Cardiology Flashcards

Question

Investigation of Mitral stenosis

Answer 1

1. ECG: p‐mitrale (broad, bifid) and atrial fibrillation 2. CXR: enlarged left atrium (splayed of carina), calcified valve, pulmonary oedema 3. TTE/TOE: valve area (<1.0 cm2 is severe), cusp mobility, calcification and left atrialthrombus, right ventricular failure

Answer 2

1. Medical: + AF: rate control and oral anticoagulants, diuretics 2. Mitral valvuloplasty: if pliable, non‐calcified with minimal regurgitation and no left atrial thrombus 3. Surgery: - -----> closed mitral valvotomy (without opening the heart) or - -----> open valvotomy (requiring cardiopulmonary bypass) or - -----> valve replacement

Answer 3

Latent asymptomatic phase 15–20 years; | NYHA > II – 50% mortality at 5 years.

Answer 4

• Immunological cross‐reactivity between Group A β‐haemolytic streptococcal infection, e.g. Streptococcus pyogenes and valve tissue

Answer 5

Proven β‐haemolytic streptococcal infection diagnosed by throat swab, rapid antigen detection test (RADT), anti streptolysin O titre (ASOT) or clinical scarlet fever plus 2 major or 1 major and 2 minor: ** Major: ======================** Minor: ------> Chorea, ================------> Raised ESR, ------> Erythema marginatum, ====------> Raised WCC, ------> Subcutaneous nodules, ===------> Previous RhF, ------> Polyarthritis, =============------> Arthralgia, ------> Carditis =================------> Pyrexia, =============================------> Prolonged PR interval

Answer 6

Rest, high‐dose aspirin and penicillin

Answer 7

⚬⚬ Primary prevention: penicillin V (or clindamycin) for 10 days ⚬⚬ Secondary prevention: penicillin V for about 5–10 years

Answer 8

1. Scars: lateral thoracotomy (valvotomy) 2. Pulse: AF, small volume 3. Apex: displaced and volume loaded 4. Palpation: thrill at apex 5. Auscultation: - Pan-systolic murmur (PSM) loudest at the apex radiating to the axilla. Loudest in expiration. - Wide splitting of A2 P2 due to the earlier closure of A2 because the LV empties sooner. - S3 indicates rapid ventricular filling from LA, and excludes significant mitral stenosis. 6. Pulmonary oedema 7. Evidence of the Cause: signs of endocarditis 8. Severity: left ventricular failure and atrial fibrillation (late). Not murmur intensity 9. Other murmurs, e.g. ASD

Answer 9

There is an association between cleft mitral valve and primum ASD

Answer 10

* Valve leaflets * * Acute - > Bacterial endocarditis * * Chronic - > Myomatous degeneration (prolapse) - > Rheumatic - > Connective tissue diseases - > Fibrosis (fenfluramine/pergolide) * Valve annulus * * Chronic - > Dilated left ventricle (functional MR) - > Calcification * Chordae/papillae * * Acute - > Rupture * * Chronic: - > Infiltration, e.g. amyloid - > Fibrosis (post‐MI/trauma)

Answer 11

1. ECG: p‐mitrale, atrial fibrillation and previous infarction (Q waves) 2. CXR: cardiomegaly, enlargement of the left atrium and pulmonary oedema 3. TTE/TOE: - Severity: size/density of MR jet, LV dilatation and reduced EF - Cause: prolapse, vegetations, ruptured papillae, fibrotic restriction and infarction

Answer 12

1- Medical ⚬⚬ Anticoagulation for atrial fibrillation or embolic complications ⚬⚬ Diuretic, β‐blocker and ACE inhibitors 2- Percutaneous: mitral clip device for palliation in inoperative cases of mitral valve prolapse 3- Surgical ⚬⚬ Valve repair (preferable) with annuloplasty ring or replacement ⚬⚬ Aim to operate when symptomatic, prior to severe LV dilatation and dysfunction

Answer 13

* Often asymptomatic for >10 years | * Symptomatic – 25% mortality at 5 years

Answer 14

• Common (5%), especially young tall women • Associated with connective tissue disease, e.g. Marfan’s syndrome and HOCM • Often asymptomatic, but may present with chest pain, syncope and palpitations • Small risk of emboli and endocarditis • Auscultation -> Mid-systolic ejection click (EC). -> Pan-systolic murmur that gets louder up to A2. -> Murmur is accentuated by standing from a squatting position or during the straining phase of the Valsalva manoeuvre, which reduces the flow of blood through the heart.

Answer 15

1. Raised JVP with giant CV waves 2. Thrill left sternal edge 3. Auscultation: - > Pan-systolic murmur (PSM) loudest at the tricuspid area (lower left sternal edge) in inspiration. - > Reverse split second heart sound due to rapid RV emptying. - > Right ventricular rapid filling gives an S3 4. Pulsatile liver, ascites and peripheral oedema 5. Endocarditis from IV drug abuse: needle marks 6. Pulmonary hypertension: RV heave and loud P2 7. Other valve lesions: rheumatic mitral stenosis

Answer 16

• Congenital: Ebstein’s anomaly (atrialization of the right ventricle and TR) • Acquired: -> Acute: infective endocarditis (IV drug user) -> Chronic: functional (commonest), rheumatic and carcinoid syndrome

Answer 17

1. ECG: p‐pulmonale (large, peaked) and RVH 2. CXR: double right heart border (enlarged right atrium) 3. TTE: TR jet, RV dilatation

Answer 18

* Medical: diuretics, β‐blockers, ACE inhibitors and support stockings for oedema * Surgical: valve repair/annuloplasty if medical treatment fails

Answer 19

1. Raised JVP with giant a waves 2. Left parasternal heave 3. Thrill in the pulmonary area 4. Auscultation: - > Ejection systolic murmur (ESM) heard loudest in the pulmonary area in inspiration. - > Widely split second heart sounds, due to a delay in RV emptying. - > Severe: inaudible P2, longer murmur duration obscuring A2. 5. Right ventricular failure: ascites and peripheral oedema 6. Tetralogy of Fallot: PS, VSD, overriding aorta and RVH (sternotomy scar) 7. Noonan’s syndrome: phenotypically like Turner’s syndrome but male sex 8. Other murmurs: functional TR and VSD

Answer 20

1. ECG: p‐pulmonale, RVH and RBBB 2. CXR: oligaemic lung fields and large right atrium 3. TTE: severity (pressure gradient), RV function and associated cardiac lesions

Answer 21

1. Pulmonary valvotomy – if gradient >70 mm Hg or there is RV failure 2. Percutaneous pulmonary valve implantation (PPVI) 3. Surgical repair/replacement

Answer 22

1. Gut primary with liver metastasis secreting 5‐HT into the blood stream 2. Toilet‐symptoms: diarrhoea, wheeze and flushing! 3. Secreted mediators cause right‐sided heart valve fibrosis resulting in tricuspid regurgitation and/or pulmonary stenosis 4. Rarely a bronchogenic primary tumour or a right‐to‐left shunt can release 5‐HT into the systemic circulation and cause left‐sided valve scarring 5. Treatment: octreotide or surgical resection

Answer 23

• Audible prosthetic clicks (metal) on approach and scars on inspection 1- Midline sternotomy (CABG, AVR, MVR) 2- Lateral thoracotomy (MVR, mitral valvotomy, coarctation repair, BT shunt) 3- Subclavicular (Pacemaker, AICD) 4- Anticubital fossa (angiography) --> Also look in the wrist and groins for angiography scars/bruising and legs for saphenous vein harvest used in bypass grafts. • Anticoagulation: bruises (metal valve) and anaemia

Answer 24

-> A metal prosthetic closing click (CC) is heard instead of A2. -> There may be an opening click (OC) and ejection systolic flow murmur. -> A bioprosthesetic valve often has normal heart sounds. -> Abnormal findings: ==> AR ==> Decreased intensity of the closing click (clot or vegetation)

Answer 25

-> A metal prosthetic closing click is heard instead of S1. -> An opening click may be heard in early diastole followed by a low-frequency diastolic rumble. -> Abnormal findings: ==> MR ==> Decreased intensity of the closing click.

Answer 26

``` Metal: --> Durable --> needs warfarin --> Indicated for: Young Pt/on warfarin, e.g. for AF Procaine: --> Less durable --> No warfarin --> Indicated for: Elderly/at risk of haemorrhage ```

Answer 27

1• Thromboembolus: 1–2% per annum despite warfarin 2• Bleeding: fatal 0.6%, major 3%, minor 7% per annum on warfarin 3• Bioprosthetic dysfunction and LVF : usually within 10 years, can be treated percutaneously (valve‐in‐valve) 4• Haemolysis: mechanical red blood cell destruction against the metal valve 5• Infective endocarditis: ⚬⚬> Early infective endocarditis (<2/12 post‐op) can be due to Staphylococcus epidermidis from skin ⚬⚬> Late infective endocarditis is often due to Strep. viridans by haematogenous spread ⚬⚬> A second valve replacement is usually required to treat this complication ⚬⚬> Mortality of prosthetic valve endocarditis approaches 60% 6• Atrial fibrillation: particularly if MVR

Answer 28

1. Incisional scar in the infraclavicular position (may be abdominal) 2. Palpation demonstrates a pacemaker 3. Signs of heart failure: raised JVP, bibasal crackles and pedal oedema 4. Medic alert bracelet 5. Local infection: red/hot/tender/fluctuant/erosion

Answer 29

1- treating people with previous serious ventricular arrhythmia, that is without a treatable cause in people who have: - -> Survived a cardiac arrest caused by either VT or VF or - -> Spontaneous sustained VT causing syncope or significant haemodynamic compromise or - -> Sustained VT without syncope or cardiac arrest, and also have an associated reduction in LVEF ≤ 35% but their symptoms are no worse than NYHA class III. 2- treating people who have: - -> A familial cardiac condition with a high risk of sudden death, such as LQTS, HOCM, Brugada syndrome or arrhythmogenic right ventricular dysplasia or - -> Undergone surgical repair of congenital heart disease.

Answer 30

``` Patient with heart failure who have left ventricular dysfunction with a LVEF ≤ 35% according to QRS duration, NYHA class and presence of LBBB 1- QRS interval <120 milliseconds ==> NYHA class I, II, III : ICD if there is a high risk of sudden cardiac death ==> NYHA class IV: ICD and CRT not clinically indicated ``` ``` 2- QRS interval 120–149 milliseconds without LBBB ==> NYHA class I, II, III : ICD ==> NYHA class IV: CRT-P ``` ``` 3- QRS interval 120–149 milliseconds with LBBB: ==> NYHA class I: ICD ==> NYHA class II: CRT-D ==> NYHA class III: CRT-P or CRT-D ==> NYHA class V: CRT-P ``` ``` 4- QRS interval ≥150 milliseconds with or without LBBB: ==> NYHA class I: CRT-D ==> NYHA class II: CRT-D ==> NYHA class III: CRT-P or CRT-D ==> NYHA class V: CRT-P ``` NB: Cardiac resynchronization therapy (CRT ) = biventricular pacemakers (BiV)

Answer 31

‘Shock box’ also delivers anti‐tachycardia pacing (ATP) – improves mortality

Answer 32

1. MI > 4 weeks ago (NYHA no worse than class III) ⚬⚬ LVEF < 35% and non‐sustained VT and positive EP study or ⚬⚬ LVEF < 30% and QRSd ≥ 120 milliseconds • Familial condition with high‐risk SCD ⚬⚬ LQTS, ARVD, Brugada, HCM, complex congenital heart disease

Answer 33

* cardiac arrest due to VT or VF or * haemodynamically compromising VT or * VT with LVEF < 35% (not NYHA IV)

Answer 34

Extra LV pacemaker lead via the coronary sinus – improves mortality/symptoms May be considered if: • LVEF < 35% • NYHA II–IV on optimal medical therapy • Sinus rhythm and QRSd > 150 milliseconds (if LBBB morphology may be >120 milliseconds)

Answer 35

This man has had previous mantle radiotherapy for lymphoma and has a chronic history of leg oedema, bloating and weight gain.

Answer 36

Predominantly right‐side heart failure A. Raised JVP ⚬⚬ Dominant, brief y‐descent due to rapid early ventricular filling and rise in diastolic pressure ⚬⚬ Kussmaul’s sign: paradoxical increase in JVP on inspiration (may need to sit the patient at 90° rather than 45° to observe the JVP meniscus) B. Pulsus paradoxus: ⚬⚬ >10 mm Hg drop in systolic pressure in inspiration (not a true paradox as it normally decreases by 2–3 mm Hg!) C. Auscultation: ⚬⚬ Pericardial knock – it’s not a knock but a high‐pitched snap (audible, early S3 due to rapid ventricular filling into a stiff pericardial sac) D. Ascites, hepatomegaly (congestion) and bilateral peripheral oedema

Answer 37

⚬⚬ TB: cervical lymphadenopathy ⚬⚬ Trauma (or surgery): sternotomy scar, post‐MI ⚬⚬ Tumour, Therapy (radio): radiotherapy tattoos, thoracotomy scar ⚬⚬ Connective Tissue disease: rheumatoid hands, SLE signs

Answer 38

1. CXR: pericardial calcification, old TB, sternotomy wires 2. Echo: high acoustic signal from pericardium, septal bounce, reduced mitral flow velocity during inspiration 3. Catheter laboratory: ⚬⚬ Dip and plateau of the diastolic wave form: square‐root sign ⚬⚬ Equalization of LV and RV diastolic pressures 4. CT: thickened pericardium

Answer 39

⚬⚬ Thickened, fibrous capsule reduces ventricular filling and ‘insulates’ the heart from intrathoracic pressure changes during respiration leading to ventricular interdependence – filling of one ventricle reduces the size and filling of the other.

Answer 40

⚬⚬ Medical: diuretics and fluid restriction | ⚬⚬ Surgical: pericardial stripping

Answer 41

It is difficult to differentiate pericardial constriction from restrictive cardiomyopathy but observing ventricular interdependence (fluctuating LV/RV pressure or MV/TV flow velocities during respiration) is highly diagnostic for constriction!

Answer 42

This young woman complains of cough and occasional palpitations. Examine her cardiovascular system.

Answer 43

• Raised JVP • Pulmonary area thrill • Auscultation --> Fixed split-second heart sounds that do not change with respiration. --> Pulmonary ejection systolic and mid-diastolic flow murmurs with large left-to-right shunts. --> There is no mumur from the ASD itself. ** Consider: • Pulmonary hypertension: RV heave and loud P2, + cyanosis and clubbing (Eisenmenger’s: right‐to‐left shunt) • Congestive cardiac failure

Answer 44

* Primum associated with AVSD and cleft mitral valve) seen in Down’s syndrome * Secundum (commonest)

Answer 45

* Paradoxical embolus * Atrial arrhythmias * RV dilatation

Answer 46

* ECG: RBBB + LAD (primum) or + RAD (secundum); atrial fibrillation * CXR: small aortic knuckle, pulmonary plethora and double‐heart‐border (enlarged RA) * TTE/TOE: site, size and shunt calculation; amenability to closure * Right heart catheter shunt calculation (not always necessary)

Answer 47

* Symptomatic: paradoxical systemic embolism, breathlessness | * Significant shunt: Qp:Qs>1.5:1, RV dilatation

Answer 48

• Severe pulmonary hypertension and Eisenmenger’s syndrome

Answer 49

• Percutaneous closure device ⚬⚬> Secundum ASD only, no left atrial appendage thrombus or anomalous pulmonary venous drainage, adequate rim to anchor device • Surgical patch repair

Answer 50

This patient has developed sudden shortness of breath. Examine his heart.

Answer 51

• Thrill at the lower left sternal edge • Auscultation: --> Systolic murmur well localized at the left sternal edge with no radiation. --> No Audible A2. --> Loudness does not correlate with size (Maladie de Roger: loud murmur due to high-ow velocity through a small VSD). --> If Eisenmenger's develops the murmur often disappears as the gradient diminishes.

Answer 52

* Other associated lesions: AR, PDA (10%), Fallot’s tetralogy and coarctation * Pulmonary hypertension: loud P2 and RV heave + cyanosis and clubbing (Eisenmenger’s) * Endocarditis

Answer 53

* Congenital | * Acquired (traumatic, post‐operative or post‐MI)

Answer 54

* ECG: conduction defect: BBB * CXR: pulmonary plethora * TTE/TOE: site, size, shunt calculation and associated lesions * Cardiac catheterization: consideration of closure

Answer 55

Surgical (pericardial patch) or percutaneous (Amplatzer® device) closure of haemodynamically significant defects.

Answer 56

1. Fallot’s tetralogy 2. Coarctation 3. Patent ductus arteriosus (PDA)

Answer 57

* Right ventricular hypertrophy * Overriding aorta * VSD * Pulmonary stenosis

Answer 58

* Partially corrects the Fallot’s abnormality by anastomosing the subclavian artery to the pulmonary artery * Absent radial pulse and scar

Answer 59

* Acute: embolism, aortic dissection, trauma, e.g. radial artery sheath * Chronic: atherosclerosis, coarctation, Takayasu’s arteritis (‘pulseless disease’), Blalock-Taussig (BT) Shunts

Answer 60

A congenital narrowing of the aortic arch that is usually distal to the left subclavian artery.

Answer 61

• Hypertension in right ± left arm (coarctation usually occurs between left common carotid and left subclavian arteries) • Prominent upper body pulses, absent/weak femoral pulses, radiofemoral delay • Heaving pressure loaded apex • Auscultation: --> continuous murmur from the coarctation and collaterals radiating through to the back. --> There is a loud A2. --> There may be murmurs from associated lesions

Answer 62

* Cardiac: VSD, bicuspid aortic valve and PDA | * Non‐cardiac: Turner’s syndrome and Berry aneurysms

Answer 63

* ECG: LVH and RBBB | * CXR: rib notching, double aortic knuckle (post‐stenotic dilatation)

Answer 64

* Percutaneous: endovascular aortic repair (EVAR) * Surgical: Dacron patch aortoplasty * Long‐term anti‐hypertensive therapy * Long‐term follow‐up/surveillance with MRA: late aneurysms and recoarctation

Answer 65

Continuity between the aorta and pulmonary trunk with left to right shunt Risk factor: rubella

Answer 66

* Collapsing pulse * Thrill second left inter‐space * Thrusting apex beat * Auscultation: loud continuous ‘machinery murmur’ loudest below the left clavicle in systole

Answer 67

* Eisenmenger’s syndrome (5%) | * Endocarditis

Answer 68

• Closed surgically or percutaneously

Answer 69

This young man has complained of palpitations whilst playing football. Examine his cardiovascular system.

Answer 70

• Jerky pulse character • Double apical impulse (palpable atrial and ventricular contraction) • Thrill at the lower left sternal edge • Auscultation: --> Ejection systolic murmur (ESM) at the lower left sternal edge that radiates throughout the precordium. --> A fourth heartsound (S4) is present due to blood hitting a hypertrophied stiff LV during atrial systole. --> Dynamic ESM accentuated by reducing LV volume, e.g. standing from squatting or during a strain phase of Valsalva. • There may be associated mitral valve prolapse (MVP) • There may be features of Friedreich’s ataxia or myotonic dystrophy

Answer 71

• ECG: LVH with strain (deep T‐wave inversion across precordial leads) • CXR: often normal • TTE: asymmetrical septal hypertrophy and systolic anterior motion of the anterior mitral leaflet across the LVOT due to misalignment of septal papillary muscle, LVOT gradient (rest/exercise or dobutamine stress) • Cardiac MR: identifies apical HCM more reliably than TTE • Cardiac catheterization: gradient accentuated by a ventricular ectopic or pharmacological stress, identification of septals • Genetic tests: sarcomeric proteins mutation

Answer 72

@ Asymptomatic: • Avoidance of strenuous exercise, dehydration and vasodilators ``` @ Symptomatic and LVOT gradient >30 mm Hg ••••> β‐Blockers ••••> Pacemaker ••••> Alcohol septal ablation ••••> Surgical myomectomy ``` @ Rhythm disturbance/high‐risk SCD • ICD @ Refractory: • Cardiac transplant @ Genetic counselling of first‐degree relatives (autosomal dominant inheritance)

Answer 73

``` • Annual mortality rate in adults is 2.5% • Poor prognosis factors: ⚬⚬⚬⚬> Young age at diagnosis ⚬⚬⚬⚬> Syncope ⚬⚬⚬⚬> Family history of sudden death ⚬⚬⚬⚬> Septal thickness > 3 cm ```

Answer 74

a: atrial systole c: closure of tricuspid valve x: movement of atrioventricular ring during ventricular systole v: filling of the atrium y: opening of the tricuspid valve

Answer 75

1. Midline sternotomy (CABG, AVR, MVR) 2. Lateral thoracotomy (MVR, mitral valvotomy, coarctation repair, BT shunt) 3. Subclavicular (Pacemaker, AICD) 4. Anticubital fossa (angiography) Also look in the wrist and groins for angiography scars/bruising and legs for saphenous vein harvest used in bypass grafts.