Cardio (station 3) Flashcards
Clinical signs of aortic stenosis?
• Slow rising, low volume pulse
• Narrow pulse pressure
• Apex beat is sustained in stenosis (HP: heaving pressure‐loaded)
• Thrill in aortic area (right sternal edge, second intercostal space)
A crescendo-decrescendo, ejection systolic murmur (ESM) loudest in the aortic area during expiration and radiating to the carotids.
Severity:
soft and delayed A2 due to immobile leaflets and prolonged LV emptying, delayed (not loud) ESM, fourth heart sound S4.
Evidence of complications in patient with aortic stenosis?
• Endocarditis: splinters, Osler’s nodes (finger pulp), Janeway lesions (palms), Roth spots (retina), temperature, splenomegaly and haematuria
• left ventricular dysfunction: dyspnoea, displaced apex and bibasal crackles
• Conduction problems: acute, endocarditis; chronic, calcified aortic valve node
Ddx for ESM / aortic stenosis
• HOCM
• VSD
• Aortic sclerosis: normal pulse character and no radiation of murmur
• Aortic flow: high output clinical states e.g. pregnancy or anaemia
Causes of aortic stenosis
Congenital: bicuspid
Acquired: age (senile degeneration and calcification); Streptococcal (rheumatic)
Associations of aortic stenosis?
• Coarctation and bicuspid aortic valve
• Angiodysplasia
Association between symptoms of aortic stenosis and mortality rate?
Signs that suggest worsening severity of aortic stenosis?
- Auscultation features:
soft and delayed A2 due to immobile leaflets and prolonged LV emptying, delayed (not loud) ESM, fourth heart sound S4. - biventricular failure (right ventricular failure is preterminal)
Ix for aortic stenosis?
• ECG: LVH on voltage criteria, conduction defect (prolonged PR interval)
• Cxr: often normal; calcified valve
• Echo: mean gradient: >40 mm Hg aortic (valve area <1.0 cm2) if severe
• Catheter: invasive transvalvular gradient and coronary angiography (coronary artery disease often coexists with aortic stenosis)
Management of asymptomatic aortic stenosis?
⚬ None specific, good dental health
⚬ Regular review: symptoms and echo to assess gradient and LV function
Management of aortic stenosis?
Surgical
⚬ Aortic valve replacement +/− CABG
- Operative mortality 3–5% depending on the patient’s EuroScore
Percutaneous
⚬ Balloon aortic valvuloplasty (BAV)
⚬ Transcutaneous aortic valve implantation (TAVI)
> Transfemoral (or transapical and transaortic)
> Maybe recommended if high surgical risk (logEuroscore >20%) or inoperable
cases (number needed to treat to prevent death at 1 year = 5)
Dukes criteria for infective endocarditis?
major:
• Typical organism in two blood cultures
• Echo: abscess, large vegetation, dehiscence*
minor:
• Pyrexia >38°C
• Echo suggestive
• Predisposed, e.g. prosthetic valve
• Embolic phenomena*
• Vasculitic phenomena (ESR↑, CRP↑)
• Atypical organism on blood culture
Diagnose if the patient has 2 major, 1 major and 2 minor, or 5 minor criteria.
(* plus heart failure/refractory to antibiotics/heart block are indicators for urgent surgery).
Clinical signs of aortic regurgitation?
• Collapsing pulse (waterhammer pulse) reflecting a wide pulse pressure, e.g. 180/45
• Apex beat is hyperkinetic and displaced laterally (tv: thrusting volume‐loaded)
• Thrill in the aortic area
Auscultation:
Early diastolic murmur (EDM) loudest at the lower left sternal edge with the patient sat forward in expiration.
There may be an aortic flow murmur and a mid-diastolic murmur (MDM) (Austin–Flint) due to regurgitant flow impeding mitral opening.
In severe AR there may be ‘free flow’ regurgitation and the EDM may be silent.
Signs of severe AR
collapsing pulse, third heart sound (S3) and pulmonary oedema
Eponymous signs of aortic regurgitation
⚬ Corrigan’s: visible vigorous neck pulsation
⚬ Quincke’s: nail bed capillary pulsation
⚬ De Musset’s: head nodding
⚬ Duroziez’s: diastolic murmur proximal to femoral artery compression
⚬ Traube’s: ‘pistol shot’ sound over the femoral arteries
Causes of aortic regurgitation
Causes of collapsing pulse
Aortic regurgitation
Pregnancy
Patent Ductus arteriosus
Paget’s disease
Anaemia
Thyrotoxicosis
Ix for aortic regurgitation
• ecg: lateral T‐wave inversion
• cxr: cardiomegaly, widened mediastinum and pulmonary oedema
• TTE/TOE:
> Severity: LVEF and dimensions, root size, jet width
> Cause: intimal dissection flap or vegetation
• Cardiac catheterization: grade severity aortogram and check coronary patency
Mx of aortic regurgitation
Medical
• ACE inhibitors and ARBs (reducing afterload)
• Regular review: symptoms and echo: LVEF, LV size and degree of AR
Surgery
For acute dissection/ Aortic root abscess/endocarditis
Chronic:
Replace the aortic valve when:
• Symptomatic: dyspnoea and reduced exercise tolerance (NYHA > II)
AND/OR
the following criteria are met:
1. wide pulse pressure >100 mm Hg
2. ECG changes (on ETT)
3. echo: LV enlargement >5.5 cm systolic diameter or EF <50%
Ideally replace the valve prior to significant left ventricular dilatation and dysfunction.
When to replace aortic valve in chronic aortic regurgitation
Symptomatic: dyspnoea and reduced exercise tolerance (NYHA > II)
AND/OR
the following criteria are met:
1. wide pulse pressure >100 mm Hg
2. ECG changes (on ETT)
3. echo: LV enlargement >5.5 cm systolic diameter or EF <50%
Prognosis of aortic regurgitation
Asymptomatic with EF > 50%: 1% mortality at 5 years.
Symptomatic and all three criteria present (wide pulse pressure > 100mmHg, ecg changes on ETT, echo EF <50% or LV enlargement >5.5cm systolic diameter−> 65% mortality at 3 years.
Heart sounds in Mitral stenosis
Loud first heart sound.
Opening snap (OS) of mobile mitral leaflets opening
followed by a mid-diastolic murmur (MDM), which is best heard at the apex, in the left lateral position in expiration
with the bell.
Presystolic accentuation of the MDM occurs if the patient is in sinus rhythm.
If the mitral stenosis is severe then the OS occurs nearer A2 and the MDM is longer.
Other clinical findings in mitral stenosis apart from HS?
• Malar flush
• Irregular pulse if AF is present
• Tapping apex (palpable first heart sound)
• Left parasternal heave if pulmonary hypertension is present or enlarged left atrium
Complications
• Pulmonary hypertension: functional tricuspid regurgitation, right ventricular heave, loud P2.
• LVF: pulmonary oedema, RVF: sacral and pedal oedema.
• Endocarditis
• Embolic complications: stroke risk is high if mitral stenosis + AF
Causes of mitral stenosis?
Congenital: (rare)
acquired
• rheumatic (commonest)
• Senile degeneration
• Large mitral leaflet vegetation from endocarditis (mitral ‘plop’ and late diastolic murmur)
Ddx for mitral stenosis
Left atrial myxoma
Austin–Flint murmur
Ix of mitral stenosis?
• ecg: p‐mitrale (broad, bifid) and atrial fibrillation
• cxr: enlarged left atrium (splayed of carina), calcified valve, pulmonary oedema
• ttE/toE: valve area (<1.0 cm2 is severe), cusp mobility, calcification and left atrial
thrombus, right ventricular failure
mx of mitral stenosis
medical: + AF: rate control and oral anticoagulants, diuretics
mitral valvuloplasty: if pliable, non‐calcified with minimal regurgitation and no left
atrial thrombus
Surgery: closed mitral valvotomy (without opening the heart) or open valvotomy
(requiring cardiopulmonary bypass) or valve replacement
prognosis in patients with mitral stenosis
Latent asymptomatic phase 15–20 years; NYHA > II – 50% mortality at 5 years.
what causes rheumatic fever?
Immunological cross‐reactivity between Group A β‐haemolytic streptococcal infection, e.g. Streptococcus pyogenes and valve tissue
Diagnostic criteria for rheumatic fever?
Proven β‐haemolytic streptococcal infection diagnosed by throat swab, rapid antigen detection test (RADT), anti‐streptolysin O titre (ASOT) or clinical scarlet fever
plus 2 major or 1 major and 2 minor criteria:
MAJOR:
Carditis
Arthritis
Sydenhams’ Chorea
Erythema Marginatum
Subcutaneous Nodules
Minor:
fever, raised ESR, raised WCC, previous rheumatic fever, arthralgia, prolonged PR interval
treatment of rheumatic fever
Rest, high‐dose aspirin and penicillin
prophylaxis of rheumatic fever?
⚬ Primary prevention: penicillin V (or clindamycin) for 10 days
⚬ Secondary prevention: penicillin V for about 5–10 years
HS findings in mitral regurgitation?
Pan-systolic murmur (PSM) loudest at the apex radiating to the
axilla. Loudest in expiration.
Wide splitting of A2P2 due to
the earlier closure of A2 because the LV empties sooner.
S3 indicates rapid ventricular filling from LA, and excludes significant mitral stenosis.
signs in Mitral regurgitation excluding heart sounds?
- Scars: lateral thoracotomy (previous valvotomy)
- Pulse: AF, small volume
- Apex: displaced and volume loaded
- Palpation: thrill at apex
- Pulmonary oedema
- Cause: signs of endocarditis
- Severity: left ventricular failure and atrial fibrillation (late). Not murmur intensity
- Other murmurs, e.g. ASD
causes of mitral regurgitation?
Chronic:
Affecting valve leaflets:
>Myomatous degeneration (prolapse) >Rheumatic
>Connective tissue diseases
>Fibrosis (fenfluramine/pergolide)
Affecting valve annulus:
> Dilated left ventricle (functional MR) >
> Calcification
Affecting chordae/papillae:
Infiltration e.g. amyloid
Fibrosis (post‐MI/trauma)
Acute: IE, Rupture of chordae/papillae
Ix of mitral regurgitation?
- ECG: p‐mitrale, atrial fibrillation and previous infarction (Q waves)
- CXR: cardiomegaly, enlargement of the left atrium and pulmonary oedema
TTE/TOE:
Severity: size/density of MR jet, LV dilatation and reduced EF
Cause: prolapse, vegetations, ruptured papillae, fibrotic restriction and infarction
Management of Mitral Regurgitation?
medical:
⚬ Anticoagulation for atrial fibrillation or embolic complications
⚬ Diuretic, β‐blocker and ACE inhibitors
Percutaneous: mitral clip device for palliation in inoperative cases of mitral valve prolapse
Surgical
⚬ Valve repair (preferable) with annuloplasty ring or replacement
> Aim to operate when symptomatic, prior to severe LV dilatation and dysfunction
Prognosis of mitral regurgitation
- Often asymptomatic for >10 years
- Symptomatic – 25% mortality at 5 years
Associations of Mitral Valve Prolapse?
Associated with connective tissue disease, e.g. Marfan’s syndrome and HOCM
how do patients with mitral valve prolapse usually present?
Often asymptomatic, but may present with chest pain, syncope and palpitations
Small risk of emboli and endocarditis
HS findings in Mitral valve prolapse
Mid-systolic ejection click (EC). Pan-systolic murmur that gets louder up to A2.
Murmur is accentuated by standing from a squatting position or during the straining phase of the Valsalva manoeuvre, which reduces the flow of blood through the heart.
Heart sound findings in tricuspid regurgitation?
Pan-systolic murmur (PSM) loudest at the tricuspid area (lower left sternal edge) in inspiration.
Reverse split second heart sound due to rapid RV emptying.
Right ventricular rapid filling gives an S3.
Clinical signs of tricuspid regurgitation apart from heart sounds?
- Raised JVP with giant CV waves
- Thrill left sternal edge
- Pulsatile liver, ascites and peripheral oedema
- Endocarditis from IV drug abuse: needle marks
- Pulmonary hypertension: RV heave and loud P2
- Other valve lesions: rheumatic mitral stenosis
causes of tricuspid regurgitation?
Congenital: Ebstein’s anomaly (atrialization of the right ventricle and TR)
acquired:
- acute: infective endocarditis (IV drug user)
- Chronic: functional (commonest), rheumatic and carcinoid syndrome
ix in tricuspid regurgitation?
- ECG: p‐pulmonale (large, peaked) and RVH
- CXR: double right heart border (enlarged right atrium)
- TTE: TR jet, RV dilatation
mx of tricuspid regurgitation?
- medical: diuretics, β‐blockers, ACE inhibitors and support stockings for oedema * Surgical: valve repair/annuloplasty if medical treatment fails
heart sounds in pulmonary stenosis?
Ejection systolic murmur (ESM) heard loudest in the pulmonary area in inspiration.
Widely split second heart sounds, due to a delay in RV emptying.
Severe: inaudible P2, longer murmur duration obscuring A2.
Clinical signs of pulmonary stenosis?
- Raised JVP with giant a waves
- Left parasternal heave
- Thrill in the pulmonary area
- Right ventricular failure: ascites and peripheral oedema
- tetralogy of fallot: PS, VSD, overriding aorta and RVH (sternotomy scar)
- Noonan’s syndrome: phenotypically like Turner’s syndrome but male sex
- Other murmurs: functional TR and VSD
ix of pulmonary stenosis?
- ECG: p‐pulmonale, RVH and RBBB
- CXR: oligaemic lung fields and large right atrium
- TTE: severity (pressure gradient), RV function and associated cardiac lesions
mx of pulmonary stenosis
- Pulmonary valvotomy – if gradient >70 mm Hg or there is RV failure
- Percutaneous pulmonary valve implantation (PPVI)
- Surgical repair/replacement
typical symptoms of carcinoid syndrome?
Toilet‐symptoms: diarrhoea, wheeze and flushing!
typical pathophysiology of carcinoid syndrome?
Gut primary with liver metastasis secreting 5‐HT (serotonin) into the blood stream
Secreted mediators cause right‐sided heart valve fibrosis resulting in tricuspid
regurgitation and/or pulmonary stenosis
Rarely a bronchogenic primary tumour or a right‐to‐left shunt can release 5‐HT into the
systemic circulation and cause left‐sided valve scarring
management of carcinoid syndrome?
octreotide or surgical resection
