Integrated Evidence Based Approach to Specific Cardiac Disorders

Question 1

What is the Framingham criteria

Answer 1

used in HF diagnosis with reduced EF
only modest sensitivity and specificity

Compared to 3 or more symptoms of S3, tachycardia, elevated JVP, low pulse pressure, rales, ajr sign - 90%

Question 2

when is HF most likely to be preserved

Answer 2

female, older, increased BMI

Question 3

PP is determined by

Answer 3

stroke volume
vascular stiffness
(can be used to assess Cardiac output)

Question 4

PP equation

Answer 4

(systolic -diastolic) / systolic

correlates well with cardiac index, stroke volume index, inverse systemic vascular resistance

Question 5

if PP is lower than 25%, cardiac index is

Answer 5

less than 2.2 L/min/m2 in 91% of patients

Question 6

if PP is greater than 25% , cardiac index is

Answer 6

greater than 2.2 L/min/m2 in 83% of patients

Question 7

using oxygen as indicator, how to assess cardiac output?

Answer 7

a time from breath to hold to nadir of finger oximetry of greater than 34 seconds has been associated with Cardiac output < 4 L/min

Question 8

TRUE or FALSE - Heart rate is also a powerful indicator of prognosis in HF

Answer 8

True , greater than 70 to 75 bpm is an independent predictor of mortality

Question 9

Explain dysautonomia in HF

Answer 9

an attenuated HR increase with immediate standing (= 3 bpm); associated with death and Hospitalization;

Question 10

simplest finding to elicit pleural effusion (LR 8.7)

Answer 10

Dullness to percussion

Question 11

Absence of such makes pleural effusion less likely (LR 0.21)

Answer 11

Absence of reduced vocal fremitus

Question 12

Signs suggesting severe mitral stenosis

Answer 12

1 long or holodiastolic murmur - indicating a persistent LA -LV gradient
2 short A2 OS interval -consistent with higher LA pressures
3 a loud P2 (or single S2) and or RV lift - suggestive of pulmonary hpn
4 elevated JVP with CV waves , hepatomegaly and lower ext edema - signs of right HF

xintensity of diastolic murmur
x presystolic accentuation

Question 13

Findings that suggest chronic severe MR:

Answer 13

1 enlarged, displaced, but dynamic LV apex beat
2 apical systolic thrill (grade 4 or greater)
3 mid-diastolic filling complex comprising of S3 and a short, low-pitched murmur - accelerated and enhanced diastolic mitral inflow
4 wide but physiologic splitting of S2 caused by early aortic valve closure
5 loud P2 or RV lift

Question 14

Findings with MVP

Answer 14

combination of non-ejection click and mid to late systolic murmur predicts MVP best (LR 2.43)

Question 15

The following findings help gauge the severity of aortic stenosis

Answer 15

1 slowly rising carotid upstroke (pulsus tardus)
2 reduced carotid stroke amplitude (pulsus parvus)
3 reduced intensity of A2 and mid-to late peaking of the systolic murmur

x intensity of murmur

Question 16

May independently predict outcome for severe aortic stenosis

Answer 16

reduced carotid upstroke amplitude

Question 17

to differentiate with aortic sclerosis (older pxs with hypertension)

Answer 17

TTE

in aortic sclerosis - no valve dysfunction, carotid upstroke normal, A2 preserved, no LV hypertrophy

Question 18

Differential diagnosis of systolic murmur related to LVOT obstruction

Answer 18

1 valvular aortic stenosis
2 hocm
3 DMSS
4 SVAS

Question 19

Presence of ejection sound in systolic murmur

Answer 19

valvular cause

Question 20

How can HOCM be distinguished with AS

Answer 20

Response of murmur to Valsalva and standing or squatting

Question 21

Will usualy have a diastolic murmur indicative of AR but not an ejection sound

Answer 21

Discrete membranous subaortic stenosis

Question 22

Right arm BP is more than 10 mmHg greater than the left arm BP

Answer 22

Supravalvular Aortic stenosis

Question 23

Signs of Aortic Regurgitation

Answer 23

pulmonary edema and signs of low forward CO
Tachycardia invariably present
Systolic BP NOT elevated
PP not widened
S1 soft due to premature closure of mitral valve

Question 24

Symptoms of chronic, severe AR include

Answer 24

dyspnea, fatigue, chest discomfort and palpitations

Question 25

True or false. The absence of diastolic murmur significantly reduces the likelihood of moderate or greater AR.

Answer 25

True. LR 0.1 The presence of typical diastolic murmur increases the likelihood of moderate or greater AR (LR 4.0 to 8.3)

Question 26

T or F | The intensity of murmur correlates with the severity of the lesion in AR.

Answer 26

T Grade 3 diastolic murmur has an LR of 4.5 (severe AR vs mild/moderate AR)

Question 27

Austin flint murmur on studies? | Hill sign?

Answer 27

``` Data conflict regarding significance of Austin flint Hill sign (Brachial popliteal systolic bp gradient >20 mmHg has moderate sensitivity of 89% - although its supporting evidence base is also weak) ```

Question 28

Symptoms and signs suggesting Tricuspid stenosis

Answer 28

elevated JVP with delayed y descent abdominal ascites edema

Question 29

Symptoms and signs suggesting Tricuspid Regurgitation

Answer 29

elevated jvp with prominent CV waves, parasternal lift, pulsatilve liver, ascites and edema

Question 30

Explain Carvallo sign

Answer 30

the intensity in the holosystolic murmur of TR increases with inspiration

Question 31

Denotes severe obstruction in Pulmonic stenosis

Answer 31

Syncope Other symptoms: fatigue, dyspnea, lightheadedness, chest discomfort (right ventricular angina)

Question 32

Describe the murmur in Pulmonic stenosis

Answer 32

it is a midsystolic murmur best heard at left 2nd ICS

Question 33

Signs of severe pulmonic stenosis

Answer 33

interval between S1 and pulmonic ejection sound narrows murmur peaks late systole and may extend beyond A2; P2 becomes inaudible

Question 34

Signs of significant RV pressure overload include

Answer 34

prominent jugular venous a wave and parasternal lift

Question 35

It occurs most often as a secondary manifestation of significant PA hypertension and annular dilatation.

Answer 35

Pulmonic regurgitation. | May also be primary valve disorder - congenital bicuspid valve) or as a complication of RVOT surgery

Question 36

Differentiate PR murmur with AR

Answer 36

The diastolic murmur secondary to PR (Graham steell) increases intensity with inspiration, it has a later onset (after A2 and with P2), it also has lower pitch

Question 37

Typical murmur of PR increases the likelihood by

Answer 37

LR 17 but the absecne of murmur does not exclude it`

Question 38

Differential diagnosis of functional limitation after valve replacement

Answer 38

prostethic valve dysfunction arrhythmia impaired ventricular dysfunction

Question 39

Causes of prostethic valve dysfunction

Answer 39

thrombosis pannus ingrowth infection structural deterioration

Question 40

First clue suggesting valve dysfunction

Answer 40

change in quality of heart sounds or appearance of a new murmur

Question 41

murmur of bioprosthesis in the mitral position

Answer 41

mid systolic (from turbulence created by systolic flow across valve struts that project into LVOT) and soft mid diastolic murmur that occurs with normal LV filling (only heard in left lateral decubitus at the apex)

Question 42

A high-pitched or holosystolic apical murmur signifies

Answer 42

para-or transvalvular regurgitation that requires echocardiographic verification and careful ffup evaluation

Question 43

A bioprosthesis in the aortic position is invariably associated with what murmur

Answer 43

midsystolic murmur at base of grade 3 or less intensity A diastolic murmur of AR is abnormal

Question 44

Indicates paravalvular regurgitation or prosthetic dysfunction in mitral/aortic prosthesis

Answer 44

mitral - high pitched apical systolic murmur aortic - decrescendo diastolic murmur signs of hemolysis should be sought

Question 45

signs of px with prosthetic valve thrombosis

Answer 45

shock, muffled heart sounds, soft murmurs

Question 46

Associated with increase in intensity of systolic murmur & other signs of prosthetic valve stenosis

Answer 46

Pannus ingrowth

Question 47

Clinical findings of high risk of short term death or MI in NSTEMI

Answer 47

``` age older than 75 tachycardia hypotension signs of pulmonary congestion new or worsening murmur of MR ```

Question 48

Radiation to trapezius ridge

Answer 48

Pericarditis

Question 49

T or F | A pericardial friction rub is almost 100% specific for pericarditis

Answer 49

T - specific | sensitivity not as high because the rub may wax and wane over the course of illness

Question 50

ECG changes in pericarditis

Answer 50

concave upward ST elevation PR segment deviation elevation in lead aVR, depression in lead II

Question 51

WHen does pericardial tamponade occur

Answer 51

when intrapericardial pressure equals or exceeds the RA pressure

Question 52

Most common associated symptom in pericardial tamponade

Answer 52

dyspnea (sensitivity 87-88%) Hypotension (sensitivity 26%) muffled heart sounds (sensitivity 28%) Pulsus paradoxus greater than 12 mmHg in a px with large pericardial effusion predicts tamponade with sensi of 98% and specificity of 83%, LR 5.9

Question 53

Causes of constrictive pericarditis

Answer 53

Previous chest irradiation cardiac or mediastinal surgery chronic tuberculosis malignancy

Question 54

CLinical presentation of constrictive pericarditis

Answer 54

Dyspnea, fatigue, weight gain, abdominal bloating , leg swelling

Question 55

Waveforms in constrictive pericarditis

Answer 55

classic M or W contour caused by prominent x and y descents | Kussmaul sign