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_MS2 Cardio > 8/14- Valvular Heart Disease 1 > Flashcards

8/14- Valvular Heart Disease 1 Flashcards

(44 cards)

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1
Q

What is stenosis?

A

Narrowing of valve that limits blood flow

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2
Q

What is insufficiency?

A

Leak across a valve that allows retrograde blood flow (aka regurgitation)

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3
Q

What are the determinants of blood flow through valves?

A
  • Pressure difference
  • Orifice geometry (valve area)
  • Time of blood flow through the valve

Also:

  • Fluid rheology
  • Chamber stiffness
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4
Q

What is the pathophysiology behind valvular heart disease?

A

Valve injury causes overload

  • Acute overload -> pulmonary edema
  • Chronic pressure/volume overload -> hypertrophy

Hypertrophy-> Heart failure

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5
Q

Regurgitation causes what type of overload? Results in?

A

Regurgitation -> Volume overload -> Eccentric Hypertrophy

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6
Q

Stenosis causes what type of overload? Results in?

A

Stenosis -> Pressure overload -> Concentric hypertrophy

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7
Q

What are some consequences of valvular heart disease (concentric or eccentric hypertrophy)?

A

Congestive Heart Failure

  • SOB
  • PND
  • Orthopnea
  • Rales
  • JVD
  • Edema

Arrythmias

  • VT/Vfib (risk of sudden cardiac death, esp AS)
  • A fib (with ALL, more with MS and MR) Infective endocarditis Embolism
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8
Q

What type of valvular heart disease most often causes VT/Vfib and sudden cardiac death?

A

Aortic stenosis

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9
Q

What type of valvular heart disease most often causes Afib?

A

Mitral stensosis and mitral regurgitation (although all can)

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10
Q

What underlies infective endocarditis? Consequences?

A

A structurally abnormal valve + turbulence is at risk for bacterial growth. May damage valves further with worsening regurgitation

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11
Q

For who is endocarditis prophylaxis routinely recommended?

A
  • Prior Hx of endocarditis
  • Prosthetic valves
  • Cardiac transplant with valvular disease
  • Congenital heart disease: cyanotic CHD or repaired with a prosthetic material in under 6 mo
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12
Q

What conditions make an embolism (systemic/cerebral) more likely?

A

Systemic and cerebral most likely with:

  • Afib
  • Large atria
  • Large LV (e.g. DCM)
  • Low EF
  • Endocarditis (vegetations can break off)
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13
Q

Where are mitral valve murmurs best heard? Radiate?

A

Mitral valve

  • Best heard at apex (about 5th ICS)
  • Radiate to axilla
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14
Q

Where are aortic valve murmurs best heard? Radiate?

A

Aortic valve

  • Best heard at base of heart over aortic area (2nd R ICS)
  • Radiate to carotids/neck
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15
Q

In what state of the valve due stenotic and insufficient valves cause problems?

A

Stenosis: with normal flow across valve [systole]

Insufficiency: when valve is (supposed to be) closed [diastole]

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16
Q

List all the systolic murmurs

A
  • Aortic stenosis
  • Mitral insufficiency
  • Tricuspid insufficiency (less common)
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17
Q

List all the diastolic murmurs

A
  • Aortic insufficiency
  • Mitral stenosis
  • Tricuspid stenosis (less common)
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18
Q

Breakdown causes of aortic stenosis by age?

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A

“Young” pts (under 70)

  • Mostly bicuspid (earlier clinical onset, 50s)
  • Rheumatic disease
  • Degenerative*

Older pts (>70)

  • Mostly degenerative
  • BIcuspid
  • Rheumatic disease

*Senile calcific “degenerative” later onset (70s-80s)

19
Q

Average onset of bicuspid aortic valve stenosis/

Study These Flashcards
A

Earlier (50s)

20
Q

Average onset of senile calcific “degenerative” aortic valve stenosis?

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A

Later (70s-80s)

21
Q

What is shown here?

Study These Flashcards
A

Bicuspid aortic stenosis

  • Two cusps
22
Q

What is shown here?

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A

Senile calcific aortic stenosis

  • Three cusps
23
Q

Explain the mechanics of aortic stenosis causing murmur. What kind of heart failure

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A

Obstruction to LV outflow

  • Pressure gradient between LV and aorta
  • LV pressure overload results in concentric LVH over time -> diastolic dysfunction (earlier) -> systolic dysfunction (later)
  • Acceleration of systolic flow produces a systolic crescendo-decrescendo murmur at base radiation to neck
24
Q

Explain the pressure gradient across the aortic valve in aortic stenosis?

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A
  • LVP > aortic P in systole
  • Pressure in LV remains higher than aorta all through systole until it finally relaxes
25
What are some key physical exam findings of aortic stenosis?
**Murmur:** - Systolic, crescendo-decrescendo - At base (R and possibly L 2nd-3rd ICS), radiating into neck - Coarse **Slow, weak carotid upstroke** **PMI forceful, sustained** **Soft S2** (if calcified, doesn't close quickly) with **delayed A2** (takes longer for LV to empty) - Single S2 or paradoxically split S2
26
What is the classical clinical triad of aortic stenosis?
Think of initials: A-S-D ## Footnote **- Angina/chest pain** **- Syncope/SCD** **- Dyspnea/CHF**
27
What causes the angina/chest pain in aortic stenosis?
- Demand increases (LVH) - Subendocardial flow decreases (high LV diastolic pressures) - +/- coronary artery stenosis
28
What causes heart failure in aortic stenosis?
- Hypertrophy with fibrosis - Chamber stiffness increases - Diastolic failure first, later systolic failure
29
What causes syncope/sudden death in aortic stenosis?
**Exercise-induced:** fixed small orifice, so unable to increase CO **Unprovoked:** - Arrhythmia: Vtach or Vfib - AV block
30
Describe the natural history of aortic stenosis (length of symptoms, survival...)
**Long initial asymptomatic course** **Once symptoms occur, prognosis worsens** _Survival is:_ - **Worst** with HF - Better with syncope - **Best** with angina (ASD triad)
31
Treatment for aortic stenosis? When done?
Valve replacement - For severe, symptomatic aortic stenosis
32
What is **acute** aortic insufficiency?
Injury to aorta or leaflets -\> sudden diastolic retrograde flow into LV resulting in heart failure - No time for compensation
33
What is **chronic** aortic insufficiency?
The pathophysiology and leak evolve slowly over years - Allows compensation by LV dilation - Delays the onset of symptoms of heart failure
34
Causes of acute aortic insufficiency?
**Aorta issues:** - Dissection! - Trauma **Cusp issues:** - Infection - Trauma
35
Causes of **chronic** aortic insufficiency?
_Aorta issues:_ - Marfan's (heritable) - Inflammatory: syphilis - Annulo-aortic ectasia _Cusp issues: (more common)_ **- Bicuspid valve** **- Rheumatic disease** - Late sequelae of infection - Prolapse - Degenerative/senile
36
What are some key features (heart sound wise) of aortic regurgitation?
Diastolic regurgitation - Causes LV volume overload Diastolic murmur - Due to regurgitation of blood into the LV Murmur duration - Shorter in acute than chronic b/c pressures "equalize" faster in acute AI
37
How to calculate % regurgitation?
**regurgitation/totalSV** = regurgitation/(regurg + forward)
38
Describe LVP and AoP during aortic insufficiency
- Pressure difference between LVP and AoP during diastole is pretty significant; decreases with regurgitation back through aorta - Quicker P equalization causes shorter murmur (earler diastole) (pic h)
39
What is the phathophysiology/consequences of acute aortic insufficiency?
Recall: acute AI = sudden disatolic leak - LV enlarges, but only minimally (not enough time) - Acute increase in volume in small chamber -\> significant increases in LV diastolic ps **Acute pulmonary edema** results **Effective forward CO is reduced acutely** - \> low BP - \> circulatory collapse (shock)
40
What is pathophysiology/consequences of chronic aortic insufficiency?
Recall: chronic AI = progressive leak over years - LV eccentric hypertrophy (LV dilation): compensatory increase in SV - Diastolic BP drops due to AI, systolic P may rise (increased SV), causing a **WIDE pulse pressure** (SBP-DBP) - Systolic function declines over years (less forward, more regurgitant volume) - Further LV dilation and untimely CHF results
41
Key clinical findings of acute vs. chronic AI? - BP - CHF - PMI - Murmur - EKG - Echo
_BP_ **- Acute**: normal or low **- Chronic**: wide pulse pressure, bounding pulse (large volume) _CHF?_ **- Acute**: Severe CHF signs **- Chronic**: No CHF signs _PMI:_ **- Acute:** normal position **- Chronic**: displaced, enlarged _Murmur:_ **- Acute:** short early diastolic murmur **- Chronic**: long diastolic murmur _EKG:_ **- Acute**: no LVH **- Chronic**: LVH _Echo:_ **- Acute:** No LVH; Al jet **- Chronic:** Eccentric LVH, Al jet
42
Treatment for aortic regurgitation?
**- MIld/moderate: vasodilators** (to decrease afterload, unload ventricle, and increase SV) **- Severe**: valve and/or aortic root repair or replacement **- Acute: surgical emergency**
43
Key Points of AI
44
Key points of AS

_MS2 Cardio (35 decks)

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