CARDIO: Valvular heart disease incl murmurs Flashcards
What is the danger of leaving valvular heart disease untreated? What can it lead to?
Irreversible ventricular dysfunction and / or pulmonary HTN
What are the three classic symptoms of aortic stenosis?
Angina
heart failure
syncope
What is the most common INITIAL symptom of aortic stenosis? i.e. what pt might recognise and then seek help as change in normal
Exercise intolerance or dyspnoea on exertion
What are some causes of aortic stenosis?
Most common: AGE -senile/degenerative calcification
congenital bicuspid valve
CKD
rheumatic fever
william’s syndrome
Where on the chest is best place to listen to murmur due to aortic stenosis?
Aortic area:
2 ICS Right sternal border
How would you describe aortic stenosis murmur ?
Ejection systolic murmur radiating to the carotid / neck
Tom says: ejection -systolic, high pitched murmur. crescendo - decrescendo character.
What are the indications for surgery in Aortic stenosis?
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
What extra should you consider doing for older patients with aortic stenosis? How is this implanted?
especially with co-morbidities
Transcatheter aortic valve implantation (TAVI)
implanted via femoral artery
When doing a cardio exam (yay) what special manoeuvres would you do to listen for mitral stenosis or aortic regurgitation?
Mitral stenosis
Listen with patient on left hand side
Aortic regurgitation
Pt sat up, leaning forward and holding exhalation
How does Aortic regurgitation ultimately lead to heart failure?
increased volume load on Left ventricle causes dilation of LV and ultimately HF
What is the most common initial symptom in aortic regurgitation?
exertional dyspnoea / reduction in exercise tolerance
What are the causes of aortic regurgitation ?
Many! Dilation of aorta (pulls the valve leaflets apart) congenital (e.g. bicuspid valves) Calcific degeneration rheumatic disease infective endocarditis Marfan's
Where is aortic regurgitation best heard on the chest?
Left sternal edge 3rd ICS
Where is aortic regurgitation best heard on the chest?
Left sternal edge
Early diastolic blowing murmur (associated with collapsing pulse + headbobbing -De Musset’s Sign)
What is the role of ACEi in aortic regurgitation?
Reduces afterload so can slow LV dilatation - standard therapy for pt with severe AR and LV dilation
Which 2 heart murmurs often have delayed presentation?
Mitral regurgitation (16 years from onset to diagnosis) Aortic regurgitation (many pt do not know they have it despite large LV dilation)
What are some of the few cases where mitral regurgitation may be acute and severe?
Ruptured chordae
ruptured papillary muscle
Infective endocarditis
Where is mitral regurgitation best heard? How would you characterise it?
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”)
What are the indications for surgery in mitral regurgitation?
Symptomatic pts
Asymptomatic w/ mild/mod LV dysfucntion (EF 30-60%)
mitral valve replacement or repair
What is the drug treatment for mitral regurgitation?
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
What are some causes of mitral stenosis?
Rheumatic heart disease
infective endocarditis
What kind murmur does mitral stenosis cause? Where should you listen to it?
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
What other examination findings is mitral stenosis associated with and why?
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
What is mitral regurgitation? (MR)
Mitral regurgitation (MR) is the backflow of blood into the left atrium during systole due to the incompetence of the mitral valve.
How common is mitral regurgitation?
MR is the most common valvular pathology.
It is estimated to affect 2% of the global population.
Pathophysiology of Mitral regurgitation? What does this lead to over time?
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.
Mitral regurgitation can be grouped by cause into two broad categories - acute and chronic.
What are acute causes of MR?
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
Signs of Chronic MR - listening at chest ?
also what extra signs if pt in decompensated HF?
- 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
Pathophysiology of Mitral Stenosis?
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.
Pathophysiology of how Rheumatic heart disease causes mitral stenosis?
- 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.
Signs of Mitral Stenosis when examaining
NOT auscultation of heart yet
think of steps when doing cardio exam
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.
Signs on auscultation of heart have mitral stenosis:
- 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)
CXR features of Mitral Stenosis
Pathophysiology of Aortic Regurg?
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.
Causes of Aortic Regurgitation
REALM mneunomic
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
What signs of Aortic Regurg when listening to the heart?
- Early diastolic murmur -
- heard best at the aortic region leaning forward and on expiration.
- Diastolic murmur follows second sound “Lub taaarr”
Pathophysiology of Aortic stenosis
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.
Signs of aortic stenosis
- 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
What are some causes of pressure overload of the LEFT ventricle?
Management of Aortic stenosis
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.
