Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Cardiology PPT 1 Rheumatic Heart Disease Lecture Notes
Rheumatic Heart Disease
Pathology
? Fibrinous necrosis: exudative
(bread and butter appearance)
? Proliferative (Aschoff nodules/Antishkow/
caterpiller cells) ? McCallum patch
? Healing and fibrosis (milk spots)
Series of Events
SORE
ACUTE
RHEUMATIC
ACUTE
THROAT
RHEUMATIC
HEART
RHEUMATIC
(GABHS)
FEVER
DISEASE
ACTIVITY
COMPLICATIONS
PREVALENCE
5-15 YRS
>15 YRS
RF
0.75/1000 (Mishra)
0.4/1000 (Verma)
RHD
4.5/1000 (Lalchandani)
4.5/1000 (Lalchandani)
5-15 YRS
Al age
Low risk pop
<2/1 lac
<1/1000
High risk pop
>2/1 lac
>1/1000
GABHS Sore Throat
MODIFIED CENTOR CRITERIA
1. AGE 5-15 YRS
0-1 +: NO AB*
SORE
2. HIGH GRADE FEVER
2-3 +: THROAT SWAB
THROAT
3. ANT CERVICAL LN
RAPID AG DET
(GABHS)
4. TONSILLAR EXUDATE
AB IF POSITIVE
5. COUGH ABSENT
4-5 +: AB
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%
*AMOXICILLIN/ AZITHROMYCIN
SN 77
SP 97
ARF: Modified Jones Criteria
MAJOR
PANCARDITIS
MINOR
MIGRATORY
HIGH FEVER
GAS INFECTION
ARTHRITIS
ARTHRALGIA
RAPID AG TEST
CHOREA
ESR>30
THROAT SWAB
SC NODULES
CRP>3
ASO
ERYTHEMA
PROLONGED PR
ANTI-DNAase
MARGINATUM
H/O ARF IN RHD
Jones criteria exempted
BLAND & JONES 30%
MS
PADMAVATI 30%
Chorea
PAUL WOOD 60%
SB ROY 60%
INDIAN VS WESTERN
WESTERN
INDIAN
COMMENTS
(BLAND & JONES)
(PADMAVATI, SANYAL)
CARDITIS
2/3
1/3
LESS IN INDIANS
ARTHRITIS
1/3
2/3
ARTHALGIA > ARTHRITIS
CHOREA
50%
10%
UNCOMMON
SCN
5%
1%
UNCOMMON
EM
5%
-
RARE
PANCARDITIS
ENDOCARDITIS
MYOCARDITIS
PERICARDITIS
Regurgitations
Cardiomegaly
Rub
MC-MR
S3
Effusion
Parchment carditis
Rare w/o
PSM
endocarditis
Careycoumb
Vs viral carditis:
EDM (AR)
No murmer
Symp improves
Long PR/ AF
VALVULAR INV IN ARF
VALVE
INVOLVEMENT
MITRAL
75%
MITRAL + AORTIC
20%
AORTIC
3%
TRICUSPID
2%
PULMONARY
-
FATE OF MR/ PSM
1/3 DISAPPEARS
1/3 SAME
1/3 PROGRESSES
VALVULAR LOAD
SVC 5
PV 10
RA 5
LA 10
RV 25/0-5
LV 120/0-10
PA 25/10
AO 120/80
TCV 20
MV 110
mmHg
mmHg
PV 5
AV 70
mmHg
mmHg
TCVA 2
MVA 40
TCVA 8-10cm2
MVA 4-6cm2
mmHg/ cm2
mmHg/cm2
PVA 2-4cm2
AVA 2-4cm2
PVA 1
AVA 25
mmHg/ cm2
mmHg/cm2
Carditis
? Acute: Dyspnea at rest
? Subacute: DOE
? Insidious: no symps, murmer+
? Subclinical: no symp, no murmer, echo+
? In jones criteria: No role of Murmer
SEVERITY OF CARDITIS
Severity
Cl/F
Mild
NYHA 2-3
Mod
NYHA 3-4 NO CARDIOMEGALY
Severe
NYHA 3-4 CARDIOMEGALY
PERICARDIAL EFFUSION
SC NODULES
JACCOUDS ARTHOPATHY
Fulminant NYHA 3-4 CARDIOMEGALY
LV FUNCTION DEPRESSED
SUB
CLINICAL
CARDITIS
CONSEQUENCE OF CARDITIS
SANYAL ET AL
ARF
CARDITIS (60%)
NO CARDITIS (40%)
2/3
1/10
RHD
RHD
(40%)
(4%)
Which murmur disappears?
Which ARFwil lead to RHD?
? No CHF/ cardiomegaly
? CARDIOMEGALY / CHF
? Low grade PSM
? >GR2 EDM
? Single valve
? OVERCROWDING
? Early penicillin
? MALNUTRITION
? First attack
? NO PEN PROPHX
? Male
? RECURRENT ATTACK
HOW MANY DIES?
BLAND & JONES
10% IN 10 YRS
20% IN 20 YRS
TOTAL
30% (1/3) IN 3 YRS
CHF
CARDIOMEGALY
50% DIES
Arthralgia/ arthritis!
Fever and joint pain
1 week after sore throat
Migratory
Stereotypic
Large joints
No small joints
NOT INVOLVED: TMJ, STERNOCLAV JOINT, ATLANTOAXIAL JOINT
Back rarely involved
Severely painful/ tender/ swollen/ red/ hot
L/O function
Symp> signs
Each joint Lasts for 1 week
Dramatic response to salicylates
Total episode resolves in 4 week
No residual deformity
Arthralgia/ arthritis!DD
VS PSRA
1. Short incubation period
2. Affects small joint
3. No response to salicylates
4. Often renal involvement
5. No carditis
TO RX PENICILLIN PROPHYLAXIS FOR 1 YEAR
VS JIA
1. MP rash incl face
2. Back inv
3. Small joints inv
4. LN
5. LFT deranged
Signifies ARA
Non-erosive
Can involve lower limbs
Subcutaneous nodules
Extensor surface
Elbow forearm
Knee joints knee
Severe carditis/ active carditis
Painless
Freely mobile
Not attached to tendon
Good response to salicylate
DD
Osler's node
Janeway lesion
Rheumatoid nodules/JIA
Painful
Macular
Palm soles
-Larger
Pulp of fingers
Smal er
blanching
-Painful
-Attached to tendons
Erythema marginatum
In crops
Painless
Axilla/ thighs+
Never on face
Annular
Evanescent
Itchy
Rare to find in indians
Carditis+
No response to salicylates
DD
Scarlet fever
Scalding
Sydenhams Chorea
Late manifestation
Never with arthritis
Carditis+
More in females
Rare in postpubertal boys
Resolves in 6m in 75% cases
Jerky speech
Pronator sign
Jack in the box
Worms in the tongue
Milkmaids grip
Spoon-like configuration
Pendular knee jerk
OCD
Poor school performance
Things fall from hands
No sensory or motor inv
Sydenhams Chorea/ DD
PANDAS
Early after sore throat
OCD
Tics
Epilepsy
TO RX PENICILLIN
TX IVIG/PLEX
WILSONS
Liver inv
No carditis
Hereditary
HUNTINGTONS
Anticipation
Psychiatric prob
Genetic/ Imaging
Antibodies
ASO > 240 TU in adults, >330 in children
ASO rises after 1 week peaks after 3 weeks
Anti DNAase B >120 TU in adults, >240 in children
Anti DNAase B rises after 2 weeks peaks after 6 weeks
Sensitivity
ASO only 65%
Anti DNAase B 85%
Together 95%
ESR>30, >50 in CHF (ESR falsely high in 50% pts of CHF)
CRP>3
Throat swab can not differentiate b/w active inf/ carrier
Multiple samples required
Yield 10%
Rapid antigen test also can not differentiate b/w active inf/ carrier
ECG features of active carditis
Heart blocks
PR prolongation despite
DD
tachy
Dengue
Relative brady
Diphtheria
VPCs
Small voltage
Progression of RHD
? Bland & Jones >20 yrs
? In india 5-10 yrs
? CMC Vellore 3months
? Depends on:
- Host factors (no penicillin prohpx)
- Environmental factors (overcrowding, malnutrition)
- Agent factors (Virulent strain, eg. Outbreak in Utah 1987)
RHD
Manjunath et el:
Mitral 60%
1/3 MS
1/3 MR
1/3 MS+MR
Mitral + aortic 25%
Aortic only 10%
Tricuspid only 10% (TR>>>TS)
Pulm valve only not reported from India
MVD 1/3
Complications of RHD
? PVH
? PAH
? LV dysfunction
? CHF
? AF
? Embolic stroke
? IE
Sudden worsening of symptoms
? Carditis/ ARA
? AF
? LV dysfunc
? Preg (carditis gravidarum)
? Vol overload
? Bact inf
? Thyrotoxicosis
? IE
? Thrombus
Recurrences
SB Roy
Bland & Jones
1. Musical murmer
2. Rub
1/5 in 5 yrs
3. Cardiomegaly
1/10 in 5-10 yrs
4. CHF
1/20 in 10-15 yrs
5. Sleeping tachycardia
1/40 in 15-20 yrs
Also
Sanyal
1. SC nodules
Carditis in 1st attack 30%
2. Prolonged PR despite tachy
3. Heart blocks
Vaishnab
4. VPCs w/o digoxin
Carditis in all attacks 90%
5. Pericardial effusion
RHD in Young
? <5 yrs: 5% (Chockalingum)
? <12 yrs: 10% (Vaishnab) ? Pediatric MS
? <20 yrs: 20% (SB Roy) ? Juvenile MS
? <40 YRS: 40%
Juvenile MS (SB Roy)
- Predominant MS
- Low ca
- Less AF
- Severe PAH
- Smal aorta
- Cuspal: symp> signs
- Good result to BMV
ARF: Management
? Bed rest 4-6 weeks
? 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)
? 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
NO PROPHYLAXIS FOR
ASYMP CARRIERS/ CONTACTS
Rebound/ Recurrence?
? On treatment:
Initial recovery. But later worsening = relpase
? Treatment completed
Symptoms reappeared after completion of tx
<6wks = rebound
>8wks = recurrence
Secondary prophylaxis
Secondary prophylaxis
Penicil in
? Recurrences
? Why 3wks?
- w/o pen: 10%
Incubation period: 9 days
- With oral pen: 3% Achieves t1/2: 19 days
- With IM pen: 0.5% Dose: 4 weekly
For developing countries: 3 wkly
? Complications
(Pen level drops after 20 days, Taiwan)
- al ergy: 3%
- Anaphylaxis: 0.5%
- Death: 0.05%
Infective endocarditis prophylaxis
Q1: Commonest cutaneous manifestation in ARF?
1. SC Nodules
2. Eryhtme Marginatum
3. Oslers Node
4. Janeway Lesion
Q2: what is the most common cause of Jaccouds arthropathy in India?
1. SLE
2. ARF
3. RA
4. TB
Q3: MS/MR patient had recurrence at 45 yrs. 2' prophyx how long?
1. None
2. 1 yrs
3. 5 yrs
4. 10 yrs
Q4: McCal um patch commonest in?
? 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?
1. A2
2. A3
3. P2
4. P3
This post was last modified on 07 April 2022