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Cardio Flashcards

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1
Q

Causes of clubbing

A

Cardiac - congenital heart disease, IE
Resp - ILD/ TB/ CF/ Bronchiectasis
Gastro - IBD
Familial

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2
Q

What is a PDA?

A

The ductus arteriousus is a connection between the proximal left pulmonary artery and the descending aorta just distal to the left subclavian artery in the foetus which allows the blood to bypass the lungs which are filled with amniotic fluid. After birth this closes to become the ligamentum arteriosus. Failure to close = PDA

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3
Q

Is PDA associated with congenital heart disease?

A

In adults it is usually an isolated finding but can be associated with congenital heart disease

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4
Q

When are patients with PDA considered for surgery?

A

If they develop either LV volume overload or RV pressure overload will be considered for closure

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5
Q

PDA murmur

A

Continuous machine like murmur ‘rolling thunder’ (quieter flow during diastole)
Heard best 2nd IC left sternal edge but also posteriorly (heard when listening to lung bases)

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6
Q

Eisenmengers syndrome features

A

Clubbing, central cyanosis, loud and widely split 2nd heart sound with associated RV heave (and no murmur = original left to right shunt has now reversed)

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7
Q

What is Eisenmengers syndrome?

A

Longstanding left to right shunt from congenital heart disease
Typically VSD/ ASD or PDA
causing pulmonary hypertension, reversal of the shunt and then cyanosis

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8
Q

Complications of Eisenmengers

A

RVF
Paradoxical embolism
IE
Haemoptysis
Hypoxia

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9
Q

Congenital syndromes associated with VSD

A

Downs
Edwards
Di George

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10
Q

What happens to murmur of VSD in Eisenmengers?

A

Murmur decreases as pulmonary hypertension ensues and subsequent reversal of shunt

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11
Q

Pulmonary hypertension management (3)

A

Endothelial antagonists - bosentan
Phosphodiesterase 5 inhibitors - sildenafil
Prostanoid infusions

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12
Q

Differentials for VSD murmur (4)

A

ASD - wide fixed split 2nd heart sound
MR - Pansystolic murmur loudest on expiration at apex and radiates to axilla
TR - pansystolic murmur heard best on inspiration at lower left sternal edge
PS - ejection systolic murmur loudest on inspiration in pulmonary area

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13
Q

Common causes of constrictive pericarditis

A

Viral or bacterial
Post surgery eg after CABG
After TB
Radiation

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14
Q

Causes of restrictive cardiomyopathy

A

Primary: endomyocardial fibrosis (Loeffler’s syndrome - eosinophils infiltrate the endocardium)

Systemic: sarcoidosis, scleroderma, haemochromatosis, malignancy, amyloidosis

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15
Q

Why do we need to differentiate between constrictive and restrictive cardiomyopathy?

A

Briefly - very diff management plans so constrictive the mainstay is surgery

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16
Q

Restrictive cardiomyopathy signs

A

Minimal unless RVF

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17
Q

What is restrictive cardiomyopathy?

A

Rare disease of myocardium
Diastolic dysfunction with restrictive ventricular physiology but systolic function usually preserved

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18
Q

Rhythm control of AF

A

Flecainide only if no structural heart disease
Or DCCV

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19
Q

Chadvasc

A

Score >1 = anticoagulation
For AF stroke risk
CCCF
HTN
>/= 75
DM
Stroke/ TIA - 2 (the rest are 1 point each)

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20
Q

Risk of stroke with AF if chadvasc = 0

A

1.9%
=1 then 2.8%
=2 then 4%
= 3 then 5.9% etc

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21
Q

2nd most frequent indication for valve surgery

A

MR

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22
Q

Most frequent aetiology of mitral regurgitation

A

Degenerative i.e. prolapse or flail leaflet

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23
Q

Secondary / functional MR is

A

Where valve leaflets and chordae are structurally normal and MR results from LV abnormality ie dilated or ischaemic cardiomyopathy

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24
Q

Management of secondary MR

A

No evidence that valve replacement helps so medical management ie of heart failure

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25
HASBLED
HTN Renal disease Liver disease Stroke Prior major bleeding or predisposition to Labile INR >65 Medications ie anti platelets nsaids Alcohol excess Score of greater than 2 = high risk for major bleeding
26
Indication for anti coagulation in mitral valve disease
Presence of AF or previous emboli
27
How to diagnose IE?
Dukes criteria 2 major and 5 minor Both major / 1 major and 3 minor / all 5 minor Major: positive echo (mobile vegetation), specific bacteria on 2 separate blood cultures Minor: fever >38, other positive BCs, different echo findings, septic embolism, janeway lesions/ osler nodes
28
Bacteria in IE
Staph aureus Strep viridans, strep bovis HACEK group
29
How does rheumatic disease most commonly affect the mitral valve?
Mixed valve disease
30
ECG of mitral valve disease
AF P mitrale due to left atrial enlargement LVH
31
CV waves in JVP
Tricuspid regurgitation
32
How might murmur change with severe mitral disease?
If pulmonary hypertension becomes pronounced then can develop tricuspid regurgitation
33
Differential for diastolic murmur
Austin flint murmur Low pitched diastolic rumbling Severe aortic regurgitation where the regurgitant jet hits the mitral valve Best heard at apex so can be mistaken for mitral stenosis
34
What’s usually the predominant lesion in mixed aortic valve disease?
Usually aortic stenosis with a mild degree of regurgitation- ie when the valve stiffens there’s some leaking
35
Aortic regurgitation caused by (simple pathophys)
Either valvular pathology ie stenosis or pathology of the aortic root
36
Acute AR caused by
IE trauma Aortic dissection
37
Why does collapsing pulse happen?
Wide pulse pressure from regurgitant volume in AR
38
Signs attributed to wide pulse pressure in AR
De maussets- head bobbing Quinkes- capillary pulsation in fingertips and lips Mullers - uvular pulsation
39
Exacerbate AR murmur
Sit up hold breath in expiration
40
Why do you roll the patient to left in CV exam?
To elicit MS murmur Mid diastolic murmur, difficult to hear Use of bell useful for low frequency murmurs
41
Why do we sit patients forwards during the CV exam?
Bring heart forwards to help to listen for AR best heard in expiration at lower left sternal edge
42
HOCM murmur
Ejection systolic caused by LVOTO Or Pan systolic murmur caused by systolic anterior of mitral valve resulting in MR
43
Causes of cardiac hypertrophy
Pressure overload is HTN, Aortic stenosis HOCM Fabreys Amyloidosis
44
HOCM treatment
Symptoms - beta blocker Myosin inhibitors Assess risk of cardiac death ? Need for ICD Genetics - familial evaluation Severe disease - septal reduction therapy (myomectomy or alcohol)
45
Congenital heart disease causes
TOF Pulmonary atresia Tricuspid atresia Pulmonary stenosis Eisenmengers syndrome Ebstein anomaly TGA
46
TOF surgery
Balloon valvuloplasty typically done to relieve pulmonary stenosis Surgery to improve blood flow to the lungs (plumbing the left subclavian into the pulmonary artery distal to the stenosis) right lateral thoracotomy scar Repair VSD - midline sternotomy scar
47
TOF features
4 VSD pulmonary stenosis Over riding aorta RVH
48
How does apex differ between AR and AS?
Pressure overload conditions cause heaving apex ie AS, HTN, LVH AR is a volume overload problem so this causes a thrusting apex beat
49
Severe AS signs
Slow rising low volume pulse Narrow pulse pressure Absent 2nd heart sound Longer murmur Radiation to carotids Evidence of LVH ie heaving apex beat and 4th heart sound
50
What is AS gradient mean?
The gradient is the pressure difference across the aortic valve so severe AS = >40 mm Hg gradient
51
Criteria for severe AS
Peak velocity >4 m/ sec Gradient >40 mm Hg Size <1 cm2
52
Features of TR
Raised JVP with giant V waves Thrill left sternal edge Pan systolic murmur Loudest on inspiration Pulsatile liver, ascites, peripheral oedema If PHTN then loud P2 and RV heave
53
Causes of TR
Congenital; ebsteins anomaly Acute; IE, trauma Chronic; PHTN, IE, rheumatic fever, carcinoid
54
Severe AS features
Soft A2 Delayed ESM LV heave Carotid radiation 4th HS w significant LVH
55
ESM ddx
AS sclerosis HOCM PS
56
PS features
ESM loudest in inspiration in pulmonary region Soft delayed P2 Palpable thrill RV heave and prominent a wave of JVP if severe
57
PS causes
Commonest is rubella TOF, turners, noonans Rarely carcinoid
58
Acyanotic heart disease
ASD small VSD Coarctation PDA
59
MV prolapse murmur
Ejection click Pan systolic murmur Loudest at apex in left lateral position
60
Drugs to avoid in severe AS
Vasodilators i.e. nitrates sildenafil ace inhibitors
61
Marfans genetics
Autosomal dominant secondary to defects on fibrillin gene
62
MR features
Af Small volume pulse Displaced Apex Thrill at Apex Pansystolic murmur at Apex radiating to the axilla Signs of LVF
63
VSD why does murmur get louder on expiration?
In left to right shunt - in expiration the venous return to the left side of the heart increases so the character of the murmur increases
64
Pinch osler Slap Jane
Osler nodes - painful on finger tips Janeway lesions - painless palm rash

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