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Questions and Answers
Which symptom is commonly associated with Aortic Stenosis?
Which symptom is commonly associated with Aortic Stenosis?
What is the most common valvular lesion in the US?
What is the most common valvular lesion in the US?
In Aortic Stenosis, where is the mid-systolic murmur typically heard?
In Aortic Stenosis, where is the mid-systolic murmur typically heard?
What does the crescendo-decrescendo murmur pattern in Aortic Stenosis indicate?
What does the crescendo-decrescendo murmur pattern in Aortic Stenosis indicate?
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When would you see symptoms in Aortic Stenosis?
When would you see symptoms in Aortic Stenosis?
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Which grade of heart murmur would be described as moderately loud without a thrill?
Which grade of heart murmur would be described as moderately loud without a thrill?
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What is the most common cause of Mitral Stenosis?
What is the most common cause of Mitral Stenosis?
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Which symptom is typically associated with Mitral Stenosis?
Which symptom is typically associated with Mitral Stenosis?
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What is the characteristic sound associated with Mitral Regurgitation?
What is the characteristic sound associated with Mitral Regurgitation?
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Which condition can be associated with Mitral Valve Prolapse?
Which condition can be associated with Mitral Valve Prolapse?
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What is the characteristic sound heard in Mitral Valve Prolapse during systole?
What is the characteristic sound heard in Mitral Valve Prolapse during systole?
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'Doming' of the anterior valve leaflet is a classic sign seen in which condition?
'Doming' of the anterior valve leaflet is a classic sign seen in which condition?
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What does the gold standard evaluation for Mitral Stenosis involve?
What does the gold standard evaluation for Mitral Stenosis involve?
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What is the primary compensatory mechanism seen in response to long term Mitral Regurgitation?
What is the primary compensatory mechanism seen in response to long term Mitral Regurgitation?
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In Aortic Stenosis, the degeneration and calcification of leaflets is primarily due to congenital factors.
In Aortic Stenosis, the degeneration and calcification of leaflets is primarily due to congenital factors.
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Aortic Stenosis is typically associated with symptoms such as angina, syncope, and heart failure.
Aortic Stenosis is typically associated with symptoms such as angina, syncope, and heart failure.
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Aortic Stenosis is only diagnosed in older individuals due to the characteristic diamond-shaped murmur pattern.
Aortic Stenosis is only diagnosed in older individuals due to the characteristic diamond-shaped murmur pattern.
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Echocardiography is used to determine valve morphology, left ventricular function, and aortic valve area & pressure gradient measurements in Aortic Stenosis.
Echocardiography is used to determine valve morphology, left ventricular function, and aortic valve area & pressure gradient measurements in Aortic Stenosis.
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What is a common symptom associated with Aortic Stenosis?
What is a common symptom associated with Aortic Stenosis?
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When might a cardiac catheterization be considered for a patient with suspected Aortic Stenosis?
When might a cardiac catheterization be considered for a patient with suspected Aortic Stenosis?
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What is the primary cause of degeneration and calcification of leaflets in Aortic Stenosis?
What is the primary cause of degeneration and calcification of leaflets in Aortic Stenosis?
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In Aortic Stenosis, which condition is associated with a risk factor profile similar to ischemic heart disease?
In Aortic Stenosis, which condition is associated with a risk factor profile similar to ischemic heart disease?
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What is the significance of an S3 sound in Aortic Stenosis?
What is the significance of an S3 sound in Aortic Stenosis?
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Why are many patients with Aortic Stenosis asymptomatic even though the condition is severe?
Why are many patients with Aortic Stenosis asymptomatic even though the condition is severe?
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Which health assessment goal does cardiac auscultation primarily help achieve?
Which health assessment goal does cardiac auscultation primarily help achieve?
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Which symptom is commonly associated with mitral stenosis?
Which symptom is commonly associated with mitral stenosis?
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In mitral regurgitation, what happens to a portion of the stroke volume?
In mitral regurgitation, what happens to a portion of the stroke volume?
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What is a common complication associated with mitral valve prolapse?
What is a common complication associated with mitral valve prolapse?
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What does a mid- to late-systolic click followed by a murmur indicate?
What does a mid- to late-systolic click followed by a murmur indicate?
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What is a classic physical exam finding in mitral stenosis?
What is a classic physical exam finding in mitral stenosis?
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Which valvular heart disease presents with an early- to mid-diastolic murmur at the apex and a low-pitched rumble radiating to the axilla?
Which valvular heart disease presents with an early- to mid-diastolic murmur at the apex and a low-pitched rumble radiating to the axilla?
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What is the significance of an S4 sound in Aortic Stenosis?
What is the significance of an S4 sound in Aortic Stenosis?
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How does the echo help in diagnosing Aortic Stenosis?
How does the echo help in diagnosing Aortic Stenosis?
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At what pressure range and valve area would symptoms typically manifest in Aortic Stenosis?
At what pressure range and valve area would symptoms typically manifest in Aortic Stenosis?
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What distinguishes a bicuspid valve from a tricuspid valve in the context of Aortic Stenosis?
What distinguishes a bicuspid valve from a tricuspid valve in the context of Aortic Stenosis?
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When might cardiac catheterization be considered for a patient with Aortic Stenosis?
When might cardiac catheterization be considered for a patient with Aortic Stenosis?
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Which condition may present with insidious progression and often nonspecific symptoms?
Which condition may present with insidious progression and often nonspecific symptoms?
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Which valvular lesion is characterized by a holosystolic murmur at the apex and high-pitched, blowing sounds?
Which valvular lesion is characterized by a holosystolic murmur at the apex and high-pitched, blowing sounds?
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What is the common symptom elicited on interview in patients with Mitral Stenosis?
What is the common symptom elicited on interview in patients with Mitral Stenosis?
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Which valvular heart disease may be associated with Marfan's Syndrome and CVA complications?
Which valvular heart disease may be associated with Marfan's Syndrome and CVA complications?
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What is a classic finding in Mitral Regurgitation related to the stroke volume?
What is a classic finding in Mitral Regurgitation related to the stroke volume?
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What is the classic sign seen in Mitral Stenosis on echocardiography?
What is the classic sign seen in Mitral Stenosis on echocardiography?
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What is the most common valvular lesion in the US?
What is the most common valvular lesion in the US?
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What is the primary compensatory mechanism seen in response to long term Mitral Regurgitation?
What is the primary compensatory mechanism seen in response to long term Mitral Regurgitation?
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Study Notes
Cardiac Auscultation and Valvular Disease
- Cardiac auscultation helps identify:
- Valvular heart disease
- Heart failure
- Dysrhythmias
- Presence of clinically significant vs. insignificant murmurs
- Goals of cardiac evaluation:
- Identify severity of cardiac disease
- Identify degree of impaired myocardial contractility
- Identify other organ involvement (kidneys, liver, brain, pancreas)
Mitral Stenosis
- Most common cause: rheumatic fever
- Females > Males
- Pathology:
- Diffuse thickening of leaflets
- Calcification of annulus
- Slow process (20-30 years) leading to:
- CHF
- Pulmonary hypertension
- RV failure
- Symptoms:
- DOE
- Orthopnea
- PND
- AF (dilated LA)
- Diastolic murmur
- Normal orifice: 4-6 cm2
- Symptoms develop at about 1.5 cm2
- Severe/critical disease: 0.6-1.0 cm2
- Transvalvular gradient of 10 mmHg
- Early- to mid-diastolic murmur at the apex
- Opening snap, low-pitched rumble radiating to axilla
- Findings warrant further workup:
- Gold standard: echo
- Looking for valve area, LV function, transvalvular pressure gradient, pulmonary hypertension
- Evaluated with EKG as well
- POCUS: classic sign is "doming" of anterior valve leaflet
Mitral Regurgitation
- Associated with MS if rheumatic in origin
- If isolated MR, assume ischemic disease until proven otherwise
- Can be ruptured chordae tendineae
- Decreased forward LV stroke volume and CO
- Portion of every stroke volume regurgitated through incompetent mitral valve back into LA
- Insidious progression, symptoms often not elicited or are nonspecific
- Long-term enlargement of LV to compensate
- Compensation of increase LA compliance/LVH accommodate increased volume
- If acute rupture: pulmonary edema/cardiogenic shock
- Holosystolic murmur at apex
- High-pitched, blowing, loud S3 radiating to axilla
- Cardiomegaly on physical exam or CXR
- EKG changes: LA/LV enlargement
- Gold standard: echo
- LA size
- Pressure
- LV wall thickness
- LV function
- Cardiac cath if severity cannot be confirmed
Mitral Valve Prolapse
- Leaflets prolapse back into LA with or without MR (during systole)
- Most common lesion: 1-2.5% of population
- Associated with:
- Marfan's Syndrome
- Rheumatic carditis
- Myocarditis
- Lupus
- Usually benign but can lead to:
- CVA (embolic)
- Dysrhythmias
- Mid- to late-systolic click and late-systolic murmur (crescendo)
- Symptoms:
- Anxiety
- Orthostatic hypotension
- Palpitations
- Dyspnea
- Fatigue
- Atypical chest pain
- Echo to determine degree of prolapse and associated LV involvement
Aortic Stenosis
- Most common valvular lesion in the US
- Degeneration and calcification of leaflets (aging)
- Bicuspid v. tricuspid valve (congenital, younger)
- Associated with risk factors similar to ischemic heart disease
- Symptoms:
- Angina (without CAD)
- Syncope
- CHF
- 75% of patients with symptoms die within 3 years without replacement
- Mid-systolic murmur in 2nd right and left parasternal spaces
- Crescendo-decrescendo diamond pattern, radiates to carotid(s), S3 and S4 if significant
- Contour of diamond relates to severity of pressure gradient across valve
- MANY PATIENTS ARE ASYMPTOMATIC, so ALL old people are at risk until ruled out
- EKG may show LVH
- Echo to determine:
- Valve morphology
- LV function
- Aortic valve area & pressure gradient measurements
- Cardiac cath may be necessary if echo is not diagnostic
- Symptoms when pressure 25-40 mmHg & valve area### Cardiac Auscultation
- Cardiac auscultation helps identify valvular heart disease, heart failure, dysrhythmias, and the presence of clinically significant murmurs.
- The technique starts with an interview and involves auscultating the heart and lungs for all patients.
Heart Valves and Murmurs
- Heart murmurs are graded on a scale of I to VI, with VI being the loudest and requiring no stethoscope.
- Mitral stenosis is the most common cause of heart murmurs, often resulting from rheumatic fever, and more common in females than males.
Mitral Stenosis
- Mitral stenosis is characterized by diffuse thickening of leaflets and calcification of the annulus, leading to a slow process (20-30 years) that eventually develops into congestive heart failure (CHF) and pulmonary hypertension.
- Symptoms of mitral stenosis include dyspnea, orthopnea, and paroxysmal nocturnal dyspnea (PND) and are often precipitated by pregnancy or illness.
- The normal mitral orifice is 4-6 cm², and symptoms develop when the orifice area is reduced to around 1.5 cm², with severe disease occurring at an orifice area of 0.6-1.0 cm².
- A transvalvular gradient of 10 mmHg is indicative of severe disease.
Mitral Regurgitation
- Mitral regurgitation is often associated with mitral stenosis if rheumatic in origin, but if isolated, it is assumed to be ischemic disease until proven otherwise.
- Ruptured chordae tendineae can also cause mitral regurgitation.
- Decreased forward left ventricular (LV) stroke volume and cardiac output are characteristic of mitral regurgitation, with a portion of every stroke volume regurgitating through the incompetent mitral valve back into the left atrium (LA).
- Long-term LV enlargement can compensate for the increased volume.
Mitral Valve Prolapse
- Mitral valve prolapse is characterized by leaflets prolapsing back into the LA with or without mitral regurgitation during systole.
- It is the most common lesion, affecting 1-2.5% of the population, and is associated with Marfan's syndrome, rheumatic carditis, myocarditis, and lupus.
- The condition is usually benign but can lead to cerebrovascular accidents (CVAs) and dysrhythmias.
Aortic Stenosis
- Aortic stenosis is the most common valvular lesion in the US, resulting from degeneration and calcification of leaflets, often due to aging or congenital bicuspid valve.
- Associated risk factors include those similar to ischemic heart disease.
- Symptoms of aortic stenosis include angina, syncope, and CHF, with 75% of patients dying within 3 years without valve replacement.
- The condition often goes undiagnosed until symptoms appear, putting all older adults at risk until ruled out.
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