Cardio: Valvular heart disease Flashcards
Left sided murmurs
How does mitral stenosis progress? [3]
Pressure builds up in the Left Atrium [1] which backs up through the pulmonary circ causing pulmonary hypertension [1]
As a result the Right heart dilates with Tricuspid and pulmonary regurgitation. [1]
Left sided murmurs
What can cause mitral stenosis? [7]
- Mainly Rheumatic Heart Disease fibrosing the valve.
- Congenital Mitral Stenosis
- Autoimmune: SLE or rheumatoid arthritis, amyloid
- Mitral Valve Prolapse
- Infect. Endocarditis
- Degenerative Disease (annular calcification)
- Ventricle enlargement stretching the valve
Left sided murmurs
What are the symptoms of mitral stenosis? [5]
- Dyspnoea & Pulmonary Oedema (secondary to pulmonary HTN)
- Chest Pain
- Haemoptysis/pink frothy sputum due to pulmonary pressures, vascular congestion
- Systemic embolisation due to enlargement of LA & LAA (left atrial appendage)
- Hoarseness (enlarged heart compresses L Recurrent Laryngeal Nerve)
Left sided murmurs
What are the clinical signs of mitral stenosis? [6]
Tachycardia, Low volume pulse
A Diastolic Thrill & Tapping Apex Beat
A RV Heave due to dilatation
Mid-late diastolic murmur on expiration.
Loud S1, opening snap
Mitral Facies
Left sided murmurs
How do we investigate suspected Mitral Stenosis? [4]
An ECG, CXR - LA enlargement
Echocardiogram - Thickening/Scarring of mitral leaflets
CMR
Left sided murmurs
How can we treat mitral stenosis? [3]
- Atrial fibrillation > warfarin
- Asymptomatic - monitoring regular ECHO
- Symptomatic - percutaneous mitral balloon valvotomy, mitral valve surgery
Left sided murmurs
What would appear on an MS ECG? [2]
Tall P wave indicating LA enlargement - p mitrale
Prominent R wave showing RVH
Left sided murmurs
How do we treat Mitral Regurgitation? Acute [2] vs Chronic MR [2]
Acute MR: Use Na nitroprusside OR Dobatumine to lower preload/afterload
Chronic MR: Diuretics can reduce symptoms but will still need surgery ie MV repair/Replacement
Left sided murmurs
Rheumatic Heart Disease What is it triggered by? [3]
Describe histology seen in RHF
Rheumatic fever
- GABHS infection - streptococcus pyogenes
- Cross-reactive Immunological reaction to recent strep pyogenes infection - antigen presentation to T cells - molecular mimicry
- 2-6w ago
- the cell wall of Streptococcus pyogenes includes M protein, a virulence factor that is highly antigenic. It is thought that the antibodies against M protein cross-react with myosin and the smooth muscle of arteries
- Aschoff bodies describes the granulomatous nodules found in rheumatic heart fever
Rheumatic Heart Disease Sequelae [5]
- Valvular stenosis + regurgitate *mitral stenosis
- LA dilation due to pressure overload > AF
- Large mural thrombi form
- Chronic venous congestion > LHF
- RV hypertrophy
RHD DX What criteria is used?
Jones criteria
RHD DX
List minor [3] and major [5] criteria
Major Criteria:
- Carditis
- Migratory polyarthritis
- Subcutaneous nodules
- Erythema marginatum skin rash
- Sydenham chorea/ St vitus dance
Jones Criteria Minor Criteria:
- Fever
- Arthralgias
- ECG changes
Left sided murmurs
Mitral valve prolapse associations
congenital heart disease: PDA, ASD
cardiomyopathy
Turner’s syndrome
Marfan’s syndrome, Fragile X
osteogenesis imperfecta
pseudoxanthoma elasticum
Wolff-Parkinson White syndrome
long-QT syndrome
Ehlers-Danlos Syndrome
polycystic kidney disease
Left sided murmurs
Characteristic murmur for mitral valve prolapse
mid-systolic click (occurs later if patient squatting)
late systolic murmur (longer if patient standing)
Left sided murmurs
Complications of MVP [3]
mitral regurgitation, arrhythmias (including long QT), emboli, sudden death
Left sided murmurs
How is MVP diagnosed
what other investigations are needed
Defined by imaging
Ant or post mitral valv leaflets cross valve plane by >2mm into left atrium during ventricular systole
Stress ECHO
Left sided murmurs
Mitral valve prolapse murmur characteristics
what happens to the murmur as severity increases
A ‘late’ crescendo murmur lasts until the end of systole (S2).
As severity of MVP increases, the murmur becomes pansystolic.
Unlike most left-sided murmurs, which are accentuated by manoeuvres that increase LV volume and therefore LV flow (increased afterload [squatting] and temporary increased left venous return [expiration])
the reverse is true of the murmur of MVP.
As the LV volume increases, the subvalvular apparatus is pulled apically, thus reducing the degree of prolapse.
Left sided murmurs
Mitral valve prolapse murmur characteristics, what is not typical of murmurs in MVP?
what happens to the murmur as severity increases
A ‘late’ crescendo murmur lasts until the end of systole (S2).
As severity of MVP increases, the murmur becomes pansystolic.
Unlike most left-sided murmurs, which are accentuated by manoeuvres that increase LV volume and therefore LV flow (increased afterload [squatting] and temporary increased left venous return [expiration])
the reverse is true of the murmur of MVP.
As the LV volume increases, the subvalvular apparatus is pulled apically, thus reducing the degree of prolapse.
Describe murmur characteristic in Mitral Regurgitation
- Pansystolic murmur (radiation to axilla) louder on expiration.
- Mid-late systolic murmur in MV prolapse (radn. to axilla, louder on inspiration).
In which would you see left heart failure? Mitral Stenosis or Mitral regurgitation
MR - you would see signs of LHF
Management of Rheumatic heart fever [3]
- Early IV antibiotics benzylpenicillin G or ceftriaxone. Follow on doses of 4-weekly IM benzylpenicillin or oral penicillin V should be continued daily for up to 0 years or into adulthood after an episode of ARF to reduce the risk of late complication with rheumatic heart disease.
- Acute carditis: oral prednisolone treatment ( mg/kg daily) to a maximum of 80 mg daily.
- Acute arthritis responds to high-dose aspirin.
Left sided murmurs
How does Aortic Stenosis lead to Heart failure?
Pressure backs up in the LH causing it to hypertrophy. This increases myocardial O2 demand eventually leading to LVF
What causes Aortic Stenosis?
Calcific degenerative disease - A slow inflammatory process thickens and calcifies the cusps (senile calcification, linked to atherosclerosis)
Rheumatic disease
Congenital Bicuspid Valve
What is the symptoms of aortic stenosis?
A long time is spent asymptomatic then suddenly:
Angina - Syncope - SOBOE - Heart Failure
What are the clinical signs of aortic stenosis?
Pulse is slow rising with narrow pulse pressure
Heaving Apex Beat, LV Heave
Aortic Thrill
Ejection systolic crescendo, descrescendo murmur with radiation to carotids
How do we investigate aortic stenosis? [4]
ECG - CXR - Echo - CMR
ECG - LV Strain pattern showing LVH (ST depression & T inversion)
CXR - LVH, calcified aortic valve
Echo then Cardiac catheterization
AVR - usually CAG done just before
How do we treat Aortic Stenosis? [3]
Medical mx: HF symptomatic treatment
If asymptomatic, then monitor with ECHO unless <50% EF LVSD + valvular gradient >40mmHg.
If asymptomatic, EF >50% then do exercise testing to strain the valve, if patient passes then can just monitor.
Symptomatic AS - no question, go for valve replacement
Valve replacement - surgical replacement or transcatheter + warfarin long term
Balloon valvuloplasty: palliative in highly symptomatic, also in children with no aortic valve calcification
How does Aortic Regurgitation progress?
The blood backs up so LV volume & pressure increases -> LVH -> increased O2 demand -> Ischaemia & LV failure`
What can cause aortic regurgitation?
Acute [3]
Chronic [7]
Acute:
- Infective endocarditis
- Ascending aortic dissection
- Chest trauma
Chronic:
- Atherosclerosis, HTN
- CTD eg Marfans
- Rheumatic heart disease
- Takayasu’s arteritis
- RA, SLE
- Myxomatous disease
- Osteogenesis imperfecta
- Syphilia aortitis
What are the symptoms of aortic regurgitation?
IF it happens acutely then LV failure, cyanosis and dyspnoea
If its chronic there will be a long time without symptoms with SOBOE and eventual RVF
What are the signs on examination of Aortic Regurgitation? [5]
A large collapsing pulse
A wide pulse pressure
Water hammer pulse palpated
Corrigans pulse - visible carotid pulsation
A hyperdynamic & displaced apex beat
A soft, early diastolic murmur on auscultation of the AV.
What would appear in an Aortic Regurgitation ECG?
An LV strain pattern of ST depression & T wave inversion. Signifying LVH
What would show up on an Aortic Regurgitation CXR? [3]
Cardiomegaly in chronic AR
Dilated ascending aorta
Pulmonary edema
What would an Echo show us in Aortic Regurgitation? [3]
AV thickening, prolapse, bicuspid and/or vegetations.
Also LV function, dilatation & hypertrophy.
A Doppler-Echo would show the regurgitant flow.
How can we treat Aortic Regurgitation? [3]
ACEi
6-12m ECHO monitoring
Aortic valve sparing or replacement surgery
Pulmonary stenosis O/E [4]
- raised JVP
- Left parasternal heave of RV hypertrophy
- End diastolic murmur at upper L sternal border
- signs of RHF, cyanosis
Pulmonary regurgitation murmur
end-diastolic murmur heard along left sternal border, signs of right heart failure may be seen
Tricuspid stenosis
- raised JVP
- mid-diastolic murmur at lower left sternal border
Tricuspid regurgitation O/E [3]
- pansystolic murmur at lower left sternal border, severe RHF, pulsatile liver
Valve replacement
Bioprosthesis or mechanical valves
◆ Bioprosthesis: xenogenic material (e.g. bovine/porcine pericardium)
◆ Mechanical prosthesis - last longer but require anticoagulation, recommended for younger patients.
Catheter based tehcniques
Describe 3 types and their indications
◆ Transcatheter aortic valve implantation (TAVI) for severe aortic stenosis.
◆ Transcatheter balloon valvuloplasty for MS (and to palliate AS).
◆ Percutaneous (catheter deployed) mitral valve intervention (i.e. mitral clipping) for severe mitral
regurgitation.
Medical management in valve disease [3]
◆ Treating symptoms/complications of valve disease.
◆ Secondary prevention of cardiovascular risk factors.
◆ Palliation where intervention is not possible.
What is contraindicated in right ventricular myocardial infarct?
Nitrates should be avoided in the likely diagnosis of right ventricular myocardial infarct due to causing reduced preload
RV infarct occurs in 30-50% of inferior MIs
Pulmonary stenosis vs aortic stenosis murmur
Pulmonary stenosis
* ejection systolic murmur, loudest in inspiration
Aortic stenosis
* same murmur but louder on expiration
Features suggesting VT rather than SVT with aberrant conduction
AV dissociation
fusion or capture beats
positive QRS concordance in chest leads
marked left axis deviation
history of IHD
lack of response to adenosine or carotid sinus massage
QRS > 160 ms
Describe what S1 and S2 represent
Describe what causes a soft, loud S1 and S2
S1
* closure of mitral and tricuspid valves
* soft if long PR or mitral regurgitation
* loud in mitral stenosis
S2
* closure of aortic and pulmonary valves
* soft in aortic stenosis
* splitting during inspiration is normal
Heart sounds
S3 (third heart sound)
- caused by diastolic filling of the ventricle
- heard in left ventricular failure (e.g. dilated cardiomyopathy)
- constrictive pericarditis (called a pericardial knock)
- mitral regurgitation
Heart sounds
Causes of fourth heart sound
- May be heard in aortic stenosis, HOCM, hypertension
- caused by atrial contraction against a stiff ventricle
- therefore coincides with the P wave on ECG
- in HOCM a double apical impulse may be felt as a result of a palpable S4
Pulses and clinical manifestations
Pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
Severe asthma
Cardiac tamponade
Pulses and clinical manifestations
When will you see a slow rising pulse?
When will you see collapsing pulse?
Slow-rising/plateau
aortic stenosis
Collapsing
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Pulses
When will you see pulsus alternans, bisferiens pulse?
Pulsus alternans
regular alternation of the force of the arterial pulse
severe LVF
Bisferiens pulse (arterial monitoring)
‘double pulse’ - two systolic peaks
mixed aortic valve disease
HOCM
What types of pulse may be associated with HOCM?
Jerky’ pulse
hypertrophic obstructive cardiomyopathy*
*HOCM may occasionally be associated with a bisferiens pulse
Sarcoidosis related syndromes
Lofgrens syndrome
Haerfordt syndrome
Lofgren’s syndrome - bilateral hilar lymphadenopathy + fever + erythema nodusum + polyarthralgia
Haerfordt syndrome - Bilateral hilar lymphadenopathy + fever + parotid enlargement + anterior uveitis
Sarcoidosis - when to give steroids?
- patients with chest x-ray stage 2 or 3 (ie parenchymal changes) disease who are symptomatic.
- Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
** hypercalcaemia - eye, heart or neuro involvement
HOCM prognostic factors
Poor prognostic factors
* syncope
* family history of sudden death
* young age at presentation
* non-sustained ventricular tachycardia on 24 or 48-hour Holter monitoring
* abnormal blood pressure changes on exercise
Management of mitral stenosis
symptomatic vs asymptomatic
asymptomatic patients
monitored with regular echocardiograms
percutaneous/surgical management is generally not recommended
symptomatic patients
percutaneous mitral balloon valvotomy
mitral valve surgery (commissurotomy, or valve replacement)
Mitral stenosis management
Percutaneous mitral balloon valvotomy vs mitral valve surgery
A ‘tight’ mitral stenosis implies a cross-sectional area of < 1 sq cm
* Percutaneous mitral balloon valvotomy - for severe MS, mitral valve area 1.5cm squared with favourable valve morphology without left atrial thrombus, without moderate to severe MR
* Mitral valve surgery in severely symptomatic patients with severe MS who are not high risk for surgery
Aortic dissection
Describe the type of pain experienced
typically severe and ‘sharp’, ‘tearing’ in nature
pain is typically maximal at onset
classically chest pain is more common in type A dissection and upper back pain is more common in type B dissection. However, there is considerable overlap and both chest and back pain are present in many patients
Aortic dissection
Describe the abnormal pulse found
weak or absent carotid, brachial, or femoral pulse
variation (>20 mmHg) in systolic blood pressure between the arms
Aortic dissection
associations
hypertension: the most important risk factor
trauma
bicuspid aortic valve
collagens: Marfan’s syndrome, Ehlers-Danlos syndrome
Turner’s and Noonan’s syndrome
pregnancy
syphilis
Aortic dissection
Spinal arteries involvement will present with…
Distal aorta involvement will present with…
spinal arteries → paraplegia
distal aorta → limb ischaemia
Aortic dissection - Stanford classification
Distinguish between type A and type B
- type A - ascending aorta, 2/3 of cases
- type B - descending aorta, distal to left subclavian origin, 1/3 of cases
