Cardiology Flashcards
Ejection systolic murmur
Aortic stenosis
Aortic sclerosis
Coarctation of the Aorta
Pulmonary stenosis
Atrial septal defect
HOCM
Pansystolic murmur
Mitral regurgitation
Mitral valve prolapse
Tricuspid regurgitation
Ventricular septal defect
Mid-Diastolic murmur
Mitral stenosis
Austin-Flint murmur (in severe aortic regurgitation)
Myxoma
Early Diastolic murmur
Aortic regurgitation
Pulmonary regurgitation
Graham-Steel murmur (in severe mitral regurgitation)
Difference between HOCM and AS on examination?
AS murmur louder
HOCM murmur increased by standing from squatting
AS murmur radiates to carotids
ALWAYS present Cardio features of:
Scars
Atrial fibrillation
Heart failure
Infective endocarditis
Bruises (anticoagulation)
Mitral stenosis examination
Malar flush
Atrial fibrillation
Palpable/loud S1
Signs of pulmonary hypertension
Rumbling mid-diastolic murmur loudest on expiration
Causes of mitral stenosis
** Rheumatic fever **
Carcinoid syndrome
Congenital
Clinical features of severe mitral stenosis?
Pulmonary hypertension
Right heart failure
Long murmur
Indications for MS valve surgery?
Pulmonary hypertension
Symptomatic heart failure
Undergoing a CABG anyway
Clinical features of Aortic regurgitation
Quincke’s nail sign
Collapsing pulse
De Musset head bobbing sign
Muller’s bobbing uvula
Corrigan’s prominent carotid pulsations
Displaced apex
!!!Austin Flint mid-diastolic murmur!!!
Causes of Aortic regurgitation
Acute:
IE, aortic dissection
Chronic:
Aortic root dilatation (age-related, hypertension)
Rheumatic fever
Connective tissue disorders - Marfan syndrome, Ank Spond
Features of severe aortic regurgitation
Wide pulse pressure
Quiet S2
Austin-flint murmur
Left-sided heart failure
Indications for aortic valve replacement?
Severe symptoms
EF <50%
Valve area <1cm2
Aortic root diameter >50mm
Aortic valve gradient >50mmHg
Undergoing a CABG anyway
Features of severe aortic stenosis on examination
Narrow BP
Quiet S2
S4
Palpable thrill
Heart failure
When would you hear Ejection systolic + pan-systolic murmur?
Gallaverdin phenomenon (dissociation of aortic stenosis murmur)
Co-existent mitral valve disease
Causes of mitral regurgitation
Acute:
Infective endocarditis
Papillary muscle rupture after MI
Chronic:
Mitral valve prolapse
Rheumatic fever
Congenital
Features of severe mitral regurgitation?
Graham Steel murmur (pulmonary regurgitation due to pulm HTN from MR)
S3
Heart failure
Description of a Murmur
Timing (to carotids)
Location
Grade 3+
Radiation
Louder on inspiration or expiration
HOCM exam
Ejection systolic murmur
Heaving apex
Double apical pulse
+/- ICD
HOCM echo
asymmetrical septal hypertrophy, systolic anterior motion of the mitral valve (SAM),
a small LV cavity
Causes of cyanotic heart patient
Tetralogy of Fallot
Shunt - ASD, VSD, PDA —> Eisenmenger syndrome
Ventricular Septal Defect murmur?
Pan-systolic murmur
Atrial septal defect
Loud systolic murmur in pulmonary area
Down syndrome
Risk of stroke
HOCM findings
Ejection-systolic loudest at left sternal edge
Murmur louder on Vasalva manoeuvre
Implantable cardiac defibrillator in place
HOCM associations
Atrial fibrillation
Friedrich’s ataxia
Myotonic dystrophy
Wolff-Parkinson-White syndrome
Aortic stenosis associations
Coarctation of the aorta
Heyde’s syndrome (AS + angiodysplasia)
Clinical indicators of severe aortic stenosis
Narrow BP
quiet S2
S4
Palpable thrill / heaving apex
Bibasal crepitations
Causes of dilated cardiomyopathy
Ischaemic heart disease
Valvular disease
Alcohol
Amyloidosis
Viral
Autoimmune
Signs of mitral valve prolapse
Pansystolic murmur
Quieter on squatting
Louder on standing
Causes of mitral valve prolapse
Acute:
Infective endocarditis
Rupture of chordae tendinae (post-MI),
Chronic:
Idiopathic
Marfan syndrome, Ehler Diablos syndrome
Clinical signs of Pulmonary hypertension
Right ventricular heave
Heaving apex
Loud P2
S4 sound
Symptoms of Mitral regurgitation
Dyspnoea
Reduced exercice tolerance
Symptoms of heart failure
Causes of S3 sound
Also known as ventricular gallop
Normal variant up to age 40y
- Aortic and Mitral regurgitation
- Systolic heart failure
Describe the JVP waveform
A wave - Right atrial (RA) contraction
C wave - Tricuspid valve (TV) closure
X descent - RA relaxation as ventricles contract
V wave - RA filling
Y descent - TV opens
Management of aortic stenosis
Digoxin, furosemide
AVR or TAVI
Statin
Caution with beta blockers
Nitrates contra-indicated
Causes of Aortic stenosis
Age-related calcification
Bicuspid valve
Congenital
Rheumatic heart disease
Aortic sclerosis is a differential
Clinical indicators of severe aortic regurgitation
Wide BP
Collapsing pulse
S3 sound
Heart failure
Austin Flint murmur (mid-diastolic)
Associations of Mitral valve prolapse
Turner syndrome
Poly cystic kidney disease
Marfan & Ehler Danlos syndromes
Osteogenesis imperfecta
Differences between S3 and S4
PPM Right atrial lead only
Sino-atrial disease in young person
PPM Right ventricular lead only
Pacing whilst in permanent atrial fibrillation
Indications for an implantable defibrillator
Primary prevention: familial cardiac conditions, previous MI with symptomatic HF
Secondary prevention: Survivors of VT or VF with no treatable cause identified
Infective endocarditis organisms
Staph Aureus (esp prosthetic valves and IVDU)
Streptococci, enterococci
HACEK organisms
Candida
Clinical signs of infective endocarditis
Splinter haemorrhages
Osler nodes (painful finger nodules)
Janeway lesions (painless palmar macules)
Clubbing
(Roth spots on retina)
Then use Duke’s criteria
Differentials for infective endocarditis
SLE - Libman-Sachs (aseptic) endocarditis
Antiphospholipid syndrome -thromboemboli & valve disease
Tuberculosis
Infective endocarditis criteria
Duke’s criteria
Major:
- positive cultures for typical organism
- findings on echocardiogram
Minor:
- risk factors
- fever
- vascular phenomena: septic emboli, janeway lesions
- immunological phenomena: Osler nodes, glomerulonephritis
- microbiology: positive blood cultures that don’t meet the Major criteria
Complications of infective endocarditis
Septic emboli to lungs or brain
Heart failure
Sepsis
Aortic root abscess
Aortic regurgitation associations
Osteogenesis imperfecta
Marfan & Ehler Danlos syndrome
Ankylosing spondylitis
SLE
Causes and Associations of pulmonary stenosis
Congenital
Tetralogy of Fallot
Carcinoid syndrome
Williams syndrome
Noonan syndrome
Apical beat
Displaced & thrusting —> MR/AR
Undisplaced & heaving —> AS / LVH
Tapping —> MS
Indications for ASD or VSD closure
Major right to left or left to right shunt including Eisenmenger syndrome
Aortic regurgitation due to the defect
Infective endocarditis
Any cardiac surgery happening anyway
Management of aortic regurgitation / aortic root dilatation
ACE inhibitors to control blood pressure
Beta blockers to slow dilatation
CCB,
Diuretics
Statins
Management of pulmonary hypertension
Treat the cause
Ambrisentan
Sildenafil
Iloprost
Mitral valve prolapse
Most common cause of MR
Mid-systolic click
Late-systolic murmur
RF: Marfan, Ehlers-Danlos, Osteogenesis Imperfecta, Pseudoxanthoma Elasticum
Symptoms of aortic stenosis
Angina
Exertional dyspnoea
Syncope
Symptoms of mitral regurgitation
Dyspnoea
Orthopnoea
Paroxysmal nocturnal dyspnoea
Fatigue
Palpitations
Symptom of mitral valve prolapse
Atypical chest pain
Symptoms of tricuspid regurgitation
Fatigue
Hepatic pain on exertion
Ascites
Peripheral oedema
Difference between MR and MVP on examination
Pansystolic vs mid-systolic click
MVP will have normal S1 then gap before murmur
Symptoms of mitral stenosis
Dyspnoea
Fatigue
Haemoptysis
Chest pain
Examination findings for TR
Giant V wave in JVP
Loud P2
No evidence of pulmonary congestion
Peripheral oedema
Causes of tricuspid regurgitation (3)
Pulmonary hypertension from lung disease of left heart disease
Rheumatic heart disease
Infective endocarditis
How to identify which valve replaced?
Abnormal S1 - mitral metallic
Abnormal S2 - aortic metallic
Systolic murmur normal in AVR
Valve replacement examination
Systolic flow murmur
?regurgitation of replaced valve
?heart failure —> unlikely
?infective endocarditis
?over anticoagulation
?atrial fibrillation
Treatment of Mitral stenosis
Balloon valvuloplasty
When to use tissue valve rather than mechanical?
Older people (because might need replacing in 10-15y, metallic valves last up to 30y)
Women who want children
Contra-indications to warfarin
Indications for pacemaker
Mobitz type 2 second degree heart block
Complete heart block
Symptomatic bradycardia (sick sinus syndrome)
Symptomatic pauses >3s
Trifascicular block with syncope
HOCM examination
Pacemaker/ICD
Jerky pulse
Double apex beat
Ejection systolic murmur
S4
Types of mechanical valves
Ball and cage
Single tilting disc
Double tilting disc
Types of tissue valves
Xenograft (porcine)
Homograft (cadaveric)
Types of VSD
Membranous
Muscular
Infundibular
Posterior
Conditions associated with VSD
Turner syndrome
Down syndrome
Tetralogy of Fallot
Myocardial infarction
Complications of VSD
Infective endocarditis
Aortic regurgitation
Pulmonary hypertension
Congestive cardiac failure
Eisenmenger’s complex
Tetralogy of Fallot repair surgery
Blalock-Taussig shunt
Blalock-Taussig shunt
Surgical repair of Tetralogy of Fallot
Anastomosis connecting the left subclavian artery with the left pulmonary artery
Complications of Tetralogy of Fallot
Endocarditis
Paradoxical embolus
Polycythaemia
Eisenmenger’s syndrome
Eisenmenger’s syndrome
Progressive process by which a longstanding R to L shunt from a congenital cardiac defect causes pulmonary hypertension and eventual reversal of the shunt into a Cyanotic L to R shunt
Examination findings HOCM
Prominent A wave in JVP
Pacemaker
Double apical impulse
Left sternal thrill
S4
ESM + PSM radiating to axilla
Management of HOCM
Propranolol
Verapamil
Dual chamber pacemaker
Septal ablation
Treat complications
Genetic counselling for family
Valve complications
Failure
Infection
Bleeding
Anaemia
Thromboembolism
