Cardiology Flashcards
1
Q
JVP: cause of dominant a wave
A
Tricuspid stenosis
Pulmonary stenosis
Pulmonary hypertension
2
Q
JVP: cause of dominant v wave
A
tricuspid regurgitation
3
Q
JVP: cause of cannon a wave
A
complete heart block
paroxsymal nodal tachycardia with retrograde atrial conduction
VT with retrograde atrial conduction or AV dissociation
4
Q
Causes of elevated CVP
A
RV failure
Tricuspid stenosis or regurgitation
Pericardial effusion or constrictive pericarditis
Superior vena caval obstruction
Fluid overload
Hyperdynamic circulation (e.g. fever, anaemia, thyrotoxicosis, AV fistula, pregnancy, exercise, beri beri)
5
Q
Arterial pulse: anacrotic
A
small volume, slow upstroke, plus a wave on upstroke.
Cause: AS
6
Q
Arterial pulse: plateau
A
slow upstroke
Cause: AS
7
Q
Arterial pulse: bisferiens
A
Anacrotic plus collapsing
Cause: AS plus AR
8
Q
Arterial pulse: collapsing
A
Cause: AR, hyperdynamic circulation, arteriosclerotic aorta, PDA, peripheral AV aneurysm
9
Q
Arterial pulse: small volume
A
Cause: AS, pericardial effusion
10
Q
Arterial pulse: alternans
A
Alternating strong and weak beats
Cause: LV failure
11
Q
Apex beat: pressure loaded
A
hyperdynamic, systolic overloadedforceful and sustained
Cause: AS, HT
12
Q
Apex beat: volume loaded
A
hyperkinetic, diastolic overloadedforceful but unsustaied
Cause: AR, MR
13
Q
Apex beat: tapping
A
Mitral stenosis
14
Q
First heart sound (S1)
A
LOUD: MS, TS, tachycardia, hyperdynamic circulation
SOFT: MR, calcified mitral valve, LBBB, 1st degree heart block
15
Q
Second heart sound: aortic (A2)
A
LOUD: congenital AS, systemic HT
SOFT: calcified aortic valve, AR (when leaflets cannot coapt)
16
Q
Second heart sound: pulmonary (P2)
A
LOUD: pulmonary HT
SOFT: PS
17
Q
Second heart sound: increased normal splitting (wider on inspiration)
A
RBBB
PS
VSD
MR (earlier A2)
18
Q
Second heart sound: fixed splitting
A
Atrial septal defect
19
Q
Second heart sound: reversed splitting (P2 first)
A
LBBB
AS (severe)
Coarctation of the aorta
Patent ductus arteriosus (large)
20
Q
Third heart sound (S3) mechanism
A
possibly tautening of the mitral or tricuspid cusps at the end of diastolic filling
21
Q
Third heart sound (S3) causes
A
LV third heart sound (louder at apex and on expiration): physiological (age <40, preg), LV failure, AR, MR, VSD, PDA.
RV third heart sound (louder at left sternal edge and on inspiration): RV failure, constrictive pericarditis
22
Q
Fourth heart sound (S4) mechanism
A
a high atrial pressure valve is probably reflected back from a poorly compliant ventricle (always abnormal!)
23
Q
Fourth heart sound (S4) causes
A
LV fourth heart sound: AS, acute MR, systemic HT, IHD, hypertrophic cardiomyopathy
RV fourth heart sound: pulmonary HT, PS
24
Q
Pansystolic murmur
A
MR
TR
VSD
Aortopulmonary shunts
25
Midsystolic murmur
AS
PS
Hypertrophic cardiomyopathy
Pulmonary flow murmur of an ASD
26
Late systolic murmur
Mitral valve prolapse
| Papillary muscle dysfunction (e.g. hypertrophic cardiomyopathy)
27
Early systolic murmur
VSD (small or large plus pulmonary HT)
Acute MR
TR
28
Early diastolic murmur
AR
| PR
29
Mid-diastolic murmur
```
MS
TS
Atrial myxoma
Austin flint murmur of AR
Carey Coombs murmur of acute rhuematic fever
```
30
Presystolic murmur
MS
TS
Atrial myxoma
31
Continuous murmur
PDA
AV fistula (coronary artery, pulmonary, systemic)
Venous hum (over right supraclavicular fossa and abolished by ipsilateral compression of internal jugular vein)
Rupture of a sinus of valsalva into the right atrium or ventricle
Aortopulmonary connection (e.g. Blalock shunt)
'Mammary souffle' (late preg or early post partum)
32
MS: definition
Valve area (cm squared)
Normal = 4-6
MS if <2-3
Severe = <1
33
MS: causes
Rheumatic (W>M)
Severe mitral annular calcification (rarely assoc with hypercalcaemia and hyperparathyroidism)
After mitral valve repair for MR (rare)
Congenital (very rare, e.g. parachute valve with all chordae inserting into one papillary muscle)
34
MS: signs of severity
Small pulse pressure
Soft S1 (immobile valve cusp)
Early opening snap (due to raised LA pressure)
Length of the mid-diastolic rumbling murmur
Diastolic thrill at the apex (rare)
Presence of pulmonary HT (signs: prominent a wave in JVP, RV impulse, loud P2, palpable P2, PR, TR)
35
MS: ECG findings
P mitrale in sinus rhythm
Atrial fibrillation (sign of chronicity)
RV systolic overload (severe disease)
Right axis deviation (severe disease)
36
MS: CXR findings
Mitral valve calcification
A big left atrium (double left atrial shadow, displaced left main bronchus, big left atrial appendage)
Signs of pulmonary HT (large central pulmonary arteries, pruned peripheral arterial tree)
Signs of cardiac failure
37
MR: causes
CHRONIC:
Degenerative disease
Mitral valve prolapse
Rheumatic (M>W, but rare to have isolated MR)
Papillary muscle dysfunction: LVF, ischaemia
CTD: RA, AS
Congenital: endocardial cushion defect (including primum ASD), parachute valve, corrected transposition
ACUTE:
IE (perforation of anterior leaflet), rupture of a myxomatous cord
Myocardial infarction (chordae rupture or papillary muscle dysfunction)
Surgery
Trauma
38
MR: signs of severity (chronic MR)
```
Englarged left ventricle
S3 (unreliable)
Early diastolic rumble
Soft S1
Earlier A2 (rapid LV decompression causes aortic valve to close early)
Small-volume pulse (very severe)
LVF
Pulmonary HT (late sign)
```
39
MR: ECG findings
P mitrale
AF
LV diastolic overload
Right axis deviation
40
MR: CXR findings
Large LA
Increased LV size
Mitral annular calcification
Pulmonary HT (less common)
41
MR: TTE findings
Thickened leaflets (suggest RHD)
Prolapsing leaflets
LA size (suggests chronicity)
LV size and function
Calcification of mitral annulus (common in elderly)
Other abnormalities (e.g. ASD assoc with mitral valve prolapse)
Signs of severity of MR on TTE:
- Vena contracta width ≥0.7 cm
- Effective regurgitant orifice area ≥0.40 cm2
- Regurgitant volume ≥60 mL
- Regurgitant fraction ≥50 percent
- Regurgitant jet area >40 percent of left atrial area, or a holosystolic eccentric jet
42
MR: indications for surgery
CHRONIC: Class III or IV symptoms, LV dysfunction, progressive increase in LV dimensions
ACUTE: haemodynamic collapse
Repair first. If replace use mechanical (tissue valve only lasts 5-7 years)
43
MS: indications for surgery
Exertional dyspnoa
| Falling valve area to under 1cm squared
44
MVP: epidemiology + aeit
Most common heart lesion (3% adults)
Men more likely to progress to MR 'systolic click-murmur syndrome'
Causes:
Myxomatous degeneration of the MV tissue
Assoc with ASD, hypertrophic cardiomyopathy, Marfan's
45
MVP: dynamic ascultation
Click murmur affected by:
- Valsalva manoeuvre (decreases preload)-> murmur longer, click earlier
- Handgrip (increases afterload) or squatting (increases preload)-> murmur shorter
46
MVP : TTE
Prolapse of a leaflet of 1cm or more into the left atrium behind the attachment point of the valve is considered abnormal
47
MVP: associations
Marfarn's syndrome
| ASD (secundum)
48
MVP: complications
MRIE
49
AR: causes of chronic AR
VALVULAR: Rheumatic (rarely sole murmur), congenital (bicuspid valve, VSD), seronegative arthropathy (esp AS)
AORTIC ROOT (may be max right sternal border): Marfarn's, aortitis (e.g. seronegative arthropathy, RA, tertiary syphilis), dissecting aneurysm, old age
50
AR: causes of acute AR
Valvular- IE
| Aortic root- marfan's, HT, dissecting aneurysm
51
AR: signs of severity in acute AR
Collapsing pulse
Wide pulse pressure (>80mmHg)
Length of the decrescendo diastolic murmur
Third heart sound (LV)
Soft aortic component of A2
Austin flint murmur (a diastolic rumble caused by limitation to mitral inflow by the regurgitation jet)
LVF
52
AR: ECG findings
LVH (diastolic overload)
53
AR: CXR findings
LV dilatation
Aortic root dilation or aneurysm
Valve calcification
54
AR: TTE findings
```
LV dimensions and function
Doppler estimation of size of regurgitant jet
Vegetations
Aortic root dimensions
Valve cusp thickening or prolapse
```
55
AR: indications for surgery
Symptoms / SOB on exertion
Worsening left ventricular function, such as low ejection fraction
Progressive LV dilatation on serial TTE, LV end systolic dimension >5.5cm
56
AS: definition by valve area
Normal 1.2-2cm
Significant = <1cm
Critical = <0.7cm or valve gradient >70mmHg
57
AS: causes
Degenerative senile calcific aortic stenosis (most common in elderly)
Rheumatic (rarely isolated)
Calcific bicuspid valve
58
AS: signs of severity (seen if valve area <1cm)
```
Plateau pulse
Reduced force of carotid pulse
Aortic thrill (very important!)
Length, harshness and lateness of the peak of the systolic murmur
Soft or absent A2
Pressure loaded apex beat
Left ventricular failure (a late sign)
```
59
AS: ECG findings
LVH (systolic overload)
60
AS: CXR findings
LVH
| Valve calcification
61
AS: TTE
Doppler estimation of gradient
Valve cusp mobility
LVH
Left ventricular dysfunction
62
AS: indications for surgery
Symptoms: exertional angina / SOB / syncope
Critical obstruction (based on cath data) and severe LV hypertrophy
Tissue valve for patients >65, last 15 years
63
TR: clinical signs
JVP v waves (elevated if RVF)
Right ventricular heave
Pansystolic murmur (maximal at lower end of the sternum and on inspiration)
Pulsatile, large and tender liver
64
TR: causes
Functional (no valve disease, RVF)
Rheumatic (rarely isolated)
IE
Congenital (Ebstein's anomaly, get multiple systolic clicks)
Tricuspid valve prolapse
Right ventricular papillary muscle infarction
Trauma (steering wheel to sternum)
65
TR: CXR findings
```
RV enlargement (biventricular if TR secondary to HF)
If Ebstein's see box shaped heart and narrow cardiac base
```
66
TR: TTE
Estimate size of regurgitant jet in RA
| Velocity of regurgitant jet (allows estimation of pressure gradient across the valve)
67
PS: signs
```
Peripheral cyanosis due to low CO
Normal or reduced due to low CO
JVP: giant a waves due to RA hypertrophy
RV heave
Thrill over pulmonary area (common)
Harsh ejection systolic murmur maximal in the pulmonary area and present on inspiration, may be preceded by ejection click
S4 Presystolic pulsation of liver
```
68
PS: signs of severity
Ejection systolic murmur peaking late in systole
Absence of an ejection click
Presence of S4
Signs of RV failure
69
PS: causes
Congenital
| Carcinoid syndrome
70
Chronic constrictive pericarditis: signs
Low BP
Pulsus paradoxus
Raised JVP (prominent x an y descent, Kussmaul's sign rare)
Impalpable apex beat
Distant heart sounds (may hear early third heart sound and early pericardial knock, as rapid ventricular filling is halted)
Hepatosplenomegaly, ascites, oedema
71
Chronic constrictive pericarditis: causes
```
Radiation
Tumour
Tuberculosis
CTD
CKD
Trauma
```
72
Hypertrophic cardiomyopathy: causes
1. Autosomal dominant with variable expressivity: sarcomeric heavy chain or troponin gene mutation
2. Idiopathic
3. Friedreich's ataxia
73
Hypertrophic cardiomyopathy: ECG signs
LVH and lateral ST segment and T wave changes
| Deep Q waves
74
Hypertrophic cardiomyopathy: CXR findings
LV enlarged with hump along the border
| No valve calcification
75
Hypertrophic cardiomyopathy: TTE
Asymmetrical hypertrophy of ventricular septum
Systolic anterior motion of the anterior mitral valve
Midsystolic closure of the aortic valve
Doppler detection of MR
Doppler estimation of the gradient in the LVOT
76
ASD: ostium secundum signs (90%, defect not involving AV valves)
PALP: normal or RV enlargement
ASCULT: fixed splitting S2, increased flow through the right side of the heart can produce a low-pitched diastolic tricuspid flow murmur and more often a pulmonary systolic ejection murmur (louder on inspiration)
SIGNS: palpable LV impulse
77
ASD: ECG findings
Right axis deviation
RBBB
RV hypertrophy (systolic overload)
78
ASD: CXR findings
Increased pulmonary vasculature
Enlarged right atrium and ventricle
Dilated main pulmonary artery
Small aortic knob
79
ASD: TTE
Paradoxical septal motion, RV dilation
Echo dropout in atrial septum
Doppler detection of a shunt at the atrial level
Shunt (bubble) study using agitated saline
Transoesophageal TTE
80
ASD: ostium primum signs
Def = endocardial cushion defect adjacent to AV valves
Signs same as ostium secundum but commonly associated with MR, TR or VSD.
ECG: left axis deviation, RBBB
Assoc: Down syndrome, Holt-Oram syndrome (skeletal upper limb defects)
On TTE as RV pressure rises, the gradient across the defect falls (sign that shunt is causing trouble)
81
PDA: definition and signs
PDA = vessel from the bifurication of pulmonary artery to the aorta. Shunt is usually from the aorta to pulmonary artery.
Shunt reversal leads to cyanosis and clubbing of toes (not fingers). Continuous murmur.
82
PDA: Ix
ECG: LV hypertrophy
CXR: increased pulmonary vasculature, calcification of the duct, enlarged left ventricle
Doppler TTE: continuous flow in the main pulmonary artery, LA size will be increased
83
Coarctation of the aorta: signs
```
Location: just distal to the origin of the left subclavian artery
Better developed upper body
Radiofemoral delay
HT in the arms
Chest collateral vessels
Midsystolic murmur over praecordium and back
Changes of HT in the fundi
May be assoc with Turner's syndrome
```
84
Coarctation of the aorta: ECG
LVH (systolic overload)
85
Coarctation of the aorta: CXR findings
Enlarged left ventricle
Enlarged left subclavian artery
Dilated ascending aorta
Aortic indentation
Aortic prestenotic and post stenotic dilation
Rib notching- second to sixth ribs on the inferior border
86
Coarctation of the aorta: TTE
LV hypertrophy
Coarctation shelf in the descending aorta
Abnormal flow patterns in the same area
87
Eisenmenger's syndrome: def
Pulmonary HT plus a large communication between the left and right circulations (e.g. VSD, PDA, ASD)
88
Eisenmenger's syndrome: signs
Cyanosis, clubbing, polycythemia
JVP dominant a wave, may have prominent v wave
Right ventricular heave and a palpable P2
Loud P2 (S2 split with loud second component)
4th heart sound
Pulmonary ejection, pulmonary regurgitation
89
Eisenmenger's syndrome: Ix
ECG
- RV hypertrophy
- P pulmonaleCXR
- RV and RA enlargement
- Pulmonary a prominence
- Increased hilar vascular markings but attenutated peripheral vessels
90
Tetralogy of fallot: def
1. VSD
2. Right ventricular outflow obstruction (determines severity)
3. Overriding aorta
4. RV hypertrophy
91
Tetralogy of fallot: signs
```
Cyanosis, clubbing, polycythemia
Right ventricular heave
Thrill at left sternal edge
Single second heart sound
Short pulmonary ejection murmur
```
92
Tetralogy of fallot: ix
ECG: RV hypertrophy, right axis deviation
CXR: normal sized heart with boot shape, RV enlargement, decreased vascularity of lung vessels, right sided aortic knob, arch and descending aorta
93
Causes of hypertension
RENAL: renovascular disease (renal a atherosclerosis, fibromuscular disease, aneurysm, vasculitis), diffuse renal disease
ENDO: conn's syndrome, cushing's syndrome, 17 and 11-B-hydroxylase defects, phaeochromocytoma, acromegaly, myxoeema, OCP
Coarctation of the aorta
OTHER: polycythemia rubra vera, uraemia, toxaemia of pregnancy, neurogenic (increased ICP, lead poisoning, acute intermittent porphyria), hypercalcaemia, alcohol, sleep apnoea
94
Fundoscopy changes in HT: grade I
Silver wiring
95
Fundoscopy changes in HT: grade II
Silver wiring (grade I)AV nipping
96
Fundoscopy changes in HT: grade III
Silver wiring + AV nipping (grade I and II)
Haemorrhages (flame shaped)
Exudates: soft (cotton wool spots, due to ischaemia), hard (due to lipid residues from leaky vessels)
97
Fundoscopy changes in HT: grade IV
```
As III plus papiloedema
Grade I Silver wiring
Grade II AV nipping
Grade III Haemorrhages (flame shaped)
Exudates: soft (cotton wool spots, due to ischaemia), hard (due to lipid residues from leaky vessels)
```
98
Causes of oedema
```
Drugs- calcium channel blockers
Cardiac- CCF, cor pulmonale, constrictive pericarditis
Renal- nephrotic syndrome
Malabsorption or starvation
Protein-losing enteropathy
Myxoedema
Cyclical oedema
```
99
Causes of SVC obstruction
```
Lung carcinoma (90%)
Retrosternal tumours (lymphoma, thymoma, dermoid)
Retrosternal goitre
Massive mediastinal lymphadenopathy
Aortic aneurysm
```
100
Grading of murmurs
1/6 very soft and not heard at first
2/6 soft, but can be detected almost immediately by an experienced auscultator
3/6 moderate, there is no thrill
4/6 loud, thrill just palpable
5/6 very loud, thrill easily palpable
6/6 very very loud, can be heard even without the stethoscope on the chest
101
MS: clinical features
GENERAL: tachypnoea, mitral facies, peripheral cyanosis (if severe)
PULSE: normal or reduced in volume (due to reduced CO), AF (secondary LA enlargement)
JVP: prominent a wave (if pulm HT), loss of a wave (if AF)
PALPATION: tapping apex beat (palpable S1), RV heave and palpable P2 (if pulm HT present), diastolic thrill (rare)
ASCULTATATION: loud S1 (valve cusps wide at systole)
102
MR: clinical features
SYMPTOMS: dyspnoea (increased LA pressure), fatigue (decreased CO).
GENERAL SIGNS: tachypnoea
PULSE: normal or sharp upstroke due to rapid LV decompression, AF common
PALPATION: apex beat displaced, diffuse and hyperdynamic, pansystolic thril is occ present at the apex, parastenal impulse (LA enlargement behind RV)
ASCULTATION: soft or absent S1 (by end of diastole, LA and LV pressures have equalised and valve cusps drifted back together), LV S3 (due to rapid LV filling in early diastole), pansystolic murmur max at apex usually radiating to axilla
103
MVP: clinical features
Systolic click or clicks at a variable time (usually midsystolic)
High pitched late systolic murmur, commencing with the click and extending throughout the rest of systole
104
AS: clinical features
SYMPTOMS: exertional chest pain, dyspnoea and syncope
PULSE: plateau or anacrotic pulse, may be late peaking (tardus) and of small volume (parvus)
PALPATION: apex beat is hyperdynamic and may be slightly displaced, systolic thrill at the base of the heart
ASCULTATION: narrowly split or reversed S2 (delayed LV ejection), a harsh midsystolic ejection murmur (max over aortic and radiates to carotids; louder with pt sitting up and in expiration). May get an ejection click if congenital AS.
105
Aortic sclerosis
No peripheral signs of aortic stenosis
| The diagnosis implies the absence of a gradient across the aortic valve despite some thickening and a murmur
106
AR: clinical features
SYMPTOMS: exertional SOB, fatigue, palpations, exertional agina
GENERAL INSPECT: marfan's, AS, seronegative arthropathy, argyl-robinson pupils
PULSE: collapsing, waterhammer, bisiferens (severe), prominent carotid pulse
BP: wide pulse pressure
PALP: hyperkinetic apex beat, diastolic thrill
ASCULTATION: soft A2, decrescendo high pitched diastolic murmur immediately after S2 loudest at 3rd and 4th intercostal space.
Note: may have associated systolic ejection flow murmur or as autin flint murmur (low pitched rumbling mid diastolic and presystolic murmur audible at apex)
107
TR: clinical features
JVP: large v waves, elevated if RHF
PALPATION: right ventricular heave
ASCULTATION: pansystolic murmur, max at lower edge of sternum that increases on inspiration
ABDO: pulsatile, large and tender liver. May have ascities and pleural effusions
LEGS: dilated, pulsatile veins
108
PS: clinical features
GENERAL: peripheral cyanosis (low CO, severe cases)
PULSE: reduced if low CO
JVP: giant a waves (secondary RA hypertrophy), JVP may be elevated
PALP: RV heave, thrill over pulmonary area
ASCULT: murmur may be preceded by an ejection click, a harsh and loud ejection systolic murmur (best heard in pulmonary area and with inspiration), RV S4 may be present due to RA hypertrophy
ABDO: pre-systolic pulsation of the liver
109
PR: clinical features
Decrescendo diastolic murmur which is high pitched and audible at left sternal edge, typically increases on inspiration
110
Hypertrophic cardiomyopathy: clinical features
SYMPTOMS: dyspnoea (increased LV end-diastolic pressure due to abnormal diastolic compliance), angina, syncope
PULSE: sharp, rising and jerky. Rapid ejection by the hypertrophied ventricle early in systole is followed by obstruction caused by the displacement of the mitral valve into the outflow tract.
JVP: prominent a wave (due to forceful atrial contraction against a non-compliant right ventricle)
PALP: double or triple apical impulse (due to presystolic expansion of the ventricle caused by atrial contraction)
ASCULT: late systolic murmur at lower left sternal edge and apex (due to the obstruction)
Dynamic manoeuvre: outflow murmur is INCREASED by the valsalva manoeuvre, standing, isometric exercise. DECREASED by squatting and isometric exercise.
111
Dilated cardiomyopathy: causes
- Idiopathic and familial
- Alcohol
- Post viral
- Postpartum
- Drugs (e.g. doxorubicin)
- Dystrophia myotonica
- Haemochromatosis
112
Dilated cardiomyopathy: signs
CCF
May have quiet heart sounds
Ventricular arrthymias common
113
Restrictive cardiomyopathy: signs
Similar to constrictive pericarditis BUT
- Kussmaul's sign more common
- Apex beat usually palpable
114
Restrictive cardiomyopathy: causes
- Idiopathic
- Esinophillic endomyocardial disease
- Endomyocardial fibrosis
- Infiltrative disease (e.g. amyloid)
- Granulomas (e.g. sarcoid)
115
VSD: clinical features
PALP: hyperkinetic displaced apex if the defect is large, thrill at the left sternal edge. Palpable systolic thrill.
ASCULT: a harsh pansystolic murmur max at the left sternal edge with a loud 3rd or 4th heart sound; louder on expiration. May have assoc MR. Murmur louder and harsher when the defect is small.
116
VSD: causes
1) Congenital
| 2) Acquired, e.g. myocardial infarction involving the septum
