Section 6: Valvular Heart Disease Flashcards Preview

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Flashcards in Section 6: Valvular Heart Disease Deck (66)
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1

Differential diagnosis of valvular heart disease in young patients

  • Mitral valve prolapse
  • Hypertrophic obstructive cardiomyopathy
  • Mitral stenosis
  • Bicuspid aortic valves.

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2143-2144).  . Kindle Edition.

2

Clue to diagnosis in valvular heart disease:

  1. Young female, general population
  2. Healthy young athlete
  3. Immigrant, pregnant
  4. Turner’s syndrome, coarctation of aorta
  5. Palpitations, atypical chest pain not with exertion

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2155-2158).  . Kindle Edition. 

 

  1. Mitral valve prolapse
  2. Hypertrophic obstructive cardiomyopathy (HOCM)
  3. Mitral stenosis
  4. Bicuspid aortic valve
  5. Mitral valve prolapse

3

List the physical findings in a patient with vascular heart disease

Most common:

  • Murmurs
  • Rales on lung exam

Less common:

  • Peripheral edema
  • Carotid pulse findings
  • Gallops

4

Causes of systolic murmurs

  • Aortic stenosis
  • Mitral regurgitation
  • Mitral valve prolapse
  • Hypertrophic obstructive cardiomyopathy (HOCM).

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2167-2168).  . Kindle Edition.

5

Cause of diastolic murmurs

  • Aortic regurgitation
  • Mitral stenosis.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2169).  . Kindle Edition.

6

  1. List the right sided murmurs
  2. What is their relationship with respiration

  1. Right-sided murmurs:
  • Pulmonic stenosis
  • Pulmonic regurgitation
  • Tricuspid stenosis
  • Tricuspid regurgitation

2.

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2177-2178).  . Kindle Edition.

7

  1. List the left sided murmurs
  2. What is their relationship with respiration

Mitral stenosis

MVP

Mitral regurgitation

Aortic regurgitation

Aortic stenosis

They increase with exhalation

8

Squatting and lifting the legs in the air ------ (1) ------ venous return to the heart.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2186-2187).  . Kindle Edition.

  1. Increases

9

Valsalva maneuver and standing up suddenly --- (1) --- venous return to the heart.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2187-2188).  . Kindle Edition.

Decrease

10

Explain Valsalva maneuver

Valsalva maneuver is exhaling against a closed glottis, like bearing down during a bowel movement or blowing against a thumb stuck in the mouth. This increases intrathoracic pressure, which decreases blood return to the heart.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2189-2191).  . Kindle Edition.

 

11

What is the effect of sudden squating or lifting the leg on blood flow to the heart?

When you suddenly squat, you are squeezing the veins of the legs, which are rather large. This essentially squeezes blood up into the heart like squeezing on a tube of toothpaste. For those too weak to squat suddenly, the physician can lift up the legs. This has the same effect as squatting, which is to drain blood into the chest from the lower extremities.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2192-2195).  . Kindle Edition.

12

The majority of murmurs increase in intensity with squatting and leg raise. List them.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2196-2197).  . Kindle Edition.

  • Aortic stenosis (AS)
  • Aortic regurgitation (AR)
  • Mitral stenosis (MS)
  • Mitral regurgitation (MR)
  •     Pulmonic stenosis
  • Pulmonic regurgitation
  • Tricuspid stenosis
  • Tricuspid regurgitation

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2196-2197).  . Kindle Edition.

13

List the only two murmurs that become softer with squatting and leg raising

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2198-2199).  . Kindle Edition.

  • Mitral valve prolapse (MVP)
  • Hypertrophic obstructive cardiomyopathy (HOCM).

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2198-2199).  . Kindle Edition.

14

What is the effect of squatting or leg raising on the following lesions:

  1. Aortic stenosis (AS)
  2. Aortic regurgitation (AR)
  3. Mitral stenosis (MS)
  4. Mitral regurgitation (MR)
  5. Ventricular septal defect (VSD)
  6. Hypertrophic obstructive cardiomyopathy (HOCM)
  7. Mitral valve prolapse (MVP)

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2223-2227).  . Kindle Edition.

  1. Increase
  2. Increase
  3. Increase
  4. Increase
  5. Increase
  6. Decrease
  7. Decrease

15

What is the effect of standing/Valsalva maneuver on the following lesions:

  1. Aortic stenosis (AS)
  2. Aortic regurgitation (AR)
  3. Mitral stenosis (MS)
  4. Mitral regurgitation (MR)
  5. Ventricular septal defect (VSD)
  6. Hypertrophic obstructive cardiomyopathy (HOCM)
  7. Mitral valve prolapse (MVP)

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2223-2227).  . Kindle Edition.

  1. Decreased
  2. Decreased
  3. Decreased
  4. Decreased
  5. Decreased
  6. Increased
  7. Increased

16

What murmures are worsened by handgrip?

  • Aortic regurgitation
  • Mitral regurgitation
  • VSD

Handgrip will make these murmurs louder

17

Handgrip is a maneuver that --- (1) --- --- (2) --- by compressing the arteries of the arm through contraction of the muscles of the arm.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2232-2233).  . Kindle Edition.

  1. Increases
  2. Afterload

18

Why are ACE inhibitors useed in the Rx of AR and MR?

Because they reduce afterload and so increase the forward flow of blood into the aorta

19

What other medication acts similar to ACE inhibitors?

Amyl nitrate

20

  1. What class of drug is amyl nitrate?
  2. How does decrease afterload?

  1. Vasodilator
  2. By dilating peripheral arteries

21

Amyl nitrate has the --- 1 --- effect of handgrip. Giving amyl nitrate is like giving an ACE inhibitor or ARB. If handgrip worsens AR and MR, then amyl nitrate improves AR and MR.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2242-2243).  . Kindle Edition.

  1. Opposite

22

  1. List murmurs handgrip improves or lessen
  2. Explain the physiology behind 1

  1. The murmurs handgrip improves are:
  • Hypertrophic obstructive cardiomyopathy (HOCM)
  • Mitral valve prolapse (MVP)
  • Aortic stenosis

2. The murmurs of MVP and HOCM lessen when the left ventricular chamber is larger or more full. What happens to the size of the left ventricular (LV) chamber if there is increased afterload? The LV chamber will not empty and, therefore, the LV will be larger. A larger LV chamber relieves or lessens the obstruction in HOCM.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2245-2247).  . Kindle Edition.

23

What is the effect of handgrip on the following murmurs?

  1. Aortic stenosis (AS)
  2. Aortic regurgitation (AR)
  3. Mitral stenosis (MS)
  4. Mitral regurgitation (MR)
  5. Ventricular septal defect (VSD)
  6. Hypertrophic obstructive cardiomyopathy (HOCM)
  7. Mitral valve prolapse (MVP)

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2268-2287).  . Kindle Edition.

  1. Decrease
  2. Increase
  3. Negligible effect
  4. Increase
  5. Increase
  6. Decrease
  7. Decrease

24

What is the effect of amyl nitrate on the following murmurs?

  1. Aortic stenosis (AS)
  2. Aortic regurgitation (AR)
  3. Mitral stenosis (MS)
  4. Mitral regurgitation (MR)
  5. Ventricular septal defect (VSD)
  6. Hypertrophic obstructive cardiomyopathy (HOCM)
  7. Mitral valve prolapse (MVP)

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2268-2287).  . Kindle Edition.

  1. Increase
  2. Decrease
  3. Negligible effect
  4. Decrease
  5. Decrease
  6. Increase
  7. Increase

25

Where is the location and radiation of the following murmurs?

  1. Aortic stenosis
  2. Pulmonic valve murmurs
  3. Aortic regurgitation, tricuspid murmurs and VSD murmurs
  4. Mitral regurgitation

 

  1. Aortic stenosis is heard best at the second right intercostal space and radiates to the carotid arteries. It is classically described as a crescendo-decrescendo murmur.
  2. Pulmonic valve murmurs are heard at the second left intercostal space.
  3. Aortic regurgitation and tricuspid murmurs, as well as VSD murmurs, are heard at the lower left sternal border.
  4. Mitral regurgitation (MR) is heard at the apex and radiates into the axilla. The apex is at the level of the 5th intercostal space, below the left nipple.

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2300-2303).  . Kindle Edition.

     

26

Grade murmurs by intensity

  1. I/ VI: Only heard with special maneuvers (e.g., Valsalva, handgrip)
  2. II/ VI and III/ VI: Majority of murmurs; no objective difference between them
  3. IV/ VI: Thrill present (a thrill is a palpable vibration you can feel from a severe valve lesion)
  4. V/ VI: Can be heard with stethoscope partially off the chest
  5. VI/ VI: Stethoscope not needed to hear it

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2305-2307).  . Kindle Edition.

 

27

Diagnostic tests for valvular heart disease

  1. Best initial test
  2. Most accurate test
  3. Other important tests on CCS

  1. Echocardiogram
  2. Left heart catherization
  3. EKG and chest X-ray

28

Rx for regurgitant lesions

Vasodilators

  1. ACE inhibitors
  2. ARBs
  3. Nifedipine

Surgical replacement if medical therapy fails

29

Rx for stenotic lesions

Anatomic repair

  • Mitral stenosis should undergo balloon valvuloplasty, even if the patient is pregnant.
  • Aortic stenosis that is severe must be surgically replaced.
  • Aortic valve replacement is well tolerated even in the very old.
  • Diuretics can decrease pulmonary vascular congestion with stenotic lesions, but they are not as effective or important as anatomic repair.

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2321-2323).  . Kindle Edition.

     

30

--- 1 --- medication is indicated if Valsalva improves murmur


--- 2 --- medication is indicated if amyl nitrate improves murmur

 

  1. Diuretics
  2. ACE inhibitor