Cardiology Flashcards
Ankylosing spondylitis is associated with what valvular dysfunction?
Aortic regurgitation
What is an argyll robertson pupil? What is its significance in cardiovascular disease?
Bilaterally small pupils that do not constrict when exposed to bright light, but do constrict when focussed on a neaby object. This finding is highly specific for tertiary syphyilis. The cardiac features of tertiary syphylis are aortic aneurysm aortic regurgitation.
What is the rash?
Janeway’s lesions
What is the ‘a’ wave in a JVP waveform? Why might you see large a waves or cannon a waves?
Atrial contraction just prior to S1. If there is complete heart block, then you may see cannon a waves as the atrium contracts against a closed tricuspid valve. A dominant or large a wave will be seen during tricuspid stenosis or anything that causes raised right ventricular pressure (e.g. pulmonary stenosis, pulmonary hypertension)
What is the x descent in the JVP waveform?
Atrial relaxation allowing filling from the jugular vein, with blood dropping down into atrium.
What is the v wave in the JVP?
Atrial filling during systole. When there is tricuspid regurgitation, the V wave is very large as the last part of systole uses ventricular force to pass blood into the internal jugular vein up the neck.
Differentials for a raised JVP?
RV failure, tricuspid stenosis, tricuspid regurgitation, pericardial effusion or constrictive pericarditis, superior vena caval obstruction, fluid overload, hyperdynamic circulation (beri, beri, fever, anaemia, thyrotoxixosis, AV fistular, pregnancy, hypoxia, hypercapnia).
What is an anacrotic carotid pulse and what is associated with?
Anacrotic pulse is small volume with a slow upstroke. It is associated with aortic stenosis.
What is a plateu carotid pulse and what pathology is it associated with?
A plateau pulse is one with a slow upstroke but normal volume. Aortic stenosis.
What is a bisferiens carotid pulse and what pathology is it associated with?
A bisferiens pulse is an anacrotic pulse (slow upstroke and small volume) PLUS collapsing. Mixed AS and AR.
What is a collapsing carotid pulse, and what pathology is it associatecd with?
A collapsing pulse is on that rapidly drains away leading to a tapping sensation on palpation. Usually also felt in the forearm (waterhammer pulse). It is associated with aortic regurgitation, hyperdynamic circulation, arteriosclerotic aorta (in elderly patients), patent ductus arteriosis or peripheral AV aneuysm.
What are the causes of a small volume carotid pulse?
AS or pericardial effusion
What is an alternans carotid pulse and what pathology is it associated with?
Alternating weak and strong pulsation. This is associated with left ventricular failure.
What type of valve pathology leads to a tapping apex beat?
Mitral stenosis
What are the causes of a loud S1?
Mitral stensois
Tricuspid stensosis
Tachycardia
Hyperdynamic circulation
What are the causes of a soft S1?
Mitral regurgitation
Calcified mitral valve
LBBB
First degree heart block
What are the causes of a loud A2?
Systemic hypertension
What are the causes of a soft A2?
Calcified aortic valve
Aortic stenosis
Aortic regurgitation
What is the causes of a loud P2?
Pulmonary hypertension
What is the cause of a soft P2?
Pulomonary stenosis
Increased normal S2 splitting?
RBBB
Pulmonary stenosis
VSD
MR
Fixed S2 splitting?
ASD
Reversed S2 splitting?
LBBB
Severe AS
Coarctation of aorta
PDA
Causes of a 3rd heart sound?
Physiological in fit people under 40 or pregnant people, LV failure, AR, MR, VSD, PDA
Causes of 4th heart sound?
LV failure, that may be associated with AS, MR, HTN, IHD or HCM
What are the differential diagnoses for a pansystolic murmur?
MR
TR
VSD
Aortopulmonary shunts
What are the differentials for a midsystolic murmur?
AS, PS, HCM, ASD
What are the differentials for a pre-systolic murmur?
Mitral stenosis, tricuspid stenosis, atrial myxoma
What are the differentials for a continuous murmur?
Patent ductus arteriosus, AV fistula, venous hum, rupture of a sinus of valsalva into the right atrium or ventricle, arotopulmonary connection, mammory souffle (pregnancy murmur). Note that a combination of a systolic and diastolic murmur might be confused with a continuous murmur.
What is the normal mitral valve area?
4-6cm squared
What valve area is considered severe for mitral stenosis?
<1cm squared
What are the causes of mitral stenosis?
Rheumatic heart disease
Congenital
Rheumatoid arthritis
SLE
Carcinoid syndrome
Whipples disease
Fabry’s disdase
Severe mitral annular calcification (occasionally associated with hypercalcaemia and hyperparathyroidism)
After mitral valve repair for mitral regurgitation
What are the signs of severity for a mitral stenosis murmur?
Small pulse pressure (due to low LV volumes)
Early-opening snap (due to raised LA pressure)
Length of the mid-diastolic rumbling murmur (persists as long as there is a gradient)
Diastolic thrill at the apex
Presence of pulmonary hypertension
- prominent a wave in the JVP
- right ventricular impulse
- loud P2, more so if palpable P2
- pulmonary regurgitation
- tricuspid regurgitation
What ECG findings do you expect to see in patients with mitral stenosis?
P mitrale - notched, enlarged P-wave - due to left atrial enlargement
Atrial fibrillation
Right ventricular systolic overload (severe disease)
Right axis deviation (severe disease)
Which leads should you use to accurately assess for axis deviation?
First, lead 1 and aVF (or lead III). If aVF (or III) has majority negative QRS complex, and therefore left access deviation is suspected, lead II can be used to confirm this. If lead II is negative, pathological left axis deviation is confirmed.
What can cause right axis deviation?
Right ventricular hypertrophy
Acute right ventricular strain (e.g. secondary to a pulmonary embolus)
Lateral MI
COPD
Pulmonary hypertension (and things that can lead to this like Mitral stenosis)
Hyperkalaemia
Sodium channel blockade (e.g. TCA poisoning)
Wolf-Parkinson White Syndrome
Dextrocardia
Ventricular ectopy
Secundum ASD
Normal paeds ECG
Left posterior fascicular block
Vertically orientated heart
What can cause left axis deviation?
Left ventricular hypertrophy
Left bundle brance block
Inferior MI
Ventricular pacing
Wolf Parkinson White Syndrome
Primum ASD
Left anterior fasciular block
Horizontally orientated heart
What might you seen on XR in mitral stenosis?
Enlarged left atrium (large left atrial appendeage, double left atrial shadow, displaced left main bronchus), signs of pulmonary hypertension (dilateted pulmonary arteries and/or pruned peripheral arterial tree), enlarged right ventricle (more easily seen on the lateral) and signs of cardiac failure. You may also see mitral valve calcification.
What are the indications for surgery in mitral stenosis?
Exertional dyspnoea and falling valve area (especially when it falls to around 1 cm squared). Surgery should be done before pulmonary oedma becomes an issue.
What are the chronic causes of mitral regurgitation?
Degenerative disease
Mitral valve prolapse
Rheumatic heart disease
Rheumatoid arthritis
SLE (libman-achs endocarditis)
Cardiomyopathy
Papillary muscle dysfunction secondary to HF or ischaemia
Connective tissue disease (particularly RA or ank spond or Marfan’s syndrome or EDS
Congenital defects
What are the acute causes of mitral regurgitation?
Infective endocarditis
Myocardial infarction
Trauma
What are the signs of severity of mitral regurgitation?
Enlarged left ventricle
Pulmonary hypertension
Third heart sound
Early diastolic rumble
Soft first heart sound
Aortic component of second heart sound is earlier than it should be
Small volume pulses
LV failure
What is seen on ECG in patients with mitral regurgitation?
(similar to MS)
P mitrale (enlarged and notched P wave)
AF
Right axis deviation
What is seen on chest XR in patients with mitral regurgitation?
Large left atriu
Increased LV size
Mitral annular calcification
Pulmonary hypertension (must less common than in MS)
If a TTE reports a thickened mitral valve leaflet and MR - what is the likely aetiology of the MR and thickening?
Rheumatic heart disease.
If a TTE reports calcification of the mitral annulus and mitral regurgitation, what is the likely aetiology the MR and the calcification?
Degenerative disease in an elderly patient
What are the indciations for sugery in a patient with mitral regurgitation?
NYHA class III or IV symptoms, or if there is LV dysfunction on TTE or if the LV dimensions have increased progressively. If the MR occurs acutely with haemodynamic collapse, this is also an indication to operate.
Repair is done in preference to replacement. If valve replacement is required, then a metal valve is typically used as the lifespan of tissue mitral valves is 5-7 years.
What are the new york heart association classes of symptomatic heart disease?
NYHA I - no symptoms of the disease. No limitation to daily activities.
NYHA II - mild symptoms, occasional swelling, sometimes limited ability to exercise or do other strenuous activities. No symptoms at rest.
NYHA III - noticeable limitation to exercise or participate in mildly strenuous activities. Comfortable at rest.
NYHA IV - Unable to do any physical activity without discomfort. Symptoms occur at rest.
What is the most common murmur in the community?
Mitral valve prolapse - systolic click-murmur syndrome. 3% of adults. More common in women. If seen in men, more likely to progress to regurgitation.
What does the valsalva manoeuvre do with regard to cardiac exam?
Reduces preload to the heart and decreases the systolic volume of the ventricles. This leads to accentuation of outflow tract murmurs that are louder with a narrower ventricle (e.g. HOCM). It quietens murmurs that rely on preload like MS or MR.
What does the handgrip manoeuvre do with regard to cardiac examination?
Increased cardiac afterload which enlarges the ventricles due to increased resistance to systole. This quietens murmurs that are ventricle diameter dependent (e.g. HOCM) and loudens most other systolic murmurs. It may sligtly soften an AS murmur due to the slowly flow rate across the aortic valve against higher resistance.
What murmurs are most commonly associated with Marfan’s disease?
Mitral prolapse and aortic regurgitation
What septal defect is associated with mitral prolapse?
ASD (secundum)