PassMED: Medical Finals Examination Revision

Valvular Disease

	Aortic Stenosis	Aortic Regurg	Mitral Regurg	Mitral Stenosis	Tricuspid Regurg
Pulse	Slow rising	Collapsing, large volume	-	AF	-
JVP	-	-	-	-	Up, large V waves
Apex	Not displaced, Pressure overloaded	Displaced, Volume overloaded	Displaced, volume overloaded	Tapping	-
Heart sounds	Soft S2	-	Soft S1	Loud S1	-
Auscul- tation	End systolic murmur radiating to carotids	End diastolic murumur at left sternal edge	Pan systolic murmur radiating to axilla	Middle diastolic murmur, ?opening snap	Pan systolic murmur left sternal edge, louder inpiration
Position	Right SE 2nd intercostal space	Right SE 2nd intercostal space	Apex beat	Apex beat	Left SE 2nd intercostal space
BP	Narrow pulse pressure	Wide pulse pressure	-	-	-
Other	-	Corrigan's, duroziez etc	-	Malar flush Valvotomy scar Pul hyper- tension	Pulsatile hepatomegaly
Causes	Bicuspid valve Senile calcification Rheumatic	Endocarditis Ank Spon Rheumatic Marfan's Syphilis	Prolapse Conn tissue Endocarditis Rheumatic	Rheumatic	Pul hypertension RV dilation

Incidental findings	Stigmata of infective endocarditis, Connective tissue disease
+ve signs	As above
Differential diagnosis	As above
Function	Dominant lesion , Pulmonary hypertension, L/R heart failure
Tests	CXR, ECG, Echo, Exercise tolerance test, Angiogram

AR: Look for infective endocarditis, Marfan's, Ankylosing spondylitis, Argyll-Robertson pupils

AS: Valve replacement indicated if symptoms or when gradient > 50mmHg, valve area < 0.6
AS: Beta blockers slow rate of rise of systolic pressure, avoid vasodilators, ACE inhibitors
AS: Impossible to have mod/severe with normal S2
Austin flint mid diastolic murmur occurs in severe AR due to regurgitant jet interfering with mitral valve
AR: Surgery when either (i) EF<50% (ii) decreased exercise capacity (iii) LV end systolic 55mm (iv) aortic root 50mm
AR: Long term nifedipine reduces/delays the need for valve replacement in asymptomatic patients with severe AR, not recommended for mild AR as good outcome with no therapy
Acute MR due to papillary rupture in MI, endocarditis
MR Indications surgery: Either (i) mod/severe symptoms despite medical therapy or (ii) EF<60% / LV end systolic dimension >45mm in absence of symptoms
MS: normal valve area 4-6 cm2 tight stenosis < 1
MS indications intervention: symptoms / pul oedema / haemoptysis / pul hypertension
MS indications percutaneous valvotomy: mobile valve, not calcified on TOE
Graham steele: End diastolic murmur of pulmonary regurg with pulmonary hypertension
Tissue aortic valve can have just loud S2
Metallic S1 = mech mitral, S2 = mech aortic, both = either double valve or ball and cage