Rheumatic Heart Disease Flashcards
What is acute rheumatic fever
Acute rheumatic fever (ARF) is an autoimmune inflammatory condition that develops as a sequela of infection of the pharynx by group A beta hemolytic Streptococcus (GABHS). It is noninfectious, non-suppurative sequalae of sore throat, typically begins 2-4 weeks after a streptococcal infection
What are some RFs of ARF
Age : 5-15
Untreated streptococcal infection
Familiar predisposition
Overcrowding (eg. schools, daycare centers)
Poverty, poor hygiene (low socioeconomic status)
Lack of access to medical care
What is the pathophysiology of ARF
Body produce antibodies against streptococci. These antibodies cross react with human tissues because of the antigenic similarity between streptococcal components and human connective tissues (molecular mimicry) Ithere is certain
amino acid sequence that is similar btw GAS and human tissue
What are the symptoms of ARF
Carditis causing heart failure so they may present with symptoms of heart failure
Arthritis (large joints like the knee, the elbow, and wrist)
Erythema marginatum (Skin rash)
Subcutaneous nodules
Sydenham’s chorea
Others: Fever, Sore throat, Abdominal pain, Arthralgia
What are the signs of ARF
Murmurs
Cardiomegaly
Pericardial rub, Pericardial effusion (pericarditis)
Signs of HF
Subcutaneous nodules ( found over the elbow, knees, wrists, ankles back of scalp, spinous processes)
What is the most common and early manifestation of ARF
Arthritis
What is arthritis
Acute painful asymmetric and migratory inflammation of the large joints. Typically affects the knees, ankles, elbows and wrists
Late neurological manifestation
Appears at least 3 months after the
episode of ARF
All the other signs may have
disappeared
Occurs in up to 1/3rd of cases and is
more common in females
Emotional breakdown or changes may
be the first feature
Typically followed by purposeless involuntary choreiform movements of
the face, hand or foot
Speech may be exploding or halting
What is being referred to here
Sydenham’s chorea (St Vitus dance)
What is the name given to the diagnostic criteria for rheumatic fever
Duckett-Jones diagnostic criteria
What are the major criteria for diagnosing ARF
Carditis
Arthritis
Subcutaneous nodules
Erythema marginatum
Sydenham’s chorea
Mnemonic: CASES
What are the minor criteria for diagnosing ARF
Fever
Raised ESR/CRP
Arthralgia
Prolonged PR interval
Previous RF
Mnemonic: FRAPP
How do conclude that someone has ARF in the Duckett-Jones diagnostic criteria
There must be evidence of streptococcal infection plus:
2 major or 1 major + 2 minor
What are some complications of ARF
Valvular heart disease
Arrhythmia (commonly atrial fibrillation)
Congestive heart failure
Infective endocarditis
Pulmonary or systemic emboli
Recurrent infections
What is an RHD
Rheumatic heart disease is a systemic immune process that is sequelae to a beta-hemolytic streptococcal infection of the pharynx
Rheumatic heart disease is permanent heart valve damage results from either a single or repeated attacks of rheumatic fever that lead to deformity and rigidity of valve cusps, the fusion of the commissures, or shortening and fusion of the chordae tendineae.
•It is thought that 40..50% of patients with ARF will go on to developing RHD
Does early valvular damage from RHD cause regurgitation or stenosis
Regurgitation
Over ensuing years, usually as a result of recurrent episodes leaflet thickening, scarring and calcifications stenosis may also develop. People with RHD are often asymptomatic for many years before the valvular heart disease progresses to heart failure
What are some complications of RHD
Atrial fibrillation
–Common in RHD
–Causes irregular heart rate / palpitations, blackouts etc,
Stroke
–Ischaemic stroke (blood clot)
Due to not enough warfarin, when atrial fibrillation or metal valve are present
- Also can complicate infective endocarditis
–Hemorrhagic stroke (bleed into brain)
•Due to too much warfarin
•Heart failure
–Symptoms: shortness of breath, swelling in the legs
-Infective endocarditis
–bacterial infection of heart valve – targets damaged valves
–Bacteria get into blood via mouth (especially when dental hygiene is poor), open skin etc
–People at high risk receive endocarditis prophylaxis prior to surgical procedures
–Dental health and hygiene reduces risk of endocarditis
What are the characteristic heart features for mitral stenosis
Mitral flush-rosy cheeks
Tapping apex beat
Apex beat-normal
Loud S1
Opening snap
Pre-systolic accentuation
Low-pitched, rumbling, mid-diastolic murmur
What are the characteristic heart features for mitral regurgitation
Absent or soft S1
Heaving apex beat
Displaced apex beat
Murmur pansystolic, most prominent at the apex and radiates to the axilla
What are the characteristic heart features for aortic stenosis
Slow rising pulse
low systolic pressure
narrow pulse pressure
Trusting apex beat
Normal in location apex beat
soft S2
Diamond-shaped, harsh systolic ejection murmur, heard best at the aortic area and radiating to
What are the characteristic heart features for aortic regurgitation
Collapsing pulse
wide pulse pressure
soft S2
Heaving apex beat
Displaced apex beat
Early harsh-diastolic murmur, heard best at the 4th LICS, with the patient lean forward
What are some investigations to make in RHD
Evidence of antecedent Group A strep infection ie a positive throat culture which is mostly positive in 25% of patients and negative in 75% of them
Elevated streptococcal antibiody titre ASO (Anti –Streptolysin O), Anti –DNAse B, Anti –Hyaluronic acid . 95-100% have an elevation in these three different antibodies
Echocardiography
ECG – AV conduction delay
Chest x ray
Acute phase reactants, C reactive proteins, erythrocyte sedimentation rate
Blood cultures
How do you treat RHD
- Treating the strep infection
•Treatment of the group A streptococcal infection :antibiotics ( oral penicilin V (500mg *2/d for 10days) / IM benzathine penicilin G ( 1.2millon unit, single dose) / Erythromycin 250mg BD for 10days, if there is penicillin allergy) - Symptomatic treatment
•Arthritis, arthralgia: salicylate, aspirin (100mg/kg/d in divided doses, max 4-8g/d, for 2 days and then 70mg/kg/d for 6weeks. Monitor salicylate level, (hyperventilation, metabolic acidosis) or NSAID
•Treatment of Carditis: corticosteroids (prednisolone, 1-2mg/kg/d in 4-5 divided doses (max:60mg) for 4-6weeks
Sydenham’s chorea: haloperidol 0.5kg/kg/day - Prophylaxis
What are some surgical treatments for RHD
Valve Repair
Valve Replacement (Bioprosthetic valves, porcine tissues. Mechanical valves: requires anticoagulation with warfarin)
What are some medical treatments for RHD
Diuretics, digoxin,
Antibiotics prophylaxis
Control arrhythmias
Percutaneous transluminal ballon valvuloplasty
