Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
Percutaneous Balloon Mitral Valvuloplasty (PBMV) is a procedure to dilated the mitral valve in the setting of rheumatic mitral valve stenosis. A catheter is inserted into the femoral vein, advanced to the right atrium and across the interatrial septum. Then the mitral valve is crossed with a balloon and it is inflated to relieve the fusion of the mitral valve commissures effectively acting to increase the mitral valve area and reduce the degree of mitral stenosis. Mitral regurgitation is a potential complication and thus PBMV is contraindicated if moderate or severe regurgitation is present. The Wilkins score examines mitral valve morphology and is determined via echocardiography to assess the likelihood of using PBMV based on certain echocardiographic criteria.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
There are many interventional cardiac procedure those need a trans septal puncture of the interatrial septum. This presentation clearly elaborates everything you need to know about the TSP.
Evaluation of prosthetic valve function and clinical utility.Ramachandra Barik
Many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis selection in the individual patient and careful medical management and follow-up after implantation.
Acute rheumatic fever (ARF), an auto-immune response to group A streptococcus (GAS)
infection of the upper respiratory tract, may result in carditis or inflammation of the mitral
and/or aortic valves. When the inflammation leads to permanent damage of the valves the
individual has rheumatic heart disease (RHD). Recurrences of rheumatic fever are likely in the
absence of preventative measures and may cause further cardiac valve and muscle damage,
leading to heart failure, strokes and premature death . Bacterial endocarditis is also a
complication.
Acute rheumatic fever usually affects children (most commonly between 5 and
15 years) or young adults, and has become very rare in Western Europe and North America
However, it remains endemic in parts of Asia, Africa and South America, with an annual
incidence in some countries of > 100 per 100 000, and is the most common cause of acquired
heart disease in childhood and adolescence.
The burden of ARF in industrialised countries
declined dramatically during the 20th century, due mainly to reduced transmission of GAS
related to improved living conditions and increased hygiene standards along with better access
to appropriate health services and increased access to penicillin-based medications. In most
affluent populations, including much of Australia, ARF is now rare, and RHD occurs
predominantly in the elderly.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
3. The theory of molecular mimicryThe theory of molecular mimicry
GAS pharyngitis triggers an autoimmune
response to epitopes in the organism that
cross-react with similar epitopes in the
heart, brain, joints, and skin, and repeated
episodes of rheumatic fever lead to RHD
Cunningham MW: Streptococcus and rheumatic fever. Curr Opin
Rheumatol 24:408, 2012.
4. French physician Ernst-Charles Lasègue - 1884French physician Ernst-Charles Lasègue - 1884
“Pathologists have long known that rheumatic fever
licks at the joints, but bites at the heart.”
7. (Modified from Parry E, Godfrey R, Mabey D, Gill G [eds]: Principles(Modified from Parry E, Godfrey R, Mabey D, Gill G [eds]: Principles
of Medicine in Africa. 3rd ed. Cambridge, Cambridge University Press,of Medicine in Africa. 3rd ed. Cambridge, Cambridge University Press,
2004, p 861.)2004, p 861.)
4 patterns RF in 150 years.
◦
A- Preantibiotic fall in the incidence of
ARF of industrialized countries
◦ B-Persistent high incidence RF
[Africa and south Asia].
◦ C-Postantibiotic fall in the incidence of
rheumatic fever in countries that
instituted comprehensive programs for
primary and secondary prevention of
rheumatic fever, such as Cuba, Costa
Rica, Martinique, and Guadeloupe.
◦ D-Fall and rise in the incidence of
rheumatic fever in the formerly Soviet
Republics of Central Asia.
10. 2 Hit hypothesis2 Hit hypothesis
Hit -1:cross reaction Hit-2:T lymphocyte invasion
Epitopes on the cell wall of
Streptococcus forms cross
reacting antibodies to host
antigens
The antigen and antibody
complex at the target site
invites T lymphocytes to
come out of vessel and
stimulates local epitheloid
cell to become Anitkoff’s
cell around the central
Fibrinoid degeneration
forming together called
“Aschoff- Geipel bodies”
11. Targets of molecular mimicryTargets of molecular mimicry
Intracellular Extracellular
Cardiac myosin
Brain tubulin
Laminin on the endothelial
surface of the valve
Lysoganglioside and
dopamine receptors in the
brain
12. Susceptibility of hostSusceptibility of host
3-6% without primary Rx
X5 time if family Hx positive
Poor fellow
No hygiene
Lives in tight pack
X6 time in monozygotic
X3 times in children if one
parent +
The heritability of rheumatic
fever is 60%
Family history is must in Rheumatic heart disease
13. PhotomicrographPhotomicrograph
Aschoff nodule of acute
rheumatic fever. The nodule is
composed of Anitschkow cells;
these have clear nuclei with a
central bar of chromatin, said to
resemble a caterpillar. There is a
central area of fibrin. This central
necrosis is further surrounded by
a mononuclear cell infiltrate.
Myocardial fibres adjacent to the
Aschoff body are undergoing
Fibrinoid necrosis. (Sebire NJ,
Ashworth M, Malone M, Jacques TS
[eds]: Diagnostic Pediatric Surgical
Pathology. Churchill Livingstone,
United Kingdom, 2010.)
14. Potential barrier to Rx RF/RHDPotential barrier to Rx RF/RHD
Streptococcal
pharyngitis- 2 to 3
Wk-no lab test +
except throat culture
Rheumatic fever
◦ 30% -asymptomatic
GAS pharyngitis
◦ 50% -asymptomatic
GAS pharyngitis in
epidemic time
◦ Age :4-15 yrs
◦ Juvenile(3-5 yrs) -India
Think of vaccine
15. ArthritisArthritis
Almost 100%
Severe in young adults than in teenagers
(82%) and children (66%)
Migratory
A few days to a week
2/3rd
-polyarthritis
resolves completely
If joint swelling persists after 4 weeks, it
is necessary to consider other conditions
16. Poststreptococcal reactive arthritisPoststreptococcal reactive arthritis
Not typical of rheumatic fever
Recent streptococcal infection
shorter latent period
responds less well to NSAID
renal manifestations
No carditis
Rx 2ndary prophylaxis with pencillin
17. CarditisCarditis
most serious
CRHD
Accidental detection with chorea
The incidence of carditis during the initial attack of RF
◦ 40%-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
18. ContdContd
CHF - 5% to 10% during initial attack
and increases with repeated carditis
Transient apical mid-diastolic murmur
(Carey-Coombs) may occur in
association with the murmur of mitral
regurgitation
19. WHF:Minimum Echocardiographic Criteria for theWHF:Minimum Echocardiographic Criteria for the
Diagnosis of Pathologic Valvular RegurgitationDiagnosis of Pathologic Valvular Regurgitation
Secondary to Rheumatic CarditisSecondary to Rheumatic Carditis
PATHOLOGIC MITRAL
REGURGITATION (ALL FOUR
DOPPLER CRITERIA MUST BE MET)
PATHOLOGIC AORTIC
REGURGITATION (ALL FOUR
DOPPLER CRITERIA MUST BE MET)
1. Seen on 2 views
1. Seen on 2 views
2. On at least 1 view jet length is ≥2 cm*
2. On at least 1 view jet length is ≥1 cm*
3. Peak velocity ≥3 meters/sec
3. Peak velocity ≥3 meters/sec
4. Pansystolic jet in at least 1 envelope
4. Pandiastolic jet in at least 1 envelope
20. Sydenham ChoreaSydenham Chorea
may be the only initial manifestation
F>M
after puberty-more
6 to 8 weeks from pharyngitis
Chorea-involuntary, purposeless, jerky
movements of the hands, arms,
shoulders, feet, legs, face, and trunk along
with hypotonia and weakness,interfere
voluntary activity and disappear during
sleep
21. Hemichorea- completely unilateral
jack-in-the-box tongue
“the milking sign”
Emotional lability
last for a week to 2 years but generally
persists for 8 to 15 weeks
Serological markers may be normal
because of long latency
22. PANDASPANDAS
subgroup of children with tic or
obsessive-compulsive disorders that are
triggered by GAS infection with no
associated cardiac valve damage
if ever, make a diagnosis of PANDAS
and should rather err on the side of
diagnosis of rheumatic fever and
implement secondary prophylaxis
23. Subcutaneous NodulesSubcutaneous Nodules
Detected over the occiput, elbows,
knees, ankles, and Achilles tendons
Over olecranon
Firm, painless, and freely movable over
the subcutaneous tissue. The nodules
vary in size from 0.5 to 2 cm
1.5%
In crops-carditis
24. Erythema MarginatumErythema Marginatum
less common
upper part of the arms or trunk but not
on the face
not pathognomonic
The rash
Evanescent, pink, and nonpruritic. It extends centrifugally
whereas the skin at the center returns to normal—hence the
name “erythema marginatum.” It has an irregular serpiginous
border. The rash may also become more prominent after a
hot shower. Erythema marginatum generally occurs only in
patients with carditis and may develop early or later in the
course of the disease.
27. 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. ROUTRAY SN2003
PRIMARY ATTACK RATE OF RF
FOLLOWING STREPTOCOCCAL
PHARYNGITIS
◦ EPIDEMICS: 3%
◦ SPORADIC:0.3%
28.
29. RF is a delayed autoimmune response to Group A streptococcal pharyngitis, and
the clinical manifestation of the response and its severity in an individual is
determined by host genetic susceptibility, the virulence of the infecting organism,
and a conducive environment
30. AGENTAGENT
Beta-haemolytic streptococci
can be divided into a
number of serological groups
on the basis of their cell-wall
polysaccharide antigen
Serological group A
(streptococcus pyogenes) can
be further subdivided into
more than 130 distinct M
types.
The available evidence does
not link streptococci in Non-
group A types with the
pathogenesis of rf and rhd
31. Group A streptococci are the most common
bacterial 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.
32.
33. RHEUMATOGENIC STRAINSRHEUMATOGENIC STRAINS
Very rich in M-
protein
Heavily
encapsulated
produce striking
"mucoid" colonies on
blood agar plates
Tropic primarily for
the throat
M 1, 3, 5, 6, 18, 19
and 24
The site of infection
must be pharyngeal
GAS virulence
◦ (Extractable and
heterotypic antigen,
the M protein)
◦ Capsule of hyaluronic
acid("mucoid"
appearance of GAS
colonies)
◦ M protein and
capsule, are primarily
responsible for the
striking resistance of
virulent strains of
GAS to phagocytosis
35. M proteinM protein
The streptococcal M-
protein extends from
the surface of the
streptococcal cell as
an alpha–helical coiled
dimer,
Shares structural
homology with cardiac
myosin and other
alpha-helical coiled
molecules, such as
Tropomyosin, keratin
and laminin(lines
valve structure and is
a target for poly
reactive antibody)
36. Nonsuppurative sequel, such as RF and RHD,
are seen only after group A streptococcal
infection of the upper respiratory tract.
Bramhanathan et al 2006
Exception: skin infection leading to RF
described in some aborginal tribes of australia
Chronic streptococcal “carrier” states do not
trigger the development of RF.
The role of group A streptococcus infection is
complex and repeated infection is necessary
to prime the immune response, quantitatively
and qualitatively ,before the first episode of
ARF occurs
37. HOST FACTORS
An inherited susceptibility to ARF and RHD is
supported by twin studies that have found a
significantly increased concordance in
monozygotic twins compared with dizygotic
twins.
2 % OF ARF INFECTIONS HAVE BEEN
FOUND TO BE FAMILIAL
Padmavathi 1962
GAS pharyngitis is primarily a disease of
children 5 to 15 years of age
38. HOST FACTORSHOST FACTORS
ARF is a rare disease in the very young;
Only 5% of first episodes arise in children
younger than age 5 years and the disease is
almost unheard of in those younger than 2
years.
39. HOST FACTORSHOST FACTORS
First episodes of ARF
are most common just
before adolescence,
wane by the end of the
second decade, and
are rare in adults
older than age 35
years.
Recurrent episodes
are especially frequent
in adolescence and
early adulthood, and
occasional cases are
seen in people older
than age 45 years
40. HOST FACTORSHOST FACTORS
In many populations, ARF and RHD are more
common in females than males
◦ ?Innate susceptibility,
◦ ? Increased exposure to group a
streptococcus because of greater
involvement of women in child rearing,
◦ ?Or reduced access to preventive medical
care for girls and women.
In populations exposed to rheumatogenic
group A streptococci, the lifetime cumulative
incidence of ARF is 3% to 6%.
49. Myosin is not present in cardiac valves, so how can an immune response against
myosin induce valvulitis?
The initial damage to the valve might be due to the presence of laminin, another
alpha-helical coiled-coil molecule present in the valvular basement membrane
and around endothelium, and which is recognised by T cells
There is also evidence that antibodies to cardiac valve tissues cross-react with N-
acetyl glucosamine in group A carbohydrate.
An exaggerated antibody response to group A carbohydrate was noted in
patients with ARF, and titres remained raised in individuals with residual mitral
valve disease, providing further support for the notion that these antibodies
cause valve damage
THE IMMUNE RESPONSE
50. Immune complexes may produce
nondestructive synovitis of the joints in
patients with ARF and nondestructive
reactions in the basal ganglia observed in
Sydenham's chorea, whereas cell mediated
autoimmune cytotoxic reactions may destroy
heart valves.
51. Are spheroidal or fusiform
distinct tiny structures or
granulomas, 1-2 mm in
size, occurring in the
interstitium of the heart in
RF.
Especially found in the
vicinity of small blood
vessels in the myocardium
and endocardium and
occasionally in the
pericardium.
Lesions similar to the
aschoff nodules may be
found in the extracardiac
tissues .
52.
53. CLINICAL FEATURES AND DIAGNOSIS OF
STREPTOCOCCAL SORE THROAT
CLINICAL ASPECTS
AROUND 20% OF
SORETHROAT
CASES
56. 2002–2003 WHO criteria for the diagnosis of
rheumatic fever and rheumatic heart disease
(based on the revised Jones criteria)
These revised WHO criteria facilitate the
diagnosis of:
— A primary episode of RF
— Recurrent attacks of RF in patients without
RHD
— Recurrent attacks of RF in patients with RHD
— Rheumatic chorea
— Insidious onset rheumatic carditis
— Chronic RHD.
57.
58.
59.
60.
61. DEFINITIONS
Recurrence: A new episode of rheumatic fever following another
GABHS infection; occurring after 8 week following stopping
treatment
Rebound: Manifestations of rheumatic fever occurring within 4-6 wk
of stopping treatment or while tapering drugs.
Relapse: Worsening of rheumatic fever while under treatment and
often with carditis.
Sub clinical carditis: When clinical examination is normal but
echocardiogram is abnormal. Around 30 percent of patients
having chorea present as subclinical carditis.
Indolent carditis: It is a common entity in our country. Patient
presents with persistent features of CHF, murmur and
cardiomegaly.
64. 75%subside within 6 weeks
90% subside within 12 weeks
<5% active after 6 months
MORTALITY FROM ARF
◦ GROVER: 7%
◦ SHARMA:1.2%
PROGRESSION TO RHD:
India 5-20yrs
West 15-40yrs.
65. CARDITIS
Most important manifestation
Most often causes no symptoms of its own
and is most often diagnosed in the course of
examination of a patient with arthritis or
chorea.
In 93% carditis develops with in 3 months
Rare to hear murmur after 6 months after the
onset of ARF
66. CARDITIS
1. SLEEPING HR >
100
2. NEW ONSET
MURMURS
3. CHF
4. CARDIOMEGALY
5. PERICARDIAL
RUB
6. S3
Incidence
◦ 33 to 55%( India)
◦ 40-50% west)
Murmurs manifest
in 85%by 2nd
or 3
rd week.
In an RHD patient
CCF should be
suspected as a
reccurence of
carditis
67. MyocarditisMyocarditis
Due to an acute hemodynamic overload on the
left ventricle from acute/ subacute mitral
and/or aortic regurgitation.
Myocarditis (alone) in the absence of
valvulitis is unlikely to be of rheumatic
origin. It should always be associated
with an apical systolic or basal diastolic
murmur.
68. PERICARDITISPERICARDITIS
Rheumatic pericarditis is relatively less common
clinically and is present in up to 15% patients.
Since pericarditis neither results in tamponade nor
constriction and clears up without leaving a residue, its
limited clinical significance lies in the fact that it
provides clear cut evidence for the presence of active
carditis as well as active RF.
Pericarditis does not occur in the absence of clinical
findings indicative of valvulitis.
Simultaneous demonstration of valvular involvement
generally considered essential.
69. CONGESTIVE HEART FAILURE
Least common but most serious
manifestation.
Occurs in5 to 10% of first attacks
of carditis.
More common in children <6yrs of
age.
70. Malignant rheumatic feverMalignant rheumatic fever
Severe disease with multi valvular
lesions, gross cardiac enlargement, and
congestive failure can occur in young
patients, and such children show more
symptoms of congestive failure than of
rheumatic disease.
This severe disease may be due in large
measure to a lack of rest during the
initial carditis
71. The wide difference in the reported prevalence of carditis
in the first attack could thus be related to clinically
undiagnosed carditis in the first attack which becomes
apparent after recurrences of acute RF
72. Arthritis and arthralgiaArthritis and arthralgia
Most common and least specific
75% of pts with 1st attack of ARF.
Occurs early in the course of the disease, as
the presenting complaint
Incidence increases with age.(Often the only
major manifestation in adolescents, as well as
in adults, where carditis and chorea become
less common in older age groups.)
73. Inflamed joints are characteristically warm,
red and swollen, and an aspirated sample of
synovial fluid may reveal a high average
leukocyte count
Important to differentiate from arthalgia( less
specific)
Usually large joint
Almost any joint can be affected
74. Tenderness in rheumatic arthritis may
be out of proportion to the objective
findings and severe enough to result in
excruciating pain on touch.
“MIGRATORY” reflects the sequential
involvement of joints, with each
completing a cycle of inflammation and
resolution, so that some joint
inflammation may be resolving while
others are beginning.
75. If untreated as many as 16 joints can be involved and
atleast 6 in half of the patients
Resolves spontneously with in 3 weeks without
sequelae( except jaccoud’s)
Inverse relation with carditis
Feinstein AR, Sterno EK, Spagnuolo M. The prognosis of acuterheumatic fever.
Am Heart J 1964; 68: 817–834
severity Total no number % carditis
1 Red hot/
swollen
179 47 26
2 tender 30 12 40
3 Joint pains 25 24 96
4 No joint
symptoms
29 29 100
77. POST STREPTOCOCCAL REACTIVE
ARTHRITIS (PSRA)
• Does not fulfill jones criteria
• Latent period is shorter (1 week).
• Arthritis is additive rather than migratory
• Poor response to salicylates
• Arthiritis persists for a mean period of two
months.
• Evidence of recent GABS infection is
Mandatory
• 6% develop mitral heart disease.
Not associated with other major
manifestations of RF
79. SYDENHAM’S CHOREA
Occurs primarily in children
Rare after the age of 20
Occurs primarily in females
Less commonin postpubertal males.
Prevalence of chorea in RF patients
varied from 5–36%
80. CHOREA
Concomitant subclinical carditis
detected by echocardiography appears
to be as high as 70%
Chorea is a uniquely delayed
manifestation of RF, with a wide range
in reported incidence between 5% and
35%, latency of 1 to 7 months, and
choreiform manifestations that may
last for months and occasionally years
81. CHOREA
There is a substantial risk of
subsequent RHD in these patients.
Neurologic deficits typically resolve
within 2 years, but residual psychiatric
disturbances occur in a small but
significant number of patients in the
subsequent decades
82. CHOREA
A syndrome of pediatric autoimmune
neuropsychiatric disorders associated
with streptococcal infections (PANDAS),
in a fashion similar to
poststreptococcal reactive arthritis, has
a temporal relationship to GABHS
infection but is not associated with
other features of RF
83. Sub cutaneous nodulesSub cutaneous nodules
Firm round painless.
0.5 to 2cms
Overlying skin freely mobile
Occurs in crops
Located over bony prominences
Lasting for 1 to 2 weeks
Incidence:
sanyal et al India: 2.3%combined with
erythema marginatum
Subcutaneous nodules are almost always
associated with cardiac involvement and are
found more commonly in patients with
severe carditis
84. Subcutaneous nodulesSubcutaneous nodules
They may also be found over the scalp,
especially theocciput, and the spinous
processes of the vertebrae.
The number of nodules varies from one
to a few dozen, but usually three or four.
They persist from days to 1–2 weeks to,
rarely, more than a month
85. Erythema marginatumErythema marginatum
Erythema marginatum occurs in up
to 15% of RF patients
In view of the evanescent nature
may be easily missed.
Appear first as a bright pink
macule or papule that spreads
outward in a circular or
seripiginous pattern.
The lesions are multiple, appearing
on the trunk or proximal
extremities, rarely on the distal
extremities, and never on the face.
They are nonpruritic and
nonpainful, blanch under pressure
86. Erythema marginatum usually
occurs early in the course of a
rheumatic attack.
It may, however, persist or recur for
months or even years, continuing
after other manifestations of the
disease have subsided, and it is not
influenced by anti-inflammatory
therapy.
Nodules and erythema marginatum
tend to occur together
87. The latent period between streptococcal infection and
onset of RF is shortest in arthritis and erythema
marginatum and longest in chorea with carditis and
subcutaneous nodules in between.
Atleast 1/3 rd of cases of acute rheumatic fever may
present with inapparent streptococcal infections
Arthralgia and fever are termed “minor”
clinical manifestations of RF in the jones
diagnostic criteria, because they lack
diagnostic specificity
88. Elevated or rising streptococcal
antibody titers.
It is recommended that acute serum be collected at the onset of illness, and that
the antibody titer be compared to a convalescent serum collected 2-4 weeks
later, to detect a rise in titer
89.
90. 1. The mitral valve is most often involved
2. Mitral regurgitation is the most common finding on color flow imaging.
3. Mitral regurgitation in rheumatic carditis is related to ventricular dilatation
and/or restriction of leaflet mobility.
4. Rheumatic carditis does not result in congestive heart failure in the absence of
hemodynamically significant valve lesions.
5. In a quarter of patients with rheumatic carditis, valve nodules were present
that may represent echocardiographic equivalents of rheumatic verrucae
91. 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,
92. Echocardiographic evidence ofEchocardiographic evidence of
definite RHDdefinite RHD
ANY OF:
a) A mitral regurgitant jet at least 2 cm from the coaptation point of the
valve leaflets, seen in two planes and persisting throughout systole plus
thickened mitral valve leaflets and/or elbow or dog leg deformity of the
anterior mitral valve leaflet.
b) An aortic regurgitant jet at least 1 cm from the coaptation point of the
valve leaflets, seen in two planes plus thickened mitral valve leaflets and/or
elbow or dog leg deformity of the anterior mitral valve leaflet.
c) Any significant mitral stenosis (defined as flow acceleration across the
mitral valve with a mean pressure gradient greater than 4mmHg
93. 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.
Currently, data do not allow subclinical valvular
regurgitation detected by echocardiography to be
included in the Jones criteria, as evidenceof a major
manifestation of carditis.
94. CARDIAC ENZYMES
Markers of myocardial damage in the form
of troponin I, myoglobin and CPK-MB were
evaluated in patients with acute rheumatic
carditis with and without cardiomegaly or
congestive cardiac failure. The markers of
myocardial damage remained normal inspite
of clinically active carditis.
Gupta M, Kaplan EL,. Serum cardiac troponin I in acute rheumatic
fever. Am J Cardiol 2002
95.
96. NATURAL HISTORY OF MSNATURAL HISTORY OF MS
In India, critical MS may be found in children
as young as 6 to 12 years old. ( UP TO 20%)
In the asymptomatic or minimally
symptomatic patient, survival is greater than
80% at 10 years,
with 60% of patients having no progression of
symptoms.
once significant limiting symptoms occur,
there is a dismal 0% to 15% 10-year survival
rate
Once there is severe pulmonary hypertension,
mean survival drops to less than 3 years.
97. 30 to 40% of patients with MS
develop atrial fibrillation (AF).
Atrial fibrillation occurs more
commonly in older patients and is
associated with a poorer
prognosis, with a 10-year survival
rate of 25% compared with 46% in
patients who remain in sinus
rhythm.
98. The mortality of untreated patients with
MS is due to
1.Progressive pulmonary and systemic
congestion in 60% to 70%,
2.Systemic embolism in 20% to 30%,
3.Pulmonary embolism in 10%,
4.Infection in 1% to 5%.
Serial hemodynamic and Doppler-
echocardiographic studies have reported
annual loss of MV area ranging from 0.09
to 0.32 cm2.
99. 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.
If AS is present with MV
involvement it is likely to be
rheumatic
100. AORTIC REGURGITATIONAORTIC REGURGITATION
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
101. ARF AND RHD INDIAN SCENARIO
1. SCHOOL HEALTH SURVEYS
2. HOSPITAL SURVEYS
3. POPULATION DATA
4. AUTOPSY SERIES
110. PERCENTAGE INCIDENCE OF VALVULAR
INVOLVEMENT IN VARIOUS AUTOPSY REPORTS
AUTHOR
&YEAR
MITRAL AORTIC MITRAL&A
ORTIC
MITRAL,AORT
IC&TRICUSPI
D
MITRAL&TRICU
SPID
TOTAL
CASES
REDDY 1968 67.5 2.5 17.5 10 2.5 40
ROY AND
TANDON
1972
22.9 3 31.8 25.1 16.6 66
KINARE
1972
35.3 1.8 32.6 22.6 8 150
B N DATTA 37.3 1.5 27 22.6 11 252
111. Kinare et alKinare et al RHEUMATIC HEART PATHOLOGY
IN THE YOUNG: AUTOPSY SERIES
1. 144 autopsy cases below the age of 18 years were
included.
2. Mitral stenosis was present in 80.23% cases. Pure mitral
valve incompetence was noted in 12.79%.
3. Tricuspid lesions were minor in most of the cases, only in
7.50% had significant stenosis.
4. Multivalvular disease was noted in 75.69%,
5. Pulmonary vasculature was affected in 75% cases.
6. Calcification of valve was uncommon and was present in
6% of mitral valve lesions and 2% of aortic valve lesions
Mitral Aortic Tricuspid Pulmonary
vasculature
100% 63.89% 54.86% 75%
112. IMPORTANT FEATURES OF
B N DATTA AUTOPSY SERIES
Mural thrombi: 13%
Active pericarditis: 30%
Aschoff bodies: 26%
Bacterial endocarditis: 9%
Organic TV disease: 34.2%
When compared to the west:
young age of death and high rate
of TV disease.
117. Study Patients ARF RECURRENCE
RATE/ PATIENT YEAR
PREVALANCE OF RHD %
UK-US 324 0.026 31.2
Wood 156 0.004 NA
Miller 47 0 NA
Tompkins 115 0.001 26.1
Thomas 73 0.013 42.5
SANYAL 65 0.006 35.4
118.
119.
120. Sujoy roySujoy roy
Clinical and physiopathological findings in 108 patients
with mitral stenosis who were below the age of 20 years.
History of at least one attack of rheumatic fever was
obtained in 71 (66%), and of more than one attack in
30(28%) patients.
Chorea and subcutaneous nodules appeared infrequently
(3%), and erythema marginatum was conspicuously
absent.
High prevalence of congestive heart-failure (45%)
Low prevalence of atrial fibrillation (6%)
The estimated mitral-valve area was less than 1 sq. Cm. In
most of the patients
Isolated mitral stenosis in patients below the age of 20
with rheumatic heart-disease is common in india.
Boys are affected oftener than girls
121. Sujoy roySujoy roy
The frequency of atrial fibrillation was found to
increase with each decade, reaching 40% in patients
over the age of 40.
Angina(12%) is due to functional impairment of the
coronary flow caused by limitation of the cardiac
output.
Absence of calcification in the mitral valve and of
thrombi could be due to the youth of the patients.
Severe pulmonary hypertension with gross pulmonary
vascular obstruction, fairly normal cardiac output
122. MS IN YOUNG( INDIAN( INDIAN
SCENARIO)SCENARIO)
In developing countries, mitral stenosis is severe
enough to require commissurotomy before the age of
20 or even 15 years.
In1408 patients with rheumatic heart disease seen at the G B Pant
Hospital, New Delhi, between 1967 and-1973
713 (51 %) had mitral stenosis
140 patients below age 20
<10 10-15 15-20
4 (2.8%) 55 (39.4%) 81 (57.8%)
123.
124.
125.
126. ECHOCARDIOGRAPHY 2010
High prevalence of rheumatic heart
disease detected by echo in school
children. PANWAR et al
1059 school children aged 6-15 years
Careful cardiac auscultation and echo.
The prevalence of lesions suggestive of
rheumatic heart disease by echo was
51 per 1,000
130. MANAGEMENT ASPECTS
PRIMARY PREVENTION OFPRIMARY PREVENTION OF
ARFARF
Treatment of GAS pharyngitis with a single
intramuscular injection of 1.2 million units of
benzathine penicillin G is the most reliable way
to prevent primary attacks of ARF
131.
132.
133.
134. Secondary prophylaxisSecondary prophylaxis
Defined as the continuous
administration of specific
antibiotics to patients
with a previous attack of
rheumatic fever, or
documented RHD
Purpose is to prevent
colonization or infection of
the upper respiratory
tract with group A beta-
hemolytic streptococci
and the development of
recurrent attacks of
rheumatic fever
After surgery or
intervention secondary
prophylaxis should be
continued
IMPORTANCE of
secondary prophylaxis
1. Prevents reccurences
2. Reduces new cardiac
damage,
3. Facilitate resolution of
previous damage
4. Reduces mortality due to
RHD.
5. The risk of reccurence is
highest in first year after
an index attack of RF
137. Because of the high infection rate
in India, it has been suggested that
penicillin should be given once
every 3 rather than 4 weeks to
maintain adequate blood levels
during reinfection, and this has
certainly resulted in a fall in the
infection rate.
Secondary prophylaxisSecondary prophylaxis
138. RECURRENCE ON PROPHYLAXISRECURRENCE ON PROPHYLAXIS
Sanyal 0.6/100 pt years
Padmavathi 0.1/100 pt years
With out prophylaxis recurrence
rate around 11.6/100 pt years
139. EFFECT OF SECONDARY PROPHYLAXIS ONEFFECT OF SECONDARY PROPHYLAXIS ON
RECCURENCE RATESRECCURENCE RATES
CATEGORY BENZATHINE
PENICILLIN
ORAL PENICILLIN SULFONAMIDES
STREPTOCOCCAL
INFECTION
6.3 6.2 16
ARF RECCURENCE 0.45 2.6 3.2
144. RHDAustralia (ARF/RHD writing group), National Heart Foundation of Australia and theRHDAustralia (ARF/RHD writing group), National Heart Foundation of Australia and the
Cardiac Society of Australia and New Zealand: Australian Guideline for Prevention, DiagnosisCardiac Society of Australia and New Zealand: Australian Guideline for Prevention, Diagnosis
and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 2nd ed. Darwin,and Management of Acute Rheumatic Fever and Rheumatic Heart Disease. 2nd ed. Darwin,
Australia, Menzies School of Health Research, 2012Australia, Menzies School of Health Research, 2012
Recommended for All Cases
White blood cell count
ESR or CRP
Throat swab before giving antibiotics for GAS culture
Blood culture if febrile
Antistreptococcal serology: both antistreptolysin O and anti-DNase B titers (repeated after 10-14 days if the first test is not
confirmatory)
Electrocardiogram
Chest radiograph
Echocardiogram
Tests for Alternative Diagnoses, Depending on Clinical Features
Repeated blood cultures with temperature spikes if infective endocarditis is suspected
Joint aspiration for possible septic arthritis (microscopy and culture)
Copper, ceruloplasmin, antinuclear antibody, and drug screen for choreiform movements
Serology and autoimmune markers for arboviral, autoimmune, or reactive arthritis
Peripheral blood smear for sickle cell disease
145. Primary prophylaxisPrimary prophylaxis
Antiobiotic Route doses
Benzathine benzylpenicillin
Single IM injection 1.2 million units; 50% if <30 kg
Phenoxymethylpenicillin
(penicillin VK)
PO for 10 days 250-500 mg tid for 10 days
Erythromycin ethylsuccinate
PO for 10 days Varies with the formulation
146. WHO Technical Report Series No. 923. Rheumatic Fever and RheumaticWHO Technical Report Series No. 923. Rheumatic Fever and Rheumatic
Heart Disease: Report of a WHO Expert Panel, Geneva 29 October-1Heart Disease: Report of a WHO Expert Panel, Geneva 29 October-1
November 2001. Geneva, WHO, 2004.November 2001. Geneva, WHO, 2004.
Medication Route Doses
Benzathine
benzylpenicillin
Single intramuscular
injection every 3-4
weeks
For adults and
children ≥30 kg in
weight: 1,200,000
units
For children <30 kg in
weight: 600,000 units
Penicillin V Oral 250 mg twice daily
Sulfonamide (e.g.,
sulfadiazine,
sulfadoxine,
sulfisoxazole)
Oral For adults and
children ≥30 kg in
weight: 1 g daily
147. WHO Technical Report Series No. 923. Rheumatic Fever and RheumaticWHO Technical Report Series No. 923. Rheumatic Fever and Rheumatic
Heart Disease: Report of a WHO Expert Panel, Geneva 29 October-1Heart Disease: Report of a WHO Expert Panel, Geneva 29 October-1
November 2001. Geneva, WHO, 2004.November 2001. Geneva, WHO, 2004.
No carditis: 5 years after the last attack
or until 18 years of age (whichever is
longer)
Mild carditis (mild mitral regurgitation or
healed carditis):10 years after the last
attack or at least until 25 years of age
(whichever is longer)
Severe valvular disease: Life-long
After valve surgery: Life-long
148. IN INDIA
Endemicity of carditis
Erythema marginatum almost nonexistent
Chorea and subcutaneous nodules infrequent
Polyarthralgia >polyarthritis
Young >Older
Short interval - ARF to RHD
Start at Young
Rapid progression
More PAH/CCF
Rheumatic fever in < 50%
High incidence of organic tricuspid valve disease
149. FUTURE PERSPECTIVESFUTURE PERSPECTIVES
Overcoming barrier to transmission
◦ Socioeconomic/Political/awareness
Special task force in highly endemicity
Identification of genetic susceptibility(3-5%)
Primary and 2ndary prophylaxis reinforcement
Very long acting penicillin(>3 months)
Vaccine
Understanding molecular genetic
150. Rx for RFRx for RF
PRIMODIAL PRIMARY SECONDARY TERTIARY
AWARENESS
SOCIOECONO
MIC
POLITICAL
Vaccine
Rx pharyngitis Penicillin Surgery/PBMV
151. Socioecomical progress does not mean the extinct of natureSocioecomical progress does not mean the extinct of nature