Cardio

Question 1

Features of pulmonary hypertension?

Answer 1

JAPPP2

• Raised JVP
• Ascites and
• Peripheral oedema
• Loud P2
• left Parasternal heave

Question 2

Clinical signs of aortic stenosis?

Answer 2

Ejection systolic murmur radiating to the carotids
Forceful apex
Slow rising pulse
Thrill in aortic area

Question 3

Clinical signs of SEVERE aortic stenosis?

Answer 3

Quiet/absent S2
S4 (atrial contraction against stiff ventricle)
Narrow pulse pressure
Decompensation: LVF

Question 4

Differentials for aortic stenosis?

Answer 4

Aortic sclerosis (no radiation, normal character)
Mitral regurgitation
HOCM

Question 5

Causes of aortic stenosis?

Answer 5

Congenital:
- Bicuspid aortic valve

Acquired:

• Calcification of valve
• Rheumatic heart disease

Question 6

Echo features of severe aortic stenosis?

Answer 6

Valve area <1cm

Pressure gradient >40mmHg

Question 7

Management of aortic stenosis?

Answer 7

Medical:
- Optimise CV risk: Statins, anti-HTN, DM, anti-plat

Surgery:

• Valve replacement +/- CABG
• TAVI

Question 8

Indications for aortic valve replacement?

Answer 8

Symptomatic AS
Severe asymptomatic AS
Severe AS undergoing CABG or other valve op

Question 9

Complications of aortic stenosis?

Answer 9

LVF; PND, orthopnoea, frothy sputum
Conduction problems
Endocarditis

Question 10

Clinical signs of severe mitral regurgitation?

Answer 10

Atrial fibrillation

LVF

Question 11

Differentials of MR?

Answer 11

AS
VSD
Tricuspid regurgitation

Question 12

Causes of MR?

Answer 12

Structural, infective, congenital

Structural:

• LV dilatation
• Papillary muscle rupture
• Mitral valve prolapse
• Calcification

Infective:

• RHD
• Infective endocarditis

Congenital:
- Connective tissue diseases

Question 13

What investigations would you do for MR and why?

Answer 13

Bedside:
- ECG (look for LVH, AF, P-mitrale)

Bloods:
- FBC, U+E, glucose, lipids

Imaging:

• CXR (calcified MV, LVH, pulmonary oedema)
• Echo (to assess severity)
• Cardiac catheterisation (assess coronaries)

Question 14

Management of MR?

Answer 14

Medical:

• Optimise CV risk: Statins, anti-HTN, DM, anti-plat
• Rate control and anticoagulation for AF
• Reduce afterload with beta blockers/ ACEis and diuretics

Surgery:
- Valve replacement (ind: symptomatic)

Question 15

Signs of SEVERE aortic regurgitation?

Answer 15

• Collapsing pulse
• Wide pulse pressure
• LVF

Question 16

Causes of aortic regurgitation?

Answer 16

Can be ACUTE or CHRONIC

Chronic:
Structural: Bicuspid aortic valve, aortic dissection type A (acute)
Infective: infective endocarditis (acute), RHD (chronic)
Connective tissue: Marfan’s
AI: Ank spond, RA

Question 17

What investigations would you do for AR and why?

Answer 17

Bedside:
- ECG (look for LVH)

Bloods:

• FBC, U+E, glucose, lipids
• AI screen: ESR, HLA-B27

Imaging:

• CXR (cardiomegaly, dilated ascending aorta, pulmonary oedema)
• Echo (to assess severity and cause)
• Cardiac catheterisation (assess coronaries)

Question 18

Examination findings of mitral stenosis?

Answer 18

• Mid diastolic murmur with loud first heart sound and opening snap (MDM OS)
• Tapping apex
• +/- AF
• Left parasternal heave
• Malar flush

Question 19

Signs of SEVERE mitral stenosis?

Answer 19

Malar flush
Longer murmur
LVF

Question 20

Causes of mitral stenosis

Answer 20

Infective: RHD, IE
Structural: Prosthetic valve, senile degeneration
Congenital

Question 21

What investigations would you do for mitral stenosis and why?

Answer 21

Bedside:
- ECG (look for LVH and AF, p mitrale)

Bloods:
- FBC, U+E, glucose, lipids

Imaging:

• CXR (calcified MV, dilated left atrium, pulmonary oedema, pulmonary haemosiderosis)
• Echo (to assess severity and LV function)
• Cardiac catheterisation (assess coronaries)

Question 22

Management of aortic regurgitation?

Answer 22

Medical:

• Optimise CV risk: Statins, anti-HTN, DM, anti-plat
• Rate control and anticoagulation for AF
• Reduce afterload with beta blockers/ ACEis and diuretics

Surgery:
- Valve replacement (ind: symptomatic NYHA >2)

Question 23

Management of mitral stenosis?

Answer 23

Medical:

• Optimise CV risk (statin, anti-HTN, anti-plat, DM)
• Consider RF prophylaxis (Pen V)
• Rate control and anticoagulation for AF
• Diuretics for Sx relief

Surgical: 
Indicated for moderate to severe MS
- Ballon valvuloplasty
- Valve repair
- Valve replacement if repair not possible

Question 24

P mitrale?

Answer 24

Broad, bifid P waves, found in mitral stenosis

Question 25

Rheumatic fever treatment and prevention?

Answer 25

Primary prevention: Pen V for 10 days | Secondary: Pen V for 5-10 years

Question 26

Risk factors for infective endocarditis and associated organisms?

Answer 26

IVDU Skin wounds Immunosuppression S. aureus, strep viridans and s. epidermidis

Question 27

What is acute rheumatic fever?

Answer 27

Immunological response to strep pyogenes

Question 28

Complications of valve replacements?

Answer 28

"BEHAVE" - Bleeding - Embolism - Haemolysis - AF - Valve failure - Endocarditis

Question 29

Causes of AF?

Answer 29

Cardiac: IHD, valve disease, heart failure, PE Metabolic: Thyrotoxicosis, Hypokalaemia Infective: Pneumonia, RHD

Question 30

How do you determine necessity of anticoagulation in AF?

Answer 30

CHA(2)DS(2)VAS Score ``` CCF Hypertension Age >75y DM Stroke/TIA Vascular disease Age 65-74 Sex female ``` If 0: aspirin If >1: Warfarin (INR 2-3)

Question 31

Management of acute AF?

Answer 31

Acute If haemodynamically unstable - cardioversion Otherwise: - Rate control with beta-blocker or rate-limiting calcium-channel blocker (diltiazem or metoprolol) - Start LMWH - DC cardioversion or medical w amiodarone

Question 32

Indications for pacemaker?

Answer 32

``` HAM ST Heart failure biventircular pacing AV node dysfunction Mobitz type 2 Sick sinus Tachyarrythmias drug resistant ```

Question 33

Pulmonary hypertension symptoms?

Answer 33

SOB Reduced exercise tolerance Peripheral oedema

Question 34

Criteria for IE

Answer 34

Duke 2 major or 1 major 3 minor "BE FIRE" Major: Blood cultures confirmed 2 seperate cultures Echo findings e.g. vegetation ``` Minor: Fever Immune; roth spots /oslers nodes, RF Risk factors (IVDU/cardiac lesions) Emboli; splinter haemorrhages, janeway lesions ```

Question 35

Criteria for RHD

Answer 35

Jones 2 major or 1 major 2 minor PACES FACER ``` MINOR: Pancarditis Arthritis Chorea Erythema marginatum Subcut nodules ``` ``` MAJOR: Fever Arthralgia CRP/ESR ECG showing prolonged PR RF previously ```

Question 36

ECG features of Wolff Parkinson White

Answer 36

``` Short PR interval Slurred upstroke (delta wave) ```