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Shorties > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Mitral regurgitation - aetiology?

A

Primary:

  • Degenerative (eg. myxomatous degeneration, mitral valve prolapse, partial flail, flail leaflet).
  • Infective endocarditis
  • Rheumatic disease
  • Congenital - possible complication of repairs

Seconday:

  • Functional secondary to LV dilatation (dilated cardiomyopathy)
  • Papillary muscle ischaemia
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2
Q

Physical findings in chronic mitral regurgitation

A
  • Atrial fibrillation
  • Displaced, dyskinetic/diffuse apex beat
  • Loss of S1
  • Split S2
  • Added S3
  • Apical pansystolic murmur that radiates to axilla, immediately after S1 and up to/obscuring S2.
  • +/- apical thrill
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3
Q

Chronic MR - signs of severity

A

Soft S1
Split S2
Presence of S3

LV dilatation (laterally displaced apex beat)
Pulmonary hypertension (loud P2 component)
LV failure and LV dysfunction (gallop sounds)
Early diastolic rumble (increased flow in diastole)

Small pulse volume (v. severe)

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4
Q

MR - indications for surgery

A

Acute MR: prompt/early surgical intervention is indicated in acute non-ischaemic MR. In patients with acute ischaemic MR, treatment depends upon the exact aetiology of valve dysfunction. Surgical intervention is necessary to treat papillary muscle rupture.

  • Chordal rupture
  • Infective endocarditis
  • Papillary muscle rupture
  • Myocardial ischaemic (PCI may lead to resolution of MR)

Chronic MR:

  • Primary chronic MR:
    • Symptomatic (NYHA III/IV) with LVEF ≥30% and LVESD ≤55 mm
    • Asymptomatic with LVEF 30-60% and/or LVESD ≥40 mm
  • Secondary MR (ie MR that is a consequence of LV dysfunction with normal MV and chords)
    • First line therapy is medical management of HFrEF, including pharmacologic and CRT.
    • Patients with persistent symptoms despite OMT.
      • Consideration of surgical intervention may be indicated
      • Consideration of surgical intervention if patient is having concurrent CTHR surgery (eg. CABG + ischaemic MR).
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5
Q

MR - indications for transcatheter mitral valve repair (MitraClip)

A

Transcatheter mitral vale repair may be consdiered for patients with primary MR who meet all of the following criteria:

  • Chronic moderate to severe or severe MR (3 to 4+)
  • Severely symptomatic (NYHA III or IV) depspite OMT
  • Favourable anatomy for the repair procedure
  • Life expectancy ≥2 years
  • Prohibitive surgical risk due to comorbidities

Contraindications include:

  • Patients who cannot tolerate procedural anticoagulation or antiplatelet agents post-procedure
  • Active endocarditis of the mitral valve
  • Rheumatic MV disease or other causes of mitral stenosis
  • Thrombus of the femoral vein, IVC or intracardiac thrombus
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6
Q

MV prolapse - physical findings

A

Symptoms: Non-specific. Including palpitations, dyspnea, exercise intolerance, dizziness.

Murmur: Systolic click-murmur syndrome

  • Non-ejection (mid or late) systolic click
  • Murmur of MR, which in MVP is usually high pitched, late systolic crescendo-decrescendo occasionally “whooping or honking”, best heard at apex

Manoeuvres:

  • Valsalva (decreases pre-load): murmur longer, click earlier
  • Handgrip (increases after-load) or squatting (increases pre-load): murmur shorter
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7
Q

What does valsalva do?

A

Valsalva decreases pre-load

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8
Q

What does handgrip do?

A

Handgrip increases after-load

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9
Q

What does squatting do?

A

Squatting increases pre-load

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10
Q

Mitral stenosis - aetiology?

A

Rheumatic

Congenital (rare)

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11
Q

Mitral stenosis - mitral valve area?

A

Normal: MVA 4-6 cm^2

Significant MS: MVA 2 cm^2

Severe MS: MVA 1.5 cm^2

Very severe MS: 1 cm^2

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12
Q

Mitral stenosis - physical findings?

A

Malar flush

Pulse: AF

JVP: prominent a wave

Apex beat: tapping

Palpable S1 (at apex), palpable P2

RVH/parasternal lift

Auscultation:

  • Accentuated/snapping S1
  • OS
  • Mid-diastolic rumbling murmur ?Pre-systolic accentuation (SR)
  • Loud P2
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13
Q

Mitral stenosis - signs of severity?

A
  • Small pulse pressure
  • OS close to S2 (increased LA pressure)
  • Long diastolic murmur (present as long as there is a gradient between LA and LV)
  • Pulmonary hypertension
  • Apical diastolic thrill
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14
Q

Signs of Aortic Regurgitation

A

Collapsing pulse Widened pulse pressure

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15
Q

Central signs of AR ?

A

Soft A2 - loss of normal splitting of S2 on inspiration Volume loaded apex beat, displaced apex beat Decrescendo diastolic murmur, loudest when sitting forward on expiration

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16
Q

AR murmur

A

Decrescendo diastolic murmur Loudest on expiration when sitting forward

17
Q

Causes of AR?

A

ACUTE Infective endocarditis Dissecting aneurysm HTN Trauma CHRONIC Rheumatic heart disease Congenital bicuspid AV Ank spon Marfan/ehlers Danlos syndromes Aortitis

18
Q

Mitral stenosis murmur?

A

Low pitched mid diastolic murmur Best heard at apex in left lateral position

19
Q

Aortic regurgitation - physical findings

A

Water-Hammer/Collapsing pulse

Femoral artery “Pistol shot” murmur

Widened artery pressure (severe AR may not have a wide pulse pressure as LV end-diastolic pressure rises)

Displaced apex beat

Diastolic thrill at left sternal edge

S3 “ventricular gallop”

Decrescendo diastolic murmur

Austin Flint murmur: mid-diastolic murmur (regurgitant jets directed at the LV free wall)

Auscultatory features accentuated by exercise

20
Q

Aortic regurgitation - signs of severity

A

Wide pulse pressure

Collapsing pulse

Long decrescendo diastolic murmur

S3

Soft A2

Austin-Flint murmur

LVF

21
Q

Natural history of AR?

A

Chronic AR generally evolves slowly with a long asymptomatic compensated phase, with some patients developing worsening regurgitation that may progress to severe AR with LV dilation, LV systolic dysfunction, and heart failure

22
Q

When is AVR recommended for AR?

A

Symptomatic patients with severe AR, regardless of LV systolic function

Asymptomatic patients with chronic severe AR and LVEF <50%

Asymptomatic patients with normal LVEF but end-systolic dimension >50 mm.

Asymptomatic patients with normal LVEF but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low

Patients with moderate or severe AR while undergoing cardiac surgery for other indications.

23
Q

Tricuspid regurgitation - Peripheral signs

A

TR is diagnosed on the basis of peripheral signs

JVP with prominent V wave and rapid Y descent

Pulsatile liver

Often RV heave

PHT, loud P2

Pansystolic murmur, left LSE, louder on inspiration

24
Q

Murmur in hypertrophic obstructive cardiomyopathy (HOCM)?

A

Late ejection systolic murmur max LSE

Pansystolic murmur of MR at apex (systolic anterior motion)

S4 (“atrial gallop”)

Louder on Valsalva, softer with hand grip

25
Q

HOCM - Apex beat character?

A

Apex beat typically double impulse (pre-systolic ventricular dilatation post atrial contraction)

26
Q

VSD - Aetiology

A

Usually congenital

Ruptured myocardial infarct

27
Q

VSD - Physical findings

A

PSM max at LSE (often louder with smaller defects)

S3/S4

Thrill

Softer with valsalva

Associated with MR, Down’s, Tetralogy of Fallot

Indication for surgery: Moderate to large shunt

28
Q

ASD - Murmur

A

Mid-systolic pulmonary ejection murmur

Increases with inspiration

Fixed splitting of S2

A mid-diastolic rumbling murmur at LSE may indicate increased flow through TV

29
Q

What is the definition of mitral valve prolapse?

A

MVP is a common cause of MR. Most patients with MVP have mild, trivial, or no MR.

MVP is the most common cuase of surgical MR in developed countries.

The definition of MVP is based on imaging alone (previously imaging + clinical findings):

  • Billowing of any portion of the mitral leaflets ≥2 mm above the annular plane in a long axis view.
  • Abnormal systolic displacement of one or both leaflets in to the LA (sustolic billowing) due to a disruption or elonation of leaflets, chordae, or papillary muscles.

Shorties (6 decks)

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