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Cardiology Flashcards

1
Q

Describe the murmur of AS and its associated features

A

Aortic area, radiating to carotids, crescendo-decrescendo ESM.

Loudest in held expiration.

Aortic thrill may be plapable.

S4

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2
Q

What are possible causes of conjunctival pallor in AS?

A

Anaemia from ACD, Heyde’s syndrome, or haemolysis across prosthetic valve.

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3
Q

What features indicate severe AS on examination?

A

Slow-rising pulse, narrow pulse pressure, quiet S2, S4, LV failure, cardiac decompensation features

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4
Q

What symptoms correlate with AS severity?

A

Angina (50% 5 yrs), Syncope (50% 3 yrs), Dyspnoea (50% 2 yrs) survival if untreated.

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5
Q

Name important negatives to mention in AS assessment.

A

Infective endocarditis, LVF, severity indicators.

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6
Q

What are differential diagnoses for an ESM?

A

AS, aortic sclerosis, HOCM, PS, (MR, VSD - only for systolic)

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7
Q

What are the common causes of AS?

A

Degenerative calcification, bicuspid valve, rheumatic fever.

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8
Q

What ECG finding is significant for TAVI planning?

A

Conduction disease or arrhythmia.

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9
Q

What echo parameters define severe AS?

A

Mean gradient > 40 mmHg, valve area < 1cm², jet velocity > 4 m/s.

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10
Q

What are surgical indications for AS?

A

Symptomatic AS, LVEF < 50%, severe AS undergoing CABG.

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11
Q

Name components of a TAVI work-up.

A

TAVI gated CT, OPG and dental check, lung function tests, carotid dopplers.

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12
Q

List complications of AS.

A

LVF + cardiac decompensation
arrhythmias
AV block (Calcified aortic valve)
anaemia/angiodysplasia
embolism
endocarditis.

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13
Q

What are TAVI complications?

A

PPM need (10%), vascular access issues, stroke, MI.

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14
Q

What are some associations with AS?

A

Bicuspid aortic valve + coarctation of the aorta, aortic dissection
Angiodysplasia

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15
Q

What drugs are contraindicated in severe AS?

A

Nitrates, sildenafil, ACE inhibitors.

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16
Q

What are the 4 pillars of HF medical management?

A

Beta blockers
MRA (spironalactone, eplerenone)
ACEi/ ARNI (sacubitril/valsartan)
SGLT2i

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17
Q

What investigations would you do in AS?

A

History (sx of severity)
Obs (BP ?narrow, ?temp if IE)
Urine dip + fundoscopy if ?IE
Bloods: FBC (anaemia), UE, LFT, CRP (if IE), Hba1c, bNP, lipids
ECG: LVH, conduction defects
CXR: Pulmonary oedema, calcified valve
Echocardiogram: diagnosis, severity, left ventricular function, other valves
Cardiac catheterisation: coronary arteries ? CABG

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18
Q

How would you manage a patient with aortic stenosis?

A

General
MDT: Cardiologist, CTS, specialist nurses, GP (TAVI MDT/CTS for surgery)

Specific
Optimise CVS risk: lipids, BP, BM
If asymptomatic and not severe: follow-up with 6 monthly echo

Surgical/interventional
If symptomatic or severe AS -> aortic valve replacement (TAVI vs surgical)
Prefer surgical if require concomitant CABG

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19
Q

Clinical features of someone with a prosthetic heart valve

A

Midline sternotomy (without signs of saphenous vein grafting but this does not exclude them having had a CABG as well as may be LIMA or radial artery)

Metallic click

Signs of anticoagulation

AF

Signs of previous lines for abx therapy?

Signs of IE? (Clubbing)

PPM i.e. post TAVI

Conjunctival pallor

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20
Q

Which murmurs are abnormal in aortic and mitral valve replacements?

A

AVR: Aortic regurgitation
MVR: Mitral regurgitation

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21
Q

If you have a midline sternotomy scar, and a murmur without a metallic click. What could this indicate?

A

Failing bioprosthetic valve or pt has had a CABG and has native valve disease

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22
Q

In someone with mutlivalvular disease/replacement, especially if they are young, what could the aetiology be?

A

Rheumatic heart disease
IE
Congenital heart disease

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23
Q

What are the significant negatives when presenting a valve replacement?

A

Signs of heart or valve failure
IE
Haemolysis (jaundice/anaemia)
Bruising

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24
Q

What are the indications for an aortic valve replacement?

A

Aortic stenosis
Aortic regurgitation
CTDs
Senile degeneration of valve
Bicuspid aortic valve
Infective endocarditis
Rheumatic heart disease

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25
What murmurs may be normal in well seated prosthetic valves?
AVR: Soft systolic murmur MVR: Soft diastolic murmur
26
What % of AVR patients require a PPM?
10%
27
INR target for MVR and AVR
MVR: 2.5-3.5 AVR 2-3
28
Which investigations in someone with a valve replacement?
History (DH - see warfarin yellow book, any new meds?) Obs (temp) Urine dip, fundoscopy Bloods: FBC (MAHA, anaemia), UE, LFT, CRP, Coag (INR), Hba1c, lipids, BNP] ECG: AF, p mitrale (MR), LVH, conduction defects i.e. post TAVI CXR: Look at valve and any pulm oedema Echo: valve and ventricular function, vegetations
29
List some complications of valve replacements
Valve failure -> cardiac decompensation Haemolysis -> anaemia and jaundice MI + Stroke (highest risk intra/post-op) Bleeding and thromboembolism Conduction defects/ arrhythmias Infective endocarditis
30
Where should IE be managed?
In a tertiary centre with access to cardiothoracics, cardiology, microbiology for IP management.
31
Clinical features on inspection in MR
Lateral thoracotomy scar if had mitral valvulotomy Bruising from anticoagulation Raised JVP
32
MR features on palpation
Pulse: AF Apex: laterally displaced and thrusting +/- apical thrill Parasternal heave of RVH Palpable P2
33
MR features on auscultation (heart + lungs)
PSM, apex, radiates to axilla, loudest in held expiration. Soft S1 Possibly S3 +/- Bi-basal crackles
34
Indicators of severity in MR
AF Right ventricular failure Cardiac decompensation
35
MR DDx
MR TR VSD AS
36
What are the causes of mitral regurgitation?
Primary (Degenerative) - MVP - Senile degeneration Primary (infective) - IE - Rheumatic heart disease Secondary (functional) - LV dilatation ie secondary to cardiomyopathy - Connective tissue disorders - Ischaemic - Fibrosis i.e. secondary to chemo - Infiltrative i.e. amyloidosis
37
Clinical features of severity in MR
AF Pulmonary HTN RVF + LVF Widespread PSM Palpable thrill
38
Ix for MR
History Obs Bloods: FBC, UE, LFT, BNP, Hba1c, lipids ECG: AF? P mitrale? RV or LV strain CXR: Pulmonary oedema? enlarged heart? Echo: diagnosis, degree of regurg, cause, other valves, ventricular function, pulmonary pressures Cardiac catheterisation done pre-op and can assess R heart pressures
39
Mx of MR
General Heart team MDT: CTS, cardiologist, specialist nurses, GP Optimise CV risk: lipids, BM, BP If asymptomatic and non severe -> monitor with follow ups and echo Specific Reduce afterload: ACEi, BB, diuretics Manage AF: Rate control + anticoagulate based on cHADSVASC Surgical (percutaneous or surgical) Symptomatic + severe -> mitral valve intervention Asymptomatic and severe -> ?other features - New AF - Left atrial dilatation - LVEF < 60% - Pulmonary pressures >50mmHg If none of above present but low surgical risk then would still tend to oeprate Decision made at heart team MDT
40
Mx of patients who are asymptomatic but have severe echocardiographic features of MR?
Depends on other associated features such as: - New AF - Left atrial dilatation - Impaired ventricular function and LVEF <60% - Pulmonary pressures > 50mmHg
41
What are some causes of a collapsing pulse?
AR Pregnancy Thyrotoxicosis Anaemia PDA Paget's disease
42
Clinical features of aortic regurgitation on examination
Inspection: Features of CTD? Ankylosing spondylitis features? IE signs Features of cardiac decomp: raised JVP, peripheral oedema Palpation: Collapsing pulse Laterally displaced, thrusting apex Aortic thrill Auscultation: EDM Soft/absent S2 Loudest at LLSE, leaning forward, in held expiration Crackles at based
43
Name some eponymous signs of AR
Corrigan's - dancing carotids Quincke's - pulsating nail bed Traubes - pistol shot femorals Water hammer pulse (only presesnt if wide PP) De musset - head bobbing Mueller's - uvula pulsation
44
What other murmurs can be heard in AR?
Austin-Flint murmur in severe AR = mid-diastolic rumbling murmur like MS due to regurgitant jet abutting mitral valve leaflet
45
Signs of severity in AR
Wide PP Collapsing pulse LV failure/pulmonary oedema S3 SHORT murmur
46
AR DDx
Right sided: pulmonary regurgitation, tricuspid stenosis Left: Mitral stenosis
47
Causes of AR
Acute - IE - Dissection - Failing AVR Chronic - BCAV - CTDs - Rheumatic heart disease - Autoimmune: AS, RA - Syphilis
48
What ix would you do in a pt with AR?
History Obs (Wide PP) ECG: LVH? LV strain (TWI in lateral leads) Bloods: FBC, UE, LFT, BNP, Hba1c, lipids (autoimmune screen like ANA, ESR, anti-CCP/Rf, HLA-B27) CXR: Pulmonary oedema, cardiac enlargement Echo: confirm diagnosis, cause, degree of regurgitation, ventricular function, other valves CT if aortopathy and want to visualise aortic root better to size it Cardiac catheterisation pre-op to assess patency of coronaries and assess need for CABG
49
Mx of patient with AR
General: Heart team MDT: CTS, Cardio, GP, specialist nurses Monitored if asymptomatic and not severe Specific: Reduce afterload: ACEi, BB, diuretics Optimise cardiac risk: BP, lipids, BM Surgical: Aortic valve replacement Indications - Dyspnoea AND/or: - Wide PP > 100mmHg - ECG changes - Echo showing LV enlargement or dysfunction (EF <50%) - Significant root dilatation
50
Signs of AR severity on echo
LVEF < 50% LV ESD > 50mm Degree of regurgitation
51
What is the characteristic murmur in MVP?
mid-systolic click + late systolic murmur, loud s1 (unlike MR)
52
What feature of the murmur can help differentiate MVP from MR?
MVP = Loud S1 MR = QUiet s1
53
What does it mean by dynamic murmur when describing MVP?
The murmur increases in intensity when standing from squatting and with valsalva
54
Which murmurs are dynamic?
HOCM and MVP - louder with standing from squatting and with valsalva
55
What can complicate MVP?
MR + Pulmonary HTN IE Cardiac decompensation
56
Aetiology of MVP
Idiopathic Familial (AD) CTD (Marfan's) Congenital e.g. Turner's
57
Which diseases associated with MVP?
WPW ADPKD PDA Marfan's/CTDs Myotonic dystrophy
58
Which cardiac conditions associated with myotonic dystrophy?
Conduction defects Arrhythmias MVP Cardiomyopathy
59
Mx of MVP
Reassurance and patient education Does not routinely require repair Medical mx ofheart failure if present
60
Features of infective endocarditis in a history/exam
Clubbing splinter haemorrhages fingers and toes Janeway, Osler Roth spots Microscopic haematuria Splenomegaly Stroke Splenic/renal/hepatic/brain infarcts
61
What might the ECG show in MVP?
Possibly p mitrale and AF (if complicated by MR) and also possible WPW
62
Which cardiological condition associated with arrhythmia is linked to MVP?
WPW
63
What signs suggest MR as a complication of MVP?
Laterally displaced, thrusting apex Soft s1 murmur radiating to axilla AF Cardiac decompensation (pulm HTN etc)
64
What type of murmur is heard in mitral stenosis?
Mid-diastolic murmur with opening snap.
65
Where is the MS murmur best heard?
At the apex, left lateral decubitus, held expiration, with bell.
66
What heart sound is often loud in MS?
S1 (S2 may be loud if pulmonary hypertension is present).
67
What facial sign may be seen in MS?
Malar flush due to pulmonary hypertension.
68
What does a tapping apex indicate in MS?
Loud S1 from forceful closure of stenotic mitral valve.
69
What rhythm abnormality is common in MS?
Atrial fibrillation.
70
What are signs of pulmonary hypertension in MS?
Loud P2, RV heave, TR murmur, palpable P2.
71
What additional murmur might be heard in severe MS?
Graham-Steell murmur (pulmonary regurgitation, eDM over pulm area).
72
What are signs of severe mitral stenosis?
AF, cardiac decompensation, longer murmur, signs of pulmonary hypertension.
73
What are significant negatives to mention in MS assessment?
No signs of IE, right heart failure, or pulmonary hypertension.
74
What are common causes of mitral stenosis?
Rheumatic heart disease, degeneration, congenital, non-valvular i.e. LA myxoma or vegetation.
75
What are differentials of MS murmur?
Austin Flint murmur, AR, LA myxoma, TS, PR (right-sided).
76
What ECG findings are associated with MS?
P mitrale, atrial fibrillation.
77
What might CXR show in MS?
LA enlargement (splaying of carina), pulmonary oedema.
78
What is the role of TTE in MS?
Confirms diagnosis, assesses severity, LV function, other valves.
79
When is TOE indicated in MS?
To assess for LA thrombus pre-intervention.
80
What is the role of cardiac catheterisation in MS?
Assess coronaries and right heart pressures pre-op.
81
What is the valve area threshold for severe MS and the PASP?
<1 cm², > 50mmHg
82
What is the preferred surgical intervention for MS?
Percutaneous balloon mitral valvulotomy.
83
When is mitral valve replacement considered in MS?
If valvulotomy not possible or failed.
84
What medical management is needed for AF in MS?
Rate control (BB), warfarin anticoagulation.
85
What general medical management is advised in MS?
Optimise CV risk factors (BP, lipids, glucose), regular echo follow-up.
86
What complications can arise from MS?
Stroke, AF, RVF/CCF, pulmonary hypertension, TR.
87
Outline the general management of MS
General: - MDT: Cardiologist, CTS, Specialist nurse, GP - Optimise CVS health (statins, bP, BM) - Follow up and echo Medical - AF: Rate, Anticoagulate if AF and benefits outweigh risk - Consider rheumatic fever prophylaxis with pen v for 5-10 years Surgical Indications: symptomatic/severe, mod-severe + asymptomatic - Percutaneous balloon mitral valvulotomy preferred - Surgical valvulotomy - MVR
88
Describe the murmur of PS
Ejection systolic murmur heard loudest over the pulmonary area in inspiration
89
Where does the murmur of PS radiate to?
The left shoulder
90
What additional features may be found on examination of a patient with PS?
Pulmonary thrill Parasternal heave due to RVH QUIET P2
91
How to differentiate betwee pulmonary hypertension and pulmonary stenosis murmurs?
In pulm HTN = LOUD P2 In PS = quiet p2
92
Causes of pulmonary stenosis
Congenital Maternal rubella Carcinoid Rheumatic heart disease
93
Which maternal infection associated with PS?
Maternal rubella
94
Which congenital conditions associated with PS?
ToF Noonan William's
95
What are 2 causes of a loud p2?
Pulm HTN Bioprosthetic pulmonary valve
96
If a patient has a parasternal heave and no palpable p2, what is the diagnosis?
Pulmonary stenosis
97
Palpable P2 but NO heave?
bioprosthetic valve
98
What are some differentials for a midline sternotomy scar?
CABG Valve replacement Congenital heart disease Transplant
99
Differentials for an impalpable apex beat?
Dextrocardia COPD/Emphysema -> barrel chest Body habitus Normal variant
100
What JVP finding characteristic of TR?
Giant CV waves
101
What systemic signs may be present in TR?
Pulsatile hepatomegaly, congestive hepatomegaly, peripheral oedema
102
What are important additional signs to offer to examine for in suspected TR?
Feel for pulsatile liver, hepatomegaly, ascites and signs of CLD
103
DDx of PSM at LLSE
TR MR VSD
104
Most common functional cause of TR?
Pulmonary HTN
105
Which congenital abnormality associated with TR?
Ebstein's anomaly
106
Causes of TR
- Pulm HTN - CCF - Secondary to severe MS/ Left sided heart murmurs - Congenital (Ebstein) - Infective endocarditis (IVDU) - Rheumatic heart disease - Carcinoind syndrome
107
Outline the mx of TR
General - MDT - Education - Follow up + echo Medical mx - Diuretics and fluid restrict if heart failure - Treatment of underlying condition giving rise to pulmonary HTN Surgical - Valvular repair considered on a case by case basis

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