Aortic stenosis signs
Pulse = slow, low, narrow
slow-rising pulse
low volume pulse
narrow pulse pressure
Apex beat is forceful but not displaced
heaving, pressure overload
Thrill in aortic area
4th heart sound
Aortic stenosis murmur
ejection systolic
crescendo-decrescendo
loudest in aortic area
radiates to carotids
if very severe, A2 is quietened
Causes of Aortic stenosis
Degenerative calcification of a normal aortic vale
Rheumatic heart disease
Bicuspid aortic valve (congenital)
Treatment of Aortic stenosis
Be guided by the symptoms as to the severity (exercise-induced syncope, angina, SOB)
Valve replacement
TAVI (transcatheter aortic valve insertion)
Causes of pressure overload to LV
hypertension
Aortic stenosis
coarctation of aorta
hypertrophic cardiomyopathy with LVOT obstruction
Aortic stenosis differential diagnoses
HOCM
VSD
Aortic sclerosis (no radiation of murmur, normal pulse character)
Aortic flow murmur (high output clinical states - pregnancy, anaemia, infection)
Stages of clubbing
Increased fluctuancy of the nail bed
Loss of angle between nail and nail bed
Increased curvature of the nail
Expansion of the terminal phalanx
Third heart sound
Normal up to 30Y
Lub Dub Ba
Blood rushing in during the rapid filling phase of early diastole
Overly compliant/dilated ventricle
Fourth heart sound
Le Lub Dub
Atria contracting against a non-compliant/hypertrophied ventricle
Low-pitched sound
Always always abnormal
Causes of fourth heart sound
hypertrophic cardiomyopathy hypertension (pressure overload) aortic stenosis heart failure MI
Causes of third heart sound
heart failure MI dilated cardiomyopathy hypertension (pressure overload) co-existing mitral or aortic regurgitation (volume overload) constrictive pericarditis
Causes of atrial fibrillation
Ischaemic heart disease
Rheumatic heart disease
Thyrotoxicosis
Causes of irregularly irregular pulse
Atrial fibrillation
Multiple ventricular ectopics
Do an exercise test: there will be fewer ectopics as the heart rate increases
What is the pulse deficit in AF and why does it happen
increased rate = reduced diastolic filling time
some ventricular contractions will happen very close together
so there isn’t enough time for the ventricles to fill enough to produce an actual cardiac output
which means that there is no palpable pulse for that beat
BUT, there is enough blood flow to move the valves, so you will still hear the heart sounds
Time the apical rate with stethoscope
<80bpm is good control
INR target in 1) AF 2) Mechanical prosthetic valve
AF with warfarin = 2-3
Prosthetic valve = 3-4
Difference in pathophysiology of aortic stenosis and aortic sclerosis
STENOSIS
fusion of commisures
narrowing of orifice
SCLEROSIS
thickening of leaflets leading to turbulent blood flow which causes a loud ejection systolic murmur
normal orifice
Mitral regurgitation causes
LEAFLET
congenital
endocarditis
degenerative
PAPILLARY MUSCLE AND CHORDAE
mitral valve prolapse
acute coronary syndrome
Marfan’s
ANNULAR DILATATION
cardiomyopathy
ischaemic heart disease with heart failure
Mitral regurgitation signs
Displaced apex beat (volume overload)
Quiet first heart sound
Second heart sound not heart separately and distinctly
Mitral regurgitation murmur
Pansystolic murmur
Radiates loudly to axilla
brrrrrrrrrrrrrrrrrr
Why do you get a displaced apex beat in Mitral regurgitation
Volume overload because:
Blood goes back into atrium during ventricular systole, and this extra volume returns back to the LV during diastole, leading to LV dilatation
Mitral regurgitation treatment
Mild/moderate: ACEinhibitors (reduce afterload), diuretics, anticoagulants if needed
Severe = valve repair (not replacement)
Mitral stenosis signs
Malar flush
atrial fibrillation
loud first heart sound
tapping apex beat, not displaced
JVP is only raised very late
CXR: prominent left atrium, has a convex edge
Mitral stenosis murmur and sounds
LOUD first heart sound
opening snap = high pitched sound just after second heart sound (listen at LLSE)
mid-diastolic murmur
LUB de durrrrrrrrrrrrrrr
Mitral stenosis causes
Rheumatic heart disease
Mitral stenosis treatment
Mild: meds - anticoagulate, diuretics, rate control of any AF
Moderate: trans-septal valvuloplasty, valve replacement
Severe: valve replacement (based on objective measured area of the valve combined with pressure gradient across the valve)
Aortic regurgitation signs
displaced apex beat (volume overload)
wide pulse pressure
Corrigan’s sign = collapsing pulse
Quinke’s sign = nailbed pulsation
De Musset’s sign = head’nodding
Traube’s sign = pistol-shot femorals
Aortic regurgitation murmur
Early diastolic murmur after second heart sound
Heart best in aortic area, leaning forward, breath held in expiration
Lub taaaaaaaarrrrrr
Aortic regurgitation causes
R - rheumatic heart disease
E - endocarditis (vegetations can perforate leaflet)
A - ankylosing spondylitis
L - luetic heart disease (=syphilis)
M - Marfan’s (also arachnodactyly, high-arched palate)
Aortic regurgitation treatment
If significant regurgitation present, valve replacement
Indications for ICD (Implantable Cardiac Defibrillator)
Sudden cardiac death: Primary prophylaxis
- familial cardiac condition with high risk of sudden death (long QT syndrome, HOCM, Brugada syndroma)
- surgical repair of congenital heart disease
Secondary prophylaxis
- previous cardiac arrest caused by VT/VF
- spontaneous sustained VT causing cyncope/sustained haemodynamic compromise
Indications for pacemaker
SYMPTOMATIC: bradycardia third degree heart block second degree heart block (type II) alternating bundle branch block
cardiac resynchronisation therapy with biventricular pacing
Types of pacemaker
Unipolar
- used when AV conduction is likely to return/recover
- if there is normal AV conduction but a sinoatrial disorder, then pacing wire in RA
Bipolar/dual-chamber
- pacing electrodes in both RA and RV
- allow maintenance of physiological relationship between atrial and ventricular contraction
- allow paced heart to increase sinus rhythm like in exercise
Biventricular
- leads in RA, RV and LV