Cardiology Flashcards
Common indications for AVR
1) Severe symptomatic aortic stenosis
2) Aortic regurgitation
3) Infective endocarditis
Advantages / disadvantages of metallic heart valve
More durable
Requires lifelong anticoagulation
Clinical signs of severe AS
Slow rising, low volume pulse
Narrow pulse pressure
Quiet/muted S2
Long murmur duration
Left ventricular heave
S4 if there is significant LVH
Echo information relevant in AS
AV area
AV gradient
AV velocity
LV function & size (?hypertrophy)
DDx ESM
Aortic stenosis
Aortic sclerosis
Hypertrophic Cardiomyopathy with septal hypertrophy
Pulmonary Stenosis
How to clinically differentiate aortic stenosis and pulmonary stenosis
Pulmonary stenosis loudest over pulmonary area, expect it in younger patient population, concurrent RV heave, louder on inspiration
Management of severe symptomatic AS
Referral for valvular intervention - surgical vs. TAVI - needs discussion in JCC
Medical:
- Beta blockers
- Avoid vasodilators as increase gradient across valve (nitrates, ACEi, sildenafil)
Valvular options in AS
Metallic surgical - more durable, but needs lifelong anticoagulation
Bioprothetic surgical - no anticoag, but not as durable
TAVI - patients not fit for surgical intervention
Pulse in aortic regurgitation
Collapsing, with wide pulse pressure
Murmur in AR
Holodiastolic murmur
Apex beat in AR
Thrusting and displaced
Long term management of metallic heart valves
Anticoagulation - typically warfarin - typically INR 3-4
Serial (yearly) TTEs & valve clinic follow up
Splitting of S2 with ASD
Would not expect variation with respiration - ASD results in equalisation of pressures
Pregnancy in congential heart disease patients
Needs TTE prior to pregnancy
Should meeting specialist obstetric cardiologists to discuss risk of preganancy
Stop any potentially teratogenic medications e.g. warfarin
If becomes pregnant would need to be closely followed and assessed
What to look for in pulmonary HTN in context of congenital heart disease
Look for any unknown shunts
Unleft, could develop Eisenmenger’s syndrome, resulting in central cyanosis
Causes of PV disease
Congenital or acquired
Rubella, Noonan’s, Down’s
3 things to consider with suspected congenital heart disease
1) Cyanotic or Acyanotic
2) Any previous surgical intervention
3) Associated conditions - Downs / Turners / Noonan’s
DDx Mitral Regurgitation
Tricuspid Regurg
VSD
Mitral valve prolapse
Clinical findings in keeping with severe MR
Pulmonary HTN - Raised JVP, Loud P2, R ventricular heave, thrusting and displaced apex
Questions to ask in Hx of someone with MR
Exercise tolerance
Dyspnoea
Fluid overload
Also ask about chest pain, give ischaemia is one of aetiological causes of MR
Ix suspected MR
Bedside:
Observations
12 lead ECG
Urinalysis - haematuria/proteinuria
Fundoscopy ?roth spots
Echocardiogram - LVEF, prolapse, vegetations suggestive of IE
Bloods - FBC, CRP, Renal, U&Es, ESR
CXR ?cardiomegaly
JVP in MR
JVP is a reflection of R atrial pressures
Mx of patient with clinical signs of MR
Refer to Cardiology with up to date echocardiogram
Would need to be discussed in JCC
Would be worth to consider working this patient up for surgery, including spirometry and carotid dopplers
Indications for mitral valve replacement
Symptomatic MR with evidence of pulmonary HTN / fluid overload
Asymptomatic MR with progressively declining LVEF or increasing LV dilatation
Normal position apex beat
5th ICS mid-clavicular line
Causes of MR
Degenerative
- age-related
- Mitral valve prolapse related (may be related to underlying CTD)
Acquired
- Ischaemia - related to papillary muscle rupture
- Infective endocarditis
What is S3?
low-pitched sound that doctors can hear when blood rushes rapidly from the heart’s atrium into the ventricle
Indicative of heart failure
Value of pathology associated with Noonan syndrome
Pulmonary stenosis
Phenotypic features of Noonan syndrome
Cubitus valgus (Forearm angled away from the body)
Broad forehead with deep set eyes
Webbed neck
Widely spaced nipples
Short stature
Other features include mild learning difficulty and delayed motor development
DDx Pulmonary Stenosis
PS can either be valvular, of supra/infra-valvular
Aortic Stenosis
ASD/VSD
Pulse pressure and pulse in AS
Narrow and slow rising
Clinical symptoms of pulmonary stenosis
Effort, intolerance
Breathlessness on exertion
Signs of right sided heart failure
Presyncope and syncope
Signs of severe pulmonary stenosis
Large A waves in the JVP (raised RA pressure)
Right ventricular heave due to hypertrophy
Pansystolic murmur from functional tricuspid regurgitation
Clinical signs of right-sided heart failure
Widely split second heart sound with quiet pulmonary component
Cardiac complications associated with Noonan syndrome
Pulmonary stenosis
Hypertrophic cardiomyopathy
Septal lesions
Eye signs in Noonan syndrome
Proptosis
Ptosis
Strabismus (abnormal eye alignment)
Echocardiographic features of severe pulmonary stenosis
Gradient >64mmHg
Velocity >4m/s
Valve area <1cm2
Signs of RV failure / Raised RV systolic pressures
Assess if supra / valvular / infra
Genetics of Noonan syndrome
Autosomal dominant
At least eight different gene mutations
Congenital heart disease is associated with an ejection systolic murmur
congenital aoritc valve disease resulting in bioprosthetic AVR
congential Pulmonary stenosis resulting in bioprosthetic pulmonary valve replacement
ToF
Transposition of great vessels
Components of the tetralogy of fallot
VSD
Overriding Aorta
Pulmonary stenosis
RVH
Confirming diagnosis with suspected congenital heart disease
Take a full Hx
Review previous letters, inc. operation notes
12 lead ECG
CXR
Echocardiogram
Cardiac MRI
May need to be considered for cardiac catheterisation if there are abnormalities on MRI
Long term follow-up for patients with congenital heart disease
Review in specialist congenital heart disease clinic
Yearly echocardiograms
Advice on importance of good oral health, given increased risk of IE (Abx prophylaxis is no longer recommended)
Causes of pulmonary stenosis
Congenital, pulmonary stenosis
Associated with syndromes -noonan, Williams,ToF
Secondary to infection (IE / Rheumatic fever)
Carcinoid syndrome
Management of Pulmonary valve disease
Monitor
Treat underlying causes, particularly if infection
Consider balloon valvuloplasty
If concurrent pulmonary regurgitation, consider PV replacement
When would you expect symptoms with pulmonary stenosis
Usually only when severe
Mild-Moderate generally haemodyanmically tolerated
Gradient of mild and moderate pulmonary stenosis
Mild <36mmHg - only need TTE every 5 years
Moderate 36-64
Vascular pathology associated with Ehlers Danlos syndrome
Mitral valve prolapse, resulting in mitral regurgitation
Conditions associated with mitral valve prolapse
Marfan syndrome
Ehlers Danlos syndrome
Osteogenesis imperfecta
Polycystic kidney disease
Eye complications associated with Ehlers Danlos
Lens dislocation
Vascular complications associted with Ehlers Danlos
Aortic dilatation
Aortic aneurysm
Aortic dissection
Also concerned about carotid artery involvement
Raynaud’s disease
Complications of mitral valve prolapse
Infective endocarditis
Thromboembolic events
Cerebrovascular accidents
The need for cardiac surgery
Sudden cardiac death
Types of mitral valve prolapse
Primary -
myxomatous degeneration
Secondary - associated with a connective tissue disease E.g. Marfan’s syndrome
Clinical signs of mitral valve, prolapse
Systolic click
Mid to late systolic murmur
High-risk patients with mitral valve prolapse
Moderate to severe
mitral regurgitation
Reduced left ventricular function
Increased end-systolic diameter
LA enlargement
Age >50
Valve thickening >5mm
Flail leaflet
Ix to perform prior to MV operation
Cardiac catheterisation
TOE ?repair
Interventions on mitral valve
Surgery
- Repair - better prognosis
- Replacement
Percutaneous
- Mitraclip - those not amenable to surgery but need favourable anatomy
PDA murmur
Continuous machinery
Typically, over pulmonary area and louder during systole
PDA concerning echocardiographic features
Raised pulmonary pressures
Dilated pulmonary arteries
Dilated RV and tricuspid regurgitation
Left ventricular dysfunction
Accentuating features in PDA
Louder on expiration
Radiation to back in particular left scapula
Pulse finding in severe PDA
Collapsing, pulse
Why are right-sided murmurs louder on inspiration?
Inspiration increases venous return, therefore resulting in increased flow across the valves and accentuation of murmurs
What is a patent ductus arteriosus?
Connection between the proximal left, pulmonary artery and the descending aorta
Typically, closes at birth, forming the ligamentum arteriosum
When is PDA closure recommended?
When associated with left ventricular volume overload or right ventricular pressure overload
Next steps in PDA, when echocardiogram demonstrates raised, pulmonary pressures
Consider cardiac catheterisation to assess pulmonary pressure
Clinical findings Eisenmengers syndrome
Clubbing
Central cyanosis
Widely split S2
RV heave
No underlying murmur when L to R shunt has reversed
Causes eisenmengers
Reversal of L to R shunt
Commonly VSD
ASD and PDA
Indications for closure of VSD
L to R shunt
Need for cardiac surgery for other reason
Infective endocarditis
Acute VSD 2o infarction
Complications of Eisenmengers
RV failure
Paradoxical embolism
IE
Hypoxaemia
Cardiac causes for clubbing
Cyanotic congenital heart disease
Subacute IE
Syndromes associated with VSD
Downs
Edward’s
Di George
Medical management of pulmonary htn
Endothelin antagonists - Bosentan
PDE5i - Sildenafil
Prostanoid infusion
LP findings CIDP or GBS
Expect a raised protein, but normal cell count
Acute Mx GBS
A to E approach
Monitor serial FVCs and escalate as necessary
Consider ABG if FVC < 1.5
Severe disease consider plasma exchange or IVIG
Chronic management of CIDP
MDT approach
Neuro - neuropathic analogesia and disease modifying agents - plasma ex, IVIG, steroids or immunosuppressants
OT PT orthotics
What is pseudoathetosis indicative of?
Sensory ataxia
What should you think about with a mixed asymmetric polyneuropathy?
Think immune
Acute - GBS
Chronic - CIDP
Complications associated with ToF surgery?
Pulmonary regurgitation
Arrhythmia
Endocarditis
Polycythaemia
Coagulopathy
Arrhythmias
How can you keep PDA open in cyanotic congenital heart disease?
Prostaglandin infusion
Common complication following surgery for ToF
Pulmonary regurgitation
Shunt used to connect arterial with pulmonary circulation in ToF
Blalock-Taussig
Associated with a weaker L radial pulse
Common causes of cyanotic heart disease?
ToF
TGA
Pulmonary stenosis / Pulmonary atresia
Tricuspid atresia
Ebsteins
Eisenmengers
Causes of acyanoric congenital heart disease
Asd
Uncomplicated vsd
Pda
Coarctation
Aortic stenosis
Echo findings of diastolic dysfunction - what to think about
Hx of HTN
?concurrent valvular lesions
Rule out constrictive pericarditis
How to determine constrictive pericarditis
CXR - calcified pericardium
Echo - thickened pericardium
Cardiac MRI
Consider L & R heart catheterisation
Causes of constrictive pericarditis
Viral or bacterial pericarditis
Recurrent pericarditis
Post-cardiac surgery
Post-TB
Post-Radiation
Causes of restrictive cardiomyopathy
Loefflers - eosinophilic infiltration
Systemic conditions - sarcoidosis, scleroderma, haemochromatosis, amyloidosis
Malignancy
Radiation
Treatment of constrictive pericarditis
Pericardectomy
Treatment of restrictive cardiomyopathy
Treat underlying cause
Treat HF symptoms - diuretics
In severe cases, consider cardiac transplantation
Causes of diastolic dysfunction
HTN
Valvular conditions
Subendocardial fibrosis
Constrictive pericarditis
Restrictive cardiomyopathy
CHA2DS2-VASc
CHF
HTN (65-74 =1, >75 = 2)
Age
Diabetes
Stroke (2 points)
Sex
Vascular disease
New bleeding risk score in AF
ORBIT-AF
MR causes
Primary
- MV prolapse
- MV flail leaflet
Secondary
- Dilated cardiomyopathy
- Ischaemic cardiomyopathy
- Infective endocarditis
Surgical indications in patients with asymptomatic primary MR
Reduced LVEF (<50%)
LVESD >45mm
AF
PASP >50mmHg
Indications for anticoagulation with MV disease
Concurrent AF
Previous emboli
How is IE diagnosed
Dukes Criteria
- 2 major & 5 minor criteria
- Diagnosis is 2 major criteria or 1 major + 3 minor or all 5 minor
Major
Blood cultures +ve (2 positive)
Echocardiogram - valvular vegetations / abscesses
Minor:
Fever
IVDU / Structural heart disease
Micro evidence
Immune phenomena - Osler’s nodes
vascular phenomena
Common cause of mixed MV disease
Rheumatic fever
Complication of mitral stenosis
Can result in raised pulmonary pressure, resulting in R sided dysfunction and TR
Causes of Aortic Stenosis
- Age-related calcific degeneration
- Bicuspid AV
- Rheumatic heart disease
- Fabry’s
- SLE
Chronic causes of AR
CTD - Marfans / Ehlers-Danlos
HTN
Osteogenesis imperfecta
Ank Spond
GCA
SLE
Acute causes of AR
Infective Endocarditis
Aortic Dissection
Trauma
Signs of AR
De-Mussets - head nodding
Quinkes - Nail bed pulsation
Mullers - Uvula pulsation
What tests should be performed in asympomtic severe disease or low flow AS?
Exercise testing - increases output therefore can better assess gradients
Why is TAVI rarely used in AR?
Due to concurrent aortic root dilatation
Main things to check on bloods in palpitations
Electrolytes
Thyroid function