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Internal Medicine (IM platinum) > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

Leading cause of mitral stenosis

A

Rheumatic heart disease

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2
Q

normal mitral valve orifice

A

4-6 cm2 in adults

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3
Q

Hemodynamic hallmark of Mitral stenosis

A

Blood can flow from from LA to LV if propelled by an abnormally elevated left atrioventricular pressure gradient (due to reduction in mitral orifice area ~2 cm2

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4
Q

Symptoms of Mitral Stenosis

A
  • Most common presenting symptoms
    • Dyspnea
    • fatigue
    • Decreased exercise tolerance
  • Symptoms due to reduced ability to increase cardiac output normally with exercise, elevtaed pulmonary venous pressure and reduced pulmonary compliance
  • Latent period from initial attack of rheumatic fever to development of symptoms is ~2 decades
  • Manifestations of EHart faiure during exertion or tachycardia
  • Atrial Fibrillation may develop in late stages
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5
Q

Most common PE findings in Mitral stenosis

A
  • irregular pulse caused by AF and signs of left and right heart failure
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6
Q

Physical Exam findings in Mitral Stenosis

A
  • Irregular pulse caused by AF and signs of left and right heart failure
  • Malar flush with pinched and blue facies
  • JVP: prominent a-wave (if in sinus rhythm)
  • Incospicuous LV on palpation
  • Apical early diastolic rumble preceeded by an opening snap
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7
Q

Chracteristic murmur for Mitral stenosis

A

Apical Early diastolic rumble preceeded by an opening snap

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8
Q

Diagnostics for Mitral Stenosis

A
  • CXR
    • Left atrial enlargement (LAE), right atrial enlargement (RAE), and right ventricular hypertrophy (RVH)
  • ECG
    • LAE, RAE, RVH; atrial fibrillation in severe/longstanding cases
  • 2D echo
    • doming motion of the mitral valve (anterior leaflet) during diastole with decreased valve area and restriction in opening; commisural fusion in RHD
      • Severe MS: Mitral valve area <1.5 cm2
      • Vere severe MS: Mitral valve area <1.0 cm2)
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9
Q

Management for Mitral Stenosis

A
  • For fluid retention:
    • Sodium restriction, diuretics
  • For rate control:
    • Beta-blokers, non-dihydropyridine CCB, digoxin (for AF)
  • For secondary prophylaxis(RF)
    • penicillin
  • For prevention of stroke
    • Warfarin (target INR 2-3)
  • Intervention
    • percutaneous transeptal mitral commissurotomy (PTMC) or mital valve replacement therapy
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10
Q

Causes of Acute Mitral Regurgitation

A
  • ACS with papillary muscle rupture
  • Chest trauma
  • endocarditis
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11
Q

Causes of Chronic Mitral Regurgitation

A
  • RHD
  • mitral valve prolapse
  • cardiomyopathies
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12
Q

Symptoms of Mitral Regurgitation

A
  • Acute MR: pulmonary edema and acute heart failure/shock
  • Chronic MR: may be asymptomatic if mild; heart faiure develops gradually
  • Most prominent symptoms:
    • Fatigue
    • Exertional dyspnea
    • Orthopnea
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13
Q

Most Prominent symptoms for Mitral Regurgitation

A
  • fatigue
  • Exertional dyspnea
  • orthopnea
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14
Q

Physical Examination Findings of Mitral Regurgitation

A
  • Soft S1 (or absent); S3 in acute severe MR
  • Apical holosystolic murmur of at least apex grade III
  • Hyperdynamic LC with brisk systolic impulse and laterally displaced apex beat
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15
Q

characteristic murmur of Mitral regurgitation

A

Apical hoosystolic murmur of at least grade III

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16
Q

Diagnostics for Mitral regurgitation

A
  • CXR:
    • LAE, LVH (sometimes RAE)
  • ECG:
    • LAE, LVH: atrial fibrillation
  • 2D Echo:
    • Mosaic color flow across the mitral valve during systole
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17
Q

Management for Mitral regurgitation

A
  • For fluid retention:
    • sodium restriction diuretics
  • For acute MR:
    • vasodialtors (decreases afterload and helps reduce severity of MR)
  • For prevention of stroke
    • Warfarin (Target INR 2-3)
  • Intervention:
    • mitral valve repair or replacement 9surgery), transcatheter mitral valve repair
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18
Q

Other names for Mitral Valve Prolapse

A
  • Floppy valve syndrome
  • Barlow’s syndrome
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19
Q

Mitral Valve Prolapse

A
  • More common in women 15-30 years old
  • More severe in men and >50 years old
  • Most patients are asymptomatic
  • Frequent finding in heritable connective tissue disease
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20
Q

Symptoms of Mitral valve Prolapse

A
  • Most are asymptomatic
  • Some present with palpitations or heart failure symptoms
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21
Q

Physical Examination findings for Mitral Valve prolapse

A
  • apical mid or late non-ejection systolic murmur preceded by a click
  • Murmur is accentuated by standing and strain phase of Valsalva, diminished by squatting and isometric exercises
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22
Q

Characteristic murmur of Mitral valve prolapse

A

Apical mid-or-late non-systolic murmur preceded by a click

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23
Q

Diagnostics for MVP

A
  • CXR or ECG
    • usually normal; but may have biphasic or inverted T in II, III, aVF (inferior leads) on ECG
  • 2D Echo:
    • systolic displacement of MV leaflets (prolapse) by at least 2 mm into left atrium superior to the mitral annular plane
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24
Q

Management for Mitral Valve Prolapse

A
  • IE prophylaxis for patients with prior endocarditis
  • Beta blockers for palpitations; warfarin if with AF (target INR 2-3)
  • Intervention: mitral valve repair (surgery) if with severe MR
25
Most common cause of Aortic stenosis in adults
Degenerative calcification of aortic cusps in adults
26
Most common congenital valve defect
Bicuspid Aortic valve
27
Symptoms of Aortic stenosis
Symptoms rarely present until valve orifice \<1 cm2 * Exertinal dyspnea, angina, syncope * Average time to death after onset of symptoms as follows: * angina: 5 years * Syncope: 3 years * Heart failure or dyspnea: 1.5-2 years
28
3 cardinal symptoms of Aortic Stenosis
* Exertional dyspnea * Angina * Syncope
29
Physical Examination findings in Aortic Stenosis
* Pulsus parvus et tardus * Sustained cadiac impulse and becomes displaced inferiorly and laterally with LV failure * Systolic thrill palpated in the 2nd right ICS or suprasternal notch * Ejection(mid) systolic crescendo-decrescendo murmur shortly after S1 * Murmur may be transmitted to apex resembling murmur of MR
30
Pulsus parvus et tardus
Weak and late-peaking/delayed pulse
31
Characteristic murmur of Aortic Stenosis
ejection (mid) systolic cresecendo-decrsecendo murmur shortly after S1
32
AS murmur transmitted to apex resmblin MR
Gallavardin effect
33
Diagnostics for Aortic Stenosis
* **CXR:** * rounding of apex (hypertrophy without dilation), dilated proximal ascending aorta * **ECG**: * LVH (with strain pattern) * **2D echo**: calcified aortic valve with restriction in opening; commisural fusion in RHD * **Mild AS:** AV orifice \>1.5-2 cm2 and gradient \<20 mmHg * **Moderate AS**: AV orifice 1-1.5 cm2 and gradient 20-39 mmHg * **Severe AS**: AV orifice \<1 cm2 and gradient \>40mmHg
34
Management for Aortic Stenosis
* Avoidance of strenuous activities and competitive sort (especially for symtpomatic patients) * Diuretics for CHF * Caution with the use of: * Nitrtes and afterload unloaders (ACEi/ARBs): theymay precipitate hypotension * Beta-Blockers: should generally be avoided as they can induce heart failure * Intervention: Trancetheter Aortic Valve implantation (TAVI), AOrtic Valve Repalcment or AVR (Surgery)
35
Cause of Aortic Regurgitation
* Can be caused by primary Aortic Valve disease or primary aortic root disease * Primary Valve disease: * RHD * Congenital bicuspid aortic valve * Endocarditis * Primary aortic root disease: * Aortic annular dilation * MArfan's syndrome
36
Symptoms of Aortic Regurgigation
* Acute Severe AR (e.g., endocarditis, aortic dissection): * Pulmonary edema and cardiogenic shock * Chronic severe AR: long asymptomatic period while the LV gradually enlarges * palpitations * Exertional dyspnea * heart failure
37
Physical Examination Findings of AR (mostly for chronic)
* Asutin Flint murmur * De Musset Sign * Quincke's pulse * Durozie sign * Muller sign * Water-hammer (Corrigan's pulse) * high-pitched, blowing, decrescendo diastolic murmur in 3rd ICS left PSB * Others: LV is displaced laterally and inferiorly, widened pulse pressure, abscence of A2 in severe AR
38
soft low pitched rumbling mid-to late diastolic murmur
Austin Flint murmur
39
jarring of the body and bobbing of the head with each systole in severe AR
De Musset sign
40
Visible capillary pulsations at the root of the nail with pressure
Quincke's pulse
41
Booming pistol shot sound over femoral arteries
Traube sign
42
to and fro murmur when femoral artery is compressed
Duroziez sign
43
Bounding and forceful pulse, rapidly increasing and subsequent collapsing
Water-hammer (Corrigan's pulse)
44
Murmur of Chronic AR
* high-itched, blowing, decrescendo diastolic murmur in 3rd ICS left PSB
45
Diagnostics of Aortic Regurgigation
* CXR: * apex is displaced downward and to the left in chronic severe AR (cardiac enlargement is minimal in acute AR) * ECG: * LVH usually with ST depression and T wave inversion in I, aVL, V5-6 (lateral heads) * 2D echo: * Mosaic color flow across the aortic valve during diastole
46
Management of Aoartic Regurgitation
* Diuretics * ACE-I * vasodilators for CHF * Intervention: * Aortic valve replacement (surgery)
47
Tricuspid Stenosis
* Generally rheumatic in origin; does not occur in isolation and usually associated with MS * Almost always accompanied by severe TR
48
Symptoms of Tricuspid Stenosis
* Gradually developing ascites and edema (disproportionate to degree of dyspnea) * I with cocomittant MS: symptoms of MS present
49
Physical examination findings for Tricuspid Stenosis
* Signs of Right sided heart failure * ascites * edema * hepatosplenomegaly * Opening snap of tricuspid valve ~0.06 sec after pulmonic valve closure * Diastolic murmur at lower left PSB, augmented during inspiration and reduced during expiration and strain phase of Valsalva
50
Murmur of Tricuspid Stenosis
diastolic murmur at lower left PSB, augmented during inspiration and reduced during expirtion and strain phase of valsalva
51
Diagnostics of Tricuspid Stenosis
* ECG: * RAE (RVH if with cocomitant TR) * 2D echo: * restriction in opening snap of the TV
52
Management of tricuspid Stenosis
* Salt restriction, bed rest, and diuretics * Intervention: * Tricuspid valve replacement surgery
53
Physical Examination findings of tricuspid Regurgitation
* Distended neck veins, hepatomegaly, ascites, hepatojugular reflux * Prominent RV pulsation along left parasternal region * Carvallo sign
54
blowing holosystlic murmur at LPSB instesified by inspiration
Carvallo sign
55
Diagnostics of Tricuspid regurgigation
* **ECG** * RAE, RVH * **2D echo:** * mosaic color flow across tricuspid valve during systole
56
Management if tricuspid Regurgigation
* isolated TR is usually tolerated and does not require surgery * Intervention: * valve annuloplasty or replacement (surgery) for severe cases
57
Most common abnormality is regurgitation form severe pulmonary arterial hypertension
Pulmonary valve disease
58
high pitched decrescendo, diastolic blowing murmur along the left sternal border seen in Pulmonic valve disease
Graham Steell murmur
59
Intervention for Pulmonic valve disease
Percutaneous pulmonic valve replacement for severe PR

Internal Medicine (IM platinum) (14 decks)

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