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Cardiology Flashcards

1
Q

Which valve prosthesis are in time with the carotid pulse

A

Mitral valve prostheses

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2
Q

Which valve prosthesis are not in time with the carotid pulse

A

Aortic valve prostheses

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3
Q

What can cause a collapsing pulse

A
  • Aortic regurgitation
  • PDA
  • hyperdynamic circulation (pregnancy, anaemia, thyrotoxicosis)
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4
Q

What causes CV waves on JVP

A

Severe TR

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5
Q

What are the indications for aortic valve replacement

A
  • severe symptomatic AS or AR
  • moderate/severe AS undergoing other cardiac surgery
  • bacterial encodarditis
  • severe AS with valve area <0.6cm^2
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6
Q

What clinical signs suggest severe AS

A
  • quiet S2 sound
  • long murmur
  • low volume pulse
  • evidence of heart failure
  • narrow pulse pressure
  • LV heave/displaced LV apex
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7
Q

What are the differentials of an ESM

A
  • AS (can be heard throughout precordium)
  • Aortic sclerosis
  • HOCM (LVOTO)
  • MR (pansystolic)
  • ASD (pulmonary)
  • VSD
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8
Q

How can you differentiate AS and PS

A
  • different valve areas
  • RV heave in PS
  • PS louder on inspiration
  • younger patients with PS, elderly patient with AS
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9
Q

What is the medical management of AS

A

None - but beta blockers can help improve cardiac output

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10
Q

Which drugs must be avoided in AS

A

Anything that causes peripheral vasodilation and increases pressure gradient:
- ACEi
- nitrates
- sildenafil

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11
Q

What is Heyde’s syndrome

A

AS, angiodysplasia and acquired von Willebrand disorder

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12
Q

What are the causes of AS

A
  • common: degeneration, bicuspid
  • uncommon: rheumatic, congenital
  • rare: IE
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13
Q

What indicates severe AS on echo

A
  • aortic valve area <1cm^2
  • mean gradient >40mmHg
  • peak velocity >4m/s
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14
Q

What are the indications for mitral valve replacement

A
  • mitral regurgitation
  • mitral stenosis
  • IE
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15
Q

What is the significance of AF in aetiology of metallic MV replacement

A

More likely to be MS instead of MR

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16
Q

When would mitral valve repair be more appropriate than replacement

A

Young person with MV prolapse

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17
Q

What are the types of ASD

A
  • primum (associated with AVSD)
  • secundum (commonest)
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18
Q

What are the complications of ASD

A
  • paradoxical embolus
  • atrial arrhythmias
  • RV dilation
  • pulmonary hypertension
  • Eisenmenger’s syndrome
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19
Q

Which type of ASD is most commonly seen in Down’s syndrome

A

Ostium primum (septum primum does not fuse with endocardial cushions)

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20
Q

What are the indications for closure of ASD

A
  • paradoxical embolus
  • breathlessness
  • RV dilation
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21
Q

What are the contraindications for closure of ASD

A

Severe pulmonary HTN, Eisenmenger’s syndrome

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22
Q

What are the indications for closure of VSD

A
  • recurrent infective endocarditis
  • development of aortic regurgitation
  • LV dysfunction
  • reversible pulmonary hypertension
  • acute VSD after MI
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23
Q

What are the contraindications to closure of VSD

A

Irreversible pulmonary HTN, Eisenmenger’s syndrome

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24
Q

What are the causes of VSD

A
  • congenital inc downs, TOF
  • acquired (MI)
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25
Q

What are the causes of an absent radial pulse

A
  • Acute: embolism, aortic dissection, trauma
  • chronic: BT shunt, atherosclerosis, coarctation, Takayasu’s arteritis
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26
Q

What conditions are associated with coarctation of the aorta

A
  • Cardiac: VSD, bicuspid AV, PDA
  • Non-cardiac: Turner’s, berry aneurysm
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27
Q

What can be seen on CXR in aortic coarctation

A

Rib notching, double aortic knuckle (post-stenotic dilatation)

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28
Q

What clinical signs are associated with patent ductus arteriosus

A
  • Collapsing pulse
  • Loud continuous machinery murmur loudest below left clavicle in systole
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29
Q

What findings on examination would suggest severe MR

A
  • evidence of pulmonary hypertension (raised JVP, loud P2, RV heave, pedal oedema)
  • thrusting, displaced apex
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30
Q

What are the indications for mitral valve replacement

A
  • symptomatic MR (eg SOB)
  • asymptomatic but declining LVEF or LV dilatation on echo
  • acute MR after myocardial infarction eg papillary wall rupture
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31
Q

What are the cardiac complications of Marfan’s syndrome

A
  • aortic root dilation
  • aortic dilation at any point along its length (and aortic dissection)
  • aortic regurgitation
  • mitral valve prolapse
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32
Q

What are the indications of aortic root replacement in Marfan’s

A
  • dilation >50mm at aortic root
  • dilation >45mm if FHx of aortic dissection
  • aortic root expanding at rate >3mm per year
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33
Q

What are the main symptoms of pulmonary stenosis

A
  • Effort exertion
  • Breathlessness on exertion
  • Signs of R heart failure
  • Pre-syncope, syncope
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34
Q

What clinical signs would you expect to see in pulmonary stenosis

A
  • raised JVP
  • RV heave
  • ESM murmur in pulmonary area
  • PSM in tricuspid area (functional TR)
  • Peripheral oedema
  • Widely split S2
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35
Q

What are the most common cardiac complications of Noonan’s syndrome

A
  1. Pulmonary stenosis
  2. HOCM
  3. Septal defects
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36
Q

What are the differential diagnoses of pulmonary stenosis

A
  • Aortic stenosis
  • VSD
  • ASD
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37
Q

What classifies severe pulmonary stenosis on echo

A
  • valve area <1cm^2
  • gradient >64mmHg
  • velocity >4m^2 across valve
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38
Q

Which cardiac abnormality is seen in William’s syndrome

A

Pulmonary stenosis

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39
Q

What are the causes of pulmonary stenosis

A
  • Isolated congenital
  • Associated syndromes (TOF, noonan’s, Williams, Alagille)
  • Infective (IE, Rheumatic)
  • Carcinoid
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40
Q

What is the management of mild asymptomatic pulmonary stenosis in adults

A

Valve surveillance with 5-yearly echos

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41
Q

What is the management of moderate/severe pulmonary stenosis

A

Percutaneous valvuloplasty or surgery

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42
Q

What are the clinical signs of tricuspid regurgitation

A
  • raised JVP with CV waves
  • thrill left sternal edge
  • PSM loudest at LLSE on inspiration
  • Reversed split S2 sound
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43
Q

What are the causes of tricuspid regurgitation

A
  • congenital: Ebstein’s abnormality
  • infective endocarditis (IVDU)
  • functional
  • rheumatic heart disease
  • carcinoid syndrome
44
Q

Which out of janeway lesions and oslers nodes are painful?

A

Osler’s nodes - tips of fingers and painful

45
Q

What are the major dukes criteria for IE

A
  • typical organism in 2 blood cultures
  • echo: abscess, large vegetation, dehiscence
46
Q

What are the minor dukes criteria for IE

A
  • Pyrexia >38
  • echo suggestive
  • predisposed eg prosthetic valve
  • embolic phenomena
  • vasculitic phenomena (raised ESR/CRP)
  • atypical organism on blood culture
47
Q

How can you diagnose IE using dukes

A
  • 2 major
  • 1 major and 2 minor
  • 5 minor
48
Q

Who should receive prophylactic ABx for IE before high risk procedures

A
  • prosthetic valves
  • previous IE
  • cardiac transplants with valvulopathy
  • certain congenital heart diseases
49
Q

What are the acute causes of AR

A

Endocarditis, aortic dissection, trauma

50
Q

What are the chronic causes of AR

A
  • Rheumatic fever
  • Hypertension
  • aortic root dilation (Marfan’s, syphilis, ank spond, Takayasu’s)
  • CTD (EDS, pseudoxanthoma elasticum)
51
Q

What are the congenital causes of AR

A

Bicuspid aortic valve, perimembranous VSD

52
Q

What are the indications for valve replacement in chronic AR

A
  1. Symptomatic
    And/or
  2. Widened pulse pressure >100, ECG changes and LVEDD >65/LVEF <50
53
Q

Describe the murmur in MS

A
  • Loud first heart sound
  • opening snap of mitral leaflets in diastole followed by mid-diastolic murmur
  • heard best in left lateral position with bell in expiration
54
Q

What are the common causes of mitral stenosis

A

Rheumatic fever (commonest)
Senile degeneration
Endocarditis

55
Q

What are the differentials of mitral stenosis

A

Left atrial myxoma
Austin-flint murmur (AR)

56
Q

What facial sign is associated with mitral stenosis

A

Malar flush

57
Q

What might an ECG show in mitral stenosis

A

P mitrale
AF

58
Q

What is the diagnostic criteria for rheumatic fever

A

Duckett-Jones criteria (proven strep on throat swab/RADT/ASOT or Scarlett fever plus 2 major/1 major and 2 minor criteria inc chorea, raised ESR, raised WCC etc)

59
Q

What are the surgical options for mitral stenosis

A
  1. Valvuloplasty - if not calcified
  2. Closed/open valvotomy
  3. Valve replacement
60
Q

What are the indications for primary prevention ICD

A
  • MI (>6wks ago) and LVEF <35% after optimal medical therapy
  • familial conditions with high risk SCD (LQTS, AVRD, HCM, Brugada, ACHD)
61
Q

What are the indications for secondary prevention ICD

A
  • cardiac arrest due to VT or VF
  • haemodynamically compromising VT
  • VT with LVEF <35%
62
Q

Which conditions are associated with mitral valve prolapse

A

Marfan’s
EDS
Osteogenesis imperfecta
PKD

63
Q

Does isolated mitral valve prolapse increase risk of AF

64
Q

How is a patent ductus arteriosus best auscultated

A

Sat forward, over left upper sternal edge or left scapula, in expiration

65
Q

What would suggest a severe patent ductus arteriosus

A
  • collapsing pulse
  • RV heave
  • LV failure (pulm/pedal oedema)
66
Q

When would a PDA be considered for closure

A
  • LV volume overload
  • RV pressure overload
67
Q

What can be seen on examination of JVP in pericardial disease

A

Rapid y-descent (due to high RA pressures causing rapid early ventricular filling)

68
Q

What is Kussmaul’s sign

A

Paradoxical increase in JVP on inspiration due to pericardial disease

69
Q

What signs are associated with pericardial disease

A
  • rapid Y descent on JVP
  • Kussmaul’s sign
  • pulsus paradoxus
  • pericardial knock (S3 sound)
70
Q

What are the common causes of pericardial disease

A
  • infection (eg TB)
  • trauma
  • radiotherapy
  • connective tissue disease (RA, SLE)
71
Q

How can you differentiate pericardial constriction from restrictive cardiomyopathy

A

Constriction will demonstrate ventricular interdependence (filling of one ventricle reduces size and filling of the other)

72
Q

What can be heard on auscultation in hypertrophic cardiomyopathy with obstruction

A
  • ESM loudest over lower left sternal edge radiating throughout precordium
  • S4 sound
  • may have late systolic murmur from mitral valve prolapse
73
Q

Which neuromuscular conditions are associated with HCM

A
  • Friedrich’s ataxia
  • Myotonic dystrophy
74
Q

What is seen on ECG in HCM

A
  • LVH with strain
  • deep TWI in precordial leads
75
Q

What is the management of symptomatic HOCM

A
  • Beta blockers
  • alcohol septal ablation
  • myomectomy
  • PPM
  • ICD if high risk SCD
76
Q

What are poor prognostic factors in HCM

A
  • young age at diagnosis
  • syncope
  • family hx of SCD
  • increased septal thickness
77
Q

Which organisms cause the majority of cases of infective endocarditis

A
  • Streptococci
  • staphylococci
  • enterococci
78
Q

Does ASD cause a murmur?

A

Not itself, but with large left to right shunts can hear pulmonary ESM and tricuspid diastolic flow murmur due to increased right heart pressure

79
Q

What can cause a loud S1 sound

A
  • hyperdynamic state (eg exercise)
  • mitral stenosis
80
Q

What causes a loud S2 sound

A

Systemic or pulmonary HTN

81
Q

What causes a soft S2 sound

A

Calcified aortic stenosis

82
Q

What are the indications for closure of a VSD

A
  • significant left to right shunt
  • undergoing cardiac surgery for any other indication
  • endocarditis
  • aortic regurgitation due to VSD
83
Q

What are the complications of eisenmenger’s syndrome

A
  • RV failure
  • paradoxical embolism
  • infective endocarditis
  • hypoxia
84
Q

What causes a loud P2 and parasternal heave

A

Pulmonary hypertension

85
Q

What causes a loud P2 but no parasternal heave

A

Bioprosthetic pulmonary valve

86
Q

What is a cardiac indication for a lateral/posterior thoracotomy scar

A

Coarctation repair

87
Q

When is MV surgery indicated in primary MR

A

Severe MR (LV dilation, regurgitant vol >60ml etc) AND

  • symptomatic with LVEF >30%
  • asymptomatic with LVEF <60%

OR

  • undergoing other cardiac surgery eg CABG
88
Q

How many port sites should be under a sternotomy scar after one cardiac surgery

A

2-3 port scars

89
Q

What are the indications of surgery for aortic regurgitation

A
  • significant enlargement of ascending aorta
  • severe symptomatic AR
  • severe asymptomatic AR with LVEF <50% or LVESD >50
90
Q

What are the complications of valve replacement

A

Acute: arrhythmias, pericardial effusion/tamponade, infection

Chronic:
- stroke
- valve haemolysis
- valve failure (regurg)
- bleeding from anticoag
- infective endocarditis

91
Q

What are the causes of mitral regurgitation

A

Primary:
- degenerative
- MVP
- IE
- papillary muscle rupture
- rheumatic heart disease

Secondary:
- dilated LV (ICM, NICM)

92
Q

What are the causes of aortic regurgitation

A

Acute:
- valve leaflet: IE, prosthetic failure
- aortic root: dissection, trauma

Chronic:
- leaflet: rheumatic fever
- root: Marfan’s, HTN, Ank spond, Takayasu’s, syphilis

Congenital: bicuspid AV, VSD

93
Q

What are the investigations for aortic regurgitation

A

Bedside: fundosxopy, urinalysis, ECG

Bloods: FBC, CRP, CTD screen, syphilis serology, cultures, BNP

Imaging: CXR, TTE, cardiac CT

94
Q

What are the indications for acute valve replacement in aortic regurgitation

A
  • aortic dissection
  • endocarditis resistant to ABx
  • aortic root abscess
  • prosthetic valve failure
95
Q

Which are the main genes associated with HCM

A

MYH7 (myosin heavy chain)
MYBPC3 (myosin binding protein C)

96
Q

What are the causes of constrictive pericarditis

A
  • viral
  • bacterial
  • post-surgical
  • tuberculosis
  • radiation
97
Q

Why is it important to differentiate between constrictive pericarditis and restrictive cardiomyopathy

A

Treatment is very different:

Constrictive - surgical

Restrictive - treat underlying cause, heart failure treatment, consider heart transplant

98
Q

What is seen on echo in restrictive cardiomyopathy

A

Diastolic dysfunction, systolic function preserved

99
Q

When is urgent surgery indicated in infective endocarditis

A
  • Heart failure
  • Refractory to antibiotics
  • Heart block
100
Q

Which scars might be seen in ToF and why

A
  • thoracotomy scar - Blalock-Taussig shunt
  • sternotomy scar - VSD repair
101
Q

What is the most common complication of pulmonary valve intervention in ToF patients

A

Pulmonary regurgitation

102
Q

What are the causes of RBBB

A
  • RVH/Cor pulmonale
  • PE
  • IHD
  • Myocarditis
  • Cardiomyopathy
  • Congenital Heart disease
  • Lenegre-lev disease
103
Q

What are the causes of LBBB

A
  • Aortic stenosis
  • IHD
  • Hypertension
  • DCM
  • Anterior MI
  • Lenegre-lev disease
  • hyperkalaemia
  • digoxin toxicity
104
Q

What are the causes of right axis deviation

A
  • LPFB
  • Lateral MI
  • RVH
  • Acute lung diseases e.g. PE
  • Chronic lung diseases e.g. COPD
  • Ventricular ectopy
  • Hyperkalaemia
  • WPW syndrome
105
Q

What are the causes of left axis deviation

A
  • LAFB
  • LBBB
  • LVH
  • Inferior MI
  • Ventricular ectopy
  • Paced rhythm
  • WPW syndrome

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