Valvular Heart Disease Flashcards
T/F: VHD ranks lower than CAD, stroke, HTN, DM, and obesity in M+M.
true
What is the MC cause of VHD?
rheumatic heart disease
What is a cause of VHD that is increasing its incidence, esp in developing countries?
infective endocarditis
What must all patients with mechanical/prosthetic cardiac valve replacements have prior to invasive procedures?
abx prophylaxis
define stenosis
inability to open the valve completely leading to obstructed blood flow going forward
define regurgiation
valve fails to close completely allowing backflow of blood
define the classifications of VHD
- stage A: at risk for VHD
- stage B: progressive VHD and asx
- stage C1: asx w/ severe VHD but normal LV function
- stage C2: asx w/ severe VHD but abnormal LV function
- stage D: symptomatic
When do you refer a patient with VHD?
- new onset murmurs
- symptomatic of VHD
- (+) echo for VHD
AS etiologies
- congenital
- atherosclerotic (i.e. degenerative)
What age does atherosclerotic AS present?
> 65 y/o
AS presentation
- long, latent asx period
- MC: functional gradual decline
- progressive DOE
- angina
- transient syncope
- exercise induced tachycardia
AS pathophys
- LV outflow obstruction ==> incr. EDV and afterload = LVH
- incr. LVH = dec LV chamber vol = incr LV diastolic pressure = transmitted to LA to pulm system = DOE
- incr/prolonged ejection phase
AS murmur
- systolic or midsystolic after S1
- crecendo-decrecendo (diamond shaped)
- heard over R 2nd ICS at SB
AS special manuvers
- handgrip, standing, and valsalva decr murmur
- intensified when pt sits up and leans forward
AS physical exam
- pulsus parvus et tardus (weak, delayed)
- paradoxically split S2 heart sound
- S4 w/ LVH
- LV heave on PMI d/t LVH
- carotid a. thrill
AS management
- echo
- CXR
- EKG
- aortic valve replacement
AR pathophys
backflow from aorta –> incr LV workload = incr SV and LVH
AR etiologies
- valvular (rheumatic fever, endocarditis, HTN, syphilis)
- root (aortic dissection, HTN, marfans)
AR murmur
- diastolic
- decrecendo
AR presentation
- LV failure
- CAD
- musset sign
- duroziez sign
- quincke pulses
define musset sign
- head bob with pulse in AR
define duroziez sign
- back and forth murmur over partially compressed peripheral a. (i.e. femoral)
define quincke pulse
nailbed capillary pulsation
AR management
- echo
- EKG
- CXR
- MRI/CT
- surgery
When is surgery indicated in AR?
abnormal LV function and/or appearance of sx dramatically increases risk of mortality
etiology/epidem mitral stenosis (MS)
- MC: rheumatic fever but incidence is decr d/t strep tx
- congenital
- SLE
- RA
- infective endocarditis
T/F: MS is less common in females than males.
- false, 3x more
MS pathophys
- rheumatic chronic inflam leads to:
= valve leaflet thickening + fibrous/calcific deposits
= mitral commissures + chordae shortening
= close papillary muscles
= rigid valve cusps -
hallmark
= decr mitral valve diameter ==> change in pressure gradient b/t LA + LV ==> decr pulm compliance ==> DOE
MS presentation
- DOE, fatigued
- orthopnea, PND
- palpitations, chest pains
- a. fib d/t LA dilatation
- hemoptysis d/t incr LV press + incr rupture of sm. bronchial v.
- thromboembolism (incr turbulence)
What are the two clinical syndromes of MS?
- mild/moderate
- severe
Describe the presentation of each of the two clinical MS syndromes
- mild/severe: asx or sx ONLY w/ extreme exertion
- severe: pulm HTN d/t decr pulm vascular compliance ==? decr CO + R heart failure ==> ascites, edema, hepatomegaly, JVD
What is the first sign of MS?
JVD
physical exam of MS
- “opening snap” followed by diastolic, “low-pitched, rumbling decrescendo”
- heard best at apex in L lat. decubitus position
diagnostics for MS
- echo
- catheritazation for pts w/ CAD
- CXR, shows LA enlargement
treatment of MS
- mitral valve replacement
- warfarin for a. fib
- refer
define MR
- d/o of mitral valve closure
etiology of MR
- acute (i.e. trauma, ruptured chordae tendinae, rheumatic fever, endocarditis, flail cusps, myxomatous dz)
- chronic (i.e. marfans, degenerative, endocarditis, rheumatic fever, SLE, drugs, congenital leaflet)
pathophysiology of MR
- backflow of LV transmits to LA causes LV + LA enlarge leading to increased EF d/t LVH as compensation
- overtime decr EF d/t persistant incr vol overload and decreased contractile function leads to heart failure, pulm HTN and edema, a. fib, sudden death
presentation of acute MR
- pulm edema d/t increased LA + pulm v. pressures
presentation of chronic MR
- LA enlarges slowly leading to DOE which leads to incr. LA/LV pressure ending in a. fib and L heart failure
physical exam of MR
- murmur = pansystolic w/ prominent S3 (kentucky) best heard over apex + radiates to axilla
- brisk upstroke of carotid pulse
diagnostics of MR
- echo
- trnasthoracic esophageal echo
- BNP
- cardiac catherization
treatment of MR
- surgery
- refer
who are candidates for surgical tx of MR?
- all symptomatic pts especially w/ pulm HTN
- asx with less than 60% EF + LV dilatation
- emergency for life threatening situation
define MVP
- mitral valve prolapse (aka floppy-valve syndrome + systolic click syndrome)
- mitral valve flops up into atria during systole
etiology of MVP
- idiopathic by can be genetically linked
- incr risk in thin pts w/ MSK deformities
pathophysiology of MVP
- prolapse mitral leaflets into LA w/ systole
causes of MVP
- ruptured chordae tendinae (flail leaflets)
- progressive annula dilataion
- disease progression as part of aging process
presentation of MVP
- usually asx
- can have non-specific chest pain, dyspnea, fatigue, palpitations
physical exam of MVP
- murmur = mid-systolic clicks followed by late systolic murmur
- prolonged murmur = holosystolic = d/t increased prolapse
diagnostics of MVP
echo
treatment of MVP
- beta-blockers
- surgery
- refer
T/F: TS is less common than MS, but also associated with MS.
true
TS pathophysiology
- change in diastolic pressure gradient b/t RA and RV d/t narrowed tricuspid valve
- incr RA pressure leads to systemic venous congestion
- block at R AV leads to RA hypertrophy which leads to hepatomegaly, ascites, edema, and palpable presystolic liver pulsation
TS physical exam
diastolic rumble murmur heard best at LSB that increases with inspiration
TS diagnostics
- EKG
- CXR
- echo/cath
TS treatment
- diuretics
- tricuspid valve replacement
TR pathophysiology
- backflow of blood from RV to RA d/t:
1. RV dilatation, caused most commonly by LV failure, opens tricuspid valve
2. RV volume overload leads to pulm a. HTN
3. pacemaker injures the valve (iatrogenic)
4. dilated cardiomyopathy
TR presentation
same as R heart failure (i.e. venous side backs up)
TR physical exam
- murmur: blowing, holosystolic heard at LSB and incr w/ inspiration and decr w/ expiration/valsalva
- audible S3
TR diagnostics
- echo/doppler
- CXR
- cath
- EKG
TR treatment
- valve replacement and anticoagulants
- diuretics for edema
PS etiology
congenital
PS pathophysiology
- systolic pressure gradient b/t RV and RA
- RVH d/t resistance and prolonged systolic ejection
- resistance leads to decr. pulm blood flow ==> cyanosis
PS presentation
- mild: asx
- mod/severe: DOE, fatigue, syncope, angina, eventual RV failure
- murmur: loud, harsh crescendo-decrescendo that radiates to shoulder and incr. with inspiration (similar to AS since they are both semilunar valves)
- palpable thrill
PS diagnostics
- echo
- EKG
- CXR
PS treatment
- all sx pts
- all w/ pressure gradients > 60mmHg, regardless of sx
- diuretics
- valve replacement
PR types
- high pressure
- low pressure
describe high pressure PR overview
- d/t pulm HTN
- decrescendo, diastolic murmur
describe low pressure PR overview
- d/t valvular dz
- no murmur
PR pathophysiology
- leads to RV enlargement + hypertrophy ==> incr. pre + afterload
- w/ incr RV pressure, RV + RA enlarge w/ JVD ==> decr. pulm blood flow
PR presentation
- most: asx
- some have RHF d/t RV overload
- RV heave/lift
- S2 split
- systolic click
- decrescendo, diastolic murmur
(same S+S of R heart failure)
PR diagnostics
- echo
- EKG
- CXR
PR treatment
- decr. pulm a. HTN via vasodilator + diuretics
- surgery
