Common Valvular Heart Disease Flashcards Preview

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

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

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

2

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

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

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

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

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

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

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

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

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

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

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

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

What investigations will you order in Valve disease?

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

What is the treatment of valve disease?

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

What are the complications of valve disease?

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

11

What are the complications of Prosthetic heart valves?

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

12

General Rules for Murmurs

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