CARDIO: Valvular heart disease incl murmurs Flashcards Preview

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Flashcards in CARDIO: Valvular heart disease incl murmurs Deck (69)
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1
Q

What is the danger of leaving valvular heart disease untreated? What can it lead to?

A

Irreversible ventricular dysfunction and / or pulmonary HTN

2
Q

What are the three classic symptoms of aortic stenosis?

A

Angina
heart failure
syncope

3
Q

What is the most common INITIAL symptom of aortic stenosis? i.e. what pt might recognise and then seek help as change in normal

A

Exercise intolerance or dyspnoea on exertion

4
Q

What are some causes of aortic stenosis?

A

Most common: AGE -senile/degenerative calcification
congenital bicuspid valve
CKD
rheumatic fever
william’s syndrome

5
Q

Where on the chest is best place to listen to murmur due to aortic stenosis?

A

Aortic area:

2 ICS Right sternal border

6
Q

How would you describe aortic stenosis murmur ?

A

Ejection systolic murmur radiating to the carotid / neck

Tom says: ejection -systolic, high pitched murmur. crescendo - decrescendo character.

7
Q

What are the indications for surgery in Aortic stenosis?

A

Symptoms (no matter severity)
Asymptomatic severe - LV systolic dysfunction
Asymptomatic severe - abnormal exercice test (drop in BP, ST elevation)
Asymptomatic severe - at time of other cardiac surgery e..g CABG

8
Q

What extra should you consider doing for older patients with aortic stenosis? How is this implanted?

A

especially with co-morbidities

Transcatheter aortic valve implantation (TAVI)

implanted via femoral artery

9
Q

When doing a cardio exam (yay) what special manoeuvres would you do to listen for mitral stenosis or aortic regurgitation?

A

Mitral stenosis
Listen with patient on left hand side

Aortic regurgitation
Pt sat up, leaning forward and holding exhalation

10
Q

How does Aortic regurgitation ultimately lead to heart failure?

A

increased volume load on Left ventricle causes dilation of LV and ultimately HF

11
Q

What is the most common initial symptom in aortic regurgitation?

A

exertional dyspnoea / reduction in exercise tolerance

12
Q

What are the causes of aortic regurgitation ?

A
Many!
Dilation of aorta (pulls the valve leaflets apart)
congenital (e.g. bicuspid valves)
Calcific degeneration
rheumatic disease
infective endocarditis
Marfan's
13
Q

Where is aortic regurgitation best heard on the chest?

A

Left sternal edge 3rd ICS

14
Q

Where is aortic regurgitation best heard on the chest?

A

Left sternal edge

Early diastolic blowing murmur (associated with collapsing pulse + headbobbing -De Musset’s Sign)

15
Q

What is the role of ACEi in aortic regurgitation?

A

Reduces afterload so can slow LV dilatation - standard therapy for pt with severe AR and LV dilation

16
Q

Which 2 heart murmurs often have delayed presentation?

A
Mitral regurgitation (16 years from onset to diagnosis)
Aortic regurgitation (many pt do not know they have it despite large LV dilation)
17
Q

What are some of the few cases where mitral regurgitation may be acute and severe?

A

Ruptured chordae
ruptured papillary muscle
Infective endocarditis

18
Q

Where is mitral regurgitation best heard? How would you characterise it?

A

Mitral area - 5th ICS in midclavicular line

Pan-systolic blowing murmur radiates to axilla

TOM: cause congestive heart failure -leaking valve = reduced ejection fraction + backlog of blood. May hear 3rd heart sound (stiff / weak ventricles + chordae “guitar string twang”)

19
Q

What are the indications for surgery in mitral regurgitation?

A

Symptomatic pts
Asymptomatic w/ mild/mod LV dysfucntion (EF 30-60%)

mitral valve replacement or repair

20
Q

What is the drug treatment for mitral regurgitation?

A

Diuretics

ACEI used in pt w/ dilated / ischaemic cardiomyopathy

LV dysfunction ? Give: ACEi and B-blockers e.g. bisoprolol and CRT reduced severity pg MR

21
Q

What are some causes of mitral stenosis?

A

Rheumatic heart disease

infective endocarditis

22
Q

What kind murmur does mitral stenosis cause? Where should you listen to it?

A

Mid-diastolic low pitched rumbling murmur

Large S1- thick valves need big systolic force to shut.

Listen at apex
Palpate a ‘tapping’ apex beat - due to loud SI

23
Q

What other examination findings is mitral stenosis associated with and why?

A

Malar flush: back pressure of blood into pulmonary system causing increase in C02 and vasodilation

Atrial fib: Left atrium struggling to push blood through stenosed valve - strain - electrical disruption - fibrillation

24
Q

What is mitral regurgitation? (MR)

A

Mitral regurgitation (MR) is the backflow of blood into the left atrium during systole due to the incompetence of the mitral valve.

25
Q

How common is mitral regurgitation?

A

MR is the most common valvular pathology.
It is estimated to affect 2% of the global population.

26
Q

Pathophysiology of Mitral regurgitation? What does this lead to over time?

A

The mitral valve should close at the beginning of systole to prevent backflow of blood into the left atrium.

In MR, the mitral valve fails to close sufficiently meaning there is a backflow of blood across the mitral valve into the LA.

Over time, this leads to the enlargement of the left atrium and leads to volume overload in the left side of the heart ultimately leading to LV failure.

27
Q

Mitral regurgitation can be grouped by cause into two broad categories - acute and chronic.

What are acute causes of MR?

A

Acute MR- is a cardiac emergency and may present with sudden-onset pulmonary oedema, hypotension and cardiogenic shock

Ischaemic causes:
* papillary muscle rupture due to Postero-inferior MR

Non-Ischaemic causes: (ruptured chordiae tendinae)
* Mitral prolapse (Myxomatous disease)
* Infective endocarditis
* Rheumatic Heart Disease
* Trauma

27
Q

Mitral regurgitation can be grouped by cause into two broad categories - acute and chronic.

Chronic causes?

A

Due to dysfunction of parts of the valve: e.g. leaflet, chordae, papillary muscle, Annualr, Prosthesis

Leaflet causes:
* Mitral valve prolapse
* Degenerative disease (causes prolapse)
* Infective endocaritits
* Infammatory disorders e.g. SLE / Scleroderma
* CT : Margans / Ehlers-Danlos

Chordae:
* Myxomatous valve disease (causing prolapse)
* Trauma

Papillary muscle causes:
* MI / Ischaemia
* Dilated cardiomyopathy

SEE Quesbook for further causes

27
Q

Symptoms and signs of acute MR ?

A

sudden-onset:
* Shortness of breath
* Exertional dyspnoea
* Fatigue
* Weakness

Signs:
* overt pulmonary oedema,
* hypotension
* cardiogenic shock.

28
Q

Symptoms of chronic MR?

A

Mild-to-moderate MR:
* asymptomatic until significant systolic dysfunction
* pulmonary HTN
* symptomatic AF

Most common:
* Fatigue
* exertional dyspnoea
due to decreased cardiac output + increased pulmonary pressures due to increased left atrial pressures.

29
Q
A
30
Q

Signs of Chronic MR - listening at chest ?

also what extra signs if pt in decompensated HF?

A
  • Apex beat usually displaced (volume overload)
  • Blowing’ pansystolic murmur
  • Loudest at the apex
  • Radiates to the axilla
  • Louder on expiration
  • Louder on rolling to the left
  • Quiet first heart sound S1

Pts in decompensated heart failure:
* Bilateral lung crepitations
* Raised JVP
* S3/S4
* Peripheral/sacral oedema oedema

31
Q

Differencials for MR?

A

Aortic Stenosis
Tricuspid Regurgitation
Aortic Regurgitation

32
Q

Your pt has Mitral regurgitation but you want to rule out a differencial of Aoritc stenosis.

What are the
1. similarities
2. differences

A

Similarities:
* both can present with symptoms of HF e.g. dyspnoea, fatigue and exercise intolerance.

Differences:
* AS - ejection systolic murmur, heard loudest in aortic region and radiates to the carotids.
* MR -pansystolic murmur loudest in the mitral region and radiates to the axilla.

33
Q

Your pt has Mitral regurgitation but you want to rule out a differencial of Tricuspid Regurgitation

What are the
1. similarities
2. differences

A

Similarities:
* present very simlarly with pansystolic murmurs.

Differences:
* MR is more common and is loudest in the mitral region.
* TR is far less common, loudest in the tricuspid region, and seen in IVDU patients with infective endocarditis.

34
Q

Your pt has Mitral regurgitation but you want to rule out a differencial of Aortic Regurgitation

  1. Similarities
  2. Differences
A

Similarities:
* both can present with symptoms of HF e.g. dyspnoea, fatigue, and exercise intolerance.

Differences:
* AR -diastolic murmur heard best at left sternal border
* MR- pansystolic murmur heard best in mitral region and radiates to the axilla.

35
Q

Investigations for Mitral Regurgitation

Bedside bloods imaging

A

Bedside
* ECG: p-mitrale (broad notched p wave due to left atrial enlargement)
* LVH and left axis deviation.

Bloods:
* NT pro-BNP: (raised in HF reflects increased ventricular stress.)

Imaging:
* CXR: evidence of pulmonary oedema and left atrial enlargement.

  • ECHO (diagnosis)
  • assesses size and pressure of regurgitant jet
  • Size of valve lesions
  • Structural complications such as left atrial enlargement or systolic dysfunction
36
Q

Conservative Management of Mitral Regurgitation

Medical and Surgical later

A

Many pts remain asymptomatic and stable and may not require treatment at all.

If a patient has asymptomatic MR they should undergo regular follow-up echocardiography

37
Q

Medical Management of Mitral Regurgitation?

A

Treat complications:

  • AF with rate control and anticoagulation
  • Heart failure with diuretics, ACE-Inhibitors, and beta-blockers.
  • Acute MR is a medical emergency and should be treated according to acute pulmonary oedema guidelines
38
Q

Surgical Management of Mitral regurg?

A
  • Mitral valve repair (mitral valvuloplasty) - preferable as is preserves all components of the native valve and avoids use of prostheses.
  • Mitral valve replacement - offers the choice between a mechanical valve (lifelong anticoagulation but long-lasting), and a bioprosthetic valve (limited durability but no need for anticoagulation)
39
Q

Complications of Mitral regurg?

A
  • Heart failure
  • Thromboembolism secondary to AF
  • Haemoptysis secondary to pulmonary HTN and symptoms of RH failure are possible but less common than in mitral stenosis
  • Infective endocarditis and associated symptoms can also complicate MR.
40
Q

Define Mitral stenosis?

A

Mitral stenosis refers to the narrowing of the mitral valve which reduces blood flow to the left ventricle.

41
Q

Pathophysiology of Mitral Stenosis?

A

The thickened and calcified mitral valve reduces the amount of blood that can flow through the valve into the left ventricle during diastole.

This leads to a reduction in the end-diastolic volume in the left ventricle and increases the volume of blood in the left atrium.

The increased volume of blood in the left atrium leads to atrial dilatation (predisposes to atrial fibrillation), pulmonary congestion and ultimately right heart failure.

42
Q

causes of mitral stenosis

One main cause!

A

rheumatic heart disease!

Rarer include:
* mitral age related calcification
* Systemic e.g. SLE/RA

see quesbook for more details

43
Q

SYMPTOMS of mitral stenosis

A
  • asymptomatic until advanced
  • Exertional dysnponea/reduced exercsie tolerance
  • Dyspnoea (pulmonary congestion)
  • Haemoptysis (pink stained/blood)
  • Palpitations e.g. AF
  • Chest pain
  • thromboembolism (due to AF)
  • Hoarseness (enlarged LA press on RLNerve/
  • Peripheral oedema/ hepatomegaly/ abdo discomfort - RHF

see quesbook for more explanation on why these symptoms

43
Q

Pathophysiology of how Rheumatic heart disease causes mitral stenosis?

A
  • the body produces antibodies to target the streptococcal antigens that occur in rheumatic fever
  • These antibodies also attack valvular tissue (autoimmune molecular mimicry) leading to valvular disease.
44
Q

Signs of Mitral Stenosis when examaining

NOT auscultation of heart yet
think of steps when doing cardio exam

A

Inspection / end of bed:
* Mitral facies (malar flush): cutaneous vasodilation due to carbon dioxide retention.

Work way up arm:
* Low volume pulse
* Irregularly irregular pusle -AF
* Elevated JVP

On chest:
* Tapping, non-displaced apex beat (palpable S1).
* Right ventricular heave (suggestive of pulmonary HTN).
* Inspiratory crepitations (pulmonary oedema)
* other signs of right heart failure.

45
Q

Signs on auscultation of heart have mitral stenosis:

A
  • Loud S1 (narrow valve kept open by atrial pressure, systole slams shut S1)
  • Opening snap heard at apex after S2
  • Mid-to-late diastolic murmur
  • Low pitched rumble, most prominent at apex
  • Loudest in expiration
  • Heard best with patient lying on left side
  • Heard best using stethoscope bell (low frequency)
46
Q

CXR features of Mitral Stenosis

A
47
Q

Investigations and their results for Mitral stenosis:

A

ECG may show:
* P-mitrale (a broad notched P wave due to left atrial enlargement)
* Right ventricular hypertrophy
* Right axis deviation
* Atrial fibrillation: caused by left atrial enlargement

CXR may show:
* pulmonary oedema
* left atrial enlargement

Echocardiogram:
* stenosis + impairment of ventricular filling.

Cardiac MRI:
* valvular vegatations.

48
Q

Management of Mitral stenosis : conservative, medical, surgical

A

Conservative:
* regular FU w/ ECHo to assess for stenosis / progression

Medical:
Treat complications e.g.
* rate control and anitcoag for AF
* Diuretics for symptoms of pulmonary congestion + peripheral odema

Invention / Surigical
* Balloon valvuloplasty:( if valve pliable, not calcified)
* Percutaneous mitral valvotomy: (moderate disease)
* Open valve repair/replacement: (severe disease + too high risk for surgery but are not candidates for percutaneous intervention. )

49
Q

Complications of Mitral stenosis

A
  • AF and thromboembolism - palpitations, poor exercise tolerance and symptoms of cardioembolic stroke.
  • Pulmonary HTN - dyspnoea and haemoptysis.
  • Dilated left atrium - can impinge on local structures, leading to hoarseness, dysphagia and bronchial obstruction.
  • Pts might present w/ decompensated HF due to valve itslef, infection or due to uncontrolled AF
50
Q

Pathophysiology of Aortic Regurg?

A

Normally, the aortic valve closes tightly at the end of systole (S2) and prevents blood from flowing back into the left ventricle.

In aortic regurgitation, the valve leaflets fail to close tightly due to valve disease or the aorta around the valve has dilated which allows the backflow of blood across the valve and into the left ventricle.

51
Q

Causes of Aortic Regurgitation

REALM mneunomic

A

R Rheumatic heart disease
E Endocarditis
**A **Ankyosing spondylitis, RA
L Luetic heart disease
**M **Marfans’ syndrome / Ehlos-Danlos

Other causes:
* aortic dissection (aortic root)
* Traumaatic rupture of valve leaflets
* Age related calcification
* congential biscuspid valve

52
Q

What signs might you find during cardio exam with a pt with aortic regurg (not auscultation)

A
  • De Quincke’s sign - nail bed pulsation
  • Collapsing pulse (Corrigan’s pulse)
  • Collapsing pulse in the neck (Corrigan’s sign)
  • Apex beat displaced
  • De Musset’s sign - head bobbing
  • Muller’s sign - pulsation of the uvula
  • Traube’s sign - pistol shot (bruit heard on auscultation of femoral pulse)
  • JVP NOT RAISED
53
Q

What signs of Aortic Regurg when listening to the heart?

A
  • Early diastolic murmur -
  • heard best at the aortic region leaning forward and on expiration.
  • Diastolic murmur follows second sound “Lub taaarr”
54
Q

Investigations for Aortic regurgitation?

A

Bedside:
* Obss: widened pulse pressure.
* Throat swab for group A strep.
* ECG: LVH and p mitrale in chronic AR.

Bloods:
* Inflammatory markers and blood cultures - infective endocarditis.
* Auto-antibody screen - rheumatological causes.

Imaging:
* Transthoracic echocardiogram - definitive diagnosis.
* Cardiac MRI - (moderate-to-severe AR with suboptimal TTE findings.)
* Invasive cardiac catheterisation - detailed information on AR severity, LV function and size, pressures and valve gradient, and dimensions of aortic root.

55
Q

Aortic regurg management

A

Conservative:
* FU w/ECHO monitoring if mild /mod

Medical:
* Slow risk of aortic root dilatation in high risk (<arfans or biscuspid aortic valve)
* Bblockers +/- Losartan used to lower systemic BP
* Monitoring freq depends on severity and LV functoin

Surgical:
* Valve replacement if significant regurgitation present as assessed by :
* Impaired LV function (ejection fraction <55%) or dilated LV (end systolic diameter >50mm)

56
Q

Complications of Aortic regurg?

A

Acute AR can lead to cardiovascular collapse and de novo acute heart failure.

Chronic AR that is not treated will lead to chronic heart failure with predominantly left ventricular symptoms (pulmonary oedema).

57
Q

Pathophysiology of Aortic stenosis

A

In AS there is a narrowing of the aortic valve which means that the left ventricle has to generate more pressure to enable sufficient blood to cross the aortic valve and pass into the aorta.

Initially, this leads to LV hypertrophy as the left side of the heart compensates for the narrowing.

Over time, the left ventricle can no longer compensate and the LV will start to enlarge, the ejection fraction will reduce, and this will ultimately leads to reduced cardiac output.

58
Q

Causes of Aortic Stenosis?

A
  • Senile calcification: most common cause in those >65y/o.
  • Congenital bicuspid valve: most common cause in those <65y/o.
  • Rheumatic heart disease
  • William’s syndrome: supravalvular stenosis
59
Q

Symptoms of Aortic stenosis?

SAD mneumonic

A
  • can be asymptomatic
  • S- Syncope
  • A- Angina
  • D -Dyspnoea

Other symptoms include:
* pre-syncope
* palpitations
* LV HF symptoms: (exertional dyspnoea, orthopnoea, PND)
* cardiac arrest/sudden cardiac death.

60
Q

Signs of aortic stenosis

A
  • Slow-rising carotid pulse
  • Narrow pulse pressure
  • Heaving (forceful), **non-displaced **apex beat due to overload (can be displaced if there is LV hypertrophy)
  • Ejection systolic murmur
  • Heard best at the second intercostal space on the right
  • Can be described as “harsh”
  • Radiates to the carotids
61
Q

What are some causes of pressure overload of the LEFT ventricle?

A
62
Q

Investigations for Aortic Stenosis

A

Bedside:
* ECG: LVH, left axis deviation, and poor R wave progression.

Imaging:
* ECHO for diagnosis
* Severity of AS can be quantified with doppler echocardiography
* Cardiac MRI - details of aortic root and valve calcficatoin

Other:
Exercise testing: for physically active patients to assess the true severity of symptos when AS is confirmed on ECHO.

63
Q

Management of Aortic stenosis

A

Conservative:
* regular FU ECHO

Medical:
* symptom management of LV failure - diuretics and optimising HF meds (e.g. bblockers + ACE i)

Surgical / Interventional:
* TAVI -transcatheter aortic valve implantation - severe comorbidities, previous heart surgery, frailty, restricted mobility, > 75 years
* SAVR - surgical aortic valve replacement- low risk, <75yrs.

64
Q

Whe is Intervention indicated in pts with Aortic stenosis?

A
  • All patients with symptomatic aortic stenosis
  • Asymptomatic patients with a left ventricular ejection fraction (LVEF) < 50%
  • Asymptomatic patients with an LVEF > 50% who are physically active, and who have symptoms or a fall in blood pressure during exercise testing

See pass book for other examples

65
Q

Complications of aortic stenosis

A

if left untreated can lead to LV failure. It is also implicated in sudden cardiac death.

66
Q
A

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