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Cardiology Flashcards

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1
Q

Causes of aortic stenosis

A
  1. Age-related calcification
  2. Congenital bicuspid valve (younger patient)
  3. Connective tissue disease
  4. Accelerated calcification e.g. CKD
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2
Q

Pathophysiology of aortic stenosis

A

Pathological narrowing of the aortic valve, causing left ventricular outflow obstruction.
This leads to LV hypertrophy as a result of chronic increased afterload.

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3
Q

What signs may be seen in aortic stenosis?

A

Inspection: if replaced, may have midline sternotomy scar

Palpation:
- Pulsus parvus et tardus (weak and slow rising pulse)
- May have LV heave due to LVH

Auscultation:
- Ejection systolic murmur radiating to carotids
- May have quiet or absent S2 if severe

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4
Q

DDx in aortic stenosis

A
  • Aortic sclerosis
  • HOCM (ESM at LLSE and apex - louder on valsalva)
  • ASD (ESM at pulm. region)
  • VSD (pan systolic at LLSE)
  • Mitral regurgitation
  • Tricuspid regurgitation
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5
Q

What is the difference between aortic stenosis and aortic sclerosis?

A

Aortic sclerosis: Thickening of the valve without narrowing
- Normal pulse volume
- No radiation of murmur to carotids

Aortic stenosis: Thickening of the valve with narrowing, causing left outflow obstruction

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6
Q

Investigations if suspecting aortic stenosis

A
  • 12-lead ECG: May see LVH
  • Echo with doppler: Assess valvular pressure gradient and valve area
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7
Q

Management of aortic stenosis

A

Symptomatic management with caution:
- Reduction in preload e.g. with AHTs or beta blockers, can increase the pressure gradient across the valve

Symptomatic or severe: Aortic valve procedure
- 1st line: surgical valve replacement (low-intermediate surgical risk)
- 2nd line: Trans-catheter Aortic Valve Implantation (if non-bicuspid and high surgical risk)

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8
Q

How can pacemakers be classified?

A

Number of chambers paced:
- Single chamber (RA or RV)
- Dual chamber (RA + RV)
- Biventricular (RA + RV + LV)

Duration:
- Permanent pacemaker
- Temporary pacemaker
- Temp-perm (insertion of a PPM until arrhythmia resolved or long-term solution achieved)

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9
Q

Indications for permanent pacemaker

A

Symptomatic sinus node disease
- Sinus bradycardia
- Sinus pauses

High-degree AV block
- Mobitz II
- CHB

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10
Q

Complications of pacemakers

A

Insertion-related:
- Pocket haematoma
- Pocket infection
- Pneumothorax
- Lead dislodgement
- Cardiac perforation or tamponade (rare)

Delayed:
- Delayed infection
- Lead fracture
- Thrombosis or stenosis of the veins through which the leads travel
- Inappropriate pacing i.e. incorrectly sensing/pacing electrical activity

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11
Q

How does ICD work?

A

Dual chamber: RA and RV

Senses high-risk ventricular arrhythmias (VT/VF) and delivers a defibrillation shock

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12
Q

ICD indications

A

Prevention of VT/VF arrest

PRIMARY PREVENTION:
- HOCM (sustained VT/cardiac arrest)
- LQTS
- Brugada (most patients)

SECONDARY PREVENTION:
- Previous VT/VF arrest
- Sustained VT

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13
Q

Cardiac resynchronisation therapy - principles and indication

A

CRT is a biventricular pacemaker with 3 leads in the RA, RV and LV

Aims to restore synchronised contractions of the left and right ventricles to improve cardiac output

Generally indicated in:
LVEF <35% and broad QRS and refractory symptoms

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14
Q

Causes of heart failure

A

Vascular causes:
- Ischaemic heart disease
- Chronic hypertension

Structural causes
- Valve pathology e.g. aortic stenosis causing LVOO
- dilated Cardiomyopathy

Infection e.g. IE

Right heart failure
- Most commonly caused by left heart failure
- Right sided valve disease (tricuspid or pulmonary)
- Lung pathology
- Pulmonary vascular disease

Iatrogenic e.g. cardiotoxic medications (chemo)

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15
Q

Signs of severe AS

A

Severe aortic stenosis:

  • Quiet or absent S2
  • Weak and slow rising pulse
  • Evidence of left ventricular failure
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16
Q

Management of heart failure

A

HFpEF: Symptomatic only (diuretics)

HFrEF:
Pharmacological: ABS
- ACE inhibitor
- Beta blocker
- Consider spironolactone
- Dapagliflozin

If refractory to medical treatment and LVEF <35% - consider cardiac resynchronisation therapy

Smoking cessation
Vaccinations

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17
Q

Investigations in suspected heart failure

A

Bedside:
- ECG
- Urine dip if suspecting IE

Blood tests:
- FBC, U+Es, LFTs (hepatic congestion)
- NT-proBNP
- Lipid profile, HbA1c
Imaging
- CXR
- Echocardiogram: assess LVEF

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18
Q

Features of mitral regurgitation

A
  • Pan systolic murmur radiating to axilla, louder on expiration
  • May have displaced, thrusting apex beat

Check for complications:
- AF
- Pulmonary HTN (P2 + raised JVP)

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19
Q

Mitral regurgitation DDx:

A
  • Mitral valve prolapse
  • Tricuspid regurgitation
  • VSD
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20
Q

Complications of mitral regurgitation:

A
  • Atrial fibrillation
  • Left ventricular dilatation
  • Cardiac failure
  • Pulmonary HTN
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21
Q

Investigations for mitral regurgitation:

A

Bedside:
- ECG
- Urine dip (protein/blood)

Bloods:
- FBC
- If suspecting endocarditis: WCC, CRP, 3x blood cultures
- NT-proBNP
- consider troponin

Imaging:
- Echocardiogram (valve function, LV function, vegetations)
- CXR (Cardiomegaly/pulm oedema)

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22
Q

Causes of mitral regurgitation

A

Valvular disease:
- Degenerative
- Infective (endocarditis, rheumatic fever)

Non-structural:
- Functional MR in LV dilatation
- Myocardial infarction - papillary muscle rupture
- Connective tissue disorder

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23
Q

Management of mitral regurgitation

A

1) Patient education: e.g. smoking cessation

2) Pharmacological:
- management of HF
- management of AF

3) Surgical
- Mitral valve repair or replacement
- Transcatheter mitral valve replacement (Mitraclip) if high anaesthetic risk

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24
Q

Indications for surgery in mitral regurgitation

A

Symptomatic

OR

Asymptomatic with
- LVEF < 60%
- LV dilatation

OR

Acute mitral regurgitation e.g. papillary muscle rupture in myocardial infarction

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25
Signs of severe AS
Quiet or absent S2 Narrow pulse pressure Weak and slow rising pulse
26
A metallic S1 is...
mitral valve replacement
27
A metallic S2 is...
aortic valve replacement
28
A right venticular heave indicates...
Pulmonary HTN (loud P2) or Pulmonary stenosis (no loud P2)
29
Pulmonary stenosis DDx
- Pulmonary hypertension (should have loud P2) - ASD (ESM at pulm area with split S2)
30
A lateral thoracotomy scar could be...
- Descending aorta surgery - Mitral valvotomy (older patients) - Lung surgery
31
What does inspiration do to venous return/preload?
INspiration INcreases venous return
32
Target INR for metallic mitral valve
3-4 (think Mitral is More than aortic)
33
Target INR for metallic aortic valve
2.5 - 3.5
34
Pulmonary HTN in congenital heart disease - management
- Assess for any shunts which may require treatment - Otherwise may develop Eisenmenger's (shunt reversal) whch can lead to central cyanosis
35
Causes of pulmonary valve disease
- Infection: maternal Rubella - Syndrome: Downs, Turner's, Noonan
36
Features of Tetralogy of Fallot
PROVE: - Pulmonary stenosis - Right ventricular hypertrophy - Over-riding aorta - Ventricular septal defect - Eisenmenger's syndrome may develop (cyanosis)
37
Causes of tricuspid regurgitation
- Pulmonary hypertension - Infection e.g. endocarditis - Congenital heart disease e.g. Ebstein's anomaly
38
Why does endocarditis tend to affect the tricuspid valve in IVDU?
The particulate that injectable recreation drugs are 'cut' with deposit mostly on the tricuspid valve, as the substances flow through the heart. This predisposes the tricuspid valve to vegetations.
39
Causes of atrial fibrillation
"SMITHA" - Sepsis - Mitral valve disease (typically stenosis) - IHD - Thyrotoxicosis - HTN - Alcohol
40
Options for rate control in AF
BCD - Beta blockers - Calcium channel blockers - Digoxin
41
Importance of valvular pathology and AF
This is an absolute indication for anticoagulation
42
Echo criteria for severe AS
- Mean pressure gradient across valve of >40 mmHg - Aortic valve area < 1cm2
43
Features of severe mitral regurgitation
Displaced apex beat Pulmonary hypertension - JVP Left ventricular failure
44
Marfan's syndrome complications
Cardiac - aortic root dilation, aortic dissection, AR, MVP Resp - spontaneous pneumothorax Eyes - lens dislocation MSK - Scoliosis, pectus excavatum, pes planus
45
Pan systolic murmur DDx
Mitral regurgitation Tricuspid regurgitation VSD (pan-systolic/ejection systolic character at LLSE)
46
Patent ductus arteriosus examination
Inspection: Can be young patient 'Differential cyanosis': pink fingers and blue toes Pulse: collapsing pulse may be present Palpation: may have right ventricular heave, palpaple P2 Auscultation: - Continuous, machine-like murmur "rolling thunder" in P area - radiating to back (loudest over left scapula) - louder in expiration
47
Complications of PDA
- Pulmonary hypertension - Right ventricular dilation → functional tricuspid regurgitation - Left ventricular dilatation - Endarteritis - infection of the PDA
48
Management of PDA
Mild: conservative management Severe: percutaneous device closure
49
Mitral valve prolapse causes
Primary: degenerative Secondary: - infection - connective tissue disorders (Marfans, Ehlers Danlos) - PKD
50
Mitral valve prolapse complications
- Left heart failure - Infective endocarditis - Thromboembolic events - Atrial fibrillation
51
Mitral valve prolapse examination
- Systolic click - Late systolic murmur in (M) area radiating to axilla - Check for signs of Marfan’s/EDS
52
Mitral valve prolapse management
- Serial monitoring with echocardiography - If decompensated: mitral valve repair (valve replacement if anatomy not amenable to repair)
53
Eisenmenger Syndrome complications
- Hypoxaemia → cyanosis - Right ventricular failure - Thromboembolic events - Infective endocarditis
54
Eisenmenger syndrome pathophysiology
Left→Right shunt reverses as RV pressure > LV pressure, and becomes Right→Left shunt Most common causes: VSD, ASD, PDA
55
Eisenmenger Syndrome examination
Inspection: Young patient, clubbing, central cyanosis, may have raised JVP Palpation: RV heave Auscultation: Fixed split S2 with loud pulmonary component
56
Pulmonary hypertension causes
Primary: excess endothelin release Secondary: 1) Respiratory disease e.g. COPD leading to cor pulmonale 2) Cardio pathology e.g. VSD, ASD, PDA 3) Systemic disease e.g. systemic sclerosis
57
Pulmonary hypertension investigations
Echo - pulmonary arterial pressure >25mmHg - Look for any shunts - can get functional TR from RV dilatation Cardiac catheterisation is diagnostic
58
Pulmonary hypertension management
Medications include: - Calcium channel blockers - Bosentan - Iloprost - Sildenafil Advise against pregnancy in women (increased mortality)
59
Complications of prosthetic valves
During intervention: - Bleeding - Infection - Damage to surrounding structure e.g. PTX - AVN dysfunction in aortic valve intervention -> conduction delay Post-intervention: - Infective endocarditis - Prosthesis failure (paravalvular leaks, displacement) - Thromboembolism - Bleeding related to anticoagulation - Haemolysis across valve
60
Diastolic murmur DDx
Aortic regurgitation Mitral stenosis Pulmonary regurgitation (rare)
61
Causes of aortic regurgitation
Acute AR = emergency - Aortic dissection - Infective endocarditis - Prosthetic valve failure e.g. displacement Chronic AR - Degenerative valve disease - Congenital bicuspid valve - Connective tissue disorder e.g. Marfan’s, ankylosing spondylitis
62
Management of aortic regurgitation
Patient education e.g. smoking cessation Medical management - Cause: e.g. antibiotics in IE - Decompensated HF management - AVOID BETA BLOCKERS Severe or symptomatic AR: - Refer for surgical valve replacement ( or TAVI) Acute AR - If in cardiogenic shock may need ICU support - Do not give beta blockers
63
Murmur in HOCM
Ejection systolic murmur Apex and lower left sternal border No radiation to carotids Loudest on valsalva Quieter on hand grip Valsalva causes decreased venous return - reduced expansion of the left ventricle - septal hypertrophy causes more obstruction -> more pronounced murmur
64
HOCM causes
Primary: genetic mutations (autosomal dominant) Secondary: - Amyloidosis - Friedrich's ataxia - Myotonic dystrophy
65
HOCM examination
Inspection: - Young patient - Cardiac device? - Myotonic dystrophy/Friedrich's ataxia Palpation: - Jerky/thrusting apex beat Auscultation: - Ejection systolic murmur loudest at apex and left lower sternal edge - Louder on valsalva - Quieter on hand grip
66
HOCM investigations
- Full history incl. FH - ECG - LVH, LBBB, VT - Echo, cMRI - Holter to assess for VT Calculate the HOCM-SCD score Consider ICD Genetic testing
67
HOCM management
- Patient education - Avoid strenuous exercise and caffeine - Inform DVLA for group 2 license only Medications: BB or CCB (AVOID ACEi, nitrates) Surgical: - Septal ablation - Septal myectomy Consider ICD if high risk for life-threatening arrhythmia
68
Complications of HOCM
- Left outflow tract obstruction -> cardiac decompensation - Life threatening arrhythmia - Sudden death
69
HOCM inheritance
Autosomal dominant (if inherited) Otherwise - de novo mutations
70
VSD causes
Primary - congenital Secondary - rupture in myocardial infarction Can be associated with Down's and DiGeorge syndrome
71
VSD - examination
May be a young patient Pansystolic murmur, loudest at LLSE No radiation
72
Complications of VSD/ASD
RVH Functional TR Pulm. HTN Eisenmenger's syndrome Endocarditis YOUNG STROKE
73
VSD/ASD management
Small - monitor Large - surgical closure
74
ASD examination
Soft ejection systolic murmur at pulmonary area with fixed widely split S2
75
Septal defects (ASD or VSD) - investigations
ECG/Holter Echo Bubble echo or cmri may be required CXR Bloods incl. infection markers
76
Causes of PDA
Primary: congenital Secondary: Neonatal rubella
77
Mitral stenosis causes
Primary: congenital Secondary: - Rheumatic fever >90% - Degenerative calcification - Infective endocarditis
78
Mitral stenosis examination
Inspection: malar flush Palpation: check for AF May have palpable P2 Auscultation: mid-diastolic murmur with opening snap - louder on expiration - radiates to axilla
79
Mitral stenosis ix
ECG Bloods incl. infection markers Echo
80
Features of severe Mitral stenosis
Symptomatic Pulmonary HTN AF Echo: Valve gradient >10mmHg Mitral valve area <1cm2 on echo
81
Mitral stenosis management
Asymptomatic: observe, W&W - Conservative mx of AF and HF Symptomatic or severe: Percutaneous balloon mitral valvuloplasty or surgical MVR
82
Atrial fibrillation - rate control indications and options
Rate control is first line in all patients EXCEPT for: - New onset AF - Heart failure - Reversible cause Options: BCD - Beta-blocker - CCB (avoid in HF) - Digoxin (sedentary patients)
83
Rhythm control options in AF
1) Pharmacological: Amiodarone or fleicanide 2) DCCV (elective, or emergency if unstable) - Ideally anticoagulate for 4 weeks before 3) Ablation if above unsuccessful - EP study first to identify correct areas to target

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