Medicine Marrow Pg 311-320 (Cardiology)

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Questions and Answers

What is a common bioprosthetic valve's advantage in Aortic Valve Replacement (AVR)?

Only suitable for elderly patients

Lower complication rates (correct)

Higher infection rates

Requires continuous anticoagulants

Trans Catheter Aortic Valve Replacement (TAVR) is a procedure that can be performed by general practitioners without special training.

False

What is one indication for performing an Aortic Valve Replacement?

Severe symptomatic Aortic Stenosis

Match the following types of valves used in TAVR with their characteristics:

Balloon-expandable valve = Requires dilation for placement Self-expanding valve = Expands automatically upon insertion Signup and view all the answers

Which of the following is a sign of wide pulse pressure?

Hill's sign Signup and view all the answers

Aortic regurgitation leads to an increase in diastolic blood pressure.

False Signup and view all the answers

What effect does resting or sleeping bradycardia have in patients with aortic regurgitation?

Worsens AR and increases angina due to prolonged diastole. Signup and view all the answers

In aortic regurgitation, the left atrial pressure (LAP) is __________ due to increased left ventricular volume.

increased Signup and view all the answers

Match the clinical findings with their relation to Aortic Stenosis (AS) or Aortic Regurgitation (AR):

Angina = First symptom in AS, nocturnal only in AR Syncope = Common in AS, absent in AR Dyspnea = Increased in both conditions, but for different reasons Palpitations = Absent in AS, present in AR Signup and view all the answers

Which of the following conditions is the most common cause of root-related chronic aortic regurgitation?

Syphilis Signup and view all the answers

Acute aortic regurgitation is characterized by gradual onset of symptoms over several months.

False Signup and view all the answers

What is the primary hemodynamic change in the left ventricle due to chronic aortic regurgitation?

Eccentric hypertrophy Signup and view all the answers

Chronic aortic regurgitation can be classified as ____, which typically has no symptoms.

mild-moderate Signup and view all the answers

Match the following causes of chronic aortic regurgitation with their categories:

Rheumatic disease = Valvular (Leaflet) Takayasu arteritis = Root Related Marfan's syndrome = Root Related Quadricuspid valves = Valvular (Leaflet) Signup and view all the answers

What kind of murmur is associated with aortic stenosis?

Harsh mixed frequency with late systolic accentuation Signup and view all the answers

Aortic stenosis typically presents with a soft first heart sound (SI) in patients with aortic valve stenosis due to degenerative pathology.

True Signup and view all the answers

What pattern on an ECG indicates left ventricular hypertrophy (LVH) associated with aortic stenosis?

Sokolov - Lyon criteria Signup and view all the answers

The _____ phenomenon describes the low pitch component of the murmur radiating to the apex in aortic stenosis.

Gallavardin Signup and view all the answers

Match the following heart sounds or characteristics with their associated conditions:

S3 = Left Ventricular Hypertrophy and Failure Ejection click = Bicuspid Aortic Valve S4 = Atrial Hypertrophy Dilated aortic arch = Aortic Stenosis Signup and view all the answers

What does a collapsing pulse indicate?

Aortic regurgitation Signup and view all the answers

A pseudocollapsing pulse has a sharp upstroke and is high volume.

False Signup and view all the answers

In which condition would you typically observe a pulsus bisferiens?

Hypertrophic cardiomyopathy (HCM) Signup and view all the answers

The ______ pulse has a high volume and sharp downstroke.

collapsing Signup and view all the answers

Match the following types of pulses with their characteristics:

Collapsing pulse = Sharp upstroke, high volume Pseudocollapsing pulse = Ill-sustained apex, normal volume Pulsus bisferiens = Two peaks in systole P > T = Hypertrophic cardiomyopathy Signup and view all the answers

Which of the following is a definitive treatment for acute aortic regurgitation?

Immediate surgery Signup and view all the answers

The SS-50 rule applies to symptomatic severe aortic regurgitation.

False Signup and view all the answers

What is the typical initial symptom of aortic dissection related to acute aortic regurgitation?

Chest pain Signup and view all the answers

In acute aortic regurgitation, the left atrial pressure (LAP) can exceed __________ mmHg.

25 Signup and view all the answers

Match the following features with their associated conditions related to aortic regurgitation:

Cardiogenic shock = LV Failure Short low pitched EDM = Aortic Regurgitation Hypotension = LV Failure Infective endocarditis = Acute AR Cause Signup and view all the answers

What is the classification for heart failure with reduced ejection fraction?

HFrEF Signup and view all the answers

Angina is not considered a first-line symptom of NYHA classification.

False Signup and view all the answers

What does the abbreviation ADHF stand for?

Acute Decompensated Heart Failure Signup and view all the answers

Heart failure classified as HFPEF has an ejection fraction of __________ or greater.

50% Signup and view all the answers

Match the NYHA class with its criteria:

Class I = Symptoms with more than ordinary activity Class II = Symptoms with ordinary physical activity Class III = Symptoms with less than ordinary activity Class IV = Symptoms at rest Signup and view all the answers

What stage of heart failure has no symptoms and only risk factors present?

Stage A Signup and view all the answers

Patients in Stage C heart failure are symptomatic, whether prior or present.

True Signup and view all the answers

What does HFrEF stand for?

Heart Failure with reduced Ejection Fraction Signup and view all the answers

The stage of heart failure that is also known as refractory heart failure is Stage ____.

D Signup and view all the answers

Match the following symptoms with their relevance to systolic failure:

Fatigue = Leads to cachexia due to TNF-a Decreased urine output = A symptom of decreased cardiac output Cool extremities = Indicates reduced blood flow Cyanosis = A sign of decreased oxygen saturation Signup and view all the answers

Which of the following symptoms is predominantly associated with heart failure?

Dyspnea Signup and view all the answers

In patients with heart failure, orthopnea occurs immediately after lying down.

True Signup and view all the answers

What condition is characterized by an increase in left atrial pressure (LAP)?

Diastolic heart failure Signup and view all the answers

In diastolic failure, the primary issue is __________ which leads to increased left ventricular end-diastolic pressure (LVEDP).

insufficient dilation Signup and view all the answers

Match the presentations of dyspnea with their descriptions:

Orthopnea = Dyspnea immediately after lying down PND = Dyspnea after 2-3 hours of lying down Crackles = Sound indicative of pulmonary congestion Pleural effusion = Fluid accumulation in the pleural space Signup and view all the answers

Where is the ejection systolic murmur typically located?

Base of the heart Signup and view all the answers

The Austin Flint murmur is characterized by a high-pitched sound.

False Signup and view all the answers

What presentation is associated with Corrigan sign?

Prominent carotid and supraclavicular pulsations Signup and view all the answers

The _____ de Musset sign is characterized by head nodding with heartbeat.

Alfred Signup and view all the answers

Match the signs to their descriptions:

Corrigan sign = Prominent carotid and supraclavicular pulsations Alfred de Musset sign = Head nodding with heart beat Signup and view all the answers

Study Notes

Aortic Valve Replacement (AVR)

Bioprosthetic valves are commonly used for AVR, offering less complications and eliminating need for anticoagulants.
AVR is indicated for severe symptomatic aortic stenosis (AS) and for severe asymptomatic AS with LV ejection fraction < 50%, gradient > 60 mmHg, peak flow ≥ 5 m/s, rapid progression on yearly echocardiogram, undergoing other procedures, or symptomatic on dobutamine stress test.
Dobutamine stress test helps differentiate severe AS from LVF with incidental AS.
AVR has potential disadvantages including more complications and difficulty obtaining fitness for elderly patients.

Trans Catheter Aortic Valve Replacement (TAVR)

Performed by cardiologists trained in TAVR.
Costly procedure but considered an option when AVR is contraindicated.
Two types of valves used in TAVR: balloon-expandable and self-expanding.

Severe/Decompensate Aortic Regurgitation (AR)

Leads to LV failure with increased end-systolic volume, decreased ejection fraction, and increased left atrial pressure, resulting in dyspnea.

Effect on Circulatory Parameters

Preload increases due to the backflow of blood from aorta to the LV.
Afterload increases due to increased systolic blood pressure, stretching the heart and boosting contractility (Frank-Starling Law).
Diastolic Blood Pressure (DBP) significantly decreases as the blood regurgitates into the LV, potentially reaching zero.
Pulse Pressure (PP) widens due to the significant difference between systolic and diastolic blood pressure.

Signs of Wide Pulse Pressure

Hill's sign: Lower limb BP - upper limb BP > 20 mmHg, considered the surest sign.
Lincoln's sign: Prominent popliteal pulsations.

Nocturnal Angina

Resting bradycardia during sleep prolongs diastole, worsening AR and leading to increased blood stealing from coronary arteries, causing angina.
Vasoconstriction increases aortic pressure, further worsening AR by increasing the gradient between the aorta and LV.
Strict blood pressure control is crucial.
AR patients generally experience better outcomes when exercising due to tachycardia, which shortens diastole.

Aortic Stenosis vs Aortic Regurgitation

	AS	AR
Angina	+++ (First symptom)	+ (Nocturnal only)
Syncope	+	-
Dyspnea	++ (Increased Left Ventricular End Diastolic Pressure)	+ (Left Ventricular Failure → Increased Left Ventricular End Diastolic Pressure)
Palpitations	- (Pressure overload)	+ (Volume overload)

Aortic Stenosis

Clinical Findings

Pulse: High volume pulse due to increased blood in the left ventricle and increased ejection fraction.

Heart Sounds

S1: Ejection click may be present in bicuspid aortic valve (BAV).
A2: Soft in degenerative pathology, loud in BAV pathology, and reverse split (late A2) in severe AS.
S3: Present due to LVH & LVF.
S4: Present.

Murmur

Harsh, mixed frequency ejection systolic murmur with late systolic accentuation.
Low pitch component radiating to carotids.
High pitch component radiating to apex (Gallavardin phenomenon).
Best heard in the aortic area.

Management

Management largely depends on symptom severity and echocardiogram findings.

Investigations

ECG: LV strain pattern (LVH) with Sokolov-Lyon criteria (V5/V6 R wave + VI/V5 S wave > 35 mm), minimal ST depression and asymmetric T inversion.
X-ray: Dilated aortic arch in AS.
ECHO: Definitive diagnosis and assessment of AS severity.

Aortic Regurgitation

Classification

Acute AR: Usually a sudden onset due to trauma, infection, or aortic dissection.
Chronic AR: Generally develops over time due to various valvular or root-related causes.

Chronic AR Causes

Valvular (Leaflet) Causes:
- Rheumatic: May be associated with mitral stenosis (MS) or aortic stenosis (AS).
- Congenital: Quadricuspid valves.
- Takayasu arteritis.
- Ankylosing spondylitis.
Root Related Causes:
- Syphilis (most common).
- Marfan's syndrome.
- Ehlers-Danlos syndrome.
- Rheumatological conditions including Takayasu arteritis, Behcet's disease, Cogan's syndrome (aortitis + interstitial keratitis + vestibulitis), and IgG4 related disease (large vessel vasculitis).

Chronic AR Classification

Mild to moderate: No or minimal symptoms, possibly palpitations.
Severe: Symptomatic due to left ventricular failure.

Chronic AR Pathology

Core: Diastolic regurgitation.
Diastolic Pressure: Significant pressure gradient between LV (around 10 mmHg) and aorta (around 80 mmHg) due to backflow.

Chronic AR Circulatory Changes

Mild to Moderate: Incompetent leaflets lead to incomplete closure, allowing blood to leak back from aorta to LV.
Ejection Fraction (EF): Normal or slightly increased.
EDV (End Diastolic Volume): May be increased.
LVEDP (Left Ventricular End Diastolic Pressure): Usually normal but may slightly increase in severe cases.

Collapsing Pulse

Also observed in regurgitation, aorta-pulmonary window, or patent ductus arteriosus.

Collapsing vs. Pseudocollapsing Pulse

	Collapsing pulse	Pseudocollapsing pulse
	Sharp upstroke, sharp downstroke	Ill-sustained apex
	High volume	(N) volume
	Seen in AR	Seen in MR

Pulsus Bisferiens

Two peaks in systole:
- P: Percussion wave
- T: Tidal wave
- Normally: P > T.
- But in Hypertrophic cardiomyopathy (HCM): P < T.

Aortic Regurgitation: Management

Symptomatic AR: Aortic valve replacement surgery required.
Asymptomatic Severe AR: LV failure is present but patient is asymptomatic. The "SS-50 rule" is applied:
- EF ≤ 55%
- LVEDD ≥ 50%

Acute AR

Causes:
- Aortic Dissection: Chest pain.
- Infective Endocarditis: Potential complication of infection.
- Rupture of Sinus of Valsalva: Right heart failure.
- Trauma: May cause damage to the valve or aorta.
Pathology:
- Acute Regurgitation: No time for the heart to adapt, leading to increased LVEDP, and elevated LAP (above 25 mmHg), causing acute pulmonary edema and LV failure.
Features:
- Short, low-pitched ejection systolic murmur (ESM) with a soft S1.
- LV Failure: Cardiovascular shock and hypotension.
Treatment:
- Definitive: Immediate surgery.
- Awaiting Surgery:
  - Nitroglycerin (NTG).
  - Nitroprusside.
  - Inotropes.

Heart Failure

ACC/AHA 2017 Definition: A complex clinical syndrome caused by any structural or functional cardiac disorder (e.g., LVH, arrhythmia) that impairs the ventricle's ability to fill with or eject blood.
Note:* ACC: American College of Clinical Cardiology; AHA: American Heart Association

Heart Failure Classification

Types of Heart Failure:

HFrEF (Reduced EF < 40%): Characterized by reduced left ventricular ejection fraction.
HFPEF/HFNEF (Preserved/Normal EF ≥ 50%): Preserved or normal left ventricular ejection fraction but impaired diastolic filling.
HFMEF (Mid-range EF 40-50%): Left ventricular ejection fraction in the mid-range.
ADHF (Acute Decompensated Heart Failure): Sudden deterioration of heart function resulting in fluid overload and reduced cardiac output.

NYHA Classification

First Line Symptoms: Angina, dyspnea, palpitations.
Syncope: Not considered a NYHA symptom.

Class	Criteria	Reason for Mortality
I	Symptoms with more than ordinary activity	Negligible mortality
II	Symptoms with ordinary physical activity	Sudden cardiac death
III	Symptoms with less than ordinary activity
IV	Symptoms with rest	LV failure symptoms

Stages of Heart Failure

Stages	Characteristics
A	- No symptoms.- No structural heart disease.- Only has risk factors: - HTN.- Atherosclerosis.- DM.- OSA.
B	- No symptoms.- Structural heart disease present.- E.g: 1.HTN patient → LVH. 2.Previous MI → Cardiac remodelling.
C	- m/c.- Patient is symptomatic (Prior/present).
D	- AKA refractory heart failure.- No response to any medical therapy.

Note: Most common presentation of heart failure: HFrEF, NYHA 2/3, Stage C.

HFrEF

Clinical Features

Systolic Failure Symptoms (LV Forward Symptoms):
- Due to decreased cardiac output, indicating left-sided heart failure.
- Fatigue: Can lead to cachexia (extreme weight loss) due to TNF-α.
- Decreased Urine Output.
- Cool Extremities.
- Cyanosis.
- Altered Mentation.
- S3 Heart Sound.
- Cardiomegaly (Dilated LV).
- Displaced Apex.
- Pulsus Alternans.
- Narrow Pulse Pressure.

Diastolic Failure Symptoms

Concentric LVH (Left ventricular hypertrophy):
- Cavity size decreases.
- Volume decreases.
Systolic Failure:
- Insufficient dilation.
- Increased end systolic volume (ESV).
Increased LVEDP (Left ventricular end diastolic pressure).
Increased LAP (left atrium pressure).
Increased PCVP (Pulmonary capillary venous pressure).
Pulmonary exudation.

Dyspnea

Crackles: Typically present in acute presentation.
Pleural Effusion: More common on the right side, patients may prefer to lie on their right side.

Presentations of Dyspnea

Orthopnea: Dyspnea that arises immediately after lying down.
Paroxysmal Nocturnal Dyspnea (PND): Dyspnea occurring 2-3 hours after lying down.
When the patient lies supine, fluid shifts from interstitial to intravascular space.
This fluid increase is not accommodated by the failing heart, leading to backflow into the pulmonary circulation and symptoms of air hunger.

Associated Murmurs

Ejection Systolic Murmurs: Heard at the base of the heart.
Austin Flint Murmur:
- Low-pitched, mid-diastolic murmur.
- Caused by displacement of the anterior mitral leaflet by the regurgitant jet.

Peripheral Signs

Sign	Presentation
Corrigan sign	Prominent carotid and supraclavicular pulsations
Alfred de musset sign	Head nodding with each heartbeat

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Description

This quiz covers key concepts related to aortic valve replacement (AVR) and transcatheter aortic valve replacement (TAVR). Learn about indications for AVR, the significance of the dobutamine stress test, and the types of valves used in TAVR. Explore complications and patient considerations in valve replacement procedures.