cardio exam unit 9

Question 1

what is stenosis vs regurgitation?

Answer 1

stenosis is obstruction to FORWARD FLOW, it leads to pressure overload in the RV LV

regurgitation is backward flow. it leads to volume overload in the heart

Question 2

what happens to valvuvlar diease as preload increases?

Answer 2

valvular diease sound gets LOUDER

Question 3

how many leafleft does mitral and tricuspid have? and where are they

Answer 3

mitral has 2 - LA and LV
tricuspid has 3 - RA and RV

Question 4

what is mitral stenosis and what is it due to M/C?

Answer 4

mitral stenosis is a progressive narrowing of the mitral valuve orfice –> casue increase RESISTANCE to FLOW

it is normally 5cm2 durting diastole but can reach to 1.5cm2

M/C due to rheumatic heart diease or rare congential defects

Question 5

explain how mitral stenosis is casues? what casues it and explain it

Answer 5

Rheumatic Carditis casues inflammation of the mitral valuve with intiail mitral regurigation

mitral valuve overtime undergoes progessive REPAIR with fusion of the commisures fibrosis of the cusps –> stenosis (narrowing)

pt dont have sx until theres sig stenosis

Question 6

what happens when it reaches 1.5cm2 for mtiral stenosis ?

Answer 6

once it reaches 1.5cm, there is sig obstruction to blood flow form LA to LV

it leads to increasd atrial pressure, enlargment, pulmonary congestion, pul HTN RIGHT side HF, venous engorgement, perpheral edema

Question 7

what happens if the LA gets large enough in mitral stenosis? Think of the nerve

Answer 7

it can lead to pressure on the reccurent laryngeal nerve which can lead to hoareness

Question 8

what is the SX and examination for mitral stenosis? M/c in F or M and what age group?

Answer 8

M/C in females ages 40-50 years
SX: LF HF sxs, figue, dyspnea, PND, JVD, papitations

exam: opening snap with LOW pitched DIASTOLIC rumble - heard best at the apex of the heart

• mumur louder with handgrips

Question 9

explain where/when the murmur is best heard in mitral stenosis

Answer 9

diastolic rumble murmur!
where: best heard at the APEX OF THE HEART (at the left lateral decubitus position)

murmur increases w increased preload/venous return

best heard with tubulant spalshing of blood agasint the valvu –> louder mumurs are heard w increased preload/venous return

Question 10

when do you hear an increases preload/venous return? what body postion

Answer 10

squatting, laying down, leg rasies

Question 11

DX for mitral stenosis?

Answer 11

ECHO: you will see diminished mitral valuve orifice (MVO < 1.5cm2)

rheumatic mitral stenosis: commissural fusion and diastolic doming of mitral valve

EKG: LA englargement: Wide P waves and Afib

Question 12

whats the tx for mitral stenosis?

Answer 12

there is no rx to tx mitral stenosis only tx the complication that comes from it

1. HR contraol mainstay:
   BB,CCB,diruetics

if its AFIB: anticoagualtion and rate control w BB CCB

if its Right HF: ACE/BB, BB, duirtetics

Question 13

how do you monitor mitral stenosis?

Answer 13

most pt are AXS until it gets to < 1.5cm2 thats when surgety is perfomed so its imp to get ECHO 3-5 years until surgury is needed

Question 14

explain the surgery mangamenet of mitral stenosis?

Answer 14

surgery is perfomred once mitral valve is < 1.5cm2 and pt is SX

1. percutanous mitral balloon valvotomy (perfered, LESS RATE OF re-stenosis)
2. mitral valuve replacement/repair: must be on warfarin/coumadin to prevent valve thrombosis (INR 2.5-3.5)

Question 15

explain mtral valvle prolapse MVP

Answer 15

M/C VALVULAR HEART DISEASE
MC IN YOUNG WOMEN 

-Idiopathic myxomatous degeneration of the mitral value causing:
- Redundant mitral value tissue with poor apposition of mitral value leaflets
- Elongated/thin/weak chordae tendinae

-ALL OF THIS CASUES MITRAL VALUVE TO FREELY OPEN/PROLAPSE 

-prolapse can cause backflow of blood INTO LA during systole  mitral regurgh

Question 16

what is the M/C valvular disease?

Answer 16

MVP

Question 17

what is the presentation/examination of MVP?

Answer 17

MOST CASES AXS
But with SX: palpitation, non-exertional CP, fatigue, dyspnea, syncope, anxiety

EXAM:
- Midsystolic click (from snapping of mitral chordae tenidnae during systole-contraction)
- LATE systolic blowing murmur (from regurg)

Question 18

which dx would you hear a midsystolic click or/and late systolic blowing murmur?

Answer 18

MVP

Question 19

which dx would you hear a LOW pitched diastolic rumble?

Answer 19

mitral stenosis

Question 20

how would you dx / tx MVP

Answer 20

ECHO

Not needed but BB can be used to relive SXS

Question 21

what is mitral regurgitation? whats its many etilogy and explain 5

Answer 21

Progressive dysfunction of the mitral apparatus allowing BACKFLOW of the blood into LEFT ATRIUM during systole (contraction)

Etiology:
-MVP (M/C/C) – due to flopping redundant values

-left ventricular dilation (dilated cardiomyopathy)

-Ischemic HD – chronic ischemia of endo tissues ischemic weak mitral apparatus

-MI w papillary rupture – acute infarction of mitral apparatus causes weak mitral apparatus  heart does not get time to compensate to thelowered CO

-Infective endocarditis/early rheumatic carditis – inflammation and destruction of mitral apparatus leads to reflux of systolic blood in LA

Question 22

whats the SX for mitral regurg? for AFIB and acute mitral regug due to MI papillary rupture

Answer 22

Progressive SOB – due to HF, pul HTN, SOB, PND, pul congestion, shock)

AFIB – due to LA stretching; irregularly irregular heart rate

Acute mitral regurg due to MI with papillary rupture: acute pul edema due to acute backflow of blood

Question 23

what sound would you hear for mitral regurg and where?

Answer 23

Holosystolic blowing murmur – heard best at the APEX

-Radiates to axilla
-Murmur intensity increased w increased venous return
-murmur heard best in LEFT LATERAL decubitus position
-lateral displacement of PMI

Question 24

main EX and suporting DX for mitral regugr?

Answer 24

ECHO: left atrium enlargement, LV hypertrophy, r/o pul HTN

Supporting tests:
CXR: pleural effusion, pul edema(crackle sounds) , cardiomegaly

EKG: AFIB, LA enlargement (wide P waves)

Question 25

tx / surgery for mitral regurg?

Answer 25

Vasodilators: Nitroprusside
- Need rx to allow LV to favor forward flow best way to reduce afterload
- NOT IDEAL!

Used to tx underlying conditions:
HF: ACE/ARB, BB, diuretics
AFIB: anticoagulation, rate control
*no need for RX if AXS MR

SURGERY:
Mitral value repair: better functional and survival benefits

Mitral value replacement: requires lifelong warfarin therpay
- Bioprosthetic value: require replacement 10-15 yrs

Question 26

what is arotic stenosis and its etiology?

Answer 26

-narrowing of the aortic valve orifice creating obstruction to LV OUTFLOW

Aortic stenosis obstruction to LV outflow (INCREASED AFTERLOAD)  DECREASED CO

LV compensates  hypertrophy  ischemia and Left systolic HF

Etiology:
1.Progressive calcification M/C – atherosclerosis; classically >70yrs, MEN 
2.Congenital bicuspid aortic valve: <70yrs
3.Rheumatic Carditis: rare

Question 27

what is the SX for artoic stenosis?

Answer 27

SX: starts with aortic value orifice <1cm2 (normal 3-4)

Angina, Syncope, sym of HF (dyspnea, JVD, edema)

Question 28

what will u see on exam what sound for arotic stenosis?

where would the murmur radiate to ?

Answer 28

EXAM:
-systolic ejection murmur radiates to the neck (since blood is leaving the heart to the aorta)
-Diminished carotid uptake: parvus et tardus: weak and delayed carotid uptake

Auscultation:
-mid systolic crescendo-decresdo murmur greatest in right upper sternal border, radiaites to carotids, best heard learning fwd,

Question 29

when is murmur increased and decreased ?

Answer 29

REMEMBER: MURMUR DECREASES W ISOMETRIC HANDGRUP; INCREASES W VENOUS RETURN (laying, squatting, leg raise)

Question 30

how would you dx arotic stenosis ?

Answer 30

ECHO: thickened aortic valve leaflets and reduced leaflet motion

Supporting dx:
EKG  LV hypertrophy
CXR: dilation of aorta and pul congestion

Question 31

how would u do sx for arotic stenosis?

Answer 31

SURGERY: SX pt with aortic valve orifice <1.0cm2

1.Surgical aortic valve replacement (SAVR)

2, Transcatheter aortic valve replacement (TAVR)

If theres CHF  diuretics and NA restriction

Question 32

what is arotic regurgitation? BIG ONE

Answer 32

Aortic valve allows BACKFLOW of blood into LV during systole  increased volume of blood
-increased volume  increased LV dilation
-can lead to systolic Left HF

Question 33

what is the etiology for aortic regurgitation? acute and chronic

Answer 33

Etiology:
ACUTE
-heart is unable to adapt, LOW CO, LOW organ perfusion
- infective endocarditis (inflammation of aortic valve)
- rheumatic carditis (inflammation and destruction of valve)
-Aortic dissection – dysfunction

CHRONIC
-can cuase acute mitral regurg
-HTN, idiopathic dilation, biscupsid valuve, rhematic heart diease, marfan syndrome

Question 34

what is the SX for arotic regurg?

Answer 34

Usually AXS UNTIL CO DECREASES

SYSTOLIC HF: SOB, edema, right HF`

Question 35

what would you see on the exam for aortic regurg? very hard!

Answer 35

EXAM:
-Wide pulse pressure
-Bounding “water hammer’ peripheral pulse
-apical pulse displaced to the left
-DIASTOLIC, BLOWING, DECRESCENDO murmur
- heart best at left upper sternal border, best heard leaning forward
- AUSTIN FLINT MURMUR: late diastolic rumble

WIDE PULSE PRESSURE: wide difference between systolic and diastolic pressure within an artery

CORRIGAN PULSE (WATER HAMMER PULSE): wide pulse pressure appreciated as a rapidly rising and rapidly falling arterial pulse
- Appreciated in radial/brachial arteries
DE MUSSET SIGN: bobbing of head w each heart beat

QUINCKE’s PULSE : capillary perfusion of the fingertip

MUELLER’S SIGN: pulsation of the uvula

Question 36

what is the dx for arotic regurg?

Answer 36

ECHO
Regurgitations jet through aortic valve into LV

EKG: LV hypertrophy
CXR: cardiomegaly, pleural effusion edema

Question 37

what is the tx/surgery for aortic regurg?

Answer 37

Systolic HF tx: ACE/ARB, BB, diuretics

SURGEY:
Aortic value replacement: mainstay of treatment
Aortic valve repair