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LMCC - Medicine > Cardiology - Valvular Disease + Heart Failure > Flashcards

Cardiology - Valvular Disease + Heart Failure Flashcards

1
Q

Discuss the cause, symptoms and findings of mitral stenosis

A 
Cause
- rheumatic heart disease
Symptoms
- left-sided heart failure
Findings
- Loud S1
- Opening snap
- diastolic rumble, loudest in left lateral decubitus
Treatment
- Increase diastolic filling time with BB or digoxin
- Surgery for NYHA III-IV
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2
Q

Discuss the cause, symptoms and findings of mitral regurgitation

A 
Causes
- Acute:
     - endocarditis
     - ruptured chordae
     - papillary muscle dysfunction
- Chronic
     - rheumatic
     - mitral prolapse
     - calcified annulus
     - dilated LV
Symptoms
- pulmonary edema 
- left sided HF
- fatigue
Findings
- holosystolic murmur at apea
- murmur worse with clenching fists
Treatment
- Decrease preload (nitrates) and afterload (ACEi)
- Surgery for acute, NYHA III-IV, worsening LV function
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3
Q

Discuss the cause, symptoms and findings of aortic stenosis

A 
Causes
- degenerative calcifications
- congenital
- rheumatic
Symptoms
- chest pain
- syncope
- dyspnea with exertion
Findings
- delayed upstroke and decrease volume at carotid
- suprasternal thrill
- Soft A2
- systolic ejection type murmur
Treatment
- Avoid nitrates/ACEi in severe AS
- Surgery for symptomatic or LV dysfunction
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4
Q

Discuss the cause, symptoms and findings of aortic regurgitation

A 
Causes
- congenital (bicuspid valve)
- endocarditis
- rheumatic
- aortic root dilatation
Symptoms
- dyspnea on exertion
- chest pain
Findings
- wide pulse pressure
- bounding pulses
- early diastolic decresendo murmur (heard best at expiration, with patient leaning forward)
Treatment
- Asymptomatic: afterload reduction
- Symptomatic: avoid exertion, treat CHD
- Surgery: NYHA III-IV, LV dilatation or LVEF <50%
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5
Q

Discuss the causes of left heart failure

A 
Systolic Dysfunction
- Impaired Contractility
     - coronary artery disease
           - MI
     - Valvular Disease
           - mitral regurgitation
           - aortic regurgitation
     - Dilated Cardiomyopathy
- Increased afterload
     - aortic stenosis
     - hypertension
Diastolic Dysfunction
- impaired diastolic filling
     - left ventricular hypertrophy
     - restrictive cardiomyopathy
     - myocardial fibrosis
     - transient myocardial ischemia
     - pericardial constriction or tamponade
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6
Q

Discuss the causes of right heart failure

A 
Cardiac Causes
- left sided heart failure
- pulmonic valve stenosis
- right ventricular infarction
Lung Diseases
- COPD
- Interstitial lung disease
- ARDS
- infection
Pulmonary Vascular Disease
- pulmonary embolism
- primary pulmonary hypertension
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7
Q

Discuss the definitions for heart failure

A

Definitions

  • Forward Failure
    - inability to pump blood forward at sufficient rate leading to low cardiac output
  • Backward Failure
    - heart able to pump at sufficient rate only if cardiac filling pressure is abnormally high, volume overload
  • Systolic dysfunction
    - unable to contract blood efficiently due to impaired contractility or increased afterload
    - decreased ejection fraction
  • Diastolic dysfunction
    - unable to fill due to decreased compliance
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8
Q

Discuss the compensation for heart failure

A

Compensation

  • increase preload
    - incomplete chamber emptying resulting in decreased stroke volume -> increase end diastolic volume -> increase stroke volume and end diastolic pressure -> volume overload
  • Neuro-hormonal axis
    - increased sympathetic activity by increased contractility, HR and vasoconstriction
    - increased renin-angiotensin system which increase BP, increase venous return, and increase aldosterone leading to Na retention and increased circulating volume and venous return
    - increase ADH which increase aldosterone
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9
Q

Discuss the presentation and investigations for heart failure

A

Presentation
- FACES
- fatigue
- activities limited, exercise intolerance
- chest congestion
- edema including ascites and peripheral edema
- SOB including orthopnea, paroxysmal nocturnal dyspnea
Investigations
- CBC, electrolytes, BUN/creatinine, LFT
- B-type natriueretic peptide (BNP)
- CXR
- ECG
Diagnosis
- normal BNP rules out heart failure
- left systolic dysfunction with LVEF <40%

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10
Q

Discuss the New York Heart Association (NYHA) classification

A 
Class 1
- no symptoms
- perform ordinary activity without limitations
- have structural heart disease but no symptoms
Class 2
- mild symptoms of dyspnea, fatigue with moderate exertion
- occasional swelling of ankles
- no symptoms at rest
Class 3
- symptoms with minimal exertion
- limitation to activity
- comfortable only at rest
Class 4
- symptoms at rest
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11
Q

Discuss the management for systolic heart failure

A

Prevention
- dyslipidemia, diabetes, hypertension, smoking
Loop Diuretics
- treat volume overload
- furosemide 20-40mg OD-BID
ACE inhibitor + Beta Blocker (Mortality benefit)
- symptomatic or LVEF <40%
- ACEi
- Captopril start at 6.25mg PO TID to 50mg PO TID
- Enalapril start at 2.5mg PO BID to 20mg PO BID
- Lisinopril start 5mg PO BID to 40mg PO BID
- ARBs
- Candesartan 4mg PO to 32mg PO
- Beta Blocker
- Carvedilol start at 3.125mg PO BID to 25-50mg PO BID
- Bisoprolol start at 1.25mg PO OD to 5-10mg PO OD
- Metoprolol start at 12.5mg PO OD to 200mg PO OD
Aldosterone Antagonist (Mortality)
- NYHA III/IV
- Spironolactone 12.5mg PO OD to 50mg PO OD
Digoxin, Nitrate, Hydralazine
- NYHA III/IV
- digoxin improve symptom and reduce hospitalization
Combined Diuretics
- NYHA III/IV
- thiazide
Implantable Cardioverter Defibrillator
- LVEF <30%
Cardiac Resynchronization Therapy
- QRS >120ms
Heart Transplant
- refractory to above treatments

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12
Q

Discuss the exacerbating factors for congestive heart failure

A 
Increased Metabolic Demands
- infection
- anemia
- hyperthyroidism
- pregnancy
Increased Circulating Volume
- excessive sodium diet
- excessive fluid administration
- renal failure
Increased Afterload
- uncontrolled hypertension
- pulmonary embolism
Impaired Contractility
- Myocardial ischemia
- excessive alcohol
Medication Incompliance
Bradycardia
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13
Q

Discuss the treatment for cold heart failure

A

Inotrope to Increase CO

  • dopamine
  • dobutamine
  • Milrinone
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14
Q

Discuss the treatment for wet heart failure

A

LMNOP

  • Lasix
    - 40-500mg IV until euvolemic based on normal JVP, no peripheral edema or pulmonary edema
    - age + BUN for lasix dose
  • Morphine
    - decrease anxiety and decrease preload by venodilation
    - 2-4mg IV
  • Nitrate
    - decrease preload
  • Oxygen
    - titrate to O2 >92%
  • Position and Positive Pressure Ventilation
    - position upright to help breathing
    - CPAP/BiPAP to decrease preload
    - used for respiratory distress, severe hypoxia, or altered LOC
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15
Q

Discuss the differential for Heart Failure with Reduced Ejective Fraction

A 
Dilated
- Idiopathic
- Infection
- Alcohol
- Familial
Secondary
- CAD
- MI
DM
- Valvular (AR, MR)
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16
Q

Discuss the differential for Heart Failure Preserved Ejection Fraction

A 
Hypertrophic Cardiomyopathy
- Genetic disorder affecting cardiac sarcomeres (septal hypertrophy)
Restrictive Cardiomyopathy
- Amyloidosis
- Sarcoidosis
- Scleroderma
- Hemachromatosis
- Carcinoid (Tricuspid or Pulmonary dysfunction)
Secondary
- HTN
- DM
- Valvular (AS)
- Post-MI
17
Q

Discuss Hypertrophyc Cardiomyopathy

A 
Histology
- Myocyte disarray, myocyte hypetrophy, interstitial fibrosis
Classification
- Hypertrophic obstructive cardiomyopathy resulting in dynamic LV outflow tract obstruction
Presentation
- Asymptomatic
- Sudden cardiac death in youth
- SOB on exertion
- Syncope
- Triple ripple (triple apical pulse)
- Spike and dome
- Harsh systolic murmur increase with decrease preload (valsava)
Investigations
- ECG: LVH, prominent Q waves in lateral
- First degree relatives screened with Echo every 12 mon during adolescence and every 5 years in adulthood
Management
- Avoidance of volume depletion as increase obstruction (sports)
- BB and avoid nitrates
- Surgical myomectomy
- Alcohol ablation

LMCC - Medicine (40 decks)

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