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Cardiology Flashcards

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1
Q

Which valve prosthesis are in time with the carotid pulse

A

Mitral valve prostheses

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2
Q

Which valve prosthesis are not in time with the carotid pulse

A

Aortic valve prostheses

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3
Q

What can cause a collapsing pulse

A
  • Aortic regurgitation
  • PDA
  • hyperdynamic circulation (pregnancy, anaemia, thyrotoxicosis)
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4
Q

What causes CV waves on JVP

A

Severe TR

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5
Q

What are the indications for aortic valve replacement

A
  • severe symptomatic AS or AR
  • moderate/severe AS undergoing other cardiac surgery
  • bacterial encodarditis
  • severe AS with valve area <0.6cm^2
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6
Q

What clinical signs suggest severe AS

A
  • quiet S2 sound
  • long murmur
  • low volume pulse
  • evidence of heart failure
  • narrow pulse pressure
  • LV heave/displaced LV apex
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7
Q

What are the differentials of an ESM

A
  • AS (can be heard throughout precordium)
  • Aortic sclerosis
  • HOCM (LVOTO)
  • MR (pansystolic)
  • ASD (pulmonary)
  • VSD
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8
Q

How can you differentiate AS and PS

A
  • different valve areas
  • RV heave in PS
  • PS louder on inspiration
  • younger patients with PS, elderly patient with AS
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9
Q

What is the medical management of AS

A

None - but beta blockers can help improve cardiac output

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10
Q

Which drugs must be avoided in AS

A

Anything that causes peripheral vasodilation and increases pressure gradient:
- ACEi
- nitrates
- sildenafil

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11
Q

What is Heyde’s syndrome

A

AS, angiodysplasia and acquired von Willebrand disorder

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12
Q

What are the causes of AS

A
  • common: degeneration, bicuspid
  • uncommon: rheumatic, congenital
  • rare: IE
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13
Q

What indicates severe AS on echo

A
  • aortic valve area <1cm^2
  • mean gradient >40mmHg
  • peak velocity >4m/s
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14
Q

What are the indications for mitral valve replacement

A
  • mitral regurgitation
  • mitral stenosis
  • IE
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15
Q

What is the significance of AF in aetiology of metallic MV replacement

A

More likely to be MS instead of MR

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16
Q

When would mitral valve repair be more appropriate than replacement

A

Young person with MV prolapse

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17
Q

What are the types of ASD

A
  • primum (associated with AVSD)
  • secundum (commonest)
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18
Q

What are the complications of ASD

A
  • paradoxical embolus
  • atrial arrhythmias
  • RV dilation
  • pulmonary hypertension
  • Eisenmenger’s syndrome
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19
Q

Which type of ASD is most commonly seen in Down’s syndrome

A

Ostium primum (septum primum does not fuse with endocardial cushions)

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20
Q

What are the indications for closure of ASD

A
  • paradoxical embolus
  • breathlessness
  • RV dilation
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21
Q

What are the contraindications for closure of ASD

A

Severe pulmonary HTN, Eisenmenger’s syndrome

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22
Q

What are the indications for closure of VSD

A
  • recurrent infective endocarditis
  • development of aortic regurgitation
  • LV dysfunction
  • reversible pulmonary hypertension
  • acute VSD after MI
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23
Q

What are the contraindications to closure of VSD

A

Irreversible pulmonary HTN, Eisenmenger’s syndrome

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24
Q

What are the causes of VSD

A
  • congenital inc downs, TOF
  • acquired (MI)
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25
What are the causes of an absent radial pulse
- Acute: embolism, aortic dissection, trauma - chronic: BT shunt, atherosclerosis, coarctation, Takayasu’s arteritis
26
What conditions are associated with coarctation of the aorta
- Cardiac: VSD, bicuspid AV, PDA - Non-cardiac: Turner’s, berry aneurysm
27
What can be seen on CXR in aortic coarctation
Rib notching, double aortic knuckle (post-stenotic dilatation)
28
What clinical signs are associated with patent ductus arteriosus
- Collapsing pulse - Loud continuous machinery murmur loudest below left clavicle in systole
29
What findings on examination would suggest severe MR
- evidence of pulmonary hypertension (raised JVP, loud P2, RV heave, pedal oedema) - thrusting, displaced apex
30
What are the indications for mitral valve replacement
- symptomatic MR (eg SOB) - asymptomatic but declining LVEF or LV dilatation on echo - acute MR after myocardial infarction eg papillary wall rupture
31
What are the cardiac complications of Marfan’s syndrome
- aortic root dilation - aortic dilation at any point along its length (and aortic dissection) - aortic regurgitation - mitral valve prolapse
32
What are the indications of aortic root replacement in Marfan’s
- dilation >50mm at aortic root - dilation >45mm if FHx of aortic dissection - aortic root expanding at rate >3mm per year
33
What are the main symptoms of pulmonary stenosis
- Effort exertion - Breathlessness on exertion - Signs of R heart failure - Pre-syncope, syncope
34
What clinical signs would you expect to see in pulmonary stenosis
- raised JVP - RV heave - ESM murmur in pulmonary area - PSM in tricuspid area (functional TR) - Peripheral oedema - Widely split S2
35
What are the most common cardiac complications of Noonan’s syndrome
1. Pulmonary stenosis 2. HOCM 3. Septal defects
36
What are the differential diagnoses of pulmonary stenosis
- Aortic stenosis - VSD - ASD
37
What classifies severe pulmonary stenosis on echo
- valve area <1cm^2 - gradient >64mmHg - velocity >4m^2 across valve
38
Which cardiac abnormality is seen in William’s syndrome
Pulmonary stenosis
39
What are the causes of pulmonary stenosis
- Isolated congenital - Associated syndromes (TOF, noonan’s, Williams, Alagille) - Infective (IE, Rheumatic) - Carcinoid
40
What is the management of mild asymptomatic pulmonary stenosis in adults
Valve surveillance with 5-yearly echos
41
What is the management of moderate/severe pulmonary stenosis
Percutaneous valvuloplasty or surgery
42
What are the clinical signs of tricuspid regurgitation
- raised JVP with CV waves - thrill left sternal edge - PSM loudest at LLSE on inspiration - Reversed split S2 sound
43
What are the causes of tricuspid regurgitation
- congenital: Ebstein’s abnormality - infective endocarditis (IVDU) - functional - rheumatic heart disease - carcinoid syndrome
44
Which out of janeway lesions and oslers nodes are painful?
Osler’s nodes - tips of fingers and painful
45
What are the major dukes criteria for IE
- typical organism in 2 blood cultures - echo: abscess, large vegetation, dehiscence
46
What are the minor dukes criteria for IE
- Pyrexia >38 - echo suggestive - predisposed eg prosthetic valve - embolic phenomena - vasculitic phenomena (raised ESR/CRP) - atypical organism on blood culture
47
How can you diagnose IE using dukes
- 2 major - 1 major and 2 minor - 5 minor
48
Who should receive prophylactic ABx for IE before high risk procedures
- prosthetic valves - previous IE - cardiac transplants with valvulopathy - certain congenital heart diseases
49
What are the acute causes of AR
Endocarditis, aortic dissection, trauma
50
What are the chronic causes of AR
- Rheumatic fever - Hypertension - aortic root dilation (Marfan’s, syphilis, ank spond, Takayasu’s) - CTD (EDS, pseudoxanthoma elasticum)
51
What are the congenital causes of AR
Bicuspid aortic valve, perimembranous VSD
52
What are the indications for valve replacement in chronic AR
1. Symptomatic And/or 2. Widened pulse pressure >100, ECG changes and LVEDD >65/LVEF <50
53
Describe the murmur in MS
- Loud first heart sound - opening snap of mitral leaflets in diastole followed by mid-diastolic murmur - heard best in left lateral position with bell in expiration
54
What are the common causes of mitral stenosis
Rheumatic fever (commonest) Senile degeneration Endocarditis
55
What are the differentials of mitral stenosis
Left atrial myxoma Austin-flint murmur (AR)
56
What facial sign is associated with mitral stenosis
Malar flush
57
What might an ECG show in mitral stenosis
P mitrale AF
58
What is the diagnostic criteria for rheumatic fever
Duckett-Jones criteria (proven strep on throat swab/RADT/ASOT or Scarlett fever plus 2 major/1 major and 2 minor criteria inc chorea, raised ESR, raised WCC etc)
59
What are the surgical options for mitral stenosis
1. Valvuloplasty - if not calcified 2. Closed/open valvotomy 3. Valve replacement
60
What are the indications for primary prevention ICD
- MI (>6wks ago) and LVEF <35% after optimal medical therapy - familial conditions with high risk SCD (LQTS, AVRD, HCM, Brugada, ACHD)
61
What are the indications for secondary prevention ICD
- cardiac arrest due to VT or VF - haemodynamically compromising VT - VT with LVEF <35%
62
Which conditions are associated with mitral valve prolapse
Marfan’s EDS Osteogenesis imperfecta PKD
63
Does isolated mitral valve prolapse increase risk of AF
No
64
How is a patent ductus arteriosus best auscultated
Sat forward, over left upper sternal edge or left scapula, in expiration
65
What would suggest a severe patent ductus arteriosus
- collapsing pulse - RV heave - LV failure (pulm/pedal oedema)
66
When would a PDA be considered for closure
- LV volume overload - RV pressure overload
67
What can be seen on examination of JVP in pericardial disease
Rapid y-descent (due to high RA pressures causing rapid early ventricular filling)
68
What is Kussmaul’s sign
Paradoxical increase in JVP on inspiration due to pericardial disease
69
What signs are associated with pericardial disease
- rapid Y descent on JVP - Kussmaul’s sign - pulsus paradoxus - pericardial knock (S3 sound)
70
What are the common causes of pericardial disease
- infection (eg TB) - trauma - radiotherapy - connective tissue disease (RA, SLE)
71
How can you differentiate pericardial constriction from restrictive cardiomyopathy
Constriction will demonstrate ventricular interdependence (filling of one ventricle reduces size and filling of the other)
72
What can be heard on auscultation in hypertrophic cardiomyopathy with obstruction
- ESM loudest over lower left sternal edge radiating throughout precordium - S4 sound - may have late systolic murmur from mitral valve prolapse
73
Which neuromuscular conditions are associated with HCM
- Friedrich’s ataxia - Myotonic dystrophy
74
What is seen on ECG in HCM
- LVH with strain - deep TWI in precordial leads
75
What is the management of symptomatic HOCM
- Beta blockers - alcohol septal ablation - myomectomy - PPM - ICD if high risk SCD
76
What are poor prognostic factors in HCM
- young age at diagnosis - syncope - family hx of SCD - increased septal thickness
77
Which organisms cause the majority of cases of infective endocarditis
- Streptococci - staphylococci - enterococci
78
Does ASD cause a murmur?
Not itself, but with large left to right shunts can hear pulmonary ESM and tricuspid diastolic flow murmur due to increased right heart pressure
79
What can cause a loud S1 sound
- hyperdynamic state (eg exercise) - mitral stenosis
80
What causes a loud S2 sound
Systemic or pulmonary HTN
81
What causes a soft S2 sound
Calcified aortic stenosis
82
What are the indications for closure of a VSD
- significant left to right shunt - undergoing cardiac surgery for any other indication - endocarditis - aortic regurgitation due to VSD
83
What are the complications of eisenmenger’s syndrome
- RV failure - paradoxical embolism - infective endocarditis - hypoxia
84
What causes a loud P2 and parasternal heave
Pulmonary hypertension
85
What causes a loud P2 but no parasternal heave
Bioprosthetic pulmonary valve
86
What is a cardiac indication for a lateral/posterior thoracotomy scar
Coarctation repair
87
When is MV surgery indicated in primary MR
Severe MR (LV dilation, regurgitant vol >60ml etc) _AND_ - symptomatic with LVEF >30% - asymptomatic with LVEF <60% _OR_ - undergoing other cardiac surgery eg CABG
88
How many port sites should be under a sternotomy scar after one cardiac surgery
2-3 port scars
89
What are the indications of surgery for aortic regurgitation
- significant enlargement of ascending aorta - severe symptomatic AR - severe asymptomatic AR with LVEF <50% or LVESD >50
90
What are the complications of valve replacement
Acute: arrhythmias, pericardial effusion/tamponade, infection Chronic: - stroke - valve haemolysis - valve failure (regurg) - bleeding from anticoag - infective endocarditis
91
What are the causes of mitral regurgitation
Primary: - degenerative - MVP - IE - papillary muscle rupture - rheumatic heart disease Secondary: - dilated LV (ICM, NICM)
92
What are the causes of aortic regurgitation
Acute: - valve leaflet: IE, prosthetic failure - aortic root: dissection, trauma Chronic: - leaflet: rheumatic fever - root: Marfan’s, HTN, Ank spond, Takayasu’s, syphilis Congenital: bicuspid AV, VSD
93
What are the investigations for aortic regurgitation
Bedside: fundosxopy, urinalysis, ECG Bloods: FBC, CRP, CTD screen, syphilis serology, cultures, BNP Imaging: CXR, TTE, cardiac CT
94
What are the indications for acute valve replacement in aortic regurgitation
- aortic dissection - endocarditis resistant to ABx - aortic root abscess - prosthetic valve failure
95
Which are the main genes associated with HCM
MYH7 (myosin heavy chain) MYBPC3 (myosin binding protein C)
96
What are the causes of constrictive pericarditis
- viral - bacterial - post-surgical - tuberculosis - radiation
97
Why is it important to differentiate between constrictive pericarditis and restrictive cardiomyopathy
Treatment is very different: Constrictive - surgical Restrictive - treat underlying cause, heart failure treatment, consider heart transplant
98
What is seen on echo in restrictive cardiomyopathy
Diastolic dysfunction, systolic function preserved
99
When is urgent surgery indicated in infective endocarditis
- Heart failure - Refractory to antibiotics - Heart block
100
Which scars might be seen in ToF and why
- thoracotomy scar - Blalock-Taussig shunt - sternotomy scar - VSD repair
101
What is the most common complication of pulmonary valve intervention in ToF patients
Pulmonary regurgitation
102
What are the causes of RBBB
- RVH/Cor pulmonale - PE - IHD - Myocarditis - Cardiomyopathy - Congenital Heart disease - Lenegre-lev disease
103
What are the causes of LBBB
- Aortic stenosis - IHD - Hypertension - DCM - Anterior MI - Lenegre-lev disease - hyperkalaemia - digoxin toxicity
104
What are the causes of right axis deviation
- LPFB - Lateral MI - RVH - Acute lung diseases e.g. PE - Chronic lung diseases e.g. COPD - Ventricular ectopy - Hyperkalaemia - WPW syndrome
105
What are the causes of left axis deviation
- LAFB - LBBB - LVH - Inferior MI - Ventricular ectopy - Paced rhythm - WPW syndrome

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