4- valvular heart disease Flashcards
what is cardiac breathlessness types?
- usually breathlessness = related to activity
- orthopnea (breathlessness when lying down) and is associated with heart failure
- paroxysmal nocturnal dyspnoea
*often associated with ankle swelling
what is new york association functional classification?
classification for breathlessness
Class I - No limitation
Class II - Slight limitation of ordinary activity
Class III - Marked limitation of less than ordinary activity
Class IV - Severe limitation of minimal activity or at rest
what is involved in clinical examination? (general cardiac one)
- general appearance
- arterial pulse (radial, carotid)
- venous pulse (JVP) - sign of HF
- palpitation - apex beat or parasternal heave
- auscultation = heart sounds & murmurs
what are signs of right heart failure?
- raised JVP
- pitting oedema at ankles & sacrum
- hepatic congestion
what is JVP test?
measured when patient at 45 degrees, measure height from JVP at sternal notch
what does tapping apex beat mean?
mitral stenosis
what does displace and diffusing apex beat mean?
means volume overload in left ventricular dilation
(displaced= unusual place & diffused = heard in large area?)
what does displaced and heaving apex beat mean?
pressure overload in LV hypertrophy
what does parasternal heave suggest? and how do you determine?
determine by hand left of sternum
- suggests RV overload or pulmonary hypertension
what is cardiac murmur?
audible noise caused by turbulence of blood flow (can be innocent or pathological)
what are ways to describe murmurs?
- Systole or diastole?
- What type of murmur?
- Where is it loudest?
- Where does it radiate to?
- What grade of murmur?
- (Influenced by respiration?)
what determines whether murmur is in systole or diastole?
depends if 1st or 2nd heart sound
- 1st sound = mitral & tricuspid valve closing = start of systole
- 2nd sound = aortic & pulmonary valves closing = start of diastole
what are types of systolic murmur?
- pansystolic
- ejection systolic
what are types of diastolic murmur?
- early diastolic
- mid diastolic
where do murmurs radiate to?
carotids = aortic stenosis
axilla = mitral regurgitation
what is the grading of murmurs?
I. Very quiet
II. Quiet - easy to hear
III. Loud
IV. Loud with a thrill
V. Very loud with a thrill
VI. Loud - audible without a stethoscope
(remember extremes - very quiet and loud audible without stethescope)
what is an innocent murmur characteristics?
- soft
- position dependant
- often early systolic (diastolic murmurs always pathological)
what is valvular stenosis?
valves which don’t open properly
what is valvular regurgitation?
valves which do not close properly
what is mixed valve disease?
valves can’t open or close properly
what murmurs are louder with inspiration?
right sided murmurs (as decreased intrathoracic pressure so increased venous return so increased filling of right chambers)
what are common murmurs?
- 2nd sound splitting
- 3rd sound
- 4th sound
- systolic clicks
- innocent murmur
- mitral regurgitation
- aortic stenosis
- aortic regurgitation
- mitral stenosis
- continuous murmur
- tricuspid regurgitation
- pericardial rub(scratching/grating sound)
what is aortic stenosis causes?
- most common = age related changes of aortic valve (calcium & cholesterol deposits in valve)
- also congenital - bicuspid valve
- occasionally rheumatic process affects
what are symptoms of aortic stenosis?
- breathlessness
- occasionally chest pain
- syncope & dizziness (late sign due to reduced cardiac output)
what are signs of aortic stenosis?
- low volume pulse
- forceful displaced apex
- ejection systolic murmur that can radiate to carotids (so can also hear same murmur in neck) - usually heard in aortic area
what is treatment for aortic stenosis?
- conventional valve replacement
- trans catheter aortic valve replacement (TAVI) - nonsurgical so better for old people
- balloon aortic valvotomy
what are pros & cons for mechanical valve?
- last long time
- but needs to be on warfarin
- usually good for younger patients
what are pros & cons for bio-prosthetic mechanical valve?
- no warfarin needed
- lasts not as long (usually 10 years)
- usually good for older patients
AVR vs TAVI?
AVR (aortic valve replacement) still preferred, long-term outcomes, no contra-indications, can do angiogram to check if CABG done as well
TAVI = comorbidity, previous sternotomy
what are symptoms of mitral regurgitation?
- breathlessness
- peripheral oedema
- fatigue
what are signs of mitral regurgitation?
- displaced apex
- pansystolic murmur
- heard at apex in mitral area and radiates to axilla
what are causes of mitral regurgitation?
leaflets prolapse:
= one of leaflets doesn’t close properly during systole
- rheumatic fever = a consequence of rheumatic fever is that the valve leaflets become scarred & distorted
- degenerative myxomatous = leaflets become floppy & thickened
- endocarditis = inflammation of endocardium directly affects leaflet function
chordae rupture
= chordae tendinae are fibrous cords that connect valve leaflets to papillary muscles, rupture can lead to mitral regurgitation
- degenerative (prolapse/flail leaflet) - chordae can rupture in cases of severe mitral valve prolapse or when there’s a flail leaflet
papillary muscles - rupture leading to inadequate valve closure
- caused by ischaemic
annulus dilation
- - secondary or functional mitral regurgitation (most common)
- annulas getting bigger due to heart failure
- functional
what is treatment for mitral regurgitation?
- medication (for secondary - you try treat cause)
- diuretics & heart failure (ACEi)
- surgical (more favoured for primary valve problems)
- repair - prolapse, aim is to preserve mitral valve
- replacement - degenerative
- percutaneous
- new technique microclips - encouraging results (less invasive for elderly)
what is cause of mitral stenosis?
- essentially rheumatic main cause
- congenital rare
what are symptoms of mitral stenosis?
- breathlessness
- fatigue
- palpitations
what are signs of mitral stenosis?
- malar flush (plum red discolouration of high cheeks)
- tapping apex beat
- mid diastolic rumbling (after 2nd heart sound), low rumbling localised to apex
- best heard with patient lying on left hand side at apex
what is treatment of mitral stenosis?
- medications
- diuretics and treat AF
- surgery
- gold standard = valve replacement
- balloon valvuloplasty - placing a balloon across valve (cracks calcium deposits and opens it up), not great longevity
what causes aortic regurgitation?
primary problem (most common)= affecting leaflets, caused by:
- endocarditis
- connective tissue diseases
- rheumatic
secondary problem affecting annulus, caused by:
- marfans
aortic dissection
what is symptom of aortic regurgitation?
breathlessness
what are signs of aortic regurgitation?
- collapsing pulse
- displaced apex
- early diastolic murmur left sternal edge
- loudest sound heard as soon as valve shuts (starts loud and fades away)
what is aortic regurgitation treatment?
- medication (ACEi)
- surgery
- symptoms & LV dilation
- valve replacement
what is primary and secondary cause of mitral regurgitation?
primary leaflet = refers to problems directly related to structure & function of mitral valve leaflets
secondary leaflet = arise from underlying heart failure conditions heart failure problem
