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1
Q

Consultation - what are the symptoms of aortic regurgitation?

A

Asymptomatic for a long time
Severe symptomatic AR - exertional dyspnoea, angina, heart failure symptoms (orthopnoea, paroxysmal nocturnal dyspnoea, ,pulmonary oedema).

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2
Q

What examination features would you expect to see in aortic regurgitation?

A

Water hammer/collapsing pulse
de Musset sign - head bobbing with each heartbeat
Quincke pulses - capillary pulsations in fingertips
Lateral displacement of the apical heart beat
Thrill at sternal notch
Early diastolic murmur, soft S1, variable S2, S3 with severely depressed LV function

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2
Q

Given the findings of blowing early diastolic murmur and collapsing pulse what is your preferred diagnosis and differentials?

A

Aortic regurgitation
Due to aortic root dilation, congenital bicuspid aortic valve, calcific valve disease, rheumatic heart disease.
DDx:
Pulmonary regurgitation
Mitral stenosis

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3
Q

How would you investigate for aortic regurgitation?

A

ECG
Echocardiogram
Cardiovascular MR imaging to evaluate moderate or severe AR with suboptimal echo

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3
Q

What is aortic regurgitation?

A

Inadequate closure of the aortic valve leaflets.

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4
Q

How would you manage a patient with aortic regurgitation?

A

If symptomatic or asymptomatic with LV dysfunction - surgery. Can be surgical replacement or transcatheter implantation.
If not candidate for surgery - medical treatment for HFrEF - diuretics, ACEi.
Manage hypertension.

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5
Q

What are the complications of aortic regurgitation?

A

Reduced LVEF with heart failure symptoms.

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6
Q

What is the prognosis of aortic regurgitation?

A

Evolves slowly with long asymptomatic compensated phase but can progress to severe AR with LV dilation and heart failure.
Mortality if severe symptoms is 25% if NYHA class III/IV.

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7
Q

Consultation - what are the symptoms of aortic stenosis?

A

Classic symptoms (represent end-stage disease) - heart failure, syncope, angina.
Earlier symptoms - dyspnoea on exertion/decreased exercise tolerance, exertional syncope/pre-syncope, exertional angina.

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7
Q

What examination features would you expect to see in aortic stenosis?

A

Low volume, slow-rising carotid pulse
Ejection systolic murmur
Single second heart sound

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8
Q

Given the findings of ejection systolic murmur and slow rising pulse what is your preferred diagnosis and differentials?

A

Aortic stenosis
Due to: congenitally abnormal valve, calcific disease of a trileaflet valve, rheumatic valve disease.
DDx:
Aortic sclerosis
Pulmonary stenosis
Cardiomyopathy

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8
Q

How would you investigate for aortic stenosis?

A

ECG
Echocardiography - diagnose and assess severity. Stage A = asymptomatic with transvalvular aortic velocity <2m/s. Stage B = murmur but no symptoms, VMAX 2.0-2.9 m/s. Stage C = no symptoms but VMAX >4m/s, valve area <1cm^2. Stage D = as C but with symptoms.

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9
Q

What is aortic stenosis?

A

Aortic valve thickening causing left ventricular outflow obstruction causing antegrade velocity across valve >2m/s.

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10
Q

How would you manage a patient with aortic stenosis?

A

Valve replacement if symptoms or severe or LVEF. TAVI or surgical replacement.
Asymptomatic - statins, hypertension management, avoid strenuous physical activity, treat AF, medical management of HFrEF.

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11
Q

What is the prognosis of aortic stenosis?

A

Variable progression in non treated disease.
Symptomatic without valve replacement = mortality high if cardiac symptoms. Heart failure = 0.5-3 years survival. Syncope = 1-4 years survival. Angina = 2-5 years.

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11
Q

What are the complications of aortic stenosis?

A

Heart failure
pulmonary hypertension
Sudden cardiac death
Arrhythmias
Endocarditis
Bleeding tendency
Embolic events

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12
Q

Consultation - what are the symptoms of aortic valve replacement?

A

Subtle symptoms of heart failure -

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13
Q

What examination features would you expect to see in aortic valve replacement?

A

Midline sternotomy scar, may have vein harvesting scars on legs for CABG done at the same time.
Bruising from warfarinisation.
Mechanical sound - S2.
Can have murmur from leak, new stenosis or new regurgitation.
Need to look out for signs of heart failure and infective endocarditis.

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14
Q

Given the findings of metallic click just after the pulse, midline sternotomy scar and no features of infective endocarditis or heart failure what is your preferred diagnosis and differentials?

A

Aortic valve.

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15
Q

How would you investigate for aortic valve replacement?

A

Bloods including inflammatory markers
Echocardiography
ECG

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15
Q

What is aortic valve replacement?

A

Replaced aortic valve generally done for severe symptomatic aortic stenosis or aortic regurgitation. Can by mechanical or bioprosthetic/tissue.

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16
Q

How would you manage a patient with aortic valve replacement?

A

If mechanical, anticoagulation therapy - warfarin.
Endocarditis prophylaxis - good oral hygeine, prophylaxis for some procedures.
Moderate exercise to maintain cardiovascular fitness.

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17
Q

What are the complications of aortic valve replacement?

A

Thromboembolism
Valve failure - regurgitation
Infective endocarditis
Bleeding secondary to antithrombotic therapy
Haemolytic anaemia

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18
Q

What is the prognosis of aortic valve replacement?

A

2% complications leading to death from surgery.
Tissue valves last 10-20 years.
Mechanical valves last 20-40 years.

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19
What examination features would you expect to see in mitral prolapse?
Slightly lower than average BMI. Nonejection click and pansystolic murmur from relapse.
19
Consultation - what are the symptoms of mitral prolapse?
Most patients are asymptomatic. Chest pain, palpitations, dyspnoea, exercise intolerance, dizziness, lean body habitus, anxiety disorders.
20
Given the findings of slightly low BMI and non-ejection click with pansystolic murmus what is your preferred diagnosis and differentials?
Mitral valve prolapse. DDx: Mitral valve regurgitation Aortic or pulmonary stenosis VSD
21
What is mitral prolapse?
Cause of primary mitral regurgitation caused by disease of one or more valve components, including leaflets, chordae tendinae, papillary muscles, or annulus.
22
How would you investigate for mitral prolapse?
Echocardiography ECG Cardiac MR
23
How would you manage a patient with mitral prolapse?
Assessment of severity and arrhythmic risk. Replacement
23
What are the complications of mitral prolapse?
Severe MR Infective endocarditis Arrhythmias
24
What is the prognosis of mitral prolapse?
Can progress to MR and worsen with time.
25
Consultation - what are the symptoms of mitral regurgitation?
Can be well tolerated but eventually heart failure symptoms and breathlessness. Acutely can cause pulmonary oedema.
25
Given the findings of laterally displaced apex beat, pansystolic murmur and atrial fibrillation what is your preferred diagnosis and differentials?
Mitral regurgitation Due to: degenerative, coronary artery disease with papillary muscle dysfunction, infective endocarditis, rheumatic fever.
26
What examination features would you expect to see in mitral regurgitation?
Pansystolic murmur at apex. Lateral displacement of the apex beat - can be brisk or hyperdynamic. Can have S3 and palpable thrill. Often in AF.
27
What is mitral regurgitation?
Failure of the mitral valve to fully close leading to back flow of blood from the LV to the LA.
28
How would you investigate for mitral regurgitation?
ECG - broad P wave Echo CXR - enlarged LA and LV Cardiac MR
29
How would you manage a patient with mitral regurgitation?
Asymptomatic - usually monitor, if severe can consider surgery. If LV dysfunction, new AF, or pulmonary hypertension - consider surgery. Acute MR - nitrates, diuretics, sodium nitroprusside, inotropic agents, intra-aortic balloon pump, ACEi if heart failure.
29
What are the complications of mitral regurgitation?
Pulmonary hypertension LV dysfunction AF (+ subsequent thromboembolism risk)
30
What is the prognosis of mitral regurgitation?
Good with surgery, can be worse with severe disease.
31
Consultation - what are the symptoms of mitral stenosis?
Asymptomatic for years but may develop gradual decrease activity. Breathlessness - progressive. AF with systemic emboli.
32
What examination features would you expect to see in mitral stenosis?
Malar flush on cheeks Raised JVP Laterally displaced apex beat RV heave Loud first heart sound with opening snap in diastole Mid-late diastolic murmur heard with bell in left lateral position AF RV failure - hepatomegaly, ascites, peripheral oedema
33
How would you investigate for mitral stenosis?
Echocardiography CXR - LA enlargement, interstital oedema ECG - AF, LA enlargement, RV hypertrophy
33
What is mitral stenosis?
Obstruction to flow through the mitral valve between the LA and LV.
34
Given the findings of malar flush, raised JVP, laterally displaced apex beat, and diastolic murmur what is your preferred diagnosis and differentials?
Mitral stenosis Due to: rheumatic fever, degenerative calcification, congenital, infective endocarditis DDx: Left atrial thrombus or myxoma Aortic regurgitation Austin-Flint murmur from severe aortic regurgitation
35
What are the complications of mitral stenosis?
Pulmonary hypertension Dilated LA AF Right heart failure
36
How would you manage a patient with mitral stenosis?
MDT approach with specialty assessment and follow up from cardiology If mild - echo every 3-5 years. Medical - diuretics and long-acting nitrate, B-blockers, anticoagulation if atrial fibrillation Surgery - percutaneous mitral commissurotomy
37
What is the prognosis of mitral stenosis?
If asymptomatic - fine Limiting symptoms and untreated - poor survival If severe pulmonary hypertension - less than 3 year survival
38
Given the findings of metallic click on S1 what is your preferred diagnosis and differentials?
Mitral valve replacement Due to: mitral valve stenosis or regurgitation DDx: Aortic valve replacement
38
Consultation - what are the symptoms of mitral valve replacement?
Leading to replacement of valve - SOBOE, AF.
39
What examination features would you expect to see in mitral valve replacement?
Mechanical - click on S1 Tissue - normal heart sounds Can have murmurs from tubrulent flow - pansystolic or diastolic Valve function - regurgitation, cardiac decompensation, infective endocarditis Anticoagulation and anaemia
40
What is mitral valve replacement?
Replacement of the MV
40
How would you investigate for mitral valve replacement?
Bloods - haemolysis on FBC, BNP CXR ECG Echocardiogram
41
How would you manage a patient with mitral valve replacement?
Monitoring asymptomatic patients - echo Slight regurgitation - medical treatment of heart failure Severe regurgitation - surgical or transcatheter intervention
42
What are the complications of mitral valve replacement?
Regurgitation and valve failure Infective endocarditis Arrhythmias
43
What is the prognosis of mitral valve replacement?
Pretty OK If tissue needs replacing after about every 10-20 years If mechanical can last 20-40 years
44
Consultation - what are the symptoms of mixed aortic and mitral valve disease?
45
What examination features would you expect to see in mixed aortic and mitral valve disease?
Mixture of findings depending on lesion: AS - low volume slow rising pulse, heaving apex, thrill over aorta, soft S2, ejection systolic murmur AR - collapsing pulse, displaced apex beat, diastolic murmur MS - early opening snap, diastolic murmus, pulmonary hypertension MR - displaced apex beat, palpable mitral thrill, soft S1, split S2, diastolic murmur
46
Given the findings of slow rising pulse, displaced apex, pansystolic murmur and ejection systolic murmur what is your preferred diagnosis and differentials?
Mixed valvular pathology including aortic stenosis and mitral regurgitation. Due to: Rheumatic heart disease Infective endocarditis Degenerative changes including calcification
46
How would you investigate for mixed aortic and mitral valve disease?
Echocardiogram ECG CXR
47
How would you manage a patient with mixed aortic and mitral valve disease?
MDT approach including cardiology follow up Medical management of symptoms Surgical management with valve repair or replacement
47
What is mixed aortic and mitral valve disease?
Combination of stenotic and regurgitant lesions on the same valve.
48
What are the complications of mixed aortic and mitral valve disease?
Heart failure Pulmonary hypertension
48
What is the prognosis of mixed aortic and mitral valve disease?
Depends on severity and if replaced
49
Consultation - what are the symptoms of Marfan's syndrome?
Can be asymptomatic Disproportionately tall and thin with unusually long arms and legs compared to trunk.
50
What examination features would you expect to see in Marfan's syndrome?
Disproportionately tall with unusually long arms and legs Arachnodactyly - Walker's wrist sign, Steinberg's thumb sign Skin - striae Cardiovascular - thoracic aortic dilatation/rupture/dissection, aortic regurgitation, mitral valve prolapse or regurgitation, abdominal aortic aneurysm Lungs - pneumothorax Eyes - lens dislocation, closed-angle glaucoma, high myopia Skeleton - hypermobility, arthralgia, joint instability Facial characteristics - maxillary/mandibular retrognathia, high arched palate
50
Given the findings of high arched palate, arachnodactyly, and diastolic murmur what is your preferred diagnosis and differentials?
Marfan's syndrome DDx: EDS Fragile X syndrome Gigantism Klinefelter's syndrome
51
What is Marfan's syndrome?
Inherited connective tissue disorder with skeletal, dermatological, cardiac, aortic, ocular and dura mater malformations. Due to mutations in the gene encoding fibrillin-1.
52
How would you investigate for Marfan's syndrome?
Echo - annually to montiro aortic root width and heart valve function Cardiac MR or CT for the whole aorta every 5 years or yearly if aneurysmal formation Holster monitoring - if symptoms
53
How would you manage a patient with Marfan's syndrome?
MDT approach including geneticist, ophthalmologist, cardiologist, orthopaedic surgeon, and psychologists Conservative - psychological support, avoid exertion at maximal capacity Drugs - B-blockers, ACE-i/ARB Surgical - prophylactic aortic root surgery to prevent aortic dissection
54
What are the complications of Marfan's syndrome?
Aortic dissection/aneurysm
55
What is the prognosis of Marfan's syndrome?
Almost normal with aortic root surgery
56
What examination features would you expect to see in ventricular septal defect?
Harsh pansystolic murmur with split S2
56
Consultation - what are the symptoms of ventricular septal defect?
If small - asymptomatic If moderate/large - difficulty feeding as a 5-6 week old baby If very large - pulmonary hypertension, Eisenmenger's syndrome
57
Given the findings of harsh systolic murmur what is your preferred diagnosis and differentials?
VSD DDx: PS Innocent physiological murmur PDA MR AS
58
What is ventricular septal defect?
Persistence of one or more holes in the septum between the LV and RV.
59
How would you investigate for ventricular septal defect?
ECG - usually normal CXR Echocardiography
60
How would you manage a patient with ventricular septal defect?
MDT approach Medical - diuretics, ACEi Surgical - closure of defect
61
What are the complications of ventricular septal defect?
Aortic valve prolapse and regurgitation Eisenmenger's syndrome Infective endocarditis
62
What is the prognosis of ventricular septal defect?
If isolate, prognosis if fine
63
What is atrial fibrillation?
The most common sustained cardiac arrhythmia with an irregularly irregular ventricular pulse and loss of association between the cardiac apex beat and radial pulsation.
63
Consultation - what are the symptoms of atrial fibrillation?
Breathlessness/dyspnoea Palpitations Syncope/dizziness Chest discomfort Stroke/TIA
64
What examination features would you expect to see in atrial fibrillation?
Pulse palpation - irregular pulse
64
Given the findings of irregularly irregular pulse what is your preferred diagnosis and differentials?
Atrial fibrillation
65
How would you investigate for atrial fibrillation?
12 lead ECG If suspected paroxysmal AF - 24 hours ambulatory ECG monitor Bloods - TFTs, FBC, renal function and electrolytes, LFTs, coagulation CXR Echo CT/MRI brain if any suggestion of stroke or TIA
66
How would you manage a patient with atrial fibrillation?
MDT with cardiology input if young, paroxysmal, contradindicated treatments, valvular disease, WPW. Treat any underlying cause. Rhythm control - cardioversion - electrical or medical with amiodarone. Rate control - B blocker or Ca channel blocker, digoxin. Thromboprophylaxis - DOAC or warfarin.
67
What are the complications of atrial fibrillation?
Stroke risk increases six-fold Acute heart failure Cardiomyopathy
68
What is the prognosis of atrial fibrillation?
Increased mortality in older patients

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