Valvular Disorders of the Heart

by / Tuesday, 27 July 2010 / Published in Internal Medicine

Valvular Diseases

Presentation:

  • Valvular heart diseases all present with shortness of breath as the chief complaint
  • Often worsens with exertion/exercise
Clue to Diagnosis Diagnosis
Young female and/or general population Miltral Valve Prolapse (MVP)
Healthy young athlete Idiopathic Hypertrophic Subaortic Stenosis (now called: Hypertrophic obstructive cardiomyopathy HOMC)
Immigrant, pregnant Mitral Stenosis
Turner’s syndrome Bicuspid aortic valve
Palpitations, atypical chest pain not associated with exertion Mitral Valve Prolapse

Physical Findings:

  • Murmur and rales (seen in all cases)
  • Peripheral edema, gallops, carotid pulse findings (possibly seen)

Murmurs:

Systolic:

  • Most commonly seen in aortic stenosis, mitral regurgitation, MVP, and HOCM

Diastolic:

  • Most commonly seen with aortic regurgitation and mitral stenosis.

All right-sided murmurs INCREASE in intensity with inhalation

All left-sided murmurs DECREASE in intensity with exhalation

Location and Radiation of murmurs:

Valvular Lesion Best heard at
Aortic Stenosis 2nd right intercostal space and radiates to the carotids
Pulmonic valve 2nd left intercostal space
Aortic regurgitation/tricuspid/VSD Left lower sternal border
Mitral regurgitation Apex (left 5th intercostal space)

Murmur intensity:

  • I/VI – only heard with special maneuvers (valsalva)
  • II/VI and III/VI – majority of murmurs
  • IV/VI – thrill present
  • V/VI – can be heard with stethoscope partially off of the chest
  • VI/VI – can be heard without a stethoscope

Diagnosis:

  • Best initial diagnostic test for valvular lesions is echocardiogram
  • The most accurate test is left heart catheterization

Treatment:

Regurgitant lesions – best treated with vasodilator therapy (ACEI, ARB)

Stenotic lesions – best treated with anatomic repair (mitral stenosis requires balloon valvuloplasty,  severe aortic stenosis requires surgical replacement)

Aortic Stenosis

  • Most commonly presents with chest pain
  • Syncope and CHF are less commonly present with aortic stenosis
  • Patient is often older and has a history of hypertension

Prognosis:

  • If coronary disease is present then 3-5yr is avg survival
  • If syncope is present then 2-3 yr avg survival
  • If CHF present then 1.5-2yr avg survival

Diagnosis:

  • TTE is the best initial diagnosis
  • TEE is more accurate
  • Left heart catheterization is the most accurate
  • EKG and CXR will show LVH

Treatment:

  • Diuretics are the best initial therapy but do not alter the long-term prognosis, and special attention must be paid since over-diuresis is a possibility
  • Treatment of choice is valve replacement

Aortic Regurgitation

  • HTN
  • Rheumatic heart disease
  • Endocarditis

Signs and Symptoms:

  • Diastolic decrescendo murmur heart best at the left sternal border

Diagnosis:

  • TTE is best initial diagnostic test
  • TEE is more accurate
  • Left heart catheterization is most accurate

Treatment:

  • ACEI’s
  • ARB’s
  • Nifedipine
  • If ejection fraction drops below 55% or the LV end-diastolic diameter goes above 55mm, surgery should be done even if the patient is asymptomatic.

Mitral Stenosis:

  • MCC of mitral stenosis is rheumatic fever
  • Seen in immigrants and pregnant patients (increased plasma vol in pregnancy)

Signs and Symptoms:

  • Dysphagia (large left atrium compresses esophagus)
  • Hoarseness (pressure on recurrent laryngeal nerve)
  • Atrial fibrillation

Physical Exam:

  • Diastolic rumble after an opening snap

Diagnosis:

  • TTE is best initial diagnostic test
  • TEE is more accurate
  • Left heart cath is most accurate
  • EKG and/or CXR showing left atrial hypertrophy

Treatment:

  • Best initial therapy is diuretics, however they do not alter progression of the disease
  • Balloon valvuloplasty is the most effective therapy (all pregnant women must have this procedure done)

Mitral Regurgitation

  • Caused by HTN, ischemic heart disease, and any condition that may lead to dilation of the heart
  • The most common complain is dyspnea on exertion

Physical exam findings:

  • Holosystolic murmur that obscures both S1 and S2
  • Best heard at the apex, radiates to the axilla

Diagnosis:

  • TTE is best initial test
  • TEE is more accurate

Treatment:

  • ACEI
  • ARB’s
  • Nifedipine
  • If LV ejection fraction drops below 60% or LV end systolic diameter is above 45mm, then surgery should be done

4 Responses to “Valvular Disorders of the Heart”

  1. […] Valvular Disorders of a Heart | USMLE SUCCESS […]

  2. dr.sohail mirza says : Reply

    very nice presentation ! thanks for sharing!

  3. thisguy says : Reply

    Thank you for the info,

    just 1 question: which murmur is more likely in RF- AR or MS?- Is it true that AR is in early RF and MS is in late RF??

    • Paul Ciurysek, MD says : Reply

      Endocarditis in RF usually affects the mitral valve, so you are most commonly going to see findings involving the mitral valve. The way it usually presents is mitral regurgitation early on, with mitral stenosis later… However, the aortic valve may also show early regurgitation and late stenosis. Either way you look at it, you are going to see regurgitation early on and stenosis with a chronic case.

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