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MRCP PACES > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What are the causes of aortic stenosis.

A

Bicuspid valve, degenerative calcification, rheumatic valve disease, congenital, infective endocarditis, paget’s disease

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2
Q

Differential diagnosis of ejection systolic murmur?

A

Aortic stenosis, HOCM, supravalvular aortic stenosis, aortic sclerosis

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3
Q

How do you classify the severity of aortic stenosis?

A

Valve area: normal 3-4cm, mild >1.5, moderate 1-1.5, severe <1

Gradient: peak >64mmHg, average >40mmHg

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4
Q

What are the clinical signs of severe aortic stenosis?

A 
Narrow pulse pressure
Slow rising pulse
Low volume pulse
Quiet or absent aortic component of second heart sound
Evidence of heart failure
Evidence of pulmonary hypertension
Delayed ejection systolic murmur
Reversed splitting of second heart sound 
Systolic thrill
Heaving apex
Fourth heart sound
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5
Q

What are the complications of aortic stenosis?

A 
Left ventricular failure
Sudden death
Pulmonary hypertension
Arrhythmia (AF, VT)
Heart block (calcification of conduction system)
Infective endocarditis
Systemic embolic complications
Haemolytic anaemia
Iron deficiency anaemia (chronic disease or Heyde’s syndrome)
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6
Q

How would you manage an asymptomatic patient with aortic stenosis?

A 
Endocarditis prophylaxis (good dentition)
Report symptoms of angina, palpitations, syncope, breathlessness
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7
Q

How would you investigate a patient with aortic stenosis?

A

ECG: left ventricular hypertrophy/strain, left atrial dilatation, conduction abnormalities
CXR: rib notching, dilated ascending aorta, calcified aortic valve, cardiomegaly, pulmonary congestion, dilated pulmonary arteries (hypertension)
Echo: grade the severity and assess left ventricular function
Coronary angiography: look for concurrent coronary artery disease

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8
Q

What are the indications for aortic valve replacement in the context of aortic stenosis?

A

Symptomatic severe aortic stenosis
Asymptomatic: undergoing other cardiac surgery, or severe AS with any of; left ventricular dysfunction, abnormal blood pressure response to exercise, ventricular tachycardia, valve area <0.6

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9
Q

What are the causes of mitral stenosis?

A

Rheumatic fever
Degenerative calcification
Rare causes include congenital, connective tissue disease, carcinoid

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10
Q

Differential diagnosis of mid-diastolic murmur?

A

Mitral stenosis
Left atrial mass
Left atrial thrombus
Severe mitral regurgitation

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11
Q

How do you classify the severity of mitral stenosis?

A

By mitral valve area (normal 4-6)
Mild is >1.5cm
Moderate is 1-1.5cm
Severe is <1.0cm

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12
Q

What are the clinical features of severe mitral stenosis?

A 
Early opening snap
Increasing length of murmur
Signs of pulmonary hypertension 
Signs of pulmonary congestion 
Pulmonary regurgitation 
Low pulse pressure
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13
Q

What are the complications of mitral stenosis?

A 
Left atrial enlargement 
Atrial fibrillation 
Left atrial thrombus formation
Pulmonary hypertension 
Pulmonary oedema
Right heart failure
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14
Q

What is the differential diagnosis of a malar flush?

A 
Mitral stenosis (low output state due to pulmonary hypertension)
Hypothyroidism 
SLE
Carcinoid
Polycythaemia
Systemic sclerosis
Irradiation 
Cold weather
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15
Q

How would you investigate a patient with mitral stenosis?

A

ECG: atrial fibrillation, left atrial hypertrophy, left atrial dilatation (p mitrale, large p wave with a notch)
CXR: double right heart border (left atrial enlargement), pulmonary congestion, prominent pulmonary arteries
Coronary angiography: check coronary artery disease
Echo: assess mitral valve, grade severity, assess left atrium and right heart function

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16
Q

How would you manage a patient with mitral stenosis?

A

Asymptomatic: endocarditis prophylaxis, regular echo
Atrial fibrillation: rate/rhythm control, anticoagulation
Symptomatic: diuretics, refer for surgery

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17
Q

What are the indications for surgery in mitral stenosis?

A

Symptomatic patients with severe lesions

Asymptomatic patients - changes in symptoms, pulmonary pressure >50mmHg

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18
Q

What surgical procedures can be used to treat mitral stenosis?

A

Closed mitral valvuloplasty, open commisurotomy, mitral valve replacement

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19
Q

What are the indications for valve replacement in aortic regurgitation?

A

Symptomatic: severe aortic regurgitation with angina or dyspnoea
Asymptomatic: mod/severe aortic regurgitation undergoing other cardiac surgery, left ventricular dysfunction, dilated left ventricle

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20
Q

What are the indications for aortic valve replacement other than aortic stenosis or aortic regurgitation?

A

Infective endocarditis not responding to medical therapy
Enlarging aortic root diameter irrespective of degree of aortic regurgitation
Sinus of valsalva aneurysm rupture
Aortic dissection causing aortic regurgitation

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21
Q

Which patients should receive bioprosthetic valves?

A

Anticoagulation is contraindicated
Life expectancy shorter than expected life span of the prosthesis
Patient age >70

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22
Q

What are the complications of prosthetic valves? (Metallic and tissue)

A 
Thromboembolism
Complications of anticoagulation 
Valve dysfunction 
Endocarditis 
Haemolysis
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23
Q

What are the advantages and disadvantages of bio prosthetic valves?

A

Advantages: anticoagulation not required
Disadvantages: reduced lifespan of valve compared to mechanical valves

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24
Q

What are the advantages and disadvantages of mechanical valves?

A

Advantages: longer life span of valve compared to biological valve
Disadvantages: need for life long anticoagulation

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25
Q

What are the indications for valve replacement in mitral regurgitation?

A

Signs of left ventricular dysfunction
Reduced ejection fraction (even in the absence of symptoms)
Dilated left ventricle

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26
Q

What are the causes of mitral regurgitation?

A

Chronic: rheumatic fever, mitral valve prolapse, connective tissue diseases, marfans syndrome, ehlers danlos syndrome, infective endocarditis, cardiomyopathy, papillary muscle dysfunction

Acute: infective endocarditis, rupture of chorade tendinae, trauma

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27
Q

What are the clinical signs of severe mitral regurgitation?

A 
Atrial fibrillation is common
Soft first heart sound
Third heart sound
Displaced apex beat
Precordial thrill
Widely split second heart sound
Signs of pulmonary hypertension 
Signs of pulmonary congestion
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28
Q

What is the differential diagnosis of a precordial pansystolic murmur?

A 
Mitral regurgitation (usually loudest at apex, radiates to axilla, loudest in expiration)
Tricuspid regurgitation (left lower parasternal edge, loudest in inspiration)
Ventricular septal defect (left lower parasternal edge)
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29
Q

How would you investigate a patient with mitral regurgitation?

A

ECG: atrial fibrillation, left atrial hypertrophy, left atrial dilatation
CXR: double right heart border, cardiomegaly, pulmonary congestion, prominent pulmonary arteries
Echo: mechanism of mitral regurgitation, assess severity, assess left ventricular function and right heart function
Coronary angiography: exclude coronary artery disease
Right heart catheterisation to estimate pulmonary artery pressure

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30
Q

How would you manage a patient with mitral regurgitation?

A

Asymptomatic: endocarditis prophylaxis, serial echo
Rate and rhythm control and anticoagulation if in atrial fibrillation
Management of heart failure
Consideration for surgery

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31
Q

What are the causes of chronic aortic regurgitation?

A 
Biscuspid aortic valve
Hypertension
Rheumatic fever
Aortitis
Rheumatoid arthritis
Connective tissues diseases
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32
Q

What are the causes of acute aortic regurgitation?

A

Aortic dissection
Infective endocarditis
Rupture of sinus of valsalva aneurysm

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33
Q

What are the signs of severe aortic regurgitation?

A 
Wide pulse pressure
Long duration of diastolic murmur
Third heart sound
Austin Flint murmur
Signs of pulmonary hypertension 
Signs of heart failure
34
Q

What are the other causes of a collapsing pulse other than aortic regurgitation?

A

Hyperdynamic circulation

Anaemia, fever, pregnancy, thyrotoxicosis, severe bradycardia, severe mitral regurgitation

35
Q

How would you investigate a patient with aortic regurgitation?

A

ECG: usually no specific findings
CXR: calcified valve, cardiomegaly, pulmonary congestion, prominent pulmonary arteries
Echo: assess valve and establish cause and severity of aortic regurgitation, assess left ventricular size and function
Coronary angiography: assess for presence of coronary artery disease
CT or MRI: assess the aortic root and ascending aorta

36
Q

How would you manage a patient with aortic regurgitation?

A

Vasodilators if severe aortic regurgitation and left ventricular dilatation
Manage fluid overload
Consider for valve replacement

37
Q

What symptoms are associated with mitral valve prolapse?

A

Usually asymptomatic

Palpitations, chest pain, fatigue, dyspnoea, anxiety

38
Q

What are the complications of mitral valve prolapse?

A 
Stroke
chordal rupture
endocarditis
arrhythmia
progression to mitral regurgitation
39
Q

How would you manage a patient with mitral valve prolapse?

A

Reassure if asymptomatic
Endocarditis prophylaxis in those with a murmur
Treat arrhythmias
Treat chest pain with analgesics or beta blockers

40
Q

What is the definition of pulmonary hypertension?

A

Mean pulmonary artery systolic pressure >25mmHg at rest

41
Q

What are the causes of secondary pulmonary hypertension?

A

Increased pulmonary venous pressure (mitral or aortic valve disease, connective tissue disease)
Decreased area of pulmonary vascular bed (interstitial lung disease, obstructive airways disease)
Chronic hypoxia
Left to right shunt

42
Q

What is primary pulmonary hypertension?

A

Pulmonary hypertension in the absence of an obvious cause
Rare
Associated with connective tissue disease and vasculitis
Median survival is three years if untreated

43
Q

How would you investigate a patient with pulmonary hypertension?

A

Confirm diagnosis and severity and look for underlying cause

ECG: right ventricular strain
ABG: type 1 or type 2 respiratory failure
CXR: prominent pulmonary arteries, oligaemic lung fields, signs of airways disease
Echo: signs of valve disease, assess right heart function, estimate pulmonary artery pressure
CTPA: chronic emboli
Lung function tests and high resolution lung CT
Right and left heart catheterisation

44
Q

What are the treatments of secondary pulmonary hypertension?

A 
Treat the cause
Diuretics
Long term oxygen therapy
Anticoagulation
Vasodilator therapy
Calcium channel blockers
Endothelin receptor antagonists (bosentan)
Phosphodiesterase 5 inhibitors (sildenafil)
Prostaglandins (epoprostenol, iloprost)
45
Q

How do you treat primary pulmonary hypertension?

A 
Diuretics
Anticoagulation
Vasodilator therapy
Atrial septostomy
Lung transplantation
46
Q

What are the causes of pulmonary stenosis?

A 
Congenital
Rheumatic heart disease
Carcinoid
Noonan’s syndrome
Congenital rubella
47
Q

What are the clinical signs of severe pulmonary stenosis?

A

Raised JVP with giant a waves
Left parasternal heave (right ventricular heave)
Thrill in pulmonary area
Widely split second heart sound
Quiet pulmonary component of second heart sound
Signs of heart failure

48
Q

What is Noonan’s syndrome?

A

Autosomal dominant condition
Male phenotypic form of Turner’s syndrome, but with normal karyotype
Right sided cardiac lesions including pulmonary stenosis, ASD, VSD

49
Q

How would you investigate a patient with pulmonary stenosis?

A

ECG: right ventricular hypertrophy
CXR: diminished pulmonary vascular markings
Echo

50
Q

How would you manage a patient with pulmonary stenosis?

A

Endocarditis prophylaxis
Mild: often require follow-up only
Moderate: follow-up
Severe: valvuloplasty, valve repair or valve replacement

51
Q

How would you grade the severity of pulmonary stenosis?

A

Trans-valvular gradient

Mild: <50mmHg
Moderate: 50-79mmHg
Severe:>80mmHg

52
Q

What are the causes of tricuspid regurgitation?

A

Congenital (Ebstein’s anomaly)

Acquired: infective endocarditis, functional, rheumatic fever, carcinoid syndrome

53
Q

What are the clinical signs of tricuspid regurgitation?

A

Raised JVP
Thrill over left sternal edge
Pulsatile liver, ascites and peripheral oedema
Evidence infective endocarditis
Pulmonary hypertension (causing tricuspid regurgitation)
Third heard sound
Pansystolic murmur

54
Q

How would you investigate a patient with tricuspid regurgitation?

A

ECG: right ventricular hypertrophy
CXR: double right heart border (large left atrium)
Echo: TR jet, right ventricular dialatation

55
Q

How would you manage a patient with tricuspid regurgitation?

A

Medical management: diuretics, beta blockers, ACE inhibitors

Surgical management if medical treatment unsuccessful

56
Q

What are the clinical signs of an atrial septal defect?

A 
Raised JVP
Pulmonary area thrill
Fixed splitting of second heart sound
Murmurs if shunt present
Signs of pulmonary hypertension 
Signs of shunt reversal (cyanosis and clubbing)
Signs of heart failure
57
Q

What are the types of atrial septal defect?

A

Primum: associated with atrioventricular septal defect and Downs syndrome
Secundum is the commonest type

58
Q

What are the complications of an atrial septal defect?

A

Paradoxical embolus through patent foramen ovale
Atrial arrhythmia
Right ventricular dilatation
Shunt reversal due to pulmonary hypertension
Right sided heart failure

59
Q

How would you investigate a patient with an atrial septal defect?

A

ECG: right bundle branch block, atrial fibrillation
CXR: pulmonary plethora and double heart border
Echo: site, size and shunt calculation, amenability to closure

60
Q

What are the indications and contraindications for closure of an atrial septal defect?

A

Indications: symptomatic (embolus, breathless), significant shunt
Contraindications: severe pulmonary hypertension and Eisenmeingers syndrome

61
Q

What are the causes of a ventricular septal defect?

A

Congenital (maternal diabetes, maternal alcohol syndrome, Downs syndrome)
Acquired (traumatic, post-op, post-MI)

62
Q

What are the complications of ventricular septal defects?

A 
Infective endocarditis 
Pulmonary hypertension 
Left ventricular dysfunction 
Aortic regurgitation 
Arrhythmia 
Eisenmeinger’s syndrome
63
Q

How would you investigate a patient with a ventricular septal defect?

A

ECG: ventricular hypertrophy, atrial hypertrophy
CXR: cardiomegaly, signs of pulmonary hypertension
Echo: location, size and direction of shunt, ventricular function
Cardiac catheterisation

64
Q

How would you manage a patient with a ventricular septal defect?

A

Reassurance if small and no pulmonary hypertension
Endocarditis prophylaxis
Diuretics
Treatment of left ventricular dysfunction
Treatment of pulmonary hypertension
Surgical closure

65
Q

Are there any contraindications to closure of a ventricular septal defect?

A

Irreversible severe pulmonary hypertension and Eisenmeinger’s syndrome

66
Q

What are the clinical signs of HOCM?

A

Jerky pulse
Double apical impulse
Features of Friedrichs ataxia or myotonic dystrophy
Ejection systolic murmur that radiates throughout the precordium
Fourth heart sound
Murmur accentuated by valsalva maneuver

67
Q

How would you investigate a patient with HOCM?

A 
ECG: left ventricular hypertrophy with deep t wave inversion 
CXR: usually normal
Echo: asymmetrical septal hypertrophy
Cardiac MRI
Genetic testing
Familial screening
68
Q

How would you manage a patient with HOCM?

A

Asymptomatic: avoidance of strenuous excercise and vasodilators
Symptomatic: beta blockers, pacemaker, septal ablation, myomectomy
ICD if high risk
Cardiac transplantation in refractory cases
Genetic counselling

69
Q

What is the prognosis of HOCM?

A

Annual mortality rate is 2.5%

Poor prognostic factors are young age at diagnosis, syncope, family history of sudden death, septal thickness >3cm

70
Q

What are the indications for anticoagulation in mitral valve disease?

A

Co-existent atrial fibrillation

Previous embolic disease

71
Q

How do you diagnose infective endocarditis?

A

Using Duke’s criteria
2 major and 5 minor criteria

To diagnose, need either

  • 2 major criteria
  • 1 major criteria and 3 minor
  • 5 minor criteria
72
Q

What are the major criteria for infective endocarditis (Duke’s)?

A 
Positive echo (mobile structure in a valve leaflet)
Positive blood cultures (e.g. staph aureus, streptococcus bovis or viridans)
73
Q

What are the minor criteria for infective endocarditis (Duke’s)

A

Temp >38
Positive blood cultures with other species not in major criteria
Echo findings consistent with endocarditis
Septic emboli
Janeway lesions or Osler’s nodes

74
Q

What is the murmur of mitral regurgitation?

A

Pansystolic
Loudest at apex
Radiates to axilla

75
Q

What is the murmur of mitral stenosis?

A

Low pitch, rumbling diastolic murmur

Loudest at the apex, best heard with the patient in the left lateral position with their breath held in expiration

76
Q

What murmurs might you hear in mixed aortic valve disease?

A

Ejection systolic murmur
Early diastolic murmur
Austin Flint murmur - rergurgitant jet passing through the aortic valve and hitting the adjacent mitral valve leaflet

77
Q

What is the treatment of mixed aortic valve disease?

A

Depends on symptoms
If asymptomatic, treat medically (beta blockers for rate control, ACEi for vasodilation, diuretics)

If symptomatic, generally surgical treatment with TAVI or open valve replacement

78
Q

What are the advantages of TAVI over open heart surgery?

A

Open heart surgery remains gold standard

TAVI is good for patients with higher pre-operative risks and multiple co-morbidities

79
Q

When might a balloon valvuloplasty be performed for aortic stenosis?

A

Usually a temporary measure pre definitive surgical management

If a patient has cardiogenic shock or unstable angina

80
Q

What are the causes of secondary hypertension?

A

Renal : renal parenchymal disease, revovascular disease, CKD

Endocrine: Cushing’s, hyperaldosteronism, adrenal hyperplasia, phaeochromocytoma, acromegaly, thyroid disease

Drug induced : NSAIDs, decongestants, oral contraceptives, corticosteroids, ciclosporin, anabolic steroids, illicit drug use

OSA
Coarctation of the aorta

81
Q

Which patients with hypertension should receive treatment?

A

10 year cardiovascular risk score >20%

Persistent BP of >160/100

All patients with co-existing diabetes or cardiovascular disease

MRCP PACES (5 decks)

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