Valvular heart disease

Question 1

What is meant by valvular heart disease?

Answer 1

This describes any condition affecting the heart valves, preventing either the proper passage of blood through the valves, or allowing blood back through the valves

Question 2

What is a murmur?

Answer 2

An auscultatable sound, caused by the turbulence of blood flow

Question 3

What are some general signs that may suggest a valvular heart disease?

Answer 3

Chest pain
Breathlessness
Collapse

Question 4

When will a diastolic murmur be heard on auscultation?

Answer 4

Between S2 and the following S1

Question 5

When will a systolic murmur be heart on auscultation?

Answer 5

Between S1 and S2

Question 6

What causes a 3rd heart sound?

Answer 6

Passive filling of the ventricle

Question 7

When can a 3rd heart sound be heard?

Answer 7

Just after S2

Question 8

What causes a 4th heart sound?

Answer 8

Active filling of the ventricle against a stiff ventricle

Question 9

Where are 3rd and 4th heart sounds heard most loudly?

Answer 9

Mitral area

Question 10

What causes physiological splitting of the 2nd heart sound

Answer 10

Inspiration decreases intrathoracic pressure
This increases venous return
This increases end diastolic volume on the right
This means the pulmonary valve closes after the aortic valve

Question 11

What are some pathological causes of a 3rd heart sound?

Answer 11

Left ventricular failure (e.g. dilated cardiomyopathy)
Constrictive pericarditis (Pericardial knock)
Mitral regurgitation

Question 12

What are some pathological causes of 4th heart sound?

Answer 12

Aortic stenosis
Hypertrophic Obstructive Cardiomyopathy
Hypertension

Question 13

What murmurs are systolic?

Answer 13

Aortic stenosis
Mitral regurgitation
Pulmonary stenosis
Tricuspid regurgitation

Question 14

What murmurs are diastolic?

Answer 14

Mitral stenosis
Aortic regurgitation
Tricuspid stenosis
Pulmonary regurgitation

Question 15

What are the 2 main types of systolic murmur?

Answer 15

Pansystolic
Ejection systolic

Question 16

What valvular condition will cause a pansystolic murmur?

Answer 16

Mitral regurgitation

Question 17

What valvular condition will cause an ejection systolic murmur?

Answer 17

Aortic stenosis

Question 18

What are the 2 main types of diastolic murmur?

Answer 18

Early diastolic
Mid diastolic

Question 19

What valvular condition will cause an early diastolic murmur?

Answer 19

Aortic regurgitation

Question 20

What valvular condition will cause a mid diastolic murmur?

Answer 20

Mitral stenosis

Question 21

What is meant by a pansystolic murmur?

Answer 21

A murmur that remains at a constant volume throughout systole

Question 22

What is meant by an ejection systolic murmur?

Answer 22

A murmur that gets quickly louder and then becomes quieter in systole

Question 23

What is meant by an early diastolic murmur?

Answer 23

A murmur that starts loud at the beginning of diastole and gets quieter

Question 24

What is meany by a mid diastolic murmur?

Answer 24

A murmur that starts mid way through diastole and gets louder

Question 25

How are murmurs graded?

Answer 25

I - Very quiet II - Quiet but audible III - Loud IV - Loud with a thrill V - Very loud with a thrill VI - Audible without stethoscope

Question 26

What sided murmur is usually louder on inspiration?

Answer 26

Right sided

Question 27

Describe the characteristics of an innocent murmur?

Answer 27

Soft (<3/6) for severity Often early systolic (Not diastolic)

Question 28

What is aortic stenosis?

Answer 28

A condition in which the aortic valve is too small, narrow or stiff, resulting in obstruction of blood flow from left ventricle to the aorta

Question 29

What are some causes of aortic stenosis?

Answer 29

Calcification (Degeneration) in older patients Congenital (Bicuspid aortic valve) Post-rheumatic fever Wiliams syndrome Hypertrophic obstructive cardiomyopathy

Question 30

What are some symptoms of aortic stenosis?

Answer 30

Think ABCD Aortic stenosis => Breathless Chest pain Dizziness

Question 31

How does aortic stenosis lead to chest pain?

Answer 31

Increased pressure through the aortic valve decreases blood flow through the coronary arteries, leading to angina

Question 32

What are some clinical signs of aortic stenosis?

Answer 32

Low volume pulse Narrow pulse pressure Ejection systolic murmur, radiating to carotids Slow rising pulse Soft/absent S2 Presence of S4 Thrill

Question 33

What valvular condition will cause S4?

Answer 33

Aortic stenosis

Question 34

What valvular condition will cause a narrow pulse pressure?

Answer 34

Aortic stenosis

Question 35

What valvular condition will cause a slow rising, narrow pulse pressure?

Answer 35

Aortic stenosis

Question 36

Where can a murmur in aortic stenosis be heard loudest?

Answer 36

Aortic region Carotids

Question 37

What are some treatment options in aortic stenosis?

Answer 37

Valve replacement Trans Catheter Aortic Valve Implantation (TAVI) Balloon aortic valvotomy

Question 38

What are the 2 types of conventional valve replacement?

Answer 38

Mechanical Bio-prosthetic (Pig)

Question 39

What are the advantages and disadvantages of Mechanical valve replacement?

Answer 39

+ They last much longer than bio-prosthetic - It requires lifetime warfarin

Question 40

What are the advantages and disadvantages of bio-prosthetic valve replacement?

Answer 40

+ Does not require warfarin - Only last around 10 years

Question 41

What are some investigations that can be carried out in suspected aortic stenosis?

Answer 41

Chest X-rays ECG Echocardiogram Cardiac CT (If indicated)

Question 42

What is mitral regurgitation?

Answer 42

A condition that causes the flow of blood back through the mitral valve during systole

Question 43

What are some causes of mitral regurgitation?

Answer 43

Prolapsed valve Rheumatic fever Myxomatous (Floppy) valve Endocarditis Chordae or papillary rupture post MI Annular dilatation due to cardiomyopathy

Question 44

What are some common symptoms of mitral regurgitation?

Answer 44

Breathless on exertion Peripheral oedema Fatigue

Question 45

What are some clinical signs of mitral regurgitation?

Answer 45

Displaced apex Pansystolic murmur, radiates to axilla Presence of S3

Question 46

Where can the murmur of mitral regurgitation be heard?

Answer 46

Mitral area Axilla

Question 47

What condition can be caused by mitral regurgitation?

Answer 47

Left ventricular hypertrophy (Cardiomegaly on x-ray)

Question 48

What are some surgical treatment options of mitral regurgitation?

Answer 48

Valve repair in cases of prolapse Valve replacement in cases of degeneration Percutaneous clips in infancy or those unable to tolerate open heart surgery

Question 49

What are some pharmacological treatment options in mitral regurgitation?

Answer 49

ACEi or ARBs Diuretics

Question 50

What are some investigations that can be performed in mitral regurgitation?

Answer 50

Chest X-ray (Shows cardiomegaly) Echocardiogram Coronary angiography (If indicated)

Question 51

What is meant by mitral stenosis?

Answer 51

A condition in which there is obstruction to flow through the mitral valve during systole

Question 52

What is the most common cause of mitral stenosis?

Answer 52

It has a mostly rheumatoid aetiology (rare calcification or congenital)

Question 53

What are some possible symptoms of mitral stenosis?

Answer 53

Breathlessness Fatigue Palpitations (A Fib)

Question 54

How does mitral stenosis cause atrial fibrillation?

Answer 54

Increased pressure in the left atrium can lead to ectopic foci formation as the atria enlarges

Question 55

What are some clinical signs of mitral stenosis

Answer 55

Malar flush Tapping apex beat Mid diastolic rumbling murmur Loud S1 Haemoptysis Opening snap

Question 56

What valvular condition causes malar flush?

Answer 56

Mitral stenosis

Question 57

What valvular condition causes a loud S1?

Answer 57

Mitral stenosis

Question 58

What valvular condition causes an opening snap?

Answer 58

Mitral stenosis

Question 59

How does mitral stenosis cause haemoptysis?

Answer 59

Increased pressure in the left atrium causes a build up of pressure in the lungs, leading to oedema and bleeding, causing pink, frothy sputum

Question 60

What are some surgical treatment options in mitral stenosis?

Answer 60

Valve replacement Balloon valvuloplasty

Question 61

What are some pharmacological treatment options in mitral stenosis?

Answer 61

Diuretics Direct oral anti-coagulation

Question 62

What are some investigations that can be performed in mitral stenosis?

Answer 62

Chest X-ray (Straight left heart border) ECG Echocardiography

Question 63

What is meant by aortic regurgitation?

Answer 63

A condition resulting in the reflux of blood from the aorta through the aortic valve and back into the left ventricle, during diastole

Question 64

What are some causes of aortic regurgitation?

Answer 64

Endocarditis Connective tissue disease Rheumatic fever Annulus dilatation

Question 65

What are some conditions that can lead to aortic regurgitation?

Answer 65

Marfan's syndrome Aortic dissection Spondylarthropathis Hypertension Ehler-Danlos syndrome Syphilis

Question 66

What are some possible symptoms of aortic regurgitation?

Answer 66

Angina Dyspnoea

Question 67

What are some clinical signs of aortic regurgitation?

Answer 67

Collapsing pulse Displaced apex Early diastolic murmur at left sternal edge Low diastolic BP Wide pulse pressure Quincke's sign (Pulsing nailbed) De Musset's sign (Head bobbing)

Question 68

What manoeuvre can be performed to increase volume of an aortic regurgitation murmur?

Answer 68

Patient leaning forward

Question 69

What valvular condition causes a collapsing pulse?

Answer 69

Aortic regurgitation

Question 70

What valvular condition causes a wide pulse pressure?

Answer 70

Aortic regurgitation

Question 71

What is the pharmacological treatment for acute aortic regurgitation?

Answer 71

Vasodilators and inotropes

Question 72

What is the pharmacological treatment for chronic, severe aortic regurgitation and heart failure?

Answer 72

ACE inhibitors

Question 73

What is the pharmacological treatment for aortic dilation in Marfan's patients?

Answer 73

ß-Blockers

Question 74

Who is surgical management of aortic regurgitation indicated in?

Answer 74

Symptomatic patients Asymptomatic patients with left ventricular dysfunction

Question 75

What are some investigations that can be carried out in aortic regurgitation?

Answer 75

ECG Chest X-ray Echocardiogram (Gold standard)