Valvular Heart Disease Flashcards
What is valvular heart disease?
Valvular heart disease is when any valve in the heart has damage or is diseased
What are examples of valvular heart disease?
Aortic stenosis
Mitral regurgitation
Aortic regurgitation
Mitral stenosis
Rheumatic fever
What are the two most common examples of valvular heart disease and indicate prosthetic valve replacement?
Aortic stenosis
Mitral regurgitation
What is aortic stenosis?
Narrowing of the aortic valve opening, restricting blood flow from the left ventricle to the aorta..
What type of murmur does aortic stenosis cause?
Ejection-systolic, high-pitched murmur.
The murmur radiates to the carotids as the turbulence continues into the neck.
Clinical features related to aortic stenosis
Heart failure
Syncope
Angina
Exertional dyspnoea
Decreased exercise tolerance
Clinical findings in Aortic Stenosis
Slow rising carotid pulse
Narrow pulse pressure
Heaving, non-displaced apex beat (can be displaced if there is left ventricular hypertrophy)
Ejection systolic murmur
Heard best at the second intercostal space on the right
- Can be described as “harsh”
- Transmitted well to the carotids
Soft S2 heart sound
ECG signs of aortic stenosis
ECG in aortic stenosis can show evidence of left ventricular hypertrophy:
Increased QRS complex voltage
Left axis deviation
Poor R-wave progression
Causes of aortic stenosis
Idiopathic age-related calcification (by far the most common cause)
Bicuspid aortic valve
Rheumatic heart disease
What is aortic regurgitation?
Incompetent aortic valve, allowing blood to flow back from the aorta into the left ventricle.
What type of murmur can aortic regurgitation cause?
Early diastolic, soft murmur.
Austin-Flint murmur. This is heard at the apex as a diastolic “rumbling” murmur.
Clinical findings of aortic regurgitation
Thrill in the aortic area on palpation
Collapsing pulse
Wide pulse pressure
Heart failure and pulmonary oedema
Causes of aortic regurgitation
Idiopathic age-related weakness
Bicuspid aortic valve
Connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome
What is mitral stenosis?
A narrowed mitral valve restricting blood flow from the left atrium into the left ventricle.
What type of murmur does mitral stenosis cause?
Low-pitched “rumbling” murmur due to a low blood flow velocity. There will be a loud S1.
Audible snap.
Clinical findings in mitral stenosis
Tapping apex beat, which is a palpable, prominent S1
Malar flush
Atrial fibrillation (irregularly irregular pulse)
Causes of mitral stenosis
Rheumatic heart disease
Infective endocarditis
What is mitral regurgitation?
Incompetent mitral valve, allowing blood to flow back from the left ventricle to the left atrium during systolic contraction of the left ventricle
What does mitral regurgitation cause?
Reduced ejection fraction and a backlog of blood waiting to be pumped through the left side of the heart, resulting in congestive cardiac failure.
What type of murmur can mitral regurgitation cause?
Pan-systolic, high-pitched “whistling”
The murmur radiates to the left axilla. You may hear a third heart sound.
Clinical features of mitral regurgitation
Thrill in the mitral area on palpation
Signs of heart failure and pulmonary oedema
Atrial fibrillation (irregularly irregular pulse)
What causes mitral regurgitation?
Idiopathic weakening of the valve with age
Ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders, such as Ehlers-Danlos syndrome or Marfan syndrome
What is tricuspid regurgitation?
Incompetent tricuspid valve, allowing blood to flow back from the right ventricle to the right atrium during systolic contraction of the right ventricle
What type of murmur does tricuspid regurgitation?
Pan-systolic murmur.
There is a split-second heart sound.
Clinical signs of tricuspid regurgitation
Thrill in the tricuspid area on palpation
Raised JVP with giant C-V waves (Lancisi’s sign)
Pulsatile liver (due to regurgitation into the venous system)
Peripheral oedema
Ascites
What causes tricuspid regurgitation?
Pressure due to left-sided heart failure or pulmonary hypertension (“functional”)
Infective endocarditis
Rheumatic heart disease
Carcinoid syndrome
Ebstein’s anomaly
Connective tissue disorders, such as Marfan syndrome
What is pulmonary stenosis?
Narrowed pulmonary valve, restricting blood flow from the right ventricle into the pulmonary arteries.
What type of murmur does pulmonary stenosis cause?
Ejection systolic murmur loudest in the pulmonary area in expiration
Signs of pulmonary stenosis
Thrill in the pulmonary area on palpation
Raised JVP with giant A waves (due to the right atrium contracting against a hypertrophic right ventricle)
Peripheral oedema
Ascites
What is pulmonary stenosis associated with?
Pulmonary stenosis is usually congenital and may be associated with:
Noonan syndrome
Tetralogy of Fallot
What is the tetralogy of Fallot?
A congenital condition where there are four coexisting pathologiesVentricular septal defect (VSD)
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy
What is rheumatic fever?
A systemic complication of Lancefield group A beta-haemolytic streptococcal infection (typically pharyngitis) that occurs two to four weeks post-infection.
Antibodies formed as a result of the infection cross-react with the myocardial tissue, causing the effects of rheumatic fever.
How are clinical features of Rheumatic Fever divided up?
Rheumatic fever typically presents with various clinical findings.
To aid diagnosis, findings are classified by the Jones criteria into major and minor manifestations.
How is rheumatic fever diagnosed?
Evidence of recent streptococcal infection (eg, history of scarlet fever, positive throat swab or rising or increased antistreptolysin O titre (ASOT) >200 U/mL or DNase B titre).
Plus two major criteria; or
One major and two minor criteria
Major symptoms with rheumatic fever
Arthritis
Pancarditis
- This may manifest clinically as a tachycardia, new murmur or new conduction defect.
Sydenham’s chorea
Neurologic disorder consisting of abrupt, non-rhythmic, involuntary movements along with muscular weakness and emotional disturbance. They are most frequently marked on one side and cease during sleep.
Erythema marginatum
Pink/red, nonpruritic rash involving mainly the trunk, thighs and arms.
Subcutaneous nodules
Firm, mobile painless lesions
What is minor Jones critera?
Fever
Arthralgia (unless if arthritis meets major criterion)
Raised acute phase proteins (ESR and CRP)
Prolonged PR interval on ECG (except if carditis meets major criterion)
Eradication of group-A beta-haemolytic streptococcal infection
Aspirin or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen.
Sydenham’s chorea is self-limiting and does not require treatment, however Haloperidol or Diazepam may be used for distressing symptoms or risk of harm.
Erythema marginatum is associated with rheumatic fever is temporary and doesn’t require treatment, although antihistamines can help with pruritus.
What type of murmur does tricuspid regurgitate?
Pan-systolic murmur.
There is a split-second heart sound.
Rheumatic fever medical treatment
Stat dose of IV benzylpenicillin
