Cardiology Flashcards
S1 is associated with closure of which valves?
Mitral and tricuspid
Wide splitting of S1 is associated with which conditions?
RBBB and Ebstein’s Anomaly
In inspiration there is increased systemic venous return to the heart and thus there is delayed closure of ______ valve
Pulmonary valve; delayed P2 sound
Widely split S2 occurs in conditions with prolonged _____ ventricular ejection time; Which conditions do you see this in?
ASD, PAPVR, Pulmonary stenosis, RBBB
You may also see wide S2 split in conditions with shortened LV ejection in conditions like ____
MR
Narrowly split S2 occurs when ____ valve closes early. It is associated with _______.
It may also be seen in conditions where _____ valve closure is delayed like _____.
Pulmonary valve closes early and associated with pulmonary hypertension.
It may also be seen when AV closure is delayed in conditions like Aortic Stenosis
Single S2 can occur when there is only one semilunar valve (i.e. conditions like _____ or ______ or _______); or when P2 is not audible (i.e. ____ or ____ or _______) or when P2 is early (in pulmonary hypertension)
Single S2 when only one semilunar valve is present (aortic or pulmonary atresia or truncus arteriosus); when P2 not audible (TGA, TOF, severe PS), when aortic closure is delayed (severe AS), or P2 is early (pulm htn)
Paradoxical split is when aortic closure follows pulmonary closure and LV ejection is greatly delayed. In which conditions is this seen?
Severe AS, WPW, LBBB
There is increased intensity of P2 with which condition?
Pulmonary hypertension
S3 is a low frequency sound heard in early diastole. This is related to ____________.
It can be normal but can also be associated if ventricular compliance is decreased in conditions like __________.
S3 is due to rapid ventricular filling, hear at apex or LL sternum.
This may be normal, but can be associated in conditions with dilated ventricles - Large VSD, CCF
S4 is a sound in late diastole. Is it always pathological?
Always pathological and associated with decreased ventricular compliance
Boot shaped heart is associated with which condition?
TOF
Paracrine regulation of blood flow:
- Vasodilatation is due to ______, _______ and _______
- Vasoconstriction is due to _______
Vasodilatation is due to Nitric oxide, bradykinin and prostacyclin.
Vasoconstriction is due to endothelin-1.
Name 5 extrinsic factors/regulators which cause increase vasoconstriction/vascular resistance?
Alpha-adrenergic sympathetic nerves, Angiotensin II, ADH (Vasopressin), Prostaglandin H2, Thromboxane (released by platelets due to decrease blood flow to injured vessels)
Name 4 extrinsic regulators of Vasodilatation?
Cholinergic sympathetic response, Parasympathetic NS, Histamine (localised vasodilatation in inflammation and allergic reactions), Prostaglandin I2
Increased Co2 or decreasedO2 causes ______ of cerebral blood vessels with aim to ______
Dilatation of cerebral blood vessels with aim to increase cerebral blood flow
4 common ECG changes seen with hypothyroidism?
Sinus bradycardia
Long QT interval
Flat or inverted T waves
Low voltage QRS complexes
3 common ECG changes with hyperthyroidism?
Sinus tachycardia
Increased QRS voltages
Atrial fibrillation
J waves on an ECG are seen in ______
Takotsubo cardiomyopathy
Hypercalcaemia
Hypothermia
A short QT interval is seen with hyper or hypothermia?
Hyperthermia
ECG features in hypocalcaemia?
Long ST segment, Long QTc interval
Prominent U waves are seen with?
Hypokalaemia
In Mitral Regurgitation you get a pansystolic murmur with an additional ___________ murmur in severe MR.
You get development of a mid diastolic rumble; this occurs because of increased blood flow over the thickened mitral valve.
AKA Carey Coombs murmur
In Atrial regurgitation you get _________ murmur
HDM +/‐ Austin flint
murmur
What are the ECG findings in Brugada syndrome?
Patients have ECG findings of ‘coved’ ST elevation in V1/V2 and pseudo-RBBB. Tachy-arrhythmias may be triggered by fever.
What are the most common CHD seen in William’s Syndrome?
Supravalvular aortic stenosis (75%)
Peripheral pulmonary stenosis (40%)
Supravalvular pulmonary stenosis (20%)
Coarctation of the aorta 2-70%
Beware of coronaries 5-10% risk of sudden death
and also screen for Renal arteries
What are the most common CHD seen in Noonan syndrome?
Pulmonary stenosis (dysplastic pulmonary valve) - 50% HOCM 20%
What are the most common CHD seen in Alagille syndrome?
Branch/peripheral pulmonary stenosis - 70%
Tetrology of fallot - 10%
ASD/VSD
Aortic stenosis
Differences in situs inversus vs situs ambiguous?
Situs inversus - everything flipped
Situs ambiguous - intermediate configuration of thoracic and abdominal viscera = heterotaxy syndrome
In situs inversus - 3-5% have CHD with most common association between ______.
20% have ________ syndrome
Associated with L-TGA
20% have associated Kartageners syndrome
Left atrial isomerism is associated with 4 common things….
Polysplenia - multiple small spleen (non-functioning)
Central transverse liver
Interrupted IVC (azygous/hemi-azygous continuation)
CHD - less common (50%) and simple acyanotic
Right atrial isomerism is associated with 4 common things…
- Asplenia
- Central/transverse liver
- Bilateral right atria and right lungs
- CHD - very common (90%) and complex cyanotic + anomalous pulmonary venous return
Blue Trisomy 21 = ______
tetrology of fallot
Turner’s syndrome = _______
Left heart lesions (bicuspid aortic valve)
William’s syndrome = ___________
Supravalvular problems (AS/PS/Peripheral PS)
Stretched marfan = _______________
Stretched aorta and/or mitral valve
Noonan syndrome associated with _____ axis
Superior axis
50% of kids with interrupted arch have _____
22q11 deletion syndrome
In WPW, _____ or ________ may increase rate of anterograde conduction and should be avoided.
Avoid Digoxin and CCB
What medication is used for SVT refractory to Adenosine in a haemodynamically stable patient?
Amiodarone
What is the medication of choice in a stable patient with VF or VT?
Stable patient, IV procainamide, sotalol, or amiodarone is acceptable. Amiodarone is preferred in patients with impaired left ventricular function or in patients with heart failure.
What is the treatment of choice for multifocal atrial tachycardia?
Sotalol
Name 4 common findings with hypokalaemia?
Prolongation of QT interval
ST-segment depression
T-wave flattening
Appearance of U waves
__________- closes from top to bottom on the right side of the heart;
Foramen ovale is created by a gap in the __________.
(ASD related)
Septum primum closes from top to bottom;
Foramen ovale is created by a gap in the septum secundum.
Most ASD cases are due to _________; failed closure
Ostium secundum
What ASD defects are most commonly seen in down syndrome?
Defects due to Ostium Prmum and thus relates to AVSD
Sinus venosus ASD are almost always associated with ……
Partial anomalous right sided pulmonary venous drainage
Most common type of VSD?
Perimembranous VSD (80%)
Inlet VSD associated with _____
AVSD
AVSD is typically a combination of….
Primum ASD and inlet VSD
if only one of the above, then partial AVSD
Once AVSD repaired complications can be ?
AV valve regurgitation
ECG for AVSD can uniquely show…
AVSD has a superior QRS axis deviation
In _____ side valve replacement is never with mechanical unless it is HLHS
Right or left?
Right - don’t need warfarin
Left side has higher pressures and thus needs mechanical
Noonan syndrome associated very commonly with?
Supravalvular pulmonary stenosis
Common syndrome associated with interrupted aortic arch?
DiGeorge Syndrome
How do you treat TET spells?
Knee to chest position
In hospital:
- Oxygen, morphine, propanolol
- IV fluid bolus
What does a BT shunt do?
It connects the L) subclavian artery to the pulmonary artery
Glen procedure occurs at what age _____
Fontan occurs at what age _____
Glen at 3-4mo
Fontan after 4yo typically
What is a Glen Shunt?
- Same as BCPC
- Connects the SVC to the Lungs
What syndromes is Pulmonary stenosis related to?
Noonan syndrome
LEOPARD syndrome (lentigines, electrocardiographic abnormalities, ocular hypertelorism, pulmonary stenosis, abnormalities of genitalia, retardation of growth, deafness syndrome)
Allagile syndrome
Positive T wave in ____ in a young child is a sign of RVH even in the absence of voltage criteria.
Positive T wave in V1
Which drainage anomalies present with greatest risk of obstruction in TAPVR?
Infracardiac nearly always cause obstruction
R) SVC drainage causes obstruction 75% of time
Snowman heart seen in _________
TAPVR (++ pulmonary oedema periphilarly and small heart)
Which is more common in infancy?
AV N RT or AVRT
AVRT
AVNRT more common in older children
The QRS complexes are wide, and the potential for more serious arrhythmias (ventricular fibrillation) is greater, especially if atrial fibrillation occurs.
Is true for Antidromic (retorgrade) or Orthodromic AVRT
This is true for Antidromic AVRT
may also see RBBB morphology
Syncope in which LQT syndrome is most commonly associated with:
- Sleep?
- Exercise?
- Emotional stress?
Exercise - LQTS1
Emotional stress - LQTS2
Sleep - LQTS3
Differentiating pericarditis and myocarditis?
Low voltage seen on ECG in myocarditis.
Children with myocarditis often more sicker and can have trop
Which cardiac complication do you screen for in children with Rett Syndrome?
Long QTS
Right ventricular heave associated with ….
Associated with right ventricular hypertrophy - likely Pulmonary stenosis .
Heave s a sign of pressure overload. Other conditions - pulmonary hypertension.
Palpable S2 is associated with …
Eisenmenger syndrome
A palpable S2 in the second left intercostal space correlates with pulmonary hypertension.
ECG changes in AVSD?
Superior axis deviation with right ventricular hypertrophy
RVH more common, but can also see LVH
What conditions can commonly have LAD?
Noonan syndrome, Primum ASD, Tricuspid atresia, inlet VSD, AVSD
Suprasternal thrill associated with…
Aortic stenosis
Mitral regurgitation can have a click when associated with …
Other features of mitral regurgitation?
Mitral valve prolapse
Other features of MR:
- Mid diastolic murmur (due to increased flow)
- Thrill at the apex
- Left parasternal heave if associated pulmonary hypertension
Double aortic arch can often have a dominant right aortic arch which forms a ring around the airway; they can present with stridor/barking cough - which is a feature of _______
Tracheomalacia
What are the 5 big causes of single S2?
Pulmonary atresia, Aortic atresia, TOF, TGA, Pulmonary hypertension
Also Truncus
2 main CHD that can present in months?
1) L-> R shunts
2) ALCAPA
6 main CHD conditions that present in days?
1) TGA with intact VS
2) ToF
3) PDA
4) TAPVR
5) Truncus arteriosus
6) SV with increased PBF
Collapsing pulse seen in?
Acyanotic - PDA, Ao regurgitation
Cyanotic - Truncus arteriosus
Fixed split S2 seen with?
Acyanotic - ASD
Cyanotic - TAPVD, common atrium
ECG changes of hypokalaemia?
- ST depression and T wave inversion
- Prominent U waves
- Long QT (fusion of T and U waves)
- Prolonged PR interval
- Increased amplitude and width of P waves
- VT
What are features of hyperkalaemia?
- Peaked T waves
- P wave widens and flattens and eventually disappears
(opposite of hypokalaemia) - PR prolongation
- Bizarre QRS morphology
-> Asystolic arrest (compared to hyperkalaemia, which leads to SVT/VT)
Which conditions have:
Differential cyanosis - so better sats post ductally?
Differential cyanosis
- Coarctation with PDA with right to left
Reversed differential cyanosis - Coarctation
- TGA (because
What are the auscultatory findings of Eisenmenger?
Loud S2 - given the pulmonary hypertension
Aortic opening click occurs in which phase?
Early ventricular ejection
In Frank Starlings law, stroke volume corresponds to?
Preload
Acyanotic CHD with ________ pulmonary blood flow present with ejection systolic murmur
Decreased pulmonary blood flow - ejection systolic murmur
Increased pulmonary blood flow - flow murmur
Does tetralogy have single S2 or widely split S2?
Single S2
Coarctation of the aorta alongside mitral valve abnormalities (a supravalvular mitral ring or parachute mitral valve) and subaortic stenosis are potential associated lesions - these left sided obstruction anomalies together are called ______
Shone complex
LAD on ECG + cyanosis is highly suggestive off ______
Tricuspid atresia
Name 4 common late complications of the Fontan procedure …
- Stenosis of the superior or inferior vena cava anastomosis, vena cava or pulmonary artery thromboembolism
- Protein-losing enteropathy,
- Plastic bronchitis
- Immune deficiency
Supraventricular arrhythmias (atrial flutter, paroxysmal atrial tachycardia), and hepatic cirrhosis (and possibly hepatic carcinoma) as a result of persistently elevated central venous pressures
AVSD often has no murmur; but the two types of murmurs you may see are:
- Ejection systolic - due to turbulent flow through the pulmonary valve
- Pansystolic - due to VSD murmur
Most common cardiac defect in Turner’s syndrome?
Bicuspid aortic valve
THEN
Coarctation of the aorta
Most common cardiac defect in Fragile X syndrome?
Bicuspid aortic valve, coarctation of the aorta
Which cardiac anomalies commonly occur in CHARGE syndrome
ToF and VSD
What is the most common cardiac defect in VACTRL?
VSD and ToF
What is the most common heart anomaly with fetal alcohol syndrome?
ASD and then VSD
Fetal valproate syndrome is associated with which cardiac anomaly?
Aortic coarctation, hypoplastic left heart (Left heart defects)
Which syndrome?
TAPVR + right lung hypoplasia with dextroposition of heart, can have pulmonary sequestration
Scimitar syndrome
Most common cardiac anomaly with Kabuki syndrome?
Coarctation of the aorta, bicuspid aortic valve
Most common cardiac anomaly with NF1?
Pulmonary stenosis, cardiomyopathy
Superior axis + HOCM = ____
Noonan Syndrome
Presence of Q weaves in III, aVF and V1 is suggestive of …
CC-TGA
AVSD and Tricuspid atresia can both have LAD or Superior axis deviation on ECG -> what may be other differentiating feature?
AVSD -> ECG would have R) heart dominance; whereas Tricuspid atresia would present with L) heart dominance
Common ECG findings in Ebsteins anomaly?
R) AD and RBBB
What does the Q wave represent?
Septal depolarisation
What does QRS segment represent?
Ventricular depolarisation
What does ST segment represent?
Refractory period
What does the T wave represent?
Ventricular re-polarisiation
How do manage neonatal flutter if adenosine does not work?
Electrical cardioversion
Why do you get diastolic murmur with truncus arteriosus?
Because regurgitation from truncal valve (crap valve)
Afterload is affected by _______
Systemic vascular resistance
Thus Ace inhibitors help with afterload by reducing peripheral resistance
Fredreich’s ataxia, Pompe’s is associated with which cardiac anomaly?
Hypertrophic cardiomyopathy
Noonan’s and Fabre’s disease is associated with which cardiac anomaly?
Hypertrophic cardiomyopathy
If an ECG has P waves, before the QRS with tachycardia (long RP tachycardia) - what sort of ventricular arrhythmia is this consistent with?
Atrial ectopic tachycardia
Other ddx: Sinus tachycardia (Sinus tachy would have beat to beat variability -> and would have sudden change to sinus tachycardia)
Short RP tachycardia (distance from RP versus PR is shorter) is associated with which arhythmia?
Associated with AVRT or AVNRT
In SVT APLS management -> how many doses of Adenosine do you give before a large (400-500microg/kg) dose of Adenosine or DC shock or amiodarone?
3 escalating doses fo Adenosine -> 100 -> 200 -> 300
IN VT with pulse + no shock -> how do you manage?
Given 5mg/kg of Amiodarone over 30mins
U waves associated with?
Hypokalaemia
Branch peripheral artery stenosis?
Alagille Syndrome and then William syndrome
Wave and fixed split of S2?
Wide and variable split of S2?
Wave and fixed split of S2 - ASD
Wide and variable split of S2 - Pulmonary stenosis
*TYPICALLY
Right atrial isomerism?
Asplenia
Left atrial isomerism?
1) Polysplenia
2) Complete heart block
Situs inversus associated commonly with?
Bilobed right lung
If in V2-V3 we have tall R and S waves that are equal ->
Suggestive of biventricular hypertrophy
Sensorihearing loss + LQTS =
Jervell and Lange Nielsen syndrome (Autosomal recessive)
Most other long QTS are autosomal dominant
1) Prostacyclin
2) Endothelin
3) Nitric oxide
What role do each of the above play with vaso-contriction/dilatation and management of PPHN?
1) Prostacyclin - Vasodilatation -> prostacyclin/glandin given to activate cAMP and lead to vasodilatation (-ol)
2) Endothelin - Vasocontriction -> thus endothelin receptor antagonist given to cause vasodilatation (-entan)
3) Nitric oxide - vasodilatation - Nitric oxide and phosphodiesterase inhibitors (sildenafil) given to activate cGMP
Which channel anomalies are seen:
- LQTS 1
- LQTS 2
- LQTS 3
- LQTS 1: prolonged potassium eflux
- LQTS 2: prolonged potassium eflux
- LQTS 3: prolonged sodium influx
SCN5A mutation is associated with?
LQT3 syndrome
