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MRCP PACES > Cardiology > Flashcards

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
Q

Does maladie de Roger need treatment?

A

Not typically as they are haemodynamically insignificant and close spontaneously

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26
Q

What are the types of VSD?

A

Membranous
- more common
- may close spontaneously

Muscular
- typical following MI

Infundibular

Atrioventricular

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27
Q

When is a patient most at risk of developing a VSD?

A

1-3 days post MI

Present with rapid haemodynamic collapse

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28
Q

When is surgery considered in VSD?

A

Very large left to right shunt
Increasing R heart pressure

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29
Q

What are the main types of ASD?

A

Primium ASD - 15%
Secundum ASD - 70%
Sinus Venosus ASD - 15%

30
Q

What is the cause of a primium ASD? What is it associated with and what ECG findings would you expect?

A

Abnormal endocardial cushion development

Associated with VSD’s

ECG - RBBB + left axis deviation

31
Q

What is the cause of a secundum ASD? What is it associated with and what ECG findings would you expect?

A

Central fossa ovalis defect

Associated with Down’s, Holt-Oram and Noonan’s

ECG - RBBB + right axis deviation

32
Q

What causes a sinus venosus ASD?

A

Defect in folding of the atrial wall near the SVC –> SVC with communication with both atria

33
Q

What examinations features may you expect with an ASD?

A

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
Q

Investigations for an ASD?

A

ECG
FBC - polycythaemia
Echo - may need TOE
Cardiac catheter

35
Q

Management of ASD?

A

Education and advice
Medical - treat co-existent problems
Surgical - closure

36
Q

When is surgical closure of an ASD advised?

A
  • 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
Q

What is Lutenbachers syndrome?

A

Association of ASD with Mitral Stenosis

  • Rheumatic heart disease related OR
  • Complication of mitral valvuloplasty
38
Q

What is a patent ductus arteriosus?

A

Failure of the ductus arteriosus to close

Embryological shunt from pulmonary trunk to Descending thoracic Aorta

39
Q

Who is at higher risk of PDA?

A

High altitude birth
Females
Premature
Neonatal rubella

40
Q

How do PDA’s present?

A

Small - incidental finding but increased risk of endarteritis

Large - LA dilation and LV failure - risk of eisenmengers

41
Q

What signs would you find in a patient with a PDA?

A

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
Q

Describe the murmur in PDA

A

Continuous machinery

Start as crescendo systolic then quieten to continuous diastolic machinery

43
Q

How is a PDA managed?

A

Surgical closure if:
- PDA that develop endarteritis (after Tx)
- Detectable PDA - unless developed unreversible Pulm. HTN
- Undetectable PDA not closed

44
Q

What is co-arctation of the aorta?

A

Congenital narrowing of the aorta, typically in the region of the PDA

Associated with Turner’s syndrome

45
Q

What signs would you look for which would make you suspect coarctation?

A

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
Q

What would you hear on auscultation in coarctation?

A

Normal/loud S1
Systolic murmur - loudest over thoracic spine
Bruit - L infraclavicular and scapula

May also have other valve mumur - Bicuspid aortic, AR

47
Q

What is co-arctation associated with?

A

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
Q

What are some complications of co-arctation?

A

LV failure
HTN
Endarteritis - present as pyrexia of unknown origin

49
Q

What are some differentials for co-arctation?

A

Anatomical:
- unusual course
- cervical rib
- mass lesion/lymphadenopathy

Iatrogenic
- ABG
- Art line
- Radial artery harvesting

Atherosclerosis

Embolism - AF

Vasculitis - takayasu’s/giant cell

50
Q

How would co-arctation be investigated?

A

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
Q

What do you look for on x-ray in co-arctation?

A

3 sign
- bulge of Left Subclavian A dilation
- Bulge of post stenotic aortic dilation
- Rib notching

Heart failure

52
Q

What do you look for on echo in co-arctation?

A
  • co-arctation,
  • bicuspid AV,
  • AS,
  • AR
  • Associated defects like VSD,
  • LV function
53
Q

What is CMR used for in co-arctation?

A

More anatomical info/detail about co-arctation

Used in f/u post repair

54
Q

How should coarctation be managed?

A

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
Q

What are the complications post co-arctation repair

A

Reco-arctation
Aneursym
Dissection

56
Q

When is repair of co-arctation indicated?

A

Symptomatic with peak pressure >30mmHg

Asymptomatic with HTN or LV failure

57
Q

What are the features of tetralogy of fallot?

A

Overriding Aorta
Pulmonary stenosis
VSD
RV hypertrophy

58
Q

What scenarios would make you consider tetralogy of fallot?

A

Breathlessness
Syncope
Growth retardation
Squatting at rest
Corrective surgery at rest

59
Q

What may you see on examination in tetralogy of fallot?

A

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
Q

What is tetralogy of fallot associated with?

A

Di George syndrome
- cleft palate (may be repaired)
- Long face
- Low ears

Polands syndrome
- unilateral pectoral hypoplasia

61
Q

How would you investigate someone with ToF?

A

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
Q

Features of pulmonary stenosis?

A

Loud ejection systolic murmur in pulmonary area
Louder on inspiration
Radiate to left infraclavicular region
Soft/Delayed P2 if severe
Palpable pulmonary thrill

63
Q

Causes of pulmonary stenosis?

A

Maternal rubella
Noonan’s syndrome
Carcinoid syndrome
Rheumatic fever
Tetralogy of Fallot

64
Q

Signs of severe pulmonary stenosis?

A

RV heave
Prominent A wave on JVP
Pansystolic murmur at left sternal edge - functional tricuspid regard
Widely split S2

65
Q

Symptoms associated with pulmonary stenosis?

A

Effort intolerance
Breathlessness
Fatigue
Fainting/syncopal episodes
Chest pain
Palpitations

66
Q

Differential diagnoses for pulmonary stenosis?

A

ASD
VSD

Can mention other systolic murmurs but mention location/character would vary

67
Q

Investigations for suspected pulmonary stenosis?

A

ECG - R heart strain
Echocardiogram - quantify severity of stenosis + aetiology.
CMRI

68
Q

Aetiology of Noonan’s syndrome

A

Autosomal dominant mutation of PTPN11 gene on chromosome 12 (>50%)
SOS1 on chromosome 2
RAF1 on chromosome 3

69
Q

Key features of Noonan’s syndrome

A

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
Q

How is Noonan’s diagnosed?

A

Usually on chorionic villus sampling/amniocentesis

71
Q

How is Noonan’s managed?

A

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

MRCP PACES (6 decks)

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