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Signs of mitral stenosis
- Exertional dyspnea
- Cough
- Systemic embolism, due to enlarged LA
- Accentuated RV precordial thrust
- Hoarse voice (if enlarged LA compresses recurrent laryngeal)
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Murmur of mitral stenosis
Mid-diastolic, low pitched rumble with opening snap
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When should a patient with valvular disease be given prophylaxis for endocarditis?
- Before dental procedures
- Before GI procedures
- Before urologic procedures
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Murmur of mitral regurg
- Loud, holosystolic
- Radiates to the axilla
- Wide splitting of S2 on inspiration
- Rapid filling of LV with blood regurgitated during systole may cause an S3
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Causes of S2 splitting
- Splitting on inspiration--mitral regurg
- Fixed splitting--ASD
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A young woman presents with atypical chest pain and a mid-systolic click
Mitral prolapse
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Murmur of mitral prolapse
- Mid-systolic click, followed by late systolic murmur
- S3 may be present
- Wide splitting of S2
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Symptoms of late stage aortic stenosis
Angina and syncope, particularly during exercise, when peripheral resistance falls and LV pressure stays the same, due to the stenotic valve
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Signs of LV strain on ECG
ST depression and T wave inversion in I, aVL, and the left precordial leads
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Narrow pulse pressure is characteristic of...
Aortic stenosis
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Indications for aortic valve replacement
- Persistent symptoms
- Valve area < 0.5 cm
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Conditions associated with proximal aortic root dissection
- Cystic medial necrosis
- Marfan's
- Syphilis
- HTN
- Ehlers-Danlos
- Turner's
- 3rd trimester of pregnancy
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Conditions associated with wide pulse pressure
- Hyperthyroidism
- Anemia
- Wet beriberi
- Hypertrophic subaortic stenosis
- Hypertension
-
Corrigan's pulse
Bounding pulses, seen in aortic regurg
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Pulsus bisferiens
Dicrotic pulse with two palpable waves in systole, seen in aortic regurg
-
Duroziez sign
- Presence of a diastolic femoral bruit when the femorals are compressed enough to hear a systolic bruit.
- Seen in aortic regurg
-
Hill's sign
- Systolic pressure in legs > 20 mmHg higher than in arms
- Seen in aortic regurg
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Quincke's sign
- Alternate flushing and blanching of the fingernails in response to light pressure
- Seen in aortic regurg
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De Musset's sign
Head bobs with heartbeat, seen in aortic regurg
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Murmur of aortic regurg
- High pitched, blowing, decrescendo diastolic murmur
- Accentuated by leaning forward
-
Austin Flint murmur
- Low pitched diastolic rumble, seen in severe aortic regurg
- Caused by regurgitated blood striking the anterior mitral leaflet
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Signs of tricuspid stenosis
- Peripheral edema
- JVD
- Hepatosplenomegaly, ascites, jaundice
- Diastolic murmur that increases with inspiration (unlike the diastolic murmur of mitral stenosis
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Murmur of tricuspid regurg
Blowing holosystolic murmur
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Infectious causes of dilated cardiomyopathy
Viral myocarditis--irreversible
-
Toxic causes of dilated cardiomyopathy
- Alcohol abuse--reversible
- Doxorubicin
- Cocaine
- Heavy metals (Pb, Hg)
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Endocrine causes of dilated cardiomyopathy
- Thyroid disease (hypo or hyper, reversible)
- Acromegaly
- Pheochromocytoma
-
Metabolic causes of dilated cardiomyopathy
- Thiamine deficiency (wet beriberi, reversible)
- Pregnancy (reversible)
- Neuromuscular disease
- Idiopathic
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Indications of dilated cardiomyopathy on ECG
- RBBB (R, S, R' in V1 and V2)
- Ventricular hypertrophy
- Arrhythmias (usually a fib)
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Causes of restrictive cardiomyopathy
- Endomyocardial fibroelastosis
- Hypereosinophilic syndrome
- Primary amyloidosis
- Hemochromatosis
- Sarcoidosis
- Carcinoid syndrome
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Signs of restrictive cardiomyopathy
- Right heart failure
- Exercise intolerance
-
Hypertrophic cardiomyopathy
- Hypertrophy of the LV septum narrows the LV outflow tract.
- Increased LV outflow tract velocity draws the anterior mitral leaflet forward, causing outflow tract obstruction
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Causes of paradoxical splitting of S2
- HCM
- Aortic stenosis
- LBBB
- (when the LV contracts against an obstructed outflow tract, which delays closure of the aortic valve--split decreases on inspiration, because delayed closure of pulmonic valve on inspiration brings pulmonic closure closer to aortic closure)
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Factors that increase and decrease the systolic ejection murmur of HCM
- Decrease--increased venous return (e.g. squatting, fluids)
- Increase--decreased venous return (e.g. exercise, valsalva)
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Most common cause of viral myocarditis
Coxsackie B
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Most common cause of acute bacterial endocarditis
Staph aureus
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Most common cause of subacute bacterial endocarditis
Strep viridans (infects previously damaged valves)
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Bacteria associated with bacterial endocarditis and colonic neoplasms
Strep bovis
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Symptoms of acute bacterial endocarditis
- Acute onset of fever, chills, and weight loss (in the DD for FUO)
- New murmur
- Metastatic infections (pneumonia, meningitis)
-
Symptoms of subacute bacterial endocarditis
- Gradual onset of fever, sweats, weakness, arthralgia, anorexia, weight loss, and cutaneous lesions
- New murmur
- Splenomegaly
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Signs of endocarditis
- Petechiae on upper chest and mucus membranes
- Osler's noes--tender, violet nodules on fingers and toes
- Janeway lesions--hemorrhagic, non-tender nodules on palms and soles
- Splinter hemorrhages
- Roth spots on fundoscopy
- Conjunctival hemorrhage
-
Diagnosis of bacterial endocarditis
- Two positive blood cultures, 12 hours apart, or 3 positive cultures, 1 hour apart
- Vegetations on echo (specific, but nonsensitive)
- Hematuria, elevated ESR/CRP, leukocytosis
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Causes of pericarditis
- Infection
- Mets (usually from breast or lung tumors)
- Acute MI
- Uremia (chronic renal failure with mental status chnages)
- Hx of radiation
- Drug reaction (procainamide, INH, hydralazine)
- SLE, scleroderma
- Myxedema
-
Signs of pericarditis on ECG
Diffuse ST elevation with PR depression
-
Tx for pericarditis
- NSAIDs
- Steroids, in severe cases (e.g. Dressler's, post-MI)
-
Pericardial tamponade
- Accumulation of fluid in the pericardial sac
- Impairs cardiac filling and reduces CO
-
Beck's triad (indicates cardiac tamponade)
- Hypotension
- Muffled heart sounds
- JVD
-
Kussmaul's sign
- Failure of jugular venous pressure to fall during inspiration
- May indicate constrictive pericarditis, restrictive cardiomyopathy, or cardiac tamponade
- (sign of limited RV filling)
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