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Valvular disease Flashcards

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1
Q

What are the causes of aortic stenosis (AS)?

A
  • calcification (>65yrs)
  • bicuspid valve (<65yrs)
  • rheumatic disease
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2
Q

What is the usual presentation of AS

A

Elderly w:

  1. angina
  2. syncope
  3. SOB
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3
Q

What are the signs of AS

A
  1. ejection systolic murmur
  2. aortic thrill
  3. heaving, non-displaced apex beat
  4. LV heave
  5. Narrow pulse pressure
  6. Slow rising pulse
  7. Soft/absent S2
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4
Q

What are the investigations for AS? What would you find?

A
  1. ECG - p mitrale (biphasic p wave)
  2. CXR - LVH, calcified aorta , post stenotic dilatation of ascending aorta
  3. ECHO - DIAGNOSTIC
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5
Q

Give the management of AS

A
  1. If asymptomatic - observe
  2. Valve replacement if: symptomatic or asymptomatic w valvular gradient >40mmhg + features of LV dysfunction
  3. balloon valvuloplasty if not fit for surgery
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6
Q

Give the causes of aortic regurgitation (AR)

A
  1. valve disease: rheumatic fever, IE, connective tissue disease (RA/SLE), bicuspid aortic valve
  2. Aortic root disease: aortic dissection, spondylarthropathies, HTN, syphilis, Marfans, Ehler Danlos
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7
Q

What are the sx of AR

A
  • SOB on exertion
  • Orthopnoea
  • PND
  • Palpitations, syncope, angina, HF
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8
Q

What are the signs of AR

A

i. collapsing water hammer pulse (on lifting arm quickly)
ii. Wide pulse pressure
iii. early diastolic murmur
iv. Quinkes sign - nailed pulsation
v. demussels - head bobbing w each heart beat
vi. mid-diastolic Austin flint murmur if severe

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9
Q

What is Austin flint murmur

A

due to partial closure of anterior mitral valve due to regurg streams

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10
Q

What are the investigations for AR, what would they show

A

ECHO
CXR- cardiomegaly, dilated ascending aorta
Cardiac catheterisation to assess severity

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11
Q

What is the management of AR

A

Main goal is to reduce systolic HTN so give ACEi

Surgery - if increasingly symptomatic, enlarged heart or ECG deterioration

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12
Q

What are the causes of mitral stenosis?

A
  1. rheumatic
  2. congenital
  3. prosthetic valve
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13
Q

What are the sx of mitral stenosis? at what point does a patient become symptomatic?

A

SOB, fatigue, palpitations, chest pain,

when the area of the mitral valve orifice is <2cm^3

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14
Q

What are the signs of mitral stenosis?

A

i. mid late diastolic murmur - best heard on expiration
ii. Loud s1 opening snap
iii. low volume pulse
iv. malar flush
v. non-displaced apex beat

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15
Q

How do the signs in MS change as the severity increaseS?

A

murmur lengthens and the opening snap is closer to S2

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16
Q

What imaging will show signs of MS?

A

CXR - LA enlargement

ECHO

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17
Q

What is the management of MS?

A
  1. rate control if in AF
  2. Diuretics to reduce preload nd risk of pulmonary congestion
  3. Surgery - balloon valvuloplasty, open valvotomy or valve replacement
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18
Q

What are the complications of MS?

Study These Flashcards
A
  • Pulm HTN
  • Emboli
  • Pressure form large LA on other tings e.g. hoarseness (recurrent laryngeal), dysphagia (oesophagus), bronchial obstruction
19
Q

What is mitral regurgitation also known as?

Study These Flashcards
A

mitral insufficiency

20
Q

Explain how MR leads to HF

Study These Flashcards
A

i. Blood leaks through valve on systole
ii. Myocardium thickens over time as O2 demand exceeds what heart can supply
iii. Thicker myometrium becomes less efficient

21
Q

What are the causes of MR

Study These Flashcards
A
  • Following CHD or post MI - if papillary muscle or chordae tendinae are affected by cardiac insult
  • MV prolapse
  • IE - vegetations prevent from closing properly
  • Rheumatic fever - inflammation of valves
22
Q

What are the sx of MR

Study These Flashcards
A

Usually asymptomatic

Sx are usually due to LV failure, arrhythmias, pulm HTN: fatigue, SOB, oedema

23
Q

What are the signs of MR

Study These Flashcards
A
  • Blowing pan systolic murmur best heard at the apex and radiating into the axilla
    Quiet S1 - incomplete closure of valve
24
Q

What are the Ix in mR

Study These Flashcards
A

ECG - broad P wave - atrial enlargement
CXR - cardiomegaly
Echo - diagnostic, assess severity

25
What is the management of MR
1. Rate control if AF 2. Anticoagulate if AF, Hx of embolism or prosthetic valve 3. HF: ACEi, BB, diuretics 4. Diuretics, nitrates, +ve inotropes + intra-aortic balloon to increase CO 5. Repair > replacement
26
What is mitral prolapse associated with?
- CHD - PDA, ASD - cardiomyopathy - Turners syndrome - Marfans - WPW - Osteogenesis imperfecta
27
What are the sx of MP?
- mid-systolic click | - late systolic murmur
28
What are the complications of MP?
- mitral regurgitation - cerebral emboli - arrhythmias - sudden death
29
What is the management of MP?
BB for palpitations and chest pain | surgery if severe regurgitation
30
What age does rheumatic fever tend to affect?
5-15yrs
31
What causes rheumatic fever?
abnormal immunological response to recent (2-6weeks) strep progenies infection (group A beta haemolytic)
32
What are the clinical features of rheumatic fever
latent interval of 2-6 weeks following a pharyngeal infection
33
What criteria re used to diagnose RF? Give them
``` Jones Diagnosis = recent strep infection +: - 2 major criteria - 1 major + 2 minor Evidence of recent strep infection: - increased strep abs - +ve throat swab - +ve rapid group A strep antigen test Major criteria: 1. erythema marginatum 2. polyarthritis 3. pancarditis (must include endocarditis) 4. subcut nodules 5. sydenhams chorea - late feature Minor criteria: 1. Raised ESR/CRP 2. Pyrexia 3. Arthralgia - not if arthritis is the major 4. Prolonged PR interval ```
34
What is the management of RF
1. Bed rest until CRP normal for 2 weeks 2. Aspirin - monitor salicylate levels (or NSAIDs) 3. + Prednisolone if carditis is bad 4. Rx HF 5. Haloperidol or diazepam for chorea
35
What is the prognosis of RF like
60% develop chronic rheumatic | Mitral stenosis is common
36
What is the secondary prophylaxis for RF
Penicillin V (phenoxymethlypenicillin) sometimes until 18-21 but can be lifelong
37
What usually points to a diagnosis of infective endocarditis (IE)
fever and murmur = IE until proven otherwise
38
What are the RFs for IE
1. strongest is prev IE 2. IVDU 3. Rheumatic valve disease 4. Prosthetic valves 5. CHDs
39
What bacteria cause IE?which is the most common?
1. Staph aureus - most common 2. strep viridans 3. coagulase -ve staph e.g. epidermidis
40
What criteria are used to diagnose IE? Give them
``` DUKE CRITERIA Diagnose if any of: - Pathological criteria +ve - 2 major - 1 major + 3 minor - 5 minor Pathological: +ve Hx or microbiology of pathological material obtained at autopsy or cardiac surgery ``` Major: i. +ve blood culture: - typical organism in 2 separate culture, or - persistently +ve blood culture ii. endocardium involved: - +ve echo or - new valvular regurg ``` Minor: I. Predisposition (IVDU, cardiac lesion) ii. fever >38 iii. Vascular/immunological signs iv. +ve blood culture not meeting criteria v. +ve echo not meeting criteria ```
41
What are the signs of IE?
1. Sepsis - fever, rigors, malaise, splenomegaly, anaemia etc 2. Cardiac lesions - new murmur, signs of regurgitation, prolonged PR interval, may lead to AV block (complete) 3. Immune complex deposition: Roth spots, splinter haemorrhages, Oslers nodes, Janeway lesions, microscopic haematuria, glomerulonephritis + AKI 4. Embolic phenomena - abscesses on relavent organ
42
What tests would you want to do for a patient w suspected IE?
1. Blood cultures - 3 sets at diff times from 3 diff sites at peak of fever 2. FBC, CRP/ESR, U+E, LFT, Mg2+ 3. urinalysis - haematuria 4. CXR - cardiomegaly 5. ECG 6. Echo - shows regurgitation 7. TOE
43
What is the management of IE?
ANTIBIOTICS 1. Initial blind therapy: - amoxicillin - if allergic - vancomycin + low-dose gentamicin - if prosthetic valve: vancomycin + low-dose gentamicin + rifampicin 2. STAPH: fluclox 3. VIRIDANS: benpen
44
What are the indications for surgery in IE?
``` HF, Valvular obstruction repeated emboli fungal endocarditis unstable inferior prosthetic valve myocardial abscess persisten bacteraemia ```

Cardiology (13 decks)

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