valvular heart disease:
- 4 commonest valve pathologies? how common? causes?
Mitral Regurgitation:
- – Commonest valvular lesion. 2% prevalence
- functional (secondary to LV dilatation)
- annular calcification (elderly)
- mitral valve prolapse
- rheumatic fever
- infective endocarditis
- ruptured chordae tendon or papillary muscle dysfunction/rupture
- connective tissue disease (Marfans, Ehlers-danlos)
- old dieting pills
- cardiomyopathy
- congenital
Mitral Stenosis:
- – Prevalence <1% in west, commoner in Asia and Africa
- rheumatic
- congenital
- ends-cardial fibroelastosis
- prosthetic valve
Aortic Stenosis:
- – Prevalence 1-2% in over 65s
- senile calcification (commonest)
- congenital (bicuspid valve)
- rheumatic
Aortic regurgitation (AR): ------ <1% prevalence --- acute - infective endocarditis - ascending aortic dissection - chest trauma --- chronic - congenital - connective tissue (Marfans/ehlers danlos) - rheumatic fever - arthritis (rheumatoid + seri-negative) - old diet pills (- other weird and wonderful stuff)
symptoms/signs of valvular heart disease?
- mitral regurg
- mitral stenosis
incl murmurs
- only curative treatment?
mitral regurg = symptoms - dyspnoea - fatigue - palpitations - symps of IE = signs - AF - displaced hyper dynamic apex beat - RV heave - pan systolic murmur (radiating to axilla)
mitral stenosis = symptoms - dyspnoea - fatigue - palpitations - chest pain - systemic emboli - haemoptysis - chronic bronchitis-like picture = signs - MALAR flush on cheeks (dt reduced cardiac output) - low-volume pulse - AF common - mid-diastolic murmur (w systolic 'snap')
valve repair or replacement surgery
symptoms/signs of valvular heart disease?
- aortic stenosis
- aortic regurg
incl murmurs
- only curative treatment?
aortic stenosis = symptoms - exertional chest pain (angina) - exertional dyspnoea - exertional lightheadedness (+/- syncope) = signs - slow rising pulse - LV heave - aortic thrill - ejection systolic murmur (radiates to carotids)
aortic regurg = symptoms - exertional dyspnoea - orthopnoea - PND (also angina, palpitations, syncope, CCF) = signs - collapsing (water-hammer) pulse - displaced, hyper dynamic apex beat - high pitched early diastolic murmur
valve repair or replacement surgery
infective endocarditis:
- who’s at risk?
- commonest 2 causative organisms?
- underlying valvular pathology/defects (incl old rheumatic heart disease)
- mechanical valves
- IVDU
- poor dental hygiene
- dental procedures
- strep viridans
- staph aureus
nb mechanical valve tends to be sub-acute, others tend to be acute
infective endocarditis:
- symptoms? 5
- signs? 6
- investigations? 2
- criteria for diagnosis?
- fever
- rigors
- night sweats
- weight loss
- anaemia
- splinter haemorrhages
- janeway lesions
- roth spots
- oslers nodes
- new/changed heart murmur
- septic emboli to other places (eg stroke)
- blood culture (when fever, need 2+ positive)
- echocardiogram (see vegetations +/- cardiac thrombi) - TOE best
nb do other blood tests as well as generally unwell (CRP, U+E, LFT, FBC etc)
- DUKES criteria
nb FBC often shows normocytic, normochromic anaemia w raised ESR + often leucocytosis
infective endocarditis:
- treatment?
empirical Abx and symptomatic treatment/resus
when cultures return, targeted Abx
surgery to repair/replace valves if severe heart failure
nb if strep bovis cultured, do colonoscopy as almost always bowel cancer
postural hypotension:
- definition?
- risk factors/causes? 10
drop of >20mmHg of systolic BP (+/or drop of >10mmHg diastolic BP) after 3mins of standing (vs sitting)
- elderly
- female
- polypharmacy
- iatrogenic hypovolemia (diuretics, anti-hypertensives)
- other drugs (eg anti-psychotics)
- addisons disease (or crisis dt sudden withdrawal of steroids)
- dehydration
- post-strenuous exercise
- autonomic neuropathy
- idiopathic (a third)
postural hypotension:
- investigations? 2
- non-pharm management? 8
- pharm treatment?
- lying and standing BP
- tilt table test (gold)
- lie down if feeling faint
- stand slowly
- review medications (+ adjust/find cause)
- refer to falls clinic
- manage autonomic neurpathy
- increase water + salt intake
- gentle exercise (build up muscle)
- reduce alcohol intake
- fludrocortisone (retains fluid - beware if CCF or renal probs, monitor weight + oedema)
nb if this fails refer to specialist
