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Hark and Paul's clinical review > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What are the causes of aortic stenosis?

A

Degenerative calcification
Rheumatic heart disease
Congenital bicuspid aortic valve

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2
Q

What are the signs of severity of aortic stenosis?

A 
Plateau/Anacrotic slow rising pulse
Narrow pulse pressure
Length of systolic murmur
Loud S2
S4
LVF
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3
Q

What are the indications for surgery in Aortic Stenosis? (HK)

A

Symptoms of heart failure regardless of EF
Asymptomatic patients with Severe AS & EF<50%
Severe AS undergoing other cardiac surgery
Critical AS with valve are <0.7cm2

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4
Q

What are the types of surgery available in Aortic Stenosis?

A

> Surgerical Aortic Valve Replacement
- Surgical AVR indicated in patients who meet an indication for AVR with low-intermediate surgical risk
Transcatheter Aortic Valve Implantation
- TAVI indicated in patients who meet an indication for AVR who have a prohibitive surgical risk & predicted post-TAVI survival >12 months
- Contraindications to TAVI include i) Estimated life expectancy <1 year, ii)Inadequate annulus size, iii) Thrombus in LV, iv) Active endocarditis, v) Bicuspid aortic valve

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5
Q

What are the causes of Aortic Regurgitation?

A

> Acute
-Infective endocarditis
-Aortic root rupture or Dissecting aneurysm
-Trauma
-Prosthetic valve failure
Chronic
-Congenital bicuspid aortic valve
-Rheumatic heart disease
-Seronegative arthropathy (ankylosing spondylitis)
-Aortitis in seronegative arthropathies or tertiary syphilis

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6
Q

What are the signs of severity of Aortic Regurgitation?

A
  • Collapsing water hammer pulse
  • Wide pulse pressure
  • Length of decrescendo diastolic murmur
  • Soft S2
  • LVF
  • Austin Flint Murmur (low pitched rumbling mid diastolic murmur at apex)
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7
Q

What are the indications for surgery in Aortic Regurgitation?

A
  • Symptoms of heart failure regardless of EF
  • Asymptomatic patients with Severe AR & EF <50%
  • Severe AR undergoing other cardiac surgery
  • Aortic root dilatation >50mm
  • Reduction in exercise EF >5%
  • Concomitant angina
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8
Q

What are the causes of Mitral Stenosis?

A
  • Rheumatic heart disease
  • Post mitral valve repair for MR
  • Severe mitral annular calcification
  • Congenital
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9
Q

What are the signs of severity of MItral Stenosis?

A
  • Narrow pulse pressure
  • Length of rumbling mid diastolic murmur
  • Diastolic thrill at apex
  • Opening snap
  • Loud S1
  • Pulmonary hypertension
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10
Q

What are the indications for surgery in Mitral Stenosis?

A
  • Percutaneous Mitral Balloon Commisurotomy (PMBC) is recommended for symptomatic severe MS (MVA <1.5cm2) & favourable valve morphology
  • Mitral Valve Surgery is recommended for symptomatic severe MS (MVA <1.5cm2) who are not high risk for surgery & are not candidates for PMBC.
  • Mitral Valve Surgery is recommended for severe MS undergoing other cardiac surgery.
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11
Q

What are the causes of Mitral Regurgitation?

A 
>Acute
-Infective endocarditis
-Trauma
-Myocardial infarction
>Chronic
-Rheumatic heart disease
-Papillary muscle dysfunction
-Connective tissue disease
-Mitral valve proplapse
-Degenerative disease
-Congenital
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12
Q

What are the signs of severity of Mitral Regurgitation?

A
  • Soft S1
  • S3
  • LVF, LVH
  • Pulmonary hypertension
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13
Q

What are the indications for surgery in Mitral Regurgitation?

A
  • Symptomatic Severe MR with LVEF >30%

- Chronic Severe MR undergoing other cardiac surgery

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14
Q

What are the causes of Tricuspid Regurgitation?

A
  • Functional TR secondary to RVF or Pulmonary HTN
  • Rheumatic heart disease
  • Infective endocarditis
  • Ebstein’s anomaly
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15
Q

What are the signs of severity of Tricuspid Regurgitation?

A
  • Soft S1
  • Elevated JVP with v waves
  • Pulsatile tender liver
  • Ascites
  • Peripheral oedema
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16
Q

What are the indications for surgery in Tricuspid Regurgitation?

A
  • Severe TR undergoing left sided valve surgery

- Symptomatic Severe TR unresponsive to medical therapy

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17
Q

What are the causes of:

i) Dominant ‘a’ wave
ii) Dominant ‘v’ wave
iii) Cannon ‘a’ wave
iv) Increased JVP

A

i) Dominant ‘a’ wave: TS, PS, Pulmonary HTN
ii) Dominant ‘v’ wave: TR
iii) Cannon ‘a’ wave: CHB
iv) Increased JVP: RVF, TR, Constrictive pericarditis

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18
Q

What are the causes of:

i) Anacrotic slow rising pulse
ii) Plateau slow rising pulse
iii) Collapsing water hammer pulse

A

i) Anacrotic slow rising pulse: AS
ii) Plateau slow rising pulse: AS
iii) Collapsing water hammer pulse: AR

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19
Q

What are the causes of:

i) Soft S1
ii) Loud S1
iii) Soft S2
iv) Loud S2
v) S3
vi) S4

A

i) Soft S1: MR, TR
ii) Loud S1: MS, TS
iii) Soft S2: AR, PR
iv) Loud S2: AS, PS
v) S3: AR, MR, VSD, PDA
vi) S4: AS, MS, PS, HOCM
* Heart sounds are soft in Regurgitation & Loud in stenosis. S3 due to regurgitation. S4 due to stenosis.

20
Q

What are the differential diagnoses for:

i) Pansystolic murmur
ii) Ejection systolic murmur
iii) Early diastolic murmur
iv) Mid-diastolic murmur
v) Continuous murmur

A

i) Pansystolic murmur: MR, TR, VSD
ii) Ejection systolic murmur: AS, PS, HOCM, ASD
iii) Early diastolic murmur: AR, PR
iv) Mid-diastolic murmur: MS, TS
v) Continuous murmur: PDA, AVF

21
Q

What is the effect of:

i) Inspiration
ii) Expiration
iii) Left lateral decubitus position
iv) Leaning forward & expiration
v) Valsalva manoeuvre

A

i) Inspiration: Increased right sided murmurs (T/P)
ii) Expiration: increases left sided murmurs (A/M)
iii) Left lateral decubitus position: Increases MS
iv) Leaning forward & expiration: Increases AR
v) Valsalva manoeuvre: Increases HOCM & MVP, Reduces AS

22
Q

What are the causes of Pulmonary Stenosis?

A
  • Congenital

- Carcinoid syndrome

23
Q

What are the signs of severity of Pulmonary Stenosis?

A
  • Length of systolic murmur
  • Loud S2
  • S4
  • RVF, Increased JVP
  • Peripheral cyanosis secondary to reduced cardiac output
24
Q

What are thet clinical findings of Hypertrophic Obstructive Cardiomyopathy?

A
  • Sharp jerky pulse
  • Double/triple apical impulse
  • Length of ESM over LLSE (increased with valsalva)
  • S4
  • MR murmur (pansystolic murmur radiating to axilla)
25
Q

What are the ECG & TTE findings of HOCM?

A
  • ECG: Interor & Lateral ST & T wave changes, Deep Q waves in Inferior & Lateral leads, LVH
  • TTE: MR, Asymmetrical septal hypertrophy, Systolic anetior motion of anterior mitral valve leaflet (Mnemonic MR ASH SAM)
26
Q

What are the markers of poor prognosis in HOCM?

A
  • History of syncope
  • FHx of sudden cardiac death
  • Presence of ventricular arrhythmias
  • Septal thickness >18 mm on TTE
  • Outflow tract gradient >40mmHg at rest
  • Poor BP response to exercise
27
Q

What is the treatment of HOCM?

What drugs are contraindicated in HOCM?

A

> Treatment of HOCM:

  • Beta-blockers, Verapamil, Amiodarone, Diuretics may improve ventricular function
  • ICD to prevent sudden cardiac death
  • Septal ablation or myomectomy for symptom relief

> Drugs Contraindicated in HOCM:
-Digoxin & Vasodilators may worsen outflow tract obstruction

28
Q

How are Congenital Heart Defects Classified?

A 
>Acyanotic
-VSD
-ASD
-PDA
-Coarctation of Aorta
-Ebstein's Anomaly
>Cyanotic
-Eisenmenger's SYndrome
-Tetralogy of Fallot
-Transposition of Great Vessels
-Truncus Arteriosus
29
Q

Atrial septal Defect

What is the mechanism of ASD?
What re the clinical findings?
What are the indications for surgical closure?

A 
>Mechanism of ASD:
-Blood flows from LA to RA through PFO
>Clinical Findings of ASD:
-RVH/RVF
-ESM in pulmonary area
-Fixed splitting of S2 (Mnemonic AF)
-Pulmonary HTN
>Indications for Surgical Closure
-Almost all cases of ASD need surgical closure
-Right Ventricular Overload
-Qp:Qs >1.5 (pulmonary flow: systemic flow)
30
Q

Ventricular Septal Defect

What is the mechanism of VSD?
What are the clinical findings?
What are the indications for surgical closure?

A 
>Mechanism of VSD:
-Blood flows from LV to RV through Ventricular septum
>Clinical Findings of VSD:
-Pansystolic (holosystolic) murmur along LSE louder on expiration
-LVH/LVF
>Indications for Surgical Closure:
-CCF not responding to medical therapy
-VSD with PS or AR
-VSD with pulmonary hypertension
-Qp: Qs >1.5
31
Q

Patent Ductus Arteriosus

What is the mechanism of PDA?
What are the clinical findings?

A 
>Mechanism of PDA:
-Blood flows from Aorta to PA
-LV receives a backflow of blood from the aorta, which causes it to become volume-overloaded
>Clinical Findings of PDA
-Continuous machinery murmur along LSE
-Reversed splitting of S2 (Mnemonic PR)
32
Q

What is reversed splitting of S2?

What are the causes of reversed splitting?

A

> What is reversed splitting of S2?
-P2 occurs before A2, rather than the usual A2-P2
What are the causes of reversed splitting?
-LBBB - due to delayed conduction
-AS - due to LV delay/overload
-Large PDA - due to LV overload

33
Q

Eisenmenger’s Syndrome

What is Eisenmenger’s Syndrome?
What are the clinical findings?
What is the treatment?

A

> Definition
-Cyanotic congenital heart disease
-Occurs when a left to right shunt reverses into a right to left shunt due to pulmonary pressure exceeding systemic pressure
Clinical Findings:
-Youthful patient with Median sternotomy scar, Clubbing, Cyanosis, Pulmonary hypertension (loud P2, PR +/- TR)
Treatment:
-Heart-Lung transplant is only curative option

34
Q

Tetralogy of Fallot

What are the four features?
What are the clinical findings?
What is the treatment?

A 
>Features: Mnemonic PROVe
-PS
-RVH
-Overriding Aorta
-VSD
>Clinical Findings:
-PS (ESM in pulmonary area)
-VSD (PSM in LSE)
-Thoracotomy scar, Central cyanosis, Clubbing
>Treatment:
-Blalock-Taussig Shunt connects left subclavian artery to left pulmonary artery
35
Q

Constrictive Pericarditis

What are the causes?
What are the clinical findings?
What is the treatment?

A 
>Causes
-Tuberculosis
-Chronic pericarditis
-Incomplete drainage of purulent pericarditis
-Post-MI infarction
>Clinical Findings:
-Cachectic, Ascites, Riased JVP with prominent x &amp; y descents, Hepatosplenomegaly, Oedema, Pulsus Paradoxus
>Treatment:
-Pericardial stripping
36
Q

Prostehtic Valves

What are the signs?
What are the complications?
What are the advantages of porcine valve?

A 
>Signs:
-Metallic S1 - mitral valve replacement.
-Metallic S2 - aortic valve replacement
>Complications:
-Thromboembolism, Valve dysfunction (leak, dehiscence, obstruction), Haemolysis, IE, Bleeding
>advantages of Porcine Valve:
-Does not require anticoagulation
-However, porcine valve degenerates &amp; undergoes calcification
37
Q

Electrocardiogram

What are the features of:

i) RAE
ii) LAE
iii) RVH
iv) LVH

=========================

A

i) RAE:
- P-pulmonale (tall P wave)
ii) LAE:
- P-mitrale (notched P wave)
iii) RVH:
- RAD (QRS Lead I negative, aVF positive)
- Tall R wave in V1, V2
iv) LVH:
- LAD (QRS Lead I positive, aVF negative)
- S in V1/V2 + R in V5/V6 >35 mm
- Tall R waves in V5/V6

38
Q

Clinical and ECG findings of ASD?

A

> Mnemonic “QRS”
- Quiet systolic murmur
- Right - axis, RBBB, RVH
- Secundum; Second heart sound fixed-splitting (normal A2 P2 but no variation with breathing)
Primum (associated with down Trisomy 21)
- Ostium primum = LEFT ax dev (only difference)
- labelled from ventricle UPwards, so primum is LOW atrium and secundum is high atrium
Common, 15% unfused foramen ovale
- can right to left. including paradoxical strokes

39
Q

What is the significance of the apex beat?

Can the apex beat be usually felt and where?

A

> Mnemonic: “VT, pH”
-Volume loaded=>thrusting; Pressure=>Heaving
-Volume => displaced; pressure=> not
-Volume: AR, MR, volume overload
-Pressure: AS, coarctation, HOCM
Apex, the most lateral/inferior point of clear pulsation, is usually felt at 5th intercostal space, mid-clavicular
However may NOT be felt at all!
-in many not easily palpable: overweight, hyperinflated from COPD; or other distances- pleural effusion, pericardial effusion, cardiomyopathy
-if impalpable, you must check for dextrocardia
-if impalpable say so: this is a valid finding

40
Q

What are the causes of a collapsing pulse?

A 
>Independent and hyperdynamic
>Mnemonic "A Collapsing Pulse" (independent and more pronounced)
-AR (look for early diastolic murmurs)
-Cirrhosis
-Patent ductus arteriosus
>Mnemonig "Think Exercise And Preg" (hyperdynamic)
-Thyrotoxicosis (look for eye disease)
-Exercise, Emotion
-Anaemia/AV fistula
-Pregnancy/Pyrexia
41
Q

What are the congenital heart conditions?

A 
>Mnemonic: "3 holes, 3 blocked tubes, 3 blue babies"
>3 holes (ASD, VSD are the most common two)
-ASD
-VSD- may close spontaneously; small ones may req no further intervention but prophylaxis SBE; mod-large symptomatic are at risk of eisenmenger, Rt to Lt (cyanosis and clubbing); and get surgery
-PDA
>3 blocked tubes
-AS
-PS
-Coarctation of aorta
>3 blue babies
-Tetralogy of fallot
-Truncus arteriosus
-Transposition of the great vessels
42
Q

What does digoxin do to the QT interval?
Where should it be used cautiously?
What does toxicity look like?

A

> QT mnemonic “Digoxin is a little QT”
- Shortens QT (unlike amiodarone, phenothiazine largactil, quinidine, tetracycline)
- also reverse tick (though this not necessarily toxic)
Caution:
-contraindicated in WPW (accessory pathway used after AV node blocked)
-CKD/AKI - cleared through kidneys
Toxicity
-Arrhythmias, particularly AV block, GI symptoms (n/v/d)
-yellow vision (xanthopsia)

43
Q

What are the causes of Eisenmenger?
What are the 3 clinical findigns?
Expected ECG findings?

A

> Mnemonic “Holes+Hypertension”
-Holes: ASD, VSD, PDA
-Pulmonary HTN (Left to Right shunt reverses)
3 Clinical Findings
-Findings: Cyanosis, Clubbing, Pulm HTN
ECG findings:
- RVH, (R in V1, S in V5, >12 small squares– whereas LVH is 7 small squares)
CXR: pulm HTN - prominent vascular markings, peripheral pruning

44
Q

Endocarditis findings?

A

> mnemonic: “Infected Valves Mean Endocarditis”
-Infective: malaise, fever, wt loss
-Vasculitis: Splinter haemorrhages, small infarcts seen in the nail, Janeway lesions are palmar macules; Oslers nodes are painful finger pulp lesions, Roth’s spots are black spots on the fundus
-Murmus
-Emboli
Common cause: strep viridans, staph aureus;
-(strep bovis is assoc with CRC requires scope f/up)

45
Q

Empiric Ix/treatment for endocarditis?

A

> mnemonic “3 cultures, 3 drugs, 2/4/6-weeks”

  • 3 blood cultures
  • Benpen 1.8g q4h, Fluclox 2g q4h, Gent
  • If prosthetic: Fluclox, Vanc, Gent
  • Antibiotics for 2 weeks inpatient, at least 4-6 weeks
46
Q

Most common valves in endocarditis?

Most common in IVDU?

A

Although mostly left sided valves; exception in IVDU in whom tricuspid is most common (particle damages the surface)

47
Q

What findings make up Fallots Tetralogy?

A

> Mnemonic: “PROVe”
-Pulmonary stenosis (pressure drop >10mmHg)
-Right ventricular hypertrophy
-Overriding aorta (this and VSD can be investigated by catheter comparing sats at aorta being lower than LV)
-VSD
Facts
-most common cause cyanosis in young patient
-most will have had correction
Findings
-clubbing, central cyanosis
-unilaterally weak radial pulse (Blalock-Taussig shunt)
-midline thoracotomy scar
-left parasternal heave (of right ventricular hypertrophy or RVH)
-loud ejection systolic murmur (PS murmur; accentuate right sided murmurs by asking to inspire maximally)

Hark and Paul's clinical review (12 decks)

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