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Cardiology cases Flashcards

1
Q

Consultation - what are the symptoms of aortic regurgitation?

A

Asymptomatic for a long time
Severe symptomatic AR - exertional dyspnoea, angina, heart failure symptoms (orthopnoea, paroxysmal nocturnal dyspnoea, ,pulmonary oedema).

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2
Q

What examination features would you expect to see in aortic regurgitation?

A

Water hammer/collapsing pulse
de Musset sign - head bobbing with each heartbeat
Quincke pulses - capillary pulsations in fingertips
Lateral displacement of the apical heart beat
Thrill at sternal notch
Early diastolic murmur, soft S1, variable S2, S3 with severely depressed LV function

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2
Q

Given the findings of blowing early diastolic murmur and collapsing pulse what is your preferred diagnosis and differentials?

A

Aortic regurgitation
Due to aortic root dilation, congenital bicuspid aortic valve, calcific valve disease, rheumatic heart disease.
DDx:
Pulmonary regurgitation
Mitral stenosis

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3
Q

How would you investigate for aortic regurgitation?

A

ECG
Echocardiogram
Cardiovascular MR imaging to evaluate moderate or severe AR with suboptimal echo

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3
Q

What is aortic regurgitation?

A

Inadequate closure of the aortic valve leaflets.

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4
Q

How would you manage a patient with aortic regurgitation?

A

If symptomatic or asymptomatic with LV dysfunction - surgery. Can be surgical replacement or transcatheter implantation.
If not candidate for surgery - medical treatment for HFrEF - diuretics, ACEi.
Manage hypertension.

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5
Q

What are the complications of aortic regurgitation?

A

Reduced LVEF with heart failure symptoms.

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6
Q

What is the prognosis of aortic regurgitation?

A

Evolves slowly with long asymptomatic compensated phase but can progress to severe AR with LV dilation and heart failure.
Mortality if severe symptoms is 25% if NYHA class III/IV.

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7
Q

Consultation - what are the symptoms of aortic stenosis?

A

Classic symptoms (represent end-stage disease) - heart failure, syncope, angina.
Earlier symptoms - dyspnoea on exertion/decreased exercise tolerance, exertional syncope/pre-syncope, exertional angina.

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7
Q

What examination features would you expect to see in aortic stenosis?

A

Low volume, slow-rising carotid pulse
Ejection systolic murmur
Single second heart sound

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8
Q

Given the findings of ejection systolic murmur and slow rising pulse what is your preferred diagnosis and differentials?

A

Aortic stenosis
Due to: congenitally abnormal valve, calcific disease of a trileaflet valve, rheumatic valve disease.
DDx:
Aortic sclerosis
Pulmonary stenosis
Cardiomyopathy

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8
Q

How would you investigate for aortic stenosis?

A

ECG
Echocardiography - diagnose and assess severity. Stage A = asymptomatic with transvalvular aortic velocity <2m/s. Stage B = murmur but no symptoms, VMAX 2.0-2.9 m/s. Stage C = no symptoms but VMAX >4m/s, valve area <1cm^2. Stage D = as C but with symptoms.

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9
Q

What is aortic stenosis?

A

Aortic valve thickening causing left ventricular outflow obstruction causing antegrade velocity across valve >2m/s.

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10
Q

How would you manage a patient with aortic stenosis?

A

Valve replacement if symptoms or severe or LVEF. TAVI or surgical replacement.
Asymptomatic - statins, hypertension management, avoid strenuous physical activity, treat AF, medical management of HFrEF.

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11
Q

What is the prognosis of aortic stenosis?

A

Variable progression in non treated disease.
Symptomatic without valve replacement = mortality high if cardiac symptoms. Heart failure = 0.5-3 years survival. Syncope = 1-4 years survival. Angina = 2-5 years.

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11
Q

What are the complications of aortic stenosis?

A

Heart failure
pulmonary hypertension
Sudden cardiac death
Arrhythmias
Endocarditis
Bleeding tendency
Embolic events

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12
Q

Consultation - what are the symptoms of aortic valve replacement?

A

Subtle symptoms of heart failure -

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13
Q

What examination features would you expect to see in aortic valve replacement?

A

Midline sternotomy scar, may have vein harvesting scars on legs for CABG done at the same time.
Bruising from warfarinisation.
Mechanical sound - S2.
Can have murmur from leak, new stenosis or new regurgitation.
Need to look out for signs of heart failure and infective endocarditis.

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14
Q

Given the findings of metallic click just after the pulse, midline sternotomy scar and no features of infective endocarditis or heart failure what is your preferred diagnosis and differentials?

A

Aortic valve.

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15
Q

How would you investigate for aortic valve replacement?

A

Bloods including inflammatory markers
Echocardiography
ECG

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15
Q

What is aortic valve replacement?

A

Replaced aortic valve generally done for severe symptomatic aortic stenosis or aortic regurgitation. Can by mechanical or bioprosthetic/tissue.

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16
Q

How would you manage a patient with aortic valve replacement?

A

If mechanical, anticoagulation therapy - warfarin.
Endocarditis prophylaxis - good oral hygeine, prophylaxis for some procedures.
Moderate exercise to maintain cardiovascular fitness.

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17
Q

What are the complications of aortic valve replacement?

A

Thromboembolism
Valve failure - regurgitation
Infective endocarditis
Bleeding secondary to antithrombotic therapy
Haemolytic anaemia

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18
Q

What is the prognosis of aortic valve replacement?

A

2% complications leading to death from surgery.
Tissue valves last 10-20 years.
Mechanical valves last 20-40 years.

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19
Q

What examination features would you expect to see in mitral prolapse?

A

Slightly lower than average BMI.
Nonejection click and pansystolic murmur from relapse.

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19
Q

Consultation - what are the symptoms of mitral prolapse?

A

Most patients are asymptomatic.
Chest pain, palpitations, dyspnoea, exercise intolerance, dizziness, lean body habitus, anxiety disorders.

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20
Q

Given the findings of slightly low BMI and non-ejection click with pansystolic murmus what is your preferred diagnosis and differentials?

A

Mitral valve prolapse.
DDx:
Mitral valve regurgitation
Aortic or pulmonary stenosis
VSD

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21
Q

What is mitral prolapse?

A

Cause of primary mitral regurgitation caused by disease of one or more valve components, including leaflets, chordae tendinae, papillary muscles, or annulus.

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22
Q

How would you investigate for mitral prolapse?

A

Echocardiography
ECG
Cardiac MR

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23
Q

How would you manage a patient with mitral prolapse?

A

Assessment of severity and arrhythmic risk.
Replacement

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23
Q

What are the complications of mitral prolapse?

A

Severe MR
Infective endocarditis
Arrhythmias

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24
Q

What is the prognosis of mitral prolapse?

A

Can progress to MR and worsen with time.

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25
Q

Consultation - what are the symptoms of mitral regurgitation?

A

Can be well tolerated but eventually heart failure symptoms and breathlessness.
Acutely can cause pulmonary oedema.

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25
Q

Given the findings of laterally displaced apex beat, pansystolic murmur and atrial fibrillation what is your preferred diagnosis and differentials?

A

Mitral regurgitation
Due to: degenerative, coronary artery disease with papillary muscle dysfunction, infective endocarditis, rheumatic fever.

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26
Q

What examination features would you expect to see in mitral regurgitation?

A

Pansystolic murmur at apex.
Lateral displacement of the apex beat - can be brisk or hyperdynamic.
Can have S3 and palpable thrill.
Often in AF.

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27
Q

What is mitral regurgitation?

A

Failure of the mitral valve to fully close leading to back flow of blood from the LV to the LA.

28
Q

How would you investigate for mitral regurgitation?

A

ECG - broad P wave
Echo
CXR - enlarged LA and LV
Cardiac MR

29
Q

How would you manage a patient with mitral regurgitation?

A

Asymptomatic - usually monitor, if severe can consider surgery.
If LV dysfunction, new AF, or pulmonary hypertension - consider surgery.
Acute MR - nitrates, diuretics, sodium nitroprusside, inotropic agents, intra-aortic balloon pump, ACEi if heart failure.

29
Q

What are the complications of mitral regurgitation?

A

Pulmonary hypertension
LV dysfunction
AF (+ subsequent thromboembolism risk)

30
Q

What is the prognosis of mitral regurgitation?

A

Good with surgery, can be worse with severe disease.

31
Q

Consultation - what are the symptoms of mitral stenosis?

A

Asymptomatic for years but may develop gradual decrease activity.
Breathlessness - progressive.
AF with systemic emboli.

32
Q

What examination features would you expect to see in mitral stenosis?

A

Malar flush on cheeks
Raised JVP
Laterally displaced apex beat
RV heave
Loud first heart sound with opening snap in diastole
Mid-late diastolic murmur heard with bell in left lateral position
AF
RV failure - hepatomegaly, ascites, peripheral oedema

33
Q

How would you investigate for mitral stenosis?

A

Echocardiography
CXR - LA enlargement, interstital oedema
ECG - AF, LA enlargement, RV hypertrophy

33
Q

What is mitral stenosis?

A

Obstruction to flow through the mitral valve between the LA and LV.

34
Q

Given the findings of malar flush, raised JVP, laterally displaced apex beat, and diastolic murmur what is your preferred diagnosis and differentials?

A

Mitral stenosis
Due to: rheumatic fever, degenerative calcification, congenital, infective endocarditis
DDx:
Left atrial thrombus or myxoma
Aortic regurgitation
Austin-Flint murmur from severe aortic regurgitation

35
Q

What are the complications of mitral stenosis?

A

Pulmonary hypertension
Dilated LA
AF
Right heart failure

36
Q

How would you manage a patient with mitral stenosis?

A

MDT approach with specialty assessment and follow up from cardiology
If mild - echo every 3-5 years.
Medical - diuretics and long-acting nitrate, B-blockers, anticoagulation if atrial fibrillation
Surgery - percutaneous mitral commissurotomy

37
Q

What is the prognosis of mitral stenosis?

A

If asymptomatic - fine
Limiting symptoms and untreated - poor survival
If severe pulmonary hypertension - less than 3 year survival

38
Q

Given the findings of metallic click on S1 what is your preferred diagnosis and differentials?

A

Mitral valve replacement
Due to: mitral valve stenosis or regurgitation
DDx:
Aortic valve replacement

38
Q

Consultation - what are the symptoms of mitral valve replacement?

A

Leading to replacement of valve - SOBOE, AF.

39
Q

What examination features would you expect to see in mitral valve replacement?

A

Mechanical - click on S1
Tissue - normal heart sounds
Can have murmurs from tubrulent flow - pansystolic or diastolic
Valve function - regurgitation, cardiac decompensation, infective endocarditis
Anticoagulation and anaemia

40
Q

What is mitral valve replacement?

A

Replacement of the MV

40
Q

How would you investigate for mitral valve replacement?

A

Bloods - haemolysis on FBC, BNP
CXR
ECG
Echocardiogram

41
Q

How would you manage a patient with mitral valve replacement?

A

Monitoring asymptomatic patients - echo
Slight regurgitation - medical treatment of heart failure
Severe regurgitation - surgical or transcatheter intervention

42
Q

What are the complications of mitral valve replacement?

A

Regurgitation and valve failure
Infective endocarditis
Arrhythmias

43
Q

What is the prognosis of mitral valve replacement?

A

Pretty OK
If tissue needs replacing after about every 10-20 years
If mechanical can last 20-40 years

44
Q

Consultation - what are the symptoms of mixed aortic and mitral valve disease?

A
45
Q

What examination features would you expect to see in mixed aortic and mitral valve disease?

A

Mixture of findings depending on lesion:
AS - low volume slow rising pulse, heaving apex, thrill over aorta, soft S2, ejection systolic murmur
AR - collapsing pulse, displaced apex beat, diastolic murmur
MS - early opening snap, diastolic murmus, pulmonary hypertension
MR - displaced apex beat, palpable mitral thrill, soft S1, split S2, diastolic murmur

46
Q

Given the findings of slow rising pulse, displaced apex, pansystolic murmur and ejection systolic murmur what is your preferred diagnosis and differentials?

A

Mixed valvular pathology including aortic stenosis and mitral regurgitation.
Due to:
Rheumatic heart disease
Infective endocarditis
Degenerative changes including calcification

46
Q

How would you investigate for mixed aortic and mitral valve disease?

A

Echocardiogram
ECG
CXR

47
Q

How would you manage a patient with mixed aortic and mitral valve disease?

A

MDT approach including cardiology follow up
Medical management of symptoms
Surgical management with valve repair or replacement

47
Q

What is mixed aortic and mitral valve disease?

A

Combination of stenotic and regurgitant lesions on the same valve.

48
Q

What are the complications of mixed aortic and mitral valve disease?

A

Heart failure
Pulmonary hypertension

48
Q

What is the prognosis of mixed aortic and mitral valve disease?

A

Depends on severity and if replaced

49
Q

Consultation - what are the symptoms of Marfan’s syndrome?

A

Can be asymptomatic
Disproportionately tall and thin with unusually long arms and legs compared to trunk.

50
Q

What examination features would you expect to see in Marfan’s syndrome?

A

Disproportionately tall with unusually long arms and legs
Arachnodactyly - Walker’s wrist sign, Steinberg’s thumb sign
Skin - striae
Cardiovascular - thoracic aortic dilatation/rupture/dissection, aortic regurgitation, mitral valve prolapse or regurgitation, abdominal aortic aneurysm
Lungs - pneumothorax
Eyes - lens dislocation, closed-angle glaucoma, high myopia
Skeleton - hypermobility, arthralgia, joint instability
Facial characteristics - maxillary/mandibular retrognathia, high arched palate

50
Q

Given the findings of high arched palate, arachnodactyly, and diastolic murmur what is your preferred diagnosis and differentials?

A

Marfan’s syndrome
DDx:
EDS
Fragile X syndrome
Gigantism
Klinefelter’s syndrome

51
Q

What is Marfan’s syndrome?

A

Inherited connective tissue disorder with skeletal, dermatological, cardiac, aortic, ocular and dura mater malformations. Due to mutations in the gene encoding fibrillin-1.

52
Q

How would you investigate for Marfan’s syndrome?

A

Echo - annually to montiro aortic root width and heart valve function
Cardiac MR or CT for the whole aorta every 5 years or yearly if aneurysmal formation
Holster monitoring - if symptoms

53
Q

How would you manage a patient with Marfan’s syndrome?

A

MDT approach including geneticist, ophthalmologist, cardiologist, orthopaedic surgeon, and psychologists
Conservative - psychological support, avoid exertion at maximal capacity
Drugs - B-blockers, ACE-i/ARB
Surgical - prophylactic aortic root surgery to prevent aortic dissection

54
Q

What are the complications of Marfan’s syndrome?

A

Aortic dissection/aneurysm

55
Q

What is the prognosis of Marfan’s syndrome?

A

Almost normal with aortic root surgery

56
Q

What examination features would you expect to see in ventricular septal defect?

A

Harsh pansystolic murmur with split S2

56
Q

Consultation - what are the symptoms of ventricular septal defect?

A

If small - asymptomatic
If moderate/large - difficulty feeding as a 5-6 week old baby
If very large - pulmonary hypertension, Eisenmenger’s syndrome

57
Q

Given the findings of harsh systolic murmur what is your preferred diagnosis and differentials?

A

VSD
DDx:
PS
Innocent physiological murmur
PDA
MR
AS

58
Q

What is ventricular septal defect?

A

Persistence of one or more holes in the septum between the LV and RV.

59
Q

How would you investigate for ventricular septal defect?

A

ECG - usually normal
CXR
Echocardiography

60
Q

How would you manage a patient with ventricular septal defect?

A

MDT approach
Medical - diuretics, ACEi
Surgical - closure of defect

61
Q

What are the complications of ventricular septal defect?

A

Aortic valve prolapse and regurgitation
Eisenmenger’s syndrome
Infective endocarditis

62
Q

What is the prognosis of ventricular septal defect?

A

If isolate, prognosis if fine

63
Q

What is atrial fibrillation?

A

The most common sustained cardiac arrhythmia with an irregularly irregular ventricular pulse and loss of association between the cardiac apex beat and radial pulsation.

63
Q

Consultation - what are the symptoms of atrial fibrillation?

A

Breathlessness/dyspnoea
Palpitations
Syncope/dizziness
Chest discomfort
Stroke/TIA

64
Q

What examination features would you expect to see in atrial fibrillation?

A

Pulse palpation - irregular pulse

64
Q

Given the findings of irregularly irregular pulse what is your preferred diagnosis and differentials?

A

Atrial fibrillation

65
Q

How would you investigate for atrial fibrillation?

A

12 lead ECG
If suspected paroxysmal AF - 24 hours ambulatory ECG monitor
Bloods - TFTs, FBC, renal function and electrolytes, LFTs, coagulation
CXR
Echo
CT/MRI brain if any suggestion of stroke or TIA

66
Q

How would you manage a patient with atrial fibrillation?

A

MDT with cardiology input if young, paroxysmal, contradindicated treatments, valvular disease, WPW.
Treat any underlying cause.
Rhythm control - cardioversion - electrical or medical with amiodarone.
Rate control - B blocker or Ca channel blocker, digoxin.
Thromboprophylaxis - DOAC or warfarin.

67
Q

What are the complications of atrial fibrillation?

A

Stroke risk increases six-fold
Acute heart failure
Cardiomyopathy

68
Q

What is the prognosis of atrial fibrillation?

A

Increased mortality in older patients

0 PACES top cases (7 decks)

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