Cardiology Flashcards
Fixed splitting of second heart sound
Due to P2 closing later than A2 secondary to increased volume in RV and/or increased resistance in pulmonary vasculature:
- Right heart failure
- PE
- Pulmonary hypertension
- ASD
Reverse splitting of second heart sound
P2 before A2 due to failing LV or increased resistance in outflow
- Aortic stenosis
- LBBB
- HOCM
Systolic murmurs
- Aortic stenosis
- Mitral regurgitation
- Pulmonary stenosis
- Tricuspid regurgitation
- Mitral valve prolapse
- HOCM
- ASD
- VSD
Ejection systolic murmur
- Aortic stenosis
- loudest in aortic region
- increases on expiration
- radiates to carotids
- reverse splitting of 2nd heart sound
- narrow pulse pressure - Pulmonary stenosis
- loudest in pulmonary area
- increases on inspiration
- no radiation
Pansystolic murmur
- Mitral regurgitation
- loudest in mitral region
- radiates to axilla
- increases on expiration - Tricuspid regurgitation
- loudest LLSE
- no radiation
- increases on inspiration
Diastolic murmur
- Aortic regurgitation
- Pulmonary regurgitation
- Mitral stenosis
- Pulmonary stenosis
- PDA
Early diastolic murmur
- Aortic regurgitation
- loudest in LLSE leaning forward
- large pulse pressure - ## Pulmonary regurgitation
Late diastolic
- Mitral stenosis
- malar flush
- mid diastolic with opening snap
- tapping apex
- heard best in left lateral position with bell of stethoscope
Aortic valve replacement indications
- Aortic regurgitation
- Aortic stenosis
- Infective endocarditis
Clinical findings of aortic valve replacement
Metallic second heart sound - click at end of pulse
ejection systolic flow murmur
features of anticoagulation
Mitral regurgitation - causes
- Degenerative
- Functional secondary to LV dilatation
- Ischaemic
- MV prolapse
- hereditary
- idiopathic
- Marfan’s syndrome
- Connective tissue disorder - Rheumatic disease
Pulmonary stenosis - causes/associated syndromes
- Congenital
- Rubella
- Down’s Syndrome
- Turner’s syndrome
- Noonan’s syndrome
- Tetralogy of Fallot - Acquired
- carcinoid syndrome
- rheumatic fever
Tetralogy of Fallot - 4 features
- Pulmonary stenosis
- VSD
- Right ventricular hypertrophy
- Overriding aorta
Marfan’s syndrome
- definition/genetic
- cardiac issues/examination
- face + hands:
- chest inspection:
Autosomal dominant condition affecting fibrillin gene
Cardio:
- aortic regurgitation secondary to aortic root dilatation
- aortic dissection/aneurysm
- on ausulcation: metallic second heart sound + ejection systolic murmur. If features of aortic incompetence (diastolic murmur, loss of second heart sound) then worry that valve is failing
- mitral valve prolapse - pansystolic murmur in mitral region
Face + hands:
- clubbing
- arachnodactyly
- hyperextensible joints
- high arched palate
- irdodonesis - upward lens dislocation
Chest inspection:
pectus carinatum or excavatum
- scoliosis
- sternotomy scar = AVR
- thoracotomy scar = thoracic aortic aneurysm/dissection surgery
- posterior chest drain scars - pneumothorax
Management of Marfan’s
Surveillance:
- monitoring of aortic root to assess for dilatation
- monitoring of valves
Medical management:
- beta blockage + ACEi to reduce dilatation of aortic root
- anti-coagulation if metallic valve/AF secondary to valvular disease
Surgical management:
- aortic valve replacement
- aortic root surgery
Genetics:
- screening of family members as autosomal dominant
Indications for aortic surgery in Marfan’s patients
- Dilatation of root >50mm
- Dilatation of root >45mm in patient with family history of aortic aneurysm/dissection
- Rate of dilatation >3mm/year
Indications for mitral valve replacement
- Severe symptomatic mitral regurgitation
- SOB - Asymptomatic mitral regurgitation with the following:
- LVEF <60%
- LV end systolic diameter >45mm
- Atrial fibrillation
- Systolic pulmonary arterial pressures >50mmHg - Acute mitral regurgitation
- papillary muscle rupture following MI
Noonan syndrome features
Phenotypic features:
- webbed neck
- wide spaced nipples
- scoliosis
- pectus carinatum/excavatum
- short stature
- ptosis
Eye signs:
- proptosis
- ptosis
- strabismus
Cardiac
- pulmonary stenosis
- hypertrophic cardiomyopathy
- ASD
- VSD
Gastro
- failure to thrive
- intestinal malrotation
- gastroparesis
Haematology
- coagulopathy
Neurological
- learning difficulties
- seizures
- Arnold Chiari malformation
Differential diagnosis of pulmonary stenosis
- Valvular pulmonary stenosis
- Infra + supra valvular pulmonary stenosis
- Aortic stenosis
- Ventricular septal defect
- Atrial septal defect
Conditions associated with mitral valve prolapse
Primary
- degenerative myxomatous disease
Secondary:
- Marfan’s syndrome
- Ehlos Danlos syndrome
- Osteogenesis imperfecta
- Polycystic kidney disease
Complications of mitral valve prolapse
- Infective endocarditis
- Thrombo-embolic events
- Cerebral vascular accidents
- Sudden death
- Requirement for mitral valve prolapse
Patent ductus arteriosus - clinical findings
Collapsing pulse
Clubbed feet but NOT clubbed hands
Thrusting apex beat
Right ventricular heave if right sided heart failure/RV hypertrophy
Loud continuous machinery murmur loudest below left clavicle and heard posterior chest loudest behind left scapula
Complications of PDA
- Right sided heart failure
2. Eisenmenger’s - left sided heart failure and cynanosis (deoxygenated blood direct flow into left sided circulation
Causes of PDA
- Congenital
- Neonatal rubella syndrome
- Prematurity
- Birth at high altitude
- Prostaglandin infusion to keep PDA open in patients with transposition of great vessels
Medical management of aortic stenosis
- Beta blockade
- Avoid vasodilating medications which will increase gradient across the valve
- ACEi + CCB + nitrites
Differential diagnosis of aortic stenosis ejection systolic murmur
- Aortic sclerosis
- has normal pulse character
- normal 2nd heart sound - Hypertrophic obstructive cardiomyopathy (HOCM)
- VSD
- Pulmonary stenosis
- loudest in pulmonary region
- no radiation
- features of right heart failure
- loudest on inspiration
How to assess for severity of aortic stenosis
- Pulse character
- low volume pulse indicates severe AS - Loss of 2nd heart sound
- Symptoms: SOB/CP/syncope
- Echo
- aortic valve area: <1cm2 = severe
- mean valve gradient: >40mmHg = severe - Features of left ventricular failure
- pulm oedema
- displaced apex beat
Duke’s criteria for IE
Major criteria:
- positive BC: typical organism in 2 separate cultures OR persistently +ve BC
- endocardium involvement: +ve Echo (vegetation/abscess/dehiscence of prosthetic valve) OR NEW valvular regurgitant murmue
Minor criteria:
- risk factor: cardiac lesion/IV drug user
- Fever >38
- vascular/immunological signs
- positive blood culture that doesn’t meet major criteria
- positive ehco findings that does not meet major criteria
2 major OR 1 major + 3 minor OR all 5 minor
Rheumatic fever diagnostic criteria
Evidence of group A beta-haemolytic strep infection + 2 major OR 1 major + 1 minor
Evidence of group A beta-haemolytic strep infection:
- +ve throat culture
- rapid streptococcal antigen test
- elevated or rising streptococcal antibody titre
- recent scarlet fever
Major criteria:
- Carditis: tachycardia/murmur/pericardial rub/CCF/cardiomegaly/conduction defects
- Arthritis: migratory polyathropathy
- Subcutaneous nodules
- Erythema marginatum
- Sydenham’s chorea
Minor criteria:
- Fever
- Raised ESR or CRP
- Athralgia
- Prolonged PR interval
- Previous rheumatic fever
5 types of pulmonary hypertension
- Secondary to chronic lung disease
- Left ventricular failure
- Idiopathic
- Chronic thromboembolic disease
- Other: sickle cell, sarcoid
3 types of Ehlos Danlos Syndrome
- Hypermobile EDS
- hypermobile joints - Classical EDS
- elastic skin - Vascular EDS
- higher risk of vascular rupture due to fragile blood vessels
- reduced life expectancy
Clinical features of Ehlos Danlos Syndrome
- Skin
- elastic
- cigarette paper thinning/atrophic scars
- translucent skin
- easy bruising
- petechiae - MSK
- hypermobile joints
- subluxation/dislocation
- osteoarthritis
- spinal deformities - kyphosis/lordosis/scoliosis
- nerve entrapment - Vascular
- AR
- mitral prolapse
- aortic aneurysm/dilatation
- Raynaud’s
- arterial rupture - GI
- hiatus hernia
- GORD
- poor GI motility
- anal prolapse
