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Year 3 - CR > Valvular heart disease and endocarditis > Flashcards

Valvular heart disease and endocarditis Flashcards

1
Q

What does a stenotic valve lead to

A
  • leads to hypertrophy followed by dilatation and reduced function
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2
Q

What does a regurgitant valve result in

A
  • Volume overload

- this leads to dilatation followed by reduced function

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3
Q

How do you assess valve disease

A
  • History
  • Examination
  • ECG
  • Echo
  • CXR
  • Cardiac catheterization +/- angiography
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4
Q

What causes aortic stenosis

A
  • Bicuspid aortic valve (presents in there 30s to 40s) and other congenital abnormality
  • Degenerative over the long term (present in there 60s, 70s, and 80s)
  • rheumatic fever
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5
Q

What causes aortic regurgitation

A
  • Bicuspid/other congenital abnormality
  • Degenerative
  • Dilated aortic root e.g. secondary to hypertension
  • Endocarditis
  • Aortic root dissection - such as marinas disease
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6
Q

What are the symptoms of aortic stenosis and how do they present

A
  • Don’t tend to get symptoms until aortic stenosis is moderately severe
    Primarily on exertion in the early phase
    • Chest pain
    • Dyspnoea
    • Syncope
    • Symptoms of CCF
  • as disease come more severe they have earlier onset and at rest
  • can eventually lead to heart failure
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7
Q

Name the symptoms of aortic stenosis

A
  • Chest pain
  • Dyspnoea
  • Syncope
  • Symptoms of CCF
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8
Q

What sounds do you hear with an aortic stenosis

A
  • systolic ejection murmur in the aortic area

- if bicuspid may hear a click after the first sound

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9
Q

What sounds do you hear with aortic regurgitation

A
  • second sound followed by an early diastolic murmur
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10
Q

What do the echo parameters look for in aortic valve disease

A
  • Valve appearance
  • Valve gradient/valve area
  • Severity of AR based on colour flow and CW Doppler
  • LV size and function - hypertrophy, enlarged, contracting well?
  • Associated or coincidental pathology
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11
Q

When do you intervene in aortic stenosis

A

• Symptoms
- LVEF less than 50%
• Irreversible changes in cardiac function
• Improve prognosis

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12
Q

What happens when you leave aortic stenosis for a long time

A

dilate and start to pump poorly

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13
Q

in what valve disease is it better to replace the valve earlier

A

Mitral regurgitation - better to replace the valve even in the absence of symptoms as once there has been changes to the valve structure the new valve may not work

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14
Q

What causes mitral stenosis

A
  • Almost always rheumatic
  • Often with associated regurgitation
  • Frequently associated with other valve disease and PHT
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15
Q

What signs is mitral stenosis associated with

A
  • mitral faces - redness of the cheek
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16
Q

What can cause mitral regurgitation

A
  • Mitral valve prolapse; myxomatous or degenerative
  • functional
  • Ischaemic
  • rheumatic
  • Infection
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17
Q

What are the symptoms of mitral stenosis

A
  • Dyspnoea
  • Fatigue
  • dizziness
  • Other symptoms of CCF
  • Palpitations (secondary to atrial arrhythmias)
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18
Q

what are the signs of mitral regurgitation

A
  • AF
  • displaced hyperdyanmic apex
  • pan systolic murmur at apex radiating to axilla
  • soft s1, split s2, loud p2

the larger the left ventricle the more severe

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19
Q

What are the signs of mitral stenosis

A
  • malar flush on cheeks
  • low volume pulse
  • AF common due to enlarged LA
  • non-displaced apex beat
  • RV heave
  • loud s1 opening snap
  • mid diastolic murmur (heard best in expiration with the patient on the left side) - the more severe the stenosis the longer the diastolic murmur
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20
Q

In mitral valve disease what do you look for in an echo

A
  • Valve appearance
  • LA size
  • LV size and function
  • Various Doppler parameters to assess severity of stenosis and regurgitation
  • Right heart size and function
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21
Q

What are the two ways to treat valve disease

A
  • Pharmacology

- mechanical interventions

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22
Q

name some drugs that you can use for valve disease

A

Beta blockers, ACE I, diuretics, calcium antagonists

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23
Q

What are the indications for intervention in mitral valve disease

A
  • Symptoms
  • Irreversible changes in cardiac function
  • Improve prognosis
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24
Q

What is the mainstay of endocarditis

A

presence or absence of vegetation on valves on echo

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25
Q

What criteria is the diagnosis of bacterial endocarditis based on

A

The Duke criteria

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26
Q

describe what is needed for a clinical diagnosis of bacterial endocarditis

A

The duke criteria
- Clinical diagnosis of definite infective endocarditis requires two major, one major and three minor or five minor criteria

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27
Q

What counts for major in the duke criteria (Bacterial endocarditis)

A
  • typical blood culture
  • positive Q-
    fever serology,
  • positive echo
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28
Q

What counts as minor in the duke criteria (Bacterial endocarditis)

A
  • predisposition
  • fever
  • vascular phenomena including new clubbing, splinter haemorrhages and splenomegally
  • immunological phenomena - raised CRP
  • suggestive echo
  • suggestive microbiology
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29
Q

what causes splinter haemorrhages

A

Bacterial endocarditis

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30
Q

What is defined as a positive echo in the duke criteria

A
  • oscillating intracardiac mass on valve or supporting structures, in the path of a regurgitant jet or on implanted material in the absence of another explanation
  • an abscess
  • new partial dehiscence of a prosthetic valve
  • completely new valve regurgitation
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31
Q

How do you use blue vauloplasty to treat mitral stenosis

A
  • Balloon is passed through a femoral vein across the right atrium to the left atrium
  • it is then inflated into the stenosed mitral valve
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32
Q

what are the options to replace valves

A
  • mechnical valves

- tissue valves

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33
Q

What is the best type of mechanical valve

A
  • best with two cusps - provide the most phsyiolgoical normal flow
  • patient requires anticoagulation wiht warfarin
  • risk of bleeding
34
Q

What are the advantages and disadvantages of a mechanical valve

A

Advantage
- lasts a long time = 30 years or more

Disadvantage

  • patient requires anticoagulation with warfarin
  • risk of bleeding
35
Q

What are the advantages and disadvantages of a tissue valve

A

Disadvantage
- lasts a shorter amount of time - 12-15 years

Advantage
- better physiologically and do not have to take anticoagulation

36
Q

How do you try to avoid valve replacement

A
  • can use an annuloplasty ring - piece of metal covered in plastic sown in to support the valve
  • avoid need for anticoagulation and persevere ventricular function
37
Q

What are the signs of aortic stenosis

A
  • Systolic thrill
  • Ejection clicks
  • Systolic ejection murmur in the aortic area
  • No displaced apex beat
  • Slow rising pulse
  • Narrow pulse pressure
38
Q

What would an ECG finding find in aortic stenosis

A
  • Left ventricular strain pattern due to pressure overload = depressed ST segments, T wave inversion in leads orientated to the left ventricle (I, AVL, V5 and V6)
  • usually sinus rhythm is present but ventricular arrhythmias may be recorded
39
Q

How do you treat an aortic stenosis

A
  • If symptomatic prognosis is poor without surgery - prompt valve replacement is usually recommended
  • if patient is not fit for surgery a TAVI may be attempted
40
Q

What is aortic sclerosis

A
  • Senile degeneration of the valve
41
Q

What happens in aortic sclerosis

A
  • Ejection systolic murmur
  • no carotid radiation
  • normal pulse - character and volume
  • S2
42
Q

What are the symptoms of aortic regurgitation

A
  • exertion dyspnoea
  • orthopnoea
  • palpitations
  • angina
  • syncope
43
Q

What are the signs of aortic regurgitation

A
  • Collapsing pulse
  • wide pulse pressure
  • hydrodynamic apex beat
  • high pitched early diastolic murmur
  • quick carotid filling up
  • Head bobbing with heart beat
44
Q

How do you manage aortic regurgitation

A

Medical therapy

  • main goal is to reduce systolic hypertension - ACEi
  • echo every 6-12 months to monitor
  • surgery to replace valve before significant LV dysfunction occurs
45
Q

what are the indications for surgery in aortic regurgitation

A
  • Severe aortic regurgitation with enlarged ascending aorta
  • increasing symptoms
  • enlarging left ventricle
  • deteriorating left ventricle function on echo
  • infective endocarditis refractory to medical therapy
46
Q

What are the symptoms of mitral regurgitation

A
  • dyspnoea
  • fatigue
  • palpitations
  • symptoms of causative factor
47
Q

How do you manage mitral stenosis

A
  • If patient has AF rate control is crucial
  • anticoagulant with warfarin
  • diuretics - decrease preload and pulmonary venous congestion
  • if this fails to control symptoms - balloon valvuloplasty, open mitral valvotomy or valve replacement
48
Q

How do you manage mitral regurgitation

A
  • control rate if fast AF
  • anticoagulant if AF
  • history of embolism, prosthetic valve, additional mitral stenosis
  • diuretics improve symptoms
  • srugery for deteriorating symptoms if aim to replace valve before LV is irreversibly impaired
49
Q

What are the symptoms and signs of tricuspid regurgitation

A

Symptoms

  • fatigue
  • hepatic pain on exertion
  • ascites
  • oedema and symptoms of the causative conditions

Signs

  • giant V waves and prominent Y descent in JVP
  • RV heave
  • pan systolic murmur -
  • inspiration
  • pulsatile hepatomegaly
  • jaundice
  • ascites
50
Q

What are the signs and symptoms of pulmonary stenosis

A

Symptoms

  • dyspenoa
  • fatigue
  • oedema
  • ascites

signs

  • dysmorphic facies
  • prominent a wave in JVP
  • RV heave
  • ejection click and ejection systolic murmur
  • widely split S2
  • in severe stenosis the murmur becomes longer and obscures A2
  • P2 becomes softer and may be inaudible
51
Q

What does an ECG look like in mitral stenosis

A
  • bifid P wave due to delayed left atrial activation
  • AF present
  • right axis deviation
52
Q

What does an ECG look like in mitral regurgitation

A
  • bifid P wave due to delayed left atrial activation
  • left ventricular hypertrophy
  • AF might be present
53
Q

What does ECG look like in aortic regurgitation

A
  • tall R waves and deeply inverted T waves in the left sided chest leads - due to left ventricular hypertrophy
  • deep S waves in the right sided leads
  • sinus rhythm is present
54
Q

What type of murmur can you hear in tricuspid stenosis

A
  • rumbling mid-diastolic murmur which is heard best at lower left sternal edge and is louder on inspiration
  • opening snap may occasionally be heard
55
Q

What type of murmur is pulmonary stenosis

A
  • harsh mid systolic ejection murmur best head on inspiration to the left of the sternum in the second intercostal space
  • murmur is often associated with a thrill
56
Q

A ….. is infective endocarditis until otherwise proven

A

A fever and new murmur is endocarditis until proven otherwise
- a fever lasting longer than 1 week in those known to be at risk must prompt blood cultures

57
Q

What is the most commonest organism that causes acute infective endocarditis

A
  • stap aureus

- Strep viridian’s is the commonest in subacute

58
Q

What are the risk factors for infective endocarditis on natural valves (acute endocarditis)

A
  • skin breaches e.g. dermatitis and IV lines and wounds
  • renal failure
  • immunosuppression
59
Q

What are the risk factors for infective endocarditis on abnormal valves (subacute endocarditis)

A
  • aortic or mitral valve disease
  • tricuspid valves in IV drug users
  • coarctation
  • patent ductus arteriosus
  • VSD
  • prosthetic valves
60
Q

Describe the causes of infective endocarditis

A
  • Bacteria - step viridian’s, staph aureus, strep bovis
  • Fungi - candida, aspergillus, histoplasma usually in IV drug abusers, immunocompromised patients or those with prosthetic valves
  • SLE, and malignancy
61
Q

What are the signs of infective endocarditis

A
  • Septic signs = fever, riggers, night sweats, malaise, weight loss, anaemia, splenomegaly, clubbing
  • any new murmur
  • vegetation on valves
  • vasculitis
  • glomerulonephritis
  • splinter haemorrhages
62
Q

What treatment can be used for infective endocarditis

A
  • antibiotic therapy

- surgery

63
Q

When do you use surgery to treat infective endocarditis

A

Surgery if

  • heart failure
  • valvular obstruction
  • repeated emboli
  • fungal
  • persistant bacteraemia
  • myocardial abscess
  • unstable infected prostehtic valve
64
Q

What causes an pan systolic murmur

A

Tricuspid regurgitation
Mitral regurgitation
Ventricular septal defect

65
Q

What causes an systolic ejection

A

Pregnancy- turblence
Pulmonary stenosis
Aortic stenosis
Aortic coarction

66
Q

What are the risk factors for acute infective endocarditis

A
  • skin breaches (dermatitis, IV lines, wounds)
  • renal failure
  • immunosuppression
  • DM
67
Q

Where does acute infective endocarditis tend to occur

A
  • tends to occur on normal valves and may present with acute heart failure and emboli
  • commonest organisms is staph aureus
68
Q

Where does subacute infective endocarditis occur

A
  • occurs on abnormal valve
69
Q

What is the risk factor for subacute infective endocarditis

A
  • aortic or mitral valve disease
  • tricuspid valves in IVDU
  • correction
  • patent ductus arteriosus
  • VSD
  • prosthetic valves - early - usually staph epidermis, poor prognosis or late
70
Q

Describe the pathogenesis of infective endocarditis

A
  • there is valvular and endocardial damage this causes platelet and firkin deposits which the bacteria adhere to and this leads to vegetations
  • valves have a lack of blood supply therefore the body cannot combat them
71
Q

What antibiotic therapy for infective endocarditis do you use if it is a native valve ( or a prosthetic valve that was implanted greater than 1 year ago

A
  • Ampicillin + Flucloxacillin + Gentamicin

If penicillin allergy: Vancomycin + Gentamicin

If thought Gram –ve: Meropenem, Vancomycin

72
Q

if the valve is prosthetic valve that has infective endocarditis what antibiotics do you give it

A

Vancomycin + Gentamicin + Rifampicin

73
Q

For staphs infective endocarditis infection what antibiotics do you give the valve

A

Native valve

  • flucloxacillin for >4 weeks
  • if allergic or MRSA: Vancomycin

Prosthetic valve

  • flucloxacillin and rifampicin and gentamicin for 6 weeks
  • if allergic or MRSA; Vancomycin + rifampicin and gentamicin
74
Q

For strep infective endocarditis infection what antibiotics do you give the valve

A

Fully sensitive to penicillin
- benzylpenicillin 1.2g/4h IV for 4-6 weeks

Less senstiive to penicillin

  • benzylpenicillin and gentamicin
  • if allergic or highly resistant strep: vancomycin and gentamicin
75
Q

For enterococci infective endocarditis infection what antibiotics do you give the valve

A
  • amoxicillin and Gentamicin
76
Q

For a fungal infective endocarditis infection what antibiotics do you give

A
  • Candida = amphotericin

- Aspergillus = voriconazole

77
Q

What causes the S1 heart sound

A
  • Closure of mitral and tricuspid valves
  • Soft if long PR or mitral regurgitation
  • Loud in mitral stenosis
78
Q

What causes the S2 heart sound

A
  • Closure of aortic and pulmonary valves
  • Soft in aortic stenosis
  • Splitting during inspiration is normal
  • ASD – loud
  • Widely split S2 – deep inspiration, RBBB, pulmonary stenosis, severe mitral regurgitation
  • Reversed split S2 – LBBB, severe aortic stenosis, right ventricular pacing, PDA
79
Q

What causes the S3 heart sound

A
  • Caused by diastolic filling of the ventricle
  • Considered normal if <30 years old
  • Heard in left ventricular failure, constrictive pericarditis and mitral regurgitation
80
Q

What causes S4 heart sound

A
  • May be heard in aortic stenosis, HOCM, hypertension

- Caused by atrial contraction against a stiff ventricle therefore coincides with the P wave on ECG

81
Q

What is the most common cause of bacterial endocarditis

A
  • Strep Viridians is most common usually followed by Staph aureus

Year 3 - CR (44 decks)

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