Ch. 6 Chest Pain and Syncope

Question 1

What is the significance of an S4?

Answer 1

Extra heart sound most frequently heard in pts with LVH

Although it is common in pts with AS, can also be heard in pts with hypertensive heart disease and hypertrophic cardiomyopathy

Question 2

What other valvar disease can be mistaken for aortic stenosis?

Answer 2

Pulmonic stenosis (similar crescendo-decrescndo murmur)

HOCM.. but can be differentiated from AS by asking pt to perform Valsalva maneuver, which would increase the murmur in HOCM but decrease its intensity in AS

Question 3

What is the most concerning symptom in pts with aortic stenosis?

Answer 3

Dyspnea, since 1/2 of these patients with evidence of CHF will succumb to the disease within 2 years without surgical valve replacement

Question 4

What are the differentiating features of various cardiac murmurs?

Murmur:

Description:

Location:

Answer 4

Question 5

Pulsus Alternans

Pulsus Bisferiens

Answer 5

Pulsus Alternans - PE finding wherein amplitude of peripheral pulse changes from beat to beat associated with changing systolic BP. Most commonly caused by LV failure.

Pulsus Bisferiens - Biphasic pulse, refers to two strong systolic pulses with midsystolic dip, in other words, two pulses during systole

• Can be seen in AR with or without AS and HOCM

Question 6

What are the classic physical findings associated with endocarditis?

Answer 6

• Fever
• Roth spots (retinitis septica) - Retinal hemorrhages, white spot close to optic disk surrounded by hemorrhage
• Osler nodes - septic emboli to microvessels in skin causing tender microabscesses
• MR
• Janeway lesions - small erythematous or hemorrhagic nontender lesions on plams, soles, distal finger pads
• Anemia
• Nail hemorrhages (splinter) - microscopic blood cloths underneath nail
• Endocarditis

Question 7

What are the three possible etiologies for development of aortic stenosis?

Answer 7

1. Senile
   
   1. Older pts; often after 6th decade
   2. Calcificatin of an otherwise normal valve ** most common cause
2. Congenital
   
   1. Middle aged; often 4th or 5th decade
   2. Calcification and fibrosis of congenitally bicuspid aortic valve
3. Rheumatic Valvar Disease
   
   1. Immigrants from countries with poor healthcare
   2. Rheumatic fever can affect aortic valve or mitral valve

Question 8

What contributes to chest pain that is commonly seen in patients with AS?

What causes the dyspnea in AS?

Answer 8

Chest pain

• High myocardial wall tension + LVH inc. myocardial oxygen demand which is further compromised by decreased diastolic coronary blood flow

Dyspnea

• Thickened ventricular cavity that may also be somewhat ischemic –> stiff ventricle that requires higher filling pressures to maintain end-diastolic volume –> inc. pulmonary venous pressures + sensation of dyspnea

Question 9

Drugs to avoid with aortic stenosis

Answer 9

Drugs that reduce BP (diuretics, beta-blockers, vasodilators)