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BRS CARDIO & RESPIRATORY > 1b Structural Heart Disease > Flashcards

1b Structural Heart Disease Flashcards

1
Q

Which side of the heart is the bicuspid (mitral) valve on?

A

Left side

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2
Q

Which side of the heart is the tricuspid valve on?

A

The right side

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3
Q

What do structural heart diseases cover?

A

Number of defects which affect the valves and chambers of the heart

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4
Q

What are some examples of congenital heart diseases?

A

Atrial Septum defects
Ventricular septem defects
Coarctation of Aorta
Tetralogy of Fallot

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5
Q

Which are the examples of Structural Heart Disease which develops later in life?

A

Due to valvular dysfunction - Atrial Stenosis / regurgitation or muscular (cardiomyopathies)

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6
Q

Describe the pathology which occurs in Atrial and Ventricular Septum Defects?

A

Holes between either ventricles or atria - separates left and right

therefore, there is mixing of the blood which is oxygenated and deoxygenated

Left = under higher pressure so when right blood enters into left = results in overload and hypertension leading to right sided heart failure

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7
Q

What are the four problems in Tetralogy of Fallot?

A
  1. Over riding aorta
  2. Right ventricular hypertrophy
  3. Ventricular septum defects
  4. Pulmonary Valve Stenosis
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8
Q

What is coarctation of the aorta?

A

When the wall of the aorta bends in on itself and becomes constricted, reducing stroke volume and cardiac output resulting in breathlessness

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9
Q

What are the four types of valvular defects?

A

Aortic Stenosis / Regurgitation
Mitral Stenosis / Regurgitation

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10
Q

Can you get pulmonary / tricuspid defects?

A

Yes but they are significantly more uncommon

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11
Q

What two things indicate aortic stenosis?

A

Early peaking, ejection systolic murmur - confirmed through echo

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12
Q

What preceeds aortic stenosis?

A

aortic sclerosis

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13
Q

What is aortic sclerosis?

A

Aortic valve thickening without flow limitation

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14
Q

What are the risk factors associated with Aortic Stenosis?

A

Hypertension
High LDL
Smoking
CRP
CKD
Radiotherapy

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15
Q

What are the causes of Aortic Stenosis?

A

Rheumatic Heart Disease
Congenital Heart Disease
Calcium Build Up

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16
Q

Why is a murmur present in aortic stenosis?

A

When there is blood which is force flowing against calcified wall results in a murmur

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17
Q

What happens to the valvular endocardium in aortic stenosis?

A

The valvular endocardium is damaged as the result of abnormal blood flow across the valve (in the case of a bicuspid valve) or by an unknown trigger.

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18
Q

Why is calcium deposited on the valve?

A

Endocardial injury initiates an inflammatory process similar to atherosclerosis and ultimately leads to leaflet fibrosis and deposition of calcium on the valve.

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19
Q

What leads to stenosis?

A

Progressive fibrosis and calcium deposition limit the leaflet mobility and eventually produce stenosis

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20
Q

Why does rheumatic disease lead to AS?

A

Autoimmune inflammatory reaction = triggered prior to streptococus infection which targets the valvular endothelium, leads to inflammation and eventually calcification

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21
Q

How can AS lead to heart failure?

A

Long standing pressure overload -> left ventricular hypertrophy as more blood in the left ventricle

Ventricle does try to maintain normal wall stress (afterload) despite the increased pressure caused by the stenosis

Eventually this becomes too much, so systolic function declines as wall stress increases resulting in systolic heart failure

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22
Q

What type of murmur will be present in patient with Aortic Stenosis?

A

Ejection systolic murmur (≥3/6 is present with a crescendo-decrescendo pattern that peaks in mid-systole and radiates to the carotid)

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23
Q

What symptoms might someone with Aortic Stenosis have?

A

Exertional dyspnoea
fatigue
Chest Pain

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24
Q

What four investigations should be done for a patient with suspected Aortic Stenosis?

A

Transthoracic echocardiography
ECG Chest X ray (LVH)
Cardiac catheterisation
Cardiac MRI

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25
Q

What is the primary treatment of symptomatic AS?

A

Aortic Valve Replacement

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26
Q

What conditions might AVR be considered for asymptomatic patients?

A

Severe AS, abnormal exercise test, elevated serum B-type natriuretic peptide levels

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27
Q

What other medications might someone with AS be placed on?

A

Anti-hypertensives
ACE Inhibitors
Statins

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28
Q

What is Aortic regurgitation?

A

The diastolic leakage of blood from the aorta into the left ventricle

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29
Q

What does acute aortic regurgitation present as?

A

medical emergency - sudden onset pulmonary oedema and hypotension or cardiogenic shock

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30
Q

What are the congenital and acquired causes of Aortic Regurgitation (5)?

A

Rheumatic heart disease
Infective endocarditis
Aortic valve stenosis
Congenital Heart defects
Congenital Bicuspid valves

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31
Q

Why does Aortic regurgitation occur?

A

due to incompetence of valve leaflets resulting from either intrinsic valve disease or dilation of the aortic root

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32
Q

What are the aortic root dilation causes of Aortic regurgitation (6)?

A

Marfans Syndrome
Connective Tissue Disease
Collagen Vascular Diseases
Idiopathic
Ankylosing spondylitis
Trauma

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33
Q

How does acute AR happen?

A

Infective Endocarditis -> rupture of leaflets
Vegetations on the valvular cusps -> cause inadequate closure of leaflets
Chest trauma -> tear in ascending aorta

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34
Q

How does rheumatic fever cause AR?

A

Fibrotic changes cause thickening and retraction of leaflets

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35
Q

Describe how Acute Aortic Regurgitation leads to a cardiogenic shock?

A

Increase blood volume in LV during systole -> LV end diastolic pressure increases- > increase in pulmonary venous pressure -> dyspnea and pulmonary oedema -> heart failure -> cardiogenic shock

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36
Q

How does chronic AR differ from acute AR?

A

Chronic - the increase in LV volume is gradual = so leads to LV enlargement and eccentric hypertrophty

Eventually, the ejection fraction falls and systolic volume rises, leading to eventual dyspnoea -> lower coronary perfusion -> ischemia, necrosis and apoptosis

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37
Q

Which signs are distinctive of Chronic Aortic regurgitation?

A

Wide pulse pressure
Corrigan (wate hammer pulse)

38
Q

What are the presentations of Acute Aortic Regurgitation?

A

Cardiogenic shock
Tachycardia
Cyanosis
Pulmonary edema
Diastolic murmur

39
Q

What is the management plan for Acute AR?

A

Valve replacement, repair, with vasodilators

40
Q

What is the management plan for chronic asymptomatic AR?

A

If LV function is normal can be managed by drugs or reassurance

41
Q

What is the management plan for chronic symptomatic AR?

A

First line = valve replacement with adjunct vasodilator therapy

42
Q

How can AR be prevented?

A

Treat rheumatic fever and infective endocarditis

43
Q

What is mitral Stenosis?

A

Obstruction to left ventricular inflow at the level of mitral valve due to structural abnormality of the mitral valve

44
Q

What is the main cause of Mitral Stenosis (in developing countries)?

A

Rheumatic Fever

45
Q

what is the prognosis of Mitral Stenosis?

A

Pulmonary hypertension and right heart failure

46
Q

What does an acute insult to the mitral valve result in?

A

Acute insult leads to formation of multiple foci and infiltrates in the endo and myocardium and along the walls of the valves

47
Q

What happens to the left atrial pressure in Mitral Stenosis?

A

Increased

48
Q

Why does Mitral Stenosis lead to exertional dyspnoea?

A

Severe mitral stenosis leads to increase in left atrial pressure , transudation of fluid into the lung interstitium leading to dyspnoea at rest or exertion

49
Q

Why does cardiac output decrease in Mitral Stenosis?

A

Restricted orifice limits the filling of the left ventricle limiting cardiac output

50
Q

What might a patient with Mitral Stenosis present with?

A

H/0 of Rheumatic fever
Dyspnoea
orthopnoea
Diastolic murmur
Loud P2
Neck vein distention
Hemoptysis

51
Q

What extra investigation might you conduct on a patient with suspected Mitral Stenosis?

A

ECG

52
Q

What is the treatment plan for severe asymptomatic Mitral Stenosis?

A

No therapy required, sometimes might do adjuvant balloon valvotomy

53
Q

What is the treatment plan for severe symptomatic Mitral Stenosis?

A

Diuretic, balloon valvotomy, valve replacement, repair adjunct, B Blockers

54
Q

What is mitral regurgitation?

A

Abnormal reversal of blood flow from the left ventricle to the left atrium.

55
Q

What are the causes of acute mitral regurgitation (5)?

A

Rheumatic heart disease
Infective endocarditis
Mitral Valve Prolapse
Following Valvular surgery
Prosthetic mitral valve dysfunction

56
Q

What are the causes of chronic Mitral Regurgitation (5)?

A

Rheumatic heart disease
SLE
Scleroderma
Hypertrophic cardiomyopathy
Drug related

57
Q

How does infective endocarditis lead to Mitral Regurgitation?

A

Infectious endocarditis: Abscess formation, vegetations, rupture of chordae tendineae and leaflet perforation

58
Q

Describe the abnormal physiology associated with Mitral Regurgitation?

A

progression leads to eccentric hypertrophy leading to elongation of myocardial fibres and increased left end diastolic volume Increase in preload & a decrease in afterload increase in end- diastolic volume and a decrease in end-systolic volume

59
Q

Which heart condition might you have atrial fibrillation?

A

Mitral Regurgitation

60
Q

What might someone with Mitral Regurgitation present with?

A

Dyspnoea
holo(pan)systolic murmer
S3 heart sound
Orthopnea
Chest pain
Atrial fibrillation

61
Q

What is the treatment plan for acute MR?

A

Surgery (repairing/ replacing the supporting valve structures). A prosthetic ring can be inserted to reshape the valve

62
Q

What is the treatment plan for Chronic Asymptomatic MR?

A

watchful waiting or surgery

63
Q

What is the treatment plan for Chronic Symptomatic MR?

A

1st Surgery + medical treatment

64
Q

What is a cardiomyopathy?

A

Cardiomyopathy is a disease of the heart muscle that makes it harder for heart to pump blood to rest of your body

65
Q

What are the three types of cardiomyopathies?

A

Dilated

Hypertrophic

Restrictive

66
Q

What are the causes of secondary dialated cardiomyopathies?

A
  • Heart Valve Disease
  • After childbirth
  • Thyroid Disease
  • Myocarditis
  • Alcoholism
  • Auto-immune
  • Ingestion of drugs
  • Inherited Disorders
67
Q

What is Dilated cardiomyopathy characterised by?

A

Dilated cardiomyopathy is characterized by ventricular chamber enlargement and systolic dysfunction with normal left ventricular wall thickness.

68
Q

What are the early compensatory mechanisms for Dilated CM?

A

Increase in heart rate and tone of the peripheral vascular system

69
Q

What happens to the ventricle and hence ejection fraction in Dilated CM?

A

Ventricle enlarges
Lower ejection fraction and increase in the ventricular wall stress and end systolic volumes

70
Q

What changes occur to the renin and angiotensin system?

A

neurohumoral activation, and increase in circulating levels of catecholamines

71
Q

What happens to natureitic peptide levels in Dilated Cardiomyopathy?

A

levels of natriuretic peptides are also increased.

72
Q

What would a patient with dilated cardiomyopathy present with?

A
  • Dyspnoea
  • Displaced apex beat
  • Fatigue
  • Angina
  • Pulmonary congestion
  • Peripheral Oedema
  • Sudden cardiac death
73
Q

What investigations should you do for someone with dilated CM?

A
  • Genetic Testing
  • Viral serology
  • ECG
  • Chest X ray
  • Cardiac catheterisation
  • Cardiac MRI/CT Scan
  • Echocardiography
74
Q

What is the management of Dilated CM?

A
  • Ace Inhibitors/ Beta Blockers/ ARBs/ Diuretics
  • Surgery (if medical ineffective)
  • Diet Modifications
  • Anticoagulants (for thrombotic events)
  • Treat arrhythmias
75
Q

What is Hypertrophic Cardiomyopathy?

A

Hypertrophic cardiomyopathy (HCM) is a genetic cardiovascular disease.

It is defined by an increase in left ventricular wall thickness that is not solely explained by abnormal loading conditions. - often asymmetrical and occurs in the absence of obvious hypertrophic stimuli

76
Q

Which area of the heart is most commonly impacted by hypertrophic cardiomyopathy?

A

Interventricular septum - results in an obstruction of flow thorough the left ventricular outflow tract

77
Q

Describe the abnormal pathology associated with hypertrophic cardiomyopathy?

A

Most patients with HCM have abnormal diastolic function, which impairs ventricular filling and increases filling pressure, despite a normal or small ventricular cavity.

78
Q

What is the presentation of a patient with hypertrophic cardiomyopathy?

A

S4 Gallop
Syncope
Fatigue
Angina
Pulmonary congestion and oedema
Systolic Murmur
Sudden cardiac death

79
Q

What are the first line treatments for HCM?

A

B blocker - if side effects then verapamil

If drugs fail, mechanical therapy (pacemaker or myectomy/ablasion surgery)

80
Q

What is the diagnosis of Restrictive cardiomyopathy based on?

A

Establishing the presence of a restrictive ventricular filling pattern

81
Q

What is restrictive CM characterised by?

A

diastolic dysfunction with restrictive ventricular physiology, whereas systolic function often remains normal. atrial enlargement occurs due to impaired ventricular filling during diastole, but the volume and wall thickness of the ventricles are usually normal.

82
Q

What causes increased stiffness of the myocardium?

A

deposition of abnormal substances (ie, amyloid proteins, noncaseating granulomas, iron) within the heart tissue = leads to diastolic dysfunction

83
Q

What is the result of restrictive cariomyopathy?

A

Patients typically have reduced compliance (increased diastolic stiffness), and the left ventricle cannot fill adequately at normal filling pressures

Reduced left ventricular filling volume leads to a reduced cardiac output.

84
Q

What might someone with restrictive CM uniquely present with?

A
  • Ascites and pitting oedema in periferies
  • Hepatomegaly- Enlarged liver
  • S4 heart sound
  • Increase in Jugular venous pressure
  • Weight loss
85
Q

What investigations should be conducted for someone with suspected Restrictive CM?

A
  • FBC
  • Serology
  • Amylodosis check
  • Chest Xray
  • ECG
  • Echocardiography
  • Catheterisation
  • MRI/Biopsy
86
Q

How is Restrictive Cardiomyopathy treated?

A
  • Heart Failure Medication - ACE Inhibitors, ARBs, Diuretics
  • Antiarrhythmic Therapy
  • Immunosuppression - steroids
  • Pacemaker
  • Cardiac transplantation
87
Q

What structural change of the heart is most commonly associated with aortic stenosis?

A

Left ventricular hypertrophy

88
Q

Which type of cardiomyopathy is associated with sudden cardiac death in athletes?

A

Hypertrophic cardiomyopathy

89
Q

What are the two main major Duke’s criteria for diagnosing infective endocarditis?

A
  1. Positive blood culture for typical micro-organisms
  2. ECHO showing valvular regurgitations
90
Q

What are the 6 minor Dukes Criteria for diagnosis of Infective Endocarditis?

A
  1. Predisposing cardiac lesion
  2. Intravenous drug use
  3. Temperature >38
  4. Embolic phenomena
  5. Immunologic phenomena
  6. Positive blood culture which doesn’t meet the main criteria organisms
91
Q

what is meant by regional blood vasodilation?

A

Increased muscle activity -> Increase oxygen demand -> increased demand is met by increasing blood flow to exercising muscle

92
Q

How is muscle vasodilation achieved?

A

Vasoactive substrates and products of muscle metabolism, eg.CO2, lactate, hydrogen peroxide and potassium ions

Vasoactive mediators released by the endothelium, eg. nitric oxide (NO),ATP, adenosine, prostaglandins

β-2 adrenoceptor activation

BRS CARDIO & RESPIRATORY (26 decks)

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