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Cardiology Flashcards

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1
Q

Common indications for AVR

A

1) Severe symptomatic aortic stenosis
2) Aortic regurgitation
3) Infective endocarditis

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2
Q

Advantages / disadvantages of metallic heart valve

A

More durable
Requires lifelong anticoagulation

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3
Q

Clinical signs of severe AS

A

Slow rising, low volume pulse
Narrow pulse pressure
Quiet/muted S2
Long murmur duration
Left ventricular heave
S4 if there is significant LVH

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4
Q

Echo information relevant in AS

A

AV area
AV gradient
AV velocity
LV function & size (?hypertrophy)

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5
Q

DDx ESM

A

Aortic stenosis
Aortic sclerosis
Hypertrophic Cardiomyopathy with septal hypertrophy
Pulmonary Stenosis

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6
Q

How to clinically differentiate aortic stenosis and pulmonary stenosis

A

Pulmonary stenosis loudest over pulmonary area, expect it in younger patient population, concurrent RV heave, louder on inspiration

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7
Q

Management of severe symptomatic AS

A

Referral for valvular intervention - surgical vs. TAVI - needs discussion in JCC

Medical:
- Beta blockers
- Avoid vasodilators as increase gradient across valve (nitrates, ACEi, sildenafil)

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8
Q

Valvular options in AS

A

Metallic surgical - more durable, but needs lifelong anticoagulation

Bioprothetic surgical - no anticoag, but not as durable

TAVI - patients not fit for surgical intervention

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9
Q

Pulse in aortic regurgitation

A

Collapsing, with wide pulse pressure

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10
Q

Murmur in AR

A

Holodiastolic murmur

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11
Q

Apex beat in AR

A

Thrusting and displaced

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12
Q

Long term management of metallic heart valves

A

Anticoagulation - typically warfarin - typically INR 3-4

Serial (yearly) TTEs & valve clinic follow up

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13
Q

Splitting of S2 with ASD

A

Would not expect variation with respiration - ASD results in equalisation of pressures

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14
Q

Pregnancy in congential heart disease patients

A

Needs TTE prior to pregnancy
Should meeting specialist obstetric cardiologists to discuss risk of preganancy
Stop any potentially teratogenic medications e.g. warfarin
If becomes pregnant would need to be closely followed and assessed

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15
Q

What to look for in pulmonary HTN in context of congenital heart disease

A

Look for any unknown shunts

Unleft, could develop Eisenmenger’s syndrome, resulting in central cyanosis

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16
Q

Causes of PV disease

A

Congenital or acquired
Rubella, Noonan’s, Down’s

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17
Q

3 things to consider with suspected congenital heart disease

A

1) Cyanotic or Acyanotic
2) Any previous surgical intervention
3) Associated conditions - Downs / Turners / Noonan’s

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18
Q

DDx Mitral Regurgitation

A

Tricuspid Regurg
VSD
Mitral valve prolapse

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19
Q

Clinical findings in keeping with severe MR

A

Pulmonary HTN - Raised JVP, Loud P2, R ventricular heave, thrusting and displaced apex

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20
Q

Questions to ask in Hx of someone with MR

A

Exercise tolerance
Dyspnoea
Fluid overload

Also ask about chest pain, give ischaemia is one of aetiological causes of MR

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21
Q

Ix suspected MR

A

Bedside:
Observations
12 lead ECG
Urinalysis - haematuria/proteinuria
Fundoscopy ?roth spots

Echocardiogram - LVEF, prolapse, vegetations suggestive of IE
Bloods - FBC, CRP, Renal, U&Es, ESR
CXR ?cardiomegaly

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22
Q

JVP in MR

A

JVP is a reflection of R atrial pressures

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23
Q

Mx of patient with clinical signs of MR

A

Refer to Cardiology with up to date echocardiogram

Would need to be discussed in JCC

Would be worth to consider working this patient up for surgery, including spirometry and carotid dopplers

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24
Q

Indications for mitral valve replacement

A

Symptomatic MR with evidence of pulmonary HTN / fluid overload

Asymptomatic MR with progressively declining LVEF or increasing LV dilatation

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25
Normal position apex beat
5th ICS mid-clavicular line
26
Causes of MR
Degenerative - age-related - Mitral valve prolapse related (may be related to underlying CTD) Acquired - Ischaemia - related to papillary muscle rupture - Infective endocarditis
27
What is S3?
low-pitched sound that doctors can hear when blood rushes rapidly from the heart's atrium into the ventricle Indicative of heart failure
28
Value of pathology associated with Noonan syndrome
Pulmonary stenosis
29
Phenotypic features of Noonan syndrome
Cubitus valgus (Forearm angled away from the body) Broad forehead with deep set eyes Webbed neck Widely spaced nipples Short stature Other features include mild learning difficulty and delayed motor development
30
DDx Pulmonary Stenosis
PS can either be valvular, of supra/infra-valvular Aortic Stenosis ASD/VSD
31
Pulse pressure and pulse in AS
Narrow and slow rising
32
Clinical symptoms of pulmonary stenosis
Effort, intolerance Breathlessness on exertion Signs of right sided heart failure Presyncope and syncope
33
Signs of severe pulmonary stenosis
Large A waves in the JVP (raised RA pressure) Right ventricular heave due to hypertrophy Pansystolic murmur from functional tricuspid regurgitation Clinical signs of right-sided heart failure Widely split second heart sound with quiet pulmonary component
34
Cardiac complications associated with Noonan syndrome
Pulmonary stenosis Hypertrophic cardiomyopathy Septal lesions
35
Eye signs in Noonan syndrome
Proptosis Ptosis Strabismus (abnormal eye alignment)
36
Echocardiographic features of severe pulmonary stenosis
Gradient >64mmHg Velocity >4m/s Valve area <1cm2 Signs of RV failure / Raised RV systolic pressures Assess if supra / valvular / infra
37
Genetics of Noonan syndrome
Autosomal dominant At least eight different gene mutations
38
Congenital heart disease is associated with an ejection systolic murmur
congenital aoritc valve disease resulting in bioprosthetic AVR congential Pulmonary stenosis resulting in bioprosthetic pulmonary valve replacement ToF Transposition of great vessels
39
Components of the tetralogy of fallot
VSD Overriding Aorta Pulmonary stenosis RVH
40
Confirming diagnosis with suspected congenital heart disease
Take a full Hx Review previous letters, inc. operation notes 12 lead ECG CXR Echocardiogram Cardiac MRI May need to be considered for cardiac catheterisation if there are abnormalities on MRI
41
Long term follow-up for patients with congenital heart disease
Review in specialist congenital heart disease clinic Yearly echocardiograms Advice on importance of good oral health, given increased risk of IE (Abx prophylaxis is no longer recommended)
42
Causes of pulmonary stenosis
Congenital, pulmonary stenosis Associated with syndromes -noonan, Williams,ToF Secondary to infection (IE / Rheumatic fever) Carcinoid syndrome
43
Management of Pulmonary valve disease
Monitor Treat underlying causes, particularly if infection Consider balloon valvuloplasty If concurrent pulmonary regurgitation, consider PV replacement
44
When would you expect symptoms with pulmonary stenosis
Usually only when severe Mild-Moderate generally haemodyanmically tolerated
45
Gradient of mild and moderate pulmonary stenosis
Mild <36mmHg - only need TTE every 5 years Moderate 36-64
46
Vascular pathology associated with Ehlers Danlos syndrome
Mitral valve prolapse, resulting in mitral regurgitation
47
Conditions associated with mitral valve prolapse
Marfan syndrome Ehlers Danlos syndrome Osteogenesis imperfecta Polycystic kidney disease
48
Eye complications associated with Ehlers Danlos
Lens dislocation
49
Vascular complications associted with Ehlers Danlos
Aortic dilatation Aortic aneurysm Aortic dissection Also concerned about carotid artery involvement Raynaud's disease
50
Complications of mitral valve prolapse
Infective endocarditis Thromboembolic events Cerebrovascular accidents The need for cardiac surgery Sudden cardiac death
51
Types of mitral valve prolapse
Primary - myxomatous degeneration Secondary - associated with a connective tissue disease E.g. Marfan's syndrome
52
Clinical signs of mitral valve, prolapse
Systolic click Mid to late systolic murmur
53
High-risk patients with mitral valve prolapse
Moderate to severe mitral regurgitation Reduced left ventricular function Increased end-systolic diameter LA enlargement Age >50 Valve thickening >5mm Flail leaflet
54
Ix to perform prior to MV operation
Cardiac catheterisation TOE ?repair
55
Interventions on mitral valve
Surgery - Repair - better prognosis - Replacement Percutaneous - Mitraclip - those not amenable to surgery but need favourable anatomy
56
PDA murmur
Continuous machinery Typically, over pulmonary area and louder during systole
57
PDA concerning echocardiographic features
Raised pulmonary pressures Dilated pulmonary arteries Dilated RV and tricuspid regurgitation Left ventricular dysfunction
58
Accentuating features in PDA
Louder on expiration Radiation to back in particular left scapula
59
Pulse finding in severe PDA
Collapsing, pulse
60
Why are right-sided murmurs louder on inspiration?
Inspiration increases venous return, therefore resulting in increased flow across the valves and accentuation of murmurs
61
What is a patent ductus arteriosus?
Connection between the proximal left, pulmonary artery and the descending aorta Typically, closes at birth, forming the ligamentum arteriosum
62
When is PDA closure recommended?
When associated with left ventricular volume overload or right ventricular pressure overload
63
Next steps in PDA, when echocardiogram demonstrates raised, pulmonary pressures
Consider cardiac catheterisation to assess pulmonary pressure
64
Clinical findings Eisenmengers syndrome
Clubbing Central cyanosis Widely split S2 RV heave No underlying murmur when L to R shunt has reversed
65
Causes eisenmengers
Reversal of L to R shunt Commonly VSD ASD and PDA
66
Indications for closure of VSD
L to R shunt Need for cardiac surgery for other reason Infective endocarditis Acute VSD 2o infarction
67
Complications of Eisenmengers
RV failure Paradoxical embolism IE Hypoxaemia
68
Cardiac causes for clubbing
Cyanotic congenital heart disease Subacute IE
69
Syndromes associated with VSD
Downs Edward’s Di George
70
Medical management of pulmonary htn
Endothelin antagonists - Bosentan PDE5i - Sildenafil Prostanoid infusion
71
LP findings CIDP or GBS
Expect a raised protein, but normal cell count
72
Acute Mx GBS
A to E approach Monitor serial FVCs and escalate as necessary Consider ABG if FVC < 1.5 Severe disease consider plasma exchange or IVIG
73
Chronic management of CIDP
MDT approach Neuro - neuropathic analogesia and disease modifying agents - plasma ex, IVIG, steroids or immunosuppressants OT PT orthotics
74
What is pseudoathetosis indicative of?
Sensory ataxia
75
What should you think about with a mixed asymmetric polyneuropathy?
Think immune Acute - GBS Chronic - CIDP
76
Complications associated with ToF surgery?
Pulmonary regurgitation Arrhythmia Endocarditis Polycythaemia Coagulopathy Arrhythmias
77
How can you keep PDA open in cyanotic congenital heart disease?
Prostaglandin infusion
78
Common complication following surgery for ToF
Pulmonary regurgitation
79
Shunt used to connect arterial with pulmonary circulation in ToF
Blalock-Taussig Associated with a weaker L radial pulse
80
Common causes of cyanotic heart disease?
ToF TGA Pulmonary stenosis / Pulmonary atresia Tricuspid atresia Ebsteins Eisenmengers
81
Causes of acyanoric congenital heart disease
Asd Uncomplicated vsd Pda Coarctation Aortic stenosis
82
Echo findings of diastolic dysfunction - what to think about
Hx of HTN ?concurrent valvular lesions Rule out constrictive pericarditis
83
How to determine constrictive pericarditis
CXR - calcified pericardium Echo - thickened pericardium Cardiac MRI Consider L & R heart catheterisation
84
Causes of constrictive pericarditis
Viral or bacterial pericarditis Recurrent pericarditis Post-cardiac surgery Post-TB Post-Radiation
85
Causes of restrictive cardiomyopathy
Loefflers - eosinophilic infiltration Systemic conditions - sarcoidosis, scleroderma, haemochromatosis, amyloidosis Malignancy Radiation
86
Treatment of constrictive pericarditis
Pericardectomy
87
Treatment of restrictive cardiomyopathy
Treat underlying cause Treat HF symptoms - diuretics In severe cases, consider cardiac transplantation
88
Causes of diastolic dysfunction
HTN Valvular conditions Subendocardial fibrosis Constrictive pericarditis Restrictive cardiomyopathy
89
CHA2DS2-VASc
CHF HTN (65-74 =1, >75 = 2) Age Diabetes Stroke (2 points) Sex Vascular disease
90
New bleeding risk score in AF
ORBIT-AF
91
MR causes
Primary - MV prolapse - MV flail leaflet Secondary - Dilated cardiomyopathy - Ischaemic cardiomyopathy - Infective endocarditis
92
Surgical indications in patients with asymptomatic primary MR
Reduced LVEF (<50%) LVESD >45mm AF PASP >50mmHg
93
Indications for anticoagulation with MV disease
Concurrent AF Previous emboli
94
How is IE diagnosed
Dukes Criteria - 2 major & 5 minor criteria - Diagnosis is 2 major criteria or 1 major + 3 minor or all 5 minor Major Blood cultures +ve (2 positive) Echocardiogram - valvular vegetations / abscesses Minor: Fever IVDU / Structural heart disease Micro evidence Immune phenomena - Osler's nodes vascular phenomena
95
Common cause of mixed MV disease
Rheumatic fever
96
Complication of mitral stenosis
Can result in raised pulmonary pressure, resulting in R sided dysfunction and TR
97
Causes of Aortic Stenosis
1. Age-related calcific degeneration 2. Bicuspid AV 3. Rheumatic heart disease 4. Fabry's 5. SLE
98
Chronic causes of AR
CTD - Marfans / Ehlers-Danlos HTN Osteogenesis imperfecta Ank Spond GCA SLE
99
Acute causes of AR
Infective Endocarditis Aortic Dissection Trauma
100
Signs of AR
De-Mussets - head nodding Quinkes - Nail bed pulsation Mullers - Uvula pulsation
101
What tests should be performed in asympomtic severe disease or low flow AS?
Exercise testing - increases output therefore can better assess gradients
102
Why is TAVI rarely used in AR?
Due to concurrent aortic root dilatation
103
Main things to check on bloods in palpitations
Electrolytes Thyroid function

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