PT 1 Flashcards
Q. Name three features of foetal circulation that differ from adult circulation
A. Ductus venosus: bypasses hepatic circulation, blood flows from umbilical vein into IVC (to the heart). Why do these close after birth?
B. Foramen ovale: blood bypasses the heart by a hole from RA to LA, straight into the aorta
C. Patent ductus ateriosus: deoxygenated blood that enters the right ventricle goes into pulmonary arteries and into the descending aorta via this shunt (due to high foetal pulmonary resistance
D. Birth = Breath = Decreased Pulmonary Vasculature Resistance = Increased LA Press. > RA Press. = Foraman Ovale Close = Increased O2 (from respiration) & Decreased Prostaglandin (from placenta separation) = Ductus Arteriosus Close
E. Indomethacin (NSAID) used to help close PDA
Q. What are the most common R L shunts in congenital heart disease? How do these babies present and how should they be managed?
A. Truncus Arteriosus
B. Transposition of Great Vessels
C. Tricuspid Atresia
D. Tetralogy of Fallot
SIG: Cyanosis, Squatting (increases peripheral vascular resistance = increases preload = increases stroke volume), Clubbing, F to Thrive, Ejection Systolic Murmur
INV: CXR (boot-shaped), ECG (RBBB, RVH), ECHO
Tx: surgical tx
Q. What are the most common L R shunts in congenital heart disease? How do these babies present and how should they be managed?
A. Ventricular septal defect (VSD), (20% of all congenital heart defects)
LV > pressure than RV.
Pt: not blue, breathless, poor feeding, failure to thirive.
Signs: increased RR, tachycardia, breathless, failure to thrive, large heart, murmur my very in intensity
Tx: large may need require fixing in infancy.
Small: asymptomatic, but endocarditis risk.
Risk of Eisenmenger’s syndrome (becomes cyanotic)
B. Atrial septal defect (ASD). Connection between Atria.
LA high pressure than RA. (L to R shunt), pt is not blue.
S&S: RH dilation, SOBOE, increased chest infections, pulmonary flow murmour, fixed split second heart sound (delayed closure of PV because more blood has to get out), big pulmonary arteries and big heart on CXR
C. Patent ductus arteriosus
Blood flows from aorta to PA\Signs: contious ‘machinary’ murmur, big heart, breathlessness, differential cyanosis (clubbed blue toes but pink not clubbed fingers).
May cause Eisenmenger’s syndrome —> CYANOTIC
Large ones need to be closed surgically.
Q. What is Eisenmenger Syndrome?
Eisenmengers syndrome: the process in which a long-standing left to right cardiac shunt caused by a congenital heart defect causes pulmonary hypertension and eventual reversal of the shunt into a cyanotic right to left shunt.
¥ High pressure pulmonary blood flow
¥ Damages to delicate pulmonary vasculature
¥ The resistance to blood flow through the lungs increases
¥ The RV pressure increases
¥ The shunt direction reverses
¥ The patient becomes BLUE
Q. What occurs in each of the heart sounds?
A. S1 = mitral and tricuspid valve closure
B. S2 = aortic and pulmonary valve closure
C. S3 = in early diastole during rapid ventricular filling, normal in children and pregnant women, associated with MR and HF
D. S4 = In late diastole, apex and patient left lateral, associated with LVH
Q. What is heard in Aortic stenosis and when?
A. Aortic valve = 2nd intercostal space, left of sternum, radiates to carotids. Open during systole, closes during diastole
B. Systolic: Crescendo-decrescendo Ejection Systolic Murmur, Loudest at Aortic Area, Radiates to Carotids.
Q. What is the commonest cause of aortic stenosis?
A. Calcific Aortic Valvular Disease (CAVD): mainly elderly, (T lymph, macrophages) results in thickening with fibrosis, lesions contain lipoproteins that calcify)
B. RF: old age, male, elevated lipoproteins, low LDL, HTN, DM, smoking
C. Bicuspid Aortic Valve (BAV): congenital – regular ECHO (associated with aortic coarctation, root dilation, aortic dissection)
D. Rheumatic Fever (progressive fusion and thickening)
E. Other: CKD, paget’s disease of bone, prev radiation exposure, homozygous familial hypercholesterolaemia)
Q. Name 4 symptoms and signs of aortic stenosis
A. Symptoms usually occur when aortic orifice reduced to 1/3rd normal size: exercise-induced syncope, angina, dyspnoea
B. Obstructed LV emptying LV hypertrophy ischemia angina, arrhythmias, LV failure
C. Signs: systolic, low pitched, ejection. Radiates to carotids, ejection click, palpable thrill
Q. What is heard due to mitral regurgitation and when?
A. Mitral valve = apex, radiating to axilla (MV prevents backflow of blood from LA during systole, opens during diastole)
B. Pansystolic High-Pitched “Blowing Murmur”, (Thrill is severe)
Mitral = Loudest at Apex and Radiates to Axilla (MR),
S3 = sudden rush of blood back in dilated LV
C. MR causes: degenerative, IHD, rheumatic heart disease, infective endocarditis (cardiomegaly, SLE, Marfan’s, Ehlers-danlos)
D. Pathology – regurg into LA = LA dilatation, LV/stroke volume must increase to compensate LV hypertrophy
Q. Name 4 symptoms of mitral regurgitation
A. Palpitation (often felt due to increase in SV), dyspnoea, orthopnoea (due to LV failure and pulmonary HTB), fatigue and lethargy (reduced CO)
Q. How would you diagnose mitral regurgitation, what would be seen? Describe the management
A. CXR: LA and LV enlargement, calcified mitral valve
B. ECG: Bifid P waves (due to LA delay), LV hypertrophy
C. ECHO: dilated LA and LV
D. Mx: mitral valve repair, prophylaxis against endocarditis
Q. Name 3 features of tetralogy of fallot
A. Pulmonary stenosis, RV hypertrophy, overriding aprta (boot shaped heart)
B. Most common congenital cyanotic disease, extreme hypoxia with cyanosis
C. Presents with: crying, clubbing, squatting, cyanosis, syncope
Q. What condition has saddle shaped (concave) ST elevation +- PR depression
A. Pericarditis
B. Sharp retrosternal chest pain, worse on movement, deep breathing and straining
C. Typically relieved on leaning forwards
D. A fever may also be present
E. (On auscultation there may be a pericardial friction rub)
Q. What is heard with a mitral valve prolapse and when?
A. Mitral valve = apex, radiating to axilla (MV prevents backflow of blood from LA during systole, opens during diastole)
B. At systole: Late Systolic Crescendo Murmur with Midsystolic Click, Loudest at Apex
Q. What is heard with Aortic regurgitation and when?
A. Diastolic: AR: High-Pitched “Blowing” Early Diastolic Decrescendo Murmur, Best Heard Sitting Forward
B. AE: acute (acute rheumatic fever, infective endocarditis, aortic dissection), chronic (rheumatic heart disease, syphilis, severe HTN, Marfan’s)
C. Signs: hyperdynamic circulation = bounding/collapsing pulse, Quinckle’s sign (capillary pulse in nail bed), De Musset’s sign (head nodding with heart beat)