Cardiology

Question 1

Characteristics of innocent murmurs

Answer 1

Soft
Systolic
Short
Symptomless
Situation dependent - quieter on standing

Question 2

Characteristics of murmurs to be worried about

Answer 2

Louder on standing
Diastolic
Associated with symptoms such as cyanosis, SOB, feeding difficulties or failure to thrive

Question 3

Examples of pan-systolic murmurs

Answer 3

Mr. Trump Repulses Vaginas

Mitral and Tricuspid regurgitation
Ventricular septal defect (VSD)

Question 4

Examples of ejection systolic murmurs

Answer 4

PAH

Aortic stenosis
Pulmonary stenosis
HOCM

Question 5

ASD murmur

Answer 5

Mid-systolic, crescendo-decrescendo murmur with fixed split S2

Question 6

Examples of cyanotic heart diseases

Answer 6

VSD
ASD
PDA
Transposition of the great vessels

(Anything that has a whole in the heart)

Question 7

Pathophysiology of PDA

Answer 7

Left to right shunt due to Aorta feeding into the pulmonary arteries -> pulmonary hypertension. Increased pressure in pulmonary system results in right heart stain -> right sided ventricular hypertrophy. Increased blood flow through pulmonary circulation leads to left sided ventricular hypertrophy.

Question 8

Presentation of PDA

Answer 8

Usually picked up during newborn assessment.

Lower respiratory tract infections
SOB
Difficulty feeding
Poor weight gain

Question 9

PDA murmur

Answer 9

Continuous crescendo-decrescendo “machinery”

Question 10

Management of PDAs

Answer 10

Monitor until 1 year old using echos. After 1 year, trans-catheter or surgical closure is performed.

Patients with evidence of heart failure due to PDA will be treated earlier.

Question 11

Presentation of ASD

Answer 11

Difficult feeding
SOB
Poor weight gain
Lower respiratory tract infections

Question 12

Complications of ASDs

Answer 12

Stroke
AF/Atrial flutter
Pulmonary hypertension and right sided heart failure
Eissenmenger Syndrome

Question 13

ASD management

Answer 13

If the ASD is small and asymptomatic, watching and waiting can be appropriate. ASDs can be corrected surgically using a transvenous catheter closure or open heart surgery. Anticoagulants (such as aspirin, warfarin and NOACs) are used to reduce the risk of clots and stroke in adults.

Question 14

What congenital abnormalities are associated with VSDs?

Answer 14

Down’s and Turner’s syndrome

Question 15

Presentation of VSDs

Answer 15

Dyspnoea
Tachycardia
Failure to thrive
Poor feeding

Question 16

VSD murmur

Answer 16

Pan-systolic murmur

Question 17

Management of VSDs

Answer 17

Small VSDs with no symptoms or evidence of pulmonary hypertension or heart failure can be watched over time.

VSDs can be corrected surgically using a transvenous catheter closure via the femoral vein or open heart surgery.

There is an increased risk of infective endocarditis in patients with a VSD. Antibiotic prophylaxis should be considered during surgical procedures to reduce the risk of developing infective endocarditis.

Question 18

Examination findings for pulmonary hypertension

Answer 18

Right ventricular heave
Loud P2
Raised JVP
Peripheral Oedema

Question 19

Management of Eisenmenger Syndrome

Answer 19

Manage underlying condition.
Only definitive treatment is heart-lung transplant.

Question 20

What is coarctation of the Aorta?

Answer 20

Stenosing/narrowing of the aorta.

Question 21

What congenital condition is coarctation of the aorta associated with?

Answer 21

Turner’s syndrome

Question 22

Presentation of the coarctation of the aorta

Answer 22

Weak femoral pulses
Tachypnoea and increased work of breathing
Poor feeding
Grey, floppy baby
Underdevelopment of the legs

Question 23

Management of coarctation of the aorta

Answer 23

After birth, prostaglandins are given to keep PDA open whilst awaiting for surgery.

Question 24

Tetralogy of Fallot conditions

Answer 24

Pulmonary stenosis
Ventricular septal defect
Overriding aorta
Right ventricular hypertrophy

Question 25

Risk factors of tetralogy of fallot

Answer 25

Rubella infection Increased age Alcohol consumption in pregnancy Diabetic mother

Question 26

Signs and symptoms of tetralogy of fallot

Answer 26

Cyanosis Clubbing Poor feeding Poor weight gain Ejection systolic murmur Tet spells

Question 27

Treatment of Tet spells

Answer 27

Older children may squat when a tet spell occurs. Younger children can be positioned with their knees to their chest. Squatting increases the systemic vascular resistance. This encourages blood to enter the pulmonary vessels. 'OB SIMP' Supplementary oxygen is essential in hypoxic children as hypoxia can be fatal. Beta blockers can relax the right ventricle and improve flow to the pulmonary vessels. IV fluids can increase pre-load, increasing the volume of blood flowing to the pulmonary vessels. Morphine can decrease respiratory drive, resulting in more effective breathing. Sodium bicarbonate can buffer any metabolic acidosis that occurs. Phenylephrine infusion can increase systemic vascular resistance.

Question 28

Management of tetralogy of fallot

Answer 28

In newborns, administering prostaglandins to keep the PDA open. Definitive management: Total surgical repair by open heart surgery.

Question 29

Presentation of transposition of the great vessels

Answer 29

Often diagnosed on antenatal scans Respiratory distress Tachycardia Poor feeding Poor weight gain Sweating

Question 30

Management of transposition of the great vessels

Answer 30

Maintain PDA - with prostaglandins Balloon septostomy - to create atrial septal defect to involves allow blood returning from the lungs (on the left side) to flow to the right side of the heart and out through the aorta to the body. Open heart surgery is the definitive management.