Cardiology

Question 1

Describe the clinical features of MS

Answer 1

Tapping apex beat
Loud first heart sound
Opening snap early diastole
mid diastolic rumbling murmur at the apex, heard best in expiration, left lateral position
AF

Question 2

What are the clinical markers of severe MS?

Answer 2

early opening snap
increasing length of murmur
signs of pulmonary HTN
signs of pulmonary congestion
Graham-Steel murmur (PR)
Low pulse pressure

Question 3

What is a Graham Steele murmur?

Answer 3

early diastolic murmur in the pulmonary area radiating down the LSE, louder in inspiration
= Pulmonary regurg, signifies elevated pulmonary artery pressures

Question 4

What are the clinical signs of pulmonary HTN?

Answer 4

raised venous pressure: systolic V waves
parasternal heave
loud, palpable P2
PR
TR: PSM LLSE, louder in insp

Question 5

What conditions give a mid diastolic rumbling murmur?

Answer 5

MS
TS
Severe MR
Left atrial mass (myxoma)
L) atrial thrombus
Cor triatrium
Austin flint murmur of AR
Carey Coombs murmur of acute rheumatic fever

Question 6

What are management options for MS?

Answer 6

Perc ballon Mitral valvotomy - usually younger patients, better rheumatic valve disease
Valve replacement - usually older as concomitant MR
Can use mitral valve split score to help determine choice. < 9 considered favourable for valvotomy

Question 7

What are the CIs to mitral valvuloplasty?

Answer 7

L) atrial thrombus
> mild MR
MV area > 1.5cm
Severe or bicommissural calcification
Absence of commissural fusion
Severe concomitant AV disease or severe combined TS and TR
Concomitant CAD requiring bypass

Question 8

What the chronic causes of mitral regurgitation?

Answer 8

Degenerative disease
Mitral valve prolapse (e.g. Marfan's)
Rheumatic - rarely MR alone
Papillary muscle dysfunction (could be due to LVF, ischaemia)
Connective tissue disease (RA/ank spend)
Congenital

Question 9

What are the acute causes of MR?

Answer 9

IE (perforation of anterior leaflet), rupture of a myxomatous cord
MI (chordae rupture or papillary muscle dysfunction)
Surgery
Trauma

Question 10

What are the clinical features of MR?

Answer 10

Pansystolic murmur - an early short murmur in acute and a late murmur in MV prolapse
Widely split S2
3rd heart sound, LVF, pulmonary HTN, narrow pulse pressure all markers of severity

Question 11

Indicators for surgery in MR?

Answer 11

Symptoms
If asymptomatic: 
- if AF/Pulm HTN
- EF 30-60% and/or LVESD > 40mm
- If EF <30%, high risk but can be considered

Question 12

What are the causes of aortic stenosis?

Answer 12

1) degenerative
2) bicuspid valve
3) rheumatic valve disease
4) congenital
5) infective endocarditis

Question 13

What is the differential diagnosis of an ESM louder in expiration?

Answer 13

AS
HOCM
Supravalvular aortic stenosis

Question 14

What are the criteria for severe AS?

Answer 14

Valve area <1cm, gradient > 40mmhg, mean velocity > 4m/s

Question 15

When would you refer for AS surgery?

Answer 15

Symptomatic or asymp and one of:

• LV systolic dysfunction
• Signs of pulmonary HTN
• abnormal blood pressure response on exercising

Question 16

What are surgical options available for AS?

Answer 16

Balloon valvuloplasty for short term symptomatic relief
Valve replacement if fit enough
TAVI for intermediate/high risk surgical candidates

Question 17

What are the clinical signs of severe AS?

Answer 17

Slow rising pulse
Narrow pulse pressure
Low volume pulse
Systolic thrill 
Heaving apex 
Reversed splitting of the 2nd HS
Soft S2
4th HS (forceful atrial contraction against a poorly compliant left ventricle)
Signs of pulmonary HTN or cardiac failure

Question 18

What is aortic sclerosis

Answer 18

?Mild thickening and/or calcification of a trileaflet aortic valve without outflow obstruction

Question 19

What is the differential for a PSM?

Answer 19

MR, TR, VSD, aortopulmonary shunts

Question 20

What is the differential for a late systolic murmur?

Answer 20

Mitral valve prolapse

Papillary muscle dysfunction

Question 21

What is the differential for an early systolic murmur?

Answer 21

Acute severe MR

Question 22

What are the causes of mitral stenosis?

Answer 22

Rheumatic
Severe mitral annular calcification
After mitral valve repair for mitral regurgitation
Congenital

Question 23

What are the indications for surgery for MS?

Answer 23

Symptoms with valve area of less than 1cm or signs of increasing r)heart pressure

Question 24

What are the clinical signs of severity of MR?

Answer 24

Enlarged L)ventricle - displaced apex beat
Pulmonary HTN
3rd HS
Early diastolic rumble
Soft 1st HS
Small volume pulse
L) ventricular failure

Question 25

What are the indications for surgery for MR?

Answer 25

Class 3 or 4 symptoms
AF or pulm HTN
If EF 30-60% and/or LVESD > 40mm consider intervention
If EF <30%, can be considered but high risk

Question 26

What are the clinical signs of mitral valve prolapse?

Answer 26

Late systolic click murmur

• valsalva makes the murmur longer and click earlier
• hand grip which increases after load makes it shorter

Question 27

Which conditions are associated with mitral valve prolapse?

Answer 27

Marfan’s syndrome
ASD
PCKD

Question 28

What are the complications of mitral valve prolapse?

Answer 28

MR

IE

Question 29

What are the causes of chronic aortic regurgitation?

Answer 29

Valvular cause:
-rheumatic
- congenital
- seronegative arthropathy, esp ank spond
Aortic root:
- marfan’s
- Aortitis (seronegative arthropathies, RA, tertiary syphilis
- dissecting aneurysm 
- old age

Question 30

What are the causes of acute AR?

Answer 30

Valvular - IE

Aortic root - marfan’s, HTN, dissecting aneurysm

Question 31

What are the clinical signs of severity of AR?

Answer 31

Collapsing pulse
Wide pulse pressure
Length if the decrescendo diastolic murmur
3rd HS
Soft A2
Austin flint murmur
L) ventricular failure

Question 32

What are the indications for surgery for AR?

Answer 32

Symptoms
Or LV dysfunction
Pulmonary HTN