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Year 3 > Week Four - Acute to Chronic Breathlessness > Flashcards

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
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2
Q

what is the bacterium in rheumatic heart disease

A

Group A beta haemolytic streptococcus

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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
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4
Q

when do symptoms begin to show in mitral valve stenosis

A

no symptoms until orifices <2cm(2)

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5
Q

what is this due to?

A

due to pulmonary hypertension, dyspnoea, Haemoptysis, recurrent bronchitis

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6
Q

what does this eventually lead to

A

right heart failure

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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

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8
Q

what are the signs in the face of mitral valve stenosis

A

mitral facies / malar flush

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9
Q

what is mitral facies / malar flush due to

A

decreased cardiac output

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10
Q

what happens to the pulse in mitral valve stenosis

A

atrial fibrillation - irregularly irregular

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11
Q

what can you hear at the apex with mitral valve disease

A

localised, tapping

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12
Q

what are the heart sounds in mitral valve stenosis

A

Loud S1, loud P2(pulmonary HTN), opening snap

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13
Q

what kind of murmur is heard in mitral valve stenosis

A

mid diastolic murmur rumbling at apex

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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

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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)

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16
Q

what medications are given for AF

A

digoxin and anticoagulation

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17
Q

what medications are given for pulmonary oedema

A

diuretics

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18
Q

what are the 4 surgical options for mitral valve stenosis

A
  1. trans-septal balloon valvotomy
  2. closed valvotomy
  3. open valvotomy
  4. mitral valve replacement
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19
Q

when would you treat with trans-septal balloon valvotomy

A

when there is a pliable, non-calcified valve

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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
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21
Q

what connective tissue diseases are connected to mitral regurgitation

A

marfan’s syndrome
ehler’s danlos

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22
Q

what is the pathophysiology behind mitral valve regurgitation

A
  1. 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)
  2. this left atrial pressure leads to pulmonary oedema
  3. there will then be decreased stroke volume due to regurgitation, therefore left ventricle hypertrophy to increase stroke volume and hence cardiac output
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23
Q

as time goes by, what ends up happening?

A

right sided heart failure

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24
Q

what symptoms appear in mitral valve registration due to pulmonary oedema

A

dyspnoea, orthopnoea, fatigue and lethargy

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25
Q

what symptoms appear due to the stoke volume

A

palpitations

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26
Q

what are the pulse signs of mitral valve regurgitation

A

sinus rhythm or AF

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27
Q

what will be heart at the apex in mitral valve regurgitation

A

forceful, displaced, systolic thrill

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28
Q

what are the heart sounds heard in mitral valve regurgitation

A

Soft S1, split S2, loud P2 . maybe a mid-systolic click (sudden prolapse of the valve)

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29
Q

what is the murmur heard in mitral valve regurgitation

A

pansystolic, radiating to the axilla

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30
Q

what will be seen on CXR in mitral valve regurgitation

A

Left atrial and left ventricular enlargement
Increased cardiac thoracic ratio
Valve calcification

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31
Q

what will be seen on ECG in mitral valve regurgitation

A

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

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32
Q

what is the pharmacological treatment for mitral valve regurgitation

A

Prophylaxis against IE
If fast AF : rate control + anticoagulated
Pulmonary oedema / HF; diuretics
ACE inhibitor

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33
Q

what is the surgical treatment for mitral valve regurgitation

A

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

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34
Q

what is the first heart sound (S1) caused by

A

the closing of the atrioventricular valves (the tricuspid and mitral valves) at the start of the systolic contraction of the ventricles

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35
Q

what is the second heart sound (S2) caused by

A

the closing of the semilunar valves (the pulmonary and aortic valves) once the systolic contraction is complete

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36
Q

what Is the third heart sound

A

S3 - is heard roughly 0.1 seconds after the second heart sound

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37
Q

what is the third heart sound caused by

A

rapid ventricular filling causing the chordae tendineae to pull to their full strength and twang like a guitar string.

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38
Q

what can the extra heart sound result in it being described as

A

a gallop rhythm

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39
Q

in who can S3 be normal in

A

young (15-40 year) healthy people, because the heart functions so well that the ventricles allow rapid filling.

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40
Q

why can S3 indicate heart failure in order people

A

because the ventricles and chordae are stiff and weak and reach their limit much faster than usual

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41
Q

what is the fourth heart sound and when it is heard

A

S4 is directly heard before S1

this is always abnormal and relatively rare to hear

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42
Q

what does S4 indicate

A

a stiff or hypertrophic ventricle and is caused by turbulent blood flow from the atria contracting against a non-compliant ventricle

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43
Q

when do you use the bell or diaphragm of a stethoscope

A

Auscultate with the stethoscope bell to better hear low-pitched sounds and the diaphragm to listen to high-pitched sounds

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44
Q

where is Erb’s point and what is it best for

A

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).

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45
Q

how do u position the patient to listen for mitral stenosis

A

position the patient on their left side

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46
Q

how do you position the patient for aortic regurgitation

A

position the patient sat up, leaning forward and holding exhalation for aortic regurgitation

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47
Q

the hypertrophy and dilation caused by valvular disease affects what chamber

A

the chamber immediately before the pathological valve

e.g the left ventricle in aortic pathology and the left atrium in mitral pathology

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48
Q

what does mitral stenosis result in

A

left atrial hypertrophy

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49
Q

what does aortic stenosis result in

A

left ventricular hypertrophy

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50
Q

what does mitral regurgitation cause

A

left atrial dilatation

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51
Q

what does aortic regurgitation cause

A

left ventricular dilatation

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52
Q

what is the most common valvular heart disease

A

aortic stenosis

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53
Q

what does aortic stenosis refer to

A

the narrowing of the aortic valve, restricting blood flow from the left ventricle to the aorta

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54
Q

what kind of murmur does aortic stenosis cause

A

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.

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55
Q

where does the murmur radiate to

A

radiates to the carotids as the turbulence continues into the neck

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56
Q

what are other signs of aortic stenosis

A

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

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57
Q

what are the causes of aortic stenosis

A

Idiopathic age-related calcification (by far the most common cause)
Bicuspid aortic valve
Rheumatic heart disease

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58
Q

what does aortic regurgitation refer to

A

an incompetent aortic valve, allowing blood to flow back from the aorta into the left ventricle

59
Q

what kind of murmur does aortic regurgitation cause

A

an early diastolic soft mumur

60
Q

what other murmur can aortic regurgitation cause and where is it heard

A

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
Q

what are the other signs of aortic regurgitation

A

Thrill in the aortic area on palpation
Collapsing pulse
Wide pulse pressure
Heart failure and pulmonary oedema

62
Q

what is a collapsing pulse or a water hammer pulse

A

a forcefully appearing and rapidly disappearing pulse

typically felt in the radial artery with the patient’s arm held straight upwards

63
Q

how does a collapsing pulse occur

A

as blood is forcefully pumped out of the left ventricle, then immediately flows backwards through the incompetent aortic valve

64
Q

what are the causes of aortic regurgitation

A

Idiopathic age-related weakness
Bicuspid aortic valve
Connective tissue disorders, such as Ehlers-Danlos syndrome and Marfan syndrome

65
Q

what is mitral stenosis

A

narrowed mitral valve restricting blood flow from the left atrium into the left ventricle

66
Q

what kind of murmur does mitral stenosis cause

A

mid-diastolic low pitched rumbling murmur due to low blood flow velocity

67
Q

why will there be a loud S1 sound in mitral stenosis

A

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
Q

what are the other signs of mitral stenosis

A

Tapping apex beat, which is a palpable, prominent S1
Malar flush
Atrial fibrillation (irregularly irregular pulse)

69
Q

what is malar flush

A

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
Q

what are the causes of mitral stenosis

A

Rheumatic heart disease
Infective endocarditis

71
Q

what are the signs of Marfan syndrome

A

tall stature, long limbs, arachnodactyly (long slender fingers) and a high-arched palate. This will make you look very clever.

72
Q

what is mitral regurgitation

A

incompetent mitral valve, allowing blood to flow back from the left ventricle to the left atrium during systolic contraction of the left ventricle

73
Q

what does the leaking valve cause

A

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
Q

what kind of murmur does mitral regurgitation cause

A

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
Q

what are the other signs of mitral regurgitation

A

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
Q

what are the causes of mitral regurgitation

A

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
Q

what is tricuspid regurgitation

A

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
Q

what kind of murmur does tricuspid regurgitation show

A

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
Q

what are the other signs of tricuspid regurgitation

A

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
Q

what are the causes of tricuspid regurgitation

A

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
Q

what is pulmonary stenosis

A

narrowed pulmonary valve, restricting blood flow from the right ventricle into the pulmonary arteries

82
Q

what kind of murmur does pulmonary stenosis cause

A

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
Q

what are the other signs of pulmonary stenosis

A

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
Q

what may pulmonary stenosis be associated with

A

Noonan syndrome
Tetralogy of Fallot

85
Q

what are the four coexisting pathologies of tetralogy of Fallot

A

Ventricular septal defect (VSD)
Overriding aorta
Pulmonary valve stenosis
Right ventricular hypertrophy

86
Q

when does acute left ventricular failure occur

A

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
Q

what is cardiac output

A

the volume of blood ejected by the heart per minute

88
Q

what is stroke volume

A

the volume of blood ejected during each blast

89
Q

what is cardiac output the result of

A

the product of stroke volume x heart rate

90
Q

what happens when blood cannot flow efficiently through the left side of the heart

A

there is a backlog of blood waiting in the left atrium, pulmonary veins and lungs

91
Q

as these areas experience an increased volume and pressure of blood, what happens

A

they start to leak fluid and cannot reabsorb excess fluid from the surrounding tissues, resulting in pulmonary oedema

92
Q

what is pulmonary oedema

A

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
Q

what is acute left ventricular failure often the result of

A

decompensated chronic heart failure

94
Q

what are the potential triggers of acute left ventricular failure

A

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
Q

how does acute LVF typically present

A

with acute shortness of breath

96
Q

what does acute LVF cause

A

a type 1 respiratory failure (low oxygen without an increased carbon dioxide)

97
Q

what are the symptoms of acute LVF

A

shortness of breath
looking and feeling unwell
cough with frothy white or pink sputum

98
Q

what are the signs of acute LVF on examination

A

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
Q

what would you find if they also have right sided heart failure

A

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
Q

where is BNP released from

A

it is a hormone released from the heart ventricles when the cardiac muscle (myocardium) is stretched beyond the normal range

101
Q

what is the action of BNP

A

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
Q

how does BNP act on the kidneys

A

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
Q

an ejection fraction over what is considered normal

A

over 50%

104
Q

what is fluid in the septal lines called

A

Kerley lines

105
Q

what type of drugs improve cardiac output

A

inotropes such as dobutamine

106
Q

what drugs may be considered in severe hypertension or acute coronary syndrome

A

intravenous nitrates

107
Q

what type of drugs act as vasodilators

A

intravenous opiates such as morphine

108
Q

why are some cardiac patients required to be on lifelong warfarin

A

mechanical valves have a lifespan over 20 years but require lifelong warfarin.

109
Q

what is the INR target range with mechanical valves

A

2.5-3.5

110
Q

what is the INR target in atrial fibrillation

A

2-3

111
Q

what are the three major complications of mechanical heart valves

A

thrombus formation
infective endocarditis
haemolytic causing anaemia

112
Q

what is a heave the result of

A

LVH and feels like something push your hand off the chest

113
Q

what is the official name for a collapsing pulse and what is it an sign of

A

Corrigan’s sign and is a sign of aortic regurgitation

114
Q

what is Gerhard Sign

A

pulsatile spleen

sign of aortic regurgitation

115
Q

what is Mueller sign

A

pulsatile uvula

sign of aortic regurgitation

116
Q

what is Quincke sign

A

exaggerated nail bed pulsations

sign of aortic regurgitation

117
Q

what is the loud sound heard in systole and diastole over the femoral artery that is sometimes describes as a pistol shot

A

Traube sign

118
Q

what is Marfan syndrome

A

an autosomal dominant connective tissue disorder

119
Q

what is the epidemiology and aetiology of Marfan syndrome

A

25% of cases occur without family history

reduced life expectancy - average is around 60

120
Q

what is the pathology behind Marfan syndrome

A

the result of a mutation in the fibrillar 1 gene (FBN-1)

this results in decreased production of extracellular microfibril

121
Q

what is microfibril involved in

A

the maintenance of elastic fibres, and as a result, there is an alteration in the properties of elastic fibres

122
Q

what can the signs of Marfan syndrome be divided into

A

major and minor

123
Q

how many major symptoms have to be present to diagnose the syndrome

A

more than 2

124
Q

what are the major signs of Marfan syndrome

A

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
Q

what do the minor signs do

A

support diagnosis

126
Q

what are the minor signs

A

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
Q

how is Marfan syndrome diagnosed

A

usually clinical. CT scan may be useful

128
Q

what can a CT scan detect in Marfan patient

A

dural ectasia

129
Q

what are the treatment aims for Marfan syndrome

A

to minimise the risk of aortic dissection by preventing excessive dilation of the aortic root.

130
Q

what is this usually managed with

A

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
Q

what disorder is usually difficult to distinguish from Marfan syndrome

A

homocystinuria

132
Q

what does homocystinuria respond to that Marfan doesn’t

A

pyridoxine

133
Q

what does the a wave represent

A

atrial contraction

134
Q

what does the v wave represent

A

ventricular contraction

135
Q

what does the c wave represent

A

atrial filling against a closed tricuspid valve

136
Q

what is happening in the QRS complex

A

ventricular contraction

closure of tricuspid and mitral valves

opening of aortic and pulmonary valve

137
Q

what is happening in the T wave

A

refractory period

138
Q

what is happening in the P wave

A

atrial contraction

tricuspid valve / mitral valves are open and atria are contracting

139
Q

what is happens in the isoelectric ling between end of T wave and beginning of next P wave

A

passive atrial filling

140
Q

how do you differentiate between the jugular veins and the carotid pulse in the neck

A

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
Q

what is the A wave of JVP

A
142
Q

what ventilation is used in type 1 respiratory failure and sleep apnea

A

CPAP

143
Q

what ventilation is used in type II respiratory failure

A

BiPAP

144
Q
A

Year 3 (63 decks)

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