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Cardiology 2 > Clin Med - Valvular dz > Flashcards

Clin Med - Valvular dz Flashcards

1
Q

what are heart murmur sounds made by?

A

fast-flowing across defective valves

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2
Q

suspected etiology of murmur is based on what?

A
  • where it is heard on the chest

- timing in the S1/S2 cycle

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3
Q

bell is used to hear what?

A
  • low pitched sounds

- use for identifying S4/S3

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4
Q

diaphragm is used for what?

A

-filtering out low pitched sounds to highlight high-pitched sounds

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5
Q

intensity of murmurs are affected by what?

A
  • body position

- inspiration and expiration

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6
Q

inspiration

A
  • negative intrathoracic pressure pulls venous blood into the right side of the heart - increasing venous return
  • lungs are expanding which decreases flow of blood out of lungs to left side of heart - this decreases left heart preload
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7
Q

expiration

A
  • venous return from body decreases d/t decreased intrathoracic pressure
  • as lungs deflate, more blood flows in to the left side of the heart - increases left preload
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8
Q

valsalva

A
  • Reduces filling/venous return of the right and then left heart - decreases BP
  • decreases intensity of most murmurs EXCEPT that associated w/ hypertrophic cardiomyopathy
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9
Q

squatting

A
  • Increases peripheral resistance and increases ventricular filling
  • increases intensity of most murmurs
  • decreases intensity of hypertrophic cardiomyopathy
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10
Q

right sided (tricuspid, pulmonic) murmur intensity changes

A
  • accentuated w/ inspiration
  • decreased w/ valsalva
  • +/- increases w/ squatting
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11
Q

left sided (aortic, mitral) murmur intensity changes

A
  • accentuated w/ expiration
  • decreased w/ valsalva
  • +/- increases w/ squatting
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12
Q

how to classify murmur

A
  • systolic vs diastolic
  • location
  • radiation
  • pitch
  • quality
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13
Q

murmur shapes

A
  • a type of classification
  • creschendo: increasing
  • decrescendo: fading
  • uniform: pan/holo
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14
Q

What grades of murmurs can you hear but not feel?

A

1-3

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15
Q

What grades of murmurs can you hear and feel?

A

4-6

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16
Q

If you feel a murmur, what is it called?

A

thrill

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17
Q

causes of aortic stenosis

A
  • most caused by degeneration of normal tricuspid aortic valves
  • 1-2% of population is born w/ bicuspid valve - tend to degenerate earlier
  • rheumatic heart dz is rarely a cause
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18
Q

progression of aortic stenosis

A
  • asymptomatic for long period of time

- once stenosis is severe, dramatic changes occur

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19
Q

mechanics of aortic stenosis

A
  • in stenosis, valve doesn’t open initially = small delay of the murmur after S1
  • when pressure finally gets strong enough to pop open the stenosed valve = ejection noise/click
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20
Q

PE in aortic stenosis

A
  • systolic ejection murmur w/ ejection click
  • crescendo/decresendo
  • radiates to the neck/carotids
  • heart best at right 2nd ICS
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21
Q

diagnosis of aortic stenosis

A
  • CXR and EKGs are rarely helpful
  • ECHO is gold standard
  • TTE is preferred initial study for eval of heart valves
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22
Q

tx of aortic stenosis

A
  • no medical therapy is helpful
  • definitive tx is surgical valve replacement - based on presence of symptoms
  • cardiac cath is necessary before surgery if CAD is present
  • balloon valvuloplasty is rarely used - usually for palliation; has higher mortality rate than surgery
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23
Q

etiology and symptoms of pulmonic stenosis

A
  • etiology: congenital

- symptoms: dyspnea w/ exertion

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24
Q

findings in pulmonic stenosis

A
  • ejection click
  • ejection systolic murmur at left upper sternal border
  • crescendo-decrescendo
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25
Q

ts of pulmonic stenosis

A
  • balloon valvuloplasy for sever symptomatic PS

- high success rate, low complication and restenosis rate

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26
Q

What are the causes of mitral regurg?

A
  • rheumatic fever
  • papillary muscle dysfunction from ischemia or MI
  • annular dilation from dilated cardiomyopathy
  • endocarditis - perforations or vegetations cause abnormal closing
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27
Q

mild to moderate mitral regurg

A

-usually asymptomatic since there is little volume overload of the ventricle

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28
Q

severe mitral regurg

A

-remain symptomatic until there is left ventricular failure, pulm. HTN, or onset of a fib

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29
Q

most common symptoms in mitral regurg

A
  • exertional dyspnea

- fatigue

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30
Q

mechanics of mitral regurg

A

-abnormal mitral valve doesn’t close completely at the beginning of systole (S1)

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31
Q

PE of mitral regurg

A
  • holosystolic murmur heard at apex
  • radiates to axilla
  • S1 may be diminished reflecting failure of the mitral valve to close properly
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32
Q

diagnosis of mitral regurg

A

-TTE is gold standard

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33
Q

tx of mitral regurg

A
  • therapy of the underlying cause if any
  • reducing afterload (BP) w/ meds could help those who are symptomatic
  • surgery considered for those w/ sever regurg
  • surgical options: mitral valve replacement or repair
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34
Q

causes of mitral valve prolapse

A
  • most cases are primary and not associated w/ other disease processes
  • sometimes familial
  • some cases associated w/ Marfan’s
  • most pts are symptomatic
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35
Q

mechanisc of mitral valve prolapse

A
  • as LV pressure increases during systole, mitral valve closes
  • as pressure continues to build, the floppy mitral valve billows up in the left atrium
36
Q

explain the click in mitral valve prolapse

A
  • as the valve pulls back on the cordae tendinae, the cords tense rapidly to attempt to hold the valve tight - this creates the click
  • the incompetent valve allows regurg of blood back in to the atrium and you hear a murmur
37
Q

PE in mitral valve prolapse

A
  • mid-systolic click w/ late systolic murmur

- heart best over apex

38
Q

diagnosis of mitral valve prolapse

A

-TTE

39
Q

tx of mitral valve prolapse

A
  • for most it is a benign condition
  • rarely associated w/ endocarditis, arrhythmias or sudden cardiac death
  • a rare few have progression of mitral regurg and eventually require surgery
40
Q

etiology of tricuspid regurgitation

A
  • endocarditis (IVDA)
  • pulmonary HTN
  • RV failure
  • MI
41
Q

PE of tricuspid regurg

A
  • may have dyspnea and lower extremetiy edema if they have heart failure
  • JVD
  • holosystolic murmur may be present that worsens w/ inspiration
  • heart best at left 4th ICS
42
Q

diagnosis of tricuspid regurg

A

-TTE

43
Q

tx of tricuspid regurg

A
  • diuretics for swelling
  • surprisingly, most pts can tolerate life w.o a tricuspid valve
  • pt w/ endocarditis not responsive to abx may have their valve taken out (not replaced)
44
Q

what are the diastolic murmurs?

A
  • aortic regurg
  • pulmonic regurg
  • mitral stenosis
  • tricuspid stenosis
45
Q

causes of aortic regurg

A
  • aortic root dilation - associated w/ HTN
  • rheumatic heart dz
  • infective endocarditis
  • marfan’s
  • aortic dissection
  • syphilis
  • collagen vascular dz
46
Q

natural history of chronic* aortic regurg

A
  • most cases are chronic and lead to volume overload
  • may eventually lead to LV dysfunction
  • pts may have dyspnea/orthopnea
  • syncope and angina can occur
47
Q

natural history of acute* aortic regurg

A
  • rarely pts can develop acute aortic regurg from a perforation from endocarditis or distortion from an aortic dissection
  • pt will feel acutely SOB and may have pulm. edema
48
Q

mechanics of aortic regurg

A
  • pressure in aorta is greater than pressure in LV

- blood regurgitates back thorugh incompetent aortic valve into LV = loud murmur

49
Q

PE in aortic regurg

A
  • early diastolic murmur in decrescendo pattern
  • b/c the blood flow is backwards toward the ventricle, often hear murmur at LSB instead of 2nd ICS
  • corrigan’s pulse could be involved: rapid rise and fall of carotid pulse
50
Q

diagnosis of aortic regurg

A

-TTE

51
Q

tx of aortic regurg

A
  • mild-moderate: none
  • severe w/o LVH and normal LV function: control BP w/ ACEi or CCB
  • severe w/ LVH and reduced EF: surgical correction
52
Q

surgery for aortic regurg involves:

A
  • replacement of aotric valve and sometimes the ascending aorta w/ graft material
  • aortic valve repaire w/ a patch of pericardial tissue
  • aortic annuloplasty - sewing of the annulus to decrease cross-sectional area
53
Q

etiology of pulmonary regurg

A
  • pulm. HTN

- carcinoid syndrome (serotonin-secreting tumor)

54
Q

findings in pulmonary regurg

A

-early diastolic decrescendo murmur
-left sternal border increasing w/ inspiraiton
-

55
Q

tx of pulmonary regurg

A
  • none

- tx underlying pulm. HTN

56
Q

causes of mitral stenosis

A
  • almost all are caused by rheumatic heart dz

- most occur in women

57
Q

natural hx of mitral stenosis

A
  • once stenosis becomes moderate/severe, pts may feel DOE/orthopnea
  • when pulm. HTN occurs, the RV may fail and lead to edema, ascites, anorexia
  • hemoptysis could occur
  • thrombus may form
  • **hoarseness may rarely occur
58
Q

mechanics of mitral stenosis

A
  • beginning of diastole/rapid filling, lots of blood coming through a small opening in stenosed mitral valve = loud murmur
  • the stiff/stenosed leaflets don’t open easily and “snap” open = opening snap
59
Q

PE of mitral stenosis

A
  • S1 may be loud if valve is stiff
  • opening snap following S2 as the valve is forced open by high atrial pressure
  • diastolic rumble that is low-pitched may be heard at apex
  • a fib is common
60
Q

diagnosis of mitral stenosis

A

-TTE

61
Q

tx of mitral stenosis

A
  • no medical therapy is helpful in slowing progression
  • diuretics are helpful in presence of right heart failure and swelling
  • warfarin is necessary for those w/ a. fib
  • balloon valvuloplasty can be helpful for long term improvement
62
Q

For those with mitral stenosis w/ a very thickened valve and/or moderate/severe mitral regurg, what surgery can be an option?

A
  • mitral commisurotomy - manually open up valve

- mitral valve replacement

63
Q

tricuspid stenosis causes

A
  • rheumatic fever
  • congenital abnormalities
  • carcinoid syndrome
  • endocarditis
64
Q

symptoms of tricuspid stenosis

A
  • fatigue
  • abdominal swelling
  • lower extremity edema
65
Q

PE of tricuspid stenosis

A
  • +/- elevated jugular venous pulse
  • mid-diastolic murmur
  • heart at left 4th ICS
  • low pitched rumble - heard better w/ bell
66
Q

tx of tricuspid stenosis

A
  • diuretics may help w/ symptoms

- if heart failure develops, valve replacement or balloon valvotomy may be used

67
Q

mechanical vs. tissue valves

A
  • mechanical valves last longer but require anticoagulation w/ coumadin
  • tissue valves degenerate quicker but no not require anticoagulation
  • both are equally susceptible to endocarditis and prophylaxis is needed
68
Q

older pts typically receive what kind of valve?

A

tissue

younger patients usually get mechanical

69
Q

When is endocarditis prophylaxis indicated?

A
  • in any pt w/ prosthetic heart valve

- any pt who has had a heart valve repaired w/ prosthetic material

70
Q

what procedures require prophylaxis?

A
  • invasive dental procedures

- procedures of the respiratory tract or infected skin, tissue just under skin, or muscuoskeletal tissue

71
Q

meds used for endocarditis prophylaxis

A
  • amoxicillin: standard
  • ampicillin
  • clindamycin
72
Q

what cardiac changes occur during pregnancy?

A
  • blood vol., heart rate, and CO all increase
  • S3 can be a normal finding
  • regurgitant lesions are tolerated
  • stenotic lesions are not tolerated
73
Q

When should pregnancy be avoided?

A
  • in pts w/ severe pulmonic/mitral/aortic stenosis

- prosthetic valve requiring anticoagulation (use of lovenox ONLY)

74
Q

when do you have a closed fixed splitting of S2?

A

-pulmonary HTN

75
Q

S3 heart sound

A
  • heard directly after S2
  • sign of volume overload
  • can be normal in young healthy pts
  • in older pts it is usually a sign of CHF
76
Q

S4 heart sound

A
  • end of diastole directly before S1
  • sign of pressure overload
  • sign of LVH and uncontrolled HTN
77
Q

S3 is aka

A
  • ventricular gallop

- caused by tensing of cordae tendineae of the ventricle

78
Q

S4 is aka

A
  • atrial gallop

- caused by atrium contracting against non-compliant ventricle

79
Q

systolic click

A
  • ejection click = aortic stenosis; popping open of stenosed valve
  • mid-systolic click = mitral valve prolapse; tensing of cardae
80
Q

opening snap

A
  • mitral stenosis

- snapping open of stenosed valve

81
Q

which valves are the most important and most common?

A

left sided valves

82
Q

a diastolic murmur has to do with ?

A
  • fast blood flow into a ventricle
  • mitral stenosis or aortic insufficiency
  • tricuspid stenosis or pulmonic insufficiency
83
Q

A systolic murmur involves what?

A
  • fast blood flow out of a ventricle
  • aortic stenosis or mitral regurg
  • pulmonic stenosis or tricuspid regurg
84
Q

murmurs that increase w/ inspiration involve which valves?

A
  • right sided valves

- w/ inspiration, blood flow increases to the right side of the heart

85
Q

valve makeup

A

-all valves have 3 leaflets except mitral which has 2

86
Q

what are the normal variant murmurs?

A

-mild MR, TR and PR are seen in most people

87
Q

review case studies

A

start at slide 79

Cardiology 2 (13 decks)

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