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Internal Med EOR > valvular disorders > Flashcards

valvular disorders Flashcards

1
Q

two types of valvular disorders

A
  • regurgitation
  • stenosis
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2
Q

clinical classification categories of valvular disease

A
  • 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
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3
Q

at what point should you refer a patient to cardiology?

A

severe disease

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4
Q

examples of congenital defects that can cause valvular disease

A

bicuspid aortic valve

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5
Q

examples of aging processes that can cause valvular heart disease

A
  • degenerative valve disease
  • valve calcification
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6
Q

illnesses that can cause valvular heart disease

A
  • infective endocarditis
  • rheumatic fever
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7
Q

congenital causes of aortic stenosis

A

more or less valve leaflets than normal

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8
Q

congenital causes of aortic stenosis usually present at what age?

A

prior to 50

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9
Q

acquired causes of aortic stenosis

A
  • rheumatic fever
  • valve calcification
  • degenerative stenosis
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10
Q

acquired causes of aortic stenosis usually present at what age?

A

after age 50

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11
Q

regardless of the cause of aortic stenosis, it leads to …. and ….. of the valve leaflets and a ….. valve opening

A

thickening; calcification; narrowed

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12
Q

aortic stenosis leads to the heart having to pump harder to push blood out into circulation, which results in …

A

LVH

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13
Q

degenerative or calcifies aortic stenosis results from …..

A

calcium deposition on the valve

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14
Q

A very large percentage of elderly patients have evidence of ….. on echo, which can progress into ….

A

aortic sclerosis; aortic stenosis

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15
Q

most common surgical valve lesion in developed countries

A

degenerative aortic stenosis

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16
Q

if the valves cant close normally, what will happen?

A

regurgitation

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17
Q

cardinal symptoms for aortic stenosis

A
  • angina
  • syncope
  • CHF
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18
Q

why do you see angina in aortic stenosis?

A

ischemia because the heart isnt able to pump blood out the aorta into the coronary arteries that supply the myocardium of the heart

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19
Q

why do you see CHF in aortic stenosis?

A

blood cannot be pumped out the aorta, so it backs up into the LA, lungs, RA, and RV

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20
Q

murmur of aortic stenosis

A
  • midsystolic
  • harsh quality
  • heard best at aortic post
  • may radiate to the carotids
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21
Q

….heart sound may also be present in aortic stenosis

A

S4

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22
Q

why is the murmur for aortic stenosis midsystolic?

A

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.

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23
Q

why do you hear S4 in aortic stenosis?

A

atria is trying to get that last bit of blood into the ventricle so it gives an extra kick which facilitates the S4 sound

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24
Q

what can you see on EKG in aortic stenosis?

A

LVH

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25
Q

imaging modality of choice in aortic stenosis

A

echo

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26
Q

pressure gradient in aortic stenosis

A

there is often >50mmHg higher pressure in the LV than in the aorta because the blood is not able to go through the valve

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27
Q

management of aortic stenosis

A

surgery

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28
Q

what types of surgery can be used to treat aortic stenosis?

A
  • open heart
  • TAVR
  • balloon valvuloplasty
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29
Q

risks associated with balloon valvuloplasty

A

can break off calcifications which can be dislodged and cause stroke or MI

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30
Q

t/f there are no medications that have been proven to slow the progression of aortic stenosis

A

true

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31
Q

what type of therapies can be given to the patient for their symptoms associated with aortic stenosis?

A
  • diuretics to help with fluid buildup and preload
  • blood pressure medications to treat afterload
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32
Q

chronic aortic regurgitation can lead to … due to the need to accommodate the additional regurgitant volume

A

LVH

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33
Q

what causes symptoms in aortic regurgitation?

A

increase in LV pressure leading to CHF

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34
Q

murmur in aortic regurgitation

A
  • early diastolic
  • blowing sound
  • best heard in the apex of the heart
  • lean forward and exhale
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35
Q

why do you hear the aortic regurgitation murmur in early diastole?

A

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

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36
Q

why do you hear the murmur for aortic regurgitation in the apex of the heart?

A

because thats where the blood is backing up at

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37
Q

why would you see a widened pulse pressure in aortic regurgitation?

A

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

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38
Q

Austin Flint murmur

A

diastolic murmur caused by aortic regurgitation

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39
Q

only valvular disorder that’s murmur doesn’t match up with the associated listening post

A

aortic regurgitation

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40
Q

diagnostic modality of choice for aortic regurgitation

A

echo

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41
Q

treatment for aortic regurgitation

A
  • surgery
  • vasodilator therapy
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42
Q

acute aortic regurgitation is a ….

A

medical emergency

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43
Q

what can cause an acute aortic regurgitation?

A
  • infective endocarditis
  • trauma (MI)
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44
Q

why is acute aortic regurgitation considered a medical emergency?

A

the heart cannot manage the stretch that fast and everything will get backed up very fast

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45
Q

s/s of acute aortic regurgitation

A
  • cardiogenic shock
  • pale, cool, weak, rapid pulse
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46
Q

murmur in acute aortic regurgitation

A

low pitched, early diastolic

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47
Q

why is the murmur for acute aortic regurgitation low pitched?

A

the valve is open so there it is not going to be going through with as much pressure

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48
Q

diagnostic modality for acute aortic regurgitation

A

echo

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49
Q

treatment of acute aortic regurgitation

A
  • want to decrease preload and afterload so give diuretics and vasodilators
  • urgent valve replacement
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50
Q

when does mitral stenosis occur?

A

when thickening and immobility of the mitral leaflets impede the flow from the left atrium to the left ventricle

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51
Q

most common cause of mitral stenosis

A

rheumatic fever

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52
Q

mitral stenosis can lead to backup of blood and …….

A

left atrial enlargement

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53
Q

buildup of blood in the left atria can lead to ……

A

pulmonary congestion

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54
Q

……can occur due to the left sided heart failure causing a backup of blood in the lungs and the pulmonary veins

A

right sided HF

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55
Q

as the stenosis progresses, filling of the LV becomes impaired, ….

A

reducing SV and CO

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56
Q

when do patients with rheumatic fever mitral stenosis develop symptoms?

A

40-50 years

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57
Q

symptoms of mitral stenosis

A
  • dyspnea/orthopnea
  • AFIB
  • hemoptysis
  • embolism
  • compression of the left recurrent laryngeal nerve leading to hoarseness
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58
Q

why would you see AFIB in mitral stenosis?

A

electricity is trying to push blood from the atria into the ventricle and freaks out since it cant

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59
Q

why would you see an embolism in mitral stenosis?

A

blood sits in the left atria and clots and then is pushed out into the body

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60
Q

why would we see compression of the left recurrent laryngeal nerve in mitral stenosis?

A

backup of blood in the LA causes hypertrophy and compression

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61
Q

murmur of mitral stenosis

A
  • rumbling
  • low pitched
  • diastolic murmur
  • best heard at the apex and mitral post
62
Q

why do you hear the murmur at diastole for mitral stenosis?

A

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

63
Q

what other heart sounds may you hear in mitral stenosis?

A

opening snap following S2

64
Q

quality of heart sounds in mitral stenosis

A

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

65
Q

why do you hear an opening snap in mitral stenosis?

A

you can hear the mitral valve open because it is hard

66
Q

what side of the stethoscope should we use to assess mitral stenosis?

A

bell. its used to hear low pitched sounds

67
Q

EKG findings of mitral stenosis

A
  • AFib
  • RV hypertrophy
68
Q

diagnostic modality for mitral stenosis

A

echo

69
Q

characteristic findings of mitral stenosis on echo

A

hockey stick sign

70
Q

treatment of mitral stenosis

A
  • mild to moderate can be managed with meds for symptom control (BB and diuretics)
  • moderate to severe needs surgery
71
Q

why do mitral stenosis patients need beta blockers?

A

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

72
Q

mitral regurgitation results from…

A

abnormalities of the leaflets, annulus, chordae tendonae, and papillary muscles

73
Q

symptoms of mitral regurgitation

A
  • fatigue
  • dyspne
  • peripheral edema
74
Q

murmur of mitral regurgitation

A
  • holosystolic
  • best heard at the apex
  • radiates to axilla and back
75
Q

why is the murmur for mitral regurgitation holosystolic?

A

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

76
Q

why does the mitral regurgitation murmur radiate to the axilla and back?

A

blood shoots backup and causes noise going back into the atria

77
Q

EKG for mitral regurgitation

A
  • LVH
  • AFib
78
Q

diagnostic modality for mitral regurgitation

A

echo

79
Q

what can a cardiac catheterization give us?

A

filling pressures

80
Q

treatment for mitral regurgitation

A
  • 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
81
Q

patients with mitral regurgitation should have _____ echos to monitor LV size and fxn

A

annual

82
Q

development of …. or … may be a surgical indication

A
  • afib
  • pulmonary HTN
83
Q

t/f MV repair is possible in many patients with mitral regurgitation instead of a full replacement

A

true

84
Q

acute mitral regurgitation

A

LA cannot dilate enough to accommodate the rapid regurgitation of blood leading to increase in LA size and pulmonary congestion

85
Q

causes of acute mitral regurgitation

A
  • endocarditis
  • trauma (MI)
86
Q

s/s of acute mitral regurgitation

A
  • cardiogenic shock:
  • tachycardia
  • hypotension
  • pallor
  • diaphoretic
87
Q

murmur in acute mitral regurgitation

A
  • low pitched
  • early systole
88
Q

treatment of acute mitral regurgitation

A

urgent valve replacement

89
Q

mitral valve prolapse

A

leaflet is pushed up into the atria, leading to no closure of the mitral valve and regurgitation

90
Q

mitral valve prolapse may be associated with ….. or …..

A

systemic or connective tissue disorders

91
Q

MVP syndrome

A

nonspecific symptoms like chest pain, palpitations, anxiety

92
Q

auscultation of mitral valve prolapse

A
  • mid systolic click
  • late systolic murmur
93
Q

why do you hear a mid-systolic click in MVP?

A

the pressure in the ventricle in systole causes the prolapsed valve to open up mid systole, resulting in the click

94
Q

why do you hear the late systolic murmur in MVP?

A

after the click which is the opening of the prolapsed valve, it allows for some regurgitation in late systole

95
Q

diagnostic modality for MVP

A

echo

96
Q

management of MVP

A

Mild: no intervention
severe: repair or replacement

97
Q

tricuspid stenosis is generally an _______ valvular disorder

A

uncommon

98
Q

tricuspid stenosis is rarely isolated and is often accompanied by __________

A

aortic stenosis or mitral stenosis

99
Q

causes of tricuspid stenosis

A
  • rheumatic heart disease
  • carcinoid disease
100
Q

what can we expect to happen physiologically and clinically when we see a patient with tricuspid stenosis?

A

peripheral edema due to backup of blood into the vena cava

101
Q

how does tricuspid stenosis affect overall heart failure?

A

it causes right sided heart failure which can lead to reduced LV output

102
Q

clinical presentation of tricuspid stenosis

A
  • ascites
  • peripheral edema
  • JVP
  • fatigue
103
Q

murmur in tricuspid stenosis

A

mid diastolic

104
Q

where can you hear the tricuspid stenosis murmur best?

A

left sternal boarder (tricuspid post)

105
Q

______ sided murmurs are heard better in inspiration and _______ sided murmurs are heard better in expiration

A

Left
Right

106
Q

why may opening snap be heard in tricuspid stenosis?

A

hardened tricuspid valve clicks open

107
Q

PE of tricuspid stenosis

A

palpable liver pulsation

108
Q

diagnosis modality for tricuspid stenosis

A

echo

109
Q

what may you see on an EKG for tricuspid stenosis?

A

tall t waves because you have right atrial enlargement

110
Q

what may you see on CXR for tricuspid stenosis?

A

cardiology

111
Q

management of tricuspid stenosis

A
  • treat HF
  • diuretics
  • eventual valve replacement
112
Q

what type of diuretic are best for treating HF in tricuspid stenosis?

A

loops

113
Q

what type of diuretics are best for treating liver congestion and ascites in HF due to tricuspid stenosis?

A

aldosterone antagonists

114
Q

what usually causes tricuspid regurgitation?

A

dilation of the right ventricle

115
Q

what can cause RV dilation?

A

pulmonary HTN

116
Q

presentation of tricuspid regurgitation

A

RHF
-fatigue
-ascites
-JVD
-peripheral edema

117
Q

murmur in tricuspid regurgitation

A

holosystolic (pansystolic)

118
Q

where is the tricuspid regurgitation murmur best heard?

A

left sternal boarder

119
Q

diagnostic modality of tricuspid regurgitation

A

echo

120
Q

management of tricuspid regurgitation

A
  • treat underlying conditions and HF
    -repair/replace valve
121
Q

cause of pulmonic stenosis

A

congenital defect

122
Q

what anatomically causes stenosis in pulmonic stenosis?

A

fused pulmonary leaflets

123
Q

presentation of critical pulmonic stenosis

A

cyanotic at birth

124
Q

presentation for normal pulmonic stenosis

A
  • usually asymptomatic until adolescence and progresses as they get older
  • fatigue and dyspnea
  • RHF symptoms
125
Q

murmur in pulmonic stenosis

A

mid systolic

126
Q

where is the murmur best heard in pulmonic stenosis?

A

left upper sternal boarder (pulmonic post)

127
Q

diagnostic modality of choice for pulmonic stenosis

A

echo

128
Q

management of mild pulmonic stenosis

A

asymptomatic and requires no intervention

129
Q

management for moderate to severe pulmonic stenosis

A

surgery

130
Q

Cause of pulmonic regurgitation

A

dilation of the pulmonic valve annulus

131
Q

what causes dilation of the pulmonic valve annulus?

A

pulmonary HTN

132
Q

symptoms of pulmonic regurgitation

A

right sided heart failure

133
Q

murmur for pulmonic regurgitation

A

holo-diastolic

134
Q

where is the pulmonic regurgitation murmur best heard?

A

pulmonic post

135
Q

treatment of pulmonic regurgitation

A
  • treat pulmonary HTN
  • surgery
136
Q

characteristics of mechanical heart valves

A
  • extremely durable
  • high clot risk, so they would have to be on warfarin for life
137
Q

goal INR of warfarin with mechanical heart valve

A

2.5-3.5 (blood needs to be thinner than DVT INR)

138
Q

characteristics of tissue replacement heart valve

A

-lower risk of clot
-less durable
-daily ASA

139
Q

Rheumatic Heart Disease

A

develops secondary to abnormal immunologic response to GABHS and the heart freaks out

140
Q

why has prevalence of RHD dropped?

A

antibiotic availability

141
Q

what characterizes RHD?

A

pancarditis

142
Q

pancarditis

A

diffuse inflammation of the heart

143
Q

histologic finding of RHD

A

aschoff body

144
Q

aschoff body

A

collection of monocytes and macrophages surrounding fibrous tissue

145
Q

what is the most common valve affected by RHD?

A

mitral

146
Q

presentation of RHD?

A

acute febrile illness 2-4 weeks after strep throat

147
Q

major criteria for diagnosing RHD

A

-carditis
-polyarthritis
-choreiform movements
-erythema marginatum
-subcutaneous nodules

148
Q

minor criteria for RHD

A
  • fever
  • arthritis
  • prior rheumatic fever or known RHD
149
Q

how can you make a diagnosis of RHD?

A
  • 2 major criteria OR 2 minor criteria and 1 major
  • documented strep infection
  • confirm with echo
150
Q

treatment of RHD

A

PCN

151
Q

prophylaxis for RHD

A

PCN G injections monthly for 10 years

Internal Med EOR (18 decks)

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