Week Four - Case Three Flashcards

1
Q

what is aortic stenosis

A

the narrowing of the three cusps that form the aortic valve

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2
Q

what are the congenital causes of aortic stenosis

A

Bicuspid Valve
Williams Syndrome

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3
Q

what is the most common cause of aortic stenosis

A

senile calcification
Look for corneal arcus

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4
Q

what are the signs of aortic stenosis

A

Ejection Systolic murmur best heard in the aortic area, ( Right 2nd intercostal space at border of sternum), radiating to the caroitds.

Slow-rising pulse, with a narrow pulse pressure (difference between systolic and diastolic pressures is small)

Heave – but apex beat is not displaced

Possible signs of:
- Heart failure / pulmonary hypertension: crackles at the lung bases, pink frothy sputum, oedema etc
- AF – irregularly irregular pulse

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5
Q

what are the symptoms of aortic stenosis

A

Angina
Syncope
Dyspnoea

Signs of any valve defect
Fatigue
Dyspnoea

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6
Q

what would an ECG show

A

L – LBBB – due do calcification
L – Left Axis Deviation
L – LVH
P – Poor R wave progression (i.e. depolarisation of the ventricles is slow)

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7
Q

what is used to estimate the pressure across the valve

A

a doppler echo

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8
Q

what are the pressure readings indicative of aortic stenosis

A

0 mmHg – normal valve

<30 mmHg – mild aortic stenosis

30-50 mmHg – moderate aortic stenosis

> 50 mmHg – severe aortic stenosis

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9
Q

what is cardiac catheritisation

A

this can assess the actual gradient across the valve as well as check for co-existing CADw

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10
Q

what is the prognosis of aortic stenosis if it goes untreated

A

This can be predicted with the presence of symptoms:
Angina present – 2 years
Syncope present – 1 year
Dyspnoea present – 6 months

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11
Q

what is the surgical management of aortic stenosis

A

Surgical –if symptomatic, then the prognosis is poor (above) and prompt valve replacement is recommended. Valve replacement is also recommended for patients with ECG signs, and moderate to severe disease on Doppler / cardiac catheterisation.

Patients should be placed on antibiotics to prevent bacterial endocarditis

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12
Q

how long to prosthetic valve replacements last

A

about 10 years, they may need a replacement

no need for long term anticoagulant therapy

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13
Q

what are the three types of a metal valve, how long do they last and what is the disadvantage

A

Metal –last a life time, but require anticoagulant therapy for life. Also noisy (often make a loud ‘click’ sound).

There are three types of metal valve:
- Tilting disc
- Double tilting disc
- Ball in a cage

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14
Q

what is the most common indication for cardiac valve surgery

A

symptomatic aortic stenosis is the most common idication

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15
Q

how may a patient with severe aortic stenosis present

A

Symptomatic fluid overload (SOB/orthopnoea/peripheral oedema)

Exertional syncope

Chest pain

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16
Q

what does aortic stenosis result from

A

progressive thickening and restricted opening of the aortic valve

this leads to a fixed obstruction to blood flow out of the left ventricle and around the body

17
Q

what are the two types of surgeries done

A

surgical aortic valve replacement or transcatheter aortic valve insertion (TAVI) depending in individual patient characteristics.

18
Q

what medication is given to patients with aortic stenosis

A

diuretics to improv symptoms

19
Q

A 60 year old male patient with a history of HF presents to clinic with worsening shortness of breath and increased ankle swelling over 3 months. He currently takes ramipril, bisoprolol, eplerenone and furosemide 20mg OD. His recent echo shows an ejection fraction of 35%.

Which is the most appropriate next medication to add in?

A

Ivabradine

20
Q

A 60 year old male presents to A&E complaining of fluttering in his chest for about a week and this morning woke feeling dizzy, unwell and short of breath. His pulse is irregularly irregular and CRT= 4 seconds. There are bibasal crackles on inspiration. ECG shows absent p waves and narrow QRS complexes. Obs show:

  • HR 230bpm
  • BP 80/44
  • RR 28 Sats 93% OA
  • T 37.1

Given the likely diagnosis, what is the next best step in management?

A

Synchronized DC cardioversion

21
Q

A 74 year old woman is diagnosed with paroxysmal atrial fibrillation. What is the minimum CHA2DS2VASC score indicated for anticoagulation consideration?

A

2

22
Q

A 70 year old female has a 4/52 history of fever and malaise. PMH: COPD and CCF. Observations:

  • HR 80bpm
  • BP 145/90
  • T 38.2
  • RR 18
  • Loud ejection systolic murmur at sternal angle, radiates to the neck.
  • Echo shows 4mm vegetation on leaflet of aortic valve.

Which additional finding is necessary to confirm the patient’s diagnosis?

A

Single positive blood culture for Coxiella burnetti

23
Q
A