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ECOS III Final > Cardiac DSA > Flashcards

Cardiac DSA Flashcards

1
Q

What is the etiology for aortic stenosis?

A

Age related calcific degeneration of a normal valve (generally age <70) or a bicuspid aortic valve
Rhuematic dz

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2
Q

What is the clinical presentation for aortic stenosis?

A

Angina, syncope, HF

Parvus et tardus (diminsed caortid upstroke, weak pulse, typically in late or severe AS)

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3
Q

What heart sounds are heard with aortic stenosis?

A

Harsh crescendo-decrescendo systolic murmur
Best heard at the 2nd right intercostal with radiation to the carotid
The more severe the stenosis, the longer duration of the murmur and the more likely it peaks later in systole

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4
Q

What is the etiology for aortic regurgitation?

A 
Aortic root problems (e.g. dilation due to age-related degeneration, HTN, ankylosing spondylitis, syphilis, dissection, Marfans)
Valve problems (e.g. bicuspid aortic valve, endocarditis, rheumatic)
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5
Q

What is the clinical presentation for aortic regurgitation?

A

Dyspnea, PND, orthopnea, palpitations when lying down, wide pulse pressure, bounding pulse

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6
Q

What heart sound is associated aortic regurgitation?

A

Diastolic blowing decrescendo murmur

Beast heard at apex/left sternal border

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7
Q

What is the etiology for mitral stenosis?

A

Rheumatic fever, mitral annular calcification (e.g. in the setting of CKD), congenital

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8
Q

What is the clinical presentation for mitral stenosis?

A

Dyspnea, hemoptysis, Afib, risk of emboli

Dilated LA can compress the recurrent laryngeal nerve and cause hoarseness (severe cases)

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9
Q

What heart sounds are associated with mitral stenosis?

A

Opening snap, low pitched diastolic rumble and loud S1

Best heard at the apex when the pt is in the left lateral decubitus position

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10
Q

What is the etiology for acute mitral regurgitation?

A

Endocarditis, MI with papillary muscle rupture, chordae tendineae rupture

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11
Q

What is the etiology for chronic mitral regurgitation?

A
  1. Primary problem with valve: mitral valve prolapse (MVP, i.e. prolapse due to myxomatous degeneration), rheumatic carditis, prior endocarditis, Marfans, carcinoid (rare)
  2. Secondary dilation of MV annulus (e.g. dilated cardiomyopathy)
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12
Q

What is the clinical presentation for mitral regurgitation?

A

Acutely may cause flash pulmonary edema, shock and death

Chronically may cause pulmonary edema (DOE, PND, orthopnea), RHF

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13
Q

What heart sounds are associated with mitral regurgitation?

A

Holosystolic murmur

Best heard at the apex radiating to the axilla, back or clavicle

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14
Q

What is the etiology for tricuspid regurgitation?

A

Either due to primary valve problem e.g. rheumatic, Ebstein anomaly, carcinoid, endocarditis or
Secondary to elevated RV pressures (e.g. pulmonary HTN, LV failure, restrictive cardiomyopathy)

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15
Q

What is the clinical presentation for tricuspid regurgitation?

A

Murmur like MR but louder with inspiration

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16
Q

Which congenital heart diseases are associated with late cyanosis with L to R shunt?

A

ASD, PFO, VSD, PDA, CoA

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17
Q

What is the etiology for atrial septal defects?

A

Defect in the middle (ostum secundum, MC) or lower (ostum premum which occurs in down syndrome) part of atrial septum

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18
Q

What is the clinical presentation for ASD?

A

small defects are often asymptomatic
large ASDs are typically detected/closed childhood; if not its may become symptomatic by middle age, causing exercise intolerance, dyspnea and fatigue

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19
Q

What are the complications associated with ASD?

A

Pulmonary HTN, Eisenmenger syndrome, RHF, Afib, stroke with paradoxical emboli

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20
Q

What heart sounds are heard with ASD?

A

Loud S1, wide flexed split S2

More pulmonic flow = mild systolic ejection murmur, diastolic rumble across the tricuspid valve

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21
Q

What is the etiology for patent foramen ovale?

A

An atrial opening that usually closes at brith

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22
Q

What is the clinical presentation for PFO?

A

common and usually benign but always consider when a pt <60 presents with TIA or stroke

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23
Q

What is the etiology for VSD?

A

defect in the muscular or membranous portion of the ventricular septum

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24
Q

What are the associations for VSD?

A

fetal alcohol syndrome, down syndrome

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25
What is the clinical presentation for VSD?
most large VSDs are detected and closed in childhood | if not patients may become symptomatic with eventual pulmonary HTN and right to left shunting
26
What heart sounds are heard with VSD?
Harsh blowing holosystolic murmur with thrill, loudest at the left third intercostal space with handgrip (smaller defect = louder murmur)
27
What is the etiology for patent ductus arterioles?
Persistent communication between the aorta and pulmonary A | Associated with congenital rubella, prematurity
28
What is the clinical presentation for PDA?
Depends on the size Small PDAs are usually asymptomatic Moderate PDAs cause Eisenmenger syndrome if not dx Large PDAs cause infantile heart failure
29
What heart sounds are heard with PDA?
Machine like murmur best heard at the left 2nd intercostal space Wide pulse pressure and bounding peripheral pulse
30
What are the signs of pulmonary HTN?
Syncope, atrial and ventricular arrhytmias, cyanosis | Late findings include R and L HF sx
31
What is the presentation of children with Eisenmenger syndrome?
cyanosis, fatigue, and sx of RHF
32
What is the presentation for adults with Eisenmenger syndrome?
Develops secondary to pulmonary vascular obstructive changes Cyanosis, clubbing, an increased RV impulse, a narrowly split S2 with a loud P2 component and a soft or absent VSD murmur Systolic murmur of tricuspid insufficiency at the LLSB, a high frequency early diastolic murmur of pulmonary insufficiency or an S3 at the LLSB Associated JVD and hepatomegaly indicating right sided filling pressures
33
What is the etiology for Coarctation of the aorta?
Infantile: LE cyanosis with weak pulses; associated with Turner's syndrome Adult: can also be acquired due to inflammation of the aorta (e.g. Takayasu's)
34
What is the clinical presentation for coarctation of the aorta?
upper extremity HTN, low/unobtainable LE BP, and diminished/delayed femoral pulse, rib notching on CXR
35
Are diastolic murmurs always pathologic?
yes
36
Inspiration causes which murmurs to be louder?
R heart murmurs
37
Expiration causes which murmurs to be louder?
L heart murmurs
38
Which murmurs increase with standing/valsalva?
Murmurs associated with MVP and hypertrophic cardiomyopathy
39
Which murmurs increase with hand grip (increased SVR)?
Increases with murmurs associated with AR, MR, VSD
40
Which murmurs decrease with hand grip (increased SVR)?
Murmur associated HCM
41
Which murmurs are systolic?
AS, MR, TR, VSD, ASD and HCM
42
Which murmurs are diastolic?
AR, MS and TS
43
What is splitting of S1 associated with?
A feature of Ebstein anomaly which is associated with right bundle branch block
44
What are the two components of S1?
The mitral component (M1) precedes the carotid pulse upstroke and the tricuspid component (T1) occurs later
45
What are the two components of S2?
aortic (A2) and pulmonary (P2) valve
46
What are the major determinants of A2 intensity (and therefore major determinants of S2)?
Aortic pressure (a major determinant of the velocity of valve closure) Relative proximity of the aorta to the chest wall Size of the aortic root Mobility and structural integrity of the aortic valve
47
What determines the intensity of P2?
Pulmonary arterial pressure particularly diastolic pressure Size of the pulmonary artery Mobility and structural integrity of the pulmonary valve
48
When is an increased P2 intensity suggested?
when it is louder over the 2nd interspace or when there is transmission to the cardiac apex
49
What can lead to increased intensity of A2?
Systemic HTN Coarctation of the aorta Ascending aortic aneurysm When the aortic root is relatively anterior and closer to the anterior chest wall as in metrology of fallout and transposition of the great arteries
50
What can cause increased P2 intensity?
Pulmonary arterial HTN of any etiology (MC) Idiopathic pulmonary artery dilation ASD MR
51
What can cause decreased intensity of A2?
Conditions that affect the mobility and integrity of the aortic valve Severe aortic regurgitation (AR) or stenosis Hypotension
52
What can lead to decreased intensity of P2?
Conditions that affect the mobility and integrity of the pulmonary valve Pulmonary stenosis and regurgitation Significant RV outflow obstruction associated with a soft and delayed P2 The low pulmonary artery pressures also play a role in attenuating P2
53
What can cause wide splitting S2?
Electromechanical delay of the RV - RBBB, artificial pacing from the LV and wolf-parkinson-white (WPW) syndrome with LV pre-excitation - Premature beats and an idioventricular rhythm of LV origin (QRS complex of RBBB morphology) are also associated with wide splitting
54
What are some hemodynamic causes of wide splitting of S2?
- Increased resistance to RV ejection and prolongation of RV ejection time - Isolated reduction of the LV ejection time (examples include severe MR when forward SV decreases with increases in regurgitant volume)
55
What can cause fixed splitting of S2?
ASD | Can also occur with RV failure, RV outflow obstruction, pulmonary HTN, and primary RV dysfunction
56
What can cause reversed (paradoxical) splitting of S2?
Electromechanical delay such as LBBB | Artificial RV pacing, pre-excitation of the RV (WPW syndrome) and premature beats of RV origin
57
Which hemodynamic factors can cause reversed (paradoxical) splitting of S2?
Markedly prolonged LV ejection time Fixed outflow obstruction as in pts with aortic valve stenosis Myocardial dysfunction, ischemia or in pts with long standing severe AR
58
What is S3?
Ventricular gallop Early diastolic sound, listen with bell Turbulent flow of blood hitting an overfilled ventricle Differential dx: can be normal in its age <35 or in pregnancy otherwise specific sign of decompensated HF
59
What is S4?
Atrial gallop/kick Late diastolic sound, listen with diaphragm Atrium pushing blood against a stiff ventricle Differential dx: always consider pathologic in its >40 May be common in athletes Associated with ventricular hypertrophy (secondary to HTN) and heart failure
60
What are the surgical considerations for aortic stenosis?
Surgery is recommended for pts <65 years or with a life expectancy of >20 years Transcatheter AVR is recommended for all pts >80 years Either surgical AVR or transcatheter AVR can be considered for all pts between 65 and 80 years But younger pts will tolerate valvuloplasty much more than older pts -- therefore not recommended in older pts with the advent of TVAR
61
When is surgery done for aortic regurgitation?
for sx, EF <50%, LV end systolic dimension >50mm, or LV end diastolic dimension >65mm all determined by echocardiography
62
What are the tx options for mitral stenosis?
Valve replacement when pulmonary edema, a decline in exercise capacity or any evidence of pulmonary HTN occurs
63
When is surgery indicated for chronic mitral regurgitation?
For sx or when the LV EF is <60% or the echocardiographic LV end systolic dimension is >4cm Also in its who have a progressive increase in LV size or decline in LVEF
64
What is indicated for pts with mitral prolapse and severe mitral regurgitation?
Earlier surgery if mitral repair can be performed successfully with a high degree of certainty
65
What are tx options for tricuspid regurgitation?
Generally well managed with diuretics Aldosterone antagonists if ascites also present Treat underlying cause
66
what is the tx for congenital heart dz?
surgical repair

ECOS III Final (14 decks)

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