Go through the Cardiovascular Short Case
Praecordium
- Palpate: left parasternal impulse = RVH or LAE
- Auscultation (apex then left sternal edge then base) (below left clavicle for PDA):
- identify 1st and second heart sounds and decide if they sound normal or are split
- listen for extra sounds or prosthetic sounds (ball case = sharp opening; tilting disc = soft open, sharp close)
- repeat palpation and auscultation in left lateral then sitting forward
- lateral for tapping apex and MS with bell
- forward at end expiration for thrills or murmurs at left sternal edge and base
- dynamic always if unsure of diagnosis
- valsalva always with systolic murmur (louder if HCM; MVP murmur longer, click earlier; softer rest)
Go through the various descriptions of carotid pulse character
Anacrotic, plateau, bisferiens, collapsing, small volume, alternans
What are the causes of a continuous murmur?
- PDA
- AVF (coronary artery, pulmonary, systemic)
- Venous hum
- over right supraclavicular fossa
- abolished by compression of ipsilateral IJV
- Ruptured sinus of valsalva into RA/RV
- Aortopulmonary connection
- Mammary souffle
- late pregnancy or early postpartum
What are the causes of a third and fourth heart sound?
Third - mechanism: tautening of mitral/tricuspid cusps at the end of rapid diastolic filling
- *Left Ventricle** (loudest at apex on expiration)
- Physiological (<40yo, pregnant)
- LVF
- AR, MR
- VSD, PDA
- *Right Ventricle** (loudest at left sternal edge on inspiration)
- RVF
- constrictive pericarditis
- *Fourth** (always abnormal)
- mechanism: high atrial pressure wave reflected from poorly compliant ventricle
- *Left Ventricle**
- AS
- acute MR
- hypertension
- IHD
- HCM
- *Right Ventricle**
- pulmonary hypertension
- PS
What are the causes of altered first heart sound?
Loud
- mitral/tricuspid stenosis
- tachycardia, hyperdynamic circulation
Soft
- mitral regurgitation, calcified mitral valve
- - LBBB
- 1st degree AVB
What are the causes of altered second heart sound?
Aortic:
- Loud: congenital AS, hypertension
- Soft: calcified AV, AR
Pulmonary:
- Loud: pulmonary hypertension
- Soft: pulmonary stenosis
Increased normal splitting
- RBBB (later P2)
- PS (later P2)
- VSD
- MR (earlier A2)
Reversed splitting
- LBBB
- AS (severe)
- coarctation
- PDA (large)
Fixed splitting
- ASD
What are the causes of mixed aortic valve disease?
Causes
- degenerative
- IE
- rheumatic
- CTD
What are the causes, signs of severity, and results of investigations for aortic regurgitation (AR)?
Early diastolic murmur with decrescendo character in aortic region (or left lower sternal edge). Loudest on exp leaning forward
Note:
- may have a loud systolic murmur without any associated aortic stenosis
- look for peripheral signs to point to the lesion
Causes
- Chronic
- Valvular: Rheumatic; congenital (bicuspid, VSD); seronegative arthropathy
- Aortic root (may be maximal at right sternal border): Marfan’s, aortitis (seroneg arth, RA, syphilis); dissection; age
- Acute
- Valvular: IE
- Aortic root: Marfan’s, hypertension, dissection
Severity
- collapsing pulse
- wide pulse pressure
- length of decrescendo diastolic murmur
- S3
- soft A2
- Austin Flint murmur (diastolic rumble/mitral stenosis due to limitation to mitral inflow by regurgitant jet)
- LVF
Investigations
- ECG: LVH
- CXR:
- LV dilatation
- aortic root dilatation
- valve calcification
Indications for surgery (symptoms, worsening LV function, progressive dilatation)
- aortic root >50mm with Marfan’s, bicuspid >50mm with RFs, others >55mm
What are the causes, signs of severity, and results of investigations for aortic stenosis (AS)?
Causes
- Degenerative (older)
- Rheumatic (rarely alone)
- Calcified bicuspid (younger)
Severity
- plateau pulse
- aortic thrill (important for severity)
- length, harshness, and lateness of the systolic murmur
- S4
- paradoxical splitting of S2 (delayed LV ejection and valve closure)
- LVF (RVF is pre-terminal)
Investigations
- ECG: LVH
- CXR
- LVH
- valve calcification
- TTE - <1cm; mean grad >40mmHg; vel >4cm; DI <0.25
- LVH/LVdysfunction
Intervention
- severe AS with symptoms related to AS (normal or with stress testing)
- severe AS and having other cardiac/aortic surgery (even if AS asymptomatic)
- severe asymptmatic AS with LV dysfunction thought due to AS
- severe asymptomatic AS with abnormal stress test thought due to AS
What are the causes, signs of severity, and results of investigations for mitral regurgitation (MR)?
- Causes
- Chronic
- Degenerative
- MVP
- Rheumatic (M > F; rarely the only murmur present)
- Papillary dysfunction (LVF; ischaemia)
- CTD (RA, AS)
- congenital: endocardial cushion defect, parachute valve, corrected transposition
- Acute
- IE (perforation anterior leaflet); rupture of myxomatous cord
- AMI (chordae rupture; papillary muscle dysfunction)
- Surgery
- Trauma
Severity
- Dilated LV
- Pulmonary hypertension
- Soft S1
- Early A2
- S3
- Early diastolic rumble
- LVF
- small volume pulse (very severe)
Investigations
- ECG: mitrale; AF; LV diastolic overload; RAD
- CXR:
- large LA
- increased LV size
- mitral annular calcification
- pulmonary hypertension
- TTE:
- thickened (rheumatic)
- prolapsing
- LA size (chronicity)
- LV size/function
- associated: aortic valve (rheumatic), ASD associated with prolapse
- annulus calcification
Indications for surgery (severe)
- repair preferable to replacement
What are the causes, signs of severity, and results of investigations for mitral stenosis (MS)?
Causes
- rheumatic
- severe annular calcification (rare)
- after repair for MR (rare)
- congenital (very rare; e.g. parachute valve with all chordae into one papillary)
Severity
- small pulse pressure
- early opening snap (raised LA pressure)
- length of mid diastolic rumbling murmur
- diastolic thrill at apex (rare)
- pulmonary hypertension
- <1cm valve area
- ECG: RV hypertrophy, RAD
Investigations
- ECG: mitrale in sinus; AF (chronicity)
- CXR:
- MV calcification
- big left atrium: –> double LA shadow, displaced left bronchus, big LA appendage, carina angle > 90 degrees, convex left atrial appendage
- pulm htn: large central PAs, pruned peripheral PAs
- cardiac failure
Associated LV dilatation, think associated:
- MR
- AV disease
- hypertension
- IHD
Indications for surgery
- symptomatic and severe
What are the causes, signs of severity, and results of investigations for pulmonary stenosis (PS)?
Causes
- congenital
- carcinoid
Signs
- peripheral cyanosis (low CO)
- normal/reduced pulse (low CO)
- JVP: giant a waves, may be elevated
- RV heave; pulmonary area thrill (common)
- presystolic pulsation of liver
- harsh ESM loudest in inspiration
- may have ejection click, may have S4
Severity
- ESM peaking late
- absent ejection click (when stenosed below the valve level)
- S4
- RVF
What are the causes, signs of severity, and results of investigations for tricuspid regurgitation (TR)?
Causes
- Functional (RVF)
- Rheumatic (very rarely alone)
- IE
- Congenital (Ebstein’s)
- Prolapse (rare)
- RV papillary muscle infarction
- Trauma
Signs
- JVP: large v waves; elevated in RVF
- RV heave
- pulsatile, large, tender liver
- ascites/oedema with pleural effusions
- PSM loudest on inspiration at lower end of sternum
Investigations
- CXR: RV enlargement (maybe bivent if TR secondary to failure)
What are the clinical features of atrial septal defect (ASD)?
- sinus venosus very uncommon in adults
- ostium primum associated with MR, TR, VSD commonly
- and look for Down syndrome or upper limb defects (holt-oram syndrome)
Signs
- fixed splitting of S2
- pulmonary ESM increasing on inspiration
- pulmonary hypertension (late)
- orthodeoxia-platypnoea (if they have position dependent shunting - caused by increased right-to-left shunting of blood on assuming an upright position, with normal pressure in the right atrium)
Investigations
- ECG:
- RAD
- RBBB
- RVH
- CXR:
- increased pulmonary vasculature
- enlarged RA/RV
- dilated main pulmonary artery
- small aortic knob
Intervention
- close if the shunt is >=1.5:1 (unless there’s reversal)
What are the clinical features of chronic constrictive pericarditis?
Think of in cachectic patient with ascites
Signs
- low BP with pulsus paradoxus
- JVP: raised with prominent x and y descents
- impalpable apex
- distant heart sounds
- may have early S3 and early pericardial knock (rapid ventricular filling abruptly halted)
- - hepatosplenomegaly, ascites, oedema
Aetiology (look for signs of these)
- radiation
- tumour
- Infection - uberculosis
- CTD - sarcoidosis
- chronic renal failure
- trauma
What are the clinical features of coarctation of the aorta?
Most commonly just distal to the origin of the left subclavian artery
Associations
- Bicuspid aortic valve + aortopathy
- Other congenital disease (Turner’s especially)
- Berry aneurysms in 10%
Signs
- more developed upper body
- radiofemoral delay
- hypertension limited to the arms
- collateral chest vessels
- hypertensive fundi changes
- midsystolic murmur (praecordium and back)
Investigations
- ECG: LVH
- CXR:
- enlarged LV
- enlarged left subclavian artery
- dilated ascending aorta
- aortic indentation
- aortic prestenotic/poststenotic dilation
- rib notching (2nd-6th ribs, inferior border)
When to do intervention
- Hypertension + peak-peak gradient 20mmHg
- Severe anatomic with significant collaterals
What are the clinical features of Eisenmenger’s syndrome?
Look for cyanosis, clubbing, polycythaemia
Signs (pulmonary hypertension)
- JVP: dominant a wave; maybe v wave
- RV heave; palpable P2
- loud P2
- S4; pulmonary ejection click
- PR, TR
Level of the shunt
- ASD: wide fixed split
- VSD: single second sound
- PDA: normal second sound or reversed split (look for differential cyanosis)
Investigations
- ECG: RVH; p pulmonale
- CXR
- RVE/RAE
- pulmonary artery prominence
- increased hilar vasculature with dropped out peripheral vasculature
- non boot shaped heart
What are the clinical features of hypertrophic cardiomyopathy?
Signs
- sharp rising, jerky pulse (rapid ejection -> obstruction)
- JVP: prominent a wave (non-compliant ventricle)
- double/triple impulse apex beat (ventricular expansion following atrial contraction)
- late systolic ejection murmur (left sternal edge)
- PSM from MR
- S4
Dynamic
- louder with: valsalva, standing, isotonic exercise (jogging) as all decrease LV filling (dec preload/inc afterload)
- softer with: squatting, raising legs, isometric exercise (handgrip) as all increase LV filling (inc preload/dec afterload)
Investigations
- ECG: LVH with lateral ST/T changes; deep Qs; conduction defects
- CXR: LV enlarged with hump on the border; no calcification
- TTE
- asymmetric hypertrophy of the ventricular septum
- systolic anterior motion of the anterior mitral valve leaflet
- midsystolic closure of AV
- LV outflow tract gradient
- MR
What are the clinical features of ventricular septal defect (VSD)?
Signs
- thrill
- harsh PSM confined to left sternal edge
- may have associated MR
- look for Down syndrome
Investigations
- ECG: LVH
- CXR
- LVH
- RVH
- increased pulmonary vasculature
When to consider ntervention
- shunt of >=1.5:1
- RV dilatation is a proxy of large shunt size
What are the signs of pulmonary hypertension?
- Prominent a wave on JVP
- RV impulse
- Loud P2
- palpable P2 more helpful
- PR or TR
What are the types and causes of diastolic murmurs?
Early diastolic
- AR/PR
Mid diastolic
- MS/TS
- atrial myxoma
- Austin Flint of AR (whenthe AR causes MR)
- Carey Coombs of acute rheumatic fever (The Carey Coombs murmur or Coombs murmur is a clinical sign which occurs in patients with mitral valvulitis due to acute rheumatic fever. It is described as a short, mid-diastolic rumble best heard at the apex, which disappears as the valvulitis improves)
Presystolic
- MS/TS
- atrial myxoma
What are the types and causes of systolic murmurs?
Pansystolic
- MR, TR
- VSD (heard at LSE)
- aortopulmonary shunts
Midsystolic
- AS, PS
- HCM
- pulmonary flow murmur of ASD
Early systolic
- VSD (very small or large with pulmonary hypertension)
- acute MR, TR
Late systolic
- Mitral valve prolapse
- papillary muscle dysfunction
What should you consider and look for if nothing is obvious on auscultation of the heart?
- MS: position and exercise
- ASD: carefully for fixed splitting
- MVP: valsalva
- Pulmonary hypertension
- Constrictive pericarditis
- think if they have bad failure and you can’t find much else
- If you can’t hear heart sounds
- think dextrocardia
Where is the normal apex beat and what are the descriptions of abnormality?
Normally 5th space 1cm medial to midclavicular line
Pressure loaded (hyperdynamic):
- systolic overloaded
- forceful and sustained
- AS, hypertension
Volume loaded (hyperkinetic):
- diastolic overloaded
- forceful but unsustained
- AR/MR
Tapping:
- palpable first heart sound
- MS
Dyskinetic:
- larger area than normal due to uncoordinated contraction
- LV aneurysm following infarction
Double/Triple:
- hypertrophic cardiomyopathy
Absent:
- obesity
- pericarditis
- COPD
- situs inversus
