Cardiology Flashcards
differentials for ejection systolic murmur
1) HOCM
2) aortic sclerosis
3) flow murmur- high output clinic state e.g. pregnancy
4) ASD
5) tetrallogy of fallot
what are the causes of aortic stenosis
congenital- bicuspid aortic valve
age- senile degeneration/ calcinosis
infection- rheumatic heart disease
indications for surgery of aortic stenosis
symptomatic AS- chest pain, syncope, dyspnoea
asymptomatic
- gradient >40mmHg and
- EF <45%,
- abnormal response to exercise,
- valve area <0.6cm2,
- LVH>15mmh
how do you differentiate aortic stenosis from aortic sclerosis
normal pulse character (not slow rising), normal second heart sound
what conditions are associated with aortic stenosis
coarctation of the aorta- radio femoral delay
angiodysplasia (Heydes syndrome)
anaemia
William’s syndrome
what are the dukes criteria for IE
2 major / 1 major + 3 minor
major
1) typical organisms in bloods culture
2) echo- abscess/ large vegetations/ dihiscence
minor
pyrexia >38
echo suggestive
prosthetic valve
embolic phenomena
vasculitic features (ESR rise)
atypical organism on blood culture
causes of IE
Staphylococcus aureus
is the most common cause of infective endocarditis.
Streptococcus viridans- commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure
coagulase-negative Staphylococci such as Staphylococcus epidermidis
commonly colonize indwelling lines and are the most cause of endocarditis in patients following prosthetic valve surgery, usually the result of perioperative contamination.
Streptococcus bovis
associated with colorectal cancer
non-infective
systemic lupus erythematosus (Libman-Sacks)
malignancy: marantic endocarditis
what are the causes of aortic regurgitation
acute causes- trauma, aortic dissection, infective endocarditis
chronic- rheumatic fever, dilation of the aortic root- marfans, HTN, ank spond
what are the indications for surgery of AR
symptomatic patients with severe AR
asymptomatic patients with severe AR who have LV systolic dysfunction
does a long murmur mean more severe AR
a short murmur suggests more severe AR due to more severe flow of bloods back into the LV
what clinical signs suggest more severe AR
clinically dilated heart (displaced apex), signs of left sided heart failure, short murmur, wide pulse pressure, collapsing pulse
what are the complications of AR
LV heart failure, endocarditis
what is the prognosis of AR
asymptomatic and LVF >50 - 1% mortality at 5 years
symptomatic with 3 criteria- wide pulse pressure, ECG changes, echo LV enlargement/ EF <50- 65% mortality at 3 years
Causes of mitral regurtitation
acute- bacterial endocarditis/ rupture
chronic- mitral valve prolapse, rheumatic, CTDs- marfans/EDS, functional MR (dilated LV), infiltrative (amyloidosis), fibrosis (post MI/ rupture)
what are the indications for surgery of mitral regurgitation
symptomatic patient with severe MR
asymptomatic:
LVEF <60%
LV end systolic dimension >45mm
AF
systolic pulmonary pressure >50mmHg
why is mitral valve repair preferable to replacement
disconnection of subvalvular apparatus can cause a 20% decline in LV function
risk of infective endocarditis in valve replacement
how is ischaemic MR managed
ischaemic MR has a poor prognosis therefore threshold for surgery is lower.
what features suggest severe or significant MR
pulmonary hypertension
displaced thrusting apex beat
AF
what are the causes of mitral stenosis
Congenital - rare
rheumatic (commonest)
age related- senile degeneration
endocarditis
what are the indications for anticoagulation
any patient with AF should be on anticoagulation, those with rheumatic AF have >3 fold increased risk of thromboembolism
how often should patients with Mitral stenosis be followed up
if asymptomic or with mild MS- annual follow ups are required
which patients should be offered percutaneous balloon mitral valvuloplasty/ surgery
if evidence of PH
new AF
symptomatic with NYHA II heart failure and valve suitable
what is the prognosis of MR???
latent asymptomatic phase of 15-20 years
NYHA II confers a 50% mortality in 5 years
what is rheumatic fever
immunological cross reactivity between group A B haemolytic strep infections and valve tissue.
what is the diagnostic criteria of rheumatic fever
Duckett Jones
proven B haemolytic infection on throat swab/ rapid antigen test/ clinical scarlett fever PLUS
2 major or 1 major+2minor
MAJOR- JONES
J- joints (polyarthralgia)
O- carditis
N- nodules (subcutaneous)
E- erythema marginatum
S- chorea
minor
high ESR, raised WCC, arthralgia, pyrexia, prolonged PR interval
treatment of rheumatic fever
rest, high dose aspirin, penicillin
Primary prevention: penicillin V for 10 days
Secondary prevention: penicillin V for about 5–10 years
discuss the merits of biological valve vs mechanical valves
metallic valves are very durable, they are often used in young patients or patients with other conditions requiring anticoagulations such as AF. metallic valves require life-long warfarin which can be cumbersome and also inappropriate for patients with a bleeding/ falls risk
biological valves are generally less durable than metallic but require no warfarinisation therefore can be more appropraite in patients with risk of haemorrhage
what are the causes of tricuspid regurgitation
acute- endocarditis
chronic- pulmonary hypertension, ebstein’s abnormality, rheumatic valve disease, carcinoidh
why is TR endocarditis more common in IVDU
substances flow through the heart after being injected and can matter can cause damage to the TV (first valve encountered) and predispose to being seeded from bacteramia
what are the 4 features of tetralogy of fallot
ventricular septal defect (VSD)
right ventricular hypertrophy/ outflow tract obstruction
pulmonary stenosis
overriding aorta
metallic 1st heart sound
mitral valve replacement
metallic 2nd heart sound
aortic valve replacement
splitting of the 2nd heart valve
mitral regurgitation
tricuspid regurgitation
pulmonary stenosis
ASD (fixed)
noonans syndome cardiac features
commonly pulmonary stenosis
HOCM
ASD
signs from severe pulmonary stenosis
R ventricular heave
ejection systolic murmur or pansystolic mumur from function TR
large a waves on JVP
palpable thrill
eye signs of noonans syndrome
proptosis, ptosis, strabismus
signs of pulmonary hypertension
RV heave and loud P2, + cyanosis
noonans syndrome
congenital disorder - autosomal dominant
males and females affected
phenotypical features- short stature, pectus excavatum, facial features, learning difficulties
causes of pulmonary stenosis
largely congenital- tetrallogy, williams, turners, noonans
congenital pulmonary stenosis
acute- infective endocarditis, rheumatic valve disease, carcinoid syndrome
duration of anticoagulation in PE
3 months if provoked
6 months if unprovoked, or in case of active malignancy
causes of Eisenmengers syndrome
reversal of a left to right shunt from pulmonary hypertension
VSD
ASD
PDA
complications of eisenmengers syndrome
RV failure
IE
haemoptosis
hypoxaemia
causes of clubbing
respiratory- malignancy, bronchiectasis, ILD
cardiac- subacute endocarditis, cyanotic congenital heart disease
GI- IBD
familial / idiopathic
cyanotic vs acyanotic congenital heart disease
cyanotic- tetrallogy of fallot, transposition of the great arteries, pulmonary atresia, pulmonary stenosis, eisenmengers, tricuspid. atresia, ebsteins
acyanotic- ASD, uncomplicated VSD, PDA, coarctation, AS
causes of constrictive pericarditis
viral/ bacterial pericarditis, post surgery, post TB, radiation
causes of restrictive pericarditis
diastolic dysfunction with restrictive ventricular physiology. systolic function preserved.
endomyocardial fibrosis (lofflers), sarcoidosis, scleroderma, malignancy, amyloidosis, iron overload
HOCM clinical signs
ejection systolic murmur from LV outflor obstruction
panystolic murmur resulting from MR
causes of cardiac hypertrophy
Hypertension
aortic stenosis
hypertrophic cardiomyopathy, which is a genetic condition.
Fabry disease
amyloidosis
management of HOCM
treating patients symptoms with beta blockers. Second line with either disopyramide or a myosin inhibitor, such as mavacamten.
assess a patient for their risk of sudden cardiac death and consider
implanting a defibrillator or ICD.
assess patient’s genetics to aid with familial evaluation
In certain cases of severe disease, patients can be referred for septal reduction
therapy
Correction of TOF
Surgical correction of these defects in the long term is always necessary. The timing of
correction depends on how symptomatic, cyanosed or hypoxaemic the child is.
Corrective repair of tetralogy of Fallot includes closure of the ventricular septal defect
with a synthetic Dacron patch. Narrowing of the pulmonary valve and the right
ventricular outflow tract obstruction are relieved by a combination of resecting
obstructive muscle tissue in the right ventricle and by enlarging the outflow pathway with
a patch.
Historically, a Blalock-Taussig Shunt, which is done by
plumbing the left subclavian artery into the pulmonary artery
