Cardiology Flashcards
The signs of severity of AS
Small volume plateau pulse Narrow pulse pressure Aortic thrill Soft rev. split S2, S4 Late peaking ejection systolic murmur that radiates to the carotids LVF
The signs of severity of MR
Small volume pulse LV dilatation / displaced apex beat soft S1, split S2, S3 early diastolic rumble LVF PHTN
Present AS
Mrs XY is frail elderly woman who presents with SOB/dizziness. My pertinent findings on examination of her cardiovascular system were that of an ejection systolic murmur consistent with aortic stenosis, graded as severe.
Mrs XY was not dyspnoic at rest, had a regular, small volume plateau pulse and a narrow pulse pressure of 110/90. Her jugular venous pressure was not elevated and had a normal wave form. There was no aortic thrill. Her second heart sound was soft and split, with a normal first heart sound and no additional. There was a harsh, late peaking ESM heard throughout the precordium, loudest at the upper left sternal edge, which radiated to the carotids. It was softer on valsalva. The apex beat was pressure loaded and non-displaced. There was no evidence of left ventricular failure, pulmonary hypertension or right ventricular failure. There was no stigmata of infective endocarditis or signs of anaemia. Raynaud’s phenomenon was present in 2 digits of her left hand, with no other stigmata of connective tissue disease.
My findings are most consistent severe aortic stenosis and the most likely cause in this patient would be calcific degeneration.
Differentials for the murmur would also include Hypertrophic obstructive cardiomyopathy - however the murmur was not louder on valsalva which would go against this.
Another differential could be aortic sclerosis however this murmur did radiate to the carotids and sclerosis alone could not account for the signs that suggest haemodynamic involvement such as the pulse character, pulse pressure and the apex beat.
There is also the possibility of a second murmur, such as a mitral valve prolapse or regurgitation as the murmur was also audible at the apex and radiated to the axilla, however I felt I could track the murmur throughout the precordium without any change in character.
I would like to review an ECG to confirm sinus rhythm and look for left ventricular hypertrophy. Review a chest xray and I would expect to see no evidence of pulmonary oedema today, I would also look for cardiomegaly and a calcified aortic valve.
I would also like an echocargiogram to confirm the valve lesion and measure the valve area and gradient and measure the LVEF.
Signs of HOCM
Jerky pulse Double impulse apex beat Murmur - late ESM, loudest at the lower LSE on valsalva \+ pansystolic murmur at apex (MR) S4
Loud on valsalva
Soft on isometric handgrip
Causes
- Autosomal dominant
- long standing hypertension
Signs of VSD
Thrill
pansystolic murmur at LSE - louder with a smaller defects & softer on valsalva
S3
S4
Severity
- PHTN and cyanosis
Signs mitral stenosis
AF with small pulse pressure Malar flush RV heave Tapping apex beat Opening snap, Snapping S1 Palpable P2 Mid diastolic rumble
Signs of severity of MS
Small pulse pressure Opening snap closer to S2 Apical diastolic thrill Length of the diastolic murmur PHTN
Causes of MS
Rheumatic
Congenital
Signs of severity of AR
Collapsing pulse Wide pulse pressure Soft S2, S3 Length of the murmur Austin flint murmur LVF
Causes of AR
RACE Rheumatic Aortic root - dissection, dilatation, Marfans, Ank spond, syphilis Congenital Endocarditis
Primary prevention of ARF
Primary prevention
- ensuring antibiotic treatment is initiated in cases of GAS pharyngitis (less evidence for skin) in at risk individuals within 9 days of symptom onset
900mg benzathine penicillin IM once
500mg bd phenoxypenicillin oral 10 days
erythromycin 800mg bd po 10 days
