3A:Cardiology

Question 1

Systolic Murmur

Answer 1

Aortic stenosis
Pulmonary stenosis

Mitral Regurgitation
Tricuspid Regurgitation

Mitral Valve prolapse
HOCM
ventricular septal defect

Question 2

Diastolic Murmur

Answer 2

Tricuspid stenosis
Mitral stenosis

Aortic Regurgitation
Pulmonary Regurgitation

Austin Flint murmur/ Severe AR

Question 3

Medical management of HF

Answer 3

Heart failure: drug management
1. ALL pts Both an ACE-i & BB ,
(one started at a time). Approved b-blkers Carvedilol, bisoprolol and nebivolol
o ACE-I and B-blkers have no effect on mortality in heart failure with preserved EF

2. 2nd-line: Aldosterone antagonist/ mineralocorticoid receptor antagonists (spironolactone & eplerenone)
3. 3rd Line:. Options include

o Ivabradine- criteria: sinus rhythm > 75/min and LVF < 35%

o sacubitril-valsartan- criteria: LVF < 35%. Should be initiated following ACEi or ARB wash-out period.

o Digoxin- strongly indicated if there is coexistent AF

o Hydralazine in combination with nitrate-this may be particularly indicated in Afro-Caribbean patients

4. cardiac resynchronisation therapy
   o indications include a widened QRS (e.g. LBBB)
   Other treatments
   SGLT-2 inhibitors

• offer annual influenza vaccine
• offer one-off pneumococcal vaccine
  statins to reduce the risk of future myocardial infarction

Question 4

What med provide prognostic benefit in heart failure

Answer 4

ACE-i & BB
SGLT-2 inhibitors

Question 5

What is the echo criteria for severe aortic stenosis

Question 6

NICE guidelines recommend ICD implantation for the following:

Answer 6

Long QT syndrome
Some cases of hypertrophic cardiomyopathy
Brugada syndrome
Arrhythmogenic right ventricular dysplasia

Question 8

Commonest cause of constrictive pericarditis?

Answer 8

TB

Question 9

Signs of Constrictive pericarditis

Answer 9

Prominent x and y descents in the JVP
Positive Kussmaul’s sign
Pericardial knock
Quiet heart sounds
Extra-cardiac signs: non-pulsatile hepatomegaly, ascites and peripheral oedema

Question 10

Beck triad

Answer 10

• hypotension,
• jugular venous distension
• muffled heart sounds.
  -pulsus paradoxus, which is when the systolic blood pressure drops with inspiration, and
  -no audible pericardial friction rub.
  =cardiac tamponade
  sinus tachycardia with low QRS voltage and electrical alternans,
• careful with fluid & ventilation –> increases preload

Question 12

What is Heyde’s syndrome

Answer 12

rare condition characterized by the association of AS +GI bleeding due to angiodysplasia, often linked to an acquired von Willebrand syndrome.

Question 13

What signs are you looking for in the mouth during a cardiovascular examination?

Answer 13

Central cyanosis
High arched palate
Problems with dentition

Question 14

What might a collapsing pulse be suggestive of?

Answer 14

Aortic regurgitation
Patent ductus arteriosus
Hyperdynamic circulation

Question 15

How can the position of the apex beat be interpreted?

Answer 15

Displaced or thrusting: Mitral regurgitation
Undisplaced or heaving: Aortic stenosis, LVH
Tapping: Mitral stenosis

Question 16

What are some echocardiographic features of severe aortic stenosis?

Answer 16

Peak velocity of > 4 m/s
Mean gradient > 40 mm Hg
Valve area < 1 cm^2

Question 17

What are the clinical indicators of severe aortic stenosis?

Answer 17

Narrow pulse pressure,
Quiet S2,
presence of S4,
heaving apex or palpable thrill,
late peaking of murmur,
bi-basal crepitations on auscultation of the lungs.

Question 18

What medications should you be cautious of in AS

Answer 18

medications that reduce afterload, such as ACE-inhibitors and GTN.

Question 19

Most common cause of native valve infective endocarditis

Answer 19

viridans group streptococci

Question 20

IVD IE bug?

Answer 20

Staphylococci
Generally right sided

Question 21

Gram-negative organisms commonly found in the human oropharynx ass. w/ IE

Answer 21

• HACEK organisms, which Haemophilus, Aggregatibacter, Cardiobacterium,
  Eikenella, and
  Kingella.

Question 22

Dukes Criteria

Answer 22

Major Criteria

B : Blood culture +ve
Typical micro-organisms in 2 seperate cultures or
Persistently +ve blood cultures drawn 12 hours apart or
Single +ve blood culture for Coxiella burnetti

E : Endocardial involvement
+ve echocardiogram (vegetation, abscess or valve dehiscence) or
New valvular regurgitation

Minor criteria

Fever > 38 oC

Immunologic phenomena (glomerulonephritis, Osler’s nodes, Roth’s spots, Rheumatoid factor)

Vascular phenomena (major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjuntival hemorrhage, Janeway lesions)

Echocardiography findings (suggestive but not definitive)

Predisposition (heart condition or IV drug user)

Microbiologic evidence (Positive blood culture but not meeting major criteria)