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Summary 2.1.2.

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2.1.2 . Shortness of breath

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Rijksuniversiteit Groningen (RuG)

Summary study book Kumar and Clark's Clinical Medicine of Adam Feather, Randall (-) - ISBN: 9780702078682, Edition: 10th Revised edition, Year of publication: - (Overview checklist)

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Checklist – week 6 – Shortness of Breath (due to heart failure)

Cardiology
The student is able to:
1. Explain how dyspnoea, palpitations, syncope, fatigue and oedema may be
secondary to heart disease.
Dyspnea: i.c.o. HF, fluid might build up in the lungs, this can cause dyspnea. Also less O2
delivery to tissues can cause this.
Palpitations: can be due to premature ventricular contractions (due to prolonged filling
time). Also by bradycardia, people feel like they skip a beat.
Syncope: loss of consciousness, can be due to arrhythmia or due to low blood pressure.
Edema: Fluid can build up in lungs due to left HF and in the periphery due to right HF.
Fatigue: less O2 supply to the tissues due to HF, so fatigue is a consequence.
2. Which heart disease comes to mind if the patient exhibits clubbing, splinter
hemorrhages and central and peripheral cyanosis?
Clubbing, splinter hemorrhages and central + peripheral cyanosis: bacterial endocarditis
3. What may cause increased central venous pressure?
Right heart failure can cause increased central venous pressure
4. What causes the first, second (including splitting, if any), third and fourth heart
sounds?
1st: closing mitral and tricuspid valve 2nd: closing semilunar valves
3rd: rushing in blood of atria into ventricles 4th: contraction atria, rushing in blood
5. Name the various types of heart murmurs, their features and causes.
Systolic murmur: Aortic/pulmonary valve stenosis or mitral/tricuspid valve insufficiency
Diastolic murmur: Aortic/pulmonary insufficiency or mitral/tricuspid valve stenosis
6. Describe the elements of a normal electrocardiogram and their relationship to
the phases of the cardiac cycle.

, 7. Name two mechanisms of cardiac arrest and potentially reversible causes of this
condition.
Cardiac arrest: due to ischemia  blood vessels are protruding into the ischemic tissue
and hypertrophy of the healthy tissue occurs
ventricular fibrillation  cardioversion, heart massage
8. Discuss the application of cardioversion and temporary and permanent
pacemakers.
Cardioversion: in atrial or ventricular fibrillation, the heart is not pumping anymore, but
pacemakers will take over function again.
Pacemaker: senses electrical activity of the heart and corrects this if needed
9. which three mechanisms may cause arrhythmia and which arrhythmias?
Dilated atria or ventricle: circus movement can be caused due to dilation
Electrolyte imbalances: spontaneous action potential cannot arise
To long dilation in AV-node: for example AV-block
10. Discuss the differences between first-degree, second-degree and third-degree
atrioventricular block.
st
1 degree: delayed conduction, longer than 0,22s
2nd: some P-waves come through, some not
3rd: complete AV-block, if in bundle, Purkinje fibers take over
11. Describe the mechanism of action, indications, main side effects of and possible
reasons for adjusting the dosage of digoxin.
Digoxin: high sensitivity of baroreceptors, higher contractility
 used for atrial fibrillation and if b-blocker doesn’t work also i.c.o. tachicardia
side effects: lower exercise tolerance, nausea, vomiting, loss of appetite, vision disorder.
 also drug interactions and ventricular extrasystole, nodal tachycardia or AV-block
12. Explain the clinical findings in patients with mitral stenosis. Discuss the
treatment options.
Main cause: rheumatic heart disease (more in women due to rheumatic fever
infection: streptococcus. Nodules at base of leaflets. Mostly no effect on valvular
function, sometimes is has:
Consequences:
- reduced orifice area (<1cm i.s.o. 4-6 cm) - left atrial pressure increased
- left atrial hypertrophy/dilation: enlarged - pulmonary venous, arterial and right heart
- small-volume pulse pressure increase  oedema
Symptoms:
- dyspnoea; due to elevation in left atrial - right heart failure; due to pulmonary
pressure and pulmonary oedea hypertension
- atrial fibrillation; due to large left atrium - Systemic emboli; due to atrial fibrillation
Investigations:
- Chest X-ray (large LA), ECG (bifid P-wave), echocardiogram (LA size)
Management:
- no treatment or sometimes diuretics - valvotomy (make orifice bigger again)
- replacement if: mitral regurgitation also is present, thrombosis are present in left
atrium despite anticoagulant

, 13. Explain the clinical findings in patients with mitral incompetence/ regurgitation.
Discuss the treatment options.
Cause: abnormalities of valve leaflets, papillary muscles or tendineae. also degenerative
myxomatous disease (= mitral valve collapse) or ischaemic heart disease and rheumatic
heart disease
Consequences:
- floppy mitral valve, it prolapses - large left atrium and higher pressure
- pulmonary pressure rises - large LV due to high CO (palpitation feeling)
Symptoms:
- most times asymptomatic and no serious problems
- lower CO, so fatigue - Dyspnea, due to pulmonary tension
- Bigger chance endocarditis and stroke - Right heart failure
Investigations:
- Chest X-ray, ECG (bifid P wave/hypertrophic tall R wave), echocardiogram (LA/LV size)
- systolic murmur, soft 1st and prominent 3rd heart sound
Management:
- prophylaxis for endocarditis - no surgery possible? ACEi, diuretics,
- replacement i.c.o. progressive enlargement anticoagulant
14. Explain the clinical findings in patients with aortic stenosis. Discuss the
treatment options.
Cause: calcification of the valves (inflammatory response, involves macrophages and T-
cells), congenital bicuspid aortic valve (unequal leaflets with raphe, stenosis there),
rheumatic fever
Consequences:
- LV hypertrophy and higher P - arrhythmias
- small volume pulse - ischaemia of LV
- dilated ascending aorta
Symptoms:
- chest pain (angina) - breathlessness
- syncope, fatigue - arrhythmia’s
Investigation:
- auscultation: systolic ejection click - Chest X-ray, ECG with left atrial delay
- cardiac catheterization i.c.o. surgery
Management:
- all aortic valve replacement or surgical intervention for ascending aorta
15. Explain the clinical findings in patients with aortic incompetence. Discuss the
treatment options.
Cause: endocarditis or other diseases which affect the aortic valve, i.e. rheumatic fever.
Or dilation ascending aorta
Consequence:
- enlarged left ventricular - diastolic blood pressure falls, so less
- coronary perfusion decreased and thus coronary perfusion
ischaemia

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