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Clinical Exam PREP > Cardiology > Flashcards

Cardiology Flashcards

Master the art of cardiology

1
Q

Loud S1

Closure of mitral and tricuspid valve

A

Mitral stenosis
Tricuspid stenosis
Tachycardia
Hyperdynamic circulation

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2
Q

Soft S1

A

Mitral Regurgitation
Calcified mitral valve
LBBB
1st degree AV block

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3
Q

A2 part of S2 (loud and soft)

A

Loud:
Aortic stenosis
Hypertension

Soft:
Aortic regurgitation
Calcified aortic valve

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4
Q

P2 part of S2 (loud and soft)

A

Loud:
Pulmonary hypertension

Soft:
Pulmonary stenosis

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5
Q

Splitting of S2 (increased normal, reverse and fixed)

A 
Increased normal splitting (wider on inspiration):
RBBB
Pulmonary stenosis
VSD 
MR 
Reverse splitting:
AS (severity sign) 
LBBB 
Coarctation of aorta
Large PDA

Fixed splitting:
ASD

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6
Q

S3 (tightening of mitral or tricuspid cusps at the end of rapid diastolic filling)
Left and right

A 
Left S3 - louder at apex on expiration:
Left ventricular failure
Aortic regurgitation 
Mitral regurgitation 
VSD

Right S3 - louder at LSE and on inspiration:
Right heart failure
Constriction pericarditis

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7
Q

S4 (high atrial pressure wave is reflected back from a poorly conpliant ventricle)
ALWAYS ABNORMAL, left and right

A 
Left S4:
Aortic stenosis 
Hypertension
Acute mitral regurgitation
HOCM

Right S4:
Pulmonary hypertension
Pulmonary stenosis

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8
Q

Signs of pulmonary hypertension

A

JVP - prominent a wave
Prominent v wave if developed functional TR
RV parasternal heave
Palpable / loud P2
Signs of right heart failure: raised JVP, pulsatile liver, ascites, sacral and peripheral oedema

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9
Q

ECG findings of pHTN

A

P pulmonale

  • right atrial enlargement
  • peaked p wave in lead II
  • upright p in V1

Atrial fibrillation

Right ventricular hypertrophy

diagnostic:
- right axis deviation
- dominant R wave in V1
- dominant S wave in V6
- QRS < 120ms

Supporting:

  • p pulmonale
  • right ventricular strain: t wave inversion / ST depression in V1-4 and II, III avF
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10
Q

Signs of tricuspid regurgitation

A

Elevated JVP
Dominant V waves
Right ventricular heave
Pansystolic murmur loudest at LLSE on inspiration
Multiple systolic clicks (if Ebatein’s anomaly)
Pulsatile liver, ascites, oedema

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11
Q

Causes of tricuspid regurgitation

A 
Functional (most common) - hence must look for causes of left and right heart failure 
Rheumatic disease 
Infective endocarditis
Congential (ebstein’s anonaly)
Tricuspid valve prolapse 
Right ventricular muscle infarction 
Trauma
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12
Q

Signs of pulmonary stenosis

A 
Peripheral cyanosis (in R-L shunt and increased R atrial pressure through ASD, PFO) 
Low volume pulse 
Giant A wave JVP 
RV heave 
Thrill over the pulmonary area 
Ejection systolic murmur
Splitting of S2
S4
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13
Q

Severity signs of PS

A

S4
Absence of ejection click (burried in S1)
Length of murmur and late peaking
Signs of right heart failure

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14
Q

Causes of PS

A

Congenital

  • Tetralogy of Fallot
  • Noonan syndrome
  • congenital rubella syndrome

Carcinoid syndrome

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15
Q

*7 Signs of Severity of Aortic Stenosis

A
  • Plateau pulse
  • Narrow pulse pressure
  • Aortic thrill
  • Length, harshness and lateness of the peak of systolic murmur
  • S4
  • Paradoxical splitting of S2
  • Signs of LVF
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16
Q

Most common cause of AS

A
  • Young - Bicuspid valve
  • Old - Degenerative Calcification

Rheumatic heart disease

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17
Q

Differential diagnosis of AS

A
  • HOCM

- William Syndrome

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18
Q

AS severity on TTE

A
  • > 40mmHg
  • Area < 1.0cm
  • Velocity D.I. <0.25
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19
Q

Difference between Stenosis and Sclerosis?

A

Sclerosis:

  • Doesn’t have reverse splitting of S2
  • Normal pulse and character
  • No displaced apex beat
  • Doesn’t radiate to the carotids
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20
Q

*8 Complications of AS

A
  • Complete Heart Block
  • LVF
  • Thromboembolism
  • Infective Endocarditis
  • Pulmonary HTN
  • Heyde’s
  • Sudden Cardiac Death
  • Arrhythmias - AF, VT
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21
Q

Worst Prognostic Factor of AS

A

***Dyspnoea

Others include: Angina, Syncope

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22
Q

ECG (2) and CXR (6) findings suggestive of AS

A

ECG:

  • L) BBB
  • L) axis deviation

CXR:

  • Rib notching
  • Post stenotic dilatation of ascending aorta
  • Pulmonary congestion
  • Valve calcification
  • Cardiomegaly
  • Pul HTN/prominent pulmonary arteries
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23
Q

Indications for surgery for AS

A
  • Gradient >40mmHg
  • Symptomatic LVF
  • VT
  • Valve area <0.6cm
  • Other planned surgery
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24
Q

What type of murmur is MS?

A
  • Mid-diastolic murmur (low frequency)
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25
Q

7 Signs of Severity of MS

A
  • Early opening snap (d/t increased L) atrial pressure)
  • Low pulse pressure (decreased cardiac output)
  • Increased length of murmur
  • Pulmonary HTN (prominent a-wave, RV heave, P2 loud/palpable)
  • Pulmonary congestion
  • Pulmonary reguirgitation (Graham Steell)
  • TR
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26
Q

Best position to hear MS

A
  • L) lateral position with bell
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27
Q

5 Causes of MS

A

1) Rheumatic heart disease
2) Mitral annular calcification
3) Post MVR for MR
4) Congenital parachute valve
5) Cardiac carcinoid, Fabry’s, RA, SLE, Whipple’s

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28
Q

Differential diagnosis of MS

A
  • TS
  • Atrial myxoma
  • L) atrial thrombus
  • Severe MR causing a mid-diastolic murmur (functional MS)
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29
Q

4 Complications of MS

A
  • Valvular AF
  • L) atrial thrombus formation
  • Pulmonary HTN
  • R) heart failure
30
Q

ECG (2) and CXR (3) findings of MS

A

ECG:

  • p-mitrale (bifid p-waves) suggestive of L) atrial hypertrophy
  • AF

CXR:

  • MAC
  • large pulmonary arteries suggestive of pul HTN
  • double R) heart border suggestive of L) atrial enlargement
31
Q

4 Indications for surgery in MS

A
  • Exertional dyspnoea
  • Pulmonary HTN
  • Pulmonary congestion
  • Recurrent thrombo-embolic events despite anticoagulation
32
Q

8 Chronic causes of MR

A

1) MVP
2) Degenerative disease
3) Rheumatic heart disease
4) Papillary muscle dysfunction due to LVF/ischemia
5) CTD - RA, Ank Spond
6) Congenital
7) Marfan’s
8) Libman–Sacks endocarditis - SLE

33
Q

4 Acute causes of MR

A

1) Infective endocarditis
2) Myocardial infarction
3) Surgery
4) Trauma

34
Q

8 Signs of Severity of MR

A
  • Soft S1
  • S3
  • Early diastolic rumble - due to increased flow across MV (functional MS)
  • Displaced apex beat/enlarged LV
  • Wide-split S2 - aortic component A2 earlier
  • Precordial thrill
  • Pulmonary HTN
  • Pulmonary congestion/LVF
35
Q

Differential diagnosis of MR

A
  • VSD

- TR

36
Q

ECG (3) and CXR (4) findings of MR

A

ECG:

  • p-mitrale
  • AF
  • R) axis deviation

CXR:

  • Gigantic L) atrium
  • double-bordered R) heart
  • MAC
  • Increased LV size
37
Q

Indications for surgery in MR

A

*Essentially if have symptoms of dyspnoea

Chronic:
- NYHA III/IV, LV dysfunction, EF <60%

Acute:
- haemodynamic compromise

*If asymptomatic, 6-monthly TTE follow up

38
Q

What type of murmur is AR?

A
  • early diastolic murmur
39
Q

Differential diagnosis of AR?

A
  • PR
40
Q

5 Chronic Causes of AR

A
  • Rheumatic heart disease
  • Congenital - bicuspid (also consider aortic root dilatation, coarctation), VSD
  • Marfan’s
  • RA, Ank Spond
  • Tertiary Syphilis
41
Q

2 Acute Chronic Causes of AR

A
  • Infective endocarditis

- Dissecting aortic root aneurysm

42
Q

8 Signs of Severity of AR

A
  • Collapsing pulse
  • Wide pulse pressure
  • Length of the decrescendo diastolic murmur
  • S3
  • Soft component of A2
  • LVF
  • Austin Flint Murmur - Functional MS
  • Pulmonary HTN
43
Q

Corrigan’s sign?

A
  • Carotid pulsations
44
Q

Quincke’s sign?

A
  • Capillary pulsations in finger nails
45
Q

De Musset’s sign?

A
  • Head-nodding with each heart beat
46
Q

Muller’s sign?

A
  • Systolic pulsations in uvula
47
Q

Traube’s sign?

A
  • Pistol shot/booming sound whilst auscultation over femorals
48
Q

ECG (1) and CXR (3) findings of AR

A

ECG:
- LVH

CXR:

  • LV dilatation
  • Aortic root dilatation/aneurysm
  • Valve calcification
49
Q

Indications for surgery in AR

A
  • Symptoms of heart failure or angina
  • LVEF < 50%
  • LV End-systolic diameter >55mm
  • LV End-diastolic diameter >75mm
  • Aortic root dilatation >50mm (CT)
50
Q

4 causes of S3

A
  • AR
  • MR
  • VSD
  • MVP
51
Q

2 causes of S4

A
  • AS

- HOCM

52
Q

Most common cause of MVP

A

1) Primary

2) Secondary:
- Marfan’s
- Ehlers Danlos Syndrome
- SLE
- PCKD
- Osteogenesis imperfecta

53
Q

6 Complications of MVP

A
  • Stroke/infective endocarditis
  • Arrhythmia’s - AF, ventricular ectopy
  • Sudden death
  • Severe MR
  • Chordal rupture
  • Cardiac necrosis
54
Q

7 Signs of severity of MVP

A
  • Displaced apex beat
  • Systolic thrill
  • Parasternal heave
  • Pulmonary HTN
  • Soft S1
  • S3
  • LVF
55
Q

DDx of MVP

A
  • AS
  • HOCM
  • PS
  • Trivial MR
56
Q

Treatment of MVP (2)

A

1) Reassurance

2) Surgery if severe MR

57
Q

Classification of significant VSD

A

Large L –> R shunt with

  • Soft murmur
  • Displaced and thrusting apex
  • Presence of pulmonary HTN
  • Loud P2

Large R –> L shunt (Eisenmengers) with

  • Clubbing
  • Cyanosis
  • Displaced and thrusting apex
  • Pulmonary HTN signs
  • Single loud S2
58
Q

DDx for the murmur of VSD

A
  • TR

- MR

59
Q

Causes of VSD

A

Maternal Factors

  • Maternal diabetes
  • Maternal phenyketonuria
  • Fetal alcohol syndrome (drunk mama)

Aneuploid Syndromes

  • Down’s (Trisomy 21)
  • Edwards (Trisomy 18)
  • Pataus (Trisomy 13)
  • Di George Syndrome (Del 22q11)
  • Deletions at 4q, 5p, 21 and 32

Acquired

  • Ischaemia
  • Iatrogenic (pacing wire through the septum)
60
Q

Classifications of VSD

A

Perimembranous

  • Most common ~ 80%
  • Lie just below the aortic valve
  • Cause LV-RA defects (Gerbode defect)

Supra-cristal

  • 5-8% of case
  • Lie beneath the pulmonary valve, tract leading to RV outflow tract

Muscular

  • 5-20% of cases
  • Lie in the muscular septum

Posterior

  • 8-10% cases
  • Posterior to the septal leaflet of the tricuspid valve
61
Q

Complications of VSD

A
  • IE
  • Pulmonary HTN
  • LV dysfunction
  • AR (with perimembranous and supra-cristal defects)
  • Ventricular arrhythmias
  • Eisenmenger’s
62
Q

Ix for VSD

A
  • CXR: cardiomegaly, pulmonary congestion, enlarged LA
  • ECG: LVH, evidence of biventricular hypertrophy, LA hypertrophy (bifid p wave in lead II), LA enlargement (bifid p wave in lead V1)
  • Echo
63
Q

Indications for VSD closure

A
  • Increasing pulmonary:systemic blood flow (Qp: Qs > 2:1)
  • LV dysfunction
  • Recurrent endocarditis
  • Development of AR
  • Rupture of the IV septum
64
Q

Contraindications for VSD closure

A

Irreversible severe pulmonary HTN

65
Q

Classification of significant ASD

A

With L –> R shunt

  • Often in AF
  • ESM murmur
  • Systolic thrill
  • Tricuspid valve flow murmur
  • Pulmonary HTN
  • Fixed-split S2 with loud P2

With R –> L shunt

  • Clubbed
  • Cyanotic
  • Pulmonary HTN
  • Fixed split S2 with loud P2

NOTE - always will have a fixed split S2, the loud P2 adds to the significance

66
Q

Types of ASD

A

Ostium secundum

  • Most common
  • Site is at the foramen ovale

Ostium primum
- Occurs at the anterior and inferior aspect of the septum often with involvement of the mitral and tricuspid valve

Sinus venosus
- Occurs at the upper atrial septum, just below the entrance of the SVC, other spot is the junction of the right atrium and IVC

Coronary sinus

  • Self-explanatory
  • Rarest of the lot
67
Q

Why do you get fixed widely split S2 in ASD

A
  • Increased R) heart volumes from the shunt means it takes longer for the right heart to empty (later P2)
  • Less blood in the L) heart (earlier A2)
  • Equalisation of pressure in the L) and R) atria causes fixing
68
Q

Difference between ASD and PFO

A

PFO - no equalisation of atrial pressure, hence no fixed split

69
Q

What age does shunt reversal occur in ASD

A

~ 20 years of age

70
Q

What may cause an ASD and mitral stenosis

A
  • Lutembacher syndrome - ASD with acquired rheumatic mitral stenosis
  • Post mitral valvotomy

Clinical Exam PREP (8 decks)

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