Internal Medicine: Cardio - Valvular Heart Disease

Front 1

Causes of Mitral Stenosis

Back 1

Immune-mediated damage, usually caused by RHEUMATIC HEART DISEASE, leads to scarring and narrowing of orifice

Front 2

How does Mitral Stenosis lead to Pulmonary Congestion?

Back 2

Mitral stenosis leads to elevated left atrial and pulmonary venous pressure

*Can eventually lead to pulmonary HTN and right ventricular failure
*Long-standing mitral stenosis can also cause A-fib

Front 3

Clinical features of Mitral Stenosis

Back 3

1) Exertion dyspnea, orthopnea, PND
2) Palpitations, chest pain
3) HEMOPTYSIS - 2/2 ruptured anastomoses of small bronchial veins
4) Thromboembolism

Front 4

Murmur of Mitral Stenosis

Back 4

1) Opening snap
2) Low-pitched diastolic rumble

Front 5

Treatment of Mitral Stenosis

Back 5

1) Diuretics (pulmonary congestion and edema)
2) INFECTIVE ENDOCARDITIS PROPHYLAXIS
3) Chronic anticoagulation with WARFARIN
4) Percutaneous balloon valvulopasty (or open commissurotomy or mitral valve replacement)

Front 6

Causes of Aortic Stenosis

Back 6

1) Calcification of bicuspid aortic valve
2) Calcification of tricuspid aortic valve in elderly
3) Congenital unileaflet valve
4) RHEUMATIC FEVER

Front 7

How can Aortic Stenosis lead to Mitral Regurgitation?

Back 7

Over time, AS causes LVH, which can pull the mitral valve annulus apart and cause mitral regurg

Front 8

Clinical features of Aortic Stenosis

Back 8

1) Asymptomatic for years
2) Angina, exertional syncope, heart failure symptoms

Front 9

Murmur of Aortic Stenosis

Back 9

1) Harsh crescendo-decrescendo SYSTOLIC murmur
2) Radiates to CAROTID ARTERIES
3) Heard best in 2nd right intercostal space

Front 10

Diagnosis of Aortic Stenosis

Back 10

1) CXR: calcified aortic valve
2) ECG: LVH, LA abnormality
3) Echo
4) Cardiac catheterization

Front 11

Indicated treatment in all patients with symptomatic Aortic Stenosis

Back 11

Aortic valve replacement

Front 12

Causes of Aortic Regurgitation

Back 12

Acute:
1) INFECTIVE ENDOCARDITIS
2) Trauma
3) Aortic dissection
Chronic:
1) Valvular, MARFAN'S, EHLERS-DANLOS, Ankylosing spondylitis, SLE
2) Aortic root disease: BEHCET'S, REITER'S, HTN

Front 13

Murmur of Aortic Regurgitation

Back 13

Diastolic decrescendo murmur best heard at left sternal border

*WIDENED PULSE PRESSURE - markedly increased systolic BP, with decreased diastolic BP

Front 14

Treatment of Aortic Regurgitation

Back 14

1) Conservative if asymptomatic: diuretics, salt-restriction, digoxin
2) Aortic valve replacement - definitive tx
3) Endocarditis prophylaxis before dental and GI/GU procedures

Front 15

Pathophysiology of Mitral Regurgitation

Back 15

Abrupt elevation of left atrial pressure in setting of normal atrial size and compliance --> backflow into pulmonary circulation --> pulmonary edema

*Hypotension and shock can occur 2/2 decreased cardiac output

Front 16

Causes of Mitral Regurgitation

Back 16

Acute:
1) ENDOCARDITIS (S. aureus MC)
2) Papillary muscle rupture (post-infarction) or dysfunction (2/2 ischemia)

Chronic:
1) RHEUMATIC FEVER
2) Marfan's syndrome
3) Cardiomyopathy

Front 17

Murmur of Mitral Regurgitation

Back 17

1) HOLOSYSTOLIC MURMUR at apex
2) Radiation to the back or clavicular area

*A-fib is a common finding

Front 18

Treatment of Mitral Regurgitation

Back 18

1) Afterload reduction (vasodilators, salt reduction, diuretics, digoxin)
2) Chronic anticoagulation (if A-fib)
3) Mitral valve repair/replacement

Front 19

Causes of Tricuspid Regurgitation

Back 19

1) Right ventricular dilatation
2) TRICUSPID ENDOCARDITIS (IVDA)
3) Epstein's anomaly - downward displacement of tricuspid valve into RV
4) Carcinoid syndrome, SLE, myxomatous valve degeneration

Front 20

Murmur of Tricuspid Regurgitation

Back 20

1) Blowing holosystolic murmur
2) Left lower sternal border
3) INTENSIFIED with INSPIRATION (decreased with expiration or Valsalva)

Front 21

Clinical features of Tricuspid Regurgitation

Back 21

1) Right ventricular failure (ascites, hepatomegaly, edema, JVD)
2) PULSATILE LIVER
3) A-fib usually present

Front 22

Surgical treatment of Tricuspid Regurgitation

Back 22

1) Native valve repair
2) Valvuloplasty of tricuspid ring
3) Valve replacement surgery - rarely performed

Front 23

Mitral Valve Prolapse

Back 23

Excessive or redundant mitral leaflet tissue due to myxomatous degeneration of mitral valve leaflets or chordae tendineae
--> Redundant leaflets prolapse into left atrium during systole

*MC in patients with genetic connective tissue disorders (Marfan's, Ehlers-Danlos, osteogenesis imperfecta)

Front 24

Murmur of Mitral Valve Prolapse

Back 24

1) Mid-to-late Systolic murmur
2) Midsystolic or late systolic click

*STANDING AND VALSALVA MANEUVER INCREASE MURMUR*

Front 25

Sustained hand grip and MVP murmur

Back 25

Increases the murmur

*Decreases murmur in Hypertrophic Cardiomyopathy (HCM)

Front 26

Rheumatic Heart Disease

Back 26

Immunologically-mediated systemic complication of Streptococcal Pharyngitis (group A strept)

Front 27

MC valvular abnormality in Rheumatic Heart Disease

Back 27

Mitral stenosis

*Aortic or tricuspid involvement as well

Front 28

Major Criteria of Acute Rheumatic Fever

Back 28

1) Migratory polyarthritis
2) Erythema marginatum
3) Cardiac involvement (pericarditis, CHF, valvular dz)
4) Chorea
5) Subcutaneous nodules

*Diagnosis requires 2 major criteria or 1 major and 2 minor

Front 29

Minor Criteria of Acute Rheumatic Fever

Back 29

1) Fever
2) Elevated ESR
3) Polyarthralgias
4) Prior history of rheumatic fever
5) Prolonged PR interval
6) Evidence of preceding streptococcal infection

*Diagnosis requires 2 major criteria or 1 major and 2 minor

Front 30

Treatment of Rheumatic Heart Disease

Back 30

1) Treat stept pharyngitis with Penicillin or erythromycin
2) Treat acute rheumatic fever with NSAIDs

*C-reactive protein used to monitor tx

Front 31

Acute Infective Endocarditis

Back 31

MCC by Staph aureus (virulent)
Occurs on NORMAL heart valve
Fatal in less than 6 weeks if untreated

Front 32

Subacute Infective Endocarditis

Back 32

Caused by less virulent organisms (Strept viridans, enterococcus)
Occurs on DAMAGED heart valves
Fatal if untreated, but takes longer than 6 weeks

Front 33

Organisms of Native Valve Endocarditis

Back 33

1) S. VIRIDANS
2) S. aureus
3) S. epidermidis
4) Enterococci
5) HACEK (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

Front 34

Organisms of Prosthetic Valve Endocarditis

Back 34

Early onset: Staph (epidermidis > aureus)
Late onset: Strep

Front 35

Organisms of IVDA Endocarditis

Back 35

MCC: S. AUREUS

*Others: Pseudomonas, enterococci, strept, Candida

Front 36

Complications of Endocarditis

Back 36

1) Cardiac failure
2) Myocardial abscess
3) Showered emboli --> solid organ damage
4) Glomerulonephritis

Front 37

Treatment of Endocarditis

Back 37

Parenteral antibiotics

*Penicillin (or vancomycin) and aminoglycoside until an organism is isolated

Front 38

Nonbacterial Thrombotic Endocarditis (Marantic Endocarditis)

Back 38

Sterile deposits of fibrin and platelets form along closure of cardiac valve leaflets
Vegetations can embolize to brain or periphery
*Associated with debilitating diseases (metastatic cancer)

Front 39

Nonbacterial Verrucous Endocarditis (Libman-Sacks Endocarditis)

Back 39

Formation of small warty vegetations on BOTH SIDES of valve leaflets (usually aortic)
Can be a source of systematic embolization

*Associated with SLE

Front 40

Endocarditis Prophylaxis

Back 40

Amoxicillin
Indicated for patients with known valvular heart disease or prosthetic valves prior to oral or GI/GU surgery

Front 41

Duke's Major Criteria for Endocarditis

Back 41

1) Sustained Bacteremia (organism known to cause endocarditis)
2) Endocardial involvement (by echo or new valvular regurg)

Front 42

Duke's Minor Criteria for Endocarditis

Back 42

1) Predisposing condition
2) Fever
3) Vascular phenomena (Janeway lesions, mycotic aneursyms, septic arterial or pulmonary emboli)
4) Immunologic phenomena (GN, Osler's nodes, Roth spots, RF)
5) Positive blood cultures
6) Positive Echo

Front 43

Janeway Lesions

Back 43

Painless erythematous lesions on palms and soles

*Associated with Endocarditis

Front 44

Osler's Nodes

Back 44

Painful, raised lesions of fingers, toes, or feet

*Associated with Endocarditis

Front 45

Roth's Spots

Back 45

Oval, retinal hemorrhages with clear, pale center

*Associated with Endocarditis