cardiology

Question 1

What are the clinical features of Marfan’s syndrome?

Answer 1

arachnoidactyly (spider fingers)
joint hypermobility
long thin limbs - arm span exceeds height
lens displacement/replacement
high arched palate
AR or MVP
coarctation of the aorta
kyphoscoliosis

Question 2

What are the clinical features of the Tetralogy of Fallot?

Answer 2

clubbing, peripheral cyanosis
facies of polycythaemia
scars from previous cardiac surgery
VSD - single S2
RVH - RV heave
RVOT obstruction - pulm. ejection murmur
overriding aorta - pulm. ejection murmur
- the latter 2 define the severity
on CXR - boot shaped heart

Question 3

What is an anacrotic carotid pulse? What pathology would it suggest?

Answer 3

small volume, slow upstroke

AS

Question 4

What are the causes of an elevated JVP?

Answer 4

fluid overload
RV failure
TS or TR
hyperdynamic circulation
SVC obstruction

Question 5

What is the Ddx for a mid-diastolic murmur?

Answer 5

MS
AR - the Austin-Flint murmur
TS
atrial myxoma
rheumatic fever

Question 6

What are the signs of aortic stenosis?

Answer 6

anacrotic pulse
visible apex beat (LVH)
aortic thrill
paradoxical split of S2
S4
ejection systolic, crescendo-decrescendo
radiation to carotids
loss of S2 = moderate-severe AS
heart failure = severe AS

Question 7

How do you grade the severity of aortic stenosis on ECHO?

Answer 7

aortic valve area (cm2):
mild - >1.5, mod. - 1-1.5, severe - <1
or peak gradient (mmHg):
mild < 20, mod. 20-40, severe > 40
- stress ECHO to determine if valve is pathogenic or not

Question 8

What are the complications of aortic stenosis?

Answer 8

endocarditis
heart failure
AV block (invasion of Ca+ in valve ring into conduction system)
embolic phenomena

Question 9

What conditions are associated with aortic stenosis?

Answer 9

coarctation of the aorta - R-F delay
angiodysplasia of the colon and anaemia (Heyde’s syndrome)
other valvular disease (Rheumatic)

Question 10

What are the indications for surgery in aortic stenosis?

Answer 10

symptomatic AS

asymptomatic with valve area < 1cm2 or mean gradient > 40

Question 11

What is pluses alternans? What conditions is it associated with?

Answer 11

alternating strong and weak carotid pulse

LV failure

Question 12

What is the Ddx of a mid-systolic murmur?

Answer 12

AS
PS
HOCM
ASD (pulmonary flow component)

Question 13

What is the Ddx of a late systolic murmur?

Answer 13

papillary muscle dysfunction (eg. HOCM or after LV infarct)

MV prolapse

Question 14

What are the causes of a hyper dynamic circulation?

Answer 14

AV fistula
anaemia
thyrotoxicosis
pregnancy
Beri beri
hypoxia/hypercapnia
sepsis
acute liver failure

Question 15

What is the Ddx of a pan systolic murmur?

Answer 15

MR
TR
VSD
pulmonary AVM

Question 16

What is the Ddx of an early systolic murmur?

Answer 16

acute MR
TR
VSD

Question 17

What are the pathological features of an S1?

Answer 17

loud - MS, TS, hyperdynamic

soft - MR, calcified MV, LBBB, 1st deg. HB

Question 18

What is pulsus bisferiens?

Answer 18

anachrotic and collapsing

= AS and AR

Question 19

What are the causes of a collapsing pulse?

Answer 19

AR
PDA
arteriosclerosis
hyperdynamic
peripheral AV aneurysm

Question 20

What are the pathological features of an S2?

Answer 20

normal = first A2 then P2
A2: loud - AS, HTN
- soft - AR, calcified AV
P2: loud - pulm. HTN, soft - PS
wide split - RBBB, PS, VSD, MR
fixed split - ASD
reversed - LBBB, severe AS, coarctation

Question 21

Describe S3.

Answer 21

the tautening of the mitral leaflets at the end of rapid diastolic filling

Question 22

What are the conditions that cause an S3?

Answer 22

LV failure, AR, MR, VSD, ASD - loud at apex
RV failure - loud at LSE
constrictive pericarditis

Question 23

Describe S4

Answer 23

atrial pressure wave reflected against a poorly compliant ventricle (therefore not present in AF). It is always pathological

Question 24

What are the conditions that cause an S4?

Answer 24

AS
HTN
HOCM
IHD - post MI fibrosis
acute MR
pulm HTN
PS

Question 25

What are the clinical signs of aortic regurgitation?

Answer 25

``` wide pulse pressure collapsing pulse soft A2 S3 long decrescendo murmur Austin flint murmur signs of LV failure ```

Question 26

What are the clinical signs of mitral stenosis?

Answer 26

narrow pulse pressure early opening snap long mid-diastolic murmur signs of pulm. HTN

Question 27

What are the clinical signs of mitral regurgitation?

Answer 27

``` displaced apex beat early systolic murmur soft S1 early A2 LV failure small volume pulse - severe ```

Question 28

What are the signs of pulmonary hypertension?

Answer 28

``` prominent a wave RV impulse loud/palpable P2 PR TR ```

Question 29

What are the clinical features of Eisenmenger syndrome?

Answer 29

``` (essentially pulmonary hypertension in a cyanosed patient) cyanosis, clubbing, polycythaemia dominant a wave RV heave, palpable P2 loud P2 with splitting S4 occasionally PR and TR look for signs of the shunt - ASD, VSD, PDA ```

Question 30

What are the clinical features of a patent ductus arteriosus?

Answer 30

collapsing pulse palpable thrill in left infraclavicular region loud systolic crescendo murmur - continues into diastole = machinery murmur eventually, Eisenmenger's develops - only then will differential cyanosis and clubbing (ie. toes not hands) develop

Question 31

What are the clinical features of a ventricular septal defect?

Answer 31

``` harsh pansystolic murmur at the LSE +/- a thrill ECG - LVH CXR - enlarged RV Rx if shunt size > 1.5:1 ```

Question 32

What are the clinical features of an atrial septal defect?

Answer 32

``` fixed splitting of S2 pulm. systolic ejection murmur pulmonary HTN - v. late sign ECG - RAD, RBBB, RVH CXR - increased pulm. vasculature TTE - doppler shunt or bubble study Rx if shunt size > 1.5:1 ```

Question 33

What are the clinical features of hypertrophic cardiomyopathy?

Answer 33

``` sharp rising jerky pulse prominent a wave double impulse of apex beat late ejection systolic murmur at apex pan systolic component from MR louder with Valsalva softer with leg raise or hand grip ```

Question 34

What are the findings on ECG and ECHO in HOCM?

Answer 34

ECG -LVH, ST depression in lateral leads, deep Q waves | ECHO - systolic anterior motion of mitral leaflets, asymmetric hypertrophy of septum

Question 35

What are the clinical features of chronic constrictive pericarditis?

Answer 35

pulsus paradoxus, hypotension raised JVP, with prominent x and y descent impalpable apex beat distant heart sounds with pericardial knock hepatomegaly ascites, peripheral oedema

Question 36

What are the causes of chronic constrictive pericarditis?

Answer 36

``` TB radiation connective tissue disease trauma tumours chronic renal failure ```

Question 37

What is the Ddx of a continuous murmur?

Answer 37

PDA AV fistula venous hum aorto-pulmonary connection (Blalock-Tausig shunt for Tetralogy) mammary souffle (pregnancy) - these could be confused with AS+AR or MS+MR

Question 38

What are the voltage criteria for left ventricular hypertrophy (LVH)?

Answer 38

``` any of the following: S in V1 + tallest R V5-V6 > 35 mm R wave in aVL > 11 mm R wave in aVF > 20 mm S wave in aVR > 14 mm ```

Question 39

What are the voltage criteria for right ventricular hypertrophy (RVH)?

Answer 39

Right axis deviation of +110° or more Dominant R in V1 (> 7mm tall or R/S ratio > 1) Dominant S in V5 or V6 (> 7mm deep or R/S ratio < 1) QRS duration < 120ms (i.e. changes not due to RBBB)

Question 40

What are the causes of a nonbacterial thrombotic (ie. marantic) endocarditis?

Answer 40

``` previous rheumatic fever APLS mucin-producing adenocarcinomas (esp. pancreatic) SLE - Libman-Sacks endocarditis hypereosinophilic syndrome Chagas disease trauma (e.g., central catheters) ```