Valvular heart disease

Question 1

Which are the 4 types?

Answer 1

Aortic stenosis
Aortic regurgitation
Mitral stenosis
Mitral regurgitation

Question 2

Which are the 2 most common types?

Answer 2

aortic stenosis and mitral regurgitation

Question 3

What is rheumatic fever?

Answer 3

an inflammatory disease that can involve the heart, joints, skin and brain
(its an autoimmune reaction - not an infection)

Question 4

What causes rheumatic fever?

Answer 4

Pharyngeal infection with streptococcus progenies

group A beta-haemolytic streptococcus

Question 5

Causes of aortic stenosis

Answer 5

Congenital - bicuspid aortic valve: presents later in life

Acquired:

1. degenerative: calcific valve disease
2. Rheumatic fever

Question 6

Pathophysiology of aortic stenosis

Answer 6

Reduced CO

LV hypertrophy

Question 7

Which valves in the heart have how many cusps?

Answer 7

All have 3 (tricuspid, aortic, pulmonary) except the mitral valve has 2

Question 8

Which side of the heart is the mitral valve?

Answer 8

left

Question 9

Symptoms of severe aortic stenosis

Answer 9

ABS

Angina - from LV hypertrophy
Breathlessness - due to HF
Syncope - exercise induced

Question 10

Signs of aortic stenosis

Answer 10

Ejection systolic murmur radiating to the carotids
Slow-rising pulse (weak and late)
LV heave
Systolic thrill over aortic area

Question 11

Causes of aortic regurgitation

Answer 11

1. Rheumatic fever

2. Infective endocarditis (likes to sit on previously damaged valves)

Question 12

Pathophysiology of AR?

Answer 12

LV failure as LV has to work harder & harder to pump sufficient blood

Question 13

Symptoms of AR?

Answer 13

Asymptomatic until LV failure occurs

• exertion dyspnoea
• orthopnoea (SOB when lying flat)
• paroxysmal nocturnal dyspnoea
• fatigue

Question 14

How would you hear an early diastolic murmur in AR?

Answer 14

left sternal edge, high pitch

Question 15

Signs of AR

Answer 15

1. Collapsing or water-hammer pulse
2. Deviated apex beat
3. Other signs e.g. Corrigan’ sign: carotid pulsation, de Musset’s sign: head nodding with each heart beat

Question 16

Cause of mitral stenosis

Answer 16

Secondary to previous rheumatic fever

Question 17

Pathophysiology of mitral stenosis

Answer 17

inflammation –> over time: valve thickening, calcium deposition, cusp fusion –> stenotic orifice, immobility of cusps

back pressure + reduced CO

Question 18

Symptoms of mitral stenosis

Answer 18

Pulmonary hypertension:

• dyspnoea
• cough - frothy blood tinged sputum

AF - palpitations

Question 19

Signs of mitral stenosis

Answer 19

mid-diastolic murmur
tapping apex beat
pink cheeks - malar flush (low CO)
AF
distension of jugular veins
RV heave (from pulm HTN - RHF)

Question 20

Mitral regurgitation - causes

Answer 20

1. Rheumatic fever (50%)
2. Mitral valve prolapse
3. Others: IHD, cardiomyopathies, IE

Question 21

Mitral regurgitation pathophysiology

Answer 21

LV failure

Question 22

Mitral regurgitation signs and symptoms

Answer 22

• *Pansystolic murmur** - heard best at apex (pan systolic = persisting throughout systole)
  2. deviated apex beat
  3. LV failure symptoms
  4. Soft S1, loud S2 (pulm hypertension)

Question 23

Treatment of valvular heart disease

Answer 23

Medical 
- treat HF if they have it
Surgical
- valvoplasty: dilate the valve with a balloon for stenotic valves
- **valve replacement**

Question 24

What valve issue is atrial fibrillation associated with

Answer 24

mitral stenosis as the enlarged atrium disrupts the normal electrical pathways

Question 25

What are the earlier signs of pulm oedema?

Answer 25

upper lobe blood diversion
kerley B lines
as fluid infiltrates the interstitial
bibasal crepitations

Question 26

if backlog from pulmonary oedema continues back into the right heart, what signs of right sided HF will be evident?

Answer 26

raised JVP

bilateral pedal oedema (foot)

Question 27

How is rheumatic fever diagnosed?

Answer 27

Jones Criteria

• either 2 major criteria
• or 1 major and 2 minor

Question 28

What are the major diagnostic criteria for rheumatic fever?

Answer 28

• carditis
• polyarthritis
• chorea (jerky involuntary movements)
• erythema marginatum (v. specific rash)
• subcut nodules

Question 29

What are the minor diagnostic criteria for rheumatic fever?

Answer 29

fever
arthralgia
previous r. fever or rheumatic heart disease
ESR/CRP/leukocytosis
prolonged PR interval

Question 30

what are s1 and what is s2 heart sounds?

Answer 30

s1 - due to AV valvue closure (mitral & tricuspid)

s2 - due to semilunar valve closure (aortic & pulmonary)

Question 31

When would you get systolic murmurs?

Answer 31

(during systole)

• aortic/pulmonary valve stenosis
• mitral/tricuspid regurgitation

Question 32

When would you get diastolic murmurs?

Answer 32

(during diastole)

• aortic/pulmonary regurgitation
• mitral/tricuspid stenosis

Question 33

Pt has had rheumatic fever and now a rumbling mid-diastolic murmur, whats Dx?

Answer 33

Mitral stenosis

Question 34

Pt has fluid on lungs, a pan-systolic murmur and a deviated apex beat, what’s Dx?

Answer 34

Mitral regurgitation

Question 35

Pt is old, has an ejection systolic murmur, slow-rising carotid pulse, what’s the Dx?

Answer 35

aortic stenosis

Question 36

Pt has had IE, and has an early diastolic murmur, as well as a collapsing/water hammer pulse, whats the Dx?

Answer 36

aortic regurgitation