Cardiology

Question 1

Causes of volume loaded apex beat

Answer 1

Diffuse and non-sustained - MR - AR - VSD

Question 2

Causes of pressure loaded apex beat

Answer 2

Focal and sustained - AS - HOCM - systemic HTN

Question 3

Cause of double impulse apex beat

Answer 3

HOCM

Question 4

Mitral Stenosis

Answer 4

Causes:

• Rheumatic (women > men)
• Severe mitral annular calcification (consider hypercalcaemia, hyperparathyroidism)
• Mitral valve repair
• Congenital

Signs of Severity

• Narrow pulse pressure
• Early opening snap (owing to raised LA pressure)
• Length of mid-diastolic rumbling murmur (persists as long as there is a gradient)
• Diastolic thrill at the apex
• Pulmonary HTN:
  
  • Prominanet a wave in JVP
  • Right ventricular impulse
  • Loud P2 or palpable P2
  • Pulmonary or tricuspid regurg

ECG

• p mitrale (in sinus - biphasic)
• AF (Sx of chronicity)
• RV systolic overload
• RAD

CXR

• Mitral valve calcification
• LA dilation - double LA shadow, displaced L) main bronchus, big L) atrial appendage
• Signs of pulmonary HTN - large central pulmonary arteries, pruned peripheral arterial tree
• LV failure

Surgery Indications

• Exertional dyspnoea and falling valve area (<1cm)
• Increasing right heart pressures

Question 5

Causes of MS

Answer 5

Rheumatic (women > men) Severe mitral annular calcification Mitral valve repair Congenital

Question 6

AS Severity

Answer 6

Anacrotic pulse (slow rising, low volume) Narrow pulse pressure (<30) Palpable systolic thrill Soft S2 S4 Late peaking Signs of heart failure/pulmonary HTN

Question 7

AR Severity

Answer 7

Wide pulse pressure (>50) Collapsing pulse S3/soft S(A)2 Long diastolic murmur Austin flint murmur Signs of heart failure, pulmonary HTN

Question 8

Signs of Pulmonary HTN

Answer 8

Prominent a wave on JVP Right ventricular impulse Loud P2 or palpable P2 Pulmonary regurg TR

Question 9

MR Severity

Answer 9

Enlarged left ventricle Pulmonary HTN S3 Early diastolic rumble Soft S1 Aortic component of S2 earlier Small volume pulse LV failure

Question 10

Causes of dominant a wave on JVP

Answer 10

Tricuspid stenosis Pulmonary stenosis Pulmonary hypertension

Question 11

Signs of TR

Answer 11

JVP - large v waves, elevated if RVF RV heave Pansystolic murmur - lower sternal edge, loudest on inspiration Pulsatile hepatomegaly Ascites and oedema

Question 12

ECG Findings in MS

Answer 12

P mitrale in sinus rhythm AF (chronic) RV Strain: ST depression and T wave inversion in leads corresponding to the right ventricle: Right precordial leads V1-3 +/- V4; Inferior leads II, III, aVF, often most pronounced in lead III as this is the most rightward facing lead Right axis deviation

Question 13

CXR Findings in MS

Answer 13

Mitral Valve Calcification LA dilation - double left atrial shadow, displaced left main bronchus, big left atrial appendage Pulmonary HTN - large central pulmonary arteries, pruned peripheral arterial tree Signs of cardiac failure