Murmurs Flashcards
How does Mitral regurg occur?
MV fails to close correctly during systole
Abnormal regurg of blood from LV, through mitral valve, into LA during systole
How is mitral regurg caused?
PRIMARY: Degenerative (Annular calcification), Acute (papillary muscle rupture- MI, infective endocarditis), MV prolapse, Rheumatic fever
SECONDARY: LVF, Cardiomyopathy, CAD
How does MV prolapse occur?
Weakened CT of chordae tendenae – mid systolic click, systolic murmur
What are the risk factors for mitral regurg?
Female ↓BMI ↑Age Prev MI/MV stenosis/MVP CT disorder (Marfan's, Ehler's Danlos)
How are the signs of mitral regurg?
REGURGS: R: RV heave E: Exertional dyspnoea squattin G: Click late, murmur short mUrmur: PANSYSTOLIC R: Radiates to L axilla Gone: Displaced apex beat S: Soft S1, Split S2
How is mitral regurg investigated?
ECHO w/Doppler: CONFIRMS DIAGNOSIS, assess LV function & aetiology & severity (degree of retrograde flow into LA)
ECG: Broad P wave, LA enlargement
CXR: Enlarged LA&V, pulmonary oedema if acute
Cardiac Catheterisation: ALSO CONFIRMS DIAGNOSIS
How is mitral regurg managed?
ACUTE: Pulmonary oedema management (LMNOP’S)
Surgery: Mechanical valve
What are the complications of mitral regurg?
AF- Backflow into LA
LHF- ↑Blood in left atrium → ↑Pre-load → volume overload → hypertrophy of myocardium → CCF
Acute PO- Following MI → papillary muscle rupture → acute mitral regurg
Chronic PO- Chronic regurg into LA → back pressure of blood into pulmonary circulation → ↑PO
Which drugs prolong QTc?
Sotalol TCAs SSRIs Haloperidol Methadone Erythromycin
How does Mitral stenosis occur?
Obstruction of mitral valve due to commissural fusion →
↓blood flow from LA, through mitral valve, into LV →
↑pressure in LA→ pulmonary congestion (LVF) → RVF
What are the causes of Mitral stenosis?
Degenerative: Calcification
Rheumatic fever
Infective endocarditis
Congenital
How does mitral stenosis present?
Signs of LVF (Dyspnoea→ Orthopnoea → PND ) Palpitations (AF) Malar flush ↑JVP Mid-diastolic rumbling murmur Loud S1 RV heave Laterally displaced apex beat
How is mitral stenosis investigated?
ECHO: TTE/TOE- DIAGNOSTIC: Assess severity, significant stenosis = <1cm
ECG: P mitrale, ?AF
CXR: LA enlargement, MV calcification, prominent pulmonary vessels
How is mitral stenosis managed?
Acute AF: Follow protocol
GTN +/- Diuretics for dyspnoea
Surgery: Balloon valvuloplasty, open mitral valvectomy/replacement
What are the complications of mitral stenosis?
Pulmonary HTN
AF
What is the mechanism of AF in mitral stenosis?
Due to LA hypertrophy → stretch pacemaker cells → ↑risk of AF → Systemic emboli → stroke, renal failure, MI
How does aortic regurg occur?
Aortic root dilatation/valvular disease
Aortic valve does not close properly (incompetent)
Leakage of blood from aorta into LV during diastole
↑SV in LV + ↑sBP + ↓dBP = ↑Pulse pressure
Eventually LV hypertrophy
What are the causes of aortic regurg?
ACUTE: Infective endocarditis, aortic dissection, chest trauma
CHRONIC: CT disorders, Rheumatic fever, RA, SLE, Bicuspid defect
How does aortic regurg present?
FLOW BACK: F: Fatigue & syncope L: Light/soft S1 O: Orthopnoea/dyspnoea/PND W: Wide pulse pressure B: Basal Crackles A: Apex beat displaced C: Collapsing pulse K: DiastoliK murmumr (high pitched decrescendo)
What is an Austin Flint murmur?
Cooing dove sound in aortic region
Indicates valve has collapsed & is absolutely incompetent
Indicates Severe AR = valve replacement
How is aortic regurg investigated?
ECHO: DIAGNOSTIC- visualise retrograde flow w/doppler MUST have ECHO every 6-12m
ECG: ↑R wave progression
CXR: Signs of HF
Cardiac catheterisation: Assess severity
How is aortic regurg managed?
HTN management
Surgery: Valve replacement/ valve sparing replacement
What are the indications for aortic valve replacement surgery?
↑symptoms
Enlarging heart on CXR/ECHO
ECG deterioration (T wave inversion in lateral leads)
IE refractory to medical Rx
How does aortic stenosis occur?
Aortic valve fails to open fully
↑Pre-load in LV
↓blood in aorta → concentric LV hypertrophy
Due to ↑stress on ventricle → ↓CO
↓end organ perfusion → respiratory + CV Sx
What are the causes of aortic stenosis?
Degenerative: Lipid deposition on aortic valve
Bicuspid valve: Congenital → ↑inc risk of calcification
Post-inflammation
Rheumatic fever
What are the signs & Sx of aortic stenosis?
Classic Triad: Angina + HF + Syncope Narrow pulse pressure Slow rising pulse Crescendo, ejection systolic murmur- radiates to carotid Aortic thrill LV heave
How is aortic stenosis investigated?
ECHO w/DOPPLER = DIAGNOSTIC, visualise defect & severity, LBBB,
ECG: P mitrale,
CXR: Valve calcification
Cardiac catheterisation
How is aortic stenosis managed?
Valve replacement (TAVI)
