1. Valvular
Disease, Conduction
Disorder &
Bradydysrhythmias
Arbi Ayvazian D.O PGY2
Emergency Medicine
ARMC 1/2014

2. Valvular Disorder

3. Valvular Disorder
 Things to know
 Endocarditiis presentation
 Murmurs, Rheumatic HD
 Specific high risk diseases

4. 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

5. 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

6. 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)

7. 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

8. Murmurs: MR. ASS, MS.AID
Mitral
Regurgitation
Mitral
Stenosis
Aortic
Stenosis
Aortic
Insufficiency
SYSYTOLIC
DIASTOLIC

9. 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)

10. 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

11. 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.

12. 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

13. Conduction Disease
 Normal Conduction system

14. 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

15. 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)

16. 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

17. 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

18. 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

19. 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.

20. Bradydsyrhythmia
Simplified!
Stable or Unstable?
Wide or Narrow?
Slow or VERY slow

21. Bradydysrhythmia
 WHY IS THIS PATIENT BRADYCARDIC
Ischemia
Drugs
Electrolytes

22. Stable or Unstable
 Same criteria as tachycardia
 BP, mentation, awake and talking? -> perfusion

23. Wide or Narrow
Wide (much worse than narrow)
= Block below AV node
= Slower
= More likely to Stop
= NOT atropine sensitive

24. Wide or Narrow
Narrow
= more stable
= Faster
=Atropine sensitive
=? Block at AV node

26. Treatment of Bradycardia
IVF, O2, Monitor
TCP (often fails) or TVP
Atropine (go slow, not good on wide QRS)
Epinephrine
Dopamine