valvular heart disease · 2021. 8. 16. · 9/10/2020 1 valvular heart disease eddie needham, md,...
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9/10/2020
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Valvular Heart Disease
Eddie Needham, MD, FAAFPProgram Director and Academic Chairman
AdventHealth Winter Park Family Medicine Residency ProgramProfessor, UCF-COMProfessor, LLU-SOM
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The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
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Disclosure Statement
It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.
All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.
Learning Objectives
1. Identify the types of valvular heart disease commonly seen
in primary care
2. Develop a diagnostic protocol for valvular heart disease
3. Accurately interpret echocardiography reports to determine
appropriate treatment strategies
4. Provide a management plan that includes follow-up testing,
and addresses comorbidities and prevents disease
complications
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Le Clinician existe toujours!
Strive to truly listen to the patientDemand excellence
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Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of CardiologyVolume 63, Issue 22, June 2014Guideline at: http://www.onlinejacc.org/content/accj/63/22/e57.full.pdf?_ga=2.117599177.1523384412.1523455157-1654496124.1487167180
Valvular Heart Disease (VHD)
•VHD contributes to more than 40,000 patient deaths and 100,000 operations annually.
•Last update to ACC/AHA VHD guidelines was 2014 with focused update in 2017.
•VHD accounts for 10-20% of all cardiac procedures in the United States.
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Creative commons license at: http://en.wikipedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).s
Valvular Heart Disease (VHD)
•The presence of symptoms in the medical history helps determine the need for surgery
•Valvular stenosis obstructs forward flow •Valvular regurgitation permits backward flow•Aortic and mitral valves are most commonly affected
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Grading of murmurs
•Grade I/VI Barely discernable
•Grade II/VI Readily discernable
•Grade III/VI Loud and easily heard
•Grade IV/VI Palpable thrill associated with murmur
•Grade V/VI Audible with edge of stethoscope on precordium
•Grade VI/VI Heard with stethoscope off chest (case)
Valvular Heart Disease (VHD)
•Pathologic murmurs requiring evaluation−Any murmur in diastole−Any murmur III/VI or louder−Any murmur in late systole−Murmurs that fall into diagnostic concern
• Hypertrophic cardiomyopathy (HCM/IHSS)•A soft murmur can still be concerning−I/VI early diastolic murmur of aortic regurgitation
Barriers to
Practice
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Busy practice murmur algorithm
Get an Echo
Learning Objectives/Goals
1. Identify the types of valvular heart disease commonly seen in primary care
2. Develop a screening protocol for valvular heart disease3. Accurately interpret echocardiography reports to
determine appropriate treatment strategies4. Provide a management plan that includes follow-up
testing, and addresses comorbidities and prevents disease complications
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Technology
•In general, a transthoracic echocardiogram is the first step in
evaluating a new cardiac murmur.
•Echo’s can also generate revenue for a busy practice
•New/emerging technologies include:
−Real-time 3D echocardiography (MV pathology)
−Cardiac MRI (excellent general applications but issues of access
and expense limit use)
−Handheld echocardiography
Cardiac Murmur
Diastolic Continuous
Early systolic orMidsystolic –
grade 3 or more;Late systolic, or
Holosystolic
Systolic
Venous hum, Mammary souffle
of pregnancy
Symptomatic or other signs of cardiac disease
Asymptomatic and no
associatedfindings
MidsystolicGrade 2 or less
No furtherevaluation
Cardiac catheterization and angiography if appropriate
EchocardiographyNo furtherevaluation
Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006, Guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol,. 2008; 52(13):e1-142
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Reality check
Electronic stethoscope
Creative commons license at: http://commons.wikimedia.org/wiki/File:Electronic_stethoscope.jpg
Auscultatory ExcellenceSystolic Murmurs
MurmurAortic stenosis
Mitral regurgitation
Pulmonary stenosis
Tricuspid regurgitation
QualityCrescendo-decrescendoHarsh, medium pitch
Mid to late crescendoHolosystolicMedium to high pitch
Crescendo-decrescendo
HolosystolicMedium to high pitch
Location2nd right ICSRadiates to carotid
ApexRadiation to axilla
2nd left ICSLouder with inspiration
Lower left sternal borderLouder with inspiration
Other findingsDelayed carotid upstrokeSoft A2 (late in course)Paradoxical S2 splitting
S3
Midsystolic click with MVP
Soft P2
Large v waves in jugular venous pulsations
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Auscultatory ExcellenceDiastolic Murmurs
MurmurAortic regurgitation
Mitral stenosis
Pulmonary regurgitation
Tricuspid stenosis
QualityDecrescendoHigh pitched blow
Low pitched rumbleCrescendo-decrescendo
Decrescendo
Low pitched rumble
LocationLower left sternal brdrLeaning forwardApex
ApexLeft lateral decubitus
2nd left ICS
Left sternal border
Other findingsWide pulse pressureOther clinical findings:
Quincke’s pulses ,etc…
Opening snap may be presentPossible loud P2
Louder with inspiration
Louder with inspiration
Heart sounds common in FM
•Split S2 – physiologic vs fixed
•Split S2 vs S3
•S3 and S4
−volume and pressure overload respectively
•Aortic stenosis
•Mitral regurgitation
•Mitral valve prolapse
Barriers to
Practice
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Heart sounds not as common in FM
•Aortic regurgitation•HCM•Ventricular septal defect (VSD)•Right-sided murmurs – vary with inspiration•Rare:−Mitral stenosis with opening snap and mid-diastolic rumble
Heart sounds
•Let’s draw a murmur| <||||> | S1 M S2
•Systolic or Diastolic•Early, mid, late, continuous•Location: −URSB – Aortic valve−ULSB – Pulmonic valve−LLSB – Tricuspid … and aortic valves−Apex – Mitral … and aortic valves
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AES Question
Question 1: Heart sounds
•Here’s the sound:•What does it look like?
S1 S2 S1 S2A. | | | |
B. | | | |
C. | | | |
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Question 1: Heart sounds
This is what each of these sounds like:
S1 S2 S1 S2A. | | | |
B. | | | |
C. | | | |
Two conditions that vary with squat to stand:
•MVP – Mitral valve prolapse
−When patient squats, click and MR murmur move later in systole
−When patient stands up, click and MR murmur move earlier in
systole
•HCM – Hypertrophic cardiomyopathy
−When patient squats, murmur gets softer – more blood in LV
−When patient stands, murmur gets louder – less blood in LV
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It’s about the waves
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Now I’m here
Common mistakes in auscultation
•Minimize ambient noise•Remove the patient’s shirt (hair?)•Push firmly with the stethoscope−If you left a ring on the skin, you pushed hard enough
•Take the time to listen well•Use provocative maneuvers (squat to stand)
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Anticipate the murmur
•Patient with BP 180/100 x 5 years−Likely to have a thick LV
• Possible S4 – Pt with palpable S4• Possible diastolic HF
•Patient with severe COPD, still smoking−Possible pulmonary HTN, listen for:
• Fixed split S2, right sided murmurs that change with respiration
•Patient with HFrEF and an EF = 15%−Likely to have mitral regurgitation murmur
AES Question
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Question 2Which one of the following heart murmurs is best heard over the right precordial area extending into the neck?
A. Mitral valve insufficiencyB. Aortic stenosisC. Mitral valve prolapseD. Aortic insufficiency
Question 2Which one of the following heart murmurs is best heard over the right precordial area extending into the neck?
A. Mitral valve insufficiencyB. Aortic stenosisC. Mitral valve prolapseD. Aortic insufficiency
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Aortic Stenosis
•Aortic Stenosis is the most common type of VHD in the US.
•Risk Factors
−Age – for every 10 year increase in age there is a twofold
increase in risk
−Male: female 2:1
−Current cigarette smoking - Relative risk ↑35%
−HTN - Relative risk ↑25%
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Aortic Stenosis
•Among patients > 70 years old:−60% have a tricuspid valve−40% bicuspid
•Among patients 50-70 years old:−66% bicuspid−33% tricuspid
•Rheumatic valvular heart disease•Up to 5% of elders > 75 years old have aortic stenosis
Bicuspid and Other Congenitally Abnormal Aortic Valves
•1% of the population born with bicuspid aortic valve, male>female
•Approximately−1/3 become stenotic−1/3 become regurgitant−1/3 experience only minor hemodynamic abnormalities
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Aortic Stenosis – Clinical Findings
•II-III/VI mid systolic murmur at upper right sternal border radiating into the carotids
•Carotid pulse – slow upstroke−Pulsus parvus et tardus
•PMI prolonged−LVH
•PMI laterally displaced−Dilated left ventricle
Diagnostic Testing
•12 lead ECG – often shows LVH, left atrial enlargement•CXR may show:−Cardiomegaly – enlarged cardiac silhouette−Pulmonary congestion−Aortic valve calcification
•Echocardiogram – indispensable!•Normal aortic valve area: 3-4 cm2
•The transvalvular gradient is the most important parameter
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Echo severity of AS
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Severity of aortic stenosis in asymptomatic patients
DegreeMean gradient
(mmHg)Aortic valve area
(cm2)
Mild <20 >1.5
Moderate 20 - 39 1.0 - 1.5
Severe >40 < 1.0
Very severe >60 < 0.6
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology Volume 63, Issue 22, June 2014
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Aortic Stenosis
•When the classic symptoms of angina, syncope, and heart
failure develop, survival declines precipitously
−50% of symptomatic patients die within 2-5 years
unless aortic valve is surgically replaced
•Prompt recognition of symptoms and evaluation for possible
severe aortic stenosis are crucial in managing the disease
TreatmentThe only proven effective therapy for symptomatic aortic
stenosis is aortic valve replacementThere is no effective medical therapy for AS.
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AV replacement surgery
•AVR should be considered for symptomatic pts−Angina, syncope, heart failure
•In asymptomatic patients, consider AVR if:−LV dysfunction −Hypotension −Symptoms with exercise
•Consider AVR at the time of CABG in patients with moderate to severe AS.
Aortic Stenosis - AVR
•Choice of valve prosthesis•Mechanical valve−Risk of thromboembolism−Bleeding from anticoagulation
•Biosynthetic valve−Limited durability – 10-15 years−Excellent choice in the elderly with limited life expectancy−This is the usual choice in patients >65 years old
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Aortic Stenosis
•Balloon valvotomy−The AV is often severely calcified with minimal response to this technique−Palliative technique in poor surgical candidates for AVR−It does not improve survival−Higher incidence of:
• Residual/recurrent stenosis• Death• Stroke• Aortic rupture• Aortic regurgitation
Transcatheter Aortic Valve Replacement (TAVR)
•For high risk patients who are not suitable candidates for surgical
valve repair, TAVR is emerging as a viable option.
•First study – 699 patients
−TAVR vs surgical repair at 2 years, outcomes are comparable (34
vs 35%)
−Increased short term risk of stroke at 30 days
• (4.7% vs 2.4%)
Kodali SK et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012 May 3;366:1686.
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Transcatheter Aortic Valve Replacement (TAVR)
•Second study: TAVR vs medical therapy−358 pts unable to undergo surgical repair−All-cause mortality at 2 years 43% (TAVR) vs 68% (Med Rx)−Stroke at 30 days 6.7% vs 1.7%−Stroke at 2 years 13.8% vs 5.5%
•TAVR is an consideration for high risk patients with severe aortic stenosis
•Mortality is less while stroke risk is elevated
Makkar RR et al. Transcatheter aortic-valve replacement fro inoperable severe aortic stenosis. N Engl J Med 2012 May 3; 366:1696.
AES Question
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Question 3Which one of the following heart murmurs is heard over the apex of the heart and sometimes the left axilla/left posterior thorax?
A. Mitral valve insufficiencyB. Aortic stenosisC. Mitral valve prolapseD. Aortic insufficiency
Question 3Which one of the following heart murmurs is heard over the apex of the heart and sometimes the left axilla/left posterior thorax?
A. Mitral valve insufficiencyB. Aortic stenosisC. Mitral valve prolapseD. Aortic insufficiency
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Mitral Regurgitation
•The mitral valve is composed of the mitral annulus, the leaflets, the chordae tendineae, and the papillary muscles
•Abnormalities in any of these structures may lead to mitral regurgitation
Mitral Regurgitation
•Causes−Mitral valve prolapse−Myocardial ischemia leading to papillary muscle dysfunction or infarction −Annular calcification−Endocarditis−Collagen vascular disease−Rheumatic heart disease
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Jessup M, Brozena S, Heart Failure, N Engl J Med 2003. 348:2007-2018, May 15, 2003
Physical Exam
•Mid to late systolic murmur best heard over apex•Radiates to left axilla•Intensity varies from soft to loud•Pitch is medium to high•Quality is blowing
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Diagnostic Testing
•12 lead ECG usually shows LVH or LAE
•Chest x-ray typically shows cardiomegaly
•Echocardiography shows the extent of left atrial and LV
enlargement
−Left atrium > 4 cm
•Transesophageal echocardiography is excellent for
assessing the left atrium and mitral valve.
TEE –TransesophealEchocardiography
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Treatment
•In mitral regurgitation associated with poor LV function, standard heart failure treatment can reduce LV volume and improve symptoms.
•Surgery is recommended for chronic severe MR•Indications for surgery:−EF < 55-60%−LV end-systolic volume > 45 mm
MV surgical options
•MV repair−Repair is preferable to replacement when possible
•MV annuloplasty−Used to decrease annular dilation in patients with functional MR from dilation of LV
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Mitral Valve Prolapse
•Definition−when one or both of the mitral valve leaflets prolapse into the left atrium superior to the mitral valve annular plane during systole
•Affects 5% of general population, equal among men and women
Mitral Valve Prolapse
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Mitral Valve Prolapse
Mitral Valve ProlapseHistory and Physical Exam
•Most frequently asymptomatic•Rarely: palpitations, syncope, chest pain•Characteristic findings−Mid-systolic click−Late systolic murmur after the click
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Diagnostic Testing
•Echocardiography useful, but not essential, esp. in patients with classic physical exam findings
Treatment
•Endocarditis prophylaxis is no longer indicated for MVP with or without regurgitation
•Treat symptomatic palpitations with beta-blockers
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Learning Objectives/Goals
1. Identify the types of valvular heart disease commonly seen in primary care
2. Develop a diagnostic protocol for valvular heart disease
3. Accurately interpret echocardiography reports to determine appropriate treatment strategies
4. Provide a management plan that includes follow-up testing, and addresses comorbidities and prevents disease complications
Who should be evaluated for VHD?
•Chest pain – demand ischemia•Dyspnea•Syncope•Dysrhythmia/palpitations•Decreasing exercise tolerance •1st degree relatives of those with VHD - HCM
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Case 1
•Mr. Juniper is a 35 year old male with a 2-3/6 mid systolic murmur.
•He can run up to 3 miles but then feels winded, no chest pain.
•He has a known bicuspid aortic valve.•No evidence of LVH on EKG.•Ddx?•What should we do?
Case 2
•23 yo male with progressive dyspnea.−Athletic build−Easily discernable 3/6 mid to late systolic murmur at upper left sternal border−Louder with inspiration−Palpable heave second left intercostal space−Ddx?
•Idiopathic pulmonary HTN with pulmonic stenosis
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Case 3
•27 yo male presents with near syncope with exercise on bi-annual Army physical fitness test−Very athletic build−Easily discernable 2-3/6 mid to late systolic murmur at left lower sternal border−With hand grip, the murmur drops to 1/6−With release of hand grip, the murmur is 3/6 before settling to 2-3/6−Ddx?
•Hypertrophic cardiomyopathy
Learning Objectives/Goals
1. Identify the types of valvular heart disease commonly seen in primary care
2. Develop a diagnostic protocol for valvular heart disease
3. Accurately interpret echocardiography reports to determine appropriate treatment strategies
4. Provide a management plan that includes follow-up testing, and addresses comorbidities and prevents disease complications
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Echocardiography
•In general, trace regurgitation is a common finding and does
not signify need for valve replacement/surgery
•While the ACC has a guideline for Echo interpretation, the
actual reports are quite dynamic
•In general, work closely with your cardiologist to determine the
best timing for interventions
Barriers to
Practice
Echo severity of AS
Severity of aortic stenosis in asymptomatic patients
DegreeMean gradient
(mmHg)Aortic valve area
(cm2)
Mild <20 >1.5
Moderate 20 - 39 1.0 - 1.5
Severe >40 < 1.0
Very severe >60 < 0.6
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology Volume 63, Issue 22, June 2014
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Echo classifications of Dia Dysfxn
•Normal dia fxn•Mild dia dysfxn/grade 1 = impaired relaxation•Moderate dia dysfxn/grade 2 = pseudonormalization•Severe dia dysfxn/grade 3 = −Reversible restrictive−Fixed restrictive
Barriers to
Practice
Learning Objectives/Goals
1. Identify the types of valvular heart disease commonly seen in primary care
2. Develop a diagnostic protocol for valvular heart disease
3. Accurately interpret echocardiography reports to determine appropriate treatment strategies
4. Provide a management plan that includes follow-up testing, and addresses comorbidities and prevents disease complications
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Follow up testing
•Echocardiography – how often?•Stress testing to reveal hidden ischemia−Consider
•Treat co-morbidities−HTN−HF
•Of note, statins do not change the course of VHD
Stages of Progression of VHD
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology Volume 63, Issue 22, June 2014
Stage Definition Description
A At risk Patients with risk factors
B Progressive Patients with progressive VHD: mild to moderate without symptoms
C AsymptomaticSevere
Asymptomatic patients who meet criteria for severe VHD
D SymptomaticSevere
Symptomatic patients due to VHD
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Follow up Echo – How often?
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Journal of the American College of Cardiology Volume 63, Issue 22, June 2014 - Link to guideline
2019 AATS/ACC/ASE/SCAI/STS Expert Consensus Systems of Care Document: A Proposal to Optimize Care for Patients With
Valvular Heart Disease
•“The roles of brief, simple, handheld echocardiographic scans during physical examinations (supported by machine learning algorithms to identify the potential need for a more detailed study) and alert notifications (e.g., suggesting referral to a specialist) on noninvasive imaging reports should also be considered.”
• Under the “Role of the Primary Care Clinician” Heading• Nishimura et al. JACC VOL. 73, NO. 20, 2019 VHD Systems of Care Document MAY 28, 2019:2609-35
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iButterfly Handheld ultrasound ~$2500
As the rippled surface of a wind-kissed lake mirrors the moon, so the diaphragm of a stethoscope reveals the
chambers of a heart
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Best Practice Recommendations
1. Use the astute clinical cardiac exam to diagnose and evaluate patients with heart murmurs.
2. Refer patients with symptomatic aortic stenosis for consideration of valve replacement surgery.
3. Work with cardiology colleagues to best follow patients with valvular heart disease, specifically the timing of echocardiography.
Contact
• Eddie.Needham.MD@FLHosp.org
• Office phone 407 646 7757
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Answers
1. C2. B3. A
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