Right Valves and Pulm HTN

Question 1

What is the most common murmur?

Answer 1

Left systolic murmur

Question 2

How common are right heart murmurs compared to left heart murmurs?

Answer 2

10 x less common on the right

Question 3

How common are diastolic murmurs compared to systolic murmurs?

Answer 3

Diastolic murmurs are 10 x less common

Question 4

Respiration will change the sound of a murmur only on the _________ side of the heart

Answer 4

right

Question 5

Deep inspiration increases or decreases the sound of a right sided murmur? Why?

Answer 5

Increases b/c inspiration increases venous return and preload to heart. More blood = more pressure = louder sound

Question 6

I am a crescendo-decrescendo murmur heard during diastole. Most people have me to a slight degree, but I become a problem if you have pulmonary hypertension

Answer 6

Pulmonary regurgitation

Question 7

I am a crescendo-decrescendo murmur heard on systole. As I get worse, my sound is louder and occurs later in the cardiac cycle. Each time I make noise you hear an ejection click.

Answer 7

Pulmonary stenosis

Question 8

I am a holosystolic murmur that gets quieter as I become more severe. You can hear me loudest when a patient inspires.

Answer 8

Tricuspid regurgitation

Question 9

I am a diastolic murmur that is very rare. I am caused by rheumatic heart disease or endocarditis. (Don’t use IV drugs, or you’ll get endocarditis.)

Answer 9

Tricuspid stenosis

Question 10

On the right side, what murmurs can be heard in systole?

Answer 10

Pulmonary stenosis and Tricuspid regurge

Question 11

On the right side, what murmurs can be heard in diastole?

Answer 11

Pulmonary regurge and tricuspid stenosis

Question 12

what causes tricuspid regurge?

Answer 12

dilation of the RV second to left sided HF or pulm htn

Question 13

How will you treat tricuspid regurge?

Answer 13

reduce afterload, treat underlying condition (LHF or pulm htn), consider valve replacement

Question 14

How do you treat tricuspid stenosis?

Answer 14

FIX VALVE (balloon or valve replacement) Diuretics can provide some symptom relief until valve is fixed.

Question 15

What is the most common cause of pulmonic stenosis?

Answer 15

congenital, bi-valve

Question 16

In pulmonic stenosis, the blood in the RV cannot get out and into the lungs fast enough, how will you treat this?

Answer 16

Really can’t treat with meds, need balloon or valve replacement.

Question 17

Pulmonic regurgitation second to pulm htn will cause ______________ which typically progresses into _______________.

Answer 17

RV hypertrophy progresses to systolic HF

Question 18

How will you treat pulmonic regurge?

Answer 18

treat underlying condition (pulm htn) and consider valve replacement

Question 19

When do you really want to look at making a diagnosis of pulmonary hypertension?

Answer 19

when you see right sided HF without left HF symptoms.

Question 20

What are typical RHF symptoms?

Answer 20

JVD, ascites, peripheral edema, hepatomegaly

Question 21

What are typical LHF symptoms?

Answer 21

dyspnea, orthopnea, cough, crackles

Question 22

What pressures have to be present to make a dx of pulm htn?

Answer 22

pulmonary arterial pressure > 25mmHg

Question 23

What happens to the heart when it has to pump against high pulmonary pressure?

Answer 23

increased afterload causes RVH which leads to RHF

Question 24

What are the 5 classifications of pulm htn?

Answer 24

1) Pulmonary Arterial HTN
2) Pulmonary Venous HTN
3) Pulm htn of hypoxia or lung dz
4) Pulm htn of thrombosis
5) Miscellaneous

Question 25

What might cause pulm artery htn?

Answer 25

HIV, sporadic onset, toxicity

Question 26

What might cause pulm venous htn?

Answer 26

LEFT SIDED HD (this is most common, but we are looking for pulm htn in the absence of left sided symptom)

Question 27

What might cause pulm htn of hypoxia or lung dz?

Answer 27

COPD* OSA* interstitial lung dz, altitude

Question 28

What might cause pulm htn of thrombosis?

Answer 28

PE***

Question 29

What are some miscellaneous causes of pulm htn?

Answer 29

sarcoidosis, anemia, histiocytosis

Question 30

In the ABSENCE of left heart symptoms, and an increased RV pressure, what 3 things must you consider and rule out?

Answer 30

pulm htn due to COPD, OSA, PE (these are by far the most common)

Question 31

How can you tell the difference b/w pulm arterial htn and pulm venous htn?

Answer 31

PAH will have mean arterial pressure >25mmHg, and a Pulm capillary WP < 15mmHg. (Meaning high pressure in pulm artery, but low pressure in LA) VS. PVH will have a high wedge pressure as well

Question 32

Sternal heaves mean you have __________

Answer 32

RV hypertrophy

Question 33

What can cause RVH?

Answer 33

pulm htn, tricuspid regurge, pulm stenosis, pulm regurge

Question 34

So if you feel a sternal heave, you need to consider these diagnoses:

Answer 34

pulm htn, tricuspid regurge, pulm stenosis, pulm regurge

Question 35

Systole begins with what heart sound?

Answer 35

S1

Question 36

What are the key valves in S1, what are they doing?

Answer 36

Mitral and Tricuspid are closing (M1 and T1)

Question 37

What heart sound ends systole?

Answer 37

S2

Question 38

What are the key valves in S2 and what are they doing?

Answer 38

Aortic and Pulmonic are closing (A2 and P2)