Structural heart disease Flashcards
what is structural heart disease?
defects affecting the valves and chambers of the heart and aorta
what is ventricular septal defect? (VSD)
congenital hole between ventricles causing the mixing of blood
what is the tetralogy of fallot?
combination of VSD, pulmonary stenosis, widening of the aortic wall and right vetricle hypertrophy
what is atrial septal defect? (ASD)
congenital hole between atria
what is a coarctation of the aorta?
narrowing of aorta at downward arc
blood struggles to push through, may develop HF
what are the 4 valvular defects?
aortic and mitral stenosis
aortic and mitral regurgitation
what is valve stenosis?
narrowing of a valve
problem when blood passes through, not when shut
what is valvular regurgitation?
incompetence of a valve causing backflow from said valve
problem when meant to be shut not when open
what is the epidemiology of mitral valve disease?
greatest rates in 70+ and females
what is the epidemiology of aortic stenosis?
most common valvular disease in UK
70-80s most commonly
what is aortic stenosis commonly preceded by?
aortic sclerosis
when is aortic sclerosis often suspected?
the presence of early peaking, shrill systolic ejection murmur
how does aortic stenosis cause abnormal physiology?
long-standing pressure overload leads to left ventricular hypertrophy in order to maintain normal afterload
as stenosis worsens, adaptive mechanism fails and LV wall stress increases, declines systolic function
results in systolic heart failure
what is the typical history of someone with aortic stenosis?
exertional dyspnoea and fatigue
chest pain
history of rheumatic fever, high lipoprotein, LDL, over 65
what pathology presents with an ejection-systolic murmur?
aortic stenosis
what pathology presents with a mid-diastolic murmur?
mitral stenosis
what pathology presents with an early diastolic murmur?
aortic regurgitation
what pathology presents with a pansystolic murmur?
mitral regurgitation
what type of murmur is an S4 sound and what pathology?
ejection systolic
aortic stenosis
what does an aortic stenosis murmur sound like?
crescendo decrescendo
loudest over aortic area
radiates to carotid
ejection systolic (between lub and dub)
what does a mitral stenosis murmur sound like?
loudest over apex
and in expiration
lub-dub-whoooosh
mid diastolic murmur
what does an aortic regurgitation murmur sound like? AR
loudest at sternal edge
and when leaning forward
after dub
eARly diastolic murmur
what does a mitral regurgitation murmur sound like?
loudest over mitral area, radiates to axilla (left)
high pitched whistling
lub-whistle-dub
pansystolic murmur
what valve is open in systole?
aortic
what valve is open in diastole?
mitral
when is the aortic valve shut?
diastole
when is the mitral valve shut?
systole
what are the investigations for valvular defects?
CXR
ECG
Transthoracic echocardiography
pos cardiac catheterisation, cardiac MRI/CT
basic pathophysiology of aortic stenosis
abnormal blood flow/trigger initiates inflammatory process similar to athersclerosis
damages valvular endocardium, leads to aortic sclerosis - leaflet fibrosis and calcium deposition
obstructs left ventricular emptying, increases pressure in left ventricle
compensatory left ventricular hypertrophy
what is aortic sclerosis
asymptomatic/pre-stenosis stage of aortic valve calcification
symptoms of aortic stenosis
syncope
angina, dyspnoea on exertion
causes of aortic stenosis
senile degeneration
congenital bicuspid valves
rheumatic fever
management of asmymptomatic aortic stenosis
observe only
management of symptomatic aortic stenosis
valve replacement
management of asymptomatic but less than 50% ejection fraction aortic stenosis
valve replacement
what is the option of treatment for aortic stenosis when not fit for surgery?
TAVI - trans-catheter aortic valve replacement
risk factors for aortic stenosis
high LDL elderly smoking hypertension high CRP congenital bicuspid valves
what is the trigger for aortic stenosis in rheumatic fever patients?
streptococcal infection triggering autoimmune reaction
symptoms of coarctation of aorta?
pale skin
irritability
sweating
difficulty breathing
management of coarctation of aorta?
surgery immediately
pathophysiology of coarctation of aorta
wall narrowing blocks normal blood flow
backflow to left ventricle, it works harder
LV hypertrophy
eventual heart failure
pathophysiology of atrial septal defect
hole between atria
blood flows from left-right
more blood goes to lungs, so lungs and heart work harder
symptoms of atrial septal defect
asymptomatic
or signs of reduced HF - SOB, murmurs, palpitations, oedema
symptoms of ventricular septal defect
murmurs
breathlessness
failure to thrive
or asymptomatic
symptoms of tetralogy of fallot
cyanosis
SOB
systolic murmur
pathophysiology of tetralogy of fallot
VSD
pulmonary stenosis
overriding aorta - enlarged, sits over VSD so blood from both ventricles enters
right ventricular hypertrophy as a result
lack of oxygenation as blood goes from right - systemic circulation, bypassing lungs
pathophysiology of mitral stenosis
acute insult leads to formation of multiple foci and infiltrates in endo/myocardium, valve walls
thickens and calcifies leading to stenosis
blood struggles to pass from left atrium - ventricle
increased left atrial pressure, enlargement
increased LA pressure leads to pulmonary hypertension, congestion and right sided dysfunction
common cause of mitral stenosis
rheumatic heart disease
symptoms of mitral stenosis
palpitations angina orthopnoea exertional dyspnoea paroxysmal nocturnal dyspnoea - wakes up short of breath
management of mild mitral stenosis
observation
management of severe asymptomatic mitral stenosis
balloon valvotomy
management of severe symptomatic mitral stenosis
beta blockers
diuretics
balloon valvotomy
valve replacement
pathophysiology of chronic aortic regurgitation
valvular incompetence leads to reflux from aorta into left ventricle
increased volume and pressure in left ventricle - LV hypertrophy
eventual reduced ejection fraction and end systolic volume increases
eventual dyspnoea and ischaemia
pathophysiology of acute aortic regurgitation
inc end systolic LV volume end diastolic pressure increases increase in pulmonary venous pressure dyspnoea and pulm oedema heart failure and cardiogenic shock
what are the main differences beyween acute and chronic aortic regurgitation
chronic allows for compensatory mechanisms - hypertrophy
symptoms of acute aortic regurgitation
cardiogenic shock tachycardia cyanosis pulmonary oedema austin flint murmur
symptoms of chronic aortic regurgitation
wide pulse pressure
corrigan pulse/traube sign (booming pulse)
management of acute aortic regurgitation
treat underlying cause
ionotropes
vasodilators
valve replacement
management of mild chronic aortic regurgitation
reduction of afterload - diuretics, vasodilators
management of severe aortic regurgitation
valve replacement
pathophysiology of mitral regurgitation following infective endocarditis
abcess formation, vegetations, rupture of chorade tendinae and valve perforations
leads to blood leakage LV-LA
pathophysiology of chronic mitral regurgitation
reflux from LV to LA
increased LA pressure, inc pulmonary pressure
congestion by fluid buildup - congestive heart failure
common cause of mitral regurgitation
prolapsing mitral valve
symptoms of mitral regurgitation
dyspnoea
orthopnoea
chest pain
fatigue
management of acute mitral regurg
nitrates, diuretics, ionotropes,
intra-arotic balloon counterpulsation
management of acute mitral regurg with severe regurg
surgery
management of chronic mitral regurg
ACEi
beta blockers
spironolactone diuretic
pathophysiology of dilated cardiomyopathy
ventricles stretch and thin
ventricular enlargement
ventricular systolic dysfunction
heart failure
cause of dilated cardiomyopathy
genetic 1/3 alcoholism drug use autoimmune thyroid hypertension/diabetes
symptoms of dilated cardiomyopathy
heart failure - pleural effusion, dyspnoea, peripheral oedema
chest pain
fatigue
syncope
management of dilated cardiomyopathy
fluid and sodium restrictions
treat underlying cause
heart failure management - diuretics, beta blockers, ACEi
pathophysiology of hypertrophic cardiomyopathy
genetic AD
abnormal increase of left ventricular wall
LV outflow obstruction, heart less able to fill, diastolic dysfunction
cause of hypertrophic cardiomyopathy
familial or sporadic mutations
symptoms of hypertrophic cardiomyopathy
asymptomatic angina syncope SOB ejection systolic murmur
management of hypertrophic cardiomyopathy
beta blockers
calcium channel blockers
if still symptomatic - pacemaker, septal myectomy, septal ablation
pathophysiology of restrictive cardiomyopathy
ventricles become rigid, restricted from stretching/filling with blood
diastolic dysfunction
reduced cardiac output
causes of restrictive cardiomyopathy
idiopathic
familial
assoc. with systemic disorders
symptoms of restrictive cardiomyopathy
peripheral oedema ascites pulmonary hypertension dyspnoea fatigue palpitations
management of restrictive cardiomyopathy
underlying cause
heart failure treatment - beta blockers, ACEi, diuretics
transplant
antiarrhythmatic therapy
what is infective endocarditis
multisystem disease
infection of heart valves +/- adjacent endocardium
bacteria enters bloodstream, forms vegetations (bacteria, platelets, fibring)
what are vegetations
bacteria
platelets
fibrin
common cause of infective endocarditis
streptococci
symptoms of infective endocarditis
fever
NEW MURMUR
process of diagnosis of infective endocarditis
DUKES criteria
dukes criteria definite infective endocarditis
2 major
1 major + 3 minor
5 minor
dukes criteria of infective endocarditis possible infective endo carditis
1 major 1 minor
3 minor
major dukes criteria
blood culture +ve for streptococci
echo with valvular vegetations
new valvular regurgitation murmur
minor dukes criteria
predisposing heart condition iv drug use fever over 38 embolic phenomena immunological phenomena - glomerulonephritis etc blood culture +ve but not usual suspects
most commonly affected valves of IE
aortic then mitral then right sided
except IV drug users - tricuspid as infection enters intravenously usually
symptoms of cardiac decompensation
SOB
frequent coughing
swelling of legs, abdomen
fatigue
clinically - raised JVP, lung crackles and oedema
complications of IE
vascular/embolic phenomena - stroke, Janeway lesions, splinter/conjunctival haemorrhage
immunological phenomena - Oslers nodes, Roth spots
what is cardiac decompensation
inability of heart to maintain adequate circulation (leading to end organ damage)
