Section 9: Valvular Heart Disease 2 Flashcards Preview

Cardiology USMLE Step 3 > Section 9: Valvular Heart Disease 2 > Flashcards

Flashcards in Section 9: Valvular Heart Disease 2 Deck (28)
Loading flashcards...
1

Rx for aortic stenosis

Diurectics (judicoius use)

Definitive rx of choice: valve replacement

  • Bioprosthetic valves (porcine, bovine) will last 10 years on average, but do not require anticoagulation with warfarin
  • Mechanical valves do not have to be replaced but must be also treated with warfarin to an INR of 2– 3
  • Valve replacement is well tolerated, even in the elderly
  • Balloon dilate AS only if the patient is too sick to undergo surgery

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2406-2410).  . Kindle Edition.

2

Causes of aortic regurgitation

  • Hypertension
  • Rheumatic heart disease
  • Endocarditis
  • Cystic medial necrosis

Rarer causes include:

  • Marfan’s syndrome
  • Ankylosing spondylitis
  • Syphilis
  • Reactive Arthritis

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2413).  . Kindle Edition.

 

3

Reactive arthritis:

What is this?

What is another name for reactive arthritis?

  • Reactive arthritis is an inflammatory arthritis of large joints, inflammation of the eyes (conjunctivitis and uveitis), and urethritis
  • Reiter’s syndrome.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2413-2414).  . Kindle Edition.

4

Most common presentation of aortic regurgitation

Shortness of breath

Fatigue

5

Describe the murmur of aortic regurgitation

  • The murmur of AR is a diastolic decrescendo murmur heard best at the left sternal border.
  • The murmur will increase in intensity with leg raising, squatting, and handgrip.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2418-2420).  . Kindle Edition.

6

Arterial or capillary pulsations in the fingernails

High bounding pulses (also known as a “water-hammer pulse”)

Head bobbing up and down with each pulse

Murmur heard over the femoral artery

Blood pressure gradient much higher in the lower extremities

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2420-2425).  . Kindle Edition.

  • Quincke pulse
  • Corrigan’s pulse
  • Musset’s sign
  • Duroziez’s sign
  • Hill sign

7

Aortic Regurgitation:

  1. Best initial test
  2. Most accurate test
  3. Findings on EKC and CXR

  1. TTE. TEE more accurate
  2. Left heart catheterization
  3. EKG and a chest x-ray, which will show left ventricular hypertrophy.

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2428).  . Kindle Edition.

8

Rx for Aortic regurgitation

ACE inhibitors, ARBs, and nifedipine are the best initial therapy.

For CCS add loop diuretics: Furosemide

Surgery is the answer when the ejection fraction drops below 55 percent or the left ventricular end systolic diameter goes above 55 mm; surgery should be done in patients with these criteria even if they are asymptomatic.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2432-2433).  . Kindle Edition.

 

9

Most common cause of Mitral stenosis

Rheumatic fever

10

Special features or presentations in mitral stenosis

  1. Dysphagia: Large left atrium pressing on the esophagus
  2. Hoarseness: Pressure on recurrent laryngeal nerve
  3. Atrial fibrillation leading to stroke

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2438-2440).  . Kindle Edition.

11

Describe the murmur of mitral stenosis

The murmur of MS is a diastolic rumble after an opening snap, which can be described as an “extra sound” in diastole.

The S1 is louder. As the mitral stenosis worsens, the opening snap moves closer to S2.

The murmur will increase in intensity with leg raising, squatting, and expiration.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2443-2445).  . Kindle Edition.

12

Mitral Stenosis

  1. Best initial test
  2. Most accurate test
  3. Findings on EKG and CXR

On chest x-ray, there is straightening of the left heart border and elevation of the left mainstem bronchus.

There may also be a description of a double density in the cardiac silhouette (from left atrial enlargement).

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2449-2451).  . Kindle Edition.

13

Rx for Mitral Stenosis

Diuretics are the best initial therapy. They do not alter progression.

Balloon valvuloplasty is the most effective therapy.

Pregnant women can and should be readily treated with balloon valvuloplasty. Pregnancy is not a contraindication to valvuloplasty.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2455).  . Kindle Edition.

 

14

Causes of mitral regurgitation

Hypertension

Ischemic heart disease

Any other condition that leads to dilation of the heart.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2457-2458).  . Kindle Edition.

15

Most common clinical presentation of mitral regurgitation

Dyspnea on exertion is the most common complaint.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2459).  . Kindle Edition.

16

Describe the murmur of mitral regurgitation

  • The murmur of MR is holosystolic and obscures both S1 and S2.
  • MR is heard best at the apex and radiates to the axilla.
  • The murmur increases in intensity with leg raising, squatting, and handgrip.
  • Standing, Valsalva, and amyl nitrate decrease the intensity. S3 gallop is often present.

 S3 gallop is associated with fluid overload states, such as congestive heart failure or mitral regurgitation. An S3 can be normal in patients under the age of 30.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2464-2467).  . Kindle Edition.

 

17

Mitral Regurgitation:

  • Best initial test
  • Most accurate test

  • TTE. TEE more accurate
  • ?Left heart catheterization

18

Rx of mitral regurgitation

  • ACE inhibitors, ARBs, and nifedipine are the best initial therapy and the medications most likely to decrease the rate of progression of the disease. 
  • Surgery is the answer when the left ventricular ejection fraction drops below 60 percent or the left ventricular end systolic diameter goes above 40 mm. Surgery should be done in patients with these criteria even if they are asymptomatic.

    Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2474-2475).  . Kindle Edition.

 

19

List the operative criteria for regurgitant lesions (aortic and mitral regurgitations)

  Aortic Regurgitation  

  • Ejection fraction              < 55%
  •  Left ventricular end systolic diameter > 55 mm

Mitral Regurgitation

  •  Ejection fraction  < 60%
  • Left ventricular end systolic diameter  > 40 mm

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2479-2487).  . Kindle Edition.

20

Clinical presentation of Ventricular Septal Defect (VSD)

  • Asymptomatic patients may present with only a holosystolic murmur at the lower left sternal border.
  • Larger defects leads to shortness of breath.
  • The murmur worsens with exhalation, squatting, and leg raise.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2489-2491).  . Kindle Edition.

21

Diagnostic tests for VSD

Echocardiography is the diagnostic test to use first, but catheterization is used to determine the degree of left-to-right shunting most precisely.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2492-2494).  . Kindle Edition.

22

Rx for VSD

Mild defects can be left without mechanical closure.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2495-2496).  . Kindle Edition.

23

Clinical presentation of Atrial Septal Defect

  • Small ASDs are asymptomatic.
  • Larger ones may lead to shortness of breath or signs of right ventricular failure, such as shortness of breath and a parasternal heave.
  • The most frequently tested knowledge is that ASD is associated with fixed splitting of S2.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2498-2500).  . Kindle Edition.

 

24

Diagnostic test for ASD

Echocardiogram

25

Rx of ASD

Percutaneous or catheter devices are the best therapy. Repair is most often indicated when the shunt ratio exceeds 1.5 to 1.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2504-2505).  . Kindle Edition.

26

List causes of wide splitting of S2 with delayed P2

 

  • Right bundle branch block
  • Pulmonic stenosis
  • Right ventricular hypertrophy
  • Pulmonary hypertension

 

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2511-2519).  . Kindle Edition.

27

List the causes of Paradoxical splitting of S2 with delayed A2

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2509).  . Kindle Edition.

  • Left bundle branch block
  • Aortic stenosis
  • Left ventricular hypertrophy
  • Hypertension

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2516-2519).  . Kindle Edition.

28

List cause of fixed splitting of S2

ASD