Valvular heart disease

Aortic stenosis
1. causes (by CALCIFICATION)
  1. congenital
  2. rheumatic fever
  3. AGE
2. symps
  1. late present: angina, exercise induced syncope, dyspnea
3. signs
  1. slow rising pulse. maybe systolic thrill.
  2. EJECTION SYSTOLIC MURMUR. crescendo decrescendo
4. Investig
  1. CXR: small heart, dilated asc aorta
  2. ECG. maybe LV hyptertrophy, (LV strain- depressed ST seg, T wave inversion)
  3. Echo. thickened, calcific + immobile arotic valve cusps. maybe LV hypertrophy
5. treat
  1. if symptomatic, aortic valve replace
Mitral Regurg
1. causes (2 most common)
  1. rheumatic heart disase 50%
  2. prolapsing mitral valve
2. pathphys: regurg into LA, LA dilat (if long standing, LA stretched, little pressure. if acute, pressure up, ...-> pulm edema)
3. synps (only late on)
  1. maybe 'palpitations'
  2. late: R heart fail -> CCF
    1. dyspnea/orthopnea b/c pulm venous hypertens
    2. fatigue
4. signs
  1. PANSYSTOLIC MURMUR. radiates to axilla
  2. soft S1
  3. lat displaced diffuse apex beat
  4. prominent S3
5. investigs
  1. CXR: LA + LV enlarge w/valve calcific + increased CTR
  2. ECG- bifid P waves (LA delay); LV hypertrophy. maybe AF
  3. echo- dilated LA + LV. use doppler for regurg jet
6. treat
  1. monitor w/echos if mild no symps
  2. prophylax agains infect endocarditis
  3. repair/replace valve if progressive heart enlarge. if not surg (ACE inhibs, diruetics, maybe anticoag)
Mitral stenosis
1. cause: RHEUMATIC HEART DISEASE
2. valve narrows, LA hypertrophy so suffic CO maintained. increases pulm venous, pulm arterial, R heart pressure. pulm edema. pulm hypterens. RV hypertrophy -> failure.
3. symps
  1. none until moderate
  2. dyspnea (progressive)
  3. cough (w/blood)
  4. (+ symps of Rheart fail, + AF (palpits, emboli)
4. signs
  1. malar flush
  2. small vol pulse (if AF, irreg irreg)
  3. if R heart fail, obvious distension in Jug veins. if pulm hypertens, q wave present
  4. tapping felt parasternally on L (palp)
  5. 1st heart sound either loud or silent
  6. RUMBLING MID-DIASTOLIC MURMUR (do roll onto L side manoeuvre, use bell)
5. investigs
  1. CXR: small heart, enlarged LA, pulm venous hypertesn
  2. ECG: bifid P wave + often AF
  3. Echo (help calculate mitral valve area)
6. treatment
  1. if mild: treat promptly the attacks of bronchitis
  2. treat breathless w/diuretic
  3. treat AF w/digoxin + anticoags
Aortic Regurg
1. common causes: rheumatic fever, infective endocarditis complicateing a previously damaged valve (either congen or rheum fever)
2. path phys: reflux of blood from aorta into LV during diastole -> LV must enlarge to allow for maintain CO (so LV has more O2demand). diastolic BP down, coronary perfusion down
3. symps (occur late b/c don't devel until LV fail)
  1. pounding of heart
  2. angina
  3. (dyspnea)
4. signs
  1. BOUNDING/COLLAPSING PULSE
  2. hyperdynamic circ, reflux into LV, increased LV size
  3. capillary pulsation in nails... and many more
  4. high pitched EARLY DIASTOLIC murmur (left sternal edge lean forward)
5. investigs
  1. CXR- LV enlarge, dilat of asc aorta
  2. ECG- LV hypertrophy. left leads- tall Rs, deeply inverted Ts. R leads- deep Ss.
  3. echo- dilat LV, vigorous contract. doppler for regurg jet
6. treat
  1. underlying cause (ie syphilitic) aortitis or infective endocarditis
  2. aortic valve replace (before signif symps, but timing critical)

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Valvular heart disease

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