Valvular heart disease

Question 1

What is the most common cause of mitral stenosis?

Answer 1

Rheumatic fever = Complication of strep throat

Question 2

What are the normal heart sounds?

Answer 2

S1 - closing AV valves - early systole (lub)
S2 - closing of semilunar valves - after systolic contraction is complete (dub)

Question 3

What is S3 heart sound?

Answer 3

Subtle
Just after S2
Rapid ventricular filling - cause chordae tendinae to pull taught
Norm in young patients, can be pathological in older patients indicate reduced flexibility of chordae tendinae

Question 4

What is the S4 heart sound?

Answer 4

Just before S1
Always pathological
Indicates blood flow into a stiff/hypertrophic ventricle - causes turbulent flow
LE LUB DUB

Question 5

What maneouvres exagerate what murmurs on cardiovascular exam?

Answer 5

Listen over carotids hold breath = aortic stenosis
Lean forwards hold breath and listen over aortic area - aortic regurgitation
Role onto left and listen over mitral area - mitral stenosis

Question 6

What are some consequences of a stenosis valvular defect on the heart?

Answer 6

Hypertrophy - due to extra work of pressing against a faulty valve

Question 7

What are the consequences of a regurgitation valvular defect?

Answer 7

Dilation of the heart chamber - blood flows back in - think stretches the chamber.

Question 8

What is a mitral stenosis?
What does it sound like?

Answer 8

Narrowing of the mitral valve - struggle/reduce for blood flow between LA and LV
Sounds - mid diastolic (as when blood moves), rumbling (blood complaining), low pitched (low velocity blood flow) murmum with an opening click
Loud S1 - due to force of shutting faulty valve
Crescendo descrescendo murmur

S1!!!!!! S drrrrrrr

Question 9

What are the common causes of mitral stenosis?

Answer 9

Infective endocarditis
Rheumatic heart disease
Mitral annular calcification (age related)

Question 10

What other clinical signs can mitral stenosis present with?

Answer 10

Palpate tapping apex beat - due to large S1
Malar flush - traffic jam into pulmonary system, inc CO2 retention causing vasodilation - flushing face
Atrial fibrillation - left atrial strain.

Question 11

What is mitral regurgitation?

Answer 11

Incompetent mitral valve - backflow between LV and LA during systole
Pan-systolic, high-pitched whistling
Whooo
occurs throughout systole - so may loose distinct S1 and S2.
Radiates to the axilla.

Question 12

What is a potential complication of mitral regurg?

Answer 12

key sign is breathlessness
Reduced ventricular ejection fraction
Backlog of blood in LV
Can lead to heart failure as reduced cardiac output.

Question 13

What are some causes of mitral regurgitation?

Answer 13

Idiopathic weakening with age
Ischemic heart disease - MI
Valve rupture
Associated with atrial fibrillation
Infective endocarditis

Question 14

What is aortic stenosis?
What does it sound like?

Answer 14

Most common - narrowing of aortic valve - difficult to push from LV to aorta
Sound - ejection systolic, high-pitched , crescendo decsrendo murmur - due to changes in speed of blood flow
Loudest on expiration over aortic area.

S1 <> S2
Burr Dub
Radiates to carotids

Question 15

What other signs/symptoms can indicate aortic stenosis outside of heart sounds?

Answer 15

Radiates to carotids
Slow rising pulse
Narrow pulse pressure (norm 40mmHg)
Exertional syncope - lightheaded and faint.

Features of Aortic Stenosis = Failure (HF), angina, syncope

Question 16

What is the cause of aortic stenosis?

Answer 16

Idiopathic age related calcification
Rheumatic heart disease e/g post strep infection
Congenital bicuspid valve (rather than tricuspid)

Question 17

What is aortic regurgitation?
What does it sound like?

Answer 17

Incompetent aortic valve - allows backflow of blood from aorta to ventricle
Early Diastolic, soft murmur, decresendo
Loudest over the lest sternal edge
Lub Tarrr - subtle

Question 18

What is another sign aside from heart sounds that indicates aortic regurgitation?

Answer 18

Collapsing pulse

Question 19

What are the common causes of aortic regurgitation?

Answer 19

Idiopathic age-related weakening
Connective tissue disorders.

Question 20

What conservative management should be used for aortic stenosis?

Answer 20

Lifestyle modifications for risk factors for IHD
aka smoking cessation, increase mobility, well controlled diabetes etc

Question 21

What medical management can be used for aortic stenosis?

Answer 21

If experience symptoms of heart failure:
Digoxin
Diuretics
ACEi
Statins should not be prescribed to slow the process of AS.

Question 22

What surgical management can be used for aortic stenosis?

Answer 22

Aortic valve replacement
TAVI - transcatheter aortic valve implantation

Question 23

What conservative management should be used for mitral regurgitation?

Answer 23

Serial testing (ECHO) to monitor LV function - when LVEF ,60% then candidate for surgery

Question 24

What is the medical management for mitral regurgitation?

Answer 24

Acute MR:
Nitrates - reducce afterload, reduce LV work, more efficient ejection
Diuretics - as above
Sodium nitroprusside - as above
Positive ionotropic agents - inc contractility, more effective ejection
Intra-aortic balloon pump

Chronic MR causing HF - ACEi B-blockers, spironolactone for symptomatic relief.

Question 25

What surgical management can be used for mitral regurgitation?

Answer 25

MR repair

Question 26

What are the main valvular defects/murmurs to be aware of in Year 3?

Answer 26

Aortic stenosis Mitral regurgitation

Question 27

What is a pulmonary stenosis?

Answer 27

Narrowing of the pulmonary valve - RV to lungs Ejection systolic murmur loudest over the pulmonary area Radiates to left shoulder/left infraclavicular region

Question 28

What is pulmonary regurgitation?

Answer 28

Early decrescendo murmur Loudest over left sternal edge Usually asymptomatic

Question 29

What is tricuspid stenosis?

Answer 29

Mid-diastolic murmum (rarelt audible) Leads to peripheral oedema and ascites due to backlog of blood into RA then peripheral system

Question 30

What is tricuspid regurgitation?

Answer 30

Pansystolic murmur Loudest over tricuspid region Loudest on inspiration Can cause signs of RHF: RV heave, peripheral oedema, hepatomegaly, ascities

Question 31

What are some symptoms/sounds (not heart sounds) for mitral regurgitation?

Answer 31

Breathlessness usually on exertion Fatgiue Reduced exercise tolerance Palpitations Lower extremity oedema May develop signs and symptoms of heart failure.

Question 32

What is the typical management of mitral stenosis?

Answer 32

If asymptomatic regular echo to manage medical - diuretics for symptomatic relief, manage Af if occurs Surgical - balloon valvuloplasty, percutneouse mitral valvotomy, open valve repair/replacement

Question 33

What investigations tend to be done for mitral valve disease?

Answer 33

ECG CXR Auscultation of heart sounds

Question 34

What is the underlying pathophysiology of mitral stenosis?

Answer 34

Thickend and calcifcied vale reduced blood flow from LA to LV during diastole. Reduced EDV in LV and increased volume in LA Leads to atrial dilation (predispose to AF), pulmonary congestion and ultimately right heart failure.

Question 35

What symptoms can occur alongside mitral stenosis?

Answer 35

Gradual exertional dysponea and reduced exercise tolerance Haemoptysis - due to increased pulmonary pressures and vascular congestion Palpitations - AF Chest pain - pulmonary HTN or right ventricular hypertrophy Hoarseness - enlarged L atrium can compress the recurrent laryngeal nerve Perioheral odema/abdo discomfort due to RSHF

Question 36

What investigations should be done for mitral stenosis?

Answer 36

ECG -p-mitrale (broad and nothced), RV hypertrophy, Right axis deviation, AF CXR - pulmonary oedema and left atrial enlargement Echo - stenosis and impaired filling Cardiac MRI - valvular vegetations

Question 37

What is the relevant pathophysiology of mitral regurgitation?

Answer 37

The mitral valve fails to close sufficiently meaning blood flows between the LV and LA during systole. Increased blood volume in LA leading to enlargement of LA and volume overload in Left heart leading to LV failure.

Question 38

What investigations should be done for a mitral regurgitation?

Answer 38

ECG = p-mitral, LVH, left axis deviation Bloods - NT-pro-BNP Imaging - CXR (pulmonary oedema and left atrial enlargement) Definifitve = echo

Question 39

What is the common treatment for aortic regurgitation?

Answer 39

Medical - beta blockers - lower systolic blood pressure Surgical transcatheter valve replacement if symptomatic, LVEF <50%, dilated heart chambers or ascending aorta.