Podcast
Questions and Answers
A 10-year-old girl presents with fever and migrating joint pains. She has a positive streptococcal test and elevated erythrocyte sedimentation rate. Which of the following conditions is MOST likely?
A 10-year-old girl presents with fever and migrating joint pains. She has a positive streptococcal test and elevated erythrocyte sedimentation rate. Which of the following conditions is MOST likely?
- Rheumatic fever (correct)
- Rheumatoid arthritis
- Septic arthritis
- Systemic lupus erythematosus
Which valve is MOST commonly affected in late sequelae of rheumatic fever?
Which valve is MOST commonly affected in late sequelae of rheumatic fever?
- Pulmonary valve
- Aortic valve
- Mitral valve (correct)
- Tricuspid valve
According to the Jones criteria, which combination is sufficient for diagnosing acute rheumatic fever after a documented streptococcal pharyngitis?
According to the Jones criteria, which combination is sufficient for diagnosing acute rheumatic fever after a documented streptococcal pharyngitis?
- Three minor criteria
- Two major criteria (correct)
- One major and two minor criteria
- One major and one minor criterion
Which of the following is considered a MAJOR criterion in the Revised Jones Criteria for acute rheumatic fever?
Which of the following is considered a MAJOR criterion in the Revised Jones Criteria for acute rheumatic fever?
A patient diagnosed with acute rheumatic fever is prescribed antibiotics. What is the PRIMARY purpose of this treatment?
A patient diagnosed with acute rheumatic fever is prescribed antibiotics. What is the PRIMARY purpose of this treatment?
A patient with a history of rheumatic fever is undergoing evaluation for valvular disease. What is the FIRST step in this evaluation process?
A patient with a history of rheumatic fever is undergoing evaluation for valvular disease. What is the FIRST step in this evaluation process?
Which of the following BEST describes the pathophysiology of aortic stenosis (AS)?
Which of the following BEST describes the pathophysiology of aortic stenosis (AS)?
Which of the following is a PRIMARY cause of calcific aortic stenosis?
Which of the following is a PRIMARY cause of calcific aortic stenosis?
Why does exertional syncope occur in patients with aortic stenosis?
Why does exertional syncope occur in patients with aortic stenosis?
Which physical exam finding is MOST indicative of severe aortic stenosis?
Which physical exam finding is MOST indicative of severe aortic stenosis?
Which echocardiographic finding is consistent with severe aortic stenosis?
Which echocardiographic finding is consistent with severe aortic stenosis?
Which of the following non-surgical treatments is generally recommended for patients with asymptomatic aortic stenosis?
Which of the following non-surgical treatments is generally recommended for patients with asymptomatic aortic stenosis?
Under what conditions would Exercise/dobutamine/adenosine stress tests be contraindicated in patients with Aortic Stenosis?
Under what conditions would Exercise/dobutamine/adenosine stress tests be contraindicated in patients with Aortic Stenosis?
What is the PRIMARY reason for performing cardiac catheterization before aortic valve replacement?
What is the PRIMARY reason for performing cardiac catheterization before aortic valve replacement?
A patient with severe aortic stenosis is not a candidate for surgical valve replacement. What is a possible alternative treatment option?
A patient with severe aortic stenosis is not a candidate for surgical valve replacement. What is a possible alternative treatment option?
What is a key difference between Bioprosthetic vs. Biomechanical valves when surgically intervening?
What is a key difference between Bioprosthetic vs. Biomechanical valves when surgically intervening?
What is a key feature when differntiating between concentric vs eccentric LVH?
What is a key feature when differntiating between concentric vs eccentric LVH?
Which of the following causes Chronic Aortic Regurgiation?
Which of the following causes Chronic Aortic Regurgiation?
In chronic aortic regurgitation (AR), how does the left ventricle typically remodels?
In chronic aortic regurgitation (AR), how does the left ventricle typically remodels?
What physical exam finding is MOST indicative of chronic aortic regurgitation?
What physical exam finding is MOST indicative of chronic aortic regurgitation?
A patient with known aortic regurgitation develops heart failure symptoms. What is the MOST appropriate initial medical management?
A patient with known aortic regurgitation develops heart failure symptoms. What is the MOST appropriate initial medical management?
When is surgical intervention MOST clearly indicated for chronic aortic regurgitation?
When is surgical intervention MOST clearly indicated for chronic aortic regurgitation?
Which medication should generally be avoided in patients with aortic regurgitation because it can worsen the condition?
Which medication should generally be avoided in patients with aortic regurgitation because it can worsen the condition?
39 male presents with DOE x 6mo-1 year, insidious onset also with L sided chest tightness when tired/stressed. Occasional lightheadedness after taking Coreg. Denies PND, orthopnea, cough, pre/syncope. What are the concerns for taking Coreg here?
39 male presents with DOE x 6mo-1 year, insidious onset also with L sided chest tightness when tired/stressed. Occasional lightheadedness after taking Coreg. Denies PND, orthopnea, cough, pre/syncope. What are the concerns for taking Coreg here?
What would be the next course of action for 39 male, presents with DOE x 6mo-1 year, insidious onset, L sided chest tightness when tired/stressed, occasional lightheadedness after taking Coreg; denies PND, orthopnea, cough, pre/syncope; Chronic LBP, Obesity, OSA/CPAP, Depression/Anxiety; carvedilol 50mg BID, Celebrex, Lasix, ASA, hydrocodone; PE: nl s1/s2, + s3 no s4;
What would be the next course of action for 39 male, presents with DOE x 6mo-1 year, insidious onset, L sided chest tightness when tired/stressed, occasional lightheadedness after taking Coreg; denies PND, orthopnea, cough, pre/syncope; Chronic LBP, Obesity, OSA/CPAP, Depression/Anxiety; carvedilol 50mg BID, Celebrex, Lasix, ASA, hydrocodone; PE: nl s1/s2, + s3 no s4;
What is the MOST common cause of mitral stenosis?
What is the MOST common cause of mitral stenosis?
A patient with mitral stenosis is at risk for developing which of the following complications?
A patient with mitral stenosis is at risk for developing which of the following complications?
What clinical manifestation is MOST closely associated with mitral stenosis?
What clinical manifestation is MOST closely associated with mitral stenosis?
A patient with mitral stenosis exhibits signs of atrial fibrillation. Which treatment strategy is MOST appropriate?
A patient with mitral stenosis exhibits signs of atrial fibrillation. Which treatment strategy is MOST appropriate?
A patient with mitral stenosis progresses to severe symptoms. What is the BEST course of action?
A patient with mitral stenosis progresses to severe symptoms. What is the BEST course of action?
In mitral Regurgitation what is most common?
In mitral Regurgitation what is most common?
What physical exam finding is MOST indicative of mitral regurgitation?
What physical exam finding is MOST indicative of mitral regurgitation?
A patient is diagnosed with Mitral Valve Prolapse. What is a diagnostic criteria?
A patient is diagnosed with Mitral Valve Prolapse. What is a diagnostic criteria?
What would be the most important aspects of the history in a pt presenting with tricuspid stenosis; select the best answer
What would be the most important aspects of the history in a pt presenting with tricuspid stenosis; select the best answer
What is primarily cause Tricuspid Valve Regurgitation?
What is primarily cause Tricuspid Valve Regurgitation?
In Pulmonary Valve Stenosis is it commonly a Acquired or Congenital disease?
In Pulmonary Valve Stenosis is it commonly a Acquired or Congenital disease?
What is one of the primary steps in treating Pulmonary Valve Regurgitation?
What is one of the primary steps in treating Pulmonary Valve Regurgitation?
When should patients be given Endocarditis prophylaxis in valves
When should patients be given Endocarditis prophylaxis in valves
A patient presents with migratory joint pains, fever, and a recent history of streptococcal pharyngitis. Which of the following physical exam findings would STRONGLY suggest acute rheumatic fever?
A patient presents with migratory joint pains, fever, and a recent history of streptococcal pharyngitis. Which of the following physical exam findings would STRONGLY suggest acute rheumatic fever?
A patient is being evaluated for possible acute rheumatic fever. Which of the following ECG findings would be considered a MINOR criterion according to the Revised Jones Criteria?
A patient is being evaluated for possible acute rheumatic fever. Which of the following ECG findings would be considered a MINOR criterion according to the Revised Jones Criteria?
Following treatment for streptococcal pharyngitis, a young patient is diagnosed with acute rheumatic fever. What is the recommended duration of prophylactic treatment with benzathine penicillin IM to prevent recurrent attacks, assuming no carditis is present?
Following treatment for streptococcal pharyngitis, a young patient is diagnosed with acute rheumatic fever. What is the recommended duration of prophylactic treatment with benzathine penicillin IM to prevent recurrent attacks, assuming no carditis is present?
A patient presents with symptoms suggestive of aortic stenosis. Which of the following etiologies is the MOST common cause of aortic stenosis in elderly patients?
A patient presents with symptoms suggestive of aortic stenosis. Which of the following etiologies is the MOST common cause of aortic stenosis in elderly patients?
A patient with Aortic Stenosis develops heart failure symptoms. Which of the following mechanisms is MOST likely contributing to the development of heart failure in this patient?
A patient with Aortic Stenosis develops heart failure symptoms. Which of the following mechanisms is MOST likely contributing to the development of heart failure in this patient?
A patient with known aortic stenosis reports exertional syncope. What pathophysiological mechanism is MOST directly responsible for this symptom?
A patient with known aortic stenosis reports exertional syncope. What pathophysiological mechanism is MOST directly responsible for this symptom?
Which of the following physical examination findings is MOST commonly associated with aortic stenosis?
Which of the following physical examination findings is MOST commonly associated with aortic stenosis?
An echocardiogram is performed on a patient suspected of having Aortic Stenosis. Which set of findings would be consistent with severe AS?
An echocardiogram is performed on a patient suspected of having Aortic Stenosis. Which set of findings would be consistent with severe AS?
A patient with severe symptomatic aortic stenosis is being evaluated for treatment options. What is the MOST appropriate initial non-surgical management strategy?
A patient with severe symptomatic aortic stenosis is being evaluated for treatment options. What is the MOST appropriate initial non-surgical management strategy?
A patient with severe aortic stenosis is deemed high-risk for surgical aortic valve replacement. Which of the following is a potential alternative treatment option for this patient?
A patient with severe aortic stenosis is deemed high-risk for surgical aortic valve replacement. Which of the following is a potential alternative treatment option for this patient?
What are the primary advantages of bioprosthetic valves over mechanical valves in surgical intervention?
What are the primary advantages of bioprosthetic valves over mechanical valves in surgical intervention?
A patient with hypertension and aortic stenosis develops left ventricular hypertrophy. What type of remodeling is MOST likely to occur in the left ventricle?
A patient with hypertension and aortic stenosis develops left ventricular hypertrophy. What type of remodeling is MOST likely to occur in the left ventricle?
A 60-year-old male presents with progressive dyspnea, fatigue, and lower extremity edema. Physical examination reveals a wide pulse pressure and a diastolic murmur best heard at the left sternal border. Which cardiac condition is MOST likely?
A 60-year-old male presents with progressive dyspnea, fatigue, and lower extremity edema. Physical examination reveals a wide pulse pressure and a diastolic murmur best heard at the left sternal border. Which cardiac condition is MOST likely?
In chronic aortic regurgitation, what compensatory mechanism initially allows the left ventricle to maintain normal cardiac output?
In chronic aortic regurgitation, what compensatory mechanism initially allows the left ventricle to maintain normal cardiac output?
Which classic physical exam finding is MOST indicative of chronic aortic regurgitation?
Which classic physical exam finding is MOST indicative of chronic aortic regurgitation?
A patient diagnosed with chronic aortic regurgitation is asymptomatic. Which of the following medications is MOST appropriate for managing their condition and delaying the need for surgical intervention?
A patient diagnosed with chronic aortic regurgitation is asymptomatic. Which of the following medications is MOST appropriate for managing their condition and delaying the need for surgical intervention?
A patient with aortic regurgitation develops symptoms of heart failure and has a left ventricular ejection fraction (LVEF) of 50%. According to guidelines, what LVEF threshold indicates the need for aortic valve replacement?
A patient with aortic regurgitation develops symptoms of heart failure and has a left ventricular ejection fraction (LVEF) of 50%. According to guidelines, what LVEF threshold indicates the need for aortic valve replacement?
What is the primary goal of vasodilator therapy in managing patients with chronic aortic regurgitation?
What is the primary goal of vasodilator therapy in managing patients with chronic aortic regurgitation?
The presence of which physical exam findings would suggest acute aortic regurgitation secondary to aortic dissection?
The presence of which physical exam findings would suggest acute aortic regurgitation secondary to aortic dissection?
A patient presents with dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination reveals a diastolic murmur with an opening snap. Echocardiography shows a thickened mitral valve with restricted opening. Which of the following is the MOST likely diagnosis?
A patient presents with dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Physical examination reveals a diastolic murmur with an opening snap. Echocardiography shows a thickened mitral valve with restricted opening. Which of the following is the MOST likely diagnosis?
A patient with known mitral stenosis develops atrial fibrillation. Which therapeutic strategy is MOST important to initiate?
A patient with known mitral stenosis develops atrial fibrillation. Which therapeutic strategy is MOST important to initiate?
A patient with mitral stenosis presents with hemoptysis. What is the MOST likely cause of hemoptysis in this patient?
A patient with mitral stenosis presents with hemoptysis. What is the MOST likely cause of hemoptysis in this patient?
A patient with severe mitral stenosis is being considered for intervention. What mean gradient value is a key indicator of severe stenosis?
A patient with severe mitral stenosis is being considered for intervention. What mean gradient value is a key indicator of severe stenosis?
A patient presents with a loud, high-pitched pansystolic murmur heard best at the apex, radiating to the axilla. Which valvular abnormality is MOST likely?
A patient presents with a loud, high-pitched pansystolic murmur heard best at the apex, radiating to the axilla. Which valvular abnormality is MOST likely?
A patient with Mitral Regurgitation has EKG readings. What EKG reading would MOST commonly indicate Mitral Regurgitation?
A patient with Mitral Regurgitation has EKG readings. What EKG reading would MOST commonly indicate Mitral Regurgitation?
A patient is diagnosed with acute mitral regurgitation secondary to infective endocarditis. What is the MOST appropriate treatment strategy?
A patient is diagnosed with acute mitral regurgitation secondary to infective endocarditis. What is the MOST appropriate treatment strategy?
A patient presents with atypical chest pain, palpitations, and occasional dizziness. Auscultation reveals a mid-systolic click followed by a late systolic murmur. Which valvular abnormality is MOST likely?
A patient presents with atypical chest pain, palpitations, and occasional dizziness. Auscultation reveals a mid-systolic click followed by a late systolic murmur. Which valvular abnormality is MOST likely?
In the assessment of a patient with suspected mitral valve prolapse (MVP), which diagnostic method is MOST effective in determining the severity of mitral regurgitation?
In the assessment of a patient with suspected mitral valve prolapse (MVP), which diagnostic method is MOST effective in determining the severity of mitral regurgitation?
A patient is diagnosed with tricuspid stenosis. Which of the following etiologies is MOST likely associated with this condition?
A patient is diagnosed with tricuspid stenosis. Which of the following etiologies is MOST likely associated with this condition?
During a physical examination, which finding is MOST likely to help differentiate tricuspid stenosis from mitral stenosis?
During a physical examination, which finding is MOST likely to help differentiate tricuspid stenosis from mitral stenosis?
A patient presents with signs of right heart failure. Which of the following exam findings point to tricuspid regurgitation?
A patient presents with signs of right heart failure. Which of the following exam findings point to tricuspid regurgitation?
What physical exam finding is specific to more severe Tricuspid Regurgitation?
What physical exam finding is specific to more severe Tricuspid Regurgitation?
A patient has moderate to severe tricuspid regurgitation. Which management is MOST likely to treat this pathology?
A patient has moderate to severe tricuspid regurgitation. Which management is MOST likely to treat this pathology?
If surgical treatment is necessary for tricuspid regurgitation (TR), which type of valve is typically used?
If surgical treatment is necessary for tricuspid regurgitation (TR), which type of valve is typically used?
What is the MOST common cause of pulmonic valve stenosis?
What is the MOST common cause of pulmonic valve stenosis?
What clinical presentation of Pulmonic Valve Stenosis would indicate the pathology is becoming more severe? Select the BEST answer.
What clinical presentation of Pulmonic Valve Stenosis would indicate the pathology is becoming more severe? Select the BEST answer.
What is the PRIMARY treatment goal for a patient diagnosed with pulmonic valve regurgitation (PR)?
What is the PRIMARY treatment goal for a patient diagnosed with pulmonic valve regurgitation (PR)?
When is Endocarditis prophylaxis required for acquired valvular disease?
When is Endocarditis prophylaxis required for acquired valvular disease?
A patient diagnosed with acute rheumatic fever is reviewed for secondary prophylaxis. In the absence of carditis, what duration of benzathine penicillin IM injections is typically recommended?
A patient diagnosed with acute rheumatic fever is reviewed for secondary prophylaxis. In the absence of carditis, what duration of benzathine penicillin IM injections is typically recommended?
In the late sequelae of rheumatic fever, which of the following valves is MOST commonly affected?
In the late sequelae of rheumatic fever, which of the following valves is MOST commonly affected?
What is the MOST common etiology of mitral stenosis?
What is the MOST common etiology of mitral stenosis?
Following an episode of acute rheumatic fever, what is the PRIMARY reason for administering penicillin?
Following an episode of acute rheumatic fever, what is the PRIMARY reason for administering penicillin?
A patient presents with a diastolic murmur at the left sternal border that increases in intensity with inspiration. This finding is MOST consistent with which valvular abnormality?
A patient presents with a diastolic murmur at the left sternal border that increases in intensity with inspiration. This finding is MOST consistent with which valvular abnormality?
A patient is diagnosed with mitral stenosis. Which of the following would be the MOST appropriate long-term management strategy to prevent thromboembolic complications?
A patient is diagnosed with mitral stenosis. Which of the following would be the MOST appropriate long-term management strategy to prevent thromboembolic complications?
A patient with severe mitral regurgitation has developed a fib. What INITIAL step would be MOST appropriate?
A patient with severe mitral regurgitation has developed a fib. What INITIAL step would be MOST appropriate?
A patient diagnosed with aortic regurgitation is prescribed vasodilators. What is the PRIMARY goal of this treatment?
A patient diagnosed with aortic regurgitation is prescribed vasodilators. What is the PRIMARY goal of this treatment?
A patient with known aortic stenosis presents with exertional syncope. What hemodynamic abnormality is MOST likely responsible for this symptom?
A patient with known aortic stenosis presents with exertional syncope. What hemodynamic abnormality is MOST likely responsible for this symptom?
Which of the following physical examination findings is MOST specific for severe tricuspid regurgitation?
Which of the following physical examination findings is MOST specific for severe tricuspid regurgitation?
In a patient presenting with chronic aortic regurgitation, which compensatory mechanism initially maintains cardiac output?
In a patient presenting with chronic aortic regurgitation, which compensatory mechanism initially maintains cardiac output?
What is the MOST likely cause for the development of pulmonic valve regurgitation
What is the MOST likely cause for the development of pulmonic valve regurgitation
A patient with aortic regurgitation has developed heart failure and is being considered for surgery. Which echocardiographic finding would STRONGLY support the need for surgical intervention?
A patient with aortic regurgitation has developed heart failure and is being considered for surgery. Which echocardiographic finding would STRONGLY support the need for surgical intervention?
A patient presents with a history of rheumatic fever and new onset dyspnea. On auscultation, a low-pitched diastolic murmur with an opening snap is heard best at the apex. Which of the following is MOST likely the diagnosis?
A patient presents with a history of rheumatic fever and new onset dyspnea. On auscultation, a low-pitched diastolic murmur with an opening snap is heard best at the apex. Which of the following is MOST likely the diagnosis?
A young patient presents for evaluation, and has a history of rheumatic fever. They report exertional dyspnea and occasional palpitations. Auscultation reveals a mid-systolic click followed by a late systolic murmur. Which valvular abnormality is MOST likely present?
A young patient presents for evaluation, and has a history of rheumatic fever. They report exertional dyspnea and occasional palpitations. Auscultation reveals a mid-systolic click followed by a late systolic murmur. Which valvular abnormality is MOST likely present?
A patient being evaluated for tricuspid stenosis denies a history of rheumatic fever, and has no cardiac risk factors. Which of the following is MOST likely associated with this condition?
A patient being evaluated for tricuspid stenosis denies a history of rheumatic fever, and has no cardiac risk factors. Which of the following is MOST likely associated with this condition?
During a physical exam to rule out tricuspid pathology, what would be the BEST next course of action?
During a physical exam to rule out tricuspid pathology, what would be the BEST next course of action?
A patient with a history of intravenous drug use presents with new onset right-sided heart failure symptoms. Which of the following valvular abnormalities is MOST likely?
A patient with a history of intravenous drug use presents with new onset right-sided heart failure symptoms. Which of the following valvular abnormalities is MOST likely?
A patient being evaluated for pulmonic stenosis reports progressive dyspnea on exertion, fatigue, and occasional lightheadedness and chest pain. WHich of the folllowing is the BEST next course of action?
A patient being evaluated for pulmonic stenosis reports progressive dyspnea on exertion, fatigue, and occasional lightheadedness and chest pain. WHich of the folllowing is the BEST next course of action?
Following surgical intervention, which patients are most likely require endocarditis prophylaxis in the case of acquired valvular disease?
Following surgical intervention, which patients are most likely require endocarditis prophylaxis in the case of acquired valvular disease?
Flashcards
Rheumatic Fever
Rheumatic Fever
Inflammatory disease after untreated strep throat.
Migratory Polyarthritis
Migratory Polyarthritis
Joint pain that migrates from one joint to another.
Erythema Marginatum
Erythema Marginatum
Skin rash of rheumatic fever with circular, snake-like edges.
Sydenham's Chorea
Sydenham's Chorea
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Penicillin
Penicillin
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Valvular Disease
Valvular Disease
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Aortic Stenosis
Aortic Stenosis
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Calcific Aortic Stenosis
Calcific Aortic Stenosis
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Bicuspid Aortic Valve
Bicuspid Aortic Valve
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Left Ventricular Hypertrophy (LVH)
Left Ventricular Hypertrophy (LVH)
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Angina
Angina
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Syncope
Syncope
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TAVR
TAVR
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Aortic Regurgitation
Aortic Regurgitation
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Eccentric LVH
Eccentric LVH
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concentric LVH
concentric LVH
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Austin Flint Murmur
Austin Flint Murmur
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Wide Pulse Pressure
Wide Pulse Pressure
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Pulsus Bisferiens
Pulsus Bisferiens
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Mitral Regurgitation
Mitral Regurgitation
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Rheumatic Heart Disease
Rheumatic Heart Disease
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Mitral Stenosis Murmur
Mitral Stenosis Murmur
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Pulmonary Hypertension
Pulmonary Hypertension
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Atrial Fibrillation
Atrial Fibrillation
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Mitral Valve Prolapse (MVP)
Mitral Valve Prolapse (MVP)
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Midsystolic Click
Midsystolic Click
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Balloon valvotomy
Balloon valvotomy
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Valve commissurotomy
Valve commissurotomy
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Rheumatic Valvulitis or Heart Disease
Rheumatic Valvulitis or Heart Disease
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Carcinoid Tumor
Carcinoid Tumor
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Tricuspid Regurgitation
Tricuspid Regurgitation
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Epstein's Abnormality
Epstein's Abnormality
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Holosystic Murmur
Holosystic Murmur
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Giant V Pulse
Giant V Pulse
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Congenital Valvulitis
Congenital Valvulitis
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Tetralogy Fallot
Tetralogy Fallot
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Septum Systolic Murmur
Septum Systolic Murmur
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Valvuloplasty Treatment
Valvuloplasty Treatment
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Pulmonic HΤΝ
Pulmonic HΤΝ
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Graham Steel
Graham Steel
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Acquired heart disease
Acquired heart disease
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Study Notes
Rheumatic Fever
- A 10-year-old girl has a fever and migrating joint pains in her knees and elbows.
- She also had a sore throat a few days prior.
- A physical exam reveals a fever, barely raised erythematous serpentine-like lesions on her back.
- A rapid streptococcal test is positive and erythrocyte sedimentation rate is elevated
- Antibiotics are needed for the treatment.
- Rheumatic fever is a consequence of infection with Group A hemolytic streptococci.
- Late sequelae includes valvular disease with the order of prevalence being Mitral greater than Aortic greater than Tricuspid.
- Mitral stenosis is the most common.
Revised Jones Criteria for Acute Rheumatic Fever
- Major Criteria: Joints (polyarthritis, 5 or more), Carditis, Nodules (subcutaneous), Erythema marginatum, Sydenham's chorea, (involuntary movements)
- Minor Criteria: Fever (38.5 C), Arthralgia (4 or fewer), Prolonged PR interval on ECG, Elevated Sedimentation rate or C-reactive protein (CRP)
- Acute Rheumatic Fever diagnosis needs 2 major OR 1 major + 2 minor criteria after documented positive streptococcal pharyngitis diagnosis.
- Treatment consists of Penicillin for streptococcal infection and Aspirin for arthralgia
- Heart Failure is treated with standard medications like ACE-I and diuretics.
- Recurrent attacks are common, so prophylaxis with Monthly Benzathine Penicillin IM should continue for the first 5-10 years after infection
Valvular Heart Disease
- Can affect the Aortic, Mitral, Tricuspid, and Pulmonary valves.
- Can result in stenosis or insufficiency of any of these valves except the mitral valve, which can also result in Valve Prolapse
- Evaluation involved in diagnosing effects valves, assessing severity, judging effect on the myocardium and deciding on treatment
Aortic Stenosis (AS)
- Narrowing of the aortic valve impedes blood flow from the left ventricle to the ascending aorta during systole.
- Major causes include Calcific aortic stenosis and Congenital bicuspid aortic valve stenosis
- Less common causes include rheumatic aortic stenosis and congenital tricuspid aortic stenosis.
- Intact Mitral valve function means the pulmonary bed is protected from the overloaded pressure from aortic stenosis.
- Concentric LVH allows the pressure-overloaded ventricle to maintain stroke volume with increased diastolic pressures, allowing patients to remain asymptomatic for years.
- Eventually, left ventricular hypertrophy occurs, potentially causing diastolic dysfunction with heart failure symptoms, myocardial oxygen needs exceeding supply causing angina, and exertional syncope due to the inability to increase cardiac output and maintain blood pressure in response to vasodilation.
Aortic Stenosis (AS) Symptoms and Findings
- Symptoms are often advanced.
- Include: Heart Failure, Angina, and Syncope
- On physical exam, a harsh late-peaking systolic ejection murmur (SEM) radiates to the neck.
- Presence of an +/- Palpable systolic thrill, weak/slow rising carotid pulse, sustained LV impulse.
- A2 decreased with a S4 gallop if LVH is present.
- Narrow pulse pressure may be present, with a BP of around 90/70
- Lab Findings: EKG showing LVH with strain pattern, chronic ischemia, and LBBB.
- CXR shows Calcification of AV leaflets and LV prominence without dilatation.
Echocardiogram for AS
- Echo shows Calcified AV, high doppler gradient, cLVH, and reduced AV area.
- AS classification via echo: Mild (Valve Area 1.5-2.0 cm², Aortic Velocity 2.5-3.0 m/sec, Pressure Gradient <25 mm Hg)
- Moderate (Valve Area 1.0-1.5 cm², Aortic Velocity 3.0-4.0 m/sec, Pressure Gradient 25-40 mm Hg)
- Severe (Valve Area 0.6-1.0 cm², Aortic Velocity >4.0 m/sec, Pressure Gradient >40 mm Hg), Critical (Valve Area <0.6 cm²)
Aortic Stenosis Treatments
- Non-Surgical: avoid strenuous activity in asymptomatic phase and treat associated Congestive Heart Failure without causing hypotension.
- Stress tests and cardiac catheterization should be considered
- Surgical: Aortic Valve Replacement Indication includes Severe AS, and associated Symptoms.
- Exercise/dobutamine/adenosine stress tests would be contraindicated in these patients
- Most patients should undergo cardiac cath before surgery to check presence of concomitant CAD, if so CABG can be scheduled
Surgical Intervention
- Surgical Interventions can be Bioprosthetic or Biomechanical.
- Bioprosthetic valves do not require AC w/ Warfarin and are good for women of childbearing age, but do not last as long.
- Patients receiving Biomechanical valves have to be on warfarin long term.
- Newer options include Transcatheter Aortic Valve Replacement (TAVR)
Aortic Insufficiency
- Aortic Stenosis is often confused with this disorder
- Concentric LVH results from aortic stenosis
- Eccentric LVH results from Aortic Regurgitation
- Incompetency of the aortic valve causing flow from the aorta into the left ventricle during diastole
- Aortic Root cause include: Aortic Dissection, Age related dilation, HTN, Medial degeneration/Marfan's
- Aortic Valve causes include: Endocarditis, Rheumatic, Bicuspid congenital aortic valve, Calcific degeneration, Myxomatous degeneration, and Degeneration of prosthetic valve
- Chronic AI causes volume overloading of the left ventricle (Increased LV EDV).
- The sequelae of aortic regurgitation reflect the severity of the diastolic leak (i.e.) left ventricular dilation and hypertrophy, with remodeling of the left ventricle to a more spherical shape
- Ejection fraction is preserved until the late stages of the disease
Aortic Insufficiency - Symptoms and Findings
- Patients remain asymptomatic for decades, often until the fourth or fifth decade of life
- Symptoms only occur after significant cardiomegaly and LV dysfunction.
- Symptoms include DOE, Orthopnea and PND as well as angina that develops later, often during nighttime
- Can also cause Palpitations and Head pounding, especially in supine position.
- Classic finding on physical exam is a Diastolic Murmur.
- Look for a High frequency during exam that is sitting up & leaning forward as well as Duration > intensity which all correlate with severity.
- Mild AI = early diastole, high pitched blowing, wheras Severe AI = holodiastolic, rough and heard best from the Primary valve disease from LSB 3-4 ICS or the Aortic root disease from RSB
- Other signs include Austin Flint Murmur, Mid-late diastolic apical rumble indicating a severe AR and Accompanying aortic systolic murmur
- Wide Pulse Pressure, Apical impulse as well as displaced Inferolateral impulse
Aortic Insufficiency Findings
- Physical exam can often reveal: Corrigan pulse, "Pulsus Bisferiens"
- Can also detect: deMusset's sign, Traube's sign, Duroziez's sign, Quincke's pulses, Mueller's sign, Becker's sign, Hill's sign
- Lab Findings EKG will display LVH, a CXR will present Cardiomegaly and LV enlargement.
- Boot shaped heart
- Dilatation of ascending aorta
Testing for Aortic Regurgitation
- The best test is Echocardiogram which displays Dilated LV and aorta and allows for Doppler estimation of severity of regurgitant jet.
- Cardiac Cath confirms diagnosis showing aortic =>LV reflux, LV function
- Medications are prescribed for reducing regurgitant volume.
- ACE-I, Nifedipine, Hydralizine, or Prazosin.
- Also include Diuretics if the patient is experiencing CHF
- Avoid vigorous exertion in symptomatic AI and avoid beta blockers which increase diastolic timing.
- Indications for surgical intervention for Chronic AI are severe cases: When more than mild symptoms develop, Symptoms with evidence of progressing LF dysfunction, LV ejection fraction (EF) < 55%, or LV end-systolic dimension (ESD) > 55 mm
Mitral Stenosis
- Narrowing of the mitral orifice impeding blood flow from the left atrium to the left ventricle during diastole.
- Most common cause is Rheumatic Heart Disease.
- Majority of patients are female.
- ~50% of those affected give no history of having Rheumatic Fever.
- Still seen today in underdeveloped nations (India, Africa).
- Clinical Manifestations: Dyspnea; Progresses insidiously as patients reduce their activity without being aware of it
- Symptoms of acute Left Heart Failure (i.e. - PND, orthopnea, DOE) occur in later symptoms of RHF
- Can cause Palpitations or Embolic Stroke if A-fib is present
- Can also cause Cough and hemoptysis if MS is Advanced.
- On physical exam: Loud P2, palpable RV heave if present with Atrial Fibrillation
- EKG may show Atrial Fibrillation or Left Atrial enlargement
- RVH can show up
Testing for Mitral Stenosis and Treatment
- Tests include Echocardiogram to measure MV area, calcification, and LA enlargement.
- Doppler is used to assess High velocity inflow and estimation of transvalvular gradient.
- Cardiac Catherization: confirms diagnosis, Quantifies transmitral gradient, measures Severe stenosis = mean gradient > 12 mmHg.
- Treatment: Asymptomatic = no treatment, HF if present should be treated, A-fib also needs to be treated with Heart control using a b-blocker to prevent tachycardia and Anticoagulation using coumadin to prevent stroke.
- Surgical intervention in severely symptomatic patients with pulmonary hypertension.
Mitral Regurgitation
- Mitral Regurgitation refers to Incompetency of the mitral valve causing flow from the left ventricle (LV) into the left atrium during systole
- Can be acute if caused by Acute Papillary Muscle dysfunction from coronary ischemia, Ruptured Papillary muscle or torn chordae tendiniae, Infective endocarditis, Acute rheumatic fever, Spontaneous, traumatic, or ischemic tears, and Acute dilation of the LV due to myocarditis or ischemia
- Can be chronic if as a result of Mitral valve prolapse (MVP), Mechanical failure of a prosthetic mitral valve, Myxomatous degeneration of the mitral leaflets or chordae tendineae, or Nonischemic papillary muscle dysfunction (due to LV enlargement)
- Physical exam identifies Pansystolic murmur with maximum intensity at apex.
- Murmurs radiate to axilla and the precordial thrust is accentuated if LVH present
- May also have S3 &S4 and HF findings if severe.
- EKG may show LAE and LVH.
- Testing will show Enlarged LA & LV as well as pulmonary congestion
- Echocardiogram is used to measure LA dimension, LV quality
- Treatment can also involve Emergency Mitral Valve Repair or Replacement.
Mitral Valve Prolapse (MVP)
- Myxomatous degeneration of the mitral valve and chordae tendineae.
- Most common disorder affecting a heart valve.
- Estimated to occur in over 15 million Americans among those with:
- Marfan's Syndrome, Ehlers Danlos syndrome (EDS), von Willebrand's syndrome, sickle cell disease, rheumatic heart disease.
- Clinical features: Patients may remain asymptotic OR experience atypical chest pain, supraventricular & ventricular arrhythmia's
- In some cases severe MR resulting in HF
- Rarely, systemic emboli from platelet-fibrin deposits on valve
- Auscultation reveals a mid-systolic click and a late systolic crescendo murmur.
- Both murmurs are variable
- In patients with severe MR may need MVR (mitral valve replacement)
Tricuspid Valve Stenosis (TS)
- Cause can be Rheumatic Valvulitis.
- Rarely seen as an isolated lesion.
- Most commonly associated with Mitral Stenosis.
- Can also be Congenital heart disease, or a Carcinoid Tumor.
- Physical Findings present a Murmur (low-pitched, rumbling), diastolic of low intensity with a presystolic crescendo when AF absent
- Best heard with bell in interspaces S1, it is accentuated with an OS present.
- MS murmur can make it difficult to differentiate
Differentiating TS from MS and Treatment for TR
- TS leads to Augmentation of murmur w/ inspiration and reduction with expiration
- The murmur of MS is best heard at the apex and TR is heard at the Lower Sternal Border.
- Tricuspid Valve Regurgitation (TR) is a type of functional disorder.
- Functional if the cause is marked RV dilatation stretching out TV ring in conjunction with with Pulmonary HTN such as an Infectious Endocarditis seen in IV drug abusers
- Can also be caused by Cardiomyopathy, LV Failure, Ischemic Heart Disease and Trauma.
- Holosystolic plateau blowing murmur over RV is noted on physical exam as well inspiration.
- Usually decreases with expiration.
- Systemic signs of venous congestion and giant v waves
- It is only used if underlying HNT is severe otherwise treatment targets the underlying problem.
Pulmonic Valve Stenosis (PS)
- Almost always Congenital and part of the Tetralogy of Fallot
- Can also be caused by Carcinoid Tumor
- Transpulmonary valve gradient less than 50 rarely causes symptoms
- Higher gradients dyspnea, fatigue and CP from RV ischemia.
- Physical exam may find a basal systolic murmur near the 2nd LICS that can radiate all along the right or left sides
- P2 is often diminished
- Right Ventricular Precordial Thrust
- JVD prominent AV
- There may be RA or RV enlargement
- Needs surgical valve plasty above 50 gradient severity
Pulmonic Valve Regurgitation (PR)
- Can be caused by Pulmonary HTN
- Symptoms: Dilatation of ring of PV by Pulmonary HTN
- Dilatation of Ring of PR
- Treatment is related to the underlying source.
- The physical exam will reveal High pitched basal blowing diastolic decrescendo murmur that can be mistaken for AI unless the patient has absence of peripheral sings of AI
Endocarditis and Valvular Disease
- Endocarditis prophylaxis is no longer recommended unless patient has a history of it or has a current valve replacement
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