Cardiology COPY Flashcards
When can you hear a loud P2?
Pulmonary hypertension
What is normal splitting of the second heart sound?
Splitting of A2 and P2 in INSPIRATION
When is normal splitting heard?
Children and young adults
What is wide mobile splitting of the second heart sound?
Wide splitting of A2 and P2 heard in BOTH inspiration and expiration, inspiration >expiration
When is wide mobile splitting of the second heart sound heard?
Pulmonary stenosis
Pulmonary hypertension
RBBB
What is reversed splitting of the second heart sound?
Wide splitting of A2 and P2 during EXPIRATION
When is paradoxical splitting of the second heart sound heard?
Aortic stenosis
LBBB
HOCM
What is wide fixed splitting of the second heart sound?
Wide splitting of A2 and P2 heard in BOTH inspiration and expiration, inspiration = expiration
When is wide fixed splitting of the second heart sound heard?
ASD
What is S3?
Heard after S2 in ventricular relaxation
Due to rapid ventricular filling
Can be normal OR pathological
1. Normal in children, athletes, pregnancy
2. Increased LV stroke volume- AR, MR
3. Restrictive ventricular filling - constrictive pericarditis, restrictive cardiomyopathy
4. Ischaemic heart disease
What is S4?
Heard before S1 in atrial contraction, before ventricular contraction Always pathological Due to forceful atrial contraction Seen in: HOCM Long-standing HTN IHD
What is an ejection click?
An extra SYSTOLIC sound.
A high pitched sound heard just after S1 - indicates maximal opening of aortic and pulmonary valve.
Heard in:
Biscuspid valve
Flexible stenotic aortic or pulmonary valve
Pulmonary dilatation
Dilated aorta
What is an opening snap?
An extra DIASTOLIC sound
Heard just after S2
Best heard in the apex
Heard in mitral stenosis- sound as the mitral leaflets suddenly dome into the LV during early diastole
What cardiac surgery gives a Left thoracotomy with a normal brachial pulse?
PDA ligation
Pulmonary artery banding
Non-cardiac
What cardiac surgery gives a Left thoracotomy scar with a normal or reduced brachial pulse?
Blalock-Taussig shunt
Co-arctation repair (left subclavian flap)
What cardiac surgery gives a Right thoracotomy scar wit a normal brachial pulse?
Right Blalock-Taussig shunt
Non-cardiac
What cardiac surgery gives a median sternotomy scar?
Any corrective cardiac surgery. Brachial artery will be normal
What is the normal axis shown by the anterior leads?
Lead I - upright (R)
Lead II- upright (R)
Lead III- equivocal
What is the LAD axis shown by the anterior leads?
Lead I - upright (R)
Lead II- equivocal
Lead III -downward (S)
What is the RAD axis shown by the anterior leads?
Lead I- downward/equivocal
Lead II- upright (R)
Lead III- upright (R)
What is the superior axis shown by the anterior leads?
S >R wave in AvF
How do you know if you are truly in sinus rhythm?
P wave reflects that it is originating from the RA (SA node)
Upright P wave in lead I (therefore originating from R) and moving left)
and in AvF (therefore moving from top to bottom)
What are features of an ASD on ECG and auscultation?
Murmur R) upper sternal edge
Mild RAD
May have partial RBBB
What are features of an ASD on ECG and other IX
ESM murmur R) upper sternal edge Fixed split of second heart sound RV lift Normal pulses Normal Axis or RAD May have partial RBBB Plethora on CXR Cardiomegaly on CXR Prominent PA on CXR
What are anterior leads on an ECG?
V3, V4
What are the inferior leads on an ECG?
II, III, AvF
What are the lateral leads on an ECG?
I, AvL, V5, V6
What are the septal leads on an ECG?
V1, V2
What ECG changes do you see in L-TGA
Deep Q wave V1
What are normal Q waves?
Q waves present in I,II,III, AvF, V5, V6
and up to 7mm in II and III
What are pathological Q-waves in children?
Broad AND deep
Present in V1 (indicate L-TGA, single ventricle, severe RVH or inferior MI
What features suggest a Still’s murmur?
2-3/6 vibratory murmur ULSE + LLSE
Normal pulses
Normal ECG
Disappears or becomes quieter on sitting up and extending the neck
What are the ULN of S waves in V1 and the R waves in V6 according to age? (looking for RVH)
S waves in V1 birth- 20mm 6m- 25mm 1yr- 12mm 10y-25mm
R waves in V6 Birth- 13mm 6m- 25mm 1yr-25mm 10y-30mm
What ECG and other changes do you get with a VSD without pulmonary HTN?
Normal ECG or LVH
Loud pansystolic murmur, may have a parasternal thrill
Normal pulses
CXR may be normal or have cardiomegaly if LVH
What ECG and sx do you get with a VSD WITH pulmonary HTN?
RVH on ECG
Loud pansystolic murmur with parasternal thrill
Loud P2 (increased flow through pulmonary valve)
+/-mid-diastolic murmur APICAL murmur if large VSD due to increased flow coming back through the lungs through mitral valve
CXR- cardiomegaly, increased pulmonary vascular markings
What ECG changes and Sx do you get with Eisenmeger syndrome?
Pansystolic murmur Cyanosis, fatigue, dyspnoea, haemoptysis Right ventricular heave Loud P2 RVH on ECG Tall and spiked P waves CXR- Cardiomegaly, prominent pulmonary artery with peripheral tapering of pulmonary vessels
What ECG changes do you expect in LVH
Tall R wave in V5/6, AVL
Deep S wave in V1/2, AVR
LAD
What are the ULN of R waves in V1 and the S waves in V6 according to age? (looking for RVH)
R wave in V1 birth- 20mm 6m- 17mm 1yr- 16mm 10yr-12mm
S wave in V6 birth-15mm 6m- 10mm 1yr-7mm 10y-5mm
What do you see on ECG in biventricular hypertrophy?
Big R wave in V1
Big R and S waves in V5/6
May have big R/S waves in V3-V4
What ECG changes do you see in RVH?
RAD
Upright T wave in V1
Tall R wave in V1
Deep S wave in V6
When is an upright T wave in V1 pathological?
when upright from the age of D4 to around 4 years old
Sign of RVH
What causes cyanosis and RVH?
- Tetralogy of fallot (right to left shunt due to outflow obstruction)
- Severe pulmonary stenosis and an ASD
- Severe pulmonary stenosis and a VSD
When can an inverted T wave be pathological?
In severe RVH due to “strain”
What changes on ECG do you see in RAH?
Tall, peaked P waves (>3mm).in lead II and V1
What causes RAH and RVH on ECG?
Total anomalous venous pulmonary drainage
What changes on ECG do you see with LAH?
Bifid P wave ( P mitrale) and prolonged (>2.5 small sq or 0.1s) in Lead II
In V1 have bifid with 1st half upright (representing RA) and 2nd half inverted and larger (representing LA)
What changes on ECG do you see with combined atrial hypertrophy?
Lead II- Bifid wave with first half tall and peaked and second half rounded
V1- Bifid wave with equiphasic waves. First half upright, second half inverted
What causes RAH?
Ebsteins anomaly Pulmonary stenosis Tricuspid regurg Tricuspid stenosis (rare) Pulmonary stenosis
What causes LAH
Mitral regurg
Large VSD
Mitral stenosis (rheumatic heart disease)
Severe untreated LVH
What changes do you see in ASD primum
LAD (conduction of bundle has shifted)
IRBBB
ESM over pulmonary area
Plethoric on CXR +/- cardiomegaly
ECG changes in ASD secundum
May have LAD
RBBB (conduction abnormalities)
Abnormalities in the right precordial leads (i.e. V3R or V4R) –> rSr or rsR
(resulting from dilation and hypertrophy of the right ventricular outflow tract caused by volume overload of the right heart.)
LAD
LVH with overload i.e.Large VSD ASD primum (AVCD) TA L-TGA LBBB (rare. broad complex)
What can cause an elevated ST segment in children?
Myocarditis, pericarditis, severe LVH
What are normal ST elevation levels
Up to 1mm in most leads
Up to 2mm in V2-V4
What congenital heart disease cause issues during fetal life causing fetal loss or hydrops?
Valvular regurgitation
- Developed heart (esp TR)
- In complete atrial ventricular canal defec
- In Truncus arteriosus (MR/TR)
- Arrythmia (complete block (bradycardia) or atrial arrhythmia (tachycardia)
What CHD may present with a critically ill child in the first 24 hours of life? (usually not breathless)
Severe vulvular regurgitation (might be born in
- especially ebstein’s anomaly (bad TR and large atria with pulmonary hypoplasia) and absent pulmonary valve syndrome –> only if severe, otherwise sats about 85% and looks ok
Obstructed TAVPD
“early” duct dependent presentation (if PDA closes)
What CHD present with a critically ill child after the first 24 hours of life? (severe cyanosis)
- Dependent on a PDA for PULMONARY blood flow
- Severe cyanosis when duct closes
e.g. critical PS, pulmonary atresia, single ventricle with PS or PA
2.Dependent on PDA for SYSTEMIC blood flow
-Low cardiac output when duct closes
e.g critical AS, critical coarctation, HLHS
What CHD present with an ill child after the first 24 hours of life- 2weeks? (severe cyanosis)
- Dependent on a PDA for PULMONARY blood flow
- Severe cyanosis when duct closes
e.g. critical PS, pulmonary atresia, single ventricle with PS or PA - Dependent on PDA for SYSTEMIC blood flow
-Low cardiac output when duct closes
e.g critical AS, critical coarctation, HLHS - Dependent on PDA for mixing
• Cyanosis when duct closes
• TGA
What is Ebstein’s anomaly?
Leaflets of Tricuspid are displaced downward and posteriorly = big RA + very small non-functioning RV
= big dilated RA of the heart (=big heart on CXR) and can cause pulmonary hypoplasia
Cyanosis since birth
Extreme cardiomegaly on CXR with oligaemia and also RA enlargement
LAD and LVH with possible delta waves (WPW) on ECG
What causes a very big heart +/- pulmonary hypoplasia on CXR?
Ebstein’s anomaly
What can cause a slightly enlarged heart with respiratory distress and pneumonia (DDX respiratory)
TAVPD with venous obstruction (confluence is)obstructed)
What is TAVPD?
Veins form behind the heart but don’t join to the heart
- either come in behind and join the anomanent (supracardiac- present more like an ASD)
- or come down and joining IVC (infra diaghragmatic) - most likely to be obstructed
Small left atrium
Left to Right shunt across PFO/ASD