Cardio Flashcards
(149 cards)
1
Q
First heart sound (S1)
• Closure of_____ and _____
A
mitral and tricuspid valves (MV, TV)
2
Q
Usually no discernible splitting of S1 but in completely normal child, a split S1 represents _____
A
asynchronous closure of the 2 valves (20−30 msec difference);
3
Q
Split S1 best heard at apex or right upper sternal border may be a click (opening of stenotic valve) may be heard in ________
A
aortic stenosis
4
Q
Apical mid systolic click of _____
A
mitral valve prolapse
5
Q
At upper left sternal border, a click may be heard from ________
A
pulmonic valve stenosis;
6
Q
What pathology?
this changes with respiration (with inspiration, venous
return is increased, thus causing the abnormal pulmonary valve to float superiorly after which the click softens or disappears)
A
pulmonic valve stenosis;
7
Q
______ (e.g., Ebstein anomaly) may cause billowing of the
leaflets and result in multiple clicks
A
Tricuspid valve abnormalities
8
Q
S1 may be inaudible at the________ mostly due to sounds that obscure the closure of the MV and TV, e.g., in VSD, PDA, mitral or tricuspid regurgitation and
severe right ventricular outflow tract obstruction
A
lower left sternal border
9
Q
if the first heart sound is not heard at the lower left sternal border, there is most likely a ________ and there will be other clinical and auscultatory findings
A
congenital heart
defect,
10
Q
Wider splitting of S2 on inspiration is related not only to increased venous return but also to ______
A
pressures in the aorta and pulmonary artery (PA) (it is significantly higher in the Ao than in the PA, so Ao valve closes first)
11
Q
Wider than normal splitting will occur with any lesion that _________
A
allows more blood to traverse the PV compared to normal
12
Q
Increased splitting of S2 may be fixed with respect to respiration if there is __________otherwise, it will continue to vary with respiration; may also hear fixed splitting with a right bundle branch block
A
increased volume and hence pressure in the right atrium (e.g., ASD);
13
Q
______: heard with PA hypertension (increased pressure closing the PV causes early closure of the anterior semilunar valve resulting in a loud single S2)
A
Loud single S2
14
Q
Hear early in diastole; creates a gallop rhythm with S1 + S2; very low frequency and is best heard with bell of the stethoscope at cardiac apex; asking patient to lie on left side may increase intensity
A
S3
15
Q
Occurs in late diastole, just prior to S1 (presystolic) and is produced by a decrease in compliance (increased stiffness) of the LV
A
Fourth heart sound (S4)
16
Q
S4
never hear with atrial fibrillation because______
A
the contraction of the atria is ineffective
17
Q
Summation gallop rhythm (S3 + S4) may be found with _______, _____ or ______
A
improving CHF, myocarditis,
or a cardiomyopathy
18
Q
Generated by blood flowing into the lungs due to
(1) pulmonary arteries, which have limited blood flow in utero and are therefore small with significantly increased blood flow after birth (turbulence from RV blood flowing through these arteries), and
(2) increasing cardiac output associated with declining [Hgb] over the first weeks of life (physiologic anemia)
A
Peripheral pulmonic stenosis
19
Q
Peripheral pulmonic stenosis
• Normal finding age ________
A
6 weeks to 1 year
20
Q
Precordial activity is normal, as are S1 and S2; the murmur is typically low-pitched (bell of stethoscope), musical-quality and often radiates throughout the precordium.
A
Still’s murmur
21
Q
Stills murmur is Murmur is loudest while supine (greater blood flow) and decreases sitting or standing—
opposite to the finding of _______
A
HOCM
22
Q
Still’s murmur
• Commonly heard first at age ______
A
3−5 years
23
Q
- Most common congenital heart lesion
* Most are membranous
A
Ventricular Septal Defect (VSD)
24
Q
VSD
Shunt determined by ratio of _______
A
PVR to SVR
25
VSD
When PVR>SVR, ______ (must not be allowed to happen)
Eisenmenger syndrome
26
VSD murmur findings
− Harsh holosystolic murmur over lower left sternal border ± thrill; S2 widely split
– With hemodynamically significant lesions, also a low-pitched diastolic rumble across the mitral valve heard best at the apex
27
Small muscular VSD more likely to close in first 1–2 years than _________
membranous
28
Indications for Sx of VSD
Failure to thrive or unable to be corrected medically
° Infants at 6–12 months with large defects and pulmonary artery hypertension
° More than 24 months of age with Qp:Qs >2:1 (shunt fraction)
29
Atrial Septal Defect (ASD)
| • ________ most common (in region of fossa ovalis)
Ostium secundum defect
30
PE of ASD
− Wide fixed splitting of S2
| − Systolic ejection murmur along left mid to upper sternal border (from increased pulmonary flow)
31
ECG of ASD
ECG—right-axis deviation and RVH
32
Sx for ASD
Surgery or transcatheter device closure for all symptomatic patients or 2:1 shunt
33
Cx of ASD
− Dysrhythmia
| − Low-flow lesion; does not require endocarditis prophylaxis
34
− When both ASDs and VSDs occur, which are contiguous, and the atrioventricular valves are abnormal
Endocardial Cushion Defect
35
SSx of Endocardial Cushion defects
Left-to-right shunt at both atrial and ventricular levels; some right-to-left shunting with desaturation (mild, intermittent cyanosis)
36
PE of Endocardial Cushion defects
Pulmonary systolic ejection murmur, low-pitched diastolic rumble at left sternal border and apex; may also have mitral insufficiency (apical harsh holosystolic murmur
radiating to left axilla
37
CXR of Endocardial Cushion defects
significant cardiomegaly, increased pulmonary artery and pulmonary blood flow and edema
38
ECG of Endocardial Cushion defects
signs of biventricular hypertrophy, right atrial enlargement, superior QRS axis
39
Sx for Endocardial cushion defects
Treatment—surgery more difficult with heart failure and pulmonary hypertension (increased pulmonary artery pressure by 6−12 months of age); must be performed in
infancy
40
Results when the ductus arteriosus fails to close; this leads to blood flow from the aorta to the pulmonary artery
Patent Ductus Arteriosus (PDA)
41
RF for Patent Ductus Arteriosus (PDA)
− More common in girls by 2:1
− Associated with maternal rubella infection
− Common in premature infants (developmental, not heart disease
42
PE of PDA
If large—heart failure, a wide pulse pressure, bounding arterial pulses, characteristic
sound of “machinery,” decreased blood pressure (primarily diastolic)
43
CXR of PDA
increased pulmonary artery with increased pulmonary markings and edema; moderate-to-large heart size
44
2D echo of PDA
Echocardiogram—increased left atrium to aortic root; ductal flow, especially in diastole
45
Pathophysio of PS
Deformed cusps → opens incompletely during systole; obstruction to right ventricular outflow → increased systemic pressure and wall stress → right ventricular
hypertrophy (depends on severity of pulmonary stenosis
46
Neonate with severe pulmonary stenosis = critical pulmonary stenosis = R → L shunt via _____
foramen ovale
47
PE of PS
Pulmonary ejection click after S1 in left upper sternal border and normal S2 (in mild); relatively short, low-to-medium−pitched SEM over pulmonic area radiating
to both lung fields
48
ECG of PS
right ventricular hypertrophy in moderate to severe; tall, spiked P-waves; right atrial enlargement (RAE)
49
CXR of PS
poststenotic dilatation of pulmonary artery; normal-to-increased heart size (right ventricle) and decreasing pulmonary vascularity
50
Tx of PS
Treatment
− Moderate to severe—______ initially; may need surgery
− Neonate with critical pulmonary stenosis—______
balloon valvuloplasty
emergent surgery
51
AS
__________—sporadic, familial, or with Williams syndrome
Supravalvular stenosis (least common form)
52
What syndrome?
| mental retardation, elfin facies, heart disease, idiopathic hypercalcemia; deletion of elastin gene 7q11.23
Williams syndrome
53
AS
If severe early in infancy = critical aortic stenosis =________
left ventricular failure and decreased cardiac output
54
Findings of severe AS
With increasing severity—decreased pulses, increased heart size, left ventricular apical thrust
55
Tx of AS
− Balloon valvuloplasty
− Surgery on valves
− Valve replacement
56
narrowing at any point from transverse arch to iliac bifurcation
Coarctation of the Aorta
57
Location of most COA
90% just below origin of left subclavian artery at origin of ductus arteriosus (juxtaductal coarctation)
58
What type of COA
Ascending aortic blood flows normally through narrowed segment to reach descending aorta, but there is left ventricular hypertrophy and hypertension
Discrete juxtaductal coarctation (adult type)
59
PE of Discrete juxtaductal coarctation (adult type)
Femoral and other lower pulses weak or absent; bounding in arms and carotids; also delay in femoral pulse compared to radial (femoral normally occurs slightly
before radial)
60
Normally, leg systolic pressure is 10–20 mm Hg higher than in arms; in coarctation, leg systolic pressure is _______
decreased (>5%)
61
Severe narrowing starting at one of the head or neck vessels and extending to the ductus
Tubular hypoplasia (preductal, infantile type)
62
Tubular hypoplasia (preductal, infantile type) SSx
Seen as differential cyanosis—upper body is pink, lower is cyanotic; prominent heart failure as ductus closes (if completely atretic = interrupted aortic arch)
63
Xray findinfs of COA
Increased size of subclavian artery-_______
Notching of inferior border of ribs from______
_________n of ascending aorta
—prominent shadow in left superior mediastinum
passive erosion of increased collaterals in late childhood
Poststenotic dilatatio
64
COA Tx
− Neonate—PGE1 infusion to maintain patent, ductus, which establishes adequate
lower extremity blood flow; surgery after stabilization
− Surgery soon after diagnosis of any significant coarctation
65
Cx of COA
− Associated cerebrovascular disease
− Systemic hypertension
− Endocarditis
− Aortic aneurysms
66
Cyanotic Lesions Associated with Decreased Pulmonary
| Blood Flow
Tetralogy of Fallot (TOF)
Tricuspid atresia
Ebstein anomaly
67
Components of TOF
− Pulmonary stenosis and infundibular stenosis (obstruction to right ventricular outflow)
− VSD
− Overriding aorta (overrides the VSD)
− Right ventricular hypertrophy
68
TOF
Pulmonary stenosis plus hypertrophy of subpulmonic muscle (crista supraventricularis)
→ varying degrees of ________
right ventricular outflow obstruction
69
What are Paroxysmal hypercyanotic attacks (tet spells)
° Acute onset of hyperpnea and restlessness → increased cyanosis → gasping → syncope (increased infundibular obstruction with further right-to-left shunting
70
Tx of Paroxysmal hypercyanotic attacks (tet spells)
place in lateral knee-chest position, give oxygen, inject subcutaneous morphine, give beta-blockers
71
PE of TOF
substernal right ventricular impulse, systolic thrill along thirdto- fourth intercostal space on left sternal border, loud and harsh systolic ejection murmur (upper sternal border), may be preceded by a click; either a single S2 or soft
pulmonic component
72
CXR of TOF
boot-shaped heart plus dark lung fields (decreased pulmonary blood flow)
73
ECG of TOF
right axis deviation plus right ventricular hypertrophy
74
Tx of TOF depends on?
Depends on degree of obstruction
75
Medical Tx of TOF
PGE1 infusion—prevent ductal closure; given if cyanotic at birth
76
Sx Tx of TOF
Augment pulmonary blood flow with palliative systemic to pulmonary shunt (modified Blalock-Taussig shunt)
77
Sx Tx of TOF
Corrective surgery (electively at age 4–12 months)—remove obstructive muscle, valvulotomy, and patching of VSD
78
What condition?
no outlet from the right atrium to the right ventricle; entire
venous (systemic) return enters the left atrium from a foramen ovale or ASD (there must be an atrial communication); left ventricular blood to right ventricle (atretic) via a VSD and is augmented by PDA;
Tricuspid atresia
79
Tricuspid atresia dependes on?
pulmonary blood flow depends on presence
| (and size) of VSD
80
PE of TA
Increased left ventricular impulse (contrast to most others with right ventricular impulse), holosystolic murmurs along left sternal border (most have a VSD; though right ventricle is small, it is still a conduit for pulmonary blood flow)
81
CXR of TA
Chest x-ray—pulmonary undercirculation
82
ECG of TA
ECG—left axis deviation plus left ventricular hypertrophy (distinguishes from most other congenital heart disease)
83
Tx of TA
− PGE1 until aortopulmonary shunt can be performed
− May need an atrial balloon septostomy (to make larger ASD)
− Later, staged surgical correction
84
Downward displacement of abnormal tricuspid valve into right ventricle; the right ventricle gets divided into two parts: an atrialized portion, which is thin-walled, and
smaller normal ventricular myocardium
Ebstein anomaly
85
Ebstein anomaly is associated with?
Development associated with periconceptional maternal lithium use in some cases
86
Why is RV output decreased in Ebstein?
− Poorly functioning, small right ventricle
− Tricuspid regurgitation
− Variable right ventricular outflow obstruction
87
Ebstein: Severity and presentation depend upon
degree of displacement of valve and degree
| of right ventricular outflow obstruction
88
PE of Ebstein
Holosystolic murmur of tricuspid insufficiency over most of anterior left chest (most characteristic finding)
89
CXR of Ebstein
Chest x-ray—heart size varies from normal to massive (increased right atrium); if severe, decreased pulmonary blood flow
90
ECG of Ebstein—
tall and broad P waves, right bundle branch block
91
Tx of Ebstein
− PGE1
− Systemic-to-pulmonary shunt
− Then staged surgery
92
Aorta arises from the right ventricle, and the pulmonary artery from the left ventricle; d = dextroposition of the aorta anterior and the right of the pulmonary artery
(normal is posterior and to the right of the pulmonary artery)
TGA
93
In TGA, Series circuit changed to 2 parallel circuits; need _______ and _______ for some mixture of desaturated and oxygenated blood; better mixing in half of patients with a VSD
foramen ovale and PDA
94
SSx of PDA
_________—as PDA starts to close, severe cyanosis and
tachypnea ensue
With intact septum (simple TGA)
95
PE of TGA
S2 usually single and loud; murmurs absent, or a soft systolic ejection murmur at
midleft sternal border
96
CXR of TGA
“Egg on a string” appearance—narrow heart base plus absence of main segment of the pulmonary artery
97
ECG of TGA—
normal neonatal right-sided dominance
98
What condition?
− Single arterial trunk arises from the heart and supplies all circulations.
− Truncus overlies a ventral septal defect (always present) and receives blood from both ventricles (total mixing).
− Both ventricles are at systemic pressure
Truncus Arteriosus
99
Truncus arteriosis is one of the major conotruncal lesions
| associated with the____________Also seen are transposition of the great arteries and aortic arch abnormalities.
CATCH-22 syndrome, i.e., DiGeorge.
100
In Truncus,
With dropping pulmonary vascular resistance in first week of life, pulmonary blood flow is greatly increased and results in___________
heart failure.
101
SSx of Truncus
Large volume of pulmonary blood flow with total mixing, so minimal cyanosis
102
PE of Truncus
Single truncal valve, which may be incompetent (high-pitched, early diastolic decrescendo at mid-left sternal border)
103
PE of Truncus
Initially, SEM with loud thrill, single S2, and minimal cyanosis
104
CXR of Truncus
Chest x-ray—heart enlargement with increased pulmonary blood flow
105
ECG of Truncus
ECG—biventricular hypertrophy
106
What condition?
Complete anomalous drainage of the pulmonary veins into the systemic venous circulation; total mixing of systemic venous and pulmonary venous blood within the
heart produces cyanosis
107
Blood flow in TAPVR
Right atrial blood → right ventricle and pulmonary artery or to left atrium via foramen ovale or ASD
108
SSx of TAPVR with obstruction
Obstruction (of pulmonary veins, usually infracardiac):
| ° Severe pulmonary venous congestion and pulmonary hypertension with decreasing cardiac output and shock
109
SSx of TAPVR without obstruction
total mixing with a large left-to-right shunt; mild cyanosis; less likely to be severely symptomatic early
110
CXR ot TAPVR
large supracardiac shadow with an enlarged cardiac shadow forms a “snowman” appearance; pulmonary vascularity is increase
111
ECG of TAPVR
− ECG—RVH and tall, spiked P waves (RAE)
112
Atresia of mitral or aortic valves, left ventricle, and ascending aorta (or any combination
Hypoplastic Left Heart Syndrome
113
In TAPVR
Right ventricle______ maintains both pulmonary and systemic circulation.
Right ventricle
114
BF on Hypoplastic Left Heart Syndrome
Pulmonary venous blood passes through foramen ovale or ASD from left atrium → right atrium and mixes with systemic blood to produce total mixing
115
IN HLHS,
________ supplies the descending aorta, ascending aorta and coronary arteries from retrograde flow
Ductus arteriosus
116
In HLHS,
Systemic circulation cannot be maintained, and if there is a moderate-to-large ASD → ________
pulmonary overcirculation
117
SSx of HLHS
− Cyanosis may not be evident with ductus open, but then gray-blue skin color (combination of hypoperfusion and cyanosis as ductus closes)
− Signs of heart failure, weak or absent pulses, and shock
118
ECG of HLHS
right ventricular hypertrophy and right arial enlargement with decreased left-sided forces
119
Best Tx for HLHS
The best treatment today is the three-stage Norwood procedure. (better results currently than cardiac transplantation
120
Abnormal cusps—billowing of one or both leaflets into left atrium toward end of systole (congenital defect)
MVP
121
Arrhythmias associated with MVP
especially uni- or multifocal premature ventricular contractions
122
PE of MVP
Apical late systolic murmur, preceded by a click—in abrupt standing or Valsalva, click may appear earlier in systole and murmur may be more prominent
123
MC organisms asstd with IE
Most are Streptococcus viridans (alpha hemolytic) and Staphylococcus aureus
124
IE organisms associations
°_______—after dental procedures
° ______—large bowel or genitourinary manipulation
°_______—intravenous drug users
° _______—after open heart surgery
° ________—indwelling intravenous catheters
S. viridans
Group D streptococci
Pseudomonas aeruginosa and Serratia marcescens
Fungi
Coagulase-negative Staphylococcus
125
Highest risk of IE with______ and _______
prosthetic valve and uncorrected cyanotic heart lesions
126
IE
Most cases occur after _____ or _____
surgical or dental procedures (high risk with poor dental hygiene) are performed.
127
IE
Splenomegaly, petechiae, embolic stroke, CNS abscess, CNS hemorrhage, mycotic aneurysm (all more with ____________
Staphylococcus
128
IE
Skin findings—rare; late findings (uncommon in treated patients); represent _________
vasculitis from circulating Ag-Ab complexes;
129
IE findings
° ______—tender, pea-sized, intradermal nodules on pads of fingers and toes
° ______—painless, small erythematous or hemorrhagic lesions on palms
and soles
° Splinter hemorrhage—linear lesions beneath nail beds
º Roth spots—
retinal exudate
Osler nodes
Janeway lesions
130
Dx of IE
Duke criteria (2 major or 1 major + 3 minor or 5 minor)
131
Major Duke Criteria
• Positive blood culture (two separate
for usual pathogens; at least two for less
common)
```
• Evidence on echocardiogram
(intracardiac or valve lesion, prosthetic
regurgitant flow, abscess, partial
dehiscence of prosthetic valve, new
valvular regurgitant flow)
```
132
Minor Criteria Duke Criteria
```
• Predisposing conditions
• Fever
• Emboli or vascular signs
• Immune complex disease (glomerulonephritis,
arthritis, positive rheumatoid
factor, Osler node, Roth spots [retinal
hemorrhages with white centers])
• Single positive blood culture
• Echocardiographic signs not meeting
criteria
```
133
Tx of Duke
Organism specific for 4−6 weeks (S. viridans, Enterococci, S. aureus, MRSA,
S. epidermidis, HACEK)
134
ARF related to what organism
Related to group A Streptococcus infection within several weeks
135
Remains most common form of acquired heart disease worldwide (but Kawasaki in United States and Japan)
Acute Rheumatic Fever
136
What is the Jones criteria
Absolute requirement: evidence of recent Streptococcus infection (microbiological or serology); then two major or one major and two minor criteria
137
ARF Tx
__________ (if allergic) for 10 days will eradicate group A strep; then need long-term prophylaxis
Oral penicillin or erythromycin
138
Anti-inflam meds for ARF
Hold if arthritis is only typical manifestation because?
(may interfere with characteristic migratory progression)
139
If carditis with CHF, _____ for 2–3 weeks, then taper; start ______ for 6 weeks
prednisone
aspirin
140
If chorea is only isolated finding, do not need aspirin; drug of choice is _______
phenobarbital
| then haloperidol or chlorpromazine
141
ARF prophylaxis
reatment of choice—
single intramuscular benzathine penicillin G every 4 weeks
142
Pathophysiology
| − Obstructive left-sided congenital heart disease
Hypertrophic Obstructive Cardiomyopathy (HOCM)
143
SSx of Hypertrophic Obstructive Cardiomyopathy (HOCM)
Clinical presentation—weakness, fatigue, dyspnea on exertion, palpitations, angina, dizziness, syncope; risk of sudden death
144
Problem with Hypertrophic Obstructive Cardiomyopathy (HOCM)
Decreased compliance, so increased resistance and decreased left ventricular filling, mitral insufficiency
145
PE with Hypertrophic Obstructive Cardiomyopathy (HOCM)
left ventricular lift, no systolic ejection click (differentiates
from aortic stenosis), SEM at left sternal edge and apex (increased after exercise, during Valsalva, and standing)
146
ECG with Hypertrophic Obstructive Cardiomyopathy (HOCM)
ECG—left ventricular hypertrophy ± ST depression and T-wave inversion; may have intracardiac conduction defect
147
2D ECHO with Hypertrophic Obstructive Cardiomyopathy (HOCM)
Echocardiogram—left ventricular hypertrophy, mostly septal; Doppler—left ventricular outflow gradient usually mid-to-late systole (maximal muscular outflow
obstruction)
148
Drugs contraindicated for HOCM
Digoxin and aggressive diuresis are contraindicated (and infusions of other inotropes)
149
Drugs indicated for HOCM
Beta blockers (propranolol) and calcium channel blockers (verapamil
