acquired heart diseases
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ACQUIRED HEART ACQUIRED HEART DISEASESDISEASES
Ma. Rhodora R. Garcia-de Leon,M.D.Ma. Rhodora R. Garcia-de Leon,M.D.FPPS, FPCCFPPS, FPCC
Acquired Heart DiseasesAcquired Heart Diseases
Acute Rheumatic FeverAcute Rheumatic Fever
Valvular Heart diseaseValvular Heart disease
Infective EndocarditisInfective Endocarditis
MyocarditisMyocarditis
PericarditisPericarditis
Kawasaki DiseaseKawasaki Disease
ACUTE RHEUMATIC FEVERACUTE RHEUMATIC FEVER
EpidemiologyEpidemiology: Most common cause of : Most common cause of acquired heart disease in all age groups acquired heart disease in all age groups In some developing countries, incidence is In some developing countries, incidence is as high as 286/100,00 populationas high as 286/100,00 populationIn the Phil. incidence is 0.9/1,000 popIn the Phil. incidence is 0.9/1,000 popIn the USA 0.5 /100,000 popIn the USA 0.5 /100,000 popAge predilection: 5-15 yrsAge predilection: 5-15 yrsPredisposing Factors: Family History, Predisposing Factors: Family History, poverty, poor hygiene, medical deprivation poverty, poor hygiene, medical deprivation
Rheumatic Fever: EtiologyRheumatic Fever: Etiology
Believed to be an immunologic lesion that Believed to be an immunologic lesion that occurs as a delayed sequela to GROUP A occurs as a delayed sequela to GROUP A STREPTOCOCCAL INFECTION of the STREPTOCOCCAL INFECTION of the pharynx, and not of the skin.pharynx, and not of the skin.
Certain serotypes of grp A strep are more Certain serotypes of grp A strep are more frequently isolated: M types 1,3, 5, 6, 18 frequently isolated: M types 1,3, 5, 6, 18
& 24& 24
Rheumatic Fever : PathologyRheumatic Fever : Pathology
The inflammatory lesion is found in many The inflammatory lesion is found in many parts of the body, notably in the HEART, parts of the body, notably in the HEART, JOINTS, BRAIN and SKINJOINTS, BRAIN and SKIN
Valvular damage most frequently involves Valvular damage most frequently involves the MITRAL VALVE, less commonly the the MITRAL VALVE, less commonly the AORTIC, rarely the TRICUSPID & AORTIC, rarely the TRICUSPID & PULMONARY VLAVESPULMONARY VLAVES
Clinical ManifestationsClinical Manifestations
Acute rheumatic fever is diagnosed by the Acute rheumatic fever is diagnosed by the use of the use of the Revised/ Updated JONE’S CRITERIA Revised/ Updated JONE’S CRITERIA5 Major criteria, 4 Minor criteria & 5 Major criteria, 4 Minor criteria & Supporting Evidence of antecedent grp A Supporting Evidence of antecedent grp A infectioninfectionHistory of strep pharyngitis 1-5 wks (ave. 3 History of strep pharyngitis 1-5 wks (ave. 3 wks) prior to onset of symptoms; latent wks) prior to onset of symptoms; latent period of 2-6 mos in isolated choreaperiod of 2-6 mos in isolated chorea
JONES CRITERIA: JONES CRITERIA: Major ManifestationsMajor Manifestations
MIGRATORY POLYARTHRITIS MIGRATORY POLYARTHRITIS * most common: seen in 75% of * most common: seen in 75% of patients * typically involves large patients * typically involves large joints: knees, joints: knees, ankles, wrists, elbows ankles, wrists, elbows * joints are generally * joints are generally swollen, hot, red, swollen, hot, red, & & exquisitely exquisitely tender * not tender * not deforming * deforming * dramatic response to salicylatesdramatic response to salicylates
Jones Criteria: Jones Criteria: Major ManifestationsMajor Manifestations
CARDITISCARDITIS * occurs in 50% - 60% of cases * occurs in 50% - 60% of cases * usually presents as tachycardia, * usually presents as tachycardia, cardiac cardiac murmurs , + / - myo or murmurs , + / - myo or pericardial pericardial involvement involvement * cardiomegaly * cardiomegaly * signs of CHF * signs of CHF * echo findings of valvular * echo findings of valvular regurg does not regurg does not satisfy criteria if no satisfy criteria if no auscultatory auscultatory evidence evidence
Jones Criteria: Major Jones Criteria: Major ManifestationsManifestations
CHOREACHOREA (Sydenham chorea) (Sydenham chorea) * occurs in 10% - 15% of cases * occurs in 10% - 15% of cases * usually presents as an isolated, subtle, * usually presents as an isolated, subtle,
neurologic behavior disorder neurologic behavior disorder * uncontrollable movements, emotional * uncontrollable movements, emotional
lability, incoordination, facial grimacing lability, incoordination, facial grimacing disappears w/ sleep disappears w/ sleep * long latent period bet. infection & chorea * long latent period bet. infection & chorea * rarely leads to neurologic sequelae * rarely leads to neurologic sequelae
Major ManifestationsMajor Manifestations
ERYTHEMA MARGINATUMERYTHEMA MARGINATUM * rare, seen in less than 3% of cases * rare, seen in less than 3% of cases * characteristic rash is * characteristic rash is erythematous, erythematous, serpiginous, macular serpiginous, macular lesions w/ pale lesions w/ pale center, non-pruritic center, non-pruritic * usually seen in the * usually seen in the trunk, not the face * accentuated trunk, not the face * accentuated by warming the skin by warming the skin
Major ManifestationsMajor Manifestations
SUBCUTANEOUS NODULESSUBCUTANEOUS NODULES
* rare, seen in less than 1 % of cases * rare, seen in less than 1 % of cases * firm nodules, 1 cm in diameter, * firm nodules, 1 cm in diameter, along along extensor surfaces, near bony extensor surfaces, near bony prominences prominences
MINOR MANIFESTATIONSMINOR MANIFESTATIONS
ARTHRALGIAARTHRALGIA in the absence of arthritis in the absence of arthritis as a major criterionas a major criterion
FEVERFEVER
ELEVATED ACUTE PHASE REACTANTSELEVATED ACUTE PHASE REACTANTS (ESR, C-reactive protein) (ESR, C-reactive protein)
PROLONGED PRPROLONGED PR interval on ECG interval on ECG
SUPPORTING EVIDENCE OF SUPPORTING EVIDENCE OF GRP A STREP INFECTIONGRP A STREP INFECTION
an ABSOLUTE REQUIREMENT for the an ABSOLUTE REQUIREMENT for the diagnosis of RFdiagnosis of RF
Streptococcal antibody tests most reliableStreptococcal antibody tests most reliable
Elevated or increasing ASO antibody titersElevated or increasing ASO antibody titers
* Titers at least 333 TU in children; * Titers at least 333 TU in children; elevated in 80% of pxs elevated in 80% of pxs
*Others: antideoxyribonuclease B, *Others: antideoxyribonuclease B, antistreptokinase, antihyaluronidaseantistreptokinase, antihyaluronidase
Clinical CourseClinical Course
Only carditis can cause permanent cardiac Only carditis can cause permanent cardiac damage. Signs of mild carditis disappear damage. Signs of mild carditis disappear rapidly in wks; severe carditis longer, 2-6 rapidly in wks; severe carditis longer, 2-6 mos.mos.Arthritis subsides in a few days to several Arthritis subsides in a few days to several wks; no permanent damagewks; no permanent damageChorea gradually subsides in 6-7 mos or Chorea gradually subsides in 6-7 mos or longer; does not cause neurologic longer; does not cause neurologic sequelae sequelae
TreatmentTreatment
Approaches to treatment: Approaches to treatment: * 1. treat the grp A streptococcal infection * 1. treat the grp A streptococcal infection
single dose benzathine PCN;single dose benzathine PCN; 10 days of appropriate oral antibiotics 10 days of appropriate oral antibiotics 2. use of anti-inflammatory agents to 2. use of anti-inflammatory agents to
control clinical manifestations:control clinical manifestations: aspirin or steroids aspirin or steroids 3. other support therapy: including Tx for 3. other support therapy: including Tx for
CHF, chorea CHF, chorea
PreventionPrevention
Primary Prophylaxis – to prevent an initial attack Primary Prophylaxis – to prevent an initial attack of RF, a 10-day course of oral PCNof RF, a 10-day course of oral PCN
Secondary Prophylaxis – to prevent Secondary Prophylaxis – to prevent colonization / infection with grp A strep every 21 colonization / infection with grp A strep every 21 or 28 days in pxs who already have RHD or had or 28 days in pxs who already have RHD or had previous RF previous RF
given for 10 yrs or longer:given for 10 yrs or longer:
benzathine PCN, 1.2 MU, IM benzathine PCN, 1.2 MU, IM oral PCN V , 250mg BID; oral erythromycin oral PCN V , 250mg BID; oral erythromycin
250mg BID; sulpha 1 gm OD250mg BID; sulpha 1 gm OD
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