Test 3 Flashcards
What are the 2 categories of valvular heart disease?
acquired congenital
What are the 3 broad etiological categories for acquired valvular diseases?
degenerative rheumatoid infectious
What are the 4 types of acquired valvular diseases? (that we’ve talked about)
Aortic stenosis, Aortic regurgitation, Mitral stenosis, Mitral regurgitation
What is the most common cause of mitral stenosis?
Rheumatic fever
Describe the the pathophysiology of mitral stenosis
stenosis of the valve increases LA pressure. This passively leads to the increase of pulmonary venous and capillary pressure, resulting in potential transudation. Dilation of the RA leads to fibrosis and an increased risk for A-fib. In addition, the relative stagnation of blood in the LA can result in the formation of thrombi
Describe the murmur mitral stenosis creates. Where would you best hear it?
The mitral valve opens with a click then proceeds with a diastolic decrescendo murmur between S2 and S1 The cardiac apex
How would you treat mitral stenosis?
- Diuretics if wet - Class II or III if arrhythmic - anticoagulation - surgery or balloon valvuloplasty
What are 6 common causes of mitral regurgitation?
- myxomatous degeneration - infectious endocarditis - hypertrophic cardiomyopathy - degenerative calcification - ruptured chordae tendineae - ischemic papillary muscle (ECG for confirmation)
What is myxomatous mean?
pathological weakening of connective tissue
Describe the the pathophysiology of mitral regurgitation.
failure to properly close the mitral valve results in back flow from the left ventricle during systole. This increases the LA pressure which leads to dilation of the LA. Dilation of the LA leads to fibrosis and increased risk for A-fib. The back flow from the LV to the LA results in a decrease in cardiac output. Depending on the volume regurgitated, LV may stretch due to increased preload (regurgitated blood + pulmonary blood), which can lead to HF
Describe the murmur mitral regurgitation creates. Where would you best hear it?
holosystolic murmur (occurs after S1) cardiac apex
Regarding mitral regurgitation, what does a mid-systolic click infer?
mitral valve prolapse (myxomatous mitral valve)
How would you treat mitral regurgitation?
- Diuretics to reduce preload (stops increased stretch) - Reduce afterload (studies show this is effective) - surgery
How would the hemodynamic profile of mitral regurgitation compare to a normal profile?
How would the hemodynamic profile of mitral stenosis compare to a normal profile?
What is the 3 most common causes of aortic stenosis?
degenerative calcification (older age) congenitally deformed aortic valve (tricuspid –> bicuspid) rheumatic fever
Describe the the pathophysiology of aortic stenosis.
The narrowing of the aortic valve results in increase LV wall tension. This results in LV hypertrophy resulting in increased LV pressure. This decreases LV filling and passively increases LA pressure resulting in dilation. This dilation causes fibrosis and increases the risk for A-fib.
How does aortic stenosis cause syncope?
poor cardiac outflow and physical exertion makes leads to poor tissue perfusion resulting in syncope
How does aortic stenosis cause heart failure?
The back up of pressures ultimately leads to LV hypertrophy and results in LV diastolic dysfunction
Describe the murmur aortic stenosis creates. Where would you best hear it?
The murmur is a crescendo decrescendo that begins after isovolumetric contraction all the way to S2. S4 murmur may be present 2nd intercostal space lateral to the sternum on the right side
How would you treat aortic stenosis?
Valve replacement for symptomatic patients
How would the hemodynamic profile of aortic stenosis compare to a normal profile?
What is the 5 most common causes of aortic regurgitation?
Degenerative
Rheumatic fever
Aortic root dilation (Marfan’s syndrome)
Systemic Lupus Erythematous
Giant cell arteritis
Describe the the pathophysiology of aortic regurgitation.
regurgitation from the aorta occurs during diastole. This means the LV has to pump regurgitated blood and blood coming from the pulmonary circulation. This leads to increased preload, which leads to LV dilation. Dilation leads to fibrosis and decreased systolic function. This increases LA pressure and results in dilation and fibrosis, increasing the risk of A-fib.
Does aortic regurgitation cause a widen-pulse pressure?
you bet! Widened pulse pressure is defined as >40mmHg
Describe the murmur aortic regurgitation creates. Where would you best hear it?
diastolic decrescendo between S2 and S1 Left upper sternal border
How would you treat aortic regurgitation?
reduce afterload, reduce preload, surgical replacement
How does aortic stenosis present on exam?
- Systolic murmur (crescendo-decrescendo) between S1 and S2 - pulses parvus et tardus (weak and late pulse) - S4 heart sound if LV is grossly enlarged (hypertrophy) - prominent and laterally displaced PMI
What type of valvular disease is Marfan’s syndrome associated with? How does Marfan’s cause this valvular disease?
Aortic regurgitation. Marfan’s can result in aortic root dilation, which makes it so the aortic valves can’t close tightly
How does mitral valve stenosis present on exam?
- Diastolic murmur best heard at the cardiac apex
What are symptoms of mitral valve stenosis?
- dyspnea on exertion - A fib - thromboembolism risk
How does mitral valve regurgitation present on exam?
Holosystolic murmur (between S1 and S2) - may have mid-systolic click which would indicated mitral valve prolapse - LA and LV dilation seen on CXR - A fib (LA dilation)
How does the difference in pressure change across a stenosis as flow increases? (equation and delta P)
(x)^2 example, it increases by 50%: (1.5)^2 = 2.25
increase in delta P
What are the criteria that indicate severe aortic stenosis?
> 40 mmHg pressure gradient, < 1 cm valve area, > 4 m/s
describe the pathophysiological consequences of mitral regurgitation?
Increased LA pressure –> increased LA size –> a-fib risk
Describe the murmur caused by aortic stenosis and where it is best heard.
Crescendo-decrescendo between S1 and S2 (during systole).Heard best at the 2nd intercostal space just lateral to the sternum.
Define atrial septal defect? What is the most common?
Birth defect in the atrial septal wall, allowing blood to freely move between left and right artia ASD secundum is the most common, then primum
What are the pathophysiological consequences of ASD?
Higher pressures in the left atrium result in a left-to-right shunt —> increased volume in the RA —> RA dilation —> RV volume overload —> RV dilation —> pulmonary hypertension —> RV stiffening —> increased right-heart pressure —> reversal of shunt direction!
What are the clinical findings of ASD?
- Fixed splitting of S2 sounds (RV has to push more blood)
What are the clinical symptoms of ASD
- most patients are asymptomatic - reduced exercise tolerance but not noticed by patient as it is their normal baseline
How do you treat ASD?
Close the hole
What extra heart sound could be heard in a patient with aortic regurgitation?
Aortic regurgitation can cause LV dilation –> S3 heart sound
What are the pathophysiological consequences of VSD?
Left-to-right shunt due to increased left heart pressures Left ventricular dilation! - Not RV dilation because the blood that is shunted into the RV is shunted during systole, and dilation of a chamber only occurs when there is increased volume/pressure during the filling phase - Left-to-right shunting during systole through the ASD over-perfuses the pulmonary artery, which comes back to the left atrium, thus over-filling the LV during diastole —> left ventricular dilation
What are the clinical findings of VSD?
Holosystolic murmur at the left sternal border
Your 34 year-old patient comes in complaining of shortness of breath, fatigue, and palpitations. On exam, you note a holosystolic murmur heard at the apex as well as a diastolic murmur, and his PMI is laterally displaced. What is at the top of your DDx and what is the likely etiology?
Likely mitral valve regurgitation from rheumatic disease. Increased LA filling pressure –> LA dilation (risk for a-fib) –> increased volume rushing into the LV during diastole results in the diastolic murmur. The systolic murmur is from the regurgitation.
How/when do you treat VSD?
If the Qp:Qs ratio is larger than 1.4:1, surgical closure is necessary
What are the most common causes of acute pericarditis?
Idiopathic, Viral, Bacterial, Connective tissue disorders, Drug-induced, Trauma, Post-MI
Define patent ductus arteriosus
Condition wherein the ductus arteriosus fails to close
What is the treatment for acute pericarditis?
NSAIDs, colchicine, narcotics for pain
What are the clinical findings of patent ductus arteriosus?
Continuous, machinery-like murmur in both systole and diastole
Describe the pathophysiology of constrictive pericarditis.
Chronic inflammation –> fusion of fibrous and serous pericardial layers –> thickening and calcification –> decreased pericardial compliance –> increased filling pressures –> pulmonary and hepatic congestion
Describe the presentation of constrictive pericarditis.
It looks like heart failure! -Pulmomary and hepatic congestion -Elevated JVP (Kussmaul’s sign) -Pericardial knock (early diastolic sound)