17.1 Valvular heart disease and infective endocarditis Flashcards
What is rheumatic fever?
An autoimmune disease that arises as a rare complication from a group A streptococcal throat infection.
What disease arises as a complication of rheumatic fever?
Rheumatic heart disease
How is rheumatic heart disease characterised?
Characterised by deforming valvular fibrotic disease- usually of the mitral valve.
What are the risk factors for rheumatic fever?
- Poverty
- Overcrowded living conditions
- Family history of rheumatic fever
- D8/17B antigen
What are the symptoms of rheumatic fever?
- Fever
- Joint pain
- Sydenham chorea (rapid irregular limb movements)
- Erythema marginatum (circular rash)
- Pancarditis (inflammation of the pericardium, myocardium and endocardium)
Give examples of valvular diseases.
- Aortic stenosis
- Aortic regurgitation
- Mitral stenosis
- Mitral regurgitation
- Tricuspid regurgitation
- Pulmonary stenosis
Which guidelines are followed with regards to valvular heart disease?
Nice guidlines for valvular heart disease Nov 2021
What is aortic stenosis?
Narrowing of the aortic valve opening causing restricted blood flow from the heart to the body.
Describe the aetiology of aortic stenosis.
- Can arise as a complication of rheumatic fever
- Congential abnormality: bicuspid aortic valve (aortic valve only has 2 cusps instead of 3)
- Degenerative cause: build up of calcium on the aortic valve over time
Describe the symptoms and presentation of aortic stenosis.
- May be asymptomatic
- Dyspnoea (shortness of breath)
- Angina
- Syncope on exertion (fainting)
What are the signs of aortic stenosis?
- Ejection systolic murmur
- Slow rising arterial pulse
- Systolic thrill (murmur)
- Left ventricular hypertrophy
What are the complications of aortic stenosis?
- Heart failure
- SBE (subacute bacterial endocarditis)
- Arrythmias
How is aortic stenosis treated?
- Aortic valve replacement
- TAVI (transcatheter aortic valve implantation)
What is aortic regurgitation?
Aortic valve doesn’t close tightly enough causing backflow of the blood back into the heart.
Describe the aetiology of aortic regurgitation.
- Complication of rheumatic fever
- Congential defect, bicuspid aortic valve
- Aortic root enlargement
- Aortic dissection (tear or injury to the aorta can cause back flow of blood through the aortic valve)
Describe the symptoms and presentation of aortic regurgitation.
- Asymptomatic
- Dyspnoea on exertion
What are the signs of aortic regurgitation?
- Early diastolic murmur
- Collapsing arterial pulse
- Left ventricle enlargement and hypertrophy
What is the possible complication of aortic regurgitation?
Heart failure
How is aortic regurgitation treated?
Aortic valve replacement
What is mitral stenosis?
Narrowing of the mitral valve orifice, restricts blood flow through the heart.
Describe the aetiology of mitral stenosis.
- Congenital (very rare)
- Rheumatic fever
Describe the symptoms and presentation of mitral stenosis.
- Asymptomatic
- Dyspnoea on exertion
- Paroxysmal noctrunal dyspnoea (sudden shortness of breath during sleep)
- Development of atrial fibrillation
- Systemic embolism
- Pulmonary hypertension
What are the signs of mitral stenosis/how is it diagnosed?
- Mid diastolic murmur
- Tapping apical impulse
- Right ventricular hypertrophy
How is mitral stenosis treated?
- Anticoagulants
- Balloon valvotomy
- Valve replacement
What is mitral regurgitation?
Mitral valve doesn’t close properly causing blood to leak backwards.
Describe the aetiology of mitral regurgitation.
- Mitral valve prolapse
- Degenerative
- Left ventricle enlargement
- Papillary muscle rupture after MI
Describe the symptoms and presentation of mitral regurgitation.
- Dyspnoaea on exertion
- Orthopnoea (shortness of breath when lying down)
- Heart failure
- Pulmonary hypertension
- Atrial fibrillation
What are the signs of mitral regurgitation?
- Pan-systolic murmur
- Enlarged left heart
- Right ventricular hypertrophy
How is mitral regurgitation treated?
- Diuretics
- ACE inhibitors
- Anticoagulation if patient is in AF
- Mitral valve repair
- Mitral valve replacement
What is tricuspid regurgitation?
Tricupsid valve between the right ventricle and right atrium don’t close properly.
What are the signs of tricuspid regurgiation?
- Pan-systolic murmur
- Enlarged right heart
- Right ventricular hypertrophy
- Pulmonary hypertension
- High JVP (jugular venous pulse)
How is tricuspid regurgitation treated?
- Diuretics (spironolactone)
- Tricuspid valve repair
What is infective endocarditis?
An infection involving the endocardium of the heart (innermost layer protecting the heart), the valves and chordae tendineae.
What are the clinical signs of infective endocarditis?
- Fever, with rigors
- Peripheral emboli
- Microscopic haematuria (blood in urine)
- Intracranial haemorrhage or septic pulmonary infarction
- New or changing cardiac murmurs
- Retinal haemorrhage / Roth spots
- Splenomegaly
- Splinter haemorrhage (nails)
What are the cutaneous signs of infective endocarditis?
- Petechial rash
- Splinter haemorrhages
- Conjunctival or palatal petechiae
- Olser’s nodes
- Janeway lesiosn
- Lecucocytoclastic vasculitis
How is suspected infective endocarditis investigated?
- Clinical assessment
- Blood cultures
- ECG
- Echocardiogram: mobile masses (vegetations) and local complications (regurgitation, perforation, abscesses, aneurysms)
- Transoesophageal echocardiogram
What criteria is used to diagnose infective endocarditis?
Duke criteria
What are the Duke major critera?
- Positive blood culture
- Evidence of endocardial involvement
- New valve regurgitation
What are the Duke minor criteria?
- Predisposing condition or behaviour
- Temperature >38 degrees celsius
- Vasulcar phenomena
- Immunological phenomena
- Blood culture (not meeting major criteria)
- Echo features not meeting major criteria
What Duke criteria must be met for a definitive infective endocarditis diagnosis?
- 2 major criteria or
- 1 major and 3 minor criteria
- 5 minor criteria
Or through pathological conformation
Is antibiotic prophylaxis against IE routinely recommended for dental treatment?
No
