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PACES > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Common indications for AVR

A

1) Severe symptomatic aortic stenosis
2) Aortic regurgitation
3) Infective endocarditis

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2
Q

Advantages / disadvantages of metallic heart valve

A

More durable
Requires lifelong anticoagulation

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3
Q

Clinical signs of severe AS

A

Slow rising, low volume pulse
Narrow pulse pressure
Quiet/muted S2
Long murmur duration
Left ventricular heave
S4 if there is significant LVH

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4
Q

Echo information relevant in AS

A

AV area
AV gradient
AV velocity
LV function & size (?hypertrophy)

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5
Q

DDx ESM

A

Aortic stenosis
Aortic sclerosis
Hypertrophic Cardiomyopathy with septal hypertrophy
Pulmonary Stenosis

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6
Q

How to clinically differentiate aortic stenosis and pulmonary stenosis

A

Pulmonary stenosis loudest over pulmonary area, expect it in younger patient population, concurrent RV heave, louder on inspiration

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7
Q

Management of severe symptomatic AS

A

Referral for valvular intervention - surgical vs. TAVI - needs discussion in JCC

Medical:
- Beta blockers
- Avoid vasodilators as increase gradient across valve (nitrates, ACEi, sildenafil)

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8
Q

Valvular options in AS

A

Metallic surgical - more durable, but needs lifelong anticoagulation

Bioprothetic surgical - no anticoag, but not as durable

TAVI - patients not fit for surgical intervention

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9
Q

Pulse in aortic regurgitation

A

Collapsing, with wide pulse pressure

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10
Q

Murmur in AR

A

Holodiastolic murmur

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11
Q

Apex beat in AR

A

Thrusting and displaced

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12
Q

Long term management of metallic heart valves

A

Anticoagulation - typically warfarin - typically INR 3-4

Serial (yearly) TTEs & valve clinic follow up

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13
Q

Splitting of S2 with ASD

A

Would not expect variation with respiration - ASD results in equalisation of pressures

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14
Q

Pregnancy in congential heart disease patients

A

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

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15
Q

What to look for in pulmonary HTN in context of congenital heart disease

A

Look for any unknown shunts

Unleft, could develop Eisenmenger’s syndrome, resulting in central cyanosis

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16
Q

Causes of PV disease

A

Congenital or acquired
Rubella, Noonan’s, Down’s

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17
Q

3 things to consider with suspected congenital heart disease

A

1) Cyanotic or Acyanotic
2) Any previous surgical intervention
3) Associated conditions - Downs / Turners / Noonan’s

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18
Q

DDx Mitral Regurgitation

A

Tricuspid Regurg
VSD
Mitral valve prolapse

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19
Q

Clinical findings in keeping with severe MR

A

Pulmonary HTN - Raised JVP, Loud P2, R ventricular heave, thrusting and displaced apex

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20
Q

Questions to ask in Hx of someone with MR

A

Exercise tolerance
Dyspnoea
Fluid overload

Also ask about chest pain, give ischaemia is one of aetiological causes of MR

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21
Q

Ix suspected MR

A

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

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22
Q

JVP in MR

A

JVP is a reflection of R atrial pressures

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23
Q

Mx of patient with clinical signs of MR

A

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

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24
Q

Indications for mitral valve replacement

A

Symptomatic MR with evidence of pulmonary HTN / fluid overload

Asymptomatic MR with progressively declining LVEF or increasing LV dilatation

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25
Q

Normal position apex beat

A

5th ICS mid-clavicular line

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26
Q

Causes of MR

A

Degenerative
- age-related
- Mitral valve prolapse related (may be related to underlying CTD)

Acquired
- Ischaemia - related to papillary muscle rupture
- Infective endocarditis

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27
Q

What is S3?

A

low-pitched sound that doctors can hear when blood rushes rapidly from the heart’s atrium into the ventricle

Indicative of heart failure

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28
Q

Value of pathology associated with Noonan syndrome

A

Pulmonary stenosis

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29
Q

Phenotypic features of Noonan syndrome

A

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

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30
Q

DDx Pulmonary Stenosis

A

PS can either be valvular, of supra/infra-valvular
Aortic Stenosis
ASD/VSD

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31
Q

Pulse pressure and pulse in AS

A

Narrow and slow rising

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32
Q

Clinical symptoms of pulmonary stenosis

A

Effort, intolerance
Breathlessness on exertion
Signs of right sided heart failure
Presyncope and syncope

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33
Q

Signs of severe pulmonary stenosis

A

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

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34
Q

Cardiac complications associated with Noonan syndrome

A

Pulmonary stenosis
Hypertrophic cardiomyopathy
Septal lesions

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35
Q

Eye signs in Noonan syndrome

A

Proptosis
Ptosis
Strabismus (abnormal eye alignment)

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36
Q

Echocardiographic features of severe pulmonary stenosis

A

Gradient >64mmHg
Velocity >4m/s
Valve area <1cm2

Signs of RV failure / Raised RV systolic pressures
Assess if supra / valvular / infra

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37
Q

Genetics of Noonan syndrome

A

Autosomal dominant
At least eight different gene mutations

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38
Q

Congenital heart disease is associated with an ejection systolic murmur

A

congenital aoritc valve disease resulting in bioprosthetic AVR

congential Pulmonary stenosis resulting in bioprosthetic pulmonary valve replacement

ToF

Transposition of great vessels

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39
Q

Components of the tetralogy of fallot

A

VSD
Overriding Aorta
Pulmonary stenosis
RVH

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40
Q

Confirming diagnosis with suspected congenital heart disease

A

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

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41
Q

Long term follow-up for patients with congenital heart disease

A

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)

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42
Q

Causes of pulmonary stenosis

A

Congenital, pulmonary stenosis
Associated with syndromes -noonan, Williams,ToF
Secondary to infection (IE / Rheumatic fever)
Carcinoid syndrome

43
Q

Management of Pulmonary valve disease

A

Monitor
Treat underlying causes, particularly if infection
Consider balloon valvuloplasty
If concurrent pulmonary regurgitation, consider PV replacement

44
Q

When would you expect symptoms with pulmonary stenosis

A

Usually only when severe

Mild-Moderate generally haemodyanmically tolerated

45
Q

Gradient of mild and moderate pulmonary stenosis

A

Mild <36mmHg - only need TTE every 5 years
Moderate 36-64

46
Q

Vascular pathology associated with Ehlers Danlos syndrome

A

Mitral valve prolapse, resulting in mitral regurgitation

47
Q

Conditions associated with mitral valve prolapse

A

Marfan syndrome
Ehlers Danlos syndrome
Osteogenesis imperfecta
Polycystic kidney disease

48
Q

Eye complications associated with Ehlers Danlos

A

Lens dislocation

49
Q

Vascular complications associted with Ehlers Danlos

A

Aortic dilatation
Aortic aneurysm
Aortic dissection
Also concerned about carotid artery involvement
Raynaud’s disease

50
Q

Complications of mitral valve prolapse

A

Infective endocarditis
Thromboembolic events

Cerebrovascular accidents
The need for cardiac surgery
Sudden cardiac death

51
Q

Types of mitral valve prolapse

A

Primary -
myxomatous degeneration

Secondary - associated with a connective tissue disease E.g. Marfan’s syndrome

52
Q

Clinical signs of mitral valve, prolapse

A

Systolic click
Mid to late systolic murmur

53
Q

High-risk patients with mitral valve prolapse

A

Moderate to severe
mitral regurgitation
Reduced left ventricular function
Increased end-systolic diameter
LA enlargement
Age >50
Valve thickening >5mm
Flail leaflet

54
Q

Ix to perform prior to MV operation

A

Cardiac catheterisation
TOE ?repair

55
Q

Interventions on mitral valve

A

Surgery
- Repair - better prognosis
- Replacement

Percutaneous
- Mitraclip - those not amenable to surgery but need favourable anatomy

56
Q

PDA murmur

A

Continuous machinery
Typically, over pulmonary area and louder during systole

57
Q

PDA concerning echocardiographic features

A

Raised pulmonary pressures
Dilated pulmonary arteries
Dilated RV and tricuspid regurgitation
Left ventricular dysfunction

58
Q

Accentuating features in PDA

A

Louder on expiration
Radiation to back in particular left scapula

59
Q

Pulse finding in severe PDA

A

Collapsing, pulse

60
Q

Why are right-sided murmurs louder on inspiration?

A

Inspiration increases venous return, therefore resulting in increased flow across the valves and accentuation of murmurs

61
Q

What is a patent ductus arteriosus?

A

Connection between the proximal left, pulmonary artery and the descending aorta

Typically, closes at birth, forming the ligamentum arteriosum

62
Q

When is PDA closure recommended?

A

When associated with left ventricular volume overload or right ventricular pressure overload

63
Q

Next steps in PDA, when echocardiogram demonstrates raised, pulmonary pressures

A

Consider cardiac catheterisation to assess pulmonary pressure

64
Q

Clinical findings Eisenmengers syndrome

A

Clubbing
Central cyanosis
Widely split S2
RV heave
No underlying murmur when L to R shunt has reversed

65
Q

Causes eisenmengers

A

Reversal of L to R shunt
Commonly VSD
ASD and PDA

66
Q

Indications for closure of VSD

A

L to R shunt
Need for cardiac surgery for other reason
Infective endocarditis
Acute VSD 2o infarction

67
Q

Complications of Eisenmengers

A

RV failure
Paradoxical embolism
IE
Hypoxaemia

68
Q

Cardiac causes for clubbing

A

Cyanotic congenital heart disease
Subacute IE

69
Q

Syndromes associated with VSD

A

Downs
Edward’s
Di George

70
Q

Medical management of pulmonary htn

A

Endothelin antagonists - Bosentan
PDE5i - Sildenafil
Prostanoid infusion

71
Q

LP findings CIDP or GBS

A

Expect a raised protein, but normal cell count

72
Q

Acute Mx GBS

A

A to E approach
Monitor serial FVCs and escalate as necessary
Consider ABG if FVC < 1.5
Severe disease consider plasma exchange or IVIG

73
Q

Chronic management of CIDP

A

MDT approach

Neuro - neuropathic analogesia and disease modifying agents - plasma ex, IVIG, steroids or immunosuppressants

OT PT orthotics

74
Q

What is pseudoathetosis indicative of?

A

Sensory ataxia

75
Q

What should you think about with a mixed asymmetric polyneuropathy?

A

Think immune

Acute - GBS
Chronic - CIDP

76
Q

Complications associated with ToF surgery?

A

Pulmonary regurgitation
Arrhythmia
Endocarditis
Polycythaemia
Coagulopathy
Arrhythmias

77
Q

How can you keep PDA open in cyanotic congenital heart disease?

A

Prostaglandin infusion

78
Q

Common complication following surgery for ToF

A

Pulmonary regurgitation

79
Q

Shunt used to connect arterial with pulmonary circulation in ToF

A

Blalock-Taussig
Associated with a weaker L radial pulse

80
Q

Common causes of cyanotic heart disease?

A

ToF
TGA
Pulmonary stenosis / Pulmonary atresia
Tricuspid atresia
Ebsteins
Eisenmengers

81
Q

Causes of acyanoric congenital heart disease

A

Asd
Uncomplicated vsd
Pda
Coarctation
Aortic stenosis

82
Q

Echo findings of diastolic dysfunction - what to think about

A

Hx of HTN
?concurrent valvular lesions
Rule out constrictive pericarditis

83
Q

How to determine constrictive pericarditis

A

CXR - calcified pericardium
Echo - thickened pericardium
Cardiac MRI
Consider L & R heart catheterisation

84
Q

Causes of constrictive pericarditis

A

Viral or bacterial pericarditis
Recurrent pericarditis
Post-cardiac surgery
Post-TB
Post-Radiation

85
Q

Causes of restrictive cardiomyopathy

A

Loefflers - eosinophilic infiltration
Systemic conditions - sarcoidosis, scleroderma, haemochromatosis, amyloidosis
Malignancy
Radiation

86
Q

Treatment of constrictive pericarditis

A

Pericardectomy

87
Q

Treatment of restrictive cardiomyopathy

A

Treat underlying cause
Treat HF symptoms - diuretics
In severe cases, consider cardiac transplantation

88
Q

Causes of diastolic dysfunction

A

HTN
Valvular conditions
Subendocardial fibrosis
Constrictive pericarditis
Restrictive cardiomyopathy

89
Q

CHA2DS2-VASc

A

CHF
HTN (65-74 =1, >75 = 2)
Age
Diabetes
Stroke (2 points)
Sex
Vascular disease

90
Q

New bleeding risk score in AF

A

ORBIT-AF

91
Q

MR causes

A

Primary
- MV prolapse
- MV flail leaflet

Secondary
- Dilated cardiomyopathy
- Ischaemic cardiomyopathy
- Infective endocarditis

92
Q

Surgical indications in patients with asymptomatic primary MR

A

Reduced LVEF (<50%)
LVESD >45mm
AF
PASP >50mmHg

93
Q

Indications for anticoagulation with MV disease

A

Concurrent AF
Previous emboli

94
Q

How is IE diagnosed

A

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

95
Q

Common cause of mixed MV disease

A

Rheumatic fever

96
Q

Complication of mitral stenosis

A

Can result in raised pulmonary pressure, resulting in R sided dysfunction and TR

97
Q

Causes of Aortic Stenosis

A
  1. Age-related calcific degeneration
  2. Bicuspid AV
  3. Rheumatic heart disease
  4. Fabry’s
  5. SLE
98
Q

Chronic causes of AR

A

CTD - Marfans / Ehlers-Danlos
HTN
Osteogenesis imperfecta
Ank Spond
GCA
SLE

99
Q

Acute causes of AR

A

Infective Endocarditis
Aortic Dissection
Trauma

100
Q

Signs of AR

A

De-Mussets - head nodding
Quinkes - Nail bed pulsation
Mullers - Uvula pulsation

101
Q

What tests should be performed in asympomtic severe disease or low flow AS?

A

Exercise testing - increases output therefore can better assess gradients

102
Q

Why is TAVI rarely used in AR?

A

Due to concurrent aortic root dilatation

103
Q

Main things to check on bloods in palpitations

A

Electrolytes
Thyroid function

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