Clinical Cardiology

Question 1

What kind of murmurs can you hear in the aortic area of auscultation?

Answer 1

Ejection type murmurs:

• Aortic stenosis
• Flow murmur

Question 2

What kind of murmur can be heard in the pulmonic area of auscultation?

Answer 2

Ejection-type murmur

• Pulmonic stenosis
• Flow murmur

Question 3

What kind of murmur can be heard in the left sternal border area of auscultation?

Answer 3

Early diastolic murmur

• Aortic regurgitation
• Pulmonic regurgitation

Question 4

What kind of murmur can be heard in the mitral area of auscultation?

Answer 4

Pansystolic murmur

• Mitral regurgitation

Mid-to-late diastolic murmur

• Mitral stenosis

Question 5

What kind of murmur can be heard in the tricuspid area of auscultation?

Answer 5

Pansystolic murmur

• Tricuspid regurgitation
• VEntricular septal defect

Mid-to-late diastolic murmur

• Tricuspid stenosis
• Atrial septal defect

Question 6

What are the only low-pitch sounds that we can hear with the bell of our stethoscope ?

Answer 6

S₃ and S₄

Heard at the left side apex

Question 7

What murmurs/sounds increase with inspiration?

Answer 7

• Tricuspid regurgitation
• Pulmonic regurgitation
• S₂ differentiates into P₂ and A₂

Question 8

What are the possible underlying pathologes associated with a systolic ejection sound?

Answer 8

• Aortic stenosis
• Pulmonic stenosis

Question 9

What are the possible underlying pathologes associated with a pansystolic sound?

Answer 9

• Mitral regurgitation
• Tricuspid regurgitation

Question 10

What are the possible underlying pathologes associated with a late systolic sound?

Answer 10

Mitral valve prolapse

Question 11

What are the possible underlying pathologes associated with a early diasystolic sound?

Answer 11

• Aortic regurgitation
• Pulmonic regurgitation

Question 12

What are the possible underlying pathologes associated with a mid-to-late diasystolic sound?

Answer 12

Mitral stenosis

Question 13

What is the etiology of aortic stenosis?

Answer 13

• Degenerative calcification
• Bicuspid aortic valve
• Rheumatic aortic valve disease

Question 14

What are the consequences of aortic stenosis ?

Answer 14

• LV undergoes concentric hypertrophy to compensate (stiffening)
• Increased afterload
• An unchanged end-diastolic volume
• An increased end-systolic volume
• A decreased stroke volume

Question 15

What is the clinical presentation of aortis stenosis?

Answer 15

• S₄ present, absent/reduced S₂
• Ejection type murmur (crescendo-decrescendo between S₁ and S₂)
• The carotid pulse is going to feel late and week
• Symptoms: angina (5 years to live), syncope (3 years to live), heart failure (2 years to live)

Question 16

What is the etiology of mitral stenosis?

Answer 16

• Congenital MS
• Mitral annulus calcification
• Infective endocarditis
• Rheumatic heart disease

Question 17

What are the consequences of mitral stenosis?

Answer 17

• Pulmonary hypertension
• Left atrial enlargement (may result in atrial fibrillation, stroke)

Question 18

What are the clinical manifestations of mitral stenosis ?

Answer 18

• Early: dyspnea on exertion, fever
• Later: dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea
• Latest: signs of right hear failure
• If asymptomatic (“ 80% 10 years survival), symptomatic (50-60% 10 years survival) and if pulmonary hypertension (3 years survival)

Question 19

What can you find at physical examination of a patient with mitral stenosis?

Answer 19

• Loud S₁ with disease progression (mitral valve snaps with LV pressure in systole)
• Reduced S₁ later with disease progression
• Opening snap (OS) after S₂ because the opening comes earlier thus at higher pressure
• Decrescendo diastolic rumble with pre-systolic accentuation (mid-to-late)
• LA enlargement, RV hypertrophy if PH present
• Thickened MV

Question 20

How do you treat an aortic or mitral stenosis?

Answer 20

• Surgical valve replacement
• Transcatheter balloon to open it
• Reduce H20 and Na+ intake, slow HR and anticoagulant if atrial fibrillation

Question 21

Explain the 2 types of right-sided stenosis

Answer 21

Trisuspid

• Rare
• Most common etiology is rheumatic
• Exam similar to MS (OS and diastolic murmur)
• Distended neck veins with large a-wave
• Treated with balloon dilatation or surgical correction

Pulmonary

• Rare
• Congenital
• Crescendo-decrescendo murmur, possible ejection click
• Treatable by balloon valvuloplasty

Question 22

What are the advantages and disadvantages of mechanical valves ?

Answer 22

Advantages

• Durable

Disadvantages

• Thrombogenic
• High risk endocarditis

Question 23

What are the advantages and disadvantages of bioprostethic valves ?

Answer 23

Advantages

• Less thrombogenis risk

Disadvantages

• High risk endocarditis
• Less durable

Question 24

What is the etiology of aortic regurgitation?

Answer 24

• Abnormality of aortic valve
• Dilatation of aortic root

Question 25

What are the consequences of aortic regurgitation?

Answer 25

* Enlarged ventricular silhouette * Rounded isovolumetric relaxation * Rounded end-diastolic filing * Rounded isovolumetric contraction * Increased diastolic LV volume

Question 26

What are the Symptoms and clinical manifestation of aortic regurgitation?

Answer 26

* Dyspnea * Wide pulse pressure, bounding pulse * Low diastolic pressure: angina * Leaky valve: blowing decrescendo diastolic murmur at left sternal border, possible Aunstin-Flint * Signs: Bisferiens pulse (double pulse) Corrignan pulse (water hammer), hill sign (popliteal), Quincke sign (lit or nail bed)

Question 27

What is the treatment of aortic regurgitation?

Answer 27

* Surgery if symptomatic * 4 years if angina and 2 years with heart failure

Question 28

What is the etiology of mitral regurgitation?

Answer 28

* Mitral annulus * Leaflets * Chordae tendineae * Papullary muscles * Left ventricle (secondary)

Question 29

What are the consequences of mitral regurgitation?

Answer 29

* Acute: sudden damage (papillary muscle or chordae tendineae ruptured) * Chronic: myxomatous degeneration, rheumatic deformity, congenital valve defect, mitral annular calcification * Secondary: rupture by outside cause (ex: LV enlargement)

Question 30

What is the pathophysiology of mitral regurgitation?

Answer 30

LA goes up, less blood pumped, rounded isovolumetric contraction, and relaxation, decreased end-systolic volume, increased diastolic LV volume and LV stroke volume increases to compensate. Contributing factors: mitral orifice, pressure gradient LV to LA, systemic vascular resistance, LA compliance, duration of regurgitation and regurgitant fraction (volume of MR/SV)

Question 31

What are the symptomes and clinical manifestations of mitral regurgitation?

Answer 31

* Acute: pulmonary edema and related symptoms * Chronic: fatigue, weakness, dyspnea, potential right heart failure * Holosystolic murmur, classically radiated to axilla, possible presence of S₃ * LA enlargement, pulmonary edema

Question 32

What is the treatment of mitral regurgitation?

Answer 32

* Acute MR need surgical emergency internveiton (20-25% 30 day mortality) * Chronic MR: related to cause (repair preferred over replacement)

Question 33

What is mitral prolapse?

Answer 33

"Parachuting" Etiology: Inherited Symptoms and clinical manifestations: * Mid-systolic click and mid-to-late-systolic murmur (less loud when squatting) * Large LV volume * Dx confirmed by echo

Question 34

What are the 2 right-sided valve regurgitation?

Answer 34

1. **Tricuspid**: very common, typically functional and cause by something else, prominent V-wave, pulsatile liver, LLSB systolic murmur, treatment includes treating underlying condition, diuresis and sometimes surgical 2. **Pulmonary** regurgitation: typically cause by pulmonary hypertension, high piteched decrescendo murmur and left sternal border