Aortic Valve Disease - Stenosis

Question 1

When we listen to the heart we should be able to hear 2 separate sounds, S1 and S2. What does S1 relate to?

1 - closing of the tricuspid and mitral valves
2 - closing of tricuspid and aortic valves
3 - closing of mitral and aortic valves
4 - closing of aortic and pulmonary valves

Answer 1

1 - closing of the tricuspid and mitral valves
- also called the atrioventricular valves, as these 2 valves relate to the atrium

Question 2

Does the S1 heart sound occur at the start of diastole or systole?

Answer 2

• systole
• mitral and tricuspid valves close to stop blood moving back into the atrium

Question 3

When we listen to the heart we should be able to hear 2 separate sounds, S1 and S2. What does S2 relate to?

1 - closing of the tricuspid and mitral valves
2 - closing of tricuspid and aortic valves
3 - closing of mitral and aortic valves
4 - closing of aortic and pulmonary valves

Answer 3

4 - closing of aortic and pulmonary valves

Question 4

Does the S2 heart sound occur at the start of diastole or systole?

Answer 4

• diastole
• aortic and pulmonary valves close to allow atria to pump blood into ventricles

Question 5

In some patients a 3rd heart sound can be heard, S3, which occurs just after S2. What causes this 3rd heart sound?

1 - mitral regurgitation
2 - ventricular septal defect
3 - chordae tendineae pulling
4 - aortic regurgitation

Answer 5

3 - chordae tendineae pulling
- papillary muscles contract and pull chordae tendineae which attach to mitral valves

• sound is because they pull so hard to fully expand the left ventricle
• can be heard in some younger patients, BUT can signify HR in older patients

Question 6

How many leaflets does the aortic valve have?

1 - 4
2 - 3
3 - 2
4 - 1

Answer 6

2 - 3
- however, some patients can have a bicuspid valve due to genetics

Question 7

Does the aortic valve open during systole or diastole?

Answer 7

• systole
• pumps blood around the body

Question 8

Does the aortic valve close during systole or diastole?

Answer 8

• diastole
• allows left ventricle to be filled

Question 9

Aortic stenosis refers to a narrowing of the aortic valve. All of the following are causes of aortic stenosis, but which is the most common cause?

1 - rheumatic fever
2 - idiopathic/senile calcification
3 - genetics (bicuspid valve)
4 - genetics (Williams syndrome)

Answer 9

2 - idiopathic/senile calcification
- leads to Ca2+ deposits and fibrosis
- essentially the valve stiffens

Question 10

Aortic stenosis due to idiopathic/senile calcification is common among older adults, and is predicted to affect up to 5% of the population. What age are particularly at risk?

1 - 35y/o
2 - 45y/o
3 - 55y/o
4 - 65y/o

Answer 10

4 - 65y/o
- most common indication for surgery

Question 11

Are patients with a genetic predisposition to having a bicuspid valve instead of a tricuspid valve more likely to have to have senile calcification and fibrosis?

Answer 11

• yes
• pressure is not spread across leaflets
• the 2 leaflets are therefore stressed more

Question 12

Rheumatic fever can cause aortic stenosis and commissural fusion of the leaflets. How does rheumatic fever do this?

1 - increases inflammation that can damage valves
2 - Group A Streptococcus release M protein that resembles self MHC-1 in cardiac and valve tissue
3 - Group A Streptococcus directly infect aortic valve
4 - all of the above

Answer 12

2 - Group A Streptococcus release M protein that resembles self MHC-1 in cardiac and valve tissue

• called molecular mimicry, essentially antibodies target the aortic valve thinking it is Group A Streptococcus

Question 13

What type of hypersensitivity is aortic stenosis caused by the release of M protein found in Group A Streptococcus?

1 - type 1 hypersensitivity
2 - type 2 hypersensitivity
3 - type 3 hypersensitivity
4 - type 4 hypersensitivity

Answer 13

2 - type 2 hypersensitivity

Question 14

Which bacteria is associated with rheumatic fever that can lead to aortic stenosis?

1 - Group A Streptococcus
2 - Corynebacterium diphtheriae
3 - Arcanobacterium haemolyticum
4 - Mycoplasma pneumoniae.

Answer 14

1 - Group A Streptococcus
- commonly referred to as strep throat

Question 15

Although aortic stenosis due to rheumatic fever is rare, it can happen. Which of the following patients is LEAST likely to develop this?

1 - <5 y/o
2 - >65 y/o
3 - low social economic background
4 - overcrowding home

Answer 15

2 - >65 y/o

Question 16

Aortic stenosis, whatever the cause can cause a murmur due to turbulent flow of blood. When would we typically expect to hear this murmur?

1 - after S2
2 - after S1
3 - after S3

Answer 16

2 - after S1
- S1 is closing of mitral and tricuspid valves]
- blood is therefore leaving via the aortic and pulmonary valve
- occurs during the whole of S1 to S2
- called pansystolic murmur or crescendo-decrescendo murmur

Question 17

Patients with aortic stenosis, in addition to the murmur will have other symptoms. Which of the following is NOT a symptom of aortic stenosis?

1 - radiation of murmur to carotids
2 - slow rising pulse
3 - narrow BP gap between SBP and DBP
4 - collapsing pulse
5 - exertional syncope

Answer 17

4 - collapsing pulse
- common in aortic regurgitation

Question 18

There is a common triad of symptoms in patients with aortic stenosis, which of the following is NOT part of this triad?

1 - angina
2 - syncope
3 - high BP
4 - heart failure

Answer 18

3 - high BP

Question 19

Patients with aortic stenosis typically do not always present with symptoms. What is it that can induce symptoms such as syncope and angina, due to reduced blood flow to the coronary arteries?

1 - immunocomprimised
2 - exertion
3 - stress
4 - indigestion

Answer 19

2 - exertion
- increases oxygen demand so we need more blood

Question 20

What is the main affect that aortic stenosis have on the heart that can be seen on an ECG?

1 - RV hypertrophy
2 - RA hypertrophy
3 - LV hypertrophy
4 - LA hypertrophy

Answer 20

3 - LV hypertrophy
- heart has to contract harder to eject blood out of narrowed valve
- this can be seen on the ECG

Question 21

Aortic stenosis can result in an inability of the heart to pump blood around the heart effectively. This can significantly increase the risk of what?

1 - aortic aneurysm
2 - MI
3 - heart failure
4 - stroke

Answer 21

3 - heart failure

Question 22

A heave is a precordial thrust/impulse that we can feel precordially (on tissue over the heart, chest essentially). In aortic stenosis what is the most likely cause of the heave?

1 - RV hypertrophy
2 - RA hypertrophy
3 - LV hypertrophy
4 - LA hypertrophy

Answer 22

3 - LV hypertrophy

Question 23

All of the following are tests to diagnose a patient with suspected aortic stenosis, but which generally provides a definitive diagnosis and is regularly used?

1 - Echocardiogram
2 - ECG
3 - CXR
4 - cardiac catheterisation

Answer 23

1 - Echocardiogram

Question 24

Which of the following is NOT a common differential for aortic stenosis?

1 - acute Coronary Syndrome.
2 - hypovolemic Shock
3 - aortic dissection
4 - mitral Regurgitation.
5 - mitral Stenosis.

Answer 24

3 - aortic dissection

Question 25

If a patient has symptoms with aortic stenosis, what should they have?

1 - medications and 24h BP monitoring
2 - monitored in hospital
3 - surgery to replace the aortic valve
4 - anti-hypertensive medication

Answer 25

3 - surgery to replace the aortic valve

Question 26

If a patient is not fit for surgery but is symptomatic with aortic stenosis, what is the next treatment option?

1 - medications and 24h BP monitoring
2 - monitored in hospital
3 - transcatheter aortic valve replacement
4 - anti-hypertensive medication

Answer 26

3 - transcatheter aortic valve replacement
- TAVI

Question 27

Complete the table below using the labels below using systole or diastole of when you would hear the murmurs:

Answer 27

Question 28

If we get a split S2 heart sound, what does this mean?

1 - mitral and aortic valves closing at different times
2 - pulmonary and aortic valves closing at different times
3 - tricuspid and aortic valves closing at different times
4 - mitral and tricuspid valves closing at different times

Answer 28

2 - pulmonary and aortic valves closing at different times