Clin Med - Valvular dz Flashcards
what are heart murmur sounds made by?
fast-flowing across defective valves
suspected etiology of murmur is based on what?
- where it is heard on the chest
- timing in the S1/S2 cycle
bell is used to hear what?
- low pitched sounds
- use for identifying S4/S3
diaphragm is used for what?
-filtering out low pitched sounds to highlight high-pitched sounds
intensity of murmurs are affected by what?
- body position
- inspiration and expiration
inspiration
- 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
expiration
- 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
valsalva
- Reduces filling/venous return of the right and then left heart - decreases BP
- decreases intensity of most murmurs EXCEPT that associated w/ hypertrophic cardiomyopathy
squatting
- Increases peripheral resistance and increases ventricular filling
- increases intensity of most murmurs
- decreases intensity of hypertrophic cardiomyopathy
right sided (tricuspid, pulmonic) murmur intensity changes
- accentuated w/ inspiration
- decreased w/ valsalva
- +/- increases w/ squatting
left sided (aortic, mitral) murmur intensity changes
- accentuated w/ expiration
- decreased w/ valsalva
- +/- increases w/ squatting
how to classify murmur
- systolic vs diastolic
- location
- radiation
- pitch
- quality
murmur shapes
- a type of classification
- creschendo: increasing
- decrescendo: fading
- uniform: pan/holo
What grades of murmurs can you hear but not feel?
1-3
What grades of murmurs can you hear and feel?
4-6
If you feel a murmur, what is it called?
thrill
causes of aortic stenosis
- 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
progression of aortic stenosis
- asymptomatic for long period of time
- once stenosis is severe, dramatic changes occur
mechanics of aortic stenosis
- 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
PE in aortic stenosis
- systolic ejection murmur w/ ejection click
- crescendo/decresendo
- radiates to the neck/carotids
- heart best at right 2nd ICS
diagnosis of aortic stenosis
- CXR and EKGs are rarely helpful
- ECHO is gold standard
- TTE is preferred initial study for eval of heart valves
tx of aortic stenosis
- 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
etiology and symptoms of pulmonic stenosis
- etiology: congenital
- symptoms: dyspnea w/ exertion
findings in pulmonic stenosis
- ejection click
- ejection systolic murmur at left upper sternal border
- crescendo-decrescendo
ts of pulmonic stenosis
- balloon valvuloplasy for sever symptomatic PS
- high success rate, low complication and restenosis rate
What are the causes of mitral regurg?
- rheumatic fever
- papillary muscle dysfunction from ischemia or MI
- annular dilation from dilated cardiomyopathy
- endocarditis - perforations or vegetations cause abnormal closing
mild to moderate mitral regurg
-usually asymptomatic since there is little volume overload of the ventricle
severe mitral regurg
-remain symptomatic until there is left ventricular failure, pulm. HTN, or onset of a fib
most common symptoms in mitral regurg
- exertional dyspnea
- fatigue
mechanics of mitral regurg
-abnormal mitral valve doesn’t close completely at the beginning of systole (S1)
PE of mitral regurg
- holosystolic murmur heard at apex
- radiates to axilla
- S1 may be diminished reflecting failure of the mitral valve to close properly
diagnosis of mitral regurg
-TTE is gold standard
tx of mitral regurg
- 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
causes of mitral valve prolapse
- most cases are primary and not associated w/ other disease processes
- sometimes familial
- some cases associated w/ Marfan’s
- most pts are symptomatic
mechanisc of mitral valve prolapse
- as LV pressure increases during systole, mitral valve closes
- as pressure continues to build, the floppy mitral valve billows up in the left atrium
explain the click in mitral valve prolapse
- 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
PE in mitral valve prolapse
- mid-systolic click w/ late systolic murmur
- heart best over apex
diagnosis of mitral valve prolapse
-TTE
tx of mitral valve prolapse
- 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
etiology of tricuspid regurgitation
- endocarditis (IVDA)
- pulmonary HTN
- RV failure
- MI
PE of tricuspid regurg
- 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
diagnosis of tricuspid regurg
-TTE
tx of tricuspid regurg
- 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)
what are the diastolic murmurs?
- aortic regurg
- pulmonic regurg
- mitral stenosis
- tricuspid stenosis
causes of aortic regurg
- aortic root dilation - associated w/ HTN
- rheumatic heart dz
- infective endocarditis
- marfan’s
- aortic dissection
- syphilis
- collagen vascular dz
natural history of chronic* aortic regurg
- 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
natural history of acute* aortic regurg
- 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
mechanics of aortic regurg
- pressure in aorta is greater than pressure in LV
- blood regurgitates back thorugh incompetent aortic valve into LV = loud murmur
PE in aortic regurg
- 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
diagnosis of aortic regurg
-TTE
tx of aortic regurg
- 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
surgery for aortic regurg involves:
- 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
etiology of pulmonary regurg
- pulm. HTN
- carcinoid syndrome (serotonin-secreting tumor)
findings in pulmonary regurg
-early diastolic decrescendo murmur
-left sternal border increasing w/ inspiraiton
-
tx of pulmonary regurg
- none
- tx underlying pulm. HTN
causes of mitral stenosis
- almost all are caused by rheumatic heart dz
- most occur in women
natural hx of mitral stenosis
- 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
mechanics of mitral stenosis
- 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
PE of mitral stenosis
- 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
diagnosis of mitral stenosis
-TTE
tx of mitral stenosis
- 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
For those with mitral stenosis w/ a very thickened valve and/or moderate/severe mitral regurg, what surgery can be an option?
- mitral commisurotomy - manually open up valve
- mitral valve replacement
tricuspid stenosis causes
- rheumatic fever
- congenital abnormalities
- carcinoid syndrome
- endocarditis
symptoms of tricuspid stenosis
- fatigue
- abdominal swelling
- lower extremity edema
PE of tricuspid stenosis
- +/- elevated jugular venous pulse
- mid-diastolic murmur
- heart at left 4th ICS
- low pitched rumble - heard better w/ bell
tx of tricuspid stenosis
- diuretics may help w/ symptoms
- if heart failure develops, valve replacement or balloon valvotomy may be used
mechanical vs. tissue valves
- 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
older pts typically receive what kind of valve?
tissue
younger patients usually get mechanical
When is endocarditis prophylaxis indicated?
- in any pt w/ prosthetic heart valve
- any pt who has had a heart valve repaired w/ prosthetic material
what procedures require prophylaxis?
- invasive dental procedures
- procedures of the respiratory tract or infected skin, tissue just under skin, or muscuoskeletal tissue
meds used for endocarditis prophylaxis
- amoxicillin: standard
- ampicillin
- clindamycin
what cardiac changes occur during pregnancy?
- blood vol., heart rate, and CO all increase
- S3 can be a normal finding
- regurgitant lesions are tolerated
- stenotic lesions are not tolerated
When should pregnancy be avoided?
- in pts w/ severe pulmonic/mitral/aortic stenosis
- prosthetic valve requiring anticoagulation (use of lovenox ONLY)
when do you have a closed fixed splitting of S2?
-pulmonary HTN
S3 heart sound
- 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
S4 heart sound
- end of diastole directly before S1
- sign of pressure overload
- sign of LVH and uncontrolled HTN
S3 is aka
- ventricular gallop
- caused by tensing of cordae tendineae of the ventricle
S4 is aka
- atrial gallop
- caused by atrium contracting against non-compliant ventricle
systolic click
- ejection click = aortic stenosis; popping open of stenosed valve
- mid-systolic click = mitral valve prolapse; tensing of cardae
opening snap
- mitral stenosis
- snapping open of stenosed valve
which valves are the most important and most common?
left sided valves
a diastolic murmur has to do with ?
- fast blood flow into a ventricle
- mitral stenosis or aortic insufficiency
- tricuspid stenosis or pulmonic insufficiency
A systolic murmur involves what?
- fast blood flow out of a ventricle
- aortic stenosis or mitral regurg
- pulmonic stenosis or tricuspid regurg
murmurs that increase w/ inspiration involve which valves?
- right sided valves
- w/ inspiration, blood flow increases to the right side of the heart
valve makeup
-all valves have 3 leaflets except mitral which has 2
what are the normal variant murmurs?
-mild MR, TR and PR are seen in most people
review case studies
start at slide 79
