Cardiovascular exam Flashcards
Causes of dominant a wave
Tricuspid stenosis
Pulmonary stenosis
Pulmonary HTN
Causes of dominant v wave
Tricuspid regurgitation
Causes of cannon a waves
Complete heart block
VT
Paroxysmal nodal tachycardia with retrograde atrial conduction
Causes of elevated central venous pressure
RV failure
Tricuspid stenosis or regurgitation
Pericardial effusion, constrictive pericarditis
SVC obstruction
Fluid overload
Hyperdynamic circulation- fever, anaemia, pregnancy, hypoxia
Collapsing pulse
Aortic regurgitation Arteriosclerotic aorta Hyperdynamic circulation Patent ductus arteriosus Peripheral AV aneurysm
Small volume pulse
Aortic stenosis, pericardial effusion
Severe mitral stenosis
Small pulse pressure
Early opening snap
Diastolic thrill at apex
Presence of pulmonary HTN- prominent a wave, RV impulse, loud P2, pulmonary regurgitation, TR
Severe MR
Enlarged LV
Pulmonary HTN
Third heart sound
Early diastolic rumble
Soft S1
A2 heart earlier
Small volume pulse
LV failure
Loud P2
Pulmonary HTN
Loud A2
Congenital aortic stenosis, systemic HTN
Fixed splitting
ASD
Causes of 3rd heart sound
Physiologic LV failure AR MR VSD PDA RV failure Constrictive pericarditis
Causes of 4th heart sound
Aortic stenosis Acute MR IHD HOCM Pulmonary HTN
Severe AR
Collapsing pulse
Wide pulse pressure
Length of decrescendo diastolic murmur
S3
Soft A2
Austin Flint murmur
LV failure
LVH
Severe AS clinical signs
Narrow pulse pressure
Plateau pulse
Aortic thrill
Length, lateness of peak, and harshness of murmur
S4
Paradoxical splitting of S2
LV failure
LVH
Causes of SVC obstruction
Lung carcinoma Retrosternal tumours Retrosternal goitre Massive mediastinal lymphadenopathy Aortic aneurysm
HOCM
Sharp rising jerky pulse
JVP- prominent a wave
Apex beat- double/triple impulse
ESM at left sternal edge- louder with Valsalva or standing, softer with handgrip or squatting
Tricuspid regurgitation
Large v waves
RV heave
Pansystolic murmur at left sternal edge, louder on inspiration
Pulsatile liver
Pulmonary stenosis
Peripheral cyanosis Giant a waves RV heave Ejection systolic murmur Presence of S4 Signs of RV failure
Grades of murmurs
1- very soft 2- soft 3- moderate but no thrill 4- loud, thrill just palpable 5- very loud, thrill easily palpable 6- audible without stethoscope
Valsalva manoeuvre
Decreases preload
Increases MVP and HOCM
Handgrip manoeuvre
Increased after load
Decreases MVP, AS and HOCM
Increases MR, AR, VSD
Murmurs loudest with expiration
Left-sided (aortic, mitral)
Murmurs loudest with inspiration
R-sided murmurs (pulmonary, triscuspid)
Loud S1
Mitral/tricuspid stenosis
Soft S1
Mitral regurgitation
Severe AS classification
Mean transvalvular pressure gradient ≥40mmHg
AVA <0.8cm
Aortic velocity ≥4m/s
LVH
Causes of pansystolic murmur
MR
TR
VSD
ASD
Causes of ejection systolic murmur
Aortic stenosis/sclerosis
HOCM
Pulmonary stenosis
ASD
Pressure loaded apex beat
Hyperdynamic, systolic-overloaded
Forceful with sustained impulse
Seen in AS, HTN
Volume-loaded apex beat
Hyperkinetic, diastolic-overloaded
Forceful but unsustained impulse
Seen in AR or MR
Causes of MR
Degenerative disease
Mitral valve prolapse
Rheumatic heart disease
Papillary muscle dysfunction- LV failure, ischaemia
CT disease- RA, ank spond
Congenital
IE
Trauma
Functiona- LV dilatation (DCM, HCM)
Causes of AR
Rheumatic
Congenital- bicuspid
CT disorders/inflammatory- seronegative spondyloarthropathies, RA, SLE
Degenerative
Collagen disorders- Marfan’s syndrome, Ehlers-Danlos, PCKD
Aortitis- tertiary syphillis, vasculitis
Dissecting aneurysm
Old age
IE
Causes of TR
Functional- RV failure, pulmonary HTN
Degenerative
Rheumatic
IE
CT disease
Congenital- Ebstein’s anomaly
Tricuspid valve prolapse
RV papillary muscle infarction
Pacemaker/defib lead
Trauma
Pulmonary stenosis signs
Peripheral cyanosis Giant a waves in JVP (due to RA hypertrophy) RV heave Pulmonary thrill Harsh ESM in pulmonary region- increases with inspiration Pulsatile liver S4 Signs of RV failure
VSD signs
Harsh pansystolic murmur in LSE Thrill LV hypertrophy on CXR/ECG Enlarged RV Associated with Down syndrome
Eisenmenger’s syndrome
Peripheral and central cyanosis
Clubbing
Polycythaemia
Dominant a wave in JVP
Pulmonary HTN- RV heave, palpable P2
RV failure
Dysmorphic features- Down’s
Systolic murmur
LVH criteria on ECG
S wave depth in V1 + R wave height in V5-6 >35mm
CHADSVASC score
CHF HTN Age >75 (2) Diabetes Stroke Hx Vascular- MI, peripheral artery disease Gender
HASBLED score
HTN Altered LFTs/renal function Stroke Hx Bleeding Hx Labile INR Elderly >65 Drugs/EtOH
Investigations in AS
ECG- LVH, LV strain
CXR- LVH, pulmonary oedema, calcified aortic annulus
Echocardiogram- severity (valve area <1cm2, mean gradient >40mmHg, peak velocity >4m/s
Causes of AS
Calcified- elderly patients
Congenital valvulopathy- bicuspid valve
Rheumatic heart disease
SLE
Fabry’s disease
Management of AS
Medical therapy- HF treatment
Balloon aortic valvuloplasty
Valve replacement- TAVI or SAVR
Investigations in AR
ECG- LVH, LA enlargement, LV strain
CXR- LV dilatation, aortic root dilation
Echo- confirm Dx, concomitant stenosis
Mitral valve prolapse
Most common heart lesion
Mid-systolic click and late systolic murmur
Longer with Valsalva
Ix in MR
ECG- AF, LA enlargement, LVH, LV strain
CXR- cardiomegaly, LA enlargement
Echo- prolapsing/thickened leaflets, cardiomyopathy, decrease in LVEF (late)
Causes of mitral stenosis
Rheumatic heart disease
Degenerative- annular calcification
Iatrogenic- following MR repair
Congenital
Investigations in mitral stenosis
ECG- AF, LA enlargement, RAD, RVH
CXR- LA enlargement
Echo- valve area <1cm
Investigations in TR
ECG- RAD, RA enlargement, RVH
CXR- cardiomegaly, RV enlargement
Causes of pulmonary stenosis
Iatrogenic- post repair for PR
Congenital
Carcinoid syndrome
Investigations in HOCM
ECG- LVH + strain, deep Q-waves
CXR- LV enlargement
Echo- asymmetric septal hypertrophy, prominent diastolic dysfunction
Exercise stress testing- inducible LV outflow tract obstruction
Causes of pulmonary HTN
I- idiopathic, CT diseases, congenital, drugs
II- left heart failure
III- chronic hypoxic pulmonary disease (COPD, IPF)
IV- chronic thromboembolic pHTN
V- misc (sarcoidosis, glycogen storage disorders)
Investigations in pulmonary HTN
ECG- RVH, RV strain, RAE
CXR- R) sided cardiomegaly
Echo- RA dilation, TR/PR, elevated RV and PA pressures
RHC
