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Heart murmurs and dysfunctions (Mitral stenosis (Signs (On auscultation -…
Heart murmurs and dysfunctions
Mitral stenosis
Broad and notched P wave
Thickening and immobility of the valve - obstruction of blood flow from left atrium to left ventricle. Reduced cardiac output (CO)
Increased pressure in left atrium which will cause atrial fibrillation, pulmonary hypertension and therefore right heart dysfunction.
Thrombus can form in the dilated left ventricle which may lead to emboli - stroke.
Pulmonary oedema due to increased pressure in pulmonary capillaries.
Signs
On auscultation - loud 1st heart sound
Lower limb (peripheral) oedema
Low volume pulse (weak) and irregular in AF
Worsening exertional dyspnoea
Malar flush - cyanotic or dusky pink discolouration in upper cheeks
AF
Opening snap on auscultation due to the stiffened valve - systolic ejection murmur pleated as a thrill.
Dyspnoea/othropnoea
Hx rheumatic fever
Cough with blood stained sputum
Management
Severe asymptomatic - no therapy or a balloon valvotomy
Severe symptomatic - Diuretic e.g. furosemide 40mg OD then migrate to max 600mg/day AND balloon valvotomy or valve replacement/repair
Progressive asymptomatic - no therapy
Aortic stenosis
Signs
Exertional dyspnoea, angina or syncope
Due to increased cardiac output
Ejection systolic murmur - crescendo/decrescendo pattern radiating to the carotid. Loudest at right upper sternal border
Obstruction of blood flow due to aortic calcification
Left ventricular hypertrophy leads to heart failure
Diminished S2 due to decreased mobility of aortic valve leaflets
Management
If clinically unstable
Balloon valvuloplasty prior to Transcatheter aortic valve replacement (TAVR)
If clinically stable assess the risk and determine if surgery is needed.
Tricuspid stenosis
Uncommon
Almost always result of rheumatic fever
Associated with mitral and aortic valve disease
Signs
Dyspnoea
Elevated JVP with prominent a-wave
Low frequency pre systolic murmur heard at lower left sternal border
Exercise intolerance and fatigue
AF
Cyanosis, oedema and ascites
Pulmonary stenosis
Mostly congenital
Systolic ejection murmur, loudest over left upper sternal border
Diagnosis confirmed and severity rated by echocardiogram
Management
Benign - cardiac follow-ups but no therapy
Valvoplasy or valvotomy for severe cases
Main consequences increased right ventricle pressure
Signs in severe PS
Syncope
cyanosis
Exercise intolerance
Dyspnoea
Regurgitation
Aortic
Loading of left ventricle resulting in hypertrophy
Stroke volume increased therefore increased pulse pressure
Signs
Apex beat displaced laterally
Early diastolic murmur
Collapsing pulse
Treatment
Vasodilators
Diuretics
ACEi in left ventricular dysfunction
Mitral
Signs and symptoms
Exertional dyspnoea, fatigue and lethargy (reduced CO)
Displaced apex beat
Pulmonary oedema
Pan-systolic murmur heard as a thrill
Third heart sound is often present (rapid filling of dilated left ventricle
Treatment
ACEi
Diuretics
Some surgical intervention if symptomatic severe disease