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Cardio Flashcards

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1
Q

Cardiac Causes of Clubbing

A
  • Atrial Myxoma
  • Bacterial Infective Endocarditis
  • Congenital Cyanotic Heart Disease
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2
Q

Causes of collapsing pulse

A
  • AR
  • Thyrotoxicosis
  • Pregnancy
  • Anaemia
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3
Q

Causes of absent radial pulse

A
  • Dead
  • Trauma
  • Thrombosis or embolism
  • Coarctation of the aorta
  • Takayasu’s Arteritis
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4
Q

Causes of impalpable apex beat

A
  • COPD
  • Obesity
  • Pericardial effusion
  • Dextrocardia
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5
Q

What are the features of Pulmonary HTN

A
  •  ↑JVP
  •  Left parasternal heave
  •  Loud P2 + PSM of TR
  •  Pulsatile hepatomegaly
  •  Ascites and peripheral oedema
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6
Q

What are the four heart sounds

A
  •  S1: mitral valve closure
  •  S2: aortic valve closure
  •  S3: rapid ventricular filling of dilated left ventricle
  •  S4: atrial contraction against stiff ventricle
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7
Q

What investigations would you want to do at the end of a cardio examination?

A
  • ECG
  • Blood
    • FBC: anaemia exacerbates cardiac symptoms
    • U+E: renovascular disease
    • NT-proBNP: heart failure
    • Fasting lipids and glucose: cardiac risk
    • Trops
  • Imaging
    • CXR
    • Echo
    • Cardiac catheterisation
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8
Q

Features of Aortic Stenosis

A
  • Crescendo decrescendo ESM
  • Right 2nd ICS
  • Radiates to carotids
  • Sitting forward in end-expiration
  • May be an ejection click in bicuspid valve disease

Features of severe disease:

  • Low-volume pulse
  • Slow-rising (anacrotic)
  • Narrow pulse pressure (<30mmHg)
  • Aortic thrill
  • Heaving apex
  • Reversed splitting of S2
  • Soft aortic component of S2
  • 4th HS
  • Pulmonary HTN
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9
Q

Ddx of AS

A
  • Aortic sclerosis: no radiation, normal pulse character
  • MR
  • HOCM:
    • valsalva ↑s murmur
    • squatting ↓s murmur
  • Right-sided: PS
  • Supra-valvular aortic stenosis (William’s syndrome)
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10
Q

Causes of AS

A

Common:

  • Age-related senile calcification
  • Bicuspid aortic valve and other congenital causes
  • Rheumatic heart disease

Rare:

  • Infective endocarditis
  • Hyperuricaemia
  • Alkaptonuria
  • Paget’s disease
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11
Q

Rx of AS

A
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12
Q

Clinical signs of severe MR

A
  • LVF
  • AF
  • Soft first HS
  • 3rd and 4th HS
  • Displaced apex beat
  • Precordial thrill
  • Mid-diastolic flow murmur
  • Widely split second HS
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13
Q

Murmur in MR

A

 Blowing PSM

 Apex

 Left lateral position in end-expiration

 Radiates to the axilla

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14
Q

DDx for MR

A

 Right-sided: TR

 AS

 VSD

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15
Q

Causes of MR

A

Chronic:

  • Functional: LV dilatation (e.g. 2O to HTN or idiopathic)
  • Annular calcification → contraction
  • Rheumatic heart disease
  • Mitral valve prolapse
  • Connective tissue disorders: Marfan’s, Ehler’s danlos, osteogenesis imperfecta
  • Cardiomyopathies
  • SLE (Libman-Sachs endocarditis)
  • Papillary muscle dysfunction (ischaemia)

Acute

  • Rupture of chordae tendinae
  • Infective endocarditis
  • Trauma
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16
Q

What might you see on ECG and CXR for a patient with MR?

A

ECG

  • AF
  • P mitrale (LA hypertrophy)

CXR:

  • LA (double right heart border) and LV hypertrophy
  • Splaying of the carina (LA dilatation)
  • Left atrial appendage
  • Mitral valve calcification
  • Pulmonary oedema
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17
Q

Echo features for severe MR

A

 Jet width >0.6cm

 Systolic pulmonary flow reversal

 Regurgitant volume >60ml

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18
Q

Specific Mx of MR

A

 AF: rate control and anticoagulation

 Emboli: anticoagulant

 ↓ afterload

 ACEi or β-B (esp. carvedilol)

 Diuretics

 Valve replacement

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19
Q

Murmur in AR

A

 High-pitched early diastolic murmur
 LLSE (3rd left IC parasternal)
 Sitting forward in end-expiration

Additional Murmurs:

 Ejection systolic flow murmur

 Austin-Flint murmur (rumbling MDM @ apex secondary to regurgitant jet fluttering the anterior mitral valve)

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20
Q

Signs of AR

A

Eponymous Signs

Quincke’s: capillary pulsation in nail beds

Corrigan’s: visible vigorous carotid pulsation

De Musset’s: head nodding

Traube’s: pistol-shot sound over femorals

Duroziez’s

 Systolic murmur over the femoral artery ̄c proximal compression.

 Diastolic murmur ̄c distal compression

Mueller’s: systolic pulsations of the uvula

Rosenbach’s: systolic pulsations of the liver

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21
Q

Causes of AR

A

Chronic

  • Bicuspid aortic valve
  • HTN
  • Rheumatic heart disease
  • Autoimmune: Ank spond, RA, SLE
  • Connective tissue: Marfan’s, Ehler’s Danlos
  • Aortitis: Takayasu, syphilis, Reiter’s syndrome
  • Perimembranous VSD

Acute

  • IE
  • Type A Aortic dissection
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22
Q

Indications of valve replacement for AR

A

 Symptomatic: NYHA >2

 LV dysfunction

 Pulse pressure >100mmHg
 ECG changes: T inversion in lateral leads

 LV enlargement on CXR or EF <50%

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23
Q

Mitral Stenosis Murmur

Study These Flashcards
A

 Opening snap

 Rumbling MDM

 Apex - tapping apex

 Left lateral position in end-expiration

 With the Bell

 Radiates to the axilla

 Loud first HS

 Pre-systolic accentuation if pt. in sinus rhythm

 Atrial contraction

 Graham Steell murmur (EDM secondary to PR)

24
Q

ECG Features of Mitral Stenosis

Study These Flashcards
A

 P-mitrale

 AF

25
Criteria for Rheumatic Fever
***Revised Duckket Jones Criteria***  2 major criteria, or  1 major + 2 minor ***Major Criteria***  Pancarditis  Arthritis  Subcut nodules  Erythema marginatum  Sydenham’s chorea ***Minor criteria***  Fever  Raised ↑ESR or ↑CRP  Arthralgia  Prolonged PR interval  Prev rheumatic fever
26
Rx of Rheumatic Fever
 Bed rest until CRP normal for 2wks  Benpen 0.6-1.2mg IM for 10 days  Analgesia for carditis/arthritis: aspirin / NSAIDs  Add oral pred if: CCF, cardiomegaly, 3rd degree block  Chorea: Haldol or diazepam  Secondary prophylaxis (Pen V 250mg/ 12h PO for 5-10 years)
27
Most likely valves to be affected by Rheumatic Heart Disease
 Mitral (70%)  Aortic (40%)  Tricuspid (10%)  Pulmonary (2%)
28
Common acute IE organisms
* S. aureus * S. epidermidis
29
Most common organisms for Bacterial ***E******ndocarditis***
 S aureus now  S. viridans (previously)  S. epidermidis (Valvular in the first two months)  S. bovis (do colonoscopy for colonic neoplasm)
30
Clinical features of subacute endocarditis
***Hands***  Clubbing  Splinters  Janeway lesions  Oslers nodes Other * Fever * Roth spots * Splenomegaly * Haematuria
31
Criteria for diagnosing Endocarditis
32
Rx of endocarditis
Depends on the organism and type of valve: * **Strep viridans or bovis** = Benpen + gent (+/- vancomycin) * **Staph** = flucloxacillin * **Staph on mechanical valve** = Flucloxacillin + rifampicin + low-dose gentamicin
33
What are the different types of heart valves for replacement?
Xenograft: * Porcine Homograft: * Cadaveric * Ross procedure → using pulmonary valve Mechanical: * Ball and cage: e.g. Starr-Edwards * Tilting disc: e.g. Bjork-Shiley * Bileaflet: e.g. St. Jude
34
Which patients would you consider a biological valve in?
 Older patients  Women of child-bearing age  Bleeding risk: e.g. peptic ulcer, frequent falls
35
Complications of a valve prosthesis
***FIBAT*** * Failure * Infective endocarditis * Bleeding: minor – 7%/yr, major – 3%/yr * Anaemia: warfarin and haemolysis * Thromboembolism: 1-2% per annum despite warfarin
36
The differentials for a Irregularly Irregular Pulse. How would you distinguish them from each other?
 AF  Multiple ventricular ectopics Clinical Distinction * Exercise pt. *  AF: pulse stays irregularly irregular *  VE: ↑ HR → regular pulse * ↓ diastole time closes window for ectopics
37
What is the CHA2-DS2-VAS Score?
 Determines necessity of anticoagulation in AF  Dabigatran may be cost-effective alternative to warfarin
38
ECG of a patient with a pacemaker
* Pacing spikes * May be absent if pt. producing adequate intrinsic rhythm * Evidence of ischaemia
39
What are some indications for pacing?
*  Complete AV block *  Mobitz Type 2 *  Symptomatic bradycardia: e.g. sick sinus syndrome *  Drug-resistant tachyarrhythmias *  Biventricular pacing in chronic heart failure
40
What are some common complications of a pacemaker?
* Insertion * Bleeding * Arrhythmia * Post Insertion * Erosion * Lead migration * Pocket infection * Malfunction
41
Causes of LHF
*  IHD *  Idiopathic dilated cardiomyopathy *  Systemic HTN *  Mitral and aortic valve disease
42
Signs of LHF
* Cold peripheries ± cyanosis * Often in AF * Cardiomegaly ̄c displaced apex * S3 + tachycardia = gallop rhythm * Wheeze (cardiac asthma) * Bibasal creps
43
Causes of RHF
* LVF * Cor pulmonale * Tricuspid and pulmonary valve disease
44
Signs of RHF
 ↑JVP + jugular venous distension  Tender smooth hepatomegaly (may be pulsatile)  Pitting oedema  Ascites
45
Causes of a displaced apex beat
* idiopathic * cardiomyopathy * congestive cardiac failure * aortic regurgitation * mitral regurgitation * ventricular septal defect
46
Features of TR
* Loudest in the tricupsid region * Louder on inspiration * Pansystolic murmur * Raised JVP * Palpable liver
47
Presenting
O/E of the hands: pulse ... , I would like the BP O/E of the head and neck ... the JVP was not raised and there were no signs of carotid bruits O/E of the chest ... both heart sounds were audible with no additional sounds, the apex was not displaced In addition ... the lung bases were clear and there was no peripheral or sacral oedema
48
What is a Graham Steele Murmur?
Soft, blowing, decrescendo early diastolic murmur of pulmonary incompetence caused by pulmonary hypertension
49
How do you classify severity of AS?
* Valve area \<1cm squared * Transaortic pressure gradient \>40mmHg * Dyspnoea has worst prognosis
50
Complications of AS?
* LVF * Sudden death * Pulmonary HTN * Arrhythmia * Heart block * Infective endocarditis * Systemic embolic complications * Haemolytic anaemia * Heyde's syndrome (iron deficiency anaemia)
51
What might you see on ECG of a patient with AS?
* LVH * LV strain * P mitrale (left atrial hypertrophy) * LAD * LBBB/1st degree heart block
52
Causes of mitral stenosis?
* Rheumatic fever (most common) * Congenital mitral stenosis * Rheumatoid arthritis * SLE * Carcinoid syndrome
53
Features of severe mitral stenosis?
* Early opening snap * Increasing length of murmur * Pulmonary HTN * Graham Steele murmur * Low pulse pressure
54
Differential dx for malar flush?
* Mitral stenosis * Hypothyroidism * Carcinoid * SLE * Systemic sclerosis * Polycythaemia
55
How to differentiate between MR and TR clinically?
* Location of murmur * Pulse may be jerky in MR * Systolic ‘v’ waves in JVP for TR * Pulsatile hepatomegaly for TR * Thrill is apical in MR and parasternal in TR
56
Complications of MI?
* **D**eath * **A**rrhythmia * **R**upture (free ventricular wall/ ventricular septum/ papillary muscles) * **T**amponade * **H**eart failure (acute or chronic) * **V**alve disease * **A**neurysm of ventricle * **D**ressler’s syndrome * thrombo**E**mbolism (mural thrombus) * **R**ecurrence/ mitral **R**egurgitation
57
**Indications for PCI**
 Poor response to medical Rx  Refractory angina but not suitable for CABG

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