MTB 3 Flashcards
MCC Mitral Stenosis
Rheumatic Fever
MC in young adults
When do we treat Mitral Stenosis
Symptomatic
Pregnant and Immigrant - Valvular dz?
Mitral Stenosis
Pregnancy - 50% increase in plasma volume
Presentation of Mitral Stenosis
SOB/Dyspnea/Orthopnea CHF Dysphagia- Esophagus Hoarseness - Laryngeal N A fib/Stroke Hemoptysis Right sided HF
Presentation of Right sided HF
Hepatomegaly
Ascites
Peripheral Edema
Murmur with Mitral Stenosis
Diastole right after opening snap
Loud S1 = MV opens when ventricle contracts, slams the valve shut
Opening Snap = MV opening after S1
What increases the intensity of Mitral Stenosis
Squatting
Leg raising
Increased venous return to the heart
Best initial test for Mitral Stenosis
TTE
Most accurate test for Mitral Stenosis
Catheterization
EKG of Mitral Stenosis
A fib very common
LA Hypertrophy = biphasic P wave in V1 and V2
CXR of Mitral Stenosis
LA Hypertrophy
- Straightening of left heart border
- Elevation of left main-stem bronchus
- Second bubble behind heart
TX for Hypertrophy
- Diuretics + Sodium restriction if fluid overload in lungs
- Balloon Valvuloplasty done with catheter
- Valve replacement if catheter cannot be done
- Warfarin for A fib
- Rate control of a fib
AE of Diuretics in pregnancy
IUGR
Causes of Aortic Stenosis
Congenital bicuspid valve
Calcifications with aging
Pathophys of Calcifications in Aortic Stenosis
Calcium leaves bones and enters aorta
Presentation of Aortic Stenosis
Angina = MC Syncope CHF Pulsus tardus et parvus Carotid thrill
What is Pulsus tardus et parvus
Pulse that is small and late
TX for Aortic Stenosis
If SAD (Syncope, Angina, Dyspnea) = Valve replacement No good medical TX
Test for Aortic Stenosis
TTE
TEE
Catherization
Murmur of Aortic Stenosis
Systolic Crescendo-decrescendo Peaks mid-systole Heart best at 2nd right IC space Radiates to Carotid Valsalva/standing - decrease murmur/improve
Why does Valsalva/standing decrease or improve murmur in Aortic Stenosis
Decreased venous return to heart
What softens murmur of Aortic Stenosis
Handgrip b/c of decreased ejection of blood
What is carotid thrill
Palpable vibration of murmur
EKG of Aortic Stenosis
LVH
S wave in V1 + R wave in V5
How long will stenotic valve survive
12-24 months
Causes of Mitral Regurgitation
HTN
Endocarditis
MI w Papillary muscle rupture
Any cause of heart dilation
Presentation of Mitral Regurgitation
CHF sx’s - distended neck veins
Murmur of Mitral Regurgitation
Holosystolic - obscure both S1 and S2
Best heard along sternal border
Radiates to Axilla
What worsens murmur of Mitral Regurgitation
Handgrip pushes more blood backwards through the valve
Squatting and leg raising -increase venous return to heart
Handgrip worsens which murmurs
Impact on preload/afterload
MR
AR
Handgrip increases afterload
Valsalva and standing do what to blood flow
Decrease venous return to heart
Squatting and leg raising do what to blood flow
Increase venous return to heart
Do all left sided murmurs increase w expiration
No
NOT HOCM + MVP
If the EF is < 60%, what does this mean for LV?
Management?
LV End systolic Diameter (LVESD) is > 40 mm
Unable to empty ventricle
Replace or repair valve before dilates more
EKG for Mitral Regurgitation
LVH and LA Enlargement
Echo for Mitral Regurgitation
LA and/or LV Dilatation
TX for Mitral Regurgitation
1. Vasodilators - ACE, ARBs = BEST. Increase EF Hydralazine if can't tolerate. 2. Digoxin, diuretics 3. Valve Replacement - symptomatic pt. ASAP when heart starts to dilate If LVESD > 40 mm OR EF < 60%
Causes of Aortic Regurgitation
Heart of Aorta Dilated MI HTN Endocarditis Marfan Cystic Medial Necrosis Inflammatory Dz - Ankylosing Spondylitis, Reiter Syphilis - Tertiary
Presentation of Aortic Regurgitation
CHF Si/Sx's Wide pulse pressure Water-hammer pulse (wide, bounding) pulse Quincke pulse (pulsations in nail bed) Hill sign (BP in legs > arm BP) Head bobbing (de Musset sign)
Murmur of Aortic Regurgitation
Diastolic
Decrescendo
Heard best at lower left sternal border
Duzoziez sign - S/D thrill/murmur over Femoral Area
Diagnostic test for Aortic Regurgitation
Echo - TTE, TEE
Catheterization
TX for Aortic Regurgitation
- ACEi/ARBs, Nifedipine as Vasodilators - increase forward flow and delay progression
- Digoxin, diuretics - little benefit
- Valve replacement if acute valve rupture
- EF < 55% or LVESD > 55mm
What improves murmur of Aortic Regurgitation
Valsalva and standing
What worsens murmur of Aortic Regurgitation
Handgrip increase afterload, compressing arteries of the arms
What is PPX for Endocarditis
Amoxicillin
Clindamycin
MVP causes
Anatomic variant - esp women
Marfan
Ehlers-Danlos
Myxamatous degeneration of MV leaflets/chordae
Presentation of MVP
Asymptomatic When Sx's - CHF sx's ABSENT - Atypical chest pain - Palpitations - Panic Attack
Murmur of MVP
Worse w?
Improved w?
Midsystolic click
Valsalva and standing Worsen
Squatting and handgrip Improve
What can MVP progress to
Endocarditis
Arrhythmias
Valve Calcifications
TIAs
TX for MVP
- Beta blockers when symptomatic for pain, palpitations, panic attack
- Valve repair w catheter - place clip to tighten
Is endocarditis PPX needed for MVP
Not recommended
