Tintinalli Valve Emergencies

Question 1

A new systolic murmur may be associated with…

Answer 1

…sepsis, anemia, AV fistula, thyrotoxicosis, fever, renal failure with volume overload, pregnancy or other high cardiac output states

Question 2

A new diastolic murmur, or murmur with symptoms at rest…

Answer 2

…should be considered pathologic. You win an echocardiogram & a ticket to a cardiologist!

Question 3

The urgency of murmur diagnosis depends on…

Answer 3

…the severity of symptoms, not the presence of the murmur.

Question 4

Who is at particular risk for a catastrophic event associated with a murmur?

Answer 4

The patient with suspected aortic stenosis & syncope who appears well at rest.

Question 5

Grade 1 murmur

Answer 5

Faint; may not be heard in all positions

Question 6

Grade 2 murmur

Answer 6

Quiet, but heard immediately upon stethoscope placement on chest wall

Question 7

Grade 3 murmur

Answer 7

Moderately loud

Question 8

Grade 4 murmur

Answer 8

Loud

Question 9

Grade 5 murmur

Answer 9

Heard with stethoscope partially off chest wall

Question 10

Grade 6 murmur

Answer 10

Heard with stethoscope entirely off chest wall

Question 11

Mitral stenosis: explain!

Answer 11

Structurally abnormal mitral valve that prevents diastolic filling of left ventricle. Increased pressure causes enlargement of left atrium (must work harder to overcome pressure)

Question 12

Mitral stenosis: what usually causes it?

Answer 12

Rheumatic fever. Latent period of 20-40 years before it becomes a problem

Question 13

What is the medical management of mitral stenosis?

Answer 13

#Intermittent diuretics for pulmonary congestion
#Treatment of atrial fib if necessary
#Anti-coagulation for those at risk for embolism (INR 2-3)

Question 14

Mitral regurgitation: explain!

Answer 14

Mitral valve fails to close fully, allowing retrograde blood flow from LV into LA during systole.

Question 15

Mitral regurg: what usually causes it?

Answer 15

#MI or ischemia
#Mitral valve prolapse syndrome (MVP)
#Left ventricle dilatation
#Rheumatic heart disease
#Collagen vascular disease

Question 16

What is the difference in presentation between chronic & acute mitral regurgitation?

Answer 16

Chronic: slow, progressive course. 1st symptom: exertional dyspnea that increases

Acute: usually caused by papillary muscle or chordae tendinae rupture. Severe dyspnea, tachycardia, & pulmonary edema upon presentation. Cardiogenic shock can develop

Question 17

Acute mitral regurg should be in the differential for ANY patient presenting with…

Answer 17

…sudden onset pulmonary edema.

Question 18

What is essential for the diagnosis of acute mitral regurg?

Answer 18

Get ‘em an ECHO!

Question 19

What is the best treatment for acute mitral regurg?

Answer 19

Emergency cardiac surgery. Get in there & fix that valve!

Before that, though: intubate, vasodilate with nitroprusside to reduce afterload, possibly help out the BP with dobutamine, & throw an IABP in there for good measure.

Question 20

What is the best treatment for asymptomatic mitral regurg?

Answer 20

Nothing! Treat symptoms like atrial fib, & when it become symptomatic, might think about replacing that leaky valve.

Question 21

What is mitral valve prolapse?

Answer 21

Systolic billowing of one or both mitral leaflets into the left atrium. It can occur with or without mitral regurgitation.

Question 22

What is the classic auscultory finding of MVP?

Answer 22

A mid-systolic click that can be moved earlier by maneuvers that decrease preload (Valsalva or standing) and moved later by increasing preload (squatting) or afterload (squatting).

Question 23

What is the treatment for asymptomatic MVP?

Answer 23

Reassurance. :) It’s gonna be fine, sweetie.

Question 24

What is the treatment for symptomatic MVP?

Answer 24

Patients may respond to beta-blockers.

Question 25

What is aortic stenosis?

Answer 25

Abnormal aortic valve preventing systolic ejection of blood from left ventricle. Causes enlargement of left ventricle due to increased workload.

Question 26

What causes aortic stenosis?

Answer 26

#Degenerative calcification
#Bicuspid aortic valve/congenital heart disease
#Rheumatic heart disease (in developing world)
#Associated with atherosclerotic risk factors

Question 27

What is the “classic triad” of aortic stenosis? It is so SAD…

Answer 27

#Syncope
#Angina
#Dyspnea

Question 28

Why is symptomatic aortic stenosis a big deal?

Answer 28

Once symptoms are present, the average survival is 2-3 years with a substantial risk for sudden death! Um, yikes?!

Question 29

Syncope in the setting of exertion or a systolic murmur should make you think…

Answer 29

…possible aortic stenosis as the cause.

Question 30

Why is atrial fibrillation a big problem for those with aortic stenosis?

Answer 30

These patients rely on atrial kick for filling (they typically have diastolic dysfunction). Atrial fibrillation can decrease cardiac output for them.

Question 31

Classic physical findings in aortic stenosis:

Answer 31

#Late peaking systolic murmur at right 2nd intercostal space (radiating to carotids)
#Single or paradoxically split S2
#S4 gallop
#Diminished carotid pulse with delayed upstroke

Question 32

Treatment for symptomatic aortic valve stenosis:

Answer 32

SURGERY! Replace dat valve, otherwise 75% of these folks will die within 3 years. Patients with severe symptoms below get admitted. 
#chest pain
#syncope
#respiratory distress

Question 33

What’s aortic regurgitation?

Answer 33

Aortic valve leaflets fail to close fully, allowing retrograde blood flow from the aorta back into the left ventricle during diastole. This results in increased end-diastolic volume in the LV, causing dilatation & LV dysfunction over time.

Question 34

How does chronic aortic regurgitation present?

Answer 34

Slowly progressive course as LV remodeling compromises function. Exertional dyspnea. Symptoms of L heart failure late in disease course.
#Murmur: high-pitched, blowing diastolic murmur immediately after S2. In 2nd intercostal space @ L sternal border. Mid-diastolic rumble possible (with bell @ apex).
#Water-hammer pulse: peripheral pulse with quick rise in upstroke then collapse

Question 35

What causes acute aortic regurgitation?

Answer 35

#Infective endocarditis
#Aortic root dissection
#Blunt chest trauma

Question 36

How does acute aortic regurg present?

Answer 36

#Dramatic!
#Dyspnea from acute pulmonary edema
#Tachycardia inadequate to maintain cardiac output
#Cardiogenic shock
#Associated symptoms provide clues: chills or fever for endocarditis; history of "ripping" or "tearing" pain suggests dissection

Question 37

Classic signs of aortic regurgitation demonstrated to be NON-EVIDENCE BASED (basically, you might see these used, but YOU’RE SMARTER THAN THAT!):

Answer 37

#Precordial apical thrust
#pulsus bisferiens
#Duroziez sign (a to-and-fro femoral murmur)
#de Musset sign (pulsatile head bobbing
)#Quincke sign (capillary pulsation visible at proximal nail bed when pressure applied at the tip)

Question 38

What procedure is recommended to confirm both diagnosis & severity of aortic regurg?

Answer 38

Echocardiogram!

Question 39

Acute aortic regurgitation is treated by…

Answer 39

…immediate surgical intervention. Page that cardiac surgeon!

While you’re waiting: nitroprusside combined with inotropes can help forward flow. Beta-blockers may be used in aortic dissection, but in acute regurg, they block compensatory tachycardia. DO NOT use IABP, as it blocks forward flow.

Question 40

Chronic aortic regurgitation is treated by…

Answer 40

…vasodilators such as ACE-inhibitors or nifedipine. Patients become candidates for valve replacement when symptomatic, have low EF, or significant LV dilatation.