Valvular Heart Disease

Question 1

Recognize etiologies of valvular heart disease (VHD).

Answer 1

Most common arise from; degenerative (senile calcification)

• Myxomatous degeneration (MVP)
• Congenital (bicuspid aortic valve)

Question 2

Explain Grading Scale for murmurs

Answer 2

Barely audible
Faint, soft
Louder, easily heard
Very loud with palpable thrill (vibration)
Heard with stethoscope barely touching the chest with thrill
Can hear without stethoscope or can hear with stethoscope close to chest: palpable thrill

Question 3

list the systolic murmurs

Answer 3

MR (Mitral Regurgitation)
TR (Tricuspid Regurgitation)
AS (Aortic Stenosis)
PS (Pulmonic Stenosis)
VSD (Ventricular Septal Defect)
ASD (Atrial Septal Defect)

Question 4

list the diastolic murmurs

Answer 4

AI or AR (Aortic insufficiency or regurgitation
PI or PR (Pul insufficiency or regurgitation
MS (mitral stenosis)
TS (Tricuspid stenosis
Atrial Myxoma

Question 5

what are some causes of acute mitral regurgitation?

Answer 5

Acute
Ischemic papillary muscle dysfunction (CAD, MI, 2nd most common cause of MR)
Rupture chordal tendineae
Infective Endocarditis
Volume overload, inc. LA pressure, pul. Edema, RVF/LVF cardiogenic shock

Question 6

what are some causes of chronic mitral regurgitation?

Answer 6

Chronic
MVP (Mitral valve prolapse) most common
Myxomatous or degeneration or MAC (mitral annular calcification)

Question 7

what will you hear on PE in regards to mitral regurgitation?

Answer 7

PE

systolic murmur, blowing at apex, radiates into left axilla. Reduced S1 use diaphragm

Question 8

what will you hear on PE in regards to mitral regurgitation?

Answer 8

PE

systolic murmur, blowing at apex, radiates into left axilla. Reduced S1 use diaphragm

Question 9

What is Mitral Valve Prolapse (MVP)?

Answer 9

Mitral Valve Prolapse (MVP) one or both leaflets prolapse into left atrium
Female (7:1), redundant tissue with myxedematous degeneration
Asymptomatic to chest pain, SVT, PVCs, dyspnea, systolic murmur at apex, may have click/murmur increase with Valsalva and standing.
Murmur increase with dec vent volume and chamber size
Rx – reassure or if symptomatic give BB

Question 10

what will you hear on PE in regards to tricuspid regurgitation?

Answer 10

Blowing, systolic murmur, 4th ICS LSB: increase on inspiration (Carvallo sign)

Question 11

what will you hear on PE in regards to tricuspid regurgitation?

Answer 11

Blowing, systolic murmur, 4th ICS LSB: increase on inspiration (Carvallo sign)

Question 12

Prominent V wave in jugular venous pulse is associated with what murmur?

Answer 12

tricuspid regurgitation

Question 13

Prominent V wave in jugular venous pulse is associated with what murmur?

Answer 13

tricuspid regurgitation

Question 14

what is the most common etiology of aortic stenosis?

Answer 14

Etiology: degenerative calcification most common

Biscuspid - AoV, RHD

Question 15

What murmur results in pressure overload and LVH?

Answer 15

aortic stenosis

Pathology: PRESSURE OVERLOAD; LVH Sever AS, if AoV area < 1 sq. cm

Question 16

what will you hear on PE in regards to aortic stenosis?

Answer 16

systolic murmur, crescendo – decrescendo, harsh 2nd ICS, RSB, radiates into sternal notch/carotids
Diminished S2

Question 17

what will you hear on PE in regards to aortic stenosis?

Answer 17

systolic murmur, crescendo – decrescendo, harsh 2nd ICS, RSB, radiates into sternal notch/carotids
Diminished S2

Question 18

what is seen on an ECG in aortic stenosis?

Answer 18

ECG – LVH, strain pattern (down sloping of ST segment – T wave)

Question 19

What is a parvus pulse?
What is a tardus pulse?
What pathological condition is this associated with?

Answer 19

Pulses:
Parvus -weak/small
Tardus – slow rising, late
Pulsus tardus et parvus, also pulsus parvus et tardus, slow-rising pulse and anacrotic pulse, is weak (parvus), and late (tardus) relative to its expected characteristics. It is caused by a stiffened aortic valve that makes it progressively harder to open, thus requiring increased generation of blood pressure in the left ventricle. It is seen in aortic valve stenosis

Narrow pulse pressure (ex. 140/100)

Question 20

what will you hear on PE in regards to a BAV?

Answer 20

IE/systolic murmur/click, LSB or apex

Question 21

what will you hear on PE in regards to a BAV?

Answer 21

IE/systolic murmur/click, LSB or apex

Question 22

what will you hear on PE in regards to pulmonic stenosis?

Answer 22

Pulmonic Stenosis – congenital

Systolic murmur, crescendo – decrescendo, 2-3 ICS LSB, radiates to left shoulder – clavicle

Question 23

what conditions are associated with pulmonic stenosis?

Answer 23

May be associated with Tetralogy of Fallot: PS, VSD, RVH, overriding aorta

Question 24

what will you hear on PE in regards to VSD?

Answer 24

Ventricular Septal Defect – Holosystolic murmur, left lower sternal border with thrill. L to R shunt/murmur increases with handgrip.

Question 25

what will you hear on PE in regards to ASD?

Answer 25

Atrial Septal Defect (ASD) – L to R shunt. Systolic murmur, upper LSB with fixed splitting of S2

Question 26

what is the etiology of mitral stenosis?

Answer 26

Mitral Stenosis
Etiology: Rheumatic Heart Disease. Group A Streptococci.
Congenital, Mitral
Annular Calcification (MAC)
MVA (area) 1 – 1.5 cm2 = significant MS.
Leads to Pul HTN, RVF, LAE, A. fib.

Question 27

what are the symptoms of mitral stenosis?

Answer 27

Symptoms: Dyspnea (DOE), orthopnea, palpitations – arrhythmias (A.fib.), hoarseness (compression of left recurrent laryngeal nerve: Ortners Syndrome)

Question 28

what will you hear on PE in regards to mitral stenosis?

Answer 28

Phy Exam – Diastolic murmur, low pitch (use bell), rumbling at apex. Inc. S1 and S2 (P2) followed by opening snap.

Question 29

what is seen on an ECG in regards to mitral stenosis?

Answer 29

ECG – LAE if in sinus rhythm

A. fib., RVH, RAD if associated with pul HTN. Anticoagulated if in A.fib.

Question 30

What is the etiology, physical exam, and ECG associated with tricuspid stenosis?

Answer 30

Tricuspid Stenosis (TS)
Etiology- Rheumatic disease; associated with MS/more common in female
Phy Exam – Diastolic murmur LSB, increases on inspiration (Carvallo sign)
Prominent A wave (atrial contraction) in Jugular vein
ECG - RAE

Question 31

What is the etiology of acute and chronic aortic insufficiency?

Answer 31

Aortic Insufficiency (Regurgitation – AR)
Acute – Infective Endocarditis, aortic dissection, chest trauma
Chronic – calcific degeneration, BAV, dilated aortic root, Rheumatic

Question 32

VOLUME OVERLOAD; LVH, Left heart failure is due to?

Answer 32

aortic regurg

Question 33

What are the symptoms of acute and chronic aortic insufficiency?

Answer 33

Symptoms – depends on rapidity of onset — if acute – pulmonary edema from IE — if chronic – dyspnea, orthopnea, angina

Question 34

what is the physical exam associated with aortic regurgitation?

Answer 34

Physical exam
Diastolic decrescendo murmur. 3nd ICS, LSB; can mimic MS (Austin Flint) Soft S2 (A2).
Wide pulse pressure (ex. 130/50)

DeMusset sign – head bob with beats

Quincke’s sign – capillary nail pulsations

Traube sign – “pistol shot” (systolic and diastolic) sounds over femoral artery

Duroziez’s sign – diastolic murmur over femoral artery when compressed with bell of stethoscope

Rx = Dec. afterload to reduce regurgitation (ACEI or ARB)

Question 35

What is pulmonary insufficiency?

Answer 35

Pulmonary Insufficiency (Regurgitation – PR)
Diastolic, decrescendo murmur, 2nd ICS, LSB (Graham Steele)
Associated with Pul HTN;    S2 (P2)