Valve Disease, Endo + Pericarditis, Pericardial Effusion

Question 1

Symptoms + signs of aortic stenosis

Answer 1

SOB on exertion 
Angina 
Dizziness + syncope 
HF
Gallavardin's phenomenon

Question 2

Aortic stenosis murmur

Answer 2

Disappearance of 2nd aortic sound

Crescendo-decrescendo systolic ejection murmur

Question 3

S+S endocarditis

Answer 3

Fever, chills, poor appetite + weight loss
Polymyalgia, heart murmurs
Fatigue, flu-like illness
Anorexia, back pain, pleuritic pain, abdo symptoms
CVA, PE or splenic emboli (any stroke with fever = IE)
Congestive HF

Question 4

What are the order that valves tend to become affected in endocarditis?

Answer 4

Mitral
Aortic
Tricuspid
Pulmonary

Question 5

Management of endocarditis

Answer 5

IV Amoxicillin + gentamicin
Oral (if IVDU) cipro, linezolid or rifampicin
Surgery if HF present

Question 6

Management of macrocytic anaemia

Answer 6

B12 then folate

Question 7

Causes of mitral stenosis

Answer 7

Rheumatic disease (most common) endo/myo/pericarditis 
Calcium build up

Question 8

Symptoms mitral stenosis

Answer 8

SOB on exertion + when lying flat
Malar flush
Decreased exercise tolerance
Haemopytsis, chest pain, fatigue + ascites

Question 9

Mitral stenosis murmur

Answer 9

Loud 1st heart sound
Normal 2nd heart sound
Opening snap after 2nd heart sound
low pitched murmur

^^Diastolic murmur

Question 10

Management of mitral stenosis

Answer 10

Antiplatelets
Surgery if symptomatic
Rheumatic MS should get abx

Question 11

Causes of mitral regurgitation (+ which is most common)

Answer 11

Degenerative changes, coronary artery disease , LV dysfunction, rheumatic heart disease, infective endocarditis

Question 12

Symptoms + signs of mitral regurgitation

Answer 12

Pulmonary oedema
Exertional SOB + fatigue
AF
Brisk pulse

Question 13

Mitral regurgitation murmur

Answer 13

Pansystolic murmur at apex

Question 14

Investigation + management of mitral regurgitation

Answer 14

Echo
Surgery
Nitrates, diuretics, ACE inhibitors

Question 15

What is the criteria for diagnosing pericarditis?

Answer 15

2 of the following:
Pericardic chest pain (sharp, pleuritic, relieved by sitting up)
Widespread ST elevations
Pericardial effusion
Pericardial rubs

Question 16

Management of pericarditis

Answer 16

Restriction of exercise
Colchicine, aspirin or ibuprofen
Continue until CRP is normalised

Question 17

Causes of pericarditis

Answer 17

Viral (coxsackie), bacterial, MI, Dressler’s, drugs, uraemia, SLE

Question 18

S+S pericarditis

Answer 18

Central chest pain relieved by sitting forward - can be pleuritic
Worse on inspiration or lying flat
Fever

Question 19

Investigations for pericarditis

Answer 19

ECG - PR depression, saddle shaped ST elevationCXR, echo (increased cardiothoracic ratio with globular or flask shaped outline)
Echo
CXR
Bloods

Question 20

Pathology of mitral regurg

Answer 20

LV has excessive volume load leading to compensatory adjustments (eventually leading to HF) causing enlargement + stress of LV

Question 21

Pathology of mitral stenosis

Answer 21

Stenosis of vale leads to obstruction in blood flow from LA to LV.
Leads to increase in pressure in LA then pulmonary vessels then right heart

Question 22

What precipitates symptoms in mitral stenosis?

Answer 22

Anything that increases cardiac output:

Exertion, stress, fever, pulmonary infection, AF, pregnancy

Question 23

Causes of aortic regurg

Answer 23

Congenital causes (bicuspid valve), rheumatic disease, infective endocarditis, degenerative disease

Question 24

RF for aortic regurg

Answer 24

SLE, Marfans + Ehlers-Danlos + Turners
Behcet’s disease
Aortic dissection

Question 25

Signs + murmur of aortic regurg

Answer 25

Exaggerated pulse (Waterhammer) Diastolic murmur in aortic area, best heard with pt sat forward + on expiration Low diastolic pressure (wide pulse pressure)

Question 26

Investigations + management of aortic regurg

Answer 26

Echo Cardiac catheterisation + surgical intervention for symptomatic pts (valve replacement) Vasodilators + inotropic agents can be used short term before surgery if HF is present

Question 27

Aortic stenosis pathology

Answer 27

Obstruction of blood flow across aortic valve | Progressive disease that presents after a long subclinical period

Question 28

RF for aortic stenosis

Answer 28

Age >60 Congenitally bicuspid aortic valve Rheumatic heart disease CKD

Question 29

Investigations + management of aortic stenosis

Answer 29

Echo + ECG Cardiac catheterisation Transcatheter aortic valve implantation (TAVI) or aortic valve replacement Diuretics + ACEi for HTN

Question 30

RF for endocarditis

Answer 30

``` Valvular heart disease + replacement Congenital heart disease Previous IE Hypertrophic cardiomyopathy Recreational drug use Invasive vascular procedures ```

Question 31

Pathology of endocarditis

Answer 31

Non bacterial thrombotic endocarditis as pre-requisite for adhesion + invasion Site of thrombus is influenced by Venturi effect (will be on the low pressure side)

Question 32

Organisms causing endocarditis

Answer 32

``` Staph aureus (most common - related to prosthetic valves _ drug abuse) Strep (viridans, D, intermedius, A, B, C + G) Pseudomonas aeruginosa ```

Question 33

When is atypical presentation of endocarditis common?

Answer 33

In elderly, after abx, in immunocompromised pt or IE with atypical organisms

Question 34

What is the most common murmur with IE?

Answer 34

Aortic regurg

Question 35

Signs on examination in endocarditis

Answer 35

``` Petechiae in conjunctivae, hands + feet, chest + abdo wall + mucosa Splinter hemorrhages Osler's nodes Clubbing Roth's spots Janeway's lesions Splenomegaly Meningitis ```

Question 36

When should IE be suspected?

Answer 36

``` Febrile illness AND: New regurg murmur Pre-existing RF Congestive HF Vascular or immunological phenomena New stroke Peripheral abscesses Any new embolic event Unexplained blood cultures ```

Question 37

Investigations for ?IE

Answer 37

CXR, ECG, bloods Blood cultures Echo (TTE) Serology testing for bacteria

Question 38

What diagnostic criteria is used for IE?

Answer 38

Duke's criteria - 2 majors, 1 major + 3 minor or 5 minor

Question 39

What are the major criteria for IE?

Answer 39

2 separate positive blood cultures for IE | Evidence of endocardial involvement (+ve echo)

Question 40

What are the minor criteria for IE?

Answer 40

``` Predisposition Fever >38 Vascular phenomena Immunological phenomena Microbiological phenomen PCR ```

Question 41

What are the vascular phenomena with IE?

Answer 41

Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages and Janeway's lesions

Question 42

What are the immunological phenomena with IE?

Answer 42

Glomerulonephritis, Osler's nodes, Roth's spots and rheumatoid factor

Question 43

Complications of IE

Answer 43

``` MI, pericarditis, cardiac arrhythmias HF, valve insufficiency Arterial emboli Stroke syndromes AKI ```

Question 44

Pathology of pericardial effusion

Answer 44

Can develop in any condition which affects the pericardium inc pericarditis

Question 45

Investigations for ?pericardial effusion

Answer 45

ECG, CXR, echo (diagnostic)

Question 46

Management of pericardial effusion

Answer 46

Tx for underlying disease Pericardial fluid drainage if there is significant hemodynamic compromise - use echo to guide pericardiocentesis + leave catheter in place for 24 hrs If not, serial echos every 5 days