Corrections - Cardiology Flashcards
What is the most common cardiac defect associated with Turner’s syndrome?
Bicuspid aortic valve
What 3 cardiac defects can be seen in Turner’s?
1) Bicuspid aortic valve
2) Aortic root dilatation
3) Coarctation of the aorta
What murmurs are heard in the following cardiac defects:
1) VSD
2) Coarctation of the aorta
3) Patent ductus arteriosus
4) Pulmonary stenosis
1) Pansystolic murmur in lower left sternal border
2) Crescendo-decrescendo murmur in the upper left sternal border
3) Continuous machinery murmur in the upper left sternal border
4) Ejection systolic murmur in the upper left sternal border
When does TGA present vs ToF?
Cyanotic congenital heart disease presenting within the first DAYS of life is TGA.
Cyanotic congenital heart disease presenting at 1-2 months of age is TOF.
What causes a heaving apex beat in PDA?
Due to left ventricular overload.
The increased volume load on the LV from the shunt causes it to work hard, leading to hypertrophy and a palpable heaving apex beat.
What causes a wide pulse pressure in PDA?
In PDA, there’s increased systolic pressure due to increased stroke volume from L to R shunting, while diastolic pressure decreases because of runoff into the pulmonary arteries during diastole.
This leads to wide pulse pressure.
What causes a left subclavicular thrill in PDA?
Thrill refers to a palpable vibration felt on physical examination, often over areas of turbulent blood flow.
In PDA, it would be caused by blood rushing through the patent ductus arteriosus from the aorta towards the pulmonary artery.
What 2 conditions is a bisferiens pulse seen in?
1) HOCM
2) Aortic regurgitation
What is the medical definition of Eisenmenger’s syndrome?
The reversal of a left to right shunt.
Exam findings in PDA?
1) continuous ‘machinery-like’ murmur
2) left subclavicular thrill
3) bounding pulse
4) widened pulse pressure
What is the risk of SSRI use during third trimester?
Persistent pulmonary HTN of the newborn
Which SSRI has an increased risk of congenital malformations, particularly in the first trimester?
Paroxetine
What is the risk of SSRI use during 1st trimester?
Small increased risk of congenital heart defects
What is a congenital diaphragmatic hernia?
Characterised by the herniation of abdominal viscera into the chest cavity due to incomplete formation of the diaphragm.
This can result in pulmonary hypoplasia and HTN which causes respiratory distress shortly after birth.
What is the best predictor of the clinical severity of ToF?
The degree of pulmonary stenosis
What causes pulsus paradoxus in cardiac tamponade?
The increased pressure in the pericardial sac during inspiration compresses the heart, impairs its filling, and reduces the cardiac output.
This results in an exaggerated drop in the systolic BP.
Which 2 cardiac defects is Turner’s most associated with?
1) Bicuspid aortic valve
2) Coarctation of the aorta
What valvular defect is associated with collagen disorders (e.g. Marfan’s & Ehlers-Danlos)?
Mitral regurgitation
Give 5 causes of mitral regurgitation
1) Following coronary artery disease or post-MI
2) Mitral valve prolapse
3) Infective endocarditis
4) Rheumatic fever
5) Congenital
What condition should widespread joint hypermobility along with skin changes indicated by striae make you think of?
Collagen disorders e.g. Marfan’s, Ehlers-Danlos
Which congenital cardiac defect causes no murmur but a loud single S2 is audible and a prominent right ventricular impulse on palpation?
TGA
What are the most serious long-term health problems for women with Turner’s?
An increased risk of aortic dilatation and dissection due to bicuspid aortic valve and coarctation of the aorta.
What murmur is Turner’s syndrome associated wtih?
Ejection systolic murmur due to bicuspid aortic valve causing aortic stenosis.
This is heard on the upper right sternal border (aortic area) and radiates to the carotid.
what is the commonest cardiac defect in Down syndrome?
AVSD
What are 2 causes of an ejecton systolic murmur that is louder on expiration?
1) Aortic stenosis
2) HOCM
What are 2 causes of an ejecton systolic murmur that is louder on inspiration?
1) Pulmonary stenosis
2) ASD
What type of innocent murmur is heard in children and sounds like a continuous blowing noise heard below the clavicles?
Venous hum
What CHD is there a ‘continuous ‘machinery-like’ murmur’?
Patent ductus arteriosus
What are 3 causes of an increased nuchal translucency on US?
1) Down’s syndrome
2) Congenital heart defects
3) Abdominal wall defects
What are 3 causes of a hyperechogenic bowel on US in pregnancy?
1) CF
2) Down’s syndrome
3) CMV infection
What causes a bisferiens pulse?
Mixed aortic valve disease (aortic regurg + stenosis).
Why does the S2 heart sound usually split into 2 separate sounds during inspiration?
Due to the negative pressure in the chest bringing in air increases the venous blood to the RA & RV.
This increases the time for the RV to squeeze extra blood to the PA, taking more time for the pulmonary valve to close.
This is PHYSIOLOGICAL.
Why is there ‘fixed’ splitting of the S2 heart sound in ASD (i.e. doesn’t change with inspiration)?
Increased blood in RA & RV (due to blood travelling across VSD from LA to RA).
This results in delay in closure of the pulmonic valve relative to the aortic valve.
What are 2 key risk factors for a PDA?
1) Prematurity
2) Congenital rubella infection
What are the 2 types of coarctation of the aorta?
1) Pre-ductal (infantile) - i.e. occurring before the DA
2) Post-ductal (adult) - i.e. occurring after the DA
Note - both types of coarctation occur AFTER the branching of the aorta (causing cyanosis of lower extremities only).
What happens in pre-ductal coarctation of the aorta?
In infants, the narrowing occurs before the PDA.
This causes pressure in the aorta to be lower that in the pulmonary artery (causing blood to move from R to L).
This causes cyanosis of the lower extremities.
What happens in post-ductal coarctation of the aorta?
Narrowing occurs after the ligamentum arteriosum (no cyanosis).
What are some complications of coarctation of aorta?
1) Raised BP in upper limbs but low BP in lower limbs.
2) Brachiofemoral delay.
3) Increased blood flow to brain (due to increased pressure before the coarctation) –> cerebral haemorrhage.
4) Increased pressure in aorta causes LVH –> HF.
5) Rib notching (due to dilated intercostal arteries)
What 2 conditions are associated with coarctation of the aorta?
1) Turner’s syndrome
2) Bicuspid aortic valve
What is pulsatile hepatomegaly most commonly caused by?
Tricuspid regurgitation
Causes of tricuspid regurgitation? (6)
1) RV infarction (MI)
2) Pulmonary HTN e.g. COPD
3) RHD
4) iInfective endocarditis (especially IVDU)
5) Ebstein’s anomaly
6) Carcinoid syndrome
What causes acute pulmonary oedema post MI?
Fluid accumulation in lungs is a consequence of the impaired LV function following MI.
Where can murmur in ASD radiate to?
ejection systolic murmur at the left upper sternal edge that can radiate through to the back
Which type of MI can cause AV block?
Inferior –> RCA supplies AV node
What pulse abnormalities might be noted in PDA?
Large volume, collapsing pulse
Is the ejection systolic murmur in ASD louder on inspiration or expiration?
Inspiration
How can a LV aneurysm following an MI present on an ECG?
Can present as persistent ST elevation in V1-6 on an ECG.
This is because the fibrosis and dead tissue is not able to properly move as expected.
How will a LV aneurysm following an MI present?
LV failure –> pulmonary oedema, S3 and S4
Describe murmur heard in PDA
Continuous machinery murmur heard before left clavicle
How can a PDA cause a bounding pulse?
Because blood runs out of the aorta into the pulmonary artery between heart beats, the patient’s diastolic blood pressure will be somewhat lower than usual. This makes their pulses feel “bounding” (very strong and forceful).
Risk of SSRI use in 3rd trimester?
Risk of persistent pulmonary HTN of newborn
Why can there be acute circulatory collapse at 2 days of age in coarctation of the aorta?
This is because the duct is supplying blood flow to the descending aorta, but when the duct closes at 2 days of age, blood flow becomes cut off.
What murmur is heard in VSD following MI?
New pansystolic murmur
What is an ejection click?
High pitched sound that occurs at the moment of maximal opening of the aortic or pulmonary valve.
When does an ejection click occur in relation to a aortic stenosis murmur?
Ejection click just before the murmur
Where is a Still’s murmur heard?
As a low pitched sound on the lower left sternal edge
What causes physiological splitting of the 2nd heart sound (S2) during INSPIRATION?
1) During inspiration, there is an increase in the negative intra-thoracic pressure
2) This increases venous return into the RA
3) This increases the volume of blood ejected by the RV
4) This causes a delay in the closure of the pulmonary valve - slightly elongates S2 compared to expiration
What causes wide FIXED splitting of S2 in ASD? (i.e. doesn’t change with inspiration/expiration)
1) Shunting of blood from L to R atrium
2) This increases volume of blood in RA and RV
3) Delays closure of pulmonary valve
Where does the murmur in PDA radiate to?
The back
Give the ‘6 S’s’ of innocent murmurs
1) Soft
2) Systolic
3) Symptomless
4) Short
5) S1 & S2 normal
6) Standing and sitting (i.e. postural) variation
What is good sign of HF in babies (instead of raised JVP)?
Hepatomegaly
What does the ductus arteriosus connect?
Pulmonary artery & aorta (so blood can bypass lungs)
What does the foramen ovale connect?
RA & LA
What is a baby’s 1st breath triggered by?
1) Hypoxia (2ary to cord clamping)
2) Stimulation
How does O2 affect pulmonary vessels in baby’s first breahts?
Causes vasodilation –> large drop in pulmonary BP –> blood is redirected through lungs.
When does ductus arteriosus tpyically close?
Within 2 days (following withdrawal of maternal prostaglandins)
When is central cyanosis visible?
When >50 g/l of Hb is deoxygenated
This occurs when O2 sats are <85%.
What is the most common CHD?
VSD
The murmur volume in VSD is inversely related to the size of the defect. What does this mean?
Smaller defect = more turbulence & louder murmur
When do most small VSDs typically close by?
Age 5
What causes recurrent chest infections in VSD?
Pulmonary congestion
What may ECG show in large VSD?
RVH –> right axis deviation, dominant R waves in V1
What may CXR show in large VSD?
Cardiomegaly, prominent pulmonary artery, plethoric lung fields
Mx of small vs large VSD?
Small –> observe w/ follow up if asymptomatic
Large –> diuretics & ACEi for HF, repair if risk of pulm HTN (surgical patch repair)
What surgical repair may be done in large VSD?
Surgical patch repair
Describe murmur in VSD
‘Blowing’ pansystolic
what are 2 possible presenting complaints of ASD?
1) HF
2) Recurrent chest infections
Also breathless when feeding
What is a common presenting complaint of ASD in adults?
Arrhythmias e.g. AF, SVT (can cause stroke - often how their picked up)
Why does ASD not cause a murmur?
Due to the low pressures in the atria
What is a key finding on auscultation in ASD?
Fixed splitting of S2
In what condition is there fixed splitting of S2?
ASD
2 surgical options for ASD?
1) Transcatheter closure (via femoral vein and IVC to RA)
2) Open heart surgery with patch repair before 5th birthday
Mx of small asymptomatic ASD?
Observe and follow up (spontaneous closure likely)
Who is PDA most commonly seen in?
Preterm
What can be found on examination in PDA?
1) Collapsing pulse
2) Wide pulse pressure
3) Continuous machinery murmur (under left clavicle/left sternal border)
What causes collapsing pulse in PDA?
The shunting leads to extra blood flow through the lungs.
Therefore, there is extra blood returning to the L side of the heart.
what causes wide pulse pressure in PDA?
High systolic BP –> due to extra blood ejected from LV
Low diastolic BP –> due to rapid ‘run off’ through ductus arteriosus
What 4 conditions is ToF associated with?
1) DiGeorge syndrome
2) Down’s syndrome
3) Foetal alcohol syndrome
4) Pre-existing diabetes in pregnancy
What can relieve a tet spell?
Squatting
When do tet spells peak?
2-4m old due to inreased O2 demand –> this worsens R to L shunt
Key CXR finding in ToF?
Boot shaped heart
When should surgery be done in ToF?
Within 1st year of life
What are the 2 aims of surgery in ToF?
1) Close VSD
2) Stretch RV outflow tract
What 2 conditions is TGA associated with?
1) DiGeorge syndrome
2) Diabetes in pregnancy
What defect is TGA often associated with (which makes it survivable)?
VSD
What defect is ToF often associated with?
PDA –> keep this open!
is there a murmur in TGA?
No
When is surgery required in TGA?
In first 2 weeks of life
Typical CXR finding in TGA?
‘Egg on a string’ –> due to enlarged cardiac silhouette and a narrowed mediastinum
Brushfield spots can be seen in Down’s syndrome.
What are these?
Speckled iris
Typical feet finding in Down’s?
Sandal gap
Important conditions to counsel parents about in Down’s?
1) Hirschsprung’s
2) Duodenal atresia
3) Hypothyroidism
4) Cardiac defects eg. VSD, mitral & tricuspid regurg
5) Squint
6) Increased lifetime risk of leukaemia
What should be given to patients with TGA and PDA?
Alprostadil –> keep PDA open
Typical murmur in coarctation of aorta?
a systolic murmur with the maximum intensity in the left sternal edge.
What condition may be associated with a bisferiens pulse?
HOCM –> double pulse that occurs due to subaortic stenosis in HOCM
What malformation is strongly associated with congenital hydrocephalus?
Arnold-Chiari malformation –> involves the cerebellum herniating through the Foramen magnum.
What can cause a heaving apex beat in PDA?
LV overload
What causes rib notching in aortic coarctation?
Collateral flow through the intercostal vessels may produce notching of the ribs, if the disease is long standing.
What is radio-femoral delay associated with?
Coarctation of aorta
