Cardiovascular conditions 2 Flashcards
2nd half of cardiovascular conditions Valve and vascular conditions
What is aortic regurgitation?
Reflux of blood from the aorta into the left ventricle during diastole, due to a weakened aortic valve. Also known as aortic insufficiency
What causes aortic regurgitation?
Abnormal backflow of blood leads to pathological changes - left ventricular chamber enlargement and hypertrophy takes place to maintain a normal CO
What are the Risk factors for aortic regurgitation?
Aortic valve leaflet abnormalities or damage
- Bicuspid aortic valve
- Infective endocarditis
- Rheumatic fever
- Trauma
- Age
Aortic root/ascending aorta dilatation
- Systemic hypertension
- Aortic dissection
- Aortitis
- Arthritides (e.g. RA, seronegative arthritides)
- Connective tissue disease (Marfan’s, Ehler-danlos)
- Pseudoxanthoma elasticum, osteogenesis imperfecta
What are the symptoms for aortic regurgitation?
Chronic
- Initially asymptomatic
- Late symptoms of heart failue (e.g. exertional dyspnoea, orthopnoea, fatigue)
- Palpitations, angina and syncope, CCF
Acute
- Sudden cardiovascular collapse (left ventricle cannot adapt to rapid increase in end-diastolic volume)
What are the signs of aortic regurgitation?
Collapsing pulse
Wide pulse pressure
Thrusting and heaving displaced apex beat
Early diastolic murmur over the aortic valve region (heard best when sitting forward with breath help at top of expiration)
An ejection systolic murmur may also be heard due to increased flow across the valve
What Eponymous signs are seen in Aortic regurgitation?
- Austin-flint mid-diastolic murmur (Heard over apex)
- Quincke’s sign (pulsation on nail bed)
- De Musset’s sign (Head nodding with pulse)
- Becker’s sign (pupil and retinal artery pulsation)
- Muller’s sign (Pulsation of uvula)
- Corrigan’s sign (Pulsation in neck)
- Traube’s sign (Pistol shot [loud systolic and diastolic sounds] on auscultation of femoral arteries)
- Durozies’s sign (systolic and diastolic bruit heard on partial compression of femoral artery)
- Rosenbach’s sign (systolic pulsations of liver)
- Gerhard’s sign (Systolic pulsation of the spleen)
- Hill’s sign (Popliteal cuff systolic pressure exceeding brachial pressure >60)
What are the investigations for Aortic regurgitation?
CXR (Cardiomegaly, dilatation of ascending aorta, signs of pulmonary oedema)
ECG (LVH)
Echocardiogram (show underlying cause, or effects of aortic regurgitation, doppler echo)
Cardiac catheterisation with angiography (functional state of ventricles or the presence of coronary artery disease) - helps assess severity of lesion, aortic root anatomy, LV function
How can you see left ventricular hypertrophy on ECG?
Deep S in V1/2
Tall R in V5/6
Inverted T waves in Lead I, aVL, V5/6
Left axis deviation
What is Aortic stenosis?
Narrowing of the left ventricular outflow at the level of the aortic valve?
What causes aortic stenosis?
Stenosis can be secondary to Rheumatic heart disease (most common worldwide)
Congenital: Calcification of a congenital bicuspid aortic valve, william’s syndrome
Calcification/degradation of a tricuspid aortic valve in the elderly (Senile calcification)
What are the risk factors for Aortic stenosis?
Age > 60
CKD
What are the symptoms of aortic stenosis?
May be asymptomatic initially
Aortic stenosis in elderly patients with chest pain, exertional dyspnoea or syncope
Angina (due to an increased Oxygen demand of the hypertrophied left ventricle)
Syncope or dizziness on exercise
Symptoms of heart failure
What are the signs of Aortic stenosis?
Narrow pulse pressure with slow-rising pulse
Heaving, undisplaced apex beat
Ejection systolic murmur at the aortic area, radiation to the carotid artery
Second heart sound may be softened or absent
A bicuspid valve may produce an eejiton click
What are the investigations for aortic stenosis?
ECG
- P mitrale
- LVH
- LBBB or complete AV block
CXR
- Post-stenotic enlargement of ascending aorta
- Calcification of aortic valve
- LVH
Echocardiogram (diagnostic)
- visualises structural changes of the valves and level of stenosis (valvar, supravalvar or subvalvar)
- Estimation of aortic valve area and pressure gradient across the valve in systole
- Assess left ventricular function
Doppler echo can estimate gradient across valves
Severe stenosis if gradient >/= 50mmHg and valve area <1cm^2
If aortic jet velocity >4ms risk of complications is increased
What is Mitral regurgitation?
Retrograde flow of blood from left ventricle to left atrium during systole due to mitral valve insufficiency
What are the causes of mitral regurgitation?
Caused by mitral valve damage or dysfunction, which in turn could be caused by any of the following:
- Rheumatic heart disease
- Infective endocarditis
- Mitral valve prolapse
- Papillary muscle rupture or dysfunction (Secondary to IHD or cardiomyopathy)
- Chordal rupture and floppy mitral valve associated with connective tissue disease
- Functional: LV dilatation
- Annular calcificaiton
- Congenital
- Cardiomyopathy
- Appetite suppressants (fenfluramine)
What are the symptoms for Mitral regurgitation?
Acute MR - May present with symptoms of LVF
Chronic MR - asymptomatic or present with:
- Exertional dyspnoea
- Palpitations if in AF
- Fatigue
Mitral valve prolapse - asymptomatic or atypical chest pain or palpitations
What are the signs of mitral regurgitation?
Pulse may be irregularly irregular (AF) Laterally displaced apex beat with thrusting Pansystolic murmur - Loudest apex beat - Radiates to axilla - Soft S1 - S3 may be heard due to rapid ventricular filling Signs of LVF in acute Mitral valve prolapse - Mid-systolic click - Late systolic murmur - The click moves towards S1 when standing and away when laying down
What investigations are done for Mitral regurgitation?
ECG (Normal, may show AF or P mitrale)
CXR
- Acute MR shows signs of LVF
- Chronic (Left atrial enlargement, cardiomegaly, mitral valve calcification, pulmonary oedema)
Echo (Perform 6-12 months)
Doppler Echo
Cardiac catheterisation to confirm diagnosis, exclude other valve disease, assess CAD
What is Mitral Stenosis?
Mitral valve narrowing causes obstruction to blood flow from the left atrium to the left ventricle
What causes Mitral stenosis?
Mainly: Rheumatic heart disease Rarer causes: - Congenital mitral stenosis - Mucopolysaccharidoses - Endocardial fibroelastosis - Prosthetic valve - SLE - Rheumatoid arthritis - Endocarditis - Atrial myxoma
What are the symptoms of Mitral stenosis?
Fatigue Exertional dyspnoea Chest pain Orthopnoea Palpitations (related to AF) Systemic emboli Rarer symptoms (chronic bronchitis type picture) - Cough -Haemoptysis - Hoarseness caused by compression of left recurrent laryngeal nerve by an enlarged left atrium
What are the signs of Mitral stenosis?
Peripheral cyanosis
Malar flush (decreased CO)
Irregularly irregular pulse
Low volume pulse
Apex beat in right place and tapping
Parasternal heave (RV hypertrophy, secondary to pulmonary hypertension)
Loud S1 with opening snap
Mid-diastolic murmur heard best in expiration with patient laying on their left
Graham steel murmur may occur
Evidence of pulmonary oedema on lung auscultation
What are the investigations for mitral stenosis?
ECG
- Normal
- May see P mitrale
- May see AF - Evidence of RVH if severe pulmonary hypertension)
CXR
- Left atrial enlargement [double shadow in Right cardiac sillhouette]
- cardiac enlargemen
- pulmonary congestion/oedema
- Mitral valve calcification [occurs in rheumatic cases])
Echocardiography
- Assess functional and structural impairments
- Transoesophageal echocardiogram (TOE) gives a better view
Cardiac catheterisation
- Measure severity of heart failure
What is tricuspid regurgitation?
Backflow of blood from the right ventricle to the right atrium during systole
What causes tricuspid regurgitation?
Congenital
- Ebstein’s anomaly
- Cleft valve in ostium primum
Functional
- Consequence of Right ventricular dilatation (e.g. due to pulmonary hypertension)
- Valve prolapse
Rheumatic heart disease
Infective endocarditis (IV drug user)
Other: Carcinoid syndrome, traume, cirrhosis, iatrogenic
Drugs e.g. Ergot-derived dopamine agonists i.e. bromocriptine, cabergoline, pergolide
What are the risk factors for Tricuspid regurgitation?
Right ventricular dilatation from pulmonary hypertension for left heart failure Rheumatic heart disease Infective endocarditis Carcinoid syndrome Permanent pacemaker Congenital
What are the symptoms of Tricuspid regurgitation?
Fatigue Breathlessness Palpitations Headaches Nausea Anorexia Epigastric pain made worse by exercise Jaundice Lower limb swelling Ascites Oedema
What are the signs of tricuspid regurgitation?
Irregularly irregular pulse Raised JVP (Giant V waves) Palpation Auscultation - Pansystolic murmur - Louder on inspiration (Carvallo sign) - Loud P2 component of second heart sound Chest exam: - Pleural effusion - Cases of pulmonary HTN Abdominal exam: - Palpable liver - Ascites - Jaundice
What investigations are done for Tricuspid regurgitation?
FBC LFT Cardiac enzymes Blood culture ECG - P pulmonale [R atrial hypertrophy] Echo - Extent of regurgitation can be estimated using doppler US - May show valve prolapse and RV dilation Right heart catheterisation - Rarely needed
What is aortic dissection?
A condition where a tear in the aortc intima allows blood to surge in the aortic wall, causing a split between inner and outer tunica media, creating a false lumen.
How do you classify aortic dissection?
Type A: Ascending aorta (most common - 70%)
Type B: Descending aorta (distal to left subclavian artery - 30%)
What causes aortic dissection?
Preceded by degenerative changes in the smooth muscle of aortic media
Expansion of false lumen leads to obstruction of branches of the aorta: Subclavian, carotid, coeliac and renal arteries
- Hypoperfusion of target organs give rise to symptoms
- Unequal arm pulses and BP
- Anterior spinal artery (acute limb ischaemia, paraplegia)
- Renal arteries (anuria)
- If moves proximally, develop aortic valve incompetence, inferior MI and cardiac arrest
What are the risk factors for aortic dissection?
Hypertension Aortic atherosclerosis Connective tissue disease (e.g. Marfan's, Ehlers-Danlos, SLE) Congenital cardiac abnormalities (coarctation of the aorta) Aortitis Iatrogenic Trauma Crack cocaine
What are the symptoms of Aortic dissection?
Main symptom: Sudden central 'tearing' pain, may radiate to the back in between shoulder blades (can mimic MI) Other symptoms caused by obstruction of branches of aorta: - Hemiparesis, dysphasia, black out - Chest pain - Ataxia, loss of consciousness - Paraplegia - Severe abdo pain - Anuria, Renal failure
What are the signs of aortic dissection?
Murmur on back (below left scapula) Hypertension Blood pressure difference between 2 arms Wide pulse pressure Hypotension suggests tamponade - Check for pulsus paradoxus - Include: Tamponade, pericarditis, chronic sleep apnoea, obstructive lung disease Signs of aortic regurgitation (high volume collapsing pulse, early diastolic murmur over aortic area)
What are the investigations of aortic dissectoin?
FBC Cross-match 10 units of blood U&Es (check renal function) Clotting screen CXR (Widened mediastinum) ECG ( Maybe signs of LVH and inferior MI) Echo (TOE allows visualisation)
What is an Abdominal Aortic Aneurysm?
A localised enlargement of the abdominal aorta such that the diameter is >3cm or >50% larger than normal diameter.
A true aneurysm is an abnormal dilatation involving all layers of the arterial wall
- Can be fusiform [most] or sac-like
What is a pseudo aneurysm?
False aneurysms involving a collection of blood in the outer layer only (adventitia) which communicates with the lumen e.g. after trauma
What causes an AAA?
No specific causes
Unruptured aneurysms occur due to degeneration of elastic lamellae and smooth muscle loss
Ruptured AAAs leak into the retroperitoneal space (relatively stable) or intraperitoneal space (results in shock)
What are the Risk Factors for AAA?
Severe atherosclerotic damage to aortic wall
Family history
Smoking
Male
Age
Hypertension
Hyperlipidaemia
Connective tissue disorders (marfan’s, Ehlers-Danlos)
Inflammatory disorders (Behcets, Takayasu arteritis)
What are the symptoms of AAA?
Unruptured - No symptoms - Incidental finding - May have pain in back, abdomen, loin or groin Ruptured - Pain in abdomen - intermittent or continuous - Pain may be sudden or severe - Syncope - low bp - Shock
What are the signs of AAA?
Pulsatile and laterally expansile mass on bimanual palpitation of the abdominal aorta
Abdominal bruit
Retroperitoneal haemorrhage (Can cause Grey-turner’s)
Hypotension
Tachycardia
What are the investigations for AAA?
FBC Clotting screen Renal function Liver function Cross-match Doppler US CT with contrast MRI angiography
At what size AAA is needed for management?
Women - 5cm
Men - 5.5cm
What are Arterial ulcers?
A localised are of drainage and breakdown of skin due to inadequate arterial blood supply.
Usually seen on feet of patients with severe atheromatous narrowing of the arteries supplying the legs
What causes arterial ulcers?
Ulcers are caused by a lack of blood flow to the capillary beds of the lower extremities
What are the risk factors for arterial ulcers?
Coronary heart disease History of stroke or TIA Diabetes mellitus Peripheral artery disease (e.g. intermittent claudication, critical limb ischaemia) Obesity and immobility
What are the symptoms of arterial ulcers?
Often distal (Dorsum of foot or between toes)
Punched-out appearance
Often elliptical with clearly defined edges
Ulcer base contains grey, granulation tissue
Night pain - hallmark of arterial ulcers (worse when supine, relieved by dangling leg off end of bed)
What are the signs of arterial ulcers?
Night pain Punched out appearance Hairlessness Pale skin Absent pulses Nail dystrophy Wasting of calf muscles
What investigations are done for arterial ulcers?
Duplex ultrasonography of lower limbs - assess patency of arteries and potential for revascularisation or bypass surgery
ABPI
Percutaneous angiography
ECG
Fasting serum lipids, fasting blood glucose and HbA1c (diabetes is major RF)
FBC (anaemia can worsen ischaemia)
What is DVT?
Formation of thrombus within deep veins (most commonly in calf or thigh)
What causes DVT?
Deep veins in the legs are more prone to blood stasis hence clots are more likely to form
Virchow’s triad
