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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
Q

Most common cause of Aortic stenosis in adults

A

Degenerative calcification of aortic cusps in adults

26
Q

Most common congenital valve defect

A

Bicuspid Aortic valve

27
Q

Symptoms of Aortic stenosis

A

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
Q

3 cardinal symptoms of Aortic Stenosis

A
  • Exertional dyspnea
  • Angina
  • Syncope
29
Q

Physical Examination findings in Aortic Stenosis

A
  • 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
Q

Pulsus parvus et tardus

A

Weak and late-peaking/delayed pulse

31
Q

Characteristic murmur of Aortic Stenosis

A

ejection (mid) systolic cresecendo-decrsecendo murmur shortly after S1

32
Q

AS murmur transmitted to apex resmblin MR

A

Gallavardin effect

33
Q

Diagnostics for Aortic Stenosis

A
  • 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
Q

Management for Aortic Stenosis

A
  • 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
Q

Cause of Aortic Regurgitation

A
  • 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
Q

Symptoms of Aortic Regurgigation

A
  • 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
Q

Physical Examination Findings of AR (mostly for chronic)

A
  • 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
Q

soft low pitched rumbling mid-to late diastolic murmur

A

Austin Flint murmur

39
Q

jarring of the body and bobbing of the head with each systole in severe AR

A

De Musset sign

40
Q

Visible capillary pulsations at the root of the nail with pressure

A

Quincke’s pulse

41
Q

Booming pistol shot sound over femoral arteries

A

Traube sign

42
Q

to and fro murmur when femoral artery is compressed

A

Duroziez sign

43
Q

Bounding and forceful pulse, rapidly increasing and subsequent collapsing

A

Water-hammer (Corrigan’s pulse)

44
Q

Murmur of Chronic AR

A
  • high-itched, blowing, decrescendo diastolic murmur in 3rd ICS left PSB
45
Q

Diagnostics of Aortic Regurgigation

A
  • 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
Q

Management of Aoartic Regurgitation

A
  • Diuretics
  • ACE-I
  • vasodilators for CHF
  • Intervention:
    • Aortic valve replacement (surgery)
47
Q

Tricuspid Stenosis

A
  • Generally rheumatic in origin; does not occur in isolation and usually associated with MS
  • Almost always accompanied by severe TR
48
Q

Symptoms of Tricuspid Stenosis

A
  • Gradually developing ascites and edema (disproportionate to degree of dyspnea)
  • I with cocomittant MS: symptoms of MS present
49
Q

Physical examination findings for Tricuspid Stenosis

A
  • 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
Q

Murmur of Tricuspid Stenosis

A

diastolic murmur at lower left PSB, augmented during inspiration and reduced during expirtion and strain phase of valsalva

51
Q

Diagnostics of Tricuspid Stenosis

A
  • ECG:
    • RAE (RVH if with cocomitant TR)
  • 2D echo:
    • restriction in opening snap of the TV
52
Q

Management of tricuspid Stenosis

A
  • Salt restriction, bed rest, and diuretics
  • Intervention:
    • Tricuspid valve replacement surgery
53
Q

Physical Examination findings of tricuspid Regurgitation

A
  • Distended neck veins, hepatomegaly, ascites, hepatojugular reflux
  • Prominent RV pulsation along left parasternal region
  • Carvallo sign
54
Q

blowing holosystlic murmur at LPSB instesified by inspiration

A

Carvallo sign

55
Q

Diagnostics of Tricuspid regurgigation

A
  • ECG
    • RAE, RVH
  • 2D echo:
    • mosaic color flow across tricuspid valve during systole
56
Q

Management if tricuspid Regurgigation

A
  • isolated TR is usually tolerated and does not require surgery
  • Intervention:
    • valve annuloplasty or replacement (surgery) for severe cases
57
Q

Most common abnormality is regurgitation form severe pulmonary arterial hypertension

A

Pulmonary valve disease

58
Q

high pitched decrescendo, diastolic blowing murmur along the left sternal border seen in Pulmonic valve disease

A

Graham Steell murmur

59
Q

Intervention for Pulmonic valve disease

A

Percutaneous pulmonic valve replacement for severe PR

Internal Medicine (IM platinum) (14 decks)

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