Valvular and Hypertensive Heart Disease

Tricuspid regurgitation (TR) is a valvular defect that allows backflow of blood from the right ventricle to the right atrium during systole. Tricuspid regurgitation can develop through a number of cardiac conditions that cause dilation of the right ventricle and tricuspid annulus. A blowing holosystolic murmur is best heard at the left lower sternal border. Mild TR may be asymptomatic or present with systemic venous congestion due to increased right atrial and venous pressures. Echocardiography can establish the diagnosis. Treatment focuses on heart failure management, and surgery is reserved for severe disease.

Valvular disorders can arise from the pulmonary valve, located between the right ventricle (RV) and the pulmonary artery (PA). Valvular disorders are diagnosed by echocardiography. Pulmonic regurgitation (PR) is the backflow of blood through the valve. Prior cardiac surgeries can lead to PR. Graham-Steell murmur, a high-pitched decrescendo murmur at the left sternal border, is a hallmark finding. Pulmonic regurgitation results in RV volume overload, from which RV failure eventually develops. Severe PR is also treated with surgical valve replacement.

Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. The disorder can usually be managed with lifestyle modification and medications, but occasionally, vascular intervention or surgery are required. Age, sex, smoking, obesity, and diet are contributing factors to hypertension, which can lead to heart attack, stroke, congestive heart failure, and CKD if not managed properly. Many individuals with hypertension are undiagnosed or undertreated.

Pulmonary hypertension (PH) or pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary arterial pressure, which can lead to chronic progressive right heart failure. Pulmonary hypertension is grouped into 5 categories based on etiology, which include primary PAH, and PH due to cardiac disease, lung or hypoxic disease, chronic thromboembolic disease, and multifactorial or unclear etiologies. Patients typically present with shortness of breath initially during exercise and then at rest. Diagnosis may involve an echocardiogram, ECG, chest X-ray, pulmonary function tests, a ventilation-perfusion scan, laboratory testing for conditions associated with PAH, and/or cardiac catheterization. Management is often complex and aimed at treating the underlying etiology. Several classes of vasodilatory agents may be used for patients with primary PAH, including calcium channel blockers and vasoactive prostaglandins.

Endocarditis is an inflammatory disease involving the inner lining (endometrium) of the heart, most commonly affecting the cardiac valves. Both infectious and noninfectious etiologies lead to vegetations on the valve leaflets. Patients may present with nonspecific symptoms such as fever and fatigue. Important clinical exam findings include a new or changed heart murmur and common extra-cardiac signs, such as Osler nodes, Janeway lesions, splinter hemorrhages, and Roth spots. The diagnosis is based on clinical findings, blood cultures, and echocardiography showing valvular vegetations. Management includes intravenous antibiotics for infectious cases, addressing the underlying etiology for noninfectious cases, and surgical repair when necessary.

Acute rheumatic fever (ARF) is an autoimmune inflammatory process that usually follows Streptococcal pharyngitis. Acute rheumatic fever usually occurs 2–4 weeks after an untreated infection and affects the heart, skin, joints, and nervous system. This condition commonly presents with fever, arthritis of the large joints, pancarditis and sometimes rash and neurologic manifestations. The diagnosis is made clinically based on the Jones criteria, and confirmed with serologic tests. Prevention of ARF is the key treatment strategy, and is based on timely antibiotic treatment of the primary infection as well as antibiotic prophylaxis of recurrent episodes. Management of acute episodes is largely supportive and includes anti-inflammatory medications. The most serious complication of ARF is development of rheumatic heart disease, which most commonly manifests as mitral valve stenosis.

Mitral valve prolapse (MVP) is the most common cardiac valvular defect, and is characterized by bulging of the mitral valve (MV) cusps into the left atrium (LA) during systole. Mitral valve prolapse is most commonly due to idiopathic myxomatous degeneration. Patients are typically asymptomatic. Auscultation generally reveals a mid-to-late systolic click, followed by a possible regurgitation murmur. The diagnosis is confirmed by an echocardiogram. Treatment is generally not required for asymptomatic patients.

Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Acute MR is an emergency because it can cause cardiogenic shock, and requires medical stabilization and surgery. In chronic severe MR, patients are evaluated for surgical repair or replacement.

Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. While rheumatic heart disease remains the most frequent etiology worldwide, degenerative AS and congenital bicuspid valve defect are the 2 usual causes in developed countries. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Doppler echocardiography is the imaging of choice, showing structural and flow changes in the valvular area. Valve replacement is the only effective treatment for symptomatic severe AS. Indications for the procedure depend on the patient's symptoms, degree of AS severity, exercise tolerance, concurrent cardiac abnormalities, surgical risk, and life expectancy.

Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Acute valvular insufficiency, which rapidly progresses to cardiogenic shock, is an emergency requiring immediate aortic valve surgery. Chronic AR develops gradually, allowing the left ventricle to adapt to the increased stroke volume. Thus, echocardiogram shows left ventricular hypertrophy and dilation along with valvular abnormalities. Eventually, congestive heart failure occurs as the left ventricle is unable to handle the hemodynamic overload. Aortic valve replacement is the mainstay of treatment for AR with left ventricular dysfunction.