6.3 MTB Step 3 - Valvular Heart Disease (Aortic Regurgitation)

Question 1

AORTIC REGURGITATION (AR)

1. What are (4) Common Causes of AR?
2. What are (4) Rarer Causes of AR?

Answer 1

Common Causes of AR:

1. Hypertension (HTN)
2. Rheumatic Heart Disease
3. Endocarditis
4. Cystic Medial Necrosis

Rarer Causes of AR:

1. Marfan Syndrome
2. Ankylosing Spondylitis
3. Syphilis
4. Reactive Arthritis - inflammatory arthritis of Large Joints, Inflammation of the Eyes (conjunctivitis & Uveitis), and Urethritis
   
   • ​​”Can’t See, Can’t Pee, Can’t climb a Tree”

Question 2

AORTIC REGURGITATION (AR)

What is the Most Common Presentation of AR?

Answer 2

Shortness of Breath (SOB)

+

Fatigue

Question 3

AORTIC REGURGITATION (AR)

Describe the Murmur of AR and where it is Best Heard on Auscultation?

Answer 3

Diastolic Descrescendo murmur Heard Best at the Left Sternal Border

Question 4

AORTIC REGURGITATION (AR)

What are (5) Unique Physical Findings that are rarely seen with AR?

Answer 4

1. Quincke Pulse: Arterial or Capillary pulsations in the Fingernails
2. Corrigan Pulse: High bounding pulses (a.k.a. “water-hammer pulse”)
3. Musset Sign: Head Bobbing up & down w/ each pulse
4. Duroziez Sign: Murmur Heard over the Femoral Artery
5. Hill Sign: Blood Pressure gradient MUCH Higher in the Lower Extremities

Question 5

AORTIC REGURGITATION (AR)

1. What is the Best INITIAL Diagnostic Test for AR?
2. What is a MORE Accurate Diagnostic Test for AR?
3. What is the Most ACCURATE Diagnostic Test for AR?

Answer 5

1. TTE
2. TEE
3. Left Heart Catheterization

**For CSS, also choose ECG & CXR (shows LVH)**

Question 6

AORTIC REGURGITATION (AR)

What are (3) Best INITIAL Therapies for AR?

Answer 6

1. ACEIs
2. ARBs
3. Nifedipine

**For CSS, add a Loop Diuretic (e.g., Furosemide)**

Question 7

AORTIC REGURGITATION (AR)

For which (2) Conditions is Surgery the answer for AR Treatment, even if the patient is Asymptomatic?

Answer 7

EF < 55%

or

LVESD > 55mm

EF = Ejection Fraction

LVESD = Left Ventricular End Systolic Diamter

Question 8

AORTIC REGURGITATION (AR)

Why does High pressure Dilate the Aortic Valve?

Answer 8

Law of LaPlace: The Wall Tension (force dilating a vessel) is proportionate to the Radius of the vessel times the Pressure on the inside of the vessel:

Tension = Radius x Pressure

• The Wider a vessel is, the Faster it will get pulled apart.
• Hence, the More the Aortic Ring or Aorta is Dilated, the Faster it will get pulled apart.
• Likewise, the Higher the Interior Pressure is, the Faster the Interior will be pulled apart.
• This force of being “Pulled Apart” (dilation) is called “Wall Tension” in the Law of LaPlace.
• ACEIs and ARBs Vasodilate Peripheral Arterioles (Lower Pressure = Lower Wall Tension)