valvular heart disease Flashcards
cardiac breathlessness
> related to activity (usually)
often associated with ankle swelling
orthopnoea
paroxysmal nocturnal dyspnoea (PND)
NYHA
class 1 - can do whatever class 4 - severe limitations of minimal activity or at rest
clinical cardiology exam
general appearance arterial pulse (radial, carotid) venous pulse (JVP) palpation (apex, parasternal heave) auscultation (heart sounds and murmurs)
the signs of right HF
raised JVP
pitting oedema
hepatic congestion
Apex beat
- normal 5th intercostal space/mid clavicle line
- tapping apex in mitral stenosis
- displaced and diffuse in left ventricular dilation (volume overload)
- displaced and heaving in LVH (pressure overload)
what is a cardiac murmur?
the hearing of turbulent blood flow
how can you describe a murmur?
systole or diastole? what type of murmur? where is it the loudest? where does it radiate to? what grade of murmur? (is it influenced by respiration?)
what is the 1st heart sound
the mitral and tricuspid valve closing
indicating the start of systole
what is the 2nd heart sound
the aortic and pulmonary valves closing indicating the start of diastole
what type of systolic murmurs
they can either be pansystolic or ejection systolic
what type of diastolic murmur
can be early diastolic or mid diastolic
where can murmurs radiate?
> if it radiates to carotid sinus its indicative of aortic stenosis
if it radiates to axilla then it’s indicative of mitral regurgitation
how to grade a murmur
1 = very quiet 6 = loud and audible without a stethoscope
what is a thrill
ie a thrill on palpation, a vibratory sensation felt on the sky over lying an area of turbulence
right side vs left side murmur
right sided murmurs typically louder with inspiration
innocent murmur
soft ie less than 3/6 severity
position dependent
often early systolic (diastolic murmurs are always pathological)
aortic stenosis murmur
a lot louder than an innocent one and tend to be late peaking (systolic murmur)
murmurs
can either be stenotic or regurgitative or a mixture of the two
valve stenosis
valves that do not open properly
valve regurgitation
valves that do not close properly
mixed valve disease
valves which neither open properly nor close properly
clinical diagnosis
history = restriction and functional capacity
physical examination = murmurs and signs of heart failure
investigations = non-invasive - echo
invasive - cardiac catheterisation
aortic stenosis
a common lesion
- degenerative (age related)
- congenital (bicuspid valve)
- rheumatic
aortic stenosis symptoms
breathlessness, chest pain, dizziness/syncope
aortic stenosis signs
low volume pulse, forceful displaced apex, ejection systolic murmur that can radiate to the carotids
aortic stenosis treatment
- conventional valve replacement
- trans catheter aortic valve replacement (TAVI)
- balloon aortic valvotomy (BAV)
prosthetic heart valves
mechanical - longevity, warfarin, younger patients
bio-prosthetic - don’t need coagulation - no warfarin, 10 years, older patients
TAVI
trans catheter aortic valve implantation
deploy through the groin and deploy the valve on a balloon mounted system
>co morbidity
>previous sternotomy
AVR
still preferred
long term outcomes
no contra-indications
CABG as well
mitral regurgitation
different cause of mitral regurgitation primary = leaflets - prolapse rheumatic myxomatous endocarditis chordae rupture = prolapse / flail leaflet papillary muscles rupture = ischaemic annular dilatin = functional
myxomatous valves
are thick and billowing mitral valves
mitral regurgitation symptoms
breathlessness on exertion
peripheral oedema
fatigue
mitral regurgitation signs
displaced apex
pan systolic murmur (axilla)
treatment of MR
medication = diuretics and ACE inhibitors
surgical = repair - prolapse
replacement - degenerative
percutaneous = clips in infancy - encouraging results
mitral stenosis
rheumatic heart disease (ongoing immunological response leads to thickening of the mitral valve) is the main cause - this is where you get rheumatic fever
congenital - rare
MS symptoms
breathlessness
fatigue
palpitations (AF)
MS signs
malar flush
tapping apex beat
mid diastolic rumbling diastolic murmur localised to apex
MS treatment
medication = diuretics and treat AF
surgery = valve replacement
balloon valvuloplasty
aortic regurgitation
causes = endocarditis connective tissue disease rheumatic marfans aortic dissection
aortic regurgitation symptoms
breathlessness
aortic regurgitation signs
collapsing pulse
displaced apex
early diastolic murmur left sternal edge
