Valvular Heart Disease Creator: Cameron McCloskey Flashcards
What is orthopnoea?
Breathlessness when lying flat
(ask how many pillows the patient sleeps with)
What is paroxysmal nocturnal dyspnoea
Breathlessness occuring at night
Leads the patient to sit on edge of bed or open window to catch breath
What is the New York Association Functional Classification?
A system used to classify the severity of heart failure using increasing classes of severity:
- Class I - no limitiation
- Class II - Slight limitation of ordinary activity
- Class III - marked limitation of less than ordinary activity
- Class IV - severe limitation of minimal activity or at rest
Heart failure can either be ______ or ______ sided
Left or right
What effect does left sided heart failure have?
Back pressure on lungs because heart inefficiently moves blood from the lungs to systemic circulation
This leads to pulmonary oedema
What effect does right sided heart failure have?
There is back pressure in the peripheral circulation cause by inefficiencies of the right heart to take in blood from the systemic circulation
This causes peipheral oedema
What are the signs of right sided heart failure?4
- Raised JVP
- Pitting oedema - ankles and even up to sacrum
- Hepatic congestion
- Parasternal heave - RVH and overload - commonyl seen in cor pulmonale and pulmonary hypertension
What are the signs of left heart failure? what beat is seen
Displaced apex beat
What is used to confirm any diagnosis of heart failure?
Echocardiogram
What is a heart murmur?
Audible turbulent blood flow that ca be either innocent or pathological
Where are the 4 areas of auscultation?
- Parasternal - 2nd intercostal space (right)
- Parasternal - 2nd intercostal space (left)
- Parasternal - 4th intercostal space (left)
- Mid-clavicular line - 5th intercostal space (left)
When will a systolic heart murmur be heard?
Between the first (S1) and second (S2) heart sounds
When will a diastolic heart murmur be heard?
Out with the first and second heart sounds
What is the first heart sound (S1)?
Mitral and tricuspid valves closing - start of systole
What is the second heart sound (S2)?
The closing of the pulmonary and aortic valves - start of diastole
What are the two main types of systolic murmur?
- Pansystolic
- Ejection systolic
What is a pansystolic murmur?
The sound remains constant between S1 and S1
What is an ejection systolic murmur?
There is increasing sound throughout systole
What are the two main types of diastolic murmur?
- Early diastolic
- Mid diastolic
There may also be late diastolic murmurs
What is an early diastolic murmur?
A murmum with decreasing sound after S2
What is a mid-diastolic murmur?
Increasing sound from S2 to S1 in crescendo configuration
If a murmur radiates to the carotids what type of murmur is it?
Ejection systolic
Due to aortic stenosis
If the murmur radiates to the axilla what is the likely cause of the murmur?
Mitral regurgitation
Which murmurs are increased during inspiration?
Right sided
Why do right sided murmurs icrease with inspiration?
There is increased blood flow (respiratory pump)
Hence, murmurs are more audible
Which murmurs are always pathological?
Diastolic
What is valve stenosis?
Valves cannot open properly
Why does valve regurgitation occur?
Valves do not close properly
What is mixed valve disease?
Valves neither open nor close properly
What is an invasive procedure for murmur investigation?
Cardiac catheterisation
What can cause aortic stenosis?
Calcification and cholesterol deposition in heart valves
What are the risk factors for aortic stenosis?
- Age
- Genetics
- Diet
- Obesity
What is a congenital condition that can lead to aortic stenosis?
Bicuspid aortic valve
Over time, what morpholical change will likey occur in the heart with an aortic stenosis?
Left ventricular hypertrophy
What are the symptoms of aortic stenosis?
- Breathlessness
- Chest pain
*exertional syncope
What are the signs of aortic stenosis?
- Low volume pulse
- Forceful displaced apex (due to LVH)
- Ejection systolic murmur that can radiate to carotids
How will aortic stenosis often present on an ECG?
Large QRS complex due to ventricular hypertrophy
What is the treatment for aortic stenosis?
Sternotomy - conventional valve replacement
Trans catheter aortic valve replacement 9TAVI) - used when surgery is not suitable, replacement vave is insterted via femoral artery or directly into the heart (transapical)and is deployed over the native valve
Balloon aortic valvotomy (BAV) - can crack through calcification, may lead to regurgiation and is onyl palliative to prolong life
Why are mechanical valves good for yound patients?
They will last a lifetime
When a mechanical valve is inserted, what drug must be administered and why?
Warfarin
To prevent coagulation and thrombosis over new valve
In what type of patient will a bio prosthetic valve be used?
Older patients as the valves do not generally last as long
In which instances may TAVI be preferred over aortic valve replacement?
Good for patients with co-morbidities or those who cannot undergo surgery
What is annular dilatation?
The valves are pulled apart
This can cause reguritation
What is the annulus?
The base of the heart valve that supports the valves
What may be some problems with heart valves themselves?
- Endocarditis
- Prolapse
- Rheumatic
- Myxomatous (floppy)
What may cause mitral regurgitation?
- Annular dilatation
- Prolapse of valves
- Chordae rupture - degenerative condition
- Papillary muscle rupture - due to ischaemia
What are the main symptoms of mitral reguritation?
- Breathlessness
- Peripheral oedema
- Fatigue
What are the signs of mitral regurgitation?
- Displaced apex
- Pansystolic murmur - axilla
Of the two, which has a better prognosis, aortic stenosis or mitral regurgitation?
Aortic stenosis
This is because aortic stenosis is often associated with more severe symptoms and complications, such as heart failure, arrhythmias, and sudden cardiac death. Additionally, aortic stenosis is often seen in older patients who may have other medical conditions that can complicate their care.
What is cardiomegaly?
An enlarged heart
What is the treatment for mitral regurgitation?
- Medication for heart failure - diuretics, ACEI
- Surgical repair of prolapse or replacement for degenerative
- Percuatanous - clips can be used in infacy to stop progression and degeneration
What may be the causes of mitrl stenosis?
Rheumatic disease
Congential defect - rare
In mitral stenosis it is common to see left atrial __________
Hypertrophy
What are the symptoms of mitral stenosis?
- Breathlessness
- Fatigue
- Palpitations (AF)
What are the signs of mitral stenosis?
- Malar flush
- Tapping apex beat
- Mid diastolic rumbling murmur localised to apex
On a CXR, what may be a tell-tale sign of mitral stenosis?
Straight left heart border due to enlarged pulmonary artery
What is the treatment for mitral stenosis?
- High thrombotic risk - diuretics and treatment for AF
- Surgery - valve replacement
- Balloon valvuloplasty
What is aortic regurgitation caused by?
Failure of valves to close properly
What can cause failure of valves to close in aortic regurgitation?
Leaflets
- Endocarditis
- Connective tissue diseases
- Rheumatic
Annulus
- Marfans - genetic disorder increasing risk of mitral valve prolapse and aortic aneurysm
- Aortic dissection
What is the main symptom of aortic regurgitation?
Breathlessness
Left atrium can not full empty its blood
What are the signs of aortic regurgitation?
- Collapsing pulse - blood rushes back to ehart due to low pressure (through aortic valve)
- Displaced apex
- Early diastolic murmur at the left sternal edge
When is aortic regurgitation more easily heard?
When sitting forward breathing out and holding
Aortic regurgitation leads to a large ___, larger ______ ________ which causes diastolic pressure to be ______ resulting in a _____ pulse presssure
EDV
Stroke volume
Lower
Wide
Volume overload in the heart often leads to what?
Cardiomegaly
What is the treatment for aortic regurgitation?
- Medication - ACEI, Beta blockers
- Surgery - based on symptoms and LV dilatation - valve replacement
Right sided vavular heart problems are usually what?
Rare and congenital
What is the most common cause of right sided heart failure?
Left sided heart failure
Why are calcium channel blockers not used in heart failure?
They will have a negative ionotropic effect, weakening heart force further causing deterioration of the condition
LVF can cause what?
Backpressure on lungs and peripheral oedema
RVF can cause what?
Back pressure on body, causing peripheral oedema
causes of Aortic regurgitation
- IE
- Aortic dissection
- Traumatic rupture
- TAVI
Chronic causes of Aortic Regurgitation
- Calcific aortic valve disease
- Myxomatous degeneration
- bicuspid aortic valve
- Rheumatic heart disease
- IE
- Marfan’s syndrome
presentations of AR can be different depending on either acute or chronic
- acute
- sudden collapse
- pulmonary odema
- peripheral vasoconstriction
- Chronic
- exertional dyspnoea
- Orthopnoea
- paroxysmal
sever AR can casuses stable angina true/ False
true
Auscultation findings for AF
early diastolic murmur
Collapsing pulse
best investigation for AF
Echocardiogram
type of medications for AR
the ones that will lower systolic hypertension
what type of bacteria causes Rheumatic fever
Lancefield group A beta-haemolytic streptococcal
what is clinical presentation of rheumatic fever causing valve disease
tachycardia, new murmur or new conduction defect. with fever and Prolonged PR interval on ECG (except if carditis meets major criterion)
how rheumatic fever is managed
STAT dose of IV Benzylpenicillin, with a ten day course of Phenoxymethylpenicillin to follow
what is the most common valve disease fallowed BY RHEUMATIC FEVER
MS
Both aortic dissection and aortic aneurysm are big risk factors of Aortic Regurgitation /True /False
True
Valve replacement is indicated in patients who are symptomatic and are categorized as having severe aortic stenosis True / False
True / False
symptoms of aortic stenosis
: SAD: Syncope + Angina + Dyspnea
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symptoms of aortic stenosis
: SAD: Syncope + Angina + Dyspnea
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- Acute Aortic Regurgitation:
- Chronic Aortic Regurgitation
- decrease stroke volume (voulme of blood pumped out of the heart lead to increase cardiac out put which lead to low BP causing cardiogenic shock and since the heart has no time to remodel and dilate to accommodate that volume. →Increases left atrial pressure → back flow of blood into the pulmonary circulation → PULMONARY EDEMA . heart has tachycardia to compensate.
- (↑↑↑) LVEDV → trigger LV dilation due to volume overload → eccentric hypertrophy of the LV (muscle cells are added in series) (↑↑↑) LVEDV → (↑↑↑) preload → (↑↑↑) SV→ (↑↑↑) CO → hyperdynamic hearts with ejection fraction of 60- 65% → reduced hypotension o Relatively asymptomatic.
- ninja nerd
*
- ninja nerd
) Decompensated Chronic AR:
- • Heart failure progression → Dilated LV with his blood volume cannot be tolerated anymore → muscle starts getting weaker → (↓) contractility → (↓) SV → (↓) CO
- this lead to
- Hypotension & Pulmonary Edema
- Wide Pulse Pressure
- Water Hammer Pulse (Corrigan’s pulse)
- LV Dilation: • Allow for rapid ventricular filling → turbulent flow → produces S3 heart sound • (↑↑↑) SV → intense contractions → thrusting PMI and lateral displacement of PMI (ninja nerd)
factors which increase intensity of murmur in AR
VR
Expiration
Afterload
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Avoid Certain Medication in both AR and AS
Venodilators
beta and calcium blockers
dehydration and excessive exertion
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