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CPR Exam 2 > Lecture 2: Murmurs, Valvular Disease > Flashcards

Lecture 2: Murmurs, Valvular Disease Flashcards

1
Q

What is the single most common sx associated w/ valvular heart disease?

A

Dyspnea on exertion

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2
Q

What are the 3 most common etiologies for valvular heart disease seen nowadays?

A
  1. Degenerative (senile calcification)
  2. Myxomatous degeneration (MVP) redundant
  3. Congenital (bicuspid aortic valve)
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3
Q

Stenosis of a valve leads to what type of overload and effect on heart?

A

Pressure overload; hypertrophy and HF

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4
Q

Regurgitation of a valve leads to what type of overload and effect on heart?

A

Volume overload; dilation

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5
Q

Which sex has a higher incidence of rheumatic heart disease?

A

Women 4:1

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6
Q

What are 6 minor jones criteria for rheumatic heart disease?

A
  1. Fever
  2. Arthralgia
  3. ↑ ESR or CRP
  4. Leukocytosis
  5. ECG - prolonged PR interval
  6. ↑ ASO titer or anti-DNAase B
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7
Q

How many major or combo of major/minor criteria need to be met for diagnosis of rheumatic heart disease?

A
  • 2 major

OR

  • 1 major + 2 minor
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8
Q

The narrowing of the mitral orifice seen in MS, leads to an increased pressure gradient where and what other changes?

A
  • ↑ left AV pressure gradient
  • LA enlargment –> afib, pulmonary vascular changes, RVH
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9
Q

Which decade is MS most common?

A

4th decade

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10
Q

Most common presenting sx’s of someone with mitral stenosis (MS)?

A
  • Fatigue assoc. w/ decreased CO
  • Dyspnea on exertion, cough, orthopnea, PND, pulmonary edema, hemoptysis
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11
Q

What is Ortner syndrome associated with MS?

A

Hoarsness due to compression of left recurrent laryngeal n. as LA ↑ in size

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12
Q

What is the common PE finding due to CO2 retention assoc. w/ pulmonary HTN seen in MS?

A

Malar rash

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13
Q

What are the ausculatory findings of S1 and S2 in pt with MS?

A
  • ↑ loud S1 + ↑ S2 (P2 if PHT is present)
  • Opening snap after S2 (if leaflet is mobile)
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14
Q

Describe the murmur associated with MS (i.e., phase of cardiac cycle, best heard where/position and with what part of stethoscope)?

A
  • DIASTOLIC, low pitch, decrescendo, rumbling murmur
  • Best heard at APEX w/ pt in left lateral decubitus position
  • Use BELL
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15
Q

In MS there will be increased loud S1 and increased S2, what would the presence of loud P2 (pulmonic valve closure) signify?

A

Presence of pulmonary HTN

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16
Q

Common EKG finding of someone presenting with sx’s of severe MS?

A

Atrial fibrillation

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17
Q

What do the ‘p’ wave findings in lead I and V1 signify?

A

Left atrial enlargement

*‘M’ shaped ‘p’ wave = P mitrale

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18
Q

What does the CXR finding signify about the heart?

A

Left atrial enlargment; notice the straight line

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19
Q

If patient with MS is in atrial fibrillation, what should be given and why?

A

Anticoagulant; risk of emboli

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20
Q

Which invasive procedure for MS has a high success rate?

A

Percutaneous balloon valvuloplasty (Mitral Commissotomy)

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21
Q

What are the 2 etiologies of chronic mitral regurgitation (MR) and which is most common?

A
  • Mitral valve prolapse = MOST common/myxomatous or degenerative MV
  • Mitral annular calcification (MAC)
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22
Q

What are 4 causes of acute mitral valve regurgitation?

Which is 2nd most common cause of MR?

A
  • Rupture of chordae tendineae
  • Rupture of papillary muscle
  • Ischemic papillary muscle dysf. due to CAD/MI = 2nd most common cause
  • Infective endocarditis (IE); valve perforation
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23
Q

Acute MR leads to an abrupt increase in what (volume/pressure) and what complications follow?

A

↑ LA PRESSURE —> pulmonary edema, LVF

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24
Q

What will be seen on the ECG of someone with chronic MR?

A
  • Left atrial enlargement
  • ‘M’ shaped p wave in lead I and negative terminality of p wave in V1
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25
How can acute MR present clinically signs/sx's? What's a serious complication that can arise?
- **Volume overload** ---\> **LV dilation** - **LA HTN** --\> **Pulmonary HTN** --\> RVF ---\> **RHF/LHF** - Orthopnea and PND - Can present with **cardiogenic shock!**
26
Upon auscultation of pt with MR what type of murmur is heard, describe it's characteristics (i.e., best heard where, radiates, use bell or diaphragm..)?
- **SYSTOLIC** murmur (**blowing, holosystolic**; may be mid-late systolic) that **radiates** ---\> **left axilla** - **Best** heard at **APEX**; use the **diaphragm**
27
What feature of the murmur heard with MR correlates with severity?
**Loudness**
28
What is the characteristic of S1 in pt with MR and if due to MVP what may be heard?
**Decreased S1** or **normal**; may have **systolic click** if **due to MVP**
29
Which manuever will move click and murmur associated with MR closer to S1? What is the effect of hand grip on the murmur?
- **Valsalva** moves click and murmur closer to S1 - **Hand grip** will ↑ murmur
30
Which drug class used for chronic MR?
ACE-I
31
Which drug class is used to **decrease afterload** in MR?
**Vasodilators** (Nitroprusside)
32
What is the rational for using an intra-aortic balloon pump (IABP) in someone with acute MR?
- Decreases afterload - Helps to perfuse coronary arteries
33
Which sex is most often affected by mitral valve prolapse (MVP) and what are congenital defects which increase risk?
- **Women 7:**1 - Assoc. with **Marfans**/**skeletal changes**
34
What are the range of sx's/signs associated with MVP?
**Asymptomatic** to **arrhythmias** (SVT, PVC's, VT), **chest pain** and/or **syncope**
35
What is the characteristics of the murmur heard with MVP?
**SYSTOLIC** murmur; may have **systolic click**
36
If patient with MVP is in hyper-adrenergic state (anxious, palpitations), consider using what drug class?
Beta-blocker
37
What is the favored tx for MVP?
**Valve REPAIR** favored over replacement
38
What are 3 causes of Aortic Stenosis and which is most common?
**- _Most common_ = Degeneration** of valve (**calcific** or **senile**) ---\> **persons \>65 yo** - **Congenital** or **acquired** **bicuspid** aortic valve (**BAV**) - **Rheumatic**/post-inflammatory scarring (radiation)
39
The obstruction in aortic stenosis leads to what type of overload (pressure/volume) and what are the downstream effects?
**PRESSURE** overload --\> **LVH** --\> **↑ LVED pressure** = **diastolic dysf** + **systolic HF**
40
Which decade does aortic stenosis typically manifest in and what are the 4 **cardinal** signs/sx's?
- **6th** decade - **Exertional dyspnea** - Angina **- Syncope** - Heart failure
41
Prognosis of aortic stenosis with and w/o tx?
- **Without tx** the prognosis is **poor** - **With tx** most will die within **3 years** of developing **syncope** and within **2 years** of onset of **HF**
42
What are the common PE findings of aortic stenosis (i.e., pulse pressure, SV and systolic pressure)?
- **NARROW** pulse pressure - **Decreased** SV and systolic pressure - **Delayed pulses** --\> ***Parvis** (weak w/* ↓ amplitude*) or **Tardus** (late/delayed)*
43
What are the characteristis of the murmur heard in aortic stenosis (heard best where, radiates)? Affect on A2 sound?
- **Decreased A2** - **HARSH, SYSTOLIC** murmur, at **2nd ICS RSB** - **Radiates** into **suprasternal notch/carotids**
44
What is the Gallavardin phenomenon associated with aortic stenosis murmur?
Murmur radiates to apex (like **MR**)
45
What does the huge amplitue of QRS in V5 and V6 along with high voltage in all chest leads indicate? Seen in which valvular disease?
- LV **hypertrophy** - Aortic Stenosis
46
What is the "bridge therapy" for aortic stenosis that can buy time before surgery or TARV?
Balloon valvuloplasty
47
What is the treatment for symptomatic, trileaflet aortic valvular sclerosis (stenosis) w/ high surgical risk; no aortic regurgitation?
**TARV** (transcatheter aortic valve replacement)
48
What are 5 causes of **acute** aortic regurgitation?
1. Infective endocarditis 2. Aortic dissection 3. BAV 4. Chest trauma 5. Balloon valvuloplasty
49
List 7 causes of **chronic** aortic regurgitation?
1. Syphilis 2. Ankylosis spondylitis 3. Ascending aortic dilation 4. BAV 5. Calcific degeneration 6. Rheumatic 7. Chest radiation
50
Aortic regurgitation leads to what type of overload (pressure/volume) and leads to increased what?
**VOLUME** overload --\> can ↑ **LVEDV** and cause **LVH --\> Left sided HF**
51
Acute aortic regurgitation is associated with what signs/sx's (think underlying causes)?
- Infective endocarditis - Aortic dissection - Acute pulmonary edema - Cardiogenic shock
52
Chronic aortic regurgitation will develop over time with what signs/sx's?
Dyspnea, orthopnea, PND, and chest pain
53
Which type of murmur is present with Aortic Regurgitation, heard best where?
**- DIASTOLIC**, decrescendo murmur, **3rd ICS LSB** **-** Systolic murmur usually present, soft
54
Which valvular heart disease has a **wide pulse pressure** and may be associated w/ De Musset sign, Corrigan's Pulse, Quincke's Pulse, Traube's sign, Hill's sign, and Durozrey's sign?
Aortic regurgitation
55
Which drug class should be prescribed to pt with aortic regurgitation to decrease afterload and in turn decrease regurgitation volume?
ARB (-sartans)
56
When is surgery to replace or repair a valve in someone with aortic regurgitation indicated?
- When **symptomatic** OR - **EF** \<50-55%
57
Tricuspid stenosis is associated with what 3 heart/valvular problems and what are 2 other general associations?
- **Mitral stenosis**, **Tricuspid Regurgitation**, and **RHD** - Can be associated with **carcinoid** and **ergot agents (cabergoline)**
58
What type of murmur is associated with Tricuspid Stenosis and where is it best heard? What causes an increase and decrease in the murmur?
- **DIASTOLIC**, LOW pitch, decrescendo murmur at **LSB** - **Increase** w/ **inspiration** (**Carvallo's sign**) - **Decrease** w/ **expiration** and **valsalva**
59
Which wave in JVP is Tricuspid Stenosis vs. Regurgitation associated with?
- **TS** = prominent "A" wave in JVP - **TR** = V wave in JVP
60
List 7 associations with Tricuspid regurgitation
1. Pulmonary HTN (COPD, cor pulmonale, RVF) 2. RV infarction 3. Inferior MI 4. Pacemaker 5. Endocarditis 6. Congenital 7. Trauma
61
What is the characteristic murmur heard with tricuspid regurgitation and best heard where? What will increase the intensity of the murmur?
- **Blowing**, **holoSYSTOLIC** murmur heard at **LSD 4th ICS** - **Increases** with **inspiration (Carvallo's sign)** --\> due to increased venous return
62
What is the characteristic murmur heard with Pulmonary Stenosis and is best heard where? Radiation? Increases with what?
- **SYSTOLIC** **crescendo-decrescendo** murmur, **ejection click** - **2nd-3rd ICS LSB**/radiates --\> **left shoulder-clavicle** and **increases** w/ **inspiration/RVH**
63
Most causes of pulmonic regurgitation (PR or PI) are due to what?
Pulmonary HTN
64
What is the characteristic murmur heard with Pulmonic Regurgitation and heard best where?
**DIASTOLIC**, decrescendo **blowing** murmur at **2nd ICS LSB = Graham Steell**
65
There will be an increased P2 if pulmonic regurgitation is due to what?
Pulmonary HTN
66
List the 5 valvular causes of systolic murmurs
- MR (MVP) - TR - AS - PS - VSD
67
Aorticopulmonary shunts will cause what type of murumur?
Early, mid, late, holosystolic/pansystolic murmur
68
List the 4 valvular causes of diastolic murmurs
- MS - TS - AR - PR
69
What are 4 causes of continous murmurs?
- PDA (**machinery**) - AV fistula - ASD w/ high LA pressure - Coarctation
70
Pulmonic stenosis may have what 2 sx's?
**Angina** and **Syncope**

CPR Exam 2 (21 decks)

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