, িবসিম ািহর রহমািনর রিহম
MRCP PART 1 & 2
NOTES FROM PASSMEDICINE, PASTEST, Notes & notes
By ABDULLAH TANVIR
ANATOMY & PHYSIOLOGY
Pulsus paradoxus ● > 10 mmHg fall in SBP during inspiration → faint or absent pulse in
inspiration
● Cardiac tamponade
● Severe asthma, COPD
● Constrictive pericarditis (less common)
Slow-rising/plateau ● Aortic stenosis
Collapsing ● Aortic regurgitation
● Patent ductus arteriosus
● Hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Pulsus alternans ● Regular alternation of the force of the arterial pulse
● Severe LVF
Bisferiens pulse ● Double pulse - two systolic peaks
● Mixed aortic valve disease, HOCM
Jerky' pulse ● HOCM
Dicrotic notch >>> Aortic valve closure
HEART SOUNDS
1st heart sound (S1) ● Caused by closure of mitral and tricuspid valve
Causes of a loud S1
● Mitral stenosis
● left-to-right shunts
● Short PR interval (WPW syndrome), atrial premature beats
● Hyperdynamic states
Causes of a quiet S1
● Mitral regurgitation, Heart failure
Variable intensity of S1 : 3° / Complete heart block
2nd heart sound (S2) ● Due to closure of aortic & pulmonary valve
○ Split on inspiration, Single on expiration
○ Causes of a loud S2
■ Hypertension: systemic (loud A2) or pulmonary (loud P2)
NOTES BY ABDULLAH TANVIR
, ■ Hyperdynamic states
○ Soft S2 : Aortic stenosis
○ Quiet or absent of 2nd heart sound : Indicates severe aortic stenosis
○ Wide & Fixed split of S2 : Atrial septal defect
● Wide & Variable split S2 :
○ Deep inspiration, RBBB, pulmonary stenosis, severe MR
● Causes of a reversed (paradoxical) split S2 (P2 occurs before A2)
○ LBBB
○ severe aortic stenosis
○ Right ventricular pacing
○ WPW type B (causes early P2)
○ Patent ductus arteriosus
3rd heart sound (S3) ● Due to abrupt cessation of rapid ventricular filling
○ LVF, MR, DCM
○ 𝗟𝗼𝘂𝗱 𝗲𝗮𝗿𝗹𝘆 𝟯𝗿𝗱 𝗵𝗲𝗮𝗿𝘁 𝘀𝗼𝘂𝗻𝗱 / 𝗣𝗲𝗿𝗶𝗰𝗮𝗿𝗱𝗶𝗮𝗹 𝗸𝗻𝗼𝗰𝗸 : 𝗖𝗼𝗻𝘀𝘁𝗿𝗶𝗰𝘁𝗶𝘃𝗲
𝗽𝗲𝗿𝗶𝗰𝗮𝗿𝗱𝗶𝘁𝗶𝘀
○ Soft : Cardiac tamponade
4th heart sound (S4) ● Due to atrial contraction against stiff ventricle
Causes
● AS, HOCM, HTN
● Coincides with p wave (After P wave) in ECG
● During late diastole, active left ventricular filling
● Absent in atrial fibrillation
𝗠𝗨𝗥𝗠𝗨𝗥
● Ejection systolic murmur
○ Aortic stenosis, Pulmonary stenosis
○ Hypertrophic obstructive cardiomyopathy (HOCM)
○ Atrial septal defect (ASD), Fallout's
● Pansystolic murmur
○ Mitral regurgitation, Tricuspid regurgitation (high-pitched and 'blowing' in character)
○ Ventricular septal defect ('harsh' in character)
● Late systolic murmur
○ Mitral valve prolapse
○ Coarctation of aorta
● Early diastolic murmur
○ Aortic regurgitation, Pulmonary regurgitation (Graham steel murmur)
● Mid diastolic murmur
○ Mitral stenosis, Tricuspid stenosis
○ Austin flint murmur (Severe AR)
○ Carey coombs murmur (In rheumatic fever)
● 𝗖𝗼𝗻𝘁𝗶𝗻𝘂𝗼𝘂𝘀 𝗺𝗮𝗰𝗵𝗶𝗻𝗮𝗿𝘆 𝗺𝘂𝗿𝗺𝘂𝗿
NOTES BY ABDULLAH TANVIR
, ○ Persistent ductus arteriosus
*** Right sided murmur increases with inspiration
*** Left sided murmur increases with expiration
Valsalva manoeuvre ● ↓ Preload >>> ↓ / Makes softermurmur
/ Abrupt standing ○ Tricuspid regurgitation, Pulmonary stenosis
○ MR, AS
● ↑ / Makes louder murmur
○ HOCM, Mitral valve prolapse
○ MS, AR
Squatting / Leg ● ↑ Most murmurs
raise ● ↓ HOCM & mitral valve prolapse
Sustained Hand grip ● ↓ Aortic stenosis
● ↑ Mitral regurgitation, Mitral valve prolapse, Aortic regurgitation, VSD,
Pregnancy ● ↓ Aortic regurgitation murmur
● ↑ All stenotic murmur
JVP
● Raised JVP, normal waveform
○ Bradycardia
○ Fluid overload
○ Heart Failure
● Raised JVP, absent pulsation
○ Superior vena cava syndrome
● Kussmaul's sign : Paradoxical rise in JVP during inspiration seen in constrictive pericarditis
● a' wave = atrial contraction
○ large a wave : TS, PS, pulmonary hypertension
○ Absent in AF
● Cannon 'a' waves
○ Caused by atrial contractions against a closed tricuspid valve
○ Irregular : Complete heart block
○ Regular : Ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular
pacing
● c wave : closure of tricuspid valve
○ Not normally visible
● v wave
○ Due to passive filling of blood into the atrium against a closed tricuspid valve
○ Giant v waves in tricuspid regurgitation
● x descent = fall in atrial pressure during ventricular systole
○ Absent 'x' descent : Tricuspid regurgitation
NOTES BY ABDULLAH TANVIR
MRCP PART 1 & 2
NOTES FROM PASSMEDICINE, PASTEST, Notes & notes
By ABDULLAH TANVIR
ANATOMY & PHYSIOLOGY
Pulsus paradoxus ● > 10 mmHg fall in SBP during inspiration → faint or absent pulse in
inspiration
● Cardiac tamponade
● Severe asthma, COPD
● Constrictive pericarditis (less common)
Slow-rising/plateau ● Aortic stenosis
Collapsing ● Aortic regurgitation
● Patent ductus arteriosus
● Hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Pulsus alternans ● Regular alternation of the force of the arterial pulse
● Severe LVF
Bisferiens pulse ● Double pulse - two systolic peaks
● Mixed aortic valve disease, HOCM
Jerky' pulse ● HOCM
Dicrotic notch >>> Aortic valve closure
HEART SOUNDS
1st heart sound (S1) ● Caused by closure of mitral and tricuspid valve
Causes of a loud S1
● Mitral stenosis
● left-to-right shunts
● Short PR interval (WPW syndrome), atrial premature beats
● Hyperdynamic states
Causes of a quiet S1
● Mitral regurgitation, Heart failure
Variable intensity of S1 : 3° / Complete heart block
2nd heart sound (S2) ● Due to closure of aortic & pulmonary valve
○ Split on inspiration, Single on expiration
○ Causes of a loud S2
■ Hypertension: systemic (loud A2) or pulmonary (loud P2)
NOTES BY ABDULLAH TANVIR
, ■ Hyperdynamic states
○ Soft S2 : Aortic stenosis
○ Quiet or absent of 2nd heart sound : Indicates severe aortic stenosis
○ Wide & Fixed split of S2 : Atrial septal defect
● Wide & Variable split S2 :
○ Deep inspiration, RBBB, pulmonary stenosis, severe MR
● Causes of a reversed (paradoxical) split S2 (P2 occurs before A2)
○ LBBB
○ severe aortic stenosis
○ Right ventricular pacing
○ WPW type B (causes early P2)
○ Patent ductus arteriosus
3rd heart sound (S3) ● Due to abrupt cessation of rapid ventricular filling
○ LVF, MR, DCM
○ 𝗟𝗼𝘂𝗱 𝗲𝗮𝗿𝗹𝘆 𝟯𝗿𝗱 𝗵𝗲𝗮𝗿𝘁 𝘀𝗼𝘂𝗻𝗱 / 𝗣𝗲𝗿𝗶𝗰𝗮𝗿𝗱𝗶𝗮𝗹 𝗸𝗻𝗼𝗰𝗸 : 𝗖𝗼𝗻𝘀𝘁𝗿𝗶𝗰𝘁𝗶𝘃𝗲
𝗽𝗲𝗿𝗶𝗰𝗮𝗿𝗱𝗶𝘁𝗶𝘀
○ Soft : Cardiac tamponade
4th heart sound (S4) ● Due to atrial contraction against stiff ventricle
Causes
● AS, HOCM, HTN
● Coincides with p wave (After P wave) in ECG
● During late diastole, active left ventricular filling
● Absent in atrial fibrillation
𝗠𝗨𝗥𝗠𝗨𝗥
● Ejection systolic murmur
○ Aortic stenosis, Pulmonary stenosis
○ Hypertrophic obstructive cardiomyopathy (HOCM)
○ Atrial septal defect (ASD), Fallout's
● Pansystolic murmur
○ Mitral regurgitation, Tricuspid regurgitation (high-pitched and 'blowing' in character)
○ Ventricular septal defect ('harsh' in character)
● Late systolic murmur
○ Mitral valve prolapse
○ Coarctation of aorta
● Early diastolic murmur
○ Aortic regurgitation, Pulmonary regurgitation (Graham steel murmur)
● Mid diastolic murmur
○ Mitral stenosis, Tricuspid stenosis
○ Austin flint murmur (Severe AR)
○ Carey coombs murmur (In rheumatic fever)
● 𝗖𝗼𝗻𝘁𝗶𝗻𝘂𝗼𝘂𝘀 𝗺𝗮𝗰𝗵𝗶𝗻𝗮𝗿𝘆 𝗺𝘂𝗿𝗺𝘂𝗿
NOTES BY ABDULLAH TANVIR
, ○ Persistent ductus arteriosus
*** Right sided murmur increases with inspiration
*** Left sided murmur increases with expiration
Valsalva manoeuvre ● ↓ Preload >>> ↓ / Makes softermurmur
/ Abrupt standing ○ Tricuspid regurgitation, Pulmonary stenosis
○ MR, AS
● ↑ / Makes louder murmur
○ HOCM, Mitral valve prolapse
○ MS, AR
Squatting / Leg ● ↑ Most murmurs
raise ● ↓ HOCM & mitral valve prolapse
Sustained Hand grip ● ↓ Aortic stenosis
● ↑ Mitral regurgitation, Mitral valve prolapse, Aortic regurgitation, VSD,
Pregnancy ● ↓ Aortic regurgitation murmur
● ↑ All stenotic murmur
JVP
● Raised JVP, normal waveform
○ Bradycardia
○ Fluid overload
○ Heart Failure
● Raised JVP, absent pulsation
○ Superior vena cava syndrome
● Kussmaul's sign : Paradoxical rise in JVP during inspiration seen in constrictive pericarditis
● a' wave = atrial contraction
○ large a wave : TS, PS, pulmonary hypertension
○ Absent in AF
● Cannon 'a' waves
○ Caused by atrial contractions against a closed tricuspid valve
○ Irregular : Complete heart block
○ Regular : Ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular
pacing
● c wave : closure of tricuspid valve
○ Not normally visible
● v wave
○ Due to passive filling of blood into the atrium against a closed tricuspid valve
○ Giant v waves in tricuspid regurgitation
● x descent = fall in atrial pressure during ventricular systole
○ Absent 'x' descent : Tricuspid regurgitation
NOTES BY ABDULLAH TANVIR
