Valvular Disorder Part 2 Flashcards
What side of the heart is MC to have a valvular disorder?
Left - the higher pressure side
Whenever you hear a murmur, what must you do?
Order an ECHO!
What is a common finding in aortic stenosis?
Radiation to the carotids
What are the valves of the right side of the heart?
Tricuspid
Pulmonic
What classes of medicine are used for contractility and fluid overloads?
Contractility = BB
Fluid overload = diuretics
Difference between stenotic murmur and regurg
Stenotic murmur = mid (have to hear valve close first)
Regurg = early (you do not hear the valve close)
What is the only thing that changes from C1 to C2 stage of murmur and how do you discover this?
Abnormal LV function in C2
Order an ECHO
-often see dyspnea on exertion, pulmonary edema (cough because of congestion, frank hemptosis if rupture, blood tinged sputum - pink frothy sputum)
What closes during S1
Atrioventricular valves close
MV and TV
Aortic stenosis hearing
Systolic mid murmur,
Heard best over the right 2nd and 3rd intercostals
-heard over carotids
-Laterally displaced, sustained apical impulse
-S4 because you hear blood hit the wall because the heart has to contract harder
-sometimes a thrill
EKG: QRS complex in 456
Aortic regurg - when is it heard?
Dyastolic (because blood comes back from aorta and goes back to ventricle)
POLO - every regurg is like this because the valve never closes
-Heard best over the left sternal post because the blood flows back to the left sternum.
-heard best at the mitral post
- S3 or S4 gallop
-widened pulse pressure because the diastolic pressure is normal or low.
When do you hear mitral stenosis?
Diastole: because we are filling LV
Typically mid systolic
Heard over the mitral post
Radiation to the axillary space in left lateral decubitus because left atria can expand out in this position
Opening snap - because you can hear calcified
-Best heard with bell (often covered with breast tissue) - often missed
When do you hear mitral regurgitation?
Systole: mitral valve is supposed to be closed, so blood jets back up
-Hear radiation to the axilla (sometimes back) because there is a strong force assocaited with systole
-holo systolic (because it is regurg)
- Mitral valve prolapse can cause regurg, so sometimes you hear a click
What is tricuspid stenosis overview
Heard during dyastole
Mid dyastole (because valve is calcified)
Backs up into SVC and IVC
Can see JVD
Can see ascites and hepatic congestion before LE edema
How common is tricuspid stenosis seen?
Rare - seen MC in females
Don’t normally see it by itself because the right side often can compensate for this
What can we expect to happen physiologically and clinically when we see a patient with tricuspid stenosis?
Reduced RA emptying leads to reduced LV output, meaning that the LV has to pump harder and faster
What is the MC of tricuspid stenosis?
Rheumatic heart disease
Because we treat GABHS, this is why it is rare
Why do you see fatigue in Tricuspid stenosis?
Stenotic blood and less O2 delivery
When do you hear the murmur in tricuspid stenosis and how do you differentiate this from mitral stenosis?
mid diastolic, heard better during inspiration because there is more blood in the right side of the heart
Heard best in tricuspid
What is the PE of tricuspid stenosis?
Right sided heart failure
JVD
ascites
LE edema
Possibly palpable pre-systolic liver pulsation coinciding with atrial contraction
What do you possibly see in EKG of tricuspid stenosis?
RAE
What do you sometimes see in CXR of tricuspid stenosis?
Cardiomegaly specifically in the right side d/t RAE
How do you treat tricuspid stenosis?
loop diuretics: Torsemide or bumetanide if bowel edema
How do you treat ascities from tricuspid stenosis?
aldosterone antagonist if liver congestion or ascites is present
What often leads to Tricuspid regurgitation?
Dilation of the RV and tricuspid annulus leads to this regurge
puts strain on the tricupsid valve, allowing blood to go back into the RA
Where does blood not reach in tricuspid regurg?
Does not get to the lungs
What differs tricuspid regurg from tricupsid stenosis on PE?
ONLY THE MURMUR
same s/s of right sided HF, because blood will back up into the RA and then into the SVC and IVC
What is a complication of pulmonary system in tricupsid regurg?
Pulmonary hypertension
What type of murmur do you hear in tricuspid stenosis and when is it louder?
Holosystolic murmur (because during systole, the blood is supposed to enter the pulmonary artery, but can get regurged from the RV into the the RA)
Loudest when increasing venous return
How do you diagnose a tricuspid regurg?
ECHO!
Treatment for tricuspid regurg?
Underlying cause
Managing for medical therapies based on s/s
Do you normally replacing the valve for tricuspid regurg?
Typically not (low pressure system)
Will replace if there is another underlying problem like a tumor
Do you do anticoagulation therapy for tricuspid regurg?
No - only if Afib is present
What typically causes pulmonic stenosis?
Congenital disorder
Seen with right-sided HF at a young age and confirmed with echo
Tri 13 and Noonan syndrome
Where does blood back up with pulmonary stenosis?
Backs up into the RV, then the RA, and then the SVC and IVC
What is the presentation of pulmonic stenosis at birth
central cyanosis
What is the murmur of pulmonary stenosis?
Systolic ejection murmur that is heard at the upper sternal border
Why do you hear an opening click in pulmonic stenosis?
Opening click and RV lift on palpation of precordium because the heart is trying hard
How do you treat pulmonic stenosis?
Cardio referal
When do you hear pulmonic stenosis?
holo diastolic, whooshing sound over pulmonic post
What is group 2 pulmonary HTN?
pulmonary hypertension due to left heart disease leads to right hearted problems
In addition to an echo, what is often ordered for pulmonic stenosis?
Cardiac MRI and CT in order to see dilated pulmonary system
How do you manage pulmonary regurg?
Treat underlying pulmonary HTN
Valve replacement is rare
What valves do we use for valve surgery?
Mechanical valve: need to be on warfarin (INR 2.5-3.5)
Prosthetic valve:
Which valves last the longest?
Mechanical can last forever - but need to be on Warfarin all of the time
Prosthetic valve: last 10 years
What is a risk of a mechanical valve?
High thromboembolic risk
NEED to be on warfarin (no other anticoag)
Goal INR 2.5-3.5
What is an advantage of prosthetic valve?
Lower risk of thrombosis
Just need aspirin therapy
only lasts like 10 years
What causes rheumatic heart disease and what age is it typically seen?
GABHS
Child 4-9 yo
What does rheumatic fever lead to?
Pancarditis often with excudate
would see lymphocytes in myocardium if there is biopsy (not normally done) because of infection
If you were to do a biopsy of rheuatic heart, what would you see?
Aschoff body (Collection of myocytes and macrophages surrounded by fibrous tissue)
What do you see commonly on the mitral valve of rheumatic heart disease?
- Valvulitis is characterized by verrucous lesions on leaflet edge
- MV most commonly affected, followed by AV
What is the major criteria of JONES criteria for rhemuatic fever?
Joints (polyarthritis)
O (carditis) = looks like a heart
Nodules (subcutaneous)
Erythema marginatum
Sydenham chorea (rhytmic movenets that are not controlled)
What do you need to dx rheuamtic fever with JONES criteria?
2 major criteria met
1 major and 2 minor criteria met
AND if criteria are present following a recent, DOCUMENTED strep infection from a provider
needs to be confirmed with an ECHO!
What are the minor criteria of rheumatic fever?
CAFE PAL
CRP
Arthralgia
Fever
Elevated ESR
Prolonged PR interval
Anamnesis of Rheumatism
Leukocytosis
What is the treatment plan of rheumatic heart disease?
PCN to eradicate strep
Salicylates used for fever and arthritis
Prophylaxis with PEN G for 10 years
