Download MBBS Cardiology PPT 1 Rheumatic Heart Disease Lecture Notes

--- Content provided by‌ FirstRanker.com ---

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

caterpiller cells) ? McCallum patch

--- Content provided by FirstRanker.com ---

? Healing and fibrosis (milk spots)
Series of Events

SORE

--- Content provided by‌ FirstRanker.com ---

ACUTE

RHEUMATIC

--- Content provided by‌ FirstRanker.com ---

ACUTE

THROAT

RHEUMATIC

--- Content provided by​ FirstRanker.com ---

HEART

RHEUMATIC

--- Content provided by‌ FirstRanker.com ---

(GABHS)

FEVER

DISEASE

--- Content provided by‌ FirstRanker.com ---

ACTIVITY

COMPLICATIONS

--- Content provided by​ FirstRanker.com ---

PREVALENCE

5-15 YRS

>15 YRS

--- Content provided by​ FirstRanker.com ---

RF

0.75/1000 (Mishra)

--- Content provided by FirstRanker.com ---

0.4/1000 (Verma)

RHD

4.5/1000 (Lalchandani)

--- Content provided by⁠ FirstRanker.com ---

4.5/1000 (Lalchandani)

5-15 YRS

--- Content provided by FirstRanker.com ---

Al age

Low risk pop

<2/1 lac

--- Content provided by‌ FirstRanker.com ---

<1/1000

High risk pop

--- Content provided by‌ FirstRanker.com ---

>2/1 lac

>1/1000

--- Content provided by⁠ FirstRanker.com ---

GABHS Sore Throat

MODIFIED CENTOR CRITERIA

1. AGE 5-15 YRS

--- Content provided by FirstRanker.com ---

0-1 +: NO AB*

SORE

--- Content provided by‍ FirstRanker.com ---

2. HIGH GRADE FEVER

2-3 +: THROAT SWAB

THROAT

--- Content provided by​ FirstRanker.com ---

3. ANT CERVICAL LN

RAPID AG DET

--- Content provided by‍ FirstRanker.com ---

(GABHS)

4. TONSILLAR EXUDATE

AB IF POSITIVE

--- Content provided by‌ FirstRanker.com ---

5. COUGH ABSENT

4-5 +: AB

--- Content provided by‌ FirstRanker.com ---

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%

--- Content provided by‍ FirstRanker.com ---

*AMOXICILLIN/ AZITHROMYCIN

SN 77

--- Content provided by​ FirstRanker.com ---

SP 97


ARF: Modified Jones Criteria

--- Content provided by FirstRanker.com ---

MAJOR

PANCARDITIS

MINOR

--- Content provided by​ FirstRanker.com ---

MIGRATORY

HIGH FEVER

--- Content provided by‍ FirstRanker.com ---

GAS INFECTION

ARTHRITIS

ARTHRALGIA

--- Content provided by‍ FirstRanker.com ---

RAPID AG TEST

CHOREA

--- Content provided by‌ FirstRanker.com ---

ESR>30

THROAT SWAB

SC NODULES

--- Content provided by‌ FirstRanker.com ---

CRP>3

ASO

--- Content provided by​ FirstRanker.com ---

ERYTHEMA

PROLONGED PR

ANTI-DNAase

--- Content provided by FirstRanker.com ---

MARGINATUM

H/O ARF IN RHD

--- Content provided by FirstRanker.com ---

Jones criteria exempted

BLAND & JONES 30%

MS

--- Content provided by FirstRanker.com ---

PADMAVATI 30%

Chorea

--- Content provided by FirstRanker.com ---

PAUL WOOD 60%

SB ROY 60%

INDIAN VS WESTERN

--- Content provided by⁠ FirstRanker.com ---

WESTERN

INDIAN

--- Content provided by⁠ FirstRanker.com ---

COMMENTS

(BLAND & JONES)

(PADMAVATI, SANYAL)

--- Content provided by⁠ FirstRanker.com ---

CARDITIS

2/3

--- Content provided by⁠ FirstRanker.com ---

1/3

LESS IN INDIANS

ARTHRITIS

--- Content provided by FirstRanker.com ---

1/3

2/3

--- Content provided by‍ FirstRanker.com ---

ARTHALGIA > ARTHRITIS

CHOREA

50%

--- Content provided by‌ FirstRanker.com ---

10%

UNCOMMON

--- Content provided by⁠ FirstRanker.com ---

SCN

5%

1%

--- Content provided by FirstRanker.com ---

UNCOMMON

EM

--- Content provided by​ FirstRanker.com ---

5%

-

RARE

--- Content provided by⁠ FirstRanker.com ---

PANCARDITIS

ENDOCARDITIS

MYOCARDITIS

--- Content provided by‍ FirstRanker.com ---

PERICARDITIS

Regurgitations

--- Content provided by FirstRanker.com ---

Cardiomegaly

Rub

MC-MR

--- Content provided by​ FirstRanker.com ---

S3

Effusion

--- Content provided by⁠ FirstRanker.com ---

Parchment carditis

Rare w/o

PSM

--- Content provided by‍ FirstRanker.com ---

endocarditis

Careycoumb

--- Content provided by‌ FirstRanker.com ---

Vs viral carditis:

EDM (AR)

No murmer

--- Content provided by‌ FirstRanker.com ---

Symp improves

Long PR/ AF

--- Content provided by⁠ FirstRanker.com ---

VALVULAR INV IN ARF

VALVE

INVOLVEMENT

--- Content provided by⁠ FirstRanker.com ---

MITRAL

75%

--- Content provided by‌ FirstRanker.com ---

MITRAL + AORTIC

20%

AORTIC

--- Content provided by​ FirstRanker.com ---

3%

TRICUSPID

--- Content provided by‍ FirstRanker.com ---

2%

PULMONARY

-

--- Content provided by‍ FirstRanker.com ---

FATE OF MR/ PSM

1/3 DISAPPEARS

--- Content provided by‍ FirstRanker.com ---

1/3 SAME

1/3 PROGRESSES
VALVULAR LOAD

--- Content provided by⁠ FirstRanker.com ---

SVC 5

PV 10

RA 5

--- Content provided by⁠ FirstRanker.com ---

LA 10

RV 25/0-5

--- Content provided by‍ FirstRanker.com ---

LV 120/0-10

PA 25/10

AO 120/80

--- Content provided by⁠ FirstRanker.com ---

TCV 20

MV 110

--- Content provided by‍ FirstRanker.com ---

mmHg

mmHg

PV 5

--- Content provided by‍ FirstRanker.com ---

AV 70

mmHg

--- Content provided by​ FirstRanker.com ---

mmHg

TCVA 2

MVA 40

--- Content provided by‌ FirstRanker.com ---

TCVA 8-10cm2

MVA 4-6cm2

--- Content provided by‍ FirstRanker.com ---

mmHg/ cm2

mmHg/cm2

PVA 2-4cm2

--- Content provided by⁠ FirstRanker.com ---

AVA 2-4cm2

PVA 1

--- Content provided by⁠ FirstRanker.com ---

AVA 25

mmHg/ cm2

mmHg/cm2

--- Content provided by⁠ FirstRanker.com ---

Carditis

? Acute: Dyspnea at rest
? Subacute: DOE

--- Content provided by FirstRanker.com ---

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

? In jones criteria: No role of Murmer

--- Content provided by⁠ FirstRanker.com ---

SEVERITY OF CARDITIS

Severity

--- Content provided by‍ FirstRanker.com ---

Cl/F

Mild

NYHA 2-3

--- Content provided by‌ FirstRanker.com ---

Mod

NYHA 3-4 NO CARDIOMEGALY

--- Content provided by⁠ FirstRanker.com ---

Severe

NYHA 3-4 CARDIOMEGALY

PERICARDIAL EFFUSION

--- Content provided by FirstRanker.com ---

SC NODULES

JACCOUDS ARTHOPATHY

--- Content provided by‌ FirstRanker.com ---

Fulminant NYHA 3-4 CARDIOMEGALY

LV FUNCTION DEPRESSED

SUB

--- Content provided by​ FirstRanker.com ---

CLINICAL

CARDITIS
CONSEQUENCE OF CARDITIS

--- Content provided by⁠ FirstRanker.com ---

SANYAL ET AL

ARF

--- Content provided by​ FirstRanker.com ---

CARDITIS (60%)

NO CARDITIS (40%)

2/3

--- Content provided by⁠ FirstRanker.com ---

1/10

RHD

--- Content provided by​ FirstRanker.com ---

RHD

(40%)

(4%)

--- Content provided by​ FirstRanker.com ---

Which murmur disappears?

Which ARFwil lead to RHD?

--- Content provided by‌ FirstRanker.com ---

? No CHF/ cardiomegaly

? CARDIOMEGALY / CHF

? Low grade PSM

--- Content provided by⁠ FirstRanker.com ---

? >GR2 EDM

? Single valve

--- Content provided by‌ FirstRanker.com ---

? OVERCROWDING

? Early penicillin

? MALNUTRITION

--- Content provided by⁠ FirstRanker.com ---

? First attack

? NO PEN PROPHX

--- Content provided by‍ FirstRanker.com ---

? Male

? RECURRENT ATTACK

--- Content provided by​ FirstRanker.com ---

HOW MANY DIES?

BLAND & JONES

10% IN 10 YRS

--- Content provided by‍ FirstRanker.com ---

20% IN 20 YRS

TOTAL

--- Content provided by⁠ FirstRanker.com ---

30% (1/3) IN 3 YRS

CHF

CARDIOMEGALY

--- Content provided by‍ FirstRanker.com ---

50% DIES

Arthralgia/ arthritis!

--- Content provided by‌ FirstRanker.com ---

Fever and joint pain

1 week after sore throat

Migratory

--- Content provided by‌ FirstRanker.com ---

Stereotypic

Large joints

--- Content provided by​ FirstRanker.com ---

No small joints

NOT INVOLVED: TMJ, STERNOCLAV JOINT, ATLANTOAXIAL JOINT

Back rarely involved

--- Content provided by FirstRanker.com ---

Severely painful/ tender/ swollen/ red/ hot

L/O function

--- Content provided by​ FirstRanker.com ---

Symp> signs

Each joint Lasts for 1 week

Dramatic response to salicylates

--- Content provided by⁠ FirstRanker.com ---

Total episode resolves in 4 week

No residual deformity

--- Content provided by FirstRanker.com ---

Arthralgia/ arthritis!DD

VS PSRA

--- Content provided by‌ FirstRanker.com ---

1. Short incubation period

2. Affects small joint

3. No response to salicylates

--- Content provided by⁠ FirstRanker.com ---

4. Often renal involvement

5. No carditis

--- Content provided by FirstRanker.com ---

TO RX PENICILLIN PROPHYLAXIS FOR 1 YEAR

VS JIA

--- Content provided by​ FirstRanker.com ---

1. MP rash incl face

2. Back inv

3. Small joints inv

--- Content provided by​ FirstRanker.com ---

4. LN

5. LFT deranged

--- Content provided by‌ FirstRanker.com ---

Signifies ARA

Non-erosive

Can involve lower limbs

--- Content provided by FirstRanker.com ---

Subcutaneous nodules

Extensor surface

--- Content provided by‌ FirstRanker.com ---

Elbow forearm

Knee joints knee

--- Content provided by​ FirstRanker.com ---

Severe carditis/ active carditis

Painless

Freely mobile

--- Content provided by‌ FirstRanker.com ---

Not attached to tendon

Good response to salicylate

--- Content provided by FirstRanker.com ---

DD

Osler's node

Janeway lesion

--- Content provided by​ FirstRanker.com ---

Rheumatoid nodules/JIA

Painful

--- Content provided by‍ FirstRanker.com ---

Macular

Palm soles

-Larger

--- Content provided by‌ FirstRanker.com ---

Pulp of fingers

Smal er

--- Content provided by‌ FirstRanker.com ---

blanching

-Painful

-Attached to tendons

--- Content provided by‌ FirstRanker.com ---

Erythema marginatum

In crops

--- Content provided by FirstRanker.com ---

Painless

Axilla/ thighs+

Never on face

--- Content provided by FirstRanker.com ---

Annular

Evanescent

--- Content provided by‌ FirstRanker.com ---

Itchy

Rare to find in indians

Carditis+

--- Content provided by⁠ FirstRanker.com ---

No response to salicylates

DD

--- Content provided by‍ FirstRanker.com ---

Scarlet fever

Scalding

--- Content provided by⁠ FirstRanker.com ---

Sydenhams Chorea

Late manifestation

Never with arthritis

--- Content provided by⁠ FirstRanker.com ---

Carditis+

More in females

--- Content provided by​ FirstRanker.com ---

Rare in postpubertal boys

Resolves in 6m in 75% cases

Jerky speech

--- Content provided by‌ FirstRanker.com ---

Pronator sign

Jack in the box

--- Content provided by FirstRanker.com ---

Worms in the tongue

Milkmaids grip

Spoon-like configuration

--- Content provided by⁠ FirstRanker.com ---

Pendular knee jerk

OCD

--- Content provided by⁠ FirstRanker.com ---

Poor school performance

Things fall from hands

No sensory or motor inv

--- Content provided by​ FirstRanker.com ---

Sydenhams Chorea/ DD

PANDAS

--- Content provided by​ FirstRanker.com ---

Early after sore throat

OCD

Tics

--- Content provided by⁠ FirstRanker.com ---

Epilepsy

TO RX PENICILLIN

--- Content provided by‌ FirstRanker.com ---

TX IVIG/PLEX

WILSONS

Liver inv

--- Content provided by‍ FirstRanker.com ---

No carditis

Hereditary

--- Content provided by‍ FirstRanker.com ---

HUNTINGTONS

Anticipation

Psychiatric prob

--- Content provided by FirstRanker.com ---

Genetic/ Imaging


Antibodies

--- Content provided by‌ FirstRanker.com ---

ASO > 240 TU in adults, >330 in children

ASO rises after 1 week peaks after 3 weeks

--- Content provided by​ FirstRanker.com ---

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

Anti DNAase B rises after 2 weeks peaks after 6 weeks

Sensitivity

--- Content provided by‍ FirstRanker.com ---

ASO only 65%

Anti DNAase B 85%

--- Content provided by FirstRanker.com ---

Together 95%

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

CRP>3

--- Content provided by​ FirstRanker.com ---

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

Multiple samples required

--- Content provided by⁠ FirstRanker.com ---

Yield 10%

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

ECG features of active carditis

--- Content provided by FirstRanker.com ---

Heart blocks

PR prolongation despite

--- Content provided by‌ FirstRanker.com ---

DD

tachy

Dengue

--- Content provided by FirstRanker.com ---

Relative brady

Diphtheria

--- Content provided by​ FirstRanker.com ---

VPCs

Small voltage
Progression of RHD

--- Content provided by​ FirstRanker.com ---

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

--- Content provided by⁠ FirstRanker.com ---

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

RHD

--- Content provided by⁠ FirstRanker.com ---

Manjunath et el:

Mitral 60%

1/3 MS

--- Content provided by‍ FirstRanker.com ---

1/3 MR

1/3 MS+MR

--- Content provided by FirstRanker.com ---

Mitral + aortic 25%

Aortic only 10%

Tricuspid only 10% (TR>>>TS)

--- Content provided by​ FirstRanker.com ---

Pulm valve only not reported from India

MVD 1/3
Complications of RHD

--- Content provided by​ FirstRanker.com ---

? PVH
? PAH
? LV dysfunction
? CHF

--- Content provided by‌ FirstRanker.com ---

? AF
? Embolic stroke
? IE

Sudden worsening of symptoms

--- Content provided by‍ FirstRanker.com ---

? Carditis/ ARA

? AF

--- Content provided by​ FirstRanker.com ---

? LV dysfunc

? Preg (carditis gravidarum)

? Vol overload

--- Content provided by​ FirstRanker.com ---

? Bact inf

? Thyrotoxicosis

--- Content provided by‍ FirstRanker.com ---

? IE

? Thrombus
Recurrences

--- Content provided by‌ FirstRanker.com ---

SB Roy

Bland & Jones

1. Musical murmer

--- Content provided by⁠ FirstRanker.com ---

2. Rub

1/5 in 5 yrs

--- Content provided by​ FirstRanker.com ---

3. Cardiomegaly

1/10 in 5-10 yrs

4. CHF

--- Content provided by‍ FirstRanker.com ---

1/20 in 10-15 yrs

5. Sleeping tachycardia

--- Content provided by​ FirstRanker.com ---

1/40 in 15-20 yrs

Also

Sanyal

--- Content provided by‌ FirstRanker.com ---

1. SC nodules

Carditis in 1st attack 30%

--- Content provided by‍ FirstRanker.com ---

2. Prolonged PR despite tachy

3. Heart blocks

Vaishnab

--- Content provided by‍ FirstRanker.com ---

4. VPCs w/o digoxin

Carditis in all attacks 90%

--- Content provided by⁠ FirstRanker.com ---

5. Pericardial effusion

RHD in Young

? <5 yrs: 5% (Chockalingum)

--- Content provided by‍ FirstRanker.com ---

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

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

--- Content provided by‌ FirstRanker.com ---

? <40 YRS: 40%

Juvenile MS (SB Roy)

- Predominant MS

--- Content provided by‍ FirstRanker.com ---

- Low ca

- Less AF

--- Content provided by‌ FirstRanker.com ---

- Severe PAH

- Smal aorta

- Cuspal: symp> signs

--- Content provided by⁠ FirstRanker.com ---

- Good result to BMV
ARF: Management

? Bed rest 4-6 weeks

--- Content provided by⁠ FirstRanker.com ---

? 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)

--- Content provided by​ FirstRanker.com ---

? 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

--- Content provided by⁠ FirstRanker.com ---

NO PROPHYLAXIS FOR

ASYMP CARRIERS/ CONTACTS

--- Content provided by FirstRanker.com ---

Rebound/ Recurrence?

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

--- Content provided by FirstRanker.com ---

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

--- Content provided by‍ FirstRanker.com ---

Secondary prophylaxis

Secondary prophylaxis

--- Content provided by​ FirstRanker.com ---

Penicil in

? Recurrences

--- Content provided by‌ FirstRanker.com ---

? Why 3wks?

- w/o pen: 10%

Incubation period: 9 days

--- Content provided by FirstRanker.com ---

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

- With IM pen: 0.5% Dose: 4 weekly

--- Content provided by FirstRanker.com ---

For developing countries: 3 wkly

? Complications

(Pen level drops after 20 days, Taiwan)

--- Content provided by⁠ FirstRanker.com ---

- al ergy: 3%

- Anaphylaxis: 0.5%

--- Content provided by‍ FirstRanker.com ---

- Death: 0.05%

Infective endocarditis prophylaxis
Q1: Commonest cutaneous manifestation in ARF?

--- Content provided by FirstRanker.com ---

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

--- Content provided by​ FirstRanker.com ---

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

1. SLE
2. ARF
3. RA

--- Content provided by​ FirstRanker.com ---

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

1. None
2. 1 yrs

--- Content provided by​ FirstRanker.com ---

3. 5 yrs
4. 10 yrs

Q4: McCal um patch commonest in?

--- Content provided by⁠ FirstRanker.com ---

? 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?

--- Content provided by FirstRanker.com ---

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

--- Content provided by⁠ FirstRanker.com ---