JH IM Board Review - Valvular Heart Disease I Flashcards
What are the 3 main causes of AS?
- Congenital unicuspid valve.
- Congenital bicuspid valve.
- Degenerative calcific disease.
What is characteristic about congenital unicuspid valve?
It is usually severe—and sx present early in childhood.
What is the age of onset for calcific AS in pts w/ bicuspid valve?
Calcific AS starts in pts 30s and 40s.
What is the prevalence of degenerative calcific disease in >65y?
25%.
What is the earliest manifestation of degenerative calcific disease?
Aortic SCLEROSIS.
==> Defined as thickening of the leaflets, presence of a heart murmur, and a gradient <25mmHg.
What is the percentage of pts w/ aortic sclerosis that will develop AS in the next 10y?
20%.
What is the effect of statins and other risk factor tx in degenerative calcific disease?
Have NOT led to slower AS progression.
**even though the progression is biologically similar to atherosclerosis + linked to the same risk factors.
What are the 3 major physical signs of AS?
- Slow-rising carotid upstroke (parvus et tardus) — May be difficult to detect in >70y w/ stiff vessels + wide pulse pressure.
- Systolic ejection murmur — crescendo/decrescendo, diamond-shaped.
- May be conducted to the apex w/ a musical quality (“Gallavardin murmur”).
What is the importance of murmur’s intensity regarding AS severity?
There is none.
What is characteristic about the murmur of severe AS?
It is “late-peaking”.
What is the effect of severe calcific AS on the intensity of A2 (aortic closure sound)?
Reduced intensity of A2 ==> Single S2.
What is the prognosis of in PREsymptomatic AS pts?
Excellent.
What is the prognosis of AS pts w/ sx.
50% 3y mortality.
What is helpful regarding the anticipation of sx in AS?
Outflow tract velocity on Doppler echo.
==> If velocity >4m/sec (ie peak gradient >64mmHg) — sx likely within 3y.
What is relatively CI in AS?
Nitrates — may be dangerous to lower preload.
What is the time for intervention in AS pts?
Indicated if LVEF <50% and pts are sx.
What is the target group of TAVR?
Older or frail pts.
What is important to keep in mind about AR dx?
It has a broad ddx and it is critical to identify the underlying cause before tx.
What are the 3 main valvular diseases that may lead to AR?
- Bicuspid aortic valve.
- Previous endocarditis.
- Rheumatic valve disease.
What are the main diseases of the aorta that may lead to AR?
3
- CTDs — Marfan, familial aortic ectasia(!), Loeys-Dietz etc.
- AD.
- Inflammatory disorders — Giant cell, takayasu, syphilis.
What are the main diseases affecting aorta and valve that lead to AR?
Spondyloarthropathies.
==> AS, Reactive arthritis, PA.
What are the other important causes of wide pulses, in addition to AR?
(3)
- PDA.
- AV fistula.
- HCM.
What is the Quincke sign?
Nail bed pulsation — chronic AR sign.
What is the Corrigan pulse?
Visible carotid pulsation—seen in chronic AR.
What is the de Musset sign?
Head bobbing to pulse — sign of chronic AR.
What is the Muller sign?
Uvula bobbing to pulse — sign of chronic AR.
What is the Duroziez sign?
Diastolic bruit w/ compression of the femoral artery at the groin (!).
— sign of chronic AR.
What is the Hill sign?
Systolic pressure in the leg >10mmHg higher than the measurement at the brachial artery.
Reflects large SV.
— sign of chronic AR.
What is the Traube sign?
Pistol-shot sounds best heard over the femoral artery — sign of chronic AR.
What is the Water-Hammer pulse?
Slapping quality of pulse when the hand is held up and the DBP is <25mmHg.
What are the main auscultatory findings in AR?
- Early diastolic murmur which starts at the instant of aortic closure — usually medium frequency.
- Austin-Flint murmur.
What is the time when the early diastolic murmur of AR is longest and loudest?
When AR is chronic and the pt is doing well.