Cardiology Flashcards
1
Q
What is the most common cardiac finding in Marfan syndrome?
A
-Dilatation of the aortic root
2
Q
What are the conditions where IE prophylaxis is recommended?
A
- Prosthetic cardiac valve or prosthetic material used for valve repair
- Previous IE
- Congenital heart disease (CHD)
1. Unrepaired cyanotic CHD, including palliative shunts and conduits
2. Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
3. Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) - Cardiac transplant recipients who develop cardiac valvulopathy
3
Q
In which types of procedures is IE prophylaxis reasonable in those with predisposing conditions?
A
- Dental: all dental procedures that involve manipulation of gingival tissue, the periapical region of the teeth or the perforation of the oral mucosa
- Invasive procedures of the respiratory tract (e.g T&A) (cover for staph aureus)
- GI/GU procedures where there are signs of infection (cover for enterococcus)
- Procedures on infected skin or MSK
4
Q
What are the ECG changes seen in 1. VSD, 2. ASD, and 3. AVSD
A
- VSD - Small: normal ECG
Moderate: LVH, occasional LAH
Large: Biventricular hypertrophy (left dominance) +/- LAH - ASD - RAD (90-180) with mild RVH OR
RBBB with RSR’ pattern in V1, right atrial enlargement - AVSD - LAD (uncommon in VSD)
-with other similar VSD changes
-RVH or RBBB
-Many also have LVH
5
Q
What is the “juvenile T wave pattern”?
A
- 1st wk of life: waves upright in precordial leads
- >1wk - ~8yo: T waves inverted in V1-V3
- >8yo: T waves become upright in V1-V3 (though may persist into adolescence)
- If upright early (e.g. 3yo): consider RVH
6
Q
What are six common findings on the pediatric ECG that are normal variants?
A
- HR > 100 bpm
- Rightward QRS axis > +90
- T wave inversions in V1-3 (“juvenile T-wave pattern”)
- Dominant R wave in V1
- RSR’ pattern in V1
- Marked sinus arrhythmia
- Short PR interval (< 120 ms) and QRS duration (<80ms)
- Slightly peaked P waves (<3mm in height is normal if <6mo)
- Q waves in the inferior and left precordial leads
7
Q
What are the most common findings on physical exam in a infant with cyanotic heart disease?
A
Normal pulses + quiet precordium
Single S2
Appears cyanotic, but minimal respiratory distress
8
Q
What is the most common cardiac lesion in an IDM?
A
Septal hypertrophy - resolves shortly after birth (in most cases)
9
Q
What is a possible cause of post-ductal saturations being higher than pre-ductal sats?
A
Very uncommon
-Most common: TGA with coarctation
10
Q
What are the ECG changes seen in digoxin toxicity?
A
- Combines: SVT + slow ventricular response
- Other findings: frequent PVCs, sinus bradycardia, slow atrial fibrillation, any type of AV block, ventricular tachycardia
11
Q
How should 1st degree relatives of people with HOCM be screened?
A
- If known pathogenic mutation: genetic screening for all close family members
- If not:
- History, physical exam, ECG, and echo
- In a child prior to puberty, if screening is NORMAL, clinical evaluation should be repeated q2-3 years until the onset of puberty.
- 12-18 yo, q1yr screening
- > 18 yo: q5yr screening
- We offer genetic testing to all patients with HCM (unless secondary causes are suspected)
12
Q
What is the cardiac defect classically associated with Williams syndrome?
A
Supravalvular aortic stenosis
13
Q
What congenital disorders may have pulmonary stenosis?
A
- Mutation in PTPN11
- Noonan syndrome
- LEOPARD syndrome (lentigines, ECG abnormalities, ocular hypertelorism, PS, abnormalities of genitalia, retardation in growth, deafness syndrome)
- Alagille syndrome
14
Q
What ECG change is characteristic of rheumatic fever?
A
Prolonged PR interval
15
Q
What is the JONES critieria
A
Criteria - 2 major or 1 major + 2 minor
Major: JONES
J - Joint involvement
O - heart (carditis, can evolve to mitral or aortic valve disease)
N - subcutaneous nodules
E - erythema marginatum
S - sydenham chorea
Minor - fever, arthralgia, elevated ESR/CRP, prolonged PR on ECG
GAS infection - ASOT, anti-DNAase B or +throat swab
16
Q
What are the specific cardiac manifestations of rheumatic fever?
A
- Most often prolonged PR (though can be seen in ⅓ of uncomplicated strep infections)
- Most common: AV conduction abnormalities, 1st degree AV block is most common
- Severe 1st degree block can lead to junctional rhythm
- 2nd and 3rd degree heart block can occur
- Typically occurs 10-20y after original illness
- Mitral regurgitation → may progress to severe mitral stenosis
17
Q
What is the common main complaint of people with HOCM?
A
Exercise intolerance
18
Q
What are worrisome features of PVCs?
A
2+ in a row, multiform, increase with exercise, R-onT phenomenon (occur on T wave of preceding beat), extreme frequency (>20% of total beats on Holter), presence of underlying heart disease, heart surgery
19
Q
In what CHD are signs of right atrial enlargement seen?
A
- Pulmonary stenosis
- Ebstein anomaly of the tricuspid valve
- Tricuspid atresia
- Cor pulmonale
20
Q
What is the differential diagnosis of syncope?
A
-
Etiology: global cerebral hypoperfusion
- Vasovagal (~70%)
- Breath-holding spells (6%)
-
Cardiac (<5%) →
- Electrical: long QT syndrome, Brugada, WPW
- Structural: hypertrophic cardiomyopathy, coronary artery anomalies, arrhythmogenic right ventricular cardiomyopathy
- Neurologic (<5%) → seizures, migraines
- Metabolic (<1%) → bleeding, hypoglycemia, electrolyte disturbances
- Psychiatric (2%) → conversion disorder
21
Q
When should an ECG done in syncope?
A
- History not in keeping with vasovagal syncope
- No prodrome before syncope
- Mid Exertional event
- Syncope triggered by loud noise or startle
- Family history of sudden death or heart disease in young individuals
- Abnormal cardiac examination
- New medication with potential cardiac side effects
22
Q
What are ‘red flag’ findings on ECGs done for syncope?
A
23
Q
What are reasons to refer a newborn to cardiology?
A
- Abnormal fetal Echocardiogram
- Underlying genetic disorder associated with CHD
- Clinical symptoms suggestive of CHD (cyanosis, FTT, WOB, diaphoresis with feeds, hepatomegaly)
- Murmur: grade >=3, holosystolic, maximally intense at LUSB, more intense when upright, harsh/blowing, diastolic = pathologic
- Presence of atypical heart sounds: clicks, rubs, gallops, abnormal S2
- Investigations: Abnormal pulse oximetry, cardiomegaly or pulmonary edema on CXR, abnormal ECG
24
Q
What is the treatment for long QTc syndrome?
A
- Start Beta-blocker (1st line - blunts HR response to exercise)
- Restrict vigorous activity (evolving recommendation) - need exercise test to prove BB is effective before doing vigorous activity
- If they do return to activity, it needs to be supervised and there has to be an accessible AED
- Indications for ICD: aborted cardiac arrest, syncopal events despite beta blockade, noncompliance or intolerance medication
25
What are the secondary causes of long QTc syndrome?
* Metabolic issues (starvation, AN, hypothyroidism)
* Electrolyte abnormalities: hypocalcemia, hypomagnesemia, hypokalemia
* Myocardial dysfunction: myocarditis, CHF, cardiac tumours
* Endocrinopathy: hyperparathyroidism, hypothyroidism, pheochromocytoma
* Neurologic: encephalitis, head trauma, stroke, SAH
* Nutrition: anorexia, starvation
* Bradyarrhythmias (sinus node dysfunction, AV block)
* Medications
* Antiarrhythmic drugs (e.g. procainamide, amiodarone, sotalol)
* Antibiotics (e.g. antimalarials, anti-parasitics, anti-TB, fluoroquinolones, HIV antiretrovirals, macrolides, septra)
* Antifungals (e.g. fluconazole, ketoconazole)
* Antihistamines (e.g. diphenhydramine)
* Antineoplastic drugs
* Analgesics (e.g. chloral hydrate, propofol)
* Psychotropic (e.g. TCAs, haloperidol, risperidone, carbamazepine)
* Others (psychotropic drugs, diuretics, antiemetics, promotility, caffeine, epinephrine)
26
What is the common cause of sudden cardiac death in teens & young adults?
Familial Hypertrophic cardiomyopathy (HOCM)
27
Describe the physical exam for HOCM?
* Abnormal peripheral pulses (hyperdynamic or diminished)
* Systolic ejection murmur in the aortic region (no associated click); worsens when upright (obstruction worsens when standing = preload decreases)
* Auscultation - hyperdynamic precordium, heave, SEM in aortic region
28
What does the ECG and CXR for TAVPR show?
* ECG: RAD + RVH
* CXR: pulmonary edema, “snowman"
29
What may the exam for someone with aortic stenosis show?
* **Systolic ejection click** (valve snapping open, thick)
* **Murmur audible maximally at RUSB**; radiates to neck, left midsternal border
* Louder = more obstruction
* Murmur does not change with position or respiration
* Usually accompanied by thrill in suprasternal notch
* S4 + quiet S1 in severe obstruction
30
What does the physical exam, ECG, CXR reveal in Truncus Arteriosus?
* _Exam_
* Mild cyanosis
* Single loud S2, SEM, early systolic ejection click
* _ECG_: right, left or combined ventricular hypertrophy (LVH/RSV)
* _CXR_: big variation (cardiomegaly develops over 1st several weeks of life), pulmonary edema
31
What are the cyanotic causes of CHD - divide by duct dependent and not necessarily duct dependent
* _Duct dependent_
* Hypoplastic left heart syndrome (like a coarct)
* Transposition of the great arteries (TGA)
* Coarctation/hypoplastic arch
* Severe pulmonary stenosis
* Severe aortic stenosis
_Not necessarily duct dependent_
* TOF
* Truncus arteriosus
* Tricuspid atresia
* TAPVR
32
Which ECG change is characteristic of acute rheumatic fever?
Prolonged PR interval
33
What does the exam, ECG and CXR show in a patient with an ASD?
* _Heart sounds_:
* **Widely split / fixed S2** (due to increased flow across PV delays closure) and Grade 2-3 SEM to LUSB
* Mid-Diastolic rumble at mid-lower R sternal border if large shunt present (increased flow across TV)
* _ECG_
* RAD (90-180) with mild RVH OR
* RBBB with rsR’ pattern in V1
* _CXR_
* Cardiomegaly with enlarged RA and RV
* Increased pulmonary vasculature if large shunt
34
What does the exam, ECG, and CXR show in a patient with TOF?
* _Physical exam_
* Right sided heave and thrill
* Loud SEM harsh crescendo-decrescendo at LUSB, radiates to back
* Loud, single S2 +/- thrill at LMSB and LLSB
* As RVOT obstruction increases or systemic resistance decreases, R-to-L shunting across VSD occurs
* May present as tachypnea, increasing cyanosis, and decreasing murmur
* _ECG:_ RAD → RAH + RVH
* _CXR:_ “Boot-shaped heart” with normal heart size +/- decreased pulmonary vasculature (“oligemic lungs”)
35
What does the exam, ECG, and CXR show in a patient with TGA?
* _Physical exam_
* Normal S1, loud S2, NO murmur (unless associated VSD or PS)
* Lungs are clear, no HSM
* _ECG_
* Can be normal - RAD and RVH (due to RV acting as systemic ventricle)
* Upright T wave in V1 after age 3d may be only abnormality
* _CXR_
* Can be normal (as per up-to-date)
* “Egg on a string” with cardiomegaly
* Normal to increased pulmonary vasculature (more prominent as baby ages and pulmonary pressures decrease)
36
What are concerning findings for PVCs warranting further investigations?
* 2 or more PVCs in a row
* Multiform PVCs
* Increase with exercise
* R-on-T phenomenon (PVC occurs on T wave of preceding beat)
* Extreme frequency (\>20% of total beats on Holter)
* Presence of underlying heart disease, history of heart surgery, or both
