structural heart disease Flashcards
what is the tricuspid valve and where is it found
atrioventricular valve on right side of heart
what is the mitral valve
bicuspid valve found on left side of heart
an atrioventricular valve
what are some examples of congenital heart disease
atrial septal defect ventricular septal defect patent foramen ovale patent ductus arteriosus tetralogy of fallot coarctation of aorta
what is ventricular septal defect
birth defect of heart where there is a hole in septum
wall fails to form
what are the symptoms of vsd in children
poor weight gain
palpitations
poor feeding esp if hole is large
how can you treat ventricular septal defect
open heart surgery
or cardiac catherisation
what is tetralogy of fallot
4 effects together:
- hole between ventricles
- pulmonary stenosis (pulmonary trunk removed)
- widening of aortic valve - also causing mixing of blood
- right ventricular hypertrophy
what is another name given to cardiac muscle
myocardium
what is the outer layer that covers muscular layer called
epicardium
what do you call epithelial cells on inner side of cardiac muscle
endocardium
what is atrial septal defect
hole between atria
walls fail to develop normally
what is coarctation of aorta
narrowing of aorta
causes ventricle to work harder and push more blood each cycle which can lead to thickening of ventricles or heart failure
needs urgent repair
what are some valvular heart defects
aortic stenosis - narrowing
aortic regurgitation - backflow
mitral stenosis
mitral regurgitation
what is aortic stenosis
most common valvular disease
preceded by aortic sclerosis
how do you suspect aortic stenosis
presence of early peaking, systolic ejection murmur and confirmed by ecg
What are some risk factors for aortic stenosis
hypertension ldl levels smoking elevated crp congenital bicuspid valves chronic kidney disease radiotherapy older age
cause of aortic stenosis
rheumatic heart disease
congenital heart disease
calcium build up
pathophysiology of aortic stenosis
valvular endocardium damaged as result of abnormal blood flow(in case of bicuspid valve) or by unknown trigger
injury initiates inflammatory process leading to leaflet fibrosis and deposition of calcium - limiting mobility
what is rheumatic heart disease
autoimmune inflammatory reaction
triggered by prior strept infection - targets valvular endothelium - leads to inflame and calcification
what does aortic stenosis cause
Long standing pressure overload in lv leading to hypertrophy
as stenosis worsens adaptive mechanism fails
left ventricular wall stress increases
systolic function declines
= systolic heart failure
how do you diagnose aortic stenosis
first:
history and presentation: exertion dyspnoea chest pain ejection systolic murmur rheumatic fever, high ldl,ckd, above 65 yrs
how do you diagnose aortic stenosis
second:
transthoracic ecg
ecg chext xray
cardiac catherterisation
cardiac mri
what is the management of aortic stenosis
aortic valve replacement - treatment for asymptomatic patients with severe as with rapid progression, abnormal exercise test and high bop levels balloon aortic valvuloplasty antihypertensives acei statins
aetiology of aortic regurgitation
occurs due to incompetence of valve leaflets from intrinsic heart disease or dilation aortic root
causes diastolic leakage of blood from aorta into left ventricle
what can chronic aortic regurgitation cause
congestive cardiac failure
what can acute aortic regurgitation cause
medical emergency
present with sudden onset of pulmonary oedema and hypotension or cardiogenic shock
what are some congenital and acquired cause of aortic regurgitation
rheumatic heart disease
infective endocarditis
what are the aortic root dilation cause of aortic regurgitation
marfans syndrome connective tissue disease idiopathic ankylosing spondylitis trauma
what is the abnormal physiology in acute ar
increase blood volume in lv during systole lv end diastolic pressure increase increase in pulmonary venous pressure dyspnoea and pulmonary oedema heart failure cardiogenic shock
what is the abnormal physiology in chronic ar
gradual increase in lv vol
lv enlargement and eccentric hypertrophy
in early stages the ejection fraction slightly increases and then falls and lv end systolic volume rises
eventual lv dyspnoea
lower coronary perfusion
inchaemia necrosis and apoptosis
how to diagnose acuteaortic regurgitation
acute - cardiogenic shock
tachycardia
cyanosis
pulmonary oedema
how to diagnose chronic aortic regurgitation
wide pulse pressure
pistol shot pulse - trauma sign
what are the investigations for ar
transthoracic ecg
cxr
cardiac catherisation
cardiac mri/ct
how can we manage acute ar
ionotropes/vasodilators
valve replacement and repair
how can we manage chronic ar
if lv function is normal - can be managed by drugs/reassurance
if symptomatic - first line is valve replacement with adjunct vasodilator therapy
what else is important in management of ar
prevention is key
treat rheumatic fever and infective endocarditis
what is mitral stenosis
obstruction to left ventricular inflow at level of mitral valve due to structural abnormality
as disease progresses leads to pulmonary hypertension and right heart failure
what is the main cause of mitral stenosis
rheumatic fever
what are some other causes of mitral stenosis
rheumatic fever carcinoid syndrome use of ergot/serotonergic drugs sle mitral annular calcification due to ageing amyloidosis rheumatoid arthritis Whipple disease congenital deformity of valve
pathophysiology of mitral stenosis
acute insult leads to formation of multiple foci and infiltrates in endo and myocardium and along walls of valves
with time becomes thickened,calcified and contracted
how is physiology of heart affected by mitral stenosis initially
initially - moderate exercise/tachycardia results in exertional dyspnoea due to increase in left atrial pressue
what does mitral stenosis cause in severe cases
increase in left arterial pressure
transudation of fluid into lung interstitium leading to dyspnoea at rest
pulmonary hypertension
limited filling of left ventricle limits cardiac output
hemoptysis. if bronchial vein ruptures
how do we diagnose mitral stenosis
rheumatic fever dyspnoea orthopnoea diastolic murmur loud p2 neck vein distention hemoptysis 40-50yrs
what investigations can we do to check for mitral stenosis
ecg transthoracic ecg cxr cardiac catherterisation cardiac mri/ scan
how can we manage mitral stenosis
progressive asymptomatic - no therapy required
severe asymptomatic - adjuvant balloon valvotomy
severe symptomatic - diuretic, balloon valvotomy, valve replacement and repair adjunct b blockers
what is mitral regurgitation
abnormal reversal of blood flow from left ventricle to left atrium
caused by disruption in any part of mitral valve apparatus
what are some acute causes of mitral regurgitation
mitral valve prolapse rheumatic heart disease infective endocarditis following valvular surgery prosthetic mitral valve dysfunction
what are some chronic causes of mitral regurgitation
rheumatic heart disese sle scleroderma hypertrophic cardiomyopathy drug related
infective endocarditis leads to
abscess formation, vegetations, rupture of chord tendinae and leaflet perforation
what does chronic mr lead to
progression leads to eccentric hypertrophy leading to elongation of myocardial fibres and increased left end diastolic vol
prolonged vol overload leads to left ventricular dysfunction and increased left ventricular endsysytolic diameter
how can we diagnose mitral regurgitation using history and presentation
dyspnoea murmur fatigue orthopnea chest pain atrial fibrillation diminished s1 pitched blowing xx
how can we diagnose mitral regurgitation using investigations
ecg transthoracic ecg cxr cardia catherterisation cardiac mri/ct
how can we manage acute mr
emergency surgery
adjunct preoperative diuretics
adjunct intra aortic balloon counterpulsation
how can we manage chronic mr
if chronic asymptomatic - ACE inhibitors
b blockers of ef less than 60%
chronic symptomatic - surgery and meds
if left ventricular ef is less than 30% 1st line is intra aortic balloon counter pulsation
what is a cardiomyopathy
disease of heart muscle that makes it harder for heart to pump blood to rest of body
what can cardiomyopathies lead to
heart failure
what are the main types of cardiomyopathies
dilated
hypertrophic
restrictive
what happens to ventricles in hypertrophic cardiomyopathy
size of left ventricle exponentially reduces
what happens to ventricles in dilated cardiomyopathy
left ventricle is very enlarged
what happens to ventricles in restrictive cardiomyopathy
stiffness of ventricle wall
what % of dilated cardiomyopathy is due to familial causes
25%
what is a primary cause of dilated cardiomyopathy
without familial history
idiopathic
what are some secondary causes of dilated cardiomyopathy
heart valve disease after child birth thyroid disease myocarditis alcoholism autoimmune disorders ingestion of drugs mitochondrial disorders
what is the pathophysiology of dilated cardiomyopathy
ventricular chamber enlargement and systolic dysfunction with normal left ventricular wall thickness
how does abnormal physiology affect normal function of the heart
-enlargement of left ventricle
lower ef and increase in ventricular wall stress and end systolic volumes
- early compensatory mechanisms = increase in hr and tone of peripheral vascular system
- neurohumoral activation of renin-angiotensin aldosterone system and increase in circulating catecholamines
- levels of natriuretic peptides are increased
- eventually compensatory mechanisms become overwhelmed and heart fails
how can we diagnose dilated cardiomyopathy using history and presentation
dyspnoea murmur fatigue angina pulmonary congestion low cardiac output displaced apex beat, s3/ systolic
how can we diagnose dilated cardiomyopathy using investigations
genetic testing viral serology ecg cxr cardiac catheterisation echocardiography cardiac mri/ct exercise stress test
how can we manage dilated cardiomyopathy
counselling is very important as condition is lifelong
treat according to problems
what is hypertrophic cardiomyopathy
genetic cvd
defined by increase in left ventricular wall thickness
occurs as autosomal dominant medelian inherited disease in approx 50% of cases
most patients with hcm are asymptomatic what could the first clinical manifestations be
sudden death
likely from ventricular tachycardia or fibrillation
where does hypertrophy frequently occur
intraventricular septum which results in obstruction of flow through left ventricular outflow tract
what does abnormal physiology do to heart
causes abnormal diastolic function
impairs ventricular filling and increases filling pressure
abnormal calcium kinetics and subendocardial ischaemia
how can we use history and presentation to diagnose hypertrophic cardiomyopathy
sudden cardiac death syncope presyncope congestive heart failure dizziness palpitations angina double carotid artery impulse s3 ejection systolic murmur
what investigations can we do to detect hypertrophic cardiomyopathy
hemoglobin levels - anaemia exacerbates chest pain and dyspnoea bnp troponin levels echocrdiography cxr cardiac mri
how can we manage hypertrophic cardiomyopathy with symptoms
beta blockers or verapamil
aetiology of restrictive cardiomyopathy
diastolic dysfunction with restrictive ventricular physiology
atrial enlargement occurs due to impaired ventricular filling during diastole
causes of restrictive cardiomyopathy
idiopathic
familial
associated with various systemic disorders e.g haemochromatosis, amyloidosis,sarcoidosis,fabrys disease, carcinoid syndrome, scleroderma, fabrys disease
how are infiltrative cardiomyopathies characterised
deposition of abnormal substances i.e amyloid proteins, non caseating granulomas within heart tissue
infiltration causes ventricular wall to stiffen
leading to diastolic dysfunction
what can adverse remodelling lead to
systolic dysfunction and ventricular arrhythmias in advanced cases
what abnormal physiology occurs in rcm
increases stiffness ventricular pressure increase filling occurs in early diastole and terminates abruptly at end of rapid folling phase reduced comliance reduced filling reduced cardiac output
how can history diagnose restrictive cardiomyopathy
frequent acsites pitting oedema of lower extremities enlarges liver with fluid weight loss cachexia easy brusing macroglossia increased jugular venour pressue pulse vol decreased
investigations for restricitve cardiomyopathy
cbc serology amyloidosis cxr ecg echocardiography catheterisation mri/biopsy
management of rcm
heart failure med acei arbs antiarrythmic therapy immunosupression - steroids pacemaker cardiac transplantation