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Cardiology Flashcards

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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
What are the indications for valve replacement in mitral regurgitation?
Signs of left ventricular dysfunction Reduced ejection fraction (even in the absence of symptoms) Dilated left ventricle
26
What are the causes of mitral regurgitation?
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
27
What are the clinical signs of severe mitral regurgitation?
``` 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 ```
28
What is the differential diagnosis of a precordial pansystolic murmur?
``` 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) ```
29
How would you investigate a patient with mitral regurgitation?
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
30
How would you manage a patient with mitral regurgitation?
Asymptomatic: endocarditis prophylaxis, serial echo Rate and rhythm control and anticoagulation if in atrial fibrillation Management of heart failure Consideration for surgery
31
What are the causes of chronic aortic regurgitation?
``` Biscuspid aortic valve Hypertension Rheumatic fever Aortitis Rheumatoid arthritis Connective tissues diseases ```
32
What are the causes of acute aortic regurgitation?
Aortic dissection Infective endocarditis Rupture of sinus of valsalva aneurysm
33
What are the signs of severe aortic regurgitation?
``` Wide pulse pressure Long duration of diastolic murmur Third heart sound Austin Flint murmur Signs of pulmonary hypertension Signs of heart failure ```
34
What are the other causes of a collapsing pulse other than aortic regurgitation?
Hyperdynamic circulation Anaemia, fever, pregnancy, thyrotoxicosis, severe bradycardia, severe mitral regurgitation
35
How would you investigate a patient with aortic regurgitation?
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
How would you manage a patient with aortic regurgitation?
Vasodilators if severe aortic regurgitation and left ventricular dilatation Manage fluid overload Consider for valve replacement
37
What symptoms are associated with mitral valve prolapse?
Usually asymptomatic | Palpitations, chest pain, fatigue, dyspnoea, anxiety
38
What are the complications of mitral valve prolapse?
``` Stroke chordal rupture endocarditis arrhythmia progression to mitral regurgitation ```
39
How would you manage a patient with mitral valve prolapse?
Reassure if asymptomatic Endocarditis prophylaxis in those with a murmur Treat arrhythmias Treat chest pain with analgesics or beta blockers
40
What is the definition of pulmonary hypertension?
Mean pulmonary artery systolic pressure >25mmHg at rest
41
What are the causes of secondary pulmonary hypertension?
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
What is primary pulmonary hypertension?
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
How would you investigate a patient with pulmonary hypertension?
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
What are the treatments of secondary pulmonary hypertension?
``` 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
How do you treat primary pulmonary hypertension?
``` Diuretics Anticoagulation Vasodilator therapy Atrial septostomy Lung transplantation ```
46
What are the causes of pulmonary stenosis?
``` Congenital Rheumatic heart disease Carcinoid Noonan’s syndrome Congenital rubella ```
47
What are the clinical signs of severe pulmonary stenosis?
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
What is Noonan’s syndrome?
Autosomal dominant condition Male phenotypic form of Turner’s syndrome, but with normal karyotype Right sided cardiac lesions including pulmonary stenosis, ASD, VSD
49
How would you investigate a patient with pulmonary stenosis?
ECG: right ventricular hypertrophy CXR: diminished pulmonary vascular markings Echo
50
How would you manage a patient with pulmonary stenosis?
Endocarditis prophylaxis Mild: often require follow-up only Moderate: follow-up Severe: valvuloplasty, valve repair or valve replacement
51
How would you grade the severity of pulmonary stenosis?
Trans-valvular gradient Mild: <50mmHg Moderate: 50-79mmHg Severe:>80mmHg
52
What are the causes of tricuspid regurgitation?
Congenital (Ebstein’s anomaly) | Acquired: infective endocarditis, functional, rheumatic fever, carcinoid syndrome
53
What are the clinical signs of tricuspid regurgitation?
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
How would you investigate a patient with tricuspid regurgitation?
ECG: right ventricular hypertrophy CXR: double right heart border (large left atrium) Echo: TR jet, right ventricular dialatation
55
How would you manage a patient with tricuspid regurgitation?
Medical management: diuretics, beta blockers, ACE inhibitors | Surgical management if medical treatment unsuccessful
56
What are the clinical signs of an atrial septal defect?
``` 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
What are the types of atrial septal defect?
Primum: associated with atrioventricular septal defect and Downs syndrome Secundum is the commonest type
58
What are the complications of an atrial septal defect?
Paradoxical embolus through patent foramen ovale Atrial arrhythmia Right ventricular dilatation Shunt reversal due to pulmonary hypertension Right sided heart failure
59
How would you investigate a patient with an atrial septal defect?
ECG: right bundle branch block, atrial fibrillation CXR: pulmonary plethora and double heart border Echo: site, size and shunt calculation, amenability to closure
60
What are the indications and contraindications for closure of an atrial septal defect?
Indications: symptomatic (embolus, breathless), significant shunt Contraindications: severe pulmonary hypertension and Eisenmeingers syndrome
61
What are the causes of a ventricular septal defect?
Congenital (maternal diabetes, maternal alcohol syndrome, Downs syndrome) Acquired (traumatic, post-op, post-MI)
62
What are the complications of ventricular septal defects?
``` Infective endocarditis Pulmonary hypertension Left ventricular dysfunction Aortic regurgitation Arrhythmia Eisenmeinger’s syndrome ```
63
How would you investigate a patient with a ventricular septal defect?
ECG: ventricular hypertrophy, atrial hypertrophy CXR: cardiomegaly, signs of pulmonary hypertension Echo: location, size and direction of shunt, ventricular function Cardiac catheterisation
64
How would you manage a patient with a ventricular septal defect?
Reassurance if small and no pulmonary hypertension Endocarditis prophylaxis Diuretics Treatment of left ventricular dysfunction Treatment of pulmonary hypertension Surgical closure
65
Are there any contraindications to closure of a ventricular septal defect?
Irreversible severe pulmonary hypertension and Eisenmeinger’s syndrome
66
What are the clinical signs of HOCM?
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
How would you investigate a patient with HOCM?
``` ECG: left ventricular hypertrophy with deep t wave inversion CXR: usually normal Echo: asymmetrical septal hypertrophy Cardiac MRI Genetic testing Familial screening ```
68
How would you manage a patient with HOCM?
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
What is the prognosis of HOCM?
Annual mortality rate is 2.5% | Poor prognostic factors are young age at diagnosis, syncope, family history of sudden death, septal thickness >3cm
70
What are the indications for anticoagulation in mitral valve disease?
Co-existent atrial fibrillation | Previous embolic disease
71
How do you diagnose infective endocarditis?
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
What are the major criteria for infective endocarditis (Duke’s)?
``` Positive echo (mobile structure in a valve leaflet) Positive blood cultures (e.g. staph aureus, streptococcus bovis or viridans) ```
73
What are the minor criteria for infective endocarditis (Duke’s)
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
What is the murmur of mitral regurgitation?
Pansystolic Loudest at apex Radiates to axilla
75
What is the murmur of mitral stenosis?
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
What murmurs might you hear in mixed aortic valve disease?
Ejection systolic murmur Early diastolic murmur Austin Flint murmur - rergurgitant jet passing through the aortic valve and hitting the adjacent mitral valve leaflet
77
What is the treatment of mixed aortic valve disease?
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
What are the advantages of TAVI over open heart surgery?
Open heart surgery remains gold standard TAVI is good for patients with higher pre-operative risks and multiple co-morbidities
79
When might a balloon valvuloplasty be performed for aortic stenosis?
Usually a temporary measure pre definitive surgical management If a patient has cardiogenic shock or unstable angina
80
What are the causes of secondary hypertension?
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
Which patients with hypertension should receive treatment?
10 year cardiovascular risk score >20% Persistent BP of >160/100 All patients with co-existing diabetes or cardiovascular disease

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