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MD2 Cardiovascular > Valvular heart disease > Flashcards

Valvular heart disease Flashcards

1
Q

What causes Rheumatic heart disease?

A
  • immune response to M protein of S.pyogenes 2-3 weeks post-infection (Scarlet fever, pharyngitis)
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2
Q

Which group of people is rheumatic heart disease most common?

A
  • children (6-15 yrs) of developing countries and NT
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3
Q

What are the clinical features of rheumatic heart disease?

Hint: major and minor criteria

A

Major criteria: “CASES”

  • Carditis: tachy, murmur, pericardial rub, CCF, cardiomegaly, conduction defects
  • Arthritis: migratory polyarthritis which affects larger joints
  • Subcutaneous nodules
  • Erythema marginatum
  • Sydenham’s chorea

Minor criteria:

  • fever
  • raised ESR/CRP
  • arthralgia
  • prolonged PR interval
  • previous rheumatic fever
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4
Q

What is the management for RHD?

A
  • bed rest until CRP normal for 2 weeks
  • benzyl penicillin IV then PO for 10 days
  • analgesia for carditis and arthritis
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5
Q

What are the cardiac sequelae for RHD?

A
  • mitral (70%)
  • aortic (40%)
  • tricuspid (10%)
  • pulmonary (2%)
  • incompetent lesions develop during the attack and stenotic lesions develop years later
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6
Q

Do incompetent lesions develop during the attack or years later in RHD?

A
  • During the attack

- stenotic lesions develop years later

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7
Q

How long does an attack of rheumatic fever last?

A
  • 3 months on average
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8
Q

In aortic regurgitation:
which chamber is affected?
what kind of load?
what is the effect?

A
  • left ventricle
  • volume
  • eccentric hypertrophy
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9
Q

In mitral regurgitation:
which chamber is affected?
what kind of load?
what is the effect?

A
  • left ventricle
  • volume
  • eccentric hypertrophy
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10
Q

In aortic stenosis:
which chamber is affected?
what kind of load?
what is the effect?

A
  • left ventricle
  • pressure
  • concentric hypertrophy
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11
Q

In mitral stenosis:
which chamber is affected?
what kind of load?
what is the effect?

A
  • left atrium
  • pressure
  • left atrial dilatation
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12
Q

With stenotic valve lesions when is it best to operate?

A

When symptoms appear, the hypertrophy will regress after surgery

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13
Q

With incompetent valve lesions when is it best to operate?

A

Before symptoms, as they coincide with irreversible changes in the left ventricle

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14
Q

What are some causes of aortic stenosis?

A
  • calcific change
  • congenital aortic stenosis/ born with bicuspid aortic valve (predisposes to stenosis)
  • rheumatic fever
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15
Q

What are some symptoms of AS?

A
  • asymptomatic while compensated

- SOB on exertion, angina and syncope

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16
Q

What are the signs of AS?

A
  • murmur: ejection systolic crescendo-decrescendo murmur best heard over the upper right sternal edge
  • may radiate to carotids
  • carotid pulse has a slow upstroke (plateau)
  • thrill over upper right sternal edge
  • heaving apex
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17
Q

What gradient and valve area are considered severe AS on echo?

A
  • gradient >50mmHg

- valve area <0.7cm2

18
Q

What are some causes of aortic regurgitation?

A
  • acute: IE, ascending aortic dissection, trauma

- chronic: congenital, connective tissue disorders, RHD, Takayasu arteritis, RA, SLE, syphilis

19
Q

What is the pathophys of aortic regurgitation?

A

Due to inadequate closure of the aortic valve leaflets from:
- damaged valve leaflets
or
- dilation of the aortic root or ascending aorta
- portion of SV leaks back into the LV -> increased LV ESV -> increased LV EDV -> hypertrophy and chamber enlargement -> raised SV to maintain CO initially

20
Q

What are some symptoms of AR?

A
  • may remain asymptomatic for decades
  • might have symptoms relating to large heart mass - palpitations, a sense of pounding in chest
  • if decompensation: symptoms of left sided heart failure
21
Q

What are some signs of AR?

A
  • relate to high volume pulse -> collapsing pulse, wide pulse pressure
  • murmur: early diastolic
22
Q

Compare the pulse felt in AS with that felt in AR

A

Aortic stenosis: plateau (slow upstroke)

Aortic regurg: collapsing (wide pulse pressure)

23
Q

What are the indicators of LV decompensation?

A
  • increasing size

- decreasing function

24
Q

What are some causes of mitral stenosis?

A
  • most common cause is RHD (espec in women)

- others include congenital, fibrosis and calcification, carcinoid tumours

25
Q

What are some symptoms of mitral stenosis?

A
  • SOB and oedema when severe
26
Q

What are some signs of mitral stenosis?

A
  • mitral facies (facial flushing due to low CO)
  • tapping apex
  • AF is common
  • RHF: ankle oedema, hepatomegaly, raised JVP
27
Q

What is the natural hx of mitral stenosis?

A

LA dilatation -> pulmonary congestion and oedema -> chronic hypoxia -> pulmonary vasoconstriction -> pulmonary htn -> right heart failure

  • note that LA dilation may also cause AF -> the poorly contracting LA will result in stasis of blood and development of thrombi -> thromboembolic events
28
Q

What are some causes of mitral regurgitation?

A
  • mitral valve prolapse is most common (aka myxomatous valve degeneration)
  • functional: LV dilatation
  • annular calcification
  • RHD
  • IE
  • ruptured chordae tendinae/ papillary muscle
  • connective tissue disorders
  • cardiomyopathy
  • congenital
  • appetite suppresants (e.g. phentermine)
29
Q

What are some symptoms of mitral regurg?

A
  • even severe MR is asymptomatic unless decompensation occurs
  • > symptoms of HF
  • SOB, ankle oedema, fatigue, palpitations
30
Q

What are some signs of MR?

A
  • murmur: pansystolic murmur best heard over the apex and may radiate to axilla
31
Q

What are some causes of tricuspid regurg?

A
  • relatively common finding in healthy people
  • functional (dilate RV)
  • RHD
  • IE (suspect if IVDU)
  • carcinoid syndrome
  • congenital
  • drugs
32
Q

What are some symptoms of TR?

A
  • fatigue
  • hepatic pain on exertion
  • ascites
  • oedema
33
Q

What are some signs of TR?

A
  • JVP: giant V waves with prominent Y descent
  • murmur: pansystolic murmur best heard over the lower left sternal edge in inspiration
  • pulsatile hepatomegaly, ascites, jaundice
34
Q

What does a fever + new murmur equal?

A
  • infective endocarditis until proven otherwise
35
Q

What are some causes of IE?

A
  • S. viridans
  • enterococci
  • S. aureus (most common acute cause)
  • diptheroids
  • others
36
Q

What are some important hx causes to ask when suspecting IE?

A
  • recent hx of medical, surgical or dental procedures
  • any prosthetics (valves, joints)
  • any IV drug use
  • any pre-existing cardiac lesions
  • any recent bacterial infections
37
Q

What are some signs/symptoms of IE?

A
  • fevers, rigors, night sweats, malaise, weight loss, splenomegaly, clubbing
38
Q

What are some examination findings of IE?

A
  • new murmur or signs of HF
  • petechiae
  • splinter haemorrhages
  • Janeway lesions
  • Osler’s nodes
  • Roth spots
  • embolic phenomena
39
Q

What are investigations that should be performed for suspected IE?

A
  • blood cultures (3 sets at different times from different locations)
  • blood tests: FBE, CRP
  • urinalysis (look for haematuria)
  • CXR
  • ECG
  • Echo or TOE (looking for vegetations)
40
Q

What is the difference between mitral regurgitation and mitral prolapse?

A

In mitral regurg the valve does not close properly, in mitral prolapse, a part of the valve bulges back into the atrium during ventricular systole

41
Q

What are the features of a mitral valve prolapse murmur?

A

Auscultation: midsystolic click followed by a middle-late systolic murmur (“blowing”)

42
Q

What is the character of the hypertrophic cardiomyopathy murmur?

A
  • heard best at apex and lower left sternal edge
  • pansystolic at apex and late systolic at lower left sternal edge
  • louder with valsalva and softer with squatting
  • may hear S4, have a double-apex beat and jerky carotid pulse

MD2 Cardiovascular (8 decks)

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