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Cardiology > Valvular heart disease > Flashcards

Valvular heart disease Flashcards

1
Q

What is the most common cause of mitral stenosis

A

Chronic rheumatic valve disease - valve scarring from repeated acute rheumatic fever attacks

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2
Q

What size is the mitral valve for patients to become symptomatic

A

1.5 cm2 (normal is 4 to 5)

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3
Q

What are the complications of mitral stenosis

A

Dilitation of left atrium1.) Risk of Afib2.) Pulmonary congestion3.) Pulmonary HTN4.) Right-sided heart failure

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4
Q

What are some symptoms of mitral stenosis

A

1.) Exertional dyspnea, orthopnea, PND (pulmonary congestion2.) Hemoptysis - ruptured anastomoses of small bronchial veins3.) Thromboembolism with Afib4.) Ascites and dependant edema - RVF

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5
Q

What are the physical exam signs seen in mitral stenosis

A

1.) Mitral stenosis murmur - opening snap with diastolic rumble, followed by loud S12.) RVF - Right ventricular heave, JVD, hepatomegaly, ascites

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6
Q

What two things makes the symptoms of mitral stenosis worse

A

1.) Exercise2.) Pregnancy

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7
Q

What two things can be used to diagnose mitral stenosis

A

1.) CXR - enlarged atrium (early)2.) Echo - most important, shows everything

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8
Q

What is the medical treatments used for mitral stenosis

A

Only for symptoms, treat pulmonary congestion and edema with diuretics, treat heart rate and cardiac output with beta blockers, give infective endocarditis prophylaxisAlso put these patients on chronic anticoagulation with warfarin

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9
Q

When is surgery indicated for mitral stenosis, and what are the best procedures

A

When severePercutaneous balloon valvuloplasty works for mitral stenosisOpen commissurotomy and mitral valve replacement if other is contraindicated

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10
Q

How should you manage asymptomatic patients with mitral stenosis

A

You don’t, could give diuretics for mild symptoms

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11
Q

What area must the aortic valve be in order to see decreased cardiac output

A

0.7cm2, cardiac output doesn’t increase with exercise, causing angina/syncope

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12
Q

What are the consequences of aortic stenosis on the heart muscle

A

First left ventricular hypertrophy, then eventually dilation pulling the mitral valve apart and causing mitral regurgitation

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13
Q

What are the causes of aortic stenosis

A

Wear and tear via calcification - in elderly (happens sooner if bicuspidRheumatic heart disease - causes fusion of commissures rather than calcification

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14
Q

What are symptoms of aortic stenosis

A

Dyspnea, angina and syncope on exertionClassic end disease triad: Angina (35%) - survival 3 yearsSyncope (15%) survival 2 yearsHeart failure (50%) - survival 1.5 years - orthoponea, PND, dyspnea on exertion

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15
Q

What are the physical exam signs of aortic stenosis

A

1.) Systolic murmur - crescendo/decrescendo murmur in right intercostal space that radiates to carotid arteries2.) Soft S23.) S44.) Parvus et tardus - diminished/delayed carotid upstrokes5.) Sustained PMI

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16
Q

What are four diagnostic modalities used for aortic stenosis

A

1.) CXR - calcified aortic valve2.) ECG - LVH, LA abnormality3.) Echo - diagnostic in most cases4.) Cardiac cath - definitive test, measures valve gradient and valve area, to do before surgery too

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17
Q

What is the treatment for aortic valve stenosis

A

Asymptomatic - no treatmentSymptomatic - Surgery only (replacement)

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18
Q

What is the mortality rate for aortic stenosis at 3 years without replacement

A

75%

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19
Q

What is the effect of aortic regurgitation on the heart muscle

A

LV dilation and eccentric hypertrophy (volume overload), eventual increased left sided and pulmonary pressure

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20
Q

What are two main causes of aortic regurgitation

A

1.) Aortic root dilation - syphilis aneurysm, aortic dissection, osteogenesis imperfecta, Reiters2.) Valve disease - Infective endocarditis most common, rheumatic fever, marfans, ehler-danlos, and more

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21
Q

What are the four causes of acute aortic regurgitation (rest would be chronic)

A

1.) Trauma2.) Infectious endocarditis3.) Failed iatrogenic replacement surgery4.) Aortic dissection

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22
Q

What are teh symptoms are aortic regurgitation

A

1.) LVH failure - dyspnea on exertion, PND, orthopnea2.) Palpitations worse when lying down3.) De Mussett’s sign - head bobbing4.) Pulsating nail bed (quincke pulse)5.) Cyanosis and shock if acute

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23
Q

What do you see on physical examination for aortic regurgitation

A

1.) Widened pulse pressure2.) Diastolic descrescendo murmur at left sternal border3.) Water hammer pulse - rapidly increasing pulse that collapses immediately, at wrist or femoral arteries4.) Displaced PMI down and to the left

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24
Q

What increases the intensity of aortic regurgitation

A

Handgrip

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25
Q

What 4 modalities can we use to diagnose aortic regurgitation

A

1.) CXR - LVH, dilated aorta2.) ECG - LVH3.) Echo - perform serially in stable patients to assess need for surgery, can see dilated aortic root too, if acute then look for early closure of mitral valve4.) Cardiac catherization - to assess severity and LV dysfunction severity

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26
Q

Who should receive treatment for aortic regurgitation

A

Stable and asymptomatic - medicalAcute AR - medical emergency, immediate replacementSymptomatic - surgery (valve replacement)

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27
Q

What treatments can you offer to stable and asymptomatic patients with aortic regurgitation?

A

Free the fluids - Salt restriction, avoid exercise, diuretics, vasodilators for sure, digoxin, afterload reduction (ACE and arterial dilators)

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28
Q

When should you give endocarditis prophylaxis for patients with mitral regurgitation

A

Before dental and GI/genitourinary procedures

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29
Q

What is the pathophysiology of acute vs. chronic mitral regurgitation and one complication of each

A

Acute = elevation of LA pressure with normal LA size and compliance - CO decreases causing hypotension and shockChronic = gradual elevation of left atrial pressure with time for LA to dilate and increase its compliance, however this causes LV dysfunction with potential pulmonary HTN from chronic backflow

30
Q

What are some acute causes of mitral regurgitation

A

1.) Endocarditis via staph aureus2.) Papillary muscule rupture (infarction) or dysfunction (ischemia)3.) Chordae tendineae rupture

31
Q

What are some chronic causes of mitral regurgitation

A

1.) Mitral valve prolapse (most common)2.) Rheumatic fever - most common symptom3.) Marfans syndrome4.) CardiomyopathyOr anything that can cause LV dilation

32
Q

What are the symptoms of mitral regurgitation

A

1.) LV failure - dyspnea on exertion, PND, orthopnea2.) Pulmonary edema

33
Q

What are the clinical exam signs of mitral regurgitation

A

1.) Holosystolic murmur at apex, radiates to axilla2.) Afib

34
Q

What two diagnostic modalities can you use to diagnose mitral regurgitation

A

1.) CXR - cardiomegaly, dilated LV, pulmonary edema2.) Echo

35
Q

Medical treatment for asymptomatic vs. symptomatic patients with mitral regurgitation

A

Asymptomatic - no treatmentSymptomatic - afterload reduction with vasodilators, chronic anticoagulation if Afib

36
Q

When is surgery indicated for mitral regurgitation

A

Most severe cases - but not too severe as LV function is severely compromised

37
Q

What percent of normal adults have mild physiologic tricuspid regurgitation

A

70%

38
Q

What are the causes of tricuspid regurgitation

A

Anything that causes RV dilation - LV failure most common, right ventricular infarction, inferior wall MI, cor pulmonalePrimary valve - Tricuspid endocarditis, ebstein’s anomaly, carcinoid syndrome, SLE

39
Q

What are the symptoms of tricuspid regurgitation

A

Asymptomatic mostlyRHF symptoms - ascites, hepatomegaly, edema, JVD, Pulsatile liverPulmonary HTNAfib (like mitral regurgitation)

40
Q

What kind of murmur is seen in tricuspid regurgitation

A

Blowing holosystolic murmur intensified with inspiration, at LLSB

41
Q

What are two diagnostic modalities used to see tricuspid regurgitation

A

EchoECG - RV and RA enlargement

42
Q

What is the medical treatment for tricuspid regurgitation

A

Diuretics, while treating endocarditis and pulmonary HTN separately

43
Q

When are you allowed to do surgery for tricuspid regurgitation

A

When severe, but no pulmonary HTN

44
Q

What kind of surgeries does one do for tricuspid regurgitation

A

Native valve repair surgery or valvuloplastly (replacement rarely performed)

45
Q

What is mitral valve prolapse

A

Myxomatous degeneration of mitral valve leaflets, redundant leaflets prolapse towrads left atrium in systole

46
Q

MVP has a higher prevalence in people with what diseases

A

1.) Osteogenesis imperfecta2.) Ehler-Danlos syndrome3.) Marfan’s syndrome

47
Q

What are the murmur characteristics of MVP

A

Midsystolic click with mid to late systolic murmurStanding and valsalva increase murmur and click by reducing LV chamber size (occurs earlier)Squatting decreases murmur and click by increasing LV chamber size (onset delayed)

48
Q

What is the only diagnostic modality you need to do for MVP

A

Echo, since establishing diagnosis is not important

49
Q

What is the treatment for MVP

A

None

50
Q

What is rheumatic heart disease

A

Progression of rheumatic heart fever which is a complication of Group A strep pharyngitis

51
Q

What is the most common valvular abnormality seen in rheumatic heart disease

A

Mitral stenosis (fish mouth), possible aortic and tricuspid involvement too

52
Q

What is the protein responsible for molecular mimickry in rheumatic heart disease

A

Bacterial protein M resembling valve tissue

53
Q

What are the five major criteria to diagnose rheumatic heart disease (only need two)

A

1.) Migratory polyarthritis - swelling/pain in large joint, goes to another joint2.) Erythema marginatum - annular nonpruritic rash with erythematous borders3.) Cardiac (pancarditis) - small vegetation lines on valve, ashoff bodies4.) Subcutaneous nodules5.) Chorea - rapid, involuntary muscle movements

54
Q

What do you use to prevent rheumatic fever

A

Treat strep pharyngitis with penicillin or erythromycin

55
Q

How do you treat acute rheumatic fever itself and what can you monitor treatment with

A

NSAIDS, monitor C-reactive protein

56
Q

What should patients with previous history of rheumatic fever receive as prophylaxis for dental/GI/GU procedures

A

Amoxicillin or erythromycin

57
Q

What is infective endocarditis?

A

Infection of endocardial surface of heart (usually cusps of valves)

58
Q

What are two major categories of endocarditis

A

Acute and subacute

59
Q

What is acute endocarditis (three characteristics)

A
  • Normal valve- Staph aureus usually- Fatal in less than 6 weeks
60
Q

What is subacute endocarditis (three characteristics)

A
  • Damaged valve- Strep viridans or enterococci- Fatal in more than 6 weeks
61
Q

What are the most common organisms, other organisms, and special groups in NATIVE valve endocarditis

A
  • Strep Viridans most common- Other: Staph (aureus more than epi), enterococci- HACEK: Haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
62
Q

What is the HACEK group of organisms (only in native valve)

A

Haemophilus, actinobacillus, cardiobacterium, eikenella, kingella

63
Q

What two major categories can prostetic valve endocarditis be divided into

A

Early-onset (60 days within surgery): Staph (epi more than aureusLate-onset (after 60 days): Strep

64
Q

IV drug users present with endocarditis on what side of heart?

A

Right side of heart

65
Q

What are common organisms in endocarditis of IV drug users

A

1.) Staph aureus - most common2.) Entercocci and strep - less common3.) Candida and pseudomonas - least common(Think about mix between acute and subacute)

66
Q

What are four complications from endocarditis

A

1.) Cardiac failure2.) Myocardial abscess3.) Organ damage from showered emboli4.) Glomerulonephritis

67
Q

What is the criteria called that is used to diagnose infective endocarditis

A

Duke’s Criteria

68
Q

What are the major criteria of Duke’s criteria for infective endocarditis (two)

A

1.) Sustained bacteremia - by organism known to cause this2.) Endocardial involvement - Echo or clearly established new valvular regurgitation

69
Q

What are the six minor criteria of Duke’s criteria for infective endocarditis (six)

A

1.) Predisposing condition (abnormal valve/abnormal risk of bacteremia)2.) Fever3.) Vascular phenomena: Septic arterial or pulmonary emboli, mycocitic aneurysism, intracranial hemorrhage, janeway lesions4.) Immune phenomena: Glomerulonephritis, osler’s nodes, roth’s spots, rheumatoid factor5.) Positive blood cultures - not meeting major crit6.) Positive echo - not meeting major crit

70
Q

What is the route of administration of antibiotics and how long should you give them for infective endocarditis

A

4 to 6 weeks based on cultures

71
Q

If you don’t get blood cultures or they’re negative, what antibiotics should you give for infective endocarditis

A

Penicillin (or vanco) + aminoglycoside

Cardiology (9 decks)

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