13. Valvular Heart Disease Flashcards
- A 49-year-old woman presents with increasing shortness of breath on exertion developing over the past three months. She has no chest pain or cough, and has noticed any ankle swelling. On examination, blood pressure is 158/61mmHg, pulse is regular at 88 beats per minute and there are crackles at both lung bases. There is a diastolic murmur at the left sternal edge. What is the most likely diagnosis?
A. Aortic regurgitation B. Aortic stenosis C. Mitral regurgitation D. Mitral stenosis E. Tricuspid regurgitation
A. Aortic regurgitation
This is a typical clinical scenario for an aortic regurgitation (A), with early cardiac failure. Note the wide pulse pressure, and it is also usual for the pulse to be rapidly collapsing. The only lesion producing a diastolic murmur, among those listed, is of course mitral stenosis (D). No other valve abnormality (B), (C) or (E) produces a wide pulse pressure as seen here, but remember that in older people, almost always over the age of 60, similarly wide or even wider pulse pressures may be noted. This would be due to isolated systolic hypertension, i.e. systolic pressure >140 mmHg and diastolic ≤90 mmHg.
- You see a 57-year-old woman who presents with worsening shortness of breath coupled with decreased exercise tolerance. She had rheumatic fever in her adolescence and suffers from essential hypertension. On examination, she has a murmur heard loudest over the mitral area. Which of the following is not a clinical sign associated with the most likely diagnosis?
A Malar flush
B. Atrial fibrillation
C. Pan-systolic murmur which radiates to axilla
D. Tapping, undisplaced apex beat
E. Right ventricular heave
C. Pan-systolic murmur which radiates to axilla
Diagnosis is mitral stenosis. Malar flush (A), atrial fibrillation (B), a tapping apex beat (D) and right ventricular heave (E), which occurs secondary to pulmonary hypertension, are all clinical signs associated with mitral stenosis. On auscultation of the praecordium, a mid-diastolic murmur (±opening snap, representing a mobile valve) is heard rather than a pan-systolic murmur (C) which is usually heard in mitral regurgitation, tricuspid regurgitation and ventricular septal defects.
An 8 year old boy comes to the GP with his mother for a check-up. You find the child to be extremely sociable and friendly, with some mild learning difficulties. You also note distinct facial features including a broad forehead, short nose and full cheeks. On auscultation of his chest, you detect a murmur in the right 2nd intercostal space, loudest on expiration. What is the most likely diagnosis?
A. Hypertrophic Obstructive Cardiomyopathy B. Infective endocarditis C. Aortic stenosis D. Aortic regurgitation E. Mitral stenosis
C. Aortic stenosis
A. Hypertrophic Obstructive Cardiomyopathy - other signs
B. Infective endocarditis - no signs/RF of Infx
D. Aortic regurgitation- Left 3rd ICS, louder on expiration
E. Mitral stenosis - Mainly due to rheumatic heart disease, no signs of it
Classify the different murmurs
A Systolic Murmur, Really Tiring Respiration:
Aortic Stenosis, Mitral Regurg, Tricuspid Regurg
(Backflow from Ventricle to Atrium, or can’t get out of ventricle)
Diastolic Murmur:
Systolic Murmurs - define causes epidemiology
AS – narrowing of LV outflow at the aortic valve
MR – reflux of blood from LV to LA during systole
TR – reflux of blood from RV to RA during systole
Systolic Murmurs Aetiology
Aetiology:
- Age-related calcification (AS)
- Infection – Infective endocarditis (?IVDU), Rheumatic heart disease
- Congenital - William’s , bicuspid aortic valve (AS)
- CTD – Marfan’s, EDS, OI
Epidemiology:3% of 75 year olds. M > FCongenital bicuspid valve = present as young adults
Symptoms of AS, MR, TR
- Dyspnoea (SOB)
- Syncope (dizziness) on exertion
- Angina (chest pain)
- Heart failure signs
- Palpitations
* Patients may also be asymptomatic
Systolic Murmurs Aetiology
Aetiology:
1. Age-related calcification (AS)
2. Infection – Infective endocarditis (?IVDU), Rheumatic heart disease
3. Congenital - William’s , bicuspid aortic valve (AS)
4. CTD – Marfan’s, EDS, OI
(idiopathic)
Epidemiology:3% of 75 year olds. M > FCongenital bicuspid valve = present as young adults
Symptoms of AS, MR, TR
- Dyspnoea (SOB)
- Syncope (dizziness) on exertion
- Angina (chest pain)
- Heart failure signs
- Palpitations
* Patients may also be asymptomatic
O/E of AS?
- BP – narrow pulse pressure
- Pulse – slow-rising
- Palpation – thrill (palpable heart murmur)
- Thrusting Apex Beat
(End) ESM
- Aortic area: 2nd IC space, right sternal edge
- Radiating to the carotids and apex
- Ask the patient to hold breath on expiration to accentuate murmur
O/E of MR
- Pulse – normal/irregularly irregular
- Palpation – laterally displaced apex beat
Pan-Systolic Murmur(apex)
- Radiating to axilla
O/E of TR
- Inspection – raised JVP
- Palpation – parasternal heave
- Signs of RHF – pleural effusion, hepatomegaly, ascites, pitting oedema
Pan-Systolic Murmur (L lower sternal border)
- Ask the patient to hold breath on inspiration to accentuate murmur
Investigations of systolic murmurs
- ECG – signs of LV hypertrophy e.g. enlarged R waves, T wave inversion
AS - Left axis deviation
TR - Tall p-wave (TR) - CXR- enlargement of ascending aorta
AS - aortic valve calcification TR - right sided enlargment MR- cardiomegaly
Diastolic murmurs Aetiology and Epidemiology
Aetiology:
1. Infection – rheumatic heart disease, infective endocarditis
2. Congenital – bicuspid aortic valve,
3. Dilation of aorta – HTN, aortitis
4. CTD
(idiopathic)
Epidemiology:late 50s – 80sMS: reduced incidence
2 Conditions that give diastolic murmurs
Aortic regurgitation: reflux of blood from aorta to LV
Mitral stenosis: narrowing of mitral valve, obstructing blood flow from LA to LV
