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Valvular Disease


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)
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
IE related to IVDU involves which valve: tricuspid
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): SA, 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 accutate dx test for mitral stenosis = left heart catheterization
Test of choice for mitral stenosis = TEE
Created by: Adam Barnard Adam Barnard