Cardiology Flashcards
Causes of Clubbing
1. Cardiovascular ● Cyanotic congenital heart disease ● Infective endocarditis 2. Respiratory - IAM CCC ● Lung carcinoma ● Chronic supportive lung disease: bronchiectasis, abscess, empyema ● Idiopathic pulmonary fibrosis ● Cystic fibrosis ● Asbestosis ● Pleural mesothelioma 3. Gastrointestinal ● Cirrhosis ● Inflammatory bowel disease ● Coeliac disease 4. Thyrotoxicosis
Causes of elevated JVP
● Right ventricular failure ● Tricuspid stenosis or regurgitation ● Pulmonary stenosis ● Pericardial effusion or constrictive pericarditis ● Superior vena caval obstruction ● Fluid overload
Causes of dominant a-wave on JVP
● Tricuspid stenosis
● Pulmonary stenosis
● Pulmonary hypertension
● Cannon a wave = complete heart block
Cause of dominant v-wave on JVP
● Tricuspid regurgitation
Characters of Apex beat
● Pressure loaded: heaving, hyperdynamic, systolic overloaded, forceful/sustained
o Causes: aortic stenosis, hypertension
● Volume loaded: diffuse, displaced, non-sustained impulse
o Causes: mitral regurgitation, dilated cardiomyopathy
● Double impulse
o Causes: hypertrophic cardiomyopathy
● Tapping
o Causes: mitral stenosis
● Loud S1:
o Mitral stenosis
● Soft S1:
o Prolonged diastolic filling time (1st degree AV block)
o Delayed LV systole (LBBB)
o Mitral regurgitation
● Loud A2:
Systemic hypertension, congenital aortic stenosis
● Loud P2:
Pulmonary hypertension
● Soft A2:
Aortic regurgitation
Causes of S3 - mid-diastolic sound - heard with bell
A S3 heart sound is produced during passive left ventricular filling when blood strikes a compliant LV.
In dilated CM
A S3 heart sound should disappear when the diaphragm of the stethoscope is used and should be present while using the bell; the opposite is true for a split S2.
● Reduced ventricular compliance, left ventricular failure/dilatation
● Causes: aortic regurgitation, mitral regurgitation, VSD, PDA
Causes of S4 - late-diastolic sound
A S4 heart sound occurs during active LV filling when atrial contraction forces blood into a noncompliant LV.
● Causes: aortic stenosis, acute mitral regurgitation, hypertension, old age
A paradoxical split S2
Splitting is heard during expiration and disappears during inspiration. Delayed closing of aortic valve.
Causes: severe aortic stenosis and hypertrophic obstructive cardiomyopathy, or in the presence of a left bundle branch block.
Persistent wide split S2
RBBB, pulmonary hypertension or pulmonic stenosis (delayed P2) or severe mitral regurgitation/ventricular septal defect
Fixed split S2
ASD
Systolic ejection click
bicuspid aortic valve.
mid systolic click
Mitral valve prolapse click
Opening snap
In the setting of MS, the increased left atrial opening pressures cause an opening snap to occur when the mitral valve leaflets suddenly tense and dome into the LV in early diastole.
Pericardial knock
A pericardial knock can be present in patients with constrictive pericarditis, as the early filling of the LV is limited from the constrictive process. The knock occurs earlier than a S3 heart sound. which is the distinguishing factor; this is because the S3 heart sound occurs from a stretch of a very compliant LV, which takes a short time longer.
Pansystolic murmurs
● Mitral regurgitation (apex)
● Tricuspid regurgitation (left lower sternal edge)
● Ventricular septal defect (left lower sternal edge)
● Aortopulmonary shunt
Ejection systolic murmur
● Aortic stenosis (right 2nd intercostal space)
● Pulmonary stenosis (left 2nd intercostal space)
● Hypertrophic cardiomyopathy (left lower sternal edge)
● Pulmonary flow murmur of an atrial septal defect (left 2nd intercostal space)
Late systolic murmur
● Mitral valve prolapse (apex)
● Papillary muscle dysfunction (apex)
Early diastolic murmur
● Aortic regurgitation (left lower sternal edge)
● Pulmonary regurgitation (left 2nd intercostal space)
Mid diastolic murmur
● Mitral stenosis (bell at apex in left lateral decubitus position after 15 seconds of bicycle kicks)
● Tricuspid stenosis
● Atrial myxoma
Continuous murmur
● Patent ductus arteriosus
● Arteriovenous fistula
Grade of murmurs
● Grade 1/6: very soft
● Grade 2/6: soft
● Grade 3/6: moderate intensity, no thrill
● Grade 4/6: loud, thrill just palpable
● Grade 5/6: very loud, thrill easily palpable
● Grade 6/6: very, very loud, even without directly placing stethoscope
Signs of Pulmonary HTN
- Pulse: Low volume pulse
- JVP: prominent a wave
- Praecordium: right ventricular heave, palpable P2
- Auscultation: ejection systolic click, loud P2, S4
- Signs of right ventricular failure
Mitral stenosis causes
● Rheumatic
● Congenital rarely
Mitral stenosis examination findings
PULSE: Atrial fibrillation, reduce in volume
BLOOD PRESSURE: small pulse pressure
PALPATION: tapping apex beat, RV heave/palpable P2. apical thrill.
AUSCULTATION
● Loud S1
● Loud P2
● Opening snap
● Low-pitched diastolic murmur (bell in left lateral decubitus position), accentuated by exercise
Mitral stenosis signs of severity
- Small pulse pressure
- Soft S1
- Early opening snap
- Long diastolic murmur
- Diastolic thrill at the apex
- Signs of pulmonary hypertension
In mild to moderate mitral stenosis, the increased left atrial pressure causes the mobile portions of the mitral valve leaflets to be more widely separated, resulting in an accentuated M1 sound. In severe to critical mitral stenosis, the valve leaflets are so calcified and immobile that the M1 sound is diminished or absent.
Mitral stenosis investigation findings
- ECG: P-mitrale in sinus rhythm, atrial fibrillation (sign of chronicity), right axis deviation
- CXR: mitral valve calcification, big left atrium, signs of pulmonary hypertension, signs of cardiac failure
Mitral stenosis indications for surgery
Valve area: normal 4-6cm2; severe mitral stenosis <1cm2
● Exertional dyspnoea and falling valve area (valve area <1cm2) with sings of increasing right heart pressure
Mitral Regurgitation causes
CAUSES – CHRONIC
- Degenerative disease
- Mitral valve prolapse
- Rheumatic
- Papillary muscle dysfunction: left ventricular failure, ischaemia
- Connective tissue disease: rheumatoid arthritis, ankylosing spondylitis
- Congenital: endocardial cushion defect (primum ASD), parachute valve,
CAUSES – ACUTE
- Infective endocarditis
- Myocardial infarction (chordae rupture or papillary muscle dysfunction)
- Surgery
- Trauma
Mitral Regurgitation - Exam findings and signs of severity
PULSE: normal or sharp upstroke, atrial fibrillation
PALPATION: displaced apex beat, diffuse & hyperdynamic (volume-loaded) apex beat, pansystolic thrill
AUSCULTATION:
● Soft or absent S1
● Left ventricular S3
● Pansystolic murmur loudest at apex, radiating towards axilla, louder on expiration
SIGNS OF SEVERE MITRAL REGURGITATION
- Small volume pulse
- Enlarged left ventricle (displaced apex beat)
- Soft S1
- Loud S3
- Split S2 (early A2)
- Early diastolic rumble
- Left ventricular failure
- Pulmonary hypertension (loud/palpable P2/right ventricular heave)
Mitral Regurgitation Investigation findings
● ECG: P-mitrale, atrial fibrillation, left ventricular diastolic overload, right-axis deviation
● CXR: large left atrium, increased left ventricular size, mitral annular calcification, pulmonary hypertension
Mitral Regurgitation indications for surgery
● Chronic MR: NYHA Class III or IV symptoms or left ventricular dysfunction or progressively increasing LV size
● Acute MR: haemodynamic collapse
Mitral valve prolapse- causes
CAUSES: ● Myxomatous degeneration of mitral valve ● Atrial septal defect ● Hypertrophic cardiomyopathy ● Marfan’s syndrome
Mitral valve prolapse - examination findings
AUSCULTATION:
● Midsystolic click at the apex
● High-pitched late systolic murmur, commencing with the click and extending throughout the rest of systole
● Murmur & click occur earlier and louder with Valsalva manoeuvre and with standing.
o Occurs later and softer with squatting/isometric exercise (handgrip)
Aortic stenosis causes
- Degenerative senile calcific aortic stenosis
- Rheumatic
- Calcific bicuspid valve
Aortic stenosis examination findings and signs of severity
PULSE: plateau pulse, slow rising, small volume pulse
BLOOD PRESSURE: narrow pulse pressure (<40mmHg)
PALPATION: pressure-loaded apex beat, systolic thrill at aortic area
AUSCULTATION:
● Narrowly-split or reversed S2
● Harsh midsystolic ejection murmur, loudest over aortic area and radiating to carotids
o Murmur is loudest with patient sitting up and in full expiration
o Associated aortic regurgitation is common
SIGNS OF SEVERE AORTIC STENOSIS (aortic valve area <1cm2)
- Plateau pulse
- Aortic thrill
- Length, harshness and lateness of the peak of the murmur
- Fourth heart sound (S4)
- Paradoxical splitting of the second heart sound (delayed left ventricular ejection & aortic valve closure)
- Left ventricular failure
Aortic stenosis investigation findings
● ECG: left ventricular hypertrophy
● CXR: left ventricular hypertrophy, valve calcification
● TTE: severe AS: AVA <1cm2, mean valve pressure gradient >40mmHg, peak jet velocity >4m/sec
Aortic stenosis indications for surgery
● Symptoms: exertional angina, exertional dyspnoea, exertional syncope
● Critical obstruction and severe left ventricular hypertrophy
Aortic regurg causes:
CAUSES – CHRONIC ● Valvular o Rheumatic o Congenital o Seronegative arthropathy, especially ankylosing spondylitis ● Aortic root o Marfan’s syndrome o Aortitis (seronegative arthropathies, rheumatoid arthritis, tertiary syphilis) o Dissecting aneurysm o Old age
CAUSES – ACUTE
● Valvular – infective endocarditis
● Aortic root – Marfan’s syndrome, hypertension, dissecting aneurysm
Aortic Regurg examination findings and signs of severity
GENERAL SIGNS: Marfan’s syndrome, ankylosing spondylitis
PULSE AND BLOOD PRESSURE: collapsing (water hammer) pulse, wide pulse pressure
NECK: prominent carotid pulsations
PALPATION: Apex beat displaced and hyperkinetic (volume-loaded), diastolic thrill at left sternal edge
AUSCULTATION:
● Soft A2
● Decrescendo high-pitched diastolic murmur beginning immediately after the second heart sound, loudest at the 3rd and 4ths left intercostal spaces
● Austin Flint murmur: mid-diastolic & presystolic murmur audible at the apex
SIGNS OF SEVERITY OF CHRONIC AORTIC REGURGITATION
- Collapsing pulse
- Wide pulse pressure
- Length of the decrescendo diastolic murmur
- Third heart sound
- Soft A2
- Austin Flint murmur (diastolic rumble caused by limitation to mitral inflow by the regurgitation jet)
- Left ventricular failure
Aortic Regurg investigation findings
INVESTIGATIONS
● ECG: left ventricular hypertrophy
● CXR: LH, aortic root dilatation/aneurysm, valve calcification
Aortic Regurg indications for surgery
● Exertional dyspnoea
● Worsening left ventricular function, such as low ejection fraction
● Progressive left ventricular dilatation on serial echocardiograms
Tricuspid Regurg causes
CAUSES OF TRICUSPID REGURGITATION
● Functional, e.g. right ventricular failure
● Rheumatic, usually mitral valve disease also present
● Infective endocarditis (e.g. IVDU)
● Tricuspid valve prolapse
● Right ventricular papillary muscle prolapse
● Trauma
● Congenital Ebstein’s anomaly
Tricuspid regurg examination findings
JVP: large V waves, elevated if right heart failure present
PALPATION: right ventricular heave
AUSCULTATION:
● Pansystolic murmur loudest at left lower sternal edge, increases on inspiration
ABDOMEN
● Pulsatile, large & tender liver
● Ascites, oedema, pleural effusion may be present
LEGS
● Dilated, pulsatile veins
Tricuspid stenosis examination findings
JVP: raised, giant a waves AUSCULTATION ● Diastolic murmur @ left sternal edge, louder on inspiration ABDOMEN ● Presystolic pulsation of the liver CAUSES ● Rheumatic heart disease
Pulmonary stenosis causes
CAUSES:
● Congenital
● Carcinoid syndrome
Pulmonary stenosis examination findings and signs of severity
GENERAL SIGNS
● Peripheral cyanosis
● PULSE: Normal or reduced pulse
● JVP: giant a waves, elevated JVP
● PALPATION: right ventricular heave, thrill over the pulmonary area
● AUSCULTATION: ejection click, harsh ejection systolic murmur loudest in pulmonary area and on inspiration, S4
● ABDOMEN: presystolic pulsation of liver
SIGNS OF SEVERE PULMONARY STENOSIS ● Ejection systolic murmur peaking late into systole ● Absence of an ejection click ● Presence of S4 ● Signs of right ventricular failure
Constrictive pericarditis causes
CAUSES OF CONSTRICTIVE PERICARDITIS ● Radiation ● Tumour ● Tuberculosis ● Connective tissue disease ● Chronic renal failure ● Trauma
Constrictive pericarditis examination findings
GENERAL SIGNS: patient is cachectic and has ascites
PULSE & BLOOD PRESSURE: a low blood pressure and pulsus paradoxus are typical
JVP: this is raised, Kussmaul’s sign is rare
APEX BEAT: impalpable
AUSCULTATION: distant heart sounds, early S3 and pericardial knock
ABDOMEN: hepatosplenomegaly, ascites and oedema
HOCM examination findings
PULSE: typically sharp, rising and jerky
JVP: prominent a wave owing to forceful atrial contraction against a non-compliant ventricle
APEX BEAT: double or triple impulse owing to a presystolic ventricular expansion following atrial contraction
AUSCULTATION:
● Late systolic ejection murmur (left sternal edge)
● Pansystolic murmur (apex) from mitral regurgitation
● Fourth heart sound
DYNAMIC MANOEUVRES:
● Murmur is louder with Valsalva manoeuvre, standing and isotonic exercise (e.g. jogging)
● Murmur is softer with squatting, raising the legs, and isometric exercise (force handgrip)
HOCM investigation findings
● ECG:
o Left ventricular hypertrophy and lateral ST segment and T wave changes
o Deep Q-waves
o Conduction defects
● CXR: left ventricle enlarged, no valve calcification
● TTE: asymmetrical hypertrophy of the ventricular septum, systolic anterior motion (SAM ) of the anterior mitral valve leaflet
ASD types and investigation findings
ASD: OSTIUM SECUNDUM
● ECG: right-axis deviation, RBBB, right ventricular hypertrophy
● CXR: increased pulmonary vasculature, enlarged right atrium/ventricle, dilated main pulmonary artery
ASD: OSTIUM PRIMUM
● Associated mitral regurgitation, tricuspid regurgitation or VSD is common
● ECG: left-axis deviation and RBBB
ASD examination findings
● Fixed splitting of S2 - delayed PV closing.
● Pulmonary systolic ejection murmur (increasing on inspiration) - increased PV flow from inc RV volume.
● Pulmonary hypertension
VSD examination findings
PALPATION: hyperkinetic displaced apex beat, thrill at left sternal edge
AUSCULTATION
● Harsh pansystolic murmur maximal at and confined to lower left sternal edge with a 3rd or 4th heart sound – murmur is louder on expiration
● Sometimes a mitral regurgitation murmur is associated
● Palpable systolic thrill
● Murmur is louder and harsher when the defect is small
VSD indications for closure
● Moderate to large left-to-right shunt (pulmonary to systemic flow >1.5 to 1)
Coarctation of the aorta - signs
● Upper body better developed than the lower
● Radiofemoral delay
● Femoral pulses are weak
● Hypertension in arms
● Midsystolic murmur audible over the praecordium and the back
Intervention - Hypertension + peak-peak gradient 20mmHg - Severe anatomic with significant collaterals
Tetralogy of Fallot
ROVR
- Right ventricular outflow obstruction
- Right ventricular hypertrophy
- VSD
- Overriding aorta
LVH ECG criteria
- V1 S wave + V5/V6 R wave = >35mm
- Delayed R wave peak >50ms
- LV strain with ST depression + TWI in lateral leads.
Signs of PDA
Signs - Continuous ‘machinery’ murmur (must listen left subclavicular) - Left subclavicular thrill - Large volume, bounding, collapsing pulse - Wide pulse pressure - Heaving apex beat
May have differential cyanosis/clubbing - if there has been reversal of the shunt -> shunted deoxygenated blood goes out distal to the aortic arch vessels
Investigations
ECG: LVH
CXR: - increased pulmonary vasculature - calcification of the duct
Intervention - PDA with more than a trivial shunt (unless pulmonary hypertension present) - if incidental finding without symptoms/murmur and has trivial shunt don’t have to close
Possible conditions if cardiac auscultation is unremarkable
MS: position and exercise
ASD: carefully for fixed splitting
MVP: valsalva
Pulmonary hypertension
Constrictive pericarditis - think if they have bad failure and you can’t find much else
If you can’t hear heart sounds - think dextrocardia
Sign of Eisenmenger syndrome
Look for cyanosis, clubbing, polycythaemia
Signs (pulmonary hypertension)
- JVP: dominant a wave; maybe v wave - RV heave; palpable P2 - loud P2 - S4; pulmonary ejection click - PR, TR
Level of the shunt - ASD: wide fixed split - VSD: single second sound - PDA: normal second sound or reversed split (look for differential cyanosis)
Investigations
ECG: RVH; p pulmonale
CXR - RVE/RAE - pulmonary artery prominence - increased hilar vasculature with dropped out peripheral vasculature - non boot shaped heart
