valvular disorders Flashcards
two types of valvular disorders
- regurgitation
- stenosis
clinical classification categories of valvular disease
- A: at risk
- B: mild to moderate with no symptoms
- C1: severe with no symptoms and normal LV function
- C2: severe with no symptoms and abnormal LV function
- D: symptoms
at what point should you refer a patient to cardiology?
severe disease
examples of congenital defects that can cause valvular disease
bicuspid aortic valve
examples of aging processes that can cause valvular heart disease
- degenerative valve disease
- valve calcification
illnesses that can cause valvular heart disease
- infective endocarditis
- rheumatic fever
congenital causes of aortic stenosis
more or less valve leaflets than normal
congenital causes of aortic stenosis usually present at what age?
prior to 50
acquired causes of aortic stenosis
- rheumatic fever
- valve calcification
- degenerative stenosis
acquired causes of aortic stenosis usually present at what age?
after age 50
regardless of the cause of aortic stenosis, it leads to …. and ….. of the valve leaflets and a ….. valve opening
thickening; calcification; narrowed
aortic stenosis leads to the heart having to pump harder to push blood out into circulation, which results in …
LVH
degenerative or calcifies aortic stenosis results from …..
calcium deposition on the valve
A very large percentage of elderly patients have evidence of ….. on echo, which can progress into ….
aortic sclerosis; aortic stenosis
most common surgical valve lesion in developed countries
degenerative aortic stenosis
if the valves cant close normally, what will happen?
regurgitation
cardinal symptoms for aortic stenosis
- angina
- syncope
- CHF
why do you see angina in aortic stenosis?
ischemia because the heart isnt able to pump blood out the aorta into the coronary arteries that supply the myocardium of the heart
why do you see CHF in aortic stenosis?
blood cannot be pumped out the aorta, so it backs up into the LA, lungs, RA, and RV
murmur of aortic stenosis
- midsystolic
- harsh quality
- heard best at aortic post
- may radiate to the carotids
….heart sound may also be present in aortic stenosis
S4
why is the murmur for aortic stenosis midsystolic?
because S1 marks the beginning of systole (mitral valve is closed and aortic valve is open) and the blood is being pushed through the aortic valve during systole, so the murmur will be heard during systole.
why do you hear S4 in aortic stenosis?
atria is trying to get that last bit of blood into the ventricle so it gives an extra kick which facilitates the S4 sound
what can you see on EKG in aortic stenosis?
LVH
imaging modality of choice in aortic stenosis
echo
pressure gradient in aortic stenosis
there is often >50mmHg higher pressure in the LV than in the aorta because the blood is not able to go through the valve
management of aortic stenosis
surgery
what types of surgery can be used to treat aortic stenosis?
- open heart
- TAVR
- balloon valvuloplasty
risks associated with balloon valvuloplasty
can break off calcifications which can be dislodged and cause stroke or MI
t/f there are no medications that have been proven to slow the progression of aortic stenosis
true
what type of therapies can be given to the patient for their symptoms associated with aortic stenosis?
- diuretics to help with fluid buildup and preload
- blood pressure medications to treat afterload
chronic aortic regurgitation can lead to … due to the need to accommodate the additional regurgitant volume
LVH
what causes symptoms in aortic regurgitation?
increase in LV pressure leading to CHF
murmur in aortic regurgitation
- early diastolic
- blowing sound
- best heard in the apex of the heart
- lean forward and exhale
why do you hear the aortic regurgitation murmur in early diastole?
S2 is the aortic valve closing but in aortic regurgitation, it doesn’t fully close, so you hear the “blowing” all throughout diastole as the blood is falling back into the ventricle
why do you hear the murmur for aortic regurgitation in the apex of the heart?
because thats where the blood is backing up at
why would you see a widened pulse pressure in aortic regurgitation?
not going to have the same pressure in the aorta because the blood is pulling back in the ventricle which will cause it to have a higher pressure
Austin Flint murmur
diastolic murmur caused by aortic regurgitation
only valvular disorder that’s murmur doesn’t match up with the associated listening post
aortic regurgitation
diagnostic modality of choice for aortic regurgitation
echo
treatment for aortic regurgitation
- surgery
- vasodilator therapy
acute aortic regurgitation is a ….
medical emergency
what can cause an acute aortic regurgitation?
- infective endocarditis
- trauma (MI)
why is acute aortic regurgitation considered a medical emergency?
the heart cannot manage the stretch that fast and everything will get backed up very fast
s/s of acute aortic regurgitation
- cardiogenic shock
- pale, cool, weak, rapid pulse
murmur in acute aortic regurgitation
low pitched, early diastolic
why is the murmur for acute aortic regurgitation low pitched?
the valve is open so there it is not going to be going through with as much pressure
diagnostic modality for acute aortic regurgitation
echo
treatment of acute aortic regurgitation
- want to decrease preload and afterload so give diuretics and vasodilators
- urgent valve replacement
when does mitral stenosis occur?
when thickening and immobility of the mitral leaflets impede the flow from the left atrium to the left ventricle
most common cause of mitral stenosis
rheumatic fever
mitral stenosis can lead to backup of blood and …….
left atrial enlargement
buildup of blood in the left atria can lead to ……
pulmonary congestion
……can occur due to the left sided heart failure causing a backup of blood in the lungs and the pulmonary veins
right sided HF
as the stenosis progresses, filling of the LV becomes impaired, ….
reducing SV and CO
when do patients with rheumatic fever mitral stenosis develop symptoms?
40-50 years
symptoms of mitral stenosis
- dyspnea/orthopnea
- AFIB
- hemoptysis
- embolism
- compression of the left recurrent laryngeal nerve leading to hoarseness
why would you see AFIB in mitral stenosis?
electricity is trying to push blood from the atria into the ventricle and freaks out since it cant
why would you see an embolism in mitral stenosis?
blood sits in the left atria and clots and then is pushed out into the body
why would we see compression of the left recurrent laryngeal nerve in mitral stenosis?
backup of blood in the LA causes hypertrophy and compression
murmur of mitral stenosis
- rumbling
- low pitched
- diastolic murmur
- best heard at the apex and mitral post
why do you hear the murmur at diastole for mitral stenosis?
during diastole, the blood should be flowing through the mitral valve, but the stenosis allows for only a little bit of blood to get through at a very high pressure, so the intense pressure of the blood hitting the ventricle produces the sound
what other heart sounds may you hear in mitral stenosis?
opening snap following S2
quality of heart sounds in mitral stenosis
S1 is loud in early mitral stenosis due to hard valve, but it softens over time because the valve becomes immobile and doesn’t fully close
why do you hear an opening snap in mitral stenosis?
you can hear the mitral valve open because it is hard
what side of the stethoscope should we use to assess mitral stenosis?
bell. its used to hear low pitched sounds
EKG findings of mitral stenosis
- AFib
- RV hypertrophy
diagnostic modality for mitral stenosis
echo
characteristic findings of mitral stenosis on echo
hockey stick sign
treatment of mitral stenosis
- mild to moderate can be managed with meds for symptom control (BB and diuretics)
- moderate to severe needs surgery
why do mitral stenosis patients need beta blockers?
their heart recognizes that there is a lack of blood being pumped through the circulation, so it picks up the rate to compensate, but its only making the problem worse because there is no blood in the ventricle to pump. as the heart does more work, it can lead to LVH and more problems
mitral regurgitation results from…
abnormalities of the leaflets, annulus, chordae tendonae, and papillary muscles
symptoms of mitral regurgitation
- fatigue
- dyspne
- peripheral edema
murmur of mitral regurgitation
- holosystolic
- best heard at the apex
- radiates to axilla and back
why is the murmur for mitral regurgitation holosystolic?
the valve is staying open, so when the heart is contracting, the blood is flowing right back up into the atria and there is a constant flow
why does the mitral regurgitation murmur radiate to the axilla and back?
blood shoots backup and causes noise going back into the atria
EKG for mitral regurgitation
- LVH
- AFib
diagnostic modality for mitral regurgitation
echo
what can a cardiac catheterization give us?
filling pressures
treatment for mitral regurgitation
- diuretics to decrease fluid and vasodilators to try to decrease the amount of pressure that the blood is pushing against, making more blood likely to pump into circulation instead of regurgitating
- surgery
patients with mitral regurgitation should have _____ echos to monitor LV size and fxn
annual
development of …. or … may be a surgical indication
- afib
- pulmonary HTN
t/f MV repair is possible in many patients with mitral regurgitation instead of a full replacement
true
acute mitral regurgitation
LA cannot dilate enough to accommodate the rapid regurgitation of blood leading to increase in LA size and pulmonary congestion
causes of acute mitral regurgitation
- endocarditis
- trauma (MI)
s/s of acute mitral regurgitation
- cardiogenic shock:
- tachycardia
- hypotension
- pallor
- diaphoretic
murmur in acute mitral regurgitation
- low pitched
- early systole
treatment of acute mitral regurgitation
urgent valve replacement
mitral valve prolapse
leaflet is pushed up into the atria, leading to no closure of the mitral valve and regurgitation
mitral valve prolapse may be associated with ….. or …..
systemic or connective tissue disorders
MVP syndrome
nonspecific symptoms like chest pain, palpitations, anxiety
auscultation of mitral valve prolapse
- mid systolic click
- late systolic murmur
why do you hear a mid-systolic click in MVP?
the pressure in the ventricle in systole causes the prolapsed valve to open up mid systole, resulting in the click
why do you hear the late systolic murmur in MVP?
after the click which is the opening of the prolapsed valve, it allows for some regurgitation in late systole
diagnostic modality for MVP
echo
management of MVP
Mild: no intervention
severe: repair or replacement
tricuspid stenosis is generally an _______ valvular disorder
uncommon
tricuspid stenosis is rarely isolated and is often accompanied by __________
aortic stenosis or mitral stenosis
causes of tricuspid stenosis
- rheumatic heart disease
- carcinoid disease
what can we expect to happen physiologically and clinically when we see a patient with tricuspid stenosis?
peripheral edema due to backup of blood into the vena cava
how does tricuspid stenosis affect overall heart failure?
it causes right sided heart failure which can lead to reduced LV output
clinical presentation of tricuspid stenosis
- ascites
- peripheral edema
- JVP
- fatigue
murmur in tricuspid stenosis
mid diastolic
where can you hear the tricuspid stenosis murmur best?
left sternal boarder (tricuspid post)
______ sided murmurs are heard better in inspiration and _______ sided murmurs are heard better in expiration
Left
Right
why may opening snap be heard in tricuspid stenosis?
hardened tricuspid valve clicks open
PE of tricuspid stenosis
palpable liver pulsation
diagnosis modality for tricuspid stenosis
echo
what may you see on an EKG for tricuspid stenosis?
tall t waves because you have right atrial enlargement
what may you see on CXR for tricuspid stenosis?
cardiology
management of tricuspid stenosis
- treat HF
- diuretics
- eventual valve replacement
what type of diuretic are best for treating HF in tricuspid stenosis?
loops
what type of diuretics are best for treating liver congestion and ascites in HF due to tricuspid stenosis?
aldosterone antagonists
what usually causes tricuspid regurgitation?
dilation of the right ventricle
what can cause RV dilation?
pulmonary HTN
presentation of tricuspid regurgitation
RHF
-fatigue
-ascites
-JVD
-peripheral edema
murmur in tricuspid regurgitation
holosystolic (pansystolic)
where is the tricuspid regurgitation murmur best heard?
left sternal boarder
diagnostic modality of tricuspid regurgitation
echo
management of tricuspid regurgitation
- treat underlying conditions and HF
-repair/replace valve
cause of pulmonic stenosis
congenital defect
what anatomically causes stenosis in pulmonic stenosis?
fused pulmonary leaflets
presentation of critical pulmonic stenosis
cyanotic at birth
presentation for normal pulmonic stenosis
- usually asymptomatic until adolescence and progresses as they get older
- fatigue and dyspnea
- RHF symptoms
murmur in pulmonic stenosis
mid systolic
where is the murmur best heard in pulmonic stenosis?
left upper sternal boarder (pulmonic post)
diagnostic modality of choice for pulmonic stenosis
echo
management of mild pulmonic stenosis
asymptomatic and requires no intervention
management for moderate to severe pulmonic stenosis
surgery
Cause of pulmonic regurgitation
dilation of the pulmonic valve annulus
what causes dilation of the pulmonic valve annulus?
pulmonary HTN
symptoms of pulmonic regurgitation
right sided heart failure
murmur for pulmonic regurgitation
holo-diastolic
where is the pulmonic regurgitation murmur best heard?
pulmonic post
treatment of pulmonic regurgitation
- treat pulmonary HTN
- surgery
characteristics of mechanical heart valves
- extremely durable
- high clot risk, so they would have to be on warfarin for life
goal INR of warfarin with mechanical heart valve
2.5-3.5 (blood needs to be thinner than DVT INR)
characteristics of tissue replacement heart valve
-lower risk of clot
-less durable
-daily ASA
Rheumatic Heart Disease
develops secondary to abnormal immunologic response to GABHS and the heart freaks out
why has prevalence of RHD dropped?
antibiotic availability
what characterizes RHD?
pancarditis
pancarditis
diffuse inflammation of the heart
histologic finding of RHD
aschoff body
aschoff body
collection of monocytes and macrophages surrounding fibrous tissue
what is the most common valve affected by RHD?
mitral
presentation of RHD?
acute febrile illness 2-4 weeks after strep throat
major criteria for diagnosing RHD
-carditis
-polyarthritis
-choreiform movements
-erythema marginatum
-subcutaneous nodules
minor criteria for RHD
- fever
- arthritis
- prior rheumatic fever or known RHD
how can you make a diagnosis of RHD?
- 2 major criteria OR 2 minor criteria and 1 major
- documented strep infection
- confirm with echo
treatment of RHD
PCN
prophylaxis for RHD
PCN G injections monthly for 10 years
