Valvular Heart Disease · 2021. 8. 16. · 9/10/2020 1 Valvular Heart Disease Eddie Needham, MD, FAAFP Program Director and Academic Chairman AdventHealth Winter Park Family Medicine

9/10/2020

1

Valvular Heart Disease

Eddie Needham, MD, FAAFPProgram Director and Academic Chairman

AdventHealth Winter Park Family Medicine Residency ProgramProfessor, UCF-COMProfessor, LLU-SOM

ACTIVITY DISCLAIMER

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.

2

1

2

9/10/2020

2

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

3

4

9/10/2020

3

5

6

9/10/2020

4

Le Clinician existe toujours!

Strive to truly listen to the patientDemand excellence

7

8

9/10/2020

5

9

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.

9

10

9/10/2020

6

Creative commons license at: http://en.wikipedia.org/wiki/File:Diagram_of_the_human_heart_(cropped).s


•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

11

12

9/10/2020

7

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)


•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

13

14

9/10/2020

8

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

15

16

9/10/2020

9

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

17

18

9/10/2020

10

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

19

20

9/10/2020

11

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

21

22

9/10/2020

12

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

23

24

9/10/2020

13

AES Question

Question 1: Heart sounds

•Here’s the sound:•What does it look like?

S1 S2 S1 S2A. | | | |

B. | | | |

C. | | | |

25

26

9/10/2020

14

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

27

28

9/10/2020

15

It’s about the waves

29

30

9/10/2020

16

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)

31

32

9/10/2020

17

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

33

34

9/10/2020

18

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?


35

36

9/10/2020

19

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%

37

38

9/10/2020

20

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

39

40

9/10/2020

21

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

41

42

9/10/2020

22

Echo severity of AS

43

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

43

44

9/10/2020

23

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.

45

46

9/10/2020

24

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

47

48

9/10/2020

25

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.

49

50

9/10/2020

26

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

51

52

9/10/2020

27

Question 3Which one of the following heart murmurs is heard over the apex of the heart and sometimes the left axilla/left posterior thorax?


Question 3Which one of the following heart murmurs is heard over the apex of the heart and sometimes the left axilla/left posterior thorax?


53

54

9/10/2020

28

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

55

56

9/10/2020

29

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

57

58

9/10/2020

30

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

59

60

9/10/2020

31

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

61

62

9/10/2020

32

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


63

64

9/10/2020

33


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

65

66

9/10/2020

34

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

67

68

9/10/2020

35




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

69

70

9/10/2020

36

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

71

72

9/10/2020

37

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






73

74

9/10/2020

38

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


75

76

9/10/2020

39

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






77

78

9/10/2020

40

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


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

79

80

9/10/2020

41

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

81

82

9/10/2020

42

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

83

84

9/10/2020

43

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

• [email protected]

• Office phone 407 646 7757

85

86

9/10/2020

44

Answers

1. C2. B3. A

© 2020 American Academy of Family Physicians. All rights reserved.

All materials/content herein are protected by copyright and are for the sole, personal use of the user.

No part of the materials/content may be copied, duplicated, distributed or retransmitted

in any form or medium without the prior permission of the applicable copyright owner.

87

88

9/10/2020

45

89

Documents

Valvular Heart Disease · 2021. 8. 16. · 9/10/2020 1 Valvular Heart Disease Eddie Needham, MD, FAAFP Program Director and Academic Chairman AdventHealth Winter Park Family Medicine