Valvular disease

Question 1

What is the pathophysiology behind rheumatic fever?

Answer 1

There is a laryngeal infection with a beta haemolystic streptococcus. This triggers rheumatic fever 2-4weeks later. This is caused by an antibody to the carbohydrate cell wall which cross reacts with valve tissue

Question 2

What are the criteria for rheumatic fever suspicion?

Answer 2

The Jones criteria includes:
Evidence of beta haemolytic stretococcal infection:
-Positive thoat culture
-Rapid strep antigen test
-Elevated strep antibody titre
-Recent scarlet fever
Major criteria:
-Carditis - tachycardia, murmurs, pericardial rub etc
-Arthritis - migratory flitting polyarthritis
-Small subcuatneous nodules
-Erythema marginatum - geographical type rash
Minor criteria:
-Fever
-Raised CRP
-Arthralgia
-Prolonged PR interval

Question 3

What is the management of rheumatic fever?

Answer 3

Bedrest until CRP normal for 2 weeks
Benzylpenicillin then phenoxymethylpenicillin
Analgesia for carditis and arthritis - asprin or nsaids
Immobilise joints in severe arthritis

Question 4

What valves are most commonly affected by rheumatic fever?

Answer 4

Mitral (70%)
Aortic (40%)
Tricuspid (10%)
Pulmonary (2%)

Question 5

What are the causes of mitral regurge?

Answer 5

Functional (LV dilation)
Annular calcification (age related)
Rheumatic fever
Infective endocarditis
Papillary rupture/dysfunction (post MI)
Connective tissue disorders (marfan's)
Cardiomyopathy
Congenital

Question 6

What are the symptoms of mitral regurge?

Answer 6

Dyspnoea, fatigue, palpatations

Question 7

What are the signs of mitral regurge?

Answer 7

Pansystolic murmur at apex radiating to axilla

Question 8

What is the management of mitral regurge?

Answer 8

Control rate if in fast AF
Anticoagulate if at risk of embolism
Aim to replace or repair surgically before it is irreversibly damaged

Question 9

What is the most common valvular abnormality?

Answer 9

mitral valve prolapse

Question 10

What are the causes of mitral stenosis?

Answer 10

Rheumatic fever
Congenital
prosthetic valve

Question 11

What are the signs of mitral stenosis?

Answer 11

malar flush

Rumbling mid-diastolic murmur

Question 12

What diagnosis does a fever + a new murmur indicate?

Answer 12

Infective endocarditis unless proven otherwise

Require blood cultures

Question 13

What is the commonest organism that causes infective endocarditis?

Answer 13

Staph aureus

Question 14

What are the causes of infective endocarditis?

Answer 14

Bacteria:
-strep viridans
-strep bovis
-staph aureus
Fungi:
-candida
-aspergillosis
Other:
-sle
-malignancy

Question 15

What are the signs of infective carditis?

Answer 15

Septic signs - fever, rigors, night sweats, malaise, weight loss
Cardiac lesions - new murmur or a change in a murmur, vegetations may cause valve obstruction or destruction
Can cause av block
Immune complex deposition - vasculitis, microscopic haematuria, aki, roth spots (boat shaped retinal haemorrhage), splinter haemorrhages, osler nodes
Embolic phenomena - can cause abscesses in various organs e.g. brain, liver, janeway lesions

Question 16

What tests should be used to diagnose infective endocarditis?

Answer 16

Three separate blood cultures should be done at the height of fever.
Blood tests for anaemia, neutophilia, rheumatoid factor (immunological)
Urinalysis for microscopic haematuria
Cxr - cardiomegaly, pulmonary oedema
Echo may show large vegetations
Ct for emboli

Question 17

What is the treatment of infective endocarditis?

Answer 17

Appropriate antibiotics and sometimes surgery e.g. valvular obstruction

Question 18

What antibiotics should be used for different causes of infective endocarditis?

Answer 18

Blind therapy - ampicillin, flucloxacillin and gentamycin
Staphs - flucloxacillin
Streps - penicillin

Question 19

What criteria os used for infective endocarditis and what are the inclusions?

Answer 19

The modified duke criteria
Major criteria:
-positive blood culture
-endocardial involvement (positive echo, ct etc)
Minor criteria:
-at risk individual
- fever greater than 38 degrees
-vascular phenomena
-immunological phenomena 

2 major or 1 major and 3 minor diagnostic

Question 20

What are the causes of aortic stenosis?

Answer 20

Senile age related calcification is most common
Congenital causes - bicuspid valve
Rheumatic heart disease

Question 21

What is the classic triad of symptoms for aortic stenosis?

Answer 21

Typically in older patients
Angina, syncope and heart failure
Also think: dyspnoea, dizziness, faints

Question 22

What are the signs of aortic stenosis?

Answer 22

SLow rising pulse with narrow pulse pressure
LV heave with non displaced apex beat
Aortic thrill
Ejection systolic murmur

Question 23

What tests should be done for aortic stenosis?

Answer 23

ECG for any abnormlities
CXR for LVH, aortic valve calcification or post stenotic dilation of ascending aorta
Echo is diagnostic - used to estimate gradient across valves - this estimates risk of complication

Question 24

What is the management of aortic stenosis?

Answer 24

Managed with valve replacement if symptomatic

If a patient is not fit for surgery then a transcatheter aortic valve replacement may be performed

Question 25

What are the causes of aortic regurgitation?

Answer 25

Acute : ascenting aorta dissection, infective endocarditis, chest trauma
Chronic : congenitatl, connective tissue disorders (marfans), rheumatic fever, SLE, Rheumatoid arthritis, seronegative arthritidies

Question 26

What are the signs and symptoms of aortic regurgitation?

Answer 26

Symptoms - exertional dyspnoea, orthopnoea and paroxysmal noctural dyspnoea
Signs - colapsing pulse, early diastolic murmur ( heard best in expiration with patient sat forward)

Question 27

What is quinkes sign?

Answer 27

This is pulsatile nailbeds felt in aortic regurge

Question 28

What tests should be done for aortic regurge?

Answer 28

ECG - LVH
CXR - cardiomegaly, pumonary oedema
echo - diagnostic
cardiac catheterisation - to assess severity of lesion

Question 29

What is the management of aortic regurge?

Answer 29

Main goal of medical therapy is to reduce systolic hypertension so usually on ACE i
If there are lots of symptoms or dilation of aorta then surgery is indicated
Aim to replace the valve before significant LV dysfunction occurs