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Brain and Behavior > Lectures 13-15: Valvular Heart Disesae > Flashcards

Lectures 13-15: Valvular Heart Disesae Flashcards

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1
Q

Acute rheumatic fever is a consequence of…When are symptoms? Primary organs?

A

Immune-mediated consequence of group A beta-hemolytic streptococcal pharyngitis; 2-3 weeks after pharyngitis; heart, skin and connective tissue

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2
Q

Where is acute rheumatic fever prevalent?

A

Highly prevalent in developing countries

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3
Q

What is the mechanism of acute rheumatic fever (protein)?

A

Autoimmune cross-reactivity b/t bacterial antigens and normal tissue (M protein)

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4
Q

Signs/symptoms of acute rheumatic fever (3)

A

Migratory polyarthralgias, Syndenham’s chorea, erythema marginatum

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5
Q

Acute rheumatic fever: heart (2 main points)

A

Pancarditis (can effect any layer) and mitral regurgitation from valvulitis

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6
Q

Acute rheumatic fever: pathology

A

Aschoff Body: granulomatous lesions w/ a fibroid center and perimeter of immune cells (acutely, eventually develops into fibrosis)

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7
Q

JONES

A

J = joints, O = heart (myocarditis), N = subcutaneous nodules, E = erythema marginatum, S = Sydenham chorea

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8
Q

To get diagnosis of acute rheumatic fever, you must have…

A

Evidence of strep and later manifestations

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9
Q

Treat acute episode with…

A

Antibiotics (penicillin) + anti-inflammatory therapy (aspirin)

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10
Q

Secondary prevention…(tx)

A

IV penicillin every 4 weeks for at least 5 years

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11
Q

What is the LT heart consequence of rheumatic fever?

A

Mitral stenosis = decades later, permanent deformity/impairment of valves

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12
Q

What does a stenotic mitral valve do to the left atrium?

A

Enlarge due to pressure/volume overload

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13
Q

Describe the hemodynamic profile of mitral stenosis

A

Left atrial pressure elevated and there is a pressure gradient b/t left atrium and left ventricle during diastole

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14
Q

Consequences of enlarged L atrium (4)

A

Pulmonary venous congestion –> heart failure; atrial fibrillation –> palpitations; atrial fibrillation –> cerebrovascular accident; impinged recurrent laryngeal –> Hoarseness (Ortner syndrome)

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15
Q

Mitral stenosis: exam findings (2)

A

Diastolic murmur and opening snap (OS)

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16
Q

Internval between S2 and OS relates _______ to severity of MS

A

Inversely

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17
Q

Mitral stenosis: ECG findings (2)

A

P Mitrale: extended, bihumped P wave in Lead II; Atrial fibrillation

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18
Q

Mitral stenosis: medical treatment (2)

A
  1. Anticoagulation (even if absence of a fib); 2. Rate control (beta-blockers or the like to increase time for ventricle filling)
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19
Q

Does medical therapy of mitral stenosis slow progression?

A

No, but helps with symptoms

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20
Q

When would a patient qualify for percutaneous balloon mitral valvuloplasty (PMBV)? What is the second option to PMBV?

A

Symptomatic patients or those with a fib/pulmonary hypertension; mitral valve replacement

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21
Q

SO: PMBV for ________ patients

A

Symptomatic

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22
Q

T/F: People with normal valves are at risk for infective endocarditis

A

False: normal valves are resistant

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23
Q

Risk factors for infective endocarditis (3)

A
  1. Turbulent blood flow across abnormal, diseased valve; 2. Lesions provoked by electrodes/catheters; 3. Repeated IV injections of solid particles in IV drug users
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24
Q

Pathology of infective endocarditis

A

Vegetation: platelets, fibrin, microorganisms

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25
Q

Most common micro-organism to cause infective endocarditis. Second most common? How do you differentiate?

A

Staph; strep; staph = catalase positive; staph aureus = coagulase positive

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26
Q

Catalase positive, coagulase positive?

A

Staph aureus

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27
Q

Catalase positive, coagulase negative?

A

Another staph, likely staph epidermidis

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28
Q

IV drug use, most common micro-organism

A

Staph aureus

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29
Q

Prosthetic valve endocarditis, most common micro-organism

A

Staph epidermidis

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30
Q

Underlying colon malignancy, most common micro-organism

A

Strep bovis

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31
Q

Subacute bacterial endocarditis following dental work, most common micro-organism

A

Viridan sreptococci

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32
Q

Culture negative, most common micro-organisms (mnemonic = 5 + one)

A

HACEK (Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella); Coxiella (Q fever)

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33
Q

Duke criteria is used to diagnose

A

Endocarditis

34
Q

Clinical manifestations of endocarditis: 2 sets of phenomenom

A

Vascular/embolic phenomenon: pieces of vegetation break off and travel; Immunologic phenomenon: deposition of circulating immune complexes

35
Q

Is infective endocarditis associated with heart murmurs?

A

Yes: you can get a new or worsened heart murmur

36
Q

What is a splinter hemorrhage? What phenomenon is it related to?

A

Black hemorrhage under nail –> skin finding of infective endocarditis; embolic phenomenon

37
Q

Eye finding of infective endocarditis. What phenomenon is it related to?

A

Roth Spot; embolic phenomenon

38
Q

Oslar nodes: What phenomenon is it related to?

A

Immunologic phenomenon

39
Q

Role of ECHO in endocarditis

A

Diagnostic: to find vegetation

40
Q

Infective endocarditis: treatment

A

Extended course of antibiotics (4+ weeks), consider methicillin-resistant if staph is suspected (vancomycin)

41
Q

If someone is not getting better, you do ________ for their endocarditis. Why else? (2)

A

Surgery; immune involvement, very large vegetation

42
Q

Etiology of aortic stenosis (three most common causes in order of prevalence)

A
  1. Calcification of normal valve (7th, 8th decade); 2. Calcification of bicuspid valve (6th decade); 3. Rheumatic disease
43
Q

Pathogenesis of aortic stenosis

A

Risk factors (bicuspid valve, smoking, dyslipidemia) –> aortic sclerosis (inflammation) –> aortic stenosis (calcification)

44
Q

Bicuspid arotic valve (%, 2 most common sequalaes and 2 associations )

A

Common –> 1 - 2 % of people; aortic stenosis is most common sequalae followed by aortic regurgitation; associated w/ other abnormalities: coarctation of aorta and thoracic aortic aneurysm

45
Q

What kills patients with BAV?

A

Thoracic aortic aneurysm

46
Q

Pathophysiology of aortic stenosis

A

Gradient b/t LV and aorta during systole –> murmur

47
Q

Three symptoms of aortic stenosis and impact on median survival

A
  1. Angina (5 years); 2. Syncope (3 years); 3. HF (2 years)
48
Q

Why does HF occur in aortic stenosis?

A

Contractile dysfunction develops because of insurmountably high afterload

49
Q

What is the murmur in aortic stenosis?

A

Coarse crescendo-decrescendo (diamond shaped) late-peaking systolic murmur

50
Q

Describe pulses in aortic stenosis

A

Weakened (parvus) and delayed (tardus) upstroke of the carotid artery

51
Q

A valve area of less than…is what?

A

1.0 cm2 = severe aortic stenosis

52
Q

Treatment for aortic stenosis..

A

No proven medical therapy

53
Q

What is the preferred treatment for symptomatic severe aortic stenosis?

A

Surgical aortic valve replacement

54
Q

Indication for aortic valve replacement

A

SYMPTOMS

55
Q

Define aortic regurgitation

A

Incomplete closure of the aortic valve in diastole resulting in retrograde flow from the aorta back into the LV (in diastole)

56
Q

Mechanisms of aortic regurgitation (6, 2 categories)

A

Abnormalities of valve leaflets: Bicuspid valve, infective endocarditis, rhematic heart disease; Dilation of aortic root: age/hypertension-related, aortic aneurysm (CT disease), aortic dissection

57
Q

Describe problem found in Marfan syndrome

A

Medial necrosis of aorta –> dilation of proximal ascending aorta –> aortic dissection AND mitral valve prolapse from dilation of mitral valve

58
Q

What gene is defective in Marfan?

A

Fibrillin

59
Q

Hemodynamic profile of aortic regurgiation

A

Aortic pressure falls rapidly during diastole with a wide pulse pressure (difference b/t systolic and diastolic blood pressure)

60
Q

Heart sound in aortic regurgitation

A

Blowing murmur in early diastole: low-frequency, mid-diastolic rumble, decrescendo

61
Q

Findings in chronic aortic regurgitation vs acute aortic regurgitation

A

Chronic: enlarged LV that has decreased pressure to LA; Acute: sudden shock of elevated pressure to LA –> pulmonary congestion

62
Q

Symptoms (3) and signs (3) of aortic regurgitation

A

Symptoms: exertional dyspnea, fatigue, uncomfortable sensation of forceful heart beat; Signs: widened pulse pressure, blowing murmur, Austin-Flint murmur

63
Q

Austin-Flint Murmur: describe and what does this cause?

A

Downward displacement (closure) of the anterior leaflet of the mitral valve during diastole by the regurgitant stream of aortic regurgitation; functional cause of mitral stenosis

64
Q

Physical findings in aortic regurgitation (3, but don’t memorize this stuff)

A
  1. Bisferiens pulse (double systolic impulse in carotid or brachial artery); 2. Quincke sign (capillary pulsations visible at proximal nail bed); 3. Bounding carotides
65
Q

Dicrotic notch is normal/abnormal. What is it?

A

Normal; rebound effect from arterial elasticity after systolic filling

66
Q

Who gets aortic regurgitation treatment? What is the treatment?

A

Medical therapy does not slow progression, but symptomatic patients may benefit from valve replacement

67
Q

Mitral regurgiation has two large categories. What are these?

A

Primary cause: structural defect of valve component; Secondary cause: valve is structurally normal but regurgitation results from LV enlargement

68
Q

Mitral regurgitation and acuity

A

If it’s acute, you have dilated high pressure LA –> pulmonary edema; chronically, LA is accommodating and it has dilated

69
Q

Hemodynamic profile of mitral regurgitation

A

Tall v wave (atrial filling) due to back-flow from ventricle

70
Q

What is the most common cause of mitral regurgiation

A

Myxomatous degeneration: extra mitral valve tissue

71
Q

What are the typical symptoms of mitral regurgitation? Why?

A

Dyspnea, orthopnea, PND = pulmonary edema

72
Q

Murmur of mitral regugitation

A

Apical holosystolic murmur that often radiates to axilla

73
Q

What does holosystolic mean?

A

All of systole = starts at S1 and extends to S2

74
Q

Define mitral valve prolapse. What is it frequently accompanied by?

A

Abnormal billowing of a portion of one or both mitral leaflets into the left atrium during ventricular systole; mitral regurgitation

75
Q

Does mitral valve prolapse always affect patients?

A

Nope: often regurge is minimal and it doesn’t cause symptoms

76
Q

Causes of mitral valve prolapse?

A

Familian, or accompanyting CT diseases (Marfan)

77
Q

What is the classic exam finding of mitral valve prolapse?

A

Midsystolic click (tensing chordae tendinae as leaflet billows into LA)

78
Q

Mitral regurgitation treatment (acute, chronic primary, chronic secondary)

A

Acute MR: surgery; Chronic primary MR: surgery for symptomatic patients = mitral valve repair (not replacement); Chronic secondary MR: medical therapy

79
Q

What is the medical therapy for acute MR?

A

Afterload reduction

80
Q

Two types of valves and key points

A

Mechanical: requires LT consistent anticoagulation; Bioprosthetic: less durable –> 50% failure in 15 years

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