Valvular Heart Disease

Question 1

symptoms of valvular heart disease

Answer 1

chest pain
breathlessness;
related to activity
associated with ankle swelling (right-sided heart failure)
orthopnoea (breathless lying down, relived by sitting up)
paroxysmal nocturnal dyspnoea

pre-syncope
syncope

Question 2

describe the new york heart association functional classification

Answer 2

specific to breathlessness
class I - no limitation
class II - slight limitation of ordinary activity (climbing stairs)
class III - marked limitation of less than ordinary activity (walking short distance)
Class IV - sever limitation of minimal activity or rest

Question 3

signs of right heart failure

Answer 3

raised JVP (back pressure effect) (with LHS HF, the effect is on the lungs)
pitting oedema (swollen ankles, abdomen)
hepatic congestion ('big liver')

Question 4

when would the apex beat be displaced

Answer 4

in left ventricular dilation

in left ventricular hypertrophy

Question 5

when would parasternal heave be felt

Answer 5

felt on the left of the sternum

due to right ventricular overload, a result of cor pulmonale/pulmonary hypertension

Question 6

what is a cardiac murmu

Answer 6

an audible turbulence of blood flow
can be innocent or pathological
stenosis - valve not opening
regurgitation - valve not opening

Question 7

how to tell if a murmur is systolic or diastolic

Answer 7

1st heart sound;
mitral and tricuspid valve closing
start of systole

2nd heart sound;
aortic and pulmonary valves closing
start of diastole

diastolic murmurs always pathological
most common murmurs always systolic (aortic stenosis, mitral regurgitation)

Question 8

describe the different types of systolic murmurs

Answer 8

pansystolic - loud sound continuously

ejection systolic - increases in sound until aortic/pulmonary valve closes

Question 9

describe the different types of diastolic murmur

Answer 9

early diastolic - begins after 2nd heart sound and fades away
mid-diastolic - begins just after 2nd hearts sound, decreases then increases until mitral and tricuspid valves closing

Question 10

steps of describing murmurs

Answer 10

systolic or diastolic
type of murmur
where is it loudest
where does it radiate to
grade of murmur
is it influenced by respiration

Question 11

grading of murmur

Answer 11

I - very quiet
II - quiet, easy to hear
III - loud
IV - loud with thrill
V - very loud with thrill
VI - loud, audible without stethoscope

Question 12

describe murmurs influenced by respiration

Answer 12

right sided murmurs - louder with inspiration

Question 13

describe innocent (functional) murmurs

Answer 13

soft (less than grade III)
position dependent
often early systolic

Question 14

describe mixed valve disease

Answer 14

valves which neither open properly nor close properly

Question 15

tests for diagnosing cardiac murmurs

Answer 15

echo

cardiac catheterisation

Question 16

describe causes of aortic stenosis

Answer 16

degenerative - e.g. age related, calcium deposits
congenital - e.g. bicuspid valve
rheumatic diseases

Question 17

symptoms of aortic stenosis

Answer 17

breathlessness
chest pain
pre-syncope
syncope

Question 18

signs of aortic stenosis

Answer 18

low volume pulse
forceful displaced apex
ejection systolic murmur that can radiate to carotids

ECG may show;
left ventricular hypertrophy
increased size of QRS complex

Question 19

treatment of aortic stenosis

Answer 19

conventional valve replacement (insertion of prosthetic heart valve, either mechanical or bio-prosthetic) - preferred treatment
trans catheter aortic valve replacement (inserted via femoral artery, high risk of stroke) - alternative for conventional valve replacement (older patients)
balloon aortic valvotomy

Question 20

causes of mitral regurgitation

Answer 20

primary causes (the valve itself);
leaflets - prolapse, rheumatic, myxomatous (floppy), endocarditis
papillary muscles rupture - ischaemic 
chordae rupture (degenerative cause) - prolapse or flail of leaflet 

functional causes (heart failure);
annular dilatation

Question 21

symptoms of mitral regurgitation

Answer 21

breathlessness
peripheral oedema
fatigue

Question 22

signs of mitral regurugitation

Answer 22

displaced apex
pansystolic murmur
radiates to axilla

CXR - cardiomegaly

Question 23

treatment of mitral regurgitation

Answer 23

diuretics and heat failure treatment (ACE inhibitors) - prevent pulmonary hypertension!

surgical;
repair - prolapse
replacement - degenerative

percutaneous;
clips in infancy - encouraging results

Question 24

causes of mitral stenosis

Answer 24

rheumatic

congenital rare

Question 25

symptoms of mitral stenosis

Answer 25

breathlessness
fatigue
palpitations (atrial fibrillation)

Question 26

signs of mitral stenosis

Answer 26

malar flush
tapping apex beat
mid-diastolic rumbling diastolic murmur localised to apex
only heard when patient on left hand side

CXR - straight left heart border

Question 27

treatment of mitral stenosis

Answer 27

diuretics and treat atrial fibrillation
surgery - valve replacement
balloon valvuloplasty

Question 28

causes of aortic regurgitation

Answer 28

leaflets;
endocarditis
connective tissue diseases
rheumatic

annulus;
marfans
aortic dissections

Question 29

symptoms of aortic regurgitation

Answer 29

breathlessness

Question 30

signs of aortic regurgitation

Answer 30

collapsing pulse
wide pulse pressure
displaced apex
early diastolic murmur left sternal edge

CXR - cardiomegaly

Question 31

treatment of aortic regurgitation

Answer 31

ACE inhibitor (preserve left ventricular function)
surgery;
symptoms and LV dilatation
valve replacement