RF , VALVULAR ,PERICARDITIS , MYOCARDITIS,SHOCK ,COARCTATION Flashcards
(30 cards)
How to diagnose RF?
diagnosis using Jones Criteria
○ Major manifestation:
■polyarthritis *MC
▪︎Carditis.
▪︎Subcutaneous nodules
▪︎S. chorea.
▪︎erythma marginatum
○Minor manifestation:
▪︎Fever. ▪︎arthralgia. ▪︎raised ESR or CRP. ▪︎Leukocytosis
▪︎Previous history of Rheumatic Fever. ▪︎First degree A.V block.
Plus+ : supporting evidence of recent streptococcus infection by:
-Raised ASO titer Or streptococcus Antibodies titer
-Recent Scarlet Fever.
-Positive throat culture.
The diagnosis using Jones Criteria:
Based on:
□Two or more major manifestation along with evidence of preceding infection.
□Diagnosis can be made without evidence of infection in: chorea or Pericarditis if other
causes are excluded.
Mention the important features of each major symptoms of RF
☆Arthritis : Occur early , asymmetric , migratory inflammation of large joints.
☆Carditis: pancarditis
□Soft: systolic murmur, due to M.R “very common”
□Soft mid-diastolic murmur(Carey Coomb’s murmur)
☆Subcutaneous nodules:Subcutaneous nodules:
Occur in 5-7% of Patient.
-Small “0.5-2 cm” -firm -Painless. -on extensor surface,-appear >3 weeks of onset.
☆Sydenham’s chorea:(St Vitus dance)
-Late , at least 3 months ,females,-Emotional liability may be first feature followed by:
Purposeless-Involuntary-choreiform movement of hands, feet or face.
-Spontaneous recovery usually occur within few months.
-About 1/4 of cases will develop chronic Rheumatic valve disease.
☆Skin lesion:
▪︎Erythema marginatum:
-Occur in <5% of patient.
-Lesion start as red macules that fed in the center but remain red at edges.
Occur mainly in trunk and proximal extremities, BUT not in face.
How to manage Acute RhF
1- rest
2- tx of HF
3- Aspirin : relieves the symptoms of arthritis rapidly and response within 24 hours helps
confirm the diagnosis.
Starting dose 60mg/kg/day divided into 6 doses.
In adults, 100mg/kg/day ,maximum dose 8 g per day
▪︎Single dose of Benzathine benzylpencillin 1.2 million U IM, Or Oral
phenoxymethylpencillin 250mg four times daily 10 days. Or
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-if Penicillin-allergic, give Erythromycin Or Cephalosporin.
▪︎Long term prophylaxis:
-Benzathine penicilin 1.2 million unit IM monthly. Or
-Oral phyenoxymethylpencilin 250mg BD daily ,Or
If penicilin-allergic, give sulfadiazine or Erythromycin.
Stop it after age 21 ,but should be extended if attack of Rheumatic Fever occurred in last 5
years ,Or If the patient lives in an area of high prevalence and has occupation with high risk
of exposure to streptococcus infection.
Or if patient of Rheumatic Fever with residual heart disease, prophylaxis continue until 10
years after last episode, or until 40 years
What are the indications of steroids in ARhF
Carditis
Severe arthritis
Prednisolone 1 - 2 mg/kg per day in divided doses,
What are the indications of steroids in ARhF
Carditis
Severe arthritis
Prednisolone 1 - 2 mg/kg per day in divided doses,
Regarding Chronic rheumatic heart ds :
1- percent of people affected
2- valves affected
3- pathogenesis .
-Develops in at least half of those affected by rheumatic fever with carditis.
-Two-thirds of cases occur in women.
The mitral valve 90% -Aortic valve- Tricuspid valve- Pulmonary valve.
-Isolated Mitral valve 25%
-Mitral regurgitation and stenosis 40%
○pathogenesis:
The main pathological process is progressive fibrosis.
Mention the causes of mitral stenosis
-Rheumatic in origin (common).
-heavy calcification (in older)
-Congenitally (very rare)
Mention the S/S of mitral stenosis
Symptoms:
1-Breathlessness: due to Pulmonary congestion, low cardiac output.
2-Fatigue: due to Low cardiac output
3-Oedema, ascites: due to Right heart failure
4-Palpitation: due to Atrial fibrillation
5-Haemoptysis: due to Pulmonary congestion
6-Cough: due to Pulmonary congestion
7-Chest pain: due to Pulmonary hypertension
8-Thromboembolism: due to Atrial stasis and atrial fibrillation
Signs:
1-Atrial fibrillation: due to Atrial dilatation
2-Mitral facies: due to Low cardiac output
3-Auscultation:
-Loud first heart sound, opening snap: due to Non-compliant, stenotic valve
-Mid-diastolic murmur
4-Crepitations: due to Left heart failure
5-Pulmonary edema
6-Pleural effusions
7-Right ventricular heave, loud P2: due to Pulmonary hypertension.
N.B: Mitral facies: abnormal flushing of checks due to cutaneous vasodil
How to manage mitral stenosis?
☆Medically:
-In mild patient use Anticoagulant for decrease risk of embolism.
-Beta blockers or rate-limiting calcium antagonists in case of AF.
-Diuretic to control pulmonary congestion.
☆ Interventional:
○Valvuloplasty (balloon):
▪︎Significant symptoms
▪︎Isolated MS
▪︎No MR
▪︎Mobile non calcified valve
▪︎Left atrium free of thrombus.
○Valvotomy .
○valve replacement: if valve calcified or rigid.
How to investigate MS ?
1-Doppler echocardiography: [The investigation of choice].
2- ECG : signs of RVH
3- ECG
4- cardiac catheter
Mention the causes of MR
1) Mitral valve prolapse.
2) dilatation of left ventricle and Mitral valve ring: coronary artery disease Or
cardiomyopathy
3) damage in valve cusps: Rheumatic heart disease, Endocarditis.
4) ischemia Or infraction in papillary muscle.
5) myocardial infraction.
Describe S/S of MR
○Symptoms:
▪︎Breathlessness .
▪︎Fatigue .
▪︎oedema,ascites .
▪︎Palpitation .
○Signs:
▪︎atrial fibrillation .
▪︎Displaced apex beat: due to cardiomyopathy
▪︎Auscultation:
-Apical Pan systolic murmur
-Soft S1 ,apical S3
▪︎Crepitations: ▪︎Pulmonary edema
▪︎Right ventricular heave
▪︎Raised JVP edema
How to manage MR ?
■Management:
○Medically: (In patient with mild to moderate symptom)
-Diuretics
-Vasodilators if hypertension is present.
-Digoxin if atrial fibrillation is present.
-Anticoagulants if atrial fibrillation is present.
○Surgically:
-Mitral valve repair or replacement:
Indicated when there is worsening in symptoms progressive cardiomyopathy Or Echo
evidence finding of deteriorating left ventricular function.
N.B: valve repair NOT done in the patient with ventricular dilatation is the underlying
cause of Mitral regurgitation
Mention the causes of AS
1- Infant, children, adolescence:
▪︎Congenital aortic stenosis
▪︎Congenital subvalvular aortic stenosis
▪︎Congenital supravalvular aortic stenosis.
2-young adults to middle aged;
▪︎Calcification and fibrosis of Congenitally bicuspid aortic valve.
▪︎Rheumatic aortic stenosis.
3-Middle aged to elderly:
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▪︎Senile degenerative aortic stenosis
▪︎Calcification of bicuspid valve.
▪︎Rheumatic aortic stenosis.
Mention S&S of AS
○Symptoms:
1-mild to moderate stenosis: usually asymptomatic.
2- Exertional Dyspnea.
3- Exertional syncope
4- Angina
5- Sudden death
6- episode of acute Pulmonary edema.
○Signs:
1-Ejection systolic murmur.
2-Narrow pulse pressure
3-Slow rising carotid pulse
4-Signs of pulmonary venous congestion.
5-Thrusting apex beat (left ventricular pressure overload).
How to manage AS ?
■Management:
Asymptomatic aortic stenosis: conservative management and follow up.
▪︎Anticoagulant: given only in patient who have AF ,or those who have had valve
replacement with mechanical prosthesis.
▪︎Aortic balloon valvoplasty :
Congenital aortic stenosis [limited value in older].
▪︎Aortic valve replacement:
Mention the causes of AR
○Causes:
◇Congenitally:
-Bicuspid valve or disproportionate cusps.
◇Acquired:
-Rheumatic disease
-Infective endocarditis
-Trauma
-Causes of aortic dissection:
•Marfan’s syndrome
•Aneurysm
•Aortic dissection
•Syphilis
•Ankylosing spondylitis
Mention the S& S OF MR
○Symptoms:
Mild to moderate aortic regurgitation:
▪︎Often asymptomatic
▪︎Palpitations.
Severe aortic regurgitation:
▪︎Breathlessness
▪︎Angina
○Signs:
-Pulses:
▪︎Large volume or collapsing pulse (water hammer pulse)
▪︎Low diastolic and increased pulse pressure
▪︎Bounding Peripheral pulses
▪︎Quincke’s sign: Capillary pulsation in nail bed.
▪︎Duroziez’s sign: Femoral bruit (pistol shot).
▪︎De musset’s sign:Head nodding with pulse:
▪︎Corrigan’s sign: Carotid pulsation.
▪︎Müller’s sign: Pulsation or bobbing of the uvula.
▪︎Becher’s sign: prominent retinal artery pulsation.
▪︎Gerhardt’s sign: pulsation of the spleen in time with heard beat.
▪︎Hill’s sign : higher blood pressure (>20mmHg) in legs than in arms.
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▪︎Landolfi’s sign: Rhythmic papillary pulsation in time with heart beat.
▪︎Lincoln sign: Excessive pulsation in the popliteal artery.
▪︎Mayne’s sign: a fall in diastolic pressure (>15mmHg) on rising the arm above the head.
▪︎Rosenbach’s sign: pulsation of the liver in time with heart beat.
▪︎Traube’s sign: a double heart sound heard over femoral artery while compressing it distally.
▪︎Ashrafian sign: pulsatile pseudo proptosis.
▪︎Sherman’s sign: an easily palpable dorsalis pedis pulse in a patient over the age of 75 years.
▪︎Shelly’s sign: pulsation of cervix.
-Murmur:
▪︎early diastolic murmur.
▪︎Systolic murmur (increased stroke volume)
▪︎Austin flint murmur (soft mid-diastolic)
-Other signs:
▪︎Displaced, heaving apex beat (volume overload)
▪︎Pre-systolic impulse
▪︎Fourth heart sound
▪︎Crepitation. (Pulmonary venous congestion)
Mention the causes of Pericarditis
▪︎Infections:
Pericarditis:
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-Viral Pericarditis (Common)
-TB Pericarditis
-Bacterial infection.
▪︎Inflammatory:
-Rheumatoid arthritis.
-Rheumatic fever.
-Systemic lupus erythematosus.
▪︎Other:
-Trauma (blunt Chest injury)
-Post-myocardial infraction
-Malignancy
-Radiation
-Drug induced Pericarditis.
How to investigate and manage a pt with pericarditis?
■Investigation:
1) ECG:
-PR interval depression is very specific indicator of acute pericarditis.
-Diffuse ST segment elevation with upward concavity, later may be T wave inversion.
2) Chest X ray:
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Enlarged cardiac shadow if there is Pericardial effusion.
3) Echo:
May show Pericardial effusion
4) underlying cause eg:viral titer:
Raised titer in case of viral Pericarditis
■Management:
▪︎NSAIDS:
- Aspirin 600mg 6 times daily.
- Ibuprofen 600-800 mg TDS.
- Indomethacin 50mg TDS daily (more potent).
▪︎Steroids: Can be given if No response to NSAIDS.
-Prednisolone 60mg OD for 2 days with tapering, the dose to zero within week. [suppress
symptoms but Not accelerate the cure, and may increase the recurrence rate]
▪︎colchicine:
With NSAIDS reduce the recurrence.
What is the C/P of pt with Pericardial effusion?
○Clinical features:
1) symptoms of underlying cause.
2) small effusion or slowly developing large effusion may be without cardiac symptoms.
3) large effusion causing compression on surrounding tissue:
Dyspnea, dysphagia, cough, hoarseness, nausea, feeling of abdominal fullness.
4) Rapid accumulating even moderate effusion may cause cardiac tamponade, or
hemodynamic compression due to decrease cardiac output.
□On examination:
1) without tamponade:
Apex beat NOT palpable, muffled heart sound, friction rub may be heard early before fluid is
accumulated.
Bronchial breathing may be heard at left lung due to compression by effusion.
2) with cardiac tamponade:
It’s interfere with diastolic filling so decrease Cardiac output.
Cardiogenic shock: tachycardia, cool extremities, hypotension, decrease consciousness,
pulsus paradoxus , increase JVP with obliteration of y descent .
How to investigate and manage a pt with pericardial effusion ?
●Investigation:
1) ECG: decrease QRS voltage, electrical alternace.
2) Chest X ray: large globular heart.
3) Echo: diastolic Collapse of RA and RV. (useful sign).
●Management:
Treatment underlying cause, resuscitation in shock.
Pericardiocentesis needle inserted just below the xiphoid process deep to the left costal
margin and directed toward the left shoulder.
N.B: There are three approaches to Pericardiocentesis:
1- Sub xiphoid approach, 2- apical approach, 3- parasternal approach.
Explain the causes and C/P of constrictive Pericarditis
●Etiology:
1) Idiopathic. 2)TB Pericarditis. 3)viral Pericarditis.
4) Haemopericardium. 5)cardiac surgery. 6)cardiac radiation therapy
●Clinical picture:
1) systemic venous congestion. (like RHF)
2) signs of left side congestion (like LHF), Dyspnea, orthopnea.
3) on examination:
-Markedly raised in JVP
-Kussmaul sign: paradoxical rise in JVP during inspiration
[normally JVP decrease during inspiration]
-Friedreich’s sign: Sudden collapse in the distended neck veins with diastole.
Pericardial effusion:
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- pulsus paradoxus of Pericardial knock early diastolic sound.
What are the clinical types of myocarditis ?
☆Fulminant myocarditis:
-Follows a viral prodromal or influenza like illness and results in severe heart failure or
cardiogenic shock.
☆Acute myocarditis:
-Presents over a longer period with heart failure, it can lead to dilated cardiomyopathy.
☆Chronic active myocarditis:
It is rare and associated with chronic myocardial inflammation.
☆Chronic persistent myocarditis:
