Valvular Heart Disease Flashcards by Courtney Birkett

What is seen in HCM that is not in aortic stenosis?

Aortic valve not calcified
Similar murmur but louder if pts stands or valsalvas (decrease venous return)
Similar ejections sounds and sxs

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Etiologies of aortic regurgitation

Rheumatic valvular disease (most), bicuspid aortic valve, dilated aortic root, bacterial endocarditis, senile degeneration, RA, Marfans, Ehlers-Danlos

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What is an Austin Flint murmur?

Soft, low pitched diastolic murmur at the apex that sounds like a mitral stenosis murmur

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Management of acute mitral regurgitation

Urgent stabilization (IV nitroprusside) and prep for surgery

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Describe the murmur of aortic stenosis

Systolic ejection murmur
Grade 3-4/6
Crescendo-decrescendo, blowing
Max intensity at 2nd RICS or apex
Radiates along carotids into neck

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Management of mitral valve prolapse

Mostly just reassure pt because it is mild (lifestyle changes)
BBs for palpitations
Treat concurrent MR if have

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Etiology of aortic stenosis 30-65

Congenital bicuspid valve which becomes calcified and stenotic (see about half calcified by age 50, can all see rheumatic valve disease)

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Management of acute aortic regurgitation

Urgent cardiology consult for meds and maybe valve replacement

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Murmur seen in mitral stenosis

Loud S1 with opening snap (early diastolic sound of forcing the valve open) followed by a mid diastolic rumbling murmur
Best heart at apex in left lateral decubitus with bell

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Other manifestations of mitral valve prolapse

Palpitations, DOE, dizziness/syncope, anxiety disorders, numbness/tingling, skeletal abnormalities, abnormal ECGs

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When do you start thinking about surgery with regards to valve area in aortic stenosis?

<1 cm2 (normal is 3-4)

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How does mitral regurgitation happen?

Abnormality to any part of apparatus (leaflets, chordae tendinae, papillary muscles, valve annulus)

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Most common symptom of mitral valve prolapse

Atypical or non-anginal chest pain

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Management of chronic aortic regurgitation

Asymptomatic and mild: just follow
Vasodilators reduce regurgitant volume and increase EF (ACE-i most helpful) - delay need for replacement
Avoid isometric exercises
Repair when symptomatic/severe or asymptomatic pts with EF<50 at rest

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Murmur of aortic regurgitation

High pitched diastolic decrescendo murmur heard best at aortic area and left sternal border (where left ventricle is)

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General sxs of all valvular diseases

Fatigue, dyspnea/orthopnea/PND, angina, syncope, palpitations

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Etiologies of mitral regurgitation

Papillary muscle necrosis secondary to ischemic heart disease
Inherited
Rheumatic heart disease
Acquired
Idiopathic
Congenital maldevelopment

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Surgical options for chronic mitral regurgitation

Valvuloplasty to repair or valve replacement

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Sxs of mitral stenosis

Usually due to the pulmonary congestion

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Sxs of aortic stenosis

Early: DOE, fatigue, decreased exercise tolerance
Later: dyspnea with normal activity and triad of angina, syncope and heart failure

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What events can precipitate the sxs of mitral stenosis?

Sudden exertion, excitement, fever, severe anemia, tachycardia, intercourse, pregnancy, thyrotoxicosis, a fib

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Describe the murmur of mitral regurgitation

High pitched, pan systolic murmur that is loudest at apex and radiates to axilla

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Management of mitral stenosis

Anticoagulate for a fib, hx of emboli or significant LAE on echo (Warfarin to 2-3)
Valve surgery for progressive sxs (valvuloplasty, mitral commisurotomy or prosthetic valve)

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What might you see on a CXR with aortic regurgitation?

Cardiac to thoracic width ratio > 50%

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Reasons for acute aortic regurgitation

Aortic dissection or infective endocarditis

How to manage symptomatic aortic stenosis

``` Cardiac catheterization (evaluate severity and site of stenosis) Maybe valve replacement (only when severe by echo and symptomatic) ```

What is mitral valve prolapse?

Ballooning of mitral leaflets into the left atrium during systole due to excess mitral valve tissue

Management of mild mitral stenosis

Diuretics and sodium restriction

How do you anticoagulate a pt with a valve replacement?

Prosthetic: last longer than require life long anticoagulation with warfarin (to INR of 2.5-3.5) Tissue: don't last as long but don't require lifelong anticoagulation

Other physical exam findings of aortic stenosis

Thrill in 2nd RICS or suprasternal notch Early systolic ejection click Narrow PP! (severe disease) May see S4 due to vigorous left atrial contraction

Correlation between sxs of aortic stenosis and mortality

Mortality is minimal in asymptomatic phase | After they develop, mortality is significant (2-3 yr survival without valve replacement)

When does rheumatic heart disease occur?

After GAS pharyngitis

Management of asymptomatic aortic stenosis

Mild: follow, educate about sxs Moderate: annual ECG/echo/CXR Moderate-severe: cardio eval and close follow up

3 classifications of aortic stenosis

Aortic valve (75%) Supravalvular (congenital or post op) Subvalvular (congenital or HCM) *may cause same sxs at any levels

What findings might be seen late in the disease?

Loud P2 and RV heave (right heart failure)

Management for acute aortic regurgitation

Urgent: stabilize (diuretics or vasodilators), surgery is usually necessary within 24 hrs of diagnosis

Tricuspid and pulmonic valve disorders

Usually congenital anomalies in infancy and childhood Adults: rheumatic scarring or connective tissue disease Tx: sodium restriction, diuretics, surgery

What can develop due to LAE of mitral regurgitation?

A fib (may later see pulmonary HTN and RVH)

Correlation between mitral stenosis and a fib

40-50% pts with MS will have a fib (might also have systemic emboli)

What does chronic aortic regurgitation result from?

LV overload with gradual dilation and hypertrophy (why asymptomatic for a while and then start developing DOE)

What does a late peak of the murmur in aortic stenosis suggest?

Severe obstruction

Tx for HCM

CCBs or BBs

What valvular disorders will we see develop acutely?

The regurgitations

Most common cause of mitral stenosis

Rheumatic heart disease

Other physical findings of aortic regurgitation

``` Wide PP (water hammer or corrigan pulse) May also have harsh systolic ejection murmur (if have aortic stenosis too) Austin flint murmur ```

Reasons for acute mitral regurgitation

Papillary muscle necrosis/rupture from ischemia or endocarditis

HCM classified as aortic stenosis

Subvalvular

Diagnostic results of aortic stenosis

ECG: normal until severe, LVH overtime CXR: normal until late, maybe post-stenotic dilation of aorta, may see calcification Echo: immobile, calcified leaflets, LVH, aortic gradient and reduced valve area

Management of acute mitral regurgitation

It is poorly tolerate so pts are miserable and often need emergent surgery

Types of prosthetic aortic valves

Ball and cage (driven by pressure) | Tilting

Etiology of aortic stenosis under age 30

Congenitally stenotic or unicuspid valve

Acute aortic regurgitation

LV pressure rises rapidly Pulmonary edema or cardiogenic shock may develop rapidly (can't compensate for vol overload) Traumatic rupture of valve cusp is rare

Etiology of aortic stenosis over age 65

Degeneration and sclerosis of valve (accounts for most cases)

Medical management of chronic mitral regurgitation

Afterload reduction: ACE-i and vasodilators Preload reduction: sodium restriction and diuretics Digitalis Anticoagulation for a fib: warfarin to 2-3 No abx prophylaxis

What maneuvers change the aortic stenosis murmur?

Louder with squatting (because increase venous return and ventricular filling)

What happens between ARF and symptomatic mitral stenosis?

20 yrs Leaflets diffusely thicken because of fibrous tissue/calcium deposits Become immobilized and rigid so it narrows

Pt education for aortic stenosis

Avoid strenuous activity Avoid dehydration Signs of worsening disease (exertional dizziness, dyspnea, palpitations) *no abx prophylaxis

What does rheumatic heart disease encompass?

Acute rheumatic fever, pericarditis, myocarditis and valvular lesions

What do you hear on auscultation in mitral valve prolapse?

Mid-late systolic click often present

Who needs antibiotic prophylaxis?

Those with a prosthetic valve or previous infective endocarditis who have dental procedures or invasive procedures that might expose blood

Other physical exam findings for mitral regurgitation

S3 gallop at later stages With pulmonary HTN- S4 gallop, loud P2 and RV heave JVD, hepatomegaly, edema (RV failure)

Valvular Heart Disease Flashcards

(61 cards)