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FRACP Short Case Nosh > Cardiology > Flashcards

Cardiology Flashcards

1
Q

What are the signs of severity for aortic stenosis? (6)

A
  • long late peaking ejection systolic murmur
  • S4
  • Paradoxical splitting of S2
  • small volume, slow rising, plateau carotid pulse
  • presence of an aortic thrill
  • left ventricular failure
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2
Q

What are the most common causes of aortic stenosis? (3)

A
  • Degeneration of an abnormal valve (unicuspid or bicuspid)
  • Calcification of a trileaflet valve
  • Rheumatic heart disease
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3
Q

What are the indications for surgery in aortic stenosis?

A
  • Symptomatic severe high-gradient AS
  • Symptomatic severe low-flow low-gradient AS with inducible high gradient on dobutamine stress test
  • Asymptomatic patients with severe high-gradient AS - -> AND
  • > LVEF <50 percent
  • > when undergoing other cardiac surgery
  • > low surgical or TAVI procedural risk
  • > decreased exercise tolerance or fall in systemic blood pressure with exercise
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4
Q

What are the causes of aortic regurg?

A
  • Rheumatic heart disease
  • Congenital with or without VSD
  • infective endocarditis
  • Aortic root dissection, in association with ankylosing spondylitis or syphilitic aortitis
  • aortic root dilation from Marfan’s syndrome
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5
Q

What are the signs of severity of aortic regurg?

A
  • Wide pulse pressure with associated collapsing pulse
  • a long decrescendo diastolic murmur
  • presence of an S3
  • presence of a soft A2
  • Austin-Flint murmur.
  • left ventricular dilatation (apex beat displaced)
  • left ventricular failure
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6
Q

What is the murmur heard in aortic regurg?

A

An early decrescendo diastolic murmur
- loudest at the left lower sternal edge and best heard at end of expiration, with the patient leaning forward

  • An Austin Flint mid-diastolic murmur may be heard at the apex in severe aortic regurgitation
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7
Q

What are the indications for surgery in aortic regurg?

A
  • symptomatic severe AR
  • asymptomatic severe AR AND
  • > LV systolic dysfunction with an LVEF <50%
  • > LV end-systolic dimension >50 mm
  • > progressive severe LV dilation (LVEDD >65 mm)
  • > while undergoing cardiac surgery for other indications
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8
Q

What are the usual causes of tricuspid regurgitation?

A
  • secondary to right ventricular dilatation
  • infective endocarditis
  • complication of pacemaker insertion / frequent trans-jugular cardiac biopsies
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9
Q

What are the signs of tricuspid regurgitation?

A
  • pansystolic murmur best heard at the left lower sternal edge, louder on inspiration
  • elevated JVP with prominent V wave & rapid Y descent
  • pulsatile liver
  • right ventricular heave
  • pulmonary hypertension
    Often accompanied by RV failure
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10
Q

What are the causes of mitral regurg?

A

Primary

  • degenerative (mitral valve prolapse)
  • Rheumatic heart disease
  • infective endocarditis

Secondary

  • LV dilatation
  • papillary muscle ischaemia
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11
Q

What are the signs of severity of mitral regurg? (8)

A
  • soft S1
  • split S2
  • S3
  • early diastolic rumble
  • LV dilatation
  • LV failure
  • Pulmonary HTN
  • small pulse volume
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12
Q

What are indications for surgery in primary mitral regurg?

A

PRIMARY
Symptomatic chronic primary severe MR
- with or without LV dysfunction, unless mitral valve not amenable to surgery

Asymptomatic chronic severe primary MR

  • > LVEF 30 - 60% and/or an LVESD ≥40 mm
  • > LVEF ≤30 percent
  • > undergoing cardiac surgery for other indications
  • > normal LV function with new onset AF or pulmonary hypertension
  • > progressive increase in LV size or decrease in LVEF on serial imaging studies, we suggest mitral valve repair
  • > if VERY low surgical risk
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13
Q

What are indications for surgery in secondary mitral regurg?

A
  • Patients with persistent symptoms despite optimum therapy

- Patients undergoing cardiac surgery for a concurrent condition

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14
Q

What is the murmur heard in mitral stenosis?

A
  • opening snap, mid-diastolic rumbling murmur best heard at apex
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15
Q

What are the signs of severity in mitral stenosis?

A
  • low pulse volume
  • long diastolic murmur
  • apical thrill
  • pulmonary hypertension
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16
Q

What are the likely auscultatory findings in HCM?

A
  • late ejection systolic murmur maximal at LLSE, louder on Valsalva
  • Pansystolic murmur of MR -> systolic anterior motion of mitral valve
  • S4
17
Q

What is reason for physiological splitting of S2?
What are causes of wide splitting?
Caused of reversed splitting ?

A

There is normal splitting of S2 during inspiration due to longer RV ejection time during inspiration compared with the LV.

Causes of wide splitting (RV ejection time is further prolonged, maximal on INSPIRATION)

  • pulmonary HTN
  • pulmonary stenosis

Causes of reverse splitting (LV ejection time is unusually prolonged, maximal on EXPIRATION)

  • severe AS
  • LBBB causing conduction delay
18
Q

What are causes of radio-radio delay?

A

Subclavian stenosis

Previous aortic dissection

19
Q

What constitutes wide pulse pressure?

A

> 60 mmHg difference

20
Q

How do you tell the difference between JVP and carotid pulsation?

A

JVP =

  • double impulse
  • impulse not palpable
  • descends with inspiration
  • fills from above when occluded
  • abdominojugular reflex elevates it
21
Q

What is Kussmaul’s sign?

A

Paradoxical increase in the JVP with inspiration
Occurs in any condition where right ventricular filling is restricted
- constrictive pericarditis
- cardiac tamponade

22
Q

Causes of dilated cardiomyopathy?

A
  • Ischaemia
  • Familial / genetic
  • Arrhythmia (chronic tachycardia)
  • Myocarditis / infection
  • ETOH
  • iron deposition
  • infiltration
  • CTD
  • Endocrine dysfunction
23
Q

ECG findings in aortic stenosis?

A

LVH

LV strain pattern -> ST depression + TWI in I, aVL, V4-6

Left atrial enlargement (broad bifid P wave in lead II = P mitrale; + large terminal negative portion of the P wave in V1)

24
Q

ECG findings in mitral regurgitation?

A

Left atrial enlargement

  • broad bifid P wave in lead II (P mitrale)
  • large terminal negative portion of the P wave in V1)

May also have findings of pulmonary HTN

  • RV strain
  • Right axis deviation
  • RVH
25
Q

Criteria for LVH on ECG?

A

Voltage criteria = S wave depth in V1 + tallest R wave height in V5-V6 > 35 mm

Non-voltage criteria =

  • Increased R wave peak time > 50 ms in leads V5 or V6
  • Left ventricular ‘strain’ pattern
26
Q

CXR findings in aortic stenosis?

A
  • Left atrial enlargement (splaying of carina, double density sign, straightening of left heart border)
  • Calcification of the aortic valve in patients with calcific AS.
27
Q

What are features of severe MR on echo?

A
  • effective regurgitant orifice area
  • regurgitant volume
  • valve morphology (flail leaflet, ruptured papillary defect)

Plus associated complications:

  • LA / LV enlargement
  • pulm HTN
28
Q

What are the features of severe aortic stenosis on echo?

A

Aortic valve area <1cm2
Mean gradient >40 mmHg
Peak velocity >4m/s

Also
- valve morphology (bicuspid, calcified)

Complications:

  • LA dilatation
  • LV hypertrophy
  • LVEF
29
Q

What are key features of severe AR on echo?

A

Jet width ≥65 percent of LV outflow tract

Holodiastolic flow reversal in the abdominal aorta

High regurgitant fraction (≥50%)

High regurgitant volume

30
Q

What are manoeuvres in cardiac exam which decrease preload?

What effect does this have on HOCM murmur?
What effect does this have on MVP murmur?

A

Valsalva
Standing upright suddenly from squatting

Will increase the LVOT obstruction and thus make HOCM murmur louder

Will make MVP murmur longer

31
Q

What are manoeuvres in cardiac exam which increase preload?

What effect does this have on HOCM murmur?
What effect does this have on MVP murmur?

A

Going from a standing to squatting position
Handgrip
Passive elevation of the legs

Makes HOCM murmur softer

Will make MVP murmur shorter

32
Q

What are differentials for pansystolic murmur?

A

Mitral regurgitation (apex)
Tricuspid regurgitation (LLSE)
VSD (LLSE)
SAM mitral valve in HOCM (apex)

33
Q

What are differentials for ejection systolic murmur?

A

Aortic stenosis
Aortic sclerosis
HOCM
Pulmonary stenosis

34
Q

What are differentials for diastolic murmur?

A 
Aortic regurgitation (early)
Mitral stenosis (mid)
Pulmonary regurgitation 
Early diastolic rumble of MR
Carey Coombs murmur of acute rheumatic fever
Atrial myxoma
35
Q

What makes up 1st heart sound?

A

Mitral and tricuspid valve closure

36
Q

What makes up 2nd heart sound?

A

Aortic and pulmonary valve closure

37
Q

S3

A

Indicated ventricular enlargement and therefore LVED pressures

38
Q

S4

A

Indicates elevated atrial pressures with decreased ventricular compliance

39
Q

Hand grip effect?

A

Increases afterload

Makes regurgitant murmurs louder, as increases backflow

FRACP Short Case Nosh (5 decks)

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