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Cardio Exam 1 > Lec 12 Valvular Heart Disease II > Flashcards

Lec 12 Valvular Heart Disease II Flashcards

1
Q

What usually causes aortic stenosis?

A

usually age related degenerative calcific changes = senile changes due to “wear and tear”

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2
Q

What is area of arotic valve normally? when symptoms of aortic stenosis?

A

normal: 3-4 cm2

symptoms = when valve area 1/4th normal < 1cm2

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3
Q

What are the 2 types of aortic stenosis and which most common?

A
  • supravalvular
  • valvular = most common!!
  • subvalvular
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4
Q

What are congenital causes of aortic stenosis? Who gets it?

A
  • congenital aortic stenosis or congenital bicuspid valve

– if pt < 70 yo more likely to have congenital cause

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5
Q

What are acquired causes of aortic stenosis?

A
  • degenerative calcification = most common “wear and tear”
  • rheumatic heart disease [have mitral also]
  • rare causes like SLE, postradiation, etc
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6
Q

What is pathophysiology of aortic stenosis?

A
  • blood can’t flow from LV to aorta during systole
  • high LV pressure = increased afterload
  • compensatory LV concentric hypertrophy
  • over time LV function declines
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7
Q

What are 3 classical symptoms of severe atrial stenosis? [mnemominc]

step1

A

SAD

  • syncope [exertional]
  • Angina
  • Dyspnea on exertion [sign of CHF]
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8
Q

What are physical exam findings of atrial stenosis? heart sounds?

A
  • systolic ejection murmur = crescendo-decrescendo sound; peaks later with more severe stenosis
  • weakened [parvus] and delayed [tardus] upstroke of carotid artery pulsations = slow rising pulse and smaller pulse amplitude
  • soft and split 2nd heart sound, S4 gallop due to LVH
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9
Q

How is timing of systolic ejection murmur peak associated with severity of atrial stenosis

A

later peak = more severe stenosis

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10
Q

What is natural history of aortic stenosis?

A

may have 20+ years of asymptomatic stage then onset of symptoms with HF/syncope/angina leading to death in severe AS

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11
Q

What tests useful in aortic stenosis?

A

echo: tells you LV wall thickness, most valuable test

cardiac catheterization: confirm severity AS

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12
Q

What valve area measurements for mild, moderate, severe aortic stenosis in cm2?

A

mild > 1.5
moderate: 1-1.5
severe < 1

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13
Q

What is treatment for aortic stenosis?

A
  • infective endocarditis prophylaxis in dental procedures
  • mechanical problem so limited medical treatment
  • vasodilators contraindicated in severe AS
  • surgical replacement = definitive treatment
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14
Q

What are indications for surgery in aortic stenosis?

A
  • any symptomatic pt with severe AS
  • any pts with decreasing EF
  • any pts undergoing CABG with moderate or severe AS
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15
Q

What is aortic regurgitation?

A

leaking of blood into left ventricle during diastole

- due to ineffective aortic valve

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16
Q

What is the pathophysiology of aoritc regurgitation? compensatory mech?

A
  • blood regurgitates back into LV during diastole = pressure and volume overload in LV
  • compensatory mech over time: LV dilation and LVH
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17
Q

What is etiology of acute aortic regurgitation?

A
  • aortic dissection –> aortic root dilation

- endocarditis

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18
Q

What is etiology of chronic aortic regurgitation

A

abnormalities of valve leaflets

  • bicuspid aortic valve
  • rheumatic fever
  • infective endocarditis
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19
Q

What happens in acute AR?

A
  • LV normal size and noncompliant
  • volume load of regurgitation –> high LV diastolic pressure –> transmitted to LA/pulmonary –> pulmonary edema + dyspnea

can be a surgical emergency requiring immediate valve replacement

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20
Q

What happens in chronic AR?

A
  • compensatory adaptations
  • LV dilates and to lesser degree increases thickness, eccentric hypertrophy
  • less of an increase in diastolic pressure in LV _ high stroke volume = bigger systolic P and smaller diastolic P
  • bigger pulse pressure [difference betwen arterial systolic and diastolic Ps]
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21
Q

What is treatment for acute AR?

A
  • can be true surgical emergency
  • give positive inotrope [dopamine, dobutamine] or vasodilator [nitroprusside]
  • avoid beta blockers
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22
Q

What are progressive symptoms of aortic regurgitation?

A
  • dyspnea: exertional, orthopnea, PND
  • nocturnal angina
  • palpitation due to increase force of contraction
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23
Q

What are physical findings of aortic regurgitation?

A
  • wide pulse pressure
  • on auscultation: diastolic blowing murmur on left sternal border; systolic ejection murmur due to increase flow across aortic valve; austin flint murmur at apex in very severe
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24
Q

What is austin flint murmur?

A

mid-diastolic rumbling murmur at apex during mid-diastole

reflects turbulence of blood flow through mitral valve during diastole due to downward displacement of mitral anterior leaflet by regurgitant stream of blood from aortic regurgitation

25
Q

What do you see on CXR/echo/aortography in aortic regurg?

A

CXR: chronic= enlarged cardiac silhouette, aortic root enlargement

Echo: measure degree of AR and identify cause

Aortography: confirm severity of disease

26
Q

What is treatment of aortic regurg?

A
  • infective endocarditis prophylaxis in dental procedures
  • medica: vaosdilators [ACEIs] improve stroke volume and decrease regurg if pt symptomatic or has HTN
  • surgical = definitive treatment if any symptoms or EF below 50%
27
Q

What is classic clinical scenario of degenerative [rather than congenital] atrial stenosis?

A

pt presents later on >60/70 and has concurrent coronary artery disease

28
Q

What happens to LV in aortic stenosis?

A

pressure overload [try to eject and has both aortic stenosis and system vascular resistance to overcome

29
Q

What are compensatory mech in aortic stenosis?

A
  • hypertrophy of LV to decrease wall stress
30
Q

What happens to LV in mitral regurgitation?

A

volume overload [some blood from LV goes back to LA so then get even more preload in LA that goes to LV in the next contraction]

31
Q

What happens to LV in mitral stenosis?

A

volume underload [not as much blood can get from LA to LV]

32
Q

What happens to LV and aortic pressures in aortic stenosis?

A

gradient after aortic valve opens = LV has higher pressure than aorta and can’t equilibrate

gradient develops when aortic valve opens and increases in early systole to reach peak then goes down

33
Q

What heart sounds in aortic stenosis?

A
  • 1st hear sound
  • then may have ejection sound [ES]
  • diamond shaped [crescendo-decrescendo] ejection murmur [systole]
  • may have quiet/absent S2 or paradoxical splitting S2
  • then may have S4
34
Q

How do you determine severity of aortic stenosis?

A

late peaking of systolic murmur = more severe aortic stenosis = LV needs to work harder to force blood through valve

absent S2 tends to occur in late peaking

35
Q

What is paradoxical splitting?

step1

A

occurs in aortic stenosis [or left BBB]
- normally S2 = A2 then P2 and splitting increases with inspiration because P2 later

in paradoxical splitting: A2 delayed; P2 before A2 and splitting decreases with inspiration because P2 closer to A2

36
Q

What is different HCM vs AS sounds?

A 
HCM = murmur starts right at S1 = holosytolic
AS = maay have splitting of first sound = loud ejection sound [ES] then crescendo-decrescendo murmur starts after
37
Q

When can you hear S4?

A

when left ventricular hypertrophy –> systemic hypertension, aortic stenosis, hypertrophic cardiomyopathy

38
Q

Which of these 3 spares isovolumic contraction?

  • aortic stenosis
  • hypertrophic obstructive cardiomyopathy
  • mitral valve regurgitation
A

aortic stenosis!

39
Q

What is valve area, mean gradient, and jet velocity in severe aortic stenosis?

A

valve area: < 1.0 cm2
mean gradient: >40 mmHg
jet velocity: > 4 m/sec

40
Q

Why should you avoid vasodilator in aortic stenosis?

A

drop BP may get syncope

41
Q

What is normal LV pressure?

A

120

42
Q

What is normal LA pressure?

A

10

43
Q

What happens to LV in aortic regurgitation?

A

volume AND pressure overload

44
Q

What compensatory mech if volume overload LV? type of hypertrophy?

A

dilation

= eccentric hypertrophy

45
Q

What compensatory mech if pressure overload LV? type of hypertrophy?

A

hypertrophy

= concentric hypertrophy

46
Q

Which valvular disease causes biggest left ventricles?

A

aortic regurgitation!!

47
Q

What is etiology of acute aortic regurgitation?

A

endocarditis

aortic dissection

48
Q

What treatment of acute aortic regurgitation?

A

true surgical emergency!!

  • give positive inotrope = dopamine, dobutamine
  • give vasodilator = nitroprusside
  • avoid beta blockers
49
Q

Should you give balloon pump in acute aortic regurg?

A

NO!!! Don’t do it!!

50
Q

What is etiology of chronic aortic regurgitation?

A
  • bicuspid aortic valve
  • rheumatic heart disease
  • infective endocarditis
51
Q

What do you see in carotid pulse of aortic regurgitation?

A

dancing carotids = low diastolic pressure = aamplification of dicrotic notch at time of aortic vavle closure and second pul

52
Q

Which murmurs increase with inspiration? expiration?

A

murmurs of right heart increase with inspiration

murmurs of left hear increase with expiration

53
Q

What are symptoms of acute regurgitation?

A

asymptomatic until 40s or 50s

progressive symptoms: dyspnea [+ signs of LH failure], nocturnal angina, palpitations [due to forced contraction]

54
Q

What are physical findings of aortic regurgitation?

A

wide pulse pressure

hyperdynamic + displaced apical impulse

55
Q

What do you hear on auscultation in aortic regurgitation?

A
  • diastolic decrescendo blowing murmur at left sternal border [main murmur]
  • austin flint murmur at apex
  • systolic ejection murmur = due
56
Q

What is austin flint murmur?

A
  • sounds like mitral stenosis = blood flowing back = fluttering of mitral valve
  • low pitched apical mid-diastolic rumble
  • occurs in aortic regurgitation
57
Q

What is corrigan pulse?

A
  • sign of aortic regurgitation

- high amplitude, abruptly collapsing pulse

58
Q

What is quincke pulse?

A

exaggerated reddening and blanching of nail beds

sign of aortic regurgitation

59
Q

What should you think it pt comes in VDRL positive with heart problems?

A

they have syphilis = historically classic cause of aortic root dilation/regurgitation

need aortic valve replacement

Cardio Exam 1 (16 decks)

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