Cardiology Flashcards
What are the common indications for aortic valve replacement?
Severe symptomatic AS/AR
Infective endocarditis
What further investigations would be appropriate in murmur/AF?
ECG
FBC, bloods, cultures
CXR
24hr tape
Echo
What are the possible complications of prosthetic valves?
Infective endocarditis early/late
thromboembolism
Anticoagulation complications
Anaemia (from haemolysis/ endocarditis/bleeding)
Valve failure (heart failure from dehisence, leaking, calcification or stiffening of leaflets)
How might infective endocarditis present in prosthetic valve replacement?
New AV block
Acute heart failure
emoblism
What types of replacement valves are available?
Tissue - xeongraft (porcine/bovine) or homograft (cadaveric)
Mechanical prosthetic
What are the advantages of mechanical valves?
Longer lifespan
but require lifelong anticoag
so better in younger patient
What are the advantages of tissue valves?
anticoag not needed
but shorter lifespan so better in older patients
can be used in IE as more resistant to infection
What does sternotomy scar with no vein harvesting suggest?
valve repair/replacement
surgery for structural heart defect
What does metallic heart sound heard after pulse suggest?
Metallic aortic valve replacement
If aortic valve replacement and no signs of LVH/HTN/CCF, what was likely reason for valve replacement?
Likely aortic regurg
If aortic valve replacement and with signs of LVH/HTN/CCF, what was likely reason for valve replacement?
AS
Differentials for second systolic murmur heard loudest at apex radiating to axilla
AS
MR
Long term management of valve replacement
Anticoag (if metallic)
Serial echos
Auscultation features of AS
High pitched loud ES murmur audible throughout precordium and louest over the aortic area, radiates to carotids louder on expiration
quiet second heart sound
Features that suggest severe AS
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
What do you want echo in AS to assess
Valve area
Gradient across valve
LV function
Differentials of an ejection systolic murmur
aortic stenosis
aortic sclerosis
HCOM
Differentials of pansystolic murmur
mitral regurg (should radiate to axilla) aortic stenosis (radiates to carotids)
Features of pulmonary stenosis
Younger patient
loudest over pulmonary area
RV heave
Louder on inspiration
Sx ax with AS
SOB
Angina
Syncope
CCF
- any sx refer ?valve replacement
Drug treatment of AS
Main = beta blockers
AVOID - ACEi, nitrates, sildenafil (increase gradient across valve)
Surgical management of AS
Mechanical valve
Tissue valve
TAVI - if not fit for surgery
Indications for mitral valve replacement
Mitral stenosis
Mitral regurgitation
Infective endocarditis
Findings to suggest mitral stenosis
Features of pulmonary HTN
AF
IE prophylaxis with metallic valve replacement
Prophylactic ABx for dental, abdo surgery or sigmoidoscopy with biopsy
Can carry cards
Not for routine dental
Concerns if new systolic murmur in mitral metallic valve replacement
?valvular incompetence
assess with echo
any other new valvular lesions eg AS or TR
How you would differentiate between aortic stenosis and tricuspid regurgitation
clinically?
TR = V waves in JVP visible from end of bed
AS is ejection systolic, TR is pan systolic
heard at different points on chest
Which heart sound is metallic aortic vs mitral
1st = mitral 2nd = aortic
(if in sinus, unlikely to be mitral)
How can you tell a mitral valve replacement is function well on examination?
No regurg murmur
in NSR
What do you need to consider as management option in mitral valve prolapse in young patient
Repair rather than replace if poss
How does splitting of the second heart sound vary with an ASD?
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
What would you say to women with congenital heart defect wanting to get pregnant?
Echo
meds r/v
cardio ref
close monitoring throughout pregnancy
What would your concern be if ASD develops PHTN
Reversal of Left to Right shunt, Eisenmengers syndrome, causes central cyanosis
Congenital syndrome causes of pulmonary valve disease?
Rubella
Downs syndrome
Noonans
Turners
What does tricuspid regurg sound like?
systolic murmur loudest at LSE, accentuated by inspiration
What does mitral regurg sound like
pansystolic murmur in mitral region radiating to axilla and apex
+ displaced apex
Features of severe mitral regurg
Raised JVP
Loud P2 or S3 gallop rhythm
RV heave
Apex thrusting/displaced
What sx would you ask about with mitral regurg
Dyspnoea
Reduction of ET
Fluid overload
What other tests would you want to perform for mitral regurg?
Urine dip - protein, blood
CRP and Echo ?IE ?ef ?increasing LV ?dilatation ?PHTN
ECG ?AF
CXR ?cardiomegaly
Fundoscopy and temp ?IE
What’s the relevance of the JVP?
Reflects pressures in RA, so reflects abnormalities in pressure eg PHTN
What would you do if you suspect severe mitral regurg?
cardio ref, expedite
better to intervene before worsening HTN
Can you tell me the indications for mitral valve replacement?
symptomatic
features of PHTN or fluid overload
declining
acute mitral regurg following MI
Differentials of mitral regurg murmur
VSD
Tricuspid regurg
MVP
Causes of mitral regurg
papillary muscle rupture from rheumatic fever or IE
Post MI
from MVP eg from connective tissues eg Ehler Danos
Relevance of abdominal scar in Marfans
thoraco abdominal/AAA repair
What is the long terms management of Marfans valve replacement?
Serial echos to assess valve function
Serial aorta imaging ?dilatation
+anticoagulation for valve
Common valve pathology in Marfans
aortic regurg
Can you tell me about the inheritance of Marfans and its implications?
Auto dom
affects fibrin gene/collagen generation
Needs genetic testing + family screening
Cardiac features of Marfans
Aortic root dilatation
Aortic dilatation at any point
aortic regurg
mitral valve prolapse
What are the indications for aortic root replacement in Marfans?
Dilation >50mm at aortic root
or 45mm with FHx of aortic dissection
or expanding >3mm/year
Causes of SOB in Marfans
arrhythmias
LV dysfunction
regurgitant valve
IE
How would you Ix SOB in Marfans
Echo
CXR
ECG
Bloods ?IE
What signs would suggest valvular incompetent in valve replacement Marfans
2nd heart sound isnt crisp or basence of silence in diastole
How would you describe pulmonary stenosis sound?
ejection systolic murmur
best heard in pulmonary area
accentuated by inspiration
radiated to left infraclavicular region
Features of Noonans syndrome
Cubitus valgus
Webbed neck
Widely spaced nipples
Short stature
Mild intellectual disabilities
Motor delay
types of pulmonary stenosis
Valvular lesion
supra or subvavular due to RVOT
How would you describe aortic stenosis sound?
ejection systolic
loudest in expiration in aortic area
radiating to carotids with narrow pulse pressure and slow rising pulse
Can you talk me through the clinical symptoms of someone who may have significant
pulmonary stenosis?
Effort intolerance
SOBOE
sx of Right sided heart failure
syncope/presyncope
In a patient with significant pulmonary stenosis, what clinical findings might you
expect to see?
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
Cardiac complications of Noonans
Pulmonary stenosis is most common
HCOM
ASD
Eye signs of Noonans
Proptosis
Ptosis
Strabismus
What would raised JVP and peripheral edema suggest in pulmonary stenosis patient?
Right sided heart failure
What would suggest that patient has decompensated pulmonary stenosis on examination?
fluid overload
features of pulmonary hypertension
SOB
reduced ET
syncope cyanosis
What can an echo tell you in pulmonary stenosis?
Quantify PS
vavular/supra/sub valvular
any co existing cardiac lesions or septal defects
Differentials for ejection systolic murmur in young patient
Pulmonary valve disease
Tetralogy of Fallot
(TGA)
ASD
VSD
Causes of pulmonary stenosis
(congenital, acquired)
Tetralogy of Fallot
Willams/Noonan/Alagille
IE
Rheumatic fever
Carcinoid
Management of pulmonary valve disease
treat underlying cause
if stenosis, balloon valvuloplasty
if regurg refer for valve replacement
Causes of sub valvular pulmonary stenosis
Tetralogy of Fallot
(overriding aorta, RVH, VSD)
Causes of supra valvular pulmonary stenosis
Tetralogy of Fallot, Noonan, Alagille, and
LEOPARD syndromes, congenital rubella syndrome and Williams
syndrome.
Pulmonary stenosis gradient severity
<36 mild asx unlikely to progress, echo 5 years
36-64 moderate, develop SOB, fatigue
>64 severe, can develop early RV failure and cyanosis
Ax conditions of mitral valve prolapse
Ehler Danos
Marfans
Osteogenesis imperfecta
CKD
Causes of systolic murmur in mitral region
primary degeneration
rheumatic heart disease
secondary mitral regurg from IE
hyperdynamic from HCOM
bicupsid aortic valve with VSD
How would you Ix ?Ehler Danos?
CXR, ECG, Bloods echo
genetic
cardiac MRI
Long term management Elher Danos?
cardio FU with regular echos ?MVP
regular opthalmology ?lens dislocation
Possible complications of mitral valve prolapse
Usually benign
but can get
IE
thromboembolism
CVA
sudden death
Features of severe/high risk MVP
mod/sev MR
reduced LV function
increased end systolic diameter
AF
LA enlargement
>50s
valve thickening ?5mm
flail leaflet
Pre op ax or mitral valve prolapse surgery
cardiac cath ?CAS
TOE ?repairability of valve
Uses mini thoracotomy, percutaneous being developed
What echo findings would concern you in PDA?
Raised pulmonary pressures
Dilated pulmonary arteries
RV dilation and tricuspid regurg
LV dysfunction
Is PDA loudest in inspiration or expiration?
Expiration
Loudest over left scapula
Examination findings of severe PDA
Collapsing pulse
RV heave
LVF
PDA in adult suggests it wasnt severe or was repaired in childhood
Why are right sided heart murmurs louder on inspiration
Inspiration increased venous return
increases flow across right side of heart
How is PDA fixed?
Percutaneously
Describe PDA murmur
continuous machine murmur
heard best at 2nd ICS left of sternum and left scaplula
louder on expiration
Indications for closure PDA
PHTN with PAP <2/3 systemis or
pulmonary vascular resistance <2/3 systemic
Follow up of PDA
No residual shunt needs no FU after 6 months
If LVF or PHTN needs 1-3 yearly FU inc congential heart disease specialist
Sx of Eisenmengers syndrome
clubbing
central cyanosis
loud widely split S2
RVH/PHTN
What is Eisenmengers syndrome
Reversal of Left to Right shunt
Causes of Eisenmengers syndrome
Large uncorrected VSD or ASDs
PDA
Indications for closure of VSD
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.
Complications of Eisenmengers syndrome
RVF
Paradoxical ambolism
IE
Haemoptysis
Hypoxaemia
often murmur reduced/absent as shunt reversed
Causes of clubbing
Cardiac - subacute IE, congenital cyanotic heart disease
Resp - ca, TB, bronchiectasis, CF, ILD
GI - IBD
Familial
Congenital syndroms causing VSD
Downs
Edwards
DiGeorge
Risks for patients with VSD
Endocarditis, heart failure
Medical management VSD
Heart failure - diuretics
PHTN - phosphodiesterae 5 inhibitiors (sildenafil), endothelin antagonists (bosentan), prostanoid infusions
Causes of cyanotic heart disease
Tetralogy of Fallot
Pulmonary Atresia
Pulmonary stenosis
Tricuspid atresia
Eisenmengers
Ebsteins anomaly
FU monitoring for tetralogy of Fallot repair
yearly echo
monitor for signs of left/right sided heart failure
Wat is Tetralogy of Fallot
VSD
overiding aorta
RV tract outflow obstruction
PS
What complications can arise with Tetralogy of Falllot repair?
Endocarditis
Coagulopathy
Polycythaemia
Pulmonary regurg
Parodixal emoblism
Arrhythmias
Heart Failure
How does Tetralogy of Fallot present?
In childhood with failure to thrive or cyanosis
Immediate management of Tetralogy of Fallot
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)
What are the valve complications do Tetralogy of Fallot develop?
Pulmonary regurg
Pulmonary stenosis
Tricuspid regurg
Tetralogy of Fallot/repair findings on examination
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
How would you investigate:
- preserved biventricular function
- biatrial dilatation
- LVH
- diastolic dysfunctio
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
How would you differentiate between constrictive and restrictive issues on imaging?
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
Common causes of constrictive pericarditis
Viral/bacterial pericarditis
Recurrent pericarditis
Post srugery eg CABG or TB
Radiation
Common causes of restrictive cardiomyopathy
Endomyocardial fibrosis
Lofflers
Systemic conditions - sarcoidosis, scleroderma, haemochromatosis
Iron overload (tx with iron chelation)
malignancy
radiotherapy
scleroderma
amyloidosis
Why is it important to differentiate between constrictive and restrictive cardiomyopathy?
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
How would you investigate mitral regurg?
Hx ?RF as child
Recent procedures/temps ?IE
Blood cultures x3, ECG, bloods
echo ?mitral regurg on doppler flow
How would you manage AF?
Cause
?sx
Rate control or rhythm control
CHADXSVAC ?anti coag to avoid thrmobus ?1 anticoagulate with DOAC/warfarin
Describe rhythm control AF options?
Can use drug options like flecanide if no structural heart disease
Or DC cardiovert if they are sufficiently anticoagulated
CHADS2VASC
CCF
HTN
AGE >65 OR >75
DIABETES
STROKE/TIA =2
VASCULAR DISEASE
AGE
SEX
What are indicators of worse prognosis/for sugery in mitral regurg?
EF <60%
End systolic dimension >45
AF
systolic pulmonary pressure >60
also if asx, good outcome, flail leaflet or LAD in NSR
Causes of mitral regurg
RF
IE
chronic dilatation in AF (annular dilatation)
LAD
What are the indications for anticoagulation in mitral valve disease?
AF
Previous emobli/hx of thromboembolic disease
LA thromus
What are Dukes criteria for endocarditis?
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.
Primary causes of mitral regurg
RF
congenital
calcification (age)
Secondary causes of mitral regurg
cardiomyopathy
IHD
RV pacign cause disynchrony
Causes of mitral stenosis?
Calcification
Fabrys
RA
SLE
Carcinoid
Whipples
What does mitral stenosis sound like?
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
Austin Flint murmur
rumbling diastolic murmur at apex
with severe aortic regurg
(regurg jet comign through aortic valve and hitting anterior mitral valve leaflet)
Causes of chronic aortic stenosis
age-related calciication
congenital bicuspid valves
RF
Fabrys
SLE
Pagets
Causes of aortic regurg
RF
Marfans/Ehler Danos
HTN
Osteogenis imperfecta
Myoxmatous disease
Ank spond
GCA
SLE
Causes of acute aortic regurg
IE
Trauma aortic dissection
De Mussetts sign
Head bobbing due to wide pulse pressure
Quinckes sign
Capillary pulsation in fingertips and lips
Mullers sign
Uvular pulsation
Gallavardians phenomeneom
AS murmur heard throughout pericordium
How do you Ix for Brugada syndrome
flecanide test
Causes of collapsing pulse
Aortic regurg
PDA
Hyperdynamic state
What does a VSD sound like?
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
Types od ASD
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
What does and ASD sound like?
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
What does mitral valve prolapse sound like?
Sytolic click with late systolic murmur
Best heard at apex on left lateral position
Questions to ask in HTN
Headaches/visual change
Pregnancy - prev/plans
Urine changes
Meds compliance
Chest pain/SOB/Palpitations
Diet
Cushings/acromegaly/thyroid sx
Tiredness ?OSA
How would you Ix for ?phaechromocytoma
24 hour urine metanephrines
Plasma metanephrines
How do you image for
Renal Artery Stenosis and/or Phaeochromocytoma?
CT/MRI kidneys and adrenals
How do you Ix ?Conns
Morning renin :aldosterone ratio
Endocrine causes of HTN
Adrenal - phaechromocytoma, Conns
Cushings
Acromegaly
Hyperthyroidism
Renal causes of HTN
Renal artery stenosis
Polycystic kidney disease
Chronic glomerulonephritis
Diabetic nephropathy
Nephrotic syndrome
Chest causes of HTN
Coarctation of aorta
OSA
Autoimmune causes of HTN
Systemic sclerosis
SLE
Wegners granulomatosis
Drug causes of HTN
NSAIDs
EPO
Cyclosporin/tacrolimus
Steroids
COCP
ETOH/liquorice
Tx for Conns
Spironalactone/Eplerone
Surgery definitive
Tx of phaeochromocytoma
Beta block
Surgery definitive
Tx of Renal Artery Stenosis
Stenting
Flash pulmonary edema after starting ACEi
RAS
Features of SAH
Nausea/vom
Neck stiffness
Photophobia
Seizures/LOC/Drowsy
Risk factors: PKD, HTN, Aneurysm FHx, Marfans, smoking
Features of Cerebral Venous Thrombosis
COCP/Preganant
Ca
Dehydration
Clotting abnormality
Infection/inflamm
Neuro Sx
Features of Cervical Artery Dissection
Trauma
Neck pain
Droopy eye/small pupil
Ringing in ears
Stroke sx
Headache: Features of Pituitary Apoplexy
Abdo pain
Dizziness
Nausea/Vom
Headache: Features of Migraine
Aura
Sensitivity to light/smell
Migraine Rx
Avoid triggers (diary)
1st line - analgesia Aspirin/ibuprofen NOT codeine
Triptans (for established headache, CI if uncontrolled HTN, CAD, CVD)
Prophylaxis - Propanolol, topirmate, Amitryptiline
Extra articular features Ank Spond
Atlanto-axial subluxation
Anterior uveitis
Apical fibrosis
Aortic regurgitation
Amyloidosis (renal)
Achilles involvement (enthesitis)
Cardiac causes of syncope
Brady/tachy
SVT
Long
QT
PPM dysfunction
Hypotension
Brugada WPW
HCOM
WPW
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
Brugada syndrome
Genetic abnormality - mutation in sodium channels
Autosomal dominant
Ventricular arrhythmia
High risk of sudden cardiac death
Needs ICD
Ax cardiac defects dextrocardia
VSD
TGA
Double outlet RV
PS/hypoplasia
Endocarrdial cushiom defect
Single ventricle
Murmur grades
- v faint, only by expert
- soft
- moderate
- loud + thrill, heard with steth partly off
- Loudest + thrill + heard outside the chest
Diastolic murmur
AR/Austin Flint
MS
Pulmonary regurg
LAD stenosis
Tricuspid stenosis
Complete heart block
