Cardiac Path 6 (RHD/Endocarditis)

Question 1

What condition?

• A systemic, immunologically mediated disease related to a Streptococcal infection
• A delayed non-suppurative sequelae to an URI with Group A. beta-hemolytic Streptococcus.

Answer 1

Acute Rheumatic Fever

Question 2

What condition?

Typically occurs ~2 weeks after a Strept throat infection.

Answer 2

Acute Rheumatic Fever

Question 3

The following describes the immune rxn to which dz:

1. The immune response elicited by the Strep antigens provides the body w/ a defense mechanism against Strept. Pyogenes
2. @ the same time, the immune rxn damages the connective tissue of the heart and several other organs and tissues.
3. The antibodies against the Strept antigens may cross-react with similar antigens found in the heart.

Answer 3

Acute Rheumatic fever

Question 4

The following antibodies develop in all pts w/ ________:

Antibodies to the Streptococcal antigen O, called Antistreptolysin O (ASLO or ASO)

Answer 4

Rheumatic Fever

Question 5

The following describes the susceptibility of which condition?

1. Principally a disease of children (median age: 9-11y/o)
2. can occur in adults
3. No differences in susceptibility related to sex, race, or ethnicity
4. Present rate in the U.S.= ~2 per 100,000

Answer 5

Acute Rheumatic Fever

Question 6

Is Acute Rheumatic fever still prevalent in the US today?

Answer 6

in first 1/2 of 20th century- RF was almost epidemic in US but has decreased dramatically since due to abx and improved socioeconomic conditions

Question 7

Is Acute Rheumatic fever still prevalent in the world today?

Answer 7

Still the leading cause of death of heart dz in ppl b/w 5-25 years worldwide

Question 8

What disease involves the following

1. the heart
2. the joints
3. subcutaneous CT of the skin
4. blood vessels
5. occasionally the brain

Answer 8

Rheumatic Heart Disease

Question 9

What is a major feature and complication of Acute Rheumatic Fever?

Answer 9

Rheumatic Heart Disease

Question 10

What is the chief cause of heart disease in persons under the age of 50 still today?

Answer 10

Rheumatic Heart Disease

Question 11

The pathology of what disease is characterized by non-bacterial, sterile, inflammatory lesions and granulomas throughout the connective tissue of the body.

Answer 11

Rheumatic Heart Disease

Question 12

What is the characteristic heart pathology in RHD?

Answer 12

RHD causes a Pancarditis, involving all three layers of the heart.

1. Pericarditis
2. Myocarditis
3. Endocarditis

Question 13

Which disease?

Recognized clinically by a pericardial friction rub and in severe cases can lead to an adhesive pericarditis.

Answer 13

Rheumatic Pericarditis

(“Bread and Butter” Pericarditis)

Question 14

The following is pathology of which disease?

2. Myocarditis:

• Usually heart is dilated
• Aschoff Bodies (aggregates of lymphocytes and macrophages around a central zone of fibrinoid necrosis) w/in the myocardium–> w/ time it assumes a granulomatous appearance–> eventually replaced by a scar

Answer 14

Rheumatic heart disease

Question 15

Which pathology of RHD is responsible for the majority of deaths in the acute phase due to conduction system fibrosis.

Answer 15

Myocarditis

Question 16

The following is pathology of what conditon?

3. Endocarditis: the most prominent changes are seen on the valves of the left heart.
   * This valvulitis begins with inflammation of the valve surfaces, leading to an ulceration.

Question 17

Pathology of RHD:

What is characteristic about the heart valve ulcerations with time?

***This was a prior board question***

Answer 17

The surface defects are covered with fibrin thrombi, which progressively grow and assume the form of larger vegetations along the lines of closure of the valve leaflets.

Question 18

Characteristics about the ____________ of RHD:

• There are no bacteria within the ___________
• Ongoing inflammation inside the valves leads to destruction, followed by fibrous scarring–> causes valve deformities.
• The chordae tendinae inserting into the mitral valve are typically shortened and thickened and becomes fused to one another (“Fish-Mouth Stenosis”)

Answer 18

Vegetations

Question 19

Which side of the heart is most affected by RHD?

Answer 19

The left

Question 20

How does the valve changes in RHD affect the heart?

Answer 20

1. deformity of the leaflets + the changes in the chordae= the valves become incompetent and do not close completely during systole (valvular insufficiency).
2. Orifice may also become stenotic

Question 21

The following is the end result of valve insufficiencies in which disease?

1. Mitral Valve Insufficiency: causes reflux of blood across the mitral valve from the L ventricle–> L atrium during systole.
2. Aortic Insufficiency: blood flows back from aorta to LV during diastole–> leads to LVH and dilation.

Answer 21

RHD

Question 22

End result of what?

1. Mitral Stenosis–> Ultimately leads to Cor Pulmonale (R heart failure)
2. Aortic Stenosis (Impedes the blood flow from the LV into the aorta)

Answer 22

End result of the valve stenoses (pathology of RHD)

Question 23

___________ causes:

• stagnation of blood in the L atrium, w/ possible clot formation–> later transmitted into the pulmonary circulation and RV
• This leads to left atrial, pulmonary, and right ventricular HTN–> all leading to Cor Pulmonale (right heart failure).

Answer 23

Mitral stenosis (an end result of valve stenoses in RHD)

Question 24

The following is the end result of what?

• To overcome the increased resistance at its outflow tract, the LV increases the ejection pressure, causing left ventricular hypertrophy
• When the heart fails, the back pressure of the blood is transmitted from the LV to left atrium and into the pulmonary circulation–> again resulting in Cor Pulmonale

Answer 24

The end result of aortic stenosis (pathology of RHD)

Question 25

**\*\*The _______ is responsible for the most deaths after the acute phase (of RHD)\*\***

Answer 25

endocarditis

Question 26

The following are major extracardiac findings in \_\_\_\_\_\_\_: 1. **Polyarthritis** (migratory arthritis- lasts 1-4 wks) 2. **Subcutaneous Nodules-** Firm, non-tender nodules, urually recurrent. Overlies extensor tendons of the extremities (MC in children) 3. **Erythema Marginatum** (migratory maculopapular rash on trunk and proximal etremities; sparing face) 4. **Sydenhams Chorea**

Answer 26

Extracardiac findings in RHD

Question 27

What extracardiac finding of RHD is described by the following: A neurologic disorder characterized by: * Involuntary movements that are continuous, non-repetitive, purposeless, jerky movements of the limbs, trunk and face muscles. * Causes impaired speech and gait

Answer 27

Sydenhams Chorea

Question 28

The following are the characteristic lab findings of what disease? 1. Sxs occur 2-3 weeks after strep throat--\> **culture is usually neg** by this time 2. Increasing serum antibodies to Group A strep antigens (**ASO titers)** 3. Increased sedimentation rate 4. Leukocytosis 5. Positive C-reactive protein

Answer 28

Lab findings of RHD \*Positive ASO titers + increased sedimentation rate + pos CRP= good justification for dx of RHD

Question 29

What lab finding provides concrete evidence of a recent infection with St. pyogenes and is a laboratory finding in RHD?

Answer 29

Increasing titers of serum antibodies to Group A Strept antigens (**ASO titers)**

Question 30

What disease? Clinical diagnosis is based on **"Jones Criteria"** - subclassified into both major and minor criteria needed for dx

Answer 30

Dx of RHD

Question 31

The following is criteria for what? 1. Pancarditis 2. Polyarthritis 3. Sydenhams Chorea 4. Subcutaneous Nodules 5. Erythema Marginatum

Answer 31

**MAJOR critera** of "Jones Criteria" which is used to dx RHD

Question 32

The following is criteria for what? ## Footnote 1. A previous history of Rheumatic Fever 2. Fever 3. Arthragias 4. EKG signs of heart damage 5. Evidence of prior Strept infection (ASO titers, C-reactive protein, increased sed. rate)

Answer 32

**MINOR critera** of "Jones Criteria" which is used to dx RHD

Question 33

When is a diagnosis of RHD made using "Jones Criteria"?

Answer 33

The clinical diagnosis is made when **2 major OR 1 major + 2 minor criteria** are fulfilled

Question 34

Complications of what disease? 1. **secondary bacterial endocarditis** b/c the thrombotic vegetations on valve can become infected (MC complication) 2. Valvular vegetations--\> give rise to **emboli**, which can cause **infarcts** of the brain, kidney or the extremities.

Answer 34

RHD

Question 35

Can RHD be cured?

Answer 35

No Most of the lesions are irreversible and can only be tx w/ surgery

Question 36

Treatment of which dz? ## Footnote - The calcified, deformed valves can be **excised and replaced by artificial valves** - Prompt tx of Strep throat w/ **abx** prevents the initial attack of RF and a recurrence of the disease.

Answer 36

RHD

Question 37

What is the #1 complication of RHD?

Answer 37

Vegetations on the valve can be come secondarily infected w/ bacteria

Question 38

The following are causes of \_\_\_\_\_\_\_\_\_\_: 1. **Bacteria (MC= pyogenic bacteria)** 2. Fungi 3. Rickettsia 4. Chlamydiae

Answer 38

Infective Endocarditis

Question 39

How is Infective Endocarditis is classified clinically?

Answer 39

1. Acute (ABE) 2. Subacute (SBE)

Question 40

Characteristics of what? ## Footnote 1. A **highly destructive infection of the valves**. 2. Frequently of a **previously normal heart valv**e. 3. May also be seen **in prosthetic heart valve**s. 4. Usually due to **highly virulent organisms** (i.e. Staph aureus or Gram neg)--\> can lead to **death w/in days**, despite abx 5. Develops in the course of **intense bacteremia**. 6. Produces **necrotizing, valvular lesion**s with chance of perforation of the valve

Answer 40

Acute Bacterial Endocarditis (ABE)

Question 41

Characteristics of\_\_\_\_: ## Footnote 1. slower 2. less virulent disease 3. caused by organisms of less virulence (i.e. St. viridans) 4. Can cause infection in previously abnormal heart valves. 5. longer course: weeks to months--\> most pts recover after appropriate abx therapy 6. The lesions are less destructive and show evidence of healing.

Answer 41

Subacute Bacterial Endocarditis (SBE)

Question 42

Pre-existing Causes for\_\_\_\_\_\_\_: ## Footnote **1. Artificial (prosthetic) valves** **2. Congenital defects** **3. Degenerative calcified valvular stenosis** **4. Bicuspid aortic valves** **5. Myxomatous mitral valve (mitral valve prolapse)** **\*\*\*All are red on the slide\*\*\*\*\***

Answer 42

Endocarditis

Question 43

What organism is responsible for the most cases of Prosthetic Valve Endocarditis?

Answer 43

Staph epidermidis

Question 44

Causative agents of \_\_\_\_\_: **1. Staph epidermidis (Most Common)** 2. Enterococci 3. Gram neg bacteria 4. Fungi

Answer 44

Endocarditis

Question 45

Clinical Effects of \_\_\_\_\_\_\_\_: 1. Fever (present in almost all pts) 2. In ABE: quick onset + chills, night sweats and weakness 3. Murmur 4. Embolization 5. SBE: low grade fever + fatigue and flu-like sxs

Answer 45

Infective Endocarditis

Question 46

Complications of Endocarditis: What are complications of the \_\_\_\_\_\_\_\_\_\_? - \_\_\_\_\_\_\_\_\_episodes (in 1/3 of pts): includes retinal (blindness), coronary (MI), cerebral (strokes), splenic, pulmonary (from IVDA’s) and renal (from renal abscesses to glomerulonephritis) complications in the form of infarcts or abscesses - CHF due to valve destruction, ruptured chordae tendonae, and myocardial muscle abscesses or MI’s may also complicate the course.

Answer 46

Septic emboli

Question 47

Dx of what condition is based on: ## Footnote 1. clinical presentation of the pt, or the common complications of this condition, or ultrasound of the vegetations 2. **positive blood cultures are required for conformation**. 3. With repeated blood samples, positive blood cultures can be obtained in about 90% of cases.

Answer 47

Diagnosis of Endocarditis

Question 48

1. **Bacteremia** from cellulitis or phlebitis at the injection site or drug contamination is the pathogenesis of this type of endocarditis. 2. The **Tricuspid valve is infected** in over 50% of pts w/ signs and symptoms of pulmonary emboli and abscesses leading to Pneumonia.

Answer 48

Endocarditis in IVDA's

Question 49

St. aureus is responsible for 50-60% of cases, followed by Strept. species and Candida (or any skin commensal)

Answer 49

Endocarditis in IVDA's