Cardiology #3 Murmurs, Hyperlipidemia, & Atrial Myxoma Flashcards
Explain the pathophysiology of aortic regurgitation.
What does this murmur sound like?
Incomplete aortic valve closure –> LV overload –> Heart failure
Diastolic blowing decrescendo murmur at LUSB
What are some symptoms of aortic regurgitation?
-Austin Flint Murmur: retrograde regurgitant jet competing with integrate flow from LA –> LV
-Bounding Pulses
-De Musset Sign: head bob with heartbeat
-Quincke Pulses: fingernail bed pulsations
-Water Hammer Pulse: swift increase and decrease of pulse with wrist elevation
What are the diagnostics done for aortic regurgitation?
Echo: shows dilated LV (thick)
Catheter: definitive
Treatment for aortic regurgitation
-Afterload reduction improves flow: ACE, ARBs, CCB
-Surgery: definitive
Explain the pathophysiology of aortic stenosis
How about some etiologies?
-LV outflow obstruction leads to a fixed CO, LVH, and LV failure eventually
-Degenerative: calcifications, wear and tear
-Congenital: Bicuspid valve (MC if < 70 years old)
-History of rheumatic heart disease
What does the murmur of aortic stenosis sound like?
Systolic crescendo/decrescendo murmur at RUSB radiating to the carotid
-Also has a weak, delayed carotid pulse
Diagnostics for aortic stenosis
-Echo: LVH, thick aortic valve
-EKG: LVH, A-fib
-Catheter is definitive
Treatment for aortic stenosis
-Surgical treatment (AV replacement)
–Mechnical: thrombogenic (needs long term anticoagulant)
–Bioprosthetic: less durable but minimally thrombogenic
–Intraaortic balloon pump: bridge before valve replacement
What are some things that the patient should avoid before valve replacement if they have aortic stenosis?
Physical exertion, venodilators (nitrates), negative inotropes (BB, CCB)
What is mitral stenosis? Where does the blood back up into in this condition?
Explain the pathophysiology.
Obstruction of flow from the LA–>LV due to narrowed mitral orifice.
blood backs up into the LA. LA pressure increases –> pulmonary congestion –> pulmonary hypertension
What is the MC etiology of mitral stenosis?
Symptoms of mitral stenosis.
Rheumatic heart disease
-Dyspnea, hemoptysis, pulmonary hypertension, cough
-A-fib due to LA enlargement
-RHF due to pulmonary congestion
-Mitral facies = flushed cheeks with facial pallor
What does the murmur of mitral stenosis sound like?
What increases the intensity?
Prominent S1, opening snap
Low pitched, mid diastolic rumbling murmur heard best at apex
Increases intensity with left lateral decubitus position
Diagnostics for mitral stenosis
ECG: ______
Echo
CXR: ______
(Definitive):________
ECG: LA enlargement, A-fib, pulmonary hypertension
CXR: LA enlargement
Definitive: catheterization
Treatment for mitral stenosis
-Percutaneous balloon valvuloplasty
-Valve replacement if unable to do balloon
What is mitral regurgitation?
What is the MCC?
Retrograde blood flow from LV–> LA leading to LA dilation and increased pulmonary pressure
MCC: MVP (leaflet etiology)
What does the murmur of mitral regurgitation sound like?
What also increases the intensity?
Blowing holosystolic murmur at apex with radiation to axilla
Increased intensity with left lateral decubitus position
Treatment for mitral regurgitation
-Symptom control (ACE, ARBs) or diuretics
-Surgical repair of valve
What is the pathophysiology of mitral valve prolapse?
Who is this MC in?
Leaflets bulge (prolapse) into the LA
MC in young women
Although most patients are asymptomatic, what symptoms CAN they have with mitral valve prolapse?
Autonomic dysfunction: atypical chest pain, panic attacks, palpitations
What does the murmur for MVP sound like?
Mid-late systolic ejection click at apex
Pulmonic stenosis is _____________ and is almost always _____ as a cause.
RV outflow obstruction
Almost always congenital, disease of the young
What does the murmur for pulmonic stenosis sound like?
Harsh mid-systolic ejection crescendo-decrescendo murmur at the LUSB that radiates to the neck and increases with inspiration
What is the preferred treatment for pulmonic stenosis?
Balloon valvulopalsty
Pulmonic regurgitation is retrograde blood flow that leads to _________.
The murmur with this condition is called a Graham-Steele Murmur. Explain this.
RV overload
brief decrescendo early diastolic murmur at LSUB with full inspiration. Increases with inspiration and decreases with expiration.
Is there any treatment needed for pulmonic regurgitation?
No treatment is needed
With tricuspid stenosis, what happens?
What does this murmur sound like?
Blood backs up into the RA –> RA enlargement –> RHF
Mid diastolic murmur at LLSB that increases with inspiration, opening snap
Treatment for tricuspid stenosis
-Diuretics, Na+ restriction to decrease RA overload
-Replacement of valve if RHF or decreased CO
What does the murmur for tricuspid regurgitation sound like?
Holosystolic, harsh blowing high pitched murmur at LLSB with NO radiation
With tricuspid regurgitation, Carvallo’s Sign is present. What is this?
Increase in intensity with inspiration
What is the acronym used for diastolic murmurs?
Systolic murmurs?
Diastolic: MS PRARTS
Systolic: MR TRASPS
What are two specific symptoms of hyperlipidemia?
Xanthomas (Achilles Tendon)
Xanthelasma (plaques on eyelids)
What are the following defintions?
-Hypercholesterolemia:
-Dyslipidemia:
Hypercholesterolemia: Total > 200
Dyslipidemia: LDL >130 and/or HDL <40
When should you initiate a statin therapy? There are 5 reasons why you would. Name them.
-DM aged 40-75
-w/o CVD 40-75 w/ > 7.5% HA or stroke risk w/in 10 yrs
- 21 or older with LDL > 190
-Anyone with atherosclerotic disease
-< 19 y/o with familial hypercholesterolemia
What are the best medications for the following actions:
-Lower LDL
-Lower TG’s
-Increase HDL
-Type II DM
Statins are best to lower LDL
Fibrates are best to lower TG’s
Niacin is best to raise HDL
Statins, Fibrates are best for DM Type II
Statins
-Drug names
-MOA
-Best to….
-Adverse Effects
Simvastatin, Rosuvastatin
Inhibit hepatic cholesterol synthesis
Best to lower LDL
Adverse: Myositis, Rhabdomyolysis, Increased LFT’s
Niacin (Nicotinic Acid)
-MOA
-Adverse Effects
Delays HDL clearance
Adverse: flushing, pruritus, dry skin, hyperglycemia, GI symptoms
With Niacin, what should you give beforehand to help with pruritus?
NSAIDs or Aspirin beforehand
Fibrates
Drug Names
MOA
Best to…
Adverse Effects
-Fenofibrate, Gemfibrozil
-Inhibit TG synthesis and increase activity of lipoprotein lipase
-Best to lower TG’s
-Adverse: myalgias, gallstones
DO NOT USE IF CKD OR BREASTFEEDING
Bile Acid Sequestrants
-Drug name
-What it does
-Is it Safe in Pregnancy?
-Often paired with?
-Adverse Effects:
Cholestyramine
Lower LDL, mildly raise HDL
Yes safe in pregnancy
Paired with statin
Adverse: GI, Increased TG’s
, Ezetemibe
-What it does
-Used in combination with…
Lowers LDL
Pair with a statin
An atrial myxoma is the MC primary cardiac tumor, however, it is rare. 80% of these occur in which chamber of the heart?
For this reason, it causes an obstruction of the mitral orifice, mimicking what condition?
80% left atrium
Mimicks Mitral stenosis
Symptoms of an atrial myxoma (much like mitral stenosis)
-Dyspnea, syncope, weight loss
-Flu like symptoms
-MS like murmur: prominent S1, low pitched diastolic murmur
Best test for an atrial myxoma and what do you see?
TEE: pedunculate mass in mitral orifice
Treatment for an atrial myxoma
Surgical removal
