Valvular Disease, Conduction Disorder & Bradydysrhythmias

Arbi Ayvazian D.O PGY2Emergency Medicine

ARMC 1/2014

Valvular Disorder

Valvular Disorder

Things to know

Endocarditiis presentation

Murmurs, Rheumatic HD

Specific high risk diseases

Infective Endocarditis

Risk Factors: Abnormal or artificial valve

Mitral valve most common, IVDA -> Tricuspid (staph)

Most common bug -> Staph

Tooth extraction -> Strep

Acute -> high fever, murmur, flu like symp., younger

Subacute -> Strep viridans, Anemia, older

Prophylaxis? Depends on bug and procedure

Infective Endocarditis

Vasculitis and Embolic manifestations

Janeway lesions: Non-tender, hemorrhagic, flat, on palms and soles.

Osler nodes -> tender, tips of fingers and toes

Roth spots and splinter hemorrhages

Infective Endocarditis

Dx by echo, blood cultures, high ESR/CRP

Rx: Vancomycin for Staph, PCN for Strep

Prophylaxis if abnormal valve and procedure

Procedure site determines bug and Abx

Classic broad question -> dental and Amoxicilin, GI/GU more gram negative coverage

Controversial in mitral valve prolapse (no on boards)

End Point of Valve Disease

Heart Fails and dilates

Valves become regurgitant

ECG shows LVH as ventricles expand

LBBB develops as heart and conduction system stretches which is poor prognostic sgin

Murmurs: MR. ASS, MS.AID

Mitral Regurgitation

Aortic Stenosis

SYSYTOLIC

Mitral Stenosis

Aortic Insufficiency

DIASTOLIC

Aortic Stenosis

Symptoms progress from : SOB, CHF, Syncope (bad!)

Murmur: Systolic, up into the neck, slow carotid upstroke

ECG : LVH, LBBB

Exercise-induced syncope

Vasodilators can make it worse

Rx: Surgical (moderate to severe)

Aortic Regurgitation

THINK AORTIC DISECCTION

Murmur: Diastolic, lower left, sternal border

LOTS Signs: water hammer pulse, Austin Flint Murmur, Duroziez’s Murmur, Quincke’s pulse, de Musset’s sign, Lighthouse, Landolfi’s, Beck’s, etc, etc, etc.

Rx: Afterload reduction…..surgical

Mitral Stenosis

Cardiovascular collapse in pregnant patient during delivery

Murmur: Diastolic, Opening SNAP

Atrial fib common, blood backs up into left atrium -> lungs = CHF, Chronic -> Hemoptysis

AF can cause decompensation, crash quick due to loss of KICK, CARDIOVERT if Acute.

Mitral Regurgitaion

Ischemia + SHOCK + new MURMUR = ruptured chordae tendineae/papillary muscle

Murmur: Radiates widely, esp. into axilla

Atrium stretches and produces A. Fib

Mitral valve prolapse can get worse and overtime lead to regurgitation

Conduction Disease

Normal Conduction system

Bundle Branch and Fascicular Blocks

RBBB:

ECD: Wide QRS, Abnormal QRS complexes in right precordical leads (V1- V2) (rSR’). We know this.

Incomplete RBBB

RBBB block morphology with a normal QRS width

Common finding in children and young adult

LBBB

ECG: Wide QRS.

Abnormal morphology: RR’ or large wide R (I, V5, V6) Anormal repol., QS or RS pattern in right precordial leads (V1,V2)

Hemi Blocks

Left anterior vs posterior block

Anterior more common (left coronary blood supply)

Ant: left axis deviation, QR (I, aVL), RS (II,III, aVF)

Post: Right axis, RS (I, aVL), QR (II,III, aVF)

Bifascicular block

Most common combination: LAF with RBBB

Marker for advance cardiac disease

Heart Blocks

SA node: Blood supply Rt corornary (65%), circumflex (25%), both (10%)

AV node: Post. Descending artery (rt coronary 90%)

SA blocks (sick sinus, sinus pause, sinus arrest, etc.)

Absence of P and ORS, and T cycles

Ventricular activity -> dependent on escape rhythm

Rx: pacemaker + medication to suppress tachydysrhythmias

AV node Blocks

First –Degree AV Block – conduction delay in AV node, PR prolong

Second –Degree Block – intermittent loss of conduction between artia and ventricle

Mobitz I (Wenckebach) : PR increases until dropped beat, generally goes not need emergency Tx

Mobitz II: PR normal from beat to beat with an occ. Abrupt dropped beat.

Rx: Can progress to complete block, pacer.

Third-degree AV Block – No conduction through AV

No assos. of P and QRS

Pace and pacemaker

Bradydysrhythmia

Sinus Bradycardia

<60bpm, high vagal tone, medications, hyothyroidism

Signs and symptoms – generally asymptomatic, or signs of hypoperfusion

Rx: Direct towards degree of patient symptoms, atropine, pacing, vasopressors.

BradydsyrhythmiaSimplified!

Stable or Unstable?

Wide or Narrow?

Slow or VERY slow

Bradydysrhythmia

WHY IS THIS PATIENT BRADYCARDIC

Ischemia Drugs Electrolytes

Stable or Unstable

Same criteria as tachycardia

BP, mentation, awake and talking? -> perfusion

Wide or Narrow

Wide (much worse than narrow)

= Block below AV node

= Slower = More likely to Stop = NOT atropine sensitive

Wide or Narrow

Narrow

= more stable

= Faster

=Atropine sensitive

=? Block at AV node

Treatment of Bradycardia

IVF, O2, Monitor

TCP (often fails) or TVP

Atropine (go slow, not good on wide QRS)

Epinephrine

Dopamine