*Valvular heart disease

Question 1

What type of symptoms are characteristic of valvular heart disease?

Answer 1

Exertional symptoms (patients with even severe valve disease don’t tend to experience symptoms at rest)

Question 2

What 4 features of breathlessness suggest cardiac breathlessness?

Answer 2

Related to activity (usually)
Often associated with ankle swelling
Orthopnoea
Paroxysmal nocturnal dyspnoea

Question 3

What is a classification system used to assess the extent of heart failure’s affect on a patients functional status?

Answer 3

New York Heart Association Functional classification

Question 4

Classes of New York Heart Association Functional classification?

Answer 4

Class I = no limitation
Class II = Slight limitation of ordinary activity
Class III = marked limitation of less than ordinary activity
Class IV = severe limitation of minimal activity or at rest

Question 5

Signs of right heart failure? (3)

Answer 5

Raised JVP
Pitting oedema (ankles and sacrum (more severe heart failure if in sacrum also))
Hepatic congestion

Question 6

Does right heart failure have a peripheral or central effect?

Answer 6

Peripheral

Question 7

Tapping apex beat?

Answer 7

Mitral stenosis (thrusting displaced palpable (but more so than normal) apex beat

Question 8

Apex beat in left ventricular dilation?

Answer 8

Displaced and diffuse (volume overload)

Question 9

Apex beat in left ventricular hypertrophy?

Answer 9

Displaced and heaving (pressure overload)

Question 10

What causes a parasternal heave over the left parasternal edge?

Answer 10

Right ventricular hypertrophy (due to right ventricular overload e.g. cor pulmonale/ pulmonary hypertension)

Question 11

What is a cardiac murmur?

Answer 11

Audible turbulence of blood flow (can be innocent or pathological)

Question 12

How to describe murmurs? (6)

Answer 12

Timing? - systolic or diastolic
Type of murmur? - ejection systolic or pan systolic/ early or mid diastolic
Where is it loudest?
Where does it radiate to?
What grade of murmur?
Does respiration influence it?

Question 13

What murmur radiates to the carotid?

Answer 13

Aortic stenosis

Question 14

What murmur radiates to the axilla?

Answer 14

Mitral regurgitation

Question 15

What causes the first heart sound?

Answer 15

Mitral and tricuspid valve closing (start of systole)

Question 16

What causes the second heart sound?

Answer 16

Aortic and pulmonary valves closing (start of diastole)

Question 17

Pansystolic murmur?

Answer 17

Mitral regurgitation

Question 18

Ejection systolic murmur?

Answer 18

Aortic stenosis

Question 19

Early diastolic murmur?

Answer 19

Aortic regurgitation

Question 20

Mid diastolic murmur?

Answer 20

Mitral stenosis

Question 21

Grading of murmurs?

Answer 21

I - very quiet (dispute of whether it is there or not)
II - quiet - easy to hear
III - loud
IV - loud with a thrill
V - very loud with a thrill
VI - loud - audible without a stethoscope

Question 22

Are right or left sided murmurs louder with inspiration?

Answer 22

Right-sided murmurs

Question 23

What are the 12 common murmurs?

Answer 23

2nd sound splitting
Third sound
Fourth sound
Systolic clicks
*Innocent murmur
*Mitral regurgitation
*Aortic stenosis
*Aortic regurgitation
*Mitral stenosis
Continuous murmur
Tricuspid regurgitation
Pericardial rub

Question 24

What is the most common cause of a continuous heart murmur?

Answer 24

Septal defect

Question 25

What is another name for an innocent murmur?

Answer 25

Functional murmur

Question 26

What are 2 features of an innocent murmur?

Answer 26

Soft (less than 3/6 severity) | Position dependent

Question 27

Are innocent murmurs systolic or diastolic?

Answer 27

Always systolic (diastolic murmurs are always pathological)

Question 28

What are the 3 types of valvular heart disease and what causes each?

Answer 28

Valve stenosis - valves which do not open properly Valve regurgitation - valves which do not close properly Mixed valve disease - valves which neither open properly nor close properly

Question 29

What type of symptoms will left heart failure cause?

Answer 29

Pulmonary symptoms and signs

Question 30

What is the most common valve lesion?

Answer 30

Aortic stenosis

Question 31

Causes of aortic stenosis?

Answer 31

Degenerative (age related - most commonly (calcification of the aortic valve)) Congenital (e.g. bicuspid valve) Rheumatic

Question 32

Symptoms of aortic stenosis? (3)

Answer 32

Breathlessness Chest pain Dizziness/ syncope

Question 33

Signs of aortic stenosis? (4)

Answer 33

Low volume pulse forceful displaced apex ejection systolic murmur that can radiate to the carotids Slow rising pulse

Question 34

What change can aortic stenosis eventually lead to on an ECG?

Answer 34

Large QRS complexes due to left ventricular hypertrophy

Question 35

Treatment of aortic stenosis?

Answer 35

Only treated if symptomatic | Treated with a valve replacement (3 different options)

Question 36

Types of valve replacements possible for aortic stenosis?

Answer 36

Conventional valve replacement Trans catheter aortic valve implantation (TAVI) - used if patients have co-morbidities Balloon aortic valvotomy (BAV) - used for patients who are very frail

Question 37

2 types of prosthetic heart valves?

Answer 37

Mechanical | Bio-prostehtic

Question 38

Advantage and disadvantage of a mechanical heart valve?

Answer 38

Advantage = longevity Disadvantage = require warfare to prevent valvular thrombosis (tends to be given to younger patients)

Question 39

Advantage and disadvantage of bio-prosthetic heart valve?

Answer 39

No warfarin | Tends to cause problems after about 10 yeas and require replacement

Question 40

Comparison of aortic valve replacement and TAVI?

Answer 40

``` AVR = preferred, can do CABG at the same time and has long term better outcomes TAVI = preferred if the patient has co-orbidities that would make a general anaesthetic difficult ```

Question 41

Causes of mitral regurgitation?

Answer 41

Leaflet problem (e.g. prolapse, rheumatic, myxomatous (weakening), endocarditis) Chordae rupture (degenerative) - prolapse/ frail leaflet Papillary muscles rupture (ischaemic) Annular dilation (functional) (the mitral valve is very complex meaning there are lots of reasons for mitral regurgitation)

Question 42

Symptoms of mitral regurgitation?

Answer 42

If severe, symptoms of left heart failure Breathlessness Oedema Fatigue

Question 43

Signs of mitral regurgitation?

Answer 43

Displaced apex | Pansystolic murmur radiating to the axilla

Question 44

Treatment of mitral regurgitation?

Answer 44

Depends on the cause: Medication = diuretics and drug treatment for heart failure if present Surgical = repair for prolapse, replace for degenerative

Question 45

What causes mitral stenosis?

Answer 45

Rheumatic is the main cause | Rarely congenital

Question 46

Symptoms of mitral stenosis?

Answer 46

Breathlessness Fatigue Palpitations (AF - as the left atrium tried to force blood through the aurifice, the right atrium get bigger and therefore there is a higher chance of AF)

Question 47

Signs of mitral stenosis?

Answer 47

Malar flush Tapping apex beat Mid diastolic rumbling localised to the apex

Question 48

Treatment of mitral stenosis?

Answer 48

Medication = diuretics and treat AF Surgery = valve replacement Ballon valvuloplasty = fragile patients

Question 49

Causes of aortic regurgitation?

Answer 49

Leaflets (endocarditis, connective tissue diseases, rheumatic) Annulus (marfans, aortic dissection)

Question 50

Symptoms of aortic regurgitation?

Answer 50

Breathlessness

Question 51

Signs of aortic regurgitation? (3)

Answer 51

Collapsing pulse Displaced apex Early diastolic murmur left sternal edge

Question 52

What is another name for a collapsing pulse?

Answer 52

Water hammer pulse (blood gets forcefully pushed through and then sucked back slightly)

Question 53

What causes cardiomegaly in aortic regurgitation?

Answer 53

Large volume of blood in the left ventricle

Question 54

Treatment of aortic regurgitation?:

Answer 54

``` Medication = ACEI Surgery = valve replacement when symptoms and LV dilation ```