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Cardiology > Valvular disease > Flashcards

Valvular disease Flashcards

1
Q

What are the causes of aortic stenosis (AS)?

A
  • calcification (>65yrs)
  • bicuspid valve (<65yrs)
  • rheumatic disease
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2
Q

What is the usual presentation of AS

A

Elderly w:

  1. angina
  2. syncope
  3. SOB
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3
Q

What are the signs of AS

A
  1. ejection systolic murmur
  2. aortic thrill
  3. heaving, non-displaced apex beat
  4. LV heave
  5. Narrow pulse pressure
  6. Slow rising pulse
  7. Soft/absent S2
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4
Q

What are the investigations for AS? What would you find?

A
  1. ECG - p mitrale (biphasic p wave)
  2. CXR - LVH, calcified aorta , post stenotic dilatation of ascending aorta
  3. ECHO - DIAGNOSTIC
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5
Q

Give the management of AS

A
  1. If asymptomatic - observe
  2. Valve replacement if: symptomatic or asymptomatic w valvular gradient >40mmhg + features of LV dysfunction
  3. balloon valvuloplasty if not fit for surgery
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6
Q

Give the causes of aortic regurgitation (AR)

A
  1. valve disease: rheumatic fever, IE, connective tissue disease (RA/SLE), bicuspid aortic valve
  2. Aortic root disease: aortic dissection, spondylarthropathies, HTN, syphilis, Marfans, Ehler Danlos
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7
Q

What are the sx of AR

A
  • SOB on exertion
  • Orthopnoea
  • PND
  • Palpitations, syncope, angina, HF
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8
Q

What are the signs of AR

A

i. collapsing water hammer pulse (on lifting arm quickly)
ii. Wide pulse pressure
iii. early diastolic murmur
iv. Quinkes sign - nailed pulsation
v. demussels - head bobbing w each heart beat
vi. mid-diastolic Austin flint murmur if severe

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9
Q

What is Austin flint murmur

A

due to partial closure of anterior mitral valve due to regurg streams

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10
Q

What are the investigations for AR, what would they show

A

ECHO
CXR- cardiomegaly, dilated ascending aorta
Cardiac catheterisation to assess severity

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11
Q

What is the management of AR

A

Main goal is to reduce systolic HTN so give ACEi

Surgery - if increasingly symptomatic, enlarged heart or ECG deterioration

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12
Q

What are the causes of mitral stenosis?

A
  1. rheumatic
  2. congenital
  3. prosthetic valve
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13
Q

What are the sx of mitral stenosis? at what point does a patient become symptomatic?

A

SOB, fatigue, palpitations, chest pain,

when the area of the mitral valve orifice is <2cm^3

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14
Q

What are the signs of mitral stenosis?

A

i. mid late diastolic murmur - best heard on expiration
ii. Loud s1 opening snap
iii. low volume pulse
iv. malar flush
v. non-displaced apex beat

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15
Q

How do the signs in MS change as the severity increaseS?

A

murmur lengthens and the opening snap is closer to S2

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16
Q

What imaging will show signs of MS?

A

CXR - LA enlargement

ECHO

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17
Q

What is the management of MS?

A
  1. rate control if in AF
  2. Diuretics to reduce preload nd risk of pulmonary congestion
  3. Surgery - balloon valvuloplasty, open valvotomy or valve replacement
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18
Q

What are the complications of MS?

A
  • Pulm HTN
  • Emboli
  • Pressure form large LA on other tings e.g. hoarseness (recurrent laryngeal), dysphagia (oesophagus), bronchial obstruction
19
Q

What is mitral regurgitation also known as?

A

mitral insufficiency

20
Q

Explain how MR leads to HF

A

i. Blood leaks through valve on systole
ii. Myocardium thickens over time as O2 demand exceeds what heart can supply
iii. Thicker myometrium becomes less efficient

21
Q

What are the causes of MR

A
  • Following CHD or post MI - if papillary muscle or chordae tendinae are affected by cardiac insult
  • MV prolapse
  • IE - vegetations prevent from closing properly
  • Rheumatic fever - inflammation of valves
22
Q

What are the sx of MR

A

Usually asymptomatic

Sx are usually due to LV failure, arrhythmias, pulm HTN: fatigue, SOB, oedema

23
Q

What are the signs of MR

A
  • Blowing pan systolic murmur best heard at the apex and radiating into the axilla
    Quiet S1 - incomplete closure of valve
24
Q

What are the Ix in mR

A

ECG - broad P wave - atrial enlargement
CXR - cardiomegaly
Echo - diagnostic, assess severity

25
Q

What is the management of MR

A
  1. Rate control if AF
  2. Anticoagulate if AF, Hx of embolism or prosthetic valve
  3. HF: ACEi, BB, diuretics
  4. Diuretics, nitrates, +ve inotropes + intra-aortic balloon to increase CO
  5. Repair > replacement
26
Q

What is mitral prolapse associated with?

A
  • CHD - PDA, ASD
  • cardiomyopathy
  • Turners syndrome
  • Marfans
  • WPW
  • Osteogenesis imperfecta
27
Q

What are the sx of MP?

A
  • mid-systolic click

- late systolic murmur

28
Q

What are the complications of MP?

A
  • mitral regurgitation
  • cerebral emboli
  • arrhythmias
  • sudden death
29
Q

What is the management of MP?

A

BB for palpitations and chest pain

surgery if severe regurgitation

30
Q

What age does rheumatic fever tend to affect?

A

5-15yrs

31
Q

What causes rheumatic fever?

A

abnormal immunological response to recent (2-6weeks) strep progenies infection (group A beta haemolytic)

32
Q

What are the clinical features of rheumatic fever

A

latent interval of 2-6 weeks following a pharyngeal infection

33
Q

What criteria re used to diagnose RF? Give them

A 
Jones 
Diagnosis = recent strep infection +:
- 2 major criteria 
- 1 major + 2 minor
Evidence of recent strep infection:
- increased strep abs
- +ve throat swab
- +ve rapid group A strep antigen test
Major criteria:
1. erythema marginatum 
2. polyarthritis
3. pancarditis (must include endocarditis)
4. subcut nodules
5. sydenhams chorea - late feature 
Minor criteria:
1. Raised ESR/CRP
2. Pyrexia
3. Arthralgia - not if arthritis is the major 
4. Prolonged PR interval
34
Q

What is the management of RF

A
  1. Bed rest until CRP normal for 2 weeks
  2. Aspirin - monitor salicylate levels (or NSAIDs)
    • Prednisolone if carditis is bad
  4. Rx HF
  5. Haloperidol or diazepam for chorea
35
Q

What is the prognosis of RF like

A

60% develop chronic rheumatic

Mitral stenosis is common

36
Q

What is the secondary prophylaxis for RF

A

Penicillin V (phenoxymethlypenicillin) sometimes until 18-21 but can be lifelong

37
Q

What usually points to a diagnosis of infective endocarditis (IE)

A

fever and murmur = IE until proven otherwise

38
Q

What are the RFs for IE

A
  1. strongest is prev IE
  2. IVDU
  3. Rheumatic valve disease
  4. Prosthetic valves
  5. CHDs
39
Q

What bacteria cause IE?which is the most common?

A
  1. Staph aureus - most common
  2. strep viridans
  3. coagulase -ve staph e.g. epidermidis
40
Q

What criteria are used to diagnose IE? Give them

A 
DUKE CRITERIA
Diagnose if any of:
- Pathological criteria +ve 
- 2 major 
- 1 major + 3 minor 
- 5 minor
Pathological: +ve Hx or microbiology of pathological material obtained at autopsy or cardiac surgery

Major:

i. +ve blood culture:
- typical organism in 2 separate culture, or
- persistently +ve blood culture
ii. endocardium involved:
- +ve echo or
- new valvular regurg

Minor:
I. Predisposition (IVDU, cardiac lesion)
ii. fever >38
iii. Vascular/immunological signs
iv. +ve blood culture not meeting criteria 
v. +ve echo not meeting criteria
41
Q

What are the signs of IE?

A
  1. Sepsis - fever, rigors, malaise, splenomegaly, anaemia etc
  2. Cardiac lesions - new murmur, signs of regurgitation, prolonged PR interval, may lead to AV block (complete)
  3. Immune complex deposition: Roth spots, splinter haemorrhages, Oslers nodes, Janeway lesions, microscopic haematuria, glomerulonephritis + AKI
  4. Embolic phenomena - abscesses on relavent organ
42
Q

What tests would you want to do for a patient w suspected IE?

A
  1. Blood cultures - 3 sets at diff times from 3 diff sites at peak of fever
  2. FBC, CRP/ESR, U+E, LFT, Mg2+
  3. urinalysis - haematuria
  4. CXR - cardiomegaly
  5. ECG
  6. Echo - shows regurgitation
  7. TOE
43
Q

What is the management of IE?

A

ANTIBIOTICS

  1. Initial blind therapy:
    - amoxicillin
    - if allergic - vancomycin + low-dose gentamicin
    - if prosthetic valve: vancomycin + low-dose gentamicin + rifampicin
  2. STAPH: fluclox
  3. VIRIDANS: benpen
44
Q

What are the indications for surgery in IE?

A 
HF,
Valvular obstruction 
repeated emboli
fungal endocarditis
unstable inferior prosthetic valve 
myocardial abscess
persisten bacteraemia

Cardiology (13 decks)

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