*Valvular heart disease Flashcards
What type of symptoms are characteristic of valvular heart disease?
Exertional symptoms (patients with even severe valve disease don’t tend to experience symptoms at rest)
What 4 features of breathlessness suggest cardiac breathlessness?
Related to activity (usually)
Often associated with ankle swelling
Orthopnoea
Paroxysmal nocturnal dyspnoea
What is a classification system used to assess the extent of heart failure’s affect on a patients functional status?
New York Heart Association Functional classification
Classes of New York Heart Association Functional classification?
Class I = no limitation
Class II = Slight limitation of ordinary activity
Class III = marked limitation of less than ordinary activity
Class IV = severe limitation of minimal activity or at rest
Signs of right heart failure? (3)
Raised JVP
Pitting oedema (ankles and sacrum (more severe heart failure if in sacrum also))
Hepatic congestion
Does right heart failure have a peripheral or central effect?
Peripheral
Tapping apex beat?
Mitral stenosis (thrusting displaced palpable (but more so than normal) apex beat
Apex beat in left ventricular dilation?
Displaced and diffuse (volume overload)
Apex beat in left ventricular hypertrophy?
Displaced and heaving (pressure overload)
What causes a parasternal heave over the left parasternal edge?
Right ventricular hypertrophy (due to right ventricular overload e.g. cor pulmonale/ pulmonary hypertension)
What is a cardiac murmur?
Audible turbulence of blood flow (can be innocent or pathological)
How to describe murmurs? (6)
Timing? - systolic or diastolic Type of murmur? - ejection systolic or pan systolic/ early or mid diastolic Where is it loudest? Where does it radiate to? What grade of murmur? Does respiration influence it?
What murmur radiates to the carotid?
Aortic stenosis
What murmur radiates to the axilla?
Mitral regurgitation
What causes the first heart sound?
Mitral and tricuspid valve closing (start of systole)
What causes the second heart sound?
Aortic and pulmonary valves closing (start of diastole)
Pansystolic murmur?
Mitral regurgitation
Ejection systolic murmur?
Aortic stenosis
Early diastolic murmur?
Aortic regurgitation
Mid diastolic murmur?
Mitral stenosis
Grading of murmurs?
I - very quiet (dispute of whether it is there or not)
II - quiet - easy to hear
III - loud
IV - loud with a thrill
V - very loud with a thrill
VI - loud - audible without a stethoscope
Are right or left sided murmurs louder with inspiration?
Right-sided murmurs
What are the 12 common murmurs?
2nd sound splitting Third sound Fourth sound Systolic clicks *Innocent murmur *Mitral regurgitation *Aortic stenosis *Aortic regurgitation *Mitral stenosis Continuous murmur Tricuspid regurgitation Pericardial rub
What is the most common cause of a continuous heart murmur?
Septal defect
What is another name for an innocent murmur?
Functional murmur
What are 2 features of an innocent murmur?
Soft (less than 3/6 severity)
Position dependent
Are innocent murmurs systolic or diastolic?
Always systolic (diastolic murmurs are always pathological)
What are the 3 types of valvular heart disease and what causes each?
Valve stenosis - valves which do not open properly
Valve regurgitation - valves which do not close properly
Mixed valve disease - valves which neither open properly nor close properly
What type of symptoms will left heart failure cause?
Pulmonary symptoms and signs
What is the most common valve lesion?
Aortic stenosis
Causes of aortic stenosis?
Degenerative (age related - most commonly (calcification of the aortic valve))
Congenital (e.g. bicuspid valve)
Rheumatic
Symptoms of aortic stenosis? (3)
Breathlessness
Chest pain
Dizziness/ syncope
Signs of aortic stenosis? (4)
Low volume pulse
forceful displaced apex
ejection systolic murmur that can radiate to the carotids
Slow rising pulse
What change can aortic stenosis eventually lead to on an ECG?
Large QRS complexes due to left ventricular hypertrophy
Treatment of aortic stenosis?
Only treated if symptomatic
Treated with a valve replacement (3 different options)
Types of valve replacements possible for aortic stenosis?
Conventional valve replacement
Trans catheter aortic valve implantation (TAVI) - used if patients have co-morbidities
Balloon aortic valvotomy (BAV) - used for patients who are very frail
2 types of prosthetic heart valves?
Mechanical
Bio-prostehtic
Advantage and disadvantage of a mechanical heart valve?
Advantage = longevity
Disadvantage = require warfare to prevent valvular thrombosis
(tends to be given to younger patients)
Advantage and disadvantage of bio-prosthetic heart valve?
No warfarin
Tends to cause problems after about 10 yeas and require replacement
Comparison of aortic valve replacement and TAVI?
AVR = preferred, can do CABG at the same time and has long term better outcomes TAVI = preferred if the patient has co-orbidities that would make a general anaesthetic difficult
Causes of mitral regurgitation?
Leaflet problem (e.g. prolapse, rheumatic, myxomatous (weakening), endocarditis)
Chordae rupture (degenerative) - prolapse/ frail leaflet
Papillary muscles rupture (ischaemic)
Annular dilation (functional)
(the mitral valve is very complex meaning there are lots of reasons for mitral regurgitation)
Symptoms of mitral regurgitation?
If severe, symptoms of left heart failure
Breathlessness
Oedema
Fatigue
Signs of mitral regurgitation?
Displaced apex
Pansystolic murmur radiating to the axilla
Treatment of mitral regurgitation?
Depends on the cause:
Medication = diuretics and drug treatment for heart failure if present
Surgical = repair for prolapse, replace for degenerative
What causes mitral stenosis?
Rheumatic is the main cause
Rarely congenital
Symptoms of mitral stenosis?
Breathlessness
Fatigue
Palpitations (AF - as the left atrium tried to force blood through the aurifice, the right atrium get bigger and therefore there is a higher chance of AF)
Signs of mitral stenosis?
Malar flush
Tapping apex beat
Mid diastolic rumbling localised to the apex
Treatment of mitral stenosis?
Medication = diuretics and treat AF
Surgery = valve replacement
Ballon valvuloplasty = fragile patients
Causes of aortic regurgitation?
Leaflets (endocarditis, connective tissue diseases, rheumatic)
Annulus (marfans, aortic dissection)
Symptoms of aortic regurgitation?
Breathlessness
Signs of aortic regurgitation? (3)
Collapsing pulse
Displaced apex
Early diastolic murmur left sternal edge
What is another name for a collapsing pulse?
Water hammer pulse (blood gets forcefully pushed through and then sucked back slightly)
What causes cardiomegaly in aortic regurgitation?
Large volume of blood in the left ventricle
Treatment of aortic regurgitation?:
Medication = ACEI Surgery = valve replacement when symptoms and LV dilation
