Valvular Disease Flashcards
What is the general epidemiology of valvular disease?
Increases with age - as degenerative aetiologies predominant
Aortic stenosis and mitral regurgitation are the most common types
What are the different types of valvular disease?
Stenosis vs. regurgitation:
- Stenosis = narrowing
- Regurgitation = failure to close
All four heart valves can be affected by either stenosis or regurgitation (8x possible pathologies)
What are some possible aetiologies of valvular heart disease?
Degenerative:
- The most common in developing world now
- Either through calcification of the valves over many years of atherosclerosis (stenosis) or thinning of chordae tendineae and leaflets (regurgitation)
Rheumatic fever:
- Infection of Group A strep e.g. inadequately treated strep throat or scarlet fever
- Leads to an inflammatory conditions of the heart (joints, skin, CNS) and subsequent damage (either stenosis or regurg - mostly aortic and mitral)
- Incidence is decreasing so no longer primary cause of AS or MR
Infective endocarditis:
- Bacterial embolus (from needles, tooth infection etc) lodges on valve and damages (again, stenosis or regurg)
Post MI:
- Damage to heart muscles following a heart attack can leave valves incompetent
Coronary artery disease:
- Papillary muscle dysfunction
- Chordae tendineae dysfunction or rupture
Other:
- Chronic HTN
- Congenital heart disease
- RA
- SLE
- Syphilis
- Radiotherapy, ergotamine, methysergide
What is the epidemiology of aortic stenosis?
Most common valvular disease
- C.10% of people over 80yrs with a mortality rate about 50% over two years unless outflow obstruction is relieved
- Predominantly a degenerative/calcific cause
- Second most common cause is congenital (presenting in younger people)
A congenital bicuspid valve predisposes to AS and aortic regurg.
What are the symptoms of aortic stenosis?
Asymptomatic
Classical triad: (but only 30-40% of those >50yrs)
- Syncope - on exertion; possible sudden death on extreme exertion (AVOID)
- Angina (late state AS, also commonly with coronary artery disease)
- Heart failure
What are the signs of aortic stenosis?
Murmur:
- Crescendo-decrescendo systolic ejection murmur shortly after the first heart sound that ends just before the second heart sound
- A rough, low-pitched sound
- Loudest at the base of the heart and most commonly heard in the second right intercostal space
- Radiation to carotids
- Possible ejection ‘click’, especially in those with bicuspid valves
Other:
- Narrow pulse pressure
- Possible thrill
- Possible apex displacement (due to LVH due to having to eject blood through a smaller valve)
What are possible findings on ECG and CXR of aortic stenosis?
ECG:
- Possible LVH or LV strain
CXR:
- Often normal except in advanced disease
- Possible cardiomegaly or calcification of aortic ring
What is the epidemiology of mitral regurgitation?
The second most common valvular disease and the second most common requiring treatment
Risk factors:
- F > M
- Lower BMI
- Advanced age
- Renal dysfunction
- Prior MI
- Prior mitral stenosis + mitral valve prolapse
A trivial form of MR is frequent in healthy subjects
What are the symptoms of mitral regurgitation?
Acute:
- Symptoms of acute pulmonary oedema e.g. dyspnoea that worsens with activity or when lying down, a feeling of suffocating or drowning, wheezing or gasping for breath, cold + clammy skin etc.
Chronic:
- Well tolerated so often asymptomatic
- Eventual LVH leads to breathlessness + other features of heart failure
What are the signs of mitral regurgitation?
Murmur:
- Pansystolic murmur
- Loudest at the apex
What are some possible ECG and CXR features of mitral regurgitation?
ECG:
- Broad, notched/bifid P wave indicating left atrial enlargement = ‘P mitrale’
CXR:
- Possible LAH + LVH
What are the symptoms and signs of aortic regurgitation?
Most common cause of acute presentation is cardiovascular collapse
Murmur:
- Early diastolic
- Best heard in aortic area with patient sitting forward (to bring aorta onto anterior chest wall) and in held expiration (to accentuate ALL diastolic murmurs)
- NOT well transmitted to carotids
Other:
- Wide pulse pressure due to low diastolic pressure; ‘water hammer’ pulse (but rare)
What are some possible ECG and CXR features of aortic regurgitation?
ECG:
- Possible LVH
CXR:
- Possible cardiomegaly, dilated ascending aorta
- Pulmonary oedema
What are the symptoms and signs of mitral stenosis?
Asymptomatic for years then a gradual decrease in activity:
- Breathlessness (on exertion, orthopnoea, paroxysmal nocturnal dyspnoea)
- Palpitations due to AF
- Possible systemic emboli and haemoptysis
Signs:
- Malar flush on cheeks (due to CO2 retention and its vasodilatory effects)
- Raised JVP
- Laterally displaced apex beat
- AF on pulse
- Possible signs of RV failure e.g. hepatomegaly, ascites and peripheral oedema
Murmur:
- Mid-late diastolic murmur
- Best heard with patient in left lateral with the bell of the stethoscope
- Loud 1st heart sound with opening ‘snap’ in early diastole
What are some possible ECG and CXR features of mitral stenosis?
ECG:
- AF
- P mitrale from LAH
- LVH
CXR:
- LAH, LVH
- Mitral calcification
- Pulmonary oedema (Kerley B lines)
