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PACES > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Murmur in ASD

A
  • Pulmonary ES
  • Fixed split S2
  • Mid-diastolic flow murmurs with large L to R shunts.

There is no mumur from the ASD itself

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2
Q

Commonest cause of AS

A
  • Calcific degeneration overall
  • If <65yr likely Congenital bicuspid valve (about 5-10%)
  • IE
  • Paget’s disease

extremely rare= Post Rh fever

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3
Q

Commonest cause of Mitral Stenosis

A

Rheumatic fever (>90%)

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4
Q

Infective endocarditis - strongest risk factor

A

Previous inf endocarditis

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5
Q

What value of pulmonary artery pressure is considered diagnostic of pulmonary arterial hypertension?

A

> 25mmHg at rest

—-measured by cardiac catheterisation

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6
Q

most common heart defect in Marfans

A

dilation of the aortic root

AR or aneurysm/dissection may develop as a consequence
MVP

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7
Q

Fatigue and SOBOE
Light compression to the tip of the fingernail bed causes capillary pulsation

…what is this sign called?

A

Quincke’s sign - in Aortic Regurge, so early Diastolic murmur

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8
Q

causes of dilated cardiomyopathy

A

Alcohol
Beriberi wet - thiamine deficiency
Coxsackie B
Doxorubicin

(HOCM has four letters - S4)

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9
Q

Management of bradycardia in heart transplant

A

Atropine is ineffective in transplant bradyarrhythmias because the heart is denervated

So theophylline or pacing

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10
Q

Causes of ejection systolic murmur

A

Loudest in aortic area
• Aortic stenosis
• Aortic sclerosis
• HOCM (tends to be younger, LL sternal edge and throughout precordium, doesn’t radiate to carotids)
• Pulmonary Stenosis - Loudest in pulmonary area- young patient but rare

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11
Q

commonest cause of pulmonary stenosis

A

Congenital (often from maternal rubella infection =commonest)

Ejection Systolic in pulmonary area
Louder on INspiration

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12
Q

where does AS murmur radiate

A

radiates to carotids

Ejection systolic murmur loudest in aortic region

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13
Q

Slow rising pulse

A

Aortic stenosis

feels weak and late

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14
Q

Anaemia in aortic stenosis

A

Heyde syndrome is a triad of

  • aortic stenosis
  • acquired Von Willebrand disease
  • anaemia (due to GI bleeding from intestinal angiodysplasia)
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15
Q

Make aortic stenosis murmur louder

A

Loudest on held expiration and when the patient is sitting forwards

Can be heard over Apex (Gallavardin phenomenon)

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16
Q

aortic stenosis vs sclerosis on examination

A

sclerosis:

  • Doesn’t radiate to Carotids as much
  • Is softer and shorter in nature

(A. sclerosis is thickening without any significant effect on function)

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17
Q

Signs of severe in aortic stenosis

A 
Late peaking mumur
Evidence of cardiac decompensation 
Slow rising low volume pulse 
Narrow pulse pressure
Absent of second heart sound
LV heave
Carotid radiation 
Fourth heart sound in LVH

Echo
• Peak gradient >64
• or mean gradient >40mm Hg
• or valve area <1 cm2

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18
Q

when would you consider TAVI vs surgical aortic valve replacement

A

If low surgical risk and <65, then SAVR

  • -> mechanical last longer but need anticoag
  • -> tissue, no anticoag

If >65 or significant-intermediate risk, then TAVI, if transfemoral possible

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19
Q

What does TAVI stand for

A

Transcatheter aortic valve implantation

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20
Q

Describe TAVI vs surgical AVR

A
  • TAVI pushes stiff / calcified valve out of the way during implantation
  • Can be done under general or local
  • Surgical operation removes the stiff valve and a new mechanical or tissue valve is in place
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21
Q

features of pulmonary stenosis

A

Often congenital, so younger

Ejection systolic murmur loudest of pulmonary area

Louder on INspiration

Radiates to left shoulder/left infraclavicular region

RV dilatation can lead to a RV heave

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22
Q

Common indications for aortic valve replacement (AVR)

A

Severe or symp AS or AR or infective endoc

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23
Q

Anticoagulation for mitral vs aortic valve replacement

A 
Depends on presence of risk factors for valve thrombosis
• prior thromboembolism
• AF
• Rh mitral stenosis (any degree)
• LVEF <35%
• Mitral > Aortic risk

Mechanical aortic INR of 2.5
Mechanical mitral INR of 3.0

Only Warfarin recommended

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24
Q

Advantage of mechanical heart valve vs tissue

A
  • They are longer lasting
  • but require anticoagulation
  • in AS, can use TAVI if not fit for surgery
  • in MR can clip
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25
Q

Collapsing pulse

A

aortic regurgitation

w hollow diastolic murmur

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26
Q

causes of pansystolic (aka holosystolic) murmur

A

High pitched and blowing from S1 to S2…
• mitral regurge (apex)
• tricuspid regurgitation (Left lower sternal edge)
• mitral valve prolapse (Mid systolic + opening click)
• VSD (harsh in character, well-localised left sternal edge)

Makes sense because s1 is sound of mitral and tricuspid closing, so if regurge then this will be extended

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27
Q

Where is apex beat?

A

near the midclavicular line in the fifth intercostal space

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28
Q

murmurs louder on inspiration vs expiration

A

Inspiration -> right heart (pulmonary and tricuspid) due to increased venous return
Expiration -> left heart (mitral and aortic)

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29
Q

Signs of severe mitral regurge

A

Pulmonary hypertension i.e. raised JVP, S3 gallop, displaced/thrusting apex, right ventricular heave

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30
Q

What is JVP

A

reflection of physical pressures in Right atrium

i.e. pulmonary hypertension causes raised

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31
Q

Consideration for surgery in mitral regurge

A
  • signs or symptoms (pul hypertension or fluid overload)
  • Acute MR following MI

or in asymp:
• Declining ejection fraction
• Increasing LV dilatation

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32
Q

causes of mitral regurge

A

DEGENERATIVE
• Age-related changes
• Mitral valve prolapse
• Connective tissue issues

ACQUIRED
• papillary muscle rupture - i.e. MI
• infection - Rheumatic fever, infective endo

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33
Q

Causes of aortic stenosis

A
  • Calcification of the aortic valves
  • Congenital bicuspid valve
  • Rheumatic heart disease
34
Q

HASBLED score

A 
Hypertension
Abnormal renal and liver function
Stroke
Bleeding predisposion
Labile INR
Elderly (>65)
Drugs or alcohol

≥3 indicates “high risk”

35
Q

drug contraindications in severe aortic stenosis

A

Vasodilators (which can increase the gradient across the valve)
ACEi
Nitrates
Sildenafil

36
Q

Rhythm control of AF

A

Medically:
• Flecainide
• only if no evidence of structural heart disease

Mechanically:
• DC cardioversion
• (with 2,3,4 anticoag, more than 2 days then 3 before and 4 after)

37
Q

common cardiac issues with ehler’s danlos

A

mitral valve prolapse

aortic dilatation

38
Q

Heart condition in Noonan’s

A

Pulmonary stenosis (ES in pul, louder with insp)

May have hypertrophic cardiomyopathy or septal defects

39
Q

Differentials of pulmonary stenosis mumur

A

PS is usually due to valvular obstruction, but may also be due to sub- or supravalvular obstruction

Right Ventricle Outflow Tract Obstruction = harsh ES murmur at the left sternal border in the second intercostal space

AS
VSD
ASD

40
Q

Features of pulmonary stenosis

A

ES in pulmonary area, louder with insp

R ventricular hypertrophy in signif (so RV heave)

Can cause delayed RA emptying, and elevated RA pressure === raised JVP with prominent A waves

41
Q

Loud metallic click in S2

A

Metallic aortic valve replacement

42
Q

pan-systolic best heard in the left lower sternal border;

A

VSD

or Tricuspid regurge

43
Q

VSD murmur

A

pan-systolic best heard in the left lower sternal border; (tricuspid region)

44
Q

Midline sternotomy differentials

A
  • CABG
  • Valve replacement
  • Transplant
45
Q

Valves causing S1 sound

A

Closing of mitral and tricuspid valves

46
Q

Valves causing S2 sound

A

Closing of aortic and pulmonary valves

47
Q

CABG without vein harvesting scar

A

via internal mammary artery

instead of greater saphenous vein

48
Q

AVR and pacemakers

A

10% of patients with aortic valve replacement need pacemaker from AV node damage

49
Q

Valve replacement with Infective endocarditis

A

Look for tunnelled lines etc

50
Q

where is infective endocarditis most likely?

A

mitral valve, causing stenosis or regurge

51
Q

Management of AF explanation points

A

If no underlying cause can be found, the treatment options are:

  • medicines to reduce the risk of a stroke
  • medicines to control atrial fibrillation
  • cardioversion (electric shock treatment)
  • catheter ablation
  • having a pacemaker fitted
52
Q

Most common causes of AF

A

common causes of AF are

  • Ischaemic heart disease
  • Hypertension
  • Valvular heart disease
  • Hyperthyroidism
53
Q

Calculate bleeding risk with AF

A

ORBIT score has taken over hasbled as doesn’t have labile INR section

TWO points for:
• Hx of GI/intracranial bleeding
• Hb <120 or 130 or hematocrit <36%

And one score for:
• Age >74 years
• GFR <60
• Treatment with antiplatelet agents

54
Q

Triggers of AF

A
  • Pulmonary embolism
  • Ischaemic heart disease
  • Respiratory disease
  • Atrial enlargement or myxoma
  • Thyroid (fhyper)
  • Ethanol
  • Sepsis/sleep
55
Q

Mitral valve prolapse murmur

A

Young women, ?marfan’s HOCM

  • Mid-systolic click (prolapse of the mitral valve into left atrium)
  • Followed by a mid or late-systolic murmur
  • Heard loudest at the apex
  • Loudest in expiration, standing from squating
56
Q

pericarditis associated conditions

A
  • Injury (Dressler syndrome - post MI)
  • Infection (COVID-19)
  • Inflammatory (SLE, RA)
  • Inherited (familial Mediterranean fever)

Gen causative organism is Staph, Strep, Pneumococcus

57
Q

Cardiac issues with Down’s

A
  • atrioventricular septal defect (AVSD)
  • patent ductus arteriosus (PDA)
  • tetralogy of Fallot
58
Q

Tetralogy of Fallot

A
  • PS
  • VSD
  • RVH
  • Overriding aorta
59
Q

Jerky pulse character

A

HOCM

ESM at the tricuspid region that radiates throughout the precordium, with S4

60
Q

echo findings of HOCM

A

MR SAM ASH
• mitral regurgitation (MR)
• systolic anterior motion (SAM) of the anterior mitral valve leaflet
• asymmetric hypertrophy (ASH)

61
Q

Mixed aortic valve pathology

A

ES murmur
Early diastolic

Can also have - Austin Flint murmur (LL sternal edge, hitting ant mitral valve)

62
Q

Causes of restrictive cardiomyopathy

A

primary
• Loeffler’s endocarditis
• endomyocardial fibrosis

secondary / infiltrative
• cardiac amyloidosis,
• cardiac sarcoidosis
• iron overload (haemochromatosis)

63
Q

Causes of Eisenmenger’s syndrome

A

VSD, ASD, or PDA causing pulmonary hypertension
Causing reversal of L to R shunt

Look for cyanosis, clubbing, aortic regurge
Can get RVF, paradoxical embolism, IE, hypoxaemia, haemoptysis

64
Q

Cardiac causes for clubbing

A
  • Infective endocarditis

* Cyanotic congenital heart disease

65
Q

Patent ductus arteriosus murmur

A
  • Loud continuous ‘machinery murmur’ loudest below the left clavicle in systole
  • Loudest in exp

“rolling thunder”

66
Q

What is Patent ductus arteriosus?

A

Connection between
• proximal left pulmonary artery
• and the descending aorta, just distal to the left subclavian artery

in the developing fetus

67
Q

Wolff-Parkinson-White syndrome ECG

A
  • Short PR interval (<120 ms)

* Widening of QRS complex due to a slurred upstroke (delta wave) of the QRS complex

68
Q

When is carotid pulse felt?

A

Just after S1 but before S2

69
Q

Ejection Fraction grading

A
  • Normal = LVEF 50 - 70%
  • Mild = 40 - 49%
  • Moderate = 35 -39%
  • Severe < 35%
70
Q

Pacemaker indications

A
  • Sick sinus syndrome
  • Symptomatic or drug-resistant AF
  • Mobitz 2 or complete heart block
71
Q

Cardiac Resynchronization Therapy indications

A

• EF <35% with QRS>120
—-> E.g. in LBBB and HF

• CRT defibrillators (CRT-D) also incorporate ICD

72
Q

implantable cardioverter defibrillator (ICD) insertion indications

A 
Primary prevention  
• MI with 
    - LVEF < 35%  
    - or LVEF < 30% and QRS ≥ 120  
• Familial condition with high‐risk SCD  
    - LQTS, ARVD, Brugada, HOCM

Secondary prevention
• Cardiac arrest due to VT or VF
• or VT with haemodynamic compromise
• or VT with LVEF < 35%

73
Q

Indications for implantable loop recorder

A
  • Last about 3 years
  • Monitor heart rate to investigate for dizzy spells, palpitations, black outs
  • Depending on the type of loop recorder, might need to use your hand-held activator when symptomatic
74
Q

Echo signs of severe aortic stenosis

A
  • Mean gradient >40mm Hg
  • or Peak gradient >64
  • or Valve area <1 cm2
75
Q

Cardiac issues with Myotonic dystrophy

A

cardiac dysrhythmia is the second leading cause of death after respiratory failure

76
Q

Causes of pulmonary hypertension

A 
Group 1:
• Idiopathic
• connective tissue diseases
• Congenital heart disease
• Drugs

Group 2:
• Left heart disease (A or M valve, LV)

Or Group 3: due to chronic resp disease

Group 4 clots
Group 5 other

77
Q

When would you admit pt with palpitations?

A
  • VT or persistent SVT
  • Haemodynamic instab
  • History of structural heart disease
Or features suggesting underlying issue:
• High degree AV block on ECG
• Significant SOB
• Chest pain, Syncope /near syncope
• Fam hx of sudden cardiac death <40y! 
• Precipitated by exercise
78
Q

Pulsatile liver

A

Tricuspid regurge (pansystolic murmur)

79
Q

Causes of tricuspid regurge

A

Congenital:
•  Ebstein’s anomaly (atrialization of the right ventricle and TR)

Acquired:
•  Acute: infective endocarditis (IV drug user)
•  Chronic: functional (commonest), rheumatic and carcinoid syndrome

80
Q

Indications for heart transplant

A

Severe heart failure
Congested cardiac failure
Cardiomyopathy
Congenital

PACES (13 decks)

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