Cardiology Flashcards
Hallmarks of an innocent murmur
The5 Ss InnoSent: 1. ASymptomatic 2. Soft blowing murmur 3. Only Systolic murmur (not diastolic) 4. Left Sternal edge - Other: No thrill, no radiation
Symptoms of heart failure
- Breathlessness
- Sweating
- Poor feeding
- Recurrent chest infections
What is the most probable cause of HF during the first week of life?
Left heart obstruction
- Coarctation of the aorta
- Hypoplastic left heart syndrome
- Aortic valve stenosis
- Interruption of the aortic arch
The cyanotic heart diseases
The 5 Ts:
- Tetralogy of Fallot
- Transposition of great vessels
- Truncus arteriosis
- Total anomalous pulmonary venous return
- Tricuspid atresia
Types of ASD
- Secundum ASD - most common (80%)
2. Partial atrioventricular septal defect (AVSD) or primum ASD
Symptoms of ASD
- None (commonly)
- Recurrent chest infections/wheeze
- Arrhythmias
Physical signs in ASD
- Ejection systolic murmur, upper left sternal border - due to increased flow across the pulmonary valve
- Fixed and widely split second heart sound
Physical signs of small VSD
- Loud pansystolic murmur at the lower left sternal edge (loud murmur implies smaller defect)
- Quiet pulmonary second sound
Clinical features of large VSD
Symptoms:
- HF - breathlessness and faltering growth
- Recurrent chest infections
Signs:
- Tachypnea, tachycardia, enlarged liver from HF
- Active precordium
- Soft pan systolic murmur or no murmur
- Apical mid-diastolic murmur (from increased flow through the mitral valve)
- Loud pulmonary second sound
Left-to-right shunt disorders
- ASD (secundum 80%)
- VSD (small 80-90%)
- Persisten ductus arteriosis
- Endocardial cushion defect
When should the ductus arteriosis close, and when can you say that it is a PDA?
Should close shortly after birth.
In PDA is has failed to close by 1 month
Clinical features of PDA
- Continuous murmur beneath the left clavicle
- Increased pulse pressure, causing a collapsing or bounding pulse
- If duct is large - increased pulmonary blood flow with HF and pulmonary HTN
Management of PDA
- Preterm infants: Indomethacin (PGe inhibitor)
- Term infants: Coil or occlusion device, surgical ligation
Right-to-left shunt disorders
- Tetralogy of Fallot
- Transposition of the great vessels/arteries
What is hyperoxia (nitrogen washout) test?
Test to determine presence of heart disease in a cyanotic neonate.
- Placed in 100% oxygen for 10 min. - if <15 kPa / 113 mmHg - diagnosis of ‘cyanotic’ congenital heart disease (lung diseases must be excluded)
Side-effects of prostaglandin infusion
- Apnea
- Jitteriness
- Seizures
- Flushing
- Vasodilation
- Hypotension
Most common cause of cyanotic congenital heart disease?
Tetralogy of Fallot
What are the features of Tetralogy of Fallot?
- Large VSD
- Overriding of the aorta
- Subpulmonary stenosis (right ventricular outflow obstruction)
- Right ventricular hypertrophy
Classic old signs of Tetralogy of Fallot
- Severe cyanosis
- Hypercyanotic spells
- Squatting on exercise
What is a hypercyanotic spell?
Rapid increase in cyanosis
- Severe hypoxia causing:
- Irritability
- Inconsolable crying
- Tissue acidosis causing:
- Breathlessness
- Pallor
Signs of Tetralogy of Fallot
- Clubbing of the fingers and toes
- Loud harsh ejection murmur at the left sternal edge from day 1 of life
- Systolic thrill
Management of Tetralogy of Fallot
- Surgical correction at around 6 months - closing VSD and relieving right ventricular outflow tract obstruction
- If very cyanosed - shunt between the subclavian artery and the pulmonary artery
Management of a hypercyanotic spell
Usually self-limiting, if >15 min:
- Sedation and pain relief
- IV propranolol
- IV fluids
- Bicarbonate
- Muscle paralysis and artificial ventilation
Symptoms of transposition of the great arteries
- Cyanosis - present of day 2 of life when duct close
Physical signs of transposition of the great arteries
- Cyanosis
- Loud and single second heart sound
- Usually no murmur
Eisenmenger syndrome
Left-to-right shunt –> increased pulmonary blood flow –> medial hypertrophy of pulmonary vessels –> increased pulmonary vascular resistance –> right-to-left shunt
Shunt reverses at about 10-15 years of age - teenagers become blue, need transplantation
Pathophys of endocardial cushion defect
- Both ASD and VSD
2. Abnormal atrioventricular valves
What is a Blalock-Taussig shunt?
Shunt between subclavian and pulmonary arteries
Clinical features of aortic stenosis
- Most asymptomatic. May present with reduced exercise tolerance, chest pain on exertion or syncope
- Carotid thrill (always)
- Ejection systolic murmur, upper right sternal edge radiating to neck
- Delayed and soft aortic second sound
- Apical ejection click
Features of pulmonary stenosis
- Most asymptomatic
- Ejection systolic murmur, upper left sternal edge, thrill may be present
- Ejection click, upper left sternal edge
Most common type of coarctation of aorta
90% juxtaductal coarctation (adult-type)
Narrowing below left subclavian artery at origin of ductus arteriosus
Clinical features of coarctation of the aorta - adult type
- Asymptomatic
- Systemic HTN in the right arm
- Ejection systolic murmur at upper sternal edge
- Radio-femoral delay
- Collateral blood vessels heard at the back
Features at chest x-ray in coarctation of aorta
- ‘Rib-notching’ - development of large collateral intercostal arteries running under the ribs
- ‘3-sign’ - visible notch in the descending aorta at site of the coarctation
What is the most common cause of collapse due to left outflow obstruction?
Coarctation of aorta - infantile type (preductal, tubular hypoplasia)
Clinical features of coarctation of aorta - infantile type
First day normal, acute circulatory collapse at 2-days of age
- A sick baby, with severe HF
- Absent femoral pulses
- Severe metabolic acidosis
Which syndrome is associated with interruption of the aortic arch?
DiGeorge syndrome
Features of hypoplastic left heart syndrome
- Mitral valve is small or atretic
- Diminutive left ventricle
- Aortic valve atresia
- Very small ascending aorta
- Invariably coarctation of the aorta
Clinical features in hupoplastic left heart syndrome
- Profound acidosis
- Rapid cardiovascular collapse
- Weakness or absence of all peripheral pulses (in contrast to weak femoral pulses in coarctation)
The surgical procedure of hypoplastic left heart syndrome
Three-stage Norwood procedure
What is the most common childhood arrhythmia?
Supraventricular tachycardia
250-300 beats/minute
Causes of syncope
Usually benign
- Neurally mediated - in response to a range of provocations and stressors
- Cardiac - arrhythmic, heart block, QT syndrome, aortic stenosis, etc.
Features indicating a cardiac cause of syncope
- Symptoms on exercise
- Family history of sudden unexplained death
- Palpitations
Pathophys. of rheumatic heart disease
Short-lived, multisystem autoimmune response to a preceding infection with group A beta-hemolytic streptococcus
Clinical features of rheumatic fever
- Latent interval of 2-6 weeks following a pharyngeal or skin infection (pharyngitis/scarlet fever)
- Polyarthritis
- Mild fever
- Malaise
Rheumatic fever, JONES criteria
J - joints (migratory arthritis)
O - Carditis (endocarditis, myocarditis, pericarditis)
N - Nodes (subcutaneous nodules, extensor surfaces)
E - Erythema marginatum (rash on trunk and limbs)
S - Sydenham chorea (involuntary movements)
Most frequent affected valve in rheumatic fever?
Mitral valve
- Long-term damage from scarring and fibrosis - mitral stenosis
Management of rheumatic fever
- Bed rest, limitation of exercise
- Anti-inflammatory agents - Aspirin
- Corticosteroids may be required
- Treatment of heart failure
Clinical signs of infective endocarditis
- Fever
- Anemia and pallor
- Splinter hemorrhages in nailbed
- Clubbing (late sign)
- Necrotic skin lesions
- Changing cardiac signs
- Splenomegaly
- Neurological signs from cerebral infarction
- Retinal infarcts
- Arthritis/arthralgia
- Microscopic hematuria
What does the vegetations in endocarditis contain?
- Fibrin
- Platelets
- Infecting organisms
What is the most common pathogen causing endocarditis?
Alpha-hemolytic streptococcus (Streptococcus viridans)
Causes of pulmonary hypertension
- Pulmonary arterial HTN
- Idiopathic
- Cardiac (post-tricuspid shunts: VSD, AVSD, PDA)
- HIV
- Peristen pulmonary HTN of the newborn
- Pulmonary venous HTN
- Left-sided heart disease
- Pulmonary vein stenosis
- With respiratory disease
- Cohronic obstructive disease, BPD
- Interstitial lung disease
