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Valvular Disease
Cardiology
| Question | Answer |
|---|---|
| Constant, sharp CP worse lying down, better sitting up and leaning forward | Pericarditis |
| Electrical alternans, narrow pulse pressure, pulsus paradoxus = | Pericardial effusion/tamponade |
| JVD, hypotension, muffled heart sounds are sxs of: | Pericardial effusion/tamponade (Beck triad) |
| Pericarditis post open heart surgery | Dressler’s syndrome; tx w/ ASA or colchicine |
| Lateral displaced PMI, Canon “a” waves, Quincke pulse, Corrigan pulse, Austin flint murmur, deMusset sx, water hammer pulse | Aortic Regurgitation/ Insufficiency |
| Peds w/ leg pain after physical activity, abnormal heart sounds, unequal UE & LE pulses, rib notching | Coarctation of aorta |
| Young female (<30yo), palpitations, long arms & fingers, pectus excavatum, ectopic lentis, flexible joints = | Marfan Syndrome: MVP, aortic regurgitation, aortic dissection, aortic root dilatation, ectopic lentis |
| CHD shunts | R to L: cyanotic; L to R: acyanotic (ASD, VSD, PDA) |
| Eisenmenger triad: | Systemic to pulmonary connection, pulmonary vascular dz, hypoxemia |
| Jones criteria are used to diagnose: | rheumatic heart disease (2 major OR 1 major and 2 minor criteria to dx) |
| Types of myocardial dz | Cardiomyopathy; myocarditis |
| 3 types of myocarditis | infectious; toxic; autoimmune/idiopathic |
| 3 types of pericardial dz | Pericarditis; Pericardial effusion / tamponade; Pericardial constriction |
| Quincke pulse = | subungual capillary pulsation (Aortic regurg) |
| Corrigan pulse = | rapid rise and fall (Aortic regurg) |
| Austin Flint murmur = | low pitch mid-diastolic murmur at apex (Aortic regurg) |
| Pericarditis Exam: | Beck triad, fever, friction rub sitting/leaning forward (pain less); pulsus paradoxus |
| Beck triad = | low arterial blood pressure, distended neck veins, and distant, muffled heart sounds. |
| Roth spots = | Small, white, exudative, edematous spots on retina surrounded by hemorrhage |
| Osler nodes = | tender, violaceous subcutaneous nodules on finger/toes fat pads (= immune complex deposition); often SBE |
| Janeway lesions = | painless red macular, blanching lesions on palms & soles (2/2 infected microemboli) |
| Acute bacterial endocarditis: common bugs = | STAPH AUREUS, Strep, H flu, Pneumococcus, N gono, Enterococcus |
| Duke criteria = | 2+ pos BC (drawn 12h apart) or 3 of 4 separate BC; TTE/TEE evidence; RF heart condition or IVDU; T >38C (100.4); vascular sxs; immune sxs; microbiological evidence (not meeting major criteria) |
| Initial Abx tx for infectious endocarditis | PCN & ceftriaxone (vs old tx: nafcillin & gentamicin) |
| Most common cause of LV OT obstruction | Aortic stenosis (pathogenesis assoc with genetics (NOTCH1) and atherosclerosis) |
| Aortic stenosis 2 types | Subvalvular (d/t: thin membrane (most common), thick fibromx ridge, diffuse tunnel-like obstruction, HCM); Supravalvular (hourglass deformity (60-75%) or more diffuse narrowing along ascending aorta) |
| Aortic stenosis Etiology | US: lipid accumulation, inflammation, CALCIFICATION ; Elsewhere: rheumatic valve dz (fusion of the commissures between the leaflets, with a small central orifice) |
| Aortic stenosis Sx/Sx: triad w/exertion: | HF, syncope, angina; Other: DOE (diastolic ventric dysfn); A-fib, V-arrhythmia, IE, Pulsus parvus et tardus |
| Aortic stenosis: echo | valve opening <3cm2; antegrade velocity across valve >2.6m/sec; progressive concentric hypertrophy |
| Aortic stenosis Tx | prevention of dz progression (statin, ?ACEI, HTN tx, IE Ppx); valve replacement (esp concurrently w/CABG); Survival = 2-3 yrs w/o valve replacement; balloon valvuloplasty |
| Mitral stenosis Pathophysiology | symmetric oval orifice & doming of the leaflets in diastole (2/2 fusion of leaflet tips); leaflet thickening / calcification 2/2 chronic turbulent flow thru deformed valve -> leaflet fusion & thickening -> obstructed LA-to-LV blood flow |
| Mitral stenosis Sx/Sx | A-fib (in 80%); pulmo HTN; dyspnea, hemoptysis, orthopnea, PND, CP, VTE, IE, right HF, hoarse; Graham Steell murmur |
| Mitral stenosis EKG | P-mitrale: broad notched P wave |
| Mitral stenosis Tx | exercise; loop diuretic if pulmo art congestion; digoxin, beta; VTE ppx, IE ppx |
| Mitral Regurgitation Pathophysiology | increases preload but reduces afterload |
| Mitral regurgitation Sx/Sx | Asx for yrs; poss left HF; exercise intolerance, dyspnea |
| Mitral regurgitation Tx | serial monitoring; tx A-fib or LA enlargement (poss vasodilators); surg if LV EF<60% or echo LV end sys diameter >4cm |
| Bacterial endocarditis pathophysiology | SA, Viridans strep & Strep bovis; Enterococci; HACEK group; Rheumatic; bicuspid valve |
| Bacterial endocarditis general Sx/Sx | Fever; regurgitant murmurs/sx of HF; small and large emboli in fundi, conjunctivae, skin, digits: petechiae, splinter hemorrhages (nonblanching, linear reddish-brown lesions found under the nail bed) |
| Bacterial endocarditis Sx/Sx (SA) | SA: more rapidly progressive & destructive infxn (acute febrile illness, early embolization, valvular regurg, myocardial abscess). |
| Bacterial endocarditis Dx studies | 3 sets blood cx; CXR, EKG; TTE & TEE: evidence of vegetation; high ESR/CRP, normo/normo anemia |
| Bacterial endocarditis Tx | Vanc 1 gm q12h IV + ceftriaxone 2gm q24h (vs staph/strep/enterococci); or Unasyn plus aminoglycoside |
| Acute rheumatic fever pathophysiology | Post-GABHS infxn; strep strains with M protein (shares epitope w/myosin, thus may cause anti-myosin Ab rxn -> fibroblasts/macrophages); perivascular granulomatous rxn w/vasculitis |
| rheumatic fever sequelae include: | arthritis, carditis (pericarditis, cardiomeg, CHF), chorea, subcutaneous nodules, erythema marginatum; abd pain, facial tics, epistaxis |
| rheumatic fever DDx | RA, osteomyelitis, IE, chronic meningococcemia, SLE, Lyme, SCD |
| Jones criteria: major criteria = | Carditis (pericarditis, cardiomegaly, CHF), erythema marginatum, sydenham chorea (late finding; face, tongue, UE), polyarthritis, subcutaneous nodules |
| rheumatic fever: non-Jones | high ASO & anti-DNAse B to dx recent infxn |
| rheumatic fever Tx | bedrest, salicylates, PCN, csteroids for joint sxs |
| Aortic regurgitation Sx/Sx | Asx for decades; wide pulse pressure; S3; water hammer pulse, Corrigan pulse (pulse collapse in carotid); |
| Aortic regurgitation Signs: | deMusset' (head bob), Duroziez (bruit when femoral art is partially compressed), Quincke (capillary pulsations in fingertips); apical impulse laterally displaced |
| Aortic regurgitation Tx | serial monitoring; ACEI, CCB; surgery/valve replacement if EF <55% |
| Acute Pericarditis symptoms: | sharp stabbing precordial or retrosternal CP; may radiate to back (L trapezial ridge), neck, shoulder, arm; worse with inspiration |
| Pericarditis pain is most severe when: | pt is supine; relieved when pt leans forward while sitting |
| Acute Pericarditis exam: | most common/important: pericardial friction rub (best heard at LLSB or apex when pt sitting forward) |
| Acute Pericarditis: viral causes: | COXSACKIE B, echo, Flu A/B, adeno, MMRV, EBV, HSV1, Enterovirus, parainfluenza 2, RSV, HIV |
| Acute Pericarditis: bacterial causes: | STREP PNEUMO; Staph / Strep, GNR: Proteus, E coli, Pseudo, Klebs, Sal/Shigella, N meningitidis, H flu. Less common: Legionella, Nocardia, tickborne, Myco, TB |
| Best test for pericarditis / pericardial effusion = | TTE / TEE |
| Acute pericarditis tx: | Firstline: NSAIDs (indomethacin / Aspirin) UNLESS 2/2 bacterial (then ABX is firstline); secondline: steroids |
| Myocarditis: relation to viral syndromes | >50% of pts have antecedent viral syndrome; cardiac-specific sxs appear in subacute virus-clearing phase (2 wks after acute viremia). |
| Myocarditis: sx/sx | Fever in 20% of patients; 35% have CP (pleuritic, sharp, stabbing precordial). DOE, palps, tachypnea, tachycardia out of proportion to fever |
| Severe myocarditis: sx/sx | Sxs of LV failure: JVD, bibasilar crackles, ascites, peripheral edema |
| Most common infectious cause of myocarditis; | Viral acute |
| More than half of myocarditis cases due to: | Coxsackie-adenovirus: CA receptor protein is target of coxsackievirus B (Enterovirus) and adnovirus serotypes 2 & 5 |
| Most common drug hypersensitivity reactions causing acute myocarditis: | PCN, ampicillin, HCTZ, methyldopa, sulfonamides. |
| Medications causing acute myocarditis include: | lithium, cocaine, numerous catecholamines, APAP, zidovudine (AZT), doxorubicin |
| Autoimmune causes of acute myocarditis: | SLE, RA, Kawasaki, sarcoid, giant cell arteritis |
| Acute myocarditis tx: | Diuresis (furosemide); ACEI |
| Mitral stenosis: most common cause = | rheumatic heart disease (sxs follow latency period of 20-40 years after initial rheumatic fever episode) |
| Rheumatic heart disease: causes damage to which valves? | 1. mitral valve; 2. aortic valve; 3. tricuspid |
| Rheumatic heart disease: peak incidence: | 5-15 y.o. |
| Jones criteria: minor criteria = | Fever >101, polyarthralgia, long PR interval, high ESR / CRP, high WBC, +ASO titer, A-fib |
| Angina pectoris: how common in severe aortic stenosis? | 30-40% [old: 50-70%] |
| Aortic regurgitation exam: | Wide pulse pressure (inc SBP & dec DBP); Korotkoff sounds to zero; Traube sign (pistol shot sounds over femoral artery) |
| Mitral regurgitation dx studies | TTE, ECG (L atrial enlargement, AF), CXR (LA / LV enlargement & inc pulmo markings) |
| Stages of mitral regurgitation: | compensated, transitional, decompensated (EF decreases) |
| Mitral regurgitation etiology | MVP (most common: 45%); rheumatic fever; IE; trauma / chordae tendinae rupture; mitral annulus calcification, CHD/Marfan, DCM |
| MVP can lead to: | flail MV regurg |
| Bulging / billowing MV leaflets into LA during systole, +/- mitral regurgitation = | MVP |
| MVP etiology | Primary: genetic (AD); Marfan; connective tissue dz (Ehlers-Danlos); Graves dz. Secondary: to CAD, rheumatic HD, or CM |
| MVP exam | Hypotension/orthostasis, dizziness, palpitations; anxiety/panic. Seen w/scoliosis, pectus excavatum, military spine |
| Narrowing of pulmonic valve -> RVOT obstruction and right sided HF = | pulmonic stenosis |
| Pulmonic stenosis etiology: | Usually congenital & dz of the young; rheumatic HD, carcinoid; severe dz presents as HF in neonates; also Rubella embryopathy |
| Pulmonic stenosis exam: | RV heave at epigastrium; thrill w/loud murmur (IV/VI); pulmonic ejection sound; wide split S2 w/soft delayed P2; S4; JVD; ascites/HJR in Rt HF |
| Pulmonic regurgitation etiology: | pHTN from left VHD or pulmo dz; congenital; Fallot tet surgery complication; IE |
| Pulmonic regurgitation sx/sx: | usually asx. Possible exercise tolerance |
| Tricuspid stenosis etiology: | Rheumatic fever (most common), often with mitral & aortic lesions; RA myxoma; carcinoid; endomyocardial fibroelastosis; IE (bacterial) |
| Endomyocardial fibroelastosis is associated with what valvular disorder? | Tricuspid stenosis |
| Tricuspid stenosis mgmt: | Na restriction, diuretics, valvotomy, CT surg if severe progressive disease |
| Tricuspid regurgitation pathophysiology: | Dilatation of annulus 2/2 functional RV dilation; TVP; chronic RV volume overload -> right CHF |
| Pulsation or fluttering sensation in neck can be due to: | Tricuspid stenosis or regurgitation |
| Tricuspid regurgitation exam: | abd bloating/pain; right HF; parasternal lift; RV S3; AF rhythm; JVD/pulsatile; palpable pulsating liver; HJR/ascites; edema |
| SBE bugs = | Strep viridans and S bovis (most common), Enterococcus, SA, HACEK |
| IE NOT related to IVDU most often involves which valve: | mitral / aorta |
| IE bugs (in IVDU): | Staph aureus (SBE bug); Staph epi, Candida, Aspergillus, Strep viridans, Enterococcus |
| Early vs late prosthetic valve endocarditis = | before vs after 60 days post-implantation |
| IE risk factors: | Prosthetic valves & other devices; congenital anomalies; prior IE; rheumatic heart dz; valvular dz; HCM; dental/surg; IVDU |
| Fever in IE | ABE: 102-105; SBE: 99-100 |
| IE exam: | Triad (fever, murmur, pos blood cx), conjunctival hemorrhage, petechiae, splinter hemorrhage, Janeway, Roth, Osler, friction rub, JVD, rales, gallups, cold extremity & focal neuro sxs if septic emboli |
| Duke criteria: vascular sxs = | major arterial emboli, septic pulmo infarcts, mycotic aneurysm, ICH, conjunctival hemorrhage, Janeway |
| Duke criteria: immunologic sxs = | Glomerulonephritis, Osler nodes, Roth spots, rheumatoid factor |
| IE lab studies | BC, high WBC, ESR / CRP, micro hematuria, anemia (SBE), positive RF (SBE), immune complexes (dec C3 & C4) |
| IE on CXR: | infiltrates, pleural effusion |
| IE mgmt | Abx x4-6 weeks: Pen G for S viridans, others guided by C&S; valve surg if severe; PPx |
| Dental procedure prophylaxis for IE is indicated for patients with: | prosthetic cardiac valves, prior IE, transplant pt who develops VHD; CHD |
| Pre-procedure prophylaxis: which Abx in which procedures? | For dental, oral, respiratory tract, infected soft tissue, & esophageal procedures: 2gm amoxicillin 1 hr prior and 1gm 2hrs after (Alt: ampicillin, clinda, CTX) |
| Most common acquired valve stenosis = | aortic stenosis |
| In patient with hemodynamic sensitivity & syncope with nitrates, consider: | aortic stenosis |
| Aortic regurgitation etiology: | 80% idiopathic; HTN; rheumatic fever; IE; SLE; RA / ankylosing spondylosis; Marfan. ?SSRIs? |
| Most common valvular lesion: | 1) aortic stenosis; 2) mitral regurgitation |
| Type of CAD/ACS most often associated with mitral regurgitation: | inferior MI |
| MVP mgmt | Beta blocker (eg, atenolol); consider dental prophylaxis |
| Tricuspid regurgitation etiology: | pulmonary HTN (2/2 COPD); rheumatic fever; CHD; myxoma; carcinoid; SBE (esp in IVDU); Phen-fen; Ebstein is most common congenital form |
| Most accurate dx test for mitral stenosis = | left heart catheterization |
| Test of choice for mitral stenosis = | TEE |
| Most diagnostic finding for pericarditis | ST elevation in all leads |
| In infective endocarditis, IVDU most commonly affects which valve? | Tricuspid |
| Patients with this condition may have higher incidence of NTG-induced syncope | Aortic stenosis |
| Most common cause of valve replacement in US | chronic rheumatic heart disease (usually mitral valve) |
| Non-IVDU SBE/ABE bug | Strep viridans |
| If endocarditis in prosthetic valve: | May add rifampin (to vanc/gent/cefepime or carbapenem); usually added after BCx have cleared |
Created by:
Abarnard
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