Valvular disease Flashcards
What is the pathophysiology behind rheumatic fever?
There is a laryngeal infection with a beta haemolystic streptococcus. This triggers rheumatic fever 2-4weeks later. This is caused by an antibody to the carbohydrate cell wall which cross reacts with valve tissue
What are the criteria for rheumatic fever suspicion?
The Jones criteria includes: Evidence of beta haemolytic stretococcal infection: -Positive thoat culture -Rapid strep antigen test -Elevated strep antibody titre -Recent scarlet fever Major criteria: -Carditis - tachycardia, murmurs, pericardial rub etc -Arthritis - migratory flitting polyarthritis -Small subcuatneous nodules -Erythema marginatum - geographical type rash Minor criteria: -Fever -Raised CRP -Arthralgia -Prolonged PR interval
What is the management of rheumatic fever?
Bedrest until CRP normal for 2 weeks
Benzylpenicillin then phenoxymethylpenicillin
Analgesia for carditis and arthritis - asprin or nsaids
Immobilise joints in severe arthritis
What valves are most commonly affected by rheumatic fever?
Mitral (70%)
Aortic (40%)
Tricuspid (10%)
Pulmonary (2%)
What are the causes of mitral regurge?
Functional (LV dilation) Annular calcification (age related) Rheumatic fever Infective endocarditis Papillary rupture/dysfunction (post MI) Connective tissue disorders (marfan's) Cardiomyopathy Congenital
What are the symptoms of mitral regurge?
Dyspnoea, fatigue, palpatations
What are the signs of mitral regurge?
Pansystolic murmur at apex radiating to axilla
What is the management of mitral regurge?
Control rate if in fast AF
Anticoagulate if at risk of embolism
Aim to replace or repair surgically before it is irreversibly damaged
What is the most common valvular abnormality?
mitral valve prolapse
What are the causes of mitral stenosis?
Rheumatic fever
Congenital
prosthetic valve
What are the signs of mitral stenosis?
malar flush
Rumbling mid-diastolic murmur
What diagnosis does a fever + a new murmur indicate?
Infective endocarditis unless proven otherwise
Require blood cultures
What is the commonest organism that causes infective endocarditis?
Staph aureus
What are the causes of infective endocarditis?
Bacteria: -strep viridans -strep bovis -staph aureus Fungi: -candida -aspergillosis Other: -sle -malignancy
What are the signs of infective carditis?
Septic signs - fever, rigors, night sweats, malaise, weight loss
Cardiac lesions - new murmur or a change in a murmur, vegetations may cause valve obstruction or destruction
Can cause av block
Immune complex deposition - vasculitis, microscopic haematuria, aki, roth spots (boat shaped retinal haemorrhage), splinter haemorrhages, osler nodes
Embolic phenomena - can cause abscesses in various organs e.g. brain, liver, janeway lesions
What tests should be used to diagnose infective endocarditis?
Three separate blood cultures should be done at the height of fever.
Blood tests for anaemia, neutophilia, rheumatoid factor (immunological)
Urinalysis for microscopic haematuria
Cxr - cardiomegaly, pulmonary oedema
Echo may show large vegetations
Ct for emboli
What is the treatment of infective endocarditis?
Appropriate antibiotics and sometimes surgery e.g. valvular obstruction
What antibiotics should be used for different causes of infective endocarditis?
Blind therapy - ampicillin, flucloxacillin and gentamycin
Staphs - flucloxacillin
Streps - penicillin
What criteria os used for infective endocarditis and what are the inclusions?
The modified duke criteria Major criteria: -positive blood culture -endocardial involvement (positive echo, ct etc) Minor criteria: -at risk individual - fever greater than 38 degrees -vascular phenomena -immunological phenomena
2 major or 1 major and 3 minor diagnostic
What are the causes of aortic stenosis?
Senile age related calcification is most common
Congenital causes - bicuspid valve
Rheumatic heart disease
What is the classic triad of symptoms for aortic stenosis?
Typically in older patients
Angina, syncope and heart failure
Also think: dyspnoea, dizziness, faints
What are the signs of aortic stenosis?
SLow rising pulse with narrow pulse pressure
LV heave with non displaced apex beat
Aortic thrill
Ejection systolic murmur
What tests should be done for aortic stenosis?
ECG for any abnormlities
CXR for LVH, aortic valve calcification or post stenotic dilation of ascending aorta
Echo is diagnostic - used to estimate gradient across valves - this estimates risk of complication
What is the management of aortic stenosis?
Managed with valve replacement if symptomatic
If a patient is not fit for surgery then a transcatheter aortic valve replacement may be performed
What are the causes of aortic regurgitation?
Acute : ascenting aorta dissection, infective endocarditis, chest trauma
Chronic : congenitatl, connective tissue disorders (marfans), rheumatic fever, SLE, Rheumatoid arthritis, seronegative arthritidies
What are the signs and symptoms of aortic regurgitation?
Symptoms - exertional dyspnoea, orthopnoea and paroxysmal noctural dyspnoea
Signs - colapsing pulse, early diastolic murmur ( heard best in expiration with patient sat forward)
What is quinkes sign?
This is pulsatile nailbeds felt in aortic regurge
What tests should be done for aortic regurge?
ECG - LVH
CXR - cardiomegaly, pumonary oedema
echo - diagnostic
cardiac catheterisation - to assess severity of lesion
What is the management of aortic regurge?
Main goal of medical therapy is to reduce systolic hypertension so usually on ACE i
If there are lots of symptoms or dilation of aorta then surgery is indicated
Aim to replace the valve before significant LV dysfunction occurs
