Cardiology Quick Notes - Copyright Dr D O'Kane 2007 |
| Defect |
Causes |
Clinical Symptoms |
Clinical Signs |
Investigations |
Management |
| Aortic
Stenosis normal orifice 3-4 cm2 - impaired LV emptying leading to a pressure overloaded left ventricle |
Congenital Bicuspid valve Rheumatic heart disease Senile Degeneration William's syndrome (high calcium) |
Chest pain - angina Dizziness Syncope Breathlessness Endocarditis Arrhythmias Sudden death |
Slow rising plateau pulse (pulsus tardus et parvus) Narrow pulse pressure Harsh Ejection systolic thrill and murmur Ejection click Sustained forceful apex Soft A2 audible S4 (SR) |
ECG - SR Left atrial
enlargement, LVH + strain, LBBB, AV block Echo - LVH, gradient, thickened cusps, reduced mobility. Peak gradient > 50 mmHg is significant and suggests moderate stenosis CXR - normal size + post stenotic dilatation Cardiac catheter done in those over 40 to look for Coronary artery disease |
Avoid exercise if heart failure Endocarditis prophylaxis Avoid vasodilators in significant disease Valve replacement in all with gradient > 75 mmHg or symptoms and gradient > 50 mmHg Aortic balloon valvuloplasty - short term solution in those not fit for valve replacement Replace before decline in LV function |
| Aortic
Incompetence Blood refluxes back into the left ventricle in diastole creating a volume overloaded left ventricle (Look for secondary causes and always exclude endocarditis) |
Rheumatic heart disease Infective endocarditis Connective tissue disease Degeneration Bicuspid valve Endocarditis Root dilation - hypertension, ankylosing spondylitis, SLE, RA, Aortic dissection |
Men > Women. Breathlessness Palpitations Endocarditis Sudden death |
Large volume collapsing pulse with wide pulse pressure - water hammer High pitched early diastolic murmur best heard at LSE in expiration Possible added systolic aortic flow murmur + S3 Austin flint murmur - low pitched diastolic AMVL vibrations Corrigan's sign - visible carotid pulsation deMussets - head nodding Quincke's - nailbed pulsations Traube's - pistol shot femorals Duroziez's - femoral diastolic murmur |
Cardiomegaly - aortic root
dilation, LV volume overloaded. Exclude endocarditis. Assess LV Echo - LV enlargement Cardiac catheter if valve replacement considered |
Vasodilator therapy - ACE,
Nifedipine Diuretics, Digoxin if AF Aortic Valve replacement if end systolic diameter > 50 mm or signs of LV dysfunction |
| Mitral
Stenosis normal valve is 4-6 cm2. Narrowing obstructs and impairs LV inflow and raises Left atrial pressure |
Rheumatic heart disease - commoner in women Congenital Lutembacher's syndrome (Left atrial myxoma can mimic Mitral stenosis) |
Exertional Dyspnoea PND Fatigue Palpitations Haemoptysis Thromboembolism Hoarseness (Ortner's syndrome) Dysphagia (pressure of LA) Frank pulmonary oedema |
AF Irregular Irregular pulse Low volume pulse Mitral facies Loud S1 and tapping apex beat Opening snap Middiastolic low pitched rumbling murmur increased with exercise Presystolic accentuation(SR) Loud P2 Closer the A2-OS the more severe the disease Pulmonary hypertension - RV lift, Loud P2, TR |
ECG - AF and P mitrale, RVH CXR - normal sized LV and straight left heart border due to increased Left atrial size. MV calcification. Pulmonary oedema Echo - fish mouth appearance Severe MS - Reduced MV area to 1 cm2 Catheterisation - raised Left atrial pressure with pulmonary hypertension |
Diuretics. Fast AF - Digoxin, Beta blockers, Verapamil to slow rate and prolong diastolic filling Warfarin for AF Mitral commissurotomy Valvuloplasty Mitral Valve replacement Oral penicillin if past rheumatic fever to prevent recurrent rheumatic fever if age < 30 |
| Mitral
Incompetence reflux of blood back into the left atrium during systole due to impaired valve function due to dilation of valve ring or abnormal valve or papillary muscle function |
Rheumatic heart disease Functional (LV dilates) Endocarditis Mitral valve prolapse Myocardial infarction - inferior wall Myxomatous degeneration Connective tissue disease Trauma Cardiomyopathy (HCM) |
Dyspnoea Palpitations Fatigue Endocarditis (Acute MR leads to a more acute and severe deterioration than chronic MR where there is time for the LA to dilate with time and dampen pressure and volume changes) |
Atrial fibrillation Displaced hyperdynamic apex PSM at apex often radiates to axilla Soft S1, Loud P2 |
Echocardiogram Cardiac catheterisation |
Diuretics Warfarin for AF Digoxin for AF Vasodilator therapy Mitral valve repair and reconstruction is preferable Mitral valve replacement if end systolic dimension > 50 mmHg or LVEF < 50% Endocarditis prophylaxis |
|
Tricuspid Stenosis Impaired filling of RV due to a narrowed tricuspid valve |
Rheumatic disease Carcinoid Congenital disease Right atrial myxoma mimics TS |
Usually coexists with
mitral valve disease. |
Large 'a' wave in JVP Slow y descent in JVP Loud S1 Low pitched MDM + PSA, Pulsatile, Hepatomegaly Jaundice, Ascites, Pedal oedema |
CXR - RAE Echo - RAE and stenosed valve |
Valve repair or replacement in
severe cases |
|
Tricuspid Incompetence blood refluxes from RV back into RA in systole |
Functional and Acquired due to
pulmonary hypertension (MS, LVF, COAD) Endocarditis due to IV drug user Carcinoid RV infarction and RV dysfunction Ebstein's anomaly |
Right heart failure Large CV waves Pulsatile liver Raised JVP, RV lift, loud P2, PSM at LSE increases with inspiration Oedema |
Large V waves in JVP
Pulsatile liver PSM at LSE louder on inspiration |
ECG - AF, P pulmonale, RBBB Echo - defines valve and helps to determine aetiology, PA pressure indirectly measured. |
Endocarditis prophylaxis Diuretics Tricupid valve repair may be undertaken along with mitral valve surgery Treat any endocarditis |
|
Pulmonary Stenosis |
Congenital Fallot's Rheumatic Turner's syndrome |
Possibly Dysmorphic Dyspnoea Fatigue Right heart failure Oedema |
Prominent a wave Ejection systolic murmur 2nd LICS Increases on inspiration Ejection click Soft P2 ?Fallot's |
P pulmonale, RAD, RVH, RBBB CXR - post stenotic dilatation of PA, large RA and RV. Pulmonary oligaemia. |
Pulmonary valvuloplasty or
Valvotomy |
| Pulmonary
Incompetence |
|
Early diastolic murmur Maximal 2/3rd LICS |
|||
| Mitral
Valve prolapse Click murmur syndrome - Common cardiac anomaly with many associations - look for those with evidence of MR |
Congenital - 2% of men and 5% of
women Autosomal dominant trait Connective tissue disease - Marfan's syndrome Multiple associations |
Nonspecific - causality
difficult to prove. Dyspnoea, chest pain and palpitations all reported. |
Mid systolic click and mid to
late systolic murmur which increases on standing and with valsalva which both reduce preload |
ECG - non specific changes Echocardiogram |
Endocarditis prophylaxis for
those with associated MR Beta blockers Warfarin if AF develops |
|
Hypertrophic Cardiomyopathy - an autosomal dominant inherited disease with left ventricular hypertrophy and diastolic dysfunction. There is a rare but significant risk of arrhythmias and sudden death in some. Only 20% have LVOT obstruction. Abnormal sarcomeric contractile proteins.
|
Usually a point mutation in the gene encoding of sarcomeric contractile proteins (actin, Beta myosin, tropomyosin etc) |
Dyspnoea - diastolic dysfunction (rise in LVEDP) Syncope or pre syncope or even sudden death Palpitations Sudden cardiac death in a relative |
|
HCM may be totally asymptomatic and picked up by screening either with an abnormal ECG - deep T wave inversion, ST and Q wave "pseudoinfarction" appearance, abnormal Echo - Asymmetrical septal hypertrophy, systolic anterior movement of AMVL |
|
|
Ventricular septal defect abnormal communication between the right and left ventricles. Can be muscular or membranous or subvalvular. Small defects can give loud murmurs. |
Congenital 2/1000 Acquired (post MI) |
Symptoms depend on size of shunt
in terms of blood flow which is a function of VSD size and pressures
across the septum. Paradoxical embolism Cardiac failure Eisenmenger's syndrome . |
Loud PSM at LSE Loud does not mean big VSD Wide split S2 S3 Middiastolic flow murmur |
ECG - LVH / RVH Cardiomegaly, pulmonary plethora Echo 2D and doppler echo diagnostic Catheter shows increase PaO2 in RV |
Surgical closure before child
starts school for moderate sized VSD Close if Shunt > 3:1 P/S flow and asymptomatic |
|
Atrial septal defect abnormal communication between the right and left atria - be aware of embryological development. Ostium Primum more severe - associated with endocardial cushion and mitral valve defects. Ostium Secundum - more benign form and commoner |
Congenital Down's syndrome and Holt Oram syndrome associated with primum defects |
None, Fatigue, Heart Failure, Arrhythmias, Paradoxical embolism Failure to thrive in childhood with Primum defect which is more severe Eisenmenger's syndrome |
Fixed split S2 Diastolic tricuspid flow murmur Systolic pulmonary flow murmur |
Ostium Primum - LAD + RBBB Ostium secundum - RAD + RBBB Atrial fibrillation CXR - large RA, large RV, large PA, Pulmonary plethora Catheter shows increase PaO2 in RA |
Warfarin and Digoxin for AF Diuretics for heart failure Treat surgically if significant shunt before Eisenmenger's syndrome usually if pulm/systemic flow is > 1.5:1 |
|
Patent Ductus Arteriosus abnormal persisting communication between aorta and pulmonary artery. LV then supplies systemic and pulmonary circulation and volume overloaded LV depends on anatomy of the ductus and pulmonary vascular resistance. Eisenmenger's can develop |
Congenital Rubella Associated with VSD and CoA |
No symptoms if small Endoarteritis of ductus High output cardiac failure Eisenmenger's syndrome - reversal of shunt - Clubbing and cyanosis of toes and not of fingers |
Continuous murmur best heard in
second left intercostal space S3 Mitral flow murmur Wide pulse pressure |
ECG - LVH CXR - cardiomegaly and pulmonary plethora Color-flow doppler Catheterisation shows higher SaO2 in PA than RV |
Small PDA inconsequential and
not operated if older middle aged asymptomatic Surgical division of the defect |
| Coarctation
of the Aorta (CoA) Narrowing of the aorta usually ust distal to the left subclavian artery giving hypertension proximally and under perfusion beyond the stenosis |
Congenital Commoner in boys |
Hypertension Headaches Nosebleeds Cold feet |
Systolic murmur maximal over apex left lung posteriorly Continuous murmur from collatorals LV Heave Weak femoral pulse Radio-femoral delay Upper body hypertension |
ECG - LVH CXR - Normal heart or enlarged LV Dilated ascending aorta Reversed 3 signs - Aortic indentation Rib notching from collatorals 2nd to 6 th ribs posteriorly Use Echocardiography or MRI Measure gradient using cardiac catheterisation |
Surgical correction |
| Fallot's
Tetralogy - components
are |
Congenital |
Heart Failure Cyanosis Tet Spells Eisenmenger's syndrome |
Cyanosis (not initially at birth - may develop) Clubbing RV Heave Thrill at LSE Single A2 Short pulmonary ejection systolic murmur |
ECG - RAD RVH Boot shaped heart (absent pulmonary artery gives concavity) RV enlarged |
Surgical correction |
| Eisenmenger's
syndrome Right to left shunt due to the development of pulmonary hypertension |
Ventricular septal defect
(single S2) Patent ductus arteriosus (differential cyanosis) Atrial Septal defect (Fixed split S2) |
Cyanosis Finger Clubbing Polycythaemia Dominant 'a' wave in JVP Prominent 'cv' wave if TR Loud P2 S4 Pulmonary ejection click Signs of TR and PR |
| Condition |
Valsalva |
Standing |
Isotonic exercise |
Squatting |
Raised legs |
Isometric(handgrip) | |
| Hypertrophic Cardiomyopathy |
Louder |
Louder |
Louder |
Softer |
Softer |
Softer |
|
| Mitral valve prolapse |
Longer murmur |
Louder |
Shorter murmur |
Shorter murmur | |||