Consultant Cardiologist Final Year Revision December 2016 Dr Cara Hendry Consultant Cardiologist

How you feel about finals

5-10% patients >65yo Lone AF Anaemia Drugs/Alcohol

Treating AF Start with ABCDE Aim for restoration of SR (flecainide / amiodarone / electrical cardioversion) Or rate control via AV node blocking drugs (beta blockers / digoxin) Anticoagulation

JVP Versus Arterial Pulsation 1. More easily seen than felt “JVP is Impalpable” 2. JVP fills from above 3. Hepato - jugular reflux 4. Double wave form MAY be visible 5. JVP varies with position 6. JVP varies with respiration 7. Timing against carotid (“a’ wave out of sync) 8. Valsalva manoevre 9. JVP fills much more slowly

Approach for murmurs

Systolic Murmurs: Commonest Causes Aortic Stenosis Mitral Regurgitation Pulmonary Stenosis Tricuspid Regurgitation Venticular Septal Defect (VSD) (Innocent/Benign Systolic Murmur!)

Systolic Murmurs: Aortic Stenosis Ejection Type Mitral Regurgitation Pan systolic Pulmonary Stenosis Ejection Type Tricuspid Regurgitation Pan systolic Venticular Septal Defect (VSD) Pan systolic (Innocent/Benign Systolic Murmur)

The Murmur of Aortic Stenosis Aortic stenosis causes an “ejection type” systolic murmur usually best heard at the 2nd right intercostal space classically radiating into the carotids. “USUALLY best heard at the 2nd right intercostal Space, but commonly WELL HEARD at the apex.

Auscultation Tips for Finals Listen at the 2nd right interspace first If you hear a systolic murmur the patient probably has aortic stenosis. If you hear a systolic murmur at the 2nd right interspace and also at the apex – the patient probably has aortic stenosis. If you can only hear a systolic murmur at the apex – the patient probably has mitral regurgitation.

Causes of Aortic Stenosis 1. Congenital (Usually Bicuspid Valve) 2. Rheumatic Heart Disease 3. Degenerative (most common nowadays)

Severe Aortic Stenosis : Prognosis

Aortic Regurgitation

Aortic Regurgitation Features Large volume pulse Collapsing Corrigan’s Sign in neck EDM at Left sternal edge “Breathe in, breathe out, stop breathing” Best heard leaning forward Wide pulse pressure RILE- Right murmurs best heard on Inspiration, Left on Expiration

Management

Mitral Regurgitation