#13 - Aortic stenosis, Aortic valve insufficiency/ Mitral Valve insufficiency (Brown) Flashcards
classic triad of symptoms for aortic valve stenosis
Exertional angina
exertional syncope
exertional dyspnea
NO FATIGUE
T/F At the time of presentation, patients with aortic valve stenosis can be monitored before intervening.
False. They deteriorate rapidly after presentation with symptoms, so you need to fix it with surgery ASAP.
Which valvulur disease would cause angina, dyspnea, and syncope with no fatigue?
aortic valve stenosis.
Case:
- low diastolic pressure
- wide pulse pressure
- long blowing murmur.
Diagnosis?
severe chronic mitral regurgitation / insufficiency
Case:
- long systolic murmur
- hyperkinetic apical impulse heard near left anterior axillary line
Diagnosis?
chronic mitral regurgitation
(aortic valve regurg has a hyperkinetic impulse, but the location isn’t changed - it would not be heard over the axillary line.
You see a patient. He has elevated JVP, which drops when he breathes in. What is the most likely diagnosis?
Pericardial effusion w/ tamponade
Case
- ascites
- leg edema
- increased JVP
- positive Kussmaul sign (JVP rises with inspiration)
Diagnosis?
Constrictive pericarditis.
Case.
- long systolic murmur
- normal diastolic pressure
- narrow pulse pressure
aortic stenosis
diastolic pressure stays normal, since filling isn’t affected.
Since the LV can’t push its fluid out normally (reduced either in volume or time), this will impact the systolic pressure, reducing the pulse pressure.
What kind of murmur is heard with aortic stenosis?
systolic murmur.
crescendo-decrescendo in nature
Physical exam findings for aortic stenosis.
- BP can be normal
- Pulse pressure often decreased (due to low systolic pressure.)
- weak carotid pulse with sustained upstroke (carotid massages your finger instead of tapping it) - due to increased time it takes to get fluid through the small hole.
- hyperkinetic apical thrust - enlarged and sustained but NOT displaced.
T/F - in aortic stenosis, the pressure gradient across the valve correlates with severity of symptoms.
True.
What happens to the Left ventricle in aortic stenosis?
It becomes hypertrophic but NOT dilated (since stenosis requires increased force but not increased storke volume. )
-it also becomes quite stiff
What labs do you do for aortic stenosis?
EKG,
CXR
Echocardiogram
What does EKG show with aortic stenosis?
LV hypertrophy.
CXR findings for aortic stenosis.
normal heart size.
- post-stenotic dilatation of the aorta may be seen.
- calcification of the aortic valve may be seen.
Echocardiogram findings for aortic stenosis.
- high pressure gradient across valve
- hypertrophy.
What are the similarities and differences between aortic stenosis and aortic regurgitation?
- both present with dyspnea and angina.
- both have increased apical impulse.
- both have left ventricle hypertrophy, look similar on EKG.
Aortic stenosis
- syncope common
- fatigue not present.
- narrow pulse pressure
- apical impulse strong, not displaced.
- systolic murmur (crescendo/decrescendo)
- carotid artery pulse slow, soft (massage)
- LV hypertrophy, but NO dilation
Aortic regurgitation
- syncope uncommon
- exertional fatigue common
- wide pulse pressure.
- apical impulse strong, displaced (due to dilation)
- diastolic murmur (decrescendo)
- carotid pulse is brisk, strong, visably pulsatile.
- femoral pistol shots maybe present.
- LV hypertrophy WITH dilation.
What are the 3 primary symptoms (along with 2 lesser ones) for aortic regurgitation?
- angina
- dyspnea
- fatigue (stroke volume is affected)
- palpitations (dilated, hyperdynamic L. ventricle
- inappropriate sweating
Why is fatigue present in regurgitation and not in stenosis?
in regurgitation, stroke volume is affected. lack of flow leads to fatigue. In stenosis, the heart usually can compensate enough to maintain normal stroke volume.
Physical exam findings of aortic regurgitation.
- hyperkinetic pulse
- widened pulse pressure
- carotids brisk, visibly pulsatile
- femoral pistol shots
- apical impulse strong, displaced down and out.
- diastolic decrescendo murmur.
What labs should you order for aortic regurgitation?
EKG, CXR, Echocardiogram.
EKG finding for aortic regurgitation
LV hypertrophy.
CXR finding for aortic regurgitation
-enlarged left ventricle, with apex displaced down and out.
Echocardiogram finding for aortic regurgitation
-tells you severity of regurgitation, and LV size/function.
How does flow across the aortic valve change the pressure gradient in aortic stenosis?
minor increases in flow create huge differences in valve gradient.
Square root/ exponential relationship.
3x increase in flow = 9x increase in gradient
How does valve area change the pressure gradient in aortic stenosis?
Minor decreases in valve area can produce huge differences in valve gradient
Square root / exponential relationship.
Halving the valve size would produce 4 fold increase in pressure gradient.
Why isn’t dilation seen in aortic valve stenosis?
stroke volume doesn’t go up.
T/F aortic valve stenosis can cause sudden cardiac death without atheroscleerosis present.
True
What is a normal pulse pressure, and what is a low pulse pressure
Anything less than 25% of the systolic pressure.
So for a systolic of 120, narrow PP would any diastolic above 90.
He says, in general, 30mm is a low pulse pressure.
What 2 categories of etiologies for aortic valve regurgitation
diseases of the aortic valve, or
diseases of the aorta (the diseased aorta can “stretch out” the leaflets so they can’t close –> regurgitation.)
What valve disease does Marfan commonly cause?
Aortic regurgitation.
What is the key feature on physical exam for chronic aortic regurgitation.
hyperkinetic pulse, and widened pulse pressure.
This is the opposite of aortic stenosis.
Explain the hyperkinetic pulse and widened pulse pressure seen in aortic regurgitation.
The heart ejects twice the normal volume faster than normal, to combat the reverse flow raising the systolic pressure. Diastolic is lower than normal because fluid is falling back through the valve during diastole (creating negative pressure.)
What are the categories of etiologies for mitral valve insufficiency?
Etiologies are divided by components of the mitral valve. 1-leaflets 2-annulus (ring) 3-chordae tendinae 4-papillary muscle
Which diseases affect the mitral valve leaflets, causing regurgitation?
rheumatic heart disease, endocarditis. Prolapse
Which diseases can affect the mitral valve annulus, causing regurgitation?
Marfan’s syndrome, also happens in elderly
Which diseases can rupture the mitral valve chordae tendinae, causing regurgitation?
endocarditis, otherwise idiopathic
What is mitral valve prolapse?
it is myxomatous degeneration of the leaflets (myxomatous -= weakening of the connective tissue)
What is the cause of mitral valve prolapse?
it is idiopathic, but probably an autosomal dominant trait
-can be part of a genetic trait like Marfan’s
What is the prevalence of Mitral vvalve prolapse?
2.5% of the population has it.
Relationship between Marfan’s and Mitral Valve Prolapse.
most with Marfan’s have it. But most of the people who have MV prolapse don’t have Marfan’s
What are the auscultatory findings in mitral valve prolapse?
“click and
