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MRCP PACES Cardiology > Mitral Stenosis and Rheumatic Fever > Flashcards

Mitral Stenosis and Rheumatic Fever Flashcards

1
Q

What are the signs/examination findings of mitral stenosis? (6)
What are features suggesting severe mitral stenosis? (5)

A

A. Inspection
- Mitral facies rash (pulmonary hypertension)
- Previous mitral valvotomy scar over left lateral chest wall

B. Pulse
- Severe: low pulse pressure (pulsus parvus)
- Complications: AF (LAH)

C. Apex beat - tapping, undisplaced

D. Heart Sound and Murmur
- Mid-diastolic rumbling MDM murmur over mitral area with presystolic accentuation
- Opening snap, loud S1
- Severe: increasing length of murmur
- Severe: shortening interval S2 and opening snap due to high LA pressure

E. Manoeuver to left lateral, expiration or exercise to accentuate murmur

F. Signs of complications
- Pulmonary hypertension: RVH and PR - loud P2, palpable P2, left parasternal heave, PR murmur (EDM)
- Heart failure: raised JVP, +/- a wave, cyanosis

Features of severe MS
1. Low pulse pressure (pulsus parvus)
2. Increasing length of murmur
3. Shortening interval between S2 and opening snap (high LA pressure)
4. Pulmonary hypertension - mitral facies rash, +/-RVH and PR - loud P2, palpable P2, left parasternal heave, PR murmur (EDM)
5. Heart failure: raised JVP, +/- a wave, cyanosis

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2
Q

Describe this heart sound

A

Mid diastolic murmur - MS

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3
Q

Differential diagnosis of mid-diastolic murmur? (6)

A

~~~
MS, atrial myxoma, thrombus, severe MR, severe AR
```

  1. Mitral stenosis
  2. Left atrial mass (atrial myxoma)
  3. Left atrial thrombus (ball-valve thrombosis)
  4. Severe mitral regurgitation (increased flow through mitral valve during diastole)
  5. Austin flint murmur (severe AR)
  6. Flow across tricuspid valve in ASD
  7. Cor triatriatum - congenital defect with 3 atria divided by fibromuscular band
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4
Q

What is the differential diagnosis of a malar flush? (8)

A
  1. Mitral stenosis (low output state due to pulmonary hypertension)
  2. Hypothyroidism
  3. SLE
  4. Carcinoid
  5. Polycythaemia
  6. Systemic sclerosis
  7. Irradiation
  8. Cold weather
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5
Q

How do patients with MS present?

A
  1. Asymptomatic
  2. Precipitationg of symptoms during pregnancy or development of AF
  3. Left sided heart failure: exertional dyspnoea, PND, orthopnoea
  4. Right sided heart failure: haemoptysis, hoarseness, limb swelling
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6
Q

What are the causes of mitral stenosis? (R4C)

A
  1. Rheumatic fever
  2. Calcific degeneration
  3. Rare causes
    - congenital: congenital parachute valve
    - connective tissue disease: SLE, RA
    - carcinoid
    - Rarer: mucopolysaccharidoses, Fabry’s disease, Whipple’s disease
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7
Q

How do you classify the severity of mitral stenosis?
A. Clinically
B. Echocardiogram

A

A. Clinically
- Mild: no pulmonary hypertension
- Moderate: pulmonary hypertension
- Severe: congestive heart failure

B. Echocardiogram
Mitral valve area (normal 4-6)
- Mild is >1.5cm
- Moderate is 1-1.5cm
- Severe is <1.0cm

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8
Q

What are the complications of mitral stenosis? (5)

A
  1. AF from left atrial enlargement
  2. LA thrombus formation and embolism
  3. Pulmonary hypertension
  4. Right heart failure and pulmonary oedema
  5. Risk of infective endocarditis
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9
Q

How would you investigate a patient with mitral stenosis?
- ECG (3)
- CXR (4)
- TTE
- Pre-surgical workup

A
  1. ECG:
    - AF
    - LAH or dilatation (p mitrale, large p wave with a notch)
    - RAD, RVH (p pulmonale)
  2. CXR:
    - Enlarged LA (double heart border, straightening of left heart border, horizontalisation of left bronchus/splaying of carina)
    - Pulmonary congestion (upper lobe diversion, Kerley B)
    - Prominent pulmonary arteries
    - Calcified mitral valves
  3. Echocardiogram
    - Assess mitral valve
    - Grade severity
    - Assess left atrium and right heart function
    - Look for complications (IE)
  4. Coronary angiography: check coronary artery disease for concomittant CABG + valve replacement
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10
Q

How would you manage a patient with mitral stenosis?

A 
Multidisciplinary team, managing complications of AF/CCF, surgical intervention

Asymptomatic
- Education
- Endocarditis prophylaxis
- Regular interval echocardiogram

Symptomatic
1. Involvement of multidisciplinary team and management of complications
2. Atrial fibrillation: rate/rhythm control, anticoagulation
3. CCF: diuretics, ACEi, spironolactone, SGLT2i
4. Refer for surgery if clinically indicated

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11
Q

What are the indications for surgery in mitral stenosis?
- Symptomatic (4)
- Asymptomatic (2)

A

Symptomatic (NYHA II-IV) patients with severe lesions:
- Valve area <1cm and valve gradient > 10mmHg
- Pulmonary hypertension
- Haemoptysis
- Recurrent thromboembolism despite anticoagulation

Asymptomatic patients
- Changes in symptoms
- Pulmonary pressure >50mmHg
(No evidence that surgical procedure improves prognosis of patients with slight or no functional impairment)

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12
Q

What surgical procedures can be used to treat mitral stenosis?

A
  1. Closed mitral ballooon valvuloplasty (PMBC) *
    (Percutaneous mitral balloon commisurotomy)
  2. Open heart commisurotomy (midline sternotomy)
  3. Mitral valve replacement
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13
Q

What are the criteria for valvuloplasty?

A
  1. Mobile valve (loud S1, has opening snap)
  2. Minimal calcification of valve and subvalvular apparatus
  3. No mitral regurgitation
  4. No LA thrombus on TEE
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14
Q

What causes tapping apex beat?

A

Accentuated first heart sound

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15
Q

What causes an opening snap in mitral stenosis?

A

Opening of stenosed mitral valve, indicating leaflets are pliable
The earlier the opening snap, the higher the LA pressure
(If > 0.1s, LA pressure < 15mmHg ; If < 0.1s, LA pressure > 20mmHg)

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16
Q

Why is the first heart sound loud in MS?

A

Mitral valve suddenly slammed shut during ventricular contraction

17
Q

What causes presystolic accentuation of MS murmur?

A

In sinus rhythm only, during atrial systole, increase flow from LA to LV through stenotic valve

18
Q

What are the two differentials of hoarseness in MS?

A
  1. Ortner’s syndrome - enlarged left atrium compresses recurrent laryngeal nerve
  2. Hypothyroidism 2’ amiodarone for AF
19
Q

In which trimester does pregnancy results in symptomatic MS?

A

Second trimester - increased blood volume

20
Q

What is Lutembacher’s syndrome

A

MS with ASD

21
Q

Haemoptysis in severe MS is due to __ from pulmonary hypertension.
It occurs in elevated LA pressure without marked elevated pulmonary resistance

A

Rupture of pulmonary-bronchial venous connections

22
Q

How do you differentiate left atrial myxoma?
- symptoms, sign, investigation

A

LA myxoma obstructs LA emptying causing dyspnoea
Diastolic murmur but changes markedly with position
Features of systemic disease: weight loss, fever, anaemia, embolism
Elevated IgG, IL-6
TTE: echo-producing mass in LA

23
Q

How do you differentiate ASD from MS?

A

No LA enlargement
No pulmonary congestions (Kerley B lines)
Fixed splitting of S2 (delayed PV closure unchanged with inspiration)
Mid systolic murmur at upper left sternal border
Large left-to-right shunt may cause functional TS

24
Q

What is rheumatic fever? What age has the highest incidence?

A

Multisystemic inflammatory disease following group A streptococcus infection

Incidence:
- Mostly childhood between 5 - 15 years old
- 20% cases are from adulthood

25
Q

How do you diagnose rheumatic fever?
- Major (JONES), Minor (6P)

A

Revised Jones Criteria:
- 2 major or 1 major + 2 minor
- Recent streptococcus infection

Major (JONES):
- Joint: migrating arthritis
- Pancarditis
- Nodules: subcutaneous nodules over bones, tendons
- Erythema marginatum: annular eruptions
- Syndenham’s chorea: abrupt purposeless movement

Minor (6P):
- Polymorphic leukocytosis
- Pyrexia
- Phase acute reactants: ESR, CRP
- Previous rheumatic fever or RHD
- Prolonged PR interval
- Polyarthralgia

Evidence of streptococcal infection
- Anti-streptolysin O titre
- Throat culture for Group A streptococcus
- Rapid GAS antigen test positive
- Recent scarlet fever

26
Q

What heart valves are commonly affected in rheumatic heart disease?

A
  1. Mitral only (50%)
  2. Mitral and aortic (40%)
  3. Mitral, aortic and tricuspic (5%)
  4. Aortic only (2%)
  5. Other combinations (3%)
27
Q

Management of Acute Rheumatic Fever and Rheumatic Heart Disease

A

Acute rheumatic fever
1. Antibiotics for group A streptococcus
Primary:
- IM benzathine Pen G x1 dose or
- Pen V for 10 days
(Allergy: cephalosporin or clindamycin for 10 days)

Secondary prophylaxis:
- IM benzathine Pen G once a month
- Pen V daily BD

Rheumatic heart disease
2. Arthritis - symptomatic: paracetamol, tramadol, NSAIDs

  1. Chorea
    - Carbamazepine 3.5-10mg/kg/dose BD
    - Valproate 7.5-10mg/kg/dose BD
    - Risperidone or haloperidol 0.25-0.5mg OD
    - Diazepam
  2. Heart failure management
  3. Immunosuppressive
    - Prednisolone 1-2mg/kg (max 80mg/day)
    - IV methylprednisolone in very severe cases
28
Q

Pathogenesis of Rheumatic Mitral Stenosis
1. Chronic inflammation leads to diffuse __ valve leaflets, with formation of __ with __ deposits.
2. Mitral commisures and chordae tendinaea __ and __, cusps become __ leading to narrowing at apex of funnel-shaped “__” valve.
3. Progressive inflammation, fibrosis and trauma to valve due to altered flow pattern eventually causes __ of valve, which immobilises leaflet and narrows orifice further
4. Thromboembolism may be due to __ or __ from LA appendage

A
  1. thickened, fibrous tissue, calcific
  2. fuse and shorten, rigid, “fish mouth”
  3. calcification
  4. calcific valve, atrial fibrillation
29
Q

Pathophysiology of mitral stenosis

A
  1. Small orifice area impedes free flow of blood
    - High LA pressure needed to propel blood from LA to LV and to maintain normal cardiac output (hallmark of MS)
    - Critical stenosis (< 1cm2) requires LA pressure 25mmHg to maintain CO
  2. LA enlargement, increase in pulmonary venous and arterial wedge pressure
    - Reduces pulmonary compliance (pulmonary congestion) causing dyspnoea
    - Chronic LA pressure causes pulmonary hypertension, PR TR and secondary right heart failure
    - Pulmonary vascular bed changes, fibrous thickening of alveoli wall and pulmonary capillaries, causes reduced VC, TLC, breathing capacity, and reduced oxygen uptake
  3. Acute decompensation in acute illness
    - Exertion, fever, anaemia, pregnancy, thyrotoxicosis, AF, etc demand for higher cardiac output
    - Pathological tachycardia shortens diastole and diminishes time available for flow across mitral valve to “augment” transvalvular pressure and elevate LA pressure -> precipitates MS
CO = HR x SV, as stroke volume limited by stenosis, HR needs to be increased to improve cardiac output

MRCP PACES Cardiology (21 decks)

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