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Internal Medicine pt.1 > Valvular heart disease > Flashcards

Valvular heart disease Flashcards

1
Q

What are the causes of aortic valve stenosis?

A
  • aortic valve sclerosis -> calcification & fibrosis of leaflets
  • bicuspid aortic valve -> congenital valve malformation
  • rheumatic fever -> commissural fusion
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2
Q

What is the pathophysiology of aortic valve stenosis?

A

1- fibrosis & calcification of valve
2- impeded blood flow through valve ————-> murmur/syncope
3- LV contracts harder to push blood against stiff valves
4- high LV-aorta pressure gradient drives blood into aorta to maintain CO (initially)
5- concentric hypertrophy —————————–> angina
6- stiff, hypertrophied LV & high LV pressure makes it harder to fill -> decreased CO (HFpEF)
7- pulmonary congestion ——————————> HF/dyspnea

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3
Q

What are the symptoms of aortic stenosis?

A

SAD

  • Syncope
  • Angina
  • Dyspnea on exertion (HF like symptoms) orthopnea, PND
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4
Q

What are the clinical features of aortic stenosis?

A
  • Crescendo-decrescendo systolic murmur -> at the 2nd right intercostal space -> radiates to carotid arteries
  • handgrip increases intensity of murmur
  • valsalva decreases or doesnt change the intensity of the murmur
  • soft S2
  • S4 if disease if progressive
  • pulsus parvus et tardus
  • precordial thrill
  • early systolic ejection click
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5
Q

How is aortic valve stenosis diagnosed?

A

ECHO (diagnostic)

  • calcification & narrowing of aortic valve
  • increased mean aortic pressure gradient & transvalvular velocity

ECG
- signs of LVH (non specific)

CXR

  • calcific aortic valve
  • enlarged LV
  • signs of heart failure
Cardiac catheterization (definitive diagnostic) 
- used in patients who echo is non-diagnostic
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6
Q

How is aortic valve stenosis managed?

A
  • surgical aortic valve replacement

- transcatheter aortic valve replacement TAVR

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7
Q

What is the age of onset of aortic valve regurgitation?

A

40-60

- severity increases with age

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8
Q

What are the causes of aortic valve regurgitation?

A

PRIMARY VALVULAR DEFECT

  • congenital bicuspid valve
  • calcific aortic valve disease
  • rheumatic heart disease

AORTIC DILATATION

  • connective tissue disorders (Marfan or Ehlers-Danlos)
  • chronic hypertension
  • aortitis
  • thoracic aortic aneurysm
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9
Q

What is the pathophysiology of acute aortic valve regurgitation?

A

increased systolic pressure & decreased diastolic pressure
1- LV cant dilate enough in response to regurgitant blood
2- LV end-diastolic pressure increases rapidly
3- pressure transmits backward into pulmonary circulation -> pulmonary edema & dyspnea
- cardiogenic shock & myocardial ischemia if severe

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10
Q

What is the pathophysiology of chronic aortic valve regurgitation?

A

increased systolic BP & decreased diastolic pressure
1- compensatory increase in stroke volume maintains CO
2- increased left ventricular end-diastolic volume
3- LV enlargement & eccentric hypertrophy
4- left ventricular systolic dysfunction

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11
Q

What are the clinical features of aortic valve regurgitation?

A
  • dyspnea on exertion, PND, orthopnea
  • palpitations
  • angina
  • cyanosis & shock in ACUTE (emergency)
  • symptoms of underlying disease (fever in infective endocarditis)
  • HIGH PITCHED BLOWING DECRESCENDO DIASTOLIC MURMUR -> heard in the left 3rd & 4th intercostal spaces
    - > increases with squatting & handgrip
  • S3
  • widened pulse pressure
  • Quincke sign -> visible capillary pulse when pressure applied to fingertips
  • De Musset sign -> rhythmic nodding of head in sync with heartbeats
  • Corrigan pulse (water-hammer pulse)
  • in chronic -> displaced PMI
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12
Q

What are the investigations used to diagnose aortic valve regurg?

A

ECHO -> dilated aortic root & reversal of blood flow in aorta

XRAY -> to assess pulmonary edema & rule out other causes of dyspnea

  • acute AR -> congestion
  • chronic AR -> left ventricular hypertrophy + congestion
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13
Q

How is acute aortic valve regurg managed?

A
  • severe acute AR -> surgical treatment ASAP

- medical management of complications

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14
Q

How is chronic aortic regurg managed?

A
  • surgery -> for symptomatic AR & severe asymptomatic AR

- medical management for comorbidities

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15
Q

What is the most common cause of mitral valve stenosis?

A

rheumatic fever

  • onset of symptoms between 20 - 39 years
  • impairs blood flow from the left atrium to the left ventricle
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16
Q

What is the pathophysiology of mitral valve stenosis?

A

1- obstruction of blood flow into the left ventricle (decreased end-diastolic LV volume)
2- decreased SV & cardiac output (forward heart failure)
3- increase in left atrial pressure
4- increased pulmonary capillary pressure -> cardiogenic pulmonary edema
5- pulmonary hypertension -> backward failure & right ventricular hypertrophy

17
Q

What are the clinical features of mitral valve stenosis?

A
  • dyspnea
  • fatigue
  • hoarseness
  • dysphagia
  • palpitations
  • mitral facies
  • irregular heart rhythm secondary to atrial fibrillation
    later stages
  • symptoms of right heart failure/pulmonary HTN
  • paroxysmal nocturnal dyspnea
  • orthopnea
  • hemoptysis
18
Q

What will be heard on auscultation of mitral valve stenosis?

A
  • diastolic murmur -> heard at 5th left intercostal space at midclavicular line
  • loud S1
  • opening snap
19
Q

What diagnostics are used for mitral valve stenosis?

A

ECHO -> most important to confirm diagnosis

  • left atrial enlargement
  • thick calcified mitral valve
  • fish mouth appearance of orfice

ECG

  • P mitrale: left atrial enlargement
  • atrial fibrillation
  • right ventricular hypertrophy

XRAY
- left atrial enlargement

20
Q

How is mitral valve stenosis managed?

A
  • no therapy in asymptomatic patients
  • medical therapy in case of mild symptoms -> diuretics for pulmonary congestion & edema -> B blockers to decrease heart rate
  • surgical treatment if severe symptoms
21
Q

What are the causes of mitral valve regurgitation?

A

PRIMARY MR (organic)

  • degenerative mitral valve disease
  • rheumatic fever
  • infective endocarditis
  • ischemic MR
SECONDARY MR (functional) 
- dilated cardiomyopathy
22
Q

What is the difference between acute & chronic mitral regurg?

A

ACUTE

  • abrupt elevation of left atrial pressure in setting of normal LA size & compliance
  • backflow into pulmonary circulation
  • CO decreases due to decreased forward flow

CHRONIC

  • gradual elevation of left atrial pressure in the setting of dilated LA & LV
  • LV dysfunction occurs due to dilation -> HF
23
Q

What are the clinical features of mitral valve regurgitation?

A
  • dyspnea on exertion
  • PND
  • orthopnea
  • palpitations
  • pulmonary edema
  • dry cough
  • fatigue
24
Q

What will be heard on auscultation of mitral valve regurgitation?

A

HOLOSYSTOLIC MURMUR (high pitched blowing) -> radiates to left axilla & heard best over apex

  • > intensity can be increased by increasing preload (leg raise) or afterload (handgrip)
  • diminished S1
  • S3 gallop
  • laterally displaced PMI
25
Q

How is mitral valve regurg diagnosed?

A

ECHO

ECG

  • acute -> non specific
  • chronic -> reflects cardiac remodeling
    - left ventricular hypertrophy
    - P mitrale
    - P pulmonale later in case of right sided strain
26
Q

How is acute mitral valve regurg managed?

A
  • urgent surgical repair or valve replacement
  • any symptoms of heart failure should be managed with medical therapy while waiting for surgery
  • > diuretics
  • > oxygen
27
Q

How is chronic mitral valve regurg managed?

A
  • identify & treat underlying cause

- manage heart failure

28
Q

What is the most common cause of mitral regurgitation in developed countries?

A

MITRAL VALVE PROLAPSE (MVP) -> structural defect that results in mitral leaflets bulging into left atrium during systole

29
Q

What are the causes of mitral valve prolapse?

A
  • mostly idiopathic
  • connective tissue disorders (Marfan & Ehlers-Danlos syndrome)
  • fragile x
  • MI
  • acute rheumatic heart disease
  • IE
  • autosomal dominant polycystic kidney disease
30
Q

What is the pathophysiology of mitral valve prolapse?

A

myxomatous degeneration of mitral valve due to one of the causes

31
Q

What are the clinical features of mitral valve prolapse?

A
  • mostly asymptomatic
  • in case of complications -> fatigue, dyspnea, cough, syncope, & palpitations
  • mitral valve prolapse click (mid-systolic click)
  • valsalva maneuver increases murmur & click (decreases LV size)
  • squatting decreases them because it increases LV size
32
Q

What diagnostics are used for mitral valve prolapse & how is it managed?

A

ECHO
ECG -> normal

  • reassurance
33
Q

Which type of prosthetic heart valves has a lower thrombogenic potential & doesn’t require lifelong anticoagulation?

A

bio-prosthetic valves

mechanic valves require lifelong anticoagulants

34
Q

What are the complications of prosthetic heart valves?

A
  • structural valve deterioration
  • paravalvular regurgitation
  • hemolytic anemia -> with mechanical valves
  • infective endocarditis
  • valve thrombosis
  • thromboembolism -> bleeding
  • prosthesis-patient mismatch
35
Q

Who are the patients that require prophylaxis for dental procedures that involve manipulation of gingival tissue or perforation of the oral mucosa?

A

Patients with

  • prosthetic cardiac valve or prosthetic material for valve repair
  • previous infective endocarditis
  • unrepaired cyanotic congenital disease
  • repaired with prosthetic material or with residual defects at site of patch or device
  • cardiac transplant with valve regurg due to structurally abnormal valve
36
Q

What are the agents used for prophylaxis?

A

single dose 30-60 mins before procedure

  • amoxicillin -> oral
  • ampicillin IM or IV -> if patient cant take oral
  • cephalexin or clindamycin or azithro/clarithro -> if patient allergic to PCN or AMP
  • cefazolin or ceftriaxone/clindamycin IM or IV -> allergic to PCN or AMP & cant take oral

Internal Medicine pt.1 (33 decks)

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