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26 Cards in this Set
- Front
- Back
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Acute rheumatic fever
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Inflammatory condition
-all 3 layers Group A Strep -2-3 weeks after throat infection -does not involve direct bacterial infection of heart Histopathologic -Aschoff body (focal fibrinoid necrosis surrounded by inflammatory cells) -Fibrous scar tissue Valvular symptoms may not manifest for 10-30 years later -most often mitral valve stenosis followed by aortic stenosis Presenting symptoms: chills, fever, fatigue, migratory arthralgias (Jones criteria) For those who have already experienced ARF -low dose penicillin prophylaxis until early adulthood |
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Mitral stenosis: etiology, pathology
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Rheumatic fever
Fibrous thickening and calcification of valve leaflets Fusion of commissures |
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Mitral stenosis: pathophysiology
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Emptying of LA is impeded and there is an abnormal pressure gradient between LA and LV
LA pressure is higher than normal Increased pulmonary venous and capillary pressures -dyspnea and other symptoms of CHF -hemoptysis Chronic elevation of right ventricular pressure leads to hypertrophy and dilation of that chamber and ultimately to right sided heart failure Chronic pressure overload of the LA in MS leads to left atrial enlargement -atrial fibrillation (could lead to stroke, requires anticoagulation) |
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Mitral stenosis: presentation
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Mild:
Dyspnea upon exertion Decompensation with hyperthyroidism, pregnancy, exercise Severe: Dyspnea at rest Orthopnea Paroxysmal nocturnal dyspnea Signs of right sided heart failure Compression of recurrent laryngeal nerves may cause hoarseness |
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Mitral stenosis: examination
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Loud S1
-in early stages -in late stages, leaflets might be immobile Opening snap -follows S2 -interval between S2 and OS relates inversely to severity of MS Diastolic rumble -low frequency decrescendo murmur after OS with presystolic accentuation -duration relates to severity Chest radiograph reveals LA enlargement, pulmonary vascular redistribution, interstitial edema, Kerley B lines Echocardiography: thickened mitral leaflets and fusion of commissures |
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Mitral stenosis: treatment
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Diuretics
If atrial fibrillation: B blocker, CCB, or digoxin to slow rapid ventricular rate and improve diastolic LV filling. Chronic anticoagulation Percutaneous balloon mitral valvuloplasty -complications: cerebral emboli, cardiac perforation, mitral regurgitation Open mitral commissurotomy Mitral valve replacement |
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Mitral regurgitation: etiology
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Myxomatous degeneration of valve
Infective endocarditis Rheumatic fever Hypertrophic obstructive cardiomyopathy Calcification of mitral annulus -can occur with normal aging but more common among HTN, diabetes, end-stage renal disease Primary rupture of chordae tendineae Ischemic heart disease LV enlargement Fen-phen |
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Mitral regurgitation: pathophysiology
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Forward cardiac output into aorta is less than LV total output (some going into LA)
Elevation of LA volume and pressure Reduction of forward cardiac output Volume related stress on LV Affected by systemic vascular resistance opposing forward LV flow -increases regurgitant fraction Left atrial compliance |
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Left atrial compliance and mitral regurgitation
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Acute MR
-no compliance yet -rapid pulmonary congestion and edema -prominent v wave Chronic MR -LA dilates and compliance increases -Prevents significant increases in pulmonary vascular pressures (at cost of reduced forward cardiac output) -Low forward cardiac output leads to weakness and fatigue -chronic LA dilation predisposes to Afib -LV undergoes gradual compensatory dilation through eccentric hypertrophy |
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Mitral regurgitation: examination
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Apical holosystolic murmur
Clench fists -murmur intensifies Severe acute MR -decrescendo murmur S3 Laterally displaced PMI Large v wave |
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Mitral regurgitation: treatment
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Medical therapy involves augmenting forward cardiac output while reducing regurgitation into LA and relieving pulmonary congestion
Diuretics Vasodilators Mitral valve surgery should be done before chronic MR results in LV contractile impairment -Mitral valve repair -Mitral valve replacement |
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Mitral valve prolapse
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Common, usually asymptomatic
Midsystolic click |
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Aortic stenosis: etiology
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Age related degenerative calcific changes (>65)
Congenitally deformed aortic valves (<65) |
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Aortic stenosis: pathology
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Common etiology with atherosclerotic vascular disease
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Aortic stenosis: Pathophysiology and presentation
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Significant elevation of LV pressure
Chronic Concentric hypertrophy -reduces ventricular wall stress -reduces compliance -elevates diastolic LV presure causes LA to hypertrophy to fill "stiff LV" May cause angina -imbalance between myocardial oxygen supply and demand May cause syncope during exertion May cause symptoms of heart failure -elevation of LA and pulmonary venous pressures Once angina, syncope, and CHF develop, they confer a significantly decreased survival |
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Aortic stenosis: exam
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Late peaking systolic ejection murmur
Weaking parvus and delayed tardus S4 Reduced intensity or complete absence of A2 |
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Aortic stenosis: natural history and treatment
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Natural history of severe symptomatic uncorrected AS is poor
-effective treatment requires replacement of valve Aortic valve replacement -severe, symptomatic -LVEF almost always increases after replacement Percutaneous valvuloplasty disappointing -high rates of restenosis Mild, asymptomatic has slow rate of progression -avoid hypotension |
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Aortic regurgitation: etiology
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Disease of aortic leaflets
Dilation of aortic root |
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Aortic regurgitation: pathophysiology
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Acute
-LV noncompliant and diastolic pressure rises -Transmitted to LA and pulmonary circulation -Dyspnea and pulmonary edema -Therefore, usually a surgical emergency Chronic: -LV compensation -Chronic dilation (eccentric), eventually results in systolic dysfunction -Widened pulse pressure -Angina |
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Aortic regurgitation: examination
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Bounding pulses
Hyperdynamic LV impulse Blowing murmur in early diastole CXR shows enlarged LV silhouette (chronic) Pulmonary vascular congestion (acute) |
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Aortic regurgitation: treatment
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Clinical progression is normal and slow
Asymptomatic: Vasodilators ACEI (when HTN present) Symptomatic: -surgical (death soon if not corrected) |
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Tricuspid stenosis
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Rare
Long term consequence of rheumatic fever OS Diastolic murmur intensifies on inspiration Neck veins distended and show large a wave |
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Tricuspid regurgitation
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Functional rather than structural (results from RV enlargement)
Rare cause is carcinoid syndrome Prominent v waves and pulsatile liver Systolic murmur louder on inspiration |
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Pulmonic stenosis
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Almost always congenital deformity of valve
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Pulmonic regurgitation
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Severe pulmonary hypertension
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Prosthetic valves
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Mechanical:
Require lifelong anticoagulation Younger Biological: Don't require long term anticoagulation Older |
