Cardiology Flashcards

Question

Outline some causes of Aortic Regurgitation

Answer 1

Bicuspid AV Ankylosing Spondylitis (and other seronegative arthropathies) Luetic heart disease (syphilis) Dissection Rheumatic heart disease Infective endocarditis Connective Tissues Disease e.g. Marfan's, Pseudoxanthoma Elasticum {Usually due to disease of AV cusps or aortic root dilatation}

Answer 2

Fatigue Angina Dyspnoea Wide pulse pressure Collapsing pulse Early diastolic murmur, increased on expiration and on leaning forwards

Answer 3

Austin Flint Murmur - Mid-diastolic murmur (due to partial closure of anterior MV cusps in severe AR) Corrigan's Pulse - visible distension and collapse of the bilateral carotid arteries - A.k.a collapsing pulse De Musset Sign - Head bobbing with each heart beat Mueller Sign - Pulsatile Uvula Quincke Sign - Exaggerated capillary pulsation of nail bed Traube Sign - "Pistol shot" noise over femoral artery Waterhammer Pulse - Collapsing pulse (e.g. radial)

Answer 4

Aortic Regurgitation PDA Hyperkinetic states e.g. anaemia, exercise, thyrotoxicosis

Answer 5

Wide pulse pressure Short murmur - this is a sign of increase volume of regurgitant blood (tap running as opposed to bucket of water being turned upside down) Features of left ventricular failure

Answer 6

Symptomatic AR Dilated heart EF<50% Regurgitant fraction >50%

Answer 7

Coarctation of Aorta Congenital (usually bilateral) Trauma (previous arterial line or coronary angio) Cervical Rib Arterial embolisation (AF)

Answer 8

Calcific degeneration of valve (common in elderly) Rheumatic heart disease MV prolapse Infective endocarditis Connective Tissue disease e.g. Marfan's Post MI (e.g. papillary muscle rupture)

Answer 9

AF! Features of heart failure Features of pulmonary HTN (e.g. P2 thrill, left parasternal heave) Displaced apex {All of above also features of severe MR!} Pansystolic murmur, radiates to axilla, increased on expiration

Answer 10

AF LVH P-mitrale (= bifid p wave, secondary to left atrial enlargement)

Answer 11

LV dysfunction (EF < 60%) New onset AF New onset pulmonary HTN Severely symptomatic Sudden onset MR e.g. post MI

Answer 12

FALSE Subvalvular apparatus disconnection can occur in replacement --> this can lead to a reduction of LVEF by 20%

Answer 13

Common condition (1-2%) in which one or both of the cusps of the mitral valve prolapse into the left atrium during systole Usually idiopathic Associated with - Congenital heart disease - Cardiomyopathy - Turner's syndrome - Marfan's syndrome - Other CTD e.g. Ehler Danlos, osteogenesis imperfecta and pseudoxanthoma elasticum - Wolf Parkinson White - Long QT syndrome - PKD (25% of APKD have valvular disorder) Mid-systolic "click" or late systolic murmur

Answer 14

Mitral Stenosis

Answer 15

Rheumatic heart disease (>90%) - 40% of patients with rheumatic MS ahve multivalvular disease Degenerative calcification Congenital (RARE) Infective Endocarditis

Answer 16

AF Malar Flush Hoarse voice (=Ortner's syndrome) - Compression of left recurrent laryngeal nerve by enlarged LA/pulm artery Features of RVF Features of pulm HTN e.g. P2 thrill, left parasternal heave Apex non displaced, tapping Loud S1, opening snap Mid-diastolic murmur (loudest in expiration and in left lateral position)

Answer 17

AF Pulmonary HTN RVF Short gap between S2 and opening snap Long mid diastolic murmur Mitral Valve Are < 1.0cm2

Answer 18

1) If they have concurrent AF 2) If their left atrium > 55mm (increased risk of thrombus formation)

Answer 19

Severe MS (MVA < 1.0cm2) Symptomatic - NHYA > II

Answer 20

Percutaneous Balloon Mitral Valvuloplasty - Indicated in symptomatic (NHYA>II) or MVA < 1.0 AND favourable morphology (Wilkin's Score <8) - in abscence of Left atrial thrombus or mod/severe mitral regurg MV Repair/Replacement - Indicated if PBMV not suitable or have concurrent coronary artery disease and would likely require CABG MV Valvotomy - if have had previous failed PBMV

Answer 21

If severe MS - Advise to avoid getting pregnant prior to any intervention Asymptomatic patients often present in 2nd trimester with symptoms due to increased HR and intravascular volume which occurs in pregnancy If develops severe MS and NHYA III/IV during pregnancy = PBMV

Answer 22

Most cases are secondary to pulmonary HTN PRIMARY - Rheumatic heart disease - Infective Endocarditis - Ebstein's congenital anomaly SECONDARY - Functional TR e.g. RV dilation secondary to chronic LVF - RV infarction - Pulmonary HTN - Carcinoid syndrome

Answer 23

Often asymptomatic Raised JVP - CW wave - "Ear wiggling" Pulsatile liver Pansystolic murmur, loudest on inspiration Left parasternal heave

Answer 24

If primary TR with no pulmonary HTN = Monitor If functional TR = 1) Correct cause of RV overload 2) Diuretics and vasodilators Last resort = Balloon valvuloplasty/TVR

Answer 25

5% of all congenital heart disease Almost always congenital (maternal rubella!) Carcinoid syndrome

Answer 26

Symptomatic sinus bradycardia (<40bpm) e.g. syncope Complete AV block (even if asympto) Advanced or symptomatic 2nd degree AV block Exercise induced 2nd or 3rd degree AV block Neuromuscular disease with AV block e.g. myotonic dystrophy

Answer 27

Diastolic dysfunction = HFpEF LV relaxation during diastole and filling is impaired CAUSES - HTN - IHD - Diabetes - HOCM - RCM - Infiltrative disease e.g. sarcoid, amyloid, haemochromatosis - Constrictive pericarditis

Answer 28

Hypertrophic Obstructive Cardiomyopathy Ventricular wall thickening and stiffening --> LVH, septal hypertrophy & LVOT obstruction and reduced compliance --> reduced cardiac output 1 in 500 Autosomal dominant - most common defect = MHY 6 gene Pansystolic murmur

Answer 29

MR SAM ASH Mitral Regurgitation Systolic anterior motion of anterior MV leaflet Asymmetric hypertrophy

Answer 30

Positive Inotropes e.g. ACE inhibitors and nitrates {Any medication that causes afterload reduction, peripheral vasodilation, intravascular volume depletion, or positive inotropy can worsen the dynamic left ventricular outflow tract obstruction}

Answer 31

MDT approach MEDICAL (ABCD) - Amiodarone (prevent ventricular arrhythmias) - Beta blockers (to reduce HR and contractility = reduce myocardial oxygen demand) - CCB (verapamil) - Diuretics SURGICAL - ICD if at risk of sudden death - Percutaneous Alcohol Septal Ablation (PASA) if evidence of LVOT obstruction and symptomatic despite medical Rx (CAUTION - risk of arrhythmogenic scar!) - Surgical myomectomy Genetic counselling/screening

Answer 32

Syncope (esp if exertional) FHx of sudden death in 1st degree relative Abnormal BP response during exercise VT LVOT pressure gradient >50mmHg at rest LV wall > 30mm

Answer 33

Endomyocardial firbosis Loeffler's endocarditis (Eosinophils) Haemochromatosis Amyloidosis Sarcoidosis Radiation Scleroderma Fabry's disease

Answer 34

CARDIAC RIND C - CTD e.g. SLE A - Aortic aneurysm R - Radiation D - Drugs e.g. hydralazine, clozapine I - Infections e.g. TB A - Acute Renal Failure (Uraemia) C - Cardiac infarction (first 48 hours) R - Rheumatic fever I - Injury (haemopericardium) N - Neoplasms D - Dressler's syndrome (2-6 weeks post MI)

Answer 35

3/4 caused by strep or staph infections Strep Viridans - URTI, dental damage Strep Pneumoniae/Pyogenes Staph Aureus Staph Epidermis Strep Bovis (colorectal cancer) Enterococcus Faecalis HACEK group = slow growing, gram negative Coxiella Burnetti "Q Fever" Yeasts & Fungi

Answer 36

Diagnostic of IE if - 2 x Major - 1x Major, 3 x Minor - 5x Minor MAJOR CRITERIA 1) Positive blood cultures 2) Evidence of endocardial involvement (characteristic echo findings e.g. vegetations) MINOR CRITERIA 1) Serological evidence of acute infection with organism consistent with IE 2) Vascular embolic phenomena e.g. Janeway lesions 3) Immunological phenomena e.g. glomerulonephritis, Osler's nodes, Roth's spots 4) Fever > 38 5) Predisposing condition e.g. valvular disease, IVDU 6) Suggestive echo findings

Answer 37

ECG Urinalysis - ?proteinuria ?haematuria ECG Multiple blood cultures - at least 3 sets CXR Echocardiogram - TOE best esp if small vegetations, ?abscess or prosthetic valves

Answer 38

MDT approach - cardiologists, microbiologists, ?cardiothoracic surgeons, vascular access team Antibiotics (guided by microbiology team) May need to refer to surgeons for valve replacement/surgical intervention

Answer 39

Aortic abscess (prolonged PR) Septal perforation Persistent infection e.g. fever > 10 days Persistent mobile vegetations > 10mm Recurrent emboli Severe valvular incompetence e.g. AR/MR Heart failure refractory to treatment Resistant/fungal infections

Answer 40

Janeway lesions Splinter haemorrhages Conjunctival haemorrhages Osler's nodes Roth spots Clubbing (subacute IE)

Answer 41

Autosomal dominant connective tissue disorder Defect in fibrillin-1 gene on chromosone 15 - Complete penetrance but variable phenotypes Diagnosed using Ghent Criteria (major criteria in at least 2 different systems) CARDIOVASCULAR FEATURES - Ascending Aorta Dilatation - Aortic dissection - MV prolapse (minor) OCULAR - Ectopic lentis SKELETAL - Pectus carinatum/excavatum - Arm span/Height ratio > 1.05 - Hypermobility - Scoliosis - Pes planus - High arched palate (minor) RESP - Spontaneous pneumothoraces (minor) SKIN - Skin striae - Recurrent/incisional herniae

Answer 42

MDT approach Genetic counselling/family screening Yearly echocardiogram due to risk of aortic dilatation and dissection Beta blockers (can reduce rate of Aortic dilatation) Indications for Aortic Root Repair - Symptomatic AR - Meets criteria for aortic regurg surgery - Dilation of Aortic root > 45mm - Aortic root growth > 1cm/year

Answer 43

= "Left to Right" ASD VSD PDA Coarctation of Aorta

Answer 44

"5 T's of Congenital Heart disease" = "Right to Left" 1) Tetralogy of Fallot 2) Transposition of the Great Vessels 3) Total anomalous pulmonary venous connection 4) Truncus arteriosus 5) Tricuspid atresia

Answer 45

This is a reversal of a left-to-right shunt in a congenital defect, secondary to pulmonary HTN This occurs due to remodelling of pulmonary vasculature --> increases pulmonary resistance --> reversal of blood flow --> right-to-left shunt

Answer 46

Rare autosomal recessive condition Dysmotility of dynein arm of cilia = 1) Dextrocardia/Situs invertus 2) Bronchiectasis 3) Infertility in men

Answer 47

50% mortality by 50 Paradoxical emboli (risk of stroke) AF Features of RV overload/RVF Pulmonary HTN --> Eisenmenger's Infective endocarditis

Answer 48

Symptomatic Paradoxical emboli Evidence of significant shunt If evidence of pulmonary HTN, closure will only be offered if evidence of reversibility on vasodilator testing

Answer 49

Significant shunting Endocarditis Significant AR due to prolapse of leaflets throughout defect Acute septal rupture due to MI If other cardiac surgery planned

Answer 50

Commonest form of cyanotic congenital heart disease Typically presents in first months of life PROV = Pulmonary stenosis RVH Overriding aorta VSD Severity of RVOT obstruction! Some associated conditions e.g. DiGeorge syndrome (cleft palate), Poland Syndrome (unilateral pectoral hypoplasia) Look for Blalock-Taussig scars

Answer 51

Pulmonary regurgitation AR or Aortic Root dilatation (due to distortion during VSD repair) Infective endocarditis Residual VSD Arrhythmias

Answer 52

Congenital condition of narrowing of aorta (usually where ductus arteriosus inserts into aortic arch) Classified according to location with ductus arteriosus e.g. pre-ductal, post-ductal FEATURES - Intermittent claudication of lower limbs - LVF - Uncontrolled HTN --> headache - Chest pain (increased risk of coronary artery disease) - Underdeveloped lower body/left arm (if preductal) - Raised BP in arms compared to legs (>20mmg difference) - Delayed radio-fem or RR - Continuous systolic-diastolic murmur (best heard between scapulae)

Answer 53

Bicuspid AV VSD Mitral valve prolapse PDA Aortic dissection Turner's syndrome Neurofibromatosis type 1 Marfan's SAH (berry aneurysms in circle of willis in 5%)

Answer 54

AVOID extreme isometric exercise e.g. weight lifting (risk of aortic dissection) Treat hypertension Manage Cardiac RFs Primary percutaneous endovascular stenting (if suitable)

Answer 55

Risk related to operation Risk related to anticoagulation Infective endocarditis

Cardiology Flashcards

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