VHD & Murmurs highlights pt 1

Question 1

What heart sound is Associated with HTN – stiff non-compliant LV from hypertrophy?

Answer 1

S4

Question 2

List 3 main characteristics of fourth heart sounds

Answer 2

1) Late diastole
2) Low frequency – bell at apex with patient in left latera position
3) When palpable double impulse at cardiac apex = stiff non-compliant left ventricle

Question 3

List the 3 states in which S3 may occur

Answer 3

1) Young healthy patient
2) HF
3) Volume overload states

Question 4

List 3 main characteristics of S3

Answer 4

1) Early diastole
2) Low pitched, bell @ apex with patient in left lateral position
3) Ventricular gallop

Question 5

Turbulence across normal Aortic or Pulmonary valve is characteristic of what?

Answer 5

Innocent murmur

Question 6

Differentiate between innocent murmur, AS (aortic stenosis), and mitral regurg

Answer 6

1) Early peaking systolic murmur – Innocent murmur
2) Late peaking systolic murmur – AS
3) Holosystolic murmur - MR

Question 7

Describe Mac’s VHD quickie overview

Answer 7

1) Valvular heart disease is a form of cardiomyopathy resulting in HF
2) Echo is the gold standard for diagnosis and monitoring
3) Generally, patients with stenotic valvular lesions can be monitored clinically until symptomatic.
4) In contrast, patients with regurgitant valvular lesions require careful Echo monitoring for LV function and may require surgery even if no symptoms
5) Aside from antibiotics, very little Rx therapy available for VHD
6) Surgery is the Tx for most symptomatic lesions or lesions causing LV dysfunction even in the absence of symptoms

Question 8

Generally, patients with ___________ valvular lesions can be monitored clinically until symptomatic.

Answer 8

stenotic

Question 9

______________ is the Tx for most symptomatic lesions or lesions causing LV dysfunction even in the absence of symptoms

Answer 9

Surgery

Question 10

______ is most common VHD, followed by AS and AR

(important)

Answer 10

MR

Question 11

If VHD suspected, _______ is the first step in evaluation

Answer 11

TTE

Question 12

Monitoring in ______________ patients with VHD (especially regurgitant valvular lesions) is important

Answer 12

asymptomatic

Question 13

What is the most common etiology of MR?

Answer 13

Degenerative disease

Question 14

VHD:
1) What in the medical history helps determine timing of intervention?
2) What 2 valves are most affected?

Answer 14

1) + symptoms (HF symptoms)
2) Aortic and mitral

Question 15

Stenotic lesions obstruct forward flow
Regurgitation permits backward flow

What can both lead to?

Answer 15

HF

Question 16

Between MS, AS, and AR, which needs the most intervention?

Answer 16

AS results in greatest need for intervention

Question 17

List the risk factors for VHD

Answer 17

1) HTN
2) Infective Endocarditis
3) RHD
4) SLE
5) Primary antiphospholipid syndrome
6) Ankylosing Spondylosis

Question 18

1) Liebman-Sacks vegetations can be caused by what?
2) What is this root condition assoc. with?

Answer 18

1) SLE
2) Embolic stroke

Question 19

VHD risk factors:
1) Systemic arterial and venous thrombosis is defined as what?
2) Define Ankylosing Spondylosis

Answer 19

1) Primary antiphospholipid syndrome
2) Aortic root disease leading to dilation and AR and mitral valve sclerosis

Question 20

What is the most common etiology of VHD?

Answer 20

Degenerative disease

Question 21

RHD is most closely linked to what?

Answer 21

MS

Question 22

What is significant in Dx of VHD?
What is focused?

Answer 22

1) Hx
2) PE

Question 23

Hx: Management of VHD depends on development of LV dysfunction and _______________

Answer 23

SYMPTOMS

Question 24

What is defined as aortic root disease leading to dilation and AR and mitral valve sclerosis?

Answer 24

Ankylosing Spondylosis

Question 25

Delayed and/or diminished carotid upstroke is a Sx of what?

Answer 25

Severe AS

Question 26

Describe the systolic murmur of AS; where can you hear it and what does it sound like?

Answer 26

1) right 2nd ICS 2) Harsh crescendo-decrescendo systolic ejection murmur

Question 27

What 3 things should you understand the physiology of with AS?

Answer 27

1) Valsalva/standing from squat position (decreased preload to heart) 2) Squatting/passive leg raise/ deep inspiration (increased preload to heart 3) Hand grip (increased afterload to left heart) so in effect decreased flows velocity thru AV, decreases intensity of AS murmur

Question 28

What is the definitive Dx/ monitoring for AS?

Answer 28

TTE 1) Calcified AV, dilated aortic valve root, LVH 2) Can non-invasively assess severity

Question 29

AS echocardiogram - staging based on what 3 things?

Answer 29

1) Valve hemodynamics 2) Valve anatomic changes 3) Hemodynamic affects on LV

Question 30

The evaluation of a patient with VHD, history and physical examination findings should be correlated with the results of what?

Answer 30

Noninvasive testing (TTE)

Question 31

Treatment of severe aortic stenosis with either a transcatheter or surgical valve prosthesis should be based primarily on what?

Answer 31

Symptoms &/or LV function

Question 32

VHD progression: 1) Who is in group C2? 2) What abt D?

Answer 32

1) At risk and asymptomatic patients are monitored, may warrant treatment if LV dysfunction evident – C2 Symptomatic patients need intervention – D

Question 33

Severe AS Defined by what? (important)

Answer 33

1) Valve hemodynamics -a peak transvalvular velocity or aortic Vmax > 4 m/s or -aortic mean gradient > 40 mmHg or 2) Valve (open) area of <1.0 cm2

Question 34

Aortic stenosis: What If symptomatic HFrEF (decompensation)?

Answer 34

intervention

Question 35

AS with HTN: What should you be careful with according to GDMT? Why?

Answer 35

1) Diuretics – reduced preload may worsen CO 2) -blockers - reduce contractility 3) Vasodilators - reduce afterload and coronary artery perfusion

Question 36

_________ for AS are not indicated, but may be indicated for other indications

Answer 36

Statins

Question 37

_________________ valves are recommended for patients of all ages who are unable to undergo long-term anticoagulation – i.e., less thrombogenic

Answer 37

Bioprosthetic

Question 38

________________ valves are generally preferred for younger patients (<60 y/o) due to greater longevity and reduce need for repeat surgery… but more thrombogenic

Answer 38

Mechanical

Question 39

Differentiate between the two main presentations of MR

Answer 39

1) Acute - Acute symptoms 2) Chronic – Chronic progressive symptoms

Question 40

1) Where is MR murmur best heard? 2) What is one important place it may radiate?

Answer 40

1) Heard best at apex, +/- thrill (4th ICS, MCL) 2) Left axilla

Question 41

How is MR diagnosed? Explain

Answer 41

TTE: 1) MR 2) Enlarged LV, LA 3) LV dilation due to volume overload

Question 42

Left atrial enlargement is a common cause of ____________, which is why it may be seen with MR

Answer 42

A fib

Question 43

List 2 different etiologies of mitral valve prolapse (MVP)

Answer 43

1) Ehler Danlos syndrome 2) Marfan syndrome

Question 44

Apical Mid-late systolic click is characteristic of what?

Answer 44

MVP murmur

Question 45

What confirms the Dx of MVP?

Answer 45

TTE confirms

Question 46

True or false: AS and MS are both systolic murmurs but have different effects on hemodynamics

Answer 46

True

Question 47

Differentiate between primary and secondary etiologies of tricuspid regurg

Answer 47

1) **Primary** Ebstein anomaly Infective endocarditis 2) **Secondary** Left HF RV dilation ACS PH

Question 48

What are the 2 primary etiologies of tricuspid regurg?

Answer 48

1) Ebstein anomaly 2) Infective endocarditis