valvular disorders

Question 1

aortic stenosis murmur location

Answer 1

2cd right ICS ; radiates to neck and LSB; often loud w/ thrill; grade 4-6, crescendo-decrescendo, midsystolic

Question 2

AS

Answer 2

M>W,most common murmur in US, sx onset when narrowed around 1-1.2 cm; may see LVH and left-sided atrial enlargement, thready pulses in carotid

Question 3

Aortic regurge

Answer 3

biscuspid valve, rheumatic infxn, aortic root dz, sever Htn

Question 4

AR CP

Answer 4

DOE, PND, orthopnea, 1 out of 4 angina,

Question 5

AR murmur

Answer 5

high pitched, blowing, decresendo, diastolic murmur heard at 3-4th ICS along LSB

Question 6

AR evaluation

Answer 6

LVH, LAD “strain pattern”

CXR: CMG, possible aortic enlargment

Question 7

MS etiology

Answer 7

rheumatic fever, lupus, RA, calcification

Question 8

MS sx

Answer 8

when valve is 1.4-2.5 cm wide; onset can be 20-40 years from rheumatic dz ; dyspnea, orthopnea, PND, fatigue, palpitaions, hemoptysis

Question 9

MS murmur

Answer 9

pronouced S1, opening snap, low pitched diastolic rumble at apex (decubitus position)

Question 10

MS EKG/CXR

Answer 10

may how enlarged P wave in II or uprighe in vV1 or atrial fib; LA, RV enlargment

Question 11

MS rx

Answer 11

rate control afib, anticoag, manage CHF prevent recurrent R. fever

Question 12

MR etiology

Answer 12

anything that disrupts MR compoenents (leaflets, annulus, myocardium cordae, paipillary)

Question 13

MR PP

Answer 13

measured in terms of severity (trace, mild, mod, sever)

Question 14

MR CP

Answer 14

fatigue, dyspnea, DOE, orthopnea, PNd, palpitaions

Question 15

MR murmur

Answer 15

holosystolic best heard at apex and radiates to axilla, S2 may be widlely split

Question 16

Mitral prolapse PP

Answer 16

connective tissue disease, genetics, idopahtic, HCM

Question 17

MP CP

Answer 17

largley asx, but isolated MR most commonly associated with MVP

Question 18

MP Murmur

Answer 18

mid-systolic click, possilbe late cresendo-decresecndo murmerr at apex

Question 19

what is the cause of most valvular dz in US?

Answer 19

degenerative calcific changes; same process as atherosclerosis

Question 20

what murmurs occur in systole

Answer 20

aortic/pulmonary stenosis

Mitral and tricupsid regurg

Question 21

diastolic murmurs?

Answer 21

M/T stenosis

A/P regurg

Question 22

timing of sx in stenosis

Answer 22

sx precede LV dysfxn; typically intervene for sx

Question 23

timing of sx in regurg

Answer 23

LV dysfxn may precede sx, monitor LV fxn, intervene for sx and to preserve cardiac fxn

Question 24

PP of valvular dz

Answer 24

excess load on mycardium (increased pressure, increase volume)
compensatory : hypertrophy from stenotic dz (pressure is problem), dilation in regurg (volume is problem)

Question 25

AS etiology

Answer 25

calcific valve dz (tx with statins

Question 26

calcific valve dz

Answer 26

proliferative and inflammatory changes w. lipid accumulation, up-regulation of ACE, infiltration of macrophages and T-lymphocytes

Question 27

AS summary

Answer 27

o WHO  older / calcific or younger / bicuspid o SYMPTOMS  angina, syncope, CHF o PE  harsh, systolic ejection murmur at right upper sternal border with radiation to neck o DIAGNOSIS  transthoracic echo, then cardiac cath o MANAGEMENT  surgery for symptoms

Question 28

AR PP?

Answer 28

- Regurgitant volumed = increased LV EDV = dilatation =increased LV EDP = pulmonary congestion

Question 29

AR etiology

Answer 29

congenital, infxn, marfan sydrome, inflammatory (SLE , RA), phentermine

Question 30

Aortic Root Syndrome

Answer 30

Marfan, syphilis, ankylosing spondylitis, cystic medial necrosis, arotic dissection, trauma

Question 31

AR PE

Answer 31

wide pulse pressure, s3 gallop, diastolic murmur, high pitched

Question 32

Water-hammer/ Corrigan's pulse (AR)

Answer 32

abrupt distension/quick collapse of pulses (radial/carotid)

Question 33

Quincke's pulse (AR)

Answer 33

capilarry pulsations seen in fingernails or lip

Question 34

Mussets sign (AR)

Answer 34

head bob w/ each heart beat

Question 35

Muller sign (AR

Answer 35

systolic pulsations of the uvula

Question 36

Traube sign (AR)

Answer 36

booming systolic and diastolic sounds heard over the femoral arther

Question 37

Duroziez sign (AR)

Answer 37

systolic murmur heard over the femoral artery when compressed proximal, diastolic murmur when compressed distally

Question 38

Hill sign

Answer 38

popliteal cuff SBP >20 over breacheal cuff SBP

Question 39

Austin Flint rumble

Answer 39

a mid-diastolic, low frequency murmur that is best heard at the apex with little radiation. It mimics rheumatic mitral stenosis in its characteristics and physiology. The murmur is the result of competition between the regurgitant jet of the aortic valve and the attempt to fill the left ventricle from the left atrium—in essence, functional mitral stenosis. It differs in that it occurs in the presence of a murmur of aortic valve insufficiency and in the absence of the rheumatic, mitral opening snap

Question 40

AR medical therapy

Answer 40

afterload reduction= ACE, ARB, or hydralazine+ntrates (vasodilators) endocarditis prophylzxix in appropriate patients

Question 41

Rule of 55

Answer 41

AR tx: LVEF < 55% or LVESD > 5.0 cm

Question 42

AR summary

Answer 42

WHO : no classic patient, think bicuspid or Marfan syndrome SYMPTOMS : CHF symptoms (dyspnea, fatigue) PE : wide pulse pressure, soft / decrescendo diastolic murmur, bounding pulses – “water-hammer,” Musset’s head bob, Quincke’s pulse DIAGNOSIS : Echo MANAGEMENT : medical therapy, surgery for acute AI, symptoms or evidence of LV changes in chronic AI

Question 43

MS hemodynamics

Answer 43

elevated LA pressure and LA enlargment, pulmonary venous congestion, reduced CO, pulm HTN, may progress to Right sided failure

Question 44

what can develop from MS? (arrhythmias/ pregnancy)

Answer 44

paroxysmal/chronic atrial fibrillation develops in 50-80% of pts sudden increase in HR may precipitate pulmonary edema (HR control is more important) In pregnancy, there is an associated increased in CO=increased transmitral pressure gradient=sx; pts w/ moderate to severl MS should have intervention poror to becoming prego, or if already prego

Question 45

MS epidemiology

Answer 45

think rheumatic heart dz first | 2/3 are women

Question 46

MS PP

Answer 46

fibrosis, scarring and thickening of leaflets, commissural fusion, chordae fusion and shortening, decrease in orifice size

Question 47

MS gradient

Answer 47

normal: 0 mild: <8 moderate: 8-12 severe: >12

Question 48

MS dx

Answer 48

echo-need to look at pressure gradient and velociyt | cardiac cath- directly measure left atrial and left ventricular pressure