Cardiology Flashcards
What are the clinical signs of aortic stenosis?
- Slow rising, low volume pulse
- Narrow pulse pressure
- Apex beat is sustained in stenosis (HP: heaving pressure-loaded)
- Thrill in aortic area (R sternal edge, second intercostal space)
- Auscultation - crescendo-decrescendo ejection systolic murmur (ESM) heard loudest in aortic area during expiration and radiating to the carotids
- If severe would hear a soft and delayed A2 due to immobile leaflets and prolonged LV emptying, delayed (not loud) ESM, fourth heart sound (S4)
What would you find if there was evidence of complications from AS?
- Endocarditis: splinters, Osler’s nodes (finger pulp), Janeway lesions (palms), Roth spots (retina), temperature, splenomegaly and haematuria
- Left ventricular dysfunction: dyspnoea, displaced apex and bibasal crackles
- Conduction problems: acute (endocarditis), chronic (calcified aortic valve node)
Name some DDx of Aortic Stenosis
- HOCM
- VSD
- Aortic sclerosis: normal pulse character and no radiation of murmur
- Aortic flow: high output clinical states e.g. pregnancy or anaemia
What are the causes of aortic stenosis?
- Congenital: Bicuspid aortic valve
- Acquired: Age (senile degeneration and calcification), Streptococcal (Rheumatic)
What conditions are associated with Aortic Stenosis?
- Coarctation of the aorta
- Bicuspid aortic valve
- Angiodysplasia
What mortality is associated with different symptoms of aortic stenosis?
- Angina - 5 years
- Syncope - 3 years
- Breathlessness - 2 years
What investigations would you request in someone with suspected AS?
- ECG: LVH on voltage criteria, conduction defect (prolonged PR interval)
- CXR: often normal; calcified valve
- Echo: mean gradient >40mmHg and aortic valve area of <1.0cm2 if severe
- Catheter: invasive transvalvular gradient and coronary angiography (coronary artery disease often co-exists)
How would you manage a patient with confirmed AS?
Asymptomatic:
- None specific, good dental health
- Regular review: symptoms and echo to assess gradient and LV function
Symptomatic:
- Surgical - aortic valve replacement +/- CABG. Operative mortality is 3-5% depending on the patient’s EuroScore
What are Duke’s criteria for infective endocarditis?
Major:
- Typical organism in 2x blood cultures
- Echo: abscess, large vegetation, dehiscence
Minor:
- Pyrexia >38
- Echo suggestive
- Predisposed e.g. prosthetic valve
- Embolic phenomena
- Vasculitis phenomena (raised ESR, CRP)
- Atypical organism on blood culture
You would diagnosis IE if patient had 2x major, 1 major and 2 minor, or 5 minor criteria.
Having associated HF or heart block or being resistant to antibiotics are an indication for urgent surgery
Who receives antibiotic prophylaxis for IE?
- Those with prosthetic valves, previous endocarditis, cardiac transplants with valvulopathy and certain types of congenital heart disease
What are the clinical signs of AR?
- Collapsing pulse (waterhammer pulse) reflecting a wide pulse pressure (e.g. 180/45)
- Apex beat is hyperkinetic and displaced laterally (TV: thrusting volume-loaded)
- Thrill in aortic area
- Auscultation: early diastolic murmur (EDM) heard loudest at the lower L sternal edge with the patient sat forward in expiration. There may be an aortic flow murmur and a mid-diastolic murmur (Austin-Flint murmur) due to regurgitant flow impeding mitral opening. In severe AR there may be ‘free flow’ regurgitation and the EDM may be silent.
What signs indicate severe AR?
- Collapsing pulse
- Third heart sound (S3)
- Pulmonary oedema
What signs are associated with AR?
- Corrigan’s sign: visible vigorous neck pulsation
- Quinke’s sign: nail bed capillary pulsation
- De Musset’s sign: head nodding
- Duroziez’s sign: diastolic murmur proximal to femoral artery compression
- Traube’s sign: ‘pistol shot’ sound over the femoral arteries
- Lighthouse sign - flushing and paling of forehead
- Muller’s sign - uvula pulsation
- Rosenbach’s sign - hepatic pulsation
- Gerhardt’s sign - splenic pulsation (if enlarged)
- Landolfi’s sign - change in pupil size synchronous with cardiac cycle
What are the causes of AR?
Congenital:
- Bicuspid aortic valve
Peri-membranous VSD
Acquired:
- Due to valve leaflet: endocarditis (acute) or rheumatic fever and drugs such as pergolide, slimming agents (chronic)
- Due to aortic root: dissection type A or trauma (acute) or due to dilatation secondary to Marfan’s or HTN or due to aortitis secondary to syphilis, ank spond or vasculitis (chronic)
Name some other causes of a collapsing pulse
- Pregnancy
- Patent ductus arteriosus
- Paget’s Disease
- Anaemia
- Thyrotoxicosis
What investigations would you request in someone with suspected AR?
- ECG: lateral T wave inversion
- CXR: cardiomegaly, widened mediastinum and pulmonary oedema
-TTE/TOE: to look for cause of AR such as intimal dissection flap or vegetation and also to check severity of AR by looking at LVEF and dimensions, root size and jet width - Cardiac catheterisation: grade severity aortogram and check coronary patency
How would you manage a patient with AR?
Medical:
- ACEi and ARBs (reducing afterload)
- Regular review: symptoms and Echo: LVEF, LV size and degree of AR
Surgical:
- Replace aortic valve when symptomatic dyspnoea and reduced exercise tolerance (NYHA >II) AND/OR wide pulse pressure >100mmHg, ECG changes on ETT, Echo: LV enlargement >5.5cm systolic diameter or EF >50%
- Ideally the valve should be replaced before there is any evidence of LVSD.
What is the prognosis of patients with AR?
- If asymptomatic with EF >50% then have a 1% mortality at 5 years
- If symptomatic and all 3 criteria present - 65% mortality at 3 years
What are the clinical signs of Mitral Stenosis?
- Malar flush
- Irregular pulse if AF is present
- Tapping apex (palpable first heart sound)
- L parasternal heave if pulmonary HTN is present or enlarged LA
- Auscultation reveals a loud first heart sound. There is also an opening snap of mobile mitral leaflets opening followed by a mid-diastolic murmur, which is best heard at the apex in the L lateral position in expiration with the bell. Pre-systolic accentuation of MDM if the patient is in sinus rhythm. If severe then the opening snap occurs nearer A2 and the MDM is longer.
What complications can arise as a result of Mitral Stenosis?
- Pulmonary Hypertension: functional tricuspid regurgitation, right ventricular heave and loud P2
- LVF: pulmonary oedema
- RVF: pedal oedema
- Endocarditis
- Embolic complications - stroke is high risk if mitral stenosis and AF
What are the causes of MS?
Congenital (rare)
Acquired:
- Rheumatic (commonest)
- Senile degeneration
- Large mitral leaflet vegetation from endocarditis (mitral ‘plop’ and late diastolic murmur)
What are the DDx of Mitral Stenosis?
- L atrial myxoma
- Austin-Flint Murmur
What investigations would you request in someone with suspected Mitral Stenosis?
- ECG: p-mitrale (broad, bifid), and AF
- CXR: enlarged L atrium (splayed of carina), calcified valve, pulmonary oedema
- TTE/TOE: valve area (<1.0cm2 is severe), cusp mobility, calcification and L atrial thrombus, right ventricular failure
How would you manage a patient with confirmed Mitral Stenosis?
- Medical: +AF - rate control and oral anti-coagulants, diuretics
- Mitral valvuloplasty: if pliable, non-calcified with minimal regurgitation and no L atrial thrombus
- Surgery: closed mitral valvotomy (without opening the heart) or open valvotomy (requiring cardiopulmonary bypass) or valve replacement
What is the prognosis of someone with Mitral Stenosis?
- Latent asymptomatic phase - 15-20 years
- NHYA >II - 50% mortality at 5 years
What is Rheumatic Fever?
Rheumatic fever occurs when there is an immunological cross-reactivity between Group A Beta-Haemolytic streptococcal infection e.g. Strep pyogenes and valve tissue
What are the Duckett-Jones diagnostic criteria?
Used for Rheumatic Fever
Require proven beta-haemolytic strep infection diagnosed by throat swab, rapid antigen detection test (RADT), anti-streptolysin O titre (ASOT) or clinic scarlet fever plus 2 major or 1 major and 2 minor criteria.
Major:
- Joint involvement (polyarthritis)
- O - myocarditis
- Nodules, subcutaneous
- Erythema marginatum
- Sydenham’s chorea
Minor:
- CRP elevated
- Arthalgia
- Fever
- Elevated ESR
- Prolonged PR interval
- Anamnesis of Rheumatic fever
- Leukocytosis
How would you treat Rheumatic Fever?
- Rest, high-dose aspirin and penicillin
What prophylactic treatment is given in Rheumatic Fever?
- Primary prevention: Pen V (or Clindamycin) for 10 days
- Secondary prevention: Pen V for about 5-10 years
What are the clinical signs associated with MR?
- Scars: lateral thoracotomy (valvotomy)
- Pulse: AF, small volume
- Apex: displaced and volume loaded
- Palpation: thrill at apex
- Auscultation: pan-systolic murmur (PSM) heard loudest at the apex radiating to the axilla. Loudest in expiration. Wide splitting of A2P2 due to the early closure of A2 because the LV empties sooner. S3 indicates rapid ventricular filling from LA, and excludes significant MS.
- Pulmonary oedema
- Potentially signs of endocarditis if this is the cause
- LVF and AF (late sign)
- Other murmurs such as ASD
What are the causes of MR?
Congenital: association between cleft mitral valve and primum ASD
Acquired:
- Related to valve leaflets:
— Acute:
——–Bacterial endocarditis
— Chronic:
——–Myomatous degeneration (prolapse)
——–Rheumatic fever
——–CTD
——–Fibrosis (fenfluramine/pergolide)
- Valve Annulus:
— Chronic:
——–Dilated L ventricle (functional MR)
——–Calcification
- Related to Chordae/Papillae:
— Acute:
——–Rupture
— Chronic:
——–Infiltration e.g. Amyloid
——–Fibrosis (post-MI, trauma)
How would you investigate a patient with suspected MR?
- ECG: p-mitrale, AF and previous infarction (Q waves)
- CXR: cardiomegaly, enlargement of the L atrium and pulmonary oedema
- TTE/TOE: to assess severity by size/density of MR jet and to check for LV dilatation and reduced EF and to look for cause e.g prolapse, vegetations, ruptured papillae, fibrotic restriction and infarction
How would you manage a patient with confirmed MR?
Medical:
- Anticoagulation for AF and embolic complications
- Diuretic, beta-blocker and ACEi
Percutaneous:
- mitral clip device for palliation in inoperative cases of mitral valve prolapse
Surgical:
- Valve repair (preferable) with annuloplasty ring or replacement
- Aim to operate when symptomatic, prior to severe LV dilatation and dysfunction
What is the prognosis of a patient with MR?
- Often asymptomatic for >10 years
- Symptomatic - 25% mortality at 5 years
Who tends to get mitral valve prolapse and how may it present? What are the associated risks?
- It is common (5%), especially in young, tall women
- Associated with CTD e.g. Marfan’s syndrome and HOCM
- Often asymptomatic, but may present with chest pain, syncope and palpitations
- Small risk of emboli and endocarditis
- Auscultation - mid-systolic ejection click. Pan-systolic murmur that gets louder up to A2. Murmur is accentuated by standing from a squatting position or during the straining phase of the Valsalva maneouvre, which reduces the flow of blood through the heart.
What are the clinical signs associated with TR?
- Raised JVP with giant CV waves
- Thrill at L sternal edge
- Auscultation: pan-systolic murmur (PSM) heard loudest at the tricuspid area (lower L sternal edge) in inspiration. Reverse split second heart sound due to rapid RV emptying. Right ventricular rapid filling gives an S3
- Pulsatile liver, ascites and peripheral oedema
- Endocarditis from IV drug abuse: look for needle marks
- Pulmonary HTN: RV heave and loud P2
- Other valve lesions: rheumatic mitral stenosis
What are the causes of TR?
Congential:
- Ebstein’s anomaly (atrialisation of the R ventricle and TR)
Acquired:
- IE (acute)
- Functional (commonest) - chronic
- Rheumatic fever - chronic
- Carcinoid syndrome - chronic
What investigations would you carry out in a patient with suspected TR?
- ECG: p-pulmonale (large, peaked) and RVH
- CXR: double R heart border (enlarged R atrium)
- TTE: TR jet, RV dilatation
How would you manage a patient with confirmed TR?
Medical:
- Diuretics, beta-blockers, ACEi and support stockings for oedema
Surgical:
- Valve repair/annuloplasty if medical treatment fails
What are the clinical signs of Pulmonary Stenosis?
- Raised JVP with giant A waves
- L parasternal heave
- Thrill in the pulmonary area
- Auscultation: ESM heard loudest in the pulmonary area on inspiration. Widely split second heart sounds due to delay in RV emptying. If severe would have inaudible P2 and longer murmur duration obscuring A2.
- RVF: ascites and peripheral oedema
- Tetralogy of Fallot: PS, VSD, over-riding aorta and RVH (sternotomy scar)
- Noonan’s syndrome: phenotypically like Turner’s syndrome but male sex
- Other murmurs: functional TR and VSD
What investigations would you request in a patient with suspected Pulmonary Stenosis?
- ECG: p-pulmonale, RVH and RBBB
- CXR: oligaemic lung fields and large R atrium
- TTE: to look at severity (pressure gradient), RV function and associated cardiac lesions
How would you manage a patient with Pulmonary Stenosis?
- Pulmonary valvotomy - if gradient >70mmHg or there is RV failure
- Percutaneous pulmonary valve implantation (PPVI)
- Surgical repair/replacement
What is carcinoid syndrome, how does it present and how is it treated?
- Gut primary with liver mets secreting 5-HT into the blood stream
- Toilet symptoms: diarrhoea, wheeze and flushing
- Secreted mediators cause R sided heart valve fibrosis resulting in tricuspid regurgitation and/or pulmonary stenosis
- Rarely a bronchogenic primary tumour or a R-to-L shunt can release 5-HT into the systemic circulation and cause L-sided valve scarring.
- Treatment: Octreotide or surgical resection
What are the clinical signs of prosthetic heart valves: aortic and mitral?
- Audible prosthetic clicks (metal) on approach and scars on inspection
Which scars are associated with which conditions?
- Midline sternotomy scar: CABG, AVR, MVR
- Lateral thoracotomy: MVR, mitral valvotomy, coarctation repair, BT shunt
- Subclavicular: Pacemaker, AICD
- Anticubital fossa: angiography
- Should also look in the wrist and groins for angiography scars/bruising and legs for saphenous vein harvest used in bypass grafts.
What is heard on auscultation of an aortic valve replacement?
Metal prosthetic closing click is heard instead of A2. There may be an opening clock and Ejection systolic flow murmur. A bioprosthetic valve often has normal heart sounds.
Abnormal findings would include AR and decreased intensity of the closing click (clot or vegetation)
What is heard on auscultation of a mitral valve replacement?
Metal prosthetic closing click is heard instead of S1. An opening click may be heard in early diastole followed by a low frequency diastolic rumble.
Abnormal findings would include MR and decreased intensity of the closing click.
What are the late complications associated with prosthetic valves?
- Thromboembolus: 1-2% per annum despite warfarin
- Bleeding: fatal 0.6%, major 3%, minor 7% per annum on warfarin
- Bioprosthetic dysfunction and LVF: usually within 10 years, can be treated percutaneously (valve-in-valve)
- Haemolysis: mechanical red blood cell destruction against the metal valve
- IE : early IE (<2 months post-op) can be due to Staph epidermidis from skin. Late IE is often due to Strep viridans by haematogenous spread. A second valve replacement is usually required to treat this complication. Mortality of prosthetic valve endocarditis approaches 60%
- AF: particularly in MV replacement
What are the pros and cons of metal vs porcine valve?
Metal Valve:
- Durable
- Requires warfarin
- Used in those who are young and on warfarin e.g. for AF
Porcine Valve:
- Doesn’t require warfarin
- Less durable
- Used in the elderly and those at risk of haemorrhage
Operative mortality is 3-5%
What are the clinical signs of an implantable device?
- Incisional scar in the infraclavicular position (may be abdominal)
- Palpation demonstrates a PPM
- Signs of HF: raised JVP, Bibasal crackles and pedal oedema
- Medic alert bracelet
- Local infection: hot, tender, red, fluctuant, erosion
When are ICDs inserted?
Primary Prevention:
MI >4 weeks ago (NYHA no worse than class III):
- LVEF <35% and non-sustained VT and positive EP study or
- LVEF <30% and QRSd >/= 120ms
Familial condition with high risk SCD:
- LQTS, ARVD, Brugada, HCM, complex congenital heart disease
Secondary Prevention (without other treatable cause):
- Cardiac arrest due to VT/VF
- Haemodynamically compromising VT or
- VT with LVEF <35% (not NYHA IV)
What are the clinical signs of pericardial disease?
- Predominantly R sided HF: Raised JVP (dominant brief y-descent due to rapid early ventricular filling and rise in diastolic pressure, rapid dominant y-descent due to high RA pressures and an early rise in RV diastolic pressure due to poor pericardial compliance)
- Kussmaul sign: paradoxical increase in JVP on inspiration (may need to sit patient at 90 degrees rather than 45 degrees to observe the JVP meniscus)
- Pulsus paradoxus: >10mmHg drop in systolic pressure in inspiration
- Auscultation: pericardial knock - high-pitched snap (audible, early S3 due to rapid ventricular filling into a stiff pericardial sac)
- Ascites, hepatomegaly (congestion) and bilateral peripheral oedema
