Week Four - Acute to Chronic Breathlessness Flashcards
1
Q
what are the causes of mitral stenosis
A
- rheumatic heart disease
- congenital
- calcification/fibrosis in elderly
- carcinoid tumour metastasising to lung
2
Q
what is the bacterium in rheumatic heart disease
A
Group A beta haemolytic streptococcus
3
Q
explain the pathology behind mitral valve stenosis
A
- to maintain cardiac output. left arterial pressure increases,
- leads to left atrial hypertrophy and dilation
- leads to pulmonary venous, arterial and right heart pressure increasing,
- leads to pulmonary oedema
- leads to pulmonary hypertension
- leads to right ventricular hypertrophy, dilation failure and subsequent tricuspid regurgitation
4
Q
when do symptoms begin to show in mitral valve stenosis
A
no symptoms until orifices <2cm(2)
5
Q
what is this due to?
A
due to pulmonary hypertension, dyspnoea, Haemoptysis, recurrent bronchitis
6
Q
what does this eventually lead to
A
right heart failure
7
Q
what are the symptoms of right heart failure
A
fatigue, leg swelling
this is due to large left arterial, favours AF, palpitations and systemic emboli
8
Q
what are the signs in the face of mitral valve stenosis
A
mitral facies / malar flush
9
Q
what is mitral facies / malar flush due to
A
decreased cardiac output
10
Q
what happens to the pulse in mitral valve stenosis
A
atrial fibrillation - irregularly irregular
11
Q
what can you hear at the apex with mitral valve disease
A
localised, tapping
12
Q
what are the heart sounds in mitral valve stenosis
A
Loud S1, loud P2(pulmonary HTN), opening snap
13
Q
what kind of murmur is heard in mitral valve stenosis
A
mid diastolic murmur rumbling at apex
14
Q
in mitral valve stenosis, what will a CXR show
A
small heart with enlarged left atrium
calcified mitral valve
sign of pulmonary oedema
15
Q
in mitral valve stenosis, what will an ECG show
A
AF
bifid P wave/P mitrale
right axis deviation / tall R waves in lead V1 (right ventricle hypertrophy)
16
Q
what medications are given for AF
A
digoxin and anticoagulation
17
Q
what medications are given for pulmonary oedema
A
diuretics
18
Q
what are the 4 surgical options for mitral valve stenosis
A
- trans-septal balloon valvotomy
- closed valvotomy
- open valvotomy
- mitral valve replacement
19
Q
when would you treat with trans-septal balloon valvotomy
A
when there is a pliable, non-calcified valve
20
Q
what are the causes of mitral regurgitation
A
- degenerative disease
- functional (Left ventricle dilation)
- annular calcification
- rheumatic fever
- endocarditis
- mitral valve prolapse
- ruptured chordae tendinae
21
Q
what connective tissue diseases are connected to mitral regurgitation
A
marfan’s syndrome
ehler’s danlos
22
Q
what is the pathophysiology behind mitral valve regurgitation
A
- mitral valve regurgitation leads to left atrial dilatation (but in acute, left atrium does not allow much dilatation, there will be rise in left atria pressure)
- this left atrial pressure leads to pulmonary oedema
- there will then be decreased stroke volume due to regurgitation, therefore left ventricle hypertrophy to increase stroke volume and hence cardiac output
23
Q
as time goes by, what ends up happening?
A
right sided heart failure
24
Q
what symptoms appear in mitral valve registration due to pulmonary oedema
A
dyspnoea, orthopnoea, fatigue and lethargy
25
what symptoms appear due to the stoke volume
palpitations
26
what are the pulse signs of mitral valve regurgitation
sinus rhythm or AF
27
what will be heart at the apex in mitral valve regurgitation
forceful, displaced, systolic thrill
28
what are the heart sounds heard in mitral valve regurgitation
Soft S1, split S2, loud P2 . maybe a mid-systolic click (sudden prolapse of the valve)
29
what is the murmur heard in mitral valve regurgitation
pansystolic, radiating to the axilla
30
what will be seen on CXR in mitral valve regurgitation
Left atrial and left ventricular enlargement
Increased cardiac thoracic ratio
Valve calcification
31
what will be seen on ECG in mitral valve regurgitation
Bifid P wave
Left ventricular hypertrophy (tall R wave in leads 1, V6 and deep S wave is V1 and V2)
AF might be present
32
what is the pharmacological treatment for mitral valve regurgitation
Prophylaxis against IE
If fast AF : rate control + anticoagulated
Pulmonary oedema / HF; diuretics
ACE inhibitor
33
what is the surgical treatment for mitral valve regurgitation
For deteriorating symptoms
Aim to repair or replace valve be4 LV irreversibly impaired (early intervention!)
Percutaneous mitral valve repair (Mitraclip)
New
Appropriate for patient unsuitable for cardiac surgery
34
what is the first heart sound (S1) caused by
the closing of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles
35
what is the second heart sound (S2) caused by
the closing of the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete
36
what Is the third heart sound
S3 - is heard roughly 0.1 seconds after the second heart sound
37
what is the third heart sound caused by
rapid ventricular filling causing the chordae tendineae to pull to their full strength and twang like a guitar string.
38
what can the extra heart sound result in it being described as
a gallop rhythm
39
in who can S3 be normal in
young (15-40 year) healthy people, because the heart functions so well that the ventricles allow rapid filling.
40
why can S3 indicate heart failure in order people
because the ventricles and chordae are stiff and weak and reach their limit much faster than usual
41
what is the fourth heart sound and when it is heard
S4 is directly heard before S1
this is always abnormal and relatively rare to hear
42
what does S4 indicate
a stiff or hypertrophic ventricle and is caused by turbulent blood flow from the atria contracting against a non-compliant ventricle
43
when do you use the bell or diaphragm of a stethoscope
Auscultate with the stethoscope bell to better hear low-pitched sounds and the diaphragm to listen to high-pitched sounds
44
where is Erb's point and what is it best for
Listen to Erb’s point. This is in the third intercostal space on the left sternal border and is the best area for listening to heart sounds (S1 and S2).
45
how do u position the patient to listen for mitral stenosis
position the patient on their left side
46
how do you position the patient for aortic regurgitation
position the patient sat up, leaning forward and holding exhalation for aortic regurgitation
47
the hypertrophy and dilation caused by valvular disease affects what chamber
the chamber immediately before the pathological valve
e.g the left ventricle in aortic pathology and the left atrium in mitral pathology
48
what does mitral stenosis result in
left atrial hypertrophy
49
what does aortic stenosis result in
left ventricular hypertrophy
50
what does mitral regurgitation cause
left atrial dilatation
51
what does aortic regurgitation cause
left ventricular dilatation
52
what is the most common valvular heart disease
aortic stenosis
53
what does aortic stenosis refer to
the narrowing of the aortic valve, restricting blood flow from the left ventricle to the aorta
54
what kind of murmur does aortic stenosis cause
Aortic stenosis causes an ejection-systolic, high-pitched murmur due to the high blood flow velocity through the aortic valve. This has a crescendo-decrescendo character due to the speed of blood flow across the value during the different periods of systole. Flow during systole is slowest at the start and end and fastest in the middle.
55
where does the murmur radiate to
radiates to the carotids as the turbulence continues into the neck
56
what are other signs of aortic stenosis
Thrill in the aortic area on palpation
Slow rising pulse
Narrow pulse pressure (the difference between systolic and diastolic blood pressure)
Exertional syncope (lightheadedness and fainting when exercising) due to difficulty maintaining a good flow of blood to the brain
57
what are the causes of aortic stenosis
Idiopathic age-related calcification (by far the most common cause)
Bicuspid aortic valve
Rheumatic heart disease
58
what does aortic regurgitation refer to
an incompetent aortic valve, allowing blood to flow back from the aorta into the left ventricle
59
what kind of murmur does aortic regurgitation cause
an early diastolic soft mumur
60
what other murmur can aortic regurgitation cause and where is it heard
It can also cause an Austin-Flint murmur. This is heard at the apex as a diastolic “rumbling” murmur. This is caused by blood flowing back through the aortic valve and over the mitral valve, causing it to vibrate.
61
what are the other signs of aortic regurgitation
Thrill in the aortic area on palpation
Collapsing pulse
Wide pulse pressure
Heart failure and pulmonary oedema
62
what is a collapsing pulse or a water hammer pulse
a forcefully appearing and rapidly disappearing pulse
typically felt in the radial artery with the patient's arm held straight upwards
63
how does a collapsing pulse occur
as blood is forcefully pumped out of the left ventricle, then immediately flows backwards through the incompetent aortic valve
64
what are the causes of aortic regurgitation
Idiopathic age-related weakness
Bicuspid aortic valve
Connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome
65
what is mitral stenosis
narrowed mitral valve restricting blood flow from the left atrium into the left ventricle
66
what kind of murmur does mitral stenosis cause
mid-diastolic low pitched rumbling murmur due to low blood flow velocity
67
why will there be a loud S1 sound in mitral stenosis
due to thick valves requiring a large systolic force to shut, then shutting suddenly.
there is an opening snap after S2 which triggers the onset of the murmur
68
what are the other signs of mitral stenosis
Tapping apex beat, which is a palpable, prominent S1
Malar flush
Atrial fibrillation (irregularly irregular pulse)
69
what is malar flush
Malar flush refers to red discolouration of the skin over the upper cheeks and nose. It is due to the back pressure of blood into the pulmonary system, causing a rise in CO2 and vasodilation.
70
what are the causes of mitral stenosis
Rheumatic heart disease
Infective endocarditis
71
what are the signs of Marfan syndrome
tall stature, long limbs, arachnodactyly (long slender fingers) and a high-arched palate. This will make you look very clever.
72
what is mitral regurgitation
incompetent mitral valve, allowing blood to flow back from the left ventricle to the left atrium during systolic contraction of the left ventricle
73
what does the leaking valve cause
a reduced ejection fraction and a backlog of blood waiting to be pumped through the left side of the heart, resulting in congestive cardiac failure
74
what kind of murmur does mitral regurgitation cause
pan-systolic, high-pitched “whistling” murmur due to high-velocity blood flow through the leaky valve. The murmur radiates to the left axilla. You may hear a third heart sound.
75
what are the other signs of mitral regurgitation
pan-systolic, high-pitched “whistling” murmur due to high-velocity blood flow through the leaky valve. The murmur radiates to the left axilla. You may hear a third heart sound.
76
what are the causes of mitral regurgitation
Idiopathic weakening of the valve with age
Ischaemic heart disease
Infective endocarditis
Rheumatic heart disease
Connective tissue disorders, such as Ehlers-Danlos syndrome or Marfan syndrome
77
what is tricuspid regurgitation
Tricuspid regurgitation refers to an incompetent tricuspid valve, allowing blood to flow back from the right ventricle to the right atrium during systolic contraction of the right ventricle.
78
what kind of murmur does tricuspid regurgitation show
Tricuspid regurgitation causes a pan-systolic murmur. There is a split second heart sound due to the pulmonary valve closing earlier than the aortic valve, as the right ventricle empties faster than the left ventricle.
79
what are the other signs of tricuspid regurgitation
Thrill in the tricuspid area on palpation
Raised JVP with giant C-V waves (Lancisi’s sign)
Pulsatile liver (due to regurgitation into the venous system)
Peripheral oedema
Ascites
80
what are the causes of tricuspid regurgitation
Pressure due to left-sided heart failure or pulmonary hypertension (“functional”)
Infective endocarditis
Rheumatic heart disease
Carcinoid syndrome
Ebstein’s anomaly
Connective tissue disorders, such as Marfan syndrome
81
what is pulmonary stenosis
narrowed pulmonary valve, restricting blood flow from the right ventricle into the pulmonary arteries
82
what kind of murmur does pulmonary stenosis cause
Pulmonary stenosis causes an ejection systolic murmur loudest in the pulmonary area with deep inspiration. There is a widely split second heart sound, as the left ventricle empties much faster than the right ventricle.
83
what are the other signs of pulmonary stenosis
Thrill in the pulmonary area on palpation
Raised JVP with giant A waves (due to the right atrium contracting against a hypertrophic right ventricle)
Peripheral oedema
Ascites
84
what may pulmonary stenosis be associated with
Noonan syndrome
Tetralogy of Fallot
85
what are the four coexisting pathologies of tetralogy of Fallot
Ventricular septal defect (VSD)
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy
86
when does acute left ventricular failure occur
when an acute event results in the left ventricle being unable to move blood efficiently through the left side of the heart and into the systemic circulation
87
what is cardiac output
the volume of blood ejected by the heart per minute
88
what is stroke volume
the volume of blood ejected during each blast
89
what is cardiac output the result of
the product of stroke volume x heart rate
90
what happens when blood cannot flow efficiently through the left side of the heart
there is a backlog of blood waiting in the left atrium, pulmonary veins and lungs
91
as these areas experience an increased volume and pressure of blood, what happens
they start to leak fluid and cannot reabsorb excess fluid from the surrounding tissues, resulting in pulmonary oedema
92
what is pulmonary oedema
where the lung tissue and alveoli are filled with interstitial fluid.
this interferes with normal gas exchange in the lungs, causing shortness of breath and reduced oxygen saturation
93
what is acute left ventricular failure often the result of
decompensated chronic heart failure
94
what are the potential triggers of acute left ventricular failure
Iatrogenic (e.g., aggressive IV fluids in a frail elderly patient with impaired left ventricular function)
Myocardial infarction
Arrhythmias
Sepsis
Hypertensive emergency (acute, severe increase in blood pressure)
95
how does acute LVF typically present
with acute shortness of breath
96
what does acute LVF cause
a type 1 respiratory failure (low oxygen without an increased carbon dioxide)
97
what are the symptoms of acute LVF
shortness of breath
looking and feeling unwell
cough with frothy white or pink sputum
98
what are the signs of acute LVF on examination
Raised respiratory rate
Reduced oxygen saturations
Tachycardia (fast heart rate)
3rd heart sound
Bilateral basal crackles (sounding “wet”) on auscultation of the lungs
Hypotension in severe cases (cardiogenic shock)
99
what would you find if they also have right sided heart failure
raised jugular venous pressure caused by the backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
peripheral oedema of the ankles, legs and sacrum
100
where is BNP released from
it is a hormone released from the heart ventricles when the cardiac muscle (myocardium) is stretched beyond the normal range
101
what is the action of BNP
to relax smooth muscle in blood vessels
this reduces systemic vascular resistance making it easier for the heart to pump blood through the system
102
how does BNP act on the kidneys
acts on the kidneys as a diuretic to promote water excretion in the urine
this reduces the circulating volume, helping to improve the function of the heart in someone that is fluid overloaded
103
an ejection fraction over what is considered normal
over 50%
104
what is fluid in the septal lines called
Kerley lines
105
what type of drugs improve cardiac output
inotropes such as dobutamine
106
what drugs may be considered in severe hypertension or acute coronary syndrome
intravenous nitrates
107
what type of drugs act as vasodilators
intravenous opiates such as morphine
108
why are some cardiac patients required to be on lifelong warfarin
mechanical valves have a lifespan over 20 years but require lifelong warfarin.
109
what is the INR target range with mechanical valves
2.5-3.5
110
what is the INR target in atrial fibrillation
2-3
111
what are the three major complications of mechanical heart valves
thrombus formation
infective endocarditis
haemolytic causing anaemia
112
what is a heave the result of
LVH and feels like something push your hand off the chest
113
what is the official name for a collapsing pulse and what is it an sign of
Corrigan's sign and is a sign of aortic regurgitation
114
what is Gerhard Sign
pulsatile spleen
sign of aortic regurgitation
115
what is Mueller sign
pulsatile uvula
sign of aortic regurgitation
116
what is Quincke sign
exaggerated nail bed pulsations
sign of aortic regurgitation
117
what is the loud sound heard in systole and diastole over the femoral artery that is sometimes describes as a pistol shot
Traube sign
118
what is Marfan syndrome
an autosomal dominant connective tissue disorder
119
what is the epidemiology and aetiology of Marfan syndrome
25% of cases occur without family history
reduced life expectancy - average is around 60
120
what is the pathology behind Marfan syndrome
the result of a mutation in the fibrillar 1 gene (FBN-1)
this results in decreased production of extracellular microfibril
121
what is microfibril involved in
the maintenance of elastic fibres, and as a result, there is an alteration in the properties of elastic fibres
122
what can the signs of Marfan syndrome be divided into
major and minor
123
how many major symptoms have to be present to diagnose the syndrome
more than 2
124
what are the major signs of Marfan syndrome
Long limbs, tall, long, spindly fingers (arachnodactyly)
- The thumb sign – the distal phalanx of the thumb extends beyond the edge of the clenched fist
Arm length height
Upwards lens dislocation in the eye (aka ectopia lentis) – the margin of the dislocation lens may been seen through an undilated pupil
Pectus deformity (e.g. excavatum or carinatum [outwards])
Aortic dissection / dilatiation – particularly at the aortic root. The arotic media is less resistant to stretching, particularly in areas of high pressure – hence the involvement of the aortic root. In severe cases, dissection can occur before the age of 10! Aortic regurg and endocarditis are also common
Dural ectasia – widening of the neural canal
125
what do the minor signs do
support diagnosis
126
what are the minor signs
Mitral valve prolapse – and accompanying late systolic murmur at the apex
High arched palate – can cause altered / unusual voice in some patients
Joint Hypermobility
Genu recuvatum – hyperextension of the knee, thus is appears to curve backwards
Scoliosis
Reduced subcutaneous fat
127
how is Marfan syndrome diagnosed
usually clinical. CT scan may be useful
128
what can a CT scan detect in Marfan patient
dural ectasia
129
what are the treatment aims for Marfan syndrome
to minimise the risk of aortic dissection by preventing excessive dilation of the aortic root.
130
what is this usually managed with
Β- blockers – e.g. atenolol, propanolol – these reduce the contractility of the heart, and thus reduce the pressure in the aortic root, reducing the risk of dilation and dissection
Annual Echocardiogram – dilation of >5cm is repaired surgically
Risk in pregnancy – pregnant women are at particularly high risk of cardiac complications.
131
what disorder is usually difficult to distinguish from Marfan syndrome
homocystinuria
132
what does homocystinuria respond to that Marfan doesn't
pyridoxine
133
what does the a wave represent
atrial contraction
134
what does the v wave represent
ventricular contraction
135
what does the c wave represent
atrial filling against a closed tricuspid valve
136
what is happening in the QRS complex
ventricular contraction
closure of tricuspid and mitral valves
opening of aortic and pulmonary valve
137
what is happening in the T wave
refractory period
138
what is happening in the P wave
atrial contraction
tricuspid valve / mitral valves are open and atria are contracting
139
what is happens in the isoelectric ling between end of T wave and beginning of next P wave
passive atrial filling
140
how do you differentiate between the jugular veins and the carotid pulse in the neck
the jugular vein sits in between the two heads of the SCM and the earlobe.
It is not visible unless it is elevated or unless pressure is placed on the liver (called the hepatojugular reflex). The carotid artery lies just medial to the internal jugular vein and is palpated at the point of the C wave, (see below) which occurs between the A and V waves of the JVP. The carotid pulsation does not alter when pressing on the liver. Unlike the carotid pulse which has one pulsatile wave, the JVP has three wave
141
what is the A wave of JVP
142
what ventilation is used in type 1 respiratory failure and sleep apnea
CPAP
143
what ventilation is used in type II respiratory failure
BiPAP
144
