Valvular Heart Disease Flashcards
What is seen in HCM that is not in aortic stenosis?
Aortic valve not calcified
Similar murmur but louder if pts stands or valsalvas (decrease venous return)
Similar ejections sounds and sxs
Etiologies of aortic regurgitation
Rheumatic valvular disease (most), bicuspid aortic valve, dilated aortic root, bacterial endocarditis, senile degeneration, RA, Marfans, Ehlers-Danlos
What is an Austin Flint murmur?
Soft, low pitched diastolic murmur at the apex that sounds like a mitral stenosis murmur
Management of acute mitral regurgitation
Urgent stabilization (IV nitroprusside) and prep for surgery
Describe the murmur of aortic stenosis
Systolic ejection murmur Grade 3-4/6 Crescendo-decrescendo, blowing Max intensity at 2nd RICS or apex Radiates along carotids into neck
Management of mitral valve prolapse
Mostly just reassure pt because it is mild (lifestyle changes)
BBs for palpitations
Treat concurrent MR if have
Etiology of aortic stenosis 30-65
Congenital bicuspid valve which becomes calcified and stenotic (see about half calcified by age 50, can all see rheumatic valve disease)
Management of acute aortic regurgitation
Urgent cardiology consult for meds and maybe valve replacement
Murmur seen in mitral stenosis
Loud S1 with opening snap (early diastolic sound of forcing the valve open) followed by a mid diastolic rumbling murmur
Best heart at apex in left lateral decubitus with bell
Other manifestations of mitral valve prolapse
Palpitations, DOE, dizziness/syncope, anxiety disorders, numbness/tingling, skeletal abnormalities, abnormal ECGs
When do you start thinking about surgery with regards to valve area in aortic stenosis?
<1 cm2 (normal is 3-4)
How does mitral regurgitation happen?
Abnormality to any part of apparatus (leaflets, chordae tendinae, papillary muscles, valve annulus)
Most common symptom of mitral valve prolapse
Atypical or non-anginal chest pain
Management of chronic aortic regurgitation
Asymptomatic and mild: just follow
Vasodilators reduce regurgitant volume and increase EF (ACE-i most helpful) - delay need for replacement
Avoid isometric exercises
Repair when symptomatic/severe or asymptomatic pts with EF<50 at rest
Murmur of aortic regurgitation
High pitched diastolic decrescendo murmur heard best at aortic area and left sternal border (where left ventricle is)
General sxs of all valvular diseases
Fatigue, dyspnea/orthopnea/PND, angina, syncope, palpitations
Etiologies of mitral regurgitation
Papillary muscle necrosis secondary to ischemic heart disease Inherited Rheumatic heart disease Acquired Idiopathic Congenital maldevelopment
Surgical options for chronic mitral regurgitation
Valvuloplasty to repair or valve replacement
Sxs of mitral stenosis
Usually due to the pulmonary congestion
Sxs of aortic stenosis
Early: DOE, fatigue, decreased exercise tolerance
Later: dyspnea with normal activity and triad of angina, syncope and heart failure
What events can precipitate the sxs of mitral stenosis?
Sudden exertion, excitement, fever, severe anemia, tachycardia, intercourse, pregnancy, thyrotoxicosis, a fib
Describe the murmur of mitral regurgitation
High pitched, pan systolic murmur that is loudest at apex and radiates to axilla
Management of mitral stenosis
Anticoagulate for a fib, hx of emboli or significant LAE on echo (Warfarin to 2-3)
Valve surgery for progressive sxs (valvuloplasty, mitral commisurotomy or prosthetic valve)
What might you see on a CXR with aortic regurgitation?
Cardiac to thoracic width ratio > 50%
Reasons for acute aortic regurgitation
Aortic dissection or infective endocarditis
How to manage symptomatic aortic stenosis
Cardiac catheterization (evaluate severity and site of stenosis) Maybe valve replacement (only when severe by echo and symptomatic)
What is mitral valve prolapse?
Ballooning of mitral leaflets into the left atrium during systole due to excess mitral valve tissue
Management of mild mitral stenosis
Diuretics and sodium restriction
How do you anticoagulate a pt with a valve replacement?
Prosthetic: last longer than require life long anticoagulation with warfarin (to INR of 2.5-3.5)
Tissue: don’t last as long but don’t require lifelong anticoagulation
Other physical exam findings of aortic stenosis
Thrill in 2nd RICS or suprasternal notch
Early systolic ejection click
Narrow PP! (severe disease)
May see S4 due to vigorous left atrial contraction
Correlation between sxs of aortic stenosis and mortality
Mortality is minimal in asymptomatic phase
After they develop, mortality is significant (2-3 yr survival without valve replacement)
When does rheumatic heart disease occur?
After GAS pharyngitis
Management of asymptomatic aortic stenosis
Mild: follow, educate about sxs
Moderate: annual ECG/echo/CXR
Moderate-severe: cardio eval and close follow up
3 classifications of aortic stenosis
Aortic valve (75%)
Supravalvular (congenital or post op)
Subvalvular (congenital or HCM)
*may cause same sxs at any levels
What findings might be seen late in the disease?
Loud P2 and RV heave (right heart failure)
Management for acute aortic regurgitation
Urgent: stabilize (diuretics or vasodilators), surgery is usually necessary within 24 hrs of diagnosis
Tricuspid and pulmonic valve disorders
Usually congenital anomalies in infancy and childhood
Adults: rheumatic scarring or connective tissue disease
Tx: sodium restriction, diuretics, surgery
What can develop due to LAE of mitral regurgitation?
A fib (may later see pulmonary HTN and RVH)
Correlation between mitral stenosis and a fib
40-50% pts with MS will have a fib (might also have systemic emboli)
What does chronic aortic regurgitation result from?
LV overload with gradual dilation and hypertrophy (why asymptomatic for a while and then start developing DOE)
What does a late peak of the murmur in aortic stenosis suggest?
Severe obstruction
Tx for HCM
CCBs or BBs
What valvular disorders will we see develop acutely?
The regurgitations
Most common cause of mitral stenosis
Rheumatic heart disease
Other physical findings of aortic regurgitation
Wide PP (water hammer or corrigan pulse) May also have harsh systolic ejection murmur (if have aortic stenosis too) Austin flint murmur
Reasons for acute mitral regurgitation
Papillary muscle necrosis/rupture from ischemia or endocarditis
HCM classified as aortic stenosis
Subvalvular
Diagnostic results of aortic stenosis
ECG: normal until severe, LVH overtime
CXR: normal until late, maybe post-stenotic dilation of aorta, may see calcification
Echo: immobile, calcified leaflets, LVH, aortic gradient and reduced valve area
Management of acute mitral regurgitation
It is poorly tolerate so pts are miserable and often need emergent surgery
Types of prosthetic aortic valves
Ball and cage (driven by pressure)
Tilting
Etiology of aortic stenosis under age 30
Congenitally stenotic or unicuspid valve
Acute aortic regurgitation
LV pressure rises rapidly
Pulmonary edema or cardiogenic shock may develop rapidly (can’t compensate for vol overload)
Traumatic rupture of valve cusp is rare
Etiology of aortic stenosis over age 65
Degeneration and sclerosis of valve (accounts for most cases)
Medical management of chronic mitral regurgitation
Afterload reduction: ACE-i and vasodilators
Preload reduction: sodium restriction and diuretics
Digitalis
Anticoagulation for a fib: warfarin to 2-3
No abx prophylaxis
What maneuvers change the aortic stenosis murmur?
Louder with squatting (because increase venous return and ventricular filling)
What happens between ARF and symptomatic mitral stenosis?
20 yrs
Leaflets diffusely thicken because of fibrous tissue/calcium deposits
Become immobilized and rigid so it narrows
Pt education for aortic stenosis
Avoid strenuous activity
Avoid dehydration
Signs of worsening disease (exertional dizziness, dyspnea, palpitations)
*no abx prophylaxis
What does rheumatic heart disease encompass?
Acute rheumatic fever, pericarditis, myocarditis and valvular lesions
What do you hear on auscultation in mitral valve prolapse?
Mid-late systolic click often present
Who needs antibiotic prophylaxis?
Those with a prosthetic valve or previous infective endocarditis who have dental procedures or invasive procedures that might expose blood
Other physical exam findings for mitral regurgitation
S3 gallop at later stages
With pulmonary HTN- S4 gallop, loud P2 and RV heave
JVD, hepatomegaly, edema (RV failure)
