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Cardio Exam 1 > Lec 11 Valvular Heart Disease I > Flashcards

Lec 11 Valvular Heart Disease I Flashcards

1
Q

What is rheumatic fever?

A
  • immuno response to group A strep pharyngitis 2-3 wks after initial infection
  • cross-reactivity between strep antigen and structural glycoprotein
  • leads to chronic rheumatic valvular heart disease = usually 10-30 yrs after ARF
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2
Q

What are the jones criteria for rheumatic fever?

A
  • J= joints [polyarthritis]
  • Heart =carditis
  • N = Nodules [subcutaneous]
  • E = erythema marginatum
  • S = sydenham chorea
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3
Q

What is erythema marginatum?

A

pink rings on trunks and inner surfaces of limbs that come and go

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4
Q

What is sydenham chorea?

A

disorder of rapid uncoordinated jerking movements primarily of face, hands, feet

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5
Q

What heart signs associated with acute rheumatic fever?

A
  • tachycardia
  • decreased LV contractility
  • pericardial friction rub
  • transient murmur of mitral or aortic regurgitation
  • mid-diastolic murmur at cardiac apex
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6
Q

What is treatment for acute rheumatic fever?

A
  • penicillin

- aspirin/corticosteroids to reduce inflammation

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7
Q

What is prophylaxis for pts with previous ARF?

A

low dose penicillin through early adulthood

b/c once you have ARF you are more susceptible to getting it again

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8
Q

What valve is most commonly affected in rheumatic fever?

A

mitral –> mitral stenosis

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9
Q

What kinds of valve disease can you get from rheumatic fever?

A
  • most common mitral stenosis

- some get mitral stenosis + aortic stenosis or regurgitation

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10
Q

What is most common cause of mitral stenosis? less common?

step1

A

rheumatic fever

other: congenital, infective endocarditis, mitral annular calcification

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11
Q

What is molecular mimicry?

step1

A

mechanism by which antibodies to M protein of strep attack own human tissue in acute rheumatic fever

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12
Q

Which valves get affected preferentially in rheumatic fever?

step1

A

mitral > aortic&raquo_space; tricuspid

most common is mitral or mitral + aortic

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13
Q

What is early valve problem in rheumatic fever? later on?

step1

A

early = mitral valve regurgitation

late = mitral stenosis

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14
Q

What is aschoff body?

step1

A

sign of myocarditis in rheumatic fever = focus of chronic inflammation with fibrinoid material and giant cells and containing anitschkow cells

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15
Q

What are anitschkow cells?

A

macrophages with wavy caterpillar nuclei located in aschoff bodies = sign of myocarditis in rheumatic fever

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16
Q

What causes early death in acute rheumatic fever?

step1

A

myocarditis

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17
Q

What causes friction rub in acute rheumatic fever?

A

pericarditis

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18
Q

How do you distinguish atrial stenosis from wear and tear vs atrial stenosis from rheumatic valve disease?

step1

A

if from rheumatic valve disease will also have mitral stenosis + aorta will have fusion of commissures in rheumatic heart disease = fish mouth appearance

stenosis of just aorta without mitral involvement and no fusion = wear and tear

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19
Q

What are complications of aortic stenosis?

step1

A
  • concentric left ventricular hypertrophy
  • angina and syncope with exercise
  • microangiopathic hemolytic anemia
20
Q

What kind of murmur with mitral stenosis?

step1

A
  • follows opening snap
  • ## have delayed rumbling late diastolic murmur
21
Q

What is significance of interval between S2 and opening snap?

step1

A

shorter interval = more severe stenosis

22
Q

What is opening snap?

step1

A

after S2 loud sound of mitral opening due to initial rapid opening followed by abrupt stop in leaflet motion in diastole b/c of stenosis

23
Q

What happens in mitral stenosis?

step1

A
  • obstruction of blood flow across mitral valve
  • difficult to empty from LA to LV
  • end up with high left atrial pressure [P in LA&raquo_space; LV]
  • valve area reduced from 4 in normal to 2 in MS
24
Q

What are clinical manifestations of mitral stenosis?

A
  • can be asymptomatic if less severe
  • can have: dyspnea, reduced exercise tolerance, fatigue, signs of pulmonary congestion [b/c high LA pressure transmitted back to lungs]
25
Q

What heart sounds in mitral stenosis?

A
  • loud S1 = best heard at apex
  • opening snap = follows S2, shorter S2 OS interval = more severe disease
  • low pitched diastolic rumbling murmur following OS
26
Q

What findings of mitral stenosis on EKG/CXR/ECHO?

A

EKG: LA enlargement, may have RV hypertrophy [b/c of pulm HTN] or AFib

CXR: LA enlargement, signs of pulm congestion, if pulm HTN: RV hypertrophy

Echo: assess thickness, mobility, area of MV

27
Q

What is treatment for mitral stenosis?

A
  • diuretics to treat vascular congestion
  • if Afib: B blocker, Ca antagonist, digoxin
  • prosthetic valves if continues; balloon mitral valvuloplasty
28
Q

What are etiologies of mitral valve regurgitation?

A

abnormalities of
- valve leaflets: rheumatic heart disease, infective endocarditis, myxomatous degeneration [mitral prolapse]

  • mitral annulus: dilatation, calcification
  • chordae tendinae: congenital, infective
  • papillary muscle: CAD
  • left ventricle dilation
29
Q

What are some consequences of MR?

A
  • high LA pressure/volume

- volume-stres on LV becuase regurgitate volume returns to LV in diastole along with normal venous return

30
Q

What do you see in acute vs chronic MR?

A

acute: normal LA size and compliance –> high LA pressure –> high pulmonary venous pressure –>pulmonary congestion and edema
chronic: big LA size and compliance –> normal LA and pulmonary venous pressure –> decreased CO

31
Q

What are symptoms of mitral regurgitation?

A

can be asymptomatic

  • acute: symptoms of pulmonary edema: dyspnes, PND
  • chronic: fatigue, weakness
  • in severe chronic = symptoms of RV failure
32
Q

What are physical exam findings of mitral regurgitation?

A
  • holosytolic murmur loudest at apex and radiating to axilla
  • increased sounds with expiration, handgrip, squatting
  • may have S3 = increased volume returning to LV in early diastole
  • in chronic: apical impulse laterally displaced toward axilla b/c LV enlarged
33
Q

How do you manage acute MR?

A
  • afterload reduction by: diuretics, nitrates
34
Q

How do you manage chronic MR?

A

vasodilators for HTN, LV systolic dysfunction

35
Q

What do you see in EKG of mitral regurgitation?

A
  • LA enlargement
  • LV hypertrophy
  • can have AFib
36
Q

What do you see in chest xray of acute/cronic MR?

A 
acute = interstitial edema
chronic = cardiomegaly [LV/LA]
37
Q

What do you see in cardiac cath/angio of mitral regurgitation?

A

large V wave on pulmonary capillary wedge pressure

38
Q

What is mitral valve prolapse?

A

billowing/floppy mitral leaflets into left atrium during ventricular systole, sometimes accompanies by mitral regurgitation

  • valve leafless enlarge and elastin matrix of leaflets replaced with loos myxomatous connective tissue
39
Q

What is etiology of mitral valve prolapse?

A
  • can be inherited autosomal dominant or associated w/ marfans, ehlers-danlos
40
Q

What are symptoms of mitral valve prolapse?

A

often asymptomatic

may have chest pain or palpitations

41
Q

What are signs of mitral valve prolapse?

A
  • midsystolic click followed by late systolic murmur
  • best heard at apex
  • decreased sound with squatting and increased by valsalva standing and handgrip
42
Q

What tests do you do in mitral valve prolapse?

A

echo to confirm diagnosis

43
Q

What are some potential complications with mitral valve prolapse?

A
  • rupture of chordae tendinae –> acute mitral regurg + pulm edema
  • infective endocarditis
  • thromboembolism
  • arrhythmias
44
Q

How do you differentiate mitral valve stenosis due to rheumatic vs other cause?

A

rheumatic = have subvalvular fibrosis/ disease

45
Q

How do you classify severity of mitral valve stenosis based on area of the valve [in cm2]?

A

1.5-2 = mild
1-1.5 = moderate
< 1 = severe

46
Q

What is the only time you get S3 without heart failure?

A

in chronic mitral regurgitation = b/c extra load of blood from LA –> LV creating a vibration

may get flow murmur in diastole as sign of severe mitral regurgitation

47
Q

What types of events are exaggerated by expiration vs inspiration?

A

expiration = left sided things [mitral]

inspiration = right sided things [tricuspid]

Cardio Exam 1 (16 decks)

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