Cardiology Flashcards
What are the features of the pulse in a patient with aortic stenosis?
Slow rising with narrow pulse pressure
What is the character of the murmur found in a patient with aortic stenosis?
Ejection systolic murmur, radiating to the carotids.
Loudest at aortic area and in expiration
What additional chest signs may be found in a patient with aortic stenosis?
Heaving apex beat
Palpable thrill over aortic area
What are the most common causes of aortic stenosis?
Calcification (more likely in older patient)
Congenital bicuspid valve
What are the indications for valve replacement in a patient with aortic stenosis?
Symptomatic patient with a gradient >50
Asymptomatic patient AND:
Mod/severe stenosis for CABG or
Severe AS with LVSD
or
Severe AS with abnormal BP response to exercise
or
VT
What are some differentials for a patient with an ejection systolic murmur?
Aortic stenosis
Aortic sclerosis
Pulmonary stenosis
Physiological flow murmur
Hypertrophic cardiomyopathy
Patient-prosthesis mismatch
Describe the murmur heard in aortic regurgitation
High-pitched early diastolic decrescendo murmur
Loudest at left sternal edge in fixed expiration
Other than a murmur, what signs may be found in a patient with aortic regurgitation?
Collapsing pulse
Wide pulse pressure
Head nodding
Dancing carotid
Pulsating nail beds
Murmur heard over femoral arteries
What are some causes of aortic regurgitation?
Acute - infective endocarditis, aortic dissection, prosthesis failure, rheumatic fever
Chronic - infective endocarditis, bicuspid aortic valve, marfan’s syndrome, syphilis, seronegative arthritides
What are the indications for surgical intervention in aortic regurgitation?
Moderate to severe acute regurgitation
Chronic AR with SOB or angina
Asymptomatic with significant root dilatation, LV dilatation and EF <50%
What are some manifestations of marfan’s syndrome?
Aortic regurgitation
Upwards lens dislocation
Arm span greater than height
Pectus excavatum
Joint laxity
Scoliosis
Pes planus
How often should aortic valve screening be done for patients with Marfan’s?
Echocardiogram annually to measure diameter of aorta
What is eisenmenger’s syndrome?
Reversal of a large left to right shunt due to increased pulmonary blood flow and pulmonary hypertension, leading to cyanotic heart disease
What are the causes of eisenmenger’s syndrome?
Large VSD
PDA
Atrioventricular septal defects
large systemic to pulmonary shunts for treatment of congenital heart disease
What are the potential complications of eisenmengers syndrome?
Secondary polycythaemia and hyperviscosity
Arrhythmias
Heart failure
Stroke
Haemoptysis
CKD
Gout
Hypertrophic osteoarthropathy
Sudden cardiac death
What is hypertrophic obstructive cardiomyopathy?
Septal hypertrophy, often causing left ventricular outflow tract obstruction
What heart sounds are present in a patient with HOCM?
Dynamic ejection systolic murmur radiating to apex. Murmur increases with valsalva manoeuvre and standing. Decreases with squatting
How can HOCM lead to mitral regurgitation?
Rapid blood flow at LV outflow tract causes systolic anterior motion of the mitral valve leaflets
What is the cause of HOCM?
Genetically inherited in 50%
Can occur de-novo
What may be seen on an ECG in someone with HoCM?
LVH
Deep q waves
ST elevation
Other than a murmur, what signs may be found in a patient with HOCM?
Jerky pulse
Low systolic blood pressure and narrow pulse pressure
Palpable thrill over aortic area
Heaving apex
Features of CCF
May be ICD present
MR murmur may be present
What information can be gained from a cardiac MRI in someone with HOCM?
Hypertrophic distribution
Wall fibrosis
LV function
How should HOCM be investigated?
ECG
Echo
Holter monitor for ?VT
Exercise tolerance test. Failure of BP to rise with exercise indicates worse LVOT obstruction
Consider genetic testing if appropriate
What are some risk factors for sudden cardiac death in a patient with HOCM?
Family history of sudden cardiac death
Episodes of ventricular arrhythmias
Abnormal BP response to exercise
High LV wall thickness
Unexplained syncope
Describe the murmur heard in a patient with mitral stenosis
Low pitched mid-diastolic murmur at apex, loudest in left lateral postion.
May be opening snap of mitral valve
May be loud P2 due to pulmonary hypertension
Other than a murmur, what signs may be found in a patient with mitral stenosis?
Malar flush
Irregular pulse
Raised JVP
Tapping apex
Palmar erythema
May be left parasternal heave if pulmonary hypertension
What are the causes of mitral stenosis?
Most common is previous rheumatic fever
Congenital
Infective endocarditis
Calcification
What are some complications of mitral stenosis?
Pulmonary hypertension and right sided heart failure
Haemoptysis
Flash pulmonary oedema
Emboli (need warfarin, DOACs not licensed)
AF
Infective endocarditis
Describe the murmur heard in a patient with mitral regurgitation
High pitched pan systolic murmur, loudest at the apex
Other than a murmur, what signs may be found in a patient with mitral regurgitation?
Features of marfan’s syndrome
Stigmata of infective endocarditis
Raised JVP
Displaced apex beat with apical thrill
Signs of heart failure
What are some causes of mitral regurgitation?
Acute: IE
Chordae tendinae rupture secondary to MI, rheumatic fever or IE
Chronic: rheumatic fever, marfans, ehlers danlos, rheumatoid arthritis
What changes may be found on an ECG in someone with mitral regurgitation?
AF
Left axis deviation
When is surgical repair of mitral regurgitation indicated?
Asymptomatic with LVEF 30-60%
Chronic MR with new AF and raised pulmonary pressures
What conditions are associated with mitral valve prolapse?
Congenital heart disease such as ASD, AVSD,PDA
Congenital disorders such as Turner’s, Marfan’s, osteogenesis imperfecta
SLE
Describe the murmur heard in mitral valve prolapse
Late systolic murmur, loudest at left sternal edge
May be midsystolic click
What are some complications associated with prosthetic heart valves?
Valve failure
Thrombosis and embolisation
Endocarditis - acute or subacute
Stroke/TIA
Haemolysis
Bleeding secondary to anticoagulation
What are the main causes of pulmonary stenosis?
Congenital due to maternal rubella
Rheumatic fever
Carcinoid syndrome
Describe the murmur heard in pulmonary stenosis?
Ejection systolic murmur, loudest during inspiration and over pulmonary area
What are the defects seen in tetralogy of fallot?
Pulmonary stenosis
Overriding aorta
Ventricular septal defect
Right ventricular hypertrophy
What are the main causes of pulmonary regurgitation?
Hypertension
Tetralogy of fallot if pulmonary valvotomy done
Congenital
What clinical signs may be seen in a patient with pulmonary regurgitation
Early diastolic murmur
Signs of right heart failure
What are the causes of tricuspid regurgitation?
Acute:
Infective endocarditis (esp from IVDU)
Trauma
Chronic:
Pulmonary hypertension
Infective endocarditis
Rheumatic fever
What are the differentials for an ejection systolic murmur?
Aortic stenosis
Pulmonary stenosis
Aortic sclerosis
HOCM
Atrial septal defect
What are the differentials for a pansystolic murmur?
Mitral regurgitation
Tricuspid regurgitation
Atrial septal defect
Ventricular septal defect
What is the genetic cause of Noonan syndrome?
Mutations in the RAS/MAPK pathway
Autosomal dominant inheritance, about 60% de novo mutations
What medications are initiated after MI?
Dual antiplatelet
Beta blocker
ACE I
Statin
Eplerenone if EF <40% and clinical signs of HF
