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Test of choice= yellow Treatment of choice = pink Cardiology Aortic stenosis Pathophysiology→ ○ Outflow obstruction leads to a fix cardiac output, increased afterload, Left Ventricular hypertrophy (LVH) and eventually LV failure ○ The aortic valve is constric...

Test of choice= yellow Treatment of choice = pink Cardiology Aortic stenosis Pathophysiology→ ○ Outflow obstruction leads to a fix cardiac output, increased afterload, Left Ventricular hypertrophy (LVH) and eventually LV failure ○ The aortic valve is constricted more so the heart is going to work harder to pump the blood which causes the LV to hypertrophy Etiology → ○ Degenerative, congenital abnormalities, rheumatic heart disease Symptoms → ○ Exertional dyspnea, decreased exercise tolerance, angina, syncope, signs of CHF Signs → ○ Weak, delayed carotid pulse ○ S2 soft, absent or paradoxically split ○ S4 (atrial gallop) ○ Murmur Murmur → ○ Position: R 2nd interspace ○ Radiation: To the carotids ○ Phase: mid-late systolic ○ Pattern: crescendo-decrescendo ○ Quality: harsh, low pitched ○ Increased by: sitting and leaning forward, squatting, supine, raising legs, expiration, inhaled amyl nitrate ○ Decreased by: valsalva, standing, inspiration, handgrip Diagnostic studies→ ○ Echocardiogram is test of choice ○ EKG is likely to show LVH, possibly also LAE or A-fib ○ CXR may show post aortic dilation, aortic valve calcification or pulmonary congestion Management → ○ Aortic valve replacement is the treatment of choice and the only effective treatment ○ Percutaneous aortic valvuloplasty only as a bridge to replacement, for pediatric patients or if replacement is contraindicated. Aortic regurgitation  Aka: aortic insufficiency Incomplete valve closure leading to blood leaking back into the left ventricle during diastole Can be chronic, slowly progressing over decades or it can be acute, usually secondary to endocarditis of aortic dissection and a medical emergency Chronic aortic regurgitation sx ○ Often asymptomatic, but if severe, left ventricular dysfunction has developed and will present with classic symptoms of heart failure: Exertional dyspnea/ decreased exercise tolerance Orthopnea Paroxysmal nocturnal dyspnea Possibly fatigue, angina or palpitations Chronic aortic regurgitation signs ○ 3 possible murmurs, best heard at ‘Erb’s point’- 3rd-4th intercostal space High pitched early diastolic murmur (often described as blowing or soft) Diastolic rumble (austin flint murmur) Systolic murmur ○ Wide pulse pressure Increased systolic and decreased diastolic pressure Water hammer pulse (radial pulse) ○ Hyperdynamic/bounding pulses Due to increased stroke volume Pulsus bisferiens if severe or if stenosis is also present ○ Displaced apical pulse Displaced laterally due to increase volume of the left ventricle Mitral stenosis Pathophysiology ○ Narrowed mitral orifice causes blood to back up into the left atrium causing volume overload, pulmonary congestion, pulmonary hypertension and with time CHF Etiology ○ Rheumatic heart disease (almost always the cause) Sequelae: ○ Left atrial enlargement ○ Atrial fibrillation ○ Strokes/TIAs ○ Right sided heart failure ○ Dysphagia ○ Ortner’s syndrome  Symptoms: ○ Exertional dyspnea, decreased exercise tolerance, fatigue, hemoptysis, signs of CHF, hoarseness Signs: ○ Mitral facies → ruddy (flushed) cheeks with facial pallor ○ Prominent/Loud S1 ○ Opening snap ○ Loud P2 Murmur ○ Position: Apex (L5th intercostal space midclavicular) ○ Radiation: none ○ Phase: mid diastolic ○ Quality: rumbling, low pitched ○ Increased by: Left lateral decubitus position, squatting, supine, raising legs, expiration ○ Decreased by: valsalva, inspiration, standing, handgrip Diagnostic studies ○ Echocardiogram is the most useful imaging modality ○ EKG is likely to show LAE, possible A-fib, or RVH/Right axis deviation Management ○ Percutaneous balloon valvuloplasty ○ Valve replacement second line option ○ Medical: diuretics and sodium restriction if volume overloaded Mitral Regurgitation Incomplete closure of the mitral valve apparatus, leading to retrograde flow from the left ventricle to the left atrium Increases left atrial pressure and pulmonary pressure which over time leads to left atrial dilation and left ventricular hypertrophy Most commonly caused by mitral valve prolapse Signs: ○ Early stages → Asymptomatic ○ Later stages → heart failure symptoms Exertional dyspnea Orthopnea Paroxysmal nocturnal dyspnea Hemoptysis Fatigue Palps if A-fib is present Symptoms:  ○ Holosystolic murmur ○ High pitched, blowing ○ Best heard at the apex ○ Radiation to left axilla or subscapular region ○ Displaced and hyperdynamic apical impulse ○ 3rd heart sound ○ Due to increased and rapid filling of the left ventricle during diastole Diagnosis ○ Echocardiogram Primary and most commonly used noninvasive test Gives valuable information on morphology and severity ○ ECG Left atrial enlargement, left ventricular hypertrophy Possible Afib ○ CXR Left atrial enlargement, left ventricular hypertrophy Pulmonary edema Management ○ Cardiology referral ○ Medical options → manage hypertension with antihypertensives ○ Surgical options → repair vs replacement Right option depends on the severity, exact symptoms and circumstances unique to the patient Mitral Valve Prolapse Pathophysiology ○ Mitral valve leaflets extend abnormally above the mitral annulus into the left atrium during systole Etiology ○ Myxomatous degeneration ○ Connective tissue diseases (Marfan, Ehlers-Danlos, osteogenesis imperfecta) Symptoms ○ Generally asymptomatic ○ Signs of mitral regurgitation are possible but rare Signs ○ Mid-late diastolic click ○ Sometimes followed by the high pitched systolic murmur of mitral regurg ○ Signs of connective tissue disorders Diagnosis ○ Echocardiogram is diagnostic test of choice  Management ○ Generally no treatment is necessary unless mitral regurg is present Pulmonic Regurgitation Pathophysiology ○ Retrograde blood flow from the pulmonary artery into the RV causing right sided volume overload Etiology ○ Primary pulmonary regurgitation is almost always congenital ○ Secondary pulmonary regurg can be due to pulmonary hypertension, pulmonary artery dilation, endocarditis or rheumatic heart disease Clinical manifestations ○ Usually asymptomatic or mild symptoms ○ May be some Right sided heart failure signs Physical exam ○ Graham steel murmur ○ Murmur increased by inspiration, increased venous return ○ Murmur decreased by expiration, decreased venous return Tricuspid Regurgitation Pathophysiology ○ RV dilation Etiology ○ LV failure ○ RV infarction ○ Inferior infarction ○ Pulmonary hypertension ○ Infective endocarditis Clinical manifestations ○ May be some right sided heart failure Physical exam ○ High pitched holosystolic blowing murmur ○ Murmur increased by inspiration, increased venous return, hepatic compression ○ Murmur decreased by expiration, decreased venous return Tricuspid Stenosis Generally rheumatic in origin Causes right sided heart failure secondary to right atrial enlargement Signs ○ Hepatomegaly, ascites, edema  ○ Opening snap possible ○ Mid-diastolic murmur at left lower sternal border ○ Increased with venous return, inspiration Cardiomyopathy Cardiomyopathy is a disease of the heart muscle. It is estimated that cardiomyopathy accounts for 5-10% of the heart failure in the United states Dilated Cardiomyopathy Often abbreviated to DCMP Most common type of cardiomyopathy ○ 90% of all cardiomyopathies Characterized by: ○ Systolic dysfunction ○ Dilation of one or both ventricles Impaired systolic function ○ Impaired contraction ○ Decreased left ventricular ejection fraction (LVEF