4. Heart Valve Disease Flashcards by Timothy Sun

What murmurs get louder with inspiration

TR and TS, PS, PR

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What murmurs get louder on expiration

AS (pt sitting foward), MR (lean to left), AR, MS

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Which valvular disease is assoc with haemoptysis

Mitral stenosis

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Pathophysiology of AS- most common cause

Degenerative calcific stenosis of the valve

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What are some causes of AS (apart from the main one)

Bicuspid valve
Rheumatic disease, radiotherapy, congenital stenosis, unicuspid valve

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What are the main complications of AS and what is the pathology behind this

Progressive restriction leads to valvular obstruction, pressure overload, and the hypertrophy and fibrosis of left ventricle

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What are the most common Sx of AS

Don’t appear until very severe stenosis
May have angina ( due to obstruction of blood flow out of LV, hypertrophy of ventricle increases demand), exertional syncope ( as CO unable to be augmented due to stenosis) , dyspnoea due to pressure overload in LV resulting in pressure in LA and pulm veins.

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What happens to BP in pts with severe AS on exertion

FALLS - leads to syncope

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Clinical signs of AS
What happens to HS

ES murmur - crescendo decrescendo , may radiate to carotids
Quiet or absent second heart sound , murmur moves closer to HS II
Slow-rising pulse due to restricted outflow from LV
Forceful apex beat - prolonged ejection and LOW VOLUME pulse

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What do normal Ix in AS show , what is main Ix

LVH - large QRScomplexes, T wave inversions in lateral leads and V5 and V6
CXR my show cardiomegaly
Key is ECHO - shows thickened and calcified leaflets in stenosed valve, may have LVH
Doppler for velocity of blood flow- higher in AS
CT can also show calcification

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Mx of AS

Surgical AVR
TAVI if not eligible

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Risks of AVR

Stroke, bleeding, endocarditis, thromborembolism, bleeding with anticoag for mech AVR

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What are the two main causes of AR

Dysfunction of AV cusps or dilatation of aortic root/ ascending aorta

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What does AR mean

Inadequate closure of aortic valve allows reflux of blood into ventricle in diastole

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main primary valve diseases that can cause AR

Rheumatic fever, endocarditis,, congenital bicuspid aortic valve

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What non-valvular conditions can cause AR

Marfans/ EDS, systemic hypertension

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What is the characteristic sign of AR

Increased/wide pulse pressure (as closure in aortic valve results in dramatic drop in diastolic pressure)

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Sx of AR and how to diff from AS

May be asymptomatic, may have dyspnoea on exertion, then PND and orthopneoa
Palpitations as LV it trying to contract vigorously due to volume overload
Peripheral oedema (HF)
Lightheadness, syncope and angina- more common in severe AS but may also occur if low DBP

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Clinical signs of AR

Tachycardia, large volume, collpasing pulse, wide pulse pressure (50mm) and corrigan sign
Displaced apex due to DILATATED LV
Early diastolic murmur - best heard along LSB @3/4th ICS with pt sitting leaning foward on peak expiration
Features of hyperdynamic circulartion
HF features like increased JVP, bibasal crackles, hepatomegaly, peripheral oedema

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Ix for AR

ECHO to confirm Dx and identify cause, assess severity
CXR for cardiomegaly or HF features
ECG for sinus tachy or LVH
Blood test for endo

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Mx for AR

Mild to mod- serial echo follow up
AVR for sever AR, aortic root/ asc aorta surgery
Diuretics and salt restriction, vasodilators for heart failure
B blockers or digoxin for arrhythmias, anticoagulants for ischaemic disease

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Anticoag for pts with mechanical AVR

Warfarin

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Most common cause of primary MR

Degenerative disease, including maxomitis and mitral valve prolapse

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What acute condition can cause MR

Acute MI may cause papillary muscle rupture

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Cause of secondary MR

LVSD/ cardiomyopathy

Sx of MR and what does it predispose to

Usually asymptomatic, but may have LV overload as severity increases LV may also dilates as result of LV overload HF sx once decompensated - exertional dyspnoea, orthopnnoea (due to pulmonary congestion), PND, fatigue, palpitations if pts have AF ( predisp to AF),ankle swelling

Signs of MR

May have irregular pulse, hyperdynamic displaced apex beat, pansystollic murmur radiating to axilla, signs of HF

Ix for MR

Echo - can be useful to assess LV size and fx, and pulm hyperT ( TTE for most cases) ECG- may show AF or broad notched P wave CXR- cardiomegaly or HF

Mx of MR

Valve repair or replacement, mitraclip in pts with high surgical risk

Inidications for mitral valve surgery in severe chronic primary MR

Sx and LVEF >30 or no Sx and LVEF<=60, LV dilatated (>45), new onset AF, or pulm hyperT ( PASP >50) Repair preferred over replacement

Tx for secondary MR

Tx underlying cardiomyopathy - diuretics, AceI, B-blocker, spironolactone CRT? for pts with LVSD

Which valvular disease is syncope common and unlikely for respectively

AS and MR

Which part of the heart is usually affected by HOCM?

Apex or LV septum

What gene mutation is common in HOCM

Cardiac sarcomere

Sx of HOCM

Chest pain/angina Breathlessness- usually on exrertion but at rest is severe HF Syncope Palpitation- may have arrythmia as prob progresses (AF, or vent arrhythmia) HF Sudden cardiac death

Signs of HOCM

Irregularly irregular if AF Double apical impulse ES murmur that is late-peaking( due to obstruction of blood near end of systole increasing flow velocity)

Ix for HOCM

ALWAYS abnormal ECG Sig LVH, tall QRS in lat leads and tall R waves in pts with normal VH Widerpread t wave inversion Echo shows asmmetric hypertrophy Cardiac MRI may confirm dx, looks for scar Embulatory ECG to rule out non sustained VT

Mx for HCM

No meds BB blockers, and NDCCB in pts with asthma who can't tolerate BB Disopyramide as second line - negatively inotropic, anti arrhythmic Anticoag if AF Loop for HF

When should surgical tx for HCM be used

If ongoing Sx despite med Rx, and high risk of sudden death

What causes murmur in regurgitation

Blood flowing backwards when vent pressures drop during diastole

Which murmurs make S2 difficult to hear and what is on common example

Holosystolic murmur- MR< TR ir VSD

What grade of systolic murmur is assoc with: A thrill Thrill and still heard with stethoscope lightly on chest Steth off chest

IV, V ,VI

What is the loudest grade diastolic murmur and what does it men

IV, loud

What pitch is the bell used to here

Low pitch

What murmur raidates to left axillary

HOCM murmur and heart sounds

Crescendo decrescendo, best heard at left lower sternal border, DOES NOT radiate to carotids, S2 is louder than in AS

Describe MR murmur

High-pitched, blowing

where is MR best heard at

apex

How to distinguish MR from TR murmur

MR does not increase with inspiration, and usually radiates to axilla

Where is TR best heard at and where does it radiate tp

L LSB, rad to R LSB

What murmur is soft, high pitched early diastolic murmur and is it crescendo or decrescendo or both

AR, decrescendo

Best position for hearing AR

Sit up and lean foward

Where is AR best heard at

Erbs point ( L ICS3), or RUSB if due to aortic root disease

Mitral stenosis murmur pitch and type

LOW Decrescendo murmur following S2, late diastolic crescendo murmur immediately befoe S1 sound due to active left vent filling forcing more blood through stenosed valve

What heart sound is common in MS

Opening snap, due to mitral valve opening

What maneuver for HOCM

Valsalva- HOCM becomes loud, unlike AS Squatting from standing and leg reasing - increases LV filling, will decrease HOCM murmur

What pulse is observed in AR - what does it mean

WHP (radial)/ Collapsing pulse/ Corrigan's pulse (AR) with rapid upstroke and descent Suggests hyperdynamic circulation

Is WHP seen in chronic or acute AR

chronic only- due to LVH and dilatation

What non cardiac causes can cause WHP

High output hyperT, liver cirrhosis,

Main cause of MS

Rheumatic feverSy

Sx and signs of MS

Dysponoea, haemoptysis due to vascular congestion (high pulm pressure) Mid late diastolic murmur Low volume pulse May have AF

Ix of MS

CXR may show left atrial enlargement, echocardiography shpws reduce CSA of mitral valve

Mx of NS

Warfarin for pts with AF Monitor with echo and percutaneous mitral balloon valvotomy or mitral valve surgery (commissurotomy, or valve replacement)