MRCP: Cardiology

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  1. 1. What does JVP reflect?
    2. How is it observed clinically?
    • 1. Patient's right atrial pressure, hence their filling status and fluid state
    • 2. With patient at 45 degrees, internal jugular vein is found between the clavicular/sternal heads of the sternomastoid muscle, 3cm above angle of Louis in the healthy
  2. Describe the waveform of the JVP
    A: Atrial contraction increases JVP and moves SVC superiorly

    X: First gravity then ventricular contraction moves heart donwards, stretching atria and decreasing pressure

    C: Mid-x closure of tricuspid valve before ventricular systole increasing pressure

    V: At end of X, increase in pressure due to passive filling of atria against closed tricuspid

    Y: Tricuspid reopens as ventricular pressure drops, passively filling ventricle and decreasing pressure
  3. Describe the abnormal presentations of increased JVP, while describing their causes
    Normal waves: (inability of atria to clear efficiently) 1: Right or bi-heart failure 2: Fluid overload 3: Severe bradycardia

    Raising on inspiration: (Kussmaul sign - atria not able to cope with increased venous return) 1: Pericardial disease 2: Pericardial fluid/effusion/tamponade

    Raised with no wave: (Severe increase in pressure- SVC syndrome) 1: Mediastinal malignancy - head/neck/arm swelling
  4. Describe pathological A waves of JVP and explain their causes
    • Absent: (No appreciable atrial contraction) 1. AF
    • Large: (Poor emptying of right atrium/heart) 1. Tricuspid stenosis 2. RHF 3. Pulmonary hypertension
    • 'Cannon': (Complete AV dissociation allowing simultaneous contraction) 1. T3 block 2. Atrial flutter/tachycardias 3. VT 4. Ectopics
  5. Describe pathological JVP waves (not A) and explain their causes
    Steep x only: (Fast atrial emptying) 1. Tamponade

    Steep x and y: (Poor atrial stretching) 1. Constrictive pericarditis

    Giant V: (Increased passive filling) 1. Tricuspid regurgitation "c-V wave"

    Slow Y: (Poor atrial emptying) 1. Triscuspid stenosis
  6. Give 6 causes of an absent radial pulse
    • Trauma
    • Takayasu's arteritis (intimal fibrosis)
    • Aortic dissection with subclavian involvement
    • Peripheral arterial thrombo-embolism
    • Blalock-Taussig shunt (surgical management of cyanotic heart disease
    • Iatrogenic e.g. post-CVC or arterial line insert
  7. Give 3 causes of a collapsing central pulse
    • 1. Aortic regurgitation (sudden pressure drop post-ventricle contraction)
    • Any large extra-cardial shunt (fast dispensation of pressure)
    • 2. PDA
    • 3. Arteriorvenous fistula
  8. Give the single causes of Jerky, Bisferiens and Alternans pulses
    Jerky: (intermittent interruption of aortic flow) HOCM

    Bisferiens: ('double shudder' from effects of aortic stenosis and regurge simulataneously) Mixed aortic valve disease, including significant regurgitation

    Alternans: (Reduced EF increases end-diastolic volume, prompting FS mechanism to improve next beat) Moderate LVF - in severe LVF alternans lost as FS not sufficient
  9. Explain the physiology and causes of Pulsus Paradoxus
    • A drop in pulse amplitude on inspiration (systolic drops >10mmHg) from compromised venous return
    • 'Paradox' is auscultating a beat but not palpating the radial pulse

    • Pathologically increased intracardiac pressure
    • 1. Tamponade
    • 2. Ventricular compression e.g. malignancy
    • 3. Constrictive pericarditis

    4. Obstructive lung disease e.g. severe asthma, COPD, chronic sleep apnoea
  10. Where is the apical beat palpated, on what does a normal impulse rely and what might its absence indicate?
    Site: 5th intercostal space, in midclavicular line

    Physiology: Requires isovolumetric contraction of both ventricles to be correct amplitude and position

    • Causes
    • 1. Pericardial restriction e.g. effusion, constriction
      2. Emphysema
    • 3. Right pneumonectomy/dextrocardia
    • 4. Obesity
  11. Explain the causes of the following pathological apical impulses:
    Heaving (1)
    Thrusting (4)
    Tapping (1)
    Displaced and diffuse (2)
    Heaving: (Increased amplitude of LV contraction) LVH of any cause

    Thrusting: (Increased left ventricular volume causing hyperdynamic contraction) 1. Mitral regurge 2. Aortic regurge 3. PDA 4. VSD

    Tapping: (Palpable first heart sound) Mitral stenosis

    D+D: (Left ventricle impairment and dilation) 1. Dilated cardiomyopathy 2. Infarction
  12. Explain the causes of the following pathological apical impulses:

    Double impulse
    Pericardial knock (1)
    Parasternal heave (4)
    Palpable 3rd heart sound
    Double impulse: (Deformity of ventricle shape) HOCM or ventricular aneurysm

    Pericardial knock: (Rigidity of pericardium) Constrictive pericarditis

    Parasternal heave (RVH modifying the impulse) 1. ASD 2. P-Htn 3. Cor Pulmonale 4. Pulmonary valve stenosis

    Palpable 3rd heart sound: Heart failure and severe mitral regurgitation
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MRCP: Cardiology
2015-04-14 22:07:23

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