Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Year 3 > Aortic valve disease (CV) > Flashcards

Aortic valve disease (CV) Flashcards

1
Q

Define aortic stenosis.

A

Degenerative, pathological narrowing of the aortic valve, leading to symptomatic obstruction of blood flow out of the left ventricle

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the difference between aortic stenosis and aortic sclerosis?

A

Aortic stenosis often follows aortic sclerosis, defined as aortic valve thickening without flow limitation (ejection-systolic murmur that DOES NOT radiate to carotids)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Define aortic regurgitation.

A

Diastolic leakage of blood from the aorta into the left ventricle, due to inadequate coaptation of valve leaflets resulting from either intrinsic valve disease of dilation of the aortic root

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are some causes/risk factors for aortic stenosis? (4)

A
  • age>60 (calcification)
  • congenital bicuspid aortic valve (most common cause of AS in younger patients<65)
  • rheumatic heart disease (developing countries)
  • chronic kidney disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are some causes/risk factors for aortic regurgitation? (5)

A
  • bicuspid aortic valve (–> proximal aortic dilation)
  • rheumatic fever
  • infective endocarditis
  • Marfan’s syndrome and related CTD (–> aortic root dilatation)
  • aortitis (secondary to systemic diseases e.g. reactive arthritis, ankylosing spondylitis)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is bicuspid aortic valve (and what condition is it associated with)?

A
  • fusion of two out of the three aortic valve leaflets in utero
  • associated with coarctation of the aorta:
    • hypertension in adults, heart failure in infants
    • radio-femoral delay
    • mid-systolic murmur, maximal over back
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

How common is rheumatic fever (as a cause of aortic valve disease)?

A

Rare due to consistent use of antibiotics in treatment of Streptococcal pharyngitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the most common cause of aortic stenosis in patients <65 and >65?

A
  • <65: bicuspid aortic valve
  • > 65: aortic sclerosis (calcification and fibrosis of aortic valve leaflets)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

List causes of acute aortic valve disease. (2)

A
  • infective endocarditis
  • aortic dissection of ascending aorta
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

List causes of chronic aortic valve disease. (3)

A
  • congenital bicuspid aortic valve
  • rheumatic heart disease
  • aortic dilatation due to connective tissue disorders (AR)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How might aortic stenosis present initially?

A

May initially be ASYMPTOMATIC

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What are some clinical features of aortic stenosis? (5)

A

Fatigue + exertional symptoms (SOB, angina, syncope, HF)

  • fatigue
  • exertional dyspnoea
  • chest pain/angina (increased O2 demand of hypertrophied LV)
  • exertional syncope (outflow obstruction)
  • signs of left heart failure
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What might you see on examination of aortic stenosis? (9)

A
  • narrow pulse pressure
  • slow-rising pulse
  • thrill in aortic area (if severe)
  • heaving, undisplaced apex beat
  • ejection systolic murmur at aortic area, radiating bilaterally to the carotids (AKA ejection-click murmur)
  • harsh crescendo-decrescendo (diamond-shaped) - louder on expiration in 2nd ICS right sternal edge
  • S2 diminished and single (softened/absent due to calcification)
  • bicuspid valve may produce an ejection click, paradoxically split S2
  • Gallavardin’s phenomenon - musical-quality, holosystolic murmur at apex of heart that occurs in older patients with calcific AS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is Gallavardin’s phenomenon in aortic stenosis?

A

Musical-quality, holosystolic murmur at apex of heart in older patients with calcific AS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the difference between chronic and acute aortic regurgitation?

A
  • chronic AR - may be asymptomatic for years until overt symptoms of congestive HF develop
    • initial symptoms - palpitations, uncomfortable awareness of pounding heart when laying on side
  • acute AR - medical emergency, sudden-onset pulmonary oedema/hypotension/cardiogenic shock, may also present as myocardial ischaemia or aortic root dissection
    • left heart rapidly decompensates due to inability to handle sudden increase in EDV due to aortic dissection/endocarditis/trauma
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

How does chronic aortic regurgitation initially present?

A

Asymptomatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the clinical features of chronic aortic regurgitation? (7)

A
  • initially ASYMPTOMATIC
  • dyspnoea + orthopnoea + tachypnoea + paroxysmal nocturnal dyspnoea
  • fatigue
  • weakness
  • palpitations
  • angina
  • syncope
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

How does severe acute aortic regurgitation present?

A

Sudden cardiovascular collapse (left ventricle cannot adapt to rapid increase in end-diastolic volume)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What might be seen on examination of aortic regurgitation? (8 + 9)

A
  • collapsing (water-hammer/Corrigan’s) pulse
  • wide pulse pressure
  • thrusting and heaving displaced apex beat
  • early diastolic murmur over the aortic valve region - heard better at left sternal edge with patient sitting forward with breath held at top of expiration
    • NB ejection-systolic murmur may also be heard due to increased flow across the valve
  • Austin Flint mid-diastolic murmur (heard at apex, caused by turbulent reflux hitting anterior cusp of mitral valve causing physiological mitral stenosis)
  • pulmonary oedema
  • rare signs associated with AR:
    • Quincke’s sign - visible pulsation on nail bed
    • de Musset’s sign - head nodding in time with pulse
    • Becker’s sign - visible pulsation of pupils and retinal arteries
    • Muller’s sign - visible pulsation of uvula
    • Corrigan’s sign - visible pulsation in neck
    • Traube’s sign - pistol shot on auscultation of femoral arteries
    • Duroziez’s sign - systolic and diastolic bruit on partial compression of femoral artery
    • Rosenbach’s sign - systolic pulsations of spleen
    • Hill’s sign - popliteal cuff systolic BP>brachial BP by >60mmHg
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What murmur is heard in aortic stenosis?

A

Ejection-systolic murmur, radiating bilaterally to carotids

(Crescendo-decrescendo heard best over 2nd ICS right sternal edge, louder on expiration)

(Aortic sclerosis - ejection systolic murmur that does not radiate to carotids)

21
Q

What murmur is heard in aortic regurgitation?

A

Early diastolic murmur - heard better at left sternal edge with patient leaning forwards with breath held at top of expiration

(May hear ejection-systolic murmur due to increased flow over valve)

Austin Flint murmur - mid diastolic murmur due to turbulent reflux hitting anterior cusp of mitral valve causing physiological mitral stenosis

22
Q

What are the 1st-line investigations for aortic valve disease? (3 + 1)

A
  • transthoracic echocardiography (including Doppler)
  • ECG
  • chest X-ray (to assess for pulmonary oedema)
  • (M-mode and 2D imaging for AR)
23
Q

What is the gold standard test for aortic valve disease?

A

Transthoracic echocardiography

24
Q

What might you see on transthoracic echocardiography in aortic stenosis? (3)

A
  • calcification and narrowing of the aortic valve
  • elevated aortic pressure gradient
  • measurement of valve area and LV ejection function
25
Q

What might you see on ECG in aortic stenosis?

A

May demonstrate LVH and absent Q-waves, atrioventricular block, hemiblock or bundle branch block

26
Q

What might we see on CXR in aortic stenosis?

A

May be normal; may show pulmonary congestion or other lung pathology

27
Q

What might an ECG show in aortic regurgitation? (3)

A

May show non-specific ST-T wave changes, LAD or conduction abnormalities

28
Q

What might CXR show in aortic regurgitation? (3)

A
  • cardiomegaly
  • dilatation of ascending aorta
  • pulmonary oedema (if accompanied by HF)
29
Q

What might you see on echocardiogram in aortic regurgitation? (4)

A
  • may show underlying cause e.g. aortic root dilatation, bicuspid aortic valve
  • may show effects of AR e.g. LV dilatation
  • doppler echo can show AR and indicate severity
  • repeat echos allow monitoring of progression (LV size and function)
30
Q

What are some differential diagnoses for aortic valve disease? (8)

A
  • aortic stenosis (ejection-systolic murmur)
  • aortic sclerosis (less intense murmur, non-radiating, doppler echo shows no significant pressure gradient)
  • aortic regurgitation (early diastolic murmur)
  • pulmonary regurgitation (diamond-shaped diastolic murmur best heard in 2nd+3rd left ICS, RVH)
  • mitral stenosis (mid-diastolic murmur, RVH)
  • mitral regurgitation (pansystolic murmur)
  • ischaemic heart disease
  • hypertrophic cardiomyopathy (athlete, young age, hand-gripping decreases murmur, standing up increases murmur)
31
Q

How can aortic stenosis be staged using doppler echo?

A
  • stage A (at risk) - bicuspid aortic valve or other congenital anomaly, or aortic valve sclerosis, maximum aortic velocity <2m/s
  • stage B (progressive) - mild if max aortic velocity 2-2.9m/s, moderate if max aortic velocity 3-3.9m/s, early LV diastolic dysfunction
  • stage C (severe asymptomatic) - valve area<1cm2, very severe if max aortic velocity>5m/s, gradient>60mmHg, mild LV diastolic dysfunction, mild LVH, possible LVEF<50%
  • stage D (severe symptomatic) - valve area<1cm2, max aortic velocity >4m/s, mean pressure>40mmHg, severe leaflet calcification/fibrosis with severely reduced leaflet motion
32
Q

How can we classify chronic aortic regurgitation? (3 + 1)

A
  • mild - width<25% of LV outflow tract (LVOT), regurgitant fraction<30%
  • moderate - regurgitant fraction 30-49%
  • severe - width>65% of LVOT, regurgitant fraction>50%
  • can also be classified as compensated, transitional and decompensated
33
Q

What is the 1st-line treatment for clinically unstable aortic stenosis? (3)

A
  • balloon valvuloplasty
  • medical therapy - vasodilators and beta-blockers (be careful with hypotension)
  • surgery (AVR) or transcatheter aortic valve replacement (TAVR) once stabilised
34
Q

What is the 1st-line management for aortic stenosis: (4)

  • clinically stable but symptomatic OR
  • asymptomatic but LVEF<50% OR
  • abnormal exercise test OR
  • rapid progression OR
  • elevated BNP
A
  • surgical or transcatheter AVR
  • long-term infective endocarditis Abx prophylaxis
  • long-term anticoagulation (warfarin)
  • medical therapy - statins, antihypertensives
35
Q

What is 1st line management for severe aortic stenosis LVEF<60% with normal LV systolic function?

A

Consider surgical AVR

36
Q

What is 1st-line management for non-severe aortic stenosis?

A
  • consider concomitant prophylactic AVR
  • medical therapy and follow-up (every 1-3 years)
37
Q

When is transcatheter AVR done over surgical AVR?

A

Preferred for older age / high risk patients (e.g. multiple comorbidities)

38
Q

What medications are contraindicated in aortic stenosis? (2)

A
  • ACEi contraindicated in moderate-severe AS (vasodilator effect might reduce coronary perfusion pressure –> cardiac ischaemia)
  • nitrates contraindicated in AS - may cause profound hypotension
39
Q

What is a summary of aortic stenosis management?

A

AVR if symptomatic, otherwise cut-off gradient of 40mmHg (if asymptomatic)

40
Q

What is the 1st-line management for acute aortic regurgitation? (3)

A
  • inotropes - dobutamine
  • vasodilators - nitroprusside
  • urgent AVR
41
Q

What is the 1st-line management for mild/moderate chronic aortic regurgitation? (2)

A
  • reassurance + monitoring (annual echo)
  • investigation and treatment of underlying cause - HTN, CAD, cardiomyopathy
42
Q

What is the 1st-line management for severe chronic aortic regurgitation (EF>50%)?

A

If positive exercise test –> vasodilator therapy (nifedipine)

43
Q

What is the 1st-line management for severe chronic aortic regurgitation (EF<50%)?

A
  • if decompensating: AVR / TAVI for people with comorbidities
  • if non-surgical: vasodilator (nifedipine) / ACEi (enalapril) / TAVI
44
Q

What is the general management plan for asymptomatic patients with aortic valve disease?

A

Monitor patients - annual echocardiogram

45
Q

What is the long-term management for metallic heart valves and why?

A
  • long-term anticoagulation with warfarin (target INR 2.5-3.5)
  • due to risk of thromboembolic event (biological valves do not need anticoagulation as low risk)
46
Q

What medication can be given in aortic valve disease to manage left HF?

A

Furosemide

47
Q

Which patients with aortic valve disease should be given prophylactic Abx?

A

Patients at high risk of infective endocarditis after AVR

48
Q

What are some complications of aortic valve disease?

A
  • congestive heart failure (LV dysfunction - diuretics, afterload reduction with vasodilators, BB and CCB used with caution)
  • sudden cardiac death
  • infection of prosthetic valve
  • thrombosis secondary to mechanical valve
  • valve dehiscence - new signs of HF
  • operative morality
  • arrhythmias
  • infective endocarditis
  • myocardial ischaemia

Year 3 (145 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions