Cardiology Flashcards
What are the signs of severity for aortic stenosis? (6)
- 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
What are the most common causes of aortic stenosis? (3)
- Degeneration of an abnormal valve (unicuspid or bicuspid)
- Calcification of a trileaflet valve
- Rheumatic heart disease
What are the indications for surgery in aortic stenosis?
- 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
What are the causes of aortic regurg?
- 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
What are the signs of severity of aortic regurg?
- 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
What is the murmur heard in aortic regurg?
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
What are the indications for surgery in aortic regurg?
- 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
What are the usual causes of tricuspid regurgitation?
- secondary to right ventricular dilatation
- infective endocarditis
- complication of pacemaker insertion / frequent trans-jugular cardiac biopsies
What are the signs of tricuspid regurgitation?
- 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
What are the causes of mitral regurg?
Primary
- degenerative (mitral valve prolapse)
- Rheumatic heart disease
- infective endocarditis
Secondary
- LV dilatation
- papillary muscle ischaemia
What are the signs of severity of mitral regurg? (8)
- soft S1
- split S2
- S3
- early diastolic rumble
- LV dilatation
- LV failure
- Pulmonary HTN
- small pulse volume
What are indications for surgery in primary mitral regurg?
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
What are indications for surgery in secondary mitral regurg?
- Patients with persistent symptoms despite optimum therapy
- Patients undergoing cardiac surgery for a concurrent condition
What is the murmur heard in mitral stenosis?
- opening snap, mid-diastolic rumbling murmur best heard at apex
What are the signs of severity in mitral stenosis?
- low pulse volume
- long diastolic murmur
- apical thrill
- pulmonary hypertension
What are the likely auscultatory findings in HCM?
- late ejection systolic murmur maximal at LLSE, louder on Valsalva
- Pansystolic murmur of MR -> systolic anterior motion of mitral valve
- S4
What is reason for physiological splitting of S2?
What are causes of wide splitting?
Caused of reversed splitting ?
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
What are causes of radio-radio delay?
Subclavian stenosis
Previous aortic dissection
What constitutes wide pulse pressure?
> 60 mmHg difference
How do you tell the difference between JVP and carotid pulsation?
JVP =
- double impulse
- impulse not palpable
- descends with inspiration
- fills from above when occluded
- abdominojugular reflex elevates it
What is Kussmaul’s sign?
Paradoxical increase in the JVP with inspiration
Occurs in any condition where right ventricular filling is restricted
- constrictive pericarditis
- cardiac tamponade
Causes of dilated cardiomyopathy?
- Ischaemia
- Familial / genetic
- Arrhythmia (chronic tachycardia)
- Myocarditis / infection
- ETOH
- iron deposition
- infiltration
- CTD
- Endocrine dysfunction
ECG findings in aortic stenosis?
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)
ECG findings in mitral regurgitation?
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
