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Ch. 1 - Cardiology Final Year > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

You are taking a history of a patient with COPD, where they mention theyve had heart problems when they were a child. You ask what it is and she tells you that shes not sure but she had to stay at home for 6 months when she was 2 years old. What did she have?
On examination, what murmur would you hear? Describe it

A

Scarlet fever/ Rheumatic fever
Mitral stenosis (Diastolic murmur, loudest at the apex and when in the left lateral position. Loud 1st HS with opening snap)

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2
Q

What is the most common cause of mitral stenosis?

A

Prior rheumatic infection (rare in the developed world)

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3
Q

What is the most common murmur in the general population?

A

Mitral regurgitation

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4
Q

List 5 causes of mitral regurgitation

A

Primary: Organic causes:
Abnormalities (mitral valve prolapse in Marfan’s and Ehler Danlos, end even pregnancy)
Perforation (Infective endocarditis)
Papillary muscle rupture (post-MI)

Secondary: Functional/ischaemic (LV dilatation from prior MI, heart failure, or cardiomyopathy)

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5
Q

A rumbling diastolic murmur with an opening snap (1st HS) and louder in the left lateral position

A

Mitral stenosis

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6
Q

What murmur is associated with pulmonary oedema?

A

Mitral regurgitation

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7
Q

A blowing diastolic murmur, louder when leaning forward is associated with what murmur?

A

Aortic regurgitation

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8
Q

What murmur is loudest on expiration?

A

Mitral regurgitation
Technically left sided murmurs

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9
Q

Describe a perfect auscultation of mitral regurgitation

A

Pansystolic murmur, loudest at the apex and on expiration, radiating to the axilla Grade 3/6

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10
Q

A laterally displaced apex beat is most associated with what 2 murmurs?

A

Mitral and aortic regurgitation

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11
Q

What murmur is associated with a crescendo decrescendo pattern?

A

Aortic stenosis

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12
Q

Describe a perfect auscultation of aortic stenosis

A

Ejection systolic murmur, loudest at the 2nd ICS right sternal border, radiating to the carotids -Crescendo-decrescendo pattern. Grade 3/6

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13
Q

What murmurs are typically louder on inspiration?

A

RIght sided murmurs => tricuspid and pulmonary valves
Tricuspid regurgitation and stenosis

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14
Q

What murmurs are loudest on expiration?

A

LEft sided murmers are louder on expiration => mitral and aortic valves

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15
Q

A soft holosystolic murmur, increasing with inspiration is what murmur?

A

Tricuspid regurgitation

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16
Q

A slow intensity diastolic murmur increasing with inspiration is associated with what murmur?

A

Tricuspid Stenosis

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17
Q

What murmur is most likely to be found on a patient with a pulsatile, enlarged liver and positive hepatojugular reflux?

A

Tricuspid regurgitation

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18
Q

What is the typical presentation of a patient with valvular disease
(for 5/5, must say which valves are most likely for each symptom)

A

Any valve can present with all of these but to be specific
Mitral: Palpitations
Aortic: Chest pain/discomfort, syncope/presyncope
Both : SOB/Dyspnoea

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19
Q

What is De Musset’s sign?

A

Head bobbing on inspiration in Aortic Regurg.

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20
Q

You are conducting a clinical exam on a patient with suspected valvular disease. When assessing their BP you notice a narrow PP. What murmur does this suggest?
You note a widened PP. What murmur does this suggest?

A

Narrow PP AS, Wide PP AR

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21
Q

What is a Water Hammer Pulse? What murmur is it associated with?

A

It is the same as a collapsing pulse a/w aortic regurgitation

22
Q

Down’s syndrome is associated with what valvular disease?

A

Mitral regurgitation

23
Q

What clinical findings are associated with marphan’s syndrome in a cardio exam? What murmur are you looking for on auscultation?

A

Tall, thin male
High arched palate
Poor eyesight

Mitral stenosis due to mitral valve prolapse

24
Q

On examination, you note splinter haemorrhages, fever, roth spots and pallor. What murmur is this patient most likely to have?

A

IE => Any regurg.

25
Q

You are conducting a cardio examination on a patient the intern says “has a murmur”. Go through the exam stating the findings you will be looking for in each part. (5/5 by saying which signs are specific to a certain murmur if applicable)
You do not need to say each murmur

A

General inspection: Dyspnoea, Head bobbing (AR),
Closer inspection: BP (Narrow PP AS, Wide PP AR), High arched palate (MR), facies of Down’s Syndrome (MR), Stigmata of IE (Any regurgitation), raised JVP
Palpation: Parasternal heave (HF), displaced apex beat (HF, CM)
Offer: Ankle oedema, sacral oedema
Auscultation: All the murmurs, HF (reduced breath sounds, bibasal crackles, wheezing)

26
Q

How would you treat mitral stenosis?

A

Pharmacological: Diuretics (improves dyspnoea + Beta blocker + Amiodarone + Warfarin
Surgical: Percutaneous Balloon Mitral Valvuloplasty

27
Q

Your differentials for any systolic murmur is all the other systolic murmurs. likewise for diastolic. What are your differentials for a continuous murmur?

A

PDA or fistula

28
Q

A patient is presenting acutely with suspected valvular disease. What valves are most likely causing an acute presentation?

A

AR or MR

29
Q

What is the general acute management of valvular disease?

A

Treating the underlying cause. Most likely IE, MI, trauma, aortic dissection, request urgent surgical opinion, and assess for signs of heart failure

30
Q

What is the general management approach to all valvular disease? Conservative, pharma, surgical

A

the management of the majority of VHD is conservative due to it being a slow degenerative problem => the risk-benefit ratio needs to be calculated and discussed.
Pharmacological treatment is typically directed at the underlying disease
Surgical management is typically reserved for severe cases or when another surgery such as CABG will be performed anyways

31
Q

How would you treat Mitral regurgitation?

A

Pharmacological: only if also HF -> treat as HF
Surgical repair only performed if severe primary. otherwise only done if there is another surgery to be done there anyways e.g. CABG

32
Q

What is the most common valvular disease in hospitalised patients?

A

Aortic stenosis

33
Q

What are the main causes of aortic stenosis?

A

Congenital: Congenital bicuspid aortic valve
Acquired: Calcified normal tri-leaflet aortic valve

34
Q

A patient has a bicuspid aortic valve with an ejection systolic murmur radiating to the carotids, louder on expiration. What other cardiac sign on examination will this patient probably have?

A

Bicuspid valve is consistent with turner’s syndrome. These patients will likely have radio-femoral delay due to coarctation of the aorta as well

Collapsing pulse is also correct as bicuspid aortic valve is also associated with aortic regurgitation => Waterhammer/collapsing pulse

35
Q

What clinical sign (not auscultation) tests for aortic regurgitation?
What does this sign also confirm?

A

Waterhamer pulse/Collapsing pulse
Consistent with AR or PDA => also consistent with PDA

36
Q

State the causes of aortic regurgitation

A

Very rare
Congenital bicuspid aortic valve
Infective endocarditis (all the regurg)
Aortopathies (marphans’s, aortic dissection, Syphilis)

37
Q

What is the management of aortic stenosis?

A

Pharmacological: Highly a/w CVD so treat underlying disease. HTN drugs, statins etc..

Surgical:
Younger -> Implanted surgical device
Older/multiple comorbidities -> TAVI
Last line: Balloon valvuloplasty/Percutaneous aortic comissurotomy (High risk of stroke though) (just like mitral stenosis)

38
Q

What is the management of aortic regurgitation?

A

Pharmacological: Symptomatic tx with Diuretics +ACE/ARBs (reduces aortic root dilatation for patients with marfans + good for the tx of HF which also causes dilatation)

Surgical repair if severely symptomatic and reduced ejection fraction

39
Q

Tricuspid stenosis is very rare as it is associated with rheumatic disease (just like mitral stenosis). Tricuspid regurgitation on the other hand may be seen in normal individuals as well as a bunch of pathological causes. State 5, separating them as primary and secondary

A

Primary:
Infective endocarditis (all regurg)
Ebstein’s anomaly
Carcinoid syndrome
Traumatic Injury

Secondary:
Increased right ventricular pressure/volume => secondary LV dilatation or pulmonary HTN (RHF)
Note: This is similar to mitral regurgitation due to LV dilatation

40
Q

Pulmonary valve abnormalities are rare in adults and mostly seen in paediatrics. What might cause that?

A

Tetralogy of fallot

41
Q

Give 5 risk factors for valvular disease in general

A

Age
Genetic: Bicuspid aortic valve, Mitral valve prolapse => Marfan’s, Ehler Danlos, Down’s, Turner’s
Infectious => Rheumatic fever, infective endocarditis
Cardiovascular -> Previous MI, HTN, HF
CKD (causes HTN)

42
Q

Which imaging technique allows for the calculation of gradients across valves leading to the assessment of severity of valvular disease?

A

Doppler ECHO

43
Q

What is the role of an Exercise ECHO?

A

Grades MR severity as MR becomes more severe with tachycardia

44
Q

What imaging techniques are used in the investigation of valvular disease? List them and indicate which is the gold standard + reasoning.

A

ECHO (TTE/TOE) including Doppler ECHO (grades severity of disease) and Exercise ECHO (grades MR severity)
CT-TAVI - CT transcatheter aortic valve implantation (assesses if percutaneous approach to valve repair is possible)
Coronary angiogram (underlying coronary artery disease - AS)
Coronary CT angio (Calcium score - severe AS)
Cardiac MRI (Gold standard)

45
Q

What imaging technique is used to calculate the Calcium score?

What valvular disease is it most relevant in?

What is the calcium score? Run me through it

A

Coronary CT angiogram. Mostly to assess for the calcium score relevant in severe aortic stenosis

The calcium score assesses the risk of heart disease
Normal: <100
Moderate: >100
Severe >1000

46
Q

What is the difference between a coronary angiogram and a coronary CT angiogram when investigating for valvular disease?
Tip: State what each does/what its used for

A

A coronary angiogram is an invasive procedure involving passing a catheter through the femoral or radial artery. It is both a highly detailed diagnostic tool as well as a therapeutic intervention if needed such as stenting.

A Coronary CT angiogram involves injecting a contrast dye and creating a 3D image of the coronary arteries. This is strictly a diagnostic tool and is used in the calculation of the Calcium score.

47
Q

What investigations are you going to carry out for a patient presenting with valvular disease? (include reasoning where applicable)

A

Bedside: ECG, ABG, Urine dipstick

Bloods:
Fasting lipids and HbA1c (RF for CVD)
LFTs (raised LFTs from hepatic congestion secondary to HF)

Imaging:
ECHO (TTE/TOE) including Doppler ECHO (grades severity of disease) and Exercise ECHO (grades MR severity)
CT-TAVI - CT transcatheter aortic valve implantation (assesses if percutaneous approach to valve repair is possible)
Coronary angiogram (underlying coronary artery disease - AS)
Coronary CT angio (Calcium score - severe AS)
Cardiac MRI (Gold standard)

48
Q

For how long, ideally, would a valve last?

A

10 years

49
Q

What are the main complications of surgical repair of a valve

A

Acute congestive HF
Infection of prosthetic valves (given prophylactic Ab)
Thrombosis (lifelong anticoag)
Re-stenosis (esp 10 years after replacement)
Valve dehiscence

50
Q

What is the treatment of tricuspid stenosis?

What is the treatment of tricuspid regurgitation?

A

No tx for tricuspid stenosis
Tricuspid regurg is just surgical repair only for those with severe symptomatic tricuspid regurgitation and only when performing another left-sided surgery

+ Pulmonary valve tx is just refer to specialised centre experienced with adult congenital heart disease

51
Q

What anticoagulant is prescribed for those with metallic valves?

What about for bioprosthetic valves?

A

Warfarin for metallic valves
DOAC for bio-prosthetic

Ch. 1 - Cardiology Final Year (12 decks)

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