Cardiology Shorts Flashcards
Mitral stenosis
-Character
-Peripheries
-Palpation
-Evidence of left/right heart decompensation
-Severity: (mild/mod/severe)
-Aetiology (4)
-DDX
-Ix
-Indications for surgery
Character:
Low pitched rumbling mid-late diastolic in mitral region
Louder expiration in left lateral position
Peripheries:
Malar flush
Irregular pulse (AF)
Raised JVP (pulm HTN) +/- other features of pulm HTN
Left thoracotomy/valvotomy scar
Palpable S1/loud S1
Tapping palpable non-displaced apex beat
Opening snap
Evidence of left/right heart decompensation:
Sacral/peripheral oedema, bibasal insp crackles
Severity: (mild/mod/severe)
Small pulse pressure
Diastolic thrill
Early opening snap
Length of murmur: earlier or continuous decrescendo
Pulmonary hypertension
Evidence of decompensation
Aetiology:
Rheumatic heart disease
Severe calcification
Congenital
Carcinoid
Complications
-Pulm HTN
-Haemoptysis
-Flash pulmonary oedema
-Emboli (stroke risk)
-AF
-IE
-left atrium compressing on recurrent laryngeal n (hoarseness), bronchial obstruction, dysphagia
DDX:
AR- early diastolic murmur, decrescendo at lower left sternal edge
PR- expected area
Left atrial myxoma
Parachute mitral valve
Severe mitral annular calcification
Thrombosed mitral valve prosthesis
Proceed:
Confirm Dx - echo
Assess complications -
. ECG: p-mitrale, AF, RAD
. CXR:
- MV calcification
- Enlarged left atrium (double shadow, carinal splaying)
- Signs of pulmonary hypertension (large central PA)
- Signs of cardiac failure.
. Echo: pulm HTN, IE
. TOE: LA thrombus
. R/L cardiac cath: wedge pressure
Management:
-Medical: diuretic, AF rate control, anticoagulation with warfarin (AF, embolic event or LA thrombus)
-Surgical: MVA <1.0, symptoms limiting activity, recurrent emboli, pulmonary oedema, deterioration due to AF
-mitral valve replacement, open valvotomy, balloon valvuloplasty (percutaneous MV commissurotomy).
Repair > replacement
Percutaneous mitral commissurotomy (PMC): favourable anatomy unless severe pulm HTN, permanent AF, persistent LAA thrombus, prior commissurotomy, other valvular disease, CAD.
Mitral regurgitation
-Character
-Severity: (mild/mod/severe)
-Aetiology (acute, chronic)
-DDX
-Ix
-Indications for surgery
Primary (acute or chronic): intrinsic lesions affect mitral valve.
Secondary: functional, valve structurally normal.
Character:
-Pan-systolic loudest at apex radiating to axilla increased on expiration and handgrip
Severity: (mild/mod/severe)
-Enlarged LV/LV failure
. thrusting and laterally displaced apex beat
. peripheral oedema, tachypnoea
. flushed face
-Pulmonary HTN
. raised JVP
. parasternal heave
-S3/Soft S1
-Small volume pulse
-Palpable thrill
-Irregular pulse
Note. IHD, dilated LV ?CABG scars or risk factors for IHD (tar staining fingers, diabetes, HTN, corneal arcus, xanthelasma)
DDx:
-MVP/HOCM- increased with valsalva
-VSD- louder L) sternal border with parasternal thrill
-TR at L) sternal border with peripheral signs.
-AS with gallavardin’s phenomena.
Aetiology:
-Acute: chorda tendinae rupture (degeneration, trauma, IE, RHD, MVP), papillary muscle rupture post-MI, papillary muscle dysfunction (ischemia), IE.
-Chronic:
. Valve: degeneration, prolapse (RHD)
. Heart: (1) Functional-LV dilation and systolic dysfunction ie dilated, ischemic cardiomyopathy (2) papillary muscle dysfunction (LVF, ischemia) (3) Congenital-endocardium (ASD), parachute valve, corrected transposition
. Systemic: CTD (SLE, RA, ankylosing spondylitis)
. Inherited: marfans, ehlers-danlos
. Hypertrophic cardiomyopathy
Ix:
-ECG: LVH, left strain, ischemia, p-mitrale, AF, RAD
-CXR: LA/LV enlargement, mitral annular calcification, pulmonary hypertension, pulmonary congestion
-Echo: aetiology (RHD, prolapse, rupture), LA/LV size/function, RV function, pulmonary artery pressure
-TOE: vegetations, papillary muscle/chordae tendinae rupture, other valvular lesions
-Doppler flow: size and site of regurgitant jet
Management:
Medical: CCF, AF, CRT with biventricular pacing
Indications for surgery:
-Chronic MR.
. NYHA III or IV
. LV dysfunction or dimensions progressing
-Acute MR: haemodynamic collapse.
-MV repair > replacement (mechanical > tissue)
-Primary MR:
. sx + severe echo (RVol >60mL, RF>50%, ERO>0.4cm2, proximal jet=VCW >0.7cm and LV dilation) + LVEF >30% = MV surgery.
. asx + LVSDysfx (LVEF 30-60%, LVESD>40mm) = MV surgery
. asx +
1) LVSDysfx (LVEF >60% LVESD <40mm)
2) New AF or PASP >50mmHg
= MV repair if (likelihood of success >95% and mortality <1%)
-Secondary MR: valve replacement/repair unlike to solve problem.
Mitral valve prolapse
-Character
-Severity
-Aetiology
-DDX
Character: normal heart sounds, mid-systolic click with late systolic MR murmur loudest at left sternal edge with valsalva or standing from squatting.
Severity: (mild/mod/severe)
-small volume pulse
-LV displaced / LV failure
-Pulmonary HTN
-S3
-Length of murmur
DDx:
-MR: holosytolic murmur mid-late systolic (severe MVP)
-AS
-HOCM
-VSD
Aetiology:
-Congenital heart disease: ASD, AVSD, PDA
-Congenital disorders: Turners, Marfans, SLE, PCKD
-Acquired: IE, papillary rupture
Complications:
-IE
-Arrythmias
-MR
-TIA/stroke (emboli)
-SCD
Sx: chest pain, palpitations, fatigue, dyspnoea
Ix:
-ECG: inferior twi, LA enlargement, AF
-CXR: cardiomegaly, LA enlargement, pulmonary oedema
-Echo: MV leaflet thickening and displacement.
Mx:
Medical: BB for palpitations
Surgical: as for MR
Antibiotic prophylaxis: not recommended
Aortic stenosis
-character
-severity
-ddx
-aetiology
-ix
-mx
Character:
-ejection systolic murmur (crescendo-decrescendo)
-aortic region
-louder on expiration and sitting forward
-decreased on valsalva and isometric manouvres
-radiating to carotids
-additional pansystolic murmur at apex radiating to axilla (gallerverdin’s phenomena or MR).
Severity:
- slow rising plateau pulse
- low systolic BP with narrow pulse pressure
- palpable systolic thrill aortic area
- heaving apex beat (pressure loaded)
- soft A2, reversed splitting of S2
- S4
-long harsh and late systolic peak, soft murmur in critical AS
-LV failure (late)
DDx:
- Aortic sclerosis: normal pulse pressure, character and A2 without radiation.
- MR or Gallavardin’s phenomenon
- HOCM (jerky pulse, double apical impulse, thrill, ESM at left lower sternal edge)
- PS
- prosthesis mismatch of aortic valve
- TR, VSD, MVP
Aetiology:
- calcified (degenerative, bicuspid)
- rheumatic
Ix:
-ECG: LVH, LA enlargement, LBBB
-CXR: LVH, valve calcification
-Echo: doppler gradient estimation (>40mmHg, >70 critical)
. valve area <1cm (<0.7cm critical)
. LVH
. LV dysfunction
Mx:
- monitoring with echo
- mx of heart failure: diuretics, ACE inhibitors or ARBs, entresto, SGLT2
- statins for secondary prevention
-Surgery v TAVR
. indications for surgery: VA <1.0 (0.7 critical) AV velocity >4m/s or AV mean gradient >40mmHg
. symptoms: exertional (dyspnoea, angina, syncope), heart faiure.
. critical obstruction and severe LVH (even if asx).
. valve: tissue (bovine / porcine IF > 65yo or younger if avoiding warfarin) ~15y life expectancy, mechanical ~20 years but anticoagulation.
. surgical risk
. life expectancy / age / anatomy
Aortic regurgitation
-character
-severity
-ddx
-aetiology
-ix
-mx
Character:
-descrescendo early diastolic murmur
-left sternal edge (3-4th ICS)
-increased on expiration and leaning forward
-decreased on valsalva
+/- associated systolic murmur (aortic stenosis, flow murmur)
Severity:
-dancing carotid (corrigans sign)
-head nodding
- nail-bed pulsation when pressed
- collapsing pulse
-wide pulse pressure (aortic compliance, ventricular stroke volume)
-Austin flint murmur (mitral stenosis - diastolic rumble from limited mitral inflow by regurgitant jet)
-length of murmur (short end-diastolic murmur)
-S3
-Soft S2
-LV failure
DDx:
-PR
-MS
Aetiology:
Acute
- valve: IE
- aortic root: dissection (marfans, HTN)
Chronic
- valve: RHD, bicuspid valve, ankylosing spondylitis and reactive arthritis
- aortic root: dilation, endocarditis, rheumatic fever, age
- aortitis: syphilitic (argyll robertson pupil)
- CTD: SLE, ehlers-danlos, osteogenesis imperfecta, marfans
- iatrogenic: following TAVI
Ix:
-ECG: LVH (35mm V1+V5/6) , lateral T-wave inversion
-CXR: LV dilation, aortic root dilation or aneurysm, valve calcification
-Echo: LV dimensions/function (<55%) and asymptomatic.
. Regurgitant fraction >50%
. RVol >60mL
. ERO >0.3cm
. Vegetation (endocarditis)
. Aortic root dimensions
. Valve cusp thickening or prolapse (associated with AS)
Mx: SOBOE, decreased LVEF, progressive LV dilation (LVESD >55mm).
- acute severe sx: urgent surgery
- surgical: AVR +/- CABG or TAVI
. sx (NYHA II-IV, angina) + severe AR
. other indication for surgery + severe AR
. asx + severe AR
- chronic: monitoring echo, heart failure, HTN.
- marfans: bb slow aortic root dilation, screen relatives.
Marfans syndrome
-character
-marfanoid
-severity
-DDx
-Ix
Character:
-AR-
.descrescendo early diastolic murmur
.left sternal edge
.increased on expiration and on leaning forward
-+/- assoc systolic murmur
-Other- MVP, dissecting aneurysm or coarctation of aorta.
-Apex beat: displaced and volume overloaded (diastolic and hyperkinetic, forceful but unsustained).
-Soft A2
-Collapsing pulse (carotid/radial)
-Wide pulse pressure
Marfanoid features:
-Tall, arm span > height, upper segment < lower segment (<0.85)
-Pectus carinatum/excavatum
-Disproportionately long, thin limbs compared with trunk
-Long, narrow face
-Kyphoscoliosis
-Pes planus
-Joint laxity: thumb/wrist sign positive (arachnodactyly, joint hypermobility)
-ocular: ectopia lentis
-mouth: high arched palate
Severity: as for AR
DDx (murmur): PR, MS
DDx (marfanoid): homocysteinuria (skeletal/ocular features without valvular heart disease).
Ix: monitor with annual echo- aortic root dilation (increased risk of dissection), slit lamp to diagnose lens dislocation.
Hypertrophic obstructive cardiomyopathy
HOCM: auto dominant, cardiac sarcomere mutation (myosin).
-Character
-DDx
-Ix
-Mx
Character:
-mid-late ejection systolic murmur at left sternal edge accentuated with valsalva
+ pansystolic murmur at apex from MR
+ S4
+ Normal A2
-Other:
. pulse: sharp rising and jerky, bifid
. BP: low BP with narrow pulse pressure
. JVP: prominent a-wave
. apex: double/triple impulse
. palpable thrill over aortic area
. ICD, MR
-Heart failure
DDx:
-AS +/-MR OR gallavardin’s phenomena
-MVP (click)
-VSD: louder with handgrip, quieter with valsalva
-Flow murmur
-Pulmonary stenosis
Ix:
-ECG: LVH, lateral ST-T wave changes, deep Q waves, conduction deficits
-CXR: LV enlargement
-Echo: LVOTO gradient >30mmHg, if >50mmHg intervene.
. asymmetrical ventricular septum hypertrophy (>15mm)
. systolic anterior motion of anterior mitral valve leaflet (SAM)
Note. septum hypertrophy + SAM = dynamic outflow obstruction
. MR
. LV dysfunction (diastolic)
-Cardiac MRI: hypertrophy severity and distribution, wall fibrosis and LV function
-Holter monitor: non-sustained VT
-Exercise tolerance test: BP drop with exertion
-Cardiac cath: aortic outflow gradient, CAD
-Genetic tests
Mx:
BB / verapamil. Avoid: other CCB, ACEI, nitrates.
Diuretics
Septal alcohol ablation
Dual chamber PPM
Surgical: septal myomectomy + MV surgery, heart transplant.
ICD insertion = risk factors for SCD (HCM risk calculator)
-FHx SCD with HOCM young age
-Unexplained syncope <30yo
-VF
-VT or nonsustained VT
-Max LV wall thickness >30mm
-Hypotension with exercise (20mmHg drop)
-LVOTO
Tricuspid regurgitation
Character:
-JVP v-waves
-right ventricular heave
-pansystolic murmur, max lower sternal edge on inspiration
-multiple systolic clicks (Ebstein’s anomaly)
-abdomen: pulsatile, large and tender liver, ascites, oedema with pleural effusions
Aetiology:
-Functional (RV failure)
-Rheumatic (usually multiple valves)
-IE (IVDU)
-Congenital (Ebstein’s anomaly)
-Tricuspid valve prolapse (rare)
-Right ventricular papillary muscle infarction
-Pacemaker or defibrillator lead
-Trauma (steering-wheel injury to sternum)
Ix:
-CXR: RV enlargement, biventricular enlargement if TR secondary to heart failure, box shaped heart and narrow cardiac base (Ebstein’s anomaly).
-Echo: structural valve abnormality, estimation of regurgitant jet into right atrium, pressure gradient.
Mx:
Medical: diuresis, ACE inhibitor, spironolactone, pulmonary vasodilators if severe TR with pulm HTN.
Surgical: TV repair (if simultaneous cardiac surg), TV replacement.
Non-cyanotic heart disease
Atrial septal defect: left -> right shunt.
1. Ostium primum (endocardial cushion defect adjacent to atroventricular valves)
- assoc. w/ MR, TR, VSD
- down syndrome
- skeletal UL defect (holt-oram syndrome)
2. Ostium secundum.
- character
- severity
- ddx
- ix
- mx
Character
- ejection systolic murmur
- pulmonary area (2nd ICS L sternal edge)
- increased on inspiration
- fixed splitting S2
- systolic thrill (severe, uncommon)
Severity
- eisenmenger’s (R-> L shunt)
- pulmonary HTN
DDx: PS, Pulmonary HTN with flow murmur, AS, MR, TR, VSD
Ix:
-ECG: RAD, RBBB, RVH
-CXR: increased pulmonary vasculature (dilated main pulmonary artery), RA/RV enlargement, small aortic knob.
-Echo: paradoxical septal motion, RV dilation.
. doppler (shunt)
. bubble study
. TOE
Mx: surgical indications (surgery / percutaneous) = RV dilation, L -> R shunt (1.5-1).
Ventricular septal defect
- character
- ix
- mx
Character:
- harsh pan-systolic murmur
- left sternal edge louder with handgrip
- thrill
- +/- MR
Ix:
-ECG- LVH
-CXR- RVH/pulmonary vasculature
-Echo- shunt/defect, RV hypertension (pressure gradient between LV and RV)
Causes:
Congenital: single, other defects (tetralogy of fallot)
Acquired: MI, trauma
Classification:
Membranous
Muscular
Atrioventricular canal
Subarterial
Complications:
IE
Pulmonary HTN
Eisenmenger’s
Aortic valve prolapse and AR (perimembranous)
Associations:
AR
PDA
Coarctation of aorta
Tetralogy of fallot (VSD, overriding aorta, pulmonary stenosis, RV hypertrophy)
Turner’s syndrome
Trisomy (21: downs, 18: edwards, 13: pataus)
Mx: L-> R shunt mod-large (1.5-1), pulmonary artery to systemic flow.
RV dilation.
Conservative.
Medical: ACEi
Surgical:
-symptomatic
-IE
-post MI (acute septal rupture)
-haemodynamic compromise/volume overload
-large shunt
-AR
Percutaneous closure
Transcatheter approach (risks of cardiac tamponade, AR, haemorrhage, CHB requiring PPM).
Non-cyanotic heart disease
Patent ductus arteriosus: aorta -> pulmonary artery.
IF reversal, cyanosis + clubbing (toes, not fingers)
- character
- ix
- mx
Character:
- continuous murmur upper left sternal border (machinery)
- thrill
- radiates to back
Ix:
-ECG- LVH
-CXR- LVH/pulmonary vasculature, duct calcification
-Echo- doppler (continuous flow), main pulmonary artery, increased left atrial seize
Mx: Closure if significant shunt ie respiratory or haemodynamic compromise, heart failure or large left to right ductus shunt.
Non-cyanotic heart disease
Coarctation of aorta: distal to origin of subclavian artery
-character
-Ix
Character:
-mid-systolic murmur left subclavicle
-radiates to back
-other features: better developed upper body, radiofemoral delay, HTN UL > LL with HTN changes on fundoscopy, collateral vessels on chest.
-associated with turners.
Ix:
-ECG: LVH
-CXR: LVH, dilated ascending aorta, rib notch (2-6)
-Echo: LVH, coarctation, abnormal flow
Eisenmengers (pulmonary HTN + features of VSD, ASD, PDA)
-character
-severity
-Ix
L -> R shunt -> pulmonary hypertension -> reversal of shunt L <- R causing cyanotic heart disease.
Character:
-central cyanosis +/- polycythemia
-finger clubbing
PULMONARY HTN
-raised JVP (prominent v/a waves)
-parasternal heave
-loud and palpable P2
+ PR = early diastolic murmur
+ TR = pansystlic murmur LSE
Causes
+ VSD = ejection systolic click pulmonary area
+ ASD = wide fixed splitting second heart sound (S2)
+ PDA = normal reversed S2
? surgically created shunts (systemic-pulmonary) for tx of congenital heart disease
Severity:
-Pulmonary HTN
-L -> R heart decompensation
Complications
-polycythemia and hyperviscosity
-arrythmia
-heart failure
-stroke
-haemoptysis
-CKD, hyperuricemia and gout
-hypertrophic osteoarthropathy
-sudden cardiac death
Ix:
-Bloods: FBC (polycythemia), renal and liver function (hepatic congestion/cholestasis), iron deficiency, uric acid (gout)
-ECG: RVH, p-pulmonale (peaked, amplitude >2.5mm in II III aVF)
-CXR: RV/RA enlarged, pulmonary artery prominence, increased hilar vascular markings but attenuated peripheral vessels.
-Echo: pulmonary pressure measurement, shunt measurement and valvular disease.
-PFTs with CO2 diffusion studies
-RHC (pulmonary pressures)
Mx:
-smoking cessation
-medical: O2, vasodilators (pulm htn), diuresis, iron, contraception, venesection (hyperviscosity)
-surgical: palliative procedure, combined heart-lung transplant
Cyanotic heart disease
Tetralogy of fallot
1. VSD
2. RV outflow obstruction (determines severity)
3. Overriding aorta
4. RV hypertrophy
Most common complication post-repair: pulmonary regurg, RV failure.
-character
-Ix
Character:
- cyanosis
- clubbing
- polycythaemia
- RV heave
- L sternal edge thrill
- A2 (single second heart sound)
- short pulmonary ejection murmur (pulmonary stenosis)
Ix:
-ECG: RVH, RAD
-CXR: boot shaped heart, RV enlargement, R sided aortic knob, arch + descending aorta
-Echo: anatomy
DDx of wide pulse pressure (3)
DDx of small pulse pressure (4)
-Decreased stroke volume
-Decreased pre-load (blood loss)
Wide pulse pressure:
AR
Arteriosclerosis or less compliant vessel
Hyperdynamic circulation (distributive shock, anaemia)
Small pulse pressure:
AS
CCF
Tamponade
MS
Infective endocarditis
Diagnosis (modified Duke’s criteria):
Definite IE: 2 major or 1 major + 3 minor
Possible IE: 1 major + 1 minor OR 3 minor
Major
-BC + typical organism (staph aureus, enterococcus, strep viridans)
-Echo valve vegetation
Minor
-predisposing cardiac lesion
-IVDU
-T >38
-Embolic phenomena
-Immunologic phenomena (glomerulonephritis)
-BC + not meeting major criteria
IE organisms:
S. sanguinis, s.aureus, s.epidermidis, s.bovis, c.burnetti, enterococcus
HACEK
-Hemophilus
-Aggregatiobater
-Cardiobacterlin
-Ekenella
-Kingella
Pseudomonas
Bartonella
Candida fungi
