Cardio station Flashcards
Why check for anaemia in aortic stenosis
Heydes syndrome
AS + Angiodysplasia
[also anaemia of chonic disease esp if elderly
-Very rare haemolysis through native valve ]
When is AS murmur loudest
held expiration
over aortic area
Pulse in AS?
Slow rising / weak
Key thing to look for on exam if suspected AS?
Signs of cardiac decompensation
- Raised JVP
- Bibasal crackles
- Peripheral oedema
Key DDx of AS murmur
Systolic murmur
- Mitral regurg - should radiate to axilla
- HOCM
- Aortic sclerosis
- VSD especially if young
- Pulmonary stenosis - very rare and should be louder on inspiration
Ix AS
ECG - ?LVH / strain
Echo - confirm gradients and function
Bloods - Full blood count - anaemia / WCC
Inflam markers - CRP
Blood cultures ?IE
Chest xray ? overload
Difference between murmur between AS and aortic sclerosis
Usually shorter and softer
Should not radiate to carotids
Aetiology of AS
80% degenerative calcific
congenital bicuspid valve
rare but possible - rheumatic fever and endocarditits
How to confirm severe aortic stenosis on exam? history? ix?
Exam
Nature of murmur - obliterates s2
slow rising pulse
evidence of cardiac decompensation
History
Angina and syncope
Ix
Echo
LVH on ECG / LBBB
[history of decompensation]
Why ECG pre TAVI
10% go on to have PPM
?Pre existing conduction disease
How to tell AS on echo
Peak gradient across valve >64
or mean gradient >40
[best measure is ratio of velocity over AV vs LVOT dimentional index]
When TAVI vs AVR
> 75 - likely TAVI
<75 - likely surgical - unless not fit
TAVI - more PPM, less bleeding risk
quicker recovery
less AF, Less CKD
Who is not suitable for a TAVI
Bad PVD
Malignant features of annulus
Bad CAD - would be too hard for stents
in <75 Who might the surgeons not want to operate on for AVR
Previous chest radiotherapy
Previous sternotomy
patient LIMA to LAD
Pulm HTN
Severe LVSD
Work up for a TAVI
Bloods - routine
Echo
ECG
If smoker - LFTs
Angio
TAVI CT
Consider carotid doppler
Key complications of TAVI
PPM - 10%
Vascular issues - Fem artery
Stroke / coronary blockage
When is JVP classes as elevated
If >3cm above sternal notch
Life expectancy AS with decompensation
50% at 1 year
Murmurs louder when?
Right-sided murmurs
- Louder during inspiration.
- inspiration increases blood flow to the vena cava, which increases venous return to the right side of the heart.
Left-sided murmurs
- louder during expiration.
- expiration increases blood flow to the left side of the heart by constricting pulmonary vessels.
What is / When do you get paradoxical splitting of s2?
How to make it more obvious?
Paradoxical splitting of S2
This occurs when the pulmonary valve (P2) is heard before the aortic valve (A2).
This is caused by conditions like severe aortic stenosis or left bundle branch block.
During inspiration, paradoxical splitting causes narrow splitting of S2, and during expiration, it causes wide splitting
Cardio exam
Hands
-Endocarditis / clubbing
- Brusing / bleeding - anticoagulated
Pulse
- AF, Radial-radial delay
- Any radial artery harvest
- collapsing pulse
Face
- Pallor
- corneal arcus
JVP
Back
-Lung bases
-sacral oedema
Chest
- Scar sternotomy
- Hickman scar
- PPM
- Audible click
- Palpation + apex
Auscultate
- include carotid
- turn to left side and bell for mitral valve
Failure
- Oedema
- Pulm odema
What does a sternotomy scar mean
Valve replacement
CABG
Loud s2 but no sternmotomy scar
Pulm HTN
Ix in endocarditis
Full history and exam
Bedside obs esp pyrexia
ECG - cardiomyopathy / LVH
Urine dip - haematuria
Bloods
FBC CRP - infection / anaemia chronic disease
U&Es for end organ damage
LFTs prior to antibiotics
Coag / INR - if anticoagulated
Blood cultures x3
Imaging
CXR - failure
Echo +/- TOE
Mechanical vs bioprosthetic valves
Mechanical
- More durable - lasts life
- Lifelong WARFARIN only
(NOACs get thrombosis)
bio valve
- lasts 10-15 years
- Short duration anticoag post op
Endocarditis no difference between
Syncope History
What do you mean?
What happened Before,
- Need to get the activity preceding
- Prev epsodes - any fainting
During
- Any witnesses
- Rigid?
- Tongue biting
After
- Recovery
Chest pain / haemoptysis
Drug history
-Any recent changes
- Hypertensives
- Drugs for arrhythmia
PMH
- Parkinsons - autonomic / postural
- Structural heart disease eg AS
Social history
- Roofers
- HGV / drive for work
Family history
- Sudden death / cardiomyopathy
- Anyone with collapses / devices in chest
Syncope vs seizure
Syncope - sudden onset
Cardiogenic - no prodrome
Quick recovery post
Does presence of abnormal movements mean seizures?
Incontinence?
Tongue biting?
No common in syncope
- Usually fairly random and short lived
- Usually flaccid rather than rigid
Incontinence happens with all syncope
Tongue biting - particularly side and back of tongue - likely seizure
- Represents clonus of jaw
Cardiac sounding syncope red flags
LOC without prodrome
Occurring on exertion
History of strucutal heart disease / family sudden death
Investigations in syncope
Pulse
Lying standing bp
Fingerprick glucose
12 lead ECG - structural / LVH / ectopy / QT interval / heart block / ion channel opathy
Bloods
HB - anaemia
WCC / CRP - infection
renal / liver - starting medications
Electrolytes / TFTs
Possible 24hr tape
Consider ECHO but not in first instance
What are you looking for with 24 hr tape
Symptom rhythm correlation
3 aspects of Management of vasovagal / neurogenic syncope
Patient education
- Avoid precipitants / triggers
Drink plenty of fluid
- Bolus water drinking
High sodium diet
Consider compression garments
Target blood pressure
<140/90 in clinic
<135/85 at home
Hypertension history
How long
Secondary causes
Brain
- Pit tumour - cushings, acromegaly
Neck
- OSA, Hyperthyroid
Kidney
- PKD, RAS, RCC
Endo
- Conns, phaeo
End organ damage
- Kidney - frothy urine, kidney problems
- Brain - headaches, blurred vision, TIA / strokes, nose bleed
- Heart - chest pain, fluid overload, SOBOE
Social
- Liquorish - aldosterone effect
- Alcohol
- Ilicit drugs - cocaine
- Smoking
Meds
- Steroids for chronic conditions
- COCP
- Are they taking antihypertensives
PMH
- Surgery when young - coarctation
- Peripheral vascular disease
- Asthma / COPD / IBS - steroids -> cushings
- CKD
FamHx
- Family history
- High cholesterol
- Fam Hx RRT / CVA ?ADPCKD
- Renal artery stenosis - tried ACEi
- Renal Ca - weight change
- Thyroid hyper
- OSA - daytime drowsiness
- Phaeo - hot flushes, palps,
chest pain, anxiety - Cushings - steroids
- Carcinoid - flushing / diarrhoea
- Acromegaly - changes in appearance / hands
- Conns
Hypertension investigations
Target organ damage
Kidneys
- Renal function - end organ damage and K+ for conns
- Renal dip for proteinuria + Albumin creatinine ratio
- Preg test
- If worried about renal artery stenosis need to do a CT
Heart
- ECG - LVH
- Consider Echo for LV mass
- CXR / BNP if any evidence of failure
Brain
- Imaging if headaches
Bloods
TFTs
HBa1c
Lipid profile
Consider - Aldolsterone renin ratio or dexamethasone supression test, pituitary profile
QRISK score
Ambulatory BP monitoring
Q RISK calculates a person’s risk of developing a heart attack or stroke over the next 10 years
Hypertension exam
Check BP
Hands Radial-radial delay
Radial femoral delay
Perform fundoscopy
Look at back of neck for buffalo hump
Carotid / femoral bruis
Thyroid palpate
Abdo
Any striae - cuhings
Polycystic kidneys
Renal bruis
Urine Dip
Simple things you might see on fundoscopy in HTN
AV nipping
flame haemorrhages
HTN given ACE and then significant deterioration in renal function
Renal artery stenosis
- would expect a doubling in creatinine
Conns Ix? what do you need to do prior
Aldosterone renin ratio
Need to stop antihypertensives that affect RASS
- Basically only one that doesnt is doxasosin
Phaeo Ix? what affects this
Urinary / blood catecholamines
-Paracetamol on urine
Cortisol excess test
Low dose dexamethasone suppression test
OSA ix
sleep study looking at saturations
Raised aldosterone - what ix now
Renal vein sampling for aldosterone
CT scan
Admit vs discharge hypertensive patient
Split into
Hypertensive urgency - sustained hypertension without end organ damage
- Aim to reduce diastolic pressure to <110
- Reduce MAP by no more than 25%
Hypertensive emergency - with end organ damage
- Aim to reduce diastolic to <115
-Use IV labetalol / GTN in a HDU environment
Drug for phaeo emergency
Phentolamine
- alpha blocker
phaeo phento
Acute pulm oedema secondary to hypertension management
IV labetalol + GTN
Support to help patients with medication compliance
Education
Reminder of times to do it eg after teeth brush
Dossett box
Autonomy of thier own care - eg BP machine and see the difference
Hypertension treatment
Lifestyle
- Salt - especially bread
- Weight loss
- Excercise
- Alcohol and smoking
ACEi /ARB or CCB if >55 / Black
Both
Thiazide
Already on ACE / CCB / Thiazide
Next steps
Compliance issues
Add in spironolactone
B blockers/ Alpha blockers if tachy
Are HCM and HOCM the same
No - one is non obstructive
how is HCM inherited ?
Autosomal dominant
- Most commonly (total 75%)
MYH7 gene - beta myosin heavy chain (MYosin Heavy)
MYBPC gene - Cardiac myosin binding protein C
HCM exam findings
Young
Hands
-nil
- Pulse - AF most common arrhythmia / ectopics
Arms
-Nil
Neck
- Large a waves in JVP -
Chest
- Scars for myectomy / ICD (check sub cut in left axilla)
- Palpation left axilla, Heave, apex
Auscultate
- Often outflow murmur
- Mitral murmur
-Get patient do do Valsalva -> does it extenuate murmur
Heart failure
- Lung bases
- Pedal oedema
Young patient for cardio exam
HCM
Cardiomyopathy / channelopathy
Congenital heart disease
Young person with syncope likely cardiac causes
Long QT
WPW
Brugada
HCM
What causes the a waves seen on JVP eg in HCM
forceful atrial contraction against non compliant RV
- due to septal hypertrophy
What might the mitral murmur in HCM mean
Systolic anterior motion of the mitral valve
-> Mitral regurg
occurs when the anterior leaflet of the mitral valve moves toward the left ventricular outflow tract (LVOT) during systole which causes a LVOTO
Differentials of HCM if no device and systolic murmur in young person
Bicuspid aorta / aortic stenosis
VSD
Mitral valve disease
Investigations HCM
What are you looking for?
12 lead ECG - rhythm / AF, large P waves if atrial enlargement
- narrow / broad QRS esp if fibrosis
- LVH - often with deep T waves in lateral leads
Bloods
- Consider genetic tests
[MYH7 gene - beta myosin heavy chain (MYosin Heavy)
MYBPC gene - Cardiac myosin binding protein C]
- Sometimes chronic low grade trop
- BNP if failure
CXR - Cardiomegaly
Echo
- LVH typically septum and asymmetric
- Systolic anterior motion of the mitral valve
- L atrial dilatation
- Measure gradient and consider exercise echo
CMRI
Why MRI in HCM
- Apical segment of HCM often not seen on echo
- Can more accurately assess gradients
- Can see scar - ectopic / ventricular arrhythmias focus
Management HCM
Cardio referral
Advise to notify DVLA especially if syncope / Ventricular arrhythmias / ICD
Conservative
- Clinical genetics + screening 1st degree relatives
- Cardiac imagining specialists
- Specialist nurses
- Aim to avoid dehydration
- Light exercise ok. Avoid weight lifting as can worsen outflow tract gradients
Medical
- Beta blockers / CCB - reduce outflow tract gradients.
- Be very careful using diuretics - especially if outflow tract obstruction
Surgical
- Primary prevention ICDs
- Septal myectomy
How to decide who gets ICD in HCM
Sudden death risk calculator
HCM on BB what could you add
disapriamide - sodium channel blocker
Then either surgical or
- Mavacamten - Brand new - cardiac myosin inhibitor
Marfans looking patient what might you hear
Either / both
Mitral regurg
Aortic regurg
where is the apex beat
5th intercostal space
Mid clavicular line
Polycythaemia diagnosis
Haematocrit >48% women and >49% in men
Must be persistently in that range
Where precursor cell are red blood cells from? Other things this precursor can turn into?
Myeloid stem cells
- can become RBCs, platelets, and neutrophils, basophils, monocytes etc
[all white cells bar lymphocytes]
- In polycythemia would expect changes in neuts and platelets
- Lymphocytes should not be affected
What are the types of polycythaemia
Apparent
- Due to eg dehydration
True
Primary = primary haem disorder polycythaemia ruba vera
Secondary (something making marrow produce more)
Appropriate
- Chronic lung disease
- Cyanotic disease
- OSA
Inappropriate - Exogenous epo
-testosterone
-PKD
-RCC
Polycythaemia history
Why was the blood test done?
- Dehydration / alcohol / D&V
Hyper-viscosity symptoms
- Arterial / venous thrombosis
- Sometimes bleeding
- Head fog / headaches [think about waldenstroms if so]
PRV
- Sweats drenching
- Weight loss 10% / 6months
- Occationally fever
- Puritis after hot shower
Symptoms of splenomegaly
- Early satiety
- LUQ pain
Secondary causes
- Chronic lung issues
- Check for SOBOE
- Snoring Daytime solomence- OSA
-Known diagnosis of tumours
PMH
- Lung / heart disease
DH
- Any diuretics
- Testosterone
SH
- Smoking
- Alcohol
FH
-PKD or renal disease
Which conditions cause both arterial and venous thrombosis
Myeloproliferative disorders
- CML
- Essential thrombocythaemia
- Myelofibrosis
Antiphospholipid syndrome
Polycythaemia
Paroyxysmal nocturnal haemaglobinuria
Polycythaemia ruba vera test
JAK 2
- Also picks up 50% of essential thrombocythaemia
Polycythaemia investigations
Bedside
- Spo2
- Examine lung disease / organomegaly
- Evidence of thrombus
Bloods
- Repeat FBC
- Epo level and JAK 2
CXR
- Undiagnosed chronic lung disease
US abdo
- Renal tumours / PKD
- Splenomegaly
-Polysonography / sleep studies
Epo levels in primary vs secondary polycythaemia
Low in PRV
High in secondary causes
Polycythaemia management
Referral to Haem
Conservative
- Stop smoking
- CV control
- Follow up as risk of developing AML
Medical
-Venesection Reduce haematocrit to 0.45 [If secondary depends on history of thrombosis and up to haem]
- Aspirin or clopi [Secondary don’t use]
- Treatment of thrombosis
If patients cant tolerate venesection in polycythaemia, how else to reduce haematocrit? Risk?
Hydroxycarbamide
-> non selectivley reduces marrow production
-> can reduce all blood counts
If struggling to differentiate MR and AS murmurs what other signs might help
MR may have AF and displaced apex
What would you expect to hear in AS? MR?
AS - crescendo decresecendo
MR - crescendo / pansystolic
Differentiate mitral regur and tricuspid regurg murmurs
MR loudest expiration
TR - loudest inspiration
When would you suspect VSD murmurs
Young - almost all are closed now
Very loud pansystolic most in inspiration
Primary vs secondary MR
Primary
- Congential
- Degenerative- Mitral prolapse, age related
- Rheumatic heart disease
- Connective tissue disease
Secondary
- ischaemic heart disease
- heart failure
- Post endocarditis
- Ruptured cordae post MI
- Ilfiltrative
Functional
- LV dilation
MR investigations
Bloods
FBC
U&E
BNP
ECG
Chest XR
Echo
Diagnosis and quantification
Mechanism
Also any other valves / haemodynamic issues such as LVD / atrial dilation
Management of MR
Mild mod
Approx risk 5% of progression over 5 years
Need regular clinic review
Severe - anyone should be considered for intervention
[If severe and symptoms need intervention
Asymptomatic + AF / atrial dilation -> likely intervention
Asymptomatic and otherwise normal echo]
What are the intervention options for MR and in who
Decisions made with surgeon, cardiologist and interventionist
Repair
Replace
Mitraclip
- those who open heart surgery would not be option
- through groin
What are the clinical and echographic features of severe MR
Clinical
- AF
- thursting displaced apex beat (means LV dilation)
- palpable thrill
Echo
- measure MR jet
- evidence of LV dilation / impairment
Palps red flags?
Secondary causes
Syncope
Features heart failure
Previous cardiac history eg MI Scarring
Family history unexplained death
DH
Recent abx which prolong QT
Recreational drugs
Secondary
Phaeo
- Tremor weight loss htn sweating flusing
OSA - snoring weight / tiredness
Thyrotoxicosis
Palps exam
Hands
Tremor
Pulse regular
BP eg phaeo
Face anaemia
Jvp / lung bases failure
Thyroid
Murmurs eg HCM
Valsava breath hold murmur
ICD scar look in axilla
Abdo flank mass
Palps ix
Bloods + extended Electrolytes
TFTs
Consider BNP
CXR
ECG
Tape 24 vs 72 vs loop looking for rhythm symptom correlation
Echo - rule out structural heart disease
Rule in murmurs
- Ideally done prior to fleccanide
Occasionally CMRI
What serious things are you looking to rule out on ecg Hx palps
Hcm - STE and t wave inversion
Brugada - Coved ST segment elevation >2mm in >1 of V1-V3 followed by a negative T wave.
QT interval
ARVC - arrythmogenic right ventricular cardiomyopathy
(Brugada)
What is ARVC arrythmogenic right ventricular cardiomyopathy?
Seen on ecg?
Autosomal dominant genetic disorder of myocardium in which there is fatty infiltration of the right ventricular free wall, predisposing to paroxysmal ventricular arrhythmias
- second most common cause of sudden cardiac death
T wave inversion in right precordial leads V1-3, in absence of RBBB (85% of patients)
Epsilon wave (most specific finding, seen in 50% of patients)
Localised QRS widening in V1-3 (> 110ms)
How to remember JVP waveforms
a,x,c,v,y
a - Atrial contraction
x - relaXation of atria
c- triCuspid Closure
v - Venous filling of atria
y - emptYing of atria
Causes of dilated cardiomyopathy
ABCCCDD
Alcohol
Beri beri
Coxackie B virus
Cocaine
Chagas disease
Doxorubicin, Daunorubicin
Name 3 of the named aortic regurg signs
Waterhammer pulse
Quicke’s sign: visible capillary pulsations in the fingernails
[caPINKY QUINKY]
De Musset’s sign: nodding of the head with each heartbeat
[Mullet head banging]
Becker’s sign: visible pulsations of retinal arteries and pupils
Muller’s sign: systolic pulsations of the uvula
[Muller Yoghurt]
Corrigan’s pulse: visible carotid pulsations
[corrigans carotid]
Rosenbach’s sign: systolic pulsations of the liver
Gerhard’s sign: systolic pulsations of the spleen
Traube’s sign: pistol shot femorals
Duroziez’s sign: ejection systolic and diastolic murmurs heard with the stethoscope when the bell is used to compress the femoral arteries
Hill’s sign: popliteal > brachial systolic pressure by > 60mmHg
Spot diagnosis thinking aortic regurg might be the answer
Marfanoid body
Aortic regurg exam
?Marfans
Hands
- IE
Feel both pulses
Collapsing pulse
Get BP
JVP / lung bases
Look in mouth at uvula - mullers sign
High arched palate
Parasternal heave + thrill
Auscultate
- Early diastolic murmur heard best over the LLSE with the patient leaned forward and in expiration
- Length of murmur correlates with severity (short is bad, volume of murmur is not)
- High-pitched, decrescendo murmur
- Ejection flow murmur over the aortic area (does not equate to co-existent aortic stenosis) from increased flow across the aortic valve
Legs - oedema
I would like a full set of observations especially BP and temperature. fundoscopy to assess for roth spots, Urine dip looking for blood
If time
- Palpate liver and spleen
- Rosenbach’s sign: systolic pulsations of the liver
Gerhard’s sign: systolic pulsations of the spleen
- Traube’s sign: pistol shot femorals
- Duroziez’s sign: ejection systolic and diastolic murmurs heard with the stethoscope when the bell is used to compress the femoral arteries
AR murmur differentials
Austin-Flint murmur
- Functional mitral stenosis caused by regurgitant jet striking mitral valve leaflets
- Marker of severe AR
- Distinguished from MS in that there is no opening snap, S1 is not loud
PR / MS / TS very hard to hear
On palpating pulse when does a systolic murmur come?
Diastolic
Systolic - just after pulse
Diastolic - just before pulse
Causes of acute AR? Chronic? Signs on exam to find them?
Acute severe - Will have florid pulmonary oedema
- Acute aortic dissection
- Infective endocaritis - Fever, janeway, oslers
- Prosthetic valve failure eg trauma to chest
Chronic - D Bad CRRAMPSS
- Dilated arotic root
- Bicuspid valve
- Congentital
- Rheumatic heart disease
- Rheumatoid arthritis:
- Anklylosing spondylisis:
- Marfan’s syndrome: high, arched palate, long limbs
- Pseudoxanthoma elasticum: neck skin
- Syphilitic aortitis: Argyll-Robertson pupil (reacts to accommodation but not to light)
- Systemic lupus erythematosus:
rash, oral ulcers, alopecia
- Hypertension / Calcific AV
- Osteogenesis imperfecta: blue sclerae, hearing aids
What are roth spots
Small, red spots with white or pale centers that appear on the retina of the eye.
They are caused by bleeding, or hemorrhages, and are usually round, oval, or flame-shaped.
Possibly in IE / Diabetes / hypertension / myeloma / leukaemia / HTN…
What murmur
AR
Pseudoxanthoma elasticum
Acute severe AR Investigations? Chronic?
Bedside
- Full set of obs especially BP and tempurature
- Urine dip for blood
- Fundoscopy for roth spots
- ECG - Evidence of LVH / strain eg TWI / LAD
Bloods
- Blood cultures
- Inflammatory markers
- NT ProBNP
CXR
Evidence of pulm pedema
Echo
- Vegitations / aortic root / look at central jet of AR / valve morphology
Dilated aortic root on echo ->
Cardiac ct
Management AR
Acute severe AR
- Referral to ICU for IV vasodilators + inotrope
- >Surgical valve replacement
Chronic
Patient education
- especially symptoms to look out for
Medical
- ACEi may provide symptomatic improvement
- If Marfanoid / Aortic root dilation - BB to reduce shear stress over valve
Surgical - If chronic AR + evidence of LVD or LVSD. OR if symptomatic
- If aortic root >55mm
Transvalvular vs paravalvular regurg
Transvalvular - though middle of valve
Paravalvular - around valve, often a sign of dehiscnece
What about AS murmur would make you think its severe
Long + Loss of second heart sound
What scoring system for infective endocarditis? Major criteria?
Dukes
2 Major or 1 major and 3 minor
Major
- Typical blug in 2x BCs
- Echo findings
Minor
- Pyrexia
- suspicious echo
- embolic pneumonia
- prostehtic valve
- vasculitic crp/esr rise
- atypical organism in BCs
Seen on ECG mitral stenosis
p mitrale - broad / bifid
AF
Right heart strain
Cause of rheumatic fever? Criteria ? how to test for it? treatment?
Strep pyogenes
B haemolytic strep
Duckett-jones diagnostic criteria
[Throat swab
rapid antigen detection test
antistreptolysin O titre
+2 major criteria]
Rest, high dose aspirin and penicillin
-> long term penicillin prophylaxis
Bar pansystolic loudest at apex what else might you describe in MR
Wide splitting of S2
Loudest on expiration
Tricuspid regurg findings on exam
Raised JVP with large v waves
thrill left sternal edge
Pansystolic murmur loudest on inspiration
Reversed split left secodn heart sound
Pulsitile liver / ascities
Peripheral oedema
Causes of tricuspid regurg
Either conditions causing RV failure
- functional - most common eg RV dilation eg post infarct
- Pulm HTN
- Rupture of papilary muscles
Conditions affecting Valve
- infective endocarditis
- rheumatic fever
- Congenitcal - ebsteins anomoly
- Marfans
- Libman sacks
- carcinoid
Classic TR findings on ECG? CXR? Echo?
ECG - p-pulmonale (peaked p), RVH
CXR - Double right hear boarder (large RA)
Echo - TR, RV /RA dilation
Pulmonary stenosis on exam
Raised JVP with giant A waves
L parasternal heave
ESM loudest on inspiration
Widely split second heart sound (delay in RV emptying)
RV failure - oedema / ascities …
Severe PS murmur on auscultation
Loss of second heart sound
ECG / CXR / Echo of PS
P Pulminale
RVH
RBBB
CXR - Oligaemic lung fields, Large RA / RV
Echo - Severity, RV function
Causes of PS
Congenital
- Congenital PS
- Tetralogy of fallot - PS, RVH, VSD, Overriding aorta
- Noonans - think turners but in men
Aquired
- Rheumatic heart disease
- Endocarditis
- Carcinoid
Options for management of Pulm stenosis
Valvulotomy - if evidence of RV failure / raised gradient >70mmHg
Percutaneous pulm valve inplantation
Surgical repair / replace
What common murmurs in normally functioning AVR ? MVR?
Flow murmur
in AVR - Systolic
- A diasolic AR murmur would indicate non funcitoning valve
MVR - Diastolic flow murmur normal
- MR would indicate non functioning valve
Some non acute complications of surgical valves
Thromboembolus - 1% per year despite warfarin
Bleeding secondary to anticoagulation
Haemolysis - much more significant with old ball-in-cage valves and may be low grade with new Eg St Jude
Endocarditis
AF - especially MVR
Valve failure - especially if tissue (can get a valve-in-valve)
- May be calcification / dehiscence
Indications for an ICD
Primary prevention
- MI > 4weeks ago +Severe LVSD + non-sustained VT in EP study / broad QRS
- Familal condition with high risk sudden caridac death
- LQTS, Brugada, HCM, Complex congenitcal heart disease
Secondary prevention
- Arrest due to VT / VF
- VT with haemodynamic compromise
CRT pacemakers consider if
- LVEF <35% NYHA >1 and on optimal medical therapy
- QRS >150ms
Constrictive pericarditis signs on exam
Raised JVP
Prominent y descent (tricuspid opening)
Kussmals sign - increase in JVP on inspiration
Pulsus paradoxus - drop of >10mmHg on inspiration
Auscultation - pericardial knock
Ascities
Peripheral oedema
Causes of constrictive pericarditis
TB - Cervical lymphadenopathy
Trauma / surgery
Tumour
Therapy (Radio)
connective Tissue disease - Rheum / SLE
TTTT
Constrictive pericarditis investigations
CXR - calcification +/- TB
Echo - high signal from pericardium
CT - thickened pericardium
Cath - equalisaition of heart pressures
Pathophysiology constrictive pericarditis
Thick fibrous capsule insulates heart from intrathroacic pressure changes with respiration
-> ventricular interdependence
- Filling one ventricle reduces size and filling of the other
ASD murmur? what else on the exam might point towards this
Fixed splitting second heart sounds
- may have pulm ESM and diastolic tricuspid flow murmur
Downs syndrome
2 types of ASD? Differentiate them on ECG
primum - AVSD (Downs)
- RBBB + LAD (wide bifid P)
Secundum - more common
- RBBB + RAD (Peaked p)
Complications of ASD that you might find on exam
Irregular, tachycardic pulse – atrial tachyarrhythmias
Pronator drift – paradoxical emboli
Cyanosis, pulmonary hypertension, cor pulmonale – Eisenmenger’s syndrome
ASD indications for closure?
Contraindication?
Symptomatic breathlessness
Paradoxical embolism
RV dilation
Significant shunt
Contraindication - Severe pulm HTN / Eisenmenger
VSD murmur? Name 2 associations
Pansystolic - no audible S2
- Tetralogy of fallot
- turners
- downs
- PDA
- Coarctation
Surgical procedure that partially corrects fallots ? finding on exam?
Blalock - taussig shunt
- anastamose subclavian artery to pulm artery
- > Absent radial pulse
Coarctation murmur ? what else on exam?
Continuous radiating to back
loud A2
- Hypertension Right +/- L arm. lower in legs
- Weak femoral pulses
Coarctation associations
VSD
Turners
bicuspid aortic valve 50-80%
Coarctation seen on ECG / CXR
ECG - LVH, RBBB
CXR - rib notching, double aortic knuckle (due to post stenotic dilation)
Coarctation management
Perc EVAR endovascular aortic repair
Surgical - patch aortoplasty
Follow up with angiograms (including cerebral for anneurysms.)
Long term antihypertensive management
Patent ductus arteriosis - what is it?
key risk factor for developing during pregnancy?
Signs on exam?
2 key complications?
Management?
Aorta -> pulm artery connection with L->R shunt
Rubella
Collapsing pulse
thrusting apex
loud continuous murmur
Eisenmengers
Endocarditis
Perc / surgical closure
If you suspect VSD in young person what should you comment on
Soft p2 - no evidence of pulm HTN
Apex not displaced, no overload, no Left parasternal heave suggesting RHF
VSD in young patient differentials
ASD
PDA
MR
TR
Pulm stenosis
Tetralogy of fallot
Tell me what you know about congenital heart disease
Can be differentiated into L->R and R->L shunts
L->R
- Associated with increased pulm blood flow
- Usually acyanotic
- May slowly lead to increased pulm, vascular resistance with pulm HTN and reversal of shunt called eisinmengers syndrome
- Eg VSD, ASD, AVSD, PDA
R->L
- Deoxygenated blood into aorta
- Tetralogy of fallot, Pulmonary atresia, transposition of great arteries, ebsteins abnormality, hypoplastic left heart syndrome
Differentiate murmur of VSD and ASD / PDA
ASD
- usually just mid/ eject systolic and usually much softer
- Often has fixed splitting of the second heart sound
[Unlikely to get in paces]
PDA - continous murmur
When might a VSD not be congenital
Post MI / trauma
Who gets antibiotic prophlaxis in ACHD
Previous endocarditis
Eisinmengers syndrome
<6months since patch repair
How are VSDs managed
Confirm diagnosis via echocardiography with assessment of shunting and pumonary pressures.
Small VSDs often managed with observation
any symptomatic/ endocarditis/large are repaired
- Patch
- Percutanous device closure
eisenmenger syndrome management
Pulm vasodilators eg Sildenafil
Prophylactic Abx
Monitoring for hyperviscosity / secondary polycythaemia
Consider referral for heart-lung transplant
How would you investigate this patinet who had clinical MR
Full history
Bedside
- ECG
- Observations esp pyrexia
- If acute consider inflam markers
Echocardiogram
- Severity of MR and cause
If consideration of surgery
- Would perform angiography toassess need for CABG at same time
How can you tell severe MR clinically? Investigation?
Clinical
- Signs and symptoms of LVF
- Evidence of AF
Echo
- Usualy on colour flow doppler
Heart sounds in MR
Pansystolic murmur which radiates to axilla
May get 3rd heart sound due to rapid LV filling
Indications for surgery in MR
- Evidence of LVSD / LV dilation
- Symptomatic
If you hear metalic first and second heart sound, especially if youngish what is most likely
Rheumatic heart disease
Aetiology of valvular pathology
AS/AR/MR/MS
AS
- Degenerative calcific
- Bicuspid
- Rheumatic fever and endocarditis
AR
- Rheumatic heart disease
- Endocarditis
- Long standing HTN
- Connective tissue disease - Eg Ank Spond, Marfans, Osteogenesis inperfecta
MR
- Most common Functional caused by LV dilation
- Rheumatic heart disease
- degeneration
- Papilllary muscle rupture post MI
- Connective tissue eg Marfans / ehlers danlos
MS
- Almost always rheumatic heart disease (99%)
- Calcific valve disease / endocarditis
Anaemia in metalic valve usually? other main causes?
Usually occult blood loss secondary to anticoag
Haemolysis - would have raised Bili
Sub acute endocarditis -> anaemia of chronic disease
Which prostetic valve more likely to get clots?
MVR
-> lower velocities so clots can stick
How would you work up a patient for valve replacement
Examination of the heart
- Detailed echo evaluation
- Angiogram - assess for CAD (simultaneous CABG)
- Carotid dopplers if AVR
Can the lungs handle it?
-Pulmonary function tests esp if smoker
- Anaesthetic assessment eg with CPET testing
Referral for MDT to discuss options eg Open vs perc / medical
How would you manage prothetic valve endocarditis
MDT in hospital
Cardiology
ID / Micro
Cardiothoracic surgery
- Highly likely to require surgery
- Acute heart failure will require diruesis and W/H any heart failure meds
- High dose IV antibiotics ideally post 3x blood cultures
Hypertensive retinography grades
- subtle narrowing of arteries
- presence of AV nipping
- Infarction (cotton wool spots), and flame haemorrhages
- Swelling of optic disk - pappiloedema
Name some causes of hypertension
Idiopathic essential (90%)
Renal - Eg Renal artery stenosis or PKD
Endocrine - Eg Cushing / conns
Anatomical - coarctation
Pre/Eclampsia
How would you manage a hypertensive patient as OP
Lifestyle modifications
Esp Smoking cessation, Low salt, exercise, diabetic controll, reduced alcohol.
Check medication compliance
Baseline ECG looing for LVH
Check bloods especially FBC, TFTs and renal function prior to medication
Meds
ACE/CCB -> Thiazide + mineralocorticoid receptor antagonis
Cardio Selective Beta blockers
Betaxolol
Acebutelol
Esmolol
Atenolol
Metoprolol
Mnemonic:
Betablockers Acting Exclusively At Myocardium
Differeniate JVP and carotid pulse
- JVP represents RA pressure
- Can be seen between insertion points of sternocleidomastoid
- JVP falls with inspiration and rises with expriation. Carotid does not
- JVP can be increased with hepatojugular reflex
- Not usually palpable
Causes of a collapsing pulse
AR
PDA
AV fistula
Examination findings in endocarditis
Non tender macular - Janeway lesions
Tender palpable - Olsers nodes
Spinter haemorrhages
Roth spots
Sternotomy scar
Murmurs
Cardiac failure
Common organisms for infective endocarditis
Native valve
- Strep viridans
- staph aureus / Gram negative eg enterococcus
- Rare HAECK- Haemophilus species, Aggregatibacter species, Cardiobacterium hominis, Eikenella corrodens, and Kingella species
Prosthetic
- Staph aureus or staph epidermis most common
Cause of IE?
Any bacteraemia
Eg Infection of any sort
Injury to skin
Dental work
Who is at risk of endocarditis
Anyone can get it
More likely in any valve abnormality / prothetic heart valves
How does a vegetaition form
Damaged valve -> exposed endothelium
-> Thombus and bacteria attach
Complications of IE
Heart failure - valve incompetence
Abscess in arotic root -> rhythm disturbance
Infective elboli
Eg brain, kidneys, bowel etc
Indications for surgery in IE
-Large vegitations
-Severe AR / MR
-Heart failure
-Fungi
Prosthetic
-Evidence of dehiscnece
-Valve obstruction
-Abscess
Relapsing infection
Bar bacterial what other types of endocarditis do you know?
Fungal
Libman-Sacks endocarditis (also known as murantic or verrucous endocarditis)
- nonbacterial endocarditis which involves the presence of sterile vegetations on the cardiac valves.
- Seen in SLE
Malignancy Eg pancreatic adenocarcinoma
What are the causes of AF
Cardio
- IHD
- HTN
- Mitral valve disease
- cardiac surgery
- congenital heart disease
- pericarditis
- cardiomyopathy
Resp
- Infections
- Lung ca
- COPD
- PE
- Connective tissue disease
Abdo
- Alcoholic liver disease
- Any infection
Other
- Hyperthyroid
2 main complications of AF
Strokes
Heart failure
AF investigations
Bedside
A-E
ECG to confirm
Bloods
Inflam markers, renal function / Thyroid function, extended elctrolytes
CXR any heart failure
Echo - assess lv and and structural disease
Tell me about some findings on examination of JVP ? Normal? pathological?
Marker of RA pressure with a normal rise and fall. Starts with A wave of atrial filling and ending with Y descent of atrial emptying
Specific findiings
- Raised - congested
- Prominent V waves and rasied - RV failure and tricuspid regurg
- Cannon A waves - Atrial contraction onto closed tricuspid in heart block
- Loss of A wave in AF as ineffective atrial contraction
What is kussmals sign JVP
JVP raises in inspiration
- Should drop
Associated with severe heart failure of any cause
Suggests inability of RV to accept increasing volume of blood during inspired venous return
How could you enhance murmur in MS
Squatting
Expiration
-> as increases cardiact output and flow
What causes rheumatic fever
group A strep
Rheumatic heart disease management
Ben pen
aspririn
Steroids
Rheumatic fever criteria
Ducket jones criteria
Mitral stenosis management
Heart failure management
AF management
Balloon valvulotomy
Surgical replacement
Mitral stenosis complications
AF
Heart failure
Left atrial englargement -> dysphagia
Endocarditis
Murmur in mitral prolapse
Systolic murmur with click as the posterior leaflet of the valve prolapses into Left atrium during systole
-> systolic click
What are the causes of mitral valve prolapse? dd?
Click
- Congentital
- connective tissue eg marfans / elhers danlos
- Osteogenesis imperfecta
- pseudoxanthoma elasticum
- HCM
- PKD
- Rheumatic heart disease
Differentials
- Atrial myxoma
- Bicuspid aortic stenosis
- Endocarditis
HFPEF evidence based treatment
SLG2 inhibitors
MRA eg spironolactone / eplenerone
Causes of heart failure without LVSD
Right sided failure
Valvular lesions
HFPEF
Why is this murmur TR rather than MR
Loudest on inspiration
Large v waves on JVP
Pulsitile liver
There is a history of IVDU and pyrexia
What is a 3rd and 4th heart sound ? heard when?
S3 - rapid ventriuclar filling
- MR / TR / VSDs
- LV failure
s4 - tubulent blood flow into stiff ventricle
- Aortic stenosis, HTN, HCM, LVH
How would you investigate / manage this patient with tricuspid regurg
Take a full history in particular asking about rheumatic fever history and recreational drug use
Bedside
ECG - RVH / arrythmias, Urine dip, fundoscopy, BP
Bloods
Blood culutes x 3 if suspicious of endocarditis
FBC and CRP for infection
U&Es as may need diuretics
Coag profile
Imaging
CXR - resp cause of TR eg pulm htn / cardiomegaly
Echo - endocarditis and heart falves / function
Treatment of TR
Optomising cause eg connective tissue disease / lung function / endocarditis
Diruesis for symptoms
Surgical
may need valve replacement
What is ebsteins abnomality
congenital defect in tricuspid valve position which causes tricuspid regug
Leads to atrialisation of a portion of the RV leading to an enlarged RA and a small RV
Asymptomatic Aortic stenosis when would you intervene
Inadequate BP response on treadmill
LV dysfunction
Severe AS on echo
Gradient over 4m/s
Valve area < 1cm
differentiate restrictive vs constrictive cardiac ?
Why do we need to differentiate?
Likely requires cardiac MRI
R and L heart catheters
Constrictive
- Infective pericarditis
- post op eg cabg
- TB
- Radiation
Restricitve
- Cardiac fibrosis
- Sarcoid
- Haemochromatosis
- Malignancy
- Radiation
Treatment is different
- Constrictive -> surgical (removal of pericardium)
- Restricitive -> treat cause eg iron overload / DMARDs
“RESTRICT vs. CONSTRICT”
RECENT INFLAMMATION (Restrictive = Infiltrative)
CHRONIC SCAR (Constrictive = Scarring)
Or:
“R.E.S.T.R.I.C.T.” (Restrictive Cardiomyopathy)
* Radiation fibrosis
* Endomyocardial fibrosis
* Sarcoidosis
* Thickened myocardium (but non-dilated)
* Restricted ventricular filling
* Infiltrative disorders (Amyloidosis, Hemochromatosis)
* Chest X-ray normal (no pericardial calcification)
* Troponin usually normal
“C.O.N.S.T.R.I.C.T.” (Constrictive Pericarditis)
* Calcified pericardium (seen on CXR/CT)
* Overall pericardial thickening
* Normal myocardium (not infiltrated)
* Square root sign on ventricular pressure tracing
* Tuberculosis (common cause worldwide)
* Reciprocal ventricular interdependence (septal bounce)
* Impaired diastolic filling
* Cardiac output drops with inspiration (Kussmaul’s sign)
* Treatment is pericardiectomy
These mnemonics emphasize the myocardial infiltrative nature of restrictive cardiomyopathy versus the pericardial scarring and constriction seen in constrictive pericarditis.
