Valvular Heart Disease Flashcards
What are the most common conditions encountered today?
Degenerative (senile calcifications)
Myxomatous degeneration (MVP)
Congenital (bicsupid aortic valve)
What is stenosis
Impeding of forward flow
Stenotic, sclerotic fibrosis, calcification
leads to pressure overload; hypertrophy and HF
What is regurgitation
Failure to close adequately (leaks)
Causes a reversal of flow, insufficiency, incompetence, leads to volume overload; dilates
Implies insufficiency (aka)
Discuss the mechanism of acquisition for VHD what is the difference between acute and chronic disease
Congenital, acquired
Acute they decompensate very rapidly
Chronic slow breakdown of the valve
Rheumatic Heart disease
Caused by Group A strep infection (pharyngitis)
Jones major criteria- carditis- inflammation of heart muscle
Migratory polyarthritis (large joints) knees and hips
SubQ nodules (painless, over bone and tendon)
Chorea
Erythema Marginatum
What is the Jones Minor Criteria
Fever, Arthralgia, Increased Sed rate or CRP, Leukocytosis, ECG- prolonged PR internal
Elevated ASO titer or anti- DNAse B
How do you Dx rheumatic fever
Two major criteria or one major and two minor criteria
Discuss Mitral Stenosis including it’s subsequent LAE and RVH. What determines severe stenosis
Normal mitral orifice 4-6 cm.
Narrowing leads to increased left AV pressure gradient and RVH. 1 cm or less is considered severe
When does MS sx start to occur? and what are those sx?
4th decade of life, DOE, cough, orthopnea, PND, pulmonary edema, hemopytsis, arterial emobli, a fib
Ortner syndrome: Hoarseness d/+ compression of left recurrent laryngeal nerve
What will you find on physical exam of MS
Malar flush- ruddy cheeks, blue facies. Increased S1; opening shape (OS) after S2
Rumbling, diastolic murmur- low pitched; best heard at apex. Use Bell
What is the Tx of MS
AC if in A fib,
Percutaneous balloon valvuloplasty; MVR (replacement)
Possible RVF
What could pt’s develop progressive sx leading to RVF
Increased LA pressure, pulmonary HTN, pulmonary edema, hepatomegalia, ascites, peripheral edema
What is the trademark of Left atrial enlargement on ECG
Notched P in I
Biphasic P wave in V1
What are some etiologies of chronic MR?
MVP- most common
MAC( mitral annlar calcification)
What are some acute causes of mitral regurgitation?
Rupture of chordal tendineae
Rupture of papillary muscle
Ischemic papillary muscle dysfunction (CAD/MI: next most common of MR) Infective endocarditis (IE); valve perforation
What is the pathophysiology of MR (acute and chronic)?
Acute Increased LA pressure abruptly; pulmonary edema, LVF
Chronic- generally well compensated
What are some MR symptoms?
Asymptomatic for years-> fatigue, DOE
Acute; Volume overload/ orthopnea, PND, RHF/LHF
What would you find on physical exam for MR
Systolic mumur (blowing, prominent at apex; radiates into left axilla)
Loudness of murmur correlates with severity
Decreased S1 or normal; may have a systolic click
What is the tx of MR?
Vasodilators- to reduced afterload
Decrease resistance to flow
ACEi- chronic MR
What is MVP, who is more likely to get it? Are there any associated congenital conditions with this condition?
One or both mitral leaflefts will prolapse into LA during systole to cause MR
7:1 ratio female associated with Marfans/skeletal changes
What are the symptoms of MVP?
Asymptomatic to arrhythmias (SVT, PVC’s, VT), chest pain, syncope
Systolic murmur, may have systolic click
Rx. If hyper adrenergic state (anxious, palpitations, consider B-blockers)
What is favored, valve repair or replacement for MVP?
Valve repair
What is the tx of MVP and thyroid disorder?
Rx- B-blocker for hyper-adrenergic state
Regulate thyroid meds
What is the etiology of Aortic Stenosis
Degenerative (calcific or senile) congenital bicuspid aortic valve (BAV) rheumatic or post inflammatory scarring
Normal AoV area is 4.0 cm
What is the pathophysiology of AS
Obstruction leads to pressure overload; LVH, increase LVED pressure
Gradient across valve
Severe AS if AoV<1.0 cm
What are the Sx of AS
6th decade of life: Exertional dyspnea, angina, syncope, heart failure
W/o tx there is a poor prognosis
W/o tx most will die within 3 yrs of developing syncope and within 2 yrs of onset of HF
What physical exam findings would you find in AS?
Narrow pulse pressure; decreased SV and systolic pressure
Delayed pulses- parvis/Tardus
Systolic murmur, harsh, 2nd ICS RSB; radiates into supra sternal notch/carotid
Gallavardin phenomenon- murmur radiates to apex
What is the Tx of AS?
Percutaneous balloon valvuloplasty- temporary AVR (aortic valve replacement)
Types of Valves
What is aortic regurgitation (AR)?
Due to leaflet abnormalities (bicuspid AoV, IE)
Due to aortic root abnormalities (Marfans syndrome, aortic dissection, aging, HTN)
What are the causes of acute and chronic AR?
Acute- IE, aortic dissection, BAV
Chronic- Syphilis, ankylosing spondylitis
What is the pathophysiology of AR?
Distinguish pathophysiology between acute and chronic AR
Volume overload can increase LVEDH, LVH, left sided HF
Symptoms- depends on rapidity of onset
Acute AR- IE, aortic dissection/ acute pulmonary edema, cardiogenic shock
Chronic- Develops over time/dyspnea, orthopnea, PND, CP
What is the PE of AR?
Also delineate the differences between the signs (8 in total)
Wide pulse pressure De Musset Sign Corrigan's pulse Quincke's pulse Traube's sign Durozrey's sign Hill's sign Bisferious pulse Diastolic decrescendo murmur 3rd ICS LSB Systolic murmur usually present, soft Austin Flint murmur, can mimic MS
What is the Tx of AR?
ARB- decreases afterload to decrease regurgitation volume
Surgery AoVR when symptomatic or EF <55%
What is TS?
Associated with MS, TR, RHD
What is the pathophysiology of TR?
Prominent “A” wave of JVP ascites, hepatomegalia (may pulsate)
What is on the PE of TS?
Diastolic murmur LSB; increase with inspiration (carvallo’s sign) and decrease with expiration and valsalva
What is associated with Tricuspid Regurgitation (TR)?
Pulmonary HTN, inferior MI/RV infarction and others
What is the phatophysiology of TR?
Prominent “v” wave in JVP
What will you find on PE or TR
Blowing systolic murmur LSB; increase with inspiration (Carvallo’s sign)
Describe Pulmonary Stenosis including inheritance patterns, PE findings, what it is associated with and tx
Can be congenital, can cause angina and syncope
ON PE- systolic murmur and ejection click
2nd-3rd ICS, LSB/radiates toward left shoulder and increases on inspiration/RVH
Associated with- TOF or TGA
May require balloon commissurotomy if pressure gradient >50 mmHg
What is the most likely cause of pulmonic regurgitation (PR or PI)
Most due to pulmonary HTN
What type of murmur will you find with pulmonic regurgitation?
Diastolic blowing murmur 2 SB (graham Steell)
What type of murmurs are associated with systole?
MR (MVP), TR
AS, PS
VSD
Aortopulmonary shunts (early, mid, late, holosystolic/pansystolic)
What murmurs are associated with diastole?
AR, PR, MS, TS atrial myxoma
what is associated with continuous murmurs?
PDA- machinery
AV fistula
ASD with high LA pressure
Coarctation
What is a wide pulse pressure? What is it associated with?
ex 160/100; associated with AR
What is De Musset Sign? What is it associated with?
Head bobs with systolic beats, associated with AR`
What is Muller’s Sign? What is it associated with?
Uvula moving with each systolic beat; associated with AR
What is Corrigan’s Pulse? What is it associated with?
Rapid upstroke of sounds(?); AR
What is Quincke’s Pulse; What is it associated with?
Pulsations at the nailbeds when it comes and goes
What is Traube’s sign? What is it associated with?
Pistol shot type of sound on ausculation; AR
What is Durozerey? What is it associated with?
Compression of the arteries 2/4 murmur of the arteries; AR
What is Hill sign? What is it associated with?
Systolic blood pressure that is higher in the legs than in the arms; AR
What is bisferious pulse? What is it associated with?
It has a double peak to it’s sound on auscultation ; AR
