Valvular disease Flashcards
Which murmurs are systolic
Aortic stenosis
Mitral regurg
What causes aortic stenosis
Bicuspid aortic valve
age related calcification
Rheumatic fever
How would aortic stenosis present
Exertional dyspneoa Syncope Exertional angina Chest pain Dizziness
What are the signs on examination in aortic stenosis
Pulse: Slow rising pulse low volume with narrow pulse pressure Palpation: heaving apex beat aortic thrill Auscultation: Ejection systolic murmur Radiating to carotids
What may be seen on CXR in a patient with aortic stenosis
Relatively small heart
Dilated ascending aorta - post stenotic dilation
Calcified aortic valve
What might an ECG show in a patient with aortic stenosis
Left ventricular hypertrophy
Left ventricular strain pattern - depressed ST segments and T wave inversion in leads oreintated towards the left ventricle
How is aortic stenosis treated
Valve replacement
If not fit for surgery - TAVI - transcatheter aortic valve implantation
Which investigations would be done in suspected aortic stenosis
Bedside obs: HR, BP
ECG
CXR
Echo - diagnostic - shows ejection fraction , and strucutre of heart and if there is any Lv dysfunction, valve area
What is aortic sclerosis
Senile degeneration of aortic valve
Ejection systolic murmur but no radiation to carotids
What are the causes of mitral regurgitation
Prolapsing mitral valve
Rheumatic MR - cusps are shrunken and fibrotic
Papillary muscle rupture
Cardiomyopathy
Connective tissue disorders - Marfans, Ehlers Danlos, Osteogenesis imperfecta
How might mitral regurg present
May be asymptomatic
Severe MR - Dilated LV - HF –> exertional dyspneoa
Acute MR (papillary muscle rupture) -> rapid pulmonary oedema –> emergency valve repair - SOB
What would be found upon examination of a patient with MR
Pulse - sinus rhythm
Face - Malar flush
Palpation - displaced apex beat (volume overload) Palpable thrill
Auscultation - Pansystolic murmur that radiates to axilla
What might be seen on CXR in Mitral Regurg
Cardiomegaly - due to left atrial and let ventricle enlargement
What would be the features on ECG if a patient had MR
Bifid P Waves
Left ventricular hypertrophy
What happens in Aortic regurg
Reflux of blood from aorta to LV during systole so cardiac output drops
for cardiac output to be maintained total volume pumped into aorta must increases there for LV increase - left ventricula hypertrophy (eccentric) - the chamber gets bigger
What causes aortic regurg
Rheumatic fever Bicupid valve Aortic root dilation infective endocarditis Marfans Tertiary syphilis
How does aortic regurg present
Dyspneoa on exertion
Syncope
What would be found on examination in a patient with aortic Regurgitation
Pulse - collapsing pulse and wide pulse pressure
Quinkes sign - pulsating capillaries in nailbed
De Mussets sign - Head nodding with each beat
Pistol shot femorals - a sharp bang heard on auscultation over femorals in time with each heart beat
Palpation - Displaced beat
Auscultation- High pitched early diastolic murmur best heard at left sternal edge in 4th ICS with patient leaning forward and expiring
What would an ECG show in a patient with aortic regurgitation
left ventricular hypertrophy
What are the effects of mitral stenosis
High LA pressure -> pulmonary venous HTN –> Pulmonary arterial HTN –> RV hypertrophy (left parasternal heave) –> tricuspid regurg –> R sided heart failure - raised JVP, oedema and ascites
What are the causes of mitral stenosis
50% have a hx of rheumatic fever or chorea
Old age and calcification
What are the signs of mitral stenosis
Pulse - AF, irregularly irregular
Face - Malar flush
Palpation - tapping apex beat due to palpable 1st heart sound
Auscultation - Loud S1 (high LA pressure keeps the valve open until late in diastole)
Opening snap (high pitched sound just after S2)
Rumbling Mid diastolic murmur - best heard with the bell at apex with patient rolled to the left
What would you see on CXR
Pulmonary oedema
Normal sized heart with enlarged LA
What would an ECG show if a patient had mitral stenosis
AF
Bifid P waves
What is infective endocarditis
Microbial infection of
- normal heart valves
- Prosthetic valves
- Endothelial surfaces of the heart
- congenital defects = ventricular septal defect, patent ductus arteriosus, valve defect
Which organisms often cause infective endocarditis
Streptococcus viridans
Others: Staph Aureus - from skin infections, abscesses, central lines, IV drug user
How might infective endocarditis
Variable presentation HEART MURMUR AND FEVER Acute, rapidly progressing or Subacute/Chronic with non specific symptoms - fever - fatigue - Flu like - weight loss - loss of appetite - Back pain - pleuritic pain
Changing murmur
- aortic regurg
- mitral regurg
- HF
- Conduction abnormalities
Embolisation
- Cerebral
- pulmonary
- Coronary
- Renal
Immune vasculitis
- roth spots - retinal infarcts with surrounding haemorrhage
- oslers nodes
- janeway lesions
- clubbing
- splinter haemorrhages
- glomerulonephritis
What is the major criteria for diagnosis of infective endocarditis
A: positive blood culture for infective endocarditis
- typical organism in 2 separate cultures
OR
- persistent positive culture (3Sets)
B: Evidence of endocardial involvement
- positive echocardiogram (vegetation, abscess, prosthetic valve damage)
or
- new valvular regurgitation
What are the minor criteria for diagnosis of infective endocarditis
1 predisposition
- Fever >38
- Vascular/immunological signs
- Positive blood culture (but does not meet major criteria)
- Positive echo (but does not meet major criteria)
What is needed to define infective endocarditis
2 Major dukes criteria
1 major and 3 minor
5 minor
What is the pathophysiology of infective endocarditis
- Endothelial damage/damaged valve
- platelets and fibrin are deposited
- Bacteraemia - delivers bacteria to the surface of the valve
- Adherence and colonisation of the bacteria
- Fibrin aggregates protect the bacteria vegetation from host defence mechanisms
Which investigations are done in suspected infective endocarditis
Bloods - FBC - U+Es - LFTs - CRP Blood cultures x3 CXR ECG Echo Urine dip
What is the treatment for infective endocarditis
A-E assesment
if hypoxic give oxygen
Involve both cardiology and microbiology
Empirical treatment is: Benzylpenicillin aand Gentamicin - 4 weeks IV
Who is more at risk of developing infective endocarditis
Structural congenital heart disease
Acquired valve disease
Prosethetic valves
Previous endocarditis
What should be explained to a patient about prevention of infective endocarditis
No longer give prophylactic abx
importance of maintaining good oral health
Tell them the symptoms and whne to seek advice should this happen
Risks of undergoing invasive procedures including body piercing or tattoing
