echo evaluation of acute carditis

3.  Group A streptococci are the most commonbacterial
cause of pharyngitis, with a peak Incidence in
children 5–15 years of age.
 15–20% of sore throats are caused by group A
streptococci.
 A patient with a true infection is at risk of developing
RF and of spreading the organism to close contacts,
while this is not thought to be the case with carriers.
 Positive throat culture rate for Gr A streptococci are
around 13.5% in Northern India in sore throat cases.

4.  1.Agent: virulence
 2. Host: Genetic susceptibility[3-5%]
 3. Environment: Challenged socioeconomic
HOTSPOT
 Kyrgyzstan
 Highest incidence of RF/RHD
 543/100,000 population per year

11.  Jones Criteria, as revised in 2015 by the
American Heart Association (AHA)
 Intended for diagnosis of the initial attack of
acute rheumatic fever and recurrent attacks.
 There are 5 major and 4 minor criteria and a
requirement of evidence of recent GAS infection.

 The 2015 revision includes separate criteria for
Low-Risk populations (defined as those with
incidence ≤2 per 100,000 school-age children
per year orall-age rheumatic heart disease
prevalence of ≤1 per thousand population)
 Moderate/High-Risk populations (defined as
those with higher incidence or prevalence rates)

13.  Diagnosis of recurrent acute rheumatic fever can
also be made only in the Moderate/High Risk
population by presence of 3 minor criteria with
evidence of preceding GAS infection.
 A major change from previous versions expands
the definition of the major criterion–carditis–to
include subclinical evidence (i.e., in the absence
of a murmur, echocardiographic evidence of
mitral regurgitation [MR]

14.  Even with strict application of the Jones criteria,
overdiagnosis as well as underdiagnosis.
 3 situations where diagnosis without strict
adherence to the Jones criteria:
 (1) when chorea occurs as the only major
manifestation of acute rheumatic fever
 (2)when indolent carditis is the only manifestation in
patients who firstcome to medical attention only
months after the apparent onset of acute rheumatic
fever.
 (3) in a limited number of patients with recurrences
of acute rheumatic fever in particularly high-risk
populations

15.  Most serious
 CRHD
 Pancarditis
 The incidence of carditis during the initial attack of RF
 50%-No echo
 91%-with echo
 Varies with the age
 ◦ 90% to 92% of children <3 years
 ◦ 50% of children 3 to 6 years of age
 ◦ 32% of teenagers aged 14 to 17 years
 ◦ 15% of adults
 Myocarditis in the absence of valvulitis is unlikely to be
rheumatic in origin

16.  In India, rheumatic fever is endemic and
remains one of the major causes of
cardiovascular disease,
 Accounting for nearly 25-45% of the acquired
heart disease.
 PRIMARY ATTACK RATE OF RF FOLLOWING
STREPTOCOCCAL PHARYNGITIS
 EPIDEMICS: 3%
 SPORADIC:0.3%

25. 2012 World Heart Federation (WHF) guidelines

26.  CHF - 5% to 10% during initial attack
 increases with repeated carditis
 Pansystolic murmur at apex
 Transient apical mid-diastolic murmur
 (Carey-Coombs) may occur in association
with the murmur of mitral regurgitation

30. THE ECHOCARDIOGRAPHIC
CRITERIA HAD SENSITIVITY OF
81% AND SPECIFICITY OF 93%
THE EFFICACY OF ECHOCARDIOGRAPHIC CRITERIONS FOR THE
DIAGNOSIS OF CARDITIS IN ACUTE RHEUMATIC FEVER .B
VIJAYALAKSHMIA1 C1, RAJAN O.VISHNUPRABHUA1, NARASIMHAN
CHITRAA1

32.  Echocardiographic demonstration of valvular
regurgitation is not a prerequisite for the
diagnosis of rheumatic carditis and should
not be considered a limitation where the
facilities are not available.
 INITIALLY, data do not allow subclinical
valvular regurgitation detected by
echocardiography to be included in the Jones
criteria, as evidence of a major manifestation
of carditis.

34.  Mitral regurgitation can be alone or with other
lesions
 As high as 70% of MR in initial attack can
disappear over a period of time.
 Severity of MR directly proportional to
subsequent RHD
 Severity of LV dysfunction related to extent of
valvulitis
 Acute mitral valvulitis shows mitral annulus
dilatation,
chordal elongation, and anterior leaflet prolapse,
with varying degrees of MR and rarely chordal
rupture.

37. AORTIC REGURGITATION
 Isolated aortic disease occurs
in 2% of cases
 Asymptomatic patients with normal LV
systolic function
 Progression to symptoms &/or LV dysfn: 6%
 Progression to asymptomatic LV dysfunction
< than 3.5% per year
 Asymptomatic patients with LV dysfunction
 Progression to symptoms: more than 25% per
year
 If AS is present with MV, involvement it is
likely to be rheumatic

49. THANK YOU
HAVE A
NICE DAY