Lecture 6-Rheumatic Heart Diseaseff.pptx
Lecture 6-Rheumatic Heart Diseaseff.pptx
- 2. Rheumatic Fever
Follows group A beta hemolytic
streptococcal throat infection
It represents a delayed immune response to
infection with manifestations appearing
after a period of 2-4 weeks
Age 5-15 yrs
A multisystem disease
Major effect on health is due to damage to
heart valvves - 3. Rheumatic Fever
A disease of poverty and low socioeconomic
status
Rare in wealthy countries, due to improved
living conditions, less overcrowding, and better
hygiene with reduction in transmission of
GABHS
Incidence: In Cambodia 2.2/1000 children,
Mozambique 2.3/1000, India 0.75/1000 - 4. Global Burden of RHD
Total cases with RHD:20 Millions
CHF: 3 Million
Valve surgery required in 1 Million
Annual incidence of RF: 0.5 Million,
nearly half develop carditis
Estimated deaths from RHD: 230,000/YR
Imposes a substantial burden on health
care systems with limited budgets - 8. Clinical Features
Onset of acute rheumatic fever is
typically characterized by an acute
febrile illness 2 to 4 weeks after an
episode of pharyngitis.
Diagnosis is primarily clinical and is
based on a constellation of signs and
symptoms, which were initially
established as the Jones criteria - 10. Modified Jones Criteria
Minor manifestations
1. Fever
2. Arthralgias
3. Previous H/O RF OR RHD
4. ↑CRP or ESR
5. Prolonged PR interval on ECG - 12. Arthritis
Most common feature: present in 80%
Earliest manifestation of ARF
Major joints: The knees and ankles,
shoulders, elbows
“Migrating”, “Fleeting” polyarthritis
Duration short < 1 week
Responds well to Salicylates
Does not progress to chronic disease - 13. Sydenham Chorea
Occur in 5-10% of cases
Abrupt Purposeless involuantry
movements of muscles of face, neck,
trunk, and limbs.
May appear even 6 months after the
attack of rheumatic fever
Clinically manifest as-clumsiness,
deterioration of handwriting,emotional
lability or grimacing of face
13 - 14. Subcutaneous Nodules
Occur in 10%
Usually 0.5 – 2 cm long
Firm non-tender
Occur over extensor surfaces of joints, on
bony prominences, tendons, spine
Short lived: last for few days
Associated with severe carditis - 16. Erythema Marginatum
Present in 5%
Reddish border, pale center, round
or irregular serpiginous borders,
non-pruritic, transient rash
Occurs on trunk, abdomen or
proximal limbs
Associated with carditis - 19. Carditis
Occurs in40- 50% of cases
Pancarditis
Only manifestation of ARF that leaves
permanent damage
Murmurs of MR or AR may occur in acute
stage while mitral stenosis occurs in late
stages
Cardiomegaly and CHF may occur - 20. Modified Jones Criteria for Diagnosis
of Acute Rheumatic Fever
A firm diagnosis requires
1) 2 Major manifestations or 1 Major and 2
Minor manifestations
and
2 ) Evidence of a recent streptococcal infection.
However, when chorea or carditis is clearly
present, evidence of an antecedent group A
streptococcal infection is not necessary. - 21. Differential Diagnosis
Juvenile rheumatiod arthritis
Infective endocarditis
Sickle cell arthropathy
Lupus
Myocarditis
Reactive arthritis
Leukemia - 23. Treatment of ARF
Salicylates : Aspirin
75-100 mg /kg/day given as 4 divided
doses for 6 -8 weeks
Attain a blood level 20-30 mg/dl
Prednisolone:
2mg/kg/day taper over 6 weeks
Given when there is carditis - 24. Treatment
Bed rest
Treat heart failure if present
Valve replacement later in life once
symptoms develop or LV dysfunction
occurs from severe valve
regurgitation or valve stenosis - 25. Secondary Prevention of Rheumatic Fever (Prevention of Recurrent
Attacks)
Agent Dose Mode
Benzathine penicillin G 1 200 000 U every 4 weeks* Intramuscular
or
Penicillin V 250 mg twice daily Oral
or
Sulfadiazine 0.5 g once daily for patients 27 kg (60 lb Oral
1.0 g once daily for patients >27 kg (60 lb)
For individuals allergic to penicillin and sulfadiazine
Erythromycin 250 mg twice daily Oral
*In high-risk situations, administration every 3 weeks is justified and
recommended - 26. Duration of Secondary Rheumatic Fever
Prophylaxis
Category Duration
Rheumatic fever with carditis and 10 y since last episode
residual heart disease or until age 40y ,(which-
(persistent valvar disease*) ever is longer), sometimes
life long prophylaxis
Rhumatic fever with carditis 10 yrs or until age 21yrs
But no residual VHD (whichever is longer)
Rheumatic fever without carditis 5 y or until age 21 y,
( whichever is longer)
* - 28. The normal MVA= 4-6 cm
In severe ms <1
High LAP
The rise in LAP causes a similar rise
in pulmonary capillaries, veins and
artery - 29. Long Asymptomatic period after initial
attack of RF until onset of class 1 / 2
symptoms: 10 – 30 yrs ( latent period )
Once symptoms develop there is another
plateau of 5 –10 yrs before onset of AF
This followed by a period of 5-10 yrs until
onset of class III- Iv symptoms - 30. Dyspnea
Fatigue
Palpitation
Hemoptysis (10%)
Hoarseness ( Ortner’s syndrome)
Dysphagia
Storoke or peripheral
embolization - 31. Cyanosis (Mitral facies,malar
flush)
Tapping apex ( S1)
Parasternal heave
Diastolic thrill
Accentuated S1 , accentuated S2
Opening snap
Mid-diastolic rumble - 32. CXR
Straightening of the left heart border
Double density
Kerley B lines , CA in MV
ECG: LAE, P Mitrale , RV dominance
ECHO:
MVA, PAP - 38. Water-hammer / collapsing pulse
Wide pulse pressure
Corrigan’s sign
De Musset sign
Muller sign
Quincke’s pulse
Hill’s sign - 42. Arterial Pulse wave form : plateau
Small { Parvus }
Slow rise { Tardus }
Sustained not displaced PMI
Systolic thrill
S4 - 43. Late peaking of murmur
Single S2 : Soft or absent
A2
Paradoxical splitting of S2
