Test 3 Flashcards
1
Q
What are the 2 categories of valvular heart disease?
A
acquired congenital
2
Q
What are the 3 broad etiological categories for acquired valvular diseases?
A
degenerative rheumatoid infectious
3
Q
What are the 4 types of acquired valvular diseases? (that we’ve talked about)
A
Aortic stenosis, Aortic regurgitation, Mitral stenosis, Mitral regurgitation
4
Q
What is the most common cause of mitral stenosis?
A
Rheumatic fever
5
Q
Describe the the pathophysiology of mitral stenosis
A
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
6
Q
Describe the murmur mitral stenosis creates. Where would you best hear it?
A
The mitral valve opens with a click then proceeds with a diastolic decrescendo murmur between S2 and S1 The cardiac apex
7
Q
How would you treat mitral stenosis?
A
- Diuretics if wet - Class II or III if arrhythmic - anticoagulation - surgery or balloon valvuloplasty
8
Q
What are 6 common causes of mitral regurgitation?
A
- myxomatous degeneration - infectious endocarditis - hypertrophic cardiomyopathy - degenerative calcification - ruptured chordae tendineae - ischemic papillary muscle (ECG for confirmation)
9
Q
What is myxomatous mean?
A
pathological weakening of connective tissue
10
Q
Describe the the pathophysiology of mitral regurgitation.
A
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
11
Q
Describe the murmur mitral regurgitation creates. Where would you best hear it?
A
holosystolic murmur (occurs after S1) cardiac apex
12
Q
Regarding mitral regurgitation, what does a mid-systolic click infer?
A
mitral valve prolapse (myxomatous mitral valve)
13
Q
How would you treat mitral regurgitation?
A
- Diuretics to reduce preload (stops increased stretch) - Reduce afterload (studies show this is effective) - surgery
14
Q
How would the hemodynamic profile of mitral regurgitation compare to a normal profile?
A
15
Q
How would the hemodynamic profile of mitral stenosis compare to a normal profile?
A
16
Q
What is the 3 most common causes of aortic stenosis?
A
degenerative calcification (older age) congenitally deformed aortic valve (tricuspid –> bicuspid) rheumatic fever
17
Q
Describe the the pathophysiology of aortic stenosis.
A
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.
18
Q
How does aortic stenosis cause syncope?
A
poor cardiac outflow and physical exertion makes leads to poor tissue perfusion resulting in syncope
19
Q
How does aortic stenosis cause heart failure?
A
The back up of pressures ultimately leads to LV hypertrophy and results in LV diastolic dysfunction
20
Q
Describe the murmur aortic stenosis creates. Where would you best hear it?
A
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
21
Q
How would you treat aortic stenosis?
A
Valve replacement for symptomatic patients
22
Q
How would the hemodynamic profile of aortic stenosis compare to a normal profile?
A
23
Q
What is the 5 most common causes of aortic regurgitation?
A
Degenerative
Rheumatic fever
Aortic root dilation (Marfan’s syndrome)
Systemic Lupus Erythematous
Giant cell arteritis
24
Q
Describe the the pathophysiology of aortic regurgitation.
A
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.
25
Does aortic regurgitation cause a widen-pulse pressure?
you bet! Widened pulse pressure is defined as \>40mmHg
26
Describe the murmur aortic regurgitation creates. Where would you best hear it?
diastolic decrescendo between S2 and S1 Left upper sternal border
27
How would you treat aortic regurgitation?
reduce afterload, reduce preload, surgical replacement
28
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
29
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
30
How does mitral valve stenosis present on exam?
- Diastolic murmur best heard at the cardiac apex
31
What are symptoms of mitral valve stenosis?
- dyspnea on exertion - A fib - thromboembolism risk
32
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)
33
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
34
What are the criteria that indicate severe aortic stenosis?
\> 40 mmHg pressure gradient, \< 1 cm valve area, \> 4 m/s
35
describe the pathophysiological consequences of mitral regurgitation?
Increased LA pressure --\> increased LA size --\> a-fib risk
36
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.
37
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
38
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!
39
What are the clinical findings of ASD?
- Fixed splitting of S2 sounds (RV has to push more blood)
40
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
41
How do you treat ASD?
Close the hole
42
What extra heart sound could be heard in a patient with aortic regurgitation?
Aortic regurgitation can cause LV dilation --\> S3 heart sound
43
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
44
What are the clinical findings of VSD?
Holosystolic murmur at the left sternal border
45
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.
46
How/when do you treat VSD?
If the Qp:Qs ratio is larger than 1.4:1, surgical closure is necessary
47
What are the most common causes of acute pericarditis?
Idiopathic, Viral, Bacterial, Connective tissue disorders, Drug-induced, Trauma, Post-MI
48
Define patent ductus arteriosus
Condition wherein the ductus arteriosus fails to close
49
What is the treatment for acute pericarditis?
NSAIDs, colchicine, narcotics for pain
50
What are the clinical findings of patent ductus arteriosus?
Continuous, machinery-like murmur in both systole and diastole
51
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
52
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)
53
Define aortic coarctation
narrowing of the aorta
54
What might you find on CXR and cardiac catheterization on a patient with constrictive pericarditis?
CXR may show pericardial calcifications Catheterization would show elevated pressures and a dip-and-plateau sign on ventricular pressure tracings
55
What are symptoms of aortic stenosis?
- syncope during exercise - angina during exercise - A fib (LA dilation) - Pulmonary congestion
56
How does mitral valve stenosis present on exam?
- Diastolic murmur best heard at the cardiac apex
57
What is the treatment for aortic coarctation?
Includes excision of the coarcted segment and end-to-end anastomosis Older children: balloon angioplasty and stents can fix
58
Describe the classic clinical triad of cardiac tamponade.
1. Hypotension
2. Elevated JVP
3. Muffled heart sounds
59
What are the pathophysiological consequences of Tetralogy de Fallot?
Pulmonary stenosis causes shunting to be right-to-left → cyanosis Lungs no longer filter microemboli and bacteria → increased risk of stroke and cerebral abscess
60
Your patient appears to be in cardiogenic shock, and catheterization shows equalization of diastolic chamber pressures. What is at the top of your DDx?
Cardiac tamponade
61
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 enlargement seen on CXR - A fib (LA dilation)
62
Approximately how much serous fluid is normally found between the pericardial layers?
50cc
63
Define transposition of the great arteries
transposition of the aortic and the pulmonary arteries
64
How does the difference in pressure change across a stenosis?
(x)^2 example, it increases by 50%: (1.5)^2 = 2.25
65
What is Eisenmenger's syndrome? What congenital conditions can progress to Eisenmenger's syndrome?
pulmonary hypertension —\> permanently increased PVR —\> reversal of the shunting ASD, VSD, PDA
66
What are the indications for carotid endarterectomy?
-70%+ stenosis - do it -50-70% stenosis w/ symptoms despite drug therapy - do it -less than 50% stenosis - treat w/ drugs
67
What are the risks associated with carotid endarterectomy?
1.5% risk of stroke 1% risk of cranial nerve injury
68
What are the signs and symptoms of critical limb ischemia?
6 Ps! pain pallor poikilothermia (cold) pulselessness paresthesia paralysis
69
What are the major symptoms that signifies the transition to critical limb ischemia with risk for tissue loss?
Pain/cramping in the muscle while at rest!
70
What is the classic clinical triad for a ruptured abdominal aortic aneurysm?
1. Abdominal/flank/back pain 2. Hypotension 3. Pulsatile abdominal mass
71
LMSB, systolic, harsh murmur. What is the murmur?
VSD murmur
72
Name 5 risk factors for developing an AAA.
1. Male sex 2. Hypertension 3. Age 4. Smoking Hx 5. Family Hx
73
What are the criteria that indicate severe mitral valve stenosis? (pressure and valve area)
\> 10 mmHg \< 1 cm^2 valve area
74
What is the regurgitant fraction?
The percentage of blood that is regurgitated back through a valve RF = [(SV x HR) - CO]/(SV x HR)
75
What is 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
76
What are the treatment indications for an AAA?
-For males, bigger than 5.5cm → treat -For females, bigger than 5cm → treat -Smaller aneurysms that have grown rapidly, are symptomatic, or are saccular should be treated
77
What is the "double product" and what is it a measure of?
Double product = heart rate x systolic BP It is a measure of cardiac work and therefore, O2 requirement
78
Your patient has stable angina so you have them do an exercise stress test. Name three things that would make you classify your patient as "high risk" during the stress test. What would be your next move?
1. ST segment changes on ECG 2. Hypotension during the test 3. Appearance of a S3 or S4 heart sound during the test Next move for stable angina patient that is high risk on stress test is angiography
79
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!
80
What are the clinical findings of ASD?
- Fixed splitting of S2 sounds (RV has to push more blood)
81
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
82
How do you treat ASD?
Close the hole
83
Define ventricular septal defect
Birth defect in the ventricular septal wall, allowing blood to freely move between left and right ventricles
84
Describe the difference in pharmacologic therapy for a patient that had a bare metal stent placed vs. a patient that had a drug-eluting stent placed.
For the patient w/ a bare metal stent: give clopidogrel for 1 month For the patient w/ a drug-eluting stent: give clopidogrel for a year
85
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
86
What are the clinical findings of VSD?
Holosystolic murmur at the left sternal border
87
How do you treat VSD?
If the Qp:Qs ratio is larger than 1.4:1, closure is necessary
88
How do you calculate Qp:Qs
(systemic arterial O2 sat - systemic venous O2 sat)/(pulmonary venous O2 sat - pulmonary arterial O2 sat)
89
What are the pathophysiological consequences of patent ductus arteriosus?
Large PDAs cause over-circulation of the pulmonary artery —\> increased LA filling —\> increased LV filling —\> LV dilation
90
What are the clinical findings of patent ductus arteriosus?
Continuous, machinery-like murmur in both systole and diastole
91
What are the clinical symptoms of patent ductus arteriosus?
If large, patient presents w/ respiratory distress due to pulmonary over-circulation
92
How do you treat patent ductus arteriosus?
Prostaglandin E holds the PDA open, so a prostaglandin inhibitor like indomethacin can close it
93
Define aortic coarctation
narrowing of the aorta
94
What are the pathophysiological consequences of aortic coarctation?
LV hypertrophy due to increased afterload Increased collateral arterial circulation through the intercostal arteries and internal thoracic arteries —\> rib notching
95
What are the clinical findings of aortic coarctation?
- Upper extremity hypertension - diminished femoral pulses - radio-femoral pulse delay - could cause heart failure due to high afterload when the ductus arteriosus closes - Precordial murmur radiating to the back
96
What are the clinical symptoms of aortic coarctation?
headache
97
What is the treatment for aortic coarctation?
Includes excision of the coarcted segment and end-to-end anastomosis Older children: balloon angioplasty and stents can fix
98
Define Tetralogy of Fallot
PROV four issues: 1) Pulmonic stenosis 2) Right ventricular hypertrophy 3) Overriding aorta (serves as outflow for both ventricles 4) VSD
99
What is a typical drug therapy regimen for a patient with stable angina?
1. Aspirin 2. Anti-anginal thearpy (B-blocker or DHP Ca2+ blocker) 3. Sublingual nitro prn or oral nitro 1x/day 4. Statins if the cat has high cholesterol
100
What are the pathophysiological consequences of Tetralogy of Fallot?
Pulmonary stenosis causes shunting to be right-to-left → cyanosis Lungs no longer filter microemboli and bacteria → increased risk of stroke and cerebral abscess
101
What are the clinical signs of Tetralogy of Fallot?
Cyanosis systolic murmur at the LSB
102
What are clinical symptoms of Tetralogy of Fallot?
Decreased exercise tolerance Cyanotic spells with exertion or crying due to a drop in SVR causing even more right-to-left shunting —\> syncope, convulsions, death
103
What is the treatment for TOF?
Surgical repair
104
What are the pathophysiological consequences transposition of the great arteries
Venous blood from the SVC/IVC goes straight back into the systemic circulation, while the left heart cycles blood to the lungs and back Problems arise postnatally when the foramen ovale and ductus arteriosus start to close ASDs, VSDs, PDAs are necessary to allow for mixing of the blood in the parallel circuits
105
What are the two factors that determine myocardial oxygen consumption?
1. Heart rate 2. Wall tension
106
What effect does ventricular wall thickness have on wall tension? What about the radius of the heart?
Increased wall thickness --\> decreased tension Increased radius --\> increased tension
107
Define the location, timing, and character of a ASD murmur
LUSB systolic blowing This is due to the increased volume moving through the pulmonic valve
108
Define the location, timing, and character of a VSD murmur
LMSB systolic harsh
109
Define the location, timing, and character of a PDA murmur
LUSB continuous Harsh (machinery)
110
Define the location, timing, and character of a tetralogy of Fallot murmur
LSB systolic Harsh
111
LUSB, systolic, blowing S2 murmur. What is the murmur?
ASD murmur
112
LMSB, systolic, harsh murmur. What is the murmur?
VSD
113
LUSB, continuous, harsh (machinery) murmur. What is the murmur?
PDA murmur
114
LSB, systolic, harsh murmur. What is the murmur?
Tetralogy murmur
115
What is the equation for Qs?
116
What is the equation for Qp?
117
What is the Qp:Qs equation? (long one)
118
What is the Qp:Qs equation? (simplified)
119
What is the equation for SVR?
120
What is the equation for PVR?
121
What are the ductal dependent lesions?
Coarctation of the aorta
Aortic stenosis
Transposition of the great arteries
Tetralogy of Fallot
Severe pulmonic stenosis
122
When an aortic coarctation is surgically corrected, what future complications should you watch out for?
Recoarctation, aneurysm, and systemic hypertension
123
What does a loud P2 indicate?
High PVR
124
How would the hemodynamic profile of aortic regurgitation compare to a normal profile?
125
Describe three factors that can cause a reduction of coronary blood flow and subendocardial ischemia during exertion in a patient with coronary narrowing.
increase in the pressure gradient across the culprit epicardial stenosis
exhaustion of vasodilator reserve
tachycardia
126
Describe the four Canadian Cardiovascular Society classes of angina.
Grade 1: angina doesn't occur with normal activity, only with very strenuous activity.
Grade 2: Slight limitation of ordinary activity.
Grade 3: Marked limitation of ordinary activity.
Grade 4: Can't do much without angina.
127
What is the duke score equation?
minutes – (5 x ST depression in mm) – (4 x angina index)
angina index is:
0 for none
1 for non-limiting angina
2 for limiting angina
128
What valve disease does this graph depict?
Aortic stenosis
129
What valve disease does this graph depict?
Mitral stenosis
130
What valve disease does this graph depict?
Mitral regurgitation
131
What valve disease does this graph depict?
Aortic regurgitation
