Medicine Marrow Pg 301-310 (Cardiology)

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Questions and Answers

Which statement about the S3 heart sound is true?

S3 is always pathological.

S3 is not audible in athletes.

S3 can be heard during the rapid filling phase. (correct)

S3 is associated with stenosed AV valves.

An S3 heart sound can be present in mitral stenosis (MS).

False

What are the three types of diastolic added sounds mentioned?

Opening snap, pericardial knock, tumor plop

The S3 heart sound occurs in the _____ phase of the cardiac cycle.

rapid filling Signup and view all the answers

Match the following valvular diseases to their associated heart sound characteristics:

Mitral Regurgitation (MR) = Heard with or without LV failure Mitral Stenosis (MS) = Not seen Aortic Stenosis (AS) = Seen in severe cases due to LVH Aortic Regurgitation (AR) = Not seen with LV failure Signup and view all the answers

What causes a loud A2 sound?

Hyperkinetic state Signup and view all the answers

Aortic stenosis caused by a degenerative process results in a loud Aa sound.

False Signup and view all the answers

What is the frequency range of the second heart sound?

120-150 Hz Signup and view all the answers

Severe pulmonary hypertension will cause a loud single ______.

Pa Signup and view all the answers

Match the following conditions with their associated second heart sound characteristics:

Aortic Stenosis (BAV) = Loud Aa Rheumatic Aortic Regurgitation = Soft Aa Moderate Mitral Stenosis with PHTN = Loud Pa Pulmonary Valve Stenosis = Soft Pa Signup and view all the answers

Which condition is associated with the presence of a pericardial knock?

Chronic constrictive pericarditis Signup and view all the answers

An S3 heart sound varies with respiration.

False Signup and view all the answers

What happens to the physiological S3 sound in an upright position?

It disappears. Signup and view all the answers

The _____ heart sound is also known as the atrial or presystolic gallop.

S4 Signup and view all the answers

Match the heart sounds with their corresponding features:

S3 = Heard in acute mitral regurgitation and aortic regurgitation S4 = Correlates with an A wave in JVP Pericardial Knock = High pitched and louder with inspiration S3 Physiology = Disappears in an upright position Signup and view all the answers

Which of the following conditions can cause an early Aa split? (Select all that apply)

LV pacing Signup and view all the answers

A paradoxical split occurs when a split is heard during inspiration and not during expiration.

False Signup and view all the answers

What does a fixed split indicate about RV and LV filling during expiration and inspiration?

There is a similar degree of alteration in RV and LV filling. Signup and view all the answers

The condition known as _____ can cause a reverse split in a patient's heart sounds.

TR Signup and view all the answers

Match the following conditions with their associated types of splits:

RBBB = Wide split LBBB = Reverse split AS = Reverse split ASD = Fixed split Signup and view all the answers

What condition is associated with concentric LVH?

HCM Signup and view all the answers

An opening snap occurs during isovolumetric contraction.

False Signup and view all the answers

What does the S2-OS interval represent in mild mitral stenosis?

<blockquote> 120 mmHg </blockquote> Signup and view all the answers

The __________ is a low-pitched sound associated with atrial myxoma.

tumour plop Signup and view all the answers

Match the following features with their corresponding terms:

Concentric RVH = Pulmonary stenosis Early diastolic sound = Tumour plop LAP >15 mmHg = Severe mitral stenosis A-V valve opening sound = Opening snap Signup and view all the answers

What typically causes an ejection click?

Stenosis of the valve Signup and view all the answers

Vascular ejection clicks are caused by the sudden distension of a vessel beyond the valve.

True Signup and view all the answers

What happens to the S₂ heart sound in valvular pathologies?

It becomes soft. Signup and view all the answers

Mitral valve prolapse is associated with _____ clicks.

non-ejection Signup and view all the answers

Match the following types of clicks with their characteristics:

Ejection Click = Heard best in the aortic area Non-Ejection Click = Associated with mitral valve prolapse Vascular Ejection Click = Due to aneurysm of vessel Valvular Ejection Click = Caused by valve stenosis Signup and view all the answers

What is the first symptom of Aortic Stenosis (AS)?

Angina Signup and view all the answers

Atrial fibrillation is a benign condition associated with Aortic Stenosis.

False Signup and view all the answers

What complication is associated with Aortic Stenosis and the colon?

Heyde's syndrome Signup and view all the answers

Aortic Stenosis causes a complete loss of gradient in _______ flow

low Signup and view all the answers

Match the symptoms of Aortic Stenosis with their time till onset:

Angina = 3 years Syncope = 3 years Dyspnea = 2 years LV failure = Very severe AS Signup and view all the answers

What is the primary shape of the aortic valve cusps?

Crescent Signup and view all the answers

A bicuspid aortic valve has an equal likelihood of causing stenosis and regurgitation.

False Signup and view all the answers

What is the normal surface area range of a healthy aortic valve?

3-4 cm² Signup and view all the answers

During isovolumetric contraction, the aortic valve and _____ valve open.

pulmonary Signup and view all the answers

Match the following types of aortic valves with their description:

Tricuspid = 3 cusps of equal size Bicuspid = 2 cusps Quadricuspid = 4 cusps Unicuspid = 1 cusp Signup and view all the answers

What is the most common cause of aortic stenosis worldwide?

Degenerative calcification Signup and view all the answers

A majority of elderly patients will develop severe stenosis due to aortic sclerosis.

False Signup and view all the answers

What combination of valvular diseases is the most common in rheumatic heart disease?

Mitral stenosis and mitral regurgitation Signup and view all the answers

Which of the following is a common congenital valve defect related to Aortic Stenosis?

Bicuspid Aortic Valve Signup and view all the answers

Aortic Stenosis is more prevalent in females than males.

False Signup and view all the answers

In patients with aortic stenosis undergoing valve replacement, a ___________ is mandatory.

coronary angiogram Signup and view all the answers

Match the etiology of aortic stenosis with the respective demographic:

Degenerative calcification = Elderly Bicuspid aortic valve = Young Rheumatic AS = Less common Aortic sclerosis = Most common valvular pathology Signup and view all the answers

What is the risk percentage of sudden cardiac death in severe Aortic Stenosis?

1% Signup and view all the answers

The __________ aortogram is mandatory before valve replacement in patients with Aortic Stenosis.

CT Signup and view all the answers

Match the types of Aortic Stenosis with their descriptions:

Valvular AS = Most common type of Aortic Stenosis Subvalvular AS = Associated with hypertrophic cardiomyopathy (HCMP) Supravalvular AS = Associated with Williams syndrome Signup and view all the answers

Study Notes

Cardiac Cycle Continuation

Protodiastole, Semilunar valves close, isovolumetric relaxation, AV valves open, rapid filling, reduced filling, atrial systole.
70% filling passively, 30% actively.

Diastolic Added Sounds

Opening snap, Pericardial Knock, Tumor plop.
Early diastolic sounds are low-pitched, like S3, S4, and tumor plop.
S3 is a mid-diastolic sound.
S4 occurs late in diastole.

S3 Heart Sound

Also known as ventricular or protodiastolic gallop rhythm.
Heard during rapid filling phase.
Requires a non-stenosed AV valve.
Physiological S3 occurs in young people, athletes, and hyperkinetic states.
Pathological S3 occurs earlier than physiological S3.
End systolic volume increase seen in LV/RV failure is linked to S3.
S3 is commonly associated with decreased filling of a hypertrophic/noncompliant ventricle.
Seen in LVH, RVH, and Restrictive Cardiomyopathy.

S3 In Valvular Diseases

Heard in MR with or without LVF.
Not seen in MS.
Seen in severe AS due to LVH.
Not seen in AR, even with LVF.
Other conditions: VSD, PDA.

Second Heart Sound

Associated with closure of the aortic and pulmonary valves.
High frequency: 120-150 Hz.
A2 is louder than Pa due to higher pressure in the aorta.

Factors Affecting Aa/Pa

Pressure beyond the valve: systemic HTN → Loud Aa, pulmonary HTN → Loud Pa.
Flow across the valve: Hyperkinetic state → Loud Aa/Pa.
Mobility of the valve.
Dilatation of the vessel beyond the valve: Pulmonary HTN → pulmonary artery dilatation → loud Pa.

Aa/Pa in Valvular Heart Diseases

AS:
- Bicuspid Aortic Valve (BAV) → Loud Aa.
- Degenerative cause → Soft Aa.
AR:
- Pathology (Rheumatic) → Soft Aa.
- Root pathology → Loud Aa (tambour Sa).
Moderate MS → PHTN → Loud Pa.
- PHTN + RVF → Loud Pa.
MR → PHTN → Loud Pa → wide split Sa.

Loud Aa	Loud Pa	Soft Aa	Soft Pa
Hyperkinetic state	PHTN	Valvular AS: degenerative	Valvular PS
HTN	ASD	AR
Aortic root dilatation
BAV

Sa Presentation

Single Sa:
- Severe PAH.
- Aging.
- Atresia of the semilunar valve.
- Severe AS or PS.
- Truncus arteriosus.

Cardiology

Auscultation location: left lateral position, at the apex.
Does not vary with respiration.
Physiological S3 disappears in the upright position.
Passive leg raising augments venous return.
S3 may be heard even if not heard in the left lateral position.
Heart failure without S3 suggests MS, TS, or pericardial tamponade.

Pericardial Knock

Seen in chronic constrictive pericarditis.
Sounds like S3.

Pericardial Knock Mechanism

Constrictive pericarditis leads to a rock-like pericarditis, restricting diastolic filling by the pericardial shell.

Pericardial Knock Features

High-pitched.
Louder with inspiration.
Early diastolic sound.
Increases with increased cardiac output/venous return.
Disappears after pericardiectomy.

S4 Heart Sound

AKA atrial/presytolic gallop.
Seen in atrial systole.
Correlates with an A wave in JVP.

S4 Mechanism

Atrial contraction increases LV end-diastolic fiber length.

S3 and S4 in Valvular Diseases

	S3	S4
AS	+	+
AR	In failure	-
ms	-	-
MR	+	-

Heard in acute MR and AR.

Wide Split Sa

Split heard even in expiration.
Causes:
- Early Aa:
  - Electrical: LV pacing, LV ectopic.
  - Mechanical: MR.
- Late Pa:
  - RBBB.
  - PHTN + RVF (MS).
  - PS.
  - VSD (L→R shunt).
  - Cardiac Tamponade.

Reverse Split Sa

Split heard in expiration but not in inspiration (Pa - A₂).
Causes:
- Early Pa:
  - Electrical: Right side pacing/ectopic, WPW syndrome (Type B).
  - Mechanical: TR.
- Delayed Aa:
  - LBBB.
  - AS.
  - AR.
  - Hypertrophic cardiomyopathy (HCM).

Fixed Split Sa

Any cause of wide variable split, with significant RV failure.
ASD: Similar degree of alteration in RV and LV filling during expiration and inspiration.

Other Conditions with S4

Concentric LVH: systemic HTN, HCM.
Concentric RVH: pulmonary stenosis (PS), PAH, RCM.
RV ischemia: d/t coronary artery disease.

Opening Snap

Sound produced by opening of the A-V valve.
Represents isovolumetric relaxation.

Auscultation

Using the bell of the stethoscope.
At the apex.
At expiration.

Prerequisite

Mobile leaflets.
Good LV function.

Opening Snap Mechanism

Increased LAP + thickened leaflets → sudden doming motion of valves into LV → Opening snap.
Opening snap (OS) is proportional to LAP.

Pathophysiology in MS

Increased LAP → early opening of AV valves → early OS → decreased S2-OS interval.
S2-OS is inversely proportional to LAP.

Mild MS

S2-OS >120 mmHg.
LAP < 5 mmHg.

Severe MS

S2-OS: 40-60 mmHg.
LAP >15 mmHg.

Features

Done in standing.
Midway between apex and lower left sternal order.
Does not vary with respiration.

Tumor Plop

Low pitched.
Associated with atrial myxoma.
Early diastolic sound.

Systolic Added Sounds

AKA clicks.

Classification

Ejection Clicks:
- Sound produced by opening of semilunar valves.
- Mechanism:
  - Valvular Ejection Click:
    - Stenosis of the valve.
    - Doming motion of the valve coming to an abrupt halt.
    - Heard in AS, PS, and BAV (Bicuspid aortic valve).
  - Vascular Ejection Click:
    - Due to sudden distension of the valve beyond the vessel.
    - Seen in aneurysm of the vessel.
  - Note:
    - Vascular (Root) pathologies → Loud S₂.
    - Valvular pathologies → Soft S₂.
- Features:
  - Absent in severe stenosis (Due to calcification).
  - Heard best in the aortic area.
  - Pulmonary ejection click → Heard better in expiration.
Non Ejection Clicks:
- Associated with mitral valve prolapse.
- Features:
  - Dynamic auscultation: - Causes long duration murmur.
  - Standing/Valsalva: Stretching of chordae → prolapse → preload → ventricular cavity size → click moves closer to S₁.

Aortic Stenosis

Aortic valve: 3 leaflets (cusps of equal size), 3 commissures, 1 fibrous annulus.
Cusps: congenital presence of more/less no. of cusps (4 cusps: Quadricuspid; 2 cusps: Bicuspid Aortic Valve (BAV); 1 cusp: Unicuspid).
Surface area of the valve: 3-4 cm².
Note:* Less number of cusps lead to increased risk of stenosis and regurgitation.
BAV: Stenosis (75%) > Regurgitation (20-25%).

Etiopathogenesis

Left ventricular pressure (LVP): 120 mmHg.
Pressure in aorta: 120 mmHg.
No pressure gradient as the aortic valve opens fully.

Clinical Features

Symptoms (Mnemonic: ASD 5/3/2):
- Angina:
  - Mechanism: LVH → ↑ LV mass → ↑ O2 demand → ↓ Coronary blood flow → ↓ capillary density.
  - Time till onset: 3 years.
- Syncope: Fixed CO that does not increase with activity.
  - Time till onset: 2 years.
- Dyspnea: Concentric LVH (cavity size ↓) → ↑ LV end-diastolic pressure (EDP) → ↑ LAP → ↑ PCWP.
  - Time till onset: 2 years.
Valve should be replaced within 5 years.
Note:
- AS can be associated with:
  - Atrial Fibrillation: Fatal (with ↑ LVEDP, Atria contributes 40% of CO).
  - Systemic HTN: can mask severity.
  - LV failure: Very severe AS.
  - Complete loss of gradient: Low flow low gradient AS.
- Heyde's syndrome: Angiodysplasia of colon + AS.
- AS is a cause for acquired von Willebrand disease.

Findings

Pulse:
- Severe AS: Tightly control BP in patients with AS.
- Very severe AS:
  - Pulsus tardus: (Slow rising but reach desired amplitude).
  - Pulses parvus et tardus: (Do not reach amplitude).
  - LVF: Narrow pulse pressure.
RAP: Nothing to do with AS.
BP: Very severe AS.
JVP: Normal.
Apex: Outward displaced (D/t LVH).
High amplitude sustained apex (Heaving apex).

Pathogenesis

Bicuspid/Tricuspid aortic valve +
- Pathological process.
- Inflammation
- Lipoprotein deposition
- RAAS activation.
- Valve myofibroblast → osteoblast.
- Ca+ hydroxy apatite deposition.
Aortic sclerosis + development of transvalvular gradient → Aortic stenosis → Symptoms.
Valvular diseases combinations in rheumatic heart disease:
- MS + MR (m/c).
- MS + AR (a.m/c).
- AR + AS.
30% elderly have sclerosis not severe enough to cause stenosis.
80% are male patients.
All patients with AS undergoing valve replacement require a mandatory coronary angiogram.

BAV showing calcific stenosis

Left (L) and Right (R) cusp fused along with calcified noncoronary cusp (N).

TAV Stenosis with Calcified Sclerotic Tricuspid with Fused Commissures

Etiology

Most common cause of AS:
- Worldwide: Degenerative calcification.
- In young: BAV.
Most common valvular pathology worldwide: Aortic Sclerosis.
Most common valvular heart disease worldwide: MR.
Rheumatic AS: Less common.

Bicuspid Aortic Valve (BAV)

Most common congenital valve defect: NOTCH-1 gene defect → ENOS enzyme defect.
More common in males than females.
Autosomal dominant.
Associated with aortopathies (aneurysm, dissection).
Mandatory CT aortogram before valve replacement.

Types of Aortic Stenosis

Type	Description
Valvular AS
Subvalvular AS	Associated with hypertrophic cardiomyopathy (HCMP).
Supravalvular AS	Associated with William syndrome (increased calcium levels, growth failure, mental retardation).

Severity of Aortic Stenosis

Severity	Description
Mild	No symptoms due to LV concentric hypertrophy. Maintains cardiac output at the expense of cavity size.
Moderate
Severe	Risk of sudden cardiac death: 1%. Aortic valve replacement is needed. Symptoms are present. 40/4/1 rule: - mean transvalvular pressure gradients >40mmHg. - Peak velocity across valve >4m/s. - valve surface area <1cm².

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Test your knowledge on the cardiac cycle and the S3 heart sound. This quiz covers topics like diastolic phases, added sounds, and the physiological implications of S3 in different conditions. Perfect for students studying cardiology or related medical fields.