rheumatic heart disease and fever INDIA

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  • Coronary artery bypass grafting is the most common type of heart surgery and improves blood flow to the heart. The surgery is mainly conducted in case severe coronary artery disease. The procedure is generally done as there is plaque formation inside the arteries which limits the blood flow to the heart. The disease of coronary artery could lead to angina and even heart attack like conditions. On successful operation it allows oxygen-rich blood to reach the heart muscle. One more fact about this surgery is that the surgeons can bypass multiple blocked coronary arteries during one surgery. Primus Super Speciality Hospital Chandragupta Marg, Chanakyapuri New Delhi-110 021, India +911166206630, 40 info@primushospital.com http://www.primushospital.com/index1.html
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rheumatic heart disease and fever INDIA

  1. 1. DR.C.R.RAWATM.D,FACC,FESC,FCSI,FISC CONSULTANT CARDIOLOGIST
  2. 2. World scenario of rheumatic heart disease
  3. 3. Area Prevalence Per 1000United States 0.6Japan 0.7India 6.0-11.0Asia (other) 0.4-21.0Africa 0.3-15.0South America 1.0-17.0
  4. 4. RF is the most commoncause of heart disease in 5-30 yr age group
  5. 5. WORLD RHD BURDENRHD REMAINS A MAJOR HEALTHCONCERN AROUND THE GLOBE15.6 million people have RHD in theworld .2,82,000 cases are added each year.2,33,000 deaths occur each year.
  6. 6. I I DI ,RHEUMATIC FEVER IS ENDEMIC NN AAND REMAINS ONE OF THE MAJOR CAUSESOF CV DISEASE ACCOUNTING FOR 25%-45 %OF ACQUIRED HEART DISEASE. INDIA IS INA PHASE OF EPIDEMIOLOGICALTRANSITION ,ON ONE HAND THERE ISBURDEN OF RHD AND ON OTHER HANDGOVERNMENT RESOURCES ARE SCARSE .
  7. 7. RHD in India Prevalence: 5/1000 population of 5-15 age group 1 million RHD cases in India Hospital admissions due to RHD is 20-30% of CVD
  8. 8.  Acute rheumatic fever (ARF) is a systemic disease of childhood It is a delayed non-suppurative sequelae to URTI with group A BETA-hemolytic streptococci It is a diffuse inflammatory disease of connective tissue,primarily involving heart,blood vessels,joints, subcut.tissue and CNS
  9. 9. Epidemiological Factors
  10. 10. Agent
  11. 11. Host Factors Age: 5-15 yrs(most susceptible) Sex: both Environmental factors over crowding, poor sanitation, poverty Incidence more during winter & early spring
  12. 12. Prevalance of rheumatic fever in different age groups
  13. 13. IMMUNE SYSTEM RESPONSE
  14. 14. 1.Arthritis Flitting & fleeting migratory polyarthritis, involving major joints Commonly involved joints-knee,ankle,elbow & wrist Occur in 80%,involved joints are exquisitely tender In children below 5 yrs:It is mild but carditis is more prominent Arthritis does not progress to chronic disease
  15. 15. 2.Carditis Manifest as pancarditis(endocarditis, myocarditis and pericarditis),occur in 50% of cases Carditis is the only manifestation of rheumatic fever that leaves a sequelae & permanent damage to the organ Valvulitis occur in acute phase Chronic phase- fibrosis,calcification & stenosis of heart valves(fishmouth valves)
  16. 16. PREVALENCE OF RHD/RF AND PATTERN OF VALVEINVOLVEMENT IN THE COMMUNITY POPULATION SCREENED 1882 MALE 909 FEMALE 973 RF/RHD 11 (5.8/1000) FEMALE 01(1.1/1000) MEAN AGE OF RF/RHD PATIENTS 30.36 YRS LESIONS TOTAL 11 NO CARDITIS 01 ISOLATED MS 02 ISOLATED MR 01 MS WITH MR 03 MS WITH AR 01 MR WITH AS 01 ISLOATED AR 01 POST MVR 01 POST PTMC 01 KNOWN RHD 07
  17. 17. MITRAL VALVE STENOSIS AS SEEN IN RHEUMATIC HEART DISEASE
  18. 18. Rheumaticheartdisease.Abnormalmitralvalve.Thick,fusedchordae
  19. 19. 3.Sydenham Chorea Occur in 5-10% of cases Mainly in girls of 1-15 yrs age Clinically manifest as-clumsiness, deterioration of handwriting, emotional lability or grimacing of face Clinical signs- pronator sign, jack in the box sign , milking sign of hands
  20. 20. 4.Erythema Marginatum Occur in <5%. Unique,transient,serpiginous lesions of 1-2 inches in size Pale center with red irregular margin More on trunks & limbs & non-itchy Worsens with application of heat Often associated with chronic carditis
  21. 21. 5.Subcutaneous nodules Occur in 10% Painless,pea-sized,palpable nodules Mainly over extensor surfaces of joints,spine,scapulae & scalp Associated with strong seropositivity Always associated with severe carditis
  22. 22. Other features (Minor features) Fever(mild) Polyarthralgia Pallor Anorexia Loss of weight
  23. 23. Onset and progression of different
  24. 24. LABORATORY DIAGNOSISHigh ESRAnemia, leucocytosisElevated C-reactive protienASO titre >200 Todd units.(Peak value attained at 3 weeks,thencomes down to normal by 6 weeks) Anti-DNAse B test Throat culture-GABH streptococci
  25. 25. # RHEUMATIC FEVER IS MAINLY ACLINICAL DIAGNOSIS #.NO SINGLE DIAGNOSTIC SIGN OR SpECIFIC LAbORATORY TEST AVAILAbLEFOR DIAGNOSIS #.DIAGNOSIS bASED ON MODIFIEDJONES CRITERIA
  26. 26. Jones Criteria (Revised) for Guidance in the Diagnosis of Rheumatic Fever*Major Manifestation Minor Supporting Evidence Manifestations of Streptococal Infection Carditis Clinical Laboratory Polyarthritis Previous Acute phase Chorea rheumatic reactants: Increased Titer of Anti-Erythema Marginatum fever or Erythrocyte Streptococcal Antibodies ASOSubcutaneous Nodules rheumatic sedimentation (anti-streptolysin O), heart disease rate, others Arthralgia C-reactive Positive Throat Culture Fever protein, for Group A Streptococcus leukocytosis Recent Scarlet Fever Prolonged P- R interval*The presence of two major criteria, or of one major and two minor criteria, indicatesa high probability of acute rheumatic fever, if supported by evidence of Group Astreptococcal nfection.
  27. 27.  If the patient has Chorea alone then it is difficult to diagnose rheumatic fever Insidious or late-onset carditis with no other explanation
  28. 28. PITFALLS IN JONES CRITERIA1. DIFFICULT TO DIAGNOSE ARF WHEN CARDITIS IS ONLY MANIFESTATION SPECIALLY IN RECCURENCE2. SUBCLINICAL CARDITIS IS DIFFICULT TO DETECT CLINICALLY3. CLINICAL CARDITIS IS PRESENT BUT SUPPORTIVE MINOR CRITERIA ARE NOT FULFILLED4. WHEN PREVIOUS CARDIAC STATUS IS UNKNOWN IT IS DIFFICULT TO SAY WHETHER THE FINDINGS ARE USUALLY ACUTE CARDITIS OR RECURRENCE OR IT IS OLD RHD.5. IN CASES OF POLYARTHRALGIA IF NOT EVALUATED FOR ARF THEY WOULD GO UNDIAGNOSED
  29. 29. Developing role ofECHOCARDIOGRAPHY INDIAGNOSIS AND MANAGEMENT OFRHEUMATIC FEVER
  30. 30. GOALS OF ECHO INTERROGATION1. IT CAN HELP IN PRECISE AND EARLY DIAGNOSIS OF ARF .2. IT CAN PREVENT OVER DIAGNOSIS OF CARDITISDEPENDING ON THE TRADITIONAL CLINICAL AUSCULTATORYFINDINGS3. REGULAR CHECK UP WITH NON INVASIVE ECHO CAN HELPTO EVALUATE THE STATUS OF RHD AND DECIDE FORELECTIVE BALOON VALVULOPLASTY FOR MITRAL STENOSISAND TIMELY DECISION FOR VALVE REPAIR /REPLACEMENT.THIS CAN REDUCE THE MORBIDITY AND MORTALITY ,BEFORETHE PATIENT DEVELOPS CHF .
  31. 31. ECHOCARDIOGRAPHIC INVESTIGATIONSM-MODE INTERROGATION.DIMENSIONS OF LEFT ATRIUM ,AORTA AND THEIR RATIO.LEFT VENTRICULAR DIMENSION IN DIASTOLE AND SYSTOLE.CROSS-SECTIONAL INTERROGATION IN LONG AXIS ,FOUR CHAMBER ,FIVECHAMBER AND SHORT AXIS.THICKNESS OF VALVES WITH <3 MM TAKEN AS NORMAL AND >4 MM AS THICKENED.BEADED APPEARANCE ,ESPECIALLY MITRAL ,TRICUSPID AND AORTIC VALVESPROLAPSE OF MITRAL VALVE ,PARTICULARLY AORTIC LEAFLET.DECREASED OR INCREASED MOBILITY OF VALVES.HYPERECHOGENICITY OF THE THICKENED SUBMITRAL APPARATUS.CHORDAL TEARS TO MITRAL LEAFLETS.PERICARDIAL EFFUSIONEND DIASTOLIC VOLUME END SYSTOLIC VOLUME AND EJECTION FRACTIONCOLOUR DOPPLER INTERROGATION.ESTABLISHMENT OF MITRAL ,AORTIC AND TRICUSPID REGURGITATION.DIFFERENTIATION OF PHYSIO AND PATHO REGURGITATION
  32. 32. INCIDENCE OF ECHO FEATURES IN RFMITRAL THICKNESS >4MM 93.62%MR GRADE 1-2 83.69%MVP 56.74%RH NODULES 26.95%AR 21.99%TR 21.99%PANCARDITIS 9.22%PERI.EFFUSION 9.22%CHORDAL TEAR 2.84%
  33. 33. VIJAYA’S ECHO CRITERIA SCORE OF >=6 IS DIAGNOSTIC FOR RHEUMATIC CARDITIS ECHO - FEATURE SCOREMV AND AV THICKNESS >=4MM 2INCREASE ECHO GEN OF SUB MITRAL STR. 2RHEUMATIC NODULES BEADED APPEARANCE 2MVP /AVP /TVP 2MR/PR/AR 2REDUCED MOBILITY OF VALVES 2CHORDAL TEAR 2PERICARDIAL EFFUSION 2TOTAL SCORE 16
  34. 34. ROLE OF ECHO IN MANAGEMENT OF ARF INFUTURETHE ECHOCARDIOGRAM IS SIMPLE ,NON-INVASIVE,REPRODUCABLE TOOL FOREARLY AND PRECISE DIAGNOSIS OF CARDITIS IN ARF .THERE IS A PROPOSAL OF INCLUDING VIJAYA’S ECHO CRITERIA OF CARDITISAS MAJOR CRITERIA INSTEAD OF ERYTHEMA MARGIRATUM WHICH ISIRRELEVANT ,WHENEVER THERE IS A REVISION OF JONE’S CRITERIA
  35. 35. A, Parasternal long-axis view showing thickening of the mitral valve leaflets. AML,anterior mitral leaflet; LA, left atrium; LV, left ventricle; RV, right ventricle; PML, posteriormitral leaflet. B, Parasternal short-axis view showing the left ventricle and mitral valve incross-section. Note fine focal nodularity along the edges of the mitral valve (arrows)suggesting verrucae. C, Electrocardiogram (lead II) with prolonged PR interval (160 ms).
  36. 36.  Juvenile rheumatiod arthritis Septic arthritis Sickle-cell arthropathy Kawasaki disease Myocarditis Scarlet fever Leukemia
  37. 37. Prevention and control Primary prevention• To prevent the first attack of RF,by detection and treatment of streptococcal throat inf.• Many inf are inapparent or undiagnosed• High risk approach: Surveillance for streptococcal pharyngitis among school children
  38. 38. Primary prevention contd…Sore throat should be swabbed and culturedIf strepto.— Give Penicillin(If culture is not possible a sore throat can be treatedwith Benzathine Benzyl Penicillin)Dose: One IM inj.,1.2 miilion units(adults),0.6 millionunits(children)Or Oral Penicillin G/Penicillin V for 10 daysErythromycin (In case of allergy to Penicillin)
  39. 39. Secondary Prevention
  40. 40. Other measures in Secondary Prevention Surveys to know the prevalence of RHD among school children Every 5 years in 6-14 years age group
  41. 41.  Rheumatic fever can recur whenever the individual experience new GABH streptococcal infection,If not on prophylactic medicines Good prognosis for older age group & if no carditis during the initial attack Bad prognosis for younger children & those with carditis with valvar lesions
  42. 42. REMEMBER TOGETHER WECAN FIGHT RHEUMATIC FEVERAND RHD….WE CAN HEAL THEFUTURE OF OUR NATION AND THE WORLD FOR SURE BYSPREADING AWARENESS AND TIMELY ACTION IN TREATING THE PATIENTS . ITS TIME TO ACT….
  43. 43. 上級醫師防止疾病醫生治療病前 明顯對下醫生治療完全成熟的病黃 DEE , HAI-CHING 在公元前 2000 年(第一屆中國醫療文本

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