valvular disorders Flashcards
aortic stenosis murmur location
2cd right ICS ; radiates to neck and LSB; often loud w/ thrill; grade 4-6, crescendo-decrescendo, midsystolic
AS
M>W,most common murmur in US, sx onset when narrowed around 1-1.2 cm; may see LVH and left-sided atrial enlargement, thready pulses in carotid
Aortic regurge
biscuspid valve, rheumatic infxn, aortic root dz, sever Htn
AR CP
DOE, PND, orthopnea, 1 out of 4 angina,
AR murmur
high pitched, blowing, decresendo, diastolic murmur heard at 3-4th ICS along LSB
AR evaluation
LVH, LAD “strain pattern”
CXR: CMG, possible aortic enlargment
MS etiology
rheumatic fever, lupus, RA, calcification
MS sx
when valve is 1.4-2.5 cm wide; onset can be 20-40 years from rheumatic dz ; dyspnea, orthopnea, PND, fatigue, palpitaions, hemoptysis
MS murmur
pronouced S1, opening snap, low pitched diastolic rumble at apex (decubitus position)
MS EKG/CXR
may how enlarged P wave in II or uprighe in vV1 or atrial fib; LA, RV enlargment
MS rx
rate control afib, anticoag, manage CHF prevent recurrent R. fever
MR etiology
anything that disrupts MR compoenents (leaflets, annulus, myocardium cordae, paipillary)
MR PP
measured in terms of severity (trace, mild, mod, sever)
MR CP
fatigue, dyspnea, DOE, orthopnea, PNd, palpitaions
MR murmur
holosystolic best heard at apex and radiates to axilla, S2 may be widlely split
Mitral prolapse PP
connective tissue disease, genetics, idopahtic, HCM
MP CP
largley asx, but isolated MR most commonly associated with MVP
MP Murmur
mid-systolic click, possilbe late cresendo-decresecndo murmerr at apex
what is the cause of most valvular dz in US?
degenerative calcific changes; same process as atherosclerosis
what murmurs occur in systole
aortic/pulmonary stenosis
Mitral and tricupsid regurg
diastolic murmurs?
M/T stenosis
A/P regurg
timing of sx in stenosis
sx precede LV dysfxn; typically intervene for sx
timing of sx in regurg
LV dysfxn may precede sx, monitor LV fxn, intervene for sx and to preserve cardiac fxn
PP of valvular dz
excess load on mycardium (increased pressure, increase volume)
compensatory : hypertrophy from stenotic dz (pressure is problem), dilation in regurg (volume is problem)
AS etiology
calcific valve dz (tx with statins
calcific valve dz
proliferative and inflammatory changes w. lipid accumulation, up-regulation of ACE, infiltration of macrophages and T-lymphocytes
AS summary
o WHO older / calcific or younger / bicuspid
o SYMPTOMS angina, syncope, CHF
o PE harsh, systolic ejection murmur at right upper sternal border with radiation to neck
o DIAGNOSIS transthoracic echo, then cardiac cath
o MANAGEMENT surgery for symptoms
AR PP?
- Regurgitant volumed = increased LV EDV = dilatation =increased LV EDP = pulmonary congestion
AR etiology
congenital, infxn, marfan sydrome, inflammatory (SLE , RA), phentermine
Aortic Root Syndrome
Marfan, syphilis, ankylosing spondylitis, cystic medial necrosis, arotic dissection, trauma
AR PE
wide pulse pressure, s3 gallop, diastolic murmur, high pitched
Water-hammer/ Corrigan’s pulse (AR)
abrupt distension/quick collapse of pulses (radial/carotid)
Quincke’s pulse (AR)
capilarry pulsations seen in fingernails or lip
Mussets sign (AR)
head bob w/ each heart beat
Muller sign (AR
systolic pulsations of the uvula
Traube sign (AR)
booming systolic and diastolic sounds heard over the femoral arther
Duroziez sign (AR)
systolic murmur heard over the femoral artery when compressed proximal, diastolic murmur when compressed distally
Hill sign
popliteal cuff SBP >20 over breacheal cuff SBP
Austin Flint rumble
a mid-diastolic, low frequency murmur that is best heard at the apex with little radiation. It mimics rheumatic mitral stenosis in its characteristics and physiology. The murmur is the result of competition between the regurgitant jet of the aortic valve and the attempt to fill the left ventricle from the left atrium—in essence, functional mitral stenosis. It differs in that it occurs in the presence of a murmur of aortic valve insufficiency and in the absence of the rheumatic, mitral opening snap
AR medical therapy
afterload reduction= ACE, ARB, or hydralazine+ntrates (vasodilators)
endocarditis prophylzxix in appropriate patients
Rule of 55
AR tx: LVEF < 55% or LVESD > 5.0 cm
AR summary
WHO : no classic patient, think bicuspid or Marfan syndrome
SYMPTOMS : CHF symptoms (dyspnea, fatigue)
PE : wide pulse pressure, soft / decrescendo diastolic murmur, bounding pulses – “water-hammer,” Musset’s head bob, Quincke’s pulse
DIAGNOSIS : Echo
MANAGEMENT : medical therapy, surgery for acute AI, symptoms or evidence of LV changes in chronic AI
MS hemodynamics
elevated LA pressure and LA enlargment, pulmonary venous congestion, reduced CO, pulm HTN, may progress to Right sided failure
what can develop from MS? (arrhythmias/ pregnancy)
paroxysmal/chronic atrial fibrillation develops in 50-80% of pts
sudden increase in HR may precipitate pulmonary edema (HR control is more important)
In pregnancy, there is an associated increased in CO=increased transmitral pressure gradient=sx; pts w/ moderate to severl MS should have intervention poror to becoming prego, or if already prego
MS epidemiology
think rheumatic heart dz first
2/3 are women
MS PP
fibrosis, scarring and thickening of leaflets, commissural fusion, chordae fusion and shortening, decrease in orifice size
MS gradient
normal: 0
mild: <8
moderate: 8-12
severe: >12
MS dx
echo-need to look at pressure gradient and velociyt
cardiac cath- directly measure left atrial and left ventricular pressure
