Valvular Disorders Flashcards
Module 3
Which valvular disease is most common in patients >60 years old due to calcific changes related to advanced age?
Aortic stenosis
S1 is louder at the
Apex
S2 is louder at the
Base
Where can the aortic valve be auscultated?
Right upper sternal border, 2nd ICS
Where can the pulmonic valve be auscultated?
Left upper sternal border, 2nd ICS
Where can the tricuspid valve be auscultated?
Lower left sternal border, 4th ICS
Where can the mitral valve be auscultated?
Cardiac apex, mid clavicular line, 5th ICS
The diaphragm of a stethoscope is best used for
Higher-pitched sounds of S1 and S2
Murmurs of aortic and mitral regurgitation and pericardial friction rub
The bell of a stethoscope is best used for
Lower-pitched sounds of S3 and S4
Low-rumbling murmur of mitral stenosis
S1 indicates
Beginning of systole - tricuspid and mitral valves close
S2 indicates
Beginning of diastole - aortic and pulmonic valves close
A split S2 is not uncommon during
Inspiration
(Right heart filling time, right ventricular stroke volume, and right ventricular ejection duration are all increased, causing delay in closure of the pulmonic valve)
The intensity of a split S2 decreases with
Aortic stenosis or pulmonic stenosis
S3 should not be audible and occurs in
Early diastole, heard just after S2S
When would an S3 heart sound be normal?
Pregnancy and kids
S3 is an early sign of
Fluid overload
S4 occurs at the end of
Diastole and should not be audible
Just before S1
S4 occurs due to
Ventricles resistant to filling/weak ventricles
An S4 heart sound is
Pathologic
What valvular disorders can be heard during diastole?
Aortic regurgitation, Mitral stenosis
What valvular disorders can be heard during systole?
Aortic stenosis, Mitral regurgitation, Mitral valve prolapse, Pulmonic stenosis
Which 2 valvular disorders create an early diastolic murmur?
Aortic regurgitation, pulmonic regurgitation
Which 2 valvular disorders create a mid-diastolic murmur?
Mitral stenosis, tricuspid stenosis
Which 2 valvular disorders create a mid-systolic crescendo-decrescendo murmur?
Aortic stenosis and pulmonic stenosis
Which 2 valvular disorders create a late-systolic crescendo murmur?
Mitral valve prolapse, tricuspid valve prolapse
Which 3 valvular disorders create a holosystolic/pansystolic murmur?
Mitral regurgitation, tricuspid regurgitation, VSD
Which valvular disorder creates a continuous murmur?
PDA or AV fistula
What are 3 causes of mitral and tricuspid stenosis?
VSD, ASD, rheumatic fever
What are 5 causes of aortic stenosis or pulmonic stenosis?
Aortic obstruction, dilation of ascending aorta, dilation of pulmonary artery, ASD (left to right shunt), hypertrophic obstructive cardiomyopathy
What causes mitral valve prolapse or tricuspid valve prolapse?
Papillary muscle dysfunction
What causes mitral regurgitation or tricuspid regurgitation?
VSD (high pressure to low pressure chamber)
The valsalva maneuver can increased the sound of which murmur?
Mid-systolic murmur (aortic stenosis, pulmonic stenosis)
What are initial diagnostic tests for valvular disorders?
Echo, 12-lead EKG, chest x-ray
If indicated, what are additional diagnostic tests for valvular disorders?
Stress test with exercise EKG, cardiac MRI, cardiac catheterization
What are 5 differential diagnoses for a systolic murmur?
Aortic stenosis, pulmonic stenosis, MVP, mitral regurgitation, tricuspid regurgitation
What are 4 differential diagnoses for a diastolic murmur?
Aortic regurgitation, pulmonic regurgitation, mitral stenosis, tricuspid stenosis
What are the 4 stages of valvular heart disease?
Stage A: at risk
Stage B: progressive (mild-mod severity and asymptomatic)
Stage C: asymptomatic severe
Stage D: symptomatic severe
Stage C: Asymptomatic severe valvular heart disease can be broken into 2 additional stages
C1: left or right ventricle remains compensated
C2: decompensation of the left or right ventricle
What are 5 red flags of valvular disorders that require immediate referral?
Diastolic murmurs, holosystolic murmurs, systolic murmurs grade 3+, murmur with presence of a new extra heart sound (S3, S4 or a click), or a murmur that increases in intensity when patient stands
Which valve operation is most common and for what valvular disorder?
Aortic valve replacement for aortic stenosis
What is the most common type of valvular heart disease?
Aortic stenosis
An aortic valve <1 cm indicates
Poor prognosis
If an aortic valve becomes a bicuspid valve in utero, risk of aortic stenosis is increased by
50%
What kind of murmur does aortic stenosis produce?
Mid-systolic crescendo-decrescendo murmur
Aortic stenosis may lead to
Left atrial enlargement, LVH, pulmonary HTN
Treatment for asymptomatic patients with aortic stenosis
Not needed
If a patient has stage D and asymptomatic or stage C with surgical risks, they may require
Transcatheter aortic valve replacement (TAVR)
The chronic slow leak of aortic regurgitation leads to
Increased left ventricular volume leading to LVH
Acute aortic regurgitation is often related to
Infective endocarditis or trauma
Clinical presentation of aortic regurgitation may progress to
HF, ascites, hepatomegaly, pulmonary congestion
What are the unique findings of aortic regurgitation?
Large, high-pitched diastolic murmur (not common), Austin Flint murmur (mitral mid-diastolic murmur)
An Austin Flint murmur indicates
Large regurgitant flow
When aortic regurgitation is secondary to inflammation, it may cause what results on an EKG?
Prolonged PRI
What are complications of aortic regurgitation?
1st degree block, atrial fibrillation, bradycardia
What is the most common cause of mitral regurgitation and mitral valve disease?
Mitral valve prolapse
What is the most common cause of mitral valve prolapse?
Idiopathic myxomatous degeneration
Mitral valve prolapse is more prevalent in
Young women
What kind of murmur does a mitral valve prolapse create?
Late systolic crescendo murmur that is loud and musical, preceded by a mid-systolic click (not always) best heard at the lower left sternal border or at the apex
Patients with MVP should have clinical and echocardiographic follow-up evaluation every
3-5 years
Mitral stenosis is common in
Pregnancy due to increased circulatory blood volume
The predominant cause of mitral stenosis is
Rheumatic fever
What is the principal symptom of mitral stenosis?
Dyspnea (class II)
For a patient with asymptomatic mitral stenosis, what classification is considered?
Functional class I
What kind of murmur does mitral stenosis cause?
Low-pitched rumble diastolic murmur best heard with the bell over the apex in exhalation in left lateral position
Patients with mitral stenosis who have fib associated with ventricular dysfunction can be treated with
Digoxin and need anticoagulation
What is the treatment for recurring rheumatic fever?
PCN prophylaxis, PO diuretics and sodium restriction
Mitral stenosis may lead to
Right ventricular hypertrophy
Which arrhythmia is common with mitral stenosis?
Atrial fibrillation
What is the hallmark of rheumatic disease?
Aschoff bodies in myocardium
What would an EKG of mitral stenosis show?
NSR with left atrial enlargement, notched p wave in limb leads
What are the second leading causes of mitral regurgitation?
Ischemic LV dysfunction and dilated cardiomyopathy
What connective tissue disease can cause mitral regurgitation?
Marfan’s syndrome
Marfan’s syndrome can cause mitral regurgitation due to
Acute, spontaneous rupture of chordae tendinae
What kind of murmur does mitral regurgitation cause?
Harsh pansystolic/holosystolic blowing murmur best heard at the apex and radiating to the axilla, back, or left sternal border
What medications can be used in mitral regurgitation?
B-adrenergic blockade, ACEIs, ARBs, aldosterone antagonists
Pulmonary stenosis commonly occurs in
Congenital defects - related to mothers with rubella
What are rare causes of pulmonary stenosis?
Endocarditis or rheumatic heart disease
What kind of murmur does pulmonary stenosis create?
Mid-systolic murmur over 2nd ICS left sternal border
Pulmonary stenosis may cause a pulmonic ejection sound best heard in the
2nd and 3rd left ics and may reveal a normal S1 and widely split S2
What is the treatment for pulmonary stenosis in infants?
Percutaneous balloon pulmonary valvuloplasty
What would an EKG reveal in pulmonary stenosis?
Right axis deviation
Patients with pulmonary stenosis should receive
Precautionary antibiotics
Pulmonary regurgitation is rare and is usually related to
Congenital heart disease
What kind of murmur does pulmonary regurgitation cause?
Early diastolic murmur over 2nd ICS left sternal border
What is the treatment for pulmonary regurgitation?
Focused on infective endocarditis and pulmonary HTN
