VALVULAR HEART DISEASE Flashcards
1
Q
What causes S1 heart sound?
A
Closure of the atrioventricular valves i.e. tricuspid and mitral valve
This happens at the start of systolic contraction of ventricles
2
Q
What causes S2 heart sound?
A
Closing of semilunar valves i.e. pulmonary and aortic valves
This happens once systolic contraction is complete to prevent blood flowing back from pulmonary arteries/aorta into the ventricles
3
Q
What is S3?
A
A third heart sound that can be heard roughly 0.1 seconds after the second heart sound
Caused by rapid ventricular filling causing chordae tendineae to pull to their full length
4
Q
What can cause S3?
A
Can be normal in 15-40 year olds (hearts function so well that ventricles allow rapid filling)
Heart failure
5
Q
What is S4?
A
A fourth heart sound heard directly before S1
Always abnormal
6
Q
What causes S4?
A
Indicates a stiff or hypertrophic ventricle and is caused by turbulent flow from an atria contracting against a non-compliant ventricle
7
Q
How do you best listen to murmurs with the stethoscope?
A
Bell of your stethoscope - low pitched sounds
diaphragm - high pitched sounds.
(To remember this think of a childs high-pitched screaming from their diaphragm)
8
Q
What is Erb’s point?
A
3rd intercostal space on left sternal border - best place for listening to heart sounds
9
Q
How can you emphasise a mitral stenosis murmur?
A
Roll pt on their left hand side
10
Q
How can you emphasises aortic regurgitation?
A
Patient sits up, leaning forward and holding expiration
11
Q
How do you assess a murmur?
A
SCRIPT
Site - where is it loudest
Character - soft, blowing, crescendo, decrescendo, crescendo-decrescendo?
Radiation - to carotids? Or left axilla?
Intensity - what grade?
pitch - high or low? (Indicates velocity)
Timing - systolic or diastolic?
12
Q
Which murmur can radiate to the carotids?
A
Aortic stenosis
13
Q
Which murmur can radiate to the left axilla?
A
Mitral regurgitation
14
Q
How do you grade a murmur?
A
Grade 1 - Difficult to hear
2 - Quiet
3 - Easy to hear
4 - Easy to hear with a palpable thrill
5 - Can hear with stethoscope barely - touching chest
6 - Can hear with stethoscope off the chest
15
Q
Which valvular heart diseases cause hypertrophy and why?
A
Mitral and aortic stenosis cause atrial and ventricular hypertrophy respectively
This is because the muscle has to try harder when pushing against a stenotic valve
16
Q
Which valvular heart diseases cause dilatation and why?
A
Mitral and aortic regurgitation cause atrial and ventricular dilatation respectively
As blood flows back into the chamber which stretches the muscle, causing dilatation
17
Q
What is mitral stenosis?
A
A narrow mitral valve which makes it difficult for the left atrium to push blood through to the ventricle
18
Q
What can cause mitral stenosis?
A
Rheumatic fever
Others which are rarer = mucopolysaccharidoses, carcinoid fibroelastosis, endocardial fibroelastosis
19
Q
What murmur does mitral stenosis cause?
A
Mid-late diastolic, low pitched murmur best heard in expiration (rumbling sound due to low velocity of blood flow)
Opening snap which is the mitral valve leaflets suddenly opening
Loud S1 (due to thick valves shutting very suddenly) and you can palpate a tapping apex beat due to this
20
Q
What is mitral stenosis associated with?
A
Malar flush
AF
21
Q
Why does mitral stenosis cause malar flush?
A
This is due to back-pressure of blood into the pulmonary system causing a rise in CO2 and vasodilation.
22
Q
Why can mitral stenosis cause AF?
A
This is caused by the left atrium struggling to push blood through the stenotic valve causing strain, electrical disruption and resulting fibrillation.
23
Q
What is mitral regurgitation?
A
an incompetent mitral valve allows blood to lead back through during systolic contraction of the left ventricle
It results in congestive cardiac failure
24
Q
Why does mitral regurgitation cause congestive cardiac failure?
A
because the leaking valve causes a reduced ejection fraction and a backlog of blood that is waiting to be pumped through the left side of the heart.
25
What type of murmur does mitral regurgitation cause?
pan-systolic, high pitched “blowing” murmur due to high velocity blood flow through the leaky valve. Best heard at the apex and radiates into the left axilla. You may hear a third heart sound if HF is present
May have a mid-systolic click
Severe MR may cause a widely split S2
26
What causes mitral regurgitation?
Idiopathic weakening of the valve with age
Mitral valve prolapse
IHD
Infective Endocarditis
Rheumatic Heart Disease
Connective tissue disorders e.g. Ehlers Danlos syndrome or Marfan syndrome (causes myxomatous degeneration)
27
What is aortic stenosis?
Narrowing of aortic valve so as blood flows during systolic contraction there is tubulance of blood flow
28
What type of murmur does aortic stenosis cause?
ejection-systolic, high pitched murmur
Crescendo-decrescendo character
Murmur radiates to the carotids
Slow rising pulse and narrow pulse pressure
Pt may complain of exertional syncope due to difficult maintaining good blood flow to the brain
29
What causes aortic stenosis?
Idiopathic age related calcification
Bicuspid valve - more at risk
Rheumatic heart disease
30
What is aortic regurgitation?
Aortic valve becomes incompetent and blood flows back from aorta into left ventricle during diastole
31
What murmur does aortic regurgitation cause?
What other features can be present?
early-diastolic blowing murmur, best heard on the left lower sternal border
Intensity of the murmur can be increased by handgrip manoeuvre
Collapsing pulse
Wide pulse pressure
Quincke’s sign
De Musset’s sign
Mid-diastolic Austin-Flint murmur in severe cases
32
What are other features of aortic regurgitation?
Wide pulse pressure
Corrigans pulse
Causes HF
Can cause Austin-Flint murmur - heard at apex and is an early diastolic rumbling murmur
33
What is Austin-Flint murmur?
A murmur heard at the apex
An early diastolic rumbling murmur
34
What causes Austin-Flint murmur?
caused by blood flowing back through the aortic valve and over the mitral valve causing it to vibrate
35
What is a Corrigans pulse?
also called a collapsing pulse and is a rapidly appearing and disappearing pulse at carotid as the blood is pumped out by the ventricles and then immediately flows back through the aortic valve back into the ventricles.
36
What causes aortic regurgitation?
Idiopathic age-related weakness/calcification
Bicuspid aortic valve
Rheumatic fever
Connective tissue disorders e.g. Ehlers Danlos syndrome or Marfan syndrome
Acute - Infective endocarditis , Aortic dissection, Hypertension
37
What can cause a loud S1?
Mitral stenosis
Left-to-right shunts
Short PR interval, atrial premature beats
Hyperdynamic states
38
What causes a quiet S1?
Mitral regurgitation
39
What causes a loud S2?
Hypertension
Hyperdynamic states
Atrial septal defect without pulmonary hypertension
40
What causes a soft S2? Why?
Aortic stenosis - because its harder for the valve to close so it may close at the same time as pulmonary valve (usually aortic valve closes first)
41
What causes a fixed split S2?
Atrial septal defect
42
What causes a widely split S2?
deep inspiration
RBBB
pulmonary stenosis
severe mitral regurgitation
43
What causes a reversed split S2?
LBBB
severe aortic stenosis
right ventricular pacing
WPW type B (causes early P2)
patent ductus arteriosus
44
Whats the most common valvular disease?
Aortic stenosis
45
What is rheumatic fever? And what is its pathophysiology?
A systemic infection that is common in developing countries and develops 2-4 weeks after a streptococcus pyogenes infection
These bacteria have M proteins which the immune system produces antibodies against. These antibodies undergo molecular mimicracy - they also target proteins found in myocardium and heart valves (type 2 hypersensitivity reaction)
46
Whats the diagnostic criteria for rheumatic fever?
JONES CRITERIA
Diagnosis is based on evidence of recent streptococcal infection accompanied by:
2 major criteria
1 major with 2 minor criteria
Evidence of recent streptococcal infection can be determined by raised/rising streptococci antibodies, positive throat swab or positive rapid group A streptococcal antigen test
Major criteria
erythema marginatum
Sydenham's chorea: this is often a late feature
polyarthritis
carditis and valvulitis (eg, pancarditis)
subcutaneous nodules
Minor criteria
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval
47
Whats the structure of the aortic valve?
3 leaflets - right left and posterior
In 1-2% of the population it is found to congenitally have 2 leaflets
48
What murmur is associated with tricuspid regurgitation?
Pansystolic high-pitched blowing murmur best heard in tricuspid area
49
Which groups of people are tricuspid diseases most common in?
IV drug users
50
Why does aortic regurgitation cause a wide pulse pressure?
Blood leaks back from aorta into left ventricle -> left ventricular end diastolic volume increases -> eccentric hypertrophy -> systolic blood pressure increases -> during diastole less blood in aorta as some has leaked back into ventricle = decreased diastolic pressure
51
Whats the effect of wide pulse pressure in aortic regurgitation?
Causes a Hyperdynamic circulation which leads to a bounding ‘water hammer’ pulse
It can cause head bobbing in tune with the heartbeat (De Musset’s sign)
Overtime it can lead to left heart failure
52
How does rheumatic fever cause valvular heart disease?
Commissural fusion of leaflets in valve and it can cause scarring of the valves
53
Why is mitral stenosis likely to cause AF?
Secondary to the increase in left atrial pressure which leads to left atrial enlargement - the larger it is the more chance of AF
54
Why does mitral stenosis cause dyspnoea and haemoptysis?
Increased left atrial pressure causes pulmonary venous hypertension
55
From the murmur alone, how can you tell the severity of mitral stenosis?
The distance between end of S2 and the opening snap - as the opening snap comes closer to S2, the valvular disease is becoming more severe whilst an opening snap that occurs later in diastole indicates a milder disease
This happens as there’s a much higher left atrial pressure in severe mitral stenosis so it takes less time for blood to pass through stenoses valves
56
Why can mitral regurgitation happen post-myocardial infarction?
If the papillary muscles or chordae tendinae are affected by a cardiac insult
57
What is mitral valve prolapse?
Myxomatous degeneration (weakened connective tissue) -> larger valve leaflet area and elongation of chordee tendinae which may rupture -> posterior leaflet folds up into left atrium on systole
Most often causes mitral regurgitation
58
Why can infective endocarditis cause mitral regurgitation?
When vegetations from the organisms colonising the heart grow on the mitral valve, it is prevented from closing properly
59
How do you investigate a heart murmur?
Echocardiogram
(Do an ECG, coronary angiogram, chest xray, bloods too)
60
What is sudden cardiac death?
Death due to cardiovascular cause that occurs within 1 hour of the onset of symptoms. It occurs when the heart stops beating and cannot beat sufficiently to maintain perfusion and life
61
What are the causes of sudden cardiac death?
Coronary artery disease - 80% of all cases
Cardiomyopathies
Heart failure
Aortic stenosis
Congenital disease - tetralogy of Fallot
Inherited channelopathies e.g. brugada syndrome or long QT syndrome
62
What are the differences between metallic and biological heart valves?
Biological valves are typically bovine or porcine. Major disadvantage is structural deterioration and calcification over time. However, long-term anticoagulation is not usually needed and only low-dose aspirin is given long term
Mechanical valves are usually the bileaflet valve. They have a low failure rate. Major disadvantage is increased risk of thrombosis so life time warfarin is used
63
What investigations should you do for suspected valvular disease?
Bloods - FBC, U+Es, LFTs, TFTs, troponin, BNP
Imaging - CXR and CT
Echocardiogram
CT coronary angiogram (likely to also have IHD)
64
What are the 2 main types of echocardiograms?
Transesophageal echo
Transthoracic echo
65
What is an echocardiogram? What can it look at?
An ultrasound of the heart that gives an accurate picture of the valves, chambers and an idea of the velocity of blood flow in certain areas
It can assess valve defects, ejection fraction, heart wall function, tamponade and vegetations seen in infective endocarditis
66
What is Transthoracic echocardiogram?
The patient lies of their left hand side with their arm behind their head. The transducer is placed at various intercostal spaces to the left of the sternum, and at the anterior axillary line.
This is the preferred test for valve defects
It is also often the first line investigation when echo is required
67
What is trans-oesophageal echocardiogram?
Usually performed under sedation and with facilities for resuscitation
It provides high resolution due to the probes proximity to the heart.
Provides good views of the posterior part of the heart
This is an invasive procedure, and usually performed by a cardiologist
This is the investigation of choice for infective endocarditis, prosthetic valve management, and searching for causes of thromboembolism.
68
How do we manage asymptomatic aortic stenosis?
Observe the pt
If valvular gradient >40mmHg and there are features such as left ventricular systolic dysfunction then consider surgery
69
How do you manage symptomatic aortic stenosis?
Valve replacement
70
What are the options for aortic valve replacement?
Surgical aortic valve replacement - choice for young, low/medium risk patients
Transcatheter AVR - used for pt with high operative risk (TAVI)
Ballon Valvuloplasty only used in adults if critical aortic stenosis and not fit for valve replacement. Can be used in children with no aortic valve calcification
71
How do you manage aortic regurgitation?
Surgery for aortic valve replacement if symptomatic or if asymptomatic but with LV systolic dysfunction
72
How do you manage asymptomatic mitral stenosis?
Monitor with regular echocardiograms
(Manage any associated AF with warfarin)
73
How do you manage symptomatic mitral stenosis?
Transcatheter valvotomy or mitral valve surgery
(Manage any associated AF with warfarin)
74
How do you manage mitral regurgitation?
Surgical mitral valve repair
Surgical mitral valve replacement if above not necessary
Consider transcatheter mitral edge-to-edge repair if surgery not suitable
75
What are the potential complications of valvular heart repair or replacement surgery?
Endocarditis
AF
Bleeding
Thromboembolism
Paraprosthetic regurgitation
Infection
Sudden cardiac death
Renal failure
Stroke
Wound infections
Mediastinitis
76
What is infective endocarditis?
Infection of the endocardium which may involve 1 or more heart valves or an intracardiac device e.g. a prosthetic valve
77
What are the 2 major disease courses of infective endocarditis?
Acute, rapidly progressive infection
Subacute, or chronic, low-grade infection
78
What are the 3 major types of infective endocarditis?
Native valve endocarditis: normal valves without previous intervention. May be acute or subacute.
Prosthetic valve endocarditis: may occur early (< 1 year) or late (> 1 year) following surgical intervention. 10-20% of cases.
Intravenous drug abuse endocarditis: classically affects the tricuspid valve (50%).
79
Whats the most common causing microorganism of IV drug abuse endocarditis?
Staph aureus
80
What are risk factors for infective endocarditis?
Age >60
Male
IV drug users
Poor dental hygiene, dental infection, certain dental procedures
Structuralheart disease
Valvular heart disease
Congenital heart disease
Prosthetic heart valves
Previous IE
Intravascular devices
Immunosuppression
Haemodialysis
81
What pathogen causes infective endocarditis?
Staph aureus - most common
Streptococcal species (more commonly subacute)
Enterococcus species (more commonly subacute)
82
What is native valve endocarditis?
commonly due to underlying rheumatic heart disease, congenital heart disease or structural heart disease.
It is usually presents with a subacute course..
83
What causes native valve endocarditis?
Streptococcal species (alpha-haemolytic, S. bovis) and enterococci: implicated in around 70% of cases.
Staphylococcal species: implicated in around 25% of cases. More aggressive disease course
84
Which pathogen causes prosthetic valve endocarditis?
Staphylococcus epidermidis - if within 2 months of surgery
(after this the spectrum of organisms which cause endocarditis return to normal i.e. staph aureus is the most common cause)
85
What is early prosthestic valve endocarditis?
When IE occurs <1 year after surgery
Acute course that can cause local abscess, fistula formation, and valvular dehiscence.
86
What is late prosthestic valve endocarditis?
Occurs >1 year after prosthetic valve placement
More subacute course
87
Which side of the heart is more commonly affected in IVDU-associated infective endocarditis? Why?
Due to injection through the venous system, IE affecting the right side of the heart
88
What is culture-negative infective endocarditis?
endocarditis with no definite microbiological aetiology despite adequate sampling.
89
What can cause culture-negative infective endocarditis?
Typical pathogens may not be cultured due to early antibiotic use
Pathogens that are fastidious - complex growth requirements
Intracellular bacteria
Non-bacterial pathogens e.g. fungi
90
What is non-infective endocarditis?
Endocarditis occurring in the absence of infection due to sterile platelet thrombi on heart valves
Rare
(Aka marantic endocarditis or Libman-Sacks endocarditis)
91
What can cause non-infective endocarditis?
Advanced maliganncy in 80% of cases
SLE
Others - Rheumatoid arthritis and burns
92
How do different staphylococcal species causing infective endocarditis present differently?
Staph aureus - acute and subacute
Coagulase negative staphylococcus - subacute course (associated with prosthetic devices)
93
Which species is most commonly seen in subacute infective endocarditis secondary to poor dentition?
Alpha-haemolytic streptococci e.g. viridans streptococci
94
What microorganisms cause infective endocarditis?
Staphylococcal spp
Streptococcal spp
Enterococcus spp
HACEK:
Haemophilus aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
95
Which fungi can cause infective endocarditis and Whats the prognosis compared to bacterial causes?
Candida spp
Aspergillus spp
Associated with a poor prognosis - 50% mortality
96
Whats the pathophysiology of infective endocarditis?
Bacteria enter the blood stream and deposit on the endocardial surface of the heart. The organisms can adhere and eventually invade and destroy the valve leaflets through vegetation’s. This destroys the valves causing regurgitant murmurs and eventually congestive cardiac failure
Embolic events can occur due to vegetations breaking off and being deposited in other organ systems. This can lead to formation of abscesses. Activation of immune system and clustering of immune complexes within vegetations can lead to immune-mediated vasculitis within distant vessels e.g. glomerulonephritis
97
Whats the order of frequency in which the valves are affected by infective endocarditis?
Mitral
Aortic
Combined mitral and aortic
Tricuspid
Pulmonary
98
How does infective endocarditis present?
Clinical presentation is very variable! It can present as an acute or subacute or chronic disease with non specific symptoms
The majority of pt will have a fever and cardiac murmurs
Others:
Malaise, anorexia, weight loss, abdominal pain from splenic abscess, haematuria, SOB, chest pain, palpitations
Features of HF, splinter haemorrhages, petechiae, Janeway lesions, Osler nodes, Roth spots, splenomegaly
99
What proportion of pt with infective endocarditis have embolic phenomenon?
25%
100
What are examples of embolic phenomenon secondary to infective endocarditis?
OSLER nodes
Janeway lesions
Roth spots
Cerebral abscess, intracerebral haemorrhage, embolic stroke, seizures
Septic emboli - splenic, renal or pulmonary abscess. Vertebral osteomyelitis, septic arthritis, psoas abscess
Glomerulonephritis amd synovitis
101
How do you diagnose infective endocarditis?
At least 3 sets of blood cultures taken at 30 minute intervals
Echocardiography (TTE)
Others - CT, MRI or nuclear imagine, urine dip, ECG, bloods
102
What findings on an echo are suggestive of infective endocarditis?
Vegetation
Abscess formation
Pseudoaneurysm
Valve perforation
New dehiscence of a prosthetic valve
103
What are the modified Duke criteria?
The major and minor criteria used to make a diagnosis of infective endocarditis
It can be diagnosed if pathological criteria are positive, or 2 major criteria or 1 major + 3 minor criteria, or 5 minor criteria
Pathological criteria - positive histology or microbiology of pathological material obtained at surgery or autopsy
Major criteria - positive blood cultures and evidence of endocardial involvement proven by positive echo or new valvular regurgitation
Minor criteria - predisposing heart condition or IV drug use, microbiological evidence that doesnt meet major criteria, fever >38, vascular phenomena, immunological phenomena
104
What is definite (pathological) infective endocarditis?
vegetation or intracardiac abscess demonstrating active endocarditis on histology
OR
microorganism demonstrated by culture or histology of a vegetation or intracardiac abscess
105
What is definite (clinical) infective endocarditis?
2 major criteria, OR 1 major and 3 minor criteria, OR 5 minor criteria.
106
What is possible infective endocarditis?
1 major and 1 minor criteria, or 3 minor criteria
107
What is rejected infective endocarditis?
firm alternative diagnosis, OR resolution of symptoms suggesting IE within 4 days of antibiotics, OR no pathological evidence of IE at surgery or autopsy within 4 days of antibiotics, OR does not meet criteria for possible IE.
108
How do you manage infective endocarditis?
Prolonged course of targeted antibiotics
If organisms is not known yet then empirical antibiotics can be started
Surgery
109
What antibiotics are used for infective endocarditis caused by staphylococcus aureus?
flucloxacillin 12 g/day in 4-6 doses. Duration 4-6 weeks.
Methicillin-resistance staphylococcus aureus (MRSA) or penicillin allergy: vancomycin 30-60 mg/kg/day in 2-3 doses. Duration 4-6 weeks.
Note - if prosthetic valves then rifampicin and gentamicin should be added and duration should be >6 weeks
110
What antibiotics are used for infective endocarditis caused by streptococcal species?
Standard four-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone
Standard two-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone combined with gentamicin.
Penicillin allergic: vancomycin for four weeks
111
What empirical therapy can be given for infective endocarditis?
Native valve endocarditis or late prothetic valve endocarditis: Ampicillin, flucloxacillin and gentamicin, OR vancomycin and gentamicin.
Early prosthetic valve endocarditis: vancomycin, gentamicin and rifampicin.
112
Whats the aim of surgery when managing infective endocarditis?
removal of infected tissue and reconstruction of cardiac anatomy e.g. valve repair or replacement
113
What are the indications for surgery in infective endocarditis?
HF
Uncontrolled infection
Prevention of embolisation
114
Can infective endocarditis be prevented?
In 2008, NICE guidance recommended against the routine use of prophylactic antibiotics for certain procedures (e.g. dental) because of a poor evidence base and cost-ineffective. However, there is feeling that a small subgroup of patients at particularly high-risk may benefit from prophylactic antibiotics.
They may be prescribed for high risk procedures or to high risk patients
115
What are some procedures that are high risk for infective endocarditis?
Cardiac procedures
Dental procedures (manipulation of gingival or perioapical region, local anaesthetic injections, treatment of superficial caries, tooth removal or orthodontic procedures)
Respiratory tract procedures (bronchoscopy, laryngoscopy, transnasal or endotracheal intubation)
Gastrointestinal procedures (transoesophageal echocardiography, gastroscopy, colonoscopy)
Urological procedures (cystoscopy)
Obstetric procedures (vaginal or caesarian delivery)
116
What makes you a high risk pt for infective endocarditis?
Prosthetic heart valves or material used for cardiac valve repair
Previous IE
Congenital heart disease
117
What are the options for prophylactic antibiotics for dental procedures for infective endocarditis?
No penicillin allergy: amoxicillin 2 g orally or IV 30-60 minutes before procedure
Penicillin allergy: clindamycin 600 mg orally or IV 30-60 minutes before procedure
118
What are complications of infective endocarditis?
HF - most common
Perivalvular abscess, pericarditis, cardiac tamponade
Neurological - stroke, abscess, meningitis, encephalitis, haemorrhage, seizures
Metastatic infection - embolisation, secessionist
Embolisation sequelae - stroke, blindness, ischaemic limb, splenic or renal infarct, PE, MI
119
Which bacterial organisms are most associated with poor dental hygiene causing infective endocarditis?
Streptococcus viridans - streptococcus mitis and streptococcus sanguinis
120
Which microorganisms is likely to cause infective endocarditis if the pt has colorectal cancer?
Streptococcus gallolyticus
121
How is rheumatic fever managed?
Bed rest until CRP is normal for 2 weeks
Antibiotics Benzylpenicillin IV stat and then phenoxymethylpenicillin 4 times daily for 10 days
High dose aspirin to limit inflammatory response
Manage any complications
Immobilise joints in severe arthritis
Haloperidol or diazepam for chorea
122
How does aortic stenosis present?
Syncope
Angina
Dyspnoea
(SAD)
123
What ECG changes might you see in severe mitral stenosis?
It can cause left atrial hypertrophy so the ECG will show a bifid P wave
It’s termed P mitrale
Most pronounced in lead 2
124
What is myxomatous degeneration of the cardiac valves?
Non-inflammatory progressive disarray of valve structure caused by a defect in the mechanical integrity of the leaflet due to altered synthesis or remodelling of the tissue
125
What is the murmur seen in mitral valve regurgitation?
Mid systolic click sometimes followed by a systolic murmur that can be longer if standing up
126
What causes the mid-systolic click seen in mitral valve prolapse?
Leaflet folding into the atrium and suddenly stopped by the chordiae tendinae
127
Whats special about the mitral valve prolapse murmur?
If squatting the click comes later and systolic murmur is shorted (increases venous return -> fills ventricles with more blood -> left ventricles larger -> larger leaflets -> takes longer for leaflets to get forced into atria on systole)
If standing/doing vasalva manouvre the click comes earlier and systolic murmur is longer
This is the same as in hypertrophic cardiomyopathy - different murmu?
128
What can cause mitral valve prolapse?
Primary - genetics, marfans syndrome, Ehlers-Danlos syndrome, osteogenesis imperfecta, congenital heart disease
Secondary - Acute MI, rheumatic heart disease, hypertrophic cardiomyopathy
129
What are complications of mitral valve prolapse?
Mitral regurgitation
Arrhythmias including long QT
Emboli
Sudden death
130
What is De Mussets sign and what does it indicate?
a visible nodding of the head in time with arterial pulsation
patients with aortic insufficiency
131
What is De quincke's sign and what does it indicate?
Visualisation of capillary pulsations upon light compression applied to the tip of the fingernail bed (visible pulsation of red colouration on the fingernail bed. Blanching makes this more obvious)
Aortic regurgitation
132
What is slow rising pulse and what does it indicate?
Delayed up-stroke particularly in brachial and carotid pulses
Aortic stenosis
133
What is wide pulse pressure and what does it indicate?
Large difference between systolic and diastolic blood pressure
Can be caused by aortic regurgitation
134
Why does aortic regurgitation cause a wide pulse pressure?
Because the aortic valve fails to close properly, some blood is allowed back from aorta into left ventricle during diastole
As a reasult, the left ventricle has to pump out a larger volume of blood during systole to compensation
135
What can cause a narrow pulse pressure?
Aortic stenosis
It restricts the blood flow from left ventricle into aorta so in systole the LV has to work harder to pump the blood through
However, during diastole the pressure in the left drops
136
Why does mitral stenosis cause malar flush?
Increased pressure in left atrium can cause vasodilation of the small blood vessels in the face
The increased pressure in the left atrium can also lead to backflow of blood into the pulmonary veins, which can cause congestion of the lungs and the development of pulmonary hypertension. This can further exacerbate the malar flush and other symptoms of mitral stenosis
137
Which groups of people are more likely to get mitral valve prolapse?
Young women (20-40) with a FHx or connective tissue disorder
138
What is tetralogy of Fallot?
A congenital heart defect that involves:
Ventricular septal defect
Pulmonary stenosis
Overriding aorta
Right ventricular hypertrophy
The combination of these four defects can result in decreased blood flow to the lungs and inadequate oxygenation of the blood. This can cause symptoms such as cyanosis (bluish discoloration of the skin and mucous membranes), shortness of breath, and difficulty feeding or gaining weight in infants.
Tetralogy of Fallot is usually diagnosed shortly after birth or during infancy, based on clinical symptoms and diagnostic tests. Typically requires surgical repair of the defects
