Download CV2 Jonathan Evans - Peer Teaching Society

Phase 2
Jonathan Evans
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Aims
Aortic Stenosis
Aortic Regurgitation
Mitral Stenosis
Mitral Regurgitation
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Causes
Symptoms
Murmur and signs
Treatment
Questions
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Valves
Mitral
Valve
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If in doubt - Rheumatic fever
• Children aged 5-15
• Common in Asia and south America
• Pharyngeal infection with:
Streptococcus Pyogenes followed by
the clinical syndrome of Rheumatic fever
• It is an autoimmune reaction – not an
infection
• After 10-20 years - valve disease
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Aortic Stenosis - Causes
• Congenital – Bicuspid valve presents
later in life
• Acquired
1. Degenerative: Calcific valve disease
2. Rheumatic fever
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Pathophysiology
Reduced
cardiac output
Left ventricular
hypertrophy
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Symptoms – severe AS
SAD
Syncope – exercise induced
Angina – from LV hypertrophy
Dyspnoea – due to Heart failure
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Signs
• Ejection Systolic murmur radiating to
the carotids
• Slow rising pulse
• Systolic thrill over aortic area
Other:
• Systolic ejection click
• Soft 2nd heart sound
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Aortic Regurgitation - Causes
1. Rheumatic fever
2. Infective endocarditis
– Likes to sit on previously damaged
valves
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Pathophysiology
Left ventricular
failure
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Symptoms
Asymptomatic until Left Ventricular Failure
occurs
• Dyspneoa
• Fatigue
• “pounding of the heart”
• Angina, but less common than in AS
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Murmur
Two murmurs to remember:
1. Early Diastolic: left sternal edge, high pitch
2. Ejection systolic – from high flow of blood
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Signs – Aortic Regurgitation
1. Collapsing or Water-hammer pulse
2. Deviated apex beat
3. Lots of signs with weird names that we don’t
need to remember.
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Mitral Stenosis - Causes
1. Rheumatic fever
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Pathophysiology
Atrial
Fibrillation
Pulmonary hypertension
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Symptoms
Pulmonary Hypertension
• Dyspnoea
• Cough – frothy blood tinged sputum
Right heart Failure
• Raised JVP
• Big liver
• Ankle swelling
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Signs
1. Rumbling Mid-diastolic murmur – heard best
with the bell at the apex with the patient
lying on the left side
2. Opening snap – at the start of the murmur
3. Pink cheeks – malar flush
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Mitral Regurgitation- Causes
1. Rheumatic fever (50%)
2. Prolapsing mitral valve
3. Other:
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Ischaemic heart disease
Cardiomyopathies
Collagen abnormalities
Drugs
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Prolapsing “floppy” mitral valve
• Usually a benign and asymptomatic
condition
• Common – 2-6% of population
• May have atypical chest pain or
palpitations
• “Mid- systolic click”
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Pathophysiology
Left ventricular
failure
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Signs and symptoms
1. Pansystolic murmur – Heard best at the apex
2. Deviated apex beat
3. Left ventricular failure
– Dyspnoea
– Orthopnoea
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Investigations
Echocardiogram to see what’s going on:
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Treatment
• Medical
–Treat Heart Failure if they have it
• Surgical
–Valvoplasty – dilate the valve with a
balloon for stenotic valves
–Replace the valve
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1. Mechanical valve
• Need anticoagulation (warfarin)
• Last longer - Younger people
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2. Bio-prosthetic valve
• Usually porcine
• Doesn’t last as long – elderly people
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Questions
Rumbling Mid-diastolic murmur?
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Answer
Mitral Stenosis
Where is it heard best?
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Answer
Apex – with the patient on their
left and using the bell
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Questions
Aortic Stenosis – what is the
murmur?
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Questions
Ejection systolic heard best right
sternal edge 2nd intercostal space
Where does it radiate?
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Questions
Carotids
Name three symptoms of Aortic
stenosis?
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Questions
Syncope
Angina
Dyspnoea
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Questions
Early diastolic murmur
Where is it heard best?
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Questions
Left sternal edge
What other murmur might you
hear?
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Questions
Ejection systolic – due to high flow
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Questions
Ejection systolic – due to high flow
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Questions
Ejection systolic – due to high flow
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Questions
Ejection systolic – due to high flow
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Previous exam question
A 78 year old man presented with episodes of
loss of consciousness on exertion. On
examination, the carotid pulse is rising slowly.
There is a loud ejection systolic murmur at the
aortic area, radiating to both carotid arteries.
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Answer
Aortic stenosis
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Question
A 32 year old lady presented with recurrent
palpitation and exertional breathlessness. On
examination, her height is 183 cm and her armsspan is 185 cm. The first heart sound is soft.
There is a mid-systolic click, followed by a
blowing late systolic murmur in the apex
radiating to the axilla.
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Answer
Mitral valve prolapse
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Question
A 45 year old lady, who moved to the UK from
India 5 years ago, presented with increasing
exertional dyspnoea and orthopnoea. On
examination, the apex beat is tapping, with a
loud first heart sound, and an apical middiastolic rumble.
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Answer
Mitral Stenosis
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Question
47 year old chap presents with intermittent
breathlessness. ECG is normal but 24 hr tape shows
runs of AF. Paroxysmal AF is diagnosed. On auscultation
he has a mid-diastolic murmur and is diagnosed with
mitral stenosis.
1. Why is he presyncopal when he’s going into AF?
2. How is the mitral stenosis causing AF?
3. 2x imaging investigations for this patient + rationales
for each
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Question
A 21 year old female intravenous drug abuser
collapses following a 2 day history of rapidly
increasing malaise, fever and a patchy rash.
Although previously well, she now has a systolic
cardiac murmur. Her urine shows both protein
and blood on dipstick test.
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Which is most likely?
1. Acute rheumatic fever
2. Amyloid valve tissue
3. Congenital valve anatomy abnormality
4. Infective endocarditis
5. Metallic valve prosthesis
6. Mitral valve prolapse
7. Non-bacterial thrombotic endocarditis
8. Normal valve
9. Senile calcific valve stenosis
10. Xenograft valve
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Answer
4. Infective endocarditis
Fever + new murmur = Endocarditis
Two main causes:
1. Streptococcus Viridans (dental problems)
2. Staphylococcus aureus (IVDU, Diabetes, Surgury)
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Question
A 71 year old male presents with anginal
symptoms, shortness of breath and syncopal
attacks when exercising. He has a harsh systolic
flow murmur at the right sternal edge 2nd
intercostal space.
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Which is most likely?
1. Acute rheumatic fever
2. Amyloid valve tissue
3. Congenital valve anatomy abnormality
4. Infective endocarditis
5. Metallic valve prosthesis
6. Mitral valve prolapse
7. Non-bacterial thrombotic endocarditis
8. Normal valve
9. Senile calcific valve stenosis
10. Xenograft valve
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Answer
9. Senile calcific valve stenosis
The commonest cause of Aortic stenosis is:
Calcific valve disease and mainly occurs in the elderly.
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Question 3
An 81 year old male patient with carcinoma of
the bronchus collapses and dies. The autopsy
shows irregular vegetations on the mitral valve.
No septic event was identified prior to the
patient’s death, and the clinicians did not detect
an ante-mortem murmur.
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Which is most likely?
1. Acute rheumatic fever
2. Amyloid valve tissue
3. Congenital valve anatomy abnormality
4. Infective endocarditis
5. Metallic valve prosthesis
6. Mitral valve prolapse
7. Non-bacterial thrombotic endocarditis
8. Normal valve
9. Senile calcific valve stenosis
10. Xenograft valve
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Answer
Non Bacterial Thrombotic Endocarditis
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