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Clinical exam > CVS SC > Flashcards

CVS SC Flashcards

1
Q

Pressure loaded apex beat and 2 causes

A

Sustained forceful apex beat

Aortic stenosis, HOCM

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2
Q

Volume loaded apex beat, cause

A

Unsustained forceful apex beat, felt over larger area

Mitral regurgitation, aortic regurgitation

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3
Q

Tapping apex beat

A

Mitral stenosis

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4
Q

Bisferiens carotid pulse

A

Two peaks in carotid pulsation

Aortic regurgitation, HOCM, mixed AR/AS

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5
Q

Signs of severity in aortic stenosis (11)

A

Low volume pulse

Slow rising, plateau carotid pulse

Narrow pulse pressure

Pressure loaded apex beat

Aortic thrill

Long late peaking ejection systolic murmur.

S4 (reduced compliance of LV)

Paradoxical splitting of S2

Soft A2

LV failure

Pulmonary HTN

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6
Q

Co-morbid lesions associated with mitral regurgitation

A

TR + pulmonary HTN

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7
Q

Indicators of MR severity

A

Peripheral:
- Small pulse volume (very severe mitral regurgitation)

Palpation:

  • LV dilatation with volume loaded diskinetic apex beat
  • Apical thrill

Heart sounds:

  • S3
  • Split S2
  • soft S1
  • early diastolic rumble

Complications:

  • LV failure/pulmonary congestion
  • Pulmonary HTN (loud S2, palpable P2, RV failure)
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8
Q

JVP waveform in TR

A

Prominent V wave, rapid Y descent

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9
Q

Causes of aortic regurgitation

A

Valve pathologies:

  • Rheumatic heart disease (although unlikely in isolated aortic regurgitation).
  • degenerative (HTN)
  • Congenital +/- VSD
  • IE

Aortic root pathologies:

  • Aortic root dilation
  • Ankylosing spondylitis.
  • Syphilitic aortitis.
  • Marfan’s syndrome.
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10
Q

Indicators of severity in AR

A

Wide pulse pressure

Collapsing pulse

Long decrescendo diastolic murmur

LV dilation - S3, volume loaded apex

Soft A2.

Austin-Flint murmur (mid-diastolic murmur at the apex)

LV failure

Pulmonary HTN

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11
Q

Indicators of severity in MS

A

Peripheral:
- Narrow pulse pressure

Palpation:
- Apical diastolic thrill

Auscultation:

  • Opening snap close to S2
  • Long diastolic murmur
  • Graham steele murmur (PR; early diastolic murmur)

Complications:

  • Pulmonary hypertension.
  • Pulmonary congestion
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12
Q

Effect of sustained hand grip on AS, MR and HOCM

A

Increases MR, AR and VSD
Decreases AS + HOCM

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13
Q

Murmurs louder with valsalva

A

HOCM (softer with hand grip - reduced preload)
Mitral valve prolapse

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14
Q

Signs in ASD

A

Parasternal heave (RV dilatation)

Pulmonary ESM flow murmur (due to increased flow across pulmonary valve)

Fixed splitting of S2.

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15
Q

Graham steel murmur

A

Pulmonary regurgitation
- diastolic murmur heard in pulmonary region

Differentiate from AR: increases with inspiration

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16
Q

Aortic stenosis features

A

Slow rising low volume pulse
Narrow pulse pressure (<25% systolic)
Heaving pressure loaded apex beat
Systolic thrill
Soft S2 (A2) with reversed splitting
S4
Harsh ESM radiating to carotids increased on expiration, softened with hand grip and valsalva

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17
Q

Causes of aortic stenosis (8)

A

Degenerative

Congenital

  • Bicuspid aortic valve
  • congenital
  • coarctation aorta (turners)

Infective

  • Rheumatic heart disease
  • Infective endocarditis

Metaboloc

  • Hyperuricemia
  • Pagets disease
  • Alkaptonuria
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18
Q

Definition of aortic stenosis

A

Aortic area <1.5; severe <1.0
Gradient >40mmhg

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19
Q

Features of mitral stenosis

A

Loudest at the apex
Malar flush
Tapping apex beat
Loud S1
Opening snap in mid diastole
Mid diastolic rumble louder on expiration in left lateral position

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20
Q

Causes of mitral stenosis (8)

A

Infective:

  • Rheumatic heart disease
  • Whipples disease

CTD
- SLE

Calcification of the valve
Congenital mitral stenosis

Fabrys disease
Carcinoid syndrome
Mucopolysaccharidoses

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21
Q

Differential of a mid diastolic rumble (4)

A

Left atrial myxoma or thrombus
Mitral stenosis
Triscuspid stenosis
Severe mitral regurgitation

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22
Q

Definition of mitral stenosis

A

Mitral area <2.5cm
Moderate 1-1.5
Severe <1.0

23
Q

What are the indications for anticoagulation in MS? Which agent

A

Valve area <1.5cm and one or more of:

  • AF
  • previous emboli
  • LA thrombus
24
Q

Aortic valve replacement findings

A

Opening “click” (S1, heard in Starr-Edwards valves), ESM, closing “click” (S2)

25
Q

Mitral valve replacement findings

A

Closing click (S1), short mid diastolic flow murmur, may have signs of pulmonary HTN (chrinic MS/MR)

26
Q

Indications for mitral valve replacement in MS and MR

A

MS +
- symptomatic severe (1.5)

chronic primary severe MR +

  • NYHA III sx despite medical Tx, LV dysfunction and EF >30%
  • asymptomatic with LVEF 30-60, and/or LVESD >40
27
Q

Indications for aortic valve replacement in AS

A

Symptomatic severe AS
Asymptomatic mod-severe AS undergoing other cardiac surgery
Asymptomatic severe AS and 1 of:
- LV dysfunction
- VT
- abnormal BP response to exercise
- valve area <0.6

28
Q

Mitral regurgitation features

A

Volume loaded apex beat
Systolic thrill
Soft S1
Wide split S2
S3, may also have S4
Pansystolic murmur at the apex, loudest in expiration radiating to axilla increased by handgrip

+/- signs of pulmonary HTN

29
Q

Causes of mitral regurgitation

A

Primary

  • Infective: Rheumatic fever, IE
  • Congenital
  • Degenerative
  • MVP

Secondary

  • Papillary muscle ischemia
  • Dilated Cardiomyopathy
  • Chordae tendinae rupture (Acute MR)

Functional MR
- LV dilatation

30
Q

Features of tricuspid regurgitation

A

Systolic V waves
Parasternal systolic thrill
Parasternal heave
Pansystolic murmur radiating to axilla, increased with inspiration
Pulsatile hepatomegal;y

31
Q

Features of aortic regurgitation

A

Water hammer pulse

Corrigans sign (visible carotid pulsations in the neck)

Quinke’s sign (fingernail capillary pulsations)

De Mussets sign (head nodding with each heart beat)

Mullers sign (systolic pulsations of the uvula)

Displaced volume loaded apex beat

Early high pitched decrescendo diastolic murmur at LSE, increased with expiration and leaning forward

“Austin flint” murmur - low pitched mid diastolic murmur combined with early high pitched diastolic murmur

May have an ejection systolic flow murmur

32
Q

Causes of a water hammer pulse

A

Hyperdynamic states:

  • anemia
  • thyrotoxicosis
  • pregnancy
  • fever
  • severe HTN

Cardiac lesions

  • AR
  • AV fistula
  • PDA
  • severe MR
33
Q

Features of tricuspid regurgitation

A

Pan systolic murmur, louder on inspiration (Carvallo’s sign)
Giant V waves
Pulmonary HTN features

34
Q

Causes of tricuspid regurgitation

A

Primary

  • pulmonary HTN
  • right heart failure

Secondary

  • rheumatic
  • IE
  • Ebsteins anomaly
  • Tricuspid valve prolapse
  • RV papillary muscle infarct
  • Trauma
  • Carcinoid syndrome
35
Q

Features of mitral valve prolapse

A

Loudest at lower LSE
Mid-systolic click followed by late systolic crescendo-decrescendo murmur
Shortened by handgrip, prolonged by valsalva/standing
AF

36
Q

Causes of mitral prolapse

A

Congeinital
CTD - Marfans syndrome, Ehlers Danlos, Pseudoxanthoma elasticum, Osteogenesis imperfecta
PCKD
SLE

37
Q

Which waves of the JVP are visible in normal subjects?

A

A wave - atrial contraction
V wave - passive filling of right atrium againsst a closed tricuspid valve

38
Q

VSD features

A

Parasternal thrill
Harsh pansystolic murmur loudest at LSE increased by hand grip
Volume loaded apex

+/- pulmonary HTN features +/- LV dilation/failure

39
Q

Features of severity in VSD

A

Soft murmur
Volume loaded apex beat
Pulmonary HTN with loud P2

OR shunt reversal (right to left shunt)

40
Q

Features of Eisenmengers syndrome (R to L shunt in VSD or ASD)

A

Clubbing
Cyanosis
No murmur
Volume loaded apex beat
Pulmonary HTN with loud S2

41
Q

Indications for surgical VSD closure

Contraindications?

A

Increasing pulmonary:systemic blood flow (Qp:Qs >2:1)
LV dilation
LV dysfunction
Recurrent endocarditis
Aortic regurgitation due to prolapse of R. coronary cusp
Rupture of interventricular septum

C/I: Irreversible severe pulmonary HTN

42
Q

Features of atrial septal defect

A

Systolic thrill at upper LSE
Fixed wide split of S2
Ejection click and ESM at upper left sternal edge
Short mid diastolic murmur (TV flow murmur)

+/- features of pulmonary HTN

43
Q

Features suggesting haemodynamic significance of ASD murmur

A

Systolic thrill
AF
ESM
TV flow murmur (mid diastolic rumble LSE)
Pulmonary HTN

OR shunt reversal (Eisenmengers)

44
Q

Causes of a widely split S2

A

Fixed:
- ASD

Physiologic (increased on inspiration)

  • VSD
  • MR
  • Pulmonary stenosis
  • RBBB
Paradoxical split (increased on expiration)
- severe aortic stenosis
45
Q

HOCM

A

JVP: Prominent a wave

Palpation: Double or triple impulse apex, pressure loaded apex

Auscultation: Late systolic murmur LSE (LVOT obstruction), Pan systolic murmur at the apex (MR), S4

Dynamic: Increased with Valsalva, Decreases with Stand to squatting and Handgrip

46
Q

Impact of valsalva
Impact of handgrip
Impact of squatting

A 
Valsalva = decreased preload 
Handgrip = increased after load 
Squatting = increased preload
47
Q

Indications for AVR in aortic regurgitation

A

Symptomatic severe AR
Asymptomatic mod-severe AR undergoing other cardiac surgery
Asymptomatic AR + LV dysfunction (<50%) or dilated LV
Infective endocarditis failed medical therapy
Enlarging arotic root diameter (>50mm)
Acute severe AR

48
Q

Indications for valve replacement in MR

A

Acute severe MR

Primary chronic severe MR with:

  • NYHA III/IV sx despite medical Tx + LV dysfunction (EF >30%)
  • no symptoms + LVEF 30-60% and/or LVESD >45

Consider if chromic primary severe + LVEF <30% + high chance successful repair

49
Q

What is Kussmaul’s sign

Causes?

A

Paradoxical increase in JVP during inspiration

Tricuspid stenosis
Cor pulmonale
Constrictive pericarditis

50
Q

How do you differentiate between group 2 pulmonary hypertension and group 1, 3 and 4?

Group 5?

A 
Group 2 (post capillary) = PCWP \>15mmhg, PVR \<3WU 
Group 1, 3 and 4 (pre capillary) = PAWP ​​≤15mmhg, PVR ≥3 WU

Group 5 (mixed) = can be pre-capillary, post-capillary or combined (PAWP >15mmhg, PVR >3WU)

51
Q

Signs of severity aortic regurg

A

Wide pulse pressure
Collapsing pulse
Length of murmur
Volume loaded apex + S3 (dilated LV)
Soft A2
Austin flint
LVF

52
Q

ECG findings right heart strain

A

ST depression and T wave inversion in anterior leads (V1 - V4, II, III, avF)

R axis deviation

Dominant R wave (V1)

Dominant S wave (V5, V6)

+/- P pulmonale due to RA enlargement (p wave >2.5mm II/III/avF, >1.5mm V1

53
Q

ECG findings left heart strain

A

ST depression and T wave inversion L heart (lateral) leads (1, aVL, V5, V6)

LV Hypertrophy voltage criteria
- S wave in V1 + R wave V5/6 greater than 7 squares (35mm)

+/- P mitrale due to LA enlargement

54
Q

Name the labels

A
  1. SVC
  2. Right atrium
  3. IVC
  4. Aortic arch
  5. Main pulmonary artery
  6. L atrial appendage
  7. L ventricle

Clinical exam (15 decks)

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