This document provides an overview of valvular heart disease, conduction disorders, and bradydysrhythmias. Key points include descriptions of infective endocarditis risk factors and presentations, characteristics of murmurs from mitral regurgitation, mitral stenosis, aortic stenosis, and aortic insufficiency. Bundle branch blocks, hemiblocks, heart blocks, and types of bradydysrhythmias are also summarized. Treatment approaches are outlined depending on whether a bradydysrhythmia is stable or unstable, has a wide or narrow QRS complex, and is slow or very slow.

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