Cardio: Valvular heart disease Flashcards
(42 cards)
Left sided murmurs
How does mitral stenosis progress? [3]
Pressure builds up in the Left Atrium [1] which backs up through the pulmonary circ causing pulmonary hypertension [1]
As a result the Right heart dilates with Tricuspid and pulmonary regurgitation. [1]
Left sided murmurs
What can cause mitral stenosis? [7]
- Mainly Rheumatic Heart Disease fibrosing the valve.
- Congenital Mitral Stenosis
- Autoimmune: SLE or rheumatoid arthritis, amyloid
- Mitral Valve Prolapse
- Infect. Endocarditis
- Degenerative Disease (annular calcification)
- Ventricle enlargement stretching the valve
Left sided murmurs
What are the symptoms of mitral stenosis? [5]
- Dyspnoea & Pulmonary Oedema (secondary to pulmonary HTN)
- Chest Pain
- Haemoptysis/pink frothy sputum due to pulmonary pressures, vascular congestion
- Systemic embolisation due to enlargement of LA & LAA (left atrial appendage)
- Hoarseness (enlarged heart compresses L Recurrent Laryngeal Nerve)
Left sided murmurs
What are the clinical signs of mitral stenosis? [6]
Tachycardia, Low volume pulse
A Diastolic Thrill & Tapping Apex Beat
A RV Heave due to dilatation
Mid-late diastolic murmur on expiration.
Loud S1, opening snap
Mitral Facies
Left sided murmurs
How do we investigate suspected Mitral Stenosis? [4]
An ECG, CXR - LA enlargement
Echocardiogram - Thickening/Scarring of mitral leaflets
CMR
Left sided murmurs
How can we treat mitral stenosis? [3]
- Atrial fibrillation > warfarin
- Asymptomatic - monitoring regular ECHO
- Symptomatic - percutaneous mitral balloon valvotomy, mitral valve surgery
Left sided murmurs
What would appear on an MS ECG? [2]
Tall P wave indicating LA enlargement
Prominent R wave showing RVH
Left sided murmurs
How do we treat Mitral Regurgitation? Acute [2] vs Chronic MR [2]
Acute MR: Use Na nitroprusside OR Dobatumine to lower preload/afterload
Chronic MR: Diuretics can reduce symptoms but will still need surgery ie MV repair/Replacement
Left sided murmurs
Rheumatic Heart Disease What is it triggered by? [3]
Describe histology seen in RHF
Rheumatic fever
- GABHS infection - streptococcus pyogenes
- Cross-reactive Immunological reaction to recent strep pyogenes infection - antigen presentation to T cells - molecular mimicry
- 2-6w ago
- the cell wall of Streptococcus pyogenes includes M protein, a virulence factor that is highly antigenic. It is thought that the antibodies against M protein cross-react with myosin and the smooth muscle of arteries
- Aschoff bodies describes the granulomatous nodules found in rheumatic heart fever
Rheumatic Heart Disease Sequelae [5]
- Valvular stenosis + regurgitate *mitral stenosis
- LA dilation due to pressure overload > AF
- Large mural thrombi form
- Chronic venous congestion > LHF
- RV hypertrophy
RHD DX What criteria is used?
Jones criteria
RHD DX
List minor [3] and major [5] criteria
Major Criteria:
- Carditis
- Migratory polyarthritis
- Subcutaneous nodules
- Erythema marginatum skin rash
- Sydenham chorea/ St vitus dance
Jones Criteria Minor Criteria:
- Fever
- Arthralgias
- ECG changes
Left sided murmurs
Mitral valve prolapse associations
congenital heart disease: PDA, ASD
cardiomyopathy
Turner’s syndrome
Marfan’s syndrome, Fragile X
osteogenesis imperfecta
pseudoxanthoma elasticum
Wolff-Parkinson White syndrome
long-QT syndrome
Ehlers-Danlos Syndrome
polycystic kidney disease
Left sided murmurs
Characteristic murmur for mitral valve prolapse
mid-systolic click (occurs later if patient squatting)
late systolic murmur (longer if patient standing)
Left sided murmurs
Complications of MVP [3]
mitral regurgitation, arrhythmias (including long QT), emboli, sudden death
Left sided murmurs
How is MVP diagnosed
what other investigations are needed
Defined by imaging
Ant or post mitral valv leaflets cross valve plane by >2mm into left atrium during ventricular systole
Stress ECHO
Left sided murmurs
Mitral valve prolapse murmur characteristics
what happens to the murmur as severity increases
A ‘late’ crescendo murmur lasts until the end of systole (S2).
As severity of MVP increases, the murmur becomes pansystolic.
Unlike most left-sided murmurs, which are accentuated by manoeuvres that increase LV volume and therefore LV flow (increased afterload [squatting] and temporary increased left venous return [expiration])
the reverse is true of the murmur of MVP.
As the LV volume increases, the subvalvular apparatus is pulled apically, thus reducing the degree of prolapse.
Left sided murmurs
Mitral valve prolapse murmur characteristics, what is not typical of murmurs in MVP?
what happens to the murmur as severity increases
A ‘late’ crescendo murmur lasts until the end of systole (S2).
As severity of MVP increases, the murmur becomes pansystolic.
Unlike most left-sided murmurs, which are accentuated by manoeuvres that increase LV volume and therefore LV flow (increased afterload [squatting] and temporary increased left venous return [expiration])
the reverse is true of the murmur of MVP.
As the LV volume increases, the subvalvular apparatus is pulled apically, thus reducing the degree of prolapse.
Describe murmur characteristic in Mitral Regurgitation
- Pansystolic murmur (radiation to axilla) louder on expiration.
- Mid-late systolic murmur in MV prolapse (radn. to axilla, louder on inspiration).
In which would you see left heart failure? Mitral Stenosis or Mitral regurgitation
MR - you would see signs of LHF
Management of Rheumatic heart fever [3]
- Early IV antibiotics benzylpenicillin G or ceftriaxone. Follow on doses of 4-weekly IM benzylpenicillin or oral penicillin V should be continued daily for up to 0 years or into adulthood after an episode of ARF to reduce the risk of late complication with rheumatic heart disease.
- Acute carditis: oral prednisolone treatment ( mg/kg daily) to a maximum of 80 mg daily.
- Acute arthritis responds to high-dose aspirin.
Left sided murmurs
How does Aortic Stenosis lead to Heart failure?
Pressure backs up in the LH causing it to hypertrophy. This increases myocardial O2 demand eventually leading to LVF
What causes Aortic Stenosis?
Calcific degenerative disease - A slow inflammatory process thickens and calcifies the cusps (senile calcification, linked to atherosclerosis)
Rheumatic disease
Congenital Bicuspid Valve
What is the symptoms of aortic stenosis?
A long time is spent asymptomatic then suddenly:
Angina - Syncope - SOBOE - Heart Failure
