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CARDIOLOGY > VALVULAR HEART DISEASE > Flashcards

VALVULAR HEART DISEASE Flashcards

1
Q

What causes S1 heart sound?

A

Closure of the atrioventricular valves i.e. tricuspid and mitral valve
This happens at the start of systolic contraction of ventricles

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2
Q

What causes S2 heart sound?

A

Closing of semilunar valves i.e. pulmonary and aortic valves
This happens once systolic contraction is complete to prevent blood flowing back from pulmonary arteries/aorta into the ventricles

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3
Q

What is S3?

A

A third heart sound that can be heard roughly 0.1 seconds after the second heart sound
Caused by rapid ventricular filling causing chordae tendineae to pull to their full length

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4
Q

What can cause S3?

A

Can be normal in 15-40 year olds (hearts function so well that ventricles allow rapid filling)
Heart failure

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5
Q

What is S4?

A

A fourth heart sound heard directly before S1
Always abnormal

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6
Q

What causes S4?

A

Indicates a stiff or hypertrophic ventricle and is caused by turbulent flow from an atria contracting against a non-compliant ventricle

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7
Q

How do you best listen to murmurs with the stethoscope?

A

Bell of your stethoscope - low pitched sounds
diaphragm - high pitched sounds.

(To remember this think of a childs high-pitched screaming from their diaphragm)

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8
Q

What is Erb’s point?

A

3rd intercostal space on left sternal border - best place for listening to heart sounds

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9
Q

How can you emphasise a mitral stenosis murmur?

A

Roll pt on their left hand side

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10
Q

How can you emphasises aortic regurgitation?

A

Patient sits up, leaning forward and holding expiration

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11
Q

How do you assess a murmur?

A

SCRIPT

Site - where is it loudest
Character - soft, blowing, crescendo, decrescendo, crescendo-decrescendo?
Radiation - to carotids? Or left axilla?
Intensity - what grade?
pitch - high or low? (Indicates velocity)
Timing - systolic or diastolic?

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12
Q

Which murmur can radiate to the carotids?

A

Aortic stenosis

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13
Q

Which murmur can radiate to the left axilla?

A

Mitral regurgitation

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14
Q

How do you grade a murmur?

A

Grade 1 - Difficult to hear
2 - Quiet
3 - Easy to hear
4 - Easy to hear with a palpable thrill
5 - Can hear with stethoscope barely - touching chest
6 - Can hear with stethoscope off the chest

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15
Q

Which valvular heart diseases cause hypertrophy and why?

A

Mitral and aortic stenosis cause atrial and ventricular hypertrophy respectively
This is because the muscle has to try harder when pushing against a stenotic valve

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16
Q

Which valvular heart diseases cause dilatation and why?

A

Mitral and aortic regurgitation cause atrial and ventricular dilatation respectively
As blood flows back into the chamber which stretches the muscle, causing dilatation

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17
Q

What is mitral stenosis?

A

A narrow mitral valve which makes it difficult for the left atrium to push blood through to the ventricle

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18
Q

What can cause mitral stenosis?

A

Rheumatic fever

Others which are rarer = mucopolysaccharidoses, carcinoid fibroelastosis, endocardial fibroelastosis

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19
Q

What murmur does mitral stenosis cause?

A

Mid-late diastolic, low pitched murmur best heard in expiration (rumbling sound due to low velocity of blood flow)
Opening snap which is the mitral valve leaflets suddenly opening
Loud S1 (due to thick valves shutting very suddenly) and you can palpate a tapping apex beat due to this

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20
Q

What is mitral stenosis associated with?

A

Malar flush
AF

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21
Q

Why does mitral stenosis cause malar flush?

A

This is due to back-pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation.

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22
Q

Why can mitral stenosis cause AF?

A

This is caused by the left atrium struggling to push blood through the stenotic valve causing strain, electrical disruption and resulting fibrillation.

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23
Q

What is mitral regurgitation?

A

an incompetent mitral valve allows blood to lead back through during systolic contraction of the left ventricle
It results in congestive cardiac failure

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24
Q

Why does mitral regurgitation cause congestive cardiac failure?

A

because the leaking valve causes a reduced ejection fraction and a backlog of blood that is waiting to be pumped through the left side of the heart.

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25
Q

What type of murmur does mitral regurgitation cause?

A

pan-systolic, high pitched “blowing” murmur due to high velocity blood flow through the leaky valve. Best heard at the apex and radiates into the left axilla. You may hear a third heart sound if HF is present
May have a mid-systolic click
Severe MR may cause a widely split S2

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26
Q

What causes mitral regurgitation?

A

Idiopathic weakening of the valve with age
Mitral valve prolapse
IHD
Infective Endocarditis
Rheumatic Heart Disease
Connective tissue disorders e.g. Ehlers Danlos syndrome or Marfan syndrome (causes myxomatous degeneration)

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27
Q

What is aortic stenosis?

A

Narrowing of aortic valve so as blood flows during systolic contraction there is tubulance of blood flow

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28
Q

What type of murmur does aortic stenosis cause?

A

ejection-systolic, high pitched murmur
Crescendo-decrescendo character
Murmur radiates to the carotids
Slow rising pulse and narrow pulse pressure
Pt may complain of exertional syncope due to difficult maintaining good blood flow to the brain

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29
Q

What causes aortic stenosis?

A

Idiopathic age related calcification
Bicuspid valve - more at risk
Rheumatic heart disease

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30
Q

What is aortic regurgitation?

A

Aortic valve becomes incompetent and blood flows back from aorta into left ventricle during diastole

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31
Q

What murmur does aortic regurgitation cause?
What other features can be present?

A

early-diastolic blowing murmur, best heard on the left lower sternal border

Intensity of the murmur can be increased by handgrip manoeuvre
Collapsing pulse
Wide pulse pressure
Quincke’s sign
De Musset’s sign
Mid-diastolic Austin-Flint murmur in severe cases

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32
Q

What are other features of aortic regurgitation?

A

Wide pulse pressure
Corrigans pulse
Causes HF
Can cause Austin-Flint murmur - heard at apex and is an early diastolic rumbling murmur

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33
Q

What is Austin-Flint murmur?

A

A murmur heard at the apex
An early diastolic rumbling murmur

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34
Q

What causes Austin-Flint murmur?

A

caused by blood flowing back through the aortic valve and over the mitral valve causing it to vibrate

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35
Q

What is a Corrigans pulse?

A

also called a collapsing pulse and is a rapidly appearing and disappearing pulse at carotid as the blood is pumped out by the ventricles and then immediately flows back through the aortic valve back into the ventricles.

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36
Q

What causes aortic regurgitation?

A

Idiopathic age-related weakness/calcification
Bicuspid aortic valve
Rheumatic fever
Connective tissue disorders e.g. Ehlers Danlos syndrome or Marfan syndrome

Acute - Infective endocarditis , Aortic dissection, Hypertension

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37
Q

What can cause a loud S1?

A

Mitral stenosis
Left-to-right shunts
Short PR interval, atrial premature beats
Hyperdynamic states

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38
Q

What causes a quiet S1?

A

Mitral regurgitation

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39
Q

What causes a loud S2?

A

Hypertension
Hyperdynamic states
Atrial septal defect without pulmonary hypertension

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40
Q

What causes a soft S2? Why?

A

Aortic stenosis - because its harder for the valve to close so it may close at the same time as pulmonary valve (usually aortic valve closes first)

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41
Q

What causes a fixed split S2?

A

Atrial septal defect

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42
Q

What causes a widely split S2?

A

deep inspiration
RBBB
pulmonary stenosis
severe mitral regurgitation

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43
Q

What causes a reversed split S2?

A

LBBB
severe aortic stenosis
right ventricular pacing
WPW type B (causes early P2)
patent ductus arteriosus

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44
Q

Whats the most common valvular disease?

A

Aortic stenosis

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45
Q

What is rheumatic fever? And what is its pathophysiology?

A

A systemic infection that is common in developing countries and develops 2-4 weeks after a streptococcus pyogenes infection
These bacteria have M proteins which the immune system produces antibodies against. These antibodies undergo molecular mimicracy - they also target proteins found in myocardium and heart valves (type 2 hypersensitivity reaction)

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46
Q

Whats the diagnostic criteria for rheumatic fever?

A

JONES CRITERIA

Diagnosis is based on evidence of recent streptococcal infection accompanied by:
2 major criteria
1 major with 2 minor criteria

Evidence of recent streptococcal infection can be determined by raised/rising streptococci antibodies, positive throat swab or positive rapid group A streptococcal antigen test

Major criteria
erythema marginatum
Sydenham’s chorea: this is often a late feature
polyarthritis
carditis and valvulitis (eg, pancarditis)
subcutaneous nodules

Minor criteria
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval

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47
Q

Whats the structure of the aortic valve?

A

3 leaflets - right left and posterior
In 1-2% of the population it is found to congenitally have 2 leaflets

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48
Q

What murmur is associated with tricuspid regurgitation?

A

Pansystolic high-pitched blowing murmur best heard in tricuspid area

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49
Q

Which groups of people are tricuspid diseases most common in?

A

IV drug users

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50
Q

Why does aortic regurgitation cause a wide pulse pressure?

A

Blood leaks back from aorta into left ventricle -> left ventricular end diastolic volume increases -> eccentric hypertrophy -> systolic blood pressure increases -> during diastole less blood in aorta as some has leaked back into ventricle = decreased diastolic pressure

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51
Q

Whats the effect of wide pulse pressure in aortic regurgitation?

A

Causes a Hyperdynamic circulation which leads to a bounding ‘water hammer’ pulse
It can cause head bobbing in tune with the heartbeat (De Musset’s sign)
Overtime it can lead to left heart failure

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52
Q

How does rheumatic fever cause valvular heart disease?

A

Commissural fusion of leaflets in valve and it can cause scarring of the valves

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53
Q

Why is mitral stenosis likely to cause AF?

A

Secondary to the increase in left atrial pressure which leads to left atrial enlargement - the larger it is the more chance of AF

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54
Q

Why does mitral stenosis cause dyspnoea and haemoptysis?

A

Increased left atrial pressure causes pulmonary venous hypertension

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55
Q

From the murmur alone, how can you tell the severity of mitral stenosis?

A

The distance between end of S2 and the opening snap - as the opening snap comes closer to S2, the valvular disease is becoming more severe whilst an opening snap that occurs later in diastole indicates a milder disease
This happens as there’s a much higher left atrial pressure in severe mitral stenosis so it takes less time for blood to pass through stenoses valves

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56
Q

Why can mitral regurgitation happen post-myocardial infarction?

A

If the papillary muscles or chordae tendinae are affected by a cardiac insult

57
Q

What is mitral valve prolapse?

A

Myxomatous degeneration (weakened connective tissue) -> larger valve leaflet area and elongation of chordee tendinae which may rupture -> posterior leaflet folds up into left atrium on systole
Most often causes mitral regurgitation

58
Q

Why can infective endocarditis cause mitral regurgitation?

A

When vegetations from the organisms colonising the heart grow on the mitral valve, it is prevented from closing properly

59
Q

How do you investigate a heart murmur?

A

Echocardiogram

(Do an ECG, coronary angiogram, chest xray, bloods too)

60
Q

What is sudden cardiac death?

A

Death due to cardiovascular cause that occurs within 1 hour of the onset of symptoms. It occurs when the heart stops beating and cannot beat sufficiently to maintain perfusion and life

61
Q

What are the causes of sudden cardiac death?

A

Coronary artery disease - 80% of all cases
Cardiomyopathies
Heart failure
Aortic stenosis
Congenital disease - tetralogy of Fallot
Inherited channelopathies e.g. brugada syndrome or long QT syndrome

62
Q

What are the differences between metallic and biological heart valves?

A

Biological valves are typically bovine or porcine. Major disadvantage is structural deterioration and calcification over time. However, long-term anticoagulation is not usually needed and only low-dose aspirin is given long term

Mechanical valves are usually the bileaflet valve. They have a low failure rate. Major disadvantage is increased risk of thrombosis so life time warfarin is used

63
Q

What investigations should you do for suspected valvular disease?

A

Bloods - FBC, U+Es, LFTs, TFTs, troponin, BNP
Imaging - CXR and CT
Echocardiogram
CT coronary angiogram (likely to also have IHD)

64
Q

What are the 2 main types of echocardiograms?

A

Transesophageal echo
Transthoracic echo

65
Q

What is an echocardiogram? What can it look at?

A

An ultrasound of the heart that gives an accurate picture of the valves, chambers and an idea of the velocity of blood flow in certain areas
It can assess valve defects, ejection fraction, heart wall function, tamponade and vegetations seen in infective endocarditis

66
Q

What is Transthoracic echocardiogram?

A

The patient lies of their left hand side with their arm behind their head. The transducer is placed at various intercostal spaces to the left of the sternum, and at the anterior axillary line.
This is the preferred test for valve defects
It is also often the first line investigation when echo is required

67
Q

What is trans-oesophageal echocardiogram?

A

Usually performed under sedation and with facilities for resuscitation
It provides high resolution due to the probes proximity to the heart.
Provides good views of the posterior part of the heart
This is an invasive procedure, and usually performed by a cardiologist

This is the investigation of choice for infective endocarditis, prosthetic valve management, and searching for causes of thromboembolism.

68
Q

How do we manage asymptomatic aortic stenosis?

A

Observe the pt
If valvular gradient >40mmHg and there are features such as left ventricular systolic dysfunction then consider surgery

69
Q

How do you manage symptomatic aortic stenosis?

A

Valve replacement

70
Q

What are the options for aortic valve replacement?

A

Surgical aortic valve replacement - choice for young, low/medium risk patients
Transcatheter AVR - used for pt with high operative risk (TAVI)
Ballon Valvuloplasty only used in adults if critical aortic stenosis and not fit for valve replacement. Can be used in children with no aortic valve calcification

71
Q

How do you manage aortic regurgitation?

A

Surgery for aortic valve replacement if symptomatic or if asymptomatic but with LV systolic dysfunction

72
Q

How do you manage asymptomatic mitral stenosis?

A

Monitor with regular echocardiograms
(Manage any associated AF with warfarin)

73
Q

How do you manage symptomatic mitral stenosis?

A

Transcatheter valvotomy or mitral valve surgery

(Manage any associated AF with warfarin)

74
Q

How do you manage mitral regurgitation?

A

Surgical mitral valve repair
Surgical mitral valve replacement if above not necessary
Consider transcatheter mitral edge-to-edge repair if surgery not suitable

75
Q

What are the potential complications of valvular heart repair or replacement surgery?

A

Endocarditis
AF
Bleeding
Thromboembolism
Paraprosthetic regurgitation
Infection
Sudden cardiac death
Renal failure
Stroke
Wound infections
Mediastinitis

76
Q

What is infective endocarditis?

A

Infection of the endocardium which may involve 1 or more heart valves or an intracardiac device e.g. a prosthetic valve

77
Q

What are the 2 major disease courses of infective endocarditis?

A

Acute, rapidly progressive infection
Subacute, or chronic, low-grade infection

78
Q

What are the 3 major types of infective endocarditis?

A

Native valve endocarditis: normal valves without previous intervention. May be acute or subacute.
Prosthetic valve endocarditis: may occur early (< 1 year) or late (> 1 year) following surgical intervention. 10-20% of cases.
Intravenous drug abuse endocarditis: classically affects the tricuspid valve (50%).

79
Q

Whats the most common causing microorganism of IV drug abuse endocarditis?

A

Staph aureus

80
Q

What are risk factors for infective endocarditis?

A

Age >60
Male
IV drug users
Poor dental hygiene, dental infection, certain dental procedures
Structuralheart disease
Valvular heart disease
Congenital heart disease
Prosthetic heart valves
Previous IE
Intravascular devices
Immunosuppression
Haemodialysis

81
Q

What pathogen causes infective endocarditis?

A

Staph aureus - most common
Streptococcal species (more commonly subacute)
Enterococcus species (more commonly subacute)

82
Q

What is native valve endocarditis?

A

commonly due to underlying rheumatic heart disease, congenital heart disease or structural heart disease.
It is usually presents with a subacute course..

83
Q

What causes native valve endocarditis?

A

Streptococcal species (alpha-haemolytic, S. bovis) and enterococci: implicated in around 70% of cases.

Staphylococcal species: implicated in around 25% of cases. More aggressive disease course

84
Q

Which pathogen causes prosthetic valve endocarditis?

A

Staphylococcus epidermidis - if within 2 months of surgery
(after this the spectrum of organisms which cause endocarditis return to normal i.e. staph aureus is the most common cause)

85
Q

What is early prosthestic valve endocarditis?

A

When IE occurs <1 year after surgery

Acute course that can cause local abscess, fistula formation, and valvular dehiscence.

86
Q

What is late prosthestic valve endocarditis?

A

Occurs >1 year after prosthetic valve placement
More subacute course

87
Q

Which side of the heart is more commonly affected in IVDU-associated infective endocarditis? Why?

A

Due to injection through the venous system, IE affecting the right side of the heart

88
Q

What is culture-negative infective endocarditis?

A

endocarditis with no definite microbiological aetiology despite adequate sampling.

89
Q

What can cause culture-negative infective endocarditis?

A

Typical pathogens may not be cultured due to early antibiotic use
Pathogens that are fastidious - complex growth requirements
Intracellular bacteria
Non-bacterial pathogens e.g. fungi

90
Q

What is non-infective endocarditis?

A

Endocarditis occurring in the absence of infection due to sterile platelet thrombi on heart valves
Rare
(Aka marantic endocarditis or Libman-Sacks endocarditis)

91
Q

What can cause non-infective endocarditis?

A

Advanced maliganncy in 80% of cases
SLE
Others - Rheumatoid arthritis and burns

92
Q

How do different staphylococcal species causing infective endocarditis present differently?

A

Staph aureus - acute and subacute
Coagulase negative staphylococcus - subacute course (associated with prosthetic devices)

93
Q

Which species is most commonly seen in subacute infective endocarditis secondary to poor dentition?

A

Alpha-haemolytic streptococci e.g. viridans streptococci

94
Q

What microorganisms cause infective endocarditis?

A

Staphylococcal spp
Streptococcal spp
Enterococcus spp

HACEK:
Haemophilus aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae

95
Q

Which fungi can cause infective endocarditis and Whats the prognosis compared to bacterial causes?

A

Candida spp
Aspergillus spp

Associated with a poor prognosis - 50% mortality

96
Q

Whats the pathophysiology of infective endocarditis?

A

Bacteria enter the blood stream and deposit on the endocardial surface of the heart. The organisms can adhere and eventually invade and destroy the valve leaflets through vegetation’s. This destroys the valves causing regurgitant murmurs and eventually congestive cardiac failure

Embolic events can occur due to vegetations breaking off and being deposited in other organ systems. This can lead to formation of abscesses. Activation of immune system and clustering of immune complexes within vegetations can lead to immune-mediated vasculitis within distant vessels e.g. glomerulonephritis

97
Q

Whats the order of frequency in which the valves are affected by infective endocarditis?

A

Mitral
Aortic
Combined mitral and aortic
Tricuspid
Pulmonary

98
Q

How does infective endocarditis present?

A

Clinical presentation is very variable! It can present as an acute or subacute or chronic disease with non specific symptoms
The majority of pt will have a fever and cardiac murmurs

Others:
Malaise, anorexia, weight loss, abdominal pain from splenic abscess, haematuria, SOB, chest pain, palpitations
Features of HF, splinter haemorrhages, petechiae, Janeway lesions, Osler nodes, Roth spots, splenomegaly

99
Q

What proportion of pt with infective endocarditis have embolic phenomenon?

A

25%

100
Q

What are examples of embolic phenomenon secondary to infective endocarditis?

A

OSLER nodes
Janeway lesions
Roth spots
Cerebral abscess, intracerebral haemorrhage, embolic stroke, seizures
Septic emboli - splenic, renal or pulmonary abscess. Vertebral osteomyelitis, septic arthritis, psoas abscess
Glomerulonephritis amd synovitis

101
Q

How do you diagnose infective endocarditis?

A

At least 3 sets of blood cultures taken at 30 minute intervals
Echocardiography (TTE)

Others - CT, MRI or nuclear imagine, urine dip, ECG, bloods

102
Q

What findings on an echo are suggestive of infective endocarditis?

A

Vegetation
Abscess formation
Pseudoaneurysm
Valve perforation
New dehiscence of a prosthetic valve

103
Q

What are the modified Duke criteria?

A

The major and minor criteria used to make a diagnosis of infective endocarditis
It can be diagnosed if pathological criteria are positive, or 2 major criteria or 1 major + 3 minor criteria, or 5 minor criteria

Pathological criteria - positive histology or microbiology of pathological material obtained at surgery or autopsy

Major criteria - positive blood cultures and evidence of endocardial involvement proven by positive echo or new valvular regurgitation

Minor criteria - predisposing heart condition or IV drug use, microbiological evidence that doesnt meet major criteria, fever >38, vascular phenomena, immunological phenomena

104
Q

What is definite (pathological) infective endocarditis?

A

vegetation or intracardiac abscess demonstrating active endocarditis on histology
OR
microorganism demonstrated by culture or histology of a vegetation or intracardiac abscess

105
Q

What is definite (clinical) infective endocarditis?

A

2 major criteria, OR 1 major and 3 minor criteria, OR 5 minor criteria.

106
Q

What is possible infective endocarditis?

A

1 major and 1 minor criteria, or 3 minor criteria

107
Q

What is rejected infective endocarditis?

A

firm alternative diagnosis, OR resolution of symptoms suggesting IE within 4 days of antibiotics, OR no pathological evidence of IE at surgery or autopsy within 4 days of antibiotics, OR does not meet criteria for possible IE.

108
Q

How do you manage infective endocarditis?

A

Prolonged course of targeted antibiotics
If organisms is not known yet then empirical antibiotics can be started
Surgery

109
Q

What antibiotics are used for infective endocarditis caused by staphylococcus aureus?

A

flucloxacillin 12 g/day in 4-6 doses. Duration 4-6 weeks.
Methicillin-resistance staphylococcus aureus (MRSA) or penicillin allergy: vancomycin 30-60 mg/kg/day in 2-3 doses. Duration 4-6 weeks.

Note - if prosthetic valves then rifampicin and gentamicin should be added and duration should be >6 weeks

110
Q

What antibiotics are used for infective endocarditis caused by streptococcal species?

A

Standard four-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone
Standard two-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone combined with gentamicin.
Penicillin allergic: vancomycin for four weeks

111
Q

What empirical therapy can be given for infective endocarditis?

A

Native valve endocarditis or late prothetic valve endocarditis: Ampicillin, flucloxacillin and gentamicin, OR vancomycin and gentamicin.

Early prosthetic valve endocarditis: vancomycin, gentamicin and rifampicin.

112
Q

Whats the aim of surgery when managing infective endocarditis?

A

removal of infected tissue and reconstruction of cardiac anatomy e.g. valve repair or replacement

113
Q

What are the indications for surgery in infective endocarditis?

A

HF
Uncontrolled infection
Prevention of embolisation

114
Q

Can infective endocarditis be prevented?

A

In 2008, NICE guidance recommended against the routine use of prophylactic antibiotics for certain procedures (e.g. dental) because of a poor evidence base and cost-ineffective. However, there is feeling that a small subgroup of patients at particularly high-risk may benefit from prophylactic antibiotics.
They may be prescribed for high risk procedures or to high risk patients

115
Q

What are some procedures that are high risk for infective endocarditis?

A

Cardiac procedures
Dental procedures (manipulation of gingival or perioapical region, local anaesthetic injections, treatment of superficial caries, tooth removal or orthodontic procedures)
Respiratory tract procedures (bronchoscopy, laryngoscopy, transnasal or endotracheal intubation)
Gastrointestinal procedures (transoesophageal echocardiography, gastroscopy, colonoscopy)
Urological procedures (cystoscopy)
Obstetric procedures (vaginal or caesarian delivery)

116
Q

What makes you a high risk pt for infective endocarditis?

A

Prosthetic heart valves or material used for cardiac valve repair
Previous IE
Congenital heart disease

117
Q

What are the options for prophylactic antibiotics for dental procedures for infective endocarditis?

A

No penicillin allergy: amoxicillin 2 g orally or IV 30-60 minutes before procedure
Penicillin allergy: clindamycin 600 mg orally or IV 30-60 minutes before procedure

118
Q

What are complications of infective endocarditis?

A

HF - most common
Perivalvular abscess, pericarditis, cardiac tamponade
Neurological - stroke, abscess, meningitis, encephalitis, haemorrhage, seizures
Metastatic infection - embolisation, secessionist
Embolisation sequelae - stroke, blindness, ischaemic limb, splenic or renal infarct, PE, MI

119
Q

Which bacterial organisms are most associated with poor dental hygiene causing infective endocarditis?

A

Streptococcus viridans - streptococcus mitis and streptococcus sanguinis

120
Q

Which microorganisms is likely to cause infective endocarditis if the pt has colorectal cancer?

A

Streptococcus gallolyticus

121
Q

How is rheumatic fever managed?

A

Bed rest until CRP is normal for 2 weeks
Antibiotics Benzylpenicillin IV stat and then phenoxymethylpenicillin 4 times daily for 10 days
High dose aspirin to limit inflammatory response
Manage any complications
Immobilise joints in severe arthritis
Haloperidol or diazepam for chorea

122
Q

How does aortic stenosis present?

A

Syncope
Angina
Dyspnoea
(SAD)

123
Q

What ECG changes might you see in severe mitral stenosis?

A

It can cause left atrial hypertrophy so the ECG will show a bifid P wave
It’s termed P mitrale
Most pronounced in lead 2

124
Q

What is myxomatous degeneration of the cardiac valves?

A

Non-inflammatory progressive disarray of valve structure caused by a defect in the mechanical integrity of the leaflet due to altered synthesis or remodelling of the tissue

125
Q

What is the murmur seen in mitral valve regurgitation?

A

Mid systolic click sometimes followed by a systolic murmur that can be longer if standing up

126
Q

What causes the mid-systolic click seen in mitral valve prolapse?

A

Leaflet folding into the atrium and suddenly stopped by the chordiae tendinae

127
Q

Whats special about the mitral valve prolapse murmur?

A

If squatting the click comes later and systolic murmur is shorted (increases venous return -> fills ventricles with more blood -> left ventricles larger -> larger leaflets -> takes longer for leaflets to get forced into atria on systole)
If standing/doing vasalva manouvre the click comes earlier and systolic murmur is longer

This is the same as in hypertrophic cardiomyopathy - different murmu?

128
Q

What can cause mitral valve prolapse?

A

Primary - genetics, marfans syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta, congenital heart disease
Secondary - Acute MI, rheumatic heart disease, hypertrophic cardiomyopathy

129
Q

What are complications of mitral valve prolapse?

A

Mitral regurgitation
Arrhythmias including long QT
Emboli
Sudden death

130
Q

What is De Mussets sign and what does it indicate?

A

a visible nodding of the head in time with arterial pulsation
patients with aortic insufficiency

131
Q

What is De quincke’s sign and what does it indicate?

A

Visualisation of capillary pulsations upon light compression applied to the tip of the fingernail bed (visible pulsation of red colouration on the fingernail bed. Blanching makes this more obvious)
Aortic regurgitation

132
Q

What is slow rising pulse and what does it indicate?

A

Delayed up-stroke particularly in brachial and carotid pulses
Aortic stenosis

133
Q

What is wide pulse pressure and what does it indicate?

A

Large difference between systolic and diastolic blood pressure
Can be caused by aortic regurgitation

134
Q

Why does aortic regurgitation cause a wide pulse pressure?

A

Because the aortic valve fails to close properly, some blood is allowed back from aorta into left ventricle during diastole
As a reasult, the left ventricle has to pump out a larger volume of blood during systole to compensation

135
Q

What can cause a narrow pulse pressure?

A

Aortic stenosis
It restricts the blood flow from left ventricle into aorta so in systole the LV has to work harder to pump the blood through
However, during diastole the pressure in the left drops

136
Q

Why does mitral stenosis cause malar flush?

A

Increased pressure in left atrium can cause vasodilation of the small blood vessels in the face

The increased pressure in the left atrium can also lead to backflow of blood into the pulmonary veins, which can cause congestion of the lungs and the development of pulmonary hypertension. This can further exacerbate the malar flush and other symptoms of mitral stenosis

137
Q

Which groups of people are more likely to get mitral valve prolapse?

A

Young women (20-40) with a FHx or connective tissue disorder

138
Q

What is tetralogy of Fallot?

A

A congenital heart defect that involves:
Ventricular septal defect
Pulmonary stenosis
Overriding aorta
Right ventricular hypertrophy

The combination of these four defects can result in decreased blood flow to the lungs and inadequate oxygenation of the blood. This can cause symptoms such as cyanosis (bluish discoloration of the skin and mucous membranes), shortness of breath, and difficulty feeding or gaining weight in infants.
Tetralogy of Fallot is usually diagnosed shortly after birth or during infancy, based on clinical symptoms and diagnostic tests. Typically requires surgical repair of the defects

CARDIOLOGY (19 decks)

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