Valvular heart disease: Difference between revisions

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__NOTOC__
'''For patient information click [[Valvular heart disease (patient information)|here]]'''
'''For patient information click [[Valvular heart disease (patient information)|here]]'''
{{CMG}}
{{Valvular heart disease}}
{{Valvular heart disease}}
{{CMG}}; {{AE}} {{TarekNafee}}<br>
{{SK}} VHD, Valve disease, Heart valve disease, Valvular dysfunction


==Overview==
==Overview==
'''Valvular heart disease''' is any disease process involving one or more [[Heart valve|valves]] of the [[heart]]. The valves in the right side of the heart are the [[tricuspid valve]] and the [[pulmonic valve]]. The valves in the left side of the heart are the [[mitral valve]] and the [[aortic valve]].  
Valvular heart disease (VHD) is the pathological defect affecting one of the four [[valves of the heart]]: [[aortic valve]], [[mitral valve]], [[pulmonic valve]], or [[tricuspid valve]]. VHD may be [[congenital]] or [[acquired]]. Congenital causes of VHD include [[tetralogy of Fallot]], [[Ebstein's anomaly]], [[Noonan syndrome]], [[congenital rubella syndrome]], and [[Bicuspid aortic valve|bicuspid valve]] among others. Acquired causes of VHD include [[rheumatic heart disease]], [[infective endocarditis]], [[Calcification of the aortic valve|senile calcification of valves]], or valve deformities secondary to structural changes of the [[myocardium]] (e.g. [[dilated cardiomyopathy]]). Regardless of the underlying cause, VHD may result in valve [[stenosis]], valve [[Regurgitation (circulation)|regurgitation]] or , in some cases, [[Prolapse|valve prolapse]]. Valvular heart disease can often be asymptomatic and may go undiagnosed. In patients who develop symptoms suggestive of valvular heart disease, [[cardiac auscultation]] for [[heart murmurs]] is often the first step of a focused physical examination to rule out valvular heart disease. [[Echocardiography]] is the gold standard diagnostic modality for valvular heart disease.  In addition to a thorough and focused physical examination, a well-performed [[echocardiogram]] aids the clinician in determining the severity of the disease, the prognosis, and the need for surgical intervention.


In March 29, 2007, [[pergolide]], a [[dopamine agonist]] used in treatment of [[Parkinson's disease]] and also off label for [[Restless legs syndrome]] (RLS), was withdrawn from the US market due to implication in valvular heart disease [http://www.fda.gov/bbs/topics/NEWS/2007/NEW01596.html]. The withdrawal was based on findings published in [[New England Journal of Medicine]], confirming previous reports associating pergolide with increased risk of regurgitation of the [[mitral valve]], [[tricuspid valve]], and [[aortic valve]] of the heart. [[Cabergoline]], a similar [[ergot]]-derived dopamine agonist, is still marketed in EU.
==Classification==
Valvular heart diseases are typically classified according to the valve that is affected as well as the nature of the pathological defect as follows:
*'''[[Aortic valve|Aortic Valve]]'''
**[[Aortic stenosis]]
**[[Aortic regurgitation]]
*'''[[Mitral valve|Mitral Valve]]'''
**[[Mitral stenosis]]
**[[Mitral regurgitation]]
**[[Mitral valve prolapse]]
*'''[[Tricuspid valve]]'''
**[[Tricuspid stenosis]]
**[[Tricuspid regurgitation]]
*'''[[Pulmonary valve]]'''
**[[Pulmonic stenosis]]
**[[Pulmonic regurgitation]]
==Differential Diagnosis==
Clinicians may differentiate among different valvular heart diseases on the basis of the characteristics of the [[Heart murmur|murmur]] and collecting a thorough patient history, as shown in the following table:
{| class="wikitable"
! rowspan="2" |Valvular Disease
! rowspan="2" |Common causes
! colspan="6" |[[Heart murmur|Murmur]] Description
! colspan="5" |Interventions that Change [[Heart murmur|Murmur]]<nowiki/> Intensity
|-
!Pitch
!Timing
!Best Heard Location
!Shape
!Other Features
!Radiation
![[Valsalva maneuver|Valsalva Maneuver]]
!Abrupt Standing
!Hand Grip
!Abrupt Squatting
![[Inhalation]]
|-
|[[Aortic stenosis]]
|
* [[Calcification of the aortic valve|Senile calcification]]
* Calcification of [[Bicuspid aortic stenosis|bicuspid valve]]
* [[Aortic stenosis causes|Other causes]]
|High
|[[Systolic murmurs|Systolic]]
|Right second [[intercostal spaces]]
|Crescendo-Decrescendo
|Systolic Ejection Click with [[Bicuspid valve|bicuspid valves]]
|Radiates towards the neck


Ergot derivatives ([[ergotamines]]) have been implicated in [[fibrosis]] not only of the heart valves but also of the [[pleura]] and [[retroperitoneum]] [http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=4468122&dopt=Abstract] and possibly other locations.
([[Gallavardin|Gallavardin dissociation]])
|'''↓'''
|'''↓'''
| -
|'''↑'''
|<nowiki>-</nowiki>
|-
|[[Subaortic stenosis]]
|
* [[Hypertrophic obstructive cardiomyopathy]]
|High
|[[Systolic murmurs|Systolic]]
|Right second [[intercostal spaces]]
|Crescendo-Decrescendo
| -
|No radiation
|'''↑'''
|'''↑'''
|<nowiki>-</nowiki>
|'''↓'''
|<nowiki>-</nowiki>
|-
|[[Aortic regurgitation]]
|
* Calcification of [[bicuspid valve]]
* [[Calcification of the aortic valve|Senile calcification]]
* [[Rheumatic heart disease]]
* [[Iatrogenesis|Iatrogenic]] (after [[valvuloplasty]])
* [[Aortic regurgitation causes|Other causes]]
|High
|[[Diastolic murmurs|Diastolic]]
|Right third [[intercostal spaces]]
([[Erb's point]])
|Decrescendo
|May present an early diastolic rumble at the [[Apex of the heart|apex]] ([[Austin Flint murmur|Austin-Flint murmur]])
| -
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|'''↑'''
|<nowiki>-</nowiki>
|'''-'''
|-
|[[Mitral stenosis]]
|
* [[Infective endocarditis]]
* [[Rheumatic heart disease]]
* [[Mitral annular calcification]]
* [[Mitral stenosis causes|Other causes]]
|Low (rumbling)
|[[Diastolic murmurs|Diastolic]]
|[[Apex of the heart|Left ventricular apex]]
|Decrescendo-Crescendo
|Opening snap
|No radiation
|<nowiki>-</nowiki>
| -
| -
| -
| -
|-
|[[Mitral regurgitation]]
|
* [[Infective endocarditis]]
* [[Ischemic heart disease]]
* [[Papillary muscle rupture]]
* [[Dilated cardiomyopathy]]
* [[Mitral regurgitation causes|Other causes]]
|High
|[[Systolic murmurs|Systolic]]
|Left [[Apex of the heart|ventricular apex]]
|[[Holosystolic murmur|Holosystolic]]
|Blowing sound
|Usually radiates to the [[axilla]]
|'''↓'''
| -
|'''↑'''
| -
|<nowiki>-</nowiki>
|-
|[[Mitral valve prolapse]]
|
* [[Marfan's syndrome]]
* [[Myxomatous degeneration]] of the valve
* [[Papillary muscle dysfunction|Papillary muscle injury]]
* [[Mitral valve prolapse causes|Other causes]]
|High
|[[Systolic murmurs|Systolic]]
|Complete [[Precordium|precordial]] area
|Late systolic
|[[Systolic click|Mid-systolic click]]
|No radiation or may radiate to the [[axilla]]
|'''↑'''
|'''↑'''
| -
|'''↓'''
|'''↓'''
|-
|[[Tricuspid stenosis]]
|
* [[Rheumatic heart disease]]
* [[Carcinoid syndrome|Carcinoid heart disease]]
* [[Cardiac tumors]]
* [[Tricuspid stenosis causes|Other causes]]
|Low
|[[Diastolic murmurs|Diastolic]]
|Left fourth or fifth [[intercostal spaces]]
| -
|Opening snap
|No radiation
|<nowiki>-</nowiki>
| -
| -
|'''↑'''
|'''↑'''
|-
|[[Tricuspid regurgitation]]
|
* [[Pulmonary hypertension]]
* [[Right ventricular failure]]
* [[Iatrogenesis|Iatrogenic]]
* [[Carcinoid syndrome|Carcinoid heart disease]]
* [[Tricuspid regurgitation causes|Other causes]]
|Low
|[[Systolic murmurs|Systolic]]
|Left lower sternal border
|Holosystolic
|<nowiki>-</nowiki>
|No radiation
|<nowiki>-</nowiki>
| -
| -
| -
|'''↑'''


==Types==
([[Carvallo's sign]])
Each valve may be too narrow (stenosis) or too wide or loose, causing regurgitation. There are different types of valvular heart disease:
|-
|[[Pulmonary stenosis]]
|
* [[Congenital rubella syndrome|Congenital Rubella Syndrome]]
* [[Tetralogy of Fallot]]
* [[Carcinoid syndrome|Carcinoid heart disease]]
* [[Right ventricular outflow tract obstruction common causes|Other causes]]
|High
|[[Systolic murmurs|Systolic]]
|Left second [[intercostal spaces]]
|Crescendo-Decrescendo
|Wide split S2
|Slight radiation to the [[neck]]
|<nowiki>-</nowiki>
| -
| -
|'''↑'''
|'''↑'''
|-
|[[Pulmonic regurgitation|Pulmonary regurgitation]]
|
* [[Carcinoid syndrome|Carcinoid heart disease]]
* [[Pulmonary hypertension]]
* [[Rheumatic heart disease]]
* [[Iatrogenesis|Iatrogenic]] ([[Tetralogy of Fallot]] repair)
* [[Pulmonic regurgitation causes|Other causes]]
|High
|[[Diastolic murmurs|Diastolic]]
|Left second and third [[intercostal spaces]]
|Decrescendo
|Blowing sound
|No radiation
|<nowiki>-</nowiki>
| -
| -
| -
|'''↑'''
([[Carvallo's sign]])
|}


* [[Aortic insufficiency]]
== 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines<ref name="pmid34709879">{{cite journal| author=Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK | display-authors=etal| title=2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. | journal=Circulation | year= 2021 | volume= 144 | issue= 22 | pages= e368-e454 | pmid=34709879 | doi=10.1161/CIR.0000000000001029 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=34709879  }}</ref> ==
* [[Aortic valve stenosis]]
* [[Endocarditis]]
* [[Libman-Sacks endocarditis]]
* [[Loeffler endocarditis]]
* [[Mitral regurgitation]]
* [[Mitral stenosis]]
* [[Mitral valve prolapse]]
* [[Pulmonary valve stenosis]]
* [[Pulmonic regurgitation]]
* [[Tricuspid insufficiency]]
* [[Tricuspid valve stenosis]]
 
==Related Chapters==
* [[Valvular heart disease and pregnancy]]
* [[Valvular heart disease (patient information)]]


=== Recommendations for Acute Chest Pain With Valvular Heart Disease ===
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen" |'''1.'''In patients presenting with acute chest pain with suspected or known history of VHD, TTE is useful in determining the presence, severity, and cause of VHD. ''(Level of Evidence: C-EO)''
|-
| bgcolor="LightGreen" |'''2.'''In patients presenting with acute chest pain with suspected or known VHD in whom TTE diagnostic quality is inadequate, TEE (with 3D imaging if available) is useful in determining the severity and cause of VHD. ''(Level of Evidence: C-EO)''
|}
{| class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon" |[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
| bgcolor="LemonChiffon" |'''1.'''n patients presenting with acute chest pain with known or suspected VHD, CMR imaging is reasonable as an alternative to TTE and/or TEE is nondiagnostic. ''(Level of Evidence: C-EO)''
|}
==References==
==References==
{{reflist|2}}
{{Reflist|2}}


{{cardiac surgery}}
{{Electrocardiography}}
{{Circulatory system pathology}}


[[Category:Cardiology]]
[[Category:Cardiology]]
[[Category:Valvular heart disease]]
[[de:Herzklappenfehler]]
[[fi:Sydämen läppäviat]]
[[ja:心臓弁膜症]]


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Latest revision as of 23:52, 7 December 2022

For patient information click here

Valvular heart disease Microchapters

Patient Information

Classification

Aortic stenosis
Aortic regurgitation
Mitral stenosis
Mitral valve prolapse
Mitral regurgitation
Tricuspid stenosis
Tricuspid regurgitation
Pulmonary stenosis
Pulmonary regurgitation

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Tarek Nafee, M.D. [2]
Synonyms and keywords: VHD, Valve disease, Heart valve disease, Valvular dysfunction

Overview

Valvular heart disease (VHD) is the pathological defect affecting one of the four valves of the heart: aortic valve, mitral valve, pulmonic valve, or tricuspid valve. VHD may be congenital or acquired. Congenital causes of VHD include tetralogy of Fallot, Ebstein's anomaly, Noonan syndrome, congenital rubella syndrome, and bicuspid valve among others. Acquired causes of VHD include rheumatic heart disease, infective endocarditis, senile calcification of valves, or valve deformities secondary to structural changes of the myocardium (e.g. dilated cardiomyopathy). Regardless of the underlying cause, VHD may result in valve stenosis, valve regurgitation or , in some cases, valve prolapse. Valvular heart disease can often be asymptomatic and may go undiagnosed. In patients who develop symptoms suggestive of valvular heart disease, cardiac auscultation for heart murmurs is often the first step of a focused physical examination to rule out valvular heart disease. Echocardiography is the gold standard diagnostic modality for valvular heart disease. In addition to a thorough and focused physical examination, a well-performed echocardiogram aids the clinician in determining the severity of the disease, the prognosis, and the need for surgical intervention.

Classification

Valvular heart diseases are typically classified according to the valve that is affected as well as the nature of the pathological defect as follows:

Differential Diagnosis

Clinicians may differentiate among different valvular heart diseases on the basis of the characteristics of the murmur and collecting a thorough patient history, as shown in the following table:

Valvular Disease Common causes Murmur Description Interventions that Change Murmur Intensity
Pitch Timing Best Heard Location Shape Other Features Radiation Valsalva Maneuver Abrupt Standing Hand Grip Abrupt Squatting Inhalation
Aortic stenosis High Systolic Right second intercostal spaces Crescendo-Decrescendo Systolic Ejection Click with bicuspid valves Radiates towards the neck

(Gallavardin dissociation)

- -
Subaortic stenosis High Systolic Right second intercostal spaces Crescendo-Decrescendo - No radiation - -
Aortic regurgitation High Diastolic Right third intercostal spaces

(Erb's point)

Decrescendo May present an early diastolic rumble at the apex (Austin-Flint murmur) - - - - -
Mitral stenosis Low (rumbling) Diastolic Left ventricular apex Decrescendo-Crescendo Opening snap No radiation - - - - -
Mitral regurgitation High Systolic Left ventricular apex Holosystolic Blowing sound Usually radiates to the axilla - - -
Mitral valve prolapse High Systolic Complete precordial area Late systolic Mid-systolic click No radiation or may radiate to the axilla -
Tricuspid stenosis Low Diastolic Left fourth or fifth intercostal spaces - Opening snap No radiation - - -
Tricuspid regurgitation Low Systolic Left lower sternal border Holosystolic - No radiation - - - -

(Carvallo's sign)

Pulmonary stenosis High Systolic Left second intercostal spaces Crescendo-Decrescendo Wide split S2 Slight radiation to the neck - - -
Pulmonary regurgitation High Diastolic Left second and third intercostal spaces Decrescendo Blowing sound No radiation - - - -

(Carvallo's sign)

2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[1]

Recommendations for Acute Chest Pain With Valvular Heart Disease

Class I
1.In patients presenting with acute chest pain with suspected or known history of VHD, TTE is useful in determining the presence, severity, and cause of VHD. (Level of Evidence: C-EO)
2.In patients presenting with acute chest pain with suspected or known VHD in whom TTE diagnostic quality is inadequate, TEE (with 3D imaging if available) is useful in determining the severity and cause of VHD. (Level of Evidence: C-EO)
Class IIa
1.n patients presenting with acute chest pain with known or suspected VHD, CMR imaging is reasonable as an alternative to TTE and/or TEE is nondiagnostic. (Level of Evidence: C-EO)

References

  1. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK; et al. (2021). "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 144 (22): e368–e454. doi:10.1161/CIR.0000000000001029. PMID 34709879 Check |pmid= value (help).

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