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MD3001 > Valvular Heart Disease, Endocarditis > Flashcards

Valvular Heart Disease, Endocarditis Flashcards

1
Q

Is valvular heart disease primary or secondary ?

A

It can be both.

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2
Q

What proportion of heart failure involve valve disease ?

A

10% of heart failures involve valve disease

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3
Q

Which valves of the heart are affected by valvular disease ?

A

All four, but mainly aortic and mitral valve

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4
Q

Give an example of how valvular heart disease could occur secondary to another event.

A

Dilatation of the heart causing an inability for the valve to close.

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5
Q

Identify the main function of heart valves.

A

To allow forward flow but prevent backflow.

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6
Q

Identify the main components of valves.

A

Valve ring
Cusps
Chordae
Papillary muscle (mitral and tricuspid only)

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7
Q

Identify the main functional failures in valves.

A

Mitral stenosis
Mitral incompetence
Aortic stenosis
Aortic incompetence

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8
Q

Although aortic and mitral valve disease are more common than pulmonary and tricuspid valve disease, are they also more serious ?

A

Yes, more common and more serious

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9
Q

Are stenosis and incompetence mutually exclusive ?

A

No, stenosis and incompetence can coexist (but even if they’re both involved, one might be dominant)

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10
Q

Why are pulmonary and tricuspid valves less likely to be affected/why is it less severe in those valves ?

A

Less involved because under less mechanical stress which also means that any disease affecting the valve is likely to be made much worse in mitral/aortic valve (hence more severe)

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11
Q

Define stenosis.

A

Narrowing of the valve outlet caused by thickening of valve cusps, or increased rigidity or scarring.

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12
Q

Define incompetence.

A

Insufficiency or regurgitation (which is what happens) caused by incomplete seal when valves close, allowing blood to flow backwards

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13
Q

Define vegetations and explain their relevance to valvular heart disease.

A

“any plantlike growth”

Something growing in a valve (typically platelets and fibrin thrombus, sometimes can be calcified scar tissue)

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14
Q

Which phase of the cardiac cycle would you notice aortic incompetence in ?

A

Diastole

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15
Q

Which phase of the cardiac cycle would you notice aortic stenosis in ?

A

Systole

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16
Q

Which phase of the cardiac cycle would you notice mitral stenosis in ?

A

Diastole

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17
Q

Identify general, common causes of cardiac valve stenosis and incompetence.

A

1) Congenital Heart Disease
- Bicuspid valve (When it should in fact have three cusps. Can be problematic) e.g. in aorta
- Atresia

2) Cardiomyopathy
- Hypertrophic
- Dilated

3) Acquired
- Rheumatic fever
- MI
- Age-related- idiopathic aortic calcific stenosis
- Endocarditis

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18
Q

Which valvular functional failure would a dilated cardiomyopathy result in ?

A

Incompetence, because the valvular ring would be dilated, so cusps cannot meet anymore

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19
Q

Which valvular functional failure would a hypertrophic cardiomyopathy result in ?

A

Stenosis or incompetence.

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20
Q

What are the possible risks of aortic stenosis ?

A
  • L ventricular hypertrophy (L ventricle has to push harder)
  • Syncope (loss of consciousness)
  • Sudden cardiac death
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21
Q

Identify causes of aortic stenosis.

A
  • Calcification of congenital bicuspid valve
  • Senile calcific degeneration
  • Rheumatic fever (inflammatory holes in cusps resulting in scarring and stenosis)
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22
Q

Identify consequences and clinical symptoms of aortic stenosis.

A
  • Increases work of the heart
  • Ventricular hypertrophy
  • Causes cardiac failure late in clinical course

Clinical symptoms include:

  • Dyspnoea (breathlessness)
  • Angina (cardiac chest pain)
  • Syncope
23
Q

Identify the main causes of aortic incompetence.

A
  • Infective endocarditis
  • Rheumatic fever
  • Marfan’s syndrome (CT too elastic)
  • Dilatation of aortic root (age-related or syphilitic)
24
Q

What are the consequences of aortic regurgitation ?

A

Increases V of blood to be pumped
Increases work to be done by the heart
Cardiac Hypertrophy
Cardiac Failure

25
Q

Can aortic regurgitation occur in the presence of aortic stenosis ?

A

Yes it can.

26
Q

Identify the main causes of mitral incompetence.

A

Cusp Damage

  • Rheumatic Heart Disease (scarring, contraction)
  • Floppy valve & Marfan Syndrome (stretch)
  • Infective endocarditis (perforation)

Chordae Damage

  • Rheumatic Heart Disease (scarring, contraction)
  • Floppy valve & Marfan Syndrome (stretch)
  • Infective endocarditis (perforation)

Papillary Muscle Damage
-Post MI

Valve ring Damage

  • Age or Hypertension (hence dilated heart, and ring)
  • Rheumatic Heart Disease (scarring, contraction)
  • Floppy valve & Marfan Syndrome (stretch)
  • Infective endocarditis (perforation)
27
Q

What is the most common cause of mitral incompetence ?

A

Rheumatic Fever

28
Q

What are the risks posed by mitral incompetence ?

A

Pulmonary hypertension
L ventricular hypertrophy
R ventricular hypertrophy

29
Q

Associate each main valvular heart disease with a kind of murmur.

A

Aortic stenosis: Ejection systolic murmur
Aortic incompetence: Diastolic murmur
Mitral stenosis: Diastolic murmur
Mitral incompetence: Systolic murmur

30
Q

Identify the main causes of mitral stenosis.

A 
Congenital (rare)
Rheumatic Fever (so rare in developed countries)
31
Q

What are the risks posed by mitral stenosis ?

A
  • Restricts blood flow to L ventricle
  • Atrial fibrillation
  • Pulmonary hypertension (due to back pressure)
  • Right heart failure
32
Q

Define infective endocarditis.

A

Infection (bacteraemia most common) of valve with formation of thrombotic vegetations (organisms within thrombus)

33
Q

What determines the severity of infective endocarditis ?

A

Virulence of organisms determines damage and severity

34
Q

How are different infective endocarditis classified ?

A

Acute and Sub-Acute

35
Q

Distinguish between the clinical presentations of acute and sub-acute infective endocarditis.

A 
Acute = Collapse (aggressive disease)
Sub-acute =  Unwell, possible fever, WBC count might be bouncing up and down (indolent but may deteriorate)
36
Q

Would blood cultures be conclusive for acute infective endocarditis ? for sub-acute infective endocarditis ?

A

Acute: Yes

Sub-Acute: Possibly, maybe not

37
Q

What are the main risk factors for infective endocarditis ?

A

1) Valve Damage
(all factors of valve damage, especially rheumatic fever)

2) Bacteraemia 
Dental
Catheterisation
10% unknown 
IV drug abuse

3) Immunosupression

38
Q

Define rheumatic fever. What is its relation to valve disease ?

A

Illness which arises as a complication of untreated or inadequately treated strep throat infection (3 weeks post Streptococcal infection, usually pharyngitis). Immune-mediated rather than direct infection.

Chronic valve disease occurs decades late.

39
Q

What is the single most common acquired risk factor for infective endocarditis ?

A

Rheumatic fever

40
Q

Which systems does rheumatic fever affect ?

A

heart (myocarditis, valvulitis, pericarditis), joints, connective tissue

41
Q

Describe the demographic distribution of rheumatic fever.

A

Occurs in children: 4-16 years

42
Q

What is the timeline of rheumatic fever (once it starts) ?

A

May occur in recurrent episodes

43
Q

Describe the composition of a vegetation.

A

Vegetation = fibrin + platelet (thrombus) +

Whole host of possible organisms within the thrombus (Group D Streptococcus, gut commensals, skin Strep, Candida)

44
Q

Identify the local and systemic complications of infective endocarditis.

A
  • Clubbing
  • Splinter haemorrhages
  • Haematuria
  • Anaemia
  • Renal infarcts/Glomerulonephritis
  • Myocarditis
  • Cerebral and retina emboli
45
Q

Distinguish between the state of the valves in acute, and sub-acute infective endocarditis.

A

ACUTE
– Valves may be normal

SUBACUTE
– abnormal valves

46
Q

Distinguish between the organisms present in acute, and sub-acute infective endocarditis.

A

ACUTE
virulent organisms, such as Staph aureus and group B streptococci

SUBACUTE
alpha-haemolytic streptococci, enterococci

47
Q

What proportion of all endocarditis cases does prosthetic valve endocarditis represent ?

A

10-20% of cases

48
Q

What proportion of of mechanical and bioprosthetic valves become infected ?

A

5% of mechanical and bioprosthetic valves become infected

49
Q

Does prosthetic valve endocarditis target any valves more than others ?

A

Mitral are more susceptible than aortic

50
Q

What organisms are associated with prosthetic valve endocarditis ?

A

– early onset: Staph aureus, gram-negative bacilli, Candida species
– late onset: staphylococci, alpha-haemolytic streptococci, enterococci

51
Q

What organism is most associated with infective endocarditis in IV drug users ?

A

Staph. aureus

52
Q

Which valve is most affected in infective endocarditis in IV drug users ? Is valvular disease the most common cause of infective endocarditis in IV drug users ?

A

50% involve the tricuspid valve

No, 75% have no underlying valvular abnormalities

53
Q

How is infective endocarditis diagnosed, treated and prevented ?

A

Treatment:
-If Strep infection, antibiotics

Prevention:

  • Prophylactic cover for invasive procedures eg dental work
  • Replace damaged valves
Diagnosis: 
• Clinical suspicion
• Clinical signs
• Imaging – especially echo cardiography (can hint at vegetations in valve, but cannot confirm infective endocarditis) 
• Blood culture (repeat it)

MD3001 (75 decks)

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