rheumatic heart disease

RHUEMATIC HEART RHUEMATIC HEART DISEASEDISEASE

Rheumatic fever (RF) is generally classified as a connective tissue or collagen-vascular disease

It is an inflammatory reaction that causes damage to collagen fibrils and to the ground substance of connective tissue

Rheumatic fever principally involves the heart, joints, CNS (Central Nervous System), skin, subcutaneous tissues.

• Recurrent attacks of RF may cause fibrosis of heart valves, leading to chronic valvular heart disease

• The term Rheumatic heart disease refers to the cardiac involvement develops to 50% of patients and may affect the endocardium, myocardium or pericardium. It may later affect the heart valves, causing chronic valvular disease.

• The extent of damage to the heart depends on where the disorder strikes.

DEFINITION• Rheumatic heart disease is a chronic

condition resulting from rheumatic fever that is characterized by scarring and deformity of the heart valves

Epidemiology•Peak incidence ages 5~15 years

•Rare before age 4 years and after age 40 years

•The incidence of RF and prevalence of rheumatic heart disease (RHD) are markedly variable in different countries:

•In developed country, such as the united states, the incidence of RF ＜ 2/100,000

•In many developing countries, the incidence of acute RF approaches or exceeds 100/100,000

Causative Factors

• GABS (Group A Beta- Hemolytic Streptococci)

• Rheumatic fever

PATHOPHYSIOLOGYRheumatic fever+ recurrent infection

Cross immune response between host and streptococcal antigens

Abnormal reaction-autoimmunity disease

rheumatic pancarditis $ Endocarditis in valves

erosion of valve leaflets

fibrous thickening $ thickened valves

stenosis and regurgitation

Causative Factors

• GABS (Group A Beta- Hemolytic Streptococci)

• Rheumatic fever

Risk Factors• 5-15 years old

• Family history of RF

• Low socioeconomic status (poverty, poor hygiene, medical deprivation)

• Untreated strepthroat

CLINICAL MANIFESTATIONJones Criteria for Diagnosis of Rheumatic Feve

MAJOR CRITERIA• carditis• Poly arthritis- sharp, sudden pain starts over sternum

and radiates to neck, shoulders, back and arms.• Erythema marginatum- Erythema marginatum: A long-

lasting reddish rash that begins on the trunk or arms as macules, which spread outward.

• Subcutaneous nodules- a firm, movable, nontender collagen fibers over bones or tendons and about 3 mm-2 cm in diameter.

• Transient chorea- involuntary grimace and an inability to use skeletal muscles in a coordinated manner.

MINOR CRITERIA1. Fever2. Arthralgia3. Previous rheumatic fever or rheumatic

heart disease4. Acute phase reactions: ESR / CRP /

Leukocytosis5. Prolonged PR interval

•Supporting evidence of an antecedent group A

•streptococcal infection: ① Positive throat culture or rapid

streptococcal antigen test ② Elevated or rising titers of

antistreptococcal antibodies (anti-streptolysin O and anti-DNase B)

Daignostic Evaluation•Modified Jones criteria were first published in 1944

by T. Duckett Jones, MD.They have been periodically revised by the American Heart Association in collaboration with other groups.

•Guidelines for the diagnosis of initial attacks of RF (Jones criteria, updated 1992)

•If supported by evidence of preceding group A streptococcal infection, the presence of two major manifestations or of one major and two minor manifestations establishes the diagnosis of acute RF

WBC count and ESR is elevated C- reactive protein is positive. Cardiac enzmes levels may increase in

severe carditis. Anti streptolysin- O titser is elevated 95% of

patients with in 2 months onset. Throat cultures continue to presence of

GABS; however they usually occur in small numbers. Isolating them is difficult.

ECG reveals no diagnostic changes, but 20% of patient show a prolonged PR interval.

TreatmentGeneral Measures Strict bed rest

Medical Measures

1. Control streptococcal infection Penicillin is of choice benzathine penicillin, 1.2 million

units im once, or procaine penicillin, 600,000

units im daily, 10 days If allergic to penicillin, erythromycin be given

2. Antirheumatic therapy(1) Salicylates Of choice in patients with little or no

cardiac involvement; Particularly effective in reducing

fever and relieving joint pain and swelling

Aspirin 0.6~0.9 g / 4h in adults; lower doses in children

(2) Corticosteroids Used in patients who do not respond

well to adequate doses of salicylates Prednisone 40~60 mg orally daily,

tapering over 2 weeks

3. Treatment of symptoms and complications

If heart failure is present, digitalis preparations should be used cautiously because cardiac toxicity may occur with conventional dosages

PreventionPrimary preventionEarly treatment of streptococcal pharyngitis Penicillin or erythromycinSecondary preventionTo prevent recurrence of rheumatic activity Long-acting penicillin (benzathine

penicillin) 1.2 million units im, every 4 weeks Sulfonamides or erythromycin may be

substituted

Nursing Daignosis

• Activity intolorence related to arthralgia secondry to joint pain

• Decreased cardiac output related to valve dysfuntion,HF

• Ineffective therapuetic regimen related to lack of knowledge

• HEALTH PROMOTION• ACUTE INTERVENTION• AMBULATORY AND HOME CARE

THANK YOU

1) ALL ARE FEATURES OF ACUTE RHEUMATIC FEVER EXCEPT:

a) Pancarditisb) Carey Coombs murmurc) Choread) Always causes residual joint damage

2) What heart problem may be caused, ironically, by the body's attempt to protect itself from a streptococcal throat infection?

A)CardiomyopathyB)rheumatic heart diseaseC)coronary atherosclerosisD)infectious endocarditis

3) When teaching a patient about the long-term consequences of rheumatic fever, the nurse should discuss the possibility of a. valvular heart diseaseb. pulmonary hypertensionc. superior vena cava syndromed. hypertrophy of the right ventricle

4) Which is a priority nursing intervention for a patient during the acute phase of rheumatic fever?a. administration of antibiotics as orderedb. management of pain with opioid analgesicsc. encouragement of fluid intake for hydrationd. performance of frequent, active range-of motion exercises

5) Which of the following nursing actions should the nurse prioritize during the care of a patient who has recently recovered from rheumatic fever?a. Teach the patient how to manage his or her physical activity. b. Teach the patient about the need for ongoing anticoagulation. c. Teach the patient about his or her need for continuous antibiotic prophylaxis. d. Teach the patient about the need to maintain standard infection control procedures.

1) D2) B3) A4) A5) C