Cardiology Flashcards
Aortic stenosis causes
Bicuspid aortic valve
Age related calcification
Rheumatic heart disease
Rarely infective endocarditis
Features of severe aortic stenosis
Clinically
- symptoms: SOB, chest pain, syncope
- quiet S2
- narrow pulse pressure
- slow rising pulse, low volume
- LV heave
Echocardiography
- valve area <1cm2
- mean valve gradient >40mmHg
Management of aortic stenosis
Valve replacement / TAVI - based on co-morbidities
- Symptomatic disease
- Severe disease based on echocardiographic features
- NB: balloon valvuloplasty for highest risk patients - temporary
Medical
- serial monitoring
- beta blockade
- avoid vasodilating drugs that drop preload -> crash in blood pressure (e.g. nitrates)
Aortic regurgitation causes
- bicuspid valve
- collagen disease e.g. Marfan’s, Ehler’s Danlos
- aortic dissection
- IE
- rheumatic heart disease
- prosthetic valve failure
- autoimmune / rheumatological e.g. ankylosing spondylitis
Features of severe aortic regurgitation
Clinically
- wide pulse pressure
- collapsing pulse
- displaced apex
- Eponymous signs
- —> Quincke’s - nail bed pulsation
- —> Corrigan’s - visible neck pulsation
- —> De Musset’s - head bobbing
- —> Muller’s - pulsation of the uvula
Echocardiocraphic
- regurgitant area > 30mm2
- regurgitant volume >60ml
- LV dilatation (end diastolic)
Management of aortic regurgitation
Valve replacement
- symptomatic disease
- severe echo criteria or LVEF <50%
Medical
- serial echocardiography
- as for heart failure -> ACEi, diuresis
Mitral stenosis causes
Rheumatic heart disease Mitral annular calcification Prosthetic valve stenosis Infective endocarditis (vegetations) Congenital
Features of severe mitral stenosis
Clinical
- Long mid-diastolic murmur
- AF
- Pulmonary hypertension
- Right heart failure
- Decompensated heart failure
Echocardiographic
- valve area <1cm2 (NB: <1.5cm2 is moderate and criteria for intervention)
-
Management of mitral stenosis
Valvular intervention
- symptomatic patients
- valve area <1.5cm2 (moderate)
- pulmonary hypertension (PA pressure >20mmHg)
Options for valvular intervention
- valvuloplasty is preferred if favourable anatomy
- valve replacement
Medical
- serial echo
- manage AF - anticoagulation / rate control
- manage heart failure: ACEi, beta blockade, diuresis
Pregnancy
- advise against pregnancy without prior treatment
Mitral regurgitation causes
Primary (valvular pathology)
- papillary muscle rupture following MI
- degenerative (annular calcification)
- infective endocarditis
- rheumatic heart disease
- connective tissue disease related e.g. Marfan’s, Ehlers Danlos
Secondary (normal valve leaflets / chordae)
- left ventricular systolic dysfunction
- ischaemic cardiomyopathy
- dilated cardiomyopathy e.g. alcohol, myocarditis
Features of severe mitral regurgitation
Clinical
- displaced apex beat
- AF
- pulmonary hypertension - RV heave
- decompensated heart failure
Echo
- LV/LA dilatation
- raised regurgitant volumes / regurgitant areas
Management of mitral regurgitation
Valve surgery (repair preferred, otherwise replacement)
- symptomatic patients
- declining LVEF
- increasing LV dilatation
- AF
- acute valvular incompetence following MI
Medical
- serial echo
- manage heart failure / AF
Causes of pulmonary stenosis
Syndrome association
- Down’s
- Turner’s
- Noonan’s
Carcinoid
Part of tetralogy of fallot
Acquired infections e.g. rubella
Features of severe pulmonary stenosis
Clinical
- RV heave
- signs of right heart failure
- raised JVP
- widely split S2 (non-fixed)
Echo
- valve area <1cm2
- valve gradient >64mmHg
Management of pulmonary stenosis
Usually asymptomatic and does not require intervention (serial monitoring)
Balloon valvuloplasty
Valve replacement if in association with PR
VSD features and causes
Features
- harsh pansystolic murmur lower left sternal edge without radiation (or radiation to the back)
Causes
- isolated findings
- Post septal MI
- Congenital
- –> Down’s
- –> Turner’s
VSD management
Septal closure
- acute septal rupture following MI
- significant left to right shunt
- endocarditis
- other concomitant heart surgery
Medical
- serial echos for surveillance
ASD features and causes
Features
- ESM upper left sternal edge (increased pulmonary flow)
- fixed splitting of the second heart sound
Haemodynamically signficant ASD features
- AF
- laterally displaced apex
- systolic thrill pulmonary area
- mid diastolic rumble tricuspid (increased left -> right shunt and tricuspid blood flow)
Causes
- 70% ostium secundum defect
- –> usually subclinical
- –> ECG: RBBB, RAD
- 15% ostium primum defect
- –> more clinically relevant
- –> associated syndromes: Down’s, Noonan’s, sometimes Turner’s
ASD management
Septal closure (surgical / percutaneous)
- symptomatic
- significant right to left shunt / right heart failure
Medical
- serial echos
Complications of ASD / VSD
Arrhythmias
Paradoxical embolism
Infective endocarditis
Right heart failure (left to right shunting -> volume overload)
Development of right to left shunt -> Eisenmenger’s
PDA clinical features
Continuous murmur, loudest in systole, pulmonary area, radiates to back, loudest in expiration
Causes and features of severe PDA
Causes
- idiopathic
- prematurity
- associated with syndromes: Down’s, Noonan’s
Clinical
- collapsing pulse
- LV failure
- PHT: loud P2, RV heave, raised JVP, TR
- Eisenmenger’s - cyanosis
Echo
- raised pulmonary pressures
- LV dysfunction (Eisenmenger’s more likely)
- RV dilatation
- TR
Management of PDA
If part of cyanotic heart disease in neonates
- keep open whilst awaiting definitive procedure! - prostaglandin infusion
Closure
- right or left sided heart failure
- continued surveillance thereafter if associated PHT or LV dysfunction
Medical
- serial echos
Tetralogy of fallot components
Overriding aorta
Right ventricular outflow tract obstruction
VSD
Right ventricular hypertrophy
Management of tetralogy of fallot
- PDA infusion at birth to keep PDA open
- Blalock Taussig shunt (palliative, plumbing subclavian into pulmonary artery to increase pulmonary blood flow)
- or total corrective surgery)
Causes of dextrocardia
Primary ciliary dyskinesia
- Kartagener’s
- –> dextrocardia
- –> situs invertus
- –> sinusitis
- –> subfertility
- Turner’s
Duke’s criteria
Infective endocarditis diagnosis
- 2 major
- 1 major + 3 minor
- 5 minor
Major
- typical positive organism in 2x blood culture (S aureus, strep viridans, strep bovis HACEK group)
- endocardial involvement on echo
Minor
- fever
- positive blood cultures not meeting major criteria
- echocardiographic features not meeting major criteria
- immune phenomena: Osler nodes, glomerulonephritis
- embolic phenomena: splinter haemorrhages, septic emboli (lung, brain)
Jones criteria
Rheumatic fever diagnosis
- evidence of recent group A strep infection
+ 2 major
OR 1 major + 2 minor
Evidence of recent group A strep infection
- ASOT
- +ve throat swab
- recent scarlet fever
- +ve strep antigen testing
Major
- polyarthritis
- carditis (including valvular incompetence)
- sydenham’s chorea
- erythema marginatum
- subcutaneous nodules
Minor
- polyarthralgia
- fever
- prolonged PR
- raised inflammatory markers
Split second heart sound cause
NORMALLY: P2 after A2 (reduced afterload)
Fixed
- ASD
Wide but variable
- pulmonary stenosis
- RBBB
- VSD
- MR
Reversed splitting
- LBBB
- severe AS
- coarctation
Features of co-arctation of the aorta
- systolic or continuous murmur: left infraclavicular anteriorly and posteriorly
- large volume right radial pulse
- radio-radio or radio-femoral delay
- chest wall collaterals
- heaving undisplaced apex
Post surgical
- left thoracotomy
- normal right radial
- no delay
- left radial may be weak
- normal heart sounds
Causes of co-arctation
Congenital
- Turner’s
- Marfan’s
Management of co-arctation
Surgical correction
- left thoracotomy approach
Percutaneous balloon angioplasty
Medical
- hypertension
Complications of co-arctation
Hypertension
Hypertensive heart failure
Infective endocarditis
Types of valves
Bioprosthetic
Metallic
- ball & cage
- –> rattles on opening & clicks on closing
- single leaflet (tilting disc)
- bileaflet
