Cardiology Flashcards
What clinical signs are associated with mitral stenosis?
Small pulse pressure Early opening snap (raised LA pressure) Mid-diastolic rumbling murmur Diastolic thrill at apex Pulmonary HTN - Loud P2 - Pulmonary regurgitation - RV heave - TR (can produce large V waves) - Prominent "a" wave
What are the clinical signs of aortic regurgitation?
Collapsing pulse / waterhammer pulse
Wide pulse pressure
Early diastolic murmur (aortic or left sternal edge)
What are the ECG findings in right ventricular hypertrophy?
Right axis deviation > 110
Dominant R wave in V1 (>7mm or R>S)
Dominant S wave in V5 or V6 (>7mm or S>R)
QRS < 120msec (not RBBB)
What findings would you expect in the following in mitral regurgitation:
- ECG
- CXR
- TTE
ECG: P mitrale, AF, LVH, Right axis deviation
CXR: LA enlargement, LV enlargement, mitral annular calcification, pulmonary HTN (large RA, prominent pulmonary arteries, pruning of peripheral pulmonary vessels)
TTE: thickened leaflets (rheumatic), prolapsing leaflet, LA size (chronicity and severity), LV size and function, L atrium regurgitant jet, mitral annulus calcification
What clinical signs are associated with aortic stenosis?
Pulse
- Low volume pulse with delayed upstroke (pulsus parvus et tardus). Sometimes anacrotic notch. Bisferens pulse if combined with AR.
Heart
- Heaving apex beat
- Systolic thrill over aortic region and carotids when sitting up in full expiration
- ES murmur radiating to carotids
- Soft S2
- Ejection click L sternal border
- S4
- S3
- Listen for early diastolic murmur (mild AR)
What clinical signs are associated with mitral regurgitation?
Pulse - bounding
Apex beat - laterally displaced , brisk/hyperdynamic
Heart sounds
- Holosystolic murmur after S1, best over apex
- Murmur usually radiates to axilla/back
- S3 and palpable thrill
- Soft S1
- Widely split S2 due to early A2 and late P2
Lungs - creps
What are the causes of mitral regurgitation?
Infective endocarditis
AMI
Surgery
Trauma
Degenerative disease
Mitral valve prolapse
Rheumatic
Papillary muscle dysfunction (LV failure or ischaemia)
Connective tissue disease (RA or AS)
Congenital - endocardial cushion defect, parachute valve, corrected transposition
What are the clinical signs of severity in mitral regurgitation?
Low volume pulse
Displaced apex beat
Systolic thrill
Soft S1 Early A2 (wide splitting) S3 S4 Diastolic rumble
Left ventricular hypertrophy
Left ventricular failure
Pulmonary HTN (late sign)
What are the clinical signs of severity in mitral stenosis?
Narrow pulse pressure Early opening snap Long duration of diastolic murmur Pulmonary HTN Pulmonary congestion Graham-Steell murmur (PR)
What are clinical signs of severity in aortic stenosis?
Low volume pulse Slow-rising pulse Plateau pulse Narrow pulse pressure Heaving apex beat Systolic thrill over aortic region Soft S2 Paradoxical splitting of S2 S4 Length, harshness and lateness of systolic murmur peak Pulmonary congestion Pumonary HTN
What are the signs of severity in aortic regurgitation?
Wide pulse pressure Long duration of decrescendo diastolic murmur 3rd heart sound Austin Flint murmur Signs of pulmonary HTN Signs of LV failure
What are the causes of a hyperdynamic circulation?
Exercise Pregnancy Fever Hypoxia Hypercapnia AVF Anaemia Beriberi (thiamine deficiency) Thyrotoxicosis
What are the causes of increased splitting (wider on inspiration) of S2?
MR
Pulmonary stenosis
VSD
RBBB
What are the causes of reversed splitting of S2?
AS
LBBB
Coarctation of the aorta
PDA (large)
What are the components of the hypertensive exam?
- Inspect: Cushing’s, acromegaly, uraemia, polycythaemia
Limbs
- BP in both arms and one leg
- Radio-femoral and radio-radial delay
- Vasculitic changes in upper limbs
Face
- Conjunctival injection (polycythaemia)
- Fundi for HTN changes
Chest
- LV failure (incl 4th heart sound)
- Coarctation (reversed splitting S2, posterior midsystolic murmur)
Abdomen
- Renal + adrenal masses
- AAA
- Renal bruits (just above the umbilicus, paramedially)
Flanks
- Systolic-diastolic murmur suggests renal AVF)
Extra
- U/A: casts, red cells
What are the changes of HTN on fundscopy?
SAV HEX OEDEMA
Grade I - Silver wiring
Grade II - AV nipping
Grade III - Haemorrhages, exudates
Grade IV - Papilloedema
What are the components of the Marfan’s examination?
Limbs
- Arachnodactyly
- Hypermobility
Face
- Iridodonesis (suggests lens dislocation)
- Blue sclera
- High arched palate
Chest
- Pectus excavatum or carinatum
- AR, MVP, MR
- AAA, coarctation
Back
- Kyphoscoliosis
- Hypermobility
Arm span > height
Upper:lower segment ratio < 0.85
What are the components of the oedema examination?
- Nutritional status (low alb, B1 deficiency)
- Myxoedema
Lower limbs
- DVT signs
- Varicose veins
Groin
- LN
Abdomen
- Inferior prominent veins that drain into umbilicus (IVC obstruction)
- Ascites
- Abdominal masses (liver, kidneys)
Neck
- JVP
- LN exam
Other
- Delayed reflexes (myxoedema)
- U/A: proteinuria
Causes of non-pitting oedema: Myxoedema, malignant infiltration, congenital disease, Milroy’s disease
What are the causea of SVC obstruction?
Lung cancer (90%)
Retrosternal masses (goitre, thymoma, lymphoma, germ cell tumour)
Massive mediastinal LN
Aortic aneurysm
What are the ECG findings in HOCM?
LVH
Q waves < 40ms in lateral leads (I, aVL, V5, V6) and inferior leads
What the features of mitral valve prolapse?
Mid-systolic click followed by systolic murmur
- Earlier with decreased cardiac volume (standing, Valsalva)
- Later with increased cardiac volume (squatting, beta blockers)
- Louder with isometric hand grip
Which conditions are associated with mitral valve prolapse?
Marfan's Ehlers-Danos Pseudoxanthoma elasticum Osteogenesis imperfecta Polycystic kidney disease SLE Psoriatic arthritis
What are the causes of secondary pulmonary stenosis?
Rheumatic heart disease
Carcinoid syndrome
Noonan’s syndrome
Tetralogy of Fallot
What are the causes of hypertrophic cardiomyopathy and what are the associated clinincal findings?
Causes
- HTN
- Aortic stenosis
- Aortic coarctation
- Autosomal dominant
- Friedrich’s ataxia
- Haemochromatosis
- Amyloidosis
- Glycogen storage diseases
- Lysosomal diseases
- Mitochondrial cardiomyopathy
Signs:
- Sharp rising and jerky or double pulse (bisferiens)
- Prominant a waves due to RA contraction against stiff RV
- Double-impulse “tapping” apex beat
- Left sided systolic murmur (LVOTO) that increases on release of Valsalva
What symptoms are associated with mitral valve prolapse?
What are the associated complications?
Symptoms
- Palpitations associated with mild tachyarrhythmias
- Increased adrenergic symptoms
- Chest pain
- Anxiety or fatigue
Complications
- Severe MR
- Arrhythmias: VEBs, VT, paroxysmal SVT
- Infective endocarditis in those with MR
- TIA, embolism
- Sudden death
What are the common causes of mixed aortic valve disease (AS+AR)?
Degenerative disease
Bicuspid aortic valve (younger)
Rheumatic heart disease
What manoeuvres increase the intensity of an MS murmur?
Valsalva
Exercise
Squatting or handgrip (increases afterload)
Why does differential cyanosis occur in a patent ductus arteriosus?
Deoxygenated blood from PDA is delivered to aorta distal to the left subclavian artery root
Where are the lines of reference to separate mechanical AVR and MVR on PA and lateral CXR?
PA: between LA appendage and right cardiophrenic recess
Lateral: Carina and cardiac apex
Pulmonary stenosis and patent ductus arteriosus are associated with which maternal infection?
Congenital rubella
What is the only right heart sound that is softer on inspiration?
Pulmonary valvular opening click
- Atrial click in inspiration prematurely opens the pulmonary valve, reducing the intensity of the opening snap
What is a Blalock-Taussig shunt?
Anastomosis of left subclavian artery to left pulmonary artery for Tetralogy of Fallot
What are the common causes of Eisenmenger’s syndrome?
Which is associated with cardiomegaly?
ASD, VSD and PDA
- ASD may cause cardiomegaly
What are the causes of bradycardia?
- Physical fitness in athletes
- Aging
- AMI
- AV nodal blockers
- Hypothyroidism
- Obstructive jaundice
- Increase ICP
- Hypothermia
- Hypokalaemia
What are the causes of TR?
- Pulmonary HTN
- AMI
- Pulmonary stenosis
- Pulmonary artery stenosis
- Infective endocarditis
- Carcinoid syndrome
- Ebstein’s anomaly
- Endomyocardial fibrosis
- Tricuspid valve prolapse
What are the indications for mitral valve repair in asymptomatic but severe mitral regurgitation?
- LVEF30-60 and/or LVESD≥40mm
- New onset AF or new PHTN
- If another cardiothoracic operation is required, MV repair may be done simulatneously
