Cardiology Valves
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- What are the most common symptoms of valvular disorders?
- dyspnea and chest pain
- What is the pathophysiology of aortic stenosis?
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⬢ obstruction of the left ventricular outflow
⬢ leads to left ventricular hypertrophy - What are the 3 cardinal signs and symptoms of aortic stenosis?
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⬢ angina
⬢ syncope
⬢ dyspnea - What are some late findings of aortic stenosis?
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⬢ left ventricular failure
⬢ severe pulmonary hypertension
⬢ resultant rightheart failure - On physical exam, what are some findings of a patient with aortic stenosis?
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⬢ lower B/P with narrowed pulse pressure
⬢ delayed and diminshed pulses
⬢ prominent "a-wave"
⬢ palpable S4 with non-displaced, sustained PMI
⬢ thrill at the base - Describe the murmur of aortic stenosis upon auscultation
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⬢ "diamond-shaped" murmur (crescendo-decrescendo) at the 2nd intercostal space at the left sternal border
⬢ low pitch murmur at the base radiating to the carotids
⬢ paradoxically S2 split from constant late A2 (P2-A2 instead of normal A2-P2) - What are some EKG findings of a patient with aortic stenosis?
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⬢ left ventricular hypertrophy and left axis deviation
⬢ possible atrial fibrillation
⬢ left bundle branch block
⬢ left atrial enlargement - What is the treatment of symptomatic patient with aortic stenosis?
- surgery (valve repair or replacement)
- What 2 types of medical therapy would you give to a patient who had a mechanical valve replacement?
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⬢ endocarditis prophylaxis
⬢ anticoagulation therapy - What is the area of the aortic valve with significant stenosis?
- less than 1.0 cm2
- What are some characteristics of aortic insufficiency?
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⬢ increased left ventricular end-diastolic volume
⬢ chamber thickens and dilates to accommodate the regurgitant volume
⬢ evntually the left ventricle fails, causing pulmonary hypertension and right venticular failure - What are some etiologies for aortic regurgitation?
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⬢ infectious - from endocarditis or syphilitic)
⬢ inflammatory - rheumatic, ankylosing spondylitis, Lupus)
⬢ Congenital - bicuspid aortic valve, prolaspe associated with ventricular septal defect, congenital fenestration
⬢ Degenerative - Marfan's, cystic medial necrosis
⬢ Traumatic - True/False: Patients with aortic regurgitation usually are asymptomatic until middle age
- The correct answer is: True
- What are some findings upon physical exam of a patient with aortic regurgitation?
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⬢ wide pulse pressure
⬢ physical findings of Marfan's
⬢ displaced PMI (due to left ventricular hypertrophy) with palpable S3 and S4
⬢ possible pulmonary congestion
⬢ diastolic "blowing" murmur along left sternal border - What part of the cardiac cycle would you hear the murmur of aortic regurgitation?
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⬢ during diastole
⬢ high pitched decrescendo diastolic murmur heard best by sitting up and leaning forward - What is an Austin-Flint murmur?
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⬢ a rumbling apical diastolic murmur heard with aortic regurgitation
⬢ regurgitant blood flow hits the mitral valve - What murmurs are heard during systole?
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⬢ aortic stenosis and mitral regurgitation
⬢ also mitral valve prolapse - What murmurs are heard during diastole?
- aortic regurgitation and mitral stenosis
- What are some findings on chest xray with aortic regurgitation?
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⬢ enlarged heart, if chronic, with signs of pulmonary congestion
⬢ possible calcified aortic valve
⬢ enlarged aorta with connective tissue disorders - What are some EKG findings with aortic regurgitation?
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⬢ left ventricular hypertrophy and left axis deviation
⬢ ST depression and T wave inversion (ischemic changes)
⬢ widened QRS (due to fibrosis) - What is the medical treatment for aortic regurg?
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⬢ vasodilators
⬢ ACE inhibitors (reduces regurg)
⬢ beta blockers in Marfans
⬢ diuretics (to reduce preload)
⬢ digoxin (to improve inotropy)
⬢ antiarrhythmics
⬢ SBE prophalaxis, penicillin for syphillis, and anticoagulation (if necessary) - When is surgery indicated in aortic regurg?
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⬢ when the patient is symptomatic
⬢ Ejection fraction < 55%
⬢ annulus > 5.0 cm - What are etiologies for mitral regurg?
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⬢. degenerative - myxomas (cardiac tumors), Marfan's, calcified annulus
⬢ infectious - infective endocarditis
⬢ structural - ruptured chorae tendineae, papillary muscle dysfunction - Why is acute mitral regurg worse that chronic mitral regurg?
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⬢ with chronic mitral regurg, the left ventricle and atria can accommodate the regurgitant flow; less blood flow goes to the lungs
⬢ with acute mitral regurg, the normal-sized left atria cannot accommodate the regurgitant flow and blood flows into the lungs - Describe the murmur of mitral regurg
- holosystolic (or pansystolic) murmur at apex radiating to the axillae
- What is the difference between acute and chronic mitral regurg on Xray?
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⬢ with chronic mitral regurg, you would see left atrial, left ventricular, and right ventricular enlargement
⬢ with acute mitral regurg, you would see pulmonary edema without chamber enlargement - What is the first line therapy in patients with mitral regurg?
- ACE inhibitors
- What is the treatment for acute mitral regurg?
- surgery is the only option with acute mitral regurg
- What are the 2 syndromes associated with mitral stenosis?
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⬢ moderate - pulmonary edema
⬢ severe- pulmonary HTN, and low cardiac output - What are the 2 major causes of mitral stenosis?
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⬢ rheumatic fever
⬢ congential disease - How do you distinguish strep throat from a viral sore throat?
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strep has:
⬢ exudates
⬢ fever
⬢ lymphadenopathy
⬢ absence of cough - What is the pathophysiology of rheumatic fever?
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⬢ antibodies form in response to the strep antigen
⬢ antibodies mistakenly attack host tissue (have an affinity for connective tissue, like valve collagen)
⬢ causes fibrous thickening and adhesion of valve - What is the criteria for a diagnosis of rheumatic fever?
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⬢ evidence of previous strep pharyngitis
⬢ need two major criteria OR 1 major and 2 minor - What are the major points of the Jones Criteria?
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⬢ migratory arthritis
⬢ carditis
⬢ sub-cutaneous nodules
⬢ erythema marginatum (redness with a margin)
⬢ Sydenham's chorea (shakes) - What are the minor points of the Jones Criteria?
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⬢ fever
⬢ elevated sed rate/C-reactive protein
⬢ arthralgias (sore joints)
⬢ increased PR interval
⬢ prior rheumatic fever or rheumatic heart disease - List the valves that affected by rheumatic heart disease (from most common to least common)
- Mitral > aortic > tricuspid (almost never pulmonic)
- What is the difference between rheumatic fever and rheumatic heart disease?
- Rheumatic heart disease is when there is residual evidence of cardiac impairment long after the acute illness has passed
- Describe the murmur of mitral stenosis
- diastolic "thrill" at the left apex in the left lateral decubitus position
- What a Graham-Steell murmur?
- murmur of pulmonic insufficiency secondary to severe pulmonary hypertension
- Why is important to maintain sinus rhythm with a patient with mitral stenosis?
- if the patient had A-fib with mitral stenosis, they do not have the atrial kick to open the stenotic valve
- What is the most common cause of mitral stenosis?
- rheumatic fever from group A beta-hemolytic strep
- Why can patient with mitral regurg have hoarseness?
- the left atria and pulmonary artery enlarges and compresses the laryngeal nerve
- What does mitral valve prolapse sound like upon auscultation?
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⬢ midsystolic click and late systolic murmur
⬢ late systolic murmur is due to mitral regurg - What are some complications of mitral valve prolapse?
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⬢ mitral regurg
⬢ infective endocarditis
⬢ atrial fibrillation
⬢ stroke
⬢ sudden cardiac death