Valvular Disease - Waldron Flashcards
What are risk factors for VHD
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
what are complications of VHD
heart failure
stroke
blood clots
heart rhythm abnormalities
death
what is the cardiovascular exam for VHD
BP
Carotid pulse - rate, rhythm, rate of rise, compliance
Inspection -JVD
Palpitation - LV apical impulse
Heart sounds - intensity, S1 and S2
MURMUR
what is atresia
valve isn’t formed; a solid sheet of tissue blocks the blood flow between the heart chambers
with a murmur, what sided murmur is louder on inspirations
Right sided murmurs are louder with inspiration
RINspiration
with a murmur what sided murmur is louder on expirations
Left sided murmurs louder on expiration
LEXpiration
what are the common presenting symptoms with VHD
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
what is the SCRIPT evaluation for murmurs
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
what is a grade 2 murmur
soft, heard in all positions, no thrills
what is grade 3 murmur
moderately loud, no thrill
what is grade 4 murmur
loud and associated with palpable thrill
what is grade 5 murmur
very loud, with thrill, heart with the stethoscope partially off the chest
what is grade 6 murmur
loudest, with thrill, heard with the stethoscope entirely off the best
what are the diagnostics tests used for VHD
Doppler Echo - TTE, TEE
ECG
CXR
MRI - gated
Exercise stress test
catheterization
what is the most common type of murmur
innocent murmur - may disappear and then reappear
caused by rapid ejection of blood across the valve - common in hyperkinetic states
what are common causes of innocent murmurs
temporary increase in blood flow: Hyperkinetic states
exercise
pregnancy
fever
hyperthyroidism
anemia
rapid growth spurts in children
always pathologicic if
diastolic murmur
holo- or late systolic
continuous - systolic and diastolic
grade > 3
concomitant cardiac symptoms or exam findings
what is one of the most common and most serious valve disease
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
what are symptoms of AS
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
what is a classic systolic murmur heard RUSB with patient sitting
Aortic stenosis
if a thrill is felt - is it not what kind of murmur
a innocent murmur
what is the treatment of AS
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
what medications can cause dangerous hypertension and should be used with caution for angina in patients with AS
nitrates
what are diastolic murmurs always
pathologic
what is the diameter of a normal Aortic valve
3.0-5.0 cm
what is the diameter of severe AS
1.0cm or less
with severe AS - when is the murmur peaked
late systolic
with mild AS. - when is the murmur peaked
early to mid systolic
what is aortic regurgitation
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
what are causes of aortic regurgitation
valvular - calcifications, bicuspid, endocarditis
Aorta - dilation, dissection
what is the most common cause of chronic aortic regurgitation in children
Ventricular septal defect (VSD) with aortic valve prolapse
what are symptoms of aortic regurgitation
mild may produce few symptoms
more severe AR may: palpitations, chest pain, fatigue, SOB
other symptoms include orthopnea, weakness, fainting or LE edema
what are the osculatory findings with aortic regurg
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
what is a corrigan’s pulse
wild pulse pressure
what is seen with severe AR
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
what is the treatment of AR
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
what is the normal mitral valve area
4-6cm
what is the pathophysiologic effect of mitral regurgitation
volume overload
what does volume overload cause with mitral regurgication
change in LV geometry (remodeling)
remodeling = LV enlargement = hypertrophy
what are the symptoms of MR
SOB (dyspnea), especially on exertion and when lying down
fatigue
palpitations
swollen feet or ankles
what are the causes of MR
mitral valve prolapse
damaged tissue cords
rheumatic fever
endocarditis
MI
cardiomyopathy: HOCM
Trauma
Congenital heart disease
medications (ergotamine)
Radiation
AFib
age
Connective tissue disease
what are complications of MR
HF, Afib, pulmonary HTN in more severe cases
what is heard on osculatory evaluation of MR
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
what is found with moderate to severe MR
brisk carotid pulse
hyperdynamic, displaced apical impulse
soft or absent S1, S3 and S4 gallops, widely split S2, diastolic rumble
what is the treatment of MR
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
what is mitral valve prolapse
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)
what is heard on auscultation with MVP
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
what is the treatment of MVP
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
what is mitral stenosis
rare
symptoms most often appear between 15-40 yo in developed nations and they can occur at any age, even childhood
what are the symptoms of MS
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
what is the pathophysiology of MS
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
what is the etiology of MS
rheumatic or annular calcification
what are the complications of MS
pulmonary hypertension
HF - pulmonary edema
heart enlargement - LA dilation
atrial fibrillation
blood clots
what are major manifestations found with rheumatic fever
carditis
polyarthritis
chorea
erythema marginatum
subcutaneous nodules
what are the minor manifestations found with rheumatic fever
fever
arthralgia
previous rheumatic fever or rheumatic heart disease
elevated ESR or positive CRP
prolonged PR interval
what is heard with auscultation with MS
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
what is the treatment of MS
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
What is the most common cause of Pulmonary stenosis (PS)
usually rare among adults, usually congenital heart defect
moderate to severe PS is most often diagnosed during childhood
when are PS symptoms first noticed
while exercising
fatigue, SOB, chest pain, LOC
what are the risk factors for PS
carcinoid syndrome
rheumatic fever
noonan syndrome
pulmonary valve replacement
what are complications of PS
infection -higher risk of infective endocarditis
RVH
R sided heart failure
arrhythmia - unless PS severe, arrhythmia not usually life threatening
what is the treatment of PS
balloon valvulopolasty for symptomatic pts and asymptomatic pts with normal systolic function and a peak gradient > 40 to 50 mmHg
what is the most common cause of pulmonary insufficiency
pulmonary hypertension or congenital heart defect (most specifically tetralogy of fallot)
what is tricuspid stenosis almost always due to
rheumatic fever; tricuspid regurg and mitral stenosis are often also present
may be related to cancer (tumors, carcinoid syndrome)
what are the symptoms of TS
severe tricuspid stenosis - fluttering discomfort in the neck, fatigue and cold skin, elevated JVD, and R upper quadrant abdominal discomfort
what is the treatment of TS
diuretics and aldosterone antagonists; surgical repair or replacement is rarely needed
what is the congenital defects associated with tricuspid insufficnency
ebsteins anomaly
marphans syndrome
idiopathy myxomatous degeneration
what is secondary Tricuspid regurgitation due to
leaflet tethering, caused by annular dilation and/or papillary muscle displacement
what is the perferred method for evaluating tricuspid Insufficiency
Cardiac MRI - should be done when echo quality is inadequate - evaluates RV size and function
what is the tx of TR
usually well tolerated, but severe cases may require annuloplasty, valve repair or valve replacement
what are the lifestyle changes for VHD
smoke-free
more active
aim for healthier weight
eat a healthy balanced diet
drink less alcohol
manage stress
what are medication options for VHD
diuretics
blood thinners/anti-thrombotics
anti-arrhytmics
antibiotics - chronic and prophylactic
what are the surgery options for VHD
valve repair: ballon valvuloplasty or annuloplasty
valve replacement: mechanical, biologic, transcatheter aortic valve implantation (TAVI/TAVR)
