Valvular heart disease Flashcards
What is meant by valvular heart disease?
This describes any condition affecting the heart valves, preventing either the proper passage of blood through the valves, or allowing blood back through the valves
What is a murmur?
An auscultatable sound, caused by the turbulence of blood flow
What are some general signs that may suggest a valvular heart disease?
Chest pain
Breathlessness
Collapse
When will a diastolic murmur be heard on auscultation?
Between S2 and the following S1
When will a systolic murmur be heart on auscultation?
Between S1 and S2
What causes a 3rd heart sound?
Passive filling of the ventricle
When can a 3rd heart sound be heard?
Just after S2
What causes a 4th heart sound?
Active filling of the ventricle against a stiff ventricle
Where are 3rd and 4th heart sounds heard most loudly?
Mitral area
What causes physiological splitting of the 2nd heart sound
Inspiration decreases intrathoracic pressure
This increases venous return
This increases end diastolic volume on the right
This means the pulmonary valve closes after the aortic valve
What are some pathological causes of a 3rd heart sound?
Left ventricular failure (e.g. dilated cardiomyopathy)
Constrictive pericarditis (Pericardial knock)
Mitral regurgitation
What are some pathological causes of 4th heart sound?
Aortic stenosis
Hypertrophic Obstructive Cardiomyopathy
Hypertension
What murmurs are systolic?
Aortic stenosis
Mitral regurgitation
Pulmonary stenosis
Tricuspid regurgitation
What murmurs are diastolic?
Mitral stenosis
Aortic regurgitation
Tricuspid stenosis
Pulmonary regurgitation
What are the 2 main types of systolic murmur?
Pansystolic
Ejection systolic
What valvular condition will cause a pansystolic murmur?
Mitral regurgitation
What valvular condition will cause an ejection systolic murmur?
Aortic stenosis
What are the 2 main types of diastolic murmur?
Early diastolic
Mid diastolic
What valvular condition will cause an early diastolic murmur?
Aortic regurgitation
What valvular condition will cause a mid diastolic murmur?
Mitral stenosis
What is meant by a pansystolic murmur?
A murmur that remains at a constant volume throughout systole
What is meant by an ejection systolic murmur?
A murmur that gets quickly louder and then becomes quieter in systole
What is meant by an early diastolic murmur?
A murmur that starts loud at the beginning of diastole and gets quieter
What is meany by a mid diastolic murmur?
A murmur that starts mid way through diastole and gets louder
How are murmurs graded?
I - Very quiet
II - Quiet but audible
III - Loud
IV - Loud with a thrill
V - Very loud with a thrill
VI - Audible without stethoscope
What sided murmur is usually louder on inspiration?
Right sided
Describe the characteristics of an innocent murmur?
Soft (<3/6) for severity
Often early systolic (Not diastolic)
What is aortic stenosis?
A condition in which the aortic valve is too small, narrow or stiff, resulting in obstruction of blood flow from left ventricle to the aorta
What are some causes of aortic stenosis?
Calcification (Degeneration) in older patients
Congenital (Bicuspid aortic valve)
Post-rheumatic fever
Wiliams syndrome
Hypertrophic obstructive cardiomyopathy
What are some symptoms of aortic stenosis?
Think ABCD
Aortic stenosis =>
Breathless
Chest pain
Dizziness
How does aortic stenosis lead to chest pain?
Increased pressure through the aortic valve decreases blood flow through the coronary arteries, leading to angina
What are some clinical signs of aortic stenosis?
Low volume pulse
Narrow pulse pressure
Ejection systolic murmur, radiating to carotids
Slow rising pulse
Soft/absent S2
Presence of S4
Thrill
What valvular condition will cause S4?
Aortic stenosis
What valvular condition will cause a narrow pulse pressure?
Aortic stenosis
What valvular condition will cause a slow rising, narrow pulse pressure?
Aortic stenosis
Where can a murmur in aortic stenosis be heard loudest?
Aortic region
Carotids
What are some treatment options in aortic stenosis?
Valve replacement
Trans Catheter Aortic Valve Implantation (TAVI)
Balloon aortic valvotomy
What are the 2 types of conventional valve replacement?
Mechanical
Bio-prosthetic (Pig)
What are the advantages and disadvantages of Mechanical valve replacement?
+ They last much longer than bio-prosthetic
- It requires lifetime warfarin
What are the advantages and disadvantages of bio-prosthetic valve replacement?
+ Does not require warfarin
- Only last around 10 years
What are some investigations that can be carried out in suspected aortic stenosis?
Chest X-rays
ECG
Echocardiogram
Cardiac CT (If indicated)
What is mitral regurgitation?
A condition that causes the flow of blood back through the mitral valve during systole
What are some causes of mitral regurgitation?
Prolapsed valve
Rheumatic fever
Myxomatous (Floppy) valve
Endocarditis
Chordae or papillary rupture post MI
Annular dilatation due to cardiomyopathy
What are some common symptoms of mitral regurgitation?
Breathless on exertion
Peripheral oedema
Fatigue
What are some clinical signs of mitral regurgitation?
Displaced apex
Pansystolic murmur, radiates to axilla
Presence of S3
Where can the murmur of mitral regurgitation be heard?
Mitral area
Axilla
What condition can be caused by mitral regurgitation?
Left ventricular hypertrophy (Cardiomegaly on x-ray)
What are some surgical treatment options of mitral regurgitation?
Valve repair in cases of prolapse
Valve replacement in cases of degeneration
Percutaneous clips in infancy or those unable to tolerate open heart surgery
What are some pharmacological treatment options in mitral regurgitation?
ACEi or ARBs
Diuretics
What are some investigations that can be performed in mitral regurgitation?
Chest X-ray (Shows cardiomegaly)
Echocardiogram
Coronary angiography (If indicated)
What is meant by mitral stenosis?
A condition in which there is obstruction to flow through the mitral valve during systole
What is the most common cause of mitral stenosis?
It has a mostly rheumatoid aetiology
(rare calcification or congenital)
What are some possible symptoms of mitral stenosis?
Breathlessness
Fatigue
Palpitations (A Fib)
How does mitral stenosis cause atrial fibrillation?
Increased pressure in the left atrium can lead to ectopic foci formation as the atria enlarges
What are some clinical signs of mitral stenosis
Malar flush
Tapping apex beat
Mid diastolic rumbling murmur
Loud S1
Haemoptysis
Opening snap
What valvular condition causes malar flush?
Mitral stenosis
What valvular condition causes a loud S1?
Mitral stenosis
What valvular condition causes an opening snap?
Mitral stenosis
How does mitral stenosis cause haemoptysis?
Increased pressure in the left atrium causes a build up of pressure in the lungs, leading to oedema and bleeding, causing pink, frothy sputum
What are some surgical treatment options in mitral stenosis?
Valve replacement
Balloon valvuloplasty
What are some pharmacological treatment options in mitral stenosis?
Diuretics
Direct oral anti-coagulation
What are some investigations that can be performed in mitral stenosis?
Chest X-ray (Straight left heart border)
ECG
Echocardiography
What is meant by aortic regurgitation?
A condition resulting in the reflux of blood from the aorta through the aortic valve and back into the left ventricle, during diastole
What are some causes of aortic regurgitation?
Endocarditis
Connective tissue disease
Rheumatic fever
Annulus dilatation
What are some conditions that can lead to aortic regurgitation?
Marfan’s syndrome
Aortic dissection
Spondylarthropathis
Hypertension
Ehler-Danlos syndrome
Syphilis
What are some possible symptoms of aortic regurgitation?
Angina
Dyspnoea
What are some clinical signs of aortic regurgitation?
Collapsing pulse
Displaced apex
Early diastolic murmur at left sternal edge
Low diastolic BP
Wide pulse pressure
Quincke’s sign (Pulsing nailbed)
De Musset’s sign (Head bobbing)
What manoeuvre can be performed to increase volume of an aortic regurgitation murmur?
Patient leaning forward
What valvular condition causes a collapsing pulse?
Aortic regurgitation
What valvular condition causes a wide pulse pressure?
Aortic regurgitation
What is the pharmacological treatment for acute aortic regurgitation?
Vasodilators and inotropes
What is the pharmacological treatment for chronic, severe aortic regurgitation and heart failure?
ACE inhibitors
What is the pharmacological treatment for aortic dilation in Marfan’s patients?
ß-Blockers
Who is surgical management of aortic regurgitation indicated in?
Symptomatic patients
Asymptomatic patients with left ventricular dysfunction
What are some investigations that can be carried out in aortic regurgitation?
ECG
Chest X-ray
Echocardiogram (Gold standard)
