Cardiology Flashcards
Murmur in ASD
- Pulmonary ES
- Fixed split S2
- Mid-diastolic flow murmurs with large L to R shunts.
There is no mumur from the ASD itself
Commonest cause of AS
- Calcific degeneration overall
- If <65yr likely Congenital bicuspid valve (about 5-10%)
- IE
- Paget’s disease
extremely rare= Post Rh fever
Commonest cause of Mitral Stenosis
Rheumatic fever (>90%)
Infective endocarditis - strongest risk factor
Previous inf endocarditis
What value of pulmonary artery pressure is considered diagnostic of pulmonary arterial hypertension?
> 25mmHg at rest
—-measured by cardiac catheterisation
most common heart defect in Marfans
dilation of the aortic root
AR or aneurysm/dissection may develop as a consequence
MVP
Fatigue and SOBOE
Light compression to the tip of the fingernail bed causes capillary pulsation
…what is this sign called?
Quincke’s sign - in Aortic Regurge, so early Diastolic murmur
causes of dilated cardiomyopathy
Alcohol
Beriberi wet - thiamine deficiency
Coxsackie B
Doxorubicin
(HOCM has four letters - S4)
Management of bradycardia in heart transplant
Atropine is ineffective in transplant bradyarrhythmias because the heart is denervated
So theophylline or pacing
Causes of ejection systolic murmur
Loudest in aortic area
• Aortic stenosis
• Aortic sclerosis
• HOCM (tends to be younger, LL sternal edge and throughout precordium, doesn’t radiate to carotids)
• Pulmonary Stenosis - Loudest in pulmonary area- young patient but rare
commonest cause of pulmonary stenosis
Congenital (often from maternal rubella infection =commonest)
Ejection Systolic in pulmonary area
Louder on INspiration
where does AS murmur radiate
radiates to carotids
Ejection systolic murmur loudest in aortic region
Slow rising pulse
Aortic stenosis
feels weak and late
Anaemia in aortic stenosis
Heyde syndrome is a triad of
- aortic stenosis
- acquired Von Willebrand disease
- anaemia (due to GI bleeding from intestinal angiodysplasia)
Make aortic stenosis murmur louder
Loudest on held expiration and when the patient is sitting forwards
Can be heard over Apex (Gallavardin phenomenon)
aortic stenosis vs sclerosis on examination
sclerosis:
- Doesn’t radiate to Carotids as much
- Is softer and shorter in nature
(A. sclerosis is thickening without any significant effect on function)
Signs of severe in aortic stenosis
Late peaking mumur Evidence of cardiac decompensation Slow rising low volume pulse Narrow pulse pressure Absent of second heart sound LV heave Carotid radiation Fourth heart sound in LVH
Echo
• Peak gradient >64
• or mean gradient >40mm Hg
• or valve area <1 cm2
when would you consider TAVI vs surgical aortic valve replacement
If low surgical risk and <65, then SAVR
- -> mechanical last longer but need anticoag
- -> tissue, no anticoag
If >65 or significant-intermediate risk, then TAVI, if transfemoral possible
What does TAVI stand for
Transcatheter aortic valve implantation
Describe TAVI vs surgical AVR
- TAVI pushes stiff / calcified valve out of the way during implantation
- Can be done under general or local
- Surgical operation removes the stiff valve and a new mechanical or tissue valve is in place
features of pulmonary stenosis
Often congenital, so younger
Ejection systolic murmur loudest of pulmonary area
Louder on INspiration
Radiates to left shoulder/left infraclavicular region
RV dilatation can lead to a RV heave
Common indications for aortic valve replacement (AVR)
Severe or symp AS or AR or infective endoc
Anticoagulation for mitral vs aortic valve replacement
Depends on presence of risk factors for valve thrombosis • prior thromboembolism • AF • Rh mitral stenosis (any degree) • LVEF <35% • Mitral > Aortic risk
Mechanical aortic INR of 2.5
Mechanical mitral INR of 3.0
Only Warfarin recommended
Advantage of mechanical heart valve vs tissue
- They are longer lasting
- but require anticoagulation
- in AS, can use TAVI if not fit for surgery
- in MR can clip
Collapsing pulse
aortic regurgitation
w hollow diastolic murmur
causes of pansystolic (aka holosystolic) murmur
High pitched and blowing from S1 to S2…
• mitral regurge (apex)
• tricuspid regurgitation (Left lower sternal edge)
• mitral valve prolapse (Mid systolic + opening click)
• VSD (harsh in character, well-localised left sternal edge)
Makes sense because s1 is sound of mitral and tricuspid closing, so if regurge then this will be extended
Where is apex beat?
near the midclavicular line in the fifth intercostal space
murmurs louder on inspiration vs expiration
Inspiration -> right heart (pulmonary and tricuspid) due to increased venous return
Expiration -> left heart (mitral and aortic)
Signs of severe mitral regurge
Pulmonary hypertension i.e. raised JVP, S3 gallop, displaced/thrusting apex, right ventricular heave
What is JVP
reflection of physical pressures in Right atrium
i.e. pulmonary hypertension causes raised
Consideration for surgery in mitral regurge
- signs or symptoms (pul hypertension or fluid overload)
- Acute MR following MI
or in asymp:
• Declining ejection fraction
• Increasing LV dilatation
causes of mitral regurge
DEGENERATIVE
• Age-related changes
• Mitral valve prolapse
• Connective tissue issues
ACQUIRED
• papillary muscle rupture - i.e. MI
• infection - Rheumatic fever, infective endo
Causes of aortic stenosis
- Calcification of the aortic valves
- Congenital bicuspid valve
- Rheumatic heart disease
HASBLED score
Hypertension Abnormal renal and liver function Stroke Bleeding predisposion Labile INR Elderly (>65) Drugs or alcohol
≥3 indicates “high risk”
drug contraindications in severe aortic stenosis
Vasodilators (which can increase the gradient across the valve)
ACEi
Nitrates
Sildenafil
Rhythm control of AF
Medically:
• Flecainide
• only if no evidence of structural heart disease
Mechanically:
• DC cardioversion
• (with 2,3,4 anticoag, more than 2 days then 3 before and 4 after)
common cardiac issues with ehler’s danlos
mitral valve prolapse
aortic dilatation
Heart condition in Noonan’s
Pulmonary stenosis (ES in pul, louder with insp)
May have hypertrophic cardiomyopathy or septal defects
Differentials of pulmonary stenosis mumur
PS is usually due to valvular obstruction, but may also be due to sub- or supravalvular obstruction
Right Ventricle Outflow Tract Obstruction = harsh ES murmur at the left sternal border in the second intercostal space
AS
VSD
ASD
Features of pulmonary stenosis
ES in pulmonary area, louder with insp
R ventricular hypertrophy in signif (so RV heave)
Can cause delayed RA emptying, and elevated RA pressure === raised JVP with prominent A waves
Loud metallic click in S2
Metallic aortic valve replacement
pan-systolic best heard in the left lower sternal border;
VSD
or Tricuspid regurge
VSD murmur
pan-systolic best heard in the left lower sternal border; (tricuspid region)
Midline sternotomy differentials
- CABG
- Valve replacement
- Transplant
Valves causing S1 sound
Closing of mitral and tricuspid valves
Valves causing S2 sound
Closing of aortic and pulmonary valves
CABG without vein harvesting scar
via internal mammary artery
instead of greater saphenous vein
AVR and pacemakers
10% of patients with aortic valve replacement need pacemaker from AV node damage
Valve replacement with Infective endocarditis
Look for tunnelled lines etc
where is infective endocarditis most likely?
mitral valve, causing stenosis or regurge
Management of AF explanation points
If no underlying cause can be found, the treatment options are:
- medicines to reduce the risk of a stroke
- medicines to control atrial fibrillation
- cardioversion (electric shock treatment)
- catheter ablation
- having a pacemaker fitted
Most common causes of AF
common causes of AF are
- Ischaemic heart disease
- Hypertension
- Valvular heart disease
- Hyperthyroidism
Calculate bleeding risk with AF
ORBIT score has taken over hasbled as doesn’t have labile INR section
TWO points for:
• Hx of GI/intracranial bleeding
• Hb <120 or 130 or hematocrit <36%
And one score for:
• Age >74 years
• GFR <60
• Treatment with antiplatelet agents
Triggers of AF
- Pulmonary embolism
- Ischaemic heart disease
- Respiratory disease
- Atrial enlargement or myxoma
- Thyroid (fhyper)
- Ethanol
- Sepsis/sleep
Mitral valve prolapse murmur
Young women, ?marfan’s HOCM
- Mid-systolic click (prolapse of the mitral valve into left atrium)
- Followed by a mid or late-systolic murmur
- Heard loudest at the apex
- Loudest in expiration, standing from squating
pericarditis associated conditions
- Injury (Dressler syndrome - post MI)
- Infection (COVID-19)
- Inflammatory (SLE, RA)
- Inherited (familial Mediterranean fever)
Gen causative organism is Staph, Strep, Pneumococcus
Cardiac issues with Down’s
- atrioventricular septal defect (AVSD)
- patent ductus arteriosus (PDA)
- tetralogy of Fallot
Tetralogy of Fallot
- PS
- VSD
- RVH
- Overriding aorta
Jerky pulse character
HOCM
ESM at the tricuspid region that radiates throughout the precordium, with S4
echo findings of HOCM
MR SAM ASH
• mitral regurgitation (MR)
• systolic anterior motion (SAM) of the anterior mitral valve leaflet
• asymmetric hypertrophy (ASH)
Mixed aortic valve pathology
ES murmur
Early diastolic
Can also have - Austin Flint murmur (LL sternal edge, hitting ant mitral valve)
Causes of restrictive cardiomyopathy
primary
• Loeffler’s endocarditis
• endomyocardial fibrosis
secondary / infiltrative
• cardiac amyloidosis,
• cardiac sarcoidosis
• iron overload (haemochromatosis)
Causes of Eisenmenger’s syndrome
VSD, ASD, or PDA causing pulmonary hypertension
Causing reversal of L to R shunt
Look for cyanosis, clubbing, aortic regurge
Can get RVF, paradoxical embolism, IE, hypoxaemia, haemoptysis
Cardiac causes for clubbing
- Infective endocarditis
* Cyanotic congenital heart disease
Patent ductus arteriosus murmur
- Loud continuous ‘machinery murmur’ loudest below the left clavicle in systole
- Loudest in exp
“rolling thunder”
What is Patent ductus arteriosus?
Connection between
• proximal left pulmonary artery
• and the descending aorta, just distal to the left subclavian artery
in the developing fetus
Wolff-Parkinson-White syndrome ECG
- Short PR interval (<120 ms)
* Widening of QRS complex due to a slurred upstroke (delta wave) of the QRS complex
When is carotid pulse felt?
Just after S1 but before S2
Ejection Fraction grading
- Normal = LVEF 50 - 70%
- Mild = 40 - 49%
- Moderate = 35 -39%
- Severe < 35%
Pacemaker indications
- Sick sinus syndrome
- Symptomatic or drug-resistant AF
- Mobitz 2 or complete heart block
Cardiac Resynchronization Therapy indications
• EF <35% with QRS>120
—-> E.g. in LBBB and HF
• CRT defibrillators (CRT-D) also incorporate ICD
implantable cardioverter defibrillator (ICD) insertion indications
Primary prevention
• MI with
- LVEF < 35%
- or LVEF < 30% and QRS ≥ 120
• Familial condition with high‐risk SCD
- LQTS, ARVD, Brugada, HOCM
Secondary prevention
• Cardiac arrest due to VT or VF
• or VT with haemodynamic compromise
• or VT with LVEF < 35%
Indications for implantable loop recorder
- Last about 3 years
- Monitor heart rate to investigate for dizzy spells, palpitations, black outs
- Depending on the type of loop recorder, might need to use your hand-held activator when symptomatic
Echo signs of severe aortic stenosis
- Mean gradient >40mm Hg
- or Peak gradient >64
- or Valve area <1 cm2
Cardiac issues with Myotonic dystrophy
cardiac dysrhythmia is the second leading cause of death after respiratory failure
Causes of pulmonary hypertension
Group 1: • Idiopathic • connective tissue diseases • Congenital heart disease • Drugs
Group 2:
• Left heart disease (A or M valve, LV)
Or Group 3: due to chronic resp disease
Group 4 clots
Group 5 other
When would you admit pt with palpitations?
- VT or persistent SVT
- Haemodynamic instab
- History of structural heart disease
Or features suggesting underlying issue: • High degree AV block on ECG • Significant SOB • Chest pain, Syncope /near syncope • Fam hx of sudden cardiac death <40y! • Precipitated by exercise
Pulsatile liver
Tricuspid regurge (pansystolic murmur)
Causes of tricuspid regurge
Congenital:
• Ebstein’s anomaly (atrialization of the right ventricle and TR)
Acquired:
• Acute: infective endocarditis (IV drug user)
• Chronic: functional (commonest), rheumatic and carcinoid syndrome
Indications for heart transplant
Severe heart failure
Congested cardiac failure
Cardiomyopathy
Congenital
