Volume 3, Issue 3, An Issue of Hospital Medicine Clinics, E-Book (eBook)

Christopher Kim (Autor)

eBook Download: PDF | EPUB

2014 | 1. Auflage
100 Seiten
Elsevier Health Sciences (Verlag)
978-0-323-31183-0 (ISBN)

Infos

This online Clinics series provides evidence-based answers to clinical questions the practicing hospitalist faces daily. The eleventh issue in our growing online database, edited by Christopher Kim, covers essential updates in the following topics: diagnosis and management of valvular heart disease, sepsis, infections in hospitalized immunocompromised patients, acid base disorders, subacute bacterial peritonitis, delirium, acute pain, and opthalmologic emergencies, as well as transfusion medicine and hospital-based QI initiatives.

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This online Clinics series provides evidence-based answers to clinical questions the practicing hospitalist faces daily. The eleventh issue in our growing online database, edited by Christopher Kim, covers essential updates in the following topics: diagnosis and management of valvular heart disease, sepsis, infections in hospitalized immunocompromised patients, acid base disorders, subacute bacterial peritonitis, delirium, acute pain, and ophthalmologic emergencies, as well as transfusion medicine and hospital-based QI initiatives.

Textauszug

Diagnosis and Management of Valvular Heart Disease

Edward S. Lee, MDa∗[e-mail], Ed L. Ha, MDa, Eric H. Yang, MDb and Gabriel Vorobiof, MDb,     aHospitalist Section, University of California, Los Angeles, 757 Westwood Blvd, Suite 7501, Los Angeles, CA 90095, USA; bDivision of Cardiology, University of California, Los Angeles, 757 Westwood Blvd, Los Angeles, CA 90095, USA

∗Corresponding author.

Valvular heart disease is a major cause of morbidity and mortality. This article addresses the 4 major left-sided valvular disorders regarding etiology, pathophysiology, clinical assessment, and management. Discussions on management focus on indications for echocardiography, key echocardiography findings, and indications for surgical intervention. Guidelines from the 2014 American College of Cardiology/American Heart Association report and the 2008 European Society of Cardiology guidelines are summarized. Right-sided valvular disease is also briefly discussed in addition to current guidelines for endocarditis prophylaxis.

Keywords

Valvular heart disease

Aortic stenosis

Aortic regurgitation

Mitral stenosis

Mitral regurgitation

Right-sided valvular disease

Endocarditis prophylaxis

Hospital Medicine Clinics Checklist

1. Patients with known or suspected valvular heart disease should be carefully questioned to assess for the presence of symptoms such as heart failure, angina, syncope, or exercise limitations.

2. Careful auscultation should be performed to identify murmurs and other findings that may point toward a particular valvular disorder.

3. The primary diagnostic imaging modality for valvular heart disease is transthoracic echocardiography.

4. Echocardiography should assess the severity of the valvular disease based on defined criteria for each type of valvular disease.

5. Indications for surgical intervention vary depending on the valve involved, but in general any patient with severe valvular disease on echocardiography or symptoms related to their valvular disease should be referred for cardiology and/or surgical evaluation.

6. Transcatheter aortic valve replacement and percutaneous mitral valve repair are now available as minimally invasive strategies, and can be considered for patients thought to be at high surgical risk.

7. Right-sided valvular disease is often congenital, rheumatic, or secondary to another process. Less clear guidelines are available for the management of right-sided lesions.

8. Endocarditis prophylaxis for valvular disease is now only recommended for patients with prosthetic material related to valve replacement/repair or a prior history of infective endocarditis.

When should an echocardiogram be ordered in a patient with a murmur?

Cardiac murmurs are a relatively common finding on physical examination. Although many are benign and warrant no further evaluation, others can be important clues to the patient’s condition and require further evaluation. Assessment of a murmur begins with a thorough history and physical examination. Symptoms of heart failure, syncope, or angina should be elicited. Signs and symptoms of endocarditis should also be pursued. Examination of the murmur should assess timing in the cardiac cycle, location, radiation, intensity, and configuration (crescendo, decrescendo, and so forth).

According to the American College of Cardiology/American Heart Association (ACC/AHA), Class I indications for echocardiography include1:

1. Diastolic, continuous, holosystolic, and late systolic murmurs

2. Murmurs associated with ejection clicks

3. Murmurs that radiate to the neck or back

4. Grade 3 or louder midpeaking systolic murmurs

5. Signs of symptoms of heart failure, myocardial ischemia, syncope, thromboembolism, endocarditis, or other structural heart disease

What are the stages of valvular heart disease?

The 2014 ACC/AHA update introduced a new classification scheme to outline the progression of patients with valvular heart disease.2 These criteria are related to, but distinct from echocardiographic criteria for severity of the valve disorder.

Stage A: Patients at risk for the development of valvular heart disease

Stage B: Patients with valvular heart disease that is not yet symptomatic or severe. Severity of valvular heart disease depends on a variety of parameters specific to the valve in question

Stage C: Patients meet criteria for severe valvular heart disease but are asymptomatic

Stage D: Patients with symptoms from valvular heart disease

Depending on the valve in question, each stage may have subcategories (C1, C2, D1, D2, and so forth).

Aortic stenosis

What are the causes of valvular aortic stenosis?

Most cases of aortic stenosis (AS) in Western countries are due to calcific valvular disease, accounting for more than 90% of cases in patients older than 75 years.3 In younger patients, AS is related to calcification of congenitally abnormal valves, including bicuspid and unicuspid valves, or rheumatic heart disease. Although the prevalence of bicuspid aortic valves is less than 1%, they make up half of the aortic valve replacements (AVRs) performed.3 Worldwide, rheumatic heart disease is the most common cause of AS, but is very rare in Western countries.4

What are the important signs and symptoms in a patient with known or suspected AS?

The most significant manifestations include angina, syncope, and heart failure, for which surgical intervention is indicated. Physical examination will frequently demonstrate a harsh, crescendo-decrescendo systolic murmur at the cardiac base, with radiation to the carotids. Paradoxic splitting of the second heart sound may be present, owing to delayed aortic valve closure. Examination of the carotid pulsation may demonstrate a slow and delayed carotid upstroke, called pulsus parvus et tardus (Table 1).5

Table 1

Common examination findings in valvular heart disease

Aortic stenosis (AS)

Harsh, midsystolic, low-pitched murmur at base with radiation to carotids

Slow and delayed carotid pulse

S2 fixed or paradoxically split

Reduced pulse pressure in severe AS

S3 and S4 possible

Prominent a-waves on jugular venous pulse

Dynamic and displaced LV impulse

Aortic regurgitation

Early high-pitched, diastolic, decrescendo murmur

Displaced LV impulse

Austin-Flint murmur (mid-diastolic rumble)

Wide pulse pressure

S3	de Musset head bobbing

Corrigan water hammer pulse

Duroziez sign: femoral artery murmur

Quinke pulse

Mitral stenosis

Low-pitched, diastolic rumbling murmur at apex

Prominent a-waves on jugular venous pulse (due to pulmonary hypertension)

S1 accentuated and delayed

Diastolic thrill at cardiac apex

S2 closely split or fixed

Edema, hepatomegaly, effusions in setting of RV failure

P2 louder

Opening snap of mitral valve

Mitral regurgitation (MR)

Holosystolic murmur at apex with radiation to axilla

Sharp arterial upstroke

S1 soft or buried

Prominent a-waves on jugular venous pulse (due to pulmonary hypertension)

S2 widely split owing to premature aortic valve closure

Hyperdynamic left ventricle with displaced apical impulse

Low-pitched S3 in severe MR owing to sudden tensing of papillary muscles, chordae, and leaflets

Mitral valve prolapse

Mid or late systolic click (may be multiple)

High-pitched, crescendo-decrescendo murmur at apex

Abbreviations: LV, left ventricular; RV, right ventricular.

What are the diagnostic methods of evaluation for AS?

Doppler echocardiography remains the major imaging modality for the diagnosis and evaluation of AS. Aortic valve...

Produkt-Details

• Erscheint lt. Verlag: 8.9.2014
• Sprache: englisch
• Themenwelt: Medizin / Pharmazie ► Medizinische Fachgebiete
• Themenwelt: Studium ► 2. Studienabschnitt (Klinik) ► Anamnese / Körperliche Untersuchung
• ISBN-10: 0-323-31183-0 / 0323311830
• ISBN-13: 978-0-323-31183-0 / 9780323311830