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Cardio 3: Valve
Notes
65
Medical
Graduate
10/15/2013

Additional Medical Flashcards

 


 

Cards

Term
Harsh systolic ejection murmur
Definition
Aortic stenosis
Term
Pulsus Parvus et Tardus
Definition

Carotid Impulse 

 

Aortic stenosis 

Term
Symptoms of aortic stenosis
Definition

Angina (5 year life expec)

 

Syncope w/exertion (3 year life expec)

 

Congestive HF (2 year life expec)

Term
TOC for aortic stenosis
Definition
  • TOC = Echo 2D/Color Doppler 

Other Tests

  • ECG - LVH and LAE 
  • Cardiac cath - helpful/confirmatory; NEEDED if pts is older to look at the coronaries 
Term
Aortic stenosis treatment of choice
Definition

**Treatment is for symptoms, NOT the actual cause**

 

  • So you are only going to treat aortic stenosis if is symptomatic or you have decreased LV fucntion 
  • Can also use aortic valve replacement (biorosthetic or mechanical) 
Term
Aortic stenosis etiology
Definition
Heart compensation for things such as HTN
Term
Aortic regurgitation etiology
Definition

Abnormal leaflets:

  • Rheumatic fever 
  • Endocarditis 
  • Bicuspid or degenerative valve

Aortic annulus dilitation:

  • Aortic aneurysm 
  • Aortic dissection
  • Inflammation (syphillis, Giant cell arteritis, Vascular disease ankylosis, spondylitits, Reiters)
  • Marfan
  • Osteogenesis imperfecta 
Term
Pathophysiology of aortic regurgitation
Definition
  • Widended pulse pressure: This is going to cause a decreased diastolic pressure
  • Imbalance b/t myocardial supply and demand:  B/c of the decreased diastolic pressure, you have decreased perfusion of the heart
  • Increased LV size:  B/c increased SV b/c regurgitation and this is going to cause increased stress on the wall of the heart = further increase in demand 
  • Pulmonary venous congestion: Acute = lots of increased pressure in the ventricle causes LV and LA to expand; chronic = less increased pressure b/c expanded and this actually worsens mitral valve regurg and causes pulmonary venous congestion. 
Term
Symtoms of aortic regurgitation
Definition
  • Exertional dyspnea:  B/c increased contraction of the heart and causes more backflow and causes pulmonary venous congestion 
  • Fatigue:  B/c you are have regurg you have less CO 
  • Diminished exercise tolerance:  B/c regurg you have less CO 
Term
Apical rumble
Definition

Aortic regurgitation 

 

Called "Austin Flint murmur"

Term
Diastolic decrescendo blowing murmur
Definition
Aortic regurgitation
Term
Physical exam findings of aortic regurgitation
Definition
  • Diastolic decrescendo blowing murmur
  • S4 that progresses to an S3 w/advancement 
  • Bounding pulses 
  • Apical rumble "austin flint murmur" (caused by regurg blood hitting the anterior mitral valve leaflet)
  • Hyperdynamic LV apical impulse 
Term

Aortic regurgitation TOC

 

Other choices 

Definition
  • Echo:  TOC 
  • ECG:  LAE and LVH 
  • Cardiac cath:  Helpful for confirmation and needed if pt is older to look for coronaries 
Term
Aortic regurgitation treatment
Definition
  • Asymptomatic:  No good medical treatment, treat risk factors such as endocarditis or causitive agents
  • Symptomatic:  Aortic valve replacement (bioprosthetic vs mechanical) 
  • Treatment of symptomatic/severe aortic regurgitation in non-surgical candidate: Palliative; Vasodilators such as ACE-I or nifedipine 
Term
Mitral regurgitation etiologies
Definition

Alterations of leaflets/commissures/annulus:

  • Rheumatic fever 
  • MVP
  • Endocarditis 

Papillary muscle dysfucntion:

  • Ischemic MI***
  • Myocarditits***
  • Dilated cardiomyopathy***

Alterations of LV or LA size and function:

  • HCM
  • LV enlargement 
  • LA enlargement 
Term
Mitral regurg chronic compensated heart
Definition

Eccentric hypertrophy:

  • The heart is goiing to have an increased "preload" b/c of the mitral regurg and also an increased "afterload" b/c of the increased dilation due to the regurg
  • Ths is going to cause an increase in the total stroke volume + an increase in forward stroke volume + LVESV is going to return to normal
Increased LA-size:
  • B/c of the regurg, the LA is going to increase its compliance 
  • It is goig to be able to accomodate larger volumes w/lower pressure 
Term
Mitral Regurg Chronic Decompensated Path
Definition

Depressed contractility:

  • Decreased SV b/c of decreased contractility 
  • Causes increased LVEDV b/c the heart cannot squeeze all of the volume from the previous stroke out

***This decompensation is goiing to cause further dilation and further increase mitral regurgitation***

Term
Mitral regurgitation symptoms
Definition
  • Fatigue
  • Dyspnea 
  • Orthopnea 
  • Left and/or right sided HR
  • MVP syndrome 
Term
Holosystolic apical blowing murmur
Definition
Mitral regurg
Term
Split S2
Definition

**This is often obscured by the murmur**

 

Mitral regurg

Atrial septal defect 

Term
Mitral regurgitation physical exam
Definition
  • Holosystolic apical blowing murmur 
  • Laterally displaced apical impulse 
  • Split S2 (obsscured by murmur) 
  • S3 gallop 
Term

TOC for Mitral Regurg 

 

ECG findings 

Definition
  • TOC:  Echno 2D Doppler
  • ECG:  LAE; LVH 
  • Cardiac cath:  Helpful/confirmatory, needed if pt. is older for looking at the coronaries 
Term
Treatment of symptomatic mitral regurg.
Definition
Medical therapy:
  • Diuretics (decreases preload/afterload pressures)
  • Vasodilators (ACE-I) to decrease pressure so the heart can push stuff out easier

Surgical therapy:

  • MV-replacement:  MVR has similar survival outcome to the disease process 
  • Operative mortality = 8-10%; 10 year survival = 50%
  • MV-repair:  Operative mortality = 2-4%; 10-year survival = 80%; CAUSES PRESERVATION OF THE MITRAL APPARATUS W/ NO INCREASED RISK OF THROMBOTIC COMPLICATIONS 
Term
Mitral valve prolapse symptoms
Definition
  • Chest pain 
  • Palpitations 
Term
Physical exam findings of mitral valve prolapse
Definition
  • Mid-systolic click
  • Late systolic murmur if it is associated with mitral regurg 
Term
Mitral valve prolapse prognosis
Definition

-It is often benign unless you have a rare complication

-Rare complications:

  • Endocarditis 
  • Progressive mitral regurg (acute and chronic)
  • Thromboembolism 
  • Atrial + ventricular arrhythmia 
Term
TOC for mitral regurg MVP
Definition
  • DOC:  Echo 2D/Color to directly visualize prolapse + presence and degreee of MR 
Term
Mitral Regurg MVP treatment
Definition
  • Beta-blockers:  B/c of the hyper-adrenergic symptoms and to stop palpitations 
  • Aspirin:  TIA w/o etiology 
  • SBE prophylaxis: ONLY if there is a history of endocarditits or vavle replacement 

What about diurectic and an ACE for vasodilation?

Term
Etiology of mitral stenosis
Definition
  • Rheumatic fever 
  • Mitral annular Ca+ (needs to be MASSIVE but that is rare)
  • Congenital (rare) 

 

Term
Normal mitral valve area vs symtomatic stenosis vs critical stenosis
Definition
  • Normal mitral valve area = 4-6 cm^2
  • Symptomatic = < 2cm^2
  • Critical = < 1cm^2 
Term
Mitral stenosis pathology (leads to what)
Definition

LA-Hypertension which leads to:

  • Pulmonary interstitial edema
  • Pulmonary hypertension (passive = obligatory b/c forward flow; reactive = protects interstitium from edema) → right sided heart failure
  • LA stretch + atrial fibrillation: This can lead to increased HR which causes decreased LV filling; Decreased atrial "kick" which leads to decreased LV filling; Atrial thrombus formation
***Limited LV filling and CO***
Term
Symptoms of mitral stenosis
Definition
  • Decreased ability to tolerate increased HR (decreased LV filling)
  • Dyspnea (pulmonary venous congestion) 
  • Fatigue (decreased CO)
  • Inability to tolerate increased volume (b/c can't move it) 
  • Hemoptysis 
Term
Loud S1
Definition
Mitral stenosis
Term
Opening snap
Definition

Mitral stenosis 

Aortic stenosis?

Term
Diastolic apical rumble (murmur)
Definition
Mitral stenosis
Term
Physical exam for mitral stenosis
Definition
  • Loud S1
  • Apical diastolic rumble (murmur) 
  • Opening snap 
  • Atrial fibrillation 
  • May be associated with other murmurs: MR or AS; right sided murmurs; PI-Graham steel murmur; TR 
Term

TOC for mitral stenosis

 

ECG findings 

Definition
  • TOC:  Echo 2D/color doppler 
  • ECG:  A-fib; LAE; RVH; RAE 
  • Cardiac cath:  Helpful, confirmatory, needed if the pt is older to look for coronaries 
Term
Symptomatic mitral stenosis treatment
Definition

***Just like aortic stenosis, treatment is ONLY for symptoms***

 

  • Diuretics: For pulmonary congestion 
  • Ca/Beta-blockers/digoxin:  For A-fib 
  • Anti-coagulation:  For A-fib 

***SBE Prophylaxis NOT recommended empirically***


  • Surgical therapy treats the cause
  • Percutaneous balloon valvuloplasty for a non-calcified pliable valve 
  • Open commissurotomy- valve repair
  • Mitral valve replacement 
Term
If hypertrophic cardiomyopathy is symptomatic, what are the sytoms?
Definition
  • This is an autosmoal dominant transmission disease w/varable penetrance 
  • Patient in this case is going to be between the ages of 12-20 and it is the leading cause of SCD in young athletes

Symptoms

  • Chest pain 
  • Dyspnea upon exertion
  • Fatigue 
  • Syncope 
Term
Harsh mid-systolic murmur at the LSB that radiates slightly laterally
Definition
HOCM
Term
HOCM physical exam
Definition
  • Harsh mid-systolic murmur at the LSB which may radiate slightly lateral 
  • Normal carotid upstrokes 
  • S4 
  • Possible reverse splitting of S2 
Term
Brockenbrough's sign
Definition

***Classic sign of HOCM***

 

  • Left-ventricle to aortic gradient increases while the aortic pulse pressure decreases after a pre-mature ventricular contraction (PVC)

Occurs in HOCM b/c increased contractility after a PVC beat increases the dynamic LVOT obstruction 

Term
Effects of HOCM
Definition
  • Diastolic dysfucntion 
  • Ischemic heart disease 
  • Dynamic outflow tract obstruction 
  • Mitral regurg + A. Fib
Term

HOCM therapy

 

Asymptomatic and Symptomatic

Definition
Asymptomatic:  No therapy

Symptomatic obstruction:  Beta-blockers or verapamil (why not dilitzem?)

Second line for symptomatic obstruction: Beta-blocker + disopyramide (so this is now going to be a neg-inotropic drug with an 1A anti-arrhythmic

Refractory:  Myomectomy is the gold standard! Or alcohol ablation (but alcohol ablation has more complications) 

Dual chamber pacing:  Controversial but this is used to time the LV contractions.  This decreases the LVOT gradient 

***All patients w/HOCM should be advised against highly competitive sports, lower activity should be encouraged***

***All patients should also be risk stratified for prophylactic ICD implantation***
Term
Disopyramide
Definition
This is a class-1A antiarrhythmic that is given with a beta-blocker in the 2nd line treatment of HOCM
Term
Major risk factors that increase the chances of a ventricular arrhythmia and need for ICD in HOCM?
Definition
  • H/o cardiac arrest
  • Sustained VT, FH of SCD
  • LV thickness > 30 mm 
  • Unexplained syncope 
  • Abnormal exercise BP
  • Holter monitor that reveals NSVT
Term
Tricuspid regurg etiolgoy
Definition
  • USUALLY it is secondary 

COPD,

Diseases leading to pulmonary HTN

Intracardiac shunts

 

  • Priimary causes can be endocarditis, carcinoid syndrome, rheumatic fever, myxomatous degeneration, RV infarct, endomyocardial biopsy 
Term
Symptoms of TR
Definition
  • These are going to be signs of Rx HF
  • Edema
  • Ascites
  • Occasionally right upper quadrant pain
Term

Murmur at the LSB which increases w/inspiration 

May radiate to the epigastrum 

Definition
Tricuspid regurg
Term
TR physical exam
Definition
  • JVD 
  • Large V-wave
  • Hepatic enlargement
  • Parasternal lift 
  • Ascites 
  • Edema
  • Murmur at the LSM which increses w/inspiration
  • Murmur may radiate to the epigastrum 
Term
TOC for TR
Definition
Echo
Term
Treatment of TR
Definition
  • Since most TR are 2ndary, then treat the cause
  • Diuretics 
  • Tricuspid repair (but rare
Term

HOCM + Valsalva 

 

Increase or decrease murmur 

Definition
Increase
Term

HOCM + Squat

 

Increase or decrease murmur

Definition
Decrease
Term

HOCM + Standing 

 

Increase or decrease murmur 

Definition
Increase
Term

HOCM + Handgrip

 

Increase or decrease murmur

Definition
Decrease
Term

MR + Squat 

 

Increse or decrease murmur

Definition
Increase
Term

MR + Stand 

 

Increase or decrease murmur?

Definition
Decrease
Term

MR + handgrip 

 

Increase or decrease murmur

Definition
Increase
Term

Handgrip + HOCM

 

Ventricular volume 

Murmur intensity

LVOT Gradient 

Definition

Ventricular volume = increases

Murmur intensity = decrease 

LVOT Gradient = decrease

Term

Valsalva + HOCM

 

Ventricular volume 

Murmur intensity 

LVOT Gradient 

Definition

Ventricular volume = decreases 

Murmur intesity = increased 

LVOT gradient = increased 

Term

Amy Nitrite + HOCM

 

Ventricular volume 

Murmur intensity 

LVOT Gradient 

Definition

Ventricular volume = decreased

Murmur intensity = increased 

LVOT gradient = increased

Term

Isoproterenol + HOCM 

 

Ventricular volume 

Murmur intensity 

LVOT gradient

Definition

Ventricular volume = decreased

Murmur intensity = increased 

LVOT gradient = increased 

Term

Beta-blocker + HOCM 

 

Ventricular volume 

Murmur intensity 

LVOT Gradient 

Definition

Ventricular volume = increased 

Murmur intesnity = decreased 

LVOT gradient = decreased 

Term

Phenylephrine + HOCM

 

Ventricular volume

Murmur intensity 

LVOT Gradient 

Definition

Ventricular volume = increased

Murmur intensity = decreased 

LVOT gradient = decreased

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