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Acute rheumatic fever and VHD 3.pptx
- 1. D R B E R E K E T . A ( M D ) Acute rheumatic fever and VHD DrBereket.A(MD)
- 2. Acute rheumatic fever etiology Group A B-hemolytic streptococcus Rheumategenic strain : M serotype 1,3,5,6,18,24 M protein is virulence factor to resist phagositosis Group A streptococcus with M protein has molecular mimicry with human tissue DrBereket.A(MD)
- 3. epidemiology Age group 5-15 yrs highest prevalence Very rare< 5yrs Only occur following post group A βhemolytic streptococcal pharygitis High prevalence developing countries Over crowding important environmental factors DrBereket.A(MD)
- 4. pharyngitis 80 % pharyngitis is viral 20% pharyngitis due to GABHS 0.3-3% untreated GABHS pharyngitis develop ARF DrBereket.A(MD)
- 5. Pathogenesis Hypothesis autoimmune disease autoantibody cross-react to human antigen due to molecular mimicry latent period 1-3 wks in support of immunologic phenomena DrBereket.A(MD)
- 6. Jones Criteria for Dx ARF Major criteria Carditis Migratory polyarthritis Sydenham chorea Erythema marginatem Subcutaneus nodules Minor criteria fever Arthralgia Elevated (ESR,CRP) DrBereket.A(MD)
- 7. Supporting evidence of a preceding streptococcal infections ECG Prolonged PR interval Elevated ASO titer Positive throat culture Rapid antigen test for group A streptococcal Recent scarlet fever DrBereket.A(MD)
- 8. Acute rheumatic fever 2 major plus evidence of preceding GABH 1major + 2 minor plus evidence of preceding GABH DrBereket.A(MD)
- 9. carditis Pancarditis Vavulitis (endocarditis) Pericarditis Myocarditis DrBereket.A(MD)
- 10. carditis Carditis is the only residual complication of ARF 40-60% Mostly affect mitral valve :MR Aortic valve secondly affected :AR Tricuspid and pulmonic valve rare Concomitant mitral and aortic common Initially the commonest manifestation is valvular insufficiency Later stenosis often combination of insufficiency and stenosis DrBereket.A(MD)
- 11. Murmurs of acute rheumatic fever Regurgitation murmurs :MR common AR Carey Coombs :mid-diastolic apical murmur associated with flow disturbances caused by mitral valve deformity secondary to valvulitis DrBereket.A(MD)
- 12. Arthritis Polyarthritis is the most frequent manifestation of RF, occurring in up to 75% It is typically very painful, migratory, and limited to the major joints of the arms and legs It is the earliest manifestation after streptococcal pharyngitis may be the only clinically apparent manifestation in one third to half of patients Inflammation in individual joints lasts 1 to 2 weeks and the polyarthritis as a whole resolves in 1 month DrBereket.A(MD)
- 13. Chorea 5-35% Emotional lability,uncoordinated movement,clumsyness,facial grimace Illigible hand writing Hand spooning,pronater sign,milkmaid manifests as involuntary, irregular movements, fibrillatory muscle movements of the tongue characteristic spooning with external rotation of the hands abolition of the movements with sleep. delayed manifestation of ARF a latency period of 1 to 7 months DrBereket.A(MD)
- 14. Subcutaneous nodules 10% typically occur in patients with moderate to severe rheumatic carditis They occur several weeks after the onset of cardiac findings consist of firm nodules found over major joints and bony prominences are asymptomatic, sometimes evanescent, typically resolving within weeks to 1 or 2 months DrBereket.A(MD)
- 15. erythema marginatum <10% typically occurs in conjunction with carditis with a milder course may last for months or years It tends to occur over the trunk or proximal extremities early in the course of RF DrBereket.A(MD)
- 16. Treatment of ARF 3 approach Treatment of GABH Use of anti-inflammatory supportive DrBereket.A(MD)
- 17. Drugs Penicillin Erythromycin for 10 days DrBereket.A(MD)
- 18. con Salicilate for athritis and carditis Glucocorticoid if sever carditis in congestive hear failure 3-4wks If CHF : diuretics,digoxine,bed rest DrBereket.A(MD)
- 19. Sydenham chorea Penicillin plus Phenobarbital Chlorpromazine Diazepam Carbamazepam haloperidol DrBereket.A(MD)
- 20. prevention Primary prevention Secondary prevention DrBereket.A(MD)
- 21. Primary prevention Treatment of GABS pharigitis to prevent an initial ARF DrBereket.A(MD)
- 22. DrBereket.A(MD)
- 23. Secondary prevention To prevent recurrence Recurrent attacks of rheumatic fever are common, especially during the first 5 to 10 years after the primary illness Monthly B –penicillin penicillin V Erythromycin Duration: life long for RVHD for 5 yrs for ARF up to a age 18 yrs DrBereket.A(MD)
- 24. Valvular Heart disease Etiologies for valvular heart disease Rheumatic heart disease Congenital heart disease Degenerative heart disease Infective endocarditis Trauma Connective tissue diseases Radiation Annular calcification DrBereket.A(MD)
- 25. RVHD The most acquired heart disease in children and young adult in developing countries. Leaflet thicking,calcification,commusural fusion Thicking,fusion of cordae tendinea Doming anterior mitral valve prolapse Pure mital valve involvement Mixed mitral, aortic valve DrBereket.A(MD)
- 27. Mitral stenosis Rheumatic fever is by far the most common cause of MS. Rarely congenital abnormalities connective tissue disorders left atrial tumors More common in woman DrBereket.A(MD)
- 29. Complication of MS Hemoptysis Pulmonary edema Atrial fibrillation Systemic embolization Infective endocarditis DrBereket.A(MD)
- 30. Severity of MS Normal mitral valve area :4-6cm2 Mild MS : 2-4 cm2 Moderate MS : 1-2 cm2 Severe MS :<1 cm2 DrBereket.A(MD)
- 31. Surgical indication for severe MS Moderate or severe MS Valve area <1.5 cm2 DrBereket.A(MD)
- 32. Mitral Regurgitation Chronic Mitral valve prolapse Left ventricular dilation Posterior wall myocardial infarction Rheumatic fever Endocarditis Acute Posterior wall or papillary muscle ischemia Papillary muscle or chordal rupture Endocarditis Prosthetic valve dysfunction DrBereket.A(MD)
- 33. Aortic Stenosis Rheumatic Congenital Degenerative More common in male DrBereket.A(MD)
- 34. The cardinal symptoms angina, syncope, and congestive heart failure DrBereket.A(MD)
- 35. the mean survival rate 2 years in patients with heart failure 3 years in patients with Syncope 5 years in patients with angina DrBereket.A(MD)
- 36. Severity AS Valve area(cm2) Peak velocity(m/s) Peak gradient(m mHg) Mean gradient(m mHg) normal 2.5-3.5 1 <10 <10 mild 1.5-2.5 1-2 <20 <20 moderate 1-1.5 2-4 20-64 20-40 severe <1 > >64 >40 DrBereket.A(MD)
- 37. Class I indications for Surgical interventions for AS Severe AS with LVEF<50% Symptomatic severe AS syncope,angina,HF DrBereket.A(MD)
- 38. Aortic Regurgitation Rheumatic fever Aortic root dilation Bicuspid aortic valve Aortic dissection Endocarditis DrBereket.A(MD)
- 39. Sign OF AR wide pulse pressure Collapsing pulse (Corrigan disease or water-hammer pulse) capillary pulsations(Quincke's pulse) pistol-shot" (Traube's sign) to-and-fro murmur (Duroziez's sign) DrBereket.A(MD)
- 40. Murmur of AR early diastolic murmur heard best in the third intercostal space along the left sternal border aneurysmal dilation of the aortic root : best along the right sternal border Austin Flint murmur: a soft, low-pitched rumbling diastolic murmur mid-systolic ejection murmur at base DrBereket.A(MD)
- 41. Severity of AR left ventricular end-systolic diameters greater than 50 mm an ejection fraction of less than 50%. DrBereket.A(MD)
- 42. Surgical interventions for AR Symptomatic severe AR Asymptomatic severe AR with LVEF<50% LV dimension ESD >55mm EDD >75mm DrBereket.A(MD)
- 43. Tricuspid stenosis most often rheumatic usually associated with mitral or aortic disease Rare causes carcinoid syndrome congenital valve abnormalities leaflet tumors vegetations DrBereket.A(MD)
- 44. Tricuspid Regurgitation most often secondary to dilation of the right ventricle and tricuspid annulus endocarditis carcinoid syndrome congenital abnormalities chest wall trauma DrBereket.A(MD)
- 45. Pulmonic stenosis is most often congenital Rheumatic deformity is rare DrBereket.A(MD)
- 46. Pulmonic regurgitation the result of dilation of the annulus secondary to pulmonary hypertension the murmur of pulmonic regurgitation early diastolic best heard at the second left intercostal space (Graham Steell murmur) DrBereket.A(MD)