Week 5/6 - E - Valvular Heart Disease (A.S/M.R - systole, A.R/M.S - diastole) - Symptoms, Signs, Treatment, other murmurs timing

Question 1

What type of symptoms are classic of valvular heart disease?

Answer 1

Exertional symptoms are characteristic of of valvular heart disease * Chest pain * Breathlessness * Collapse/Dizzy spells

Question 2

Where is the apex beat normally palpated? What is it known as when the apex beat is palpable as the first heart sound? What causes this?

Answer 2

Apex beat is normally palpated in the left 5th intercostal space, mid-clavicular line In mitral stenosis, the first heart sound is loud and may be palpable - this is known as a tapping apex beat

Question 3

What is left ventricular dilatation and left ventricular hypertrphy assoicated with in changes to the apex beat?

Answer 3

Left ventricular dilatation is associated with a displaced and diffuse apex beat (volume overload) Left ventricular hypterophy is associated with a heaving and maybe displaced apex bet (pressure overload)

Question 4

How is a parasternal heave palpated and what causes it?

Answer 4

Parasternal heave is palpated with a hand to the left of the sternum - it is causes by right ventricular overlad - usually due to cor pulmonale /pulmonary hypertension

Question 5

What is a cardiac murmur? What are the two categories? What is a cardiac thrill? What is a cardiac heave?

Answer 5

A cardiac murmur is the audible turbulence of blood flow It can either be innocent or pathological A thrill is a palpable murmur and feels like a soft vibration A heave feels like an abnormally large beating of the heart - usually due to ventricular hypertrophy

Question 6

What are the four cardiac auscultatory areas?

Answer 6

2nd intercostal space right sternal edge - aortic valve 2nd intercostal space left sternal edge - pulmonary valve 4th intercostal space left sternal edge - tricuspid valve 5th intercostal space left mid clavicular line - mitral (bicuspid) valve

Question 7

How is a murmur described?

Answer 7

Systole or diastole The type of murmur Where is it heard loudest Where does it radiate to What grade of murmur is it (is it influenced by respiration)

Question 8

The closing of which valves make the 1st and 2nd heart sound? What do these hearts sounds signify the beginning of?

Answer 8

1st heart sound is due to the mitral (left side) and tricuspid (right side) valves closing and signifies the beginning of systole 2nd heart sound is due to the aortic and pulmonary valves closing and signifies the beginning of diastole

Question 9

When are 3rd and 4th heart sounds heard and what do they signify? What condition can make you hear these and what is the rhythm known as?

Answer 9

3rd heart sounds- heard mid diastole - related to the rapid filling of blood into the ventricle during passive filling of cardiac cycle 4th heart sound - heard just before S1 and is due to atrial contraction (completes the EDV) Can hear these in heart failure - gallop rhythm

Question 10

What is the easiest way to remember which of the big 4 murmurs are systolic and which are diastolic?

Answer 10

MRS ASS Mitral regurgitation systolic Aortic stenosis systolic Mitral stenosis diastolic Aortic regurgitation diastolic

Question 11

There are different types of murmurs * Normal * Aortic stenosis * Mitral regurgitation * Aortic regurgitation * Mitral stensosis * Patient ductus arteriosus * Tricuspid regurgitation Describe how these are heard?

Answer 11

Normal - early systolic Aortic stenosis - ejection systolic Mitral regurgitation - pan systolic Aortic regurgitation - early diastolic Mitral stenosis - rumbling mid diastolic Patent ductus arteriosus - continuous machine like Tricuspid regurgitation - pansytolic

Question 12

The murmurs are usually loudest in their specific auscultatory areas Where do they radiate - which murmur radiates to the carotids and which to the axilla?

Answer 12

MRS ASS Aortic stenosis - the ejection systolic murmur radiates to the carotids Mitral regurgitation - the pansystolic murmur radiates to the axilla

Question 13

So the two murmurs that radiate are the systolic murmurs, and the two murmurs that are heard best on expiration are the diastolic murmurs What position are the murmurs that are heard best on expiration heard?

Answer 13

Aortic regurgitation - this is heard best in expiration with the patient sat forward Mitral stenosis - heard best in expiration with the patient on the left side

Question 14

What are the different gradings for describing a murmur?

Answer 14

Garde 1 - very quiet Grade 2 - quiet - easy to hear Grade 3 - loud Grade IV - loud with a thrill Grade V - very loud with a thrill Grade VI - loud - audible without a stethoscope

Question 15

Which murmurs are louder with inspiration?

Answer 15

Right sided murmurs - * Tricuspid regurgitation * Tricuspid stenosis * Pulmonary stenosis all heard louder with inspiration

Question 16

What is an innocent murmur also known as? When is it heard? What grade is it?

Answer 16

An innocent murmur is also known as a functional murmur or a physiological murmur It is heard usually early systole and is a soft murmur (grade 3 max - no thrill)

Question 17

Valvular heart disease includes * Valve stenosis * Valve regurgitation * Mixed valve disease What do these mean?

Answer 17

Valve stenosis - this is when the valves do not open properly - more difficult to pump blood out Valve regurgitation - valves which do not close properly allowing for backflow of blood Mixed valve disease - valves which neither open properly nor close properly

Question 18

What is the diagnostic test for all murmurs heard in cardiology?

Answer 18

This would be an echocardiogram (transthoracic echo)

Question 19

AORTIC STENOSIS What are the common causes of aortic stensosis?

Answer 19

Commonest cause is senile calcification where there is calcium build up on the valve (degenerative) Also can be a congenital defect which cause the aortic valve to be bicuspid instead of tricuspid Also rheumatic heart disease

Question 20

What are the symptoms of aortic stenosis? There is a classic triad due to it

Answer 20

Symptoms include - especially on exertion - breathlessness, chest pain, dizziness and syncope Classic triad of angina, syncope and heart failure

Question 21

What are the signs of aortic stenosis? (signs are usually on examination)

Answer 21

Low volume pulse Heaving apex due to left ventricular hypertophy Ejection systolic murmur that radiates to the carotids

Question 22

Why is it that aortic stenosis murmurs are better heard in mild stenosis versus severe aortic stenosis?

Answer 22

As aortic stenosis worsens, it takes longer for blood to be ejected through the valve. Thus, mild AS would have an early peaking murmur, while in severe AS the murmur peaks later in systole.

The murmur in mild disease would also be louder as the valves are more flappy creating more turbulent blood flow. In severe AS, the valves are stiffer (due to the clacification usually) creating less movement and therefore less noise

Question 23

What is seen on the ECG in patients with aortic stenosis?

Answer 23

ECG often shows left ventricular hypertophy - shows deep S waves in leads V1-V3 and large R waves in V4-V6

Question 24

What is the treatment of aortic stenosis? What if this fails?

Answer 24

Treatment Prompt conventional valve replacement is gold standard recommended - surgery If patient not fit for surgery - transcatheter aortic valve implantation may be attempted (TAVI) Balloon aortic valvuloplasty - stretches the aortic valve to improve the symptoms of aortic stenosis - potentially for patients with congenital disease

Question 25

What are the difference in heart valves * Which lasts longer? * Which requires anti-coagulation?

Answer 25

Mechanical heart valves Last longer and therefore used in younger patients however requires anti-coagulation with warfarin Bio-prosthetic heart valves Last approximately 10 years so used in older patients however no need for warfarin

Question 26

What is the differences between aortic valve replacement and transcatheter aortic valve replacement? Ie why is AVR preferred?

Answer 26

AVR still preferred due to long term outcomes and no-contraindications, can also give CABG at same time as open surgery TAVI is second line

Question 27

MITRAL REGURGITATION What are the different causes of mitral regurgitation?

Answer 27

Mitral vale prolapse Functional - due to left ventricular dilatation Ruptured chordae tendinae Annular calcification in the elderly Rheumatic fever Endocarditis

Question 28

Which connective tissue diseases are also linked to mitral regurgitation?

Answer 28

Mitral regurgitation is seen in connective tissue disease - Ehler’s Danlos syndrome and Marfan’s

Question 29

What are the symptoms of mitral regurgitation?

Answer 29

Symptoms include breathlessness, peripheral oedema, fatigue, chest pain

Question 30

What are the signs of mitral regurgitation? What can it lead to?

Answer 30

Displaced apex beat Pansytolic murmur that radiates to the axilla Can lead to atrial fibrillation, pulmonary hypertension and heart failure

Question 31

What is the management of mitral regurgitation? When is medical vs surgical used?

Answer 31

Medical management usually used if patients mild or unable to tolerate surgery * Diuretics to treat the oedema and heart failure management (ACEI and Bblocker) * Medication to treat AFib - and anti-coagulate Surgery is curative Mitral valve repair if a prolapse Mitral valve replacement if degnerative or rupture

Question 32

AORTIC REGURGITATION What are the causes of aortic regurgitation?

Answer 32

Causes include Endocarditis Rheumatic fever Marfan’s, Ehler’s Danlos RA, SLE Aortic dissection

Question 33

What are the symptoms of aortic regurgitation?

Answer 33

Symptoms are similar to those of heart BREATHLESSNESS usually worse on exertion and breathlessness when lying flat eg orthopnoea, paroxysmal nocturnal dysnpnoea

Question 34

What are the signs of aortic regurgitation?

Answer 34

Collapsing pulse (aka water hammer pulse) Displaced apex beat due to LVH Early diastolic murmur left sternal edge (best heard on expiration when patient leaning forward) Wide pulse pressure

Question 35

How is a collapsing pulse elicited?

Answer 35

Collapsing pulse (aka water hammer pulse) - elevate the patients arm and feel a bounding pulse initially (rapid upstroke) and then followed by a rapid fall in the pulse(rapid downstroke)

Question 36

What is the treatment of aortic regurgitation?

Answer 36

ACE inhibitors If severe and a surgical candidate - valve replacement

Question 37

MITRAL STENOSIS What are the causes of mitral stenosis?

Answer 37

Essentially almost always caused by rheumatic fever Congenital is rare

Question 38

What are the symptoms of mitral stenosis?

Answer 38

Breathlessness, fatigue, palpitations (if AF - common complication of enlarging left atrium) Left atrial pressure transmitted to pulmonary vasculature causing pulmonary hypertension

Question 39

What are the signs of mitral stenosis?

Answer 39

Tapping apex beat - palatable first heart sound Malar flush - due to decreased cardiac output and increase of CO2 - CO2 is a natural vasodilator Mid diastolic rumbling murmur localised to apex - best heart on expiration when patient on left side

Question 40

What is the treatment of mitral stenosis?

Answer 40

Diuretic to control symptoms of pulmonary congestion and treat AF (BBlocker, Warfarin) If this fails to control symptoms Surgery - valve replacement or balloon valvuloplasty

Question 41

We have discussed the big four murmurs * AS- ejection systolic * MR- pan systolic * AR- early diastolic * MS- mid diastolic rumbling What other murmurs occur at these times? CLUE: aortic w pulmonary mitral with tricuspid

Answer 41

Ejection systolic murmurs - eg crescendo decrescendo * Aortic stenosis * Pulmonary stenosis Pan systolic murmurs * Mitral regurgitation * Tricuspid regurgitation * Ventricular septal defect Early diastolic murmurs * Aortic regurgitation * Pulmonary regurgitation (rare) Mid diastolic rumbling murmurs * Mitral stenosis