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Cardiology > Valvular heart disease > Flashcards

Valvular heart disease Flashcards

1
Q

What type of murmur do you get with aortic stenosis?

A

Ejection systolic murmur

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2
Q

What does an ejection systolic murmur in AS sound like?

A

“Burr de”
Audible gap between the murmur and HS2
Second sound is quiet in severe stenosis

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3
Q

Signs of AS

A 
Slow rising pulse 
Low volume pulse 
Low pulse pressure 
JVP not elevated
Forceful apex beat but not displaced (pressure overload)
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4
Q

Causes of AS

A

Most common: degenerative calcific aortic stenosis (affecting a normal valve)
Congenital bicuspid valve with degenerative changes (occurs earlier)
Rheumatic heart disease (least common)

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5
Q

What happens to the ventricle in aortic stenosis?

A

The ventricle is pumping against a stenotic aortic valve which requires more force, increased pressure so the ventricle wall thickens into the ventricle

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6
Q

What happens to the ventricle in aortic regurgitation?

A

AR –> Volume overload in the ventricle –> ventricle dilates, wall of ventricle gets thinner and apex is displaces outwards

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7
Q

Causes of pressure overload to the left ventricle

A

Hypertension
Aortic stenosis
Coarctation of the aorta
Hypertrophic cardiomyopathy (with LV outflow tract obstruction: subvalvular stenosis)

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8
Q

How can you gauge the severity of AS?

A

Triad of:
Exercise induced syncope, angina and breathlessness
Their presence infers high severity

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9
Q

Aortic stenosis treatment

A

Valve replacement is definitive treatment

Transcatheter aortic valve insertion (TAVI) offered to those unfit for cardiopulmonary bypass

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10
Q

What is the difference between aortic stenosis and aortic sclerosis?

A

Aortic stenosis: the ejection systolic murmur radiates to the neck, powerful apex beat, LVH on echocardiogram

Aortic sclerosis: leaflet thickening –> blood turbulence –> systolic turbulence but no radiation to the neck –> no change in orifice size

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11
Q

Causes of mitral regurgitation

A

Leaflet: congenital, endocarditis, degenerative
Papillary muscle and chordae: MV prolapse, ACS, Marfan’s
Annular dilatation: cardiomyopathy, ischaemic heart disease with HF

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12
Q

Signs of mitral regurgitation

A

Apex beat is displaced (volume overload)
Quiet first heart sound
Pan systolic murmur radiates LOUDLY to axilla
Second heart sound not heard separately

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13
Q

What murmur is present in MR

A

Pan systolic murmur

“Burrrrr”

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14
Q

MR treatment

A

Mild and moderate: medical treatment with ACEi, diuretics +/- anticoagulants
Severe: valve repair

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15
Q

Summary of systolic murmurs: aortic sclerosis

A

Ejection systolic murmur - aortic area
No radiation into carotids
Normal pulse
Normal apex

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16
Q

Summary of systolic murmurs: aortic stenosis

A

Ejection systolic murmur - aortic area
Radiates to carotids
Powerful non-displaced apex
Slow rising pulse in carotids

17
Q

Summary of systolic murmurs: mitral regurgitation

A

Pansystolic murmur at apex
Radiates to axilla
Displaced apex
Normal pulse

18
Q

How does bacterial tonsillitis cause RHD and diastolic murmurs

A

Group A beta haemolytic streptococcus throat infection
After 2-4 weeks –> acute rheumatic fever:
- antibodies form to the strep M protein which cross react with heart, joints and brain (molecular mimicry)
- particularly in those with HLA DR7
- pericarditis and Aschoff body granulomas
After 10-20 years (during which time there are subclinical episodes and/or auto-immune processes) –> chronic rheumatic heart disease:
- leaflet thickening and fusion of commisures

  • -> Mitral stenosis
  • -> Aortic regurgitation
19
Q

Signs of mitral stenosis

A 
Malar flush --> associated with pulmonary arterial HTN
AF --> high LA pressure
JVP not raised until late
Apex beat not displaced 
Apex beat is tapping in quality
20
Q

Mitral stenosis murmur sounds like:

A

“LUB de de”
LOUD first heart sound (high left atrial pressure keeps valve open until late in diastole, systole then slams it shut)
Opening snap (high pitched sound just after HS2)
Best heard at lower left sternal edge with diaphragm

21
Q

Mitral stenosis mid-diastolic murmur sounds like:

A

LUB de-derrrr
Rumbling low pitched and mid-diastolic if mild stenosis
Severe disease, murmur may extend later into the diastole

22
Q

Where is it best to hear MS mid-diastolic murmur

A

Very slowly move bell held very lightly around apex region (very localised)

23
Q

What manoeuvre accentuates a MS murmur?

A

Patient on their left side, listen with the bell

24
Q

What manoeuvre is used for aortic regurgitation?

A

Patient sitting forward, at the end of expiration, using the diaphragm

25
Q

What is a sign of mitral stenosis that can be seen on CXR

A

Prominent left atrium
Normal = there should be a dip in just below hilum
In MS - the LA is enlarged due to high pressure so the dip is missing

26
Q

How does mitral stenosis lead to right heart failure?

A

Mitral stenosis –> high LA pressure (loud HS1)–> pulmonary venous hypertension (septal lines/ kerly B lines) –> pulmonary arterial hypertension (loud P2. prominent a wave in JVP +/- pulmonary regurgitation) –> right ventricular hypertrophy (left parasternal heave) –> tricuspid hypertension (v wave in JVP)–> right heart failure (raised JVP, oedema, ascites)

27
Q

What is the treatment for mitral stenosis?

A

Mild: watch and wait - medical management with anticoagulants, diuretics, rate control of atrial fibrillation

Moderate:
In older pt/ with coomorbidities - trans septal valvuloplasty
In fit pt - valve replacement

Severe:
Valve area reduced from normal 5cm2 to 1.5cm2 with >5mm gradient: valve replacement

28
Q

What does the murmur sound like in aortic regurgitation?

A

Lub taaarrr

Use diaphragm to listen because high pitched (unless severe)

29
Q

What are the signs of AR

A

Collapsing pulse (Corrigan’s pulse)
Collapsing pulse in the neck = Corrigan’s sign
JVP not raised
Apex beat displaced
Diastolic murmur follows second heart sound

30
Q

What murmur is heard in AR?

A

Early diastolic, soft murmur

31
Q

What are the causes of AR?

A 
REALM
Rheumatic heart disease
Endocarditis
Ankylosing spondylitis
Luetic heart disease (tertiary syphilis)
Marfan's syndrome
32
Q

Sign’s in Marfan’s to look out for (cause of AR)

A

Arachnodactyly - spidery fingers

High arched palate

33
Q

Treatment of AR?

A

Valve replacement if there is significant regurgitation present

34
Q

AR results in?

A

Heart failure, due to a back pressure of blood waiting to get through the left side of the heart

35
Q

What is an Austin Flint murmur?

A

An early diastolic, rumbling murmur heard at the apex - because the aortic insufficiency causes blood to roll back through the aortic valve and over the mitral valve, causing it to vibrate

36
Q

In mechanical prosthetic valve e.g. Starr-Edwards prosthesis in the aortic area, which is the loudest heart sound?

A

S2 - “click THUD”

37
Q

If the Starr-Edwards mechanical prosthesis were in the mitral valve, which heart sound would be loudest?

A

S1 - “THUD-click”

38
Q

What type of murmur is heard in patients with an aortic mechanical prosthetic valve?

A

Ejection murmur due to turbulent flow over the ball in systole

Cardiology (9 decks)

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