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Cardiology Flashcards

1
Q

What are the common indications for aortic valve replacement?

A

Severe symptomatic AS/AR
Infective endocarditis

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2
Q

What further investigations would be appropriate in murmur/AF?

A

ECG
FBC, bloods, cultures
CXR
24hr tape
Echo

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3
Q

What are the possible complications of prosthetic valves?

A

Infective endocarditis early/late
thromboembolism
Anticoagulation complications
Anaemia (from haemolysis/ endocarditis/bleeding)
Valve failure (heart failure from dehisence, leaking, calcification or stiffening of leaflets)

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4
Q

How might infective endocarditis present in prosthetic valve replacement?

A

New AV block
Acute heart failure
emoblism

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5
Q

What types of replacement valves are available?

A

Tissue - xeongraft (porcine/bovine) or homograft (cadaveric)
Mechanical prosthetic

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6
Q

What are the advantages of mechanical valves?

A

Longer lifespan
but require lifelong anticoag
so better in younger patient

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7
Q

What are the advantages of tissue valves?

A

anticoag not needed
but shorter lifespan so better in older patients
can be used in IE as more resistant to infection

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8
Q

What does sternotomy scar with no vein harvesting suggest?

A

valve repair/replacement
surgery for structural heart defect

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9
Q

What does metallic heart sound heard after pulse suggest?

A

Metallic aortic valve replacement

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10
Q

If aortic valve replacement and no signs of LVH/HTN/CCF, what was likely reason for valve replacement?

A

Likely aortic regurg

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11
Q

If aortic valve replacement and with signs of LVH/HTN/CCF, what was likely reason for valve replacement?

A

AS

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12
Q

Differentials for second systolic murmur heard loudest at apex radiating to axilla

A

AS
MR

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13
Q

Long term management of valve replacement

A

Anticoag (if metallic)
Serial echos

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14
Q

Auscultation features of AS

A

High pitched loud ES murmur audible throughout precordium and louest over the aortic area, radiates to carotids louder on expiration
quiet second heart sound

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15
Q

Features that suggest severe AS

A

Quiet second heart sound
Long duration of murmur
low volume pulse, narrow pressure, slow rising
Forceful apex beat
4th heart sound if LVH
…suggesting significant gradient across valve

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16
Q

What do you want echo in AS to assess

A

Valve area
Gradient across valve
LV function

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17
Q

Differentials of an ejection systolic murmur

A

aortic stenosis
aortic sclerosis
HCOM

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18
Q

Differentials of pansystolic murmur

A 
mitral regurg (should radiate to axilla) 
aortic stenosis (radiates to carotids)
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19
Q

Features of pulmonary stenosis

A

Younger patient
loudest over pulmonary area
RV heave
Louder on inspiration

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20
Q

Sx ax with AS

A

SOB
Angina
Syncope
CCF

  • any sx refer ?valve replacement
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21
Q

Drug treatment of AS

A

Main = beta blockers
AVOID - ACEi, nitrates, sildenafil (increase gradient across valve)

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22
Q

Surgical management of AS

A

Mechanical valve
Tissue valve
TAVI - if not fit for surgery

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23
Q

Indications for mitral valve replacement

A

Mitral stenosis
Mitral regurgitation
Infective endocarditis

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24
Q

Findings to suggest mitral stenosis

A

Features of pulmonary HTN
AF

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25
Q

IE prophylaxis with metallic valve replacement

A

Prophylactic ABx for dental, abdo surgery or sigmoidoscopy with biopsy
Can carry cards
Not for routine dental

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26
Q

Concerns if new systolic murmur in mitral metallic valve replacement

A

?valvular incompetence
assess with echo
any other new valvular lesions eg AS or TR

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27
Q

How you would differentiate between aortic stenosis and tricuspid regurgitation
clinically?

A

TR = V waves in JVP visible from end of bed
AS is ejection systolic, TR is pan systolic
heard at different points on chest

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28
Q

Which heart sound is metallic aortic vs mitral

A 
1st = mitral 
2nd = aortic

(if in sinus, unlikely to be mitral)

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29
Q

How can you tell a mitral valve replacement is function well on examination?

A

No regurg murmur
in NSR

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30
Q

What do you need to consider as management option in mitral valve prolapse in young patient

A

Repair rather than replace if poss

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31
Q

How does splitting of the second heart sound vary with an ASD?

A

ASD doesn’t vary with resp - fixed and widely split, because in ASD the communication between R/L equalises pressures
other split second heart sounds do vary

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32
Q

What would you say to women with congenital heart defect wanting to get pregnant?

A

Echo
meds r/v
cardio ref
close monitoring throughout pregnancy

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33
Q

What would your concern be if ASD develops PHTN

A

Reversal of Left to Right shunt, Eisenmengers syndrome, causes central cyanosis

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34
Q

Congenital syndrome causes of pulmonary valve disease?

A

Rubella
Downs syndrome
Noonans
Turners

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35
Q

What does tricuspid regurg sound like?

A

systolic murmur loudest at LSE, accentuated by inspiration

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36
Q

What does mitral regurg sound like

A

pansystolic murmur in mitral region radiating to axilla and apex
+ displaced apex

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37
Q

Features of severe mitral regurg

A

Raised JVP
Loud P2 or S3 gallop rhythm
RV heave
Apex thrusting/displaced

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38
Q

What sx would you ask about with mitral regurg

A

Dyspnoea
Reduction of ET
Fluid overload

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39
Q

What other tests would you want to perform for mitral regurg?

A

Urine dip - protein, blood
CRP and Echo ?IE ?ef ?increasing LV ?dilatation ?PHTN
ECG ?AF
CXR ?cardiomegaly
Fundoscopy and temp ?IE

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40
Q

What’s the relevance of the JVP?

A

Reflects pressures in RA, so reflects abnormalities in pressure eg PHTN

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41
Q

What would you do if you suspect severe mitral regurg?

A

cardio ref, expedite
better to intervene before worsening HTN

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42
Q

Can you tell me the indications for mitral valve replacement?

A

symptomatic
features of PHTN or fluid overload
declining
acute mitral regurg following MI

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43
Q

Differentials of mitral regurg murmur

A

VSD
Tricuspid regurg
MVP

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44
Q

Causes of mitral regurg

A

papillary muscle rupture from rheumatic fever or IE
Post MI
from MVP eg from connective tissues eg Ehler Danos

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45
Q

Relevance of abdominal scar in Marfans

A

thoraco abdominal/AAA repair

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46
Q

What is the long terms management of Marfans valve replacement?

A

Serial echos to assess valve function
Serial aorta imaging ?dilatation
+anticoagulation for valve

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47
Q

Common valve pathology in Marfans

A

aortic regurg

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48
Q

Can you tell me about the inheritance of Marfans and its implications?

A

Auto dom
affects fibrin gene/collagen generation
Needs genetic testing + family screening

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49
Q

Cardiac features of Marfans

A

Aortic root dilatation
Aortic dilatation at any point
aortic regurg
mitral valve prolapse

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50
Q

What are the indications for aortic root replacement in Marfans?

A

Dilation >50mm at aortic root
or 45mm with FHx of aortic dissection
or expanding >3mm/year

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51
Q

Causes of SOB in Marfans

A

arrhythmias
LV dysfunction
regurgitant valve
IE

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52
Q

How would you Ix SOB in Marfans

A

Echo
CXR
ECG
Bloods ?IE

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53
Q

What signs would suggest valvular incompetent in valve replacement Marfans

A

2nd heart sound isnt crisp or basence of silence in diastole

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54
Q

How would you describe pulmonary stenosis sound?

A

ejection systolic murmur
best heard in pulmonary area
accentuated by inspiration
radiated to left infraclavicular region

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55
Q

Features of Noonans syndrome

A

Cubitus valgus
Webbed neck
Widely spaced nipples
Short stature
Mild intellectual disabilities
Motor delay

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56
Q

types of pulmonary stenosis

A

Valvular lesion
supra or subvavular due to RVOT

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57
Q

How would you describe aortic stenosis sound?

A

ejection systolic
loudest in expiration in aortic area
radiating to carotids with narrow pulse pressure and slow rising pulse

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58
Q

Can you talk me through the clinical symptoms of someone who may have significant
pulmonary stenosis?

A

Effort intolerance
SOBOE
sx of Right sided heart failure
syncope/presyncope

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59
Q

In a patient with significant pulmonary stenosis, what clinical findings might you
expect to see?

A

Large A waves in JVP due to delayed RA emptying
RV heave from PHTN
may be pansystolic murmur at LSE due to functional tricuspid regurg from Right heart dilation
sx of right sided heart failure
widely splt 2nd heart sound with pulmonary component

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60
Q

Cardiac complications of Noonans

A

Pulmonary stenosis is most common
HCOM
ASD

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61
Q

Eye signs of Noonans

A

Proptosis
Ptosis
Strabismus

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62
Q

What would raised JVP and peripheral edema suggest in pulmonary stenosis patient?

A

Right sided heart failure

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63
Q

What would suggest that patient has decompensated pulmonary stenosis on examination?

A

fluid overload
features of pulmonary hypertension
SOB
reduced ET
syncope cyanosis

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64
Q

What can an echo tell you in pulmonary stenosis?

A

Quantify PS
vavular/supra/sub valvular
any co existing cardiac lesions or septal defects

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65
Q

Differentials for ejection systolic murmur in young patient

A

Pulmonary valve disease
Tetralogy of Fallot
(TGA)

ASD

VSD

66
Q

Causes of pulmonary stenosis

(congenital, acquired)

A

Tetralogy of Fallot
Willams/Noonan/Alagille

IE
Rheumatic fever
Carcinoid

67
Q

Management of pulmonary valve disease

A

treat underlying cause
if stenosis, balloon valvuloplasty
if regurg refer for valve replacement

68
Q

Causes of sub valvular pulmonary stenosis

A

Tetralogy of Fallot

(overriding aorta, RVH, VSD)

69
Q

Causes of supra valvular pulmonary stenosis

A

Tetralogy of Fallot, Noonan, Alagille, and
LEOPARD syndromes, congenital rubella syndrome and Williams
syndrome.

70
Q

Pulmonary stenosis gradient severity

A

<36 mild asx unlikely to progress, echo 5 years
36-64 moderate, develop SOB, fatigue
>64 severe, can develop early RV failure and cyanosis

71
Q

Ax conditions of mitral valve prolapse

A

Ehler Danos
Marfans
Osteogenesis imperfecta
CKD

72
Q

Causes of systolic murmur in mitral region

A

primary degeneration
rheumatic heart disease
secondary mitral regurg from IE
hyperdynamic from HCOM
bicupsid aortic valve with VSD

73
Q

How would you Ix ?Ehler Danos?

A

CXR, ECG, Bloods echo
genetic
cardiac MRI

74
Q

Long term management Elher Danos?

A

cardio FU with regular echos ?MVP
regular opthalmology ?lens dislocation

75
Q

Possible complications of mitral valve prolapse

A

Usually benign
but can get
IE
thromboembolism
CVA
sudden death

76
Q

Features of severe/high risk MVP

A

mod/sev MR
reduced LV function
increased end systolic diameter
AF
LA enlargement
>50s
valve thickening ?5mm
flail leaflet

77
Q

Pre op ax or mitral valve prolapse surgery

A

cardiac cath ?CAS
TOE ?repairability of valve

Uses mini thoracotomy, percutaneous being developed

78
Q

What echo findings would concern you in PDA?

A

Raised pulmonary pressures
Dilated pulmonary arteries
RV dilation and tricuspid regurg
LV dysfunction

79
Q

Is PDA loudest in inspiration or expiration?

A

Expiration
Loudest over left scapula

80
Q

Examination findings of severe PDA

A

Collapsing pulse
RV heave
LVF

PDA in adult suggests it wasnt severe or was repaired in childhood

81
Q

Why are right sided heart murmurs louder on inspiration

A

Inspiration increased venous return
increases flow across right side of heart

82
Q

How is PDA fixed?

A

Percutaneously

83
Q

Describe PDA murmur

A

continuous machine murmur
heard best at 2nd ICS left of sternum and left scaplula
louder on expiration

84
Q

Indications for closure PDA

A

PHTN with PAP <2/3 systemis or
pulmonary vascular resistance <2/3 systemic

85
Q

Follow up of PDA

A

No residual shunt needs no FU after 6 months
If LVF or PHTN needs 1-3 yearly FU inc congential heart disease specialist

86
Q

Sx of Eisenmengers syndrome

A

clubbing
central cyanosis
loud widely split S2
RVH/PHTN

87
Q

What is Eisenmengers syndrome

A

Reversal of Left to Right shunt

88
Q

Causes of Eisenmengers syndrome

A

Large uncorrected VSD or ASDs
PDA

89
Q

Indications for closure of VSD

A

Any significant Left to Right shunt
If having any other cardiac surgery
Endocarditis
significant aortic regurgitation caused by prolapse
of the aortic valve leaflets through the defect.

90
Q

Complications of Eisenmengers syndrome

A

RVF
Paradoxical ambolism
IE
Haemoptysis
Hypoxaemia
often murmur reduced/absent as shunt reversed

91
Q

Causes of clubbing

A

Cardiac - subacute IE, congenital cyanotic heart disease
Resp - ca, TB, bronchiectasis, CF, ILD
GI - IBD
Familial

92
Q

Congenital syndroms causing VSD

A

Downs
Edwards
DiGeorge

93
Q

Risks for patients with VSD

A

Endocarditis, heart failure

94
Q

Medical management VSD

A

Heart failure - diuretics
PHTN - phosphodiesterae 5 inhibitiors (sildenafil), endothelin antagonists (bosentan), prostanoid infusions

95
Q

Causes of cyanotic heart disease

A

Tetralogy of Fallot
Pulmonary Atresia
Pulmonary stenosis
Tricuspid atresia
Eisenmengers
Ebsteins anomaly

96
Q

FU monitoring for tetralogy of Fallot repair

A

yearly echo
monitor for signs of left/right sided heart failure

97
Q

Wat is Tetralogy of Fallot

A

VSD
overiding aorta
RV tract outflow obstruction
PS

98
Q

What complications can arise with Tetralogy of Falllot repair?

A

Endocarditis

Coagulopathy

Polycythaemia

Pulmonary regurg

Parodixal emoblism

Arrhythmias

Heart Failure

99
Q

How does Tetralogy of Fallot present?

A

In childhood with failure to thrive or cyanosis

100
Q

Immediate management of Tetralogy of Fallot

A

Monitoring O2 sats

if critically low - prostaglandin infusion to keep PDA open to maintain pulmonary blood flow and oxygenation

Surgery always needed eventually (repair of VSD with patch, resection of RV muscle)

101
Q

What are the valve complications do Tetralogy of Fallot develop?

A

Pulmonary regurg

Pulmonary stenosis

Tricuspid regurg

102
Q

Tetralogy of Fallot/repair findings on examination

A

PosteroLateral thoracotomy scar

Midline sternotomy scar without vein harvesting

Left pulse

(Blalock-Taussig shunt subclavian artery attached to pulmonary artery)

+murmurs of pulmonary regurg/stenosis, tricuspid regurg

+- sx of heart failure

103
Q

How would you investigate:

  • preserved biventricular function
  • biatrial dilatation
  • LVH
  • diastolic dysfunctio
A

For diastolic dysfunction want to check for hx of HTN, valvular pathology

Other want to look for constrictive or restrictive issues

Echo then further imaging

104
Q

How would you differentiate between constrictive and restrictive issues on imaging?

A

CXR could show pericardial calcification from restriction

Echo - bright white thick pericardiam in pericardial disease

Cardiac MRI - restrictive cardiomyopathy

CT - restrictive/constrictive

Cardiac catheterisation - measure invasive haemodynamics

105
Q

Common causes of constrictive pericarditis

A

Viral/bacterial pericarditis

Recurrent pericarditis

Post srugery eg CABG or TB

Radiation

106
Q

Common causes of restrictive cardiomyopathy

A

Endomyocardial fibrosis

Lofflers

Systemic conditions - sarcoidosis, scleroderma, haemochromatosis

Iron overload (tx with iron chelation)

malignancy

radiotherapy

scleroderma

amyloidosis

107
Q

Why is it important to differentiate between constrictive and restrictive cardiomyopathy?

A

Tx v different

constrictive - surgical stripping of pericardium

restrictive - address underlying cause eg with DMARDS

tx heart failure with diuretics

if low cardiac output - heart transplant

108
Q

How would you investigate mitral regurg?

A

Hx ?RF as child

Recent procedures/temps ?IE

Blood cultures x3, ECG, bloods

echo ?mitral regurg on doppler flow

109
Q

How would you manage AF?

A

Cause

?sx

Rate control or rhythm control

CHADXSVAC ?anti coag to avoid thrmobus ?1 anticoagulate with DOAC/warfarin

110
Q

Describe rhythm control AF options?

A

Can use drug options like flecanide if no structural heart disease

Or DC cardiovert if they are sufficiently anticoagulated

111
Q

CHADS2VASC

A

CCF

HTN

AGE >65 OR >75

DIABETES

STROKE/TIA =2

VASCULAR DISEASE

AGE

SEX

112
Q

What are indicators of worse prognosis/for sugery in mitral regurg?

A

EF <60%

End systolic dimension >45

AF

systolic pulmonary pressure >60

also if asx, good outcome, flail leaflet or LAD in NSR

113
Q

Causes of mitral regurg

A

RF

IE

chronic dilatation in AF (annular dilatation)

LAD

114
Q

What are the indications for anticoagulation in mitral valve disease?

A

AF

Previous emobli/hx of thromboembolic disease

LA thromus

115
Q

What are Dukes criteria for endocarditis?

A

Major criteria :

o positive echocardiography findings (baceteria on mitral valve)

o specific bacteria found on two separate blood cultures these bacteria include staphylococcus aureus, staphylococcus bovus, staphylococcus viridans, or members of the HACEK group.

minor:

o a temperature of over 38 °C

o other positive blood cultures

o different echocardiography findings consistent with endocarditis

o septic emboli o other immunological findings, such as janeway lesions or Osler’s nodes.

116
Q

Primary causes of mitral regurg

A

RF

congenital

calcification (age)

117
Q

Secondary causes of mitral regurg

A

cardiomyopathy

IHD

RV pacign cause disynchrony

118
Q

Causes of mitral stenosis?

A

Calcification

Fabrys

RA

SLE

Carcinoid

Whipples

119
Q

What does mitral stenosis sound like?

A

low pitched rumbling murmur

best heard with bell

loudest at apex

patient on left hand side

expiration

opening snap

(reducing splitting of S2 as progresses)

enlarged P wave with notch LA hypertrophie P mitrale

120
Q

Austin Flint murmur

A

rumbling diastolic murmur at apex

with severe aortic regurg

(regurg jet comign through aortic valve and hitting anterior mitral valve leaflet)

121
Q

Causes of chronic aortic stenosis

A

age-related calciication

congenital bicuspid valves

RF

Fabrys

SLE

Pagets

122
Q

Causes of aortic regurg

A

RF

Marfans/Ehler Danos

HTN

Osteogenis imperfecta

Myoxmatous disease

Ank spond

GCA

SLE

123
Q

Causes of acute aortic regurg

A

IE

Trauma aortic dissection

124
Q

De Mussetts sign

A

Head bobbing due to wide pulse pressure

125
Q

Quinckes sign

A

Capillary pulsation in fingertips and lips

126
Q

Mullers sign

A

Uvular pulsation

127
Q

Gallavardians phenomeneom

A

AS murmur heard throughout pericordium

128
Q

How do you Ix for Brugada syndrome

A

flecanide test

129
Q
A
130
Q

Causes of collapsing pulse

A

Aortic regurg

PDA

Hyperdynamic state

131
Q

What does a VSD sound like?

A

Pansystolic with ejection character

Loudest between pulmonary and tricuspid area

Larger VSD is quieter

V loud from small WSD = Maladie de roger

Doens’t vary with insp/exp

Part of tetralogy of Fallot

+- signs of Right sided heart failure esp raised JVP

if cyanotic - Eisenmengers

132
Q

Types od ASD

A

Primum - just above AV valves, due to abnormal developemnt endocardial cushions, ax with VSD

Secundum - commonest, due to defect in fossa ovalis, RBBB with RAD

Benous sinus - SVC communicates with atria

133
Q

What does and ASD sound like?

A

Soft ES murmur loudest at pulmonary area (due to increased flow across pulmonary valve

similar to PS but not as harsh

Fixed split S2 (increased flow across Pulmonary valve means it closes later)

Signs of PHTN/ Right sided heart failure

134
Q

What does mitral valve prolapse sound like?

A

Sytolic click with late systolic murmur

Best heard at apex on left lateral position

135
Q

Questions to ask in HTN

A

Headaches/visual change

Pregnancy - prev/plans

Urine changes

Meds compliance

Chest pain/SOB/Palpitations

Diet

Cushings/acromegaly/thyroid sx

Tiredness ?OSA

136
Q

How would you Ix for ?phaechromocytoma

A

24 hour urine metanephrines

Plasma metanephrines

137
Q

How do you image for

Renal Artery Stenosis and/or Phaeochromocytoma?

A

CT/MRI kidneys and adrenals

138
Q

How do you Ix ?Conns

A

Morning renin :aldosterone ratio

139
Q

Endocrine causes of HTN

A

Adrenal - phaechromocytoma, Conns

Cushings

Acromegaly

Hyperthyroidism

140
Q

Renal causes of HTN

A

Renal artery stenosis

Polycystic kidney disease

Chronic glomerulonephritis

Diabetic nephropathy

Nephrotic syndrome

141
Q

Chest causes of HTN

A

Coarctation of aorta

OSA

142
Q

Autoimmune causes of HTN

A

Systemic sclerosis

SLE

Wegners granulomatosis

143
Q

Drug causes of HTN

A

NSAIDs

EPO

Cyclosporin/tacrolimus

Steroids

COCP

ETOH/liquorice

144
Q

Tx for Conns

A

Spironalactone/Eplerone

Surgery definitive

145
Q

Tx of phaeochromocytoma

A

Beta block

Surgery definitive

146
Q

Tx of Renal Artery Stenosis

A

Stenting

147
Q

Flash pulmonary edema after starting ACEi

A

RAS

148
Q

Features of SAH

A

Nausea/vom

Neck stiffness

Photophobia

Seizures/LOC/Drowsy

Risk factors: PKD, HTN, Aneurysm FHx, Marfans, smoking

149
Q

Features of Cerebral Venous Thrombosis

A

COCP/Preganant

Ca

Dehydration

Clotting abnormality

Infection/inflamm

Neuro Sx

150
Q

Features of Cervical Artery Dissection

A

Trauma

Neck pain

Droopy eye/small pupil

Ringing in ears

Stroke sx

151
Q

Headache: Features of Pituitary Apoplexy

A

Abdo pain

Dizziness

Nausea/Vom

152
Q

Headache: Features of Migraine

A

Aura

Sensitivity to light/smell

153
Q

Migraine Rx

A

Avoid triggers (diary)

1st line - analgesia Aspirin/ibuprofen NOT codeine

Triptans (for established headache, CI if uncontrolled HTN, CAD, CVD)

Prophylaxis - Propanolol, topirmate, Amitryptiline

154
Q

Extra articular features Ank Spond

A

Atlanto-axial subluxation

Anterior uveitis

Apical fibrosis

Aortic regurgitation

Amyloidosis (renal)

Achilles involvement (enthesitis)

155
Q

Cardiac causes of syncope

A

Brady/tachy

SVT

Long

QT

PPM dysfunction

Hypotension

Brugada WPW

HCOM

156
Q

WPW

A

Abnormal conduction accessory pathway w hypertrophic cardiomyopathy

Can lead to episodes of SVT/AF

+- sx like dizziness, palpitations, SOB, faint

Or sudden cardiac death

Needs management of acute arrhythmia then ablation

157
Q

Brugada syndrome

A

Genetic abnormality - mutation in sodium channels

Autosomal dominant

Ventricular arrhythmia

High risk of sudden cardiac death

Needs ICD

158
Q

Ax cardiac defects dextrocardia

A

VSD

TGA

Double outlet RV

PS/hypoplasia

Endocarrdial cushiom defect

Single ventricle

159
Q

Murmur grades

A
  1. v faint, only by expert
  2. soft
  3. moderate
  4. loud + thrill, heard with steth partly off
  5. Loudest + thrill + heard outside the chest
160
Q

Diastolic murmur

A

AR/Austin Flint

MS

Pulmonary regurg

LAD stenosis

Tricuspid stenosis

Complete heart block

PACES (7 decks)

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