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Cardiology > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

Causes of aortic stenosis.

A

Senile calcification - most common
Congenital - bicuspid valve
William’s syndrome
Rheumatic heart disease

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2
Q

How does AS present

A

Think of AS in any elderly patient with

  • chest pain
  • exertional dyspnoea
  • syncope
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3
Q

What is the classic triad of AS

A

Angina
Syncope
Heart failure

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4
Q

Clinical features of AS

A 
Chest pain
Syncope
Dyspnoea 
Dizziness
Faints 
Systemic emobli - if infective endocarditis 
Sudden death
Slow rising pulse with narrow pulse pressure 
- feel for diminished and delayed carotid upstroke 
Heave 
Non-displaced apex beat 
LV heave 
Aortic thrill
Ejection systolic murmer
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5
Q

Describe the murmurs associated with AS

A

Ejection systolic murmur - aortic stenosis murmur
- heard at the base, LL sternal adge and over the aortic region
- radiation to carotids
Quiet A2 - inaudible in severe stenosis
May be an ejection click or a fourth heart sound

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6
Q

What investigations should be performed in ?AS

A 
ECG
CXR
Echo - diagnostic 
Cardiac catheter 
- assesses valve gradient, LV function, coronary artery disease
- risk of generating an embolus
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7
Q

Describe changes on ECG in AS

A 
LVH with strain pattern
P-mitrale 
Left axis deviation
Poor R-wave progression 
LBBB
Complete AV block (due to the calcified ring)
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8
Q

Describe CXR changes in AS

A

LVH
Calcified aortic valve
Post-stenotic dilation of the ascending aorta

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9
Q

Describe the use of echo in AS, and what can be seen

A

Doppler echo can estimate the gradient across the valves
- severe if peak gradient >40mmHg (but beware this may be due to a poor left ventricle not being able to generate the gradient)
Size of valve area <1cm2
If aortic jet velocity is >4m/s there is an increased risk of complications

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10
Q

Differential diagnoses for AS

A

Hypertrophic cardiomyopathy

Aortic sclerosis

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11
Q

What is aortic sclerosis

A

Senile degeneration of the valve
Ejection systolic murmur present, but no carotid radiation
Normal pulse - character and radiation
Normal S2

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12
Q

Management of AS

A

Symptomatic - poor prognosis without surgery
- prompt valve replacement recommended
Non-symptomatic
- if severe stenosis and a deteriorating ECG, valve replacement is also recommended
If patient isn’t medically fit for surgery
- percutaneous valvuloplasty /replacement (TAVI - transcatheter aortic valve implantation)

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13
Q

Causes of acute aortic regurgitation

A

Infective endocarditis
Chest trauma
Ascending aortic dissection

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14
Q

Causes of chronic aortic regurgitation

A 
Congenital 
Connective tissue disorders - Marfan's syndrome, Ehlers-Danlos
Rheumatic fever 
Takayasu arteritis 
Rheumatoid arthritis 
SLE
Seronegative arthritides (AnkSpond, psoriatic arthropathy)
Hypertension
Osteogenesis imperfecta
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15
Q

Signs and symptoms of AR

A 
Exertional dyspnoea
Orthopnoea 
PND e.g. coughing at night 
Palpitations
Angina 
Syncope 
Collapsing pulse 
Wide pulse pressure 
Displaced, hyperdynamic apex beat 
High pitched, early diastolic murmur - heard best in expiration with the patient sat forwards 
Carotid pulsatation 
Head nodding with each heartbeat 
Capillary pulsation in nail beds 
Pistol shot sound over the femoral artery
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16
Q

Investigations required in ?AR, and what would you expect to see

A

ECG - LVH
CXR - cardiomeagly, pulmonary oedema and dialted ascending aorta
Echo - diagnostic
Cardiac catheterisation - assesses severity of lesion, anatomy of the aortic root, LV function, coronary artery disease and other valve diseases

17
Q

Management of AR

A

Goal of medical therapy is to reduce systolic hypertension
- ACEI
Echo every 6-12 months to monitor
Valve replacement surgery - aim to perform before significant LV dysfunction occurs

18
Q

When is surgery indicated in AR

A

Severe AR with enlarged ascending aorta
Increasing symptoms
Enlarging left ventricle or deteriorating LV function on echo
Infective endocarditis refractory to medical therapy

19
Q

What is mitral regurgitation

A

Backflow through the mitral valve during systole

20
Q

Cause of MR

A 
Functional - LV dilatation 
Annular calcification - elderly 
Rheumatic fever 
Infective endocarditis
Mitral valve prolapse 
Ruptured chordae tendinae 
Papillary muscle dysfunction and rupture (e.g. post-MI)
Connective tissue disorders
Cardiomyopathy
Congenital - more likely to be associated with other defects as well
21
Q

Clinical features of MR

A 
Dyspnoea 
Fatigue 
Palpitations 
Symptoms of causative factor - e.g. fever 
AF
Displaced, hyperdynamic apex beat 
Pansystolic murmur - apex radiating to axilla 
Soft S1 and split S2
Loud P2 if pulmonary hypertension
22
Q

Investigations required in ?MR

A

ECG - P-mitrale if in sinus rhythm (indicates increased LV size) and LVH
CXR - large LA and LV, mitral valve calcification and pulmonary oedema
Echo
Cardiac catheterisation - confirms diagnosis, excludes other valve disease and assesses coronary artery disease

23
Q

Describe the use of echo in the assessment of MR

A

Assesses LV function and MR severity and aetiology

TOE is required to assess severity and suitability for repair rather than replacement

24
Q

Management of MR

A 
Control rate if caused by fast AF
Anticoagulation if
- AF
- history of embolism 
- prosthetic valve 
- presence of mitral stenosis as well
Diuretics improve symptoms 
Surgery 
- indicated in deteriorating symptoms 
- aim to replace or repair the valve before LV is irreversibly impaired
25
Q

What is mitral valve prolapse + and what can it often occur with

A 
Most common cause of valvular abnormality 
Occurs alone or with 
- atrial septal defect
- patent ductus arteriosus 
- cardiomyopathy 
- Turner's syndrome 
- Marfan's syndrome 
- osteogenesis imperfecta 
- WPW
26
Q

Signs and symptoms of mitral valve prolapse

A 
Asymptomatic 
Atypical chest pain 
Palpitations
Autonomic dysfunction symptoms 
Mid-systolic click and/or late systolic murmur
27
Q

Complications of mitral valve prolapse

A

Mitral regurgitation
Cerebral emboli
Arrhythmias
Sudden death

28
Q

Investigations and treatment in mitral valve prolapse

A

Echo - diagnostic
ECG - may show inferior T-wave inversion
Management
- beta-blockers to help palpitations and chest pain
- surgery if associated with severe MR

29
Q

Cause of mitral stenosis

A 
Rheumatic fever 
Congenital 
Mucopolysacchardisoses
Malignant carcinoid
Prosthetic valve
30
Q

How does MS present

A 
Symptoms start when mitral valve orifice <2cm2
Pulmonary hypertension 
- dyspnoea 
- haemoptysis 
- chronic bronchitis-like picture 
Pressure from the large left atrium on local structures 
- hoarseness (recurrent laryngeal nerve)
- dysphagia 
- bronchial obstruction 
Fatigue 
Palpitations 
Chest pain 
Systemic emboli 
Infective endocarditis
31
Q

Signs found when examining a patient with MS

A

Malar flush - decreased cardiac output
Low-volume pulse
AF common - due to enlarge left atrium
Tapping, non-displaced apex beat (palpable S1)
RV heave
Auscultation
- loud S1
- opening snap
- rumbling mid-diastolic murmur (heard best in expiration with patient on left hand side)
- the longer the murmur and the closer the opening snap is to S2, the more severe the MS

32
Q

Investigations required in ?MS

A

ECG - P-mitrale, RVH, progressive RAD
CXR - left atrial enlargement, pulmonary oedema and mitral valve calcification
Echo - diagnostic
?Cardiac catheterisation

33
Q

Indications for cardiac catheterisation in MS

A 
Previous valvtomy 
Signs of other valve disease 
Angina 
Severe pulmonary hypertension 
Calcified mitral valve
34
Q

Management of MS

A 
If in AF 
- rate control 
- anticoagulation with warfarin 
Diuretics reduce preload and pulmonary venous congestion 
If symptoms still present 
- vavuloplasty (if pliable, non-calcified valve)
- open mitral valvotomy
- valve replacement

Cardiology (13 decks)

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