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Cardiology Flashcards

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1
Q

Murmur in ASD

A
  • Pulmonary ES
  • Fixed split S2
  • Mid-diastolic flow murmurs with large L to R shunts.

There is no mumur from the ASD itself

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2
Q

Commonest cause of AS

A
  • Calcific degeneration overall
  • If <65yr likely Congenital bicuspid valve (about 5-10%)
  • IE
  • Paget’s disease

extremely rare= Post Rh fever

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3
Q

Commonest cause of Mitral Stenosis

A

Rheumatic fever (>90%)

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4
Q

Infective endocarditis - strongest risk factor

A

Previous inf endocarditis

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5
Q

What value of pulmonary artery pressure is considered diagnostic of pulmonary arterial hypertension?

A

> 25mmHg at rest

—-measured by cardiac catheterisation

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6
Q

most common heart defect in Marfans

A

dilation of the aortic root

AR or aneurysm/dissection may develop as a consequence
MVP

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7
Q

Fatigue and SOBOE
Light compression to the tip of the fingernail bed causes capillary pulsation

…what is this sign called?

A

Quincke’s sign - in Aortic Regurge, so early Diastolic murmur

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8
Q

causes of dilated cardiomyopathy

A

Alcohol
Beriberi wet - thiamine deficiency
Coxsackie B
Doxorubicin

(HOCM has four letters - S4)

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9
Q

Management of bradycardia in heart transplant

A

Atropine is ineffective in transplant bradyarrhythmias because the heart is denervated

So theophylline or pacing

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10
Q

Causes of ejection systolic murmur

A

Loudest in aortic area
• Aortic stenosis
• Aortic sclerosis
• HOCM (tends to be younger, LL sternal edge and throughout precordium, doesn’t radiate to carotids)
• Pulmonary Stenosis - Loudest in pulmonary area- young patient but rare

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11
Q

commonest cause of pulmonary stenosis

A

Congenital (often from maternal rubella infection =commonest)

Ejection Systolic in pulmonary area
Louder on INspiration

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12
Q

where does AS murmur radiate

A

radiates to carotids

Ejection systolic murmur loudest in aortic region

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13
Q

Slow rising pulse

A

Aortic stenosis

feels weak and late

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14
Q

Anaemia in aortic stenosis

A

Heyde syndrome is a triad of

  • aortic stenosis
  • acquired Von Willebrand disease
  • anaemia (due to GI bleeding from intestinal angiodysplasia)
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15
Q

Make aortic stenosis murmur louder

A

Loudest on held expiration and when the patient is sitting forwards

Can be heard over Apex (Gallavardin phenomenon)

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16
Q

aortic stenosis vs sclerosis on examination

A

sclerosis:

  • Doesn’t radiate to Carotids as much
  • Is softer and shorter in nature

(A. sclerosis is thickening without any significant effect on function)

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17
Q

Signs of severe in aortic stenosis

A 
Late peaking mumur
Evidence of cardiac decompensation 
Slow rising low volume pulse 
Narrow pulse pressure
Absent of second heart sound
LV heave
Carotid radiation 
Fourth heart sound in LVH

Echo
• Peak gradient >64
• or mean gradient >40mm Hg
• or valve area <1 cm2

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18
Q

when would you consider TAVI vs surgical aortic valve replacement

A

If low surgical risk and <65, then SAVR

  • -> mechanical last longer but need anticoag
  • -> tissue, no anticoag

If >65 or significant-intermediate risk, then TAVI, if transfemoral possible

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19
Q

What does TAVI stand for

A

Transcatheter aortic valve implantation

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20
Q

Describe TAVI vs surgical AVR

A
  • TAVI pushes stiff / calcified valve out of the way during implantation
  • Can be done under general or local
  • Surgical operation removes the stiff valve and a new mechanical or tissue valve is in place
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21
Q

features of pulmonary stenosis

A

Often congenital, so younger

Ejection systolic murmur loudest of pulmonary area

Louder on INspiration

Radiates to left shoulder/left infraclavicular region

RV dilatation can lead to a RV heave

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22
Q

Common indications for aortic valve replacement (AVR)

A

Severe or symp AS or AR or infective endoc

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23
Q

Anticoagulation for mitral vs aortic valve replacement

A 
Depends on presence of risk factors for valve thrombosis
• prior thromboembolism
• AF
• Rh mitral stenosis (any degree)
• LVEF <35%
• Mitral > Aortic risk

Mechanical aortic INR of 2.5
Mechanical mitral INR of 3.0

Only Warfarin recommended

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24
Q

Advantage of mechanical heart valve vs tissue

A
  • They are longer lasting
  • but require anticoagulation
  • in AS, can use TAVI if not fit for surgery
  • in MR can clip
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25
Collapsing pulse
aortic regurgitation | w hollow diastolic murmur
26
causes of pansystolic (aka holosystolic) murmur
High pitched and blowing from S1 to S2... • mitral regurge (apex) • tricuspid regurgitation (Left lower sternal edge) • mitral valve prolapse (Mid systolic + opening click) • VSD (harsh in character, well-localised left sternal edge) Makes sense because s1 is sound of mitral and tricuspid closing, so if regurge then this will be extended
27
Where is apex beat?
near the midclavicular line in the fifth intercostal space
28
murmurs louder on inspiration vs expiration
Inspiration -> right heart (pulmonary and tricuspid) due to increased venous return Expiration -> left heart (mitral and aortic)
29
Signs of severe mitral regurge
Pulmonary hypertension i.e. raised JVP, S3 gallop, displaced/thrusting apex, right ventricular heave
30
What is JVP
reflection of physical pressures in Right atrium | i.e. pulmonary hypertension causes raised
31
Consideration for surgery in mitral regurge
* signs or symptoms (pul hypertension or fluid overload) * Acute MR following MI or in asymp: • Declining ejection fraction • Increasing LV dilatation
32
causes of mitral regurge
DEGENERATIVE • Age-related changes • Mitral valve prolapse • Connective tissue issues ACQUIRED • papillary muscle rupture - i.e. MI • infection - Rheumatic fever, infective endo
33
Causes of aortic stenosis
* Calcification of the aortic valves * Congenital bicuspid valve * Rheumatic heart disease
34
HASBLED score
``` Hypertension Abnormal renal and liver function Stroke Bleeding predisposion Labile INR Elderly (>65) Drugs or alcohol ``` ≥3 indicates "high risk"
35
drug contraindications in severe aortic stenosis
Vasodilators (which can increase the gradient across the valve) ACEi Nitrates Sildenafil
36
Rhythm control of AF
Medically: • Flecainide • only if no evidence of structural heart disease Mechanically: • DC cardioversion • (with 2,3,4 anticoag, more than 2 days then 3 before and 4 after)
37
common cardiac issues with ehler's danlos
mitral valve prolapse | aortic dilatation
38
Heart condition in Noonan's
Pulmonary stenosis (ES in pul, louder with insp) May have hypertrophic cardiomyopathy or septal defects
39
Differentials of pulmonary stenosis mumur
PS is usually due to valvular obstruction, but may also be due to sub- or supravalvular obstruction Right Ventricle Outflow Tract Obstruction = harsh ES murmur at the left sternal border in the second intercostal space AS VSD ASD
40
Features of pulmonary stenosis
ES in pulmonary area, louder with insp R ventricular hypertrophy in signif (so RV heave) Can cause delayed RA emptying, and elevated RA pressure === raised JVP with prominent A waves
41
Loud metallic click in S2
Metallic aortic valve replacement
42
pan-systolic best heard in the left lower sternal border;
VSD | or Tricuspid regurge
43
VSD murmur
pan-systolic best heard in the left lower sternal border; (tricuspid region)
44
Midline sternotomy differentials
* CABG * Valve replacement * Transplant
45
Valves causing S1 sound
Closing of mitral and tricuspid valves
46
Valves causing S2 sound
Closing of aortic and pulmonary valves
47
CABG without vein harvesting scar
via internal mammary artery instead of greater saphenous vein
48
AVR and pacemakers
10% of patients with aortic valve replacement need pacemaker from AV node damage
49
Valve replacement with Infective endocarditis
Look for tunnelled lines etc
50
where is infective endocarditis most likely?
mitral valve, causing stenosis or regurge
51
Management of AF explanation points
If no underlying cause can be found, the treatment options are: * medicines to reduce the risk of a stroke * medicines to control atrial fibrillation * cardioversion (electric shock treatment) * catheter ablation * having a pacemaker fitted
52
Most common causes of AF
common causes of AF are * Ischaemic heart disease * Hypertension * Valvular heart disease * Hyperthyroidism
53
Calculate bleeding risk with AF
ORBIT score has taken over hasbled as doesn't have labile INR section TWO points for: • Hx of GI/intracranial bleeding • Hb <120 or 130 or hematocrit <36% And one score for: • Age >74 years • GFR <60 • Treatment with antiplatelet agents
54
Triggers of AF
* Pulmonary embolism * Ischaemic heart disease * Respiratory disease * Atrial enlargement or myxoma * Thyroid (fhyper) * Ethanol * Sepsis/sleep
55
Mitral valve prolapse murmur
Young women, ?marfan's HOCM * Mid-systolic click (prolapse of the mitral valve into left atrium) * Followed by a mid or late-systolic murmur * Heard loudest at the apex * Loudest in expiration, standing from squating
56
pericarditis associated conditions
* Injury (Dressler syndrome - post MI) * Infection (COVID-19) * Inflammatory (SLE, RA) * Inherited (familial Mediterranean fever) Gen causative organism is Staph, Strep, Pneumococcus
57
Cardiac issues with Down's
* atrioventricular septal defect (AVSD) * patent ductus arteriosus (PDA) * tetralogy of Fallot
58
Tetralogy of Fallot
* PS * VSD * RVH * Overriding aorta
59
Jerky pulse character
HOCM | ESM at the tricuspid region that radiates throughout the precordium, with S4
60
echo findings of HOCM
MR SAM ASH • mitral regurgitation (MR) • systolic anterior motion (SAM) of the anterior mitral valve leaflet • asymmetric hypertrophy (ASH)
61
Mixed aortic valve pathology
ES murmur Early diastolic Can also have - Austin Flint murmur (LL sternal edge, hitting ant mitral valve)
62
Causes of restrictive cardiomyopathy
primary • Loeffler's endocarditis • endomyocardial fibrosis secondary / infiltrative • cardiac amyloidosis, • cardiac sarcoidosis • iron overload (haemochromatosis)
63
Causes of Eisenmenger's syndrome
VSD, ASD, or PDA causing pulmonary hypertension Causing reversal of L to R shunt Look for cyanosis, clubbing, aortic regurge Can get RVF, paradoxical embolism, IE, hypoxaemia, haemoptysis
64
Cardiac causes for clubbing
* Infective endocarditis | * Cyanotic congenital heart disease
65
Patent ductus arteriosus murmur
* Loud continuous ‘machinery murmur’ loudest below the left clavicle in systole * Loudest in exp "rolling thunder"
66
What is Patent ductus arteriosus?
Connection between • proximal left pulmonary artery • and the descending aorta, just distal to the left subclavian artery in the developing fetus
67
Wolff-Parkinson-White syndrome ECG
* Short PR interval (<120 ms) | * Widening of QRS complex due to a slurred upstroke (delta wave) of the QRS complex
68
When is carotid pulse felt?
Just after S1 but before S2
69
Ejection Fraction grading
* Normal = LVEF 50 - 70% * Mild = 40 - 49% * Moderate = 35 -39% * Severe < 35%
70
Pacemaker indications
* Sick sinus syndrome * Symptomatic or drug-resistant AF * Mobitz 2 or complete heart block
71
Cardiac Resynchronization Therapy indications
• EF <35% with QRS>120 ----> E.g. in LBBB and HF • CRT defibrillators (CRT-D) also incorporate ICD
72
implantable cardioverter defibrillator (ICD) insertion indications
``` Primary prevention • MI with - LVEF < 35% - or LVEF < 30% and QRS ≥ 120 • Familial condition with high‐risk SCD - LQTS, ARVD, Brugada, HOCM ``` Secondary prevention • Cardiac arrest due to VT or VF • or VT with haemodynamic compromise • or VT with LVEF < 35%
73
Indications for implantable loop recorder
* Last about 3 years * Monitor heart rate to investigate for dizzy spells, palpitations, black outs * Depending on the type of loop recorder, might need to use your hand-held activator when symptomatic
74
Echo signs of severe aortic stenosis
* Mean gradient >40mm Hg * or Peak gradient >64 * or Valve area <1 cm2
75
Cardiac issues with Myotonic dystrophy
cardiac dysrhythmia is the second leading cause of death after respiratory failure
76
Causes of pulmonary hypertension
``` Group 1: • Idiopathic • connective tissue diseases • Congenital heart disease • Drugs ``` Group 2: • Left heart disease (A or M valve, LV) Or Group 3: due to chronic resp disease Group 4 clots Group 5 other
77
When would you admit pt with palpitations?
* VT or persistent SVT * Haemodynamic instab * History of structural heart disease ``` Or features suggesting underlying issue: • High degree AV block on ECG • Significant SOB • Chest pain, Syncope /near syncope • Fam hx of sudden cardiac death <40y! • Precipitated by exercise ```
78
Pulsatile liver
Tricuspid regurge (pansystolic murmur)
79
Causes of tricuspid regurge
Congenital: •  Ebstein’s anomaly (atrialization of the right ventricle and TR) Acquired: •  Acute: infective endocarditis (IV drug user) •  Chronic: functional (commonest), rheumatic and carcinoid syndrome
80
Indications for heart transplant
Severe heart failure Congested cardiac failure Cardiomyopathy Congenital

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