Cardiovascular Examination Flashcards by A D

Causes of a raised JVP - PQRST

Pulmonary hypertension/PE/PS/pericardial effusion Quantity of fluid i.e. overload
RVF
SVC obstruction
Tamponade/TR

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VIVA

What are the 4 causes of aortic stenosis?

Senile calcification
Congenital
Bicuspid aortic valve
Rheumatic

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VIVA

What are the causes of aortic regurgitation?

Acute causes include:
Infective endocarditis
Aortic dissection

Chronic causes include:
Connective tissue disorders (e.g. Marfan’s, ankylosing spondylitis)
Rheumatic
Syphilis
Congenital
Long standing hypertension

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VIVA

What are the causes of mitral regurgitation?

Papillary muscle dysfunction (e.g. post-MI)
Dilated cardiomyopathy
Rheumatic
Infective endocarditis
Congenital
Connective tissue disorders (e.g. Marfan’s)

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VIVA

What are the causes of mitral stenosis?

Rheumatic (most)
Other causes rare, e.g. congenital

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VIVA

Name the five eponymous signs of aortic regurgitation?

de Musset’s: head nodding with each heart beat
Quincke’s: nail bed pulsation
Traube’s: pistol shot sounds heard while auscultating the femoral artery
Duroziez’s: diastolic murmur heard when stethoscope bell compresses femoral artery
Müller’s: pulsation of uvula.

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VIVA

What is an Austin Flint murmur?

An Austin Flint murmur is a rumbling diastolic murmur heard over the apex. It is caused by blood jets from severe aortic regurgitation, that displace the mitral valve.

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VIVA

How would you differentiate between aortic stenosis and aortic sclerosis?

Both aortic stenosis and aortic sclerosis cause an ejection systolic murmur. However, aortic sclerosis does not radiate and is not associated with any other the other clinical signs of aortic stenosis (e.g. narrow pulse pressure, slow rising pulse, heaving apex beat.

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VIVA

How would you differentiate between mitral regurgitation and tricuspid regurgitation?

Both mitral regurgitation and tricuspid regurgitation cause a pansystolic murmur.

With regards to the murmur, two things can help:
1. Tricuspid regurgitation is loudest at the lower left sternal edge; whereas, mitral regurgitation is loudest at the apex
2. Mitral regurgitation radiates the the axilla
3. Mitral regurgitation is louder on expiration (lEft-sided); tricuspid regurgitation is louder on inspiration (rIght-sided)

Other signs can help differentiate too:
1. Mitral regurgitation causes a displaced apex beat
2. Tricuspid regurgitation causes giant V waves in the JVP
3. The most common cause of tricuspid regurgitation is pulmonary hypertension, so there may be signs of chronic respiratory disease on examination

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What are the possible examination findings in heart failure?

Tachypnoea/tachycardia
Cool peripheries
Raised JVP
Displaced apex S3 (ventricular gallop)
Bi-basal fine crepitations
Peripheral oedema

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What are the possible examination findings in ASD?

Soft ejection systolic flow murmur (pulmonary area)
Fixed, widely split S2
RV heave

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What are the possible examination findings in a VSD?

Pansystolic murmur (loudest at left lower sternal edge) Associated thrill
RV heave/loud P2

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Scar name + possible causes?

Midline sternotomy

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Reason for bruising in cardiovascular exam?

From anticoagulation?
From underlying clotting disorder?

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Osler’s nodes (painful)

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Clincial findings with cor pulmonale

Plethoric facial appearance
Central cyanosis
Raised JVP (large ‘a’ waves)
Giant V waves + pansystolic murmur (if secondary TR)
Right ventricular heave
Palpable/loud S2
Pedal oedema

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Clinical findings with HOCM

Pacemaker/implantable cardioverter defibrillator
Jerky pulse/pulsus bisferiens
Double apex beat
Ejection systolic murmur (left lower sternal edge)
S4

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Clinical findings in Tetralogy of Fallot (repair)

Sternotomy scar (from repair)
Lateral thoracotomy scar (if had Blalock-Taussig shunt)
Left pulse weaker (if had Blalock-Taussig shunt)
Clubbing
Loud pulmonary stenosis

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Clinical findings in coarctation of the aorta

Radio-femoral delay
Weak left radial pulse (if stenosis proximal to left subclavian artery)
Systolic vascular murmur over region of stenosis (most commonly left interscapular or left infraclavicular)
Severe hypertension

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Which type of scar for coarctation of aorta repair?

Left lateral thoracotomy scar

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VIVA

What is Eisenmenger syndrome?

Eisenmenger syndrome is when a long standing left-to-right shunt (e.g. ASD, VSD) causes pulmonary hypertension and eventually reverses to form a right-to-left shunt.

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VIVA

What are the different types of valves that can be used for a valve replacement?

Manufactured mechanical valve:
Often last for the patient’s entire life
Patient will also need to take anticoagulation medication (warfarin)

Tissue valve (animal donor valve):
Also known as bioprosthetic valves
Often last 10-15 years then need replacing
Pigs (porcine) or cows’ (bovine) valves are used most commonly

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How would you differentiate between left and right sided heart failure based on clinical findings?

Left sided heart failure “L for Lungs”:
Displaced apex beat
S3 heart sound
Pulmonary congestion

Right sided heart failure “R for Rest of body”:
Elevated JVP
Hepatomegaly
Ascites
Significant peripheral oedema

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VIVA

Which conditions would cause a crescendo-decrescendo systolic murmur?

Left side:
Aortic stenosis
Aortic sclerosis
Hypertrophic obstructive cardiomyopathy

Right side:
Pulmonary stenosis (rare)

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# VIVA What are the different types of cardiomyopathies?

* Hypertrophic: this can be genetic or idiopathic * Dilated: often idiopathic but can be caused by genetics, alcohol, chemotherapies, and viruses * Restrictive: can be idiopathic or can be due to amyloidosis, sarcoidosis, or haemochromatosis * Arrhythmogenic right ventricular: the cause is unknown but there is often a familial link * Peripartum cardiomyopathy * Takotsubo: triggered by an extremely stressful or emotional event. Often called ‘broken heart syndrome’

# VIVA What is the tetrad of abnormalities of Tetralogy of Fallot?

* Ventricular septal defect * Pulmonary stenosis * Overriding aorta * Right ventricular hypertrophy

How would you clinically assess the severity of aortic stenosis?

Pulse volume (slow-rising) Pulse pressure (narrows) S2 intensity (reduces) Murmur volume (becomes louder)

What are the general indications for a valve replacement?

**Left-sided valve dysfunction:** Any valve: associated LVF, symptomatic If regurgitation, also: acute onset, associated LV dilation If mitral, also: presence of pulmonary hypertension If prosthetic valve, surgery also indicated if: <2 months post-op, valve dysfunction, or Staphylococcus aureus infection **Infective endocarditis:** Associated heart failure Uncontrolled infection (fistula, enlarging vegetation, false aneurysm, aortic root abscess, persistently positive blood cultures, fungal/multidrug-resistant organism) High embolic risk (persistent large vegetation)

What are the possible risks and complications of a valve replacement?

* Perioperative risks: arrhythmias, stroke/TIA, infections (wound/lung/endocarditis), bleeding/haemothorax, thromboembolism, pulmonary oedema/acute respiratory distress syndrome, acute kidney injury * Valve complications: leakage, dehiscence, obstruction, thromboembolism, haemolytic anaemia, infective endocarditis * Warfarin side effects: bleeding

What are the causes of a wide and narrow pulse pressure?

The pulse pressure is the difference between the systolic and diastolic blood pressure. It is related to the amount of blood expelled from the left ventricle during systole. * Wide pulse pressure: aortic regurgitation, arteriovenous malformation, arterial stiffness, hyperthyroidism * Narrow pulse pressure: aortic stenosis, cardiac tamponade, left ventricular failure

Aortic sclerosis murmur

What are the red flag symptoms for cardiac syncope?

**Arrhythmogenic:** No warning Palpitations/feel strange before Syncope when supine Chest pain New/unexplained breathlessness Cardiac history/severe LVF Family history of sudden death **Structural (e.g. HOCUM, valve disease):** Syncope on exertion Cardiac history/lesion Family history of sudden death

In a patient whom you suspect has cardiac syncope, what would you look for specifically in the ECG?

* QT: Long QT or short QT interval * Rhythm strip: tachy/bradycardias, pauses * PR: heartblock; Delta waves/short PR (WPW) * QRS: pathological Q waves (cardiomyopathies); bundle branch block/bifascicular/trifascicular block; ventricular hypertrophy (HOCUM, AS) * ST: Brugada pattern (Brugada syndrome); Epsilon waves (AVRD) * T: T wave inversion (right leads = AVRD, PE)

Which bacteria commonly cause infective endocarditis?

Acute IE: Staphylococcus aureus (most), beta-haemolytic Streptococci, Streptococcus pneumoniae, Enterococci Subacute IE: viridans group Streptococci, Enterococci Other causes: HACEK organisms

What is a TAVI and when may this be indicated?

A TAVI is a transcatheter aortic valve replacement. It is performed percutaneously. It is an option for patients with severe aortic stenosis, who are high-risk for open hear surgery.

What are the complications of pacemaker insertion?

Infection (including pocket site, infective endocarditis) Pneumothorax/haemothorax Haematoma/bleeding Thromboembolism Lead dislodgement Cardiac perforation (rare)

What are the chest radiograph findings in heart failure?

**ABCDE**: Alveolar shadowing (bat’s wings sign) B-lines (interstitial oedema) Cardiomegaly Diversion of blood to upper lobes Effusion

What does a giant V wave in the JVP suggest?

Tricuspid regurgitation

What is cardiac output dependent on?

Cardiac output = stroke volume x heart rate Stroke volume depends on preload, contractility and afterload

What is Kussmaul's sign?

Kussmaul’s sign is a paradoxical increase in the JVP during inspiration (it normally decreases during inspiration due to the reduction in thoracic pressure). It is caused by impaired right ventricular filling. Conditions that may cause this include: Cardiac tamponade/large pericardial effusion Constrictive pericarditis Restrictive cardiomyopathy Severe right-sided heart failure

Causes of radioradial delay?

Cervical rib, aortic coarctation / dissection, embolism

Midline sternotomy surgeries?

What are the key JVP abnormalities?

Central vs peripheral cyanosis?

DDx for central cyanosis?

DDx for peripheral cyanosis?

DDx for irregularly irregular pulse?

Six important causes of AF?

Causes of an absent radial pulse?

Features of JVP (vs carotid pulse)?

Define pulsus paradoxus

Define Kussmaul's sign

Causes of non-palpable apex beat?

Causes of S3?

Causes of S4?

DDx for heaving apex (LVH)

CXR features of LHF

Causes of pericarditis

Causes of cardiac failure

Pulse pressure findings

Narrow = AS Wide = AR

Indications for surgery in mitral stenosis

Indications for surgery in mitral regurgitation

Indications for surgery in aortic stenosis

Indications for surgery in aortic regurgitation

Mitral stenosis DDx

Mitral regurgitation DDx

Aortic stenosis DDx

Aortic regurgitation DDx

System for describing features of a heart murmur

Grading of murmur intensity

Stigmata of infective endocarditis

Aortic sclerosis features

Complications of prosthetic valves?

Eponymous signs in AR

Description, radiation, features and management of: **aortic stenosis**

Description, radiation, features and management of: **aortic regurgitation**

Description, radiation, features and management of: **mitral stenosis**

Description, radiation, features and management of: **mitral regurgitation**

Aortic stenosis aetiology

Aortic stenosis associated features

Aortic stenosis investigations + indicators of increasing severity

Management of aortic stenosis

Aetiology of aortic regurgitation

Features associated with AR

Management of AR

Murmur in AR

early diastolic ULSE, may be quieter if severe

Aetiology of MS

RHEUMATIC HEART DISEASE, calcification/degenerative

Features of MS

Mitral stenosis murmur

mid-late diastolic, rumbling, loudest at the apex

Thresholds to remember for severe MS

severe MS when mitral valve area <1.5 cm?

Management of MS

Aetiology of MR

Define PMC

Murmur of MR

pan-systolic apex

Associations of MR

Management of MR

Investigations of MR

Prosthetic valves - factors favouring mechanical vs bioprosthetic

Anticoagulation with prosthetic valve

Risk factors for AF

Acute AF management

Chronic AF management

Anticoagulation in AF

STEMI criteria

Primary vs secondary management of STEMI

Simplified management of STEMI

Criteria for defining NSTEMI

Primary vs secondary management

NSTEMI simplified managemenet

Acute HF triggers

Initial management of acute HF

Heart failure CXR

Chronic HF management

Midline sternotomy indications

Posterolateral and anterolateral thoracotomy

Clamshell incision indications

Subclavicular incision