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Yr 4 - ACC > Cardiology: Valves > Flashcards

Cardiology: Valves Flashcards

1
Q

What is the most common valvular disorder in developed countries?

A

Aortic stenosis (AS)

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2
Q

What are the main causes of AS?

A

1) Age-related Calcification

2) Bicuspid Aortic Valve (congenital)

3) Rheumatic Heart Disease

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3
Q

What is the most common cause of AS in developed countries?

A

age-related degenerative calcification (typically >65 y/o)

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4
Q

Why does a bicuspid aortic valve predispose to AS?

A

This predisposes to early calcification and stenosis.

This congenital abnormality is associated with earlier and more aggressive AS.

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5
Q

What is aortic stenosis?

A

It refers to narrowing of the aortic valve, restricting blood flow from the left ventricle to the aorta.

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6
Q

Where is the aortic valve found?

A

Between LV and aorta

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7
Q

Patients with aortic stenosis (AS) may be asymptomatic for a prolonged period of 10-20 years.

What are some ‘classical’ symptoms include the following of AS?

A

1) Exertional SOB (most common initial complaint)

2) Exertional angina

3) Exertional syncope or presyncope (10% of patients with symptomatic severe AS)

4) May also have signs of HF e.g. PND, orthopnoea etc

5) AF (common in patients with HF from AS)

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8
Q

Examination findings in AS?

A

1) Loud mid-late systolic ejection murmur.

With more severe AS:

1) Slow-rising and low volume carotid pulse

2) Soft or absent second heart sound (S2)

3) Narrow pulse pressure

4) Thrill in the aortic area on palpation

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9
Q

Describe murmur in AS.

a) sound?
b) radiation?
c) what makes it more prominent?

A

a) Loud mid-to-late systolic ejection murmur

b) Radiates to carotids

c) More prominent with sitting forward and in expiration

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10
Q

How does level of stenosis affect murmur in AS?

A

Murmur becomes softer the more severe the stenosis

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11
Q

Investigations in AS?

A

1) ECG

2) CXR

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12
Q

How is LV affected in severe AS?

A

LV hypertrophy is present in about 80% of severe AS patients.

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13
Q

Definitive management of AS?

A

Definitive –> surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI).

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14
Q

Mortality of AS?

A

Average survival is only 2-3 years after symptoms begin

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15
Q

Complications of AS?

A

1) HF

2) Sudden cardiac death (may be due to ventricular tachyarrhythmia)

3) Arrhythmias e.g. AF

4) GI bleeding

5) Endocarditis

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16
Q

What is aortic regurgitation (AR)?

A

Aortic regurgitation is a condition where the aortic valve fails to close properly, leading to blood flowing back into the left ventricle during diastole.

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17
Q

Causes of aortic regurg?

A

Causes (due to valve disease):
1) Rheumatic fever
2) Infective endocarditis
3) Connective tissue diseases e.g. RA/SLE
4) Bicuspid aortic valve

Causes (due to aortic root disease):
1) Aortic dissection
2) Spondylarthropathies (e.g. ankylosing spondylitis)
3) Hypertension
4) Syphilis
5) Marfan’s, Ehler-Danlos syndrome

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18
Q

What murmur does AR cause?

A

1) Early diastolic, soft murmur (most common)

2) It can also cause an Austin-Flint murmur –> heard at the apex as a diastolic “rumbling” murmur.

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19
Q

Cardiac exam signs on AR?

A

1) Early diastolic murmur

2) Thrill in the aortic area on palpation

3) Collapsing pulse

4) Wide pulse pressure

5) Heart failure and pulmonary oedema

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20
Q

What is a collapsing pulse?

A

A forcefully appearing and rapidly disappearing pulse.

It occurs as blood is forcefully pumped out of the left ventricle, then immediately flows backwards through the incompetent aortic valve.

21
Q

What is the intensity of the murmur in AR increased by?

A

Handgrip manouevre

22
Q

Where is the mitral valve located?

A

Between the LA and LV.

23
Q

What is mitral stenosis?

A

The narrowing of the mitral valve orifice, leading to obstructed blood flow from the left atrium to the left ventricle

24
Q

What is the 1ary cause of MS?

A

Rheumatic fever (90%)

25
Q

Clinical features of MS?

A

1) SOB

2) Haemoptysis

3) Malar flush

4) Murmur –> mid-late diastolic (best heard in expiration)

5) AF

6) Tapping apex beat, which is a palpable, prominent S1

26
Q

What causes SOB in MS?

A

Increased LA pressure causes pulmonary venous HTN.

27
Q

What is malar flush?

A

Malar flush refers to red discolouration of the skin over the upper cheeks and nose.

It is due to the back pressure of blood into the pulmonary system, causing a rise in CO2 and vasodilation (seen in MS).

28
Q

Describe murmur heard in MS

A

Mid-diastolic, low-pitched “rumbling” murmur (due to a low blood flow velocity).

There is an opening snap after S2, which triggers the onset of the murmur.

29
Q

Cause of AF in MS?

A

Atrial fibrillation is caused by the left atrium struggling to push blood through the stenotic valve causing strain, electrical disruption and resulting fibrillation.

30
Q

What are the 2 main causes of MS

A

1) Rhemuatic heart disease

2) Infective endocarditis

30
Q

When examining a patient with heart valve pathology, look for signs of the potential underlying cause.

What should you look for in:

a) mitral stenosis

b) aortic regurg

A

a) signs of infective endocarditis:
- splinter haemorrhages
- Janeway lesions
- Osler’s nodes
- splenomegaly
- fundoscopy: Roth spots

b) signs of Marfans:
- tall stature
- long limbs
- arachnodactyly (long slender fingers)
- high arched palate

31
Q

Key complications of MS?

A

1) AF

2) Pulmonary HTN

3) Thromboembolism

4) Infective endocarditis: Damaged mitral valve leaflets are more susceptible to infection.

32
Q

What is mitral regurgitation (MR)?

A

Occurs when blood leaks back through the mitral valve from the LV to LA on systole.

33
Q

Causes of MR?

A

1) Idiopathic weakening of the valve with age

2) Ischaemic heart disease or post-MI (if the papillary muscles or chordae tendinae are affected)

3) Infective endocarditis

4) Rheumatic heart disease

5) Connective tissue disorders, such as Ehlers-Danlos syndrome or Marfan syndrome

34
Q

Mitral regurgitation can result after an MI due to damage to which structure?

A

Papillary muscles

35
Q

Clinical features of MR?

A

1) Murmur: pan-systolic, high-pitched “whistling” murmur (due to high-velocity blood flow through the leaky valve)
- radiates to left axilla

2) You may hear a third heart sound.

3) Thrill in the mitral area on palpation

4) Signs of heart failure and pulmonary oedema

5) Atrial fibrillation (irregularly irregular pulse)

36
Q

Describe the murmur in MR

A

pan-systolic, high-pitched “whistling” murmur

37
Q

Where does the murmur radiate to in MR?

A

Left axilla

38
Q

What are the 2 most common valves that need replacing?

A

Aortic & mitral

39
Q

What are the 2 main options for valve replacement?

A

1) Biological (bioprosthetic) e.g. bovine or porcine

2) Mechanical valves

40
Q

What is the most common type of valve replacement?

A

Bileaflet valve (mechanical)

41
Q

What is the main disadvantage of biological valves?

A

structural deterioration and calcification over time.

42
Q

Who is likely to receive a biological valve?

A

Most older patients ( > 65 years for aortic valves and > 70 years for mitral valves) receive a bioprosthetic valve

43
Q

Long-term anticoagulation in biological valves?

A

Long-term anticoagulation not usually needed.

Warfarin may be given for the first 3 months depending on patient factors.

Low-dose aspirin is given long-term.

44
Q

What is the main disadvantage of mechanical valves?

A

Increased risk of thrombosis (long-term anticoagulation needed).

45
Q

1st line anticoagulation in mechnical valves?

A

Warfarin.

46
Q

What is the most common causative organism of infective endocarditis in patients following prosthetic valve surgery?

A

Coagulase-negative Staphylococci such as Staphylococcus epidermidis.

47
Q

What is the most common causes of AS in:

a) patients ≤65
b) patients >65

A

a) bicuspid aortic valve
b) calcification

48
Q
A

Yr 4 - ACC (73 decks)

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