L5-6 - Stenosis & Regurg Flashcards
What is involved with examination of the CV system?
NOT just auscultation
History, physical, X ray, ECG & other (echo etc.)
Which valvular problems are mainly a pressure overload? Which is mainly a volume overload?
Stenosis = pressure
Regurg = volume
This is for aortic & mitral
What is the origin and importance of a murmur that a patient has had since childhood?
Congenital
Probably not relevant to current problem
What is endocarditis prophylaxis? What does this finding in the history mean?
Antibiotics during dental procedures
Probably doesn’t have endocarditis
What is important about a BP of 110/80?
Narrow pulse pressure
Suggests aortic stenosis
Narrow pulse pressure points towards what?
Aortic stenosis
Not as much blood is pumped out (low SV), so systolic is lower (while diastolic is similar). Also seen in CHF & shock
What is suggested with a physical finding of slow rising pulses or apex?
Aortic stenosis
Weak pulses because LV pressure is much higher than aortic pressure
What is suggested by the physical finding of flat neck veins?
Normal RA pressure
What is parasternal lift? What is suggested by this finding?
Palpable or visible impulse at chest wall just to the L of the sternum.
Severe = Represents RV hypertrophy due to respiratory problem or pulmonary stenosis
Mild = Aortic regurg
What is suggested by the the finding of crescendo decrescendo systolic ejection murmur?
Aortic Stenosis
What is suggested by a normal ECG with an elevated QRS voltage?
Stiff/thick ventricular wall associated with aortic stenosis or HTN
What diagnoses can be made with the ECG?
ECG findings are consistent with other findings, but it cannot diagnose anything on its own other than HR
When looking for calcified aortic valve, what view should be used on the X ray?
Lateral, on AP the spine gets in the way
Describe the flow of blood leaving the ventricle in a normal valve & stenotic valve?
nl = bolus of blood
stenotic = squirt of blood as volume is squeezed through smaller opening
What is suggested by a wide pulse pressure?
Aortic regurg
Increased SV
Also seen during exercise as more blood is in arterial system at any one moment –> higher systolic & lower dystolic
What is suggested by the physical finding of bounding pulse?
Aortic regurg
Leaping and forceful pulse that quickly disappears. Also associated with HTN & high stroke volume
What is suggested by bisferriens at the carotid pulse?
= double pulse per 1 cardiac cycle (first is systolic & second is high diastolic)
Aortic regurg
What is suggested by a bounding & collapsing apex impulse?
Aortic regurg
High pressure which rapidly drops during diastole
What is suggested by quincke pulsations in the nail bed?
red —> blanching –> red …
Aortic regurg
Not enough blood in nail beds during diastole
What causes muffled S1?
Blood coming in from mitral & aortic (regurg) so the heart fills faster & the valves doesn’t have to move as much –> muffled
Aortic regurg
What is suggested by systolic flow murmur?
Aortic regurg
cuz blood is flowing back through aortic valve, more blood must be ejected during systole –> higher SV
Flow murmur = only caused by increased blood flow
What is suggested by ST depression at V5 & V6?
Aotic regurg
What is suggested by tricuspid valve regurg on echo?
Probably trivial. A lot of people have it
What is the most common valvular disorder?
Mitral regurg
What is mitral valve prolapse?
When thick mitral valve is displaced into atrium
Some asymptomatic, but often associated with regurg
What is suggested by the absence of S1?
Mitral regurg
What is a holosystolic murmur?
starts at S1 and extends to S2. Causes by mitral regurg
What is suggested by an enlarged RA?
Mitral regurg
What is suggested by a double density LA on CXR?
Mitral regurg
What is a double density atria?
Right edge of the left atrium pushes behind the right cardiac shadow, forming its own distinct silhouette
See edge of ventricle at one location & edge of atrium at a distinctly different location
Why is the LV easily emptied in mitral regurg?
Reduction in afterload because some blood flowing back into LA which has a low pressure
What is suggested by a prominent V wave on ECG?
Mitral regurg
atrial filling is accelerated because of regurg
What is the first heart sound?
Lub sound of Lub-dub. Indicates the beginning of ventricular systole & the closure of the mitral/tricuspid valve
Blood that was flowing into the ventricle is forced to change direction and sloshes around the now closed chamber
What is the second heart sound?
Dub sound of Lub-dub. Indicates the end of ventricular systole & the closure of the aortic/pulmonic valve (pressure plateau)
Blood leaves ventricle –> aorta & pulmonic trunk are elastic –> Stretch –> recoil at end on ventricular contraction –> compresses blood in them –> pushed blood downstream & pushed back up stream against the valves
Has splitting due to inspiration
What is the third heart sound?
Indicates near maximal ventricular dilation at the end of rapid ventricular filling –> point of initial decrease in filling speed
Early in ventricular diastole
Creates a “Ken-tucky” like cadence
What is the fourth heart sound?
Indicates abnormal filling during atrial contraction. Related to the failure of the ventricle to fill –> louder atrial contraction needed to fill it. Usually the result of the ventricle not being able to stretch properly (hypertrophy)
Late in ventricular diastole
Right before S1 (sounds sort of like a split S1)
Creates a “Tenne-ssee”
Most common cause(s) of aortic stenosis?
[From wikipedia not lecture]
Calcification of normal valve (present later)
Calcification of a congenital bicuspid valve (present earlier)
What is an ejection click? When is it heard?
Aortic stenosis
Impact of left ventricular outflow against the partially fused aortic valve leaflets. Right after first heart sound
A crescendo decrescendo systolic murmur is heard with what valvular problem?
Aortic stenosis
What causes a decreased/soft second heart sound?
Aortic stenosis or aortic regurg
As gets calcified, the aortic valve doesn’t snap shut anymore –> less crisp of a sound in stenosis
You may hear a 4th heart sound in what valvular problem?
Aortic stenosis
High afterload –> hypertrophy –> difficulty filling –> needs extra push from atria
Which valvular problem(s) has/have decreased effective forward flow (flow from heart to body) when compared to SV?
Aortic Regurg = A fraction of blood ejected from heart is regurgitated back into heart. So only a fraction of SV actually makes it to the body
Mitral regurg = some of blood ejected is going back into atria
Which valvular problem presents with decreased systemic diastolic pressure? Increased?
Aortic Regurg
Aortic Stenosis
In undeveloped nations, what is the main cause of aortic insufficiency?
Rhuematic fever
Causes of aortic regurg?
[not from lecture]
Age related deterioration in patient with HTN
Congenital mono or bicuspid
Endocarditis
Rheumatic fever
Marfans
Trauma
Aortic dissection, anuerysm or root dilation
Rhuematic fever as a child can lead to what valvular problem many years later?
Mitral stenosis most likely, but can cause stenosis or regurg in mitral & aortic valves
What is the main cause of mitral stenosis?
Rhuematic fever
What is suggested by a loud first heart sound?
Mitral stenosis
What is suggested by a loud pulmonic component of the second heart sound?
Pulmonary hypertension secondary to Mitral stenosis
What is suggested by an opening snap?
Mitral stenosis
Forceful opening of the mitral valve as atrial pressure increases & the valve now opens at a relatively higher diastolic ventricular pressure
What is suggested by a rumbling mid-diastolic murmur?
Mitral stenosis
What is suggested by prominent neck veins?
Mitral stenosis
Everyone has visible neck veins while lying down, this is when people have it while standing/sitting
LA pressure backs up into venous system
What is suggested by irregularly irregular ecg?
Mitral stenosis
What is suggested by prominent pulmonary arteries?
Mitral regurg
What is suggested by kerly b lines?
Mitral regurg
What is suggested by a barium swallow with displaced esophogus?
Mitral regurg –> big LA –> pushes esophagus posteriorly
What is suggested by trivial aortic insufficiency?
Mitral regurg –> mitral & aortic valve connected somewhat
What is suggested by L atrial size of 5 cm?
Mitral regurg
What is suggested by mitral gradient of 15 mm Hg?
Mitral regurg
What valvular problem gives you a big LV? Big LA?
Aortic regurg
Mitral regurg
What is Rhuematic fever?
[From Wikipedia, Not lecture]
Strep pyogenes (group A) infection in pharynx –> molecular mimicry –> autoimmune Ab cross reactivity –> progressive inflammation & scarring of heart tissue –> over many years causes leaflet thickening & commisural fusion
Effects mainly mitral valve, but also aortic valve some. Can cause stenosis or regurg
What is infective endocarditis?
[From wikipedia, not lecture]
Valve damaged by some other process (likely rhuematic heart disease) –> makes valve good landing place for bacterial attachment –> during bacteremia (dental work) bacteria attach –> forms vegetation
Can effect mitral or aortic valves. Can cause regurgitation or stenosis
What is suggested by a mitral gradient of 5 mm Hg?
Normal (no mitral regurg)
What is normal pulse pressure?
40 mm Hg
30 or less is low
What does a slow pulse mean?
Delayed compared to heart beat
What causes increased S1? Decreased? Absent? Normal?
Aortic Regurg
Mitral Stenosis
Mitral Regurg
Aortic stenosis
What causes loud S1 & S2?
Mitral stenosis
What causes decreased S2? Increased?
Aortic stenosis & regurg
Mitral Stenosis
Which valvular problems do not effect pulses?
Mitral problems
Which valvular problem has a diastolic murmur?
Mitral stenosis
What does ES stand for?
Ejection sound/Ejection click
Size of enlarged LV? Normal?
6.5 cm
5-5.5 cm
Size of enlarged LA? Normal?
4 cm
3.5 cm
Which valvular disorder is more common in females?
Mitral stenosis
Which valvular disease can present with breathelessness?
Basically all of them
Which valvular problems present with aortic dilation?
Aoritc Stenosis
Aortic Regurg
What valvular problem can present with crackles?
Aortic Regurg
Mitral Stenosis
Which valvular problems present with mitral gradient?
Mitral stenosis
Mitral regurg
