Heart valve disease Flashcards
Heart sounds - S1 and S2
S1: closure of mitral and tricuspid valves, start of ventricular systole
S2: closure of aortic and pulmonary valves, end of ventricular systole, start of diastole
Levine scale for cardiac murmurs
1: v.faint, expert in optimum conditions
2: faint, non-expert in optimum conditions
3: easily audible, no thrill
4: loud with thrill
5: very loud, wide area with thrill
6: heard without stethoscope
Aortic stenosis:
Murmur, causes, examination
SAD:
- syncope
- angina
- dyspnoea on exertion
Ejection Systolic Murmur (ESM):
- crescendo-decrescendo
- loudest over aortic area - 2nd R ICS
- radiates to carotid arteries
- loudest on expiration and sitting forwards
Severe aortic stenosis:
- narrow pulse pressure
- slow rising pulse
- thrill palpable over cardiac apex
- S4 = LVH
- a soft/absent/reverse splittin of S2
Causes:
1) Calcification of aortic valves (most common in developed countries)
2) Congenital abnormality - bicuspid instead of tricuspid
3) Rheumatic heart disease
When to refer heart murmur patient for Echo and onwards to cardiology
Refer for Echo:
- if suspect valve disease + signs/symptoms, abnormal ECG
- ESM with reduced S2 but no other signs/symptoms.
**- within 2 weeks if SM + exertional syncope **
- **consider within 2 weeks if severe symptoms - angina, SOB on minimal exertion or rest **
Consider Echo is suspected valve disease and no other signs/symptoms
Refer to cardiology:
- Moderate or severe valve disease.
- bicuspid aortic valve disease of any severity
Mitral stenosis:
Murmur, causes, examination
Pansystolic murmur:
- heard loudest over mitral area
- radiating to axilla
- loudest on expiration in L lateral decubitus position
Causes:
1) Infective endocarditis
2) Acute MI with rupture of papillary muscles
3) Rheumatic heart disease
4) Congenital heat defects of mitral valve
5) Cardiomyopathy
Examination:
- displaced, hyperdyanamic beat
Consider BB if MS + HF
Aortic regurgitation:
Murmur, causes, examination
Diastolic murmur:
- decrescendo early systolic murmur heard loudest at L sternal edge or aortic area
- Austin-Flint murmur: low pitched rumbling mid-diastolic murmur heard best at apex if severe
Causes:
1) Congenital bicuspid aortic valve
2) Rheumatic heart disease
3) Infective endocarditis
4) Aortic dissection
5) Connective tissue diseases eg. Marfan’s
6) Aortitis
Examination:
- collapsing pulse (water-hammer pulse)
- wide pulse pressure
- displaced, hyperdynamic apex beat
- Corrigan’s sign: visible distension and collapse of carotid arteries in neck
- De Musset’s sign: head bobbing with each heartbeat
- Quincke’s sign: pulsations in nail bed with each heartbeat when nail bed lightly compressed
- Traube’s sign: pistol shot sound when stethoscope placed over femoral artery
- Muller’s sign: uvula pulsations with each heartbeat
Mitral Stenosis:
Murmur, causes, examination
Mid-diastolic murmur:
- low-pitched rumbling MDM with opening click heard in mid-diastole with MV opens
- loudest over apex
- loudest in LL decubitus position on expiration
Causes:
1) Congenital
2) Left atrial myxoma
3) Connective tissue disorders
4) Mucopolysaccharidosis
Examination:
- Low-volume pulse which may be irregularly irregular (AF common)
- Loud S1 with tapping apex beat (feel MV close)
- Malar flush
Mitral valve prolapse:
Murmur, incidence
Mid-systolic click followed by mid/late systolic murmur:
- loudest at apex
- loudest in expiration
Most common valvular abnormality (affects 5%)
Tricuspid regurgitation:
Murmur, causes, examination
Pansystolic murmur:
- loudest over tricuspid region
- loudest during inspiration
Causes:
1) RV dilatation secondary to pulmonary stenosis or HTN
2) Rheumatic fever
3) Infective endocarditis.IVDU
4) Carcinoid syndrome
5) Congenital - ASD/Ebstein’s anomaly (abnormal attachment of tricuspid leaflets)
Examination:
- large v-waves visible in jugular veins
- visible/palpable hepatic pulsations
- signs of RHF: RV heave, peripheral oedema, hepatomegaly, ascites
Pulmonary stenosis:
Murmur, causes, examination
Ejection systolic murmur:
- heard loudest in pulmonary area
- loudest during inspiration
- radiated to L shoulder/L infraclavicular region
- widely split S2
Causes:
1) congenital: Turner’s. Noonan’s, William’s, Tetralogy of Fallot
2) Rheumatic fever
3) Carcinoid syndrome
Examination:
- prominent a waves in jugular veins
- RV dilatation: RV heave, tricuspid regurgitation, peripheral oedema, ascites
Pulmonary regurgitation:
Murmur, causes
Early decrescendo murmur heart loudest over L sternal edge:
- loudest during inspiration
- Graham-Steel murmur when associated with mitral stenosis - pulmonary HTN
Causes:
1) Pulmonary HTN.
2) Infective endocarditis
3) Congenital valvular heart disease
Tricuspid stenosis:
Murmur, causes, examination
Soft mid-diastolic murmur:
- loudest at 3rd-4th intercostal space at L sternal edge
- loudest during inspiration
Causes:
1) Rheumatic fever (most common)
2) Congenital disease
3) Infective endocarditis
Examination:
- raised JVP with giant a waves
- peripheral oedema, ascites
Antithrombotic therapy following mechanical heart valve replacement
Lifelong warfarin
Aortic valve: target 3.0
Mitral valve target: 3.5
And apirin
What medication is contraindicated in AS?
ACEI - risk of profound hypotension
Antithrombotic therapy following bioprosthetic valve replacement
Aspirin
