Cardiovascular Examination Flashcards
Causes of a raised JVP - PQRST
Pulmonary hypertension/PE/PS/pericardial effusion Quantity of fluid i.e. overload
RVF
SVC obstruction
Tamponade/TR
VIVA
What are the 4 causes of aortic stenosis?
Senile calcification
Congenital
Bicuspid aortic valve
Rheumatic
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
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)
VIVA
What are the causes of mitral stenosis?
Rheumatic (most)
Other causes rare, e.g. congenital
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.
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.
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.
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
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
What are the possible examination findings in ASD?
Soft ejection systolic flow murmur (pulmonary area)
Fixed, widely split S2
RV heave
What are the possible examination findings in a VSD?
Pansystolic murmur (loudest at left lower sternal edge) Associated thrill
RV heave/loud P2
Scar name + possible causes?
Midline sternotomy
Reason for bruising in cardiovascular exam?
From anticoagulation?
From underlying clotting disorder?
Osler’s nodes (painful)
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
Clinical findings with HOCM
Pacemaker/implantable cardioverter defibrillator
Jerky pulse/pulsus bisferiens
Double apex beat
Ejection systolic murmur (left lower sternal edge)
S4
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
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
Which type of scar for coarctation of aorta repair?
Left lateral thoracotomy scar
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.
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
VIVA
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
VIVA
Which conditions would cause a crescendo-decrescendo systolic murmur?
Left side:
Aortic stenosis
Aortic sclerosis
Hypertrophic obstructive cardiomyopathy
Right side:
Pulmonary stenosis (rare)
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
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
Features of MS
Management of MS
Aetiology of MR
Define PMC
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
