Cardio Flashcards
Basic circulatory changes at birth
Before birth: little return to left atrium from lungs so blood in right atrium pressed across to left via foramen ovale.
At birth lung venous return increases and as not placenta in circulation return to right atrium decreases, new pressure difference = close foramen ovale.
5 ways a congenital heart defect could broadly present
On antenatal ultrasound With heart failure Cyanosis With a heart murmur Shock
Innocent murmur features
Asymptomatic Soft blowing sound murmur Systolic not diastolic Heard at the left sternal edge No radiation No thrill No added heart sounds
Left to right shunts examples
Atrial septal defect
Ventricular septal defect
Persistent ductus arteriosus
Right to left shunts examples
Tetralogy of Fallot
Transposition of the great arteries
Common mixing examples
Atrioventricular septal defect
Tricuspid atresia and other complex congenital heart disease
Outflow obstruction heart disease
pulmonary stenosis and aortic stenosis
Vital treatment for survival in a cyanotic neonate
Prostaglandin, maintain duct patency.
Clinical features of an atrial septal defect
Asymptomatic.
Recurrent chest infections and wheeze.
Fixed and widely split second heart sound.
Systolic murmur at upper left sternal edge from pulmonary blood flow.
Investigations and results from atrial septal defect
CXR = cardiomegaly, enlarged pulmonary artery. ECG = right axis deviation due to right side hyperplasia and right bundle branch block Echocardiogram = diagnostic to decipher partial or secundum ASD.
Management of atrial septal defect
Secundum ASD = cardiac catheterisation plus occlusion device.
Partial ASD = cardiac corrective surgery at 3-5yrs
Ventricular septal defect clinical features
Dependent on size. Small are asymptomatic, large cause heart failure (breathlessness, failure to thrive, recurrent infections)
Signs: Loud pan-systolic murmur at left sternal edge - the louder the murmur the smaller the defect.
Investigations and results from ventricular septal defect
CXR = cardiomegaly and pulmonary engorgement and cane have pulmonary oedema if large. ECG = ventricular hypertrophy
Management of ventricular septal defect
Small are self-resolving, large need surgery.
Treat with HF meds e.g. diuretic
Anatomy of ductus arteriosus
Connects the pulmonary artery to descending aorta.
Definition of patent ductus arteriosus and persistent
Persistent = term babies, not closed by 1month after birth. Patent = preterm babies failure to close 1 month after due date
Flow of blood in a patent ductus arteriosus
From aorta to pulmonary artery.
Clinical features of patent ductus arteriosus
Asymptomatic unless large defect = HF and hypertension. Failure to thrive, breathless, recurrent infections, hepatomegaly. Increased risk of infective endocarditis.
Signs = continuous machine murmur below left clavicle, thrill, collapsing, gallop pulse (increase pulse pressure), loud S2.
Investigations for patent ductus arteriosus
CXR and ECG = normal.
Management of patent ductus arteriosus
Patent in preterms = Ibuprofen/NSAID to close
Persistent in term = endovascular surgery to reduce risk of bacterial endocarditis. Coil or occlusion device fitted.
Machine murmur under left clavicle
Patent ductus arteriosus
Loud pan-systolic murmur at left sternal edge
Ventricular septal defect
Systolic murmur at upper left sternal edge
Atrial septal defect +split and wide 2nd heart sounds.
General symptoms of a left to right shunt
Breathless or asymptomatic
General symptoms of a right to left shunt
Cyanosis!
Four cardinal features of tetralogy of fallot
Large ventricular septal defect.
Overriding aorta
Subpulmonary stenosis
Right ventricular hypertrophy.
Clinical features in tetralogy of fallot
Cyanotic, Toddler squat, Clubbing.
Loud, harsh ejection systolic murmur at the left sternal edge due to pulmonary stenosis.
Antenatal diagnosis
Investigations for tetralogy of fallot
CXR - small heart, untitled apex and right ventricular hypertrophy = boot shaped, pulmonary artery bay,
ECG = right bundle branch block from RV hypertrophy.
Genetics for 22q deletion.
Management of tetralogy of fallot
Surgery at 6months of age, may need beta-blocker.
Complication of tetralogy of fallot
Sudden short severe exacerbations of cyanosis, hypoxia and hypercapnia. Can precipitate MI and stroke.
Transposition of the great arteries anatomy
Aorta blood flows from right ventricle and the pulmonary artery flows from left ventricle. Usually occurs with a septal defect to allow blood mixing, otherwise it is incompatible for life.
Clinical features of transposition of the great arteries
Cyanotic, weak pulse, tachycardia, tachypnoea.
Antenatal diagnosis.
Investigations for transposition of the great arteries.
CXR - narrow upper mediastinum, egg-shaped heart.
Echocardiogram
Management of transposition of the great arteries
Prostaglandin if septal defect present to keep missing or balloon septostomy.
Surgical correction
Eisenmenger syndrome
Untreated left to right shunt causes pulmonary arteries to thicken and increase blood flow resistance. Shunt decreases and patient becomes less symptomatic.
In 10-15yrs the shunt reverses and patient becomes cyanotic = Eisenmenger syndrome. Eventually die of right side heart failure.
Patients group who commonly have a complete atrioventricular septal defect
Down syndrome, trisomy 21
Clinical features of complete atrioventricular septal defect
Antenatal screening.
Cyanosis and heart failure within first weeks of life.
No murmur
ECG = superior axis
Aortic stenosis clinical features
Reduced exercise tolerance, chest pain on exertion and syncope.
Carotid thrill
Ejection systolic murmur heard at upper right sternal edge.
Delayed and soft S2
Apical ejection click.
Investigations and management of aortic stenosis
ECG: left ventricular hypertrophy changes, downing T wave.
Balloon valvotomy.
Clinical features of pulmonary stenosis
Ejection systolic murmur and click best heart at upper left sternal edge, radiates to back.
Heave if server on right ventricular area.
Types of atrial septal defects
Secundum = no valve effect
Primum = 3 leaf mitral valve
Sinus venous ASD
Coarctation of the aorta pathology
Tissue encircles and constricts the aorta usually at area of ductus arteriosus in the aortic arch.
Clinical features of coarctation of the aorta
Weak femoral pulses, especially compared to brachial pulse. Discrepancy between upper limb and lower limb BP.
Older patients get murmur on back as co-laterals develop.
Severe metabolic acidosis and sick baby if duct has closed.
Management of coarctation of the aorta
Surgical repair.
Those at risk of bacterial endocarditis
Congenital heart disease (except sesundum ASD) - create turbulent blood flow in aorta or ductus arteriosus.
prosthetic valve replacement.
Valvular heart disease
Poor oral hygiene.
Clinical features of infective endocarditis
Sustained fever Malaise Raised ESR Anaemia Haematuria (microscopic) Splinter haemorrhage + clubbing in fingers Splenomegaly Rash
Main causative organism for infective endocarditis
Streptococcus viridians. alpha-haemolytic strep.
Investigations for infective endocarditis
Raised inflammatory markers
Blood cultures - at least 3 at different times and sites.
Echocardiogram = vegetations made up of fibrin and platelets and infectious organism.
Management of infective endocarditis
Benzylpenicillin + gentamicin.
Prophylaxis of infective endocarditis
No routine use of antibiotics.
Educate on good oral hygiene.
Diagnostic criteria for rheumatic fever
Jones criteria. Need 2 major or 1major+2minor+evidence of preceding infection.
Evidence of a preceding group A strep infection
Raised ASO titre to show antibodies.
Scarlet fever
Throat swab msc with group A strep
Main organism in rheumatic fever and pathophys
Rheumatic fever symptoms come on 2-3weeks after a Strep pharyngitis infection. Group A beta-haemolytic strep infections. Susceptible patients have a systemic inflammatory response to the organism.
Common age for occurrence of rheumatic fever
5-15yrs
Major signs for Jones Criteria of Rheumatic heart disease
Carditis Polyarthritis Erythema marginatum Subcut nodules Sydenham's chorea
Carditis components in rheumatic heart disease
changed murmur CCF cardiomegaly Friction rub Signs on echocardiogram
Minor symptoms in Jones Criteria for rheumatic heart disease
Fever Arthralgia (pain no swelling) Prolonged PR interval on ECG Raised ESR and CRP Previous rheumatic fever or rheumatic heart disease
Histological feature of rheumatic fever on valves
MacCallum plaques of Aschoff bodies.
Management of rheumatic fever
Bed rest.
Aspirin - anti-inflammatory for joints and heart.
Steroids e.g. prednisolone for persistent fever and inflammation.
Phenomoxymethylpenicillin then Benpen for persistent infection.
Prophylaxis of rheumatic fever
Secondary - phenoxymethylpenicillin prevent reoccurrence.
Cardiac pathology and Turner’s
Bicuspid aortic valve
Coarctation of aorta
Causes of heart failure
critical aortic valve stenosis (left heart obstruction) hypoplastic left heart syndrome VSD (left to right shunt) AVSD large patent ductus arteriosus Esinmenger syndrome Cardiomyopathy
CFx of heart failure
breathlessness (on feeding) sweating poor feeding recurrent chest infections Faltering growth TP, TC. Cardiomegaly Hepatomegaly Murmur
Heave + ejection systolic murmur heard best at the right second interspace which does not radiate
Aortic stenosis
Regular jerky pulse. The cardiac impulse is hyperdynamic & not displaced. There is a mid-systolic murmur, with no ejection click, loudest at the left sternal edge.
Hypertrophic cardiomyopathy
