Section 9: Valvular Heart Disease 2 Flashcards
Rx for aortic stenosis
Diurectics (judicoius use)
Definitive rx of choice: valve replacement
- Bioprosthetic valves (porcine, bovine) will last 10 years on average, but do not require anticoagulation with warfarin
- Mechanical valves do not have to be replaced but must be also treated with warfarin to an INR of 2– 3
- Valve replacement is well tolerated, even in the elderly
- Balloon dilate AS only if the patient is too sick to undergo surgery
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2406-2410). . Kindle Edition.
Causes of aortic regurgitation
- Hypertension
- Rheumatic heart disease
- Endocarditis
- Cystic medial necrosis
Rarer causes include:
- Marfan’s syndrome
- Ankylosing spondylitis
- Syphilis
- Reactive Arthritis
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2413). . Kindle Edition.
Reactive arthritis:
What is this?
What is another name for reactive arthritis?
- Reactive arthritis is an inflammatory arthritis of large joints, inflammation of the eyes (conjunctivitis and uveitis), and urethritis
- Reiter’s syndrome.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2413-2414). . Kindle Edition.
Most common presentation of aortic regurgitation
Shortness of breath
Fatigue
Describe the murmur of aortic regurgitation
- The murmur of AR is a diastolic decrescendo murmur heard best at the left sternal border.
- The murmur will increase in intensity with leg raising, squatting, and handgrip.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2418-2420). . Kindle Edition.
Arterial or capillary pulsations in the fingernails
High bounding pulses (also known as a “water-hammer pulse”)
Head bobbing up and down with each pulse
Murmur heard over the femoral artery
Blood pressure gradient much higher in the lower extremities
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2420-2425). . Kindle Edition.
- Quincke pulse
- Corrigan’s pulse
- Musset’s sign
- Duroziez’s sign
- Hill sign
Aortic Regurgitation:
- Best initial test
- Most accurate test
- Findings on EKC and CXR
- TTE. TEE more accurate
- Left heart catheterization
- EKG and a chest x-ray, which will show left ventricular hypertrophy.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2428). . Kindle Edition.
Rx for Aortic regurgitation
ACE inhibitors, ARBs, and nifedipine are the best initial therapy.
For CCS add loop diuretics: Furosemide
Surgery is the answer when the ejection fraction drops below 55 percent or the left ventricular end systolic diameter goes above 55 mm; surgery should be done in patients with these criteria even if they are asymptomatic.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2432-2433). . Kindle Edition.
Most common cause of Mitral stenosis
Rheumatic fever
Special features or presentations in mitral stenosis
- Dysphagia: Large left atrium pressing on the esophagus
- Hoarseness: Pressure on recurrent laryngeal nerve
- Atrial fibrillation leading to stroke
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2438-2440). . Kindle Edition.
Describe the murmur of mitral stenosis
The murmur of MS is a diastolic rumble after an opening snap, which can be described as an “extra sound” in diastole.
The S1 is louder. As the mitral stenosis worsens, the opening snap moves closer to S2.
The murmur will increase in intensity with leg raising, squatting, and expiration.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2443-2445). . Kindle Edition.
Mitral Stenosis
- Best initial test
- Most accurate test
- Findings on EKG and CXR
On chest x-ray, there is straightening of the left heart border and elevation of the left mainstem bronchus.
There may also be a description of a double density in the cardiac silhouette (from left atrial enlargement).
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2449-2451). . Kindle Edition.
Rx for Mitral Stenosis
Diuretics are the best initial therapy. They do not alter progression.
Balloon valvuloplasty is the most effective therapy.
Pregnant women can and should be readily treated with balloon valvuloplasty. Pregnancy is not a contraindication to valvuloplasty.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2455). . Kindle Edition.
Causes of mitral regurgitation
Hypertension
Ischemic heart disease
Any other condition that leads to dilation of the heart.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2457-2458). . Kindle Edition.
Most common clinical presentation of mitral regurgitation
Dyspnea on exertion is the most common complaint.
Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2459). . Kindle Edition.