VHD and murmurs pt 2

Question 1

Give 2 examples of diastolic murmurs

Answer 1

Aortic regurgitation
Mitral stenosis

Question 2

All ___________ murmurs need evaluation

Answer 2

diastolic

Question 3

Give 3 acute examples of aortic regurg

Answer 3

Endocarditis
Aortic dissection
trauma

Question 4

Give some chronic examples of aortic regurg

Answer 4

Rheumatic heart disease
Congenital bicuspid valve
Prior endocarditis
Aortic root dilation
Calcific degenerative valve

Question 5

Describe the pathogenesis of aortic regurg

Answer 5

Aortic valve leaflets unable to close
Retrograde flow during diastole
Increased LV volume
LV enlargement – dilation and hypertrophy
Heart failure

Question 6

Is AR always symptomatic?

Answer 6

May be symptomatic

Question 7

How does acute AR present?

Answer 7

Pulmonary edema, severe dyspnea, acute HF

Question 8

Describe chronic onset AR presentation

Answer 8

DOE, fatigue, palpitations, orthopnea, paroxysmal nocturnal dyspnea
h/o AS, HTN, bicuspid AV, Marfan Syndrome

Question 9

Name a sign of aortic regurg

Answer 9

widened pulse pressure

Question 10

Define each of the following examples of widened pulse pressure:
1) Corrigan pulse
2) Quincke pulse
3) De Musset sign
4) Mueller sign

(know these)

Answer 10

1) Corrigan pulse = “water hammer pulse”
2) Quincke pulse = visualization of pulse over the nail beds during light pressure to distal nail bed
3) De Musset sign = rhythmic bobbing of the head in sync with the heartbeat
4) Mueller sign – pulsation or bobbing of the uvula

Question 11

Describe the murmur with AR and where it’s heard best

Answer 11

High pitched and blowing decrescendo diastolic murmur
Heard at LSB 2-4th ICS
Heard best - At Erb’s point – 3rd ICS, sitting up and leaning forward, during exhalation

Question 12

Austin-Flint murmur may be appreciated with AR; describe this murmur

Answer 12

1) Mid diastolic rumble murmur heard best at apex
-Caused by AR jet turbulent flow hitting anterior leaflet of 2) MV resulting in premature closure resembling & mistaken for mitral stenosis
3) Sign of significant AR

Question 13

Describe the murmurs affecting the AR murmr

Answer 13

Afterload dependent
Increased with squatting and handgrip
Decreased with standing

Question 14

What should you do for asymptomatic AR murmurs?

Answer 14

Afterload reduction
1) GDMT for HTN … ACEi or ARB, CCB, diuretics, salt restriction
2) Management of HF if present

Question 15

Describe symptomatic AR management

Answer 15

Acute AR – emergent AV replacement
Referral to cardio team for surgical intervention

Question 16

Describe the pathogenesis of mitral stenosis

Answer 16

1) Cross reaction between Strep Ag and mitral valve tissue
2) Scarring and narrowing of valve opening (forward flow murmur)
3) LA enlargement, pulmonary congestion and RV failure secondary to PH type 2

Question 17

List 3 causes of mitral stenosis

Answer 17

Strep pharyngitis and rheumatic heart disease
MV calcific degeneration
Infective endocarditis

Question 18

List the symptoms of MS

Answer 18

DOE, orthopnea
Cough, hemoptysis
Palpitations, chest pain
Dysphagia

Question 19

MS may cause _____________________ due to enlarged LA

Answer 19

Atrial fibrillation

Question 20

What may be seen on an MS exam?

Answer 20

S1 may be palpable over apex
Pulmonary congestion – rales may be noted
Diastolic murmur

Question 21

Describe the murmur with MS

Answer 21

Heard best at apex with patient lying in left lateral recumbency
Opening snap followed by low pitched rumbling diastolic murmur just after S2 – similar timing as S3
MV opens and suddenly stops due to stenosis

Question 22

List 3 maneuvers that can affect MS murmurs

Answer 22

Pre-load dependent
Squatting increases intensity of murmur
Valsalva and standing decrease intensity

Question 23

Describe what you may see on an EKG with MS

Answer 23

May show LAE (P mitrale)
LAE increases risk of A. Fib
LAE may result in dysphagia – esophagus runs posterior to LA in mediastinum
PH, type 2 may lead to RVH and HF – associated signs of right HF

Question 24

Describe TTE with MS

Answer 24

may need TEE to visualize the LA well
MV thickening
Enlarged LA

Question 25

Describe the treatments for MS & when to refer

Answer 25

1) Early referral to cardio team 2) Unlike other valve disease, intervention is recommended earlier, prior to symptoms onset -Antihypertensives – diuretics, BB, CCB -Anticoagulation -Mild to moderate: Balloon valvuloplasty -Severe: MV replacement performed when valve area is < 1.5 cm squared

Question 26

Differentiate MS and AR. Which is preload dependent and which is afterload dependent?

Answer 26

1) MS: loud opening snap after S2, low pitched, rumbling, -apex with patient in LL position Preload dependent murmur 2) AR: begins at S2, blowing, high pitched, left 3rd or 4th ICS with patient leaning forward -Afterload dependent murmur

Question 27

Pregnancy causes increased HR, SV, CO. What should you do as a result?

Answer 27

Preconception evaluation prior to pregnancy – this rarely happens Some beneficial HF drugs must be avoided….??

Question 28

Regurgitant lesions ___________ tolerated than stenotic lesions in pregnancy

Answer 28

better

Question 29

Describe when you should treat VHDs and pregnancy

Answer 29

Severe MS or AS – best to treat prior to conception Moderate MS – heart rate control, balloon commissurotomy Reproductive age with significant AS = bicuspid valve Valve repair….balloon for temporizing

Question 30

Who manages VHDs in pregnancy?

Answer 30

Low risk managed by OB/FP + cardiology consult Higher risk & prosthetic valves managed by special clinic

Question 31

Describe mechanical prosthetic valves

Answer 31

Lifelong anticoagulation Warfarin Higher INR target ~2.5-3.5 teratogenic + ASA low dose Valves last longer Antibiotic prophylaxis before some surgical or dental procedures to prevent endocarditis (SBE prophy)

Question 32

Describe bioprosthetic mechanical valves

Answer 32

Anticoagulation ~ 3 months Fewer bleeding complications Low dose ASA for Aortic or mitral valves Less durable Repeat procedures = morbidity and mortality Antibiotic prophylaxis before some surgical or dental procedures to prevent endocarditis

Question 33

List some Additional Risk Factors for Thromboembolism

Answer 33

A. Fib Previous Thromboembolism LV dysfunction (systolic dysfunction) Hypercoagulation

Question 34

Describe sports and anticoags

Answer 34

1) Abstain from contact sports 2) Otherwise, no other restrictions from recreational activity 3) Competitive sports: Sports classified as high dynamic or high static demands are NOT recommended

Question 35

Describe PHV and Thromboembolism

Answer 35

Incidence ~ 6% per year with mechanical, rare with bioprosthetic heart valve Highest risk first 3 months post-op Most TE events related to subtherapeutic dosing

Question 36

Describe prosthetic heart valves and dental procedures

Answer 36

In theory, patients with prosthetic heart valves have increased risk of Infective endocarditis (IE) with dental procedures…even simple dental cleaning…precise risk unknown Best available data indicates: Prosthetic heart valve confers ~ 50X risk of IE over general population Development of IE within first 60-90 days post valve replacement = higher mortality rate Antimicrobial prophy recommended with single dose of 2 gm amoxicillin or suitable alternative (Sanford Guide) 1 hour prior to dental procedures More to follow in IE lecture