Cardiology

Question 1

differentials for ejection systolic murmur

Answer 1

1) HOCM
2) aortic sclerosis
3) flow murmur- high output clinic state e.g. pregnancy
4) ASD
5) tetrallogy of fallot

Question 2

what are the causes of aortic stenosis

Answer 2

congenital- bicuspid aortic valve
age- senile degeneration/ calcinosis
infection- rheumatic heart disease

Question 3

indications for surgery of aortic stenosis

Answer 3

symptomatic AS- chest pain, syncope, dyspnoea
asymptomatic
- gradient >40mmHg and
- EF <45%,
- abnormal response to exercise,
- valve area <0.6cm2,
- LVH>15mmh

Question 4

how do you differentiate aortic stenosis from aortic sclerosis

Answer 4

normal pulse character (not slow rising), normal second heart sound

Question 5

what conditions are associated with aortic stenosis

Answer 5

coarctation of the aorta- radio femoral delay
angiodysplasia (Heydes syndrome)
anaemia
William’s syndrome

Question 6

what are the dukes criteria for IE

Answer 6

2 major / 1 major + 3 minor

major
1) typical organisms in bloods culture
2) echo- abscess/ large vegetations/ dihiscence

minor
pyrexia >38
echo suggestive
prosthetic valve
embolic phenomena
vasculitic features (ESR rise)
atypical organism on blood culture

Question 7

causes of IE

Answer 7

Staphylococcus aureus
is the most common cause of infective endocarditis.

Streptococcus viridans- commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure

coagulase-negative Staphylococci such as Staphylococcus epidermidis
commonly colonize indwelling lines and are the most cause of endocarditis in patients following prosthetic valve surgery, usually the result of perioperative contamination.

Streptococcus bovis
associated with colorectal cancer

non-infective
systemic lupus erythematosus (Libman-Sacks)
malignancy: marantic endocarditis

Question 8

what are the causes of aortic regurgitation

Answer 8

acute causes- trauma, aortic dissection, infective endocarditis

chronic- rheumatic fever, dilation of the aortic root- marfans, HTN, ank spond

Question 9

what are the indications for surgery of AR

Answer 9

symptomatic patients with severe AR

asymptomatic patients with severe AR who have LV systolic dysfunction

Question 10

does a long murmur mean more severe AR

Answer 10

a short murmur suggests more severe AR due to more severe flow of bloods back into the LV

Question 11

what clinical signs suggest more severe AR

Answer 11

clinically dilated heart (displaced apex), signs of left sided heart failure, short murmur, wide pulse pressure, collapsing pulse

Question 12

what are the complications of AR

Answer 12

LV heart failure, endocarditis

Question 13

what is the prognosis of AR

Answer 13

asymptomatic and LVF >50 - 1% mortality at 5 years
symptomatic with 3 criteria- wide pulse pressure, ECG changes, echo LV enlargement/ EF <50- 65% mortality at 3 years

Question 14

Causes of mitral regurtitation

Answer 14

acute- bacterial endocarditis/ rupture
chronic- mitral valve prolapse, rheumatic, CTDs- marfans/EDS, functional MR (dilated LV), infiltrative (amyloidosis), fibrosis (post MI/ rupture)

Question 15

what are the indications for surgery of mitral regurgitation

Answer 15

symptomatic patient with severe MR
asymptomatic:
LVEF <60%
LV end systolic dimension >45mm
AF
systolic pulmonary pressure >50mmHg

Question 16

why is mitral valve repair preferable to replacement

Answer 16

disconnection of subvalvular apparatus can cause a 20% decline in LV function

risk of infective endocarditis in valve replacement

Question 17

how is ischaemic MR managed

Answer 17

ischaemic MR has a poor prognosis therefore threshold for surgery is lower.

Question 18

what features suggest severe or significant MR

Answer 18

pulmonary hypertension
displaced thrusting apex beat
AF

Question 19

what are the causes of mitral stenosis

Answer 19

Congenital - rare
rheumatic (commonest)
age related- senile degeneration
endocarditis

Question 20

what are the indications for anticoagulation

Answer 20

any patient with AF should be on anticoagulation, those with rheumatic AF have >3 fold increased risk of thromboembolism

Question 21

how often should patients with Mitral stenosis be followed up

Answer 21

if asymptomic or with mild MS- annual follow ups are required

Question 22

which patients should be offered percutaneous balloon mitral valvuloplasty/ surgery

Answer 22

if evidence of PH
new AF
symptomatic with NYHA II heart failure and valve suitable

Question 23

what is the prognosis of MR???

Answer 23

latent asymptomatic phase of 15-20 years
NYHA II confers a 50% mortality in 5 years

Question 24

what is rheumatic fever

Answer 24

immunological cross reactivity between group A B haemolytic strep infections and valve tissue.

Question 25

what is the diagnostic criteria of rheumatic fever

Answer 25

Duckett Jones proven B haemolytic infection on throat swab/ rapid antigen test/ clinical scarlett fever PLUS 2 major or 1 major+2minor MAJOR- JONES J- joints (polyarthralgia) O- carditis N- nodules (subcutaneous) E- erythema marginatum S- chorea minor high ESR, raised WCC, arthralgia, pyrexia, prolonged PR interval

Question 26

treatment of rheumatic fever

Answer 26

rest, high dose aspirin, penicillin Primary prevention: penicillin V for 10 days Secondary prevention: penicillin V for about 5–10 years

Question 27

discuss the merits of biological valve vs mechanical valves

Answer 27

metallic valves are very durable, they are often used in young patients or patients with other conditions requiring anticoagulations such as AF. metallic valves require life-long warfarin which can be cumbersome and also inappropriate for patients with a bleeding/ falls risk biological valves are generally less durable than metallic but require no warfarinisation therefore can be more appropraite in patients with risk of haemorrhage

Question 28

what are the causes of tricuspid regurgitation

Answer 28

acute- endocarditis chronic- pulmonary hypertension, ebstein's abnormality, rheumatic valve disease, carcinoidh

Question 29

why is TR endocarditis more common in IVDU

Answer 29

substances flow through the heart after being injected and can matter can cause damage to the TV (first valve encountered) and predispose to being seeded from bacteramia

Question 30

what are the 4 features of tetralogy of fallot

Answer 30

ventricular septal defect (VSD) right ventricular hypertrophy/ outflow tract obstruction pulmonary stenosis overriding aorta

Question 31

metallic 1st heart sound

Answer 31

mitral valve replacement

Question 32

metallic 2nd heart sound

Answer 32

aortic valve replacement

Question 33

splitting of the 2nd heart valve

Answer 33

mitral regurgitation tricuspid regurgitation pulmonary stenosis ASD (fixed)

Question 34

noonans syndome cardiac features

Answer 34

commonly pulmonary stenosis HOCM ASD

Question 35

signs from severe pulmonary stenosis

Answer 35

R ventricular heave ejection systolic murmur or pansystolic mumur from function TR large a waves on JVP palpable thrill

Question 36

eye signs of noonans syndrome

Answer 36

proptosis, ptosis, strabismus

Question 37

signs of pulmonary hypertension

Answer 37

RV heave and loud P2, + cyanosis

Question 38

noonans syndrome

Answer 38

congenital disorder - autosomal dominant males and females affected phenotypical features- short stature, pectus excavatum, facial features, learning difficulties

Question 39

causes of pulmonary stenosis

Answer 39

largely congenital- tetrallogy, williams, turners, noonans congenital pulmonary stenosis acute- infective endocarditis, rheumatic valve disease, carcinoid syndrome

Question 40

duration of anticoagulation in PE

Answer 40

3 months if provoked 6 months if unprovoked, or in case of active malignancy

Question 41

causes of Eisenmengers syndrome

Answer 41

reversal of a left to right shunt from pulmonary hypertension VSD ASD PDA

Question 42

complications of eisenmengers syndrome

Answer 42

RV failure IE haemoptosis hypoxaemia

Question 43

causes of clubbing

Answer 43

respiratory- malignancy, bronchiectasis, ILD cardiac- subacute endocarditis, cyanotic congenital heart disease GI- IBD familial / idiopathic

Question 44

cyanotic vs acyanotic congenital heart disease

Answer 44

cyanotic- tetrallogy of fallot, transposition of the great arteries, pulmonary atresia, pulmonary stenosis, eisenmengers, tricuspid. atresia, ebsteins acyanotic- ASD, uncomplicated VSD, PDA, coarctation, AS

Question 45

causes of constrictive pericarditis

Answer 45

viral/ bacterial pericarditis, post surgery, post TB, radiation

Question 46

causes of restrictive pericarditis

Answer 46

diastolic dysfunction with restrictive ventricular physiology. systolic function preserved. endomyocardial fibrosis (lofflers), sarcoidosis, scleroderma, malignancy, amyloidosis, iron overload

Question 47

HOCM clinical signs

Answer 47

ejection systolic murmur from LV outflor obstruction panystolic murmur resulting from MR

Question 48

causes of cardiac hypertrophy

Answer 48

Hypertension aortic stenosis hypertrophic cardiomyopathy, which is a genetic condition. Fabry disease amyloidosis

Question 49

management of HOCM

Answer 49

treating patients symptoms with beta blockers. Second line with either disopyramide or a myosin inhibitor, such as mavacamten. assess a patient for their risk of sudden cardiac death and consider implanting a defibrillator or ICD. assess patient's genetics to aid with familial evaluation In certain cases of severe disease, patients can be referred for septal reduction therapy

Question 50

Correction of TOF

Answer 50

Surgical correction of these defects in the long term is always necessary. The timing of correction depends on how symptomatic, cyanosed or hypoxaemic the child is. Corrective repair of tetralogy of Fallot includes closure of the ventricular septal defect with a synthetic Dacron patch. Narrowing of the pulmonary valve and the right ventricular outflow tract obstruction are relieved by a combination of resecting obstructive muscle tissue in the right ventricle and by enlarging the outflow pathway with a patch. Historically, a Blalock-Taussig Shunt, which is done by plumbing the left subclavian artery into the pulmonary artery