Aortic valve disease

Question 1

Most common cause of aortic regurg in US is?

Other causes?

Answer 1

-Congenital bicuspid valve

• degeneration of aging
• rheumatic fever
• endocarditis-staphylococcal
• degeneration of bioprosthesis
• dilation of aortic root
• marfans syndrome

Question 2

Pathophys of Aortic regurg?

Answer 2

-blood ejected by the LV regurgs=
=inc LVEDV –> hyptrophy and LV dilation
=LVEF normal to high (includes normal EF plus) and SV is als normal to high

hypertrophy–>dilation–>HF

Question 3

Aortic regurg

-History:

Answer 3

• underlying disease is nice to have
• long illness -up to 60 years of illness
• asymptomatic until LV dysfunction begins 40s-50s
• DYSPNEA
• nonspecific chest pain
• palpitations
• angina pectoris

Question 4

Aortic regurg

-Physical exam:

Answer 4

• Wide pulse pressure - up to 100mmHg
• LV apex diffuse, hyperdynamic and displaced left and downward
• S1 and S2 normal to soft
• S3 common with LV dysfunction
• Korotkof sounds persist to 0
• aortic efection sounds
• Diastolic murmur = always pathologic –> the longer the murmur the worse the regurg
• Austin flint murmur- mid to late diastolic rumble of functional Mitral Stenosis (mitral valve may be normal)

Question 5

Other signs of Aortic regurg on physical exam:

Answer 5

• austin flint
• corrigan pulse (collapsing or “water hammer pulse”
• de Musset’s sign - head bobs with each systole
• Duroziez sign -to and fro bruit in femoral artery
• Hills sign - popliteal BP>brachial by 60mmHG
• Mullers sign-systolic pulsations in uvula
• Quickes pulse-visible of bluish nailbed in systole/blanching in diastole
• traubes sign - pistol shot sound

Question 6

Diagnostic tool for aortic regurg?

Answer 6

echocardiography-fluttering of anterior mitral valve leaflet in diastole

Question 7

Aortic regurg -tx?

Answer 7

• usually a long clinical course
• want to reduce high systemic diastolic pressure (AVOID BETA BLOCKERS)
• vasodilators (ACEI, and dihydropyridine calcium channel blockers (reduce afterload, improve LV ejection)
• Valve replacement - only for symptomatic patients

Question 8

Drug of choice for aortic regurg?

Answer 8

-ACEI

Question 9

prevalence of Aortic stenosis?

Answer 9

<1% of total population

Question 10

Aortic stenosis -onset/prognosis:

Answer 10

• long latent period without symptoms

- prognosis is poor when symptoms develop: angina or syncope and HF in 50%

Question 11

3 symptoms of aortic stenosis:

Answer 11

angina
syncope
-HF

Question 12

cuase of aortic stenosis:

Answer 12

congeital or degeneration

Question 13

pathophys of aortic stenosis:

Answer 13

• obstruction to outflow= pressure gradient across the valve
• inc LVEDP inc wall stress = LV hypertrophy
• reduced sub-endocardial perfusion

Question 14

Aortic stenosis - history:

Answer 14

• may have history of rheumatic fever
• often asymptomatic for decades
• Angina pectoris
• syncope - secondary to exertion
• GI bleed - colon angiodysplasia
• HF is a late sign

Question 15

Exertonal syncope think:

Answer 15

aortic stenosis

Question 16

Aortic stenosis: Physical exam:

Answer 16

• takes longer to push blood out through the narrow arotic valve that doesnt move=arterial pulses are small and late
• carotids display a systolic THRILL (coarse vibration)
• carotids peak after LV apical impulse
• Apical impulse= sustained lift-moves left and downward in HF

Question 17

Aortic stenosis - heart sounds:

Answer 17

-S1 normal to soft
-S2 varies - often single
A2 may be softened by immobility of valve
P2can be buried in the prolonged murmur
-may have paradoxical split A2 follows P2 if LV failing

Question 18

Aortic stenosis murmurs:

Answer 18

• heard best at the base of the haert
• crescendo/decerscendo is loud and peaks late (DIAMOND SHAPED)
• commonly radiates to carotids, occasionally at apex
• may have diastolic murmur of AR

Question 19

Aortic stenosis- ECG

Answer 19

same as if you were to see hypertrophy

-dont do stress testin!

Question 20

Aortic stenosis treatment:

Answer 20

1) drugs little use:
- diuretics reduce fluids burden but may cause orthostasis by lowering cardiac output
- digitalis glycosides may help improve LV performance
- beta blckers must be avoided
2) a fib must be converted bc we need the atrial kick

3) VALVE REPLACEMENT!!!!!!!!