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Valvular heart disease

Rheumatic heart disease is the leading cause of mitral stenosis in developed countries. Its incidence has declined sharply wherever standards of living have improved and where penicillin is routinely used during episodes of pharyngitis due to group A streptococcus. Occasional small epidemics still occur in the US.

Causes of Valvular Heart Disease

Rheumatic heart disease

Endocarditis

Infective

Non-infective. thrombotic

Congenital

Myxomatous valve degeneration

Marfan's Syndrome

Ehlers-Danlos Syndrome

Osteogenesis imperfecta

Mucopolysaccharidoses

Degenerative, calcific disease

Ischemic heart disease

Miscellaneous

Carcinoid syndrome

Systemic lupus erythematosus

Rheumatoid arthritis

Ankylosing spondylitis Reiter's syndrome

Endomyocardial fibrosis

Trauma

Aortic disease

dissection of aneurysm syphilis

Hypertrophic cardiomyopathy

The major manifestations of VHD include both valvular heart disease, murmurs, aortic stenosis, mitral stenosis, mitral regurgitation, mitral prolapse, mitral valve prolapse left and right heart failure, left and right ventricular hypertrophy, atrial and ventricular arrythmias, syncope, angina. pulmonary and systemic emboli, and endocarditis. With the exception of infectious etiologies, there are no known medical therapies that arrest the natural progression of the primary valvular stenotic or regurgitant lesions, and severe lesions ultimately require surgical therapy. Afterload reduction for chronic valvular heart disease, murmurs, aortic stenosis, mitral stenosis, mitral regurgitation, mitral prolapse, mitral valve prolapse aortic regurgitation can postpone the need for surgery, without compromising long-term outcome.

Recognition of VHD

Many patients with milder forms of VHD will be asymptomatic, with only a click or a murmur evident on exam. Most healthy adults do not have "benign" flow murmurs (except during pregnancy and certain systemic illnesses), and a murmur therefore usually represents some degree of valvular pathology. Correct identification of the origin of murmurs is essential, since quality of life and life span are limited in most severe forms of VHD. Murmurs due to organic VHD must be distinguished from functional murmurs caused by LV or RV dilation, hypertrophic cardiomyopathy, ischemic heart disease, or from murmurs due to intracardiac shunts and aortic coarctation. Congenital and myxomatous VHD must be identified because of the important risk of endocarditis. A new murmur in a previously evaluated patient should raise the question of ischemic heart disease, endocarditis, prosthesis malfunction, or other systemic illness causing alterations of cardiac output.

Evaluation of a Murmur

In some cases, accurate diagnosis can be made at the bedside. However, body habitus can alter the cadence, intensity, and precordial distribution of murmurs. Multiple valvular abnormalities are common and can cause a constellation of sounds; at other times, a single lesion may cause a murmur that is heard widely across the precordium, but which sound different at different locations. A soft murmur may sometimes occur in the most severe forms of VHD.

The EKG can provide evidence of chamber enlargement and arrhythmia which further suggest significant pathology. A CXR can reveal calcification in valve, chamber sizes and evidence of pulmonary. congestion. However,