CVS Flashcards
Describe CVS examination (12)
•Introduce, orientate, rapport, position 45’ and expose
• General appearance: acute/chronic, dyspnoea, tachypnoea, orthopnoea, attachments
• vitals including bp 4 limb;
• General exam:
→ jaccold, polycythaemia,
→ limbs: peripheral pulses, splinter haemorrhages, janeway lesions, examine joints, rate rhythm character radial pulse , xanthomata, arachnodactyly, Osler nodes, temp, cap refill, plethora, subcut nodules
→ face: malar flush
• JVP character, carotid pulse character
• inspect precordium: Harrison sulcus, pulsations, JVP
• palpate: apex beat, right para-sternal heave, thrill, suprasternal notch
• percuss heart and liver border
• auscultate
• examine lungs
• examine abdomen
• summarise: nature of lesion, clinical pathological diagnosis, cyanotic vs acyanotic, etiology eg congenital acquired, presenCe complications eg pulmonary ht, heart failure, pneumonia, SBE; ddx
• diagnostic plan: CXR, ECG, sonar, bloods
• Management: acute eg oxygen, long term eg surgery
What is and causes malar flush?
Plum-red discolouration of cheeks associated with mitral stenosis
Normal apex beat position children?
<4 years: 4th iCs
> 4: 5th
If displaced → left ventricle enlarged
Cause pulsatile liver?
Severe tricuspid incontinence due to CCF
What are xanthomata and what do they indicate?
Raised yellow cholesterol rich deposits on palm / tendons of wrist/elbow
Hyperlipidaemia, typically familial
Which heart defect is associated with marfan syndrome? (2)
- Mitral/aortic valve prolapse
- aortic dissection
Name 4 primary causes clubbing
(Rare)
- idiopathic
-Inherited/familial
- Pachydermoperiostosis (pdp) (AD/ar/x linked)
- hypertrophic osteoarthropathy (Pierre Marie - bamberger syndrome)
Name 10 secondary causes clubbing in children
3 heart
- Cyanotic heart defects!
-Infective endocarditis!
-Pht
- other: atrial myxoma (very rare)
3 lung
- suppurative!: empyema, lung abscess, bronchiectasis, Cf
- chronic lung disease: PTB, interstitial lung disease!
- lung metastases
- other: lypoid pneumonia, cryptogenic fibrosing alveolitis, PHT
3 git
- liver: primary biliary or hepatic cirrhosis!
- inflammatory bowel disease, esp uc!
- malabsorption, achalasia
Other: cancer of thyroid, thymus, Hodgkin’s lymphoma
Describe how clubbing develops (5)
- Fluctuation and softening nail bed (increased ballotability)
- Loss of normal <165 angle (lovibond angle) between nailbed and fold
- Increased convexity of nail fold
- Thickening whole distal finger, resembling drumstick.
- Shiny aspect and striation of nail and skin
Pathophysiology clubbing?
- Digital vasodilation causes increased blood flow to terminal oedema
- increased interstitial oedema
-Proliferation vascular connective tissue
What are and causes splinter haemorrhages? (5)
Longitudinal, red-brown haemorrhage under nail that looks like wood splinter. Due to microemboli in end arteries due to vegetations in heart valve
- local trauma
- Infective endocarditis!
- sepsis
- psoriatic nail disease
- Vasculitis
What are and causes janeway lesions?
Nontender haemorrhagic lesions that occur on thenar and hypothenar eminences of palms and soles
- infective endocarditis
What are and causes Osler’s nodes?
Red-purple slightly raised tender! Lumps often with pale centre, usually on fingers or toes
- infective endocarditis
What cardiac condition is associated with cool and sweaty/clammy hands?
Acute coronary syndrome
Name 2 causes radio-radial delay
- Subclavian artery stenosis eg compression by cervical rib
- Aortic dissection
How assess for collapsing pulse?
- Palpate radial purse with hand wrapped around wrist
- Palpate brachial pulse with other hand while supporting patient’s elbow
- raise pts arm above head briskly
- should be able to feel tapping pulse through muscle bulk of arm as blood rapidly empties from arm in diastole ; if not, collapsing pulse
Name 2 causes collapsing pulse
Widened pulse pressure:
- aortic regurgitation
- PDA
Name 4 types of pulse character and causes
- Normal
- slow-rising: aortic stenosis
- bounding: aortic regurgitation, co 2 retention
- thready: intravascular hypovolemia eg sepsis
What does bruit on auscultation indicate?
Artery stenosis
How examine carotid?
Nb to auscultate first! If bruit present (carotid stenosis) best heard when hold breath, palpation can be dangerous - risk dislodge carotid plaque and cause ischaemic stroke.
Palpation: assess character (normal /slow rising / bounding / thready) and volume
What is normal JvP in children and how measure?
Vertical distance between sternal angle, and top of ejv perpendicular
Normal < 2,5 cm
(Big kids <4)
How elicit hepatojugular reflex?
- Apply pressure to liver and observe ejv for rise
- healthy: ejv rises no longer than 1-2 cardiac cycles, then fall
- positive: ejv rise sustained and 4 cm or more
What are cholesterol rich deposits around eye associated with hypercholesterol called?
Xanthelasma
What are Kayser Fleischer rings and what causes it?
Dark rings around iris
Wilson’s disease (can cause cardiomyopathy)
Name 2 abnormal characters of apex beat and causes
- Heaving (thrusting, forceful and sustained , often visible ): LVH
- tapping ( palpable s1 short duration): severe MS
How palpate for heave? Causes? (2)
Heel of hand (3 fingers young children) parallel to left sternal edge - will feel hand being lifted for sustained period of time (>2/3 of systole )
Left parasternal heave = Right ventricular hypertrophy
Epigastric heave (gently push up towards heart, hand pushed back ) = more severe right ventricular hypertrophy
How feel thrill, and what does it indicate?
Place finger tips in intercostal spaces over all valves
Palpable vibration caused by turbulent blood flow through heart valve. Thrill = palpable murmur
What does palpable P2 indicate
PHT
Dilated Pulmonary valve slamming closed
Approach to chest heart auscultation?
- Carotid arteries while hold breath: listen for radiation ejection systolic murmur (aortic stenosis)
- aortic area during expiration: early diastolic murmur (aortic regurg)
- roll onto left side, mitral area during expiration with diaphragm: pansystolic murmur (mitral regurg )
- mitral area with bell during expiration: mid-diastolic murmur (mitral stenosis)
How describe murmur? (6)
- Location
- systolic / diastolic,
- grade (systolic / 6, diastolic /4)
- radiation
- character: harsh, blowing, high pitched
- change with change in position/ respiration
Bell vs diaphragm of stethoscope?
- Bell better for low frequency sounds eg mid diastolic murmur of mitral stenosis
- diaphragm better for high frequency eg ejection systolic of aortic stenosis, early diastolic of aortic regurg and pansystolic of mitral regurg
Name 2 types and causes of murmurs found in right upper sternal border (aortic area)
Acyanotic congenital lesion
- normal pulmonary blood flow: aortic stenosis (ejection systolic)
continuous murmur:
- right bt shunt (surgery that connect subclavian and pulmonary artery to increase flow to lungs done for eg TOF, pulmonary atresia)
- venous hum (benign, Normal blood flow through jugular veins)
Name 2 types and 8 causes of murmurs found in left upper sternal border ( pulmonary area)
Acyanotic congenital
- normal PBF
→ pulmonary stenosis (ejection systolic)
- increase PBF
→ patent ductus arteriosus (continuous)
→ atrial septal defect (ejection systolic)
Cyanotic congenital
- Increase PBF
→ transposition of the great arteries with PDA (continuous)
→ TAPVD with ps (ejection systolic)
- decrease PBF
→ TOF with ps (ejection systolic)
→ critical ps with PDA (continuous)
→ pulmonary atresia with PDA (continuous)
Ejection systolic
- pulmonary stenosis (congenital acyanotic lesion; TAPVD; TOF )
- ASD (congenital acyanotic)
- Innocent murmur
Continuous
- PDA (congential acyanotic; critical ps ; pulmonary atresia; tga)
Name types and 2 causes of murmurs found in apex ( mitral area)
Acyanotic congenital lesions.
- Increased PBF
→ AVSD with mitral regurgitation
- normal PBF
→ (mitral incompetence)
Pansystolic
- mitral regurgitation
- AVSD with mitral regurgitation
( Late systolic
- mitral valve prolapse )
( Mid diastolic
- mitral stenosis )
Name 2 types and 6 causes of murmurs found in left lower sternal border ( tricuspid area)
Acyanotic congenital
- increased PBF
→ vSD (pansystolic)
→ avSD with tricuspid regurg (pansystolic)
- Normal PBF
→ (tricuspid incontinencepansystolic)
Cyanotic congenital
- decreased PBF
→ tricuspid atresia with vSD (pansystolic)
→ Ebstein anomaly with tricuspid regurgitation (pansystolic)
- increased PBF
→ truncus arteriosus with VSD (pansystolic, sometimes mid)
→ TAPVD with tricuspid stenosis (mid diastolic)
Pansystolic
- tricuspid regurgitation (caused by avSD, Ebstein anomaly )
- vSD (congenital acyanotic; tricuspid atresia; truncus arteriosus)
- (tricuspid incontenence)
Diastolic
- Tricuspid stenosis (caused by TAPVD - mid diastolic)
- aortic regurgitation
Still’s murmur (innocent)
Name 2 types and causes of murmurs found in back
Systolic
- between scapulae: coarctation
- peripheral pulmonary oedema
Continuous
-PDA
Identify picture 3 and what it indicates
Janeway lesions: infective endocarditis
Approach to cyanosis (7)
** no respiratory distress **
Peripheral cyanosis
- warm, reassure
Differential and central cyanosis
- cardiac evaluation for congenital heart disease→ rX: start pge1
→ hyperoXia test:
> pao2 <100 → cardiac → rX: start pge1
> pao2 100 - 150 → pphn (persistent pulmonary hypertension in the neonate)
> pa02 > 150 → resp management: give oxygen, ventilate if needed
** respiratory distress **
- No obstruction → hyperoXia test
- obstruction → ent evaluation
Name 4 broad causes central cyanosis
- Inadequate ventilation
- desaturated blood bypassing lungs
- methaemoglobinaemia: congenital/toxins
- Poisoning: carbon monoxide
Name 6 causes central cyanosis due to inadequate ventilation
- Pneumonia
- airway obstruction
- structural changes in lungs
- CNS depression
- inadequate ventilatory drive: obesity, pickwick syndrome
- weak respiratory muscles
Name 3 causes central cyanosis due to desaturated blood bypassing lungs
- Cyanotic heart defects: r to l shunting
- Pulmonary AVMs: hepato pulmonary syndrome, HHT (hereditary haemorrhagic telangiectasia)
- Pphn
Name 3 broad mechanisms heart failure
- Volume overload
- pressure overload
- myocardial dysfunction
Name 3 causes each of systolic and diastolic heart failure
Systolic dysfunction (pump failure)
- myocarditis
- dilated cardiomyopathy
- Malnutrition
- ischaemia
Diastolic (failure to relax)
- Pericardial constriction / tamponade
- Hypertrophic cardiomyopathy
- restrictive cardiomyopathy
Name 4 causes heart failure due to volume overload
Cardiac
- left to right shunts eg VSD
- Rheumatic heart disease
Non -cardiac
- fluids, low albumin
- Anaemia
Name 2 causes heart failure due to pressure overload
Cardiac: obstructive lesions eg critical pulmonary stenosis
Non-cardiac: hypertension
Name 6 causes heart failure due to myocardial insufficiency
Cardiac
- Arrhythmia
- cardiomyopathies: dilated, hypertrophic, restrictive
- myocarditis
- malnutrition
Non - cardiac
- Decrease oxygen carrying capacity eg anemia
- increased demand eg sepsis
Name 5 likely causes heart failure ( hydrops foetalis ) in fetus
- anaemia: Rh sensitization, fetal-maternal transfusion
- arrhythmia: SvT, complete heart block
- myocardial dysfunction: myocarditis / cardiomyopathy
- large AVMs
- Structural heart disease: rare
Name 6 likely causes heart failure in neonates and infants <2 months
- Structural heart disease
- myocardial disease: primary myopathic abnormality, inborn errors of metabolism
- metabolic: hypoxia, acidosis, hypoglycaemia, hypocalcaemic
- respiratory illnesses, BPD
- Anaemia
- sepsis
Name 8 likely causes heart failure in older children
Pressure overload
- Cor pulmonale ( upper resp obstruction, severe lung disease)
- Ht
- Congenital cardiac disease : left sided obstructive disease: as, coarctation
Volume overload
- renal failure
Acquired myocardial failure
- myocarditis, cardiomyopathy
- arrhythmia
- myocardial ischaemia
- illicit drugs
Name 5 symptoms and signs left heart failure
- Tachypnoea
- Dyspnoea
- orthopnoea
- decrease exercise capacity
- pulmonary oedema
Name 6 symptoms and signs right heart failure
SvC congestion
- increased JVP
- distended neck veins
- orbital oedema
IvC congestion
- hepatomegaly
- ascites
- Pedal edema
Name 5 investigations for heart failure
- CXR: cardiomegaly (essential to call it CCf), pulmonary congestion
- ECG
- echo to see lesion, chamber enlargement, lv function
- bloods
- urine dipstix: exclude renal disease
Management heart failure? (6)
General: bed rest at 30º; oxygen, salt restrict, high energy diet, daily weighing
Treat underlying cause and any predisposing causes
Medications
- decrease preload: diuretics (furosemide, sipironolactone, hctz)
- increase contractility: inotropes ( digoxin po, iv options dopamine and dobutamine)
- Decrease afterload: ace inhibitors eg captopril elanapril
- control overcompensatory mechanisms: beta blockers eg carvedilol
Right heart border on ap orientation? (2)
- Svc
- right atrium
Left heart border on ap orientation? (4)
- Aorta knuckle
- pulmonary artery knuckle
- left atrium appendage
- left ventricle
Anterior heart border on lateral orientation?
Right ventricle
Posterior heart border on lateral orientation? (2)
- Descending aorta
- left atrium
Cause of suprasternal thrill?
Aortic stenosis (very sensitive sign )
Cause carotid thrill?
Severe turbulence over severe aortic stenosis
Name 3 sign aortic stenosis
- Suprasternal thrill
- displaced apex beat
- severe: carotid thrill
Name CVS cause splenomegaly
Infective endocarditis
Define cor pulmonale
Cardiac failure due to pulmonary ht due to airway disease
Name 3 differentials massive cardiomegaly
- Ebstein anomaly
- pulmonary atresia with no vSD
- huge pericardial effusion
How tell if right atrium enlargement on CXR?
Ap: prominent r heart border
How tell if right ventricle enlargement on CXR?
Lateral: increased sternal contact > bottom 1/3
How tell if left atrium enlargement on CXR?
Ap: angle of carina >60
Lateral: prominent posterior bulge
How tell if left ventricle enlargement on CXR?
Ap: apex displaced down and out - long, straight L heart
Lateral: increased diaphragm contact > anterior 1/3
Name and classify 7 types acyanotic congenital heart disease
Normal pulmonary blood flow (CAP)
RH:
- pulmonary stenosis (ejection systolic ULSB)
- (tricuspid incontinence) (common physiological, pulsatile liver if severe, pansystolic LLSB)
LH:
- aortic stenosis (ejection systolic RUSB)
- coarctation/interrupted aortic arch (continuous over back)
- (mitral incompetence) (congenital abnormal MV or 2ndary to LH dilatation; pansystolic apex)
Increased pulmonary blood flow (left to right shunts)
- patent ductus arteriosus (continuous ULSB)
- ventricular septal defect (pansystolic LLSB)
- atrio-ventricular septal defect (pansystolic from mitral (over apex)/tricuspid (LLSB) regurg OR no murmur bc pressure balance quickly)
- atrial septal defect (ejection systolic ULSB)
( eisenmenger syndrome)
Name and classify 9 types cyanotic congenital heart disease
Increased pulmonary blood flow (3 ts)
- transposition of the great arteries (ULSB continuous due to PDA)
- total anomalous pulmonary venous drainage (ejection systolic ULSB due to PS and/or mid diastolic LLSB due to TS)
- Truncus arteriosus (pansystolic LLSB due to VSD, or midsystolic)
- hypoplastic left heart syndrome
(Eisenmenger syndrome)
Right to left shunts
Decreased pulmonary blood flow (PPETT) (blockage RH to lungs)
- tetralogy of fallot (ejection systolic LUSB due to PS)
- critical pulmonary stenosis (cont LUSB due to PDA)
- Pulmonary valve atresia (cont LUSB due to PDA)
- Ebstein anomaly (pansystolic LLSB due to TR)
- tricuspid atresia (pansystolic LLSB due to VSD)
Name 3 symptomps/ complications of acyanotic congenital heart diseases with normal pulmonary blood flow
- asymptomatic unless severe stenosis
- Ventricle hypertrophy
- low cardiac output ( hr x Sv )
Name 6 symptomps/ complications of acyanotic congenital heart diseases with increased pulmonary blood flow
- Flood lungs (lead to pht)
- cardiomegaly
- chest deformities ( barrel chest, Harrison sulci)
- CCF
- Pht
- Ftt - poor feeding, poor weight gain
- recurrent chest infections
Profuse sweating
Name 9 symptomps/ complications of cyanotic congenital heart diseases with increased pulmonary blood flow
- Flood lungs
- cardiomegaly
- chest deformities
- CCF
- PHT
- FTT
- cyanotic due to mixing
- all present at young age <3-6 months
- CXR plethoric lung fields
Name 2 symptomps/ complications of cyanotic congenital heart diseases with decreased pulmonary blood flow
- severe cyanosis due to too little flow to lungs
- stunting if longstanding
- CXR: oligaemic lung fields
No cardiomegaly, no CCF, no PHT
When is cyanosis visible
Saturation <85%
Name 6 symptoms hypercyanotic cells in TOF
- Tachypnoea ( acidotic breathing)
- hyperventilation
- hyperinflation
- worsening cyanosis
- Acidotic
- Limpness, convulsions → death
Treatment hypercyanotic spells in TOF (8)
- Knee chest position (squatting) (make them feel better - compress femoral and peripheral arteries so increase systemic vascular resistance → increase bp → increase lv pressure → force blood into pulmonary arteries to oxygenate)
- 100% oxygen (usually minimal effect, in case intubation )
- morphine 0,1 my/kg (calm down, relax infundibular spasm )
- fluid bolus 10 - 20 ml/kg over 20 minutes crystalloid/colloid (increase preload → increase bp→prevent shunt)
- sodium bicarb if severe acidosis
- Beta blocker (esmolol iv, long term oral propranolol - slow hr, allow better filling → improve output, prevent future spells)
- Phenylephrine (vasoconstrictions → increase svr)
- emergency surgery if medical treatment fail
Treatment PDA dependant lesions
- PG E1 IV or E2 oral
- treat metabolic acidosis
- refer for surgery
Name 3 complications cyanosis
- polycythaemia
- cerebrovascular events (stroke)
- clotting and bleeding risk
Clinical findings of VSD? (7)
- Pansystolic llsb murmur (tricuspid area) initially
- initially displaced apex (lv dilatation)
- Thrill
Later
- palpable p2, loud s2 ( Pht )
- left parasternal, epigastric heave (rvh)
Eventually cyanosis whole body: Eisenmenger
CCF signs: hepatomegaly
Pathophysiology VSD? (7)
La dilatation bc receiving too much blood from lungs → lv dilate → displaced apex
Later: volume overload left heart → CCF
Increased pulmonary blood flow → tachypnoea, dyspnoea
Later: pulmonary a hypertrophy → la + lv smaller → apex less displaced → murmur softer
→ PHT → RVH to push into pulmonary arteries → left parasternal, epigastric heave
Later: apex back to normal, murmur softer, CCF better.
Later: severe RVH → worsening PHT → palpable P2, loud S2
→ pressure overloadright heart → CCF
Later: further increase pulmonary artery + rv pressure → murmur disappear because no pressure difference
Late: severe RVH → shunt reverse r-l flow → Eisenmenger syndrome: cyanosis whole body.
Pressure differences in heart?
Left heart
- Lv 90/0
- aorta 90/60
Right heart
- Rv 30/O
- pulmonary trunk arteries 30/15
What is unique about ASD of the acyanotic increased PBF defects? (3)
- Usually asymptomatic. If symptoms, fatigue and arrhythmic (afib)
- usually only picked up in adulthood
- low pressure shunt
- CCF only if big shunt or secondary to PHT.
Clinical features ASD? (3)
Mostly no signs.
- Ejection systolic murmur ULSB (increased volume blood squeezing into pulmonary arteries increase turbulence)
- left parasternal heave ( ra dilatation → Rv dilatation)
- CCF features only if volume overload right heart, likely only later in life
- Split S2 ( increased rv filling → increased rv ejection time → pulmonary valve closure delayed after aortic)
Clinical features PDA? (3)
- CCF: enlarged liver
- continuous ULSB murmur
- Thrill ULSB
- Bounding pulses, wide pulse pressure
- Cyanosis only in feet when later develop Eisenmenger
Pathophysiology PDA?
Left to right shunt aorta → pulmonary artery
Changes same as VSD
Pathophysiology AVSD? (3)
- Endocardial cushion defect
- Trisomy 21 commonly associated
- same as vSD but deteriorate much faster.
Clinical features pulmonary stenosis? (4)
- Usually asymptomatic even with RVH
- parasternal, epigastric heave (RVH)
- murmur ejection systolic ULSB; turbulence over lung fields
- softer s2: pulmonary valve not opening widely so doensn’t close hard
Clinical features aortic stenosis? (4)
- Asymptomatic unless severe: decreased cardiac output, syncope, sudden cardiac death
- displaced apex, heaving apex (LVH)
- suprasternal, carotid thrill (LVH)
- murmur ejection systolic RUSB
What is tetralogy of Fallot?
- VSD sub-aortic
- overriding aorta (rv + lv connected to aorta)
- pulmonary stenosis caused by infundibular hypertrophy (rv outflow tract obstruction)
- rVh (to get blood into pulmonary artery)
Prov
Name clinical findings TOF (3)
- Pulmonary stenosis → ejection systolic LUSB with post radiation (not VSD murmur - rv and lv pressure equal)
- RVH → left parasternal heave
- Cyanotic spells due to rv outflow tract obstruction - emergency
CXR feature of TOF?
Boot shaped heart
Pathophysiology transposition of the great arteries?
Aorta arise from rv and pulmonary artery from lv
→ deoxygenated blood from rv circulated around body
Need stunt to keep alive: pfo/asd; PDA; vSD
Clinical findings and CXR features transposition of the great arteries?
No murmur unless PDA. (Ulsb cont)
CXR: egg on a string
Pathophysiology tricuspid atresia? (3)
Cyanotic lesion with decreased PBF
- need ASD and VSD (mostly) (if no VSD, then PDA dependent)
- blood from ra → through ASD / patent foremen ovale → La
- hypoplastic rv
Name 4 clinical features tricuspid atresia
- Cyanosis
- CCF: hepatomegaly (rare unless late present)
- single S2
- vSD → pansystolic murmur llsb or PDA murmur (continous ulsb)
Pathophysiology Ebstein’s anomaly? (4)
- Tricuspid valve set lower in r heart towards apex, very long and tethered so not good flow, degree of stenosis (if stenosis severe, need PDA)
- arterialisation of rv (smaller) → poor flow to pulmonary vessels
- dependent on ASD shunt → mixing blood to La → deoxygenated blood → cyanosis
- associated with wolf Parkinson white Syndrome
RAT = RV small, ASD dependent, TV lower + long + tethered
Clinical presentation Ebstein’s anomaly? (4)
- CCF: oedema
- cyanosis
- pansystolic murmur llsb due to tricuspid regurgitation
Gallop rhythm bc addition 3rd and 4th heart sounds - arrhythmia!
CXR Ebstein’s anomaly?
Wall to wall heart (massive dilatation ra)
Pathophysiology total anomalous pulmonary venous drainage?
(3)
- Cyanotic lesion, increase PBF
- Pulmonary veins don’t drain to la.
- can be:
→ supracardiac (to SVC ).
→ infra (ivc)
→ cardiac (RA) - need ASD. Bigger defect do better
Clinical features total anomalous pulmonary venous drainage? (3)
- Murmurs:
→ ejection systolic LUSB due to relative ps (rh volume overload ) or
→ mid diastolic llsb due to relative ts - R heart failure: hepatomegaly
Fixed splitting s2 due to volume overload rv
CXR total anomalous pulmonary venous drainage?
Snowman in supracardiac anomalous pulmonary venous connection
Name 7 types acquired heart disease
Pericardium
- Pericarditis (TB, S aureus )
- pericardial effusion (transudate/exudate/haemorrhagic)
Myocardium
- myocarditis (viral: Adeno, influenza, coxsackie, entero, RSV, CMV in utero )
- cardiomyopathy (restrictive/ hypertrophic/ dilated)
Endocardium
- rheumatic heart disease
- Infective endocarditis
Vascular
- vasculitis (great/medium/small arteries)
Name 3 types pericardial effusion and their causes
Transudative
- Ccf
- viral
- thyroid
Exudative
- bacterial: tb, S aureus
Haemorrhagic
- malignancy
Name and describe 3 types cardiomyopathy
- Restrictive: fibrotic, rigid muscle
- hypertrophic: grossly thickened muscle
- dilated: huge, weak heart
Name 2 acquired heart disease causes of arrhythmias
- Myocarditis
- cardiomyopathy
Arrythmias can also cause dilated cardiomyopathy
Name 3 types vasculitis and 2 causes each
Great arteries
- takayasu
- HIV
- syphilis
Medium arteries
- Kawasaki
- HIV
Small arteries
- Bacteraemia
- varicella
- HIV
Name 5 symptoms infective endocarditis
- Fever, generally low grade and intermittent
- Pallor
- anorexia and wasting
- flu like symptoms
- abdominal: RUQ pain, vomiting, appendicitis like symptoms
Name 10 signs infective endocarditis
Classic:
- petechiae
- sub- ungal splinter haemorhages
- Osler nodes
- janeway lesions
- Roth spots (retinal haemorrhages with small clear centers-rare)
Cardiac
- 85% murmurs
- cardiac failure: gallop rhythm, edema etc
- arrhythmia
- pericardial / pleural rubs
Abdomen
- splenomegaly
- Ruq pain, appendicitis like
General
- pallor, anorexia, wasting
Neuro disease (40%)
- embolic stroke with focal neurologic deficits: paralysis, hemiparesis, aphasia
- intra cerebral haemorrhage: stiff neck, delirium
- multiple micro-abscesses
- conjunctival haemorrhage
Diagnosis infective endocarditis?
Duke criteria: 2 major or 1 major 3 minor or 5 minor
Major criteria
- Positive blood cultures (typical pathogens from at least 2 separate cultures more than 12 hours apart; or 3 or more least 1 hour apart)
- Evidence endocardial involvement by echocardiography (oscillating intra-cardiac mass on valve or on supporting structures / in path of regurgitant jets/ on implanted material; myocardial abscess; partial dehiscence of prosthetic valve; new valve regurg)
Minor
- predisposition (heart condition, iv drug)
- Fever 38 or more
- microbiologic evidence (single positive blood culture for typical pathogen)
- vascular phenomena (arterial emboli , mycotic aneurysm, septic pulmonary infarcts, conjunctival haemorrhages, janeway lesions)
- echo findings consistent with endocarditis but doesn’t meet major criteria
- immunologic phenomena (glomerulonephritis, osler nodes, Roth spots, rheumatoid factor positive)
Aetiology infective endocarditis?
Turbulent blood flow through heart and super-imposed bacteremia
Name 2 types infective endocarditis
- acute: usually underlying normal heart valve with very aggressive bacteria that damage endocardium eg S aureus
- subacute: abnormal heart valves with “mild” bacteria eg strep viridans
Management infective endocarditis? (10)
- Antibiotics
→ obtain 3-5 sets blood cultures within 60 -90 minutes
→ empiric antibiotics: ampicillin + cloxacillin + gentamicin; adjust when culture’s back
→ continue 4-6 weeks! Initially 4 weeks iv. If patient is responding, last 2 weeks oral.
→ initiate anti-fungal cover if deep lines or vp shunt; immunosuppressed eg premature, oncology;
→ vancomycin (or linezolid if impaired renal function) if suspect MRSA
→ nosocomial infections: meropenem - Treat congestive heart failure
- Oxygen
- haemodialysis may be necessary in renal failure
- suspect s aureus: investigate for septic emboli to brain, kidneys, bone. May need to do whole body scan
Name 10 indications for infective endocarditis prophylaxis
High risk developing bacteremia:
- Dental procedures
- deep lines ( cv line, drains…)
- any incision into respiratory mucosa
- infected skin/muscle procedures eg abscess drain
- non-medical invasive procedures eg body piercing, tattooing
- iv drug abusers
- poor oral health: gingivitis most common source
High risk patients
- congenital heart disease with high pressure gradient lesion eg vSD, ps, as
- complex congenital cyanotic heart defects
- prosthetic heart valve
- prosthetic material eg vSD patch 6 months post op
- history of ie
- cardiac transplant patients who develop cardiac valvulopathy
Which drugs are used for infective endocarditis prophylaxis? (3)
- Amoxicillin 50 mg/kg stat 1 hour before procedure or ampicillin 50 mg/kg iv 30 min before
- erythromycin or clindamycin if penicillin allergy
- Add gentamicin 1,5 mg/kg prior to any git procedure in high risk patients
Name 10 causative organisms infective endocarditis and some differences between them.
Acute
- Staph aureus: most common! Usually acute. Risk factors = intravascular lives, cancer, diabetes, corticosteroids, alcoholism, renal failure, intravenous drugs.
- strep intermedius group
- group B streptococci: In pregnant, older with underlying disease. Usually need valve replacement.
- group A, c, G strep:
- Pseudomonas aeruginosa:
Subacute
- strep viridans: Most common cause subacute. Immunological signs.
- strep intermedius group: acute/subacute. Can actively invade tissue and form abscesses, esp CNS,
- group D strep: From git /genitourinary. 3rd most common cause. High resistance.
- nonenterococCal group d: usually underlying large bowel abnormality eg uc, polyps, cancer.
- coagulase negative S aureus: staph lugdunensis is a type, but is extremely aggressive.
- HACEK: haemophilus aphrophilus, actinobacillus actinomycetemcomitans, cardiobacterium hominis, eikenella corrodens, kingella kingae: most common gram negatives.
- fungal: mostly Candida.
Define rheumatic fever and explain pathophysiology (5)
- Immunological attack on own tissue
- From group A strep (pyógenes) throat infection
- produce antibodies against:
→ M proteins: cross react with glycoproteins in heart , joints
→ cell wall polysaccharide: cross react against cardiac valves
→ hyaluronate capsule: against human hyaluronate in joints
→ membrane antigens: smooth and cardiac muscle, dermal fibroblasts, neurons of caudate nucleus
Diagnosis rheumatic fever?
Jones criteria
Major criteria (Jones)
- Joints: poly arthritis
- ❤️: carditis
- Nodules subcutaneous
- Erythema marginatum
- Sydenham chorea
Minor criteria
- prolonged Pr interval ECG
- arthralgia
- Increased crp/ESR/wbc
- fever
- previous rf
Diagnosis = evidence of strep infection + 2 major/ 1 major 2 minor criteria.
Diagnosis group A strep throat infection? (7)
Clinical!
Symptoms
- Fever
- sore throat
- halitosis
Signs
- swollen uvula
- whitish follicles on tonsils
- red swollen tonsils, throat red
- gray furry tongue
Treatment group A strep throat infection?
- Benzathine penicillin G stat IM (best): <30kg 600 000 iu; > 30kg 1,2 milu or
- penicillin v oral (problem = compliance): 15 mg / kg / bd x 10 days before meals or
- penicillin allergy - erythromycin po x 10 days
Management acute rheumatic fever? (7)
- Antibiotics: benzathine penicillin G IM or penicillin V po (erythromycin if allergy)
- Bed rest: reduce work heart. No walking until joints normal, no cardiomegaly, normal resting pulse
- Anti-inflammatories for arthritis
- Salicylates: alleviate pain, reduce fever but no effect on value damage.
- aspirin
- steroids (predrisone): can be lifesaving in severe pancarditis bc reduce activity quickly - Monitor disease activity
- baseline: FBC, UCE, ESR, crp, ASOT (antistreptolysin o titer, test antibodies), blood culture
- weekly: FBC, UCE, ESR, crp - Manage chorea (teenage girls “clumsy” and emotional) - haloperidol, risperidore po
6 manage CCF
- supportive: bed rest semi-fowler , oxygen
- decrease preload: diuretics (furosemide, spironolactone)
- Increase contractility and function heart: inotropes - digoxin, dopamine in ICU
- decrease after load: ace inhibitors - captopril (vasodilate)
- Surgery when needed: severe valve dysfunction, intractable CCF
Name 3 broad causes pulmonary hypertension
- Increased flow to lungs: left to right shunts (Acyanotic with increased pbf) (most common)
- lung disease: from nose to alveoli
- decreased flow out of lungs: left heart disease
Name 7 causes pulmonary hypertension due to increased flow to lungs
Left to right shunts.
Acyanotic
- vSD
- ASD
- avsd
- PDA
Cyanotic with increased PBF
- TAPVD
- TGA
- Truncus arteriosus
Pathophysiology pulmonary hypertension due to increased flow to lungs
- Pulmonary artery hypertrophy - lumen smaller and smaller until close completely
- close from smallest capillaries on outskirts of lungs progressively to central proximal = “pruning” of pulmonary arterial tree (on imaging can’t see distal, prox dilated)
Name 4 causes pulmonary hypertension due to lung/airway disease
Acute
- Upper airway: croup (viral, usually parainfluenza)
- lower: ARDS, infections, volume loss
Chronic
- upper: cor pulmonale (pht causing Rh failure)
- lower: obstructions / restriction/destruction
Pathophysiology pulmonary hypertension due to lung/airway disease
Hypoxia and hypercarbia → constriction pulmonary arteries.
Will also decrease flow returning to left heart so cardiac output will drop
Name 7 causes pulmonary hypertension due to decreased flow out of lungs
Left heart obstruction
- coarctation
- aortic stenosis
- mitral stenosis and regurgitation
Left heart dysfunction
- dilated cardiomyopathy
- post-bypass
- sepsis
- Ischaemia
- hypoxia
Pathophysiology pulmonary hypertension due to decreased flow out of lungs
Blocked or reduced flow out of left heart → increase pressure La and pulmonary veins
Treatment pulmonary ht caused by increased blood flow to lungs?
- Operate heart defect!
- selective pulmonary artery vasodilators: nitric oxide, prostacyclin, sildenafil, bosentan (long term)
- decompensation PAH: aggressive combination of treatment for rv failure, pulmonary vasodilators, inotropes
Treatment pulmonary ht caused by lung/airway disease?
- Treat disease
- manage complications
Pulmonary artery vasodilators won’t help.
Treatment pulmonary ht caused by decreased blood flow out of lungs?
- Optimize LHF
- relieve lvoto by eg surgery
- valvular disease management
- support cardiac output.
Name 6 PDA dependent lesions
Cyanotic with decreased PBF
- pulmonary atresia caused by severe Ebstein anomaly
- tricuspid atresia with intact ventricular septum
- critical pulmonary stenosis
Left heart obstruction
- coarctation aorta
- critical aortic stenosis
- hypoplastic left heart syndromes
Name 3 symptoms myocarditis
- Flu like illness
- chest pain
- decrease effort tolerance
Name 8 signs cardiac tamponade
Beck’s triad
- low bp
- distended neck veins
- muffled heart sounds
- raised JvP
- dyspnoea
- cold clammy extremities
- edema, ascites
- pulsus paradoxus (bp drop >10mm with inspiration)
Name sign constrictive pericarditis
- kussmaul sign: paradoxical increase venous distension on inspiration
Name 4 causes Cardiac tamponade
- Metabolic
- Infective
- fluid overload
- tumours
Characteristic clinical sign TOF
Squatting
3 Symptoms 5 signs supraventricular tachycardia?
Symptoms
- Irritable
- lethargy
- vomiting
Signs
- dyspnoea
- mottling + peripheral cyanosis
- tachycardia
- CCF
- myopathic lv if longstanding
Treatment supraventricular tachycardia? (7)
- Correct electrolyte imbalances, hypoxia, acidosis
- check perfusion/bp
- vagal maneuvers: cough, ice on forehead, immerse face in cold water,
- carotid massage
- drugs in stable patient: adenosine, best via CvP , 100 ug / kg then 200,300
- cardiovert in unstable: 2j/kg
- overdrive pacing: atrial in cath lab
Name 4 cause complete heart block?
Congenital
- isolated: maternal autoimmune disease (sle)
- complex CHD: avSD, corrected TGA
Acquired
- myocarditis
- Post cardiac surgery
3 Symptoms 5 signs complete heart block?
Symptoms
- bradycardia
- syncope
Signs
- CCF signs if hr<50 neonates: hepatomegaly
- hypotension
RX = pacemaker
Name 6 symptoms Kawasaki disease
Warm cream,
- warm: fever - 5 days
- conjunctivitis bilateral non-puralent
- rash erythematous maculopopular
- erythema hands and soles
- adenopathy unilateral, cervical
- mucous membranes: red mouth and tongue
Define functional systolic murmur
Mid systole
Grade 3/6 or less
Identify picture 25
Atrial flutter
Normal saturations of the heart chambers? (8)
La: 100%
Lv: 100%
Aorta: 100%
Ra: 70%
Rv: 70%
SVC: 75%
IVC: 70%
Pulmonary trunk: 70%
Treatment Kawasaki disease?
Polygam (immunoglobulin) 2g/kg iv over 12 hours (boosts immune system)
Identify picture 26
Kawasaki disease
- erythematous rash and fever
- Red mouth and tongue
- swelling hands and feet
- red conjunctivitis
Prophylaxis in child with established rheumatic fever to prevent recurrence?
Benzathine penicillin IM every 3 weeks
