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Cardiology Flashcards

1
Q

What are the signs for a prosthetic valve?

A

Midline sternotomy scar
Look for vein harvesting - ?CABG
Look for signs of endocarditis
Bruising - warfarin –> metallic valve
Anaemia - ?haemolysis

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2
Q

What should you listen for if suspecting a prosthetic valve?

A

Metallic click
- 1st = mitral
- 2nd = aortic
Can be both!

Low pitched timbre - tissue valve

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3
Q

What are some complications of prosthetic valves?

A

Valve failure
Valve thrombosis
Acute valvular dehiscence
Acute endocarditis
IE
CVA/TIA - embolic
Haemolysis
Bleeding from warfarin

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4
Q

How does a metallic aortic valve replacement sound?

A

Metallic S2
Ejection systolic murmur - doesn’t radiate to carotids

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5
Q

What are some signs of endocarditis?

A

Osler nodes
Janeway lesions
Splinter haemorrhages
Clubbing

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6
Q

What signs would indicate early aortic valve failure?

A

Early diastolic murmur - AR
S2 not crisp
Displaced or thrusting apex beat
Prominent carotids
Collapsing pulse
Features of HF

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7
Q

What are some “before issues” for AVR? - Issues developed in lag time before surgery?

A

Pulm. HTN
LV hypertrophy - Heaving, non displaced apex

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8
Q

Signs of pulmonary HTN?

A

RV Heave
Loud S2
Tricuspid regurgitation
- Pan systolic murmur
- Giant V waves
- Raised JVP

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9
Q

Common causes for AVR?

A

Aortic Stenosis - bicuspid if young, calcified if old

AR
- Connective tissue disorders
- Ank Spond
- Rheumatic fever
- IE

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10
Q

Investigations for AVR?

A

Bedside:
- ECG - ?LVH, ?conduction abnormalities
- Urine dip - blood/protein - IE
- Fundoscopy - Roth Spots - IE

Bloods:
- FBC - anaemia
- Coag - INR
- CRP/ESR - IE

Imaging:
- Echo - valve function, LV function
- CXR - ?HF

Consider aortic root dilation in connective tissue disease

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11
Q

How are AVR’s managed?

A

Education r.e. complications/symptoms to look out for
Monitor function with serial echocardiography
Manage any complications
Surgical replacement if required

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12
Q

Which patients should be considered for non mechanical (tissue) valves?

A
  • anticoagulation contraindicated
  • Short life expectancy - older patients
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13
Q

What is the diagnostic criteria for IE?

A

Modified Duke - 2 major OR 1 major + 3 minor OR 5 minor

Major:
- 2x positive BC’s with likely organisms
- Echo findings - abscess, dehiscence or oscillating mass

Minor:
- Echo findings not meeting major criteria
- BC’s not meeting major criteria
- Predisposing - IVDU/Underlying lung phenomena
- Immunological phenomena - Oslers node, glomerulonephritis, Roth spots, positive RF
- Vascular phenomena - splinter haemorrhage, laneway lesions, septic emboli
- Fever

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14
Q

What are the likely organisms in IE?

A

Gram positive Staph, Strep or enterococcus

Typically Staph aureus.
Also Staph epidermidis, strep viridans, strep bovis

Coxiella Burnetti - only need 1BC for major criteria
More rare = HACEK organisms or fungal - candida

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15
Q

Which valves are most commonly affected by IE?

A

Mitral

Then Aortic

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16
Q

Cyanotic congenital heart diseases?

A

Tetralogy of Fallot
Transposition of the great arteries
Tricuspid Atresia
Total anomalous venous return
Persistent Truncus Arteriosus

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17
Q

Acyanotic Heart Defects?

A

ASD
VSD
PDA
Co-arctation of the aorta

Acyanotic defects can become cyanotic with shunting later in life - Eisenmengers

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18
Q

How would a VSD present?

A

Breathlessness
Reduced exercise tolerance
Fatigue
Orthopnoea
Paroxysmal Nocturnal Dyspnoea

Cyanosis - severe

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19
Q

Causes of VSD?

A

Congenital
- Isolated
- Tetralogy of Fallot
- Syndromic - Down’s/Turner

Acquired
- Post MI Septal Rupture

Usually determine based off age
- Young - likely congenital - look for other defects
- Old - likely acquired - look for scars

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20
Q

Examination findings for VSD?

A

Apex beat - forceful and displaced
Systolic thrill
Pansystolic murmur:
- L sternal edge
- No variation with resp. or radiation

Complications:
- HF - raised JVP, bibasal craps, peripheral oedema
- Eisenmengers - clubbing, cyanosis, L parasternal heave, loud P2, EDM over pulmonary area
- IE - splinter haemorrhage, oslers nodes, janeway lesions

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21
Q

How would you investigate a VSD?

A

Bedside:
ECG - LVH, left axis deviation, conduction defects

Bloods
- FBC - eisenmengers

Imaging
- CXR - prominent pulm. vasculature
- Echo

Special
- Cath - step up in O2 sats in RV

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22
Q

What are you generally looking for on echo in congenital heart defects?

A

Size and position of defect
Direction of shunt - with doppler
Other cardiac abnormalities
RV/LV function

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23
Q

How is a VSD managed?

A

Non pharmacological - Advice and education

Medical - manage HF and IE

Surgical - open/percutaneous transcatheter device

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24
Q

What is maladie de roger?

A

Small VSD causing a loud murmur due to high turbulence but otherwise normal cardiac exam

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25
Does maladie de Roger need treatment?
Not typically as they are haemodynamically insignificant and close spontaneously
26
What are the types of VSD?
Membranous - more common - may close spontaneously Muscular - typical following MI Infundibular Atrioventricular
27
When is a patient most at risk of developing a VSD?
1-3 days post MI Present with rapid haemodynamic collapse
28
When is surgery considered in VSD?
Very large left to right shunt Increasing R heart pressure
29
What are the main types of ASD?
Primium ASD - 15% Secundum ASD - 70% Sinus Venosus ASD - 15%
30
What is the cause of a primium ASD? What is it associated with and what ECG findings would you expect?
Abnormal endocardial cushion development Associated with VSD's ECG - RBBB + left axis deviation
31
What is the cause of a secundum ASD? What is it associated with and what ECG findings would you expect?
Central fossa ovalis defect Associated with Down's, Holt-Oram and Noonan's ECG - RBBB + right axis deviation
32
What causes a sinus venosus ASD?
Defect in folding of the atrial wall near the SVC --> SVC with communication with both atria
33
What examinations features may you expect with an ASD?
AF Fixed splitting of S2 - doesn't vary with respiration Systolic murmur across pulm. valve - increased blood flow through R heart Pulmonary thrill/click Possible functional TR Heart failure features Paradoxical emboli - hemiparesis, intracerebral abscess IE Eisenmengers
34
Investigations for an ASD?
ECG FBC - polycythaemia Echo - may need TOE Cardiac catheter
35
Management of ASD?
Education and advice Medical - treat co-existent problems Surgical - closure
36
When is surgical closure of an ASD advised?
- Symptomatic ASD (symptoms of RVF) - Paradoxical embolism - Asymptomatic patient with significant shunt - Significant pulmonary HTN (>2/3 systemic pressure) that improves on vasodilation testing
37
What is Lutenbachers syndrome?
Association of ASD with Mitral Stenosis - Rheumatic heart disease related OR - Complication of mitral valvuloplasty
38
What is a patent ductus arteriosus?
Failure of the ductus arteriosus to close Embryological shunt from pulmonary trunk to Descending thoracic Aorta
39
Who is at higher risk of PDA?
High altitude birth Females Premature Neonatal rubella
40
How do PDA's present?
Small - incidental finding but increased risk of endarteritis Large - LA dilation and LV failure - risk of eisenmengers
41
What signs would you find in a patient with a PDA?
Displaced thrusting apex beat - large PDA Wide pulse pressure Collapsing pulse Signs of pulm HTN - loud P2, parasternal heave Machinery murmur - stops in Eisenmenger.
42
Describe the murmur in PDA
Continuous machinery Start as crescendo systolic then quieten to continuous diastolic machinery
43
How is a PDA managed?
Surgical closure if: - PDA that develop endarteritis (after Tx) - Detectable PDA - unless developed unreversible Pulm. HTN - Undetectable PDA not closed
44
What is co-arctation of the aorta?
Congenital narrowing of the aorta, typically in the region of the PDA Associated with Turner's syndrome
45
What signs would you look for which would make you suspect coarctation?
Radio femoral delay Differing UL and LL BP Signs of infective endocarditis Signs of surgical repair - left thoracotomy Radial-radial - if proximal to left subclavian Thrusting apex Prominent carotids
46
What would you hear on auscultation in coarctation?
Normal/loud S1 Systolic murmur - loudest over thoracic spine Bruit - L infraclavicular and scapula May also have other valve mumur - Bicuspid aortic, AR
47
What is co-arctation associated with?
Bicuspid aortic valve - 20-50% Turners - short female, webbed neck, high arched palate MV disease, aortic dissection, VSD, PDA Berry aneurysm - renal tract abnormalities, haemangiomas Hypertension - uncontrolled Neurofibromatosis 1 and Marfans
48
What are some complications of co-arctation?
LV failure HTN Endarteritis - present as pyrexia of unknown origin
49
What are some differentials for co-arctation?
Anatomical: - unusual course - cervical rib - mass lesion/lymphadenopathy Iatrogenic - ABG - Art line - Radial artery harvesting Atherosclerosis Embolism - AF Vasculitis - takayasu's/giant cell
50
How would co-arctation be investigated?
Bedside - BP in both arms - ECG - Fundoscopy - Urine dip Bloods - FBC, UE, Inflammatory markers Imaging - CXR - Echo - Cardiac MR Special - Cardiac Cath - pressure/collaterals
51
What do you look for on x-ray in co-arctation?
3 sign - bulge of Left Subclavian A dilation - Bulge of post stenotic aortic dilation - Rib notching Heart failure
52
What do you look for on echo in co-arctation?
- co-arctation, - bicuspid AV, - AS, - AR - Associated defects like VSD, - LV function
53
What is CMR used for in co-arctation?
More anatomical info/detail about co-arctation Used in f/u post repair
54
How should coarctation be managed?
MDT - regular cardio f/u - young females - pre-conception counsel + obstetric Monitor BP - antihypertensives Monitor for IE Monitor LV function Repair: - L subclavian flap repair - Resection with end to end anastamosis - Patch aortoplasty - Balloon angio and stenting
55
What are the complications post co-arctation repair
Reco-arctation Aneursym Dissection
56
When is repair of co-arctation indicated?
Symptomatic with peak pressure >30mmHg Asymptomatic with HTN or LV failure
57
What are the features of tetralogy of fallot?
Overriding Aorta Pulmonary stenosis VSD RV hypertrophy
58
What scenarios would make you consider tetralogy of fallot?
Breathlessness Syncope Growth retardation Squatting at rest Corrective surgery at rest
59
What may you see on examination in tetralogy of fallot?
MUST HAVE BEEN REPAIRED - (poor prognosis if not) Surgical repair - midline sternotomy scar - RV heave - RV failure - JVP, TR, Pulm. oedema Blalock-Taussig shunt - L lateral thoracotomy scar - Radial radial pulse deficit - weaker on side of shunt (L) - Underdeveloped shunt arm (L) Complications: - Regurg of any valve - Restenosis of RVOT - Pacemaker - AV block or ventricular arrhythmia
60
What is tetralogy of fallot associated with?
Di George syndrome - cleft palate (may be repaired) - Long face - Low ears Polands syndrome - unilateral pectoral hypoplasia
61
How would you investigate someone with ToF?
ECG - conduction blocks, arrhythmia, LV hypertrophy Urine dip, temp, fundoscopy - IE Bloods - infection CXR - boot shaped heart, enlarged RV, reduced pulm. vasculature, R sided aortic knuckle Echo - pressure gradients, ventricular function CMR - more detailed assessment
62
Features of pulmonary stenosis?
Loud ejection systolic murmur in pulmonary area Louder on inspiration Radiate to left infraclavicular region Soft/Delayed P2 if severe Palpable pulmonary thrill
63
Causes of pulmonary stenosis?
Maternal rubella Noonan's syndrome Carcinoid syndrome Rheumatic fever Tetralogy of Fallot Infective Endocarditis
64
Signs of severe pulmonary stenosis?
RV heave Prominent A wave on JVP Pansystolic murmur at left sternal edge - functional tricuspid regard Widely split S2
65
Symptoms associated with pulmonary stenosis?
Effort intolerance Breathlessness Fatigue Fainting/syncopal episodes Chest pain Palpitations
66
Differential diagnoses for pulmonary stenosis?
ASD VSD Can mention other systolic murmurs but mention location/character would vary
67
Investigations for suspected pulmonary stenosis?
ECG - R heart strain Echocardiogram - quantify severity of stenosis + aetiology. CMRI
68
Aetiology of Noonan's syndrome
Autosomal dominant mutation of PTPN11 gene on chromosome 12 (>50%) SOS1 on chromosome 2 RAF1 on chromosome 3
69
Key features of Noonan's syndrome
CVS - Pulmonary stenosis most common - HCM - ASD/VSD/TOD Short stature Facial - Triangular shaped face - Downslanting palpebral fissues - Short webbed neck - Hypertelorism Ocular - Strabismus - Ptosis - Amblyopia - Refractive errors Pectus excavatum/carinatum Wide spaced nupples Cubitus valgus - wide carrying angles Pubertal delay Mild learning disability
70
How is Noonan's diagnosed?
Usually on chorionic villus sampling/amniocentesis
71
How is Noonan's managed?
Non pharmacological - Growth and puberty monitoring - Education, psychology and support - Support with feeding - Genetic counselling Pharma - Manage HF - Growth hormone Surgical - Valve surgery - Gastrostomy - Treat cryptorchidism
72
Young patient, midline sternotomy scar ± murmur
Think about congenital causes Possible have been fixed
73
How can pulmonary stenosis be managed?
Treat underlying cause Consider balloon valvuloplasty If evidence of regurgitation - consider valve replacement
74
Examination findings which would be suggestive of Eisenmenger's syndrome?
Clubbing Cyanosis RV heave Raised JVP - CV waves Widely split S2
75
Causes of Eisenmengers syndrome?
Most common - VSD ASD PDA
76
Differentials for Eisenmengers
Pulm HTN TOF ASD/VSD without shunt reversal
77
Management of Eisenmengers syndrome
Non Pharma: - Childhood vaccines - Pneumococcal + annual influenza - Phlebotomy for hyperviscosity - Counsel r.e. risk of pregnancy Pharma - Treat HF - Vasodilators - Iron supplementation Surgery - Heart-lung transplant
78
Complications of Eisenmengers Syndrome
RV failure Infective endocarditis Hyperviscosity Bleeding Thrombosis - paradoxical embolism
79
What is Ebsteins Anomoly?
Atrialisation of RV - Low sitting tricuspid leaflets = large RA + TR
80
Risk factors for Ebsteins Anomoly
Lithium Maternal benzodiazepines use
81
Features of HOCM
2 murmurs - ES murmur + pansystolic mumur (axilla) Thrusting/heaving apex - undisplaced Jerky pulse Look for signs of IE/HF
82
What is HOCM associated with?
AF MV prolapse Friedreich's ataxia Myotonic dystrophy
83
Management of HOCM?
Non Pharma - genetic counselling - educate - avoid strenuous exercise Medical - beta blockers - amiodarone - Mavacemten (new) Surgical - Alcohol septal ablation - Septal myomectomy
84
Indications for mitral valve surgery
Acute severe MR Symptomatic Asymptomatic + LVSD/LV dilatation/AF/Pulm HTN

MRCP PACES (6 decks)

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