Murmurs, Valvular Disease, Endocarditis Flashcards
Types of valvular heart disease
• Degenerative (senile calcification)
• Myxomatous degeneration (MVP)
• Congenital (Bicuspid aortic valve)
• Stenosis (AS, MS)
o Impedes forward flow
o Stenotic, sclerosis, fibrosis, calcification
o Leads to pressure overload, hypertrophy and HF
• Regurgitation – failure to close adequately, leaks (AI, MR)
o Reversal of flow
o Insufficiency, incompetence
o Leads to volume overload, dilates
Rheumatic heart disease
o Group A Strep o Carditis – inflammatory of heart muscle (myocarditis, pericarditis) o Migratory polyarthritis (large joints) o SQ nodules – painless, over bone and tendon o Sydenham’s Chorea (St. Vitus’s dance) – rapid purposeless movement of face and arms o Erythema marginatum – rash • Circular with clear center o Jones Minor Criteria • Fever • Arthralgia • Increased Sed rate or CRP • Leukocytosis • ECG – prolonged PR interval • Elevated ASO titer or anti-DNase B
Mitral stenosis
o Normal MV orifice 4-6 cm2
o Narrowing leads to increased left AV pressure gradient
• LAE – afib, pulmonary vascular changes, RVH
• LAE on ECG – I notched p wave; V1 – biphasic p wave
• Orifice 1 cm2 or less is severe that leads to pulmonary HTN, RVF
o Symptomatic in 40s
• DOE, cough, orthopnea, PND, pulmonary edema, hemoptysis, arterial emboli, A fib
o Ortner Syndrome: hoarseness d/+ compression of left recurrent laryngeal n.
o Malar flush – ruddy cheeks, blue facies
o Increase S1; opening shape after S2
o Rumbling, diastolic murmur – low pitched, best heard at apex – use bell
o Tx:
• Anticoagulant if in a. fib
• Percutaneous balloon valvuloplasty
• MVR (replacement)
• Progressive symptoms – possible RVF
• Increase LA pressure, pulmonary HTN, pulmonary edema, hepatomegalia, ascites, peripheral edema
Mitral regurgitation
o Chronic
• MVP – most common
• MAC – mitral annular calcification – aging
o Acute (“something broke”) • Rupture of chordae tendineae • Rupture of papillary muscle • Ischemic papillary muscle dysfunction • Infective Endocarditis, valve perforation
o Acute MR – Increased LA pressure abruptly, pulmonary edema, LVF
o Chronic MR – generally well compensated
o Symptoms: Asymptomatic years → fatigue, DOE
• Acute: volume overload, orthopnea, PND, RHF/LHF
o Physical Exam:
• Systolic murmur – blowing, prominent at apex, radiates into left axilla
• Loudness of murmur correlates with severity
• Decreased S1 or normal, may have systolic click
o Treatment:
• Vasodilators – afterload reduction
• Decrease resistance to flow
• ACEI – chronic MR
Mitral Valve Prolapse
o One or both mitral leaflets will prolapse into LA during systole to cause MR
o 7:1 ratio female
o Associated with Marfans/skeletal changes
o Symptoms:
• Asymptomatic to arrhythmias (SVTs, PVCs, VT), CP, syncope
• Systolic murmur, may have systolic click
o Treatment: if hyper adrenergic state – anxious, palpitations, consider BB
• Valve repair favored over replacement
Aortic Stenosis
o Etiology • Degenerative – calcific or senile • Congenital bicuspid aortic valve (BAV) • Rheumatic or post inflammatory scarring • Normal AoV area is 4.0 cm2
o Obstruction leads to pressure overload, LVH, increase LVED pressure
o Gradient across valve
o Severe AS if AoV <1.0 cm2
o Symptoms:
• 6th decade – exertion dyspnea, angina, syncope, heart failure
• Without treatment prognosis is poor
• Most will die within 3 years of developing syncope, within 2 of onset of HF
o Physical exam:
• Narrow pulse pressure, decreased SV and systolic pressure
• Delayed pulses – Parvis/Tardus
• Systolic murmur, harsh, raspy, 2nd ICS RSB, radiates into suprasternal notch/carotids
• Gallavardin phenomenon – murmur radiates to apex (like MR)
o ECG – high voltage, LVH with strain pattern
o Tx:
• Percutaneous balloon valvuloplasty – temporary AVR (replacement)
o Tests: Echocardiogram, ECG, CXR, cardiac enzymes
Aortic Regurgitation
o Due to leaflet abnormalities (bicuspid AoV, IE)
o Due to aortic root abnormalities (Marfans, aortic dissection, aging, HTN)
o Causes of acute AR – Infective Endocarditis, aortic dissection, BAV
o Causes of chronic AR – syphilis, ankylosing spondylitis
o Volume overload can increase LVEDV, LVH, left sided HF
o Symptoms depend on rapidity of onset
• Acute AR: IE, aortic dissection/acute pulmonary edema, cardiogenic shock
• Chronic AF: develops over time, dyspnea, orthopnea, PND, CP
o Wide pulse pressure – ex: BP 140/60
o Diastolic, decrescendo murmur, 3rd ICS LSB – hallmark for AI
o Systolic murmur usually present, soft
o Austin Flint murmur – can mimic MS
o Tx: ARB decreases afterload, surgery if EF <55%
Pulses and signs unique to AR
o De Musset Sign – head bobs with each systole
o Corrigan’s Pulse – rapid water hammer , rapid upstroke
o Quincke’s Pulse – nail bed pulsations
o Traube’s Sign – pistol shot sound
o Durozrey’s sign – compression over artery will hear to and fro murmur over arteries
o Hill’s sign – systolic BP higher in legs than arms
o Bisferious pulse – double peak to it
