Valvular Heart Disease Flashcards
Characteristic symptoms of valvular heart disease?
EXERTIONAL symptoms are characteristic; at rest, valve issues can be asymptomatic:
Breathlessness
Chest pain
Collapse/dizzy spells
Describe cardiac related breathlessness
Usually related to exertion and is often associated with ankle swelling
Patients describe orthopnoea and PND - ask how many pillows they sleep with?
Patients describe sitting up as relieving symptoms - this relieves venous congestion (effect of gravity)
Which type of heart failure are orthopnoea and PND associated with?
Left-sided heart failure (has effects on lungs)
New York Heart Association Functional Classification (NYHA)?
Class I - no limitation (but do have heart disease)
Class II - slight limitation of ordinary activity, on marked exertion
Class III - marked limitation of less than ordinary activity, e.g: on minimal activity
Class IV - severe limitation of minimal activity or symptoms at rest
Signs of right-sided heart failure?
Raised JVP
Ankle/sacral pitting oedema - venous congestion changes hydrostatic pressure in capillaries
Hepatic congestion - liver is vulnerable to circulatory disturbances so right-sided heart failure causes this
Apex beat in mitral stenosis?
Tapping apex
Apex beat in left ventricular dilatation?
There is volume overload and a displaced and diffuse apex
Apex beat in left ventricular hypertrophy?
There is pressure overload and a displaced and heaving apex
Sometimes, the apex is be displaced. Heaves may be felt though
When do parasternal heaves occur?
Thrusting feeling
When there is right ventricular overload due to COR PULMONALE (right-sided heart failure secondary to pulmonary hypertension and lung disease)
What is a cardiac murmur?
Audible turbulence of blood flow
Types of cardiac murmurs?
Innocent and pathological
Important information when describing murmurs?
Systolic or diastolic murmur?
What type of murmur?
Where is it loudest?
Where does it radiate to?
What grade of murmur?
Is the murmur influenced by breathing?
Differentiating between systolic and diastolic murmurs?
Feel carotids:
Systolic murmurs occur after S1 and are in time with the pulse
Diastolic murmurs occur after S2 and will not be in time with the pulse
Types of systolic murmurs?
Pansystolic - heard at a constant volume throughout systole
Ejection systolic - increase in volume towards S2 before dropping off
ADD PICTURE
Types of diastolic murmurs?
Early diastolic - decrease in volume towards S1
Mid-diastolic (rumbling) - variable volume towards S1 (increase, decrease, increase in volume)
Where do murmurs commonly radiate to?
Carotids (aortic stenosis)
Axilla (mitral regurgitation)
Grading system of murmurs?
I - very quiet II - quiet but easy to heart III - loud IV - loud with a thrill V - very loud with a thrill VI - loud and audible without a stethoscope
How does inspiration affects murmurs?
Right-sided murmurs tend to be louder with inspiration
When are systolic clicks heard?
Mitral valve prolapse (two valve flaps do not close evenly)
When is a continuous murmur heard?
Ventricular-septal defect (can occur post-MI)
When is a pericardial rub heard?
Heard throughout the cycle and indicates pericarditis (swelling of pericardial sac)
Features of innocent (functional) murmurs?
Soft (less than 3/6 severity)
Position-dependent (these murmurs tend to be influenced by venous return so position changes are important)
Often early systolic murmurs (diastolic murmurs are never innocent)
No thrills are felt
What is valve stenosis?
Valves which do not open properly, e.g: aortic stenosis (most common valve lesion)
What is valve regurgitation?
Valves which do not close properly
What is mixed valve disease?
Valves which neither open properly nor close properly - mixture of stenosis and regurgitation
Causes of aortic stenosis?
Degenerative (age-related) due to calcification
Congenital, e.g: a common abnormality is the aortic bicuspid valve (should have 3 cusps)
Rheumatic
3 symptoms of aortic stenosis?
Breathlessness
Chest pain - coronary arteries are above aortic valve so coronary perfusion is affected
Dizziness/syncope
3 signs on examination of aortic stenosis?
Low volume pulse - not enough blood being pumped into systemic circulation
Forceful displaced apex - left ventricular hypertrophy (tall QRS complexes on ECG)
Ejection systolic murmur that can radiate to carotids
Treatment of aortic stenosis?
Conventional valve replacement - very successful; mostly normal life span if there is no left ventricular hypertrophy
Trans-catheter aortic valve replacement (TAVI) - crush valve with stent-balloon
Balloon aortic valvotomy (BAV) -
Types of prosthetic heart valves and facts?
Mechanical - longevity is an advantage and tend to be used in younger patients; will be on life-long warfarin
Bio-prosthetic - normally last 10 years and tend to be used in older patients; no warfarin is required
Valve replacement vs TAVI?
Valve replacement is still preferred due to good long-term outcomes, there are no contra-indications and a CABG can be done at the same time (all patients will have a coronary angiograph beforehand)
TAVI - tends to be used in those with co-morbidites and if they have had a previous sternotomy
Causes of mitral regurgitation, separated into broad categories?
Leaflets: Prolapse (can be congenital or due to chordae rupture) Rheumatic (immune complex deposition) Myxomatous (floppy leaflets) Endocarditis
Chordae rupture (tends to be degenerative and age-related) - prolapse/flail leaflet
Papillary muscle rupture - ischaemic
Annular (ring attached mitral valve) dilatation - functional (there is poor leaflet apposition)
Symptoms of mitral regurgitation?
Breathlessness
Pulmonary oedema
Fatigue
Examination signs of mitral regurgitation?
Displaced apex
Pansystolic murmur that radiate to the axilla
Cardiomegaly on CXR
Treatment of mitral regurgitation using medication, surgery, etc?
Medications - diuretics (for functional mitral regurgitation with heart failure); also, ACEIs
Surgical:
Repair - only an option for mitral valve prolapse
Replacement
Percutaneous - clips in infancy are showing encourgaing results so far
Causes of mitral stenosis?
Essentially, RHEUMATIC is the main cause
Rare causes include congenital
Symptoms of mitral stenosis?
Breathlessness
Fatigue
Palpitation (AF) - many patients with mitral stenosis will get AF due to left atrial hypertrophy
Examination signs of mitral stenosis?
Malar flush - sign of advanced disease
Tapping apex beat
Mid-diastolic rumbling; a diastolic murmur that is LOCALISED at the apex
Straight left heart border on CXR
Treatment of mitral stenosis with medication, surgery, etc?
Medication - diuretics and treat AF
Surgery - valve replacement
Balloon valvuloplasty
Causes of aortic regurgitation?
Leaflets:
Endocarditis
Connective tissue diseases
Rheumatic
Annulus:
Marfans (disease of connective tissue)
Aortic dissection
Symptoms of aortic regurgitation?
Breathlessness
Examination signs of aortic regurgitation?
Collapsing pulse
Displaced apex
Early diastolic murmur at the left sternal edge (tricuspid area) - best heart with patient sitting up and holding an exhalation
Cardiomegaly on CXR
Treatment of aortic regurgitation with medication, surgery, etc?
Medications - ACEIs (for dilated left ventricle)
Surgery - to deal with symptoms and LV dilatation; options include valve replacement
