Important cardiovascular presentations Flashcards
Symptoms of mitral stenosis
Dyspnoea.
Reduced exercise tolerance.
Cough productive of frothy (pink?) sputum.
Palpitations (often associated with AF and resultant emboli).
Dysphagia (oesophagus compressed by enlarge left atrium).
Signs of mitral stenosis
Palmar erythema. Malar flush. 'Tapping' apex beat. Left parasternal heave. Giant v waves in JVP. Loud S1. High-pitched early-diastolic (Graham Steell) murmur ± opening snap.
Symptoms of mitral regurgitation
Acute dyspnoea.
Pulmonary congestion.
Signs of mitral regurgitation
Thrusting apex beat displaced to the left (volume overload).
Possible systolic thrill over the apex.
Soft S1.
Loud S2 (pulmonary component).
Pansystolic murmur heard at the apex radiating to left axilla (best heard in the left lateral position) ± mid-systolic click.
Signs of decompensation in mitral regurgitation
Small volume pulse. Raised JVP. Displaced thrusting apex with a systolic thrill. Left parasternal heave. 3rd heart sound (ken-tuc-ky). Mid-diastolic flow murmur. Bibasal crackles. Peripheral oedema.
Mitral prolapse: overview
Displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole, mimicking and leading to mitral regurgitation.
Occurs in ~5% of the population.
More common in females.
Signs of mitral prolapse
Mid-systolic click.
Late systolic murmur heard best at the apex.
Squatting delays the click and standing increases the murmur.
Symptoms of aortic stenosis
Angina.
Syncope.
Dyspnoea.
Sudden death.
Signs of aortic stenosis
Small volume slow rising pulse (‘pulsus tardus et parvus’).
Narrow pulse pressure.
Sustained and powerful apex beat (displaced if ventricular dysfunction and dilatation present).
Ejection systolic (crescendo-decrescendo) murmur heard at the left sternal edge and (loudest leaning forward at end-expiration) radiating to carotids.
Soft S2.
Signs of decompensation in aortic stenosis
Raised JVP. Left parasternal heave. Gallop rhythm. Bibasal crackles. Peripheral oedema.
Symptoms of aortic regurgitation
Similar to aortic stenosis: Angina. Syncope. Dyspnoea. Sudden death.
Signs of aortic regurgitation
Large volume ‘collapsing’ pulse which is exaggerated at the radial artery if you hold the patient’s arm up (‘waterhammer’ pulse).
Wide pulse pressure.
Sustained and displaced apex beat.
Soft S2.
Early diastolic murmur at the left sternal edge (often described as ‘blowing’ or decrescendo).
May also hear ‘pistol shot’ sound over the femoral artery with severe aortic regurgitation.
Tricuspid stenosis: overview
Usually occurs along with mitral or aortic valvular disease (e.g. in rheumatic fever) and is often the less serious of the patient’s problems.
Signs of tricuspid stenosis
Auscultation similar to that of mitral stenosis.
Hepatomegaly.
Pulsatile liver.
Venous congestion.
Signs of tricuspid regurgitation
Dilated neck veins. Prominent v wave in JVP. Pansystolic murmur louder on inspiration with a loud pulmonary component of S2. Left parasternal heave. Pulsatile liver. Peripheral and sacral oedema. Ascites.
Signs of pulmonary stenosis
Normal pulse with an ejection systolic murmur radiating to lung fields often with a palpable thrill over the pulmonary area.
Other signs of right heart strain or failure.
Signs of pulmonary regurgitation
Loud S2 which may be palpable.
Early diastolic murmur heard at the pulmonary area and high at the left sternal edge.
Symptoms of large ventricular septal defect
Infant with breathlessness, poor feeding, and failure to thrive.
Signs of large ventricular septal defect
As the pulmonary vascular resistance falls, a large defect may present with cardiac failure in the first few months of life.
Associated features include low volume pulse, mid-diastolic murmur due to high flow through the mitral valve.
Symptoms of small ventricular septal defect
Usually asymptomatic and called ‘Maladie de Roger’.
Signs of small ventricular septal defect
Normal pulse.
Normal JVP.
Harsh pansystolic murmur at the lower left sternal edge.
No evidence of decompensation.
Atrial septal defect: overview and variants
The commonest congenital lesion and often an asymptomatic finding discovered on investigating a murmur.
Ostium primum: 15% of cases may be associated with mitral and tricuspid regurgitation or a VSD. Usually identified early in childhood, associated with congenital syndromes (Down’s, Noonan’s, Klinefelter’s). ECG shows RBBB with left axis deviation.
Ostium secondum: 70% of cases. Usually central fossa ovalis defects, occasionally associated with mitral valve prolapse, ECG shows RBBB with right axis deviation.
Sinus venosus: 15% of cases. Defect in upper septum involving inflow from SVC or IVC, associated with defects of pulmonary drainage.
Symptoms of primum atrial septal defect
Symptoms of heart failure in childhood with failure to thrive, chest infections, and poor development.
In adults, there may be syncope (heart block), and symptoms of endocarditis.
Symptoms of secondum atrial septal defect
Asymptomatic if small.
Fatigue, dyspnoea, palpitations (atrial arrhythmias), recurrent pulmonary infections, right heart failure.
Also migraine and paradoxical emboli.
Signs of atrial septal defect
Irregularly irregular pulse (AF).
Apex beat undisplaced and palpable.
Fixed splitting of S2.
Ejection systolic murmur at upper left sternal edge.
Atrial septal defect: Halt-Oram syndrome
Triphalangeal thumb/ other upper limb anomalies associated with ASD. Autosomal dominant (incomplete penetrance).
Signs of atrial septal defect if haemodynamically significant
Irregularly irregular pulse (AF). Apex beat displaced laterally. Left parasternal heave (RV overload). Systolic thrill over the pulmonary area. Wide fixed splitting of S2. Ejection systolic murmur in the pulmonary area with ejection click (pulmonary artery dilatation). Mid-diastolic rumble over tricuspid area (increased flow through the tricuspid valve from the large left-to-right shunt). Pulmonary regurgitation.
Patent ductus arteriosus: overview
A persistent embryonic connection between the pulmonary artery and the aorta.
Blood flows from the aorta into the pulmonary artery.
Symptoms of patent ductus arteriosus
Often asymptomatic.
Severe cases = dyspnoea on exertion.
Signs of patent ductus arteriosus
Bounding pulse.
Wide pulse pressure.
Displaced heaving apex beat.
‘Machinery’ (continuous) murmur heard all over the precordium.
S2 not heard.
Systolic or diastolic thrill in the 2nd intercostal space on the left.
Coarctation of the aorta: overview
A congenital narrowing of the aorta at or beyond the arch.
Symptoms of coarctation of the aorta
Usually asymptomatic.
May include headache, epistaxis, dizziness, and palpitations.
Claudication and leg fatigue are also features.
The coarctation may also cause the heart to strain and give symptoms of congestive cardiac failure.
Signs of coarctation of the aorta
Large volume radial pulse.
Radio-radial or radio-femoral delay.
Blood pressure discrepancy between upper and lower limbs.
Superficial collateral vessels on the chest wall.
‘Heaving’ undisplayed apex beat.
Thrill over the collaterals and in the suprasternal notch.
Systolic or continuous murmur heard in the left infraclavicular area anteriorly and the left infra scapular area posteriorly.
Weak femoral pulses.
May also have underdeveloped limbs.
Coarctation of the aorta: signs after surgical correction
Left thoracotomy scar. Normal right radial pulse. Weak left radial pulse. Normal heart sounds. No radio-femoral delay.
Causes of pericarditis
Collagen diseases.
TB.
Post-infarction.
Idiopathic.
Symptoms of acute pericarditis
Constant retrosternal ‘soreness’.
Worse on inspiration (pleuritic).
Relieved slightly by sitting forwards.
Not related to movement or exertion.
Signs of chronic or constrictive pericarditis
Kussmaul's sign.
Impalpable apex beat.
S3.
Hepatomegaly.
Splenomegaly.
Ascites ('pseudo-cirrhosis').Signs of pericardial effusion
Pulsus paradoxus. Raised JVP. Impalpable apex beat. Soft heart sounds. Hepatomegaly. Ascites. Peripheral oedema.
Infective endocarditis: overview
Bacteraemia can follow a wide range of events including dental work, brushing teeth, IV drug use, iatrogenic.
Symptoms of infective endocarditis
Malaise. Lethargy. Fevers. Anorexia. Weight loss. Myalgia. Arthralgia. Heart failure. Embolic stroke.
Signs of infective endocarditis
Pyrexia.
Petechial rash.
Splinter haemorrhages.
Osler nodes (small, red/purple, raised, tender lesions often on finger pulps).
Janeway lesions (irregular, flat, red, non-tender macules on palmar aspect of hands/feet).
Roth spots (‘cotton wool’ spots on the retina).
Digital infarcts.
Digital clubbing.
Murmur.
Hepatosplenomegaly.
Symptoms of hypertrophic cardiomyopathy
Can present with sudden cardiac death.
Otherwise usually asymptomatic.
If outflow obstruction: dyspnoea, reduced exercise tolerance, palpitations, syncope, chest pain.
Signs of hypertrophic cardiomyopathy
‘Jerky’ peripheral pulse with a steep upstroke.
‘a’ wave seen at JVP.
Forceful apex beat.
Ejection systolic murmur at the left sternal edge radiating to the axilla (does not radiate to the neck) and increases in intensity on Valsalva.
4th heart sound in some cases.
Poor prognostic factors of hypertrophic cardiomyopathy
Young age at diagnosis.
FHx of sudden death.
Syncopal symptoms.
Ventricular arrhythmias documented on ambulatory monitoring.
Congestive heart failure: overview
The inability of the heart to maintain an adequate cardiac output for perfusion of vital organs with variable severity.
Left or right heart failure, but usually an element of both (biventricular).
Symptoms of left ventricular failure
Shortness of breath on exertion. Orthopnoea. Paroxysmal nocturnal dyspnoea. Cough with pink frothy sputum. Fatigue. Weight loss. Muscle wasting. Anorexia.
Symptoms of right ventricular failure
Peripheral oedema. Facial swelling. Shortness of breath on exertion. Orthopnoea. Paroxysmal nocturnal dyspnoea. Cough with pink frothy sputum. Fatigue. Weight loss. Muscle wasting. Anorexia.
Signs of left ventricular failure
May appear tired. Pale. Sweaty. Clammy. Tachycardia. Thready pulse. Low blood pressure. Narrow pulse pressure. Displaced apex beat (murmur of an underlying valvular abnormality?). 3rd and 4th heart sounds. Tachypnoea. Crepitations at the lung bases.
Signs of right ventricular failure
Raised JVP. Hepatomegaly. Ascites. Peripheral (sacral?) oedema. Pulsatile liver (if tricuspid regurgitation). May appear tired. Pale. Sweaty. Clammy. Tachycardia. Thready pulse. Low blood pressure. Narrow pulse pressure. Displaced apex beat (murmur of an underlying valvular abnormality?). 3rd and 4th heart sounds. Tachypnoea. Crepitations at the lung bases.
Subclavian steal syndrome: overview
Subclavian steal phenomenon is flow reversal in the left vertebral artery due to left subclavian artery occlusive disease proximal to the origin of the vertebral artery.
If associated with transient neurological symptoms due to cerebral ischaemia, it becomes the syndrome.
Symptoms of subclavian steal syndrome
Exercising the left arm produces muscle cramping, dizziness, vertigo, dysarthria, syncope, diplopia, nystagmus.
Signs of subclavian steal syndrome
Evidence of left upper limb ischaemia (pallor, cyanosis, ulcers).
Left radial and brachial pulses weak.
Reduced systolic blood pressure in the left arm.
Supraclavicular bruit on the left.
Symptoms of DVT
Calf pain.
Swelling.
Loss of use.
Signs of DVT
Warm. Tense. Swollen limb. Erythema. Dilated superficial veins. Cyanosis. Palpable thrombus in the deep veins. Pain on palpation of calf.
