Cardiology Flashcards
What are clinical signs of aortic stenosis? (6)
Slow rising, low volume pulse
Narrow pulse pressure
Heaving apex beat
Thrill in aortic area
Ejection systolic murmur in aortic area
Radiation to carotids
What are features of the murmur in severe aortic stenosis? (6)
Soft and delayed/absent S2
Delayed ESM
S4 sound
Narrow pulse pressure
Systolic thrill and heaving apex
CCF
What are examination features of endocarditis ? (8)
Splinter haemorrhages
Oslers nodes (finger pulp)
Janeway lesions (palms)
Roth spots (retina)
Temperature
Splenomegaly
Haematuria
New murmur
What are complications of aortic stenosis? (3)
Endocarditis
LVSD
Conduction problems
What are differentials for aortic stenosis? (6)
HOCM
VSD
Aortic sclerosis: normal pulse character, no radiation
Aortic flow murmur: high output states - pregnancy or anaemia
Pulmonary stenosis
Supravalvular AS
What are causes of aortic stenosis? (3)
Congenital: bicuspid
Age: senile degeneration and calcification
Rheumatic: streptococcal
What are some associations of aortic stenosis? (2)
Coarctation and bicuspid aortic valve
Angiodysplasia
What are mortality rates associated with symptoms of Aortic stenosis?
Angina: 50% mortality at 5 years
Syncope: 50% at 3 years
Breathlessness: 50% at 2 years
What are some investigations and findings on them for aortic stenosis? (5)
Bloods: FBC, U&Es, LFTs
ECG: LVH, conduction defect
CXR: calcified valve, HF changes
Echo: mean gradient >40 Hg
Catheter: invasive transvalvular gradient and coronary angio
What is management for aortic stenosis?
Asymptomatic: good dental health, regular review with echo to assess gradient and LV function
Symptomatic: surgical valve replacement +/- CABG, balloon aortic valvuloplasty, TAVI
What is dukes criteria for endocarditis?
Major: typical organism on 2 blood cultures, echo vegetation, abscess or dehiscence
Minor: pyrexia, echo suggestive, prosthetic valve, embolic phenomena, vasculitic phenomena, atypical organism
Diagnose if 2 major, 1 major and 2 minor or 5 minor
What are signs of aortic regurgitation? (10)
Collapsing pulse
Wide pulse pressure
Apex beat hyperkinetic and displaced laterally
Thrill in aortic area
Early diastolic murmur at left lower sternal edge with patient sat forwards in expiration
Corrigans: visible neck pulsation
Quinckes: nail bed pulsation
De mussets: head nodding
Duroziezs: diastolic murmur proximal to femoral artery compression
Traubes: pistol shot sound over femoral artery
What are causes of aortic regurgitation? (13)
Congenital: bicuspid aortic valve, peri membranous VSD
Valve leaflet: endocarditis, rheumatic fever, pergolide, slimming agents
Aortic root: type A dissection, trauma, marfans, HTN, syphilis, ank spond, vasculitis
What are causes of a collapsing pulse? (6)
Aortic regurgitation
Pregnancy
Patent ductus arteriosus
Paget’s disease
Anaemia
Thyrotoxicosis
What are some investigations for aortic regurgitation? (4)
ECG: lateral t wave inversion (LV strain)
CXR: cardiomegaly, wide mediastinum, pulmonary oedema
Echo: LVEF, root size, jet width, dissection flap or vegetation
Cardiac catheterisation: grade severity aortogram and coronary patency
What are management steps for aortic regurgitation? (4)
ACE inhibitors / ARB reduce after load
Regular echo’s
Acute; Surgery for dissection, aortic root abscess, endocarditis
Chronic: surgery if symptomatic, pulse pressure >100, ECG changes, LV enlargement >5.5cm or EF <50%
What is an Austin flint murmur?
Mid diastolic, low pitch rumble murmur heard best at the apex with the patient leaning forward and breathing out
Due to regurgitant flow impeding mitral opening
What is prognosis for aortic regurgitation?
Asymptomatic with EF >50% - 1% mortality at 5 years
Symptomatic and 3 criteria met (PP >100, ECG changes, LV enlargement/ EF <50%) - 65% mortality at 3 years
What are clinical signs of mitral stenosis? (6)
Malar flush
Irregular pulse
Tapping apex
Left parasternal heave
Loud first heart sound, opening snap
Mid diastolic murmur at apex
What are features of haemodynamic significance in mitral stenosis? (3)
Pulmonary HTN: functional TR, right ventricular heave, loud p2
LV failure: pulmonary oedema
RVF: sacral and pedal oedema, raised JVP
What are causes of mitral stenosis? (5)
Congenital
Rheumatic (most common)
Senile degeneration
Endocarditis
RA/SLE
What are differentials of mitral stenosis murmur? (2)
Left atrial myxoma
Austin flint murmur
What are investigations of mitral stenosis? (3)
ECG: p mitrale, AF
CXR: enlarged left atrium, calcified valve, pulmonary oedema
Echo: valve area <1cm severe, cusp mobility, calcification, left atrial thrombus, RV failure
What is management of mitral stenosis? (4)
AF rate control and anticoagulation
Diuretics
Mitral valvuloplasty
Surgery: closed or open valvotomy, valve replacement
What is mortality of mitral stenosis?
Latent asymptomatic phase 15-20 years
NYHA >II - 50% mortality at 5 years
What causes valve disease in rheumatic fever?
Immunological cross reactivity between group a beta haemolytic strep (pyogenes) and valve tissue
What is duckett jones criteria for rheumatic fever?
Proven beta haemolytic strep - throat swab, rapid antigen detection test, ASOT or clinical scarlet fever
Plus 2 major and 2 minor
Major: chorea, erythema marginatum, subcutaneous nodules, polyarthritis, carditis
Minor: raised ESR, raised WCC, arthralgia, previous rheumatic fever, pyrexia, prolonged PR interval
What is treatment for rheumatic fever? (3)
Rest
High dose aspirin
Penicillin
What is prophylaxis for rheumatic fever?
Primary prevention: pen V or clinda for 10 days
Secondary prevention: pen V for 5-10 years
What are signs of mitral incompetence? (5)
Pulse: AF, small volume
Apex: displaced and volume loaded
Thrill at apex
Pan systolic murmur at apex radiating to axilla
Wide splitting of a2p2
What are causes of mitral incompetence? (10)
Congenital - cleft mitral valve with primum ASD
Endocarditis
Mitral prolapse
Rheumatic fever
Connective tissue disease
Fibrosis from pergolide
Functional MR from dilated cardiomyopathy
Calcification
Amyloid
Chord/ papilla rupture
What are investigations for mitral incompetence? (3)
ECG: p mitrale, AF, previous infarction
CXR: cardiomegaly, left atrial enlargement, pulmonary oedema
Echo: density of MR jet, LV dilation, reduced EF, prolapse, vegetations
What are treatments for mitral incompetence?
Anticoagulation for AF
Diuretics
Beta blocker
ACE inhibitors
Mitral clip - palliative
Surgical: repair or replacement
Who gets mitral prolapse? (5)
Young tall women
Connective tissue disease - marfans, EDS, pseudoxanthoma elasticum, SLE
HOCM
PKD
Muscular dystrophy
How does mitral prolapse present? (3)
Chest pain
Syncope
Palpitations
What does mitral prolapse sound like?
Mid systolic ejection click
Pan systolic murmur gets louder up to a2
Accentuated by valsalva
What are clinical signs of tricuspid incompetence ? (7)
Raised JVP with giant CV waves
Thrill left sternal edge
Pulsatile liver, Ascites, peripheral oedema
Pan systolic murmur loudest at left lower sternal edge in inspiration
Reverse split second heart sound
S3
If pulmonary HTN: RV heave and loud p2
What are causes of tricuspid incompetence? (5)
Ebsteins anomaly: atrialisation of right ventricle with TR
Endocarditis
Functional TR
Rheumatic fever
Carcinoid syndrome
What are investigations of tricuspid incompetence? (3)
ECG: p pulmonale and RVH
CXR: double right heart border from enlarged right atrium
Echo: TR jet, RV dilation
What is management of TR? (4)
Diuretics
Beta blockers
ACE inhibitors
Surgical: valve repair/annuloplasty
What are signs of pulmonary stenosis? (6)
Raised JVP with giant a waves
Left parasternal heave
Thrill in pulmonary area
Ejection systolic murmur in pulmonary area in inspiration
Widely split second heart sound
Right heart failure - Ascites, oedema
What are some associated syndromes with pulmonary stenosis? (2)
Tetralogy of fallot: PS, VSD, overriding aorta, RVH - will have sternotomy scar
Noonans syndrome: PS, male, wide forehead, low set ears, wideset nipples, webbed neck, small chin
What are investigations of tricuspid incompetence? (3)
ECG; p pulmonale, RVH, RBBB
CXR: oligaemic lung fields, large right atrium
Echo: pressure gradient for severity, RV function
What is the management of pulmonary stenosis? (3)
Pulmonary valvotomy if gradient >70 or RV failure
Percutaneous pulmonary valve implantation
Surgical repair/replacement
How does carcinoid syndrome link to heart valve issues?
Gut primary with liver mets secrete 5-HT into blood stream
Diarrhoea, wheeze and flushing
Secreted mediators cause right sided valve fibrosis - TR or PS
Treatment is octreotide or surgical resection
What are signs of prosthetic heart valves? (3)
Audible prosthetic clicks
Scars
Signs of anticoagulation - bruising/anaemia
What cardiac scars might you see and what do they mean? (5)
Midline sternotomy: CABG, AVR, MVR
Lateral Thoracotomy: MVR, mitral valvotomy, coarctation repair, BT shunt
Subclavicular: PPM, ICD
Anticubital fossa/ wrist: angiography
Saphenous vein harvest scar
What are late complications of heart valve replacements? (6)
Thromboembolism despite warfarin
Bleeding on warfarin
Bioprosthetic dysfunction and LVF
Haemolysis
Endocarditis
AF especially mitral
What are clinical signs of implantable cardiac devices? (4)
Incisional scar in infraclavicular position
Palpable pacemaker
Signs of heart failure - JVP, crackles, oedema
Medic alert bracelet
What are primary prevention indications for an ICD? (3)
MI > 4 weeks ago with LVEF <35% and non sustained VT with positive EP
MI > 4 weeks ago with LVEF <30% and QRS >120 ms
Familial condition with high risk sudden cardiac death: LQTS, ARVD, brugada, HCM, complex congenital heart disease
What are secondary prevention indications for an ICD? (3)
Cardiac arrest due to VT or VF
Haemodynamically compromising VT
VT with LVEF <35%
What are criteria for CRT pacemaker? (3)
LVEF <35%
NYHA II-IV on optimal medical therapy
Sinus rhythm and QRS >150 or LBBB >120
What are features of constrictive pericarditis? (5)
Right heart failure
Kussmauls sign: paradoxical increase in JVP on inspiration
Pulsus paradoxus: >10mmhg drop in systolic pressure in inspiration
Pericardial knock
Congestive hepatomegaly
What are causes of constrictive pericarditis? (6)
TB
Trauma or surgery
Post MI
Tumour
Radiotherapy
Connective tissue disease
What are investigations for constrictive pericarditis? (4)
CXR: pericardial calcification, old TB, sternotomy wires
Echo: high signal from pericardium, septal bounce
Cardiac catheterisation - pressures
CT: thickened pericardium
What is the pathophysiology of constrictive pericarditis?
Thickened fibrous capsule reduces ventricular filling and insulates heart from intrathoracic pressure changes leading to ventricular interdependence- filling of one ventricle reduces size and filling of the other
What is treatment for constrictive pericarditis? (3)
Diuretics
Fluid restriction
Pericardial stripping
What are signs of ASD? (6)
Raised JVP
Pulmonary area thrill
Fixed split second heart sounds that do not changed with respiration
Pulmonary ESM and mid diastolic flow murmur
Pulmonary HTN: RV heave and loud P2
Eisenmengers: cyanosis and clubbing, right to left shunt
What are types of ASD? (2)
Primum: associated with AVSD and cleft mitral valve in Down’s syndrome
Secundum: commonest
What are complications of ASD? (3)
Paradoxical embolus
Atrial arrhythmias
RV dilatation
What are investigations of ASD? (4)
ECG: RBBB, LAD (primum), RAD (secundum), AF
CXR: small aortic knuckle, pulmonary plethora, double heart border from enlarged RA
Echo: site, size, shunt calculation
Right heart catheter: shunt calculation
What are the indications for closure of ASD? (3)
paradoxical embolism
breathlessness
Significant shunt with RV dilatation
What are contraindications for closure of ASD? (2)
Severe pulmonary HTN
Eisenmengers syndrome
How can an ASD be closed? (2)
Percutaneous: secundum only
Surgical patch repair
What are signs of VSD? (2)
Thrill at left lower sternal edge
Systolic murmur at left sternal edge with no radiation
What other lesions can be associated with a VSD? (4)
AR
PDA
Tetralogy of fallot
Coarctation of aorta
What is tetralogy of fallot? (4)
ventricular septal defect
overriding aorta
pulmonary stenosis
right ventricular hypertrophy
What are features of coarctation of aorta? (6)
HTN in upper limbs
Prominent upper limb pulses
Weak pulses in lower limbs
Radiofemoral delay
Heaving pressure loaded apex
Continuous murmur radiating to back, loud a2
May be other murmurs associated from other lesions
What are causes of VSD? (2)
Congenital
Acquired: traumatic, post op, post MI
What are investigations of VSD? (4)
ECG: conduction defect, BBB
CXR: pulmonary plethora
Echo: site, size, shunt calculation
Cardiac catheterisation: consideration of closure
What are management options for VSD? (2)
Surgical: pericardial patch
Percutaneous amplatzer device
What is a bhalock taussig shunt?
Partially corrects fallots tetralogy by anastamosing the subclavian artery to the pulmonary artery
Causes absent radial pulse and scar
What are causes of an absent radial pulse? (6)
Embolism
Aortic dissection
Trauma eg radial artery sheath
Atherosclerosis
Coarctation
Takayasus arteritis
What is coarctation of aorta?
Congenital narrowing of aortic arch usually distal to left subclavian artery
What are some associations of coarctation of aorta? (5)
VSD
Bicuspid aortic valve
PDA
Turner’s syndrome
Berry aneurysms
What are investigations of coarctation of aorta? (2)
ECG: LVH and RBBB
CXR: rib notching, double aortic knuckle - post stenotic dilatation
What are management options for coarctation of aorta? (4)
Percutaneous endovascular aortic repair
Surgical: Dacron patch aortoplasty
Long term anti hypertensive therapy
Surveillance with MRA for aneurysms and recoarctation
What is PDA?
Continuity between aorta and pulmonary trunk with left to right shunt
What are risk factors for PDA? (4)
Rubella during pregnancy
Prematurity
FH congenital heart disease
Smoking during pregnancy
What are signs of PDA? (4)
Collapsing pulse
Thrill second left intercostal space
Thrusting apex
Loud continuous machinery murmur below left clavicle, loudest in systole
What are complications of PDA? (2)
Eiesenmengers syndrome
Endocarditis
What is management of PDA?
Closure surgically or percutaneously
What are signs of hypertrophic cardiomyopathy? (6)
Jerky pulse character
Double apical impulse
Thrill at left lower sternal edge
ESM at left lower sternal edge radiates throughout precordium accentuated by valsalva
4th heart sound
Maybe be associated MVP
Which conditions are associated with hypertrophic cardiomyopathy ? (2)
Friedreichs ataxia
Myotonic dystrophy
What investigations should be done for hypertrophic cardiomyopathy? (6)
ECG: LVH with strain
CXR: normal
Echo: asymmetrical septal hypertrophy and systolic anterior motion of mitral leaflet across LVOT, LVOT gradient
Cardiac MR: apical HCM
Cardiac catheterisation: gradient accentuated by ventricular ectopic or pharmacological stress
Genetic testing: sarcomeric protein mutation
What is the management for hypertrophic cardiomyopathy? (5)
Asymptomatic: avoid strenuous exercise, dehydration and vasodilators
Symptomatic and LVOT gradient >30: beta blockers, PPM, alcohol septal ablation, surgical myomectomy
Rhythm disturbance/high risk SCD: ICD
Refractory: cardiac transplant
Genetic counselling of first degree relatives (autosomal dominant)
What are poor prognosis factors in hypertrophic cardiomyopathy? (4)
Young age at diagnosis
Syncope
Family history sudden death
Septal thickness >3cm
What are features of severity in MR? (4)
Larger left ventricle - displaced heaving apex
S3 sound
AF
LV failure
How do you accentuate an AR murmur?
Sit patient forwards
Auscultate with breath held at end of inspiration
Early diastolic high pitched murmur at left sternal edge
What are signs of severity in AR? (6)
Wide pulse pressure
Soft second heart sound
Duration of murmur
Presence of 3rd heart sound
Austin flint murmur
LV failure
How do you differentiate aortic stenosis from aortic sclerosis?
Sclerosis: pulse normal volume, apex not shifted, murmur localised
What is a 3rd heart sound?
Ventricular gallop
during passive left ventricular filling when blood strikes a compliant LV
Sign of systolic heart failure
What is s4 sound?
atrial gallop results from the contraction of the atria pushing blood into a stiff or hypertrophic ventricle
Sign of diastolic failure
How to differentiate between s3 and split s2?
S3 is a low-pitched sound; disappears when diaphragm used. Appreciated at apex
S2 is high pitched. Disappears when bell used. Appreciated in pulmonary region
What is the inheritance of Marfans?
Autosomal dominant mutation of fibrillin gene which affects collagen formation
What are cardiac complications of marfans? (4)
Aortic root dilation
Aortic dissection
Aortic regurgitation
Mitral valve replacement
What are indications for aortic root replacement in marfans? (3)
Dilation of 50mm at aortic root
>45mm if family history of dissection
If expanding >3mm per year
What are phenotypic features of noonans? (9)
Wide spaced nipples
Pectus excavatum
Cubitus valgus
Webbed neck
Short stature
Ptosis
Strabismus
Widely spaced eyes
Low set ears
Differentials for pulmonary stenosis (4)
Aortic stenosis
Infra or supra valvular lesions
ASD
VSD
Findings of significant pulmonary stenosis (5)
Large A waves JVP
RV heave
PSM murmur from functional TR
Right heart failure
Widely split second heart sound with quiet P2
Cardiac issues in noonans (3)
Pulmonary stenosis (most common)
HCM
Septal defects
What numbers signify severity in pulmonary stenosis? (3)
Gradient >64mmHg
Velocity >4m/sec
Valve area <1cm2
What is the name of the finding of AS murmur radiating across whole chest into apex?
Gallavardin phenomenon
What are causes of restrictive cardiomyopathy? (7)
Primary: loefflers endocarditis
Secondary: amyloid, sarcoidosis, iron overload, carcinoid, radiotherapy, scleroderma
What are causes of constrictive pericarditis? (6)
Viral
TB
Dresslers
Post surgery
Connective tissue disease
Uraemia
What echo finding is suggestive of restrictive cardiomyopathy? (4)
Diastolic dysfunction
biatrial dilatation
hypertrophied ventricles with decreased compliance
normal to depressed systolic function
