Doctor123.org

Valvular Heart Disease, Emergency Medicine

Basics

Description

- Aortic stenosis: - Obstruction of LV outflow with increased systolic gradient - Progressive increase in LV systolic pressure and concentric hypertrophy

- Mitral stenosis: - Rheumatic fever - Cardiac tumors - Rheumatologic disorders (lupus, rheumatoid arthritis) - Myxoma - Congenital defects: Parachute valve

- Mitral regurgitation: - Acute pulmonary edema - Jugular venous pressure (JVP) exhibits cannon A-waves and giant V-waves. - Harsh blowing apical crescendo " decrescendo murmur radiating to the axilla - Palpable thrill at apex - S3 and S4 - Palpitations - Atrial fibrillation - Dyspnea - Orthopnea - Nocturnal paroxysmal dyspnea - Peripheral edema - Systemic emboli - Normal JVP - Left ventricular hypertrophy (LVH) - Apical high-pitched pansystolic murmur - Decreased or obscured S1 - Widely split S2 - S3

- Aortic stenosis: - Exertional angina - Syncope (during exercise) - CHF (initially diastolic failure, then systolic) - Sudden death secondary to ventricular fibrillation - Harsh crescendo " decrescendo (diamond-shaped) systolic murmur at aortic focus radiating to carotids - Absent aortic component of S2 - Delayed upstroke in peripheral pulse (pulsus parvus et tardus) - S4 gallop - Ejection click

- Aortic regurgitation: - Fatigue - Dyspnea on exertion - Paroxysmal nocturnal dyspnea - Orthopnea - Syncope - Acute pulmonary edema - High-pitched blowing decrescendo diastolic murmur at aortic area - Accentuated A2 heart sound - Wide pulse pressure - Corrigan pulse (collapsing pulse) - Duroziez sign (to-and-fro murmur) - De Musset sign (head bobbing with systole) - Quincke pulse (nail bed pulsations) - Austin Flint murmur (soft diastolic rumble)

- Mitral regurgitation: - LV and LA enlargement in chronic cases - Pulmonary edema and normal LV and LA dimensions in acute cases

- Aortic stenosis: - LVH - Aortic calcification - Dilation of ascending aorta - Pulmonary congestion and cardiomegaly

- ECG: - Quality assessment of valvular structures - Measurements of flow through valves - Identification of regurgitation - Ventricular dilatation or hypertrophy

- Aortic stenosis: - LVH most common - Atrial fibrillation - Interventricular conduction delay - Complete AV block

- Mitral stenosis: - Treat symptoms of CHF. - Rate control if in atrial fibrillation - Digoxin - ²-blockers - Heparin (if new-onset atrial fibrillation) - Diuretics - Endocarditis prophylaxis/education

- Aortic stenosis: - Gentle diuresis if CHF - Mild hydration if hypotensive and not in CHF - Avoid nitrates and afterload reduction. - Digoxin - Intra-aortic balloon pump (temporize for surgery) - Endocarditis prophylaxis/education

  • Mitral stenosis:Obstruction of diastolic blood flow into the left ventricle (LV)
  • Mitral regurgitation:Inadequate closure of the leaflets allows retrograde blood flow into the left atrium (LA).Acute: Pressure overload in LA and pulmonary veins causing acute pulmonary edemaChronic: LV volume overload with dilatation and hypertrophy with LA enlargement
  • Aortic stenosis:Obstruction of LV outflow with increased systolic gradientProgressive increase in LV systolic pressure and concentric hypertrophy
  • Aortic regurgitation:Acute LV pressure and volume overload leading to left-heart failure and pulmonary edemaChronic volume overload with LV dilation and hypertrophy

Pregnancy is associated with significant hemodynamic changes that can aggravate valvular heart disease and increase the risk of thromboembolic events.

  • Degenerative valvular disease is most common (aortic stenosis and mitral regurgitation)
  • Aortic valve replacement is the most common surgical procedure

Etiology

  • Mitral stenosis:Rheumatic feverCardiac tumorsRheumatologic disorders (lupus, rheumatoid arthritis)MyxomaCongenital defects: Parachute valve
  • Mitral regurgitation (acute):Ruptured papillary muscle (infarction, trauma)Papillary muscle dysfunction (ischemia)Ruptured chordae tendineae (trauma, endocarditis, myxomatous)Valve perforation (endocarditis)Weight-loss medications (fenfluramine, dexfenfluramine)
  • Aortic stenosis:Congenital aortic stenosis: Male > female (4:1)Congenital bicuspid valve (1 " 2%)Rheumatic aortic stenosisCalcific aortic stenosis
  • Aortic regurgitation:Infective endocarditisRupture of sinus of ValsalvaAcute aortic dissectionChest traumaFollowing valve surgeryBicuspid aortic valveRheumatic feverWeight-loss medications (fenfluramine, dexfenfluramine)Collagen vascular or connective-tissue diseasesSystematic lupus erythematosusMarfan syndromePseudoxanthoma elasticumAnkylosing spondylitisEhlers " Danlos syndromePolymyalgia rheumatica

Diagnosis

Signs and Symptoms

  • Mitral stenosis:Malar flush ( "mitral facies " )Prominent jugular A-wavesRight ventricular liftLoud S1Opening snapLow-pitched diastolic rumbleExertional dyspneaFatiguePalpitationsParoxysmal nocturnal dyspneaOrthopneaHemoptysisSystemic emboliPulmonary edema
  • Mitral regurgitation:Acute pulmonary edemaJugular venous pressure (JVP) exhibits cannon A-waves and giant V-waves.Harsh blowing apical crescendo " decrescendo murmur radiating to the axillaPalpable thrill at apexS3 and S4PalpitationsAtrial fibrillationDyspneaOrthopneaNocturnal paroxysmal dyspneaPeripheral edemaSystemic emboliNormal JVPLeft ventricular hypertrophy (LVH)Apical high-pitched pansystolic murmurDecreased or obscured S1Widely split S2S3
  • Aortic stenosis:Exertional anginaSyncope (during exercise)CHF (initially diastolic failure, then systolic)Sudden death secondary to ventricular fibrillationHarsh crescendo " decrescendo (diamond-shaped) systolic murmur at aortic focus radiating to carotidsAbsent aortic component of S2Delayed upstroke in peripheral pulse (pulsus parvus et tardus)S4 gallopEjection click
  • Aortic regurgitation:FatigueDyspnea on exertionParoxysmal nocturnal dyspneaOrthopneaSyncopeAcute pulmonary edemaHigh-pitched blowing decrescendo diastolic murmur at aortic areaAccentuated A2 heart soundWide pulse pressureCorrigan pulse (collapsing pulse)Duroziez sign (to-and-fro murmur)De Musset sign (head bobbing with systole)Quincke pulse (nail bed pulsations)Austin Flint murmur (soft diastolic rumble)

Essential Workup

  • History and symptoms
  • Thorough cardiopulmonary exam
  • ECG

Diagnosis Tests & Interpretation

Lab

  • Blood cultures
  • Presumed endocarditis
  • CBC:

Imaging

  • CXR:Mitral stenosis:Enlarged LAPulmonary vascular congestion (Kerley B lines)Prominent pulmonary arteriesMitral regurgitation:LV and LA enlargement in chronic casesPulmonary edema and normal LV and LA dimensions in acute casesAortic stenosis:LVHAortic calcificationDilation of ascending aortaPulmonary congestion and cardiomegalyAortic regurgitation:Acute = normal cardiac silhouette and pulmonary edemaChronic = enlarged LV and dilated aorta
  • ECG:Quality assessment of valvular structuresMeasurements of flow through valvesIdentification of regurgitationVentricular dilatation or hypertrophy
  • Spiral CT scan:To exclude aortic dissection with acute aortic regurgitation

Diagnostic Procedures/Surgery

EKG:

  • Mitral stenosis:LA enlargement (broad notched P-waves)RV hypertrophyRight axis deviationAtrial fibrillationAcute mitral regurgitation:Left atrial enlargementLVHLeft axis deviation
  • Aortic stenosis:LVH most commonAtrial fibrillationInterventricular conduction delayComplete AV block
  • Aortic regurgitation:Acute = LV strainChronic = LVH and strain

Differential Diagnosis

See Etiology.

Treatment

Pre-Hospital

Avoid vasodilators in aortic stenosis.

Initial Stabilization/Therapy

  • ABCs
  • Administer oxygen.
  • Monitor and measure pulse oximetry.
  • IV access

Ed Treatment/Procedures

  • Mitral stenosis:Treat symptoms of CHF.Rate control if in atrial fibrillationDigoxin ²-blockersHeparin (if new-onset atrial fibrillation)DiureticsEndocarditis prophylaxis/education
  • Mitral regurgitation:Differentiate between acute and chronic MR:Acute:Afterload reduction (nitroglycerin, morphine, or sodium nitroprusside)DiuresisIntra-aortic balloon pump (temporizing for urgent surgery)Chronic:DiuresisNitratesHydralazineACE inhibitorDigoxin ²-adrenergic blocker (ventricular rate control)Calcium antagonist (ventricular rate control)Heparin (if atrial fibrillation)Endocarditis prophylaxis/education
  • Aortic stenosis:Gentle diuresis if CHFMild hydration if hypotensive and not in CHFAvoid nitrates and afterload reduction.DigoxinIntra-aortic balloon pump (temporize for surgery)Endocarditis prophylaxis/education
  • Aortic regurgitation:Chronic:Preload and afterload reductionDigoxinDiureticsEndocarditis prophylaxis/educationAcute:Preload and afterload reductionIntra-aortic balloon pumpUrgent surgery

Medication

  • Atenolol: 0.3 " 2 mg/kg/d PO, max. 2 mg/kg/d (peds: 1 " 2 mg/kg/dose PO daily suggested)
  • Digoxin: 0.5 mg bolus IV, then 0.25 mg IV q2h up to 1 mg; 0.125 " 0.375 mg/d PO
  • Diltiazem: 0.25 mg/kg IV over 2 min (repeat in 15 min PRN with 0.35 mg/kg) then 5 " 15 mg/h
  • Enalapril: 1.25 mg IV q6h; PO 2.5 " 10 mg BID (peds: 0.1 " 0.5 mg/kg/d PO div. q12 " 24h; max.: 0.58 mg/kg/d or 40 mg/d
  • Esmolol: IV: 500 ¼g bolus, then 50 " 400 ¼g/kg/min
  • Furosemide: 20 " 80 mg/d PO/IV/IM; titrate up to 600 mg/d for severe edematous states (peds: 1 mg/kg IV/IM slowly under close supervision; not to exceed 6 mg/kg)
  • Heparin: 80 U/kg IV bolus, then 18 U/kg/h drip, adjust to maintain partial thromboplastin time 1.5 " 2 control (INR 2 " 3)
  • Hydralazine: 10 " 25 mg IV q2 " 4h (peds: 0.1 " 0.5 mg/kg IM/IV q4 " 6h; max. 20 mg/dose)
  • Metoprolol: 5 mg IV q2min 3 doses; then 50 mg PO q6h 48 hr
  • Nitroglycerin: Start at 20 ¼g/min IV and titrate to effect (up to 300 ¼g/min); SL 0.3 " 0.6 mg PRN; USE NON-PVC tubing. Start at 5 ¼g/min, titrate up by 5 ¼g/min every 3 " 5 min until desired effect. Topical 1/2 " 2 in of 2% q6h (peds: 0.25 " 0.5 ¼g/kg/min IV, increase by 0.5 " 1 mg/kg/min; max. 20 ¼g/kg/min)
  • Phentolamine: 5 mg bolus IV, then 1 " 2 mg/min IV infusion
  • Propranolol IV: 1 " 3 mg at 1 mg/min
  • Sodium nitroprusside IV: 0.5 ¼g/kg/min; increase in increments of 0.5 to 1 ¼g/kg/min q5 " 10min up to 10 ¼g/kg/min
  • Amoxicillin: 2 g PO 1 h before the procedure; alternatively, 3 g PO 1 h before the procedure, followed by 1.5 g PO 6 h after the initial dose:Pediatric dose: 50 mg/kg PO 1 h before procedure
  • Ampicillin: 2 g IV/IM 30 min before the procedure (peds: 50 mg/kg IV/IM 30 min before the procedure)
  • Clindamycin: 600 mg PO 1 h before procedure (peds: 20 mg/kg PO 1 h before procedure; not to exceed 600 mg)

Follow-Up

Disposition

Admission Criteria

  • New-onset atrial fibrillation
  • CHF/pulmonary edema
  • Hemodynamically unstable
  • Acute mitral or aortic regurgitation
  • Cardiac ischemia
  • Angina
  • Syncope
  • Arrhythmias

Discharge Criteria

  • Hemodynamic stability
  • Unchanged ECG
  • Resolution of CHF symptoms with diuresis
  • Chronic mitral regurgitation

Issues for Referral

  • For patients who are candidates for outpatient management, close follow-up with a cardiologist to assess severity of valvular disease and need for cardiac surgery
  • Educate patient about risks of valvular heart disease and need for antibiotic prophylaxis with dental and medical procedures.

Pearls and Pitfalls

In patients with chest pain and aortic stenosis, nitrates are contraindicated.

Additional Reading

  • Bonow RO, Cheitlin MD, Crawford MH, et al. Task Force 3: Valvular heart disease. J Am Coll Cardiol. 2005;45(8):1334 " 1340.
  • Carabello BA, Crawford FA. Valvular heart disease. N Engl J Med. 1997;337(1):32 " 41. [Erratum: N Engl J Med. 1997;337:507].
  • Chen RS, Bivens MJ, Grossman SA. Diagnosis and management of valvular heart disease in emergency medicine. Emerg Med Clin North Am. 2011;29(4):801 " 810.
  • Elkayam U, Bitar F. Valvular heart disease and pregnancy part I: Native valves. J Am Coll Cardiol. 2005;46:223 " 230.
  • Rahimtoola SH. The year in valvular heart disease. J Am Coll Cardiol. 2013;61(12):1290 " 1301.
  • Roldan CA, Shively BK, Crawford MH. Value of the cardiovascular examination for detecting valvular heart disease in asymptomatic subjects. Am J Cardiol. 1996;77:1327 " 1331.

Codes

ICD9

  • 394.0 Mitral stenosis
  • 424.0 Mitral valve disorders
  • 424.90 Endocarditis, valve unspecified, unspecified cause
  • 395.0 Rheumatic aortic stenosis
  • 429.5 Rupture of chordae tendineae
  • 429.6 Rupture of papillary muscle
  • 746.4 Congenital insufficiency of aortic valve
  • 746.89 Other specified congenital anomalies of heart

ICD10

  • I05.0 Rheumatic mitral stenosis
  • I34.0 Nonrheumatic mitral (valve) insufficiency
  • I38 Endocarditis, valve unspecified
  • I06.0 Rheumatic aortic stenosis
  • I51.1 Rupture of chordae tendineae, not elsewhere classified
  • I51.2 Rupture of papillary muscle, not elsewhere classified
  • Q23.1 Congenital insufficiency of aortic valve
  • Q24.8 Other specified congenital malformations of heart

SNOMED

  • 368009 Heart valve disorder (disorder)
  • 79619009 Mitral valve stenosis (disorder)
  • 48724000 Mitral valve regurgitation (disorder)
  • 72011007 Rheumatic aortic stenosis (disorder)
  • 274098004 Rupture of chordae tendineae (disorder)
  • 5919001 Rupture of papillary muscle
  • 70320004 congenital anomaly of heart valve (disorder)
  • 72352009 bicuspid aortic valve (disorder)