Cardiology

Question 1

What are the four heart sounds and what causes them?

Answer 1

S1 - due to Mitral and tricuspid closure at start of systole

S2 - Due to aotic and pulmonary closure at end of systole

S3 (pathological) - Low pitched mid diastolic. Sounds like kentucky. Late sign of LV/RV dilation and failure

S4 (pathological) - Late diastolic sounds, higher pitch than S3. Sounds like Tennesse. Due to atrial kick into non compliant ventricle due to LV hypertrophy (AS, HTN, HCM)

Question 2

What are the two components of S2? which sound is first? What abnormalities or S2 can there be and why do they occur?

Answer 2

Physiologically split with A2 coming before P2 due to higher pressures in aorta
- increased split with inspiration is normal

Fixed usually wide split S2 - Due to atrial septal defect

Increased split S2 - occurs due to delayed emptying of the RV. Due to RBBB, Pul stenosis, VSD (due to increased RV volume load) and MR (due to earlier A2)

Reverse split - Due to significant delayed LV emptying (due to severe AS, coarctation of the aorta, LBBB, increased LV volume load)

Loud A2 - Higher Aortic pressure forced Aortic shut with more force

Loud P2 - due to pul HTN. Palpable P2 correlated better with Pul HTN than loud P2

Question 3

What are abnormalities of S1 and what causes them?

Answer 3

Loud S1 - mitral and tricuspid valve remain wide open at the start of systole causing them to rapidly go from 100% open to closed (usually mitral and tri valve drift shut during late diastole as flow reduces). Due to mitral and tricuspid stenosis. Tachycardia will also cause Loud S1 for same reason

Soft S1 - Mitral regurg due to failure of leaflets to oppose. Delayed diastole due to PR prolonged, or delayed onset of systole due to LBBB

Split S1 - Rare. Not normally heard. Due to conduction block such as complete RBBB

Question 4

What is an opening snap and what causes it? WHere is it best heard?

Answer 4

High pitched variable timing heart sound some time after S2
Due to mitral stenosis. Caused by opening of the mitral valve leaflets in stenosed valve

Best heard with dia at lower left sternal edge

Question 5

How can Opening snap be distinguished from split S2? WHat about from S3, 4?

Answer 5

Usually occurs later in S2 than split S2 (even wide split S2)

Higher pitch than S3 or 4

Question 6

What is a diastolic pericardial knock? What causes it?

Answer 6

Heard in diastole when diastole suddenly stops due to constrictive pericarditis (sort of similar mechanism to S4)

Question 7

What are the three different types of systolic murmur?

Answer 7

Pansystolic - occurs throughout systole

Mid systolic (AKA cresendo decresendo murmur) - greatest in mid systole and wanes towards S2

Late systolic - Begins in mid to late systole and continues in intensity up until S2

Question 8

What are the differentials for a pansystolic murmur?

Answer 8

Mitral regurgitation (most common)

Tricuspid regurgitation

Ventricular septal defect (if small, large wont have murmur)

Question 9

What are the differentials for a mid systolic murmur (ie cresendo decresendo murmur)?

Answer 9

Aortic stenosis

Pulmonary stenosis

Question 10

What are the differentials for a late systolic murmur?

Answer 10

Mitral valve prolapse or papiliary muscle dysfunction

Question 11

What are the two types of diastolic mumrur? Describe them

Answer 11

Early diastolic - begins right after S2 and diminishes and then stops before S1

Mid diastolic - starts in mid dia and continues until S1 usually. Usually lower in ptich that early diastolic murmur. Can be accompanied be presytolic accentuation due to atrial kick

Question 12

What are the differentials for a early diastolic murmur?

Answer 12

Aorti regurgitation
Pul regurg

Question 13

What are the differentials for mid diastolic mumur?

Answer 13

Mitral stenosis

Tricuspid stenosis

Question 14

What are continuous murmurs? What are differentials for continuous murmurs?

Answer 14

Occur sustained throughout systole and diastole and are due to a sustained pressure differential and therefore flow throughout the cardiac cycle

patent ductus arteriosus

Aortopulmonary

AV fistula

Question 15

What is a pericardial rub? What accentuates it?

Answer 15

Additional sound due to pericarditis
High pitched scratching sounds similar to walking on snow

Can occur at anytime in the cycle

Loudest when sitting forward and breathing out

Question 16

What accentuates right sided murmurs?

Answer 16

Breathing in and holding breath
Left side will be unchanged or softer

Question 17

What accentuates left sided murmurs?

Answer 17

Breathing out and holding breath
RIght side will be unchanged or softer

Question 18

What does sitting forward and breathing out accentuate?

Answer 18

Aortic regurg (mainly), technically aortic stenosis

Pericardial rub

Question 19

What does left lateral position accentuate?

Answer 19

Mitral regurg

Question 20

Utility of valsava?

Answer 20

If you hear mid systolic murmur then could be HCM or AS

Valsava with make HCM louder and will make AS softer (both due to reduced cardiac ouput). Therefore can be used to distinguish between them as they both sound the same otherwise

Question 21

What is pulsus paradoxus? what causes it?

Answer 21

This is a fall or more than 10mmHg with inspiration (pathological)

Occurs in tamponade or constrictive pericarditis. Inspiration increased RV filling which impedes LV filling as both exist in a close space together

Question 22

Signs of chronic constrictive pericarditis?

Answer 22

Pulse and BP:
- Narrow pulse pressure
- Pulsus paradoxus

JVP:
- Raised JVP (due to decreaed compliance of RV)
- Kussmals sign - lack of change in JVP with inspiration (usually will fall with inspiration)
- Prominent X and Y decent

Apex beat:
- Impalpable

Auscultation:
- Distant sounds
- S3 / pericardial knock (abrupt ceasation fo blood flow during dia due to poor compliance

Abdo:
- hepatosplenomegally due to raised venous pressure
- Ascites

Legs:
- oedema

Question 23

Causes of chronic constrictive pericarditis?

Answer 23

• Distant cardiac trauma or surgery
• Infection: TB, histoplasmosis, past pyogenic infection
• Radiation: Medisatinal radiation
• CTD - RA
• Metabolic: CKD with uraemic pericarditis

Question 24

Signs of acute cardiac tamponade?

Answer 24

Note that chronic tamponade does not usualyl cause signs as pericardium stretches to accomodate fluid

• Pulse and BP: Narrow pulse pressure, thready pulse, tachycardia and hypotension, pulsus paradoxus
• JVP: prominent X but absent y decent
• Apex beat - not palpable
• Auscultation - soft heart sounds

Question 25

Difference between acute tamponade and chronic constructive pericaridits?

Answer 25

Deep X and Y descent with pericarditis. Absent y descent with tamponade due to no RA emptying Kussmals sign (pardoxical filling of JVP with inspiration) frequently occurs with pericarditis, rare with acute tamponade Pulsus paradoxus frequent in tamponate, rate in pericarditis

Question 26

Signs of infective endocarditis?

Answer 26

General: - Fever, LOW, pallor (due to anaemia) Hands: - Splinter haemorhages (non specific) - Oslers nodes (rare), janeways lesions (very rare) - Clubbing - occurs with chronic IE Arms: - evidence of IVDU Eyes: - pale conjunctiva - Retinal or conjunctival haemorhages. Roth spots are fundal vasulitis lesions with yellow centre surrounded by red ring Heart: signs of aquired and congenital heart disease - Mitral regurg/ stenosis - Aortic regurg / stenosis - Signs of congential heart disease (PDA, setal defects, coarctation aorta) - Iatrogenic valves or implants Abdomen: - Splenomegaly Peripheries: - evidence of embolisation to legs or lungs or elsewhere

Question 27

Causes of hypertension (primary and secondary)?

Answer 27

Primary: - Idiopathic / essential HTN. Associated with etoh, obesity, salt consumption, and OSA Secondary (<5%) - Renal disease: Bilateral RAS, PKD, CT associated nephropathy (systemic sclerosis), Diabetic nephropathy, reflux nephropathy - Endocine: Cushings, Conns (primary hyperaldosteronism), acromegally, Phaeochromocytoma, THyrotoxicosis / hypothyroid, CAH, hyperparathyroidism - Coaractation of the aorta

Question 28

Main complications of systemic HTN?

Answer 28

CVD: - CCF - CVAs Renal failure Hypertensive retinopathy leading to blindness

Question 29

Signs of pulmonary hypertension?

Answer 29

Pulse and BP: - Low pulse pressure in severe disease due to low CO JVP: - Prominent a waves due to forceful RA contraction Apex and precordium: - RV heave (RV hypertrophy) - Palpable P2 over pul valve area Auscultation: - Systolic ejection click due to dilation of the pulmonary arteries - Loud P2 - S4s (mainly due to atrial contraction into decreased compliance RV) - Pul ejection systolic murmur due to dilation of pulmonary arteries causing turbulent flow (not due to valve path) - Pul regurgitation murmur due to pul valve annulus dilation causing functional regurg Signs of RV failure (late sign; termed Cor pulmonale)

Question 30

Causes of pul HTN?

Answer 30

There are five types of Pul HTN classified by aetiology - Type 1 - Pul artery HTN (artery pressure is increased, wedge pressure is normal (ie it is not LV problem) - Type 2 - Pul HTN due to left heart disease (ie LV failrue). Pul art pressure and wedge pressure increased - Type 3 - Pul HTN caused by lung pathology - Type 4 - Caused by Pul arty obstruction (ie CTEPH or acute massive PE) - Type 5 - Unknown or multifactorial

Question 31

Signs of mitral stenosis?

Answer 31

General: - Mitral faces Pulse and BP: - AF often present due to LA enlargment JVP: - Normal. May have prominent a wave if Pul HTN present due to LV failure (type 2 pul HTN) Palpation: - Tapping quality apex beat (palpable S1). Signs of Pul HTN if present (palpable P2, loud P2, RV heave etc) Auscultation - Loud S1 - Opening snap during early distole - Low pitched rumbling late diastolic murmur with late diastolic accentuation

Question 32

Describe MS murmur? where is it best heard? accentuation? How is it different from AR in quality?

Answer 32

Low pitched rumbling late diastolic murmur with late diastolic accentuation Best heard with bell over mitral area with pt in left latera position and breathing out Quite dif from AR which is higher pitched early diastolic decrescendo murmur without late diastolic accentation

Question 33

Signs of severity MS?

Answer 33

Signs of severe MS include: - Small pulse pressure - Soft first heart sound (usually expect loud S1 however if valve become immobile in severe then will become soft) - Longer duration murmur (ie begins earlier in diastole) - Murmur assocaited with diastolic thrill at apex - Signs of Pul HTN present (type 2 pul HTN)

Question 34

Signs of mitral regurg (not acute)?

Answer 34

Pulse and BP: - Atrial fibrillation often present Palpation: - Apex beat often displaced and hyperdynamic due to LV dilation (needing to accommodate large volume of fluid to maintain CO) - Pansystolic thrill over apex - Parasternal impulse may be present due LA enlargment Ausculatation: - Soft of absent S1 (similar to normal heart sounds) - Pan systolic murmur at mitral valve area radiating to axilla

Question 35

Describe MR mrumur quality? where is it heard best? accentuation?

Answer 35

Pan systolic murmur at mitral valve area radiating to axilla Accentuated by breathing out and left lateral position

Question 36

Signs of severity: MR?

Answer 36

Signs of severe MR include: - Early A2 manifesting as wide split S2. Due to early emptying of LV - Early diastolic rumble and loud S3

Question 37

Causes of MR?

Answer 37

- Mitral valves prolapse - Papillary muscle dysfunction including rupture due to ischemic event - Cardiomyopathy (hypertrophy, dilated or restrictive) ie through annulus dialtion and funcitonal regurg - Rheumatic heart disease - Connective tissue disease (Marfans, RA, Ank spond) - Congenital - Degenerative

Question 38

Explain the auscultation findings of mitral valve prolapse?

Answer 38

Usually mid systolic click occurs (this is the prolapse happening), then a mid to late systolic murmur until S2 (subsequent mitral regurg) Note lack of click does not indicate there is not prolapse. Therefore murmur that begins in mid to late diastole that continues until S2 but may be MR due to mitral prolapse Mid systolic click and murmur is made louder by valsalva and standing (low CO states), this is in contrast to ejection click of AS or PS which are made softer.

Question 39

Causes of mitral valve prolpase?

Answer 39

- Myxomatous degeneration of the mitral valve tissue (most common condition leading to mitral regurg and repair - Harfans - HCM

Question 40

Signs of AS?

Answer 40

Pulse and BP - plateauing or late peaking pulse. Small volume Palpation: - Pressure loaded and slightly displaced Apex beat - Systolic thrill base of the heart (aortic area) Auscultation: - Narrow split or reverse split S2 (takes longer to empty LV meaning A2 occurs later) - Harsh midsystolic ejection murmur heard loudest over the apex but may be heard widely over precordium and at apex - Louder with pt sitting forward (brings base of heart closer to chest wall) - Louder with expiration - Softer with valsava - Often associated with AR (soft decresendo diastolic murmur over lower left sternal edge) - EJection click may be heard prior to murmur in pts with immobile valves cusps. CLick will be absent in calcified / degenerative valve (ie most elderly pts with AS), or if sub aortic stenosis (ie HCM)

Question 41

Difference between AS and aortic sclerosis on examination?

Answer 41

Both AS and aortic sclerosis have similar murmur. However AS has other signs such as pulse changes. Aortic sclerosis is due to turbulent flow over sclerotic valve (ie bumpy surface) but nil gradient

Question 42

Signs of severity: AS?

Answer 42

TTE findings: - Valve area <1cm2, or valve gradient > 50mmHg - Plateauing pulse or reduced volume carotid pulse - Reverse split S2 with softer or absent A2 - Long and late peaking systolic murmur

Question 43

Causes of AS?

Answer 43

- Degenerative and calcified AV (most common in elderly) - Calcified AS in younger pts usually due to biscuspid valve - Rheumatic heart disease

Question 44

WHat are some other forms of aortic outflow obstruction aside from AS?

Answer 44

HCM - this is dynamic aortic outflow obstruction sub valvular Subvalvular - membranous diaphragm or risge below the AV causes jet lesion that degenerates the cusps Supravalvular lesion - narrowing of teh ascending aorta/ coarctation. Fiberous diaphragm above AV

Question 45

SIgns of aortic regurg?

Answer 45

General inspection: - Marfans appearance, ank spond or other seronegative athritis - Argyl robinsons pupils (rare) Pulse and BP: - Characteristic collapsing or water hammer pulse. Most obvious if hand is raised while palpating radial - May have wide pulse pressure Neck: - Prominent carotid pulsations (collapsing or water hammer pulse) Palpation: - Apex beat displaced and hyperdynamic (reflex volume loaded condition) - Diastolic thrill over left sternal edge when pt sits forwards and breaths out Auscultation: - Soft S2 (specifically soft A2) - Decresendo high pitched early disatoic murmur that begins right after A2 and continues to variable time in diastole - Best heard over left parasternal line 3rd and 4th intercostal space (NOT over aortic area due to direction of regurgitant jet) - Often associated ejection systolic mumur due to torential flow over AV or concurrect AS - Austin flint murmur

Question 46

What is an austin flint murmur. How is it ditinguished from other similar mumurs?

Answer 46

Austin flint murmur is low pitched mid distolic and presystolic murmur heard over at teh apex. It is a murmur associated with AR due to regurgitant jet fluttering Mitral valve leaflets Distinguished from MS due to normal sounding S1 (S1 will be loud in MS usually) and nil opening snap

Question 47

Signs of severity: AR?

Answer 47

Collapsing pulse Wide pulse pressure >80mmHg Long duration decresendo dia murmur with left Vent S3 Austin flint mumur Disecting aneurysm

Question 48

Aortic root dilation can cause what murmur? WHat are the causes of root dilation?

Answer 48

Can cause AR by widening the aortic anulus Caused by: - Marfans -Aortitis (due to seronegative arthritis, RA, tirtiary syphilus) - Dissecting aneurysm

Question 49

Signs of tricuspid stenosis?

Answer 49

JVP - raised with giant a waves and slow y descent Auscultation: - Mid to late diastolic murmur heard over the left sternal edge loudest on inspiration. SImilar in character to MS but dif due to where heard and accentuation - Other murmurs such as TR and mitral stenosis are often present as well Abdomen: - pre systolic pulsation of liver edge by forceful atrial contraction

Question 50

Causes of TS?

Answer 50

Rheum heart disease

Question 51

Signs of TR?

Answer 51

JVP: - large V waves (first major wave). JVP will be elevated if RHF is present Palpation: - RV heave (parasternal impulse) Ausculatation: - pansystolic mumur maximal at the lower left sternal edge, accentuated by inspiration Abdomen: - pulsitile liver edge and tender liver edge is often palpable. May cause right nipple to dance in time with HR Legs: - may see pulsitile vein in the legs

Question 52

Causes of TR?

Answer 52

Functional: - no disease of the valve leaflets, RV failure with dilation often causes Rheumatic: - Would be very rare for TR to occur in isolation, usually mitral disease is also present Infective endocarditis (Right heart disease in IVDU pts) Tricuspid valve polpase: RV pap muscle infarction Trauma: usually caused by steering wheel to sternum MVA

Question 53

Pul stenosis signs?

Answer 53

JVP: Giant a waves due to RV hypertrophy, JVP may be elevated from RV failure Palpation: - RV heave, thrill over pul area Auscultation: - Murmur preeceeded by mid systolic ejection click, then harsh usually loud murmur heard over the pul area loudest with inspiration. Not well heard over carotid which distinguishes it from AS - RV S4 may be present

Question 54

Causes of PS?

Answer 54

Congenital Carcinoid syndrome

Question 55

Signs of PR?

Answer 55

Auscultation: - decrescendo high pitched diastolic murmur heard at the left sternal edge, typically but not always increased with inspiration (differentiates from AR) - Note a diastolic murmur at the left sternal edge is more likely AR than PR

Question 56

What is a graham steel murmur?

Answer 56

This is a PR functional murmur caused by dilation of the pul arteries from pul HTN. Sounds like regular PR

Question 57

Causes of PR?

Answer 57

Pul HTN (graham steel murmur) IE Following balloon valvotomy for pul stenosis or surgery for pul atresia Congenital abscence of pul valve

Question 58

Explain dynamic outflow tract obstruction in HCM?

Answer 58

LV shortens and rotates on contraction, this progressive brings the walls of the LVOT closer together and in pts with HCM and hypertrophied muscles this can cause LVOT obstruction in late systole

Question 59

Signs of HCM?

Answer 59

Pulse: - sharp rising pulse to to initial goods ejection followed by sudden obstruction caused by anterior movent of the mitral valve during systole. Dif from AR and AS murmur JVP: - Prominent a wave due to forceful contration against a non compliant RV (RV also hypertrophied in HCM) Palpation: - double or even tripple apical impulse due to pre systolic expansion of teh ventricle caused by atrial contraction (ie palpable S4). Also pressure loaded Auscultation: - Late systolic murmur at left sternal edge and apex. Often with pansystolic murmur at mitral area with axilla radiation due to concurrent MR - S4 Dynamic manouvers: - Outflow murmur is incleased by valsava, by standing rapidly and by isometric exersise (all of these decreased CO which results in greater opposition of the walls) Opposite will be true of AS murmur

Question 60

How is the HCM pulse dif from teh AR and AS pulse?

Answer 60

HCM pulse: sharp rising pulse. Dif from AR which is normal rising but fast falling Dif from AS which is slow rising

Question 61

Causes of HCM?

Answer 61

Idopathatic Esosinophilic endomytocardial disease Endomyocardial fiboris Infiltrative disease Granulomatous disease ie sarcoidosis

Question 62

Can ischemic cause dilated cardiomyopathy?

Answer 62

No. Ischemia is not a cause by definition because this would be called ischemic cardiomyopathy

Question 63

What are the sings of dilated cardiomyopathy?

Answer 63

Signs are those of CCF but also may have Functional MR and TR due to annulus dilation. Also HS usually very quiet

Question 64

Causes of dilated cardiomyopathy?

Answer 64

Idiopathic or familial Alcohol Post viral Post partum Drugs (eg doxorubicin, RCHOP) Haemachromatosis

Question 65

Causes of restrictive cardiomyopathy?

Answer 65

Causes are very similar to HCM causes which is essentially a form of restriction due to low compliance Idioppathic or familial Eosinophilic endomyocardial disease endomyocardial fibrosis Infiltrative disease eg amyloid Granulomatous eg sarcoid

Question 66

What are some causes of acyanotic congenital heart disease?

Answer 66

VSD ASD PDA Coarctation of the aorta

Question 67

What are some common grown up congenital heard disease?

Answer 67

Corrected tetrallogy of fallot (will die if not corrected) Transposition of the great vessels usually corrected or palliative mustard procedure

Question 68

What are some causes of cyanotic congenital heart disease?

Answer 68

Tetrallogy of fallot Transposition of the great vessels Eisenmengers syndrome with right to left shunt

Question 69

Signs of VSD? Causes of VSD?

Answer 69

Auscultation: - harsh pansystolic murmur heard over the lower left sternal edge often with 3rd of 4th heart sounds present - Accentuated by expiration - Murmur paradoxically loudest and harshest when defect is small to to increased turbulent flow Causes: Congential MI affecting septum

Question 70

What are the two types of ASD and what distinguishes them?

Answer 70

Defect in the osteum secundum does not affect the atrioventricular valves Defect in the osteum primum does affect the AV valves

Question 71

What are the signs of ASD? (both secundum and primum ASD)

Answer 71

Signs of primum are same as secundum but may also hear associated MR, TR or VSD Ausculatation: Nil murmur specifically, however increased flow in right side can cause right sided flow murmurs

Question 72

Signs of PDA?

Answer 72

Pulse and BP: - Sharp upstroke then collapsing (kinda like a combination of AR and HCM pulse). Due to compensatory ejection of large volume of blood into empty aorta and then rapid draining into Pul artery Auscultation: - No split of S2 if the defect is moderate - Contionuous loud machinery murmur maximal at the left 1st intercostal space

Question 73

What congenital conditions are associated with co-arctation of teh aorta?

Answer 73

Turners syndrome and bicuspid aortic valve

Question 74

What are the four features of tetrallogy of fallot?

Answer 74

- VSD - Overriding aorta - RVOT obstruction (this determines the severity of the obstruction and may be sub valvular or valvular - RV hypertrophy

Question 75

What are the signs of grown up tetrallogy of fallot?

Answer 75

Always have PR due to repair of RVOT and widening of teh annulus Can also have ventricular arrhythmias due to past cardiac surgery