AS, AR, TS, TR, PS, PR Flashcards
What are the common causes of aortic stenosis?
• Calcification: bicuspid if young, tricuspid if elderly
• Rheumatic heart disease
Calcification is a significant factor in the development of aortic stenosis, especially in younger patients with a bicuspid aortic valve.
What is the pathophysiology of aortic stenosis?
• Stenotic valve → LV outflow obstruction → LVH
• Smaller valve → CO fails to increase on exertion → angina on exertion
• LVH → LV dilation → LV dysfunction/MR
LVH stands for left ventricular hypertrophy, which can lead to further complications if untreated.
What are the classic symptoms of aortic stenosis?
• Asymptomatic for years
• Triad: angina, exertional syncope, dyspnea
• +/- symptoms of HF → poor prognosis
HF refers to heart failure, which can complicate the prognosis of aortic stenosis.
What are the key signs of aortic stenosis on physical examination?
• Normal S1, Soft muffled S2
• S4 added sound
• AS SEM: Systolic ejection murmur
• Parvus et tardus
• Reduced pulse pressure
Parvus et tardus describes a low volume and slow rising carotid pulse, which is characteristic of aortic stenosis.
What is the significance of the S4 sound in aortic stenosis?
It indicates that the left atrium contracts forcefully against a stiff or hypertrophic ventricle (atrial gallop)
The presence of S4 suggests underlying left ventricular hypertrophy or stiffness.
What are the clinical signs of severity in aortic stenosis?
• Symptomatic (dyspnea is the most severe symptom)
• Soft S2 & Paradoxical splitting of S2
• Added S4
• Systolic thrill at aortic area
• Heaving apex
Paradoxical splitting of S2 occurs when P2 is heard earlier than A2, indicating significant obstruction.
What findings on a chest X-ray suggest aortic stenosis?
• Calcified aortic valve
• Post-stenotic aortic dilatation
• Normal size (late may show LA & LV dilation)
• Pulmonary edema
LA refers to left atrium and LV refers to left ventricle.
What ECG changes are associated with aortic stenosis?
• LV strain pattern (ST depression, T wave inversion)
• LVH: Deep S in V1 V2, tall R in V5 V6, both together > 35 mm
These changes indicate increased workload on the left ventricle due to outflow obstruction.
What echocardiographic signs indicate severity of aortic stenosis?
• Aortic valve area: < 1 cm² (index <0.5 cm/m²)
• Peak flow velocity > 4 m/s
• Mean pressure gradient > 40 mmHg
These measures help assess the degree of obstruction and potential need for intervention.
What is the primary treatment for aortic stenosis?
Aortic valve replacement
In cases where open surgery is unsuitable, TAVR (transcatheter aortic valve replacement) may be performed.
What are the risks associated with TAVR?
• Higher risk of residual AR
• Need for pacemaker
AR refers to aortic regurgitation, which can occur post-procedure.
What are the acute causes of aortic regurgitation?
• Infective endocarditis
• Acute rheumatic fever
• Aortic dissection
• Failed prosthetic heart valve
• Myocardial infarction
Acute causes can lead to sudden onset of symptoms and require immediate medical attention.
What are the chronic causes of aortic regurgitation?
• Rheumatic heart disease
• Bicuspid aortic valve
• Marfan syndrome
• Ehlers-Danlos syndrome
• Rheumatoid arthritis
• Ankylosing spondylitis
• Reiter syndrome
• Systemic lupus erythematosus
• Syphilis
• Osteogenesis imperfecta
Chronic causes may develop over years and often lead to gradual symptom onset.
What is the pathophysiology of aortic regurgitation?
Inadequate closure of the aortic valve → reflux of blood from the aorta into LV during diastole → increased LV volume loads the left ventricle → LV dilatation → increased stroke volume and pulse pressure → eventual deterioration of ventricular contraction → left ventricular failure
This sequence of events highlights the progressive nature of the condition.
What are the common symptoms of aortic regurgitation?
• Asymptomatic for years
• Signs of left ventricular failure (dyspnea, orthopnea, etc.)
• Acute aortic regurgitation: cyanosis and shock
Symptoms can vary significantly based on the progression and severity of the condition.
What are the signs of aortic regurgitation?
• Widened pulse pressure (increased systolic and decreased diastolic BP)
• Collapsing water-hammer pulse (Corrigan pulse)
• S3 added sound may be present
• Early diastolic murmur (increased when sitting forward and holding breath in expiration)
• Austin Flint murmur (mid-diastolic murmur)
• Quincke pulse: pulsation in nailbed, blushing & blanching of nail capillaries
• Head bobbing
• Hill sign: popliteal systolic BP > brachial systolic BP by 60mmHg or more
These signs can aid in the clinical diagnosis of aortic regurgitation.
What diagnostic tests are used for aortic regurgitation?
• Chest X-Ray: LVH, dilated aorta
• Echocardiogram to assess LV size and function and look for dilated aortic root
Imaging studies are critical in evaluating the severity and impact of aortic regurgitation.
What is the treatment for acute aortic regurgitation?
• Medical emergency: emergent aortic valve replacement
• Symptomatic relief with nifedipine & ACE inhibitors
• Definitive treatment is aortic valve replacement
Timely intervention is essential to prevent serious complications.
What is tricuspid stenosis frequently associated with?
Mitral and aortic valve disease
The presence of tricuspid stenosis often complicates the clinical picture due to its association with other valvular diseases.
What is a common cause of tricuspid regurgitation?
Secondary to pulmonary HTN due to conditions like mitral stenosis leading to left heart failure.
This sequence causes right heart failure and right ventricular dilation, contributing to tricuspid regurgitation.
What are some causes of tricuspid regurgitation?
- Post MI
- Congenital (Ebstein anomaly)
- Right-sided infective endocarditis related to drug abuse
- Dilated cardiomyopathy
- Rheumatic heart disease
- Carcinoid syndrome
These conditions can lead to either direct damage to the tricuspid valve or increased pressure that affects valve function.
What is a characteristic sign of tricuspid regurgitation?
Pan systolic murmur at the left lower sternal border, high in intensity with inspiration.
This murmur can be distinguished from that of ventricular septal defect (VSD) by its intensity change with respiration.
What does elevated JVP indicate in tricuspid regurgitation?
Prominent V-wave with S1 due to increased atrial filling in systole.
This occurs because of regurgitation of blood back into the atrium.
What are common signs of tricuspid regurgitation?
- Pulsatile tender hepatomegaly
- Severe peripheral edema
- Ascites
These signs result from systemic venous congestion due to right heart failure.
What is the primary cause of pulmonary stenosis?
Mostly congenital conditions like Tetralogy of Fallot (TOF) and Noonan syndrome.
Acquired cases are rare.
What symptoms are associated with pulmonary stenosis?
Fatigue, syncope, and right ventricular failure.
These symptoms often present in adulthood.
What are physical examination findings in pulmonary stenosis?
- Left parasternal heave
- Systolic thrill in pulmonary area
- Prominent a-wave on JVP
- Harsh ejection systolic murmur at the pulmonary area
- Possible S4 sound
The murmur is best heard during inspiration and is typically graded at 4.
What is a common imaging finding in pulmonary stenosis?
Post-stenotic dilatation and oligemic lung fields on chest X-ray.
Oligemic lung fields indicate reduced blood flow to the lungs due to right ventricular outflow obstruction.
What treatments are available for pulmonary stenosis?
Valvuloplasty or surgery.
These interventions aim to relieve the obstruction and improve heart function.
What causes pulmonary regurgitation?
Pulmonary hypertension and dilatation of the valve ring.
It may also result from endocarditis, particularly in IV drug abusers.
What is the auscultation finding in pulmonary regurgitation?
Early diastolic murmur heard at the upper left sternal edge (Graham Steell murmur).
This murmur is similar to that of aortic regurgitation.
What are the usual symptoms of pulmonary regurgitation?
Usually asymptomatic; treatment is rarely required.
Most patients do not experience significant symptoms unless the condition is severe.
