Mehl. Cardio: mitral reg/stenosis; MVP; Rheumatic heart disease 04-02 (2) Flashcards
M. Mitral regurgitation. what murmur?
Holosystolic (pan-systolic) or just regular “systolic,” 29 times out of 30
M. Mitral regurgitation.
Q on NBME 20 offline for Step 1 has MR as “mid-systolic,” but I contend this is erratum.
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M. Mitral regurgitation.
Most USMLE questions will not mention it radiating to the axilla.
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M. Mitral regurgitation. Seen acutely in????
Rheumatic heart disease as a kid (valve scars over years later and becomes mitral stenosis).
M. Mitral regurgitation. Can cause (venous) …?
Can cause JVD (i.e., back up all the way to the right heart); this is mentioned numerous times on the new NBMEs.
M. Mitral stenosis. Murmur?
Described as “rumbling diastolic murmur with an opening snap”; can also be described as “decrescendo mid-late diastolic murmur” (i.e., following the opening snap).
M. Mitral stenosis. What S sound?
Can cause a right-sided S4 if the pressure backs up all the way to the right heart (seen on NBMEs sometimes; this confuses students because they think S4 must be LV, but it’s not the case). An S4 is a diastolic sound heard in either the LV or RV when there is diastolic stiffening due to high afterload.
M. Mitral stenosis. 99 proc cause?
99% of mitral stenoses are due to Hx of rheumatic heart disease (i.e., the patient had rheumatic fever as a child, where at the time it was mitral regurg, but years later it has now become mitral stenosis).
M. MVP. Most common murmur.
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M. MVP. what click?
Described as mid-systolic click.
M. MVP. buzzy?
“Myxomatous degeneration” is buzzy term that refers to connective tissue degeneration causing MVP in Marfan and Ehlers-Danlos.
M. MVP. in what pathologies??
MVP in Marfan and Ehlers-Danlos.
M. MVP. symptoms?
almost always asymptomatic
M. MVP. USMLE loves using MVP as a distractor in panic disorder questions, particularly on the 2CK Pysch CMS forms. They will give long paragraph about panic attack/disorder + also mention there’s a mid-systolic click; they’ll ask for cause of patient’s presentation -> answer = panic disorder, not MVP -> student is confused because they say mid-systolic click, but the MVP isn’t the cause of the patient’s presentation; the panic disorder is; MVP’s are usually incidental, benign, and asymptomatic.
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M. Rheumatic heart disease. Mo? mechanism
Strep pyogenes (Group A Strep) oropharyngeal infection results in production of antibodies against S. pyogenes’ M-protein that cross-react with the mitral valve (i.e., molecular mimicry; type II hypersensitivity).
M. Rheumatic heart disease.
Can occur with the aortic valve in theory, but on USMLE, it is always mitral valve.
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M. Rheumatic heart disease. what valve always in usmle?
always mitral valve.
in theory - aortic valve
M. Rheumatic heart disease. results in what valvular changes?
Results in mitral regurgitation acutely and mitral stenosis late, as discussed earlier
M. Rheumatic heart disease. CP?
- Presents as JONES (J©NES) -> Joints (polyarthritis), © Carditis, subcutaneous Nodules, Erythema marginatum (annular, serpent-like rash), Sydenham chorea (autoimmune basal ganglia dysfunction that results in dance-like movements of the limbs).
M. Rheumatic heart disease.
- Cutaneous Group A Strep infections don’t cause rheumatic fever, but can still cause PSGN.
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M. Rheumatic heart disease. Tx?
= penicillin.
!!! M. Mitral regurgitation. ADULTS. Highest yield cause of MR on USMLE is????????
Highest yield cause of MR on USMLE is post-MI papillary muscle rupture. USMLE is obsessed with this. They’ll say hours to days after an MI, patient has new-onset systolic murmur. answer = MR.
M. Mitral regurgitation. ADULTS. Can be caused by ….?2
Can be caused by general ischemia / dilated cardiomyopathy.
M. Mitral regurgitation. ADULTS. Can cause JVD (i.e., back up all the way to the right heart); this is asked multiple times on the new NBMEs.
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M. Mitral regurgitation. ADULTS. You do not do preoperative stress tests to determine perioperative MI risk if the patient has mere mitral regurg without other risk factors. For example, one of the 2CK forms gives a Q where smoker with MR has no shortness of breath or chest pain with exertion, and the answer is “no further management indicated,” where exercise stress test is wrong.
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M. Mitral regurgitation. ADULTS. If the patient has Sx of heart failure or ischemia, then we do pre-op stress test to determine MI risk. I discuss stress tests later in this chapter.
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M. Mitral regurgitation. ADULTS. When valve replacement?
The mitral valve is replaced if the patient develops severe pulmonary symptoms (i.e., shortness of breath / reduced exercise tolerance), reduced ejection fraction, arrhythmia, or endocarditis if valve function is destroyed.
M. Mitral stenosis. ADULTS.
Other HY presentation on USMLE is pregnant women with new-onset dyspnea in 2nd trimester and a diastolic murmur. This is because 50% increase in plasma volume by 2nd trimester causes the underlying subclinical MS to become symptomatic. Don’t confuse this with severe dyspnea and peripheral edema in late third-trimester, which is instead peripartum cardiomyopathy (antibody-mediated).
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M. Mitral stenosis. ADULTS. The 1% of MS that’s not due to Hx of RF can be marantic (non-bacterial thrombotic endocarditis; NBTE)àendocarditis seen due to hypercoagulable state in the setting of malignancy, where the vegetations are small and verrucous, on both sides of the valve. This is in contrast to bacterial endocarditis, which causes large, floppy vegetations that lead to MR, not MS.
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M. Mitral stenosis. ADULTS. Libman-Sacks endocarditis seen in SLE is due to antiphospholipid antibodies and is a type of NBTE.
M. Mitral stenosis. ADULTS. First line Tx?
Balloon valvuloplasty is the 1st-line Tx for mitral stenosis. This is done if patient has minimal calcification of the valve + has pulmonary HTN.
M. Mitral stenosis. ADULTS. When valve replacement?
Mitral valve replacement is done if balloon valvuloplasty fails, if patient has severe MS with dyspnea, arrhythmia, or calcification of the valve.
M. MVP. does not progress to mitral regurg almost always. So don’t think that MVP and MR are the same.
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