1: Valvular heart disease Flashcards
What are some characteristic symptoms of valvular heart disease?
Chest pain
Breathlessness
Collapse / dizziness
Patients will often describe their cardiac chest pain using characteristic ___.
gestures
What are some traits of cardiac chest pain?
Heavy, squeezing, crushing, gripping
Cardiac breathlessness is usually related to ___.
activity / exertion
What other cardiac symptom may you see alongside breathlessness?
Ankle oedema
What is orthopnea?
Breathlessness when lying flat - usually due to pulmonary oedema
What is paroxysmal nocturnal dyspnoea?
Gasping / having to sit up during the night due to pulmonary oedema
What key questions should you ask a patient who you suspect is suffering pulmonary oedema?
Do you lie flat at night?
Do you need 2+ pillows to sleep?
Do you feel better if you get up and do something?
What is the NYHA?
New York Heart Association Functional Classification
NYHA grades are used to classify cardiac ___.
breathlessness
What should you be thinking about when you feel a patient’s pulse?
RRCV
Rate, rhythm, character, volume
An elevated JVP is an indicator of __-sided heart failure.
right
What are some signs of right sided heart failure?
Raised JVP
Pitting oedema
Hepatic congestion
(all related to build-up of fluid due to failure of heart as a pump)
Where can pitting oedema be found?
Ankles
Sacrum
What is pitting oedema?
Swelling in an area of the body - if you press on it, dents will remain for a period of time
What is a tapping apex indicative of?
Mitral stenosis
Volume ___ causes __ ventricular dilatation and displaces the __ beat.
overload , left , apex
What causes a right parasternal heave?
Right ventricular overload
(cor pulmonale / pulmonary hypertension)
What is a cardiac murmur?
Audible turbulence of blood flow
Murmurs are either ___ or ___.
systolic , diastolic
The first heart sound is made by the ___ and ___ closing and signs the start of ___.
mitral , tricuspid
systole
The second heart sound is made by the ___ and ___ valves closing and signals the start of ___.
aortic , pulmonary
diastole
What is a pansystolic murmur?
A murmur which doesn’t increase/decrease in volume during cardiac cycle
What is an ejection systolic murmur?
A murmur where the heart sound peaks at some point (e.g aortic stenosis)
Where does aortic stenosis radiate?
Carotid arteries
Where does mitral regurgitation radiate?
Towards the axilla
Which type of murmurs are louder with inspiration?
Why?
Right-sided murmurs
Venous return is greater
When are innocent murmurs heard?
Early systole (remember that diastolic murmurs are always pathological)
What are some characteristics of an innocent murmur?
Early systolic
Soft
Position dependent
More common in young, thin people
What is valve stenosis?
Valves which don’t open properly
What is valve regurgitation?
Valves which do not close properly
Apart from stenosis and regurgitation, what other valvular disease can you get?
Mixed valve disease (i.e both at once)
What should be asked about during a history-taking of someone with suspected valvular disease?
Restriction to activities and function capacity
What is a non-invasive method of investigating valvular disease?
Echocardiogram
What is an invasive method of investigating valvular disease?
Cardiac catheterisation
The most common valvular disease you will see is ___ ___.
aortic stenosis
Why may aortic stenosis occur?
Degeneration due to age (e.g calcification)
Congenital (e.g bicuspid valve instead of tricuspid aortic valve)
Rheumatic aortic stenosis
What are some common symptoms of aortic stenosis?
Exertional breathlessness (insufficient cardiac output)
Chest pain (insufficient perfusion of coronary arteries, overlap with CHD but not neccessarily)
Dizziness/syncope
What are some common signs of aortic stenosis?
Low volume pulse
Forceful displaced apex (due to left ventricular hypertrophy - pressure overload)
Ejection systolic murmur which radiates to the carotids
Valvular diseases cause either __ overloads or __ overloads.
volume
pressure
What may you see in the ECG of a patient with aortic stenosis?
Indications of left ventricular hypertrophy
i.e elevated QRS complexes in lateral chest leads
How is aortic stenosis treated?
Valve replacement
Which sort of valve replacement would be done in younger patients?
Mechanical
Which sort of valve replacement would be done in older patients or those with a poorer prognosis?
Prosthetic (e.g pig tissue)
Which treatment needs to be started in those with mechanical valve replacements?
Warfarin (/rivaroxaban)
Which treatment involves fitting a stent-like device to open the aortic valve?
Transcatheter aortic valve implantation (TAVI)
Currently, (AVR / TAVI) is the preferred treatment in patients with aortic stenosis.
Aortic valve replacement
People with aortic stenosis who are asymptomatic (are / aren’t) operated on immediately.
aren’t
Generally, people with aortic stenosis are monitored carefully without intervention until they become ___.
symptomatic
Many patients with mitral regurgitation have it as a ___ complication of their ___ ___.
functional , heart failure
Degeneration of leaflets, chordae and papillary muscles causes ___ ___.
mitral regurgitation
Which inflammatory disease can damage the mitral valve leaflets and cause mitral regurgitation?
Endocarditis
What are some symptoms of mitral regurgitation?
Exertional breathlessness
Peripheral oedema
Fatigue
(all symptoms of right-sided heart failure as the regurgitation causes back pressure into the right side of the heart)
What are some signs of mitral regurgitation?
Displaced apex
Pansystolic murmur radiating to the axilla
The two most common valvular diseases you will encounter are…
aortic stenosis
mitral regurgitation
On a CXR of a patient with mitral regurgitation you may see ___.
cardiomegaly
Mitral regurgitation causes a ___ overload, ___ of the left ventricle and ___ back pressure which leads to right-sided heart failure.
volume , dilation , increased
Which medication would you give to someone with mitral regurgitation?
Diuretics
ACE Inhibitors (same as heart failure)
In terms of surgery, prolapsed mitral valves are ___ and degenerating mitral valves are ___.
repaired , replaced
What is the main cause of mitral stenosis?
Rheumatic fever
Severe mitral stenosis commonly results in ___ ___ due to hypertrophy, remodelling and eventual failure of the atria.
atrial fibrillation
What are some signs of mitral stenosis?
MALAR FLUSH
Tapping apex peat
Mid-diastolic rumbling localised in the apex, brought out by turning the patient to their left
What are some symptoms of mitral stenosis?
Breathlessness
Fatigue
Palpitations (AF)
On a CXR of someone with mitral stenosis, you may see a straight __ __ __. Why?
straight left heart border
Pulmonary hypertension
What causes aortic regurgitation?
Leaflet problems - they don’t meet properly and blood flows back into the left atrium
Endocarditis, connective tissue diseases, rheumatic causes
Also: Marfan’s Syndrome, Aortic dissection
Aortic regurgitation causes ___ overload.
volume
Volume overload causes ___ of heart chambers.
dilatation
What is the main symptom of aortic regurgitation?
Breathlessness
What are some signs of aortic regurgitation?
Collapsing pulse (backflow of blood back into the atrium)
Displaced apex (due to dilatation)
Early diastolic murmur heard at the left sternal edge (tricuspid area?), brought out best when patient sits forward
On a CXR of someone with aortic regurgitation, you may see ____ (chamber dilatation).
cardiomegaly
___ ___ are shown to be useful in reducing dilatation of the left ventricle in aortic regurgitation.
ACE inhibitors
