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My MRCP > Cardio: Valvular heart disease > Flashcards

Cardio: Valvular heart disease Flashcards

1
Q

Left sided murmurs

How does mitral stenosis progress? [3]

A

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]

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2
Q

Left sided murmurs

What can cause mitral stenosis? [7]

A
  • 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
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3
Q

Left sided murmurs

What are the symptoms of mitral stenosis? [5]

A
  • 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)
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4
Q

Left sided murmurs

What are the clinical signs of mitral stenosis? [6]

A

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

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5
Q

Left sided murmurs

How do we investigate suspected Mitral Stenosis? [4]

A

An ECG, CXR - LA enlargement

Echocardiogram - Thickening/Scarring of mitral leaflets

CMR

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6
Q

Left sided murmurs

How can we treat mitral stenosis? [3]

A
  • Atrial fibrillation > warfarin
  • Asymptomatic - monitoring regular ECHO
  • Symptomatic - percutaneous mitral balloon valvotomy, mitral valve surgery
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7
Q

Left sided murmurs

What would appear on an MS ECG? [2]

A

Tall P wave indicating LA enlargement - p mitrale

Prominent R wave showing RVH

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8
Q

Left sided murmurs

How do we treat Mitral Regurgitation? Acute [2] vs Chronic MR [2]

A

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

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9
Q

Left sided murmurs

Rheumatic Heart Disease What is it triggered by? [3]

Describe histology seen in RHF

A

Rheumatic fever

  1. GABHS infection - streptococcus pyogenes
  2. Cross-reactive Immunological reaction to recent strep pyogenes infection - antigen presentation to T cells - molecular mimicry
  3. 2-6w ago
  4. 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
  5. Aschoff bodies describes the granulomatous nodules found in rheumatic heart fever
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10
Q

Rheumatic Heart Disease Sequelae [5]

A
  1. Valvular stenosis + regurgitate *mitral stenosis
  2. LA dilation due to pressure overload > AF
  3. Large mural thrombi form
  4. Chronic venous congestion > LHF
  5. RV hypertrophy
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11
Q

RHD DX What criteria is used?

A

Jones criteria

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12
Q

RHD DX

List minor [3] and major [5] criteria

A

Major Criteria:

  • Carditis
  • Migratory polyarthritis
  • Subcutaneous nodules
  • Erythema marginatum skin rash
  • Sydenham chorea/ St vitus dance

Jones Criteria Minor Criteria:

  • Fever
  • Arthralgias
  • ECG changes
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13
Q

Left sided murmurs

Mitral valve prolapse associations

A

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

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14
Q

Left sided murmurs

Characteristic murmur for mitral valve prolapse

A

mid-systolic click (occurs later if patient squatting)
late systolic murmur (longer if patient standing)

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15
Q

Left sided murmurs

Complications of MVP [3]

A

mitral regurgitation, arrhythmias (including long QT), emboli, sudden death

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16
Q

Left sided murmurs

How is MVP diagnosed

what other investigations are needed

A

Defined by imaging
Ant or post mitral valv leaflets cross valve plane by >2mm into left atrium during ventricular systole

Stress ECHO

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17
Q

Left sided murmurs

Mitral valve prolapse murmur characteristics

what happens to the murmur as severity increases

A

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.

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18
Q

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

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.

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19
Q

Describe murmur characteristic in Mitral Regurgitation

A
  • Pansystolic murmur (radiation to axilla) louder on expiration.
  • Mid-late systolic murmur in MV prolapse (radn. to axilla, louder on inspiration).
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20
Q

In which would you see left heart failure? Mitral Stenosis or Mitral regurgitation

A

MR - you would see signs of LHF

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21
Q

Management of Rheumatic heart fever [3]

A
  • 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.
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22
Q

Left sided murmurs

How does Aortic Stenosis lead to Heart failure?

A

Pressure backs up in the LH causing it to hypertrophy. This increases myocardial O2 demand eventually leading to LVF

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23
Q

What causes Aortic Stenosis?

A

Calcific degenerative disease - A slow inflammatory process thickens and calcifies the cusps (senile calcification, linked to atherosclerosis)
Rheumatic disease
Congenital Bicuspid Valve

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24
Q

What is the symptoms of aortic stenosis?

A

A long time is spent asymptomatic then suddenly:

Angina - Syncope - SOBOE - Heart Failure

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25
Q

What are the clinical signs of aortic stenosis?

A

Pulse is slow rising with narrow pulse pressure
Heaving Apex Beat, LV Heave
Aortic Thrill
Ejection systolic crescendo, descrescendo murmur with radiation to carotids

26
Q

How do we investigate aortic stenosis? [4]

A

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

27
Q

How do we treat Aortic Stenosis? [3]

A

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

28
Q

How does Aortic Regurgitation progress?

A

The blood backs up so LV volume & pressure increases -> LVH -> increased O2 demand -> Ischaemia & LV failure`

29
Q

What can cause aortic regurgitation?
Acute [3]
Chronic [7]

A

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
30
Q

What are the symptoms of aortic regurgitation?

A

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

31
Q

What are the signs on examination of Aortic Regurgitation? [5]

A

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.

32
Q

What would appear in an Aortic Regurgitation ECG?

A

An LV strain pattern of ST depression & T wave inversion. Signifying LVH

33
Q

What would show up on an Aortic Regurgitation CXR? [3]

A

Cardiomegaly in chronic AR
Dilated ascending aorta
Pulmonary edema

34
Q

What would an Echo show us in Aortic Regurgitation? [3]

A

AV thickening, prolapse, bicuspid and/or vegetations.
Also LV function, dilatation & hypertrophy.
A Doppler-Echo would show the regurgitant flow.

35
Q

How can we treat Aortic Regurgitation? [3]

A

ACEi
6-12m ECHO monitoring
Aortic valve sparing or replacement surgery

36
Q

Pulmonary stenosis O/E [4]

A
  • raised JVP
  • Left parasternal heave of RV hypertrophy
  • End diastolic murmur at upper L sternal border
  • signs of RHF, cyanosis
37
Q

Pulmonary regurgitation murmur

A

end-diastolic murmur heard along left sternal border, signs of right heart failure may be seen

38
Q

Tricuspid stenosis

A
  • raised JVP
  • mid-diastolic murmur at lower left sternal border
39
Q

Tricuspid regurgitation O/E [3]

A
  • pansystolic murmur at lower left sternal border, severe RHF, pulsatile liver
40
Q

Valve replacement

Bioprosthesis or mechanical valves

A

◆ Bioprosthesis: xenogenic material (e.g. bovine/porcine pericardium)
◆ Mechanical prosthesis - last longer but require anticoagulation, recommended for younger patients.

41
Q

Catheter based tehcniques

Describe 3 types and their indications

A

◆ 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.

42
Q

Medical management in valve disease [3]

A

◆ Treating symptoms/complications of valve disease.
◆ Secondary prevention of cardiovascular risk factors.
◆ Palliation where intervention is not possible.

43
Q

What is contraindicated in right ventricular myocardial infarct?

A

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

44
Q

Pulmonary stenosis vs aortic stenosis murmur

A

Pulmonary stenosis
* ejection systolic murmur, loudest in inspiration

Aortic stenosis
* same murmur but louder on expiration

45
Q

Features suggesting VT rather than SVT with aberrant conduction

A

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

46
Q

Describe what S1 and S2 represent
Describe what causes a soft, loud S1 and S2

A

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

47
Q

Heart sounds

S3 (third heart sound)

A
  • caused by diastolic filling of the ventricle
  • heard in left ventricular failure (e.g. dilated cardiomyopathy)
  • constrictive pericarditis (called a pericardial knock)
  • mitral regurgitation
48
Q

Heart sounds

Causes of fourth heart sound

A
  • 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
49
Q

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

A

Severe asthma
Cardiac tamponade

50
Q

Pulses and clinical manifestations

When will you see a slow rising pulse?
When will you see collapsing pulse?

A

Slow-rising/plateau
aortic stenosis

Collapsing
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)

51
Q

Pulses

When will you see pulsus alternans, bisferiens pulse?

A

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

52
Q

What types of pulse may be associated with HOCM?

A

Jerky’ pulse
hypertrophic obstructive cardiomyopathy*

*HOCM may occasionally be associated with a bisferiens pulse

53
Q

Sarcoidosis related syndromes

Lofgrens syndrome
Haerfordt syndrome

A

Lofgren’s syndrome - bilateral hilar lymphadenopathy + fever + erythema nodusum + polyarthralgia

Haerfordt syndrome - Bilateral hilar lymphadenopathy + fever + parotid enlargement + anterior uveitis

54
Q

Sarcoidosis - when to give steroids?

A
  • 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
55
Q

HOCM prognostic factors

A

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

56
Q

Management of mitral stenosis
symptomatic vs asymptomatic

A

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)

57
Q

Mitral stenosis management

Percutaneous mitral balloon valvotomy vs mitral valve surgery

A

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

58
Q

Aortic dissection
Describe the type of pain experienced

A

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

59
Q

Aortic dissection
Describe the abnormal pulse found

A

weak or absent carotid, brachial, or femoral pulse
variation (>20 mmHg) in systolic blood pressure between the arms

60
Q

Aortic dissection

associations

A

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

61
Q

Aortic dissection

Spinal arteries involvement will present with…

Distal aorta involvement will present with…

A

spinal arteries → paraplegia
distal aorta → limb ischaemia

62
Q

Aortic dissection - Stanford classification

Distinguish between type A and type B

A
  • type A - ascending aorta, 2/3 of cases
  • type B - descending aorta, distal to left subclavian origin, 1/3 of cases

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