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PACES Revision Cards > Cardiology Flashcards > Flashcards

Cardiology Flashcards

1
Q

Cardiac Causes of Clubbing

A

Subacute infective endocarditis

Cyanotic congenital heart disease

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2
Q

Outline causes of left sided heart failure

A

HTN (most common)
IHD
Cardiomyopathy
Myocarditis
Valvular disorders e.g. aortic stenosis

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3
Q

What is Congestive Cardiac Failure?

A

When there is evidence of biventricular failure (both RVF and LVF)

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4
Q

NYHA Classification of Heart Failure

A

I = No effect on normal activities

II = Can walk 100m on flat without SoB

III = SoB on minimal exertion, normal at rest

IV = SoB at rest

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5
Q

Management of Heart Failure

A

CONSERVATIVE
- MDT approach, heart failure team
- Exercise training
- Modifiable risk factors (CVD) e.g. stop smoking

MEDICAL
- Diuretics
- ACEIs/ARBS (affect prognosis)
- Beta blockers
- K+-sparing diuretics if NYHA > III
- Digoxin
- Entresto (sacubitril-valsartan) if NYHA III/IV with reduced ejection fraction already on ACEI/ARB

SURGICAL/INTERVENTIONAL
- Biventricular pacing
—- Indicated if wide QRS and LVEF<35%

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6
Q

What is S1?

A

Sound of mitral and tricuspid valves closing

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7
Q

What is S2?

A

Sound of aortic and pulmonary valves closing

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8
Q

Differentials for a systolic murmur

A

Aortic stenosis (Ejection systolic)
Mitral regurgitation (Pansystolic)
— Mitral Valve prolapse (mid click or late systolic)
Pulmonary stenosis
Tricuspid stenosis
ASD
VSD (pansystolic)
HOCM (ejection systolic)

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9
Q

Differentials for a Diastolic Murmur

A

Aortic regurgitation (early)
Mitral Stenosis (mid-diastolic)
Pulmonary regurgitation
Tricuspid Stenosis

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10
Q

Which murmurs are loudest during inspiration?

A

Right sided murmurs (Tricuspid and pulmonary) due to increased blood flow across these valves during inspiration (increased venous return)

{RILE = Right Inspiration, Left Expiration}

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11
Q

Outline the pros and cons of Biological vs Mechanical Valves

A

BIOLOGICAL
- Usually bovine/porcine
- Do NOT require anticoagulation long term
- Higher risk of structural deterioration over time (esp aortic valves)
- Usually offered to older patients
—– AV >65, MV > 70

MECHANICAL
- More durable
- Low failure rate
- Require long term anticoagulation
- Valve of choice in <60s

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12
Q

Outline the INR targets for metallic valves

A

Aortic - INR 2.0-3.0

Mitral - INR 2.5-3.5

Multiple Valves - INR 2.5-3.5

Concurrent AF - INR 2.5-3.5

{MV requires higher INR target as associated with increased thromboembolism risk - ?due to lower flow rates across MV compared to AV}

RIGHT SIDED VALVES DO NOT GET MECHANICAL VALVES

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13
Q

Causes of Aortic Stenosis

A

Degenerative calcific aortic valve (common in elderly)
Congenital bicuspid valve
Rheumatic heart disease

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14
Q

Features of Aortic Stenosis

A

Syncope
Angina (due to reduced diastolic coronary perfusion time)
Dyspnoea

Slow-rising pulse (anacrotic)
Narrow pulse pressure
Ejection systolic, radiating to carotids, loudest in expiration

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15
Q

Features of Severe Aortic Stenosis

A

Soft/absent S2
Syncope
Slow-rising pulse
Quieter the murmur, the more severe

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16
Q

Potential complications of Aortic Stenosis

A

Concurrent mitral regurgitation
Heart failure
Infective endocarditis
Injury due to syncope
AV block (due to invasion of calcium from valve into His-Purkinje system)

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17
Q

Echocardiogram features of Aortic Stenosis

A

Valve area < 1.5cm2
- SEVERE if <1cm

Pressure gradient across valve > 20
- SEVERE if >40mmHg

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18
Q

Outline how you would investigate a patient with a new murmur?

A

ABCDE

Set of observations
ECG

Bloods
- Routine (FBC, U&Es, LFTs, inflam)

CXR
- Exclude features of heart failure

Echocardiogram (Key investigation)
- Investigating for valve disorder

Coronary angiogram
- Exclude coronary artery disease; if present, could undergo CABG at same time as valve repair/replacement

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19
Q

Indications for Surgical Intervention for Aortic Stenosis

A

Symptomatic AS

Asymptomatic and gradient >40mmHg AND….
- Evidence of LVSD (EF<45%)
- Valve area < 0.6
- LVH > 15mm
- Abnormal exercise response e.g. hypotension during exercise
- Ventricular tachycardias

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20
Q

How often should asymptomatic patients with mild-moderate AS be followed up?

A

6-12 monthly follow up with echocardiograms

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21
Q

What is a TAVI?

A

Transcatheter Aortic Valve Implantation

This is a surgical intervention for Aortic Stenosis

Indicated for patients with severe AS who are:
>75 years old
<75 years old but not a candidate for open heart surgery (e.g. due to pulmonary HTN, severe LVSD)

CONTRAINDICATED IF:
- Evidence of Peripheral vascular disease (access issue)
- Evidence of severe coronary artery disease

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22
Q

Potential Complications of TAVI procedure

A

Failure
Conduction abnormality - may require PPM
Damage to vasculature/surrounding structures
Stroke
MI

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23
Q

What is Heydes Disease?

A

Association between Aortic Valve Stenosis & Angiodysplasia (particularly colonic)

Mild form of von Willebrand disease due to sheer stresses around aortic valve = increase in vW factor breakdown

= consider in patients with SoBOE, anaemia and ejection systolic murmur

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24
Q

Outline the differences between Aortic Stenosis and Aortic Sclerosis

A

STENOSIS
= valve narrowing
- ECG may show LVH
- Ejection systolic murmur, radiating to carotids

SCLEROSIS
= valve thickening
- Usually normal ECG
- Ejection systolic murmur, non radiating

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25
Q

Outline some causes of Aortic Regurgitation

A

Bicuspid AV

Ankylosing Spondylitis (and other seronegative arthropathies)

Luetic heart disease (syphilis)

Dissection

Rheumatic heart disease

Infective endocarditis

Connective Tissues Disease e.g. Marfan’s, Pseudoxanthoma Elasticum

{Usually due to disease of AV cusps or aortic root dilatation}

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26
Q

Features of Aortic Regurgitation

A

Fatigue
Angina
Dyspnoea

Wide pulse pressure
Collapsing pulse
Early diastolic murmur, increased on expiration and on leaning forwards

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27
Q

Eponymous Signs of Aortic Regurgitation

A

Austin Flint Murmur
- Mid-diastolic murmur (due to partial closure of anterior MV cusps in severe AR)

Corrigan’s Pulse
- visible distension and collapse of the bilateral carotid arteries
- A.k.a collapsing pulse

De Musset Sign
- Head bobbing with each heart beat

Mueller Sign
- Pulsatile Uvula

Quincke Sign
- Exaggerated capillary pulsation of nail bed

Traube Sign
- “Pistol shot” noise over femoral artery

Waterhammer Pulse
- Collapsing pulse (e.g. radial)

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28
Q

Causes of a Collapsing Pulse

A

Aortic Regurgitation
PDA
Hyperkinetic states e.g. anaemia, exercise, thyrotoxicosis

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29
Q

Features of Severe AR

A

Wide pulse pressure
Short murmur
- this is a sign of increase volume of regurgitant blood (tap running as opposed to bucket of water being turned upside down)
Features of left ventricular failure

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30
Q

Indications for surgical intervention for Aortic Regurgitation

A

Symptomatic AR
Dilated heart
EF<50%
Regurgitant fraction >50%

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31
Q

Causes of Absent Radial Pulse

A

Coarctation of Aorta
Congenital (usually bilateral)
Trauma (previous arterial line or coronary angio)
Cervical Rib
Arterial embolisation (AF)

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32
Q

Causes of Mitral Regurgitation

A

Calcific degeneration of valve (common in elderly)
Rheumatic heart disease
MV prolapse
Infective endocarditis
Connective Tissue disease e.g. Marfan’s
Post MI (e.g. papillary muscle rupture)

33
Q

Features of Mitral Regurgitation

A

AF!
Features of heart failure
Features of pulmonary HTN (e.g. P2 thrill, left parasternal heave)
Displaced apex

{All of above also features of severe MR!}

Pansystolic murmur, radiates to axilla, increased on expiration

34
Q

What ECG findings may you see in MR?

A

AF

LVH

P-mitrale (= bifid p wave, secondary to left atrial enlargement)

35
Q

Indications for surgical intervention in MR

A

LV dysfunction (EF < 60%)
New onset AF
New onset pulmonary HTN
Severely symptomatic
Sudden onset MR e.g. post MI

36
Q

True or False:

MV replacement is preferred over MV repair

A

FALSE

Subvalvular apparatus disconnection can occur in replacement –> this can lead to a reduction of LVEF by 20%

37
Q

What is Mitral Valve Prolapse?

A

Common condition (1-2%) in which one or both of the cusps of the mitral valve prolapse into the left atrium during systole

Usually idiopathic

Associated with
- Congenital heart disease
- Cardiomyopathy
- Turner’s syndrome
- Marfan’s syndrome
- Other CTD e.g. Ehler Danlos, osteogenesis imperfecta and pseudoxanthoma elasticum
- Wolf Parkinson White
- Long QT syndrome
- PKD (25% of APKD have valvular disorder)

Mid-systolic “click” or late systolic murmur

38
Q

Which condition is more likely to have AF associated with it?

Mitral Stenosis or Mitral Regurgitation?

A

Mitral Stenosis

39
Q

Causes of Mitral Stenosis

A

Rheumatic heart disease (>90%)
- 40% of patients with rheumatic MS ahve multivalvular disease
Degenerative calcification
Congenital (RARE)
Infective Endocarditis

40
Q

Features of Mitral Stenosis

A

AF

Malar Flush
Hoarse voice (=Ortner’s syndrome)
- Compression of left recurrent laryngeal nerve by enlarged LA/pulm artery
Features of RVF
Features of pulm HTN e.g. P2 thrill, left parasternal heave

Apex non displaced, tapping

Loud S1, opening snap
Mid-diastolic murmur (loudest in expiration and in left lateral position)

41
Q

Features of severe Mitral Stenosis

A

AF
Pulmonary HTN
RVF
Short gap between S2 and opening snap
Long mid diastolic murmur

Mitral Valve Are < 1.0cm2

42
Q

When would you consider giving warfarin to a patient with Mitral Stenosis?

A

1) If they have concurrent AF

2) If their left atrium > 55mm (increased risk of thrombus formation)

43
Q

Indication for surgical intervention in Mitral Stenosis

A

Severe MS (MVA < 1.0cm2)
Symptomatic - NHYA > II

44
Q

Outline examples of surgical intervention for Mitral Stenosis

A

Percutaneous Balloon Mitral Valvuloplasty
- Indicated in symptomatic (NHYA>II) or MVA < 1.0 AND favourable morphology (Wilkin’s Score <8)
- in abscence of Left atrial thrombus or mod/severe mitral regurg

MV Repair/Replacement
- Indicated if PBMV not suitable or have concurrent coronary artery disease and would likely require CABG

MV Valvotomy
- if have had previous failed PBMV

45
Q

Management of Mitral Stenosis in Pregnancy

A

If severe MS
- Advise to avoid getting pregnant prior to any intervention

Asymptomatic patients often present in 2nd trimester with symptoms due to increased HR and intravascular volume which occurs in pregnancy

If develops severe MS and NHYA III/IV during pregnancy = PBMV

46
Q

Outline causes of tricuspid regurgitation

A

Most cases are secondary to pulmonary HTN

PRIMARY
- Rheumatic heart disease
- Infective Endocarditis
- Ebstein’s congenital anomaly

SECONDARY
- Functional TR e.g. RV dilation secondary to chronic LVF
- RV infarction
- Pulmonary HTN
- Carcinoid syndrome

47
Q

Features of tricuspid regurgitation

A

Often asymptomatic

Raised JVP
- CW wave
- “Ear wiggling”
Pulsatile liver

Pansystolic murmur, loudest on inspiration
Left parasternal heave

48
Q

Outline the management of tricuspid regurgitation

A

If primary TR with no pulmonary HTN
= Monitor

If functional TR =
1) Correct cause of RV overload
2) Diuretics and vasodilators

Last resort = Balloon valvuloplasty/TVR

49
Q

Outline causes of Pulmonary Stenosis

A

5% of all congenital heart disease

Almost always congenital (maternal rubella!)
Carcinoid syndrome

50
Q

Indications for Pacing

A

Symptomatic sinus bradycardia (<40bpm) e.g. syncope
Complete AV block (even if asympto)
Advanced or symptomatic 2nd degree AV block
Exercise induced 2nd or 3rd degree AV block
Neuromuscular disease with AV block e.g. myotonic dystrophy

51
Q

What is diastolic dysfunction? Outline some causes of this

A

Diastolic dysfunction = HFpEF

LV relaxation during diastole and filling is impaired

CAUSES
- HTN
- IHD
- Diabetes
- HOCM
- RCM
- Infiltrative disease e.g. sarcoid, amyloid, haemochromatosis
- Constrictive pericarditis

52
Q

What is HOCM?

A

Hypertrophic Obstructive Cardiomyopathy

Ventricular wall thickening and stiffening –> LVH, septal hypertrophy & LVOT obstruction and reduced compliance –> reduced cardiac output

1 in 500

Autosomal dominant - most common defect = MHY 6 gene

Pansystolic murmur

53
Q

What features would you expect to see on echocardiogram of a patient with HOCM?

A

MR SAM ASH

Mitral Regurgitation

Systolic anterior motion of anterior MV leaflet

Asymmetric hypertrophy

54
Q

Which medications must you AVOID in HOCM?

A

Positive Inotropes e.g. ACE inhibitors and nitrates

{Any medication that causes afterload reduction, peripheral vasodilation, intravascular volume depletion, or positive inotropy can worsen the dynamic left ventricular outflow tract obstruction}

55
Q

Outline the management of HOCM

A

MDT approach

MEDICAL (ABCD)
- Amiodarone (prevent ventricular arrhythmias)
- Beta blockers (to reduce HR and contractility = reduce myocardial oxygen demand)
- CCB (verapamil)
- Diuretics

SURGICAL
- ICD if at risk of sudden death
- Percutaneous Alcohol Septal Ablation (PASA) if evidence of LVOT obstruction and symptomatic despite medical Rx (CAUTION - risk of arrhythmogenic scar!)
- Surgical myomectomy

Genetic counselling/screening

56
Q

Features of HOCM which suggest increase risk of sudden cardiac death?

A

Syncope (esp if exertional)
FHx of sudden death in 1st degree relative
Abnormal BP response during exercise
VT
LVOT pressure gradient >50mmHg at rest
LV wall > 30mm

57
Q

Outline causes of Restrictive Cardiomyopathy

A

Endomyocardial firbosis
Loeffler’s endocarditis (Eosinophils)
Haemochromatosis
Amyloidosis
Sarcoidosis
Radiation
Scleroderma
Fabry’s disease

58
Q

Outline causes of Constrictive Pericarditis

A

CARDIAC RIND

C - CTD e.g. SLE
A - Aortic aneurysm
R - Radiation
D - Drugs e.g. hydralazine, clozapine
I - Infections e.g. TB
A - Acute Renal Failure (Uraemia)
C - Cardiac infarction (first 48 hours)

R - Rheumatic fever
I - Injury (haemopericardium)
N - Neoplasms
D - Dressler’s syndrome (2-6 weeks post MI)

59
Q

Outline examples of common causative organisms of Infective Endocarditis

A

3/4 caused by strep or staph infections

Strep Viridans - URTI, dental damage

Strep Pneumoniae/Pyogenes

Staph Aureus

Staph Epidermis

Strep Bovis (colorectal cancer)

Enterococcus Faecalis

HACEK group = slow growing, gram negative

Coxiella Burnetti “Q Fever”

Yeasts & Fungi

60
Q

Outline Duke’s Criteria

A

Diagnostic of IE if
- 2 x Major
- 1x Major, 3 x Minor
- 5x Minor

MAJOR CRITERIA
1) Positive blood cultures
2) Evidence of endocardial involvement (characteristic echo findings e.g. vegetations)

MINOR CRITERIA
1) Serological evidence of acute infection with organism consistent with IE
2) Vascular embolic phenomena e.g. Janeway lesions
3) Immunological phenomena e.g. glomerulonephritis, Osler’s nodes, Roth’s spots
4) Fever > 38
5) Predisposing condition e.g. valvular disease, IVDU
6) Suggestive echo findings

61
Q

How would you investigate for Infective Endocarditis?

A

ECG
Urinalysis - ?proteinuria ?haematuria

ECG

Multiple blood cultures - at least 3 sets

CXR

Echocardiogram
- TOE best esp if small vegetations, ?abscess or prosthetic valves

62
Q

How would you manage a patient with Infective Endocarditis?

A

MDT approach - cardiologists, microbiologists, ?cardiothoracic surgeons, vascular access team

Antibiotics (guided by microbiology team)

May need to refer to surgeons for valve replacement/surgical intervention

63
Q

What are some of the indications for surgical intervention for Infective Endocarditis?

A

Aortic abscess (prolonged PR)
Septal perforation
Persistent infection e.g. fever > 10 days
Persistent mobile vegetations > 10mm
Recurrent emboli
Severe valvular incompetence e.g. AR/MR
Heart failure refractory to treatment
Resistant/fungal infections

64
Q

Can you give some examples of “stigmata of Infective Endocarditis”?

A

Janeway lesions
Splinter haemorrhages
Conjunctival haemorrhages

Osler’s nodes
Roth spots

Clubbing (subacute IE)

65
Q

What is Marfan’s Syndrome?

A

Autosomal dominant connective tissue disorder

Defect in fibrillin-1 gene on chromosone 15
- Complete penetrance but variable phenotypes

Diagnosed using Ghent Criteria (major criteria in at least 2 different systems)

CARDIOVASCULAR FEATURES
- Ascending Aorta Dilatation
- Aortic dissection
- MV prolapse (minor)

OCULAR
- Ectopic lentis

SKELETAL
- Pectus carinatum/excavatum
- Arm span/Height ratio > 1.05
- Hypermobility
- Scoliosis
- Pes planus
- High arched palate (minor)

RESP
- Spontaneous pneumothoraces (minor)

SKIN
- Skin striae
- Recurrent/incisional herniae

66
Q

Outline the management of Marfan’s Syndrome from a cardiology perspective

A

MDT approach

Genetic counselling/family screening

Yearly echocardiogram due to risk of aortic dilatation and dissection

Beta blockers (can reduce rate of Aortic dilatation)

Indications for Aortic Root Repair
- Symptomatic AR
- Meets criteria for aortic regurg surgery
- Dilation of Aortic root > 45mm
- Aortic root growth > 1cm/year

67
Q

Outline examples of Acyanotic Congenital Heart Disease

A

= “Left to Right”

ASD
VSD
PDA
Coarctation of Aorta

68
Q

Outline examples of Cyanotic Congenital Heart Disease

A

“5 T’s of Congenital Heart disease” = “Right to Left”

1) Tetralogy of Fallot
2) Transposition of the Great Vessels
3) Total anomalous pulmonary venous connection
4) Truncus arteriosus
5) Tricuspid atresia

69
Q

What is Eisenmenger’s ?

A

This is a reversal of a left-to-right shunt in a congenital defect, secondary to pulmonary HTN

This occurs due to remodelling of pulmonary vasculature –> increases pulmonary resistance –> reversal of blood flow –> right-to-left shunt

70
Q

What is Kartagener’s Syndrome?

A

Rare autosomal recessive condition
Dysmotility of dynein arm of cilia
=
1) Dextrocardia/Situs invertus
2) Bronchiectasis
3) Infertility in men

71
Q

Outline possible complications of an Atrial Septal Defect

A

50% mortality by 50

Paradoxical emboli (risk of stroke)

AF

Features of RV overload/RVF

Pulmonary HTN –> Eisenmenger’s

Infective endocarditis

72
Q

Indications for surgical closure of an ASD

A

Symptomatic
Paradoxical emboli
Evidence of significant shunt

If evidence of pulmonary HTN, closure will only be offered if evidence of reversibility on vasodilator testing

73
Q

Indications for surgical closure of VSD

A

Significant shunting

Endocarditis

Significant AR due to prolapse of leaflets throughout defect

Acute septal rupture due to MI

If other cardiac surgery planned

74
Q

What is Tetralogy of Fallot?

A

Commonest form of cyanotic congenital heart disease
Typically presents in first months of life

PROV =
Pulmonary stenosis
RVH
Overriding aorta
VSD

Severity of RVOT obstruction!

Some associated conditions e.g. DiGeorge syndrome (cleft palate), Poland Syndrome (unilateral pectoral hypoplasia)

Look for Blalock-Taussig scars

75
Q

Possible complications following ToF surgical repair

A

Pulmonary regurgitation

AR or Aortic Root dilatation
(due to distortion during VSD repair)

Infective endocarditis

Residual VSD

Arrhythmias

76
Q

Coarctation of the Aorta

A

Congenital condition of narrowing of aorta (usually where ductus arteriosus inserts into aortic arch)

Classified according to location with ductus arteriosus e.g. pre-ductal, post-ductal

FEATURES
- Intermittent claudication of lower limbs
- LVF
- Uncontrolled HTN –> headache
- Chest pain (increased risk of coronary artery disease)
- Underdeveloped lower body/left arm (if preductal)
- Raised BP in arms compared to legs (>20mmg difference)
- Delayed radio-fem or RR
- Continuous systolic-diastolic murmur (best heard between scapulae)

77
Q

Conditions associated with coarctation of the aorta

A

Bicuspid AV
VSD
Mitral valve prolapse
PDA
Aortic dissection

Turner’s syndrome
Neurofibromatosis type 1
Marfan’s

SAH (berry aneurysms in circle of willis in 5%)

78
Q

Management of coarctation of aorta

A

AVOID extreme isometric exercise e.g. weight lifting (risk of aortic dissection)

Treat hypertension

Manage Cardiac RFs

Primary percutaneous endovascular stenting (if suitable)

79
Q

Outline risks associated with valve replacement

A

Risk related to operation

Risk related to anticoagulation

Infective endocarditis

PACES Revision Cards (9 decks)

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