Valvular Heart Disease Flashcards
What are the four phases of the cardiac cycle?
- Ventricular filling (Diastole)
- Isovolumetric contraction (Systole)
- Ejection (Systole)
- Isovolumetric relaxation (Diastole)
Each phase has distinct physiological events that contribute to heart function.
What occurs during ventricular filling?
Passive filling of the atria from the vena cava and pulmonary veins into the left and right atria, flowing into ventricles; mitral and tricuspid valves open, semilunar valves closed
At the end of diastole, atrial contraction occurs, contributing to ventricular filling.
What happens during isovolumetric contraction?
Pressure builds in the ventricles, causing closure of the AV valves; all valves are closed and ventricular pressure rises without volume change.
This phase is critical for assessing cardiac contractility.
What happens during ejection?
SYSTOLE where ventricular pressure exceeds the aorta and this triggers the opening of the semi-lunar valves and blood passes through to the rest of the body, where the end systolic volume is created and can be used to determine ejection fraction. Eventually ventricular pressure is below arterial pressure, so the semilunar valves close, creating a rise in arterial pressure
What causes the diacrotic notch?
The closure of the semilunar valves, which indicates end of systole closure and successful prevention of backflow stream.
What triggers the ejection phase of the cardiac cycle?
Ventricular pressure exceeds aortic pressure, opening the semilunar valves and allowing blood to flow into the aorta.
This phase results in the creation of end-systolic volume.
What is the dicrotic notch?
A rise in arterial pressure created by the closure of the semilunar valves, indicating the end of systole.
It is an important feature in arterial pressure waveform analysis.
What is isovolumetric relaxation?
DIASTOLE where both sets of valves are now closed and ventricular pressure begins to reduce to below atrial pressure, which leads to opening of the atrioventricular valves and restarting of the cycle
What does the S1 heart sound indicate?
Closure of the atrioventricular valves during early systole.
It is one of the primary heart sounds used in auscultation.
What does the S2 heart sound indicate?
Closure of the semilunar valves during late systole, creating a dicrotic notch on a graph.
S2 is typically louder than S1 due to higher pressures on the left side of the heart.
What is a split S2 heart sound?
Occurs when the closure of the aortic and pulmonary valves is out of sync, often normal during inspiration.
Pathological causes can include conditions like pulmonary hypertension and right bundle branch block.
What is paradoxical split S2?
Delay in closure of the aortic valve, causing greater splitting during expiration and pulmonary valve to close first.
This can occur due t conditions affecting the aortic valve such as severe aortic stenosis, hypertrophic obstructive cardiomyopathy or left bundle branch block.
This can occur due to conditions such as severe aortic stenosis.
What is fixed split S2?
Fixed split S2 is where there is a delay in closure of the pulmonary valves with no effect from insipiration.
This can occur due to an atrial septal defect, where expiration causes presssure in the right atrium to decrease as normal but high pressure blood flows abnormally from the left to the right atria through the defect, which disrupts the pressure gradient and delays closure of the PV valve.
What are the features of the mitral valve?
Mitral valve is bicuspid, with the anterior leaflet longer than the posterior leaflet.
What is S3 heart sound?
S3 heart sound is a low pitched sound in the isovolumetric diastole phase after S2, indicating fast ventricular filling. It can indicate systolic heart failure, where the left ventircle is compliant due to dilation. This sound occurs with mitral and aortic regurgitation.
This can be normal finding in children, pregnant women and young athletes.
What is the S4 heart sound?
S4 heart sound occurs prior to S1 heart sound in the diastole ventricular filling phase due to reduced ventricualr compliance And slow filling, assoicated with left ventircular hypertrophy.
What are the atrioventricular valves?
Atrioventricular valves consist of
-> Tricuspid
-> Mitral which is bicuspid, between the left atrium and ventricle and anterior leaflet is longer than left.
They are attached by fibrous cords called the chordate tendinae to connect it to the valve cusps at the papillary muscles on the ventricles, which work simultaneously to promote valve closure. Papillary muscles contract during ventricular systole to prevent valve prolapse into atria.
What is the consequence of volume overload?
Volume overload of the heart chamber causes eccentric hypertrophy, where dilatation thins the chamber walls, resulting in S3 heart sound due to issue with systole causing backflow of blood.
What is the consequence of pressure overload?
Pressure overload of the heart chamber causes concentric hypertrophy to enlarge the myocardial cells hypertrophy to accomodate for increased force of contraction, resulting in S4 heart sounds due to issue with diastole filling.
Which valvular diseases cause pressure overload?
Aortic stenosis
Mitral stensois
Aortic regurgitation
What is acute rheumatic fever?
Acute rheumatic fever is an autoimmune condition that occurs 2-4 weeks following a Group A Strep with a throat infection such as streptococcus pyogenes. This has an M protein that is targeted by immune cells, however its similar structure to cardiomycin results in molecular mimicry and susceptibility to pericarditis, myocarditis, mitral regurgitation, heart failure and infective endocarditis.
Which valvular diseases cause volume overload?
mitral Regurgitation
Aortic regurgitation
What is the presentation of acute rheumatic fever?
Clinical presentation is with fever, abdominal pain and epistaxis
JONES
* Joint pain with asymmetrical poly arterial IgA
* Carditis, resulting in chest pain, dyspnoea and palpitations. Pericarditis may resolve in haemodynamic instability while the myocarditis may result in acute heart failure and arrythmia. Endocarditis commonly affects the mitral valve most, followed by the aortic valve and tricuspid valve, where regurgitation and heart failure occur.
* Nodules that are subcutaneous found on the extensor regions of the hands,s feet and knees lasting for 2 weeks, occurring after pericarditis
* Erythema marginatum, where a large red circle with a clear border forms on the centre of the chest. It begins
* Syndenham’s chorea: involuntary jerky movements due to inflammation of the caudate nucleus and putamen, involved in movement regulation
How is diagnosis of rheumatic fever made?
Evidence of recent streptococcal infection from swab or antibody test alongside fulfilling:
2 major criteria or
1 minor criteria with 2 major criteria
What is the major criteria for rheumatic fever?
Erythema marginatum
Sydenham’s chorea
Poly arthritis
Carditis and valvulitis
Subcutaneous nodules
What is the minor criteria for rheumatic fever?
Raised ESR or CRP
Pyrexia
Arthralgia
Prolonged PR interval
How is rheumatic fever treated?
Management of rheumatic fever is with oral or IV penicillin, NSAIDs and treatment of complications that may arise like heart failure.
Prophylactic antibiotics include erythromycin and benzylpenicillin
What is the pathophysiology of mitral stenosis?
Pressure overload: There is limitations to the passive filling of the left atria and pressure in the left atria increases, creating an abnormal pressure gradient that causes backflow into the pulmonary vasculature and resulting in pulmonary hypertension and congestive heart failure. There is also left atrial diliatation which may result in atrial fibrillation and increases the risk of emboli formation . The pulmonary hypertension may result in pulmonary and tricuspid valve regurgitation, leading to right sided heart failure. Normal ventricular function maintains normal cardiac output initially, however reduced filling in diastole due to stenosis leads to loss of compensatory increase in CO during exertion.
What is the presentation of mitral stenosis?
Patients typically present with symtpoms of heart failure with
Shortness of breath, Paroxysmal nocturnal dyspnoea: SOB which worsens at night
Ascites , Oedema Hepatomegaly Fatigue and weakness on exertion ( reduced cardiac ouptut)
There is a risk of atrial fibrillation due to left atrial volume and pressure overload.
What are signs of mitral stenosis?
Tapping apex beat
Palpable and louder S1 sound due to stiff mitral valve
Opening snap sound due to stiff mitral valve
Mid-diastolic rumbling murmur at left heart apex due to reduced filling
S4 heart sound
Parasternal heave due to right ventricle hypertrophy
Prominent a waves in JVP
Malar flush
These signs reflect the hemodynamic changes due to the narrowed valve.
What is the clinical presentation of acute rheumatic fever?
- Fever
- Abdominal pain
- Epistaxis
- Joint pain (JONES criteria)
- Carditis
- Nodules
- Erythema marginatum
- Syndenham’s chorea
The JONES criteria help in diagnosing this autoimmune condition.
What is the treatment for rheumatic fever?
- Prophylactic antibiotics (e.g., erythromycin, benzylpenicillin)
- Aspirin for inflammation
- Management of heart failure with diuretics, ACE inhibitors, and digoxin
Early treatment is important to prevent long-term complications.
What is Malar flush?
Malar flush may occur, where there is reddening across the nose and cheeks due to CO2 retention from mitral valve stenosis, where back pressure into the right ventricle reduces gas exchange in the lungs.
What are the signs of right sided heart failure?
Raised JVP
Pedal oedema and ascites
Hepatomegaly
Early diastolic murmur due to pulmonary regurgitation from pulmonary hypertension
Signs of left sided heart failure:
Orthopnea
Exertional dyspnoea
Paroxysmal nocturnal dyspnoea
Fatigue
What are the ECG findings for mitral stenosis?
ECG which shows:
bifid (double peaked) P waves indicating left atrial enlargement
Atrial fibrillation
Right axis deviation when right ventricle hypertrophy occurs due to pulmonary hypertension
What does X-ray show for mitral stenosis?
Double border of right ventricle, indicating hypertrophy
Pulmonary congestion
Enlargement of all heart chambers (severe stage)
Prominent pulmonary arteries indicating hypertension
Mac-Callum’s patch
Kerley B lines indicating pulmonary oedema
What is Mac-Callum’s patch?
Irregular area of thickening in the left atrial wall due to previous severe rheumatic fever endocarditis
How is mitral stenosis managed?
Management is dependent on symptom severity
Mild/conservative management: salt restriction, diuretics,
Prophylactic antibiotic benzylpenicillin for those with rheumatic fever
Anti-arrythmia drugs, beta blocker or calcium channel blocker for rate control
Anti-coagulants due to risk of blood clots
Diuretics to manage heart failure
What is the pathophysiology of mitral valve regurgitation?
VOLUME OVERLOAD: The backflow of blood into the left atrium causes the left atria to increase with pressure and volume overload. Due to the regurgitation back into the left atria, during the diastolic filling phase, there is more blood in the left atria and this passes to the left ventricle which undergoes hypertrophy. The anelargmeent of the left atria may compress the oesophagus and cause Chronic mitral regurgitation causes Fatigue, palpitations diaphoresis, exertional dyspnoea and pedal oedema.
What are the acute causes of mitral regurgitation?
Acute causes include infective endocarditis, acute myocardial infarction or trauma to the valve.
What are the chronic causes of mitral regurgitation?
Chronic damage to the valve, from mitral valve prolapse, dilatation cardiomyopathy, collagen vascular disease or hypertrophic cardiomyoapthy.
How does MI cause mitral regurgitation?
Myocardial infarction due to papillary muscle rupture or cardiac remodelling, where infarction induces myocyte necrosis and recruitment of immune cells such as neutrophils and macrophages which cause further damage and increase the ifnarcted area. This region is unable to withstand the blood pressure, and results in thinning and dilatation of the left ventricle chamber and cause thinning and dilatation of the left ventricle and the infarcted area stretches. The remaining healthy cardiomycytes undergo hypertrophy due to their compensatory effort to maintain ejection fraction, which dilates the chamber further making it prone to mitral valve regurgitation. The neurohormonal activation of the RAAS system and sympathetic system can further induce fibrosis.
How does dilated cardiomyopathy cause mitral regurgitation?
Dilated cardiomyopathy where the chambers become larger and the myocardium becomes thinner allows blood to leak more easily through the valves, that cannot of
Hypertrophic cardiomyopathy mitral valve does not adapt quickly enough and moves anteriorly during systole due to stenosis of septum pulling the anterior leaflet inwards and the annulus enlarges through dilatation, resulting in backflow of blood into left atrial
What are common causes of mitral valve regurgitation?
- Acute infective endocarditis
- Acute myocardial infarction
- Mitral valve prolapse
- Dilated cardiomyopathy
- Papillary muscle rupture
Chronic causes can include degenerative changes or rheumatic heart disease.
What can cause bacteraemia in infective endocarditis?
It can arise from a contaminated prosthetic valve, chronic inflammation, devices-related trauma or turbulent blood flow around diseased valves
Which areas are affected in infective endocarditis?
This typically affects highly vascularised organs like the heart affects the aortic and mitral valve, causing heart failure and increases the risk for stroke in the brain and glomerulonephritis, spleen infarction and abscess and pulmonary embolism.
Dental sepsis is a common risk.
Which organism is the most common cause of infective endocarditis?
staphylococcus aureus, forming part of the normal pharynx and URT
Which organism is associated with dental plaques in infective endocarditis?
Streptococcus viridans is the most common cause in developing country and found in the mouth, associated with dental plaques.
Which organism is associated with prosthetic valve surgery in infective endocarditis?
Staphylococcus epidermis following prosthetic valve surgery and from central venous catheters.
What are the investigations for infective endocarditis?
Investigations include:
Blood cultures, FBC for u&Es, LFTs, ESR
Urinalysis
ECG to assess for AV block or conduction defects
CXR for pulmonary oedema or infarction from septic embolism
ECHO for valve lesions
What is bicuspid aortic valve characterised by?
It is characterised by fusion of left and right coronary cusp, with a low-pitched systolic ejection murmur. It typically abuses aortic stenosis or aortic regurgitation.
Which patients are at risk for infective endocarditis?
There is greater risk factor for patinets with pre-existing cardiac conditions or rheumatic fever, prosthetic valve, hypertrophic cardiomyoapthy, mitral reflux and ventiruclar aneurysm
What is the blood culture protocol for infective endocarditis?
Blood cultures prior to antibiotic treatment, 3 times over an hour from different sites of the body to avoid contamination,
How does infective endocarditis present?
Fever,anorexia, stiff neck, rigours/chills, fatigue, dyspnoea, pleuritic chest pain and haematuria with blackening of extremities due to emboli.
The mesenteric ischaemia can cause abdominal symptoms like vomiting and right upper quadrant pain.
What is the stigmata of infective endocarditis?
splinter haemorrhages
Janeaway lesions
Osler nodes
Haematuria with blackening of extremities
What is bicuspid aortic valve associated with?
It is associated with Turner syndrome, William syndrome and ventricular septal defect but is higher in males.
What is the management of infective endocarditis?
High dose IV antibiotics should be started with IV penicillin for upt to 4 weeks with gentamycin for 2 weeks.
What is a consideration for infective endocarditis of the prosthetic valves?
Combination antibiotic with non-beta-lactam as they have no bactericidal activity against enterococci.
What is the prophylaxis for infective endocarditis?
Prophylaxis for at risk patients involves 2g of amoxicillin or clindamycin 600mg for allergic patients
-> vancomycin is an alternative
What is the most common causative agent of subacute infective endocarditis?
staphylcoccus aureus
Staphylococcus epididermis
What is myxomatous degeneration?
Myxomatosis degenration where mucopolysaccharides are deposited in the spongiest layer of the leaflets causes thickened leaflets that cauases chorae tendinae to elongate and eventually rupture, resulting in prolapse during ventricular systole.
This condition can predispose valves to further dysfunction.
What are Janeway lesions and Osler nodes?
- Osler nodes are tender nodules found on the distal fingers and toes due to chronic endocarditis and are an immunological manifestation.
2.Janeway lesions are non-tender haemorrhagic plaques on the palms or soles and are a vascular manifestation
Both are cutaneous manifestations of infective endocarditis.
What investigations are used for infective endocarditis?
- Blood cultures
- FBC for u&Es, LFTs, ESR
- Urinalysis
- ECG for AV block
- CXR for pulmonary complications
- ECHO for valve lesions
These investigations help confirm the diagnosis and assess the severity.
What are the clinical signs of mitral regurgitation?
Pansystolic murmur radiating to axillary during systole due to backflow of blood into left atria during systole
Diminished S1 heart sound
Left ventricular heave which is Palpable apex thrill due to left ventricular hypertrophy
Splitting of S2 due to premature aortic valve closure because of early LV systole as a result of reduced resistance of blood from backflow into left atria affecting pressure gradient
S3 heart sound due to systolic heart failure indicating deceleration of blood from left atrial to left ventricle due to
What are the investigations for mitral regurgitation?
Bifid P wave from left atria enlargement
Left axis deviation due to left ventricular hyertrophy
Atrial fibrillation
What is acute mitral regurgitation?
normal compliance does not affect enlargement of left atria, however left atria rises in pressure and can lead to backflow, causing pulmonary oedema.the left ventricle remains abnormal size and no compensatory enlargement occurs, resulting in a reduced cardiac output.
What is chronic mitral regurgitation?
Enlargement of LA occurs to accommodate volume overload and results in dilataiton and induces the left ventricle to dilate which eventually has volume overload, resulting in a large stroke volume to maintain ejection fraction.
What does a Wilkins score assess?
The mitral valve to predict the success of balloon valvuloplasty based on leaflet thickness, calcification, fusion, and mobility.
This score helps in planning intervention strategies for mitral stenosis.
What are the symptoms of embolism?
Fever, rigours/chills, fatigue, dyspnoea, chest pain, haematuria, blackening of extremities due to emboli
What are Janeway lesions?
Non-tender haemorrhagic plaques on the palms or soles, a vascular manifestation
What are Osler nodes?
Tender nodules found on the distal fingers and toes due to chronic endocarditis, an immunological manifestation
What investigations show raised inflammatory markers in embolism?
CRP, ESR, leukocytosis
What is the typical management for infective endocarditis?
Antibiotics, fluid resuscitation, monitoring for sepsis
What is mitral valve prolapse?
Mitral valve prolapse is where the leaflets of the mitral valve billow during systole and collapse Ito the left atria, which are associated with connective tissue disorders like Ehers-Danlos syndrome and Marfan syndrome. Myxomatosis degenration where mucopolysaccharides are deposited in the spongiest layer of the leaflets causes thickened leaflets that cauases chorae tendinae to elongate and eventually rupture, resulting in prolapse during ventricular systole. Osteogenesis imperfecta can cause mitral valve.
What is the presentation of mitral valve prolapse?
Presentiation is atypical chest pain and palpitations from ventricular arrythmias. There may be a mid or late systolic click due to tensing of chordae tendinae and leaflet prolapse. Activation of the sympathetic nervous system to compensate causes anxiety, syncope and panic attacks.
What is the signs of mitral valve prolapse?
Irregularly irregular heart rate
Displaced apex beat due to hypertrophy of left ventricle from increased pressure from built up left atria
Mid-late systolic click murmur over mitral area due to regurgitation which is more easily heard with Valsalva manoeuvre which increases intrabdominal pressure and reduces preload and lengthen the murmur
ECG is typically normal or with atrial fibrillationand CXR unless mitral regurgitation occurs. Diagnosis is based on echocardiogram.
Management is mitral valve repair, anticoagulants for arrythmias and beta blockers for chest pain or palpitations
What causes late prosthetic valve endocarditis?
Abnormal flow around prosthetic valve producing micro thrombi and non-bacterial thrombotic vegetations becoming infected
What is the difference between early and late prosthetic valve endocarditis?
Early occurs due to staphylococci in the pre-operative period; late occurs due to abnormal flow around the valve
What are the complications of prosthetic valve endocarditis?
High degree AV block, perforated IV septum
Name the types of mitral regurgitation according to Carpentier’s classification.
- Type 1: normal leaflet motion
- Type 2: leaflet prolapse from myxomatous degeneration
- Type 3a: restricted leaflet opening from rheumatic disease
- Type 3b: restricted leaflet closing from ischaemic dilated cardiomyopathy
How is the left ventircle affected in MR?
dilatated cardiomyoapthy due to volume overload
What are the acute presentations of mitral regurgitation?
Cardiogenic shock, pulmonary oedema, hypotension
What are the clinical signs of mitral regurgitation?
- Pansystolic murmur radiating to axilla
- Diminished S1 heart sound
- Left ventricular heave
What are the stages of mitral regurgitation?
- Acute: normal compliance, left atrial pressure rises
- Chronic: enlargement of left atrium and left ventricle dilation
What does the auscultation of mitral regurgitation reveal?
- Soft S1
- Splitting of S2
- Mid-diastolic flow murmur
- S3 heart sound
- Pansystolic murmur
What are the key investigations for mitral regurgitation?
- ECG: bifid P wave, left axis deviation, atrial fibrillation
- CXR: cardiomegaly, left atrial and ventricular enlargement
- Transoesophageal echocardiogram
What is the prognosis for mitral regurgitation?
Poor with more symptoms, majority of deaths due to arrhythmia or heart failure
What is the management for mitral regurgitation?
- Salt restriction
- Treatment of heart failure
- Surgical repair if left ventricular ejection fraction below 60%
What is mitral valve prolapse?
Condition where the leaflets of the mitral valve billow during systole and collapse into the left atrium
What are the clinical signs of mitral valve prolapse?
- Irregularly irregular heart rate
- Displaced apex beat
- Mid-late systolic click murmur
What is the most common valvular diseases?
Aortic Stenosis.
What is aortic stenosis commonly associated with?
Old age and aortic regurgitation
What are the risk factors for aortic stenosis?
- Hypertension
- Obesity
- Hyperlipidaemia
- Smoking
- Diabetes
What are the symptoms of aortic stenosis?
- Syncope
- Angina
- Dyspnoea
What are the causes of aortic stenosis?
Congenital Heart disease With vicusppid valve
Rheumatic fever
Calcification
What is the pathophysiology of aortic stenosis?
Decreased pumping capacity of the left ventircle results in increased after load and concentric hypertrophy. Pressure overload from failed ejection of blood results in a high end-systolic pressure and causes left ventricular hypertrophy that increases oxygen demand and systolic heart failure that progresses to congestive heart failure. The increased demand for oxygen results in angina. There is increased risk of ventricular arrythmias that can result in sudden cardiac death. The failure of the left ventricle when untreated leads to congestive heart failure. The narrowing of the valve decreases flow (volume) of blood but increases. There is dilatation of ascending aorta post-stenosis.
What are the clinical signs of aortic stenosis?
- Pulses parvus et tardus: slow rising low volume pulse at carotid due to reduced cardiac output
- Mid-systolic crescendo-decrescendo ejection murmur with a click in the right upper sternum
- Normal S1
- Paradoxical splitting of S2
- S4 gallop sound
What is the diagnosis for aortic stenosis based on?
- ECG: bifid P waves, left ventricular hypertrophy
- Echocardiogram: calcified valve, hypertrophy
- CXR: calcification in valve, aortic root dilatation
- Cardiac catheterisation for coronary arteries
What are the treatments for aortic stenosis?
- Management of heart failure
- Beta blockers
- Transcatheter aortic valve implantation
- Surgical aortic valve replacement
What are the causes of aortic regurgitation?
- Aortic root dilatation
- Hypertension
- Marfan syndrome
- Rheumatic heart disease
- Infective endocarditis
- Congenital bicuspid aortic valve
- Calcification of valve
What is the pathophysiology of aortic regurgitation?
Backflow of blood returning from the aorta combined with blood entering the left ventircle during the filling diastolic phase due to volume overload and eccentric hypertrophy, causing dilatation of the heart chamber, overtime reducing LV function. There is a compensatory increase in left ventricle contraction, resulting in hypertrophy. This can lead to mitral valve stenosis over time.
What is the presentation of aortic regurgitation?
It presents with exertional dyspnoea, chest pain and exertional psynpea due to reduced cardiac output and coronary blood flow. Patients can tolerate this for years and has a good prognosis if chronic, however acute regurgitation is associated with left ventricular fibrillation.
What is a key clinical sign of aortic regurgitation?
High pulse pressure and collapsing pulse
What are the signs of aortic regurgitation?
- Apical systolic thrill
- Displaced apex beat
- Diastolic decrescendo murmur
- Austin-Flint murmu, mimicking mitral stenosis that is a mid-diastolic murmur at apex due to mitral valve orifice over time narrowed from high left ventricular pressure resulting in anterograde blood flow
What investigations are used for aortic regurgitation?
- ECG: left ventricular hypertrophy
- CXR: LVH, aortic dilation
- Cardiac catheterisation
- Doppler echocardiogram is best for assessing regurgitation
What are the management strategies for aortic regurgitation?
- Observation for asymptomatic patients
- Non-pharmacological management
- Surgical management for significant LV dysfunction
How are heart murmurs graded?
Based on the Levine scale from 1 (very faint) to 6 (extremely loud without a stethoscope)
What is a thrill in cardiology?
A palpable vibration caused by turbulent flow through a valve
What are the risks associated with mechanical heart valves?
- Valve thrombosis
- Embolisation
- Haemolysis
- Endocarditis
- Structural valve degeneration
- Patient-prosthesis mismatch
What are the characteristics of tissue valves compared to mechanical valves?
Do not require anticoagulation therapy but have lower durability
What is S3 and what conditions is it associated with?
Rapid ventricular filling immediately following closure of semilunar valves due to:
* Systolic heart failure
* Dilated cardiomyopathy
* Young athletes
S3 is often referred to as a ‘ventricular gallop’.
What is S4 and what conditions is it associated with?
Slow ventricular filling with late atrial contraction occurring prior to closure of AV valves due to resistance of ventricular filling:
* Hypertrophic cardiomyopathy
* Aortic stenosis
* Hypertension
* Diastolic heart failure
S4 is often referred to as an ‘atrial gallop’.
Where is the aortic area located for auscultation?
Right second intercostal space to listen for systolic murmurs and aortic stenosis.
This area is used to listen for systolic murmurs and aortic stenosis.
Where is the pulmonary area located for auscultation?
Left second intercostal space.
This area is used for listening to pulmonary valve sounds.
What is Erb’s point and what is it used for?
Located in the 3rd intercostal space, it is used to listen for diastolic murmurs, aortic regurgitation, and hypertrophic cardiomyopathy
Erb’s point is a key area for auscultating heart sounds.
Where is the tricuspid area located for auscultation?
Left 4th intercostal space. it is ideal for listening for holosystolic murmurs and aortic and ventricualr septal defect.
This area is ideal for listening to holosystolic murmurs and ventricular septal defects.
Where is the mitral area located for auscultation?
Left 5th intercostal space on mid-clavicular line For listening to holosystolic murmurs and ventricualr septal defect.
This area is used to listen for holosystolic murmurs, systolic murmurs, and diastolic murmurs.
What defines a holosystolic murmur?
A murmur that occurs throughout systole, due to:
* Mitral regurgitation
* Ventricular septal defect
* Tricuspid systolic murmur
Holosystolic murmurs can be heard continuously from S1 to S2.
What is mitral regurgitation characterized by?
A pansystolic murmur which is loudest at the mitral area and radiates to the axilla
It is best heard with the patient in the left lateral position.
What is tricuspid regurgitation characterized by?
A pansystolic murmur loudest on inspiration
Tricuspid regurgitation is associated with right-sided heart failure.
What are the types of systolic murmurs?
Systolic murmurs include:
* Crescendo murmurs
* Holosystolic murmurs
These murmurs can indicate various cardiac conditions.
What causes a crescendo-decrescendo murmur?
Aortic stenosis
Hypertrophic cardiomyopathy
It radiates from the aortic area to the carotid.
What is the feature of aortic stenosis murmur?
It radiates from the aortic area to the carotid.
What is the best position to hear hypertrophic cardiomyopathy?
Best heard in Erb’s point; can be louder with leaning forwards, Valsalva technique, lifting legs, or decreased afterload by providing nitrates
This condition leads to dynamic outflow obstruction.
Where are holosystolic murmurs heard?
It is best heard at the apex; an Ejection click followed by a murmur throughout systole between S1 and S2.
What is the cause of holosystolic murmurs?
Typically occurs due to mitral valve prolapse, mitral regurgitation or ventricualr septal defect.
What is unique about holosystolic murmur in mitral valve prolapse?
The murmur will radiate to the apex. It is louder with leaning on the left side, Valsalva technique, and decreased afterload by providing nitrates
It may also radiate to the apex.
What is unique about holosystolic murmur in mitral regurgitation?
It radiates to the axilla in absence of valve relapse.It will be louder with leaning on left side, increasing afterload by using handgrips, lifting legs up.
Where is the ventricular septal defect best heard?
Holosystolic murmur best heard in the Left 4th intercostal space in the tricuspid; heard better with lifting legs up
This condition causes a continuous murmur.
What defines diastolic murmurs?
Occur after S2 and before S1
They are often associated with conditions like aortic regurgitation and mitral stenosis.
What is a characteristic of aortic regurgitation?
Blood flowing back into the left ventricle; best heard at Erb’s point
It is louder by leaning forwards, using handgrips to increase afterload, and lifting legs up.
What increases the sound of aortic regurgitation?
It will be louder by leaning forwards, using handgrips to increase afterload and lifting legs up.
What is mitral stenosis characterized by?
An opening snap with decrescendo murmur best heard at the apex. Better heard with leaning on left side and lifting leg
It is better heard with leaning on the left side and lifting the leg.
What are continuous murmurs typically seen in?
Pediatric populations, often due to a patent ductus arteriosus; best heard in the left infraclavicular area
Continuous murmurs span from S1 -> S2 and continue after S2.
How do right-sided murmurs change with respiration?
Increase in intensity with inspiration due to more right atrial venous return
This is important in assessing right-sided heart conditions.
How do left-sided murmurs change with respiration?
Decrease in intensity with expiration due to less left atrial venous return. Increases with expiration due to more left atrial venous return from pulmonary capillaries
This can affect the assessment of left-sided heart conditions.
What increases the intensity of aortic murmurs?
Leaning forwards. And expiration
This position brings the aortic valve closer to the chest wall.
What increases the intensity of mitral murmurs?
Leaning to the left
This position brings the mitral valve closer to the chest wall.
What increases the intensity of most murmurs?
Lifting the leg/squatting increases venous return to both right atrium and left atrium
-> except mitral valve prolapse and hypertrophic cardiomyopathy
This is due to increased preload.
What increases the intensity of mitral regurgitation and hypertrophic cardiomyopathy?
Valsalva technique: reduces venous return and increases the intensity of ONLY mitral regurgitation and hypertrophic cardiomyopathy
This is due to decreased preload.
Which murmurs increase in intensity with greater afterload?
Increased sound in aortic regurgitation and mitral regurgitation due to more backflow;
This is due to the effect on the heart’s workload.
Which murmurs decrease in intensity with greater afterload?
aortic stenosis, mitral valve prolapse and hypertrophic cardiomyoapthy
Which murmurs increase in intensity with lower afterload using nitrates?
Increases sound of mitral valve prolapse, and hypertrophic cardiomyopathy;
This is due to reduced resistance against which the heart must pump.
Which murmurs decrease in intensity with lower afterload using nitrates?
decreases sound in aortic regurgitation and mitral regurgitation
What is the most common valvular diseases cause in the elderly?
aortic stenosis
What is important in prevention of thrombosis in valve replacement?
warfarin
-> first 3 months in bio prosthetic
-> lifelong for mechanical
What is the first clinical sign of right ventiruclar failure?
raised JVP
What is the TAVI procedure?
transcatheter aortic valve implantation where a narrow flexible catheter is inserted through a vessel in the leg and inserts a replacement valve over the old. It is used for treatment of aortic stenosis, and is a useful alternative to heart valve replacement. There is risk of clotting so long term anticouagulation therapy is requires.
What is the mitraclip procedure?
It is used to repair the mitral valve when treating mitral regurgitation via Percutaneous reconstruction, using a catheter.
