Week 5 Flashcards
What is the normal range of the mitral valve area?
4-6 cm^2
what is the normal size range of the aortic valve?
3-4 cm^2
What is mitral stenosis?
- Mitral stenosis (MS) is the impaired opening of the mitral valve affecting blood flow from the left atrium to the ventricle.
mitral stenosis aetiology
rheumatic heart disease
congenital mitral stenosis
systemic conditions: systemic lupus erythematosus, rheumatoid arthritis.
what is long QT syndrome? and what can it cause?
A normal QT interval is less than 440ms (two large squares).
Any interval above 450 ms is considered prolonged.
This can lead to prolonged ventricular repolarisation which predisposes to malignant ventricular arrhythmias.
discuss the genetics of long QT syndrome
Genetic (Sodium or potassium channel mutations):
- Jervell and Lange-Nielson syndrome (associated with deafness).
- Romano Ward Syndrome.
discuss the investigations of long QT syndrome
Electrocardiogram +- 24 hour tape
Echocardiogram to look for structural heart disease
Genetic testing as required
discuss the management of long QT syndrome
Beta blockade
Cardiac Pacing
Manage underlying cause
Implantation of ICD
what is cardiomyopathy?
A structural and functional abnormality of the myocardium without coronary artery disease, hypertension, valvular or congenital heart diseases.
what are the main subtypes of cardiomyopathy?
Dilated - most common
Hypertrophic
Restrictive
Arrhythmogenic right ventricular cardiomyopathy
what is dilated cardiomyopathy? where does it typically start? what does it make more difficult?
Myocardium disease that causes the ventricles to thin and stretch, growing larger. It typically starts in the left ventricle. Dilated cardiomyopathy makes it harder for the heart to pump blood to the rest of the body.
discuss the genetics of dilated cardiomyopathy
Genetic and congenital - may be related to familial dilated cardiomyopathy, however some sporadic gene mutations may be responsible for idiopathic cases. Autosomal dominant in most cases.
epidemiology of hypertrophic cardiomyopathy? what is it often the cause of?
Hypertrophic cardiomyopathy is the commonest genetic heart condition. It is often the cause of sudden cardiac death in young people and athletes.
discuss the inheritance of hypertrophic cardiomyopathy
It is inherited in an autosomal dominant fashion.
Mutations can be identified in approximately 60% of patients.
discuss the genetics and aetiology of turners syndrome
Turner’s syndrome is a condition that affects only females and results when one of the X chromosomes is missing or partially missing.
discuss the cardiovascular presentation of Turner’s syndrome
Congenital heart defects - bicuspid aortic valve (most common), coarctation of the aorta.
This increases the risk of aortic stenosis and/or aortic dissection.
what are some genetic causes or aortic regurgitation?
congenital disease e.g., bicuspid aortic valve
Marfan’s syndrome
what are some causes of aortic root dilatation?
Congenital bicuspid aortic valve
Genetic syndromes e.g. Marfan’s, Ehlers-Danlos, osteogenesis imperfecta
pulmonary stenosis is often acquired and associated with which syndromes?
Noonan syndrome (valvular)
Williams syndrome (supravalvular)
Tetralogy of Fallot (valvular)
What is Brugada’s syndrome?
Brugada syndrome is a genetic condition caused by sodium channelopathies.
what are the clinical features of Brugada’s syndrome?
Patients may be asymptomatic or present with palpitations and syncope due to arrhythmias such as AV nodal re-entrant tachycardias (AVNRTs), VT or VF.
what is mitral stenosis?
Mitral stenosis (MS) is the impaired opening of the mitral valve affecting blood flow from the left atrium to the ventricle.
aetiology of mitral stenosis
o Rheumatic heart disease.
o Congenital mitral stenosis.
o Systemic conditions: systemic lupus erythematosus, rheumatoid arthritis.
what is mitral regurgitation?
- Mitral regurgitation (MR) is the backflow of blood across the mitral valve during systole due to incompetence of the mitral valve.
mitral regurgitation aetiology
o Rheumatic heart disease.
o Mitral valve prolapse (MVP).
o Infective endocarditis (IE).
o Degenerative.
o Functional MR due to LV and annular dilatation.
what is aortic stenosis?
- Aortic stenosis is a narrowing of the aortic valve opening and is one of the most common and serious heart problems.
aortic stenosis aetiology
o Degenerative.
o Rheumatic.
o Bicuspid aortic valve.
aortic regurgitation definition
- Aortic regurgitation (AR) is the reverse flow of blood across the aortic valve in diastole due to the incompetence of the valve.
aetiology of aortic regurgitation
o Aorta:
Dilated aorta (Marfans, hypertension).
Connective tissue disorders.
o Leaflets:
Bicuspid aortic valve.
Rheumatic heart disease.
Endocarditis.
Myxomatous degeneration.
Criteria and pathophysiology of mitral stenosis
-mitral valve orifice < 2cm^2
-left atrium pressure increases
-pulmonary venous and capillary pressure increases
-pulmonary vascular resistance increases
-pulmonary hypertension develops
-right heart dilatation with tricuspid regurgitation and pulmonary regurgitation
Criteria and aetiology of aortic stenosis
o AVA < 1.5-2 cm2.
o Rheumatic: retraction and stiffening of free cusp margins.
o Degenerative: linked to atherosclerosis.
pathophysiology of aortic regurgitation
o LV accommodates both SV and regurgitant volume.
o Increased LV end-diastolic volume and LV systolic pressure.
o LV hypertrophy and LV dilatation.
o Increased myocardial oxygen consumption.
o Myocardial ischaemia.
o LV failure.
symptoms of mitral stenosis
dyspnoea
palpitations if in AF
heart failure
haemoptysis
signs of mitral stenosis
malar flush
tapping apex beat and diastolic thrill
hoarse voice
irregularly irregular pulse if in AF
auscultation: low-pitch mid-diastolic murmur with opening snap
symptoms of acute MR (valve perforation, chordal/papillary muscle)
breathlessness, pulmonary oedema, cardiogenic shock
chronic mitral regurgitation symptoms
o Fatigue, exhaustion (low CO), right heart failure.
o Dyspnoea or palpitations due to atrial fibrillation.
symptoms of aortic stenosis
syncope
dyspnoea
angina
heart failure
signs of aortic stenosis
narrow pulse pressure
slow rising pulse
aortic regurgitation symptoms
dyspnoea
angina
heart failure
complications of aortic stenosis
sudden cardiac death
arrhythmia
heart failure
infective endocarditis
complications of aortic regurgitation
heart failure
arrhythmia
infective endocarditis
complications of mitral stenosis
AF
heart failure
infective endocarditis
complications of mitral regurgitation
AF
heart failure
infective endocarditis
pulmonary hypertension
aortic stenosis investigations
ECG: LV hypertrophy; AV block.
CXR: poststenotic dilation of the ascending aorta; may see calcification of valve on lateral view.
ECHO: confirms diagnosis; allows severity and valve area to be assessed.
aortic regurgitation investigations
ECG: LV hypertrophy
CXR: may see cardiomegaly and pulmonary oedema if patient has heart failure.
ECHO: confirms diagnosis: allows severity and aortic root to be assessed.
mitral stenosis investigations
ECG: atrial fibrillation, bifid P waves > 0.12 secs.
CXR: pulmonary oedema and enlarged left atrium may be seen.
ECHO: confirm diagnosis, allows severity and valve area to be assessed.
mitral regurgitation investigations
ECG: atrial fibrillation, bifid P waves > 0.12 secs.
CXR: may see cardiomegaly and pulmonary oedema if patient has heart failure.
ECHO: confirms diagnosis, allows severity to be assessed.
discuss the treatment of mitral stenosis
diuretics and restriction of sodium intake
manage atrial fibrillation and heart failure via NICE guidelines
surgical valve replacement
MR treatment
In acute MR preload and afterload reduction may be life-saving.
Manage heart failure and AF by following NICE guidelines.
Surgical valve repair is preferred to replacement.
aortic stenosis treatment
manage CV risk factors e.g., control blood pressure.
surgical valve replacement
aortic regurgitation treatment
manage heart failure by following NICE guidelines
surgical valve replacement
what is cardiac tamponade? (complication of open heart surgery)
- Cardiac tamponade occurs when the accumulation of fluid, blood, purulent exudate or air in the pericardial space raises the intra-pericardial pressure. Subsequently, the diastolic filling is reduced thereby reducing the cardiac output. It is a life-threatening emergency that requires prompt diagnosis with an echocardiogram and treatment.
symptoms of cardiac tamponade
o SOB.
o Tachycardia.
o Confusion.
o Chest pain.
o Abdominal pain.
signs of cardiac tamponade
o Hypotension.
o Quiet heart sounds.
o Raised JVP.
- Secondary features:
o Oliguria.
o Increased oxygen requirements.
o Metabolic acidosis.
list the types of prosthetic valves in common use and their advantages/disadvantages
- Biological valve: no warfarin is required but the valve wears out after 15 years.
- Mechanical valve: warfarin is required for life. Valve lasts for > 40 years.
discuss the medical treatment of infective endocarditis
Medical: some examples of empirical therapy include benzylpenicillin and gentamicin.
streptococci: benzylpenicillin and amoxicillin
staphylococci: flucloxacillin and gentamicin
aspergillus:miconazole
Surgical valve repair or replacement.
what is infective endocarditis?
It is an infection of the endocardium usually involving the heart valves, with ‘vegetation’ of the infectious agent.
The mitral valve is more commonly affected but the tricuspid valve is implicated in drug users.
infective endocarditis risk factors
IV drug abuse
cardiac lesions
rheumatic heart lesions
dental treatment
most common infective organisms in infective endocarditis
streptococcus viridans
staphylococcus aureus
staphylococcus epidermis
ennterococci
HACEK organisms- haemophilus, actinobacillus, cardiobacterium, eikenella and kingella.
signs and symtpoms of infective endocarditis
(Remember FROM JANE).
Fever.
Roth’s spots.
Osler’s nodes.
Murmur (new)
Janeway lesions
anaemia
nails: splinter haemorrhages
emboli
investigations of infective endocarditis
blood cultures: take 3 seperate cultures from 3 peripheral sites
bloods for anaemia
urinalysis; microscopic haematuria
CXR
ECG
transoesophageal/transthoracic ECHO for vegetations
discuss the classification of infective endocarditis using the Modified Duke’s Criteria
o Definitive IE – two major criteria OR one major + three minor criteria OR five minor criteria.
o Possible IE – one major + one minor OR three minor criteria.
o Major Duke’s criteria:
Blood culture positive for typical microorganisms (e.g., Staphylococcus aureus, Enterococcus, viridans streptococci.
Echocardiogram showing valvular vegetation.
o Minor Duke’s criteria (FIVE):
Fever > 38 degrees Celsius.
Intravenous drug use or predisposing cardiac lesion.
Immunological phenomena e.g., glomerulonephritis, Osler’s nodes, Roth’s spots, rheumatoid factor.
Vascular phenomena e.g., arterial emboli, mycotic aneurysms, intracranial or conjunctival haemorrhages, Janeway lesions.
- ECHO findings.
What ECG finding in a patient with IE is an indication for surgery?
PR prolongation
what are some complications of rheumatic heart disease?
Heart failure. This can occur from either a severely narrowed or leaking heart valve.
Bacterial endocarditis. …
Complications of pregnancy and delivery due to heart damage. …
Ruptured heart valve.
clinical features of rheumatic heart disease
dyspnoea
symptoms of heart failure
outline the investigations in rheumatic heart disease
ECG: finding are not specific for RHD, they may demonstrate left atrial or ventricular enlargement and ventricular strain. In more severe degrees of mitral valve damage, especially in older patients, atrial fibrillation may be present.
CXR: may show an enlarged left atrium or ventricle and radiological signs of pulmonary venous congestion in more advanced cases.
ECHO: RHD typically affects left-sided valves, with greater affinity and consequence for the mitral valve. Mitral stenosis +/- regurgitation. Aortic stenosis or regurgitation are less common.
rheumatic heart disease treatment
o Diuretics.
o Vasodilators: ACEi/ARB.
o Treatment for AF: beta-blockers/digoxin, anticoagulation (WARFARIN).
o Balloon mitral valvuloplasty:
Effective if symptomatic mitral stenosis.
Suitable for younger patients and pregnancy.
o Cardiac surgery:
When valvuloplasty is not possible.
Severe MR associated artic and tricuspid valve disease.
Repair might not be feasible.
Bioprosthetic vs mechanical prosthetics.
discuss down syndrome and CV effects
trisomy of chromosome 21
15% have atrioventricular septal defects
discuss 22q11 deletion syndrome (Di George) effects
cardiac malformation
abnormal facies
thymic hypoplasia
cleft palate
hypoparathyroidism
discuss williams syndrome
o Deletion of elastin on chromosome 7.
aortic stenosis (supravalvular)
what are some teratogens of congenital heart disease
o Fetal alcohol syndrome.
o Antiepileptic drugs.
o Rubella.
o Maternal diabetes mellitus.
discuss marfan’s syndrome
o Autosomal dominant.
o Fibrillin 1 gene mutation, located on chromosome 15.
o Multisystem.
o Connective tissue affected.
aortic dilatation/dissection
Long QT syndrome Romano-Ward symptoms
syncope
siezure
sudden death
can be exacerbated by: emotion, exercise and drugs.
Whats the mechanism of a venous thromboembolism?
Combination of Virchow’s triad, especially - stasis and hypercoagulability.
what does a venous thromboembolism result in?
back pressure
what are venous thromboembolism diseases?
DVT and PE
what is the composition of a venous thromboembolism?
red blood cells and fibrin
‘red thrombus’
what is a thromboembolism?
the movement of blood clots along a vessel
symptoms and signs of DVT
o Unilateral limb swelling.
o Persisting discomfort.
o Calf tenderness.
o Warmth.
o Redness.
o Prominent collateral veins.
o Unilateral pitting oedema.
o May be clinically silent.
potential long term consequences of DVT
o Post-thrombotic syndrome:
Damage to venous valves.
Incidence of 20-60% within 2 years of DVT.
Swelling.
Discomfort.
Pigmentation.
Ulceration in severe form.
symptoms and signs of PE
o Pleuritic chest pain.
o Dyspnoea.
o Haemoptysis.
o Rapid heart rate- tachycardia.
o Pleural rub on auscultation – usually due to pulmonary infarction.
symptoms and signs of massive PE
o Severe dyspnoea of sudden onset.
o Collapse.
o Blue lips and tongue.
o Tachycardia.
o Hypotension.
o Raised JVP.
o May cause sudden death.
long-term consequences of PE
o Most fully recover.
o Pulmonary arterial hypertension (4% of patients).
diagnosis of DVT:
o Clinical assessment and pretest probability score (Wells score).
o Blood test: D-dimer if low pre-test probability score.
o Imaging: compression ultrasound if positive D-dimer or high pre-test probability score.
Doppler ultrasound or CT/MR venogram
what is a D-dimer?
A D-dimer is a breakdown product of cross-linked fibrin produced during fibrinolysis. High sensitivity and low specificity for VTE.
diagnosis of PE
o Clinical assessment and pre-test probability score (Wells score or Geneva score).
o Blood test: D-dimer if low pre-test probability score.
o Imaging: if D-dimer positive or high pre-test probability score:
Isotope ventilation/perfusion scan.
CT pulmonary angiogram.
treatment of DVT
- Anticoagulation - either a Direct Oral Anticoagulant (DOAC), Low Molecular Weight Heparin (LMWH) or warfarin (which can be bridged with LMWH. NICE guidelines recommend DOACs such as Apixaban or Rivaroxaban as first line therapy.
- Percutaneous mechanical thrombectomy, used in massive DVTs.
- IVC filter: This will not actually treat the DVT but will reduce the risk of the DVT embolising into the pulmonary arteries causing a PE.
treatment of PE
- Thrombolysis (an intravenous bolus of Alteplase) is indicated in a massive PE (features of haemodynamic instability). There is debate over whether it should be administered in a sub-massive PE.
- anticoagulation
What are Roth spots?
Roth spots are seen in infective endocarditis, they are retinal haemorrhages with a pale centre.
which arteries can be used as conduits in a CABG?
Arteries such as the internal mammary or the radial artery can be used as conduits in a CABG.
what is the classic triad of aortic stenosis?
The classic triad of the presentation of Aortic stenosis is syncope, angina and heart failure.
Di George’s syndrome CATCH 22
Cardiac malformation
Abnormal facies
Thymic hypoplasia
Cleft palate
Hypoparathyroidism
22 q11 deletion.
what is the classic pulse of aortic regurgitation?
collapsing pulse
what are the classic cardiac associations of Noonan syndrome?
pulmonary stenosis and hypertrophic cardiomyopathy
what is the pulse pressure in aortic regurgitation like?
The pulse pressure is the difference between systolic and diastolic pressure. In Aortic regurgitation the pulse pressure is wide.
what are Osler’s nodes?
These are painful, erythematous nodules found on the hands and soles of feet. They are associated with infective endocarditis as well as other conditions.
what is the classic pulse of aortic stenosis?
small volume and slow rising
what is pericarditis?
Acute pericarditis is inflammation of the pericardium, a fibroelastic sac surrounding the heart.
causes of pericarditis?
- Infective causes: viruses, bacteria, fungi and parasites.
- Malignant causes
- Heart failure may cause pericarditis
- Post-cardiac injury syndrome (Dressler’s syndrome) including post-trauma
- Radiation.
-Drugs and toxin causes
-Rheumatological disease: SLE, RA etc.
-Other causes: renal failure (uraemia), hypothyroidism, IBD, ovarian hyperstimulation.
clinical features of pericarditis?
Chest pain (usually pleuritic and worse on lying flat)
Fever
Pericardial friction rub
ECG changes
Widespread saddle-shaped ST elevation
PR depression
Raised troponin
what is constrictive pericarditis?
Constrictive pericarditis is the result of scarring and loss of elasticity of the pericardial sac. The upper limit of cardiac volume is constrained by the rigid pericardium, which prevents normal cardiac filling. As a result of the restriction on ventricular volume, stroke volume and cardiac output are limited.
clinical features of constrictive pericarditis?
Raised JVP
Kussmaul’s sign (paradoxical rise in JVP with inspiration),
Pulsus paradoxus (drop in cardiac output on inspiration)
Heart sounds may also be quiet (if pericardial effusion also present)
Third heart sound (S3) may be present (due to rapid early diastolic ventricular filling).
complications of pericarditis
Complications are rare but include cardiac tamponade and pericardial effusion requiring pericardiocentesis. In the long term patient can occasionally develop constrictive pericarditis.
which heart defect/s is associated with Di George syndrome?
Tetralogy of fallot
which heart defect/s is associated with Down’s syndrome?
AVSD, ASD > VSD
which heart defect/s is associated with Edwards syndrome (trisomy 18)?
ASD, VSD, PDA
which heart defect/s is associated with Turner’s syndrome 45XO?
coarctation of the aorta
which heart defect/s is associated with Noonan’s syndrome?
pulmonary valve stenosis
ASD/VSD
which heart defect/s is associated with William’s syndrome?
supravalvular aortic stenosis and pulmonary artery stenosis
which heart defect/s is associated with Marfan’s syndrome?
aortic root dilatation causing aneurysm/ dissection and valve problems due to pressure
which heart defect/s is associated with Ehlers Danlos syndrome?
mitral valve prolapse
