Valvular disease Flashcards
What are the causes of aortic stenosis (AS)?
- calcification (>65yrs)
- bicuspid valve (<65yrs)
- rheumatic disease
What is the usual presentation of AS
Elderly w:
- angina
- syncope
- SOB
What are the signs of AS
- ejection systolic murmur
- aortic thrill
- heaving, non-displaced apex beat
- LV heave
- Narrow pulse pressure
- Slow rising pulse
- Soft/absent S2
What are the investigations for AS? What would you find?
- ECG - p mitrale (biphasic p wave)
- CXR - LVH, calcified aorta , post stenotic dilatation of ascending aorta
- ECHO - DIAGNOSTIC
Give the management of AS
- If asymptomatic - observe
- Valve replacement if: symptomatic or asymptomatic w valvular gradient >40mmhg + features of LV dysfunction
- balloon valvuloplasty if not fit for surgery
Give the causes of aortic regurgitation (AR)
- valve disease: rheumatic fever, IE, connective tissue disease (RA/SLE), bicuspid aortic valve
- Aortic root disease: aortic dissection, spondylarthropathies, HTN, syphilis, Marfans, Ehler Danlos
What are the sx of AR
- SOB on exertion
- Orthopnoea
- PND
- Palpitations, syncope, angina, HF
What are the signs of AR
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
What is Austin flint murmur
due to partial closure of anterior mitral valve due to regurg streams
What are the investigations for AR, what would they show
ECHO
CXR- cardiomegaly, dilated ascending aorta
Cardiac catheterisation to assess severity
What is the management of AR
Main goal is to reduce systolic HTN so give ACEi
Surgery - if increasingly symptomatic, enlarged heart or ECG deterioration
What are the causes of mitral stenosis?
- rheumatic
- congenital
- prosthetic valve
What are the sx of mitral stenosis? at what point does a patient become symptomatic?
SOB, fatigue, palpitations, chest pain,
when the area of the mitral valve orifice is <2cm^3
What are the signs of mitral stenosis?
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
How do the signs in MS change as the severity increaseS?
murmur lengthens and the opening snap is closer to S2
What imaging will show signs of MS?
CXR - LA enlargement
ECHO
What is the management of MS?
- rate control if in AF
- Diuretics to reduce preload nd risk of pulmonary congestion
- Surgery - balloon valvuloplasty, open valvotomy or valve replacement
What are the complications of MS?
- Pulm HTN
- Emboli
- Pressure form large LA on other tings e.g. hoarseness (recurrent laryngeal), dysphagia (oesophagus), bronchial obstruction
What is mitral regurgitation also known as?
mitral insufficiency
Explain how MR leads to HF
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
What are the causes of MR
- 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
What are the sx of MR
Usually asymptomatic
Sx are usually due to LV failure, arrhythmias, pulm HTN: fatigue, SOB, oedema
What are the signs of MR
- Blowing pan systolic murmur best heard at the apex and radiating into the axilla
Quiet S1 - incomplete closure of valve
What are the Ix in mR
ECG - broad P wave - atrial enlargement
CXR - cardiomegaly
Echo - diagnostic, assess severity
What is the management of MR
- Rate control if AF
- Anticoagulate if AF, Hx of embolism or prosthetic valve
- HF: ACEi, BB, diuretics
- Diuretics, nitrates, +ve inotropes + intra-aortic balloon to increase CO
- Repair > replacement
What is mitral prolapse associated with?
- CHD - PDA, ASD
- cardiomyopathy
- Turners syndrome
- Marfans
- WPW
- Osteogenesis imperfecta
What are the sx of MP?
- mid-systolic click
- late systolic murmur
What are the complications of MP?
- mitral regurgitation
- cerebral emboli
- arrhythmias
- sudden death
What is the management of MP?
BB for palpitations and chest pain
surgery if severe regurgitation
What age does rheumatic fever tend to affect?
5-15yrs
What causes rheumatic fever?
abnormal immunological response to recent (2-6weeks) strep progenies infection (group A beta haemolytic)
What are the clinical features of rheumatic fever
latent interval of 2-6 weeks following a pharyngeal infection
What criteria re used to diagnose RF? Give them
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
What is the management of RF
- Bed rest until CRP normal for 2 weeks
- Aspirin - monitor salicylate levels (or NSAIDs)
- Prednisolone if carditis is bad
- Rx HF
- Haloperidol or diazepam for chorea
What is the prognosis of RF like
60% develop chronic rheumatic
Mitral stenosis is common
What is the secondary prophylaxis for RF
Penicillin V (phenoxymethlypenicillin) sometimes until 18-21 but can be lifelong
What usually points to a diagnosis of infective endocarditis (IE)
fever and murmur = IE until proven otherwise
What are the RFs for IE
- strongest is prev IE
- IVDU
- Rheumatic valve disease
- Prosthetic valves
- CHDs
What bacteria cause IE?which is the most common?
- Staph aureus - most common
- strep viridans
- coagulase -ve staph e.g. epidermidis
What criteria are used to diagnose IE? Give them
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
What are the signs of IE?
- Sepsis - fever, rigors, malaise, splenomegaly, anaemia etc
- Cardiac lesions - new murmur, signs of regurgitation, prolonged PR interval, may lead to AV block (complete)
- Immune complex deposition: Roth spots, splinter haemorrhages, Oslers nodes, Janeway lesions, microscopic haematuria, glomerulonephritis + AKI
- Embolic phenomena - abscesses on relavent organ
What tests would you want to do for a patient w suspected IE?
- Blood cultures - 3 sets at diff times from 3 diff sites at peak of fever
- FBC, CRP/ESR, U+E, LFT, Mg2+
- urinalysis - haematuria
- CXR - cardiomegaly
- ECG
- Echo - shows regurgitation
- TOE
What is the management of IE?
ANTIBIOTICS
- Initial blind therapy:
- amoxicillin
- if allergic - vancomycin + low-dose gentamicin
- if prosthetic valve: vancomycin + low-dose gentamicin + rifampicin - STAPH: fluclox
- VIRIDANS: benpen
What are the indications for surgery in IE?
HF, Valvular obstruction repeated emboli fungal endocarditis unstable inferior prosthetic valve myocardial abscess persisten bacteraemia
