a delayed pulmonic valve closure in ASD and what does in sound like?
Because there is extra blood flowing into the RV. Splitting of the S2
What are cerebral berry aneurysms?
When a wall of a cerebral artery becomes weak and balloons out. May enlarge and burst, sending blood into brain.
Severe cases of right-sided heart failure due to pulmonary stenosis may be related to……
Congenital rubella.
At risk for embolism
Atrial Septal Defect. Clot flows from right to left and end ups in brain.
What is a Holosystolic murmur?
Blood flowing back through duration of systole
What is Carvallo’s Sign?
A murmur that gets louder with inspiration because there is negative pressure which brings more blood back into the heart.
What condition is the only RIGHT SIDED HEART SOUND that DECREASES with INSPIRATION?
Pulmonary Stenosis
Hypertension in arms, but NOT in legs.
Coarctation of the Aorta
You see a patient with his head bobbing “pulsatively”
Aortic Regurgitation..caused by increased Sys pressure and Decreased Diastolic pressure
Incomplete right bundle branch block present in nearly all cases of
ASD
Describe the heart sound in aortic stenosis.
Ejection click..Loud Murmur that gets quieter…Pressure build up..clicking through..turbulence.A crescendo-Decrescendo murmur.
What are symptoms of Coarctation of the Aorta (generally in adults)?
Headache. Epistaxis. Chest pressure. Claudication w/ exercise.
Does the murmur in pulmonary stenosis radiate to the right or left?
Left. (Because of the flow pattern)
What is a complication of an ASD?
Embolis-Deep Vein Thrombosis moving into brain.
What is a recommended treatment for severe pulmonary stenosis?
Percutaneous Balloon Valvulosplasty
What might you see on an ECG for pulmonary stenosis?
Right Axis deviation. Peaked P waves (because of right atrial overload).
Babies with clubbing in fingers and toes. Sign of.
Tetralogy of Fallot
How does mitral valve regurgitation cause left sided heart failure?
Blood pumped back into atrium, which causes an increased preload and causes volume overload, which causes eccentric hypertrophy..or building to left ventricle muscle..which can cause the LV to be exhausted.
Crescendo-Decrrescendo murmur is found in what?
Pulmonary Stenosis–pressure build up followed by a click.
Thickening of Pulmonary Valve
Pulmonary Stenosis
How does adult coarctation differ from infant?
No patent ductus arteriosus. NO MIXING OF DEOXYGENATED BLOOD, JUST A PINCH IN THE AORTA.
What happens to heart sound with patients with mitral valve regurgitation when they are squatting?
Click comes later and the murmur is shorter.
Risk of berry aneurysms
Coarctation of the Aorta
You hear a LOUD HARSH SYSTOLIC MURMUR. SPLIT S2. It DECREASES with INSPIRATION. What might this suggest?
Pulmonary Stenosis
What are the four abnormalities in Tetralogy of Fallot?
1) Narrowing of pulmonary valve or infundibulum (de02 blood harder to flow out).
2) Myocardium of RV hypertrophy. (Boot Shaped)
3) Large Ventricular septal defect (VERY CYANOTIC).
4) Aorta overrides septal defect (variable).
What does the mitral valve do during systole?
Closes-blood flows out through aorta.
Patient has dyspnea, dysphagia, fatigue, and harder to breath.
Mitral valve stenosis
This can create schystocytes
Pulmonary stenosis
What happens to blood in ASD?
Oxygenated blood is pushed from the Left atrium to Right Atrium.
What causes aortic regurgitation?
Aortic Root Dilation-leaflets pulled apart and not able to close all the way.
Mid-systolic click followed by a systolic murmur
Mitral valve regurgitation
Characteristic EJECTION click
Stenosis
What is associated with a bicuspids aortic valve?
Coarctation of the Aorta
What does “optimum secundum mean”?
“Second opening”
WEAK FEMORAL PULSATOINS
Coarctation of the Aorta
Enlarged liver and spleen
Hepatosplenomegaly
The most common cardiac anomaly.
Atrial Septal Defect.
Described what can happen during a larger VSD.
02 blood initially left to right shunt. LV weakens. De02 blood flows right to left shunt out into AORTA, causing CYANOSIS!
Treatment usually involves balloon valvuloplasty
Pulmonary Stenosis (other answers)
Associated with Noonan Syndrome and Congenital Rubella
Pulmonary Stenosis
What are common symptoms of severe pulmonary stenosis?
Cyanosis. Shortness of breath and fatigue (Can’t get O2 to lungs! Because pulmonary valve is obstructed!)
Most common of all valvular conditions.
Mitral Valve Prolapse
Explain what happens to blood flow in mitral valve stenosis.
Increased blood volume-increased pressure–blood flows back into hearts–causes pulmonary congestion and edema.-pulmonary hypertension–can make it harder for the right ventricle to pump blood to the lungs…over time right ventricle will hypertrophy…pace maker cells stretch and become more irritable..increasing risk of atrial fibrillation..causing static pools of blood..thrombus formation..which can immediately get into the systemic circulation…if atrium dilates it can compress the esophagus.
What is the most common congenital defect amongst babies?
VSD
Associated with Turner’s Syndrome
Patent Ductus Arteriosus
What size of commissar all fusion can be found in mitral valve stenosis?
2 cm
What is pulmonary stenosis?
Increases resistance of the right ventricle outflow because the pulmonary valve does not completely open.
Atrial septal defect is common associated with:
Fetal Alcohol Syndrome. Downs Syndrome.
Found in 25% of patients with Down Syndrome.
Ostium Primum Atrial Septal Defect
What ribs are particularly effected by rib notching?
Ribs 3-9, mostly 3 and 4
What kind of pulse might you find in the femur of adults with Coarctation of the Aorta?
Weak
How does coarcatation of the aorta happen in infants?
The ductus arteriosus exists during fetal development and usually closes after birth, but doesn’t.
PREDUCTAL COARCTATION
Narrowing of the aortic arch distal to the origin of the left subclavian artery
Coarctation of the Aorta
Increased pressure in upper extremities of the head
Coarctation of the aorta
When should you definitely consider an intervention for Coarctation of the Aorta?
Greater than 20 mm Hg.
What is the most common cause of cyanotic congenital heart defect?
Tetralogy of Fallot
What is tetralogy of Fallot associated with?
Chromosome 22 deletions and DiGeorge Syndrome
A infant shows cyanosis in his legs, what might cause this?
Coarctation of the Aorta.
First heart sound followed by a click then a rough systolic murmur and a single or split S2
Pulmonary Stenosis
What happens to blood and heart with a tricuspid valve regurgitation?
Blood flows back into atrium, causes a larger volume and back flow, or preload. The right ventricle becomes larger because it is working harder. This can lead to stretching of the annulus, worse regurgitation, and right sided heart failure. (Distended neck veins, swelling of ankles and feet).
What is a decrescendo murmur caused by?
Back flow of blood–increases the blood volume–more work of ventricle. Eccentric ventricular hypertrophy.
Loud harsh systolic murmur. Radiates to the left shoulder.
Pulmonary Stenosis
Causes scalloping of the ribs.
Coarctation of the Aorta-thoracic arteries high pressure wear away ribs.
Increased o2 saturation in right atrium, right ventricle, pulmonary artery…slight delay in pulmonic valve closure
ASD
What happens to aortic valve during stenosis?
Thickens/stiffens and opens to LESS THAN 1 cm
What happens during systole (or heart contraction) with tricuspid valve regurgitation?
Heart flows back into the right atrium
What are the heart sounds of Tricuspid Valve Regurgitation?
Holosystolic Murmur
Can present with severe cyanosis.
Pulmonary Stenosis (other answers possible)
Is pulmonary stenosis common in children or adults?
Adults
What is a common cause of cryptogenic stroke in patients under 55?
ASD
Digital clubbing is common with this condition.
Pulmonary Stenosis
What happens during Phase 1 of the action potential of ventricular myocytes?
The notch.
Efflux of K+ and Cl-, initial rapid repolarization
What happens during Phase 1 of the action potential of ventricular myocytes?
The notch.
Efflux of K+ and Cl-, initial rapid repolarization
What size is a Stenosis aortic valve (usually)?
<1cm2
Who is at more risk for aortic stenosis?
Patients with bicuspid aortic valve (stress on 2 leaflets instead of 3, more calcification).
What is a cause of Aortic Valve Stenosis?
Rheumatic Fever-causes increase inflammation of valve—repeated damage and repair.
What causes commissural fusion and where does it usually occur?
Rheumatic Fever. Fusion of Aortic Valve.
You see a patient with a bobbing head, bounding pulse, pulsing capillary beds in his fingers….
Aortic Regurgitation (LV working really hard to pump blood out during systole, increased stroke volume).
A young person with hyperthyroidism what might you consider?
A-fib
“Holiday heart” can be caused by __________
A fib
Symptoms are caused by DECREASE CARDIAC OUTPUT.
A fib
*Decreased diastolic filling and decreased ventricular contractility
A fib is associated with a ________ fold increase risk of stroke.
5
A fib is associated with a ________fold increase in RISK OF HEART FAILURE.
3
A fib is associated with a ___________fold RISK OF DEMENTIA.
2
How do you diagnose A fib?
- Irregular and often rapid pulse
- MAY find murmur, gallop (S3), JVD (may also be b/c of heart failure), peripheral edema
What might you find on an EKG with A fib?
ERRATIC, DISORGANIZED atrial activity between discrete QRS complexes occurring in an irregular pattern.
Rate ranges from slow to extremely rapid, but irregular (ALL OVER THE PLACE), unless there is an underlying heart block or a ventricular pacemaker has taken over control of pacing the heart.
The atrial activity may appear as VERY FINE WAVES or QUITE COARSE (can be confused with ATRIAL FLUTTER).
Besides an ECG what else might you use for A fib?
Echocardiogram (know more about what the heart is doing)
Ambulatory rhythm monitoring (paroxysmal a fib, comes and goes, patients may not be experience A fib during a visit, this allows for consistent monitoring to catch events when they occur)
Metabolic profile, thyroid panel (Rule out metabolic and/or thyroid causes)
A patient comes in with A fib, but does not show any symptoms at the clinic, what might you use as a diagnostic study?
Ambulatory rhythm monitoring
Define paroxysmal a fib.
Spontaneous
Terminates by itself.
Returns to normal after an intervention
Define persistent A fib.
Continuous. LASTING > 7DAYS
Define chronic/permanent A fib.
No treatment to restore or maintain sinus rhythm.
Lasts forever. Can’t keep them in sinus rhythm.
What do you think about in terms of A fib treatment?
Rate vs. Rhythm Control
What are the key points for rate control in A fib treatment?
Reduces ventricular rate WITHOUT changing rhythm.
Goal: SYMPTOM MANAGEMENT. PREVENT TACHYCARDIA-MEDIATED CARDIOMYOPATHY.
Target heart rates: Resting: < 80 bpm. Ambulatory: <100 bpm
What do you use to manage rate control in a fib?
AV nodal blocking agents: Beta blockers and Calcium channel blockers
DIGOXIN: may add synergistic rate control effect when combined with beta blockers or CCBs. (Needs monitoring)
What are key points for rhythm control in A fib?
Preferred when:
- symptomatic despite rate control
- difficult to rate control
- develop tachycardia-mediated cardiomyopathy
- are younger
- have a first episode or have AFib triggered by acute illness.
How is rhythm control achieved in AFib?
Cardioversion
Anti arrhythmias
Ablation
Electrical cardioversion restores sinus rhythm in _______% of patients.
75-90%
For rhythm control, initial shock of _________ Joules is administered in synchrony with the _________wave
100-200, R
In cardioversion rhythm control if the conversion does not occur an additional attempt at _____________Joules is indicated.
360
Following cardioversion Rhythm Control
AFib recurs in _________of patients at 3 months.
AFib recurs in__________o Patients at 12 months.
40-60%
60-80%