Cardiology Flashcards
Cardiac Causes of Clubbing
Subacute infective endocarditis
Cyanotic congenital heart disease
Outline causes of left sided heart failure
HTN (most common)
IHD
Cardiomyopathy
Myocarditis
Valvular disorders e.g. aortic stenosis
What is Congestive Cardiac Failure?
When there is evidence of biventricular failure (both RVF and LVF)
NYHA Classification of Heart Failure
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
Management of Heart Failure
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%
What is S1?
Sound of mitral and tricuspid valves closing
What is S2?
Sound of aortic and pulmonary valves closing
Differentials for a systolic murmur
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)
Differentials for a Diastolic Murmur
Aortic regurgitation (early)
Mitral Stenosis (mid-diastolic)
Pulmonary regurgitation
Tricuspid Stenosis
Which murmurs are loudest during inspiration?
Right sided murmurs (Tricuspid and pulmonary) due to increased blood flow across these valves during inspiration (increased venous return)
{RILE = Right Inspiration, Left Expiration}
Outline the pros and cons of Biological vs Mechanical Valves
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
Outline the INR targets for metallic valves
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
Causes of Aortic Stenosis
Degenerative calcific aortic valve (common in elderly)
Congenital bicuspid valve
Rheumatic heart disease
Features of Aortic Stenosis
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
Features of Severe Aortic Stenosis
Soft/absent S2
Syncope
Slow-rising pulse
Quieter the murmur, the more severe
Potential complications of Aortic Stenosis
Concurrent mitral regurgitation
Heart failure
Infective endocarditis
Injury due to syncope
AV block (due to invasion of calcium from valve into His-Purkinje system)
Echocardiogram features of Aortic Stenosis
Valve area < 1.5cm2
- SEVERE if <1cm
Pressure gradient across valve > 20
- SEVERE if >40mmHg
Outline how you would investigate a patient with a new murmur?
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
Indications for Surgical Intervention for Aortic Stenosis
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
How often should asymptomatic patients with mild-moderate AS be followed up?
6-12 monthly follow up with echocardiograms
What is a TAVI?
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
Potential Complications of TAVI procedure
Failure
Conduction abnormality - may require PPM
Damage to vasculature/surrounding structures
Stroke
MI
What is Heydes Disease?
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
Outline the differences between Aortic Stenosis and Aortic Sclerosis
STENOSIS
= valve narrowing
- ECG may show LVH
- Ejection systolic murmur, radiating to carotids
SCLEROSIS
= valve thickening
- Usually normal ECG
- Ejection systolic murmur, non radiating
Outline some causes of Aortic Regurgitation
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}
Features of Aortic Regurgitation
Fatigue
Angina
Dyspnoea
Wide pulse pressure
Collapsing pulse
Early diastolic murmur, increased on expiration and on leaning forwards
Eponymous Signs of Aortic Regurgitation
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)
Causes of a Collapsing Pulse
Aortic Regurgitation
PDA
Hyperkinetic states e.g. anaemia, exercise, thyrotoxicosis
Features of Severe AR
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
Indications for surgical intervention for Aortic Regurgitation
Symptomatic AR
Dilated heart
EF<50%
Regurgitant fraction >50%
Causes of Absent Radial Pulse
Coarctation of Aorta
Congenital (usually bilateral)
Trauma (previous arterial line or coronary angio)
Cervical Rib
Arterial embolisation (AF)
Causes of Mitral Regurgitation
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)
Features of Mitral Regurgitation
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
What ECG findings may you see in MR?
AF
LVH
P-mitrale (= bifid p wave, secondary to left atrial enlargement)
Indications for surgical intervention in MR
LV dysfunction (EF < 60%)
New onset AF
New onset pulmonary HTN
Severely symptomatic
Sudden onset MR e.g. post MI
True or False:
MV replacement is preferred over MV repair
FALSE
Subvalvular apparatus disconnection can occur in replacement –> this can lead to a reduction of LVEF by 20%
What is Mitral Valve Prolapse?
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
Which condition is more likely to have AF associated with it?
Mitral Stenosis or Mitral Regurgitation?
Mitral Stenosis
Causes of Mitral Stenosis
Rheumatic heart disease (>90%)
- 40% of patients with rheumatic MS ahve multivalvular disease
Degenerative calcification
Congenital (RARE)
Infective Endocarditis
Features of Mitral Stenosis
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)
Features of severe Mitral Stenosis
AF
Pulmonary HTN
RVF
Short gap between S2 and opening snap
Long mid diastolic murmur
Mitral Valve Are < 1.0cm2
When would you consider giving warfarin to a patient with Mitral Stenosis?
1) If they have concurrent AF
2) If their left atrium > 55mm (increased risk of thrombus formation)
Indication for surgical intervention in Mitral Stenosis
Severe MS (MVA < 1.0cm2)
Symptomatic - NHYA > II
Outline examples of surgical intervention for Mitral Stenosis
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
Management of Mitral Stenosis in Pregnancy
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
Outline causes of tricuspid regurgitation
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
Features of tricuspid regurgitation
Often asymptomatic
Raised JVP
- CW wave
- “Ear wiggling”
Pulsatile liver
Pansystolic murmur, loudest on inspiration
Left parasternal heave
Outline the management of tricuspid regurgitation
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
Outline causes of Pulmonary Stenosis
5% of all congenital heart disease
Almost always congenital (maternal rubella!)
Carcinoid syndrome
Indications for Pacing
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
What is diastolic dysfunction? Outline some causes of this
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
What is HOCM?
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
What features would you expect to see on echocardiogram of a patient with HOCM?
MR SAM ASH
Mitral Regurgitation
Systolic anterior motion of anterior MV leaflet
Asymmetric hypertrophy
Which medications must you AVOID in HOCM?
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}
Outline the management of HOCM
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
Features of HOCM which suggest increase risk of sudden cardiac death?
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
Outline causes of Restrictive Cardiomyopathy
Endomyocardial firbosis
Loeffler’s endocarditis (Eosinophils)
Haemochromatosis
Amyloidosis
Sarcoidosis
Radiation
Scleroderma
Fabry’s disease
Outline causes of Constrictive Pericarditis
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)
Outline examples of common causative organisms of Infective Endocarditis
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
Outline Duke’s Criteria
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
How would you investigate for Infective Endocarditis?
ECG
Urinalysis - ?proteinuria ?haematuria
ECG
Multiple blood cultures - at least 3 sets
CXR
Echocardiogram
- TOE best esp if small vegetations, ?abscess or prosthetic valves
How would you manage a patient with Infective Endocarditis?
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
What are some of the indications for surgical intervention for Infective Endocarditis?
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
Can you give some examples of “stigmata of Infective Endocarditis”?
Janeway lesions
Splinter haemorrhages
Conjunctival haemorrhages
Osler’s nodes
Roth spots
Clubbing (subacute IE)
What is Marfan’s Syndrome?
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
Outline the management of Marfan’s Syndrome from a cardiology perspective
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
Outline examples of Acyanotic Congenital Heart Disease
= “Left to Right”
ASD
VSD
PDA
Coarctation of Aorta
Outline examples of Cyanotic Congenital Heart Disease
“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
What is Eisenmenger’s ?
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
What is Kartagener’s Syndrome?
Rare autosomal recessive condition
Dysmotility of dynein arm of cilia
=
1) Dextrocardia/Situs invertus
2) Bronchiectasis
3) Infertility in men
Outline possible complications of an Atrial Septal Defect
50% mortality by 50
Paradoxical emboli (risk of stroke)
AF
Features of RV overload/RVF
Pulmonary HTN –> Eisenmenger’s
Infective endocarditis
Indications for surgical closure of an ASD
Symptomatic
Paradoxical emboli
Evidence of significant shunt
If evidence of pulmonary HTN, closure will only be offered if evidence of reversibility on vasodilator testing
Indications for surgical closure of VSD
Significant shunting
Endocarditis
Significant AR due to prolapse of leaflets throughout defect
Acute septal rupture due to MI
If other cardiac surgery planned
What is Tetralogy of Fallot?
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
Possible complications following ToF surgical repair
Pulmonary regurgitation
AR or Aortic Root dilatation
(due to distortion during VSD repair)
Infective endocarditis
Residual VSD
Arrhythmias
Coarctation of the Aorta
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)
Conditions associated with coarctation of the aorta
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%)
Management of coarctation of aorta
AVOID extreme isometric exercise e.g. weight lifting (risk of aortic dissection)
Treat hypertension
Manage Cardiac RFs
Primary percutaneous endovascular stenting (if suitable)
Outline risks associated with valve replacement
Risk related to operation
Risk related to anticoagulation
Infective endocarditis
