0722 - Valvular Heat Dissease - RM

Question 1

Narrowing – stenosis
Leak – regurgitation/incompetence
Both – mixed valved disease with both stenosis and regurgitation.

Answer 1

Narrowing – stenosis
Leak – regurgitation/incompetence
Both – mixed valved disease with both stenosis and regurgitation.

Question 2

What physiological changes occur with heart valve stenosis?

Answer 2

Increase in pressure required to drive blood across the valve can lead to hypertrophy.
Increase in pressure in veins behind the valve can lead to oedema
Significantly increased pressure gradient across the valve.

Question 3

What physiological changes occur with valve regurgitation?

Answer 3

Increased volume load for chamber (or veins) behind the valve can lead to venous engorgement or chamber dilation.

Question 4

What are the five causes of valve disease?

Answer 4

Congenital
Rheumatic
Infective
Degenerative
Secondary (to another heart or vessel disease)

Question 5

What are the characteristics of congenital valve disease?

Answer 5

Generally complex and associated with other cardiac malformations, though can have an isolated pulmonary or aortic stenosis, or mitral valve prolapsed.
Associated with genetic conditions (Down’s, Marfan’s etc).

Question 6

What are the characteristics of rheumatic heart disease?

Answer 6

Very rare in non-Indigenous Australia, caused by an auto-immune reaction following a streptococcal infection. Most commonly affects Mitral, but Aortic as well is not uncommon.

Question 7

What are the characteristics of degenerative valve disease?

Answer 7

Aortic stenosis or regurgitation and/or mitral regurgitation in the elderly. Believed to be an active inflammatory process in at least some cases.

Question 8

What are the symptoms of a left-sided valvular heart disease?

Answer 8

Dyspnoea – generally gradual onset, but can occur suddenly.
Exertional chest tightness or syncope (these can be due to severe aortic stenosis and are not always from coronary artery disease).

Question 9

What are the symptoms of right sided valvular heart disease?

Answer 9

Peripheral Oedema and raised JVP
Fatigue
Dyspnoea
Cyanosis

Question 10

What should you look for in a history of a patient with possible valve disease?

Answer 10

Any previous valve problems, surgery, or investigations for heart issues.
Change in exercise ability (because of dyspnoea, chest tightness, or exertional syncope)
Symptoms of late heart failure including orthopnoea, PND, oedema, fatigue
Any history of rheumatic fever
Any advice given to them to take prophylactic antibiotics for dental or surgical procedures.

Question 11

What would you look for in the first steps of an exam on a patient with possible heart failure?

Answer 11

Abnormal body (Down’s, Marfans?)
General appearance – breathless, unwell, oedematous, cyanosed?
General Exam – BP, Pulse, Scars from previous heart surgery.

Question 12

What would you look for in a chest exam on a patient with possible heart failure?

Answer 12

Position and character of apex beat (indicative of heart size)
Presence of parasternal impulse (suggest big RV or LA)
Palpable thrills (suggest significant murmur)
Heart sounds (loud or soft? Any prosthetic? Any added?)
Murmurs
Perform Dynamic auscultation (e.g. Valsalva manoeuvre)

Question 13

What investigations would you consider for a patient with possible heart failure?

Answer 13

CXR
ECG
Echocardiography – most useful, but not always available.