Integrated Evidence Based Approach to Specific Cardiac Disorders Flashcards
What is the Framingham criteria
used in HF diagnosis with reduced EF
only modest sensitivity and specificity
Compared to 3 or more symptoms of S3, tachycardia, elevated JVP, low pulse pressure, rales, ajr sign - 90%
when is HF most likely to be preserved
female, older, increased BMI
PP is determined by
stroke volume
vascular stiffness
(can be used to assess Cardiac output)
PP equation
(systolic -diastolic) / systolic
correlates well with cardiac index, stroke volume index, inverse systemic vascular resistance
if PP is lower than 25%, cardiac index is
less than 2.2 L/min/m2 in 91% of patients
if PP is greater than 25% , cardiac index is
greater than 2.2 L/min/m2 in 83% of patients
using oxygen as indicator, how to assess cardiac output?
a time from breath to hold to nadir of finger oximetry of greater than 34 seconds has been associated with Cardiac output < 4 L/min
TRUE or FALSE - Heart rate is also a powerful indicator of prognosis in HF
True , greater than 70 to 75 bpm is an independent predictor of mortality
Explain dysautonomia in HF
an attenuated HR increase with immediate standing (= 3 bpm); associated with death and Hospitalization;
simplest finding to elicit pleural effusion (LR 8.7)
Dullness to percussion
Absence of such makes pleural effusion less likely (LR 0.21)
Absence of reduced vocal fremitus
Signs suggesting severe mitral stenosis
1 long or holodiastolic murmur - indicating a persistent LA -LV gradient
2 short A2 OS interval -consistent with higher LA pressures
3 a loud P2 (or single S2) and or RV lift - suggestive of pulmonary hpn
4 elevated JVP with CV waves , hepatomegaly and lower ext edema - signs of right HF
xintensity of diastolic murmur
x presystolic accentuation
Findings that suggest chronic severe MR:
1 enlarged, displaced, but dynamic LV apex beat
2 apical systolic thrill (grade 4 or greater)
3 mid-diastolic filling complex comprising of S3 and a short, low-pitched murmur - accelerated and enhanced diastolic mitral inflow
4 wide but physiologic splitting of S2 caused by early aortic valve closure
5 loud P2 or RV lift
Findings with MVP
combination of non-ejection click and mid to late systolic murmur predicts MVP best (LR 2.43)
The following findings help gauge the severity of aortic stenosis
1 slowly rising carotid upstroke (pulsus tardus)
2 reduced carotid stroke amplitude (pulsus parvus)
3 reduced intensity of A2 and mid-to late peaking of the systolic murmur
x intensity of murmur
May independently predict outcome for severe aortic stenosis
reduced carotid upstroke amplitude
to differentiate with aortic sclerosis (older pxs with hypertension)
TTE
in aortic sclerosis - no valve dysfunction, carotid upstroke normal, A2 preserved, no LV hypertrophy
Differential diagnosis of systolic murmur related to LVOT obstruction
1 valvular aortic stenosis
2 hocm
3 DMSS
4 SVAS
Presence of ejection sound in systolic murmur
valvular cause
How can HOCM be distinguished with AS
Response of murmur to Valsalva and standing or squatting
Will usualy have a diastolic murmur indicative of AR but not an ejection sound
Discrete membranous subaortic stenosis
Right arm BP is more than 10 mmHg greater than the left arm BP
Supravalvular Aortic stenosis
Signs of Aortic Regurgitation
pulmonary edema and signs of low forward CO
Tachycardia invariably present
Systolic BP NOT elevated
PP not widened
S1 soft due to premature closure of mitral valve
Symptoms of chronic, severe AR include
dyspnea, fatigue, chest discomfort and palpitations
True or false. The absence of diastolic murmur significantly reduces the likelihood of moderate or greater AR.
True. LR 0.1
The presence of typical diastolic murmur increases the likelihood of moderate or greater AR (LR 4.0 to 8.3)
T or F
The intensity of murmur correlates with the severity of the lesion in AR.
T
Grade 3 diastolic murmur has an LR of 4.5 (severe AR vs mild/moderate AR)
Austin flint murmur on studies?
Hill sign?
Data conflict regarding significance of Austin flint Hill sign (Brachial popliteal systolic bp gradient >20 mmHg has moderate sensitivity of 89% - although its supporting evidence base is also weak)
Symptoms and signs suggesting Tricuspid stenosis
elevated JVP with delayed y descent
abdominal ascites
edema
Symptoms and signs suggesting Tricuspid Regurgitation
elevated jvp with prominent CV waves, parasternal lift, pulsatilve liver, ascites and edema
Explain Carvallo sign
the intensity in the holosystolic murmur of TR increases with inspiration
Denotes severe obstruction in Pulmonic stenosis
Syncope
Other symptoms: fatigue, dyspnea, lightheadedness, chest discomfort (right ventricular angina)
Describe the murmur in Pulmonic stenosis
it is a midsystolic murmur best heard at left 2nd ICS
Signs of severe pulmonic stenosis
interval between S1 and pulmonic ejection sound narrows
murmur peaks late systole and may extend beyond A2;
P2 becomes inaudible
Signs of significant RV pressure overload include
prominent jugular venous a wave and parasternal lift
It occurs most often as a secondary manifestation of significant PA hypertension and annular dilatation.
Pulmonic regurgitation.
May also be primary valve disorder - congenital bicuspid valve) or as a complication of RVOT surgery
Differentiate PR murmur with AR
The diastolic murmur secondary to PR (Graham steell) increases intensity with inspiration, it has a later onset (after A2 and with P2), it also has lower pitch
Typical murmur of PR increases the likelihood by
LR 17 but the absecne of murmur does not exclude it`
Differential diagnosis of functional limitation after valve replacement
prostethic valve dysfunction
arrhythmia
impaired ventricular dysfunction
Causes of prostethic valve dysfunction
thrombosis
pannus ingrowth
infection
structural deterioration
First clue suggesting valve dysfunction
change in quality of heart sounds or appearance of a new murmur
murmur of bioprosthesis in the mitral position
mid systolic (from turbulence created by systolic flow across valve struts that project into LVOT) and soft mid diastolic murmur that occurs with normal LV filling (only heard in left lateral decubitus at the apex)
A high-pitched or holosystolic apical murmur signifies
para-or transvalvular regurgitation that requires echocardiographic verification and careful ffup evaluation
A bioprosthesis in the aortic position is invariably associated with what murmur
midsystolic murmur at base of grade 3 or less intensity
A diastolic murmur of AR is abnormal
Indicates paravalvular regurgitation or prosthetic dysfunction in mitral/aortic prosthesis
mitral - high pitched apical systolic murmur
aortic - decrescendo diastolic murmur
signs of hemolysis should be sought
signs of px with prosthetic valve thrombosis
shock, muffled heart sounds, soft murmurs
Associated with increase in intensity of systolic murmur & other signs of prosthetic valve stenosis
Pannus ingrowth
Clinical findings of high risk of short term death or MI in NSTEMI
age older than 75 tachycardia hypotension signs of pulmonary congestion new or worsening murmur of MR
Radiation to trapezius ridge
Pericarditis
T or F
A pericardial friction rub is almost 100% specific for pericarditis
T - specific
sensitivity not as high because the rub may wax and wane over the course of illness
ECG changes in pericarditis
concave upward ST elevation
PR segment deviation
elevation in lead aVR, depression in lead II
WHen does pericardial tamponade occur
when intrapericardial pressure equals or exceeds the RA pressure
Most common associated symptom in pericardial tamponade
dyspnea (sensitivity 87-88%)
Hypotension (sensitivity 26%)
muffled heart sounds (sensitivity 28%)
Pulsus paradoxus greater than 12 mmHg in a px with large pericardial effusion predicts tamponade with sensi of 98% and specificity of 83%, LR 5.9
Causes of constrictive pericarditis
Previous chest irradiation
cardiac or mediastinal surgery
chronic tuberculosis
malignancy
CLinical presentation of constrictive pericarditis
Dyspnea, fatigue, weight gain, abdominal bloating , leg swelling
Waveforms in constrictive pericarditis
classic M or W contour caused by prominent x and y descents
Kussmaul sign
