Cardiology Flashcards by Timothy Davies

Causes of loud 1st heart sound

Mitral stenosis
Tricuspid stenosis

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Causes of soft 1st heart sound

Mitral regurgitation
RBBB

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Causes of loud 2nd heart sound (aortic)

hypertension

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Causes of soft 2nd heart sound (aortic)

aortic stenosis, aortic regurgitation

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Causes of loud 2nd heart sound (pulmonary)

pulmonary hypertension

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Causes of soft 2nd heart sound (pulmonary)

pulmonary stenosis

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What causes increased normal splitting of the second heart sound?

RBBB, pulmonary stenosis, mitral regurgitation
(Aortic closing early or pulmonary closing late)

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What causes fixed splitting of second heart sound?

ASD

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What causes reversed splitting of second heart sound?

LBBB, severe aortic stenosis

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What is the mechanism of the third heart sound?
What are the causes?

tautening of mitral or tricuspid cusps at the end of rapid diastolic filling

LV 3rd = louder at apex in expiration, LV failure, AR, MR, VSD, patent ductus arteriosus
RV 3rd = left sternal edge in inspiration, RV failure, constrictive pericarditis

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What is the mechanism of the fourth heart sound?
What are the causes?

high atrial pressure wave reflected back by poorly compliant ventricle

LV 4th= AS, MR, hypertension, IHD, HOCM
RV 4th= pulmonary hypertension, pulmonary stenosis

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Systolic murmurs

Left - MR (pansystolic), AS (ESM), HCM (valsalva)
Right - TR, PS

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Diastolic murmurs

Left - AR, MS
Right - PR, TS

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Continuous murmurs

PDA

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Causes of Mitral stenosis

Calcific, rheumatic, post mitral valve repair

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Clinical signs of MS severity

Small pulse pressure
Early opening snap
Long diastolic rumbling
Diastolic thrill at apex (rare)
Presence of pulmonary hypertension
a. Prominent A-wave on JVP
b. RV impulse
c. Loud P2 / palpable P2
d. Pulmonary regurgitation
e. Tricuspid regurgitation

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MS investigations

Investigations
- ECG – p-mitrale, AF (chronic), RV systolic overload, right axis deviation
- CXR – MV calcification, big left atrium, pulmonary hypertension, signs of cardiac failure
- Echo – colour mapping across Mitral valve

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MS indications for surgery

Indications for surgery
- Exertional dyspnoea + MV area <1cm + evidence of increased right heart pressures

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Mitral regurgitation causes

Degenerative
Mitral valve prolapse
Rheumatic (usually associated with MS murmur)
Papillary muscle dysfunction (LVF or ischaemia)
Connective tissue disease (ank spon, RA)
Congenital – including corrected transposition of the great arteries

MR signs of severity

Signs of severity
1. Enlarged LV
2. Pulmonary hypertension (late sign)
3. 3rd heart sound
4. Soft first heart sound
5. Split S2 (aortic early)
6. LVF

MR investigations

Investigations
1. ECG – p-mitrale, LV overload, right axis deviation
2. CXR – large LA, increased LV size, pulmonary hypertension
3. ECHO – leaflet morphology (thickened, calcific), LA size, LV size and function, mapping of regurgitant jet, estimation of pulmonary pressures

MR indications for surgery

Indications for surgery
- Class 3 or 4 symptoms
- LV dysfunction

Aortic regurgitation - causes / associations

Valvular - rheumatic, congenital (bicuspid valve), seronegative arthropathy
Aortic root - marfans, aortitis, dissecting aneurysm, old age

Marfans
- mode of inheritance
- gene most common
- disease manifestations

autosomal dominant
fibrillin 1
arachnodactyly, joint hypermobility, narrow face, lens disclocation, high arched palate, pectus excavatum / carinatum, AR + MV prolapse, arm-span

AR - signs of severity

1. collapsing pulse 2. wide pulse pressure 3. long decrescendo diastolic murmur 4. third heart sound 5. LV failure

AR - investigations

ECG - LVH CXR - LV dilatation, aortic root dilatation or aneurysm, valve calcification Echo - LV dimensions and function, doppler estimate of regurgitant jet, aortic root dimensions

AR - indications for surgery

1. exertional SOB 2. worsening LV function 3. progressive LV dilatation on serial echocardiograms (LV end-systolic dimension of >5.5cm)

Aortic stenosis - causes

degenerative rheumatic calcific bicuspid valve

Aortic stenosis - clinical signs of severity

1. plateau pulse 2. length, harshness, lateness of the peak of the systolic murmur 3. Aortic thrill 4. 4th heart sound 5. paradoxical splitting of the second heart sound (delayed LV ejection and aortic valve closure) 6. LV failure (late sign)

Aortic stenosis - investigations

ECG - LVH CXR - LVH, valve calcification Echo - AVA <1cm, gradient >40mmHg, velocity 4m/s

Aortic stenosis - indications for surgery

exertional symptoms critical obstruction even if asymptomatic

Life expectancy of a bioprosthetic valve

15 years

Tricuspid regurgitation - clinical signs

1. JVP - V-waves 2. RV heave 3. pansystolic murmur maximal at lower end of the sternum and on inspiration 4. multiple systolic clicks are assocaited with Ebstein anomaly 5. Pulsatile and tender liver, ascites and peripheral oedema

Tricuspid regurgitation - causes

1. functional (RV failure causing dilatation) 2. Rheumatic 3. IE (esp. IVDU) 4. Congenital - Ebstein's anomaly 5. RV papillary muscle infarction 6. Pacemaker or defibrillator lead 7. Trauma (steering wheel to sternum)

Tricuspid regurgitation - investigations

CXR - right ventricular enlargement ECHO - size of jet, and gradient

Pulmonary stenosis - causes

congenital carcinoid syndrome

Pulmonary stenosis - clinical signs

Signs of low LV cardiac output: - peripheral cyanosis, small volume pulse Signs of RV overload / failure: - RV heave, thrill over pulmonary area, hepatic congestion, S4 Severe = late peaking systolic murmur, S4 or right heart failure signs

What is Kussmaul's sign What is it a sign of?

Increased JVP with inspiration Constrictive pericarditis

Constrictive pericarditis clinical signs

Low BP, pulsus paradoxus Elevated JVP Apex beat is not palpable Distant heart sounds Hepatosplenomegaly, peripheral oedema

Constrictive pericarditis causes

radiation, tumour, post cardiac surgery, tuberculosis, connective tissue disease, chronic renal failure

Hypertrophic cardiomyopathy signs

1. pulse - sharp rising / jerky pulse 2. JVP - prominent a wave 3. double or triple impulse of the apex beat 4. Auscultation: late ejection systolic murmur at left sternal edge, pansystolic murmur at apex from mitral regurgitation 5. 4th heart sound 6. Dynamic manoeuvres - louder with valsalva and standing. Softer with squatting or isometric exercise.

HCM - investigations

ECG - LVH and lateral ST segment / t-wave changes - deep Q waves CXR - LV hump, absence of valve calcification ECHO - asymmetric hypertrophy, systolic anterior motion of the MV leaflet, LVOT gradient

VSD - clinical signs - disease associations

Harsh pansystolic murmur confined to left sternal edge Associated with trisomy

Patent ductus arteriosus - where does blood shunt to and from - clinical signs

from the aorta to the pulmonary artery Continuous murmur (often mistaken for AS with AR)

How do you differentiate Eisenmenger syndrome from tetralogy of fallot?

Eisenmenger has pulmonary hypertension