Valvular heart disease

Question 1

what grade of murmurs is loud, and associated with a thrill

Answer 1

Grade 4/6

Question 2

function of echocardiography

Answer 2

• evaluate chamber size and valve abnormalities, including pressure gradients

Question 3

function of angiography

Answer 3

• provides detailed info preoperatively
• evaluate for CAD

Question 4

aortic stenosis

Answer 4

narrowing of aortic outflow tract

Question 5

aortic stenosis can occur at what 3 levels

Answer 5

• aortic valve: 75% of cases
• supravalvular: congenital or post-operative
• subvalvular: congenital or hypertrophic cardiomyopathy

Question 6

etiology of aortic stenosis below age 30

Answer 6

congential, unicuspid valve

Question 7

etiology of aortic stenosis age 30-65

Answer 7

• congenital bicuspid valve which becomes calcified and stenotic

Question 8

rheumatic valve disease account for what percentage of aortic stenosis between ages 30-70

Answer 8

6-27%

Question 9

etiology of aortic stenosis over age 65

Answer 9

degeneration of sclerosis of valve

Question 10

when does mortality become significant in patients with aortic stenosis

Answer 10

• after symptoms develop
• average survival without valve replacement is 2-3 years with a high risk of sudden death

Question 11

early symptoms of aortic stenosis

Answer 11

• dyspnea on exertion
• fatigue
• decreased exercise tolerance

Question 12

later symptoms of aortic stenosis

Answer 12

• dyspnea with normal activity
• angina
• syncope
• heart failure

Question 13

aortic stenosis is associated with what murmur? where would you hear the murmur

Answer 13

• systolic ejection murmur
  
  • high pressure to high pressure
• 2nd RICS or apex

Question 14

what type of pulse pressure indicates severe aortic stenosis disease

Answer 14

small pulse pressure

Question 15

CXR findings of aortic stenosis

Answer 15

• LVH
• calcification may be seen in valve

Question 16

management of mild asymptomatic aortic stenosis

Answer 16

• follow, educate regarding sxs

Question 17

management of moderate asymptomatic aortic stenosis

Answer 17

• annual ECG, echo, cxr

Question 18

management of severe asymptomatic aortic stenosis

Answer 18

• cardiolgoy evaluation and f/u

Question 19

patient education regarding aortic stenosis

Answer 19

• avoid strenuous physical activity
• avoid dehydration
• signs of worsening disease
  
  • exertional dizziness, dyspnea, palpitations

Question 20

what is the definitive technique for evaluating severity and site of stenosis

Answer 20

cardiac catheterization

Question 21

normal aortic valve area

Answer 21

3-4 cm²

Question 22

classification of severe aortic stenosis

Answer 22

severe < 1.0

Question 23

which patients with aortic stenosis are candidates for valve replacement

Answer 23

• severe, symptomatic aortic stenosis

Question 24

differentiate clinically between prosthetic valves and tissue valves (in aortic vavle replacement)

Answer 24

• prosthetic valves last longer but require lifelong anticoagulation
  
  • warfarin
• tissue valves do not last as long but do not require lifelong anticoagulation

Question 25

hypertrophic cardiomyopathy

Answer 25

* a form of subvalvular aortic stenosis * disease of cardiac muscle characterized by severe myocardial hypertroph, in the absense of a cause for secondary hypertrophy (HBP, AS) * familial, inherited in 60% of cases

Question 26

hypertrophic cardiomyopathy's murmur compared to AS

Answer 26

* murmur is similar except it is **louder if patient stands or valsalvas** (opposite of valvular AS)

Question 27

treatment for hypertrophic cardiomyopathy

Answer 27

* calcium channel blocker * beta blocker

Question 28

aortic regurgitation (insufficiency)

Answer 28

* leakage of blood back through aortic valve during diastole

Question 29

primary etiologies of aortic regurgitation (insufficiency)

Answer 29

* rheumatic valvular disease (29%) * bicuspid aortic valve (12%) * dilated aortic root (12%) * acutely dissecting aortic aneurysm

Question 30

acute causes of aortic regurgitation (insufficiency)

Answer 30

* aortic dissection * infective endocarditis

Question 31

treatment of acute aortic regurgitation (insufficiency)

Answer 31

urgent cardiology consult for medication and consideration of valve replacement

Question 32

clinical presentation * LV overload and gradual dilation and hypertrophy * patients may be asymptomatic for 20+ years, then develop only mild DOE * eventually develop signs of heart failure

Answer 32

chronic aortic regurgitation

Question 33

murmur associated with aortic regurgitation (insufficiency). where is it best heard

Answer 33

* high-pitched diastolic decrescendo murmur * aortic area and left sternal border

Question 34

austin flint murmur

Answer 34

* soft, low-pitched diastolic murmur at the apex which sounds like a diastolic mitral stenosis murmur * may be associated with aortic regurgitation (insufficiency)

Question 35

wide pulse pressure is seen in which condition

Answer 35

aortic regurgitation (insufficiency) due to increased systolic and decreased diastolic pressures -\> "water hammer" or "corrigan pulse"

Question 36

CXR findings of aortic regurgitation (insufficiency)

Answer 36

* normal if acute * LVH if chronic, possible CHF/pulmonary edema

Question 37

treatment of chronic aortic regurgitation (insufficiency)

Answer 37

* if asymptomatic, f/u q 6-12 months (ECG, echo, CXR) * vasodilators reduce regurgitant volume and increase EF * ACE inhibitors are most helpful * valve replacement is available if symptomatic

Question 38

mitral regurgitation

Answer 38

* leakage of blood from LV into left atrium * may develop due to abnormality of * valve leaflets * chordae tendinae * papillary muscles * valve annulus

Question 39

etiologies of mitral regurgitation

Answer 39

* papillary muscle necrosis secondary to ischemic heart disease * inherited * mitral valve prolapse * marfans * rheumatic heart disease (5-15% cases) * congenital

Question 40

causes of acute mitral regurgitation

Answer 40

* papillary muscle necrosis from ischemia * endocarditis * \*\*\*poorly tolerated and often required emergent surgery

Question 41

explain what happens in chronic mitral regurgitation

Answer 41

* LV adapts to larger blood volume by enlarging and increasing SV * heart may compensate for years with normal CO but eventually it is unable to keep up with demands and CHF develops * A-Fib frequently develops due to left atrial enlargement * pulmonary HTN and RVH may also develop

Question 42

what often develops with chronic mitral regurgitation

Answer 42

A-Fib due to left atrial enlargement

Question 43

murmur associated with mitral regurgitation. where is heard best

Answer 43

* high pitched, pansystolic murmur * loudest at apex * later stages, S3 develops (early passive rapid filling of the ventricles with blood from atria)

Question 44

CXR findings common in mitral regurgitation

Answer 44

* left atrial enlargement * LVH

Question 45

treatment of chronic mitral regurgitation

Answer 45

* afterload reduction: ACE inhibitors and vasodilators * sodium restriction and diuretics (Reduce preload) * anticoagulation for A-Fib * surgery: * repair valve vs valve replacement

Question 46

mitral valve prolapse

Answer 46

due to ballooning of mitral leaflets into the left atrium during systole

Question 47

heart sounds associated with mitral valve prolapse

Answer 47

* mid-late systolic clicks * mitral regurgitation may also occur with late systolic murmur

Question 48

prevelance of mitral valve prolapse

Answer 48

* 5% of general population * usually benign

Question 49

diagnostic study for mitral valve prolapse

Answer 49

echocardiogram

Question 50

management of mitral valve prolapse associated with palpitations or arrhythmias

Answer 50

* B-blockers may be helpful * if symptomatic or worsening, follow as with other patients with MR

Question 51

pathophysiology of mitral stenosis

Answer 51

* narrowing of mitral valve * obstructs flow from LA to LV * increases LA pressure * increase pulmonary vascular pressure

Question 52

most common cause of mitral stenosis

Answer 52

rheumatic heart disease

Question 53

rheumatic heart disease

Answer 53

* spectrum including acute rheumatic fever, pericarditis, myocarditis, and valvular lesions * delayed sequela following group A steptococcus pharyngitis

Question 54

signs and symptoms expected in mitral stenosis

Answer 54

* usually due to pulmonary congestion * dyspnea, orthopnea, PND, fatigue * pulmonary edema with hemoptysis * pulmonary HTN -\> RHF * A-Fib in 40-50% * 20% have systemic emboli, usually to brain

Question 55

40-50% of patients with mitral stenosis have what conditions

Answer 55

AFIB

Question 56

murmur associated with mitral stenosis. where is it best heard

Answer 56

* **Loud S1** with **opening snap** * **mid diastolic rumbling murmur** * apex with patient in left lateral decubitus position, with bell

Question 57

CXR findings with mitral stenosis

Answer 57

* Left atrial enlargement * later, pulmonary congestion and RVH * kerley B lines

Question 58

management of mitral stenosis

Answer 58

* mild symptoms: diuretics and sodium restriction * anticoags for A-Fib * valve sx for progressive symptoms

Question 59

who needs antibiotic prophylaxis

Answer 59

* prosthetic cardiac valve or prosthetic material used for cardiac valve repair * previous infectious endocarditis