Valvular Disease Flashcards
Mitral Stenosis Causes Presentation Signs Tests Management
Rheumatic, congenital etc
Symptoms begin when orifice is >2cm2: dyspnoea, fatigue, palpitations, chest pain, systemic emboli.
Signs: malar flush on cheeks (due to decrease CO); low-volume pulse; AF; TAPPING, NON-DISPLACED APEX BEAT; loud S1; opening snap; rumbling, MID DIASTOLIC murmur.
Tests: ECG; CXR; Echo is diagnostic.
Management: if AF, rate control; anticoagulate with warfarin; diuretic to reduce preload & pulmonary venous congestion.
Mitral Regurgitation Causes Symptoms & signs Tests Echo? Management
Causes: function (LV dilatation); annular calcification (elderly); rheumatic fever; infective endocarditis.
S&S: dyspnoea; fatigue; palpitations; infective endocarditis; AF; DISPLACED, HYPERDYNAMIC APEX; RV heave; PANSYSTOLIC murmur at APEX, radiating to AXILLA.
Tests: ECG; CXR; Echo - to assess LV function & aetiology.
Management: control rate if fast AF; anticoagulate if AF/Hx of embolism; diuretics to improve symptoms; surgery for deteriorating symptoms.
Mitral Valve Prolapse Epidemiology What does it tend to occur with if not alone? Symptoms & signs Tests Rx Complications
Most common valvular abnormality.
Occurs alone or with: ASD; patent ductus arteriosus; cardiomyopathy; Turner’s syndrome; Marfan’s syndrome; osteogenesis.
Symptoms: asymptomatic or atypical chest pain & palpitations.
Symptoms: mid-systolic click.
Tests: Echo is diagnostic; ECG may show T wave inversion.
Rx: B-blocker may help palpitations & chest pain; if symptoms are severe, surgery may be needed,
Complications: Mitral regurgitation; cerebral emboli; arrhythmias; sudden death.
Aortic Stenosis Causes Presentation (classic triad?) Signs Tests Differential Management
Causes: senile calcification is the commonest; congenital; rheumatic.
Presentation: always think AS is elderly with chest pain, exertional dyspnoea or syncope. Classic triad is angina, syncope and heart failure.
Signs: SLOW RISING PULSE with narrow pulse pressure; heaving, NON DISPLACED APEX BEAT; LV heave; aortic thrill; ejection systolic murmur (heard at the base, sternal edge and aortic area, RADIATING TO THE CAROTIDS.
Tests: ECG - p-mitrale, LVH etc; CXR - LVH, calcified aortic valve; echo is diagnostic.
Differential: hypertrophic myopathy.
Management - prognosis is poor without surgery; surgical replacement is curative; if patient is not fit for surgery, percutaneous valvuloplasty/replacement may be performed.
Aortic Sclerosis
How does it occur?
Describe the murmur.
Caused be senile degeneration of the valve.
EJECTION SYSTOLIC murmur, no carotid radiation, normal pulse.
Aortic Regurgitation Acute & chronic causes Symptoms Signs Tests Management
Acute: infective endocarditis; ascending aortic dissection; chest trauma.
Chronic: congenital; connective tissue disorders; (Marfan’s syndrome, Ehlers-Danlos); rheumatic fever; Takayasu arteritis.
Symptoms: exertional dyspnoea, orthopnoea; PND; palpitations; angina; syncope.
Signs: COLLAPSING (water hammer) pulse; DISPLACED, HYPERDYNAMIC apex beat; Corrigan’s sign - carotid pulsation; de Musset’s sign - head nodding with each heart beat etc.
Tests - ECG, CXR - cardiomegaly; dilated ascending aorta; pulmonary oedema; Echo is diagnostic.
Management: main goal is to reduce systolic hypertension; ACEI are helpful; monitor every 6-12 months; may need surgery to replace the valve.
Tricuspid Regurgitation Causes Symptoms Signs Management
Causes: functional (RV dilatation e.g. due to pulmonary hypertension); rheumatic fever; infective endocarditis (think IV drug users); congenital.
Symptoms: fatigue; hepatic pain on exertion; ascites.
Signs: Giant V waves and prominent Y descendant in JVP; ; RV heave; pansystolic murmur; best heard at lower sternal age on inspiration.
Management: treat underlying cause; drugs - diuretics, digoxin, ACEI; valve replacement.
Tricuspid Stenosis Causes Symptoms Signs Diagnosis Treatment
Causes: rheumatic fever. Symptoms: fatigue, ascites, oedema. Signs: giant A wave and slow Y descent in JVP; opening snap; early diastolic murmur heard at left sternal edge on inspiration. Diagnosis: echo. Treatment: diuretics, surgical repair.
Pulmonary Stenosis Causes Symptoms Signs Tests Treatment
Causes: usually congenital (Turners syndrome, Fallots tetraology etc); rheumatic; carcinoid.
Symptoms: dyspnoea; fatigue; oedema; ascites.
Signs: ejection click; ejection systolic murmur.
Tests: ECG; CXR; cardiac cathaterisation is diagnostic.
Treatment: pulmonary valvuloplasty or valvotomy.
Pulmonary Regurgitation
Cause
Describe murmur
Caused by any cause of pulmonary hypertension.
A decrescendo murmur is heard in early diastole at the left sternal edge.
Rheumatic Fever Epidemiology Jones Criteria for Diagnosis Management Prognosis Secondary prophylaxis
Common in developing countries; peak incidence 5-15 years; tends to recur unless prevented.
Diagnosis
- Evidence of group A B-haemolytic strep infection; positive throat culture (usually gone by the time symptoms appear)
- Carditis: tachycardia, murmurs, pericardial rub, CCF, cardiomegaly
- Arthritis: migratory polyarthritis, usually affecting larger joints
- Subcutaneous nodules: small, painless nodules on extensor surfaces of joints & spine
- Erythema marginatum: rash in trunk, thighs & arms
Management
- Bed rest until CRP normal for 2 weeks (may be 3 months)
- Benzylpenicillin IV, then penicillin oral
- Analgesia - aspirin
- Immobilise joints in severe arthritis
Prognosis - 60% with carditis develop rheumatic heart disease.
Secondary prophylaxis is penicillin.
What is the most common causative organism in post rheumatic calcified aortic valve endocarditis?
Streptococcus viridans
What is the most common causative organism in patients with endocarditis from a prosthetic valve replacement?
Staphylcoccus aureus
Left atrial enlargement is a risk factor for developing what?
AF
What clinical finding would you expect to find alongside congenital coarctation of the aorta?
Notching of the inferior margins of the ribs, caused by enlarged intercostal arteries
What is the best place to auscultate if there is pre subclavian coarctation of the aorta?
Left of the inter-scapular area
What is low volume pulse associated with?
Mitral stenosis
What is left subclavicular thrill associated with?
Patent ductus arteriosus
What is wide pulse pressure associated with?
Aortic regurgitation or patent ductus arteriosus
Which murmurs are associated with inspiration and which with expiration?
Left sided on expiration
Right sided on inspiration
What is the fourth heart sound associated with?
Atrial contraction - always pathological
What is the third heart sound associated with?
Rapid ventricular filling
What kind of murmur is dilated cardiomyopathy likely to show?
Mitral regurgitation
What murmur can come secondary to endocarditis?
Aortic regurgitation
