Cardiology Flashcards
What are the causes of aortic stenosis?
Degenerative calcification
Rheumatic heart disease
Congenital bicuspid aortic valve
What are the signs of severity of aortic stenosis?
Plateau/Anacrotic slow rising pulse Narrow pulse pressure Length of systolic murmur Loud S2 S4 LVF
What are the indications for surgery in Aortic Stenosis? (HK)
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
What are the types of surgery available in Aortic Stenosis?
> 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
What are the causes of Aortic Regurgitation?
> 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
What are the signs of severity of Aortic Regurgitation?
- 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)
What are the indications for surgery in Aortic Regurgitation?
- 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
What are the causes of Mitral Stenosis?
- Rheumatic heart disease
- Post mitral valve repair for MR
- Severe mitral annular calcification
- Congenital
What are the signs of severity of MItral Stenosis?
- Narrow pulse pressure
- Length of rumbling mid diastolic murmur
- Diastolic thrill at apex
- Opening snap
- Loud S1
- Pulmonary hypertension
What are the indications for surgery in Mitral Stenosis?
- 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.
What are the causes of Mitral Regurgitation?
>Acute -Infective endocarditis -Trauma -Myocardial infarction >Chronic -Rheumatic heart disease -Papillary muscle dysfunction -Connective tissue disease -Mitral valve proplapse -Degenerative disease -Congenital
What are the signs of severity of Mitral Regurgitation?
- Soft S1
- S3
- LVF, LVH
- Pulmonary hypertension
What are the indications for surgery in Mitral Regurgitation?
- Symptomatic Severe MR with LVEF >30%
- Chronic Severe MR undergoing other cardiac surgery
What are the causes of Tricuspid Regurgitation?
- Functional TR secondary to RVF or Pulmonary HTN
- Rheumatic heart disease
- Infective endocarditis
- Ebstein’s anomaly
What are the signs of severity of Tricuspid Regurgitation?
- Soft S1
- Elevated JVP with v waves
- Pulsatile tender liver
- Ascites
- Peripheral oedema
What are the indications for surgery in Tricuspid Regurgitation?
- Severe TR undergoing left sided valve surgery
- Symptomatic Severe TR unresponsive to medical therapy
What are the causes of:
i) Dominant ‘a’ wave
ii) Dominant ‘v’ wave
iii) Cannon ‘a’ wave
iv) Increased JVP
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
What are the causes of:
i) Anacrotic slow rising pulse
ii) Plateau slow rising pulse
iii) Collapsing water hammer pulse
i) Anacrotic slow rising pulse: AS
ii) Plateau slow rising pulse: AS
iii) Collapsing water hammer pulse: AR
What are the causes of:
i) Soft S1
ii) Loud S1
iii) Soft S2
iv) Loud S2
v) S3
vi) S4
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.
What are the differential diagnoses for:
i) Pansystolic murmur
ii) Ejection systolic murmur
iii) Early diastolic murmur
iv) Mid-diastolic murmur
v) Continuous murmur
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
What is the effect of:
i) Inspiration
ii) Expiration
iii) Left lateral decubitus position
iv) Leaning forward & expiration
v) Valsalva manoeuvre
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
What are the causes of Pulmonary Stenosis?
- Congenital
- Carcinoid syndrome
What are the signs of severity of Pulmonary Stenosis?
- Length of systolic murmur
- Loud S2
- S4
- RVF, Increased JVP
- Peripheral cyanosis secondary to reduced cardiac output
What are thet clinical findings of Hypertrophic Obstructive Cardiomyopathy?
- Sharp jerky pulse
- Double/triple apical impulse
- Length of ESM over LLSE (increased with valsalva)
- S4
- MR murmur (pansystolic murmur radiating to axilla)
What are the ECG & TTE findings of HOCM?
- 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)
What are the markers of poor prognosis in HOCM?
- 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
What is the treatment of HOCM?
What drugs are contraindicated in HOCM?
> 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
How are Congenital Heart Defects Classified?
>Acyanotic -VSD -ASD -PDA -Coarctation of Aorta -Ebstein's Anomaly >Cyanotic -Eisenmenger's SYndrome -Tetralogy of Fallot -Transposition of Great Vessels -Truncus Arteriosus
Atrial septal Defect
What is the mechanism of ASD?
What re the clinical findings?
What are the indications for surgical closure?
>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)
Ventricular Septal Defect
What is the mechanism of VSD?
What are the clinical findings?
What are the indications for surgical closure?
>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
Patent Ductus Arteriosus
What is the mechanism of PDA?
What are the clinical findings?
>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)
What is reversed splitting of S2?
What are the causes of reversed splitting?
> 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
Eisenmenger’s Syndrome
What is Eisenmenger’s Syndrome?
What are the clinical findings?
What is the treatment?
> 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
Tetralogy of Fallot
What are the four features?
What are the clinical findings?
What is the treatment?
>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
Constrictive Pericarditis
What are the causes?
What are the clinical findings?
What is the treatment?
>Causes -Tuberculosis -Chronic pericarditis -Incomplete drainage of purulent pericarditis -Post-MI infarction >Clinical Findings: -Cachectic, Ascites, Riased JVP with prominent x & y descents, Hepatosplenomegaly, Oedema, Pulsus Paradoxus >Treatment: -Pericardial stripping
Prostehtic Valves
What are the signs?
What are the complications?
What are the advantages of porcine valve?
>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 & undergoes calcification
Electrocardiogram
What are the features of:
i) RAE
ii) LAE
iii) RVH
iv) LVH
=========================
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
Clinical and ECG findings of ASD?
> 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
What is the significance of the apex beat?
Can the apex beat be usually felt and where?
> 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
What are the causes of a collapsing pulse?
>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
What are the congenital heart conditions?
>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
What does digoxin do to the QT interval?
Where should it be used cautiously?
What does toxicity look like?
> 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)
What are the causes of Eisenmenger?
What are the 3 clinical findigns?
Expected ECG findings?
> 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
Endocarditis findings?
> 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)
Empiric Ix/treatment for endocarditis?
> 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
Most common valves in endocarditis?
Most common in IVDU?
Although mostly left sided valves; exception in IVDU in whom tricuspid is most common (particle damages the surface)
What findings make up Fallots Tetralogy?
> 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)
