Common Valvular Heart Disease Flashcards Preview

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Flashcards in Common Valvular Heart Disease Deck (12)
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1
Q

What are the locations of each of the main valves in the heart?

A

Mitral - LA -> LV
Aortic - LV -> Aorta
Tricuspid - RA -> Rv
Pulmonary RV -> Lung

2
Q

What are the causes and what will you find on history/examination of Mitral regurgitation?

A
Causes:
Prolapsing mitral valve
Papillary muscle rupture post MI
Rheumatic Fever
Connective tissue disorders
Cardiomyopathy

Symptoms:
Asymptomatic
Regurgitation  LVH  Left heart failure

Risk Factors:
Prolapsing mitral valve

Differentials:
Left Heart Failure 
Aortic Valve Disease
Papillary muscle rupture post MI
Rheumatic Fever
Connective tissue disorders
Cardiomyopathy

Examination:
Chest:
Pan-Systolic murmur that radiates to Axilla
One constant sound with no gap between S1/2
“Burrrrr”
Displaced apex best - volume overload
Palpable thrill

3
Q

What are the causes and what will you find on history/examination of Mitral regurgitation?

A
Causes:
Prolapsing mitral valve
Papillary muscle rupture post MI
Rheumatic Fever
Connective tissue disorders
Cardiomyopathy

Symptoms:
Asymptomatic
Regurgitation  LVH  Left heart failure

Risk Factors:
Prolapsing mitral valve

Differentials:
Left Heart Failure 
Aortic Valve Disease
Papillary muscle rupture post MI
Rheumatic Fever
Connective tissue disorders
Cardiomyopathy

Examination:
Chest:
Pan-Systolic murmur that radiates to Axilla
One constant sound with no gap between S1/2
“Burrrrr”
Displaced apex best - volume overload
Palpable thrill

4
Q

What are the causes and what will you find on history/examination of Mitral stenosis?

A

Causes:
Rheumatic Fever
Old Age – Calcification

Symptoms:
Left Atrial Dilation  Pulmonary Congestion  Dyspnoea and Right Heart Failure
Left Atrial Dilation  Pacemaker Damage  AF
Left Atrial Dilation  Oesophageal Compression  Dysphagia
Left Atrial Dilation  Bronchial Vein Rupture  Haemoptysis

Risk Factors:
Rheumatic Fever
Old Age – Calcification

Differentials:
Atrial Myoxoma - Benign tumour in the left atrium that blocks valve (seen on ultrasound). Will have weight loss and systemic signs

Examination:
End of the bed - Signs of heart failure e.g Peripheral oedema
Hands - Pulse (May be in AF)
Neck - Raised JVP
Face - Malar Flush
Chest:
Rumbling mid diastolic murmur
Best heard with bell of stethoscope in apex when patient lying on left side
“Lub de Derrrr
Loud S1 sound - High LA pressure keeps valve open till later and then slams shut
Opening snap - High pitched sound after S2
Left parasternal heave - RVH
Tapping apex beat due to palpable S1

5
Q

What are the causes and what will you find on history/examination of Mitral regurgitation?

A

Symptoms:
Heart Failure
Commonly present as AF
Haemoptysis (bronchial vein rupture due to raised Left atrial pressure)

Risk Factors:
Rheumatic Fever
Old Age - Calcification

Cardiac History Questions to ask:
Chest pain
Shortness of breath (exercise tolerance, orthopnoea, paroxysmal nocturnal dyspnoea)
Cough - Sputum/Haemoptysis  
Palpitations - Tap out the rhythm 
Oedema 
Syncope
Cardiovascular history- Stroke, PVD, smoking, high cholesterol, high blood pressure, diabetes, family history of early cardiac death. 

Differentials to rule out:
Atrial Myoxoma - Benign tumour in the left atrium that blocks valve (seen on ultrasound). Will have weight loss and systemic signs

6
Q

What will you find/look for on examination of a patient with Aortic regurgitation?

A
Causes:
Rheumatic fever
Bicuspid valve
Infective Endocarditis
Connective Tissue Disorders 
Syphilis

Symptoms:
Asymptomatic
Left heart failure

Risk Factors:
Rheumatic fever
Bicuspid valve
Infective Endocarditis
Connective Tissue Disorders 
Syphilis

Examination:
Hand:
Collapsing Pulse
Wide Pulse Pressure
Quinckes Sign - Capillary pulsation in mail bed
Face - De Musset’s sign (Head nodding with each heartbeat)
Chest:
High pitched early diastolic murmur
Best heard left sternal edge, 4th intercostal space with patient leaning forward in expiration
“Lub Taarrrr”
Displaced Apex beat
Legs - Pistol shot femoral pulses (Sharp bang on auscultation of femorals with each heartbeat)

7
Q

What will you find/look for on examination of a patient with Aortic stenosis?

A

Causes:
Under 65 - Bicuspid Aortic Valve
Over 65 - Age Related Calcification
Rheumatic Fever

Symptoms:
Classic Triad of Angina, Syncope and Dyspnoea on exertion caused by impaired blood flow to brain/heart
Sudden cardiac death

Risk Factors:
Under 65 - Bicuspid Aortic Valve
Over 65 - Age Related Calcification
Rheumatic Fever

Differentials:
Angina

Examination:
Hands 
Slow rising pulse
Low volume pulse
Narrow pulse pressure 
Chest:
Ejection systolic murmur radiating to the carotids 
"Lub Whooosh Dub" 
Forceful apex beat
Soft S2 heart sound
8
Q

What investigations will you order in Valve disease?

A

Bedside:
ECG
Mitral Regurgitation - Bifid P waves, LVH (S wave in V1 + R wave in V5/6 > 3.5 large squares)
Mitral stenosis – Atrial Fibrillation, Bifid P wave, RVH (right axis deviation, tall R waves in V1/2)
Aortic regurgitation - LVH
Aortic stenosis - LVH, left ventricular strain (depressed ST and inverted T waves in LV leads)

Bloods:
BNP - Rule out heart failure
FBC - Look for anaemia
U&E/LFT - Giving drugs like ace inhibitors

Imaging:
CXR - Mitral Regurgitation (Heart Failure), Mitral stenosis (Large left atrium and Pulmonary oedema), Aortic Stenosis (Small heart with dilated ascending aorta)
Echo - Diagnostic test

9
Q

What is the treatment of valve disease?

A

Medical:
Diuretics and Nitrates for symptom management until surgery
If not for surgical management then treat as heart failure (Ace inhibitor, Beta Blocker, Spironolactone)

Surgical:
Asymptomatic - Yearly review of patients with known valvular disease
Symptomatic – Valve replacement

10
Q

What are the complications of valve disease?

A
Heart Failure on affected side
Sudden cardiac death (aortic stenosis)
Arrhythmia's
Stroke/Clots
Infective endocarditis
11
Q

What are the complications of Prosthetic heart valves?

A
Structural valve failure
Paravulvular leak
Thrombosis and obstruction
Infective endocarditis
Intravascular haemolysis
Complications relating to warfarin they need to take
12
Q

General Rules for Murmurs

A

General Rules of Valve Lesions:
Left sided murmurs - Best on expiration
Right sided murmurs - Best on inspiration
Regurgitation - Displaced Apex
Stenosis – Change in apex but no displacement

Summary of murmurs:
Ejection systolic - aortic stenosis, pulmonary stenosis, HOCM, ASD, Fallot’s
Pan systolic - Mitral/Tricuspid regurgitation (high-pitched and ‘blowing’ in character), VSD (‘harsh’ in character)
Late systolic - mitral valve prolapse, coarctation of aorta
Early diastolic -aortic regurgitation (high-pitched and ‘blowing’ in character), Graham-Steel murmur (pulmonary regurgitation, again high-pitched and ‘blowing’ in character)
Mid-late diastolic - mitral stenosis (‘rumbling’ in character), Austin-Flint murmur (severe aortic regurgitation, again is ‘rumbling’ in character)
Continuous machine-like murmur -patent ductus arteriosus