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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
Mitral valve replacement findings
Closing click (S1), short mid diastolic flow murmur, may have signs of pulmonary HTN (chrinic MS/MR)
26
Indications for mitral valve replacement in MS and MR
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
Indications for aortic valve replacement in AS
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
Mitral regurgitation features
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
Causes of mitral regurgitation
Primary - Infective: Rheumatic fever, IE - Congenital - Degenerative - MVP Secondary - Papillary muscle ischemia - Dilated Cardiomyopathy - Chordae tendinae rupture (Acute MR) Functional MR - LV dilatation
30
Features of tricuspid regurgitation
Systolic V waves Parasternal systolic thrill Parasternal heave Pansystolic murmur radiating to axilla, increased with inspiration Pulsatile hepatomegal;y
31
Features of aortic regurgitation
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
Causes of a water hammer pulse
Hyperdynamic states: - anemia - thyrotoxicosis - pregnancy - fever - severe HTN Cardiac lesions - AR - AV fistula - PDA - severe MR
33
Features of tricuspid regurgitation
Pan systolic murmur, louder on inspiration (Carvallo's sign) Giant V waves Pulmonary HTN features
34
Causes of tricuspid regurgitation
Primary - pulmonary HTN - right heart failure Secondary - rheumatic - IE - Ebsteins anomaly - Tricuspid valve prolapse - RV papillary muscle infarct - Trauma - Carcinoid syndrome
35
Features of mitral valve prolapse
Loudest at lower LSE Mid-systolic click followed by late systolic crescendo-decrescendo murmur Shortened by handgrip, prolonged by valsalva/standing AF
36
Causes of mitral prolapse
Congeinital CTD - Marfans syndrome, Ehlers Danlos, Pseudoxanthoma elasticum, Osteogenesis imperfecta PCKD SLE
37
Which waves of the JVP are visible in normal subjects?
A wave - atrial contraction V wave - passive filling of right atrium againsst a closed tricuspid valve
38
VSD features
Parasternal thrill Harsh pansystolic murmur loudest at LSE increased by hand grip Volume loaded apex +/- pulmonary HTN features +/- LV dilation/failure
39
Features of severity in VSD
Soft murmur Volume loaded apex beat Pulmonary HTN with loud P2 OR shunt reversal (right to left shunt)
40
Features of Eisenmengers syndrome (R to L shunt in VSD or ASD)
Clubbing Cyanosis No murmur Volume loaded apex beat Pulmonary HTN with loud S2
41
Indications for surgical VSD closure Contraindications?
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
Features of atrial septal defect
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
Features suggesting haemodynamic significance of ASD murmur
Systolic thrill AF ESM TV flow murmur (mid diastolic rumble LSE) Pulmonary HTN OR shunt reversal (Eisenmengers)
44
Causes of a widely split S2
Fixed: - ASD Physiologic (increased on inspiration) - VSD - MR - Pulmonary stenosis - RBBB ``` Paradoxical split (increased on expiration) - severe aortic stenosis ```
45
HOCM
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
Impact of valsalva Impact of handgrip Impact of squatting
``` Valsalva = decreased preload Handgrip = increased after load Squatting = increased preload ```
47
Indications for AVR in aortic regurgitation
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
Indications for valve replacement in MR
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
What is Kussmaul's sign Causes?
Paradoxical increase in JVP during inspiration Tricuspid stenosis Cor pulmonale Constrictive pericarditis
50
How do you differentiate between group 2 pulmonary hypertension and group 1, 3 and 4? Group 5?
``` 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
Signs of severity aortic regurg
Wide pulse pressure Collapsing pulse Length of murmur Volume loaded apex + S3 (dilated LV) Soft A2 Austin flint LVF
52
ECG findings right heart strain
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
ECG findings left heart strain
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
Name the labels
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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