Download MBBS Cardiology PPT 1 Rheumatic Heart Disease Lecture Notes

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