Download MBBS Cardiology PPT 1 Rheumatic Heart Disease Lecture Notes

Rheumatic Heart Disease

Pathology

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? Fibrinous necrosis: exudative
(bread and butter appearance)
? Proliferative (Aschoff nodules/Antishkow/

caterpiller cells) ? McCallum patch

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? Healing and fibrosis (milk spots)
Series of Events

SORE

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ACUTE

RHEUMATIC

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ACUTE

THROAT

RHEUMATIC

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HEART

RHEUMATIC

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(GABHS)

FEVER

DISEASE

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ACTIVITY

COMPLICATIONS

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PREVALENCE

5-15 YRS

>15 YRS

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RF

0.75/1000 (Mishra)

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0.4/1000 (Verma)

RHD

4.5/1000 (Lalchandani)

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4.5/1000 (Lalchandani)

5-15 YRS

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Al age

Low risk pop

<2/1 lac

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<1/1000

High risk pop

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>2/1 lac

>1/1000

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GABHS Sore Throat

MODIFIED CENTOR CRITERIA

1. AGE 5-15 YRS

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0-1 +: NO AB*

SORE

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2. HIGH GRADE FEVER

2-3 +: THROAT SWAB

THROAT

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3. ANT CERVICAL LN

RAPID AG DET

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(GABHS)

4. TONSILLAR EXUDATE

AB IF POSITIVE

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5. COUGH ABSENT

4-5 +: AB

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SORE THROAT to ARF: 3% (epidemic) 0.3% (endemic)

Once RF after sore throat, 50% chance of RF recurrence after another sore throat

THROAT SWAB: YIELD 5-10%

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*AMOXICILLIN/ AZITHROMYCIN

SN 77

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SP 97


ARF: Modified Jones Criteria

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MAJOR

PANCARDITIS

MINOR

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MIGRATORY

HIGH FEVER

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GAS INFECTION

ARTHRITIS

ARTHRALGIA

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RAPID AG TEST

CHOREA

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ESR>30

THROAT SWAB

SC NODULES

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CRP>3

ASO

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ERYTHEMA

PROLONGED PR

ANTI-DNAase

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MARGINATUM

H/O ARF IN RHD

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Jones criteria exempted

BLAND & JONES 30%

MS

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PADMAVATI 30%

Chorea

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PAUL WOOD 60%

SB ROY 60%

INDIAN VS WESTERN

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WESTERN

INDIAN

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COMMENTS

(BLAND & JONES)

(PADMAVATI, SANYAL)

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CARDITIS

2/3

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1/3

LESS IN INDIANS

ARTHRITIS

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1/3

2/3

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ARTHALGIA > ARTHRITIS

CHOREA

50%

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10%

UNCOMMON

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SCN

5%

1%

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UNCOMMON

EM

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5%

-

RARE

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PANCARDITIS

ENDOCARDITIS

MYOCARDITIS

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PERICARDITIS

Regurgitations

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Cardiomegaly

Rub

MC-MR

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S3

Effusion

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Parchment carditis

Rare w/o

PSM

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endocarditis

Careycoumb

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Vs viral carditis:

EDM (AR)

No murmer

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Symp improves

Long PR/ AF

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VALVULAR INV IN ARF

VALVE

INVOLVEMENT

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MITRAL

75%

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MITRAL + AORTIC

20%

AORTIC

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3%

TRICUSPID

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2%

PULMONARY

-

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FATE OF MR/ PSM

1/3 DISAPPEARS

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1/3 SAME

1/3 PROGRESSES
VALVULAR LOAD

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SVC 5

PV 10

RA 5

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LA 10

RV 25/0-5

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LV 120/0-10

PA 25/10

AO 120/80

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TCV 20

MV 110

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mmHg

mmHg

PV 5

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AV 70

mmHg

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mmHg

TCVA 2

MVA 40

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TCVA 8-10cm2

MVA 4-6cm2

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mmHg/ cm2

mmHg/cm2

PVA 2-4cm2

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AVA 2-4cm2

PVA 1

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AVA 25

mmHg/ cm2

mmHg/cm2

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Carditis

? Acute: Dyspnea at rest
? Subacute: DOE

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? Insidious: no symps, murmer+
? Subclinical: no symp, no murmer, echo+

? In jones criteria: No role of Murmer

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SEVERITY OF CARDITIS

Severity

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Cl/F

Mild

NYHA 2-3

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Mod

NYHA 3-4 NO CARDIOMEGALY

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Severe

NYHA 3-4 CARDIOMEGALY

PERICARDIAL EFFUSION

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SC NODULES

JACCOUDS ARTHOPATHY

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Fulminant NYHA 3-4 CARDIOMEGALY

LV FUNCTION DEPRESSED

SUB

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CLINICAL

CARDITIS
CONSEQUENCE OF CARDITIS

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SANYAL ET AL

ARF

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CARDITIS (60%)

NO CARDITIS (40%)

2/3

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1/10

RHD

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RHD

(40%)

(4%)

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Which murmur disappears?

Which ARFwil lead to RHD?

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? No CHF/ cardiomegaly

? CARDIOMEGALY / CHF

? Low grade PSM

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? >GR2 EDM

? Single valve

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? OVERCROWDING

? Early penicillin

? MALNUTRITION

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? First attack

? NO PEN PROPHX

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? Male

? RECURRENT ATTACK

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HOW MANY DIES?

BLAND & JONES

10% IN 10 YRS

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20% IN 20 YRS

TOTAL

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30% (1/3) IN 3 YRS

CHF

CARDIOMEGALY

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50% DIES

Arthralgia/ arthritis!

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Fever and joint pain

1 week after sore throat

Migratory

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Stereotypic

Large joints

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No small joints

NOT INVOLVED: TMJ, STERNOCLAV JOINT, ATLANTOAXIAL JOINT

Back rarely involved

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Severely painful/ tender/ swollen/ red/ hot

L/O function

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Symp> signs

Each joint Lasts for 1 week

Dramatic response to salicylates

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Total episode resolves in 4 week

No residual deformity

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Arthralgia/ arthritis!DD

VS PSRA

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1. Short incubation period

2. Affects small joint

3. No response to salicylates

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4. Often renal involvement

5. No carditis

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TO RX PENICILLIN PROPHYLAXIS FOR 1 YEAR

VS JIA

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1. MP rash incl face

2. Back inv

3. Small joints inv

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4. LN

5. LFT deranged

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Signifies ARA

Non-erosive

Can involve lower limbs

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Subcutaneous nodules

Extensor surface

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Elbow forearm

Knee joints knee

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Severe carditis/ active carditis

Painless

Freely mobile

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Not attached to tendon

Good response to salicylate

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DD

Osler's node

Janeway lesion

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Rheumatoid nodules/JIA

Painful

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Macular

Palm soles

-Larger

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Pulp of fingers

Smal er

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blanching

-Painful

-Attached to tendons

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Erythema marginatum

In crops

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Painless

Axilla/ thighs+

Never on face

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Annular

Evanescent

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Itchy

Rare to find in indians

Carditis+

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No response to salicylates

DD

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Scarlet fever

Scalding

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Sydenhams Chorea

Late manifestation

Never with arthritis

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Carditis+

More in females

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Rare in postpubertal boys

Resolves in 6m in 75% cases

Jerky speech

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Pronator sign

Jack in the box

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Worms in the tongue

Milkmaids grip

Spoon-like configuration

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Pendular knee jerk

OCD

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Poor school performance

Things fall from hands

No sensory or motor inv

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Sydenhams Chorea/ DD

PANDAS

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Early after sore throat

OCD

Tics

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Epilepsy

TO RX PENICILLIN

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TX IVIG/PLEX

WILSONS

Liver inv

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No carditis

Hereditary

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HUNTINGTONS

Anticipation

Psychiatric prob

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Genetic/ Imaging


Antibodies

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ASO > 240 TU in adults, >330 in children

ASO rises after 1 week peaks after 3 weeks

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Anti DNAase B >120 TU in adults, >240 in children

Anti DNAase B rises after 2 weeks peaks after 6 weeks

Sensitivity

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ASO only 65%

Anti DNAase B 85%

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Together 95%

ESR>30, >50 in CHF (ESR falsely high in 50% pts of CHF)

CRP>3

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Throat swab can not differentiate b/w active inf/ carrier

Multiple samples required

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Yield 10%

Rapid antigen test also can not differentiate b/w active inf/ carrier

ECG features of active carditis

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Heart blocks

PR prolongation despite

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DD

tachy

Dengue

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Relative brady

Diphtheria

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VPCs

Small voltage
Progression of RHD

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? Bland & Jones >20 yrs
? In india 5-10 yrs
? CMC Vellore 3months
? Depends on:
- Host factors (no penicillin prohpx)

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- Environmental factors (overcrowding, malnutrition)
- Agent factors (Virulent strain, eg. Outbreak in Utah 1987)

RHD

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Manjunath et el:

Mitral 60%

1/3 MS

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1/3 MR

1/3 MS+MR

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Mitral + aortic 25%

Aortic only 10%

Tricuspid only 10% (TR>>>TS)

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Pulm valve only not reported from India

MVD 1/3
Complications of RHD

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? PVH
? PAH
? LV dysfunction
? CHF

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? AF
? Embolic stroke
? IE

Sudden worsening of symptoms

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? Carditis/ ARA

? AF

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? LV dysfunc

? Preg (carditis gravidarum)

? Vol overload

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? Bact inf

? Thyrotoxicosis

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? IE

? Thrombus
Recurrences

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SB Roy

Bland & Jones

1. Musical murmer

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2. Rub

1/5 in 5 yrs

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3. Cardiomegaly

1/10 in 5-10 yrs

4. CHF

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1/20 in 10-15 yrs

5. Sleeping tachycardia

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1/40 in 15-20 yrs

Also

Sanyal

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1. SC nodules

Carditis in 1st attack 30%

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2. Prolonged PR despite tachy

3. Heart blocks

Vaishnab

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4. VPCs w/o digoxin

Carditis in all attacks 90%

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5. Pericardial effusion

RHD in Young

? <5 yrs: 5% (Chockalingum)

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? <12 yrs: 10% (Vaishnab) ? Pediatric MS

? <20 yrs: 20% (SB Roy) ? Juvenile MS

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? <40 YRS: 40%

Juvenile MS (SB Roy)

- Predominant MS

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- Low ca

- Less AF

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- Severe PAH

- Smal aorta

- Cuspal: symp> signs

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- Good result to BMV
ARF: Management

? Bed rest 4-6 weeks

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? Good nutrition
? Benz Pen (<27 kgs) 6lac IU (>27 kgs) 12lac IU deep IM in buttock, small needle
? OR oral Pen V 250 TDSX5d (children) 500TDSX5d (adult)
? OR Erythromycin 250 QDSx10d (2omg/kg/d upto 1 gram in 3-4 divided doses)
? OR azithromycin 500 in day and 250 ODX4d (12.5 mg/kg/d x 5d)

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? Arthtitis: ASA 100mg/kg/day in 3-4 divided doses
? Carditis: ASA 100mg/kg/day in 3-4 divided doses
? Salicylism: Resp alk (hyperventilation) ? paradoxical aciduria ? met acidosis
? CHF: prednisolone 1mg/kg/d in two divided doses
? Review after 1 weeks, 2 weeks and 4 weeks and FU with echo/ clin

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NO PROPHYLAXIS FOR

ASYMP CARRIERS/ CONTACTS

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Rebound/ Recurrence?

? On treatment:
Initial recovery. But later worsening = relpase

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? Treatment completed
Symptoms reappeared after completion of tx
<6wks = rebound
>8wks = recurrence

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Secondary prophylaxis

Secondary prophylaxis

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Penicil in

? Recurrences

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? Why 3wks?

- w/o pen: 10%

Incubation period: 9 days

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- With oral pen: 3% Achieves t1/2: 19 days

- With IM pen: 0.5% Dose: 4 weekly

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For developing countries: 3 wkly

? Complications

(Pen level drops after 20 days, Taiwan)

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- al ergy: 3%

- Anaphylaxis: 0.5%

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- Death: 0.05%

Infective endocarditis prophylaxis
Q1: Commonest cutaneous manifestation in ARF?

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1. SC Nodules
2. Eryhtme Marginatum
3. Oslers Node
4. Janeway Lesion

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Q2: what is the most common cause of Jaccouds arthropathy in India?

1. SLE
2. ARF
3. RA

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4. TB
Q3: MS/MR patient had recurrence at 45 yrs. 2' prophyx how long?

1. None
2. 1 yrs

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3. 5 yrs
4. 10 yrs

Q4: McCal um patch commonest in?

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? Ventr side of LV
? Atrial side of LA
? Ventr side of AML
? Atrial side of PML
Q4: In RHD least involved mitral scal ops is?

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1. A2
2. A3
3. P2
4. P3

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