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Cardiology (Fall 2023) > Valvular Disorders part 2 > Flashcards

Valvular Disorders part 2 Flashcards

1
Q

what are the 2 types of valve disorders

A

regurgitation
stenosis

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2
Q

what are the 6 clinical classification categories of valve disorders based on anatomy and symptoms

A

stage A - at risk for valvular heart disease
Stage B - mild/moderate² progressive valvular heart disease but asymptomatic
Stage C - severe valvular heart disease but asymptomatic
C1 - severe valve lesion but asymptomatic with normal LV function
C2 - severe valve lesion but asymptomatic with abnormal LV function
Stage D - symptomatic patients due to valvular heart disease

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3
Q

what occurs with vlaves during systole

A

mitral and tricuspid (AV) valves close and aortic/pulmonic valves open

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4
Q

what occurs with valves during diastole

A

mitral and tricuspid (AV) valves open
aortic/pulmonic valves close

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5
Q

what is the PE presentation of aortic stenosis

A
  • Murmur
  • laterally displaced sustained apical impulse
  • S4 gallop may be present
  • EKG may demonstrate LVH
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6
Q

describe the murmur that would present with aortic stenosis:
Systolic or diastolic?
Holo or mid?
Location of maximal intensity?
Radiation?

A
  • Midsystolic, crescendo-decrescendo
  • Best heard at the right 2nd interspace, with radiation to the carotids
  • Medium pitch, harsh quality, often loud with a thrill
  • Heard best with the patient sitting and leaning forward
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7
Q

Describe the Murmur in aortic regurgitation:
Systolic or diastolic?
Holo or mid?
Location of maximal intensity?
Radiation?

A
  • Early diastolic, decrescendo, blowing
  • High pitched, best heard in the 2nd to 4th left interspaces, with radiation to the apex
  • Best heard with the patient sitting, leaning forward with breath held after exhalation
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8
Q

what are general PE findings in aortic regurgitation

A
  • murmur
  • widened pulse pressure
  • S3 or S4 gallops may be present
  • A low-pitched, diastolic mitral murmur, may be heard at the apex (Austin Flint murmur)
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9
Q

describe the murmur presenting with mitral stenosis:
Systolic or diastolic?
Holo or mid?
Location of maximal intensity?
Radiation?

A
  • low pitched rumbling diastolic murmur.
  • best heard at apex with patient in left lateral decubitus position.
  • S1 is loud in early MS, S1 softens as leaflets become more calcified and immobile
  • an opening snap following S2 is usually present
  • P2 palpable if pulm pressure high.
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10
Q

describe the murmur present in mitral regurgitation:
Systolic or diastolic?
Holo or mid?
Location of maximal intensity?
Radiation?

A
  • Holosystolic murmur best heard at apex and radiates to axilla and back.
  • mid-systolic click may be present if mitral valve prolapse (MVP) present.
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11
Q

what is the clinical presentation of MVP

A
  • most patients asymptomatic
  • some nonspecific symptoms (CP, palps, dizzy, anxiety,) called MVP syndrome
  • murmur!
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12
Q

describe the murmur present in MVP:
Systolic or diastolic?
Holo or mid?
Location of maximal intensity?
Radiation?

A
  • mid-systolic click usually followed by a late systolic murmur
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13
Q

research shows that what medications can be used to treat MVP syndrome?

A

Beta blockers
SSRIs

(this was in the notes at the bottom of the powerpoint)

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14
Q

If i were yall id memorize this cuz it seems kinda helpful

A

okie dokie

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15
Q

are right sided or left sided valve issues usually tolerated better? why?

A

Right side heart valve issues are typically better tolerated than left sided valve issues because this is a lower pressure system.

(in notes at bottom of slide 14)

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16
Q

who is tricuspid stenosis MC in

A

females. but this is generally an uncommon disorder. <3% prevalence worldwide.

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17
Q

what are the usual causes of tricuspid stenosis

A
  • rheumatic heart disease (MC worldwide)
  • carcinoid disease and prosthetic valve degeneration (MC in US)
  • congenital abnormalities, leaflet tumor/vegetation
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18
Q

what is carcinoid disease

A

rare cancerous process that can cause tumors in multiple locations of the body.

(in notes at bottom of slide 15)

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19
Q

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

A
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20
Q

what is the clinical presentation of tricuspid stenosis

A
  • Right heart failure (presenting as hepatomegaly, ascites, peripheral edema and fatigue)
  • elevated JVP
  • murmur
  • might see palpable pre-systolic liver pulsation (coincides w atrial contraction)
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21
Q

describe a murmur that would be seen in tricuspid stenosis:
Systolic or diastolic?
Holo or mid?
Location of maximal intensity?
Radiation?

A
  • Soft, high-pitched, diastolic rumbling murmur along lower left sternal border
  • Mimics mitral stenosis except there is INCREASED sounds with inspiration
  • opening snap may be heard
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22
Q

what causes the increased sounds with inspiration in tricuspid stenosis?

A

increased venous return to the heart during inspiration

(written in notes under slide 18)

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23
Q

what is the diagnosis evaluation of choice for tricuspid stenosis? what is seen on this test?

A

ECHO!
* TV area <1.0 cm² is diagnostic (normal TV area is 10 cm²)

she said shes not interested in us memorizing numbers, just wants us to know that we need an echo.
thank tha lort

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24
Q

what other testing results may be seen in tricuspid stenosis

A

EKG → right atrial enlargement
CXR → cardiomegaly

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25
Q

how do you manage tricuspid stenosis

A
  • treat HF with diuretics (loops preferred, torsemide or bumetanide if bowel edema)
  • add aldosterone antagonist if liver congestion or ascites is present
  • TV replacement is surgical intervention of choice but is only indicated if patient is symptomatic.
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26
Q

why is valvuloplasty not recommended in tricuspid stenosis

A

high occurrence of subsequent tricuspid regurgitation

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27
Q

what is the typical cause of tricuspid regurgitation

A
  • Typically results from any dilation of the right ventricle and tricuspid annulus (due to anatomic placement of chordal attachments)
  • TV annulus is saddle shaped so as valve collapses and become elliptical w RV failure, regurg will worsen.
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28
Q

what are causes of RV dilation

A

Pulmonary HTN, LV failure, PV stenosis, severe PV regurgitation, cardiomyopathy, infiltrative processes (sarcoidosis)

29
Q

what are other causes of tricuspid regurgitation other than RV dilation

A

Endocarditis, carcinoid syndrome, congenital abnormality, chest wall trauma

30
Q

what cardiac complication is often seen in tricuspid regurgitation?

A

These patients can have right ventricular hypertrophy because there is extra volume dumping into RV, which causes extra pressure on the valve resulting in RVH

(in notes below slide 25)

31
Q

What can we expect to happen physiologically and clinically when we see a patient with tricuspid regurgitation?

A

same symptoms as tricuspid stenosis with exception of murmur description

32
Q

what is the symptoms of tricuspid regurgitation

A

in absence of pulmonary HTN, TR is well toelrated.

as it progresses pts present with sympotms of RV failure (fatige, ascites, peripheral edema)

33
Q

what are the PE findings in tricuspid regurgitation

A
  • signs of R HF (LE edema, JVD, Ascites)
  • hepatic congestion and palpable systolic liver pulsation
  • murmur
34
Q

describe the murmur present in tricuspid regurgitation

A
  • Murmur is high-pitched and pansystolic, best heard at left sternal border
  • Accentuated with inspiration or leg-raising by increasing venous return
35
Q

what is the diagnostic study of choice in tricuspid regurgitation? what would be seen?

A

Echoooo!

  • Provides info on RV systolic pressure, RV size, and RV function
  • RV systolic pressure <40 mmHg highly suspicious for TV regurg

(dont have to know numbers)

36
Q

what other tests can be done to evaluate tricuspid regurgitation and what would they show?

A
  • EKG → afib/flutter possible
  • Cardiac cath can confirm elevated RA pressure
37
Q

what if a tricuspid valve on echo looks normal but the patient has regurg? what could be occurring?

A

On echo the tricuspid valve may look completely normal, but the patient has regurg. This most likely means there is a left heart issue leading to right heart problems, so if we fix that issue the tricuspid regurg will improve.

(in notes at bottom of slide 30)

38
Q

what is NOT common in tricuspid regurgitation patients

A

Afib

( in notes at bottom of 30)

39
Q

How do you manage tricuspid regurgitation

A

treat underlying cause and HF symptoms.

  • annuloplasty is typically considered in pts with persistent symptoms
  • replacement must be considered for unedrlying primary leaflet pathology
  • anticoagulation not needed unless Afib is present (rare)
40
Q

what is physiologically occuring during pulmonic stenosis

A

usually a result of fused pulmonary leaflets

this creates pressure-overloaded state that results in RVH

41
Q

what typically the cause of pulmonic stenosis

A

it is typically an isolated congenital defect
- rheumatic disease rare
- can occur as result of genetic syndromes (noonan, Trisomy 13)

42
Q

what is noonan syndrome

A

genetic disorder of chromosome 12

characteristics include:
short stature, heart defects, other physical problems and possible developmental delays.

(in notes below slide 33)

43
Q

what is trisomy 13

A

genetic abnorality presenting with

heart defects, brain or spinal cord abnormalities, very small or poorly developed eyes (microphthalmia), extra fingers or toes, a cleft lip with or without a cleft palate, and hypotonia.

(below slide 33)

44
Q

In neonates with pulmonic stenosis, how would mild-moderate, moderate-severe, or critial PS present?

A
  • Mild-moderate: generally asymptomatic
  • Moderate/severe: progressive fatigue and dyspnea on exertion onset in adolescence and young adulthood (can lead to RV dysfunction or failure)
  • Critical - neonate presenting with cyanosis at birth
45
Q

how does the murmur present in a pt with pulmonic stenosis

A
  • systolic ejection murmur on left upper sternal border (increased w inspiration, radiates to L shoulder)
  • S1 followed by opening click that is louder with expiration
  • RV lift on palpation of precordium
46
Q

In mild to moderate pulmonic stenosis the ejection click sound DECREASES with inspiration - the increased RV filling from inspiration prematurely opens the valve during atrial systole when there is increased blood flow to the right heart from inspiration (this is the only right sided auscultatory event that decreases with inspiration)

A

ASK ABOUT THIS

47
Q

what is evaluation of pulmonic stenosis

A

ECHOOOOO ECHoooo Echoo echo hahha

48
Q

what are the interventions indicated for pulmonic stenosis

A
  • Mild PS - asymptomatic and requires no intervention
  • Moderate PS - if symptomatic requires balloon valvuloplasty or surgical valve replacement
  • Moderate/sevrer PS - require balloon valvuloplasty or surgical valve replacement
49
Q

what causes pulmonic regurgitation

A

Typically due to dilation of the PV annulus secondary to pulmonary HTN

50
Q

describe the murmur present in pulmonic regurgitation

A

Murmur is diastolic, high-pitched, blowing quality, best heard at second left intercostal space

51
Q

what diagnostic studies can be done to evaluate and diagnose pulmonic regurgitation

A
  • ECHOOO obv
  • cardiac MRI/CT may be helpful (gives size of PA and helps exclude causes of PHTN)
  • EKG NOT helpful but RBBB is commonly seen
52
Q

how do you manage pulmonic regurgitation

A
  • treat the cause of pulmonary HTN
  • valvular intervention - PV replacement (rare in PR pts unless intractable RV failure)
53
Q

what are the two types of prosthetic heart valves

A

mechanical
tissue

54
Q

what are the pros and cons of mechanical valves

A

Pros:
- extremely durable

Cons:
- high thromboelmolic risk and requires lifelong anticoagulation with WARFARIN ONLY

55
Q

what is the only anticoagulation approved for mechanical heart valves

A

coumadin (warfarin)

i feel like this is gonna be a test question

56
Q

what is the goal INR for a patient with a mechanical valve being treated with warfarin

A

INR 2.5-3.5

(she said this would be a board question and to “please dont miss this” so def know this)

57
Q

what are the pros and cons of tissue valve

A

Pros:
- lower risk of thromboembolic events
- only have to use ASA to reduce risk of thromboembolic events

Cons:
- less durable (10 years)

58
Q

what are some factors taken into consideration when deciding between mechanical and tissue valves

A
  • patient age
  • compliance with warfarin
  • valve position
59
Q

what is the cause of rheumatic heart disease

A

GABHS

60
Q

what occurs pathophysiologically during rheumatic heart disease

A
  • characterized by pancarditis (diffuse inflammation of the heart)
  • exudative pericarditis is common
  • myocardium is infiltrated with lymphocytes and areas of necrosis may occur
  • valvulitis
61
Q

what is found in histology of rheumatic heart disease

A

aschoff bodies - collection of myocytes and macrophages surrounded by fibrous tissues

62
Q

how is valvulitis characterized in rheumatic heart disease

A

verrucous lesions on leaflet edges

63
Q

what valve is MC affected by rheumatic heart disease

A

MV MC followed by AV

64
Q

what is the PE presentation of a patient with rheumatic heart disease

A

acute, febrile illness 2-4 weeks following streptococcal pharygitis infection.

65
Q

what is the jones criteria for diagnosing RHD

A

must have 2 major critera or 1 major and 2 minor criteria with evidence of recent strep infection.

major:
- carditis (pleuritic CP, friction rub, HF)
- polyarthritis
- chorea
- erythema marginatum
- subcutaneous nodules

minor:
- fever
- arthritis
- previous rheumatic fever or known RHD

66
Q

how must you confirm RHD

A

Echo showing BOTH morphological valvular involvement of mitral and/or aortic valves AND doppler evidence of pathologic valvular regurgitation

67
Q

can you diagnose RHD without a documented strep infection

A

TECHNICALLY NOOOOOOo

68
Q

how do you treat RHD

A
  • PCN to eradicate strep infection
  • Salicylates for fever/arthritis
  • prophylaxis should be continued for up to 10 YEARS. PCN IM monthly!

Cardiology (Fall 2023) (45 decks)

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