FNP III: Week 6: Valvular Heart Disease

What is the average age of death with mitral stenosis?

48 years

Diastolic murmurs

ARMS Aortic regurgitation Mitral stenosis

Causes of pulmonic regurgitation

Infection Surgery

Hallmark of mitral stenosis, stage 2

Pulmonary congestion

Hallmark of mitral stenosis, stage 3

Pulmonary hypertension

Causes of mitral valve stenosis

Rheumatic fever Marfan syndrome Ehlers- Danlos syndrome Chordae rupture during trauma damage to papillary muscles during MI

Treatment for tricuspid stenosis

Surgically repaired or replaced

MR PM AS MVP (Mr. Payton Manning as MVP)

Systolic murmurs Mitral regurgitation Physiologic murmur Aortic stenosis Mitral valve prolapse

T/F An S2 spilt over the pulmonic area that disappears during expiration can be a normal finding in young athletes

True

Treatment for pulmonic stenosis

balloon valvuloplasty

Which murmur increases with the Valsalva maneuver?

pulmonic stenosis

What is the most common systolic murmur?

Aortic stenosis

The nurse practitioner notices a medium-pitched harsh systolic murmur during an episodic examination of a 37-year-old woman. It is best heard at the right upper border of the sternum. Which condition is most likely?

Aortic stenosis One of the most frequent pathologic systolic murmurs is due to aortic stenosis. The murmur of aortic stenosis is typically a midsystolic ejection murmur, heard best over the "aortic area" or right second intercostal space, with radiation to the right neck. It has a harsh quality and may be associated with a palpably slow rise of the carotid upstroke. Additional heart sounds, such as an S4, may be heard secondary to hypertrophy of the left ventricle, which is caused by the greatly increased work required to pump blood through the stenotic valve.

Describe mitral stenosis, stage 1

Asymptomatic for a long period, then gradual reduction in exercise tolerance

A mild to moderately loud murmur

Grade 2

What bacteria causes rheumatic fever

beta-hemolytic group A streptococcus

Most common valvular complication from rheumatic fever

mitral regurgitation

Identify: Right ventricular hypertrophy on ECHO and Left atrium enlarged on CXR

mitral stenosis

Identify: A harsh, mid-systolic murmur that is best heard at the right sternal border, 2nd intercostal space and is louder when squatting.

Aortic stenosis

Causes of pulmonic stenosis

Congenital*** Tetralogy of Fallot

Which type of murmurs are not heard in conjunction with the pulse and are always bad?

Diastolic murmurs

ARMS

Diastolic murmurs Aortic regurgitation Mitral stenosis

The patient with mild aortic stenosis wants to know how often he will need to have a repeat echocardiogram given that he has mild disease. Your answer is:

Every 3 to 5 years

What are the three cardinal symptoms (triad) of aortic stenosis?

Exertional dyspnea Angina Syncope

A very soft murmur heard only under optimal conditions

Grade 1

Loud murmur that is easily heard once the stethoscope is placed on the chest.

Grade 3

A louder murmur. First time that a thrill is present.

Grade 4

Very loud murmur heard with edge of stethoscope off the chest. Thrill is more obvious.

Grade 5

Murmur is so loud that it can be heard even with the stethoscope off the chest. The thrill is easily palpated.

Grade 6

How can you better hear aortic stenosis?

It is louder when squatting

How is aortic regurgitation best heard?

Leaning forward post exhale @ the left lower sternal border

Identify: A holosystolic murmur with an absent S1 and displaced PMI that is best heard at the radius of the heart. This murmur radiates to the axilla and sternum.

Mitral regurgitation

Identify: This valvular disease has a long asymptomatic period with CHF developing in the 4th- 6th decade of life.

Mitral regurgitation

A 6-year-old child with a history of rheumatic fever is being examined by the nurse practitioner in a follow-up after hospitalization. Auscultation of the heart reveals a loud blowing, high-pitched murmur radiating to the axilla. Which diagnosis is most likely?

Mitral regurgitation Mitral regurgitation is a pansystolic murmur heard best at the apex or apical area of the heart; it radiates to the axilla and is a loud blowing, high-pitched murmur. Rheumatic fever (a complication of untreated strep throat) can damage the mitral valve, leading to mitral valve regurgitation early or late in life. Aortic stenosis is best heard at the right side of the sternum and is a harsh and noisy murmur. Mitral stenosis is a low-pitched diastolic rumbling murmur. Aortic regurgitation is also a blowing, high-pitched murmur, but it is heard at the right side of the sternum.

The nurse practitioner notes a high-pitched, blowing pansystolic murmur while assessing a 70-year-old male patient. It is grade 2/6 and is best heard at the apical area. What is the most likely?

Mitral regurgitation Mitral regurgitation is best heard at the apical area and manifests as a high-pitched, blowing pansystolic murmur. It occurs when the mitral valve does not close properly. It is the abnormal leaking of blood from the left ventricle, through the mitral valve, and into the left atrium. When the ventricle contracts, there is backflow (regurgitation) of blood into the left atrium. Mitral regurgitation is the most common form of valvular heart disease. Murmurs are graded (classified) depending on how loud they sound with a stethoscope. The scale is 1 to 6 on loudness. A grade 2/6 is a grade 2 on the 6-point scale.

Identify: A low-pitched, rumbling diastolic murmur that radiates towards the axilla, has an opening snap, and loud S1. This murmur is best heard at the apex of the heart with the patient laying in a left lateral recumbent position.

Mitral stenosis

Causes of tricuspid stenosis

Mitral stenosis Rheumatic fever

Identify: A mid- late systolic click that is best heard at the apex of the heart This murmur moves if the patient moves between squatting and standing or Valsalva maneuver

Mitral valve prolapse

Identify: Leaflets blowing 2mm into atria followed by a small- volume mitral regurgitation seen on echocardiogram

Mitral valve prolapse

Which valvular disease is common in women aged 15- 30?

Mitral valve prolapse

Treatment for mitral valve prolapse

Monitor with echocardiogram every 3-5 years Encourage fluids

Systolic murmurs

Mr. Payton Manning as MVP Mitral Regurgitation Physiologic murmur Aortic stenosis Mitral valve prolapse

The nurse practitioner is assessing a patient who presents with syncope, dyspnea, and angina. Which additional assessment data would confirm a diagnosis of aortic valve stenosis?

Murmur that radiates to neck A patient with aortic valve stenosis will present with SAD: syncope, angina, and dyspnea. Additional assessment findings include a harsh and noisy murmur that is heard on the right side of the sternum and radiates to the neck region. A patient with mitral regurgitation will have a loud blowing, high-pitched murmur at the apical area that radiates to the axillae.

Treatment for moderate to severe aortic stenosis

No competitive sports For stage B and higher, consider surgical intervention

Upon auscultation of a 6-year-old patient, the nurse practitioner hears a systolic murmur that sounds like a musical vibration and becomes louder in the supine position. The murmur is a Grade I/II in intensity with minimal radiation. The nurse practitioner will:

Note on the record to monitor on annual physical exam The findings are indicative of a Still's murmur. It is a benign murmur that is common in school-age children and usually resolves by adolescence. The murmur sound is of musical quality with minimal radiation. Because the condition is benign and usually self-resolves, the most appropriate action is to monitor on annual physical exam.

Identify: A systolic crescendo-decrescendo murmur with a severe S2 wide split and ejection click that is best heard at the left sternal border, 2nd IC space. S4 can sometimes be heard below the xiphoid process. Can radiate towards left shoulder and neck Increases with Valsalva maneuver. Has a thrill.

Pulmonary stenosis

Identify: A diastolic decrescendo murmur that is best heard at the LSB, 3-4th IC space while the patient is sitting, leaning forward during inspiration.

Pulmonic regurgitation

Where should an aortic murmur be auscultated?

Right sternal border 2nd intercostal space

Causes of tricuspid regurgitation

Right ventricular remodeling trauma Infective endocarditis

A 75-year-old male presents to your office for a complete physical examination before prostate surgery. On examination, you notice a 3/6 harsh, mid-systolic ejection murmur heard best at the upper right sternal border and radiating to the neck. S1 and S2 are normal. An echocardiogram demonstrates mild aortic stenosis. Currently he is asymptomatic. The indications for valve replacement surgery include:

Severe aortic stenosis in a patient undergoing coronary bypass grafting

Identify mitral stenosis stage: Asymptomatic for a long period, then gradual reduction in exercise tolerance

Stage 1

Pulmonary congestion is a hallmark of with mitral stenosis stage?

Stage 2

Pulmonary hypertension is the hallmark of which stage of mitral stenosis

Stage 3

Reduced cardiac output is a hallmark of what stage of mitral stenosis?

Stage 4

Identify: A holosystolic, blowing murmur that increases with inspiration, decreases with expiration. Can be early, mid, late, or pansystolic. Best heard at the left lower sternal border

Tricuspid regurgitation

Identify: A low-pitched, diastolic decrescendo murmur associated with a diastolic thrill. May have opening snap @ 4th left IC space Best heard at LLSB near xiphoid

Tricuspid stenosis

Treatment of pulmonic regurgitation

Valve replacement if heart failure develops

How is mitral stenosis best heard?

With the patient positioned in left lateral recumbent. Listen at the apex.

Valvotomy

incision of a valve to increase the size of the opening;

A 20-year-old woman reports that for several years, she has had random episodes of palpitations and shortness of breath that resolve spontaneously. She denies chest pain, arm pain, and syncope. Her past medical and family histories are negative for coronary artery disease, stroke, and lung disease. During the cardiac exam, the nurse practitioner notices a grade 3/6 murmur that is accompanied by a midsystolic click, which is best heard at the apical area. The apical pulse is 78 beats/min, blood pressure is 120/60 mmHg, and temperature is 98.6°F. The cardiac exam is highly suggestive of which condition?

mitral valve prolapse A systolic murmur that is accompanied by a midsystolic click located at the apical area is a classic finding of MVP. Most cases of MVP are asymptomatic. To detect MVP, order an echocardiogram with Doppler imaging.

Hallmark of mitral stenosis, stage 4

reduced cardiac output