Valvular Heart Disease | Flashcards
4 main types of valvular heart disease:
- Aortic stenosis
- Aortic regurgitation
- Mitral stenosis
- Mitral regurgitation
Cardiovascular clinical exam - 5
- General appearance
- Arterial pulse - radial + carotid
- Venous pulse - JVP
- Palpation - apex + heaves
- Auscultation - heart sounds and murmurs
GAVPA
What is the main disease valvular diseases can cause and its main signs/symptoms
Heart failure
- Raised JVP
- Pitting Oedema
- Hepatic congestion
Apex beat Palpation - 3 causes of change
Tapping apex beat - mitral stenosis
Displaced and weak - LV dilatation
Displaced and heaving - LV hypertrophy
Parasternal heave - how and cause
Hand left of sternum
RV overload
What is a cardiac murmur
Audible turbulence of blood flow
Can be innocent or pathological
Normally caused by valve restricting exit or allowing blood to leak back in
Describing a murmur - 6
- Timing - systole or diastole
- What type of murmur
- Where is it the loudest
- Where does it radiate to
- What grade of murmur
- Is it influenced by respiration
What causes the first heart sound and what does it indicate
Mitral and tricuspid valves closing
Start of systole
What causes second heart sound and what does it indicate
Aortic and pulmonary valves closing
Start of diastole
Types of systolic murmur
Pansystolic - consistent sound
Ejection systolic - crechendos
Types of diastolic murmur
Early diastolic
Mid diastolic
What are the 4 areas murmurs are listened for
Right 2nd intercostal space, sternal edge - aortic valve
Left 2nd intercostal space, sternal edge - pulmonary valve
Left 4th intercostal space, sternal edge - tricuspid valve
Left 5th intercostal space, mid-clavicular line - mitral valve
What two places do you check for radiation and what does it mean if murmur is heard here
Carotids - aortic stenosis
Axilla - mitral regurgitation
Grades of murmur
- Very quiet
- Easy to hear
- Loud
- Loud with thrill
- Very loud with thrill
- Audible without stethoscope
What effect does respiration have on sound of murmurs
Right side murmurs are louder with inspiration
What is an innocent murmur and when is it heard
Physiological increased flow
Soft + Early systolic
Affected by position and exercise
What is valve stenosis
When valves do not open properly
What is valve regurgitation
Valves do not close properly
What is aortic stenosis
Where aortic valve is too small, narrow, or stiff obstructing blood flow from LV to aorta
Aortic stenosis - causes
Congenital defect - bicuspid not tricuspid - younger patients
Calcifications on aortic valve - older patients
Rheumatic heart disease
Aortic stenosis - symptoms
No symptoms unless severe
When severe:
- Dyspnoea
- Exercise induced syncope
- Angina
Aortic stenosis - signs + auscultation
Low volume pulse
Left ventricular hypertrophy + displaced apex
Ejection systolic murmur
Best heard at 2nd right intercostal space, sternal edge
Radiates to carotids
Investigations for all valvular diseases
Chest X ray
ECG
Echocardiogram
Others if needed: Cardiovascular Magnetic Resonance, Cardiac CT
Aortic stenosis - management + benefits
Conventional valve replacement preferred (AVR)
- Long term
Patients unable to tolerate operation
Trans-catheter Aortic Valve replacement (TAVI)
- Percutaneous
Or Balloon Aortic valvotomy
2 Types of prosthetic valves and differences
Mechanical
- Warfarin
- Last lifetime :. Younger patients
Bio-prosthetic
- No warfarin
- Last 10 years :. Older patients
What is Aortic Regurgitation
Reflux of blood from the aorta through aortic valve into ventricle during diastole
Aortic Regurgitaion - causes
Valve disease
- Rheumatic fever
- Infective endocarditis
- Connective tissue diseases
- Bicuspid aortic valve
Aortic root disease (affect annulus)
- Aortic dissection
- Marfans
- Hypertension
Aortic Regurgitation - symptoms
Dyspnoea
Symptoms normally don’t develop until LV failure
Angina
Aortic Regurgitation - Signs
Collapsing pulse
High pitched early diastolic murmur
Best heard at 4th left intercostal space, sternal edge with patient leaning forward and breath held in expiration
Apex beat is displaced laterally and downwards
Cardiomegaly
Aortic Stenosis - management
Treat underlying cause if appropriate
ACEi used when severe
Beta blockers in Marfans patients
Valve replacement in symptomatic patients or when LV function is reduced
What is Mitral Stenosis
Obstruction to the flow through mitral valve during diastole
Mitral stenosis - causes
Rheumatic fever - main cause
Calcification in older patients
Can be congenital but rare
Mitral stenosis - symptoms
Dyspnoea
Fatigue
Palpitations - AF
- increased atrial pressure causing it to enlarge which can cause AF
Mitral Stenosis - signs
Malar flush - plum red discolouration of high cheeks
Mid-diastolic murmur best heard at Apex
Tapping Apex beat
Straight left heart border
Mitral Stenosis - management
Diuretics
Treat AF
Valve replacement
Balloon valvuloplasty if can’t tolerate
What is Mitral Regurgitation
When blood leaks back through the mitral valve during systole
Mitral regurgitation - causes
Primary valve disorder
- Infective endocarditis
- MI causing valve prolapse
- Rheumatic fever
- Valve becomes myxomatosis (floppy)
Chordae rupture - prolapse
Papillary muscle rupture - ischaemic
Can occur secondary to LV dysfunction (HF)
E.g. cardiomyopathy or MI
Mitral Regurgitaion - symptoms
Dyspnoea
Peripheral oedema
Fatigue
Mitral Regurgitation - signs
Displaced apex - cardiomegaly
Pan-systolic murmur best heart at Apex
5th left intercostal space, mid-clavicular line
Radiates to axilla
Aortic stenosis - management
Diuretics
ACEi if HF develops
Open heart surgery and valve repair (for prolapse) or replacement
Percutaneous - MitraClip if can’t tolerate surgery
