Valvular disease Flashcards
When should you repeat BP readings and what should you do if that criteria remains
Repeat measurements if difference in readings between arms in >15mmHg
If the difference in readings between arms remains more than 15 mmHg on the second measurement, measure subsequent blood pressures in the arm with the higher reading
Define malignant hypertension
BP ≥ 200/130 mmHg
What are the 3 stages of hypertension
Stage 1 Hypertension: 140/90 to 159/99 mmHg
Stage 2 Hypertension: 160/100 to 179/119 mmHg
Stage 3 Hypertension: sBP ≥ 180 mmHg or dBP ≥ 120 mmHg
Who should you offer ABPM to
People with clinic blood pressure of 140/90 mmHg or higher
What do you do to confirm hypertension (2 criteria)
clinic blood pressure of 140/90 mmHg or higher and
ABPM daytime average or HBPM average of 135/85 mmHg or higher
What are the investigations for target organ damage (8)
Proteinuria – estimation of albumin:creatinine ratio (ACR) + test haematuria Glycated haemoglobin (HbA1C) Electrolytes Creatinine eGFR Total cholesterol and HDL cholesterol Fundi (hypertensive retinopathy) 12-lead ECG
Endocrine causes of hypertension (8)
Diabetes, hyperthyroidism, Cushing’s, Conn’s, hyperparathyroidism, phaeochromocytoma, Congenital Adrenal Hyperplasia, Acromegaly
Renal causes of hypertension (5)
Renal artery stenosis
Chronic glomerulonephritis, pyelonephritis
Polycystic kidney disease
Renal failure
Cardio causes of hypertension (2)
Coarctation of the aortaIncreased intravascular volume
Drugs that cause hypertension (3)
Sympathomimetics, corticosteroids, oral contraceptives
Pregnancy cause of hypertension
Pre-eclampsia
Causes of hypertension due to raised instravascular volume (3)
heart failure, liver failure, nephrotic syndrome
What abnormal heart sounds can you hear in hypertension (2)
may hear loud S2, S4
Mx of hypertension (think of the populations, also there is 4 stages)
HT diabetes or under 55 and not black ACEi or ARB then ACEi or ARB and CCB or thiazide-like diuretic then all all
Age 55 or black without diabetes CCB then CCB + ARB/ACEi or thiazide-like diuretic then all 4
Stage 4 os confirm resistant hypertension, seek help, or add spironolactone/alpha/beta blocker
Example of CCB (2)
Amlodipine
Verapamil
Common S.E. of ACEi (3)
Cough
High potassium
Increased creatinine
Common S.E. of CCBs (1)
Oedema
Common S.E. of BB (1)
Dizziness
Common S.E. of diuretics (3)
Dry mouth
Thirst
Low potassium levels
Common S.E. of alpha-blockers (1)
Dizziness
BP targets (clinic and home, for the two demographics)
<80 years
Clinic <140/90 mmHg
Home <135/85 mmHg
> 80 years
Clinic <150/90 mmHg
Home <145/85 mmHg
What is losartan
An AT2R antagonist
What causes the second heart sound
Thefirst heart sound(S1) is caused by the closing of theatrioventricular valves(thetricuspidandmitral valves) at the start of thesystolic contractionof theventricles
What causes normal physiological splitting of S2
inspiration lowers intrathoracic pressure, increasing the compliance of the pulmonary vascular bed, and augmenting right heart filling. Right ventricular systole is lengthened as a result, causing the pulmonic valve to close after the aortic valve, resulting in splitting of the second sound at 3LICS or 4LICS.
What causes paradoxical splitting of S2 (2)
results from delayed onset or prolongation of left ventricular systole (Prolong LV emptying, AS, LBBB)
What causes normal, wide splitting of S1 (3)
Normal wide splitting S1 – RBBB, LV pacing, ectopic beats
What cause widened splitting of S2 (2)
prolong PV emptying – pulmonay stenosis, RBBB
What cause fixed splitting of S2
ASD
What is the cadence of the third heart sound
Kentucky
What is the cause of the third heart sound physically
S3 produced during passive rapid left ventricular filling when blood strikes a compliant left ventricle.
What does a third heart sound indicate
In older patients it can indicated heart failure, as theventriclesandchordaeare stiff and weak so they reach their limit much faster than normal
What is the cadence of the fourth heart sound
Tennessee
What is the cause of the fourth heart sound physically
Results from a forceful atrial contraction during presystole that ejects blood into a hypertrophied ventricle which cannot expand further
What does a fourth heart indicate (3)
HTN, aortic stenosis, hypertrophic cardiomyopathy
Which pathology is accentuated on auscultation with the patient on the LHS
Mitral stenosis
Which pathology is accentuated on auscultation with the patient leaning forward
Aortic regurgitation
What is crescendo-decrescendo murmur also known as
Ejection systolic
What is ejection systolic murmur also known as
Crescendo-descrescendo
Clinical signs of aortic stenosis (4)
Crescendo decrescendo systolic murmur
(radiate to carotids)
Heaving apex beat
Slow rising pulse
What does a narrow pulse pressure indicate
Aortic stenosis
What is seen on an ECG of aortic stenosis
Evidence of LVH
Where does mitral regurgitation radiate to
Left axilla
What does a mitral regurgitation murmur sound like
High pitched ‘whistling’ mumur
Mitral regurgitation - what during the heart beat is the abnormal heart sound?
Pan-systolic
What is mitral regurgitation associated with (4)
IHD
Idiopathic weaknening of valve with age
Connective tissue disorder e.g. EDS, MS
What does a mitral stenosis murmur sound like
Low pitched rumbling
When during the heart beat is the abnormal heart sound in mitral stenosis
Mid-diastolic
What heart sounds change in mitral stenosis
Loud S1
Mid diastolic low pitched rumbling murmur
What pathology causes a loud S1/opening snap
Mitral stenosis
What is mitral stenosis associated with (3)
Often associated with Atrial Fibrilation
Malar flush = Red cheeks
Associated with rheumatic fever
Signs of aortic regurgitation (4)
Watson’s water hammer pulse, also known asCorrigan’s pulseorcollapsing pulse
Quincke’s sign
De Musset’s Sign
Becker’s sign
What murmur is heard in aortic regurgitation, describe it and what is its name
Austin Flint
Mid-diastolic rumbling murmur
What is an Austin Flint murmur
Mid diastolic rumbling murmur of aortic regurgitation
What is Carvallos sign
Of tricuspid regurgitation, pansystolic murmur heard louder on inspiration
Clinical feature of tricuspid regurgitation
Elevated JVP with giant V waves
5 manifestations of rheumatic fever
Arthritis, Carditis(Carey Coombs murmur -mid-diastolic murmur due to mitral vasculitis, pericarditis, pericardial effusion or rub, etc), Sydenham’sChorea(+/-slurred speech), SC nodules, Erythema marginatum
What is a Graham Steel murmur associated with
Pulmonary regurgitation
How to differentiate AR and MS?
Wide PP in AR
Buzzwords - which valvular pathology:
narrow PP
Aortic stenosis – exertional syncope, SOB, angina
Buzzwords - which valvular pathology:
soft 2nd heart sound
Aortic stenosis – exertional syncope, SOB, angina
Buzzwords - which valvular pathology:
heaving apex beat
Aortic stenosis – exertional syncope, SOB, angina
Buzzwords - which valvular pathology:
blowing pansystolic murmur at apex
Mitral regurgitation
Buzzwords - which valvular pathology:
soft 1st heart sound
Mitral regurgitation
Buzzwords - which valvular pathology:
wide PP
Aortic regurgitation
Buzzwords - which valvular pathology:
end diastolic murmur at left sternal edge
Aortic regurgitation
Buzzwords - which valvular pathology:
murmur best heard leaning forward at expiration
Aortic regurgitation
Buzzwords - which valvular pathology:
rumbling mid-diastolic murmur at apex
Mitral stenosis
Buzzwords - which valvular pathology:
pansystolic murmur at left lower sternal edfe
Tricuspid regurgitation
Buzzwords - which valvular pathology:
IVDU
Tricuspid regurgitation
Buzzwords - which valvular pathology:
increased JVP
Tricuspid regurgitation
Buzzwords - which valvular pathology:
tapping apex beat
Mitral stenosis
