Cardiovascular Flashcards
What is the most common congenital heart defect?
A. Coarctation of the aorta
B. Ventricular septal defect (VSD)
C. Atrial septal defect
D. Patent ductus arteriosus
E. Transposition of the great arteries
B. Ventricular septal defect (VSD
1 B One-third of all congenital heart defects are VSDs (B). All others are much less common. The second most commonly seen is the patent ductus arteriosis (D) which makes up just over 10 per cent. Atrial septal defects (C), coarctation of the aorta (A) and transposition of the great arteries (E) each make up approximately 5 per cent.
Which of the following is not a presenting symptom or sign associated with congenital heart disease?
A. Respiratory distress with feeds
B. Cyanosis
C. Hepatosplenomegaly
D. Vomiting with feeds
E. Sweating with feeds
D. Vomiting with feeds
2 DCongenital heart disease may be diagnosed antenatally on the anomaly ultrasound or at the baby check if a murmur is heard. However, if the signs are not present or seen at these time points, it is important to know the possible symptoms and signs that may evolve over the next few weeks or months that might be associated with congenital heart disease. Classically, children become breathless (A) and sweaty (E) with feeds. The effort of feeding burns calories and tires the child so that growth becomes restricted and the child may fail to thrive. Infants with heart failure may develop hepatomegaly and potentially splenomegaly, as a result of back-pressure secondary to right-sided heart failure (C). This sign is more helpful than looking for jugular venous distension in an infant, since the neck is short and the jugular veins are difficult to observe. Any cardiac defect with a right-to-left shunt may present with cyanosis (B). It would be unusual for congenital heart disease to be associated with vomiting (D) unless there were other illnesses such as gastro-oesophageal reflux or pyloric stenosis as well.
Which of the following is not a feature of an innocent murmur?
A. Systolic murmur
B. Diastolic murmur
C. Asymptomatic
D. Heard only at the left sternal edge
E. No heaves or thrills
B. Diastolic murmur
3 B Characteristics of an innocent murmur include: a soft blowing systolic murmur (A), localized to the left sternal edge (D), with no radiation, and no diastolic component (B) or parasternal thrill (E) and normal heart sounds in an asymptomatic patient (C).
You are asked to see a 2-year-old child with difficulty in breathing, a runny nose and a barking cough. His mother tells you he had a heart defect repaired as a baby and he still has a murmur. On examination he has noisy breathing with mild subcostal recession. He is apyrexial with a respiratory rate of 44 breaths per minute and heart rate of 152 beats per minute; capillary refill is 1–2 seconds. His throat is red and the tonsils are enlarged with no exudate. On his chest you see a midline sternotomy scar with a drain scar and a right thoracotomy scar. On auscultation the lung fields are clear, but he has an ejection systolic murmur in the left upper sternal edge which radiates to the back. He does not have a gallop rhythm. There are transmitted upper airway sounds only on the lung fields and the abdomen is soft with no organomegaly. What is the most appropriate management?
A. Admit for IV antibiotics
B. Give IV furosemide and admit
C. Admit for observation
D. Send home on oral antibiotics
E. Give oral dexamethasone and observe
E. Give oral dexamethasone and observe
4 E This child has had corrective cardiac surgery and has a residual murmur of pulmonary stenosis. The most likely explanation for this acute presentation is croup, which should be treated with dexamethasone as for any other child. His breathing and observations should have improved before he goes home (E). This child does not have a fever and there is no pus on the tonsils to suggest a bacterial infection. Croup is largely due to viral upper respiratory infections, and dexamethasone should be all that is required. He does not need antibiotics ((A) and (D)). Admission for observation (C) would not be unreasonable as a tachycardic child should not be sent home without careful evaluation, but it is not the best answer because you should treat his respiratory distress due to the croup with dexamethasone (E) and admit if no improvement. He is not in heart failure (no gallop rhythm, no crackles in his lung fields, and no hepatomegaly) and he therefore does not need furosemide (B).
A 3-day-old baby is brought to accident and emergency with acute respiratory distress. She is tachypnoeic, tachycardic, cyanosed and her capillary refill is 5 seconds centrally. You note she has a flat nasal bridge, down sloping palpebral fissures and epicanthic folds. On auscultation there is a loud ejection systolic murmur at the left sternal edge. What is the most likely diagnosis?
A. Coartation of the aorta
B. VSD
C. Transposition of the great arteries
D. Tetralogy of Fallot
E. Patent ductus arteriosus
D. Tetralogy of Fallot
5 DThis is a presentation of a duct-dependent type of congenital heart defect. The ductus arteriosus is a short vessel connecting the pulmonary artery to the aortic arch. It allows most of the blood from the right ventricle to bypass the fetal lungs which are filled with fluid. Within hours or at the most a few days following birth, the duct closes to form the ligamentum arteriosum. However, any congenital heart defect that results in decreased blood flow from the heart to the lungs, or decreased oxygenated blood on reaching the systemic circulation, will depend on blood flowing through the ductus arteriosus to compensate for the abnormal anatomy. When the duct closes, that circulation stops and infants with Tetralogy of Fallot (D), pulmonary atresia, tricuspid atresia, transposition of the great arteries (C) and total anomalous pulmonary venous drainage will go blue. These duct-dependent lesions require urgent re-opening of the duct with prostaglandin. This situation is the opposite of a patent ductus arteriosus (E). The other information you are given describes dysmorphic features of Down’s syndrome (trisomy 21). Down’s syndrome is associated with atrioventricular septal defects, VSDs and Tetralogy of Fallot (D). Coarctation of the aorta (A) does not produce central cyanosis, although the left arm and lower limbs may have reduced blood pressure and saturations depending on the severity of the stenosis. VSDs (B) produce a left-to-right shunt (thus the infant is not cyanosed) unless they are left untreated, when Eisenmenger’s syndrome develops, typically in the teenage years where pulmonary hypertension results in a right-to-left shunt and cyanosis. This process develops slowly and does not present in infancy.
You are doing a baby check on the post-natal ward on a baby who is 23 hours old. His mother tells you that he is not feeding well. On examination he is unsettled with a respiratory rate of 76 and a heart rate of 182. You think his hands and feet look blue and there is a soft systolic murmur heard at the left upper sternal border. You ask the midwives to check his saturations which are 85 per cent in air and start some oxygen. You explain to the mother that he needs to be managed on the neonatal unit. What is the next step in your management?
A. Stop the oxygen as this may drive the closure of the ductus arterioles
B. Give prostaglandin intravenously to open the duct while organizing an echocardiogram
C. Give antibiotics and prostaglandin intravenously while organizing an echocardiogram
D. Give indomethacin intravenously to open the duct while organizing an echocardiogram
E. Give indomethacin and antibiotics intravenously while organizing an echocardiogram
C. Give antibiotics and prostaglandin intravenously while organizing an echocardiogram
6 C The correct answer is to cover the baby for sepsis with antibiotics and to maintain the patency of the ductus arteriosus while organizing an echocardiogram to elucidate the underlying cardiac anatomy (C). A blue baby with a murmur should be treated as a duct-dependent anomaly until proven otherwise. A septic baby could be mottled and present with a flow murmur and until the echocardiogram has been performed it is difficult to rule out sepsis; thus not covering with antibiotics would be wrong (B). You should always administer oxygen to a cyanotic child (A) unless specifically told not to by the cardiology team, and in this situation there would be clear guidelines to maintain the saturations between an upper and lower limit, typically in the 80s. Indomethacin is wrong ((D) and (E)); this is used to close the duct in children who have a persistent ductus arteriosus resulting in significant respiratory distress or impaired systemic oxygen delivery.
A 7 year old with a 3-day history of upper respiratory tract infection is brought to accident and emergency by his mother because he suddenly went pale and sweaty and seems to be working hard to breath. The triage nurse calls you to see him urgently because his heart rate is 200 beats per minute. You take him round to the resuscitation area, give him oxygen and connect him to the cardiac monitor. The electrocardiogram (ECG) shows a narrow complex tachycardia with a rate of 180 beats per minute. He remains alert, with a respiratory rate of 40. What is the most appropriate initial diagnosis?
A. Supraventricular tachycardia (SVT)
B. Wolff–Parkinson–White syndrome
C. Ventricular fibrillation
D. Atrial fibrillation
E. Ventricular tachycardia
A. Supraventricular tachycardia (SVT)
7 AThe ECG shows a narrow complex tachycardia with a rate of 180 beats per minute. At this rate it is hard to say if P waves are present or not; however this history of a child with an intercurrent illness suddenly becoming unwell with a tachycardia is suggestive of an SVT (A). SVTs may be triggered by Wolff–Parkinson–White syndrome (B), a re-entry tachycardia due to an accessory pathway between the atria and the ventricle. Once the rhythm has slowed down there will be a delta wave visible in all QRS complexes, which is a slanting upstroke of the R wave, and this is associated with a short PR interval. All that can be said of this child is that the QRS complexes are narrow and fast, suggesting a supraventricular origin. Ventricular fibrillation (C) would be characterized by a fast wide irregular complex on ECG, with no discernible P waves. Ventricular tachycardia (E) will be characterized by a regular wide complex tachycardia with no visible P waves. Atrial fibrillation (D) would have the classical saw toothed baseline of P waves with a slower rate of QRS complexes superimposed.
A 7 year old with a 3-day history of upper respiratory tract infection is brought to accident and emergency by his mother because he suddenly went pale and sweaty and seems to be working hard to breath. The triage nurse calls you to see him urgently because his heart rate is 200 beats per minute. You take him round to the resuscitation area, give him oxygen and connect him to the cardiac monitor. The electrocardiogram (ECG) shows a narrow complex tachycardia with a rate of 180 beats per minute. He remains alert, with a respiratory rate of 40.
What is the first step in management?
A. Non-synchronized shock
B. Adenosine
C. Adrenaline
D. Vagal manoeuvres
E. Synchronized shock
D. Vagal manoeuvres
8 DThe first step in management for a child who is still alert would be vagal manoeuvres (D) such as asking a child to blow a syringe like a balloon, unilateral carotid massage or putting the head in ice. Ideally, these should be carried out while the child is on recorded cardiac monitoring to assess the response. If these do not work, adenosine (B) would be the next step. Failing these actions, sedated synchronized cardioversion (E) is indicated while the patient remains alert. If a patient becomes cardiovascularly compromised, for example is losing consciousness, then the synchronized cardioversion should be carried out urgently without waiting for sedation. Adrenaline (C) would not be used unless the patient loses output. Non-synchronized cardioversion (A) is only indicated for ventricular fibrillation (VF) or ventricular tachycardia with no cardiac output; this is because in all other situations if the shock lands on the QRS complex it may cause VF.
A 2-year-old child is referred to hospital by the GP after his third visit that week; he now has a rash and the GP is worried he has meningitis. He has had a fever for 5 days up to 39.5°C or above every day and is not eating or drinking well. On examination, he has a temperature of 38.5°C, heart rate of 150, respiratory rate of 30 and is miserable. He has a blanching macular rash on his torso, swollen hands and feet, red eyes, red cracked lips, large tonsils with no pus, and a left-sided 2 cm × 3 cm cervical lymph node which is mobile. There is no photophobia or neck stiffness. His chest is clear with normal heart sounds and his abdomen is soft with a palpable liver edge. You note his BCG scar is inflamed. What is the most likely diagnosis?
A. Viral tonsillitis
B. Bacterial tonsillitis
C. Meningitis
D. Hand, foot and mouth disease
E. Kawasaki’s disease
E. Kawasaki’s disease
9 E The most likely diagnosis is Kawasaki’s disease (E) as he fulfils the diagnostic criteria (5 out of 6): 1) fever for more than 5 days, 2) bilateral non-purulent conjunctivitis, 3) rash, 4) oral changes such as dry, cracked,
red lips, strawberry tongue, 5) erythema and oedema of the hands or feet and 6) cervical lymphadenopathy. Inflammation at the BCG scar is common but is not a diagnostic criterion. Kawasaki’s disease is a vasculitis of unknown aetiology that typically affects young children and is complicated by coronary aneurysm formation. Treatment is with intravenous immunoglobulin and high dose aspirin. By 5 days the fever caused by a viral tonsillitis (A) should be settling, even though other symptoms such as cough may persist for some time. This child could have a bacterial tonsillitis (B) and covering with antibiotics would be prudent, but it would be unusual to have conjunctivitis and swollen hands and feet with bacterial tonsillitis. You might expect to see pus on the tonsils if it is due to a bacterial infection. Hand, foot and mouth disease (D) produces a mild coryzal illness, mouth ulcers and painful papules on the hands and feet in young children and is caused by a coxsackie virus infection. He has no signs of meningism – neck stiffness or photophobia and his rash is blanching – making meningitis (C) or meningococcal septicaemia less likely.
A 14-year-old refugee from Afghanistan who has lived in the UK for 2 years comes to see you complaining of increasing fatigue and breathlessness on exertion. On examination she appears cyanosed and has bilateral basal fine crepitations and a soft pansystolic murmur with a displaced apex beat. She has never been in hospital and has no surgical scars. You urgently refer her for a cardiology review. What is the most likely diagnosis?
A. Bacterial endocarditis
B. Tetralogy of Fallot
C. VSD producing a left-to-right shunt
D. Eisenmenger’s syndrome
E. Ebstein’s anomaly
D. Eisenmenger’s syndrome
10 D This child grew up in an area without resources for congenital cardiac corrective surgery. She likely has a large VSD which has led to left ventricular hypertrophy and failure, to the extent that she now has pulmonary hypertension and a right-to-left shunt resulting in cyanosis, i.e. Eisenmenger’s syndrome (D). There are no infective features to suggest bacterial endocarditis (A). Without surgical correction, a child with Tetralogy of Fallot (B) would not survive to their teens. Young children with a VSD have a left-to-right shunt (C) with blood flowing from the high pressure left ventricle to the right ventricle and this does not produce cyanosis. Ebstein’s anomaly (E) is another congenital heart defect that would not survive without surgery and is a combination of an abnormal tricuspid valve, hypoplastic right ventricle and pulmonary stenosis.
The major criteria for rheumatic fever include all of the following features except?
A. A new murmur
B. Swollen right knee for the past 8 days
C. A geographic shaped rash with central pallor on the abdomen
D. Involuntary movements of the arms
E. Fever
E. Fever
11 E Rheumatic fever is one of the post-infectious complications of group A streptococcal infection and classically occurs after an episode of tonsillitis. Diagnosis is made on the presence of two major, or one major with two minor, criteria, plus evidence of streptococcal infection such as a throat swab or positive antistreptolysin titre. Major criteria include: pancarditis such as endocarditis – murmur (A) or valvular dysfunction, myocarditits – heart failure, pericarditis – rub, effusion or tamponade; polyarthritis common in the knees (B), wrists, and ankles and may flit from joint to joint, lasting for more than 1 week in total (to distinguish this from reactive arthritis); Sydenham’s chorea results in involuntary movements (D) starting 2–6 months after the infection; erythema marginatum (C) is an early feature which is a flat erythematous rash on the trunk or limbs that expands with a topographical map-like border and fades from the centre; subcutaneous nodules are painless pea sized nodules on the extensor surfaces. Minor criteria include fever (E); arthralgia; family or personal history of rheumatic fever; raised inflammatory markers; and ECG changes such as a prolonged PR interval.
A 5-year-old child was admitted overnight awaiting surgical repair of a broken right ankle and was noted to have a raised blood pressure consistently above 130/90 mmHg despite adequate analgesia. On examination he has a plaster on his right foot and appears comfortable at rest. On auscultation there is a soft systolic murmur heard at the right upper sternal edge. His femoral pulse is difficult to find, but present bilaterally. When felt with the radial pulse, the impulse in the femoral pulse occurs slightly later. His abdomen is soft and there are no bruits heard. The blood pressure done in the right arm is 136/92 mmHg but the left arm gives a reading of 124/80. What is the most likely diagnosis?
A. Normal blood pressure in the left arm with a spurious result from the right
B. Coarctation of the aorta
C. Renal artery stenosis
D. Phaeochromocytoma
E. White coat hypertension
B. Coarctation of the aorta
12 B This child is hypertensive in both arms but there is a discrepancy between the right and left arm with a radio-femoral delay and a systolic murmur heard in the aortic area, supporting a diagnosis of coarctation of the aorta (B). This is likely to be a mild stenosis which is why it was not picked up earlier. The restricted blood flow to the abdomen and kidneys results in feedback loops producing hypertension to maintain perfusion. The blood pressure in the left arm is still high (A) but it is lower than the right arm because of the coarctation restricting blood flow to the left and lower body. There is no bruit heard on examining the abdomen and other findings point to coarctation, making renal artery stenosis (C) unlikely, but to rule it out an abdominal ultrasound with Doppler would be required. Phaeochromocytoma (D) is a rare cause of hypertension caused by an adrenal tumour producing catecholamines and imaging would be required to diagnose this; therefore it is extremely unlikely to be the correct answer. White coat hypertension (E) is raised blood pressure associated with anxiety, induced by the presence of medical professionals. There is an underlying reason found on examination for his hypertension; therefore (E) is not the correct answer.
Which of the following is not a feature of cardiac insufficiency?
A. Scattered wheeze on auscultation of the chest
B. Central cyanosis
C. Sacral oedema
D. Tachypnoea with the apex beat palpable in the 7th intercostal space just lateral to the mid-clavicular line
E. Hepatomegaly
B. Central cyanosis
13 B All of these may be present in cardiovascular disease. However, while cyanosis (B) may either be due to lung pathology or a right-to-left cardiac shunt, it is not, in itself, a sign of heart failure. Both wheeze (A) or bi-basal crackles are features of heart failure due to pulmonary oedema. Dependent oedema (C) is a feature of heart failure and in an infant who mostly is lying down this will collect on the back as well as the feet. Tachypnoea and a displaced apex beat suggestive of left ventricular hypertrophy are suggestive of cardiac failure (D). Hepatomegaly (E) occurs in heart failure due to back pressure in the venous system resulting in congestion in the portal vein.
Forty per cent of children with trisomy 21 have congenital heart defects. Which of the following is not associated with Down’s syndrome?
A. Tetralogy of Fallot
B. Atrioseptal defect (ASD)
C. VSD
D. Atrioventricular septal defect (AVSD)
E. Transposition of the great arteries
E. Transposition of the great arteries
14 E Forty per cent of cardiac defects in children with Down’s syndrome are
AVSDs (D). Thirty per cent have a VSD (C), 10 per cent an ASD (B) and 6 per cent have Tetralogy of Fallot (A). While transposition of the great arteries (E) is often associated with ASDs or VSDs, it is not classically associated with trisomy 21 and is therefore the correct answer.
A 14-year-old girl was seen in accident and emergency following her third collapse this year and referred to cardiology for review of a low rumbling murmur heard at the left upper sternal edge. Her ECG in accident and emergency was normal. Her blood sugar was 5.3 mmol/L. Urea and electrolytes were normal. The most recent collapse occurred at school while waiting for exam results to be given out. Previously they occurred while watching a parade all afternoon standing in a crowded street, and at a party. On all three occasions she felt dizzy beforehand, was unconscious for less than 10 seconds and fully alert following the episode, but did feel nauseous. Her echocardiogram today is normal. What is the most likely diagnosis?
A. Venous hum murmur and vasovagal syncope
B. Innocent murmur and epilepsy
C. Wolff–Parkinson–White syndrome
D. Patent foramen ovale and sick sinus syndrome
E. Neurocardiogenic syndrome
A. Venous hum murmur and vasovagal syncope
15 A A low rumbling murmur heard above the nipple line with a normal echocardiogram is a venous hum and a normal finding in children. In light of all her cardiovascular investigations being normal, the most likely diagnosis is vasovagal syncope (A), associated with prolonged standing or anxiety. You have not been given an electroencephalography report and there is no suggestion that she was convulsing or post-ictal following her collapses, making epilepsy unlikely (B). Wolff–Parkinson–White (C) syndrome would have delta waves on the ECG, whereas her ECG is normal. A patent foramen ovale would be seen on echocardiogram and sick sinus syndrome would show bradycardia on the ECG (D). Neurocardiogenic syndrome (E) could be diagnosed on a tilt table test, which has not been mentioned, and would not typically have prodromal symptoms.
