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2020 CPR II Cardio Exam 1 > Clinical Medicine 3: Murmurs, Valvular Disease (Johnston) > Flashcards

Clinical Medicine 3: Murmurs, Valvular Disease (Johnston) Flashcards

1
Q

What is the single most common sx associated w/ valvular heart disease?

A

Dyspnea on exertion

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2
Q

What are the 3 most common etiologies for valvular heart disease seen nowadays?

A
  1. Degenerative (senile calcification)
  2. Myxomatous degeneration (MVP) redundant
  3. Congenital (bicuspid aortic valve)
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3
Q

Stenosis of a valve leads to what type of overload and effect on heart?

A

Pressure overload; hypertrophy and HF

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4
Q

Regurgitation of a valve leads to what type of overload and effect on heart?

A

Volume overload; dilation

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5
Q

Which sex has a higher incidence of rheumatic heart disease?

A

Women 4:1

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6
Q

What are 6 minor jones criteria for rheumatic heart disease?

A
  1. Fever
  2. Arthralgia
  3. ↑ ESR or CRP
  4. Leukocytosis
  5. ECG - prolonged PR interval
  6. ↑ ASO titer or anti-DNAase B
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7
Q

How many major or combo of major/minor criteria need to be met for diagnosis of rheumatic heart disease?

A
  • 2 major

OR

  • 1 major + 2 minor
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8
Q

The narrowing of the mitral orifice seen in MS, leads to an increased pressure gradient where and what other changes?

A
  • ↑ left AV pressure gradient
  • LA enlargment –> afib, pulmonary vascular changes, RVH
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9
Q

Which decade is MS most common?

A

4th decade

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10
Q

Most common presenting sx’s of someone with mitral stenosis (MS)?

A
  • Fatigue assoc. w/ decreased CO
  • Dyspnea on exertion, cough, orthopnea, PND, pulmonary edema, hemoptysis
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11
Q

What is Ortner syndrome associated with MS?

A

Hoarsness due to compression of left recurrent laryngeal n. as LA ↑ in size

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12
Q

What is the common PE finding due to CO2 retention assoc. w/ pulmonary HTN seen in MS?

A

Malar rash

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13
Q

What are the ausculatory findings of S1 and S2 in pt with MS?

A
  • ↑ loud S1 + ↑ S2 (P2 if PHT is present)
  • Opening snap after S2 (if leaflet is mobile)
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14
Q

Describe the murmur associated with MS (i.e., phase of cardiac cycle, best heard where/position and with what part of stethoscope)?

A
  • DIASTOLIC, low pitch, decrescendo, rumbling murmur
  • Best heard at APEX w/ pt in left lateral decubitus position
  • Use BELL
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15
Q

In MS there will be increased loud S1 and increased S2, what would the presence of loud P2 (pulmonic valve closure) signify?

A

Presence of pulmonary HTN

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16
Q

Common EKG finding of someone presenting with sx’s of severe MS?

A

Atrial fibrillation

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17
Q

What do the ‘p’ wave findings in lead I and V1 signify?

A

Left atrial enlargement

*‘M’ shaped ‘p’ wave = P mitrale

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18
Q

What does the CXR finding signify about the heart?

A

Left atrial enlargment; notice the straight line

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19
Q

If patient with MS is in atrial fibrillation, what should be given and why?

A

Anticoagulant; risk of emboli

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20
Q

Which invasive procedure for MS has a high success rate?

A

Percutaneous balloon valvuloplasty (Mitral Commissotomy)

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21
Q

What are the 2 etiologies of chronic mitral regurgitation (MR) and which is most common?

A
  • Mitral valve prolapse = MOST common/myxomatous or degenerative MV
  • Mitral annular calcification (MAC)
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22
Q

What are 4 causes of acute mitral valve regurgitation?

Which is 2nd most common cause of MR?

A
  • Rupture of chordae tendineae
  • Rupture of papillary muscle
  • Ischemic papillary muscle dysf. due to CAD/MI = 2nd most common cause
  • Infective endocarditis (IE); valve perforation
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23
Q

Acute MR leads to an abrupt increase in what (volume/pressure) and what complications follow?

A

↑ LA PRESSURE —> pulmonary edema, LVF

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24
Q

What will be seen on the ECG of someone with chronic MR?

A
  • Left atrial enlargement
  • ‘M’ shaped p wave in lead I and negative terminality of p wave in V1
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25
Q

How can acute MR present clinically signs/sx’s?

What’s a serious complication that can arise?

A
  • Volume overload —> LV dilation
  • LA HTN –> Pulmonary HTN –> RVF —> RHF/LHF
  • Orthopnea and PND
  • Can present with cardiogenic shock!
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26
Q

Upon auscultation of pt with MR what type of murmur is heard, describe it’s characteristics (i.e., best heard where, radiates, use bell or diaphragm..)?

A
  • SYSTOLIC murmur (blowing, holosystolic; may be mid-late systolic) that radiates —> left axilla
  • Best heard at APEX; use the diaphragm
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27
Q

What feature of the murmur heard with MR correlates with severity?

A

Loudness

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28
Q

What is the characteristic of S1 in pt with MR and if due to MVP what may be heard?

A

Decreased S1 or normal; may have systolic click if due to MVP

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29
Q

Which manuever will move click and murmur associated with MR closer to S1?

What is the effect of hand grip on the murmur?

A
  • Valsalva moves click and murmur closer to S1
  • Hand grip will ↑ murmur
30
Q

Which drug class used for chronic MR?

31
Q

Which drug class is used to decrease afterload in MR?

A

Vasodilators (Nitroprusside)

32
Q

What is the rational for using an intra-aortic balloon pump (IABP) in someone with acute MR?

A
  • Decreases afterload
  • Helps to perfuse coronary arteries
33
Q

Which sex is most often affected by mitral valve prolapse (MVP) and what are congenital defects which increase risk?

A
  • Women 7:1
  • Assoc. with Marfans/skeletal changes
34
Q

What are the range of sx’s/signs associated with MVP?

A

Asymptomatic to arrhythmias (SVT, PVC’s, VT), chest pain and/or syncope

35
Q

What is the characteristics of the murmur heard with MVP?

A

SYSTOLIC murmur; may have systolic click

36
Q

If patient with MVP is in hyper-adrenergic state (anxious, palpitations), consider using what drug class?

A

Beta-blocker

37
Q

What is the favored tx for MVP?

A

Valve REPAIR favored over replacement

38
Q

What are 3 causes of Aortic Stenosis and which is most common?

A

- Most common = Degeneration of valve (calcific or senile) —> persons >65 yo

  • Congenital or acquired bicuspid aortic valve (BAV)
  • Rheumatic/post-inflammatory scarring (radiation)
39
Q

The obstruction in aortic stenosis leads to what type of overload (pressure/volume) and what are the downstream effects?

A

PRESSURE overload –> LVH –> ↑ LVED pressure = diastolic dysf + systolic HF

40
Q

Which decade does aortic stenosis typically manifest in and what are the 4 cardinal signs/sx’s?

A
  • 6th decade
  • Exertional dyspnea
  • Angina

- Syncope

  • Heart failure
41
Q

Prognosis of aortic stenosis with and w/o tx?

A
  • Without tx the prognosis is poor
  • With tx most will die within 3 years of developing syncope and within 2 years of onset of HF
42
Q

What are the common PE findings of aortic stenosis (i.e., pulse pressure, SV and systolic pressure)?

A
  • NARROW pulse pressure
  • Decreased SV and systolic pressure
  • Delayed pulses –> Parvis (weak w/ ↓ amplitude) or Tardus (late/delayed)
43
Q

What are the characteristis of the murmur heard in aortic stenosis (heard best where, radiates)?

Affect on A2 sound?

A
  • Decreased A2
  • HARSH, SYSTOLIC murmur, at 2nd ICS RSB
  • Radiates into suprasternal notch/carotids
44
Q

What is the Gallavardin phenomenon associated with aortic stenosis murmur?

A

Murmur radiates to apex (like MR)

45
Q

What does the huge amplitue of QRS in V5 and V6 along with high voltage in all chest leads indicate?

Seen in which valvular disease?

A
  • LV hypertrophy
  • Aortic Stenosis
46
Q

What is the “bridge therapy” for aortic stenosis that can buy time before surgery or TARV?

A

Balloon valvuloplasty

47
Q

What is the treatment for symptomatic, trileaflet aortic valvular sclerosis (stenosis) w/ high surgical risk; no aortic regurgitation?

A

TARV (transcatheter aortic valve replacement)

48
Q

What are 5 causes of acute aortic regurgitation?

A
  1. Infective endocarditis
  2. Aortic dissection
  3. BAV
  4. Chest trauma
  5. Balloon valvuloplasty
49
Q

List 7 causes of chronic aortic regurgitation?

A
  1. Syphilis
  2. Ankylosis spondylitis
  3. Ascending aortic dilation
  4. BAV
  5. Calcific degeneration
  6. Rheumatic
  7. Chest radiation
50
Q

Aortic regurgitation leads to what type of overload (pressure/volume) and leads to increased what?

A

VOLUME overload –> can ↑ LVEDV and cause LVH –> Left sided HF

51
Q

Acute aortic regurgitation is associated with what signs/sx’s (think underlying causes)?

A
  • Infective endocarditis
  • Aortic dissection
  • Acute pulmonary edema
  • Cardiogenic shock
52
Q

Chronic aortic regurgitation will develop over time with what signs/sx’s?

A

Dyspnea, orthopnea, PND, and chest pain

53
Q

Which type of murmur is present with Aortic Regurgitation, heard best where?

A

- DIASTOLIC, decrescendo murmur, 3rd ICS LSB

- Systolic murmur usually present, soft

54
Q

Which valvular heart disease has a wide pulse pressure and may be associated w/ De Musset sign, Corrigan’s Pulse, Quincke’s Pulse, Traube’s sign, Hill’s sign, and Durozrey’s sign?

A

Aortic regurgitation

55
Q

Which drug class should be prescribed to pt with aortic regurgitation to decrease afterload and in turn decrease regurgitation volume?

A

ARB (-sartans)

56
Q

When is surgery to replace or repair a valve in someone with aortic regurgitation indicated?

A
  • When symptomatic

OR

  • EF <50-55%
57
Q

Tricuspid stenosis is associated with what 3 heart/valvular problems and what are 2 other general associations?

A
  • Mitral stenosis, Tricuspid Regurgitation, and RHD
  • Can be associated with carcinoid and ergot agents (cabergoline)
58
Q

What type of murmur is associated with Tricuspid Stenosis and where is it best heard?

What causes an increase and decrease in the murmur?

A
  • DIASTOLIC, LOW pitch, decrescendo murmur at LSB
  • Increase w/ inspiration (Carvallo’s sign)
  • Decrease w/ expiration and valsalva
59
Q

Which wave in JVP is Tricuspid Stenosis vs. Regurgitation associated with?

A
  • TS = prominent “A” wave in JVP
  • TR = V wave in JVP
60
Q

List 7 associations with Tricuspid regurgitation

A
  1. Pulmonary HTN (COPD, cor pulmonale, RVF)
  2. RV infarction
  3. Inferior MI
  4. Pacemaker
  5. Endocarditis
  6. Congenital
  7. Trauma
61
Q

What is the characteristic murmur heard with tricuspid regurgitation and best heard where?

What will increase the intensity of the murmur?

A
  • Blowing, holoSYSTOLIC murmur heard at LSD 4th ICS
  • Increases with inspiration (Carvallo’s sign) –> due to increased venous return
62
Q

What is the characteristic murmur heard with Pulmonary Stenosis and is best heard where?

Radiation?

Increases with what?

A
  • SYSTOLIC crescendo-decrescendo murmur, ejection click
  • 2nd-3rd ICS LSB/radiates –> left shoulder-clavicle and increases w/ inspiration/RVH
63
Q

Most causes of pulmonic regurgitation (PR or PI) are due to what?

A

Pulmonary HTN

64
Q

What is the characteristic murmur heard with Pulmonic Regurgitation and heard best where?

A

DIASTOLIC, decrescendo blowing murmur at 2nd ICS LSB = Graham Steell

65
Q

There will be an increased P2 if pulmonic regurgitation is due to what?

A

Pulmonary HTN

66
Q

List the 5 valvular causes of systolic murmurs

A
  • MR (MVP)
  • TR
  • AS
  • PS
  • VSD
67
Q

Aorticopulmonary shunts will cause what type of murumur?

A

Early, mid, late, holosystolic/pansystolic murmur

68
Q

List the 4 valvular causes of diastolic murmurs

A
  • MS
  • TS
  • AR
  • PR
69
Q

What are 4 causes of continous murmurs?

A
  • PDA (machinery)
  • AV fistula
  • ASD w/ high LA pressure
  • Coarctation
70
Q

Pulmonic stenosis may have what 2 sx’s?

A

Angina and Syncope

2020 CPR II Cardio Exam 1 (31 decks)

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