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Clin Med II > L7: Valvular Heart Disease > Flashcards

L7: Valvular Heart Disease Flashcards

1
Q

What are 5 common sx associated with valvular disease?

A
  • Fatigue
  • Dyspnea, orthopnea, PND
  • Angina
  • Syncope
  • Palpitations

**Any HF sx can = valvular disease

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2
Q

What would you note on PE with valvular disease?

A
  • Heart sounds and murmurs

- Venous and arterial pulses

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3
Q

What are the gradations of murmurs (1-6)?

A

1: BARELY AUDIBLE in a quiet room
2. QUIET but clearly audible
3. Moderately LOUD
4. Loud, associated with THRILL
5. Very loud, hear with stethoscope PARTIALLY OFF CHEST, obvious thrill
6. Very loud, heard with stethoscope ENTIRELY OFF CHEST, obvious thrill

***3-6 most important for valvular disease

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4
Q

What does an EKG detect?

A

Nonspecific; electrical function, chamber enlargement

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5
Q

What does a CXR detect?

A

Chamber size, pulmonary vasculature, calcification

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6
Q

What does echocardiography with doppler detect?

A 
DIAGNOSTIC TEST OF CHOICE 
-Non invasive 
-Evals chamber size and valve abnormalities, including pressure gradients
-Diagnostic and assess severity
(TTE, TEE)
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7
Q

What does an angiography detect?

A
  • Invasive
  • Provides detailed info pre-operatively
  • Eval for CAD
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8
Q

List the 3 locations and causes of aortic stenosis. Which location is the most common?

A
  • Aortic valve (most common)
  • Supravalvular: congenital or post-operative
  • Subvalvular: congenital or hypertrophic cardiomyopathy (HCM)
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9
Q

Aortic stenosis at _____ may cause symptoms.

A

ANY level

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10
Q

Describe the characteristics of aortic stenosis in pts below age 30.

A
  • Congenitally stenotic

- Unicuspid!

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11
Q

Who is most at risk for developing aortic stenosis? What is occuring in their hearts?

A
  • Pts over age 65
  • Degeneration and sclerosis of valve

*Accounts for most AS

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12
Q

Describe the characteristics of AS in pts between 30-65 years old.

A

-Congenital bicuspid valve, which becomes calcified and stenotic

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13
Q

When does mortality from AS become significant?

A

After symptoms develop (pts usually asymptomatic until later in the disease and mortality is minimal)

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14
Q

What are the early sx of aortic stenosis?

A
  • Dyspnea on exertion (DOE)
  • Fatigue
  • Decreased exercise tolerance
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15
Q

What is the triad of aortic stenosis? What are the survival rates?

A
  1. Angina (survival 3 years)
  2. Syncope (survival 3 years)
  3. Heart failure (survival 1.5-2 years)

***Pts will also have dyspnea with normal activity

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16
Q

What kind of murmur would you hear with aortic stenosis? Describe the characteristics.

A

MIDSYSTOLIC MURMUR

  • Grade 3-4/6
  • Crescendo-decrescendo
  • Radiates to neck (carotids)
  • Late peak of murmur suggests severe obstruction
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17
Q

How can you make an AS murmur louder?

A

Squatting (increased venous return and ventricular filling)

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18
Q

Where can you best here an AS murmur?

A

Max intensity at 2nd RICS or apex (will have thrill in this area with severe disease)

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19
Q

______ pulse pressure indicates severe disease.

A

Small

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20
Q

What would an EKG show in a patient with aortic stenosis?

A

Normal until stenosis is severe

-LVH may appear

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21
Q

What would a CXR show in a patient with aortic stenosis?

A
  • Normal until late, then LVH

- May see calcification or post-stenotic dilation of aorta

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22
Q

What would an echo show in a patient with aortic stenosis?

A
  • Immobile calcified leaflets
  • LVH
  • Aortic gradient and reduced valve area
  • *MOST IMPORTANT INFO FROM ECHO!
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23
Q

What is the management for asymptomatic aortic stenosis (mild, moderate, mod-severe)

A

Mild: Educate on sx, Echo every 3-5 years
Moderate: Echo every 1-2 years
Mod-Severe: Echo every 6-12 months, CARDIOLOGY eval and close follow-up

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24
Q

What 3 things should you educate your patient about if they have AS?

A
  1. Avoid strenuous physical activity (over-exertion increases risk of arrhythmias, HF, and sudden death)
  2. Avoid dehydration (reduces CO)
  3. Monitor for sxs/signs of worsening disease (exertional dizziness, dyspnea, palpitations)
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25
Q

What is the management for symptomatic AS?

A
  • Referral for cardiothoracic surgery or interventional cardiology (possible aortic valve replacement)
  • Cardiac catheterization (definitive technique for eval of severity and site of stenosis)

SEVERE > SX > SURGERY

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26
Q

What are the 2 kinds of mechanical valves?

A
  • Ball and cage

- Tilting valve

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27
Q

What are the 2 kinds of bioprosthetic valves?

A
  • Tissue valves

- Porcine (pig) aortic valve

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28
Q

Patients with a prosthetic aortic valves are at an increased risk of:

A

Endocarditis

-Require antibiotic prophylaxis

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29
Q

Which kind of valve lasts longer? How does this affect anticoagulation therapy?

A
  • Mechanical valves last longer
  • Require life long anticoagulation

*Bioprosthetic valves do not last as long and does not require anticoagulation

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30
Q

What anticoagulant used for a pt with a mechanical valve and what is the goal INR?

A

Warfarin with INR goal of 2.5-3.5

*Consult cardiology when bridging meds for noncardiac procedures

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31
Q

Hypertrophic cardiomyopathy is a form of _____ aortic stenosis.

A

SUBVALVULAR aortic stenosis

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32
Q

What is HCM?

A

A disease of cardiac muscle characterized by SEVERE MYOCARDIAL HYPERTROPHY in the absence of a cause for secondary hypertrophy (like HTN, AS)

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33
Q

What is occuring in the LV with HCM?

A

LV is hypercontractile and during systole ejects all of its blood with high wall stress

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34
Q

HCM is most commonly due to a ______ cause.

A

Familial (60% of cases)

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35
Q

How is HCM different/similar from valvular aortic stenosis?

A

Differences:

  • Aortic valve NOT calcified
  • Murmur similar EXCEPT louder if patient stands or valsalvas (opposite of valv. AS)

Similarities:
-Sx are similar

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36
Q

How can you make a HCM murmur louder?

A

Valsalva/standing

decreased venous return and ventricular filling

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37
Q

What 2 pharmacological treatments do you use for HCM?

A
  • Beta blockers

- Nondihydropyridine CCB

38
Q

What is aortic regurgitation (AKA insufficiency)?

A

Leakage of blood back through aortic valve during diastole

volume overloading of LV

39
Q

Aortic regurgitation can be _____ or _____ and can have sxs/signs of _____.

A

Acute or chronic

Sxs/signs of HF

40
Q

Is acute or chronic aortic regurgitation more common?

A

Chronic

41
Q

What are 2 causes of acute aortic stenosis?

A
  • Endocarditis

- Aoritc dissection

42
Q

What are 3 causes of chronic aortic stenosis?

A
  • Valve disease (calcific*)
  • AORTIC ROOT DILATION*
  • Both valve disease + aortic root dilation (Bicuspid aortic valve*)

*Most common

43
Q

What are 4 signs/sx of acute aortic regurgitation?

A
  • LV pressure rises rapidly (no time for ventricle to dilate)
  • Decreased CO
  • Profound hypotension, cardiogenic shock, and/or pulmonary edema may develop rapidly
  • Sxs/signs of endocarditis or aortic dissection
44
Q

What are signs/sxs of chronic regurgitation?

A
  • LV overload with gradual dilation + eccentric hypertrophy overtime
  • Patients may be asymptomatic for 20+ years then develop only mild DOE
45
Q

Once sx of chronic aortic regurgitation develop, ____.

A

Deterioration is RAPID! (<2 year survival)

46
Q

Describe the murmur associated with aortic regurgitation?

A
  • PMI displaced laterally/inferiorly

- High pitched, blowing DIASTOLIC DECRESCENDO

47
Q

A _____ _____ _____ is a characteristic sign of aortic regurgitation (PE finding).

A

Wide pulse pressure

due to increased SBP and decreased DBP

48
Q

An Austin-Flint murmur is associated with

A

Aortic regurgitation

49
Q

What is cardiomegaly?

A
  • Cardiac to thoracic width ratio >50%

- LVH

50
Q

What is the management for acute aortic regurgitation?

A

EMERGENT valve surgery!

  • Stabilize
  • Surgery usually necessary within 24 hours of dx
51
Q

What is the management of chronic, asymptomatic aortic regurgitation (mild, mod, mod-severe)?

A

Mild: Monitor for sx, echo every 3-5 years
Mod: Echo every 1-2 years
Mod-severe: Echo every 6-12 months + cardiology eval and close follow up

52
Q

What is the management of chronic, symptomatic aortic regurgitation?

A

Referral to cardiothoracic surgery or interventional cardiology for likely aortic valve replacement (repair is an option in SOME patients)

53
Q

What are 2 types of surgical intervention for aortic regurgitation?

A

Root replacement

Pulmonary autograft

54
Q

What is mitral regurgitation?

A

Leakage of blood from LV into LA

55
Q

Mitral regurgitation may develop due to an abnormality of any part of:

A

VALVE APPARATUS

  • valve leaflets
  • chordae tendineae
  • papillary muscles
  • valve annulus
56
Q

What is an acute, ischemic cause of mitral regurgitation?

A

Papillary muscle/rupture damage

57
Q

What is an acute, nonischemic cause of mitral regurgitation?

A

Rupture of mitral chordae tendineae (flail leaflet)

58
Q

What are 5 causes of chronic mitral regurgitation?

A
  • Inherited (Marfan)
  • Rheumatic heart disease
  • Acquire connective tissue disease (SLE)
  • Idiopathic valve calcification of elderly
  • Congenital maldevelopment of valve
59
Q

What are the sx of acute mitral regurgitation?

A
  • Acute MR is POORLY TOLERATED

- Clinical presentation based on underlying cause w/ pulmonary edema. hypotension, shock

60
Q

What frequently develops in pts with chronic mitral regurgitation?

A

a. fib due to left atrial enlargement

MASSIVE LAE often occurs

61
Q

What are the sx of mild to moderate MR?

A
  • Often asymptomatic
  • Sx appear gradually over years
  • DYSPNEA, FATIGUE
  • When LAE, RVH, and pulm. HTN develops: DOE, PNE, and pulm edema can occur in some pts
62
Q

Describe the murmur associated with mitral regurgitation.

A
  • High pitched, PANSYSTOLIC MURMUR (aka holosystolic)

- Radiates to LEFT AXILLA

63
Q

What is the management for a pt with acute mitral regurgitation?

A

Urgent surgical consult

Stabilization

64
Q

What is the management with nonischemic mitral regurgitation?

A
  • Limit activities which produce sxs
  • Medical
  • Surgical if needed
65
Q

How would you treat a pt with chronic MR and HTN?

A

Afterload reduction = ACE-I + vasodilators

66
Q

How would you treat a pt with chronic MR and hypervolemia?

A

Preload reduction = NA restriction and diuretics

67
Q

What is the anticoagulant therapy + goal INR for pts with a. fib and chronic MR?

A

Warfarin INR 2.0 - 3.0

68
Q

Describe the murmur of a mitral valvle prolapse.

A

Mid-late systolic clicks

69
Q

Why does mitral valve prolapse occur?

A

Ballooning of mitral leaflet(s) into the LA during systole

70
Q

Is mitral valve prolapse common or uncommon? Benign or concerning?

A

Common and bengin

71
Q

What are the sxs of mitral valve prolapse?

A

Most common: atypical or non-anginal chest pain

Can also have
-Palpitations
-Dyspnea 
-Exercise intolerance
Etc....
72
Q

What is the diagnostic test for mitral valve prolapse?

A

Echocardiogram

73
Q

What is the management for mitral valve prolapse?

A
  • Most cases are mild (reassure pts, discuss benefits of lifestyle changes)
  • If palpitations/arrhythmias: Beta blockers
  • Tx if symptomatic or worsening MR
74
Q

What is the most common cause of mitral stenosis?

A

Rheumatic heart disease

75
Q

What is rheumatic heart disease?

A

Spectrum including acute rheumatic fever (ARF), pericarditis, and valvular lesions

76
Q

What is the acute condition associated with rheumatic heart disease?

A

MR with/without AR

77
Q

How long is the latent period between ARF and symptomatic mitral stenosis?

A

20+ years

78
Q

Describe the valve leaflets in a pt with rheumatic heart disease.

A

ARF:

  • Diffusely thickened due to fibrous tissue or Ca deposits
  • Leaflets become immobilized and rigid
  • Narrowing of mitral valve (but can affect and valve)
79
Q

Mitral stenosis is initially ______ and can range from ______ to ______.

A

Asymptomatic

Mild to severe&progressive

80
Q

What are some preceding events that can cause sx of mitral stenosis?

A
  • Sudden exertion
  • Excitement
  • Fever
  • Severe anemia
  • Tachycardia
  • Sexual intercourse
  • Pregnancy
  • Thyrotoxicosis
  • A. fib
81
Q

What is the avg. length of time between onset of mitral stenosis sxs and total disability?

A

7 years

82
Q

What are the sxs of mitral stenosis? What are they typically due to?

A

Sxs usually due to pulmonary congestion

  • Dyspnea, orthopnea, PND, fatigue
  • Pulmonary edema with hemoptysis
  • Pulmonary HTN develops, then RHF
83
Q

______ occurs in 40-50% of pts with mitral stenosis.

A

A. fib

84
Q

Describe the murmur associated with mitral stenosis?

A
  • Loud S1 with an opening snap

- MID-LATE DIASTOLIC rumbling murmur

85
Q

What is the management for mitral stenosis?

A
  • Mild sxs: diuretics and Na restriction
  • Anticoagulation for a. fib, hx of emboli, or evidence of significant LAE on echo (Warfarin)
  • Valve surgery for progressive sxs
86
Q

What are the potential adverse effects of a. fib?

A
  • Reduced CO
  • Atrial/atrial appendage thrombus formation
  • Increased mortality

+/- sxs (many pts asymptomatic)

87
Q

What does an EKG look like for a patient with a. fib?

A

Irregularly irregular rhythm (no pattern)

88
Q

What is the tx for a. fib?

A
  • PREVENTION OF SYSTEMIC EMBOLIZATION (can lead to ischemic stroke)
  • Mechanical heart valve: warfarin
  • Consider cardioversion (electrical or pharmacologic)
  • Rhythm or rate control strategy to improve sxs
89
Q

List 2 causes of tricuspid/pulmonic valve disorders.

A
  • Congenital abnormalities in infancy/childhood

- Adults: rheumatic scarring or connective tissue disease

90
Q

What would a CXR show in a pt with a tricuspid/pulmonic valve disorder?

A
  • Prominent R heart border

- Dilation of SVC

91
Q

How would you dx and tx tricuspid/pulmonic valve disorder?

A
  • Echo or cardiac cath: definitive ID of structural/functional abnormalities
  • Tx: Na restriction, diuretics, surgical repair or replacement

Clin Med II (9 decks)

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