Exam 1: Valvular Heart Disease Flashcards
What is likely the etiology of aortic stenosis of patients over the age of 65?
Degeneration and sclerosis of the valve, which accounts for most aortic stenosis
What is likely the etiology of aortic stenosis in patients between the ages of 30-65?
Congenital bicuspid valve which becomes calcified and stenotic
What is likely the etiology if aortic stenosis in a patient under the age of 30?
Congenitally stenotic unicuspid valve
What is the triad of symptoms of aortic stenosis?
Angina, syncope, and heart failure
What kind of murmur is heard with aortic stenosis? Where is is best heard?
Midsystolic murmur, grade 3-4/6, crescendo decrescendo. Best heard at the 2nd RICS
What kind of murmur is louder with squatting due to increased ventricular return and ventricular filling?
Aortic stenosis
What is the recommended management for asymptomatic mild aortic stenosis?
Educate regarding symptoms and echo every 3-5 years
What is the recommended management for asymptomatic moderate aortic stenosis?
Echo every 1-2 years
What is the recommended management for asymptomatic moderate-severe aortic stenosis?
Echo every 6-12 months and cardiology evaluation and close follow up
What is the patient education you should give with asymptomatic aortic stenosis?
Avoid strenuous physical activity, avoid dehydration, and monitor for worsening signs/symptoms
What is the management for symptomatic aortic stenosis?
Referral to cardiothoracic surgeon or interventional cardiology (possible aortic valve replacement)
-Cardiac cath
What is the definitive technique for evaluating severity and site of stenosis?
Cardiac cath
What are the two types of mechanical valves?
Ball and cage and the tilting valve
What are the risks associated with prosthetic valves?
Increased risk of endocarditis, requires antibiotic prophylaxis
What kind of valve requires life long anticoagulation?
Mechanical valves, Should keep INR between 2.5 and 3.5
How does the heart sounds differ from HCM and aortic stenosis?
Murmur is similar, except is HCM murmur is louder with valsalva and standing due to decreased venous return and ventricular filling
What are both of the acute etiologies for aortic regurgitation?
Endocarditis and aortic dissection
What are the 3 etiologies for chronic aortic regurgitation?
1) valve disease (calcific)
2) aortic root dilation
3) both (bicuspid aortic valve)
How does acute aortic regurgitation occur?
LV pressure rises rapidly and the ventricle does not have time to dilate. There is decreased cardiac output, which results in profound hypotension, cardiogenic shock, and/or pulmonary edema
How does chronic aortic regurgitation occur?
Results from LV overload with gradual dilation and eccentric hypertrophy overtime.
Patient may be asymptomatic for 20 years, but once they do develop symptoms, deterioration is rapid
What kind of murmur is found is aortic regurgitation? Where is it best heard?
High pitched, blowing diastolic decrescendo murmur.
Best heard at the 2nd-4th LICS
What happens to the blood pressure in aortic regurgitation?
There is a wide pulse pressure from increased SBP and decreased DBP, gives rise to water hammer or corrigan pulse
What is an austin flint murmur?
A soft, low pitched diastolic murmur at the apex which sounds like a mitral stenosis murmur
What might you see on EKG in a patient with chronic aortic regurgitation?
LVH
What is the management of acute aortic regurgitation?
Emergent valve surgery and stabilization with IV vasodilators and possible inotropic agents
What is the management for asymptomatic mild chronic aortic regurgitation?
Monitor for symptoms and echo every 3-5 years
What is the management for asymptomatic moderate chronic aortic regurgitation?
Echo every 1-2 years
What is the management for asymptomatic moderate-severe chronic aortic regurgitation?
Echo every 6-12 months and cardiology evaluation and follow up
What is the management for symptomatic chronic aortic regurgitation?
Referral to cardiothoracic surgery or interventional cardiology. Surgical aortic valve replacement is the treatment of choice.
What are the two surgical options for aortic regurgitation?
Root replacement and pulmonary autograft
What are the acute causes of mitral regurgitation?
- ischemic: papillary muscle rupture and damage
- Nonishcemic: rupture mitral chordae tendineae from MVP, endocarditis, trauma, and ARF
What are the chronic etiologies of mitral regurgitation?
- inherited: mitral valve prolapse and mar fans
- Rheumatic heart disease
- Acquired connective tissue disease
- Idiopathic valve calcification
- Congential maldevelopment of the valve
How does chronic mitral regurgitation progress?
LV adapts to larger blood volume by enlarging and increasing the stroke volume. Overtime more than half the blood volume ejects into the LA during systole.
What often results from LAE in mitral regurgitation?
Atrial fibrillation
How does mild to moderate MR often present?
Often asymptomatic and gradually appear over years (dyspnea and fatigue). with LAE and RVH, pulmonary HTN develops
What kind of murmur is heard with mitral regurgitation? Where is the best heard?
High pitched, pansystolic murmur. Best heard at the apex and radiates tot he left axilla
What is often seen on EKG in a patient with mitral regurgitation?
Usually LAE, often LVH, and atrial fibrillation is possible
What is often seen on CXR in patient with mitral regurgitation?
LAE and LVH
What is the management for acute mitral regurgitation?
Urgent surgical consult and stabilization with IV nitroprusside
What is the management for chronic mitral regurgitation?
- limit activities that produce symptoms
- If HTN, reduce afterload
- if hypervolemic, reduce preload
- if A fib, anticoagulants (INR 2-3)
- possible surgery for valvuloplasty or valve replacement
What is mitral valve prolapse?
Ballooning of the mitral leaflets into the left atrium during systole
What is often heard on auscultation in a patient with mitral valve prolapse?
Mid to late systolic clicks
What is diagnostic for mitral valve prolapse?
Echo
What is the management of mitral valve prolapse?
- Most cases are mild and patient should be reassured with lifestyle changes
- if associated palpitation, beta blockers
- if symptomatic, follow as though MR
What is the pathophysiology of mitral stenosis?
Narrowing of the mitral valve, obstructs flow of the LA to LV, increases LA pressure, increases pulmonary vascular pressure
What is the most common cause of mitral stenosis?
Rheumatic heart disease
What are the symptoms of mitral stenosis?
-Initially asymptomatic, but symptoms may be precipitated by sudden exertion, excitement, fever, severe angina, tachycardia, sex, pregnancy, a fib, etc
What usually causes the symptoms of mitral stenosis?
Pulmonary congestion
What other condition is seen with mitral stenosis about 50% of the time?
Atrial fibrillation
What is heard on auscultation in a patient with mitral stenosis?
Loud S1 with opening snap followed by mid-late diastolic rumbling murmur
What is the management for mild mitral stenosis?
Diuretics and sodium restriction
What is the management of atrial fibrillation?
- possible cardioversion
- prevention of systemic embolization (warfarin recommended for mechanical heart valves and NOACs (Dabigatran, Rivaroxaban, Apixiban, and edoxaban) are recommended except in moderate to severe MS