Cardiology Flashcards
What are the causes of aortic stenosis.
Bicuspid valve, degenerative calcification, rheumatic valve disease, congenital, infective endocarditis, paget’s disease
Differential diagnosis of ejection systolic murmur?
Aortic stenosis, HOCM, supravalvular aortic stenosis, aortic sclerosis
How do you classify the severity of aortic stenosis?
Valve area: normal 3-4cm, mild >1.5, moderate 1-1.5, severe <1
Gradient: peak >64mmHg, average >40mmHg
What are the clinical signs of severe aortic stenosis?
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
What are the complications of aortic stenosis?
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)
How would you manage an asymptomatic patient with aortic stenosis?
Endocarditis prophylaxis (good dentition) Report symptoms of angina, palpitations, syncope, breathlessness
How would you investigate a patient with aortic stenosis?
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
What are the indications for aortic valve replacement in the context of aortic stenosis?
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
What are the causes of mitral stenosis?
Rheumatic fever
Degenerative calcification
Rare causes include congenital, connective tissue disease, carcinoid
Differential diagnosis of mid-diastolic murmur?
Mitral stenosis
Left atrial mass
Left atrial thrombus
Severe mitral regurgitation
How do you classify the severity of mitral stenosis?
By mitral valve area (normal 4-6)
Mild is >1.5cm
Moderate is 1-1.5cm
Severe is <1.0cm
What are the clinical features of severe mitral stenosis?
Early opening snap Increasing length of murmur Signs of pulmonary hypertension Signs of pulmonary congestion Pulmonary regurgitation Low pulse pressure
What are the complications of mitral stenosis?
Left atrial enlargement Atrial fibrillation Left atrial thrombus formation Pulmonary hypertension Pulmonary oedema Right heart failure
What is the differential diagnosis of a malar flush?
Mitral stenosis (low output state due to pulmonary hypertension) Hypothyroidism SLE Carcinoid Polycythaemia Systemic sclerosis Irradiation Cold weather
How would you investigate a patient with mitral stenosis?
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
How would you manage a patient with mitral stenosis?
Asymptomatic: endocarditis prophylaxis, regular echo
Atrial fibrillation: rate/rhythm control, anticoagulation
Symptomatic: diuretics, refer for surgery
What are the indications for surgery in mitral stenosis?
Symptomatic patients with severe lesions
Asymptomatic patients - changes in symptoms, pulmonary pressure >50mmHg
What surgical procedures can be used to treat mitral stenosis?
Closed mitral valvuloplasty, open commisurotomy, mitral valve replacement
What are the indications for valve replacement in aortic regurgitation?
Symptomatic: severe aortic regurgitation with angina or dyspnoea
Asymptomatic: mod/severe aortic regurgitation undergoing other cardiac surgery, left ventricular dysfunction, dilated left ventricle
What are the indications for aortic valve replacement other than aortic stenosis or aortic regurgitation?
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
Which patients should receive bioprosthetic valves?
Anticoagulation is contraindicated
Life expectancy shorter than expected life span of the prosthesis
Patient age >70
What are the complications of prosthetic valves? (Metallic and tissue)
Thromboembolism Complications of anticoagulation Valve dysfunction Endocarditis Haemolysis
What are the advantages and disadvantages of bio prosthetic valves?
Advantages: anticoagulation not required
Disadvantages: reduced lifespan of valve compared to mechanical valves
What are the advantages and disadvantages of mechanical valves?
Advantages: longer life span of valve compared to biological valve
Disadvantages: need for life long anticoagulation
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
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
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
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)
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
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
What are the causes of chronic aortic regurgitation?
Biscuspid aortic valve Hypertension Rheumatic fever Aortitis Rheumatoid arthritis Connective tissues diseases
What are the causes of acute aortic regurgitation?
Aortic dissection
Infective endocarditis
Rupture of sinus of valsalva aneurysm
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
What are the other causes of a collapsing pulse other than aortic regurgitation?
Hyperdynamic circulation
Anaemia, fever, pregnancy, thyrotoxicosis, severe bradycardia, severe mitral regurgitation
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
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
What symptoms are associated with mitral valve prolapse?
Usually asymptomatic
Palpitations, chest pain, fatigue, dyspnoea, anxiety
What are the complications of mitral valve prolapse?
Stroke chordal rupture endocarditis arrhythmia progression to mitral regurgitation
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
What is the definition of pulmonary hypertension?
Mean pulmonary artery systolic pressure >25mmHg at rest
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
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
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
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)
How do you treat primary pulmonary hypertension?
Diuretics Anticoagulation Vasodilator therapy Atrial septostomy Lung transplantation
What are the causes of pulmonary stenosis?
Congenital Rheumatic heart disease Carcinoid Noonan’s syndrome Congenital rubella
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
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
How would you investigate a patient with pulmonary stenosis?
ECG: right ventricular hypertrophy
CXR: diminished pulmonary vascular markings
Echo
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
How would you grade the severity of pulmonary stenosis?
Trans-valvular gradient
Mild: <50mmHg
Moderate: 50-79mmHg
Severe:>80mmHg
What are the causes of tricuspid regurgitation?
Congenital (Ebstein’s anomaly)
Acquired: infective endocarditis, functional, rheumatic fever, carcinoid syndrome
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
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
How would you manage a patient with tricuspid regurgitation?
Medical management: diuretics, beta blockers, ACE inhibitors
Surgical management if medical treatment unsuccessful
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
What are the types of atrial septal defect?
Primum: associated with atrioventricular septal defect and Downs syndrome
Secundum is the commonest type
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
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
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
What are the causes of a ventricular septal defect?
Congenital (maternal diabetes, maternal alcohol syndrome, Downs syndrome)
Acquired (traumatic, post-op, post-MI)
What are the complications of ventricular septal defects?
Infective endocarditis Pulmonary hypertension Left ventricular dysfunction Aortic regurgitation Arrhythmia Eisenmeinger’s syndrome
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
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
Are there any contraindications to closure of a ventricular septal defect?
Irreversible severe pulmonary hypertension and Eisenmeinger’s syndrome
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
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
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
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
What are the indications for anticoagulation in mitral valve disease?
Co-existent atrial fibrillation
Previous embolic disease
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
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)
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
What is the murmur of mitral regurgitation?
Pansystolic
Loudest at apex
Radiates to axilla
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
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
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
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
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
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
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
