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Clin Med 2 - CARDS > Valvular Disease - Waldron > Flashcards

Valvular Disease - Waldron Flashcards

1
Q

What are risk factors for VHD

A

older age
history of infections that can affect the heart
history of heart disease or heart attack- High BP, high cholesterol, DM
congenital heart disease

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2
Q

what are complications of VHD

A

heart failure
stroke
blood clots
heart rhythm abnormalities
death

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3
Q

what is the cardiovascular exam for VHD

A

BP
Carotid pulse - rate, rhythm, rate of rise, compliance
Inspection -JVD
Palpitation - LV apical impulse
Heart sounds - intensity, S1 and S2
MURMUR

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4
Q

what is atresia

A

valve isn’t formed; a solid sheet of tissue blocks the blood flow between the heart chambers

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5
Q

with a murmur, what sided murmur is louder on inspirations

A

Right sided murmurs are louder with inspiration
RINspiration

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6
Q

with a murmur what sided murmur is louder on expirations

A

Left sided murmurs louder on expiration
LEXpiration

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7
Q

what are the common presenting symptoms with VHD

A

chest pain
abnormal swelling (more common with advanced tricuspid regurgitation)
fatigue
SOB, with activity or when lying down
swelling of ankles and feet
dizziness
fainting
irregular heartbeat

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8
Q

what is the SCRIPT evaluation for murmurs

A

S - Site - where the murmur is heard
C - Character - crescendo, decrescendo, blowing, harsh, musical
R - Radiation - carotids (AS), axillary (MR)
I - Intensity - Grading I- VI
P - pitch - high or low
T - timing - systolic vs diastolic, holosystolic, early, late

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9
Q

what is a grade 2 murmur

A

soft, heard in all positions, no thrills

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10
Q

what is grade 3 murmur

A

moderately loud, no thrill

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11
Q

what is grade 4 murmur

A

loud and associated with palpable thrill

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12
Q

what is grade 5 murmur

A

very loud, with thrill, heart with the stethoscope partially off the chest

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13
Q

what is grade 6 murmur

A

loudest, with thrill, heard with the stethoscope entirely off the best

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14
Q

what are the diagnostics tests used for VHD

A

Doppler Echo - TTE, TEE
ECG
CXR
MRI - gated
Exercise stress test
catheterization

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15
Q

what is the most common type of murmur

A

innocent murmur - may disappear and then reappear
caused by rapid ejection of blood across the valve - common in hyperkinetic states

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16
Q

what are common causes of innocent murmurs

A

temporary increase in blood flow: Hyperkinetic states
exercise
pregnancy
fever
hyperthyroidism
anemia
rapid growth spurts in children

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17
Q

always pathologicic if

A

diastolic murmur
holo- or late systolic
continuous - systolic and diastolic
grade > 3
concomitant cardiac symptoms or exam findings

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18
Q

what is one of the most common and most serious valve disease

A

aortic stenosis
- mainly affects older people - results of scarring and calcium buildup
family members may notice decline in patients routine physical activities or significant fatigue

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19
Q

what are symptoms of AS

A

breathlessness (HF)
chest pain (angina), pressure or tightness; progressively worsening ‘exertional fatigue’
fainting/syncope
palpitations or a feeling of heavy, founding, or noticeable heartbeats
decline in activity level or reduced ability to do normal activities requiring mild exertion

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20
Q

what is a classic systolic murmur heard RUSB with patient sitting

A

Aortic stenosis

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21
Q

if a thrill is felt - is it not what kind of murmur

A

a innocent murmur

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22
Q

what is the treatment of AS

A

valve replacement is indicated once symptoms begin, or LV dysfunction occurs
surgical or transcatheter aortic valve replacement (TAVR) are options for many patients
control co-morbidities

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23
Q

what medications can cause dangerous hypertension and should be used with caution for angina in patients with AS

A

nitrates

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24
Q

what are diastolic murmurs always

A

pathologic

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25
Q

what is the diameter of a normal Aortic valve

A

3.0-5.0 cm

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26
Q

what is the diameter of severe AS

A

1.0cm or less

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27
Q

with severe AS - when is the murmur peaked

A

late systolic

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28
Q

with mild AS. - when is the murmur peaked

A

early to mid systolic

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29
Q

what is aortic regurgitation

A

leakage of the aortic valve each time LV relaxes; volume overload of LV occurs because the LV receives blood regurgitated from the aorta during diastole in addition to blood from the left atrium

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30
Q

what are causes of aortic regurgitation

A

valvular - calcifications, bicuspid, endocarditis
Aorta - dilation, dissection

31
Q

what is the most common cause of chronic aortic regurgitation in children

A

Ventricular septal defect (VSD) with aortic valve prolapse

32
Q

what are symptoms of aortic regurgitation

A

mild may produce few symptoms
more severe AR may: palpitations, chest pain, fatigue, SOB
other symptoms include orthopnea, weakness, fainting or LE edema

33
Q

what are the osculatory findings with aortic regurg

A

heard best with the patient supine
normal S1, slapping/sharp S2, diastolic murmur
mild: soft, high pitched, blowing; decrescendo diastolic murmur, usu. early at the RUSB or LUSB
moderate to severe: louder, low pitched (*may be absent); systolic ejection murmur

34
Q

what is a corrigan’s pulse

A

wild pulse pressure

35
Q

what is seen with severe AR

A

wild pulse pressure - corrigan’s pulse
brisk carotid pulse
hyperdynamic, displaced apical impulse
length of murmur correlates with severity
soft or absent S1 and S2
S3 and S4 gallops
austin-flint murmur

36
Q

what is the treatment of AR

A

acute AR: requires prompt aortic valve replacement or repair
chronic AR: requires aortic valve replacement/repair when symptoms or LV dysfunction develops
those who are not candidates for surgery benefit from treatment of HF

37
Q

what is the normal mitral valve area

A

4-6cm

38
Q

what is the pathophysiologic effect of mitral regurgitation

A

volume overload

39
Q

what does volume overload cause with mitral regurgication

A

change in LV geometry (remodeling)
remodeling = LV enlargement = hypertrophy

40
Q

what are the symptoms of MR

A

SOB (dyspnea), especially on exertion and when lying down
fatigue
palpitations
swollen feet or ankles

41
Q

what are the causes of MR

A

mitral valve prolapse
damaged tissue cords
rheumatic fever
endocarditis
MI
cardiomyopathy: HOCM
Trauma
Congenital heart disease
medications (ergotamine)
Radiation
AFib
age
Connective tissue disease

42
Q

what are complications of MR

A

HF, Afib, pulmonary HTN in more severe cases

43
Q

what is heard on osculatory evaluation of MR

A

classic systolic murmur presentation heard best with patient supine
mild - systolic murmur may be abbreviated or occur late in systole
mod/severe - holosytolic, high pitched, heard best at apex with diaphragm of stethoscope with patient in L lateral decubitus position
radiation to axilla or to left sternal border
increases in intensity with handgrip and decreases intensity with standing or valsalva maneuver

44
Q

what is found with moderate to severe MR

A

brisk carotid pulse
hyperdynamic, displaced apical impulse
soft or absent S1, S3 and S4 gallops, widely split S2, diastolic rumble

45
Q

what is the treatment of MR

A

acute MR: may cause acute pulmonary edema or cardiogenic shock or SCD
chronic MR: causes slowly progressive symptoms of heart failure and if afib develops, palpitations

valve replacement or repair

46
Q

what is mitral valve prolapse

A

most common cause of isolated MR
thickened leaflets billow more than 5mm posterior to annulus
associated with MR:
anterior prolapse - posteriorly directed jet (axilla)
posterior prolapse - anteriorly directed jet (LSB)

47
Q

what is heard on auscultation with MVP

A

normal S1 and S2
mid to late sharp systolic click - most specific sign of MVP
- click heard earlier with valsalva maneuver
classic murmur presentation best heard with patient supine
- mild to late systolic murmur following the click

48
Q

what is the treatment of MVP

A

does not usually require treatment
BB relieve symptoms of excess sympathetic tone and reduces risk for tachyarrhythmias (atenolol or propranolol)
treatment of AF may be required
treatment of MR depends on severity and associated LA and LV changes
abx prophylaxis against endocarditis is no longer recommended

49
Q

what is mitral stenosis

A

rare
symptoms most often appear between 15-40 yo in developed nations and they can occur at any age, even childhood

50
Q

what are the symptoms of MS

A

SOB especially with exertion of laying down
faitgue, during increased Physical activity
swollen feet or legs
palpitations
dizziness or fainting
coughing up blood
chest discomfort/pain

51
Q

what is the pathophysiology of MS

A

pressure builds up in the LA and sent back to lungs, resulting in congestion and SOB
1. thickened leaflets, commissural fusion and sub valvular thickening
2. annular calcification

52
Q

what is the etiology of MS

A

rheumatic or annular calcification

53
Q

what are the complications of MS

A

pulmonary hypertension
HF - pulmonary edema
heart enlargement - LA dilation
atrial fibrillation
blood clots

54
Q

what are major manifestations found with rheumatic fever

A

carditis
polyarthritis
chorea
erythema marginatum
subcutaneous nodules

55
Q

what are the minor manifestations found with rheumatic fever

A

fever
arthralgia
previous rheumatic fever or rheumatic heart disease
elevated ESR or positive CRP
prolonged PR interval

56
Q

what is heard with auscultation with MS

A

S1 loud and snappy - hallmark of MS
opening snap-heard best at apex w/ diaphragm at end expiration with patient in left lateral decubitus position
mid-diastolic

57
Q

what is the treatment of MS

A

mild symptomatic pts usually response to diuretic and if sinus tachycardia or afib is present: BB or CCB for rate control
anticoagulation for AF
commissurotomy or valve replacement

58
Q

What is the most common cause of Pulmonary stenosis (PS)

A

usually rare among adults, usually congenital heart defect
moderate to severe PS is most often diagnosed during childhood

59
Q

when are PS symptoms first noticed

A

while exercising
fatigue, SOB, chest pain, LOC

60
Q

what are the risk factors for PS

A

carcinoid syndrome
rheumatic fever
noonan syndrome
pulmonary valve replacement

61
Q

what are complications of PS

A

infection -higher risk of infective endocarditis
RVH
R sided heart failure
arrhythmia - unless PS severe, arrhythmia not usually life threatening

62
Q

what is the treatment of PS

A

balloon valvulopolasty for symptomatic pts and asymptomatic pts with normal systolic function and a peak gradient > 40 to 50 mmHg

63
Q

what is the most common cause of pulmonary insufficiency

A

pulmonary hypertension or congenital heart defect (most specifically tetralogy of fallot)

64
Q

what is tricuspid stenosis almost always due to

A

rheumatic fever; tricuspid regurg and mitral stenosis are often also present
may be related to cancer (tumors, carcinoid syndrome)

65
Q

what are the symptoms of TS

A

severe tricuspid stenosis - fluttering discomfort in the neck, fatigue and cold skin, elevated JVD, and R upper quadrant abdominal discomfort

66
Q

what is the treatment of TS

A

diuretics and aldosterone antagonists; surgical repair or replacement is rarely needed

67
Q

what is the congenital defects associated with tricuspid insufficnency

A

ebsteins anomaly
marphans syndrome
idiopathy myxomatous degeneration

68
Q

what is secondary Tricuspid regurgitation due to

A

leaflet tethering, caused by annular dilation and/or papillary muscle displacement

69
Q

what is the perferred method for evaluating tricuspid Insufficiency

A

Cardiac MRI - should be done when echo quality is inadequate - evaluates RV size and function

70
Q

what is the tx of TR

A

usually well tolerated, but severe cases may require annuloplasty, valve repair or valve replacement

71
Q

what are the lifestyle changes for VHD

A

smoke-free
more active
aim for healthier weight
eat a healthy balanced diet
drink less alcohol
manage stress

72
Q

what are medication options for VHD

A

diuretics
blood thinners/anti-thrombotics
anti-arrhytmics
antibiotics - chronic and prophylactic

73
Q

what are the surgery options for VHD

A

valve repair: ballon valvuloplasty or annuloplasty
valve replacement: mechanical, biologic, transcatheter aortic valve implantation (TAVI/TAVR)

Clin Med 2 - CARDS (11 decks)

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