Cardiovascular Clinical Signs Flashcards
Short 4th & 5th metacarpals
Hypoplastic/hyperconvex nails
Wide carrying angle
Low post hairline
Neck webbing
High palate
Shield chest and wide nipples
Bicuspid AV
Coarctation of the aorta
Turner’s
Assoc horseshoe kidney and AI hypothyroidism
Right HF
Hepatomegaly
Edema
Ascites
Distended neck veins
Left HF
Cough
Haemoptysis
Orthopnea (SOB)
Pulmonary congestion
Single palmar crease
T21
Arachnodactyly
Marfans
Radial thumb abnormalities
VACTERL & Holt Oram
Overlapping fingers, CLP, ASD, VSD, micrognathia and low set ears
T18 (Edward’s)
Polydactyly, CLP, cutis aplasia, microopthlamia
Rocker bottom feet
Omphalocoele
VSD/ASD/PDA/Coarctation/Bicuspid aortic
T13 (Patau’s)
HR 4-6 years
75-115
HR NN
110-150
HR 6+
60-100
HR 2-4 years
85-125
Collapsing pulse causes
AR, PDA (run-off lesions)
Slow rising pulse causes
AS (impaired ejection from ventricle)
Pulsus paradoxus
Tamponade. Pericarditis. Severe asthma
- Decreased right heart functional reserve = MI and tamponade
- Right ventricular inflow or outflow obstruction = SVC obstruction or PE
- Decreased blood to the left heart due to lung hyperinflation = Asthma or anaphylaxis
Exaggeration or an increase in the fall of systolic BP beyond 10 mmHg during inspiration.
BP Infant 0-2yrs
80-95 Systolic
BP 2-5 yrs
80-100 Systolic
BP 5-12 years
90-110 Systolic
BP > 12 years
100-120 Systolic
Right lateral thoracotomy
BT Shunt; Lobectomy; TOF repair
Left lateral thoracotomy
BT shunt; Coarct repair; PDA ligation; PA band; Lobectomy
Widely split S2
ASD:
RV volume overload, such as atrial septal defect (ASD), the split is usually wide and fixed.
PS:
RV outflow obstruction, such as pulmonary stenosis.
RBBB:
Delayed RV depolarization such as complete right bundle branch block.
Paradoxical Split S2
Severe AS, LBBB, HOCM
Delayed closure of the aortic valve
Normal: S1 A2P2 (splits on inspiration)
Paradox: S1 P2A2 (splits on expiration)
4th HS before 1st HS
Reduced ventricular compliance/ Pulmonary HTN . With tachycardia = Gallop rhythm
S4 – “atrial gallop”
Occurs in late diastole
Occurs during active LV filling
Almost always abnormal
Requires a noncompliant LV
Can be a sign of diastolic congestive HF
Ejection click
AV or PV stenosis; coarct of aorta; PDA
Thickened aortic valve leaflets - bicuspid aortic valve
ULSE ESM
Pulmonary Stenosis
URSE ESM to carotids
Aortic Stenosis
ULSE Continuous radiates to back
PDA
MLSE/LLSE Pansystolic
VSD; TR
HOCM (crescendo-decrescendo, midsystolic, increased by valsalva)
LLSE Diastolic
1x best in exp, sit forward
2x mid
AR (early, best in exp, sit forward)
Mitral Stenosis (mid)
Tricuspid Stenosis (mid)
MLSE Continuous/diastolic
ASD (if large)
Classically mid systolic murmur with a split S2
Apex (Mitral) Pansystolic
Mitral regurgitation (rad to axilla)
VSD
If late, MV prolapse
Expiration effect on murmurs
Emphasises Left sided murmurs
Case: Small, central cyanosis, no dysmorphism.
SOB, clubbed with peripheral cyanosis. R thoracotomy scar. Continuous murmur over the right side of the chest and single 2nd HS.
Pulmonary Atresia
DORV
Univentricular heart + Pulmonary atresia
Case: T21 features, No cyanosis or clubbing. Central sternotomy scar. Apex, systolic murmur
Mitral regurgitation after AVSD repair
If no corrected -> Eisenmenger’s
Eisenmenger’s
Left to right shunt -> abnormally high blood flow and pressure to the right heart circulation = pulmonary hypertension as increased right-sided volume and pressure-> damage to the delicate pulmonary capillaries -> scar tissue. Less flexibility and compliance increases in pulmonary blood pressure, heart must pump harder, more capillary damage.
Due to increased resistance and decreased compliance of the pulmonary vessels, elevated pulmonary pressures cause RVH. When RVH causes right heart pressures to exceed that of the left , leading to reversal of blood flow through the shunt (i.e., blood moves from the right side of the heart to the left side).
Case: Central cyanosis, normal pulses, median sternotomy scar, apex on right side with normal HS
Central shunt procedure: cavo-pulmonary anastomoses
Case: Well, pink and no clubbing. Normal pulses with ESM 2/6, no radiation. Quiet when sitting forward. Normal HS
Innocent murmur
Case: Well, no SOB, absent right radial pulse
Cardiac catheterisation scar. R thoracotomy scar and midline sternotomy scar.
Complex cardiac disease - non-specific
Case: No cyanosis, no clubbing, no SOB. Normal pulses. 3/6 pansystolic murmur. HS normal, apex normal.
VSD
(Tx w diuretics +- ACE inhbitors. May need feed supplementation)
Case: no clubbing, pulses normal, suprasternal and carotid thrill, G4 systolic murmur over aortic area with radiation to carotids PLUS G2 ESM in pulmonary area radiating to the back.
Face: widely spaced teeth, a long philtrum, and a flattened nasal bridge
AS, likely supravalvular 2ry to Williams PLUS branch pulmonary stenosis
Cocktail party attitude and stellate iris
VSD
Assoc:
O/E: HS & Murmur
Commonest 1:500
LV overload and increased pulm blood flow
O/E: signs of HF. Displaced apex
Pansystolic murmur at LSE +- Diastolic murmur at apex = large defect.
Loud 2nd HS. Thrill L sternal edge
VSD
ECG:
CXR:
Tx
ECG: biventricular hypertrophy +- LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: cardiomegaly
80% close spontaneously
Tx: diuretics/ACE inhibitors/supplements if mild. Surgical correction if pulm:systemic flow is >2:1.
ASD
2 types
O/E: Murmur & HS
Commonest is ostium secondum (80%)
RV overload and increased pulm blood flow
O/E: Apex normal
ESM murmur at ULSE (or no murmur).
Large L -> R = Sometimes mid diastolic murmur (high flow across tricuspid)
2nd HS split and fixed.
ASD
ECG:
Tx:
ECG: Secondum: RAD and pRBBB
Primum (partial AVSD): LAD and pRBBB
(Incomplete RBBB is defined as an RSR’ pattern in V1-3 with QRS duration < 120ms.)
If <6mm usually close spontaneously
Tx: Surgical correction by 3 years - can be transcatheter. Needs Abx prophylaxis as per local guidelines
AVSD
Assoc w:
O/E: HS and murmur
4% of anomalies - assoc w T21
L->R shunt
O/E: HF signs
Loud S2 = pulm HTN. Post op = residual MR at apex
RV heave; thrill LLSE & pansystolic murmur.
Hepatomegaly
AVSD
ECG:
CXR:
Tx:
ECG: Superior axis, RVH, prolonged PR
CXR: cardiomegaly
Tx: diuretics/ACE inhibitors/supplements if mild. Surgical correction within 1st 6 months - prevent pulm HTN.
AR
Assoc w:
O/E: HS and murmur
Assoc w Ehlers Danlos/Marfans/Turners. Rheum fever, SLE. Reduced exercise tolerance.
O/E: Bounding radial pulse. Wide PP.
Decrescendo diastolic murmur on LSE - Emphasised when sitting and expiration.
Soft S1
Austin-Flint: mid-diastolic rumble
AR
ECG:
CXR:
Tx:
ECG: LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: Cardiomegaly
Tx: Valve replacement if exercise tolerance symptoms +- anticoagulation
PS
Assoc:
O/E: Systemic. Murmur, HS
Supravalvular assoc w Williams & Rubella.
Periph PA Stenosis Rubella & Alagille.
Also Noonan
PS - RV overload. In NN cyanosis from shunting thru FP = prostaglandin
O/E: RVH or thrill
ULSE ESM radiate to back.
Split 2nd HS or absent p component
PS
ECG:
CXR:
Tx
ECG: Normal. If severe - RVH and RAD
CXR: Normal ? prominent R A&V.
Tx: Balloon valvuloplasty = no scar
If surgical = midline scar. Post op = residual systolic & diastolic murmur
AS
Assoc:
O/E: Systemic; Murmur & thrill
Valvular assoc with Coarct/ Turners
Supravalv assoc w Williams
LV hypertrophy. SOB, syncope, CP
O/E: Severe -> Weak peripheral pulses. Narrow PP.
Suprasternal/Carotid thrill. Displaced Apex.
Ejection click at LLSE. ESM at URSE radiating to neck.
If AR: early diastolic
Radio-fem delay
AS
ECG:
CXR:
Tx:
ECG: Often normal. Poss LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: Often normal. ?Prominent LV
Tx: If gradient >60mmHg -> balloon valvuloplasty
Post op: AS murmur and AR murmur
Coarctation of Aorta
Assoc:
O/E: Systemic. Murmur and HS
Assoc w Turners. Pre-ductal more serious
Disparity in BP for UL & LL - delay in fem. BP lower in legs than arms. If R arm > L arm = L SC artery involvement
O/E: radio-fem pulses and BP
N Apex. Systolic murmur loudest at back. Ejection click in bicuspid aortic valve (70%).
Coarctation of Aorta
ECG:
CXR:
Tx
ECG: Often normal. Poss LVH (Tall R waves V5 & 6; Inverse T in 1, aVL, V5 &6)
CXR: Rib notching after 7 yrs
Tx: Subclavian flap - L sided thoracotomy if normal arch. Complications: re-coarct = balloon.
Complex Cyanotic Cardiac Disease - Shunt options
Modified BT shunt: Synthetic tube from systemic artery (typically right subclavian) to pulmonary artery
RSC->Pulm Art
Rarely - Classic Blalock- Taussig shunt (BT shunt): subclavian artery to right pulmonary artery
SC->Pulm Art
Central shunt: Synthetic tube from the aorta to the pulmonary artery - median sternotomy or lateral thoracotomy
Aorta -> Pulm Art
Classic: subclavian artery (left or right) and anastomosis to the ipsilateral pulmonary artery (PA).
Advantage: Shunt grows with the patient
Disadvantage: Loss of pulses in the ipsi UL & resulting decreased growth.
Modified BT shunt (MBTS) a Gore-Tex (PTFE) graft
between the innominate or subclavian artery and the
ipsilateral pulmonary artery (PA). Routinely on right side, through a lateral thoracotomy.
Inotropes post shunt
If inotropic support required:
1st line: adrenaline to support cardiac performance
2nd line: noradrenaline or vasopressin if low diastolic pressure/ over-shunting (Noradrenaline or vasopressin increase SVR)
Some random shit:
Manoeuvres to increase PVR (to reduce Qp)
-Reduce oxygen
-Increase PEEP
-Allow pCO2 to rise gently (aim arterial PaCO2 ~8Kpa)
Manoeuvres to reduce SVR (to increase Qs)
-Consider reducing vasopressor therapy slowly
-Consider vasodilation – e.g. Milrinone or SNP. This may potentially worsen coronary steal by lowering diastolic BP further (discuss with intensive care consultant)
Cardiac causes of cyanosis
Decreased pulmonary blood flow, e.g. tetralogy of fallot, pulmonary atresia, Ebstein’s anomaly, tricuspid atresia
Poor mixing e.g. transposition of the great arteries
Common mixing, e.g. truncus, arteriosus double outlet right ventricle, total anomalous pulmonary venous, drainage or univentricular heart
Pulmonary atresia
Poor prognosis
Treatment by unifocalisation - fashioning a main pulmonary artery like structure out of which other vessels available. This can be incorporated into Glenn or Fontan operation.
Transposition of the great arteries
Neonates at presentation need a prostaglandin infusion and transfer to Cardiology unit
Arterial switch is performed in the first few days
Truncus arteriosus
Associated with 22Q deletion syndrome
Double outlet right ventricle
Early pulmonary, banding if pulmonary blood flow is high or shunt procedure followed by definitive repair later
Univentricular heart?
Palliation only
Shunt procedure if cyanosis severe
Pulmonary artery banding, if the pulmonary blood flow is high
Glenn procedure - superior vena cava to pulmonary artery
3-5y: Fontan procedure - total cavopulmonary, anastomosis
Hypoplastic left heart syndrome
Left sided heart structure are underdeveloped so blood flow to aorta is minimal and therefore PDAs are essential to maintain peripheral circulation
Tx: Norwood
Bidirectional Glenn
Fontan
60% success rate
Fallots tetralogy
Pathology
CXR & ECG
To
Complications
Right ventricular outflow obstruction: infundibular or pulmonary stenosis
Ventricular septal defect
Overriding aorta
Right ventricular hypertrophy
CXR: boot shaped, heart, and oligaemic lung fields
ECG: RAD RVH RAH
Tx: 1st year VSD repair and widen PS
BT shunt is a bridging option
Complications:
SOB - tet spells
Brain abscess or thrombosis
Infective endocarditis
Arrthymias
Case: Cyanosis or clubbing
Normal pulses or absent left sided, pulse and left sided thoracotomies scar
Central sternotomy scar
Right ventricular impulse
Systolic thrill at LLSE
ESM 3/6 at ULSE -radiating to back
Shunt murmur if thoracotomy
Single 2nd HS
Tetralogy of Fallot
Central cyanosis with clubbing
RV heavE
Short ESM and ejection click
Loud S2
CXR: right, ventricular prominence with small, peripheral, pulmonary vessels
ECG:RAH (peaked p waves) RVH (tall waves in V1)
Eisenmenger syndrome
Treated with heart, Lung transplant
Hypertrophic cardiomyopathy
Auto Dom in >50%
Thick and stiff heart muscle leads to decreased cardiac output
Decrease exercise tolerance, cough and arrhythmias
End stage: LVF
Murmur: ESM or MR murmur
Tx: beta blockers and antiarrhythmics
Myectomy
Dilated cardiomyopathy
Assoc muscular dystrophies, Barth syndrome
Preceding viral illness in 50%
Dilation and systolic dysfunction L>R
Sx: Cough, poor feeding, sweating, poor weight gain, shortness of breath
CXR: massive cardiomegaly w pulmonary oedema
Mx: diuretics, digoxin, ACE inhibitors, B-Blockers, ICD
End stage: transplant
Case: displaced Apex beat. Mitral regurgitation or tricuspid regurgitation.
Third heart sound
Signs of left or right heart failure
Dilated cardiomyopathy
Infective endocarditis
Associated with disease teeth
Signs
Fever
Oslers nodes, Janeway lesions, splinter, haemorrhages, conjunctival, petechiae, clubbing, hepatosplenomegaly, congestive cardiac failure. Mama Roth spots (retinal haemorrhage with pale centre, ) microscopic haematuria.
Sandal gap
Middle ear disease
Hypotonia
Characteristic facies
50% CHD - VSD, AVSD then PDA or ToF
T21
Hypotelorism
Antimongoloid slant
Epicanthic folds
Ptosis
Micrognathia
Low set ears
Wide nipples
Short stature, pubertal delay, cryptorchidism, hernias
Pulmonary stenosis
ASD, cardiomyopathy
Noonan Syndrome
Round face with full cheeks and lips
Stellate Iris,
Strabismus
Supravalvular aortic, stenosis
Branch pulmonary artery stenosis
Hypercalcaemia
Friendly personality,
Williams
Narrow palpebral fissures
Bulbous, nasal tip
Nasal speech
Cleft lip or palate
Hypotonia
Hypocalcaemia
Immune deficiency
Long face
Hypospadias
Long fingers
Aortic arch, abnormality,
Truncus arteriosus
Pulmonary atresia, or VSD
DiGeorge
or CATCH 22
Coloboma
Heart disease - Fallot/ VSD/AVSD/DORV
Atresia Chonae
Retarded growth
Genital abnormalities
Ear abnormalities
CHARGE
Vertebral defects
Anal atresia
Cardiac defects - Fallot/ VSD
TOF
Renal defects
Limb Abnormalities
VACTERL
Abnormal tone
Microcephalic
Wide fontanelle
Growth retardation
Rocker bottom feet
Overlapping fingers
VSD/ASD/PDA/coarctation of aorta /bicuspid, aortic valve
T18
Tall stature
Hypermobile
Wide span
Hi arched palate
Lens abnormalities - up and out
Scoliosis
Aortic aneurysm
AR/MR
Marfans
Cigarette paper scarring
Easy bruising
Joint hypermobility
Flat foot arch
Aortic root dilation
Ehlers Danlos
Flat philtrum
Developmental delay
Course features
VSD/ PDA/ ASD/ToF
Fetal alcohol syndrome
Lentigines
ECG conduction abnormalities
Ocular hypertelorism
PS
Abnormalities of genitalia
Retardation of growth
Deafness
Leopard syndrome 
Clubbing Differential
Cardiac
Congenital heart disease with cyanosis
Infective endocarditis
AV malformations
Endocrine
Acromegaly
AI Hyperthryoidism (Graves’) - acropachy
Hyperparthryoidism
Gastrointestinal
Achalasia
Coeliac disease
Cirrhosis
Crohn’s disease
Tropical sprue
Ulcerative colitis
Infectious disease
Tuberculosis
Pulmonary
Cystic fibrosis
Interstitial lung disease – particularly bronchiectesis
Abscess and empyema
Lung cancer – primary and metastatic
Sarcoidosis
Other
Hypertrophic osteopathy – primary and secondary
Malignancy
Palmoplantar keratoderma
Pregnancy
Pseudoclubbing - familial inheritance
Pericarditis
Sharp CP better when sitting up, worse on inspiration
Fever, Weakness, Palpitations, SOB
Pericardial rub on LLSE, diaphoresis, hpotension, muffled HS and distension of jugular vein.
Often viral
ECG: electrical alternans
Tx: anti-inflammatory drugs
Colchicine
