Create
Learn
Share

IM - VALVULAR HEART DISEASE

rename
tonystep1's version from 2017-08-29 02:57

VALVULAR HEART DISEASE MURMURS

Question Answer
Mitral StenosisThe opening snap is followed by a low-pitched diastolic rumble and presystolic
accentuation.
This murmur increases in length as the disease worsens.
Heard best with bell of stethoscope in left lateral decubitus position
Aortic Stenosis (AS)• Harsh crescendo-decrescendo systolic murmur
• Heard in second right intercostal space
• Radiates to carotid arteries
Aortic RegurgitationDiastolic decrescendo murmur best heard at left sternal border
Mitral Regurgitation 􀂍MR)a. Holosystolic murmur (starts with s1 and continues on through s2) at the apex,
which radiates to the back or clavicular area, depending on which leaflet is involved
b. AFib is common finding
c. Other findings: s3 gallop; laterally displaced PMI; loud, palpable P 2
Tricuspid Regurgitation 􀂍TR)Inspiratory s3 along left lower sternal border (LLSB) may be present
Blowing holosystolic murmur
a. At LLSB
b. Intensified with inspiration; reduced during expiration or the Valsalva maneuver
Mitral Valve Prolapse (MVP)a. Midsystolic or late systolic click(s)
b. Mid-to-late systolic murmur
c. Some patients have midsystolic click without the murmur; others may have the
murmur without the click.
d. Standing and the Valsalva maneuver increase murmur and click because these
maneuvers reduce LV chamber size, allowing the click and murmur to occur
earlier in systole.
e. Squatting decreases murmur and click because it increases LV chamber size,
thus delaying the onset of the click and murmur
memorize

VALVULAR HEART DISEASE SIGNS

Question Answer
Mitral StenosisSigns
a. • The opening snap is followed by a low-pitched diastolic rumble and presystolic
accentuation. This murmur increases in length as the disease worsens.
• Heard best with bell of stethoscope in left lateral decubitus position
b. S2 is followed by an opening snap. The distance between S2 and the opening
snap can give an indication as to the severity of the stenosis. The closer the
opening snap follows S2, the worse is the stenosis.
c. Murmur is followed by a loud S1 . A loud S1 may be the most prominent physical
finding.
d. With longstanding disease, will find signs of RVF (e.g. , right ventricular heave,
JVD, hepatomegaly, ascites) ancllor pulmonary HTN (loud P2)
e. All signs and symptoms will increase with exercise and during pregnancy
Aortic Stenosis (AS)Signs
a. Murmur
• Harsh crescendo-decrescendo systolic murmur
• Heard in second right intercostal space
• Radiates to carotid arteries
b. S4
c. Parvus et tardus-diminished and delayed carotid upstrokes
d. Sustained PMI
e. Precordial thrill
Aortic RegurgitationPhysical examination
a. Widened pulse pressure-markedly increased systolic BP, with decreased
diastolic BP
b. Diastolic decrescendo murmur best heard at left sternal border
c. Corrigan's pulse (water-hammer pulse)-rapidly increasing pulse that collapses
suddenly as arterial pressure decreases rapidly in late systole and diastole; can
be palpated at wrist or femoral arteries
d. Austin-Flint murmur-low-pitched diastolic rumble due to narrowing of
mitral valve orifice by aortic regurgitation, resulting in relative mitral
stenosis
e. Displaced PMI (down and to the left) and S3 may also be present.
Mitral Regurgitation 􀂍MR)2. Signs
a. Holosystolic murmur (starts with S1 and continues on through S2) at the apex,
which radiates to the back or clavicular area, depending on which leaflet is involved
b. AFib is common finding
c. Other findings: S3 gallop; laterally displaced PMI; loud, palpable P
Tricuspid Regurgitation 􀂍TR)l. Signs and symptoms of RVF (ascites, hepatomegaly, edema, JVD)
2. Pulsatile liver
3. Prominent V waves in jugular venous pulse with rapid y descent
4. Inspiratory S3 along left lower sternal border (LLSB) may be present
5. Blowing holosystolic murmur
a. At LLSB
b. Intensified with inspiration; reduced during expiration or the Valsalva maneuver
6. Right ventricular pulsation along LLSB
7. AFib is usually present.
Mitral Valve Prolapse (MVP)Signs
a. Midsystolic or late systolic click(s)
b. Mid-to-late systolic murmur
c. Some patients have midsystolic click without the murmur; others may have the
murmur without the click.
d. Standing and the Valsalva maneuver increase murmur and click because these
maneuvers reduce LV chamber size, allowing the click and murmur to occur
earlier in systole.
e. Squatting decreases murmur and click because it increases LV chamber size,
thus delaying the onset of the click and murmur.
f. Sustained handgrip increases the murmur of MVP; in contrast, it decreases the
murmur of hypertrophic cardiomyopathy (HCM ) .
memorize

VALVULAR HEART DISEASE TREATMENT AND MANAGEMENT

Question Answer
Mitral Stenosisl. Medical
a. Diuretics-for pulmonary congestion and edema
b. Infective endocarditis prophylaxis
c. Chronic anticoagulation with warfarin is indicated (especially if patient has AFib)
2. Surgical (for severe disease)
a. Percutaneous balloon valvuloplasty usually produces excellent results.
b. Open commissurotomy and mitral valve replacement are other options if valvotomy
is contraindicated.
3. Management
a. No therapy is required in asymptomatic patients.
b. Diuretics can be used if the patient has mild symptoms.
c. If symptoms are more severe, surgical treatment is recommended.
d. If AFib develops at any time, treat accordingly (see discussion on AFib).
Aortic Stenosis (AS)l. Medical therapy has a limited role.
2. Surgical therapy: Aortic valve replacement is the treatment of choice. It is indicated
in all symptomatic patients.
Aortic Regurgitationl. Conservative if stable and asymptomatic: salt restriction, diuretics, vasodilators,
digoxin, afterload reduction (i.e., ACE inhibitors or arterial dilators) , and restriction
on strenuous activity
2. Definitive treatment is surgery (aortic valve replacement). This should be considered
in symptomatic patients, or in those with significant LV dysfunction on
echocardiogram.
3. Acute AR (e.g., post-MI): Medical emergency-Perform emergent aortic valve
replacement!
4. Endocarditis prophylaxis before dental and GVgenitourinary procedures
Mitral Regurgitation 􀂍MR)Treatment
l. Medical
a. Afterload reduction with vasodilators; also salt reduction, diuretics, digoxin,
and antiarrhythmics
b. Chronic anticoagulation if patient has atrial fibrillation
c. IABP as bridge to surgery for acute M R
2. Surgical
a. Mitral valve repair or replacement
b. Must be performed before left ventricular function is too severely compromised
Tricuspid Regurgitation 􀂍TR)l. Treat left-sided heart failure, endocarditis, or pulmonary HTN.
2. Severe regurgitation may be surgically corrected if pulmonary HTN is not present.
a. Native valve repair surgery
b. Valvuloplasty of tricuspid ring
c. Valve replacement surgery: rarely performed
Mitral Valve Prolapse (MVP)l. If patient is asymptomatic: reassurance
2. If patient has systolic murmur or thickened valve: antibiotic prophylaxis for dental
procedures to prevent infective endocarditis
3. For chest pain, /3-blockers have been useful, but they are unlikely to be
required.
4. Surgery rarely is required. The condition is generally benign.
memorize

CAUSES OF ENDOCARDITIS AND RHEUMATIC HEART DISEASE

Question Answer
Rheumatic heart diseaseRheumatic heart disease occurs as a complication of streptococcal pharyngitis (group A streptococcus) .
Acute endocarditisMost commonly caused by Staphylococcus aureus (virulent)
Subacute endocarditisCaused by less virulent organisms, such as Streptococcus viridans and enterococcus
5%-10% of community-acquired native-valve endocarditis cases in patients who do not use intravenous drugs. HACEK group of organisms: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella
Non bacterial Thrombotic Endocarditis (Marantic Endocarditis)Associated with debilitating illnesses such as metastatic cancer (found in up to 20% of cancer patients)
Non bacterial Verrucous Endocarditis (Libman·Sacks Endocarditis)Typically involves the aortic valves in individuals with SLE
memorize

DIAGNOSTIC CRITERIA FOR RHEUMATIC HEART DISEASE

Question Answer
l. Major criteriaa. Migratory polyarthritis
b. Erythema marginatum
c. Cardiac involvement (e.g., pericarditis, CHF, valve disease)
d. Chorea
e. Subcutaneous nodules
2. Minor criteriaa. Fever
b. Elevated erythrocyte sedimentation rate
c. Polyarthralgias
d. Prior history of rheumatic fever
e. Prolonged PR interval
f. Evidence of preceding streptococcal infection
How many major and minor criteria for Rheumatic heart disease(requires two major criteria or one major
and two minor criteria)
memorize

DIAGNOSTIC CRITERIA FOR INFECTIVE ENDOCARDITIS

Question Answer
Major Criteria1. Sustained bacteremia (by an organism known to cause endocarditis
2. Endocardial involvement - documented by echo
Minor Criteria1.Predisposing condition
2. fever
3. Vascular phenomenon
4. Immune phenomenon
5. Positive blood cultures
6. Postive echocardiogram
How many major and minor criteria for a diagnosis of Infective EndocarditisTwo major criteria // one major and three minor criteria // five minor criteria
What are Janeway lesions?Flat, painless, erythematous lesions associated with Endocarditis
What are Roth spots?Roth's spots are retinal hemorrhages with white or pale centers.
What are Osler nodes?Osler's nodes are painful, red, raised lesions found on the hands and feet. They are associated with a number of conditions, including infective endocarditis, and are caused by immune complex deposition.
memorize

TREATMENT AND MANAGEMENT OF RHEUMATIC HEART DISEASE AND INFECTIVE ENDOCARDITIS

Question Answer
Acute Rheumatic feverTreated with NSAIDs, C-reactive protein is used to monitor treatment.
Patient with prior history of Rheumatic feverThese patients should receive antibiotivc prophylaxis with erythromycin or amoxicillin for dental/GI/genitourinary procedures
Streptococcal pharyngitisThis condition is treated with penicillin or erythomycin to prevent Rheumatic fever.
Infective endocarditisParenteral antibiotics based on culture results for extended periods (4 to 6 weeks)
Culture negative infective endocarditis if cultures are negative but there is a high clinical suspicion, treat empirically with a penicillin or vancomycin plus an aminoglycoside until the organism can be isolated
memorize

Recent badges