Transcript
OS 213: Circulation and Respiration (Cardiovascular Module) LEC 08: RHEUMATC !E"ER and R#eu$atic Heart %isease OUT&'E
". #heu$ #heu$ati atic c %e&er %e&er an' #heu$atic (eart Disease A. #heu$atic #heu$atic %e&er %e&er ). #heu$atic (eart Disease C. E*i'e$iolo+y: E*i'e$iolo+y: #% , #(D D. #is %actors %actors "". #heu$atic #heu$atic %e&er %e&er A. atho+e atho+enesis nesis o/ #heu$atic %e&er ). Etiolo+y Etiolo+y C. La est /or AS onsillo*haryn+itis onsillo*haryn+itis D. A#%: A#%: A+e , Se3 Distriution E. atholo+ atholo+y y
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%. Dia+nosis: Dia+nosis: Jones Jones Criteria 1442 . Dia+nosis: #% 5o'i6e' Jones Criteria 1442 (. #%: 7ther 7ther Laoratory E3a$s ". 5ana 5ana+e +e$e $ent nt """.#heu$atic (eart Disease A. Descri*tion Descri*tion ). Dia+nosis Dia+nosis C. 5e'ical 5ana+e$ent D. Disease ro+ression ro+ression an' "nter&ention E. Dierentia Dierentiatin+ tin+ #% an' #(D %. 5ana+e$e 5ana+e$ent nt "9. "9. Questions an' an' Ansers Ansers
RHEUMATC !E"ER A'% RHEUMATC HEART %SEASE R#eu$atic !ever 5ost 5ost co$$on co$$on cause o/ acuired heart 'isease in chil'ren! a'olescents an' youn+ a'ults orl'i'e atholo+y: atholo+y: 'iuse in;a$$ation o/ connecti&e tissues o/ heart! as a se?uelae an' onset 'e*en's hether it as 'etecte' early or not or treate' early or not #elationshi* ith rou* A @-he$olytic Streptococcus estalishe'
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R#eu$atic Heart %isease Chroni Chronic c &al&ul &al&ular ar heart heart 'iseas 'isease e as a se?uel se?uelae ae o/ rheu$atic /e&er =#%> hen recurrent #% causes scarrin+ o/ the heart! it eco$es #heu$atic (eart Disease =#(D> o 5ust ha&e oth the recurrence an' the scarrin to consi'er #(D as a se?uelae o/ #% o E3actly henB
"t 'e*e 'e*en' n's s on the the *ati *atien entt hen hen in the the continuu$! 'i' heshe sou+ht inter&entionB inter&entionB 'oes heshe tae $e'ication re+ularly! etc.
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Epide$iolo*: R! and RH% Ta+le 1, -revalence o. R! and RH% in Sc#ool C#ildren Countr* Rate 18. 1000 %evelopin countries Philippines 141-1480 0.4 1000 1481-1440 0. 1000 2010 0. 1000 %eveloped countries USA 141-1480 0. 1000 12.F 1000 Australia 1481-1440 =ecause o/ aori+ines> •
hili**ines o "n a stu' stu'y y at the the ( ( =148 =148-14 1440 40>! >! the the *ea *ea inci'ence o/ #% an' #(D is /ro$ /01/ *ears old o Deaths /ro$ #% an' #(D =Achutti , Achutti! 1442> 1G o/ car'io&ascular 'eath 200!000 cases year
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orl'i'e =orl' (eart %e'eration> o 1. $illion *eo*le aecte' orl'i'e o Al$ost 00!000 ne cases each year o A**ro3i$ately F0!000 'eaths each year o 5ost occur in 'e&elo*in+ countries =/or 'e&elo*e' countries! this is alrea'y *art o/ the +ran' roun's>
4EREE& STT %A5 %A5A'
hyB they can aor' a chec-u* ecause they ha&e the $oney
Ris !actors #is /actors /or #% o o&erty o oor housin+! o&ercro'e' housin+ o #e'uce' access to health care #is /actor /or #(D #ecurrent e*iso'es o/ #% o #ecurrent RHEUMATC !E"ER -at#oenesis o. R#eu$atic !ever Actual $echanis$ unnon ostulate: Autoi$$une or #*persensi #*persensitivit tivit* * reaction reaction to o Autoi$$une rou* rou* A Stre* Stre* =AS> =AS> *ro'uces *ro'uces *atho+enic *atho+enic autoantio'ies to car'iac tissues o Anti-stre*tococcal antio'ies $a'e y the in/ecte' host cross-react cross-react ith host connecti&e connecti&e tissue tissue =ie. car'iac! *ul$onary! syno&ial! *eritoneal> anti+ens an' lea' to en'-or+an 'a$a+e y an i$$unolo+ic $echanis$. is eli elie& e&e' e' to e caus cause' e' y anti antio o'y 'y cross crosso "t reacti&ity. his his cros crosss-re reac acti ti&i &ity ty is a T*pe *pe #*persensitivit* reaction an' is ter$e' $olecular $olecular $i$icry. Hsually! Hsually! sel/-reacti&e sel/-reacti&e ) cells re$ain aner+ic in the *eri*hery ithout cell co-sti$ula co-sti$ulation. tion. Durin+ Durin+ a Stre*toco Stre*tococcus ccus in/ection in/ection!! $ature anti+en *resentin+ cells such as $acro*ha+es *resent the acterial anti+en to CDI cells hich 'ierentiate into hel*er 2 cells. (el*er 2 cells suse?uently acti&ate the ) cells to eco$e *las$a cells an' in'uce the *ro'uction o/ antio'ies a+ainst the cell all o/ Stre*tococcus. (oe&er the antio'ies $ay also react a+ainst the $yocar'iu$ an' ! so$eti$es acute +lo$erulone*hritis =AK> o "/ the *atient co$*lains to you o/ tonsillitis! as yoursel/ hether it is a &iral in/ection or not o Chec /or *resence o/ e3u'ates o
Ko e3u'ate 'oes not $ean no ris /or #% E3u'ate E3u'ate ill usually usually a**ear a/ter se&eral se&eral 'ays so ree3a$ine the *atient "/ still still no e3u'a e3u'ate! te! usual usually ly &iral &iral in/e in/ecti ction on.. "/ ith ith e3u'ate! consi'er ris /or #%. %eatur eatures es su++e su++esti sti&e &e o/ viral etiolo+y: etiolo+y: con cou+h 'iarrhea
Sin in/ection only lea's to AK ut ne&er #% ersistence ersistence o/ &irulent strain AS or+anis$ Antio'y res*onse A+e: usually at a+es -1 ecause o/ e3*osure to school +roun's ene eneti tic c or /a$i /a$ili lial al ten' ten'en ency cy:: s*ec s*eci6 i6c c ) cell cell alloanti+en =D81> , (LA i'enti6e' =not yet *ro&en> Socio-econo$ic status o&erty!! o&ercro o&ercro'e' 'e' housin+! housin+! re'uce' re'uce' access access to o o&erty health care still the $ost co$$on ris /actor o
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OS 213: Circulation and Respiration (Cardiovascular Module) LEC 08: RHEUMATC !E"ER and R#eu$atic Heart %isease o
"n the hili**ines =an' *roaly in other 'e&elo*in+ countries as ell> e are ca*ale o/ treatin+ itM it is o 5-*rotein o "n'uces antio'ies o Seroty*es ! , 14 cross react ith $yosin Enzy$es o Stre*tolysin o Deo3yrionuclease o %irinolysin o Di*hos*ho*yri'ine nucleoti'ase o (yaluroni'ase
9aluale /or con6r$ation o/ *re&ious stre*tococcal in/ections in *atients sus*ecte' o/ ha&in+ acute #% =A#%> or *ost-stre*tococcal +lo$erulone*hritis =SK> o (el*/ul in *ros*ecti&e e*i'e$iolo+ical stu'ies /or 'istin+uishin+ *atients ith acute in/ection /ro$ *atients ho are carriers o A *ositi&e anti-stre*tococcal antio'y titers 'oes not necessarily $ean that #% is *resent! Jones criteria $ust still e /olloe' o cut-o: 220 units "n su$$ary! the Dia+nosis o/ AS onsillo*haryn+itis o Clinical , E*i'e$iolo+ical %in'in+s o Laoratory tests throat culture an'or #a*i' Anti+en o
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AR!: Ae and %istri+ution 5ost co$$on in a+es -1 years ol' #are in chil'ren less than years ol' "n the hili**ines! ith re+ar' to *ea inci'ence! there are less than cases ho are a+e' 2-F years ol' -at#olo* E3u'ati&e 'e+enerati&e in;a$$atory lesions o ransient $ani/estations o #es*on's to anti-in;a$$atory a+ents roli/erati&e lesions o Aschos no'ules Areas o/ in;a$$ation o/ the connecti&e tissue o/ the heart! or /ocal interstitial in;a$$ation %ully 'e&elo*e': +ranulo$atous structures consistin+ o/ 6rinoi' chan+e! ly$*hocytic in6ltration! occasional *las$a cells an' characteristically anor$al $acro*ha+es =$ay /use to /or$ $ultinucleate' +iant cells> surroun'in+ necrotic cells Dia+nostic /or #% Done on io*sy ut to'ay in #! not 'one any$ore.
!iure 1, Streptococcal Tonsillop#ar*nitis, 'ote t#e presence o. patc#* discrete e;udates ( Epide$ioloical !indin > %ianosis o. 9AS Tonsillop#ar*nitis 1.(istory o/ e3*osure 2.atient a+e' 1 years F.Su''en onset sore throat I.%e&er , (ea'ache ."n;a$$ation o/ *haryn3 an' tonsils *atchy 'iscrete e3u'ates .resentation in inter or early s*rin+ .en'er! enlar+e' anterior cer&ical no'es 8.Kausea! &o$itin+! an' a'o$inal *ain
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&a+orator* Test .or 9AS Tonsillop#ar*nitis hroat sa an' culture =+ol' stan'ar'> /or 'ocu$entation o/ AS in u**er o Stan'ar' res*iratory tract , /or con6r$ation o/ clinical 'ia+nosis o/ acute stre* *haryn+itis o "/ 'one correctly sensiti&ity o/ 40-4G o Disa'&anta+e there is 'elay =a/ter aout I8 hours> in otainin+ the result #a*i' Anti+en Detection ests =#AD> ut this is &ery e3*ensi&e so not 'one any$ore Anti-stre*tococcal Antio'y iters ='one in (> o Can re;ect *ast ut not *resent i$$unolo+ic e&ents o Ko &alue in the 'ia+nosis o/ acute *haryn+itis
4EREE& STT %A5A'
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ersists /or $any years %ianosis: 4ones Criteria 1??2 Estalish initial attac o/ acute rheu$atic /e&er Kot inten'e' o o estalish 'ia+nosis o/ inacti&e or chronic #(D o o $easure rheu$atic acti&ity o o *re'ict course or se&erity o/ 'isease re&ious #% or #(D not inclu'e' as $ani/estation Ma@or Mani.estations $ost co$$on a$on+ hos*italize' o Car'itis *atients o olyarthritis $ost co$$on $ani/estation o&erall =$i+ratory> o Chorea o Erythe$a $ar+inatu$ =least co$$on> o Sucutaneous no'ule Minor Mani.estations o %e&er =hi+h-+ra'e! shoul' last / or at least 'ays> o Arthral+ia acute *hase reactants: ele&ate' o "ncrease' erythrocyte se'i$entation rate =ES#> an' Creacti&e *rotein =C#> st o rolon+e' # inter&al &ia EC test ill cause 1 'e+ree A9 loc
Ho to Use 4ones Criteria •
here is a hi+h *roaility o/ #% hen the *atient has o 2 $a@or $ani.estations ! or $a@or an' 2 $inor $ani/estations *lus o 1 su**ortin+ e&i'ence o/ precedin 9AS in.ection (ala*s)
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OS 213: Circulation and Respiration (Cardiovascular Module) LEC 08: RHEUMATC !E"ER and R#eu$atic Heart %isease o
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AS in/ection: throu+h =1> antio'y sensin+ an' =2> stre*tococcal culture +ol' stan'ar' Kote: $ani/estations shoul' e to unrelate' sy$*to$s such as i/ you use pol*art#ritis as $a MAT- (Mitral Aortic Tricuspid o Mne$onic: and -ul$onic) in order o. +ein aBected t#e $ost Cardio$eal* o not *resent in $il' car'itis Restin tac#*cardia no i/ the restin+ tachycar'ia is 'ue to /e&er or car'itis o Hsually associate' ith /e&er o eneral rule in chil'ren: an increase o/ one 'e+ree Celsius in te$*erature corres*on's to an increase o/ heart rate y 10 eats *er $inute -ericardial .riction ru+ o 7nce *ericar'ial eusion is *resent! no $ore soun' o Hsually seen in *ost-o* *atients or usually &ery early in a 'isease Conestive #eart .ailure o +allo* rhyth$ =SF> o $uVe' heart soun's o arrhyth$ia o E'e$a in oth L an' # o %or #: *ul$onary e'e$a
#a*i' healin+ ithout se?uelae in contrast ith Ju&enile #heu$atoi' Arthritis hich is *rolon+e' an' can cause 'e/or$ities Hsually resol&es in W2I hrs hen +i&en as*irin
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Sy'enha$s choreaM St. 9itus 'anceM chorea $inor #heu$atic in&ol&e$ent o/ asal +an+lia , cau'ate nucleus ur*oseless , in&oluntary $o&e$entM $uscular incoor'ination , eanessM 'artin+ ton+ueM e$otional laility , slurre' s*eechM su''en ;in+in+ o/ ar$sM 'eterioration o/ han'ritin+ X$il $ai's si+nY Delaye' $ani/estation or sel/-li$itin+ E3ce*tion to the Jones criteria: hen chorea is *resent ithout any other sy$*to$s! auto$atically it is rheu$atic in ori+in unless *ro&en otherise can stan' alone also an e3ce*tion: indolent carditis as #% in ori+in auto$atically Aects a'olescentsM 'isa**ear in 12 s! e&en ithout treat$entM $ore co$$on in o$en reat ith *enicillin
Ma@or Mani.estation : Er*t#e$a Marinatu$ • • • •
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Kot easy to see! usually occurs ith /e&er "rre+ularly-sha*e' an' $a*-lie lesion Distincti&e non-*ruritic transient rash ale centers ith roun' or ser*i+inous =sloly *ro+ressin+cree*in+> $ar+in )lanches run , *ro3i$al e3tre$itiesM not the /ace Hrticaria-lie ut is in'uce' y heat ='isa**ears hen col' so co&er ith lanet to elicit>
T5-ES O! CAR%TS •
Mild carditis no car'io$e+aly an' no C(% o can e cure' an' the heart can re&ert ac to its nor$al state Moderate carditis o $il' car'io$e+aly , C(% o co$$only *rocee's to se&ere car'itis Severe carditis o car'io$e+aly ith se&ere *ul$onary con+estion or e'e$a o $ay 'ie on a'$ission Ec#ocarditis - Echocar'io+ra*hic anor$alities lie 59! 5#! or A# in acute rheu$atic /e&er in the asence o/ clinical car'itis =&al&ular re+ur+itation> Mitral stenosis in c#ildren $ost *roaly con+enital ecause you nee' at least years o/ #% in or'er to *ro'uce $itral stenosis Su+clinical carditis Car'iac in&ol&e$ent in the o asence o/ &al&ulitis sy$*to$sM 'ia+nose' ith 2D echo. Contro&ersy hether to inclu'e o suclinical car'itis in the $o'i6e' Jones Criteria “Although echocardiography is o
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!iure 2, -in0to0red non0pruritic $acules or papules located on t#e trun and pro;i$al li$+s +ut never on t#e .ace, T#e lesions spread outard to .or$ a serpiinous rin it# er*t#e$atous raised $arins and central clearin, Ma@or Mani.estation /: Su+cutaneous 'odules • •
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S$all! 6r$! *ainless! /reely $o&ale , transient E3tensor sur/ace o/ elos! nees! , ristsM scal* , s*inal areas =alays *al*ate car'iac *atient o/ rheu$atic ori+in in scal* an' s*ine> 7/ten seen ith car'itis
Ma@or Mani.estation 2: Mirator* Art#ritis • • • •
5ost /re?uent , eni+n ut least s*eci6c Asy$$etric , $i+ratory "n;a$$ation Lar+er
Ta+le 3, -ri$ar* -rop#*la;is or -revention o. R#eu$atic !ever Aent
)enzathine
!iure 3, 'odules are Dr$ non0tender .ree .ro$ attac#$ents to t#e overl*in sin and t#e* rane .ro$ a .e $illi$eters to 102c$
enicillin enicillin 9
R! ModiDed 4ones Criteria 1??2 Ta+le 2, Ma@or and Minor Mani.estations o. R! Accordin to t#e 4ones Criteria Ma@or Mani.estations Minor Mani.estations Car'itis %e&er olyarthritis Arthral+ia Sy'enha$s Chorea Ele&ate' acute *hase reactants Erythe$a $ar+inatu$ rolon+e' # "nter&al Sucutaneous no'ules ZLHS su**ortin+ e&i'ence o/ *rece'in+ AS in/ection •
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Clinical: %e&er $ust last $ore than 'ays. %e&er $ust e at least F8oC Arthral+ia
Dia+nostic:
EC # inter&al is *rolon+e' su++estin+ 1 o A9 loc "ncrease' acute *hase reactants: ES# , C# are increase' Co$*lete )loo' Count =C)C> an' Chest O-#ay =CO#> not s*eci6c to #%
Jones Criteria 1442! Su**ortin+ E&i'ence Antece'ent rou* A Stre*tococcal "n/ection o ositi&e throat culture or ra*i' anti+en test o Ele&ate' or risin+ Stre*tococcal antio'y titer
Estolate Ethylsuccinate
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C)C o Ane$ia =he$olysis an' 'ilutional ane$ia 'ue to heart /ailure> o Leuocytosis =in;a$$ation! in/ection> EC o Sinus tachycar'ia o o 1 A9 loc[*rolon+e' # inter&al o Ko cha$er enlar+e$ent =as o**ose' to #(D> 2o A9 loc! lo &olta+es! S- a&e o #arely chan+es CO# o Kor$al =ut $ay 'e*en' on se&erity o/ &al&ular lesion> o Car'io$e+aly o ul$onary con+estion an' e'e$a Manae$ent ro*hyla3is Anti-in;a$$atory a+ents
-ri$ar* prop#*la;is : prevents 1st episode o. R!
4EREE& STT %A5A'
7ral
10 '
7ral
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20-I0 $++'
7ral
10 '
2-I 3 'ay =$a3: 1+'>
7ral
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I0 $++' 2-I 3 'aily =$a3: 1+'>
7ral
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00!000 H /or *atients \ 2 + 1266666 U .or patients 2F C#ildren: 20 $+ 2-F3'ay AdolescentsGadults: 00 $+ 2-F3'ay
Secondar* -rop#*la;is : prevents recurrences o. R! " 2/6 $ tice dail* o -enicillin (-C') 1,2 M units ever* 21 da*s o 8enIat#ine -C' est choice ecause lon+ actin+! cost eecti&e an' 'ue to +oo' co$*lianceM a'$inistere' &ia the intra$uscular route or depot ecause this $aes the le&els in the loo' constant
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/or %ili*inos: e&ery 21 'ays ecause *enicillin le&els +o 'on a/ter 21 'ays Short actin+ enzyl *enicillin 7ral *enicillin - 23 a 'ay /or 10 'ays =i$*ortant to stress co$*liance ith the nu$er o/ 'ays the antiiotic is a'$inistere' to ensure that the $icroor+anis$ ill e co$*letely era'icate'> Azithro$ycin - +i&en only /or 'ays
Duration o/ recurrence>
2o *ro*hyla3is =or *re&ention o/
Arthritis - $ini$u$ o/ years or until a+e 21 hiche&er is lon+er assu$in+ no recurrence o/ the 'isease eteen -21 years. "/ there is recurrence! a'' $ore years /ro$ last onset. Car'itis - at least 10 years assu$in+ recurrence /ree , no resi'ual heart 'isease or 21 hiche&er is lon+er i/ #(D! lon+-ter$ *ro*hyla3is ecause o/ scarrin+ i/ oth are *resent! choose the lon+-ter$ so treat car'itis
Ta+le , Secondar* -revention o. R#eu$atic !ever Aent )enzathine enicillin
-rop#*la;is •
%urati on 7nce
00 $+ on 6rst 'ay 7ral ' 20 $+' /or the ne3t I ' Bonow et al., A!A"A #AS$ %'( '(P'# )A *ol. +, -o. , -ov /0012 /3145/11A!A"A 6uidelines for the 7anagement of Patients 8ith*alvular "eart 9isease
R!: Ot#er &a+orator* E;a$s •
Mod e "5
Azithro$ycin
Kotes $inor $ani/estations o Clinical &s Dia+nostic
%or *eo*le aller+ic to enicillin: Erythro$ycin
%ose
enicillin 9
%ose 1266666 U ever* 21 da*s .or !ilipinos (ver* i$portant) =e&ery F /or hi+h ris *atients such as those ith resi'ual car'itis> 20 $+ 23'ay
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OS 213: Circulation and Respiration (Cardiovascular Module) LEC 08: RHEUMATC !E"ER and R#eu$atic Heart %isease Sul/a'iazine
0. + once 'aily /or *atients \ 2 + 1.0 + once 'aily /or *atients ] 2 +
7ral
%or *eo*le aller+ic to *enicillin an' sul/a'iazine: Erythro$ycin 20 $+ tice 'aily 7ral :"igh5ris; patients include those with residual rheumatic carditis as well as patients from economically disadvantaged populations.
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Mitral Stenosis •
Ta+le /, %uration o. Secondar* -rop#*la;is 9roup
A#% =no car'itis> 5il'-$o'erate car'itis =or heale' car'itis>
%uration o. Secondar* -rop#*la;is 5ini$u$ o/ years a/ter last A#%! or Hntil a+e 21 years hiche&er is lon+er 5ini$u$ o/ 10 years a/ter last A#%! or Hntil a+e 2 years =hiche&er is lon+er> Continue /or li/e
Se&ere #(DM a/ter sur+ery a 200 orl' (ealth %e'eration e start countin+ the 'uration o/ *ro*hyla3is (EK rheu$atic /e&er is cure' c %or car'itis! you start countin+ 10 years /ro$ the ti$e the heart as cleare' /ro$ car'itis ' "n the hili**ines! the cut o a+e is 21 years
Anti0inJa$$ator* Aents •
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%or -8 ees o *re'nisone 2 $++'ay o as*irin 100 $++'ay *lus co$*lete e' rest /or at least F $onths /or se&ere car'itis =$ay e&en sto* schoolin+> RHEUMATC HEART %SEASE %escription (eart 'isease as a se?uelae o/ chronic #% an' its recurrences (eart &al&es are scarre' 'ue to healin+ *rocess /olloin+ A#% #(D is $ore liely to 'e&elo* /olloin+ A#% i/ o he initial e*iso'e o/ A#% as se&ere o he heart as aecte' ith A#% o A#% occurre' at a youn+ a+e o here has een recurrent A#% 0G o/ *eo*le ith #(D 'o not re$e$er ha&in+ A#% ecause so$e sy$*to$s are sel/-li$itin+ "alve Reuritation su++ests that heart &al&es o Are thicene' an' stic a+ainst the alls o/ the heart =the loo' ;os acar's o&er the o Leaa+e &al&e> "alve Stenosis su++ests that heart &al&es o )eco$e sti not allo loo' to ;o throu+h easily o Do =restricte' /orar' ;o>
hy 'oes it ra'iate to the a3illaB the le/t atriu$ is the $ost *osterior cha$er o/ the heart 5ost co$$on o EC - nor$alM LAE! L9( o CO# - nor$alM LAE! L9(M *ul$onary con+estion o Echo - thicene' &al&eM 'ilate' 59 annulusM ECKor$alM LAE! L9(
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lo-*itche'! 'iastolic ru$le hear' est at the a*e3 ith the ell o/ the stethosco*e an' ith the *erson lyin+ in the le/t lateral *osition. 7nce the $itral &al&e is 'a$a+e'! hen the *atient is cure' it can return to its nor$al state hen the aortic &al&e is 'a$a+e'! it cannot return to its ori+inal state! its /ore&er 'a$a+e' o "n 10-F0G o/ cases o ro'uces a thrill u*on EM thou+h not all 'o
Aortic Reuritation •
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a 'iastolic loin+ 'ecrescen'o $ur$ur est hear' at the le/t sternal or'er ith the *erson sittin+ u* an' leanin+ /orar' in /ull e3*iration EC - L9(M Strain *attern CO# - L9(M Dilate' aorta Echocar'io+ra$ - thicene' lea;ets ith *rola*se' (ea&e in'icati&e o/ &olu$e o&erloa' %irosis an' contracture o/ the aortic &al&e #e+ur+itation across inco$*etent &al&e! increase in L9 &olu$e! aortic run-o L9 'ilation 'ecrease' $yocar'ial contractility #arely isolate' =icus*i' aortic &al&e i/ isolate'>M usually ith 5# ro$inent caroti' *ulse Corri+ans *ulse Katural (istory: C(%! chest *ain =in A# &s 5#>! in/ecti&e en'ocar'itis o "sche$ic A# less coronary *er/usion 'urin+ 'iastole
Ot#ers •
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Aortic stenosis : not co$$onM i/ there is! then its $ost *roaly con+enital Tricuspid reuritation Tricuspid stenosis : rare =least co$$on> -ul$onar* reuritation: relate' to *ul$onary hy*ertension -ul$onar* stenosis: &ery rare
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%ianosis Clinical history an' *hysical e3a$ination )loo' e3a$inations =C)C! ES#! Anti-Stre* Antio'y iters! C#! loo' culture stu'y> , urinalysis EC an' CO# Echocar'io+ra*hy: E =transthoracic>! EE =transeso*ha+eal>
EC - Kor$alM LAE! #9( CO# - LAE! #9(M ul$onary con+estionM Dilate' 5A Echo - hicene' 63e' lea;etsM S$all 59A =6sh$outh co$$isure> (istory o/ C(%! #9%
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EC9 Kor$al i/ lesions are $il' 5#: LAE! L9( 5S: LAE! #9( A#: L9( #: #AE! #9( C#est K0Ra* ul$onary &enous con+estionM chronic , se&ere lesions
a *ansystolic $ur$ur hear' lou'est at the a*e3 an' ra'iatin+ laterally to the a3illaM so/t S1
4EREE& STT %A5A'
5A
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Medical Manae$ent
Mitral Reuritation •
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Anti-C(%
U-CM 2617 8: O9"! alan+ Pa*antay
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OS 213: Circulation and Respiration (Cardiovascular Module) LEC 08: RHEUMATC !E"ER and R#eu$atic Heart %isease OUT&'E
". #heu$ #heu$ati atic c %e&er %e&er an' #heu$atic (eart Disease A. #heu$atic #heu$atic %e&er %e&er ). #heu$atic (eart Disease C. E*i'e$iolo+y: E*i'e$iolo+y: #% , #(D D. #is %actors %actors "". #heu$atic #heu$atic %e&er %e&er A. atho+e atho+enesis nesis o/ #heu$atic %e&er ). Etiolo+y Etiolo+y C. La est /or AS onsillo*haryn+itis onsillo*haryn+itis D. A#%: A#%: A+e , Se3 Distriution E. atholo+ atholo+y y
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%. Dia+nosis: Dia+nosis: Jones Jones Criteria 1442 . Dia+nosis: #% 5o'i6e' Jones Criteria 1442 (. #%: 7ther 7ther Laoratory E3a$s ". 5ana 5ana+e +e$e $ent nt """.#heu$atic (eart Disease A. Descri*tion Descri*tion ). Dia+nosis Dia+nosis C. 5e'ical 5ana+e$ent D. Disease ro+ression ro+ression an' "nter&ention E. Dierentia Dierentiatin+ tin+ #% an' #(D %. 5ana+e$e 5ana+e$ent nt "9. "9. Questions an' an' Ansers Ansers
RHEUMATC !E"ER A'% RHEUMATC HEART %SEASE R#eu$atic !ever 5ost 5ost co$$on co$$on cause o/ acuired heart 'isease in chil'ren! a'olescents an' youn+ a'ults orl'i'e atholo+y: atholo+y: 'iuse in;a$$ation o/ connecti&e tissues o/ heart! as a se?uelae an' onset 'e*en's hether it as 'etecte' early or not or treate' early or not #elationshi* ith rou* A @-he$olytic Streptococcus estalishe'
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R#eu$atic Heart %isease Chroni Chronic c &al&ul &al&ular ar heart heart 'iseas 'isease e as a se?uel se?uelae ae o/ rheu$atic /e&er =#%> hen recurrent #% causes scarrin+ o/ the heart! it eco$es #heu$atic (eart Disease =#(D> o 5ust ha&e oth the recurrence an' the scarrin to consi'er #(D as a se?uelae o/ #% o E3actly henB
"t 'e*e 'e*en' n's s on the the *ati *atien entt hen hen in the the continuu$! 'i' heshe sou+ht inter&entionB inter&entionB 'oes heshe tae $e'ication re+ularly! etc.
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Epide$iolo*: R! and RH% Ta+le 1, -revalence o. R! and RH% in Sc#ool C#ildren Countr* Rate 18. 1000 %evelopin countries Philippines 141-1480 0.4 1000 1481-1440 0. 1000 2010 0. 1000 %eveloped countries USA 141-1480 0. 1000 12.F 1000 Australia 1481-1440 =ecause o/ aori+ines> •
hili**ines o "n a stu' stu'y y at the the ( ( =148 =148-14 1440 40>! >! the the *ea *ea inci'ence o/ #% an' #(D is /ro$ /01/ *ears old o Deaths /ro$ #% an' #(D =Achutti , Achutti! 1442> 1G o/ car'io&ascular 'eath 200!000 cases year
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orl'i'e =orl' (eart %e'eration> o 1. $illion *eo*le aecte' orl'i'e o Al$ost 00!000 ne cases each year o A**ro3i$ately F0!000 'eaths each year o 5ost occur in 'e&elo*in+ countries =/or 'e&elo*e' countries! this is alrea'y *art o/ the +ran' roun's>
4EREE& STT %A5 %A5A'
hyB they can aor' a chec-u* ecause they ha&e the $oney
Ris !actors #is /actors /or #% o o&erty o oor housin+! o&ercro'e' housin+ o #e'uce' access to health care #is /actor /or #(D #ecurrent e*iso'es o/ #% o #ecurrent RHEUMATC !E"ER -at#oenesis o. R#eu$atic !ever Actual $echanis$ unnon ostulate: Autoi$$une or #*persensi #*persensitivit tivit* * reaction reaction to o Autoi$$une rou* rou* A Stre* Stre* =AS> =AS> *ro'uces *ro'uces *atho+enic *atho+enic autoantio'ies to car'iac tissues o Anti-stre*tococcal antio'ies $a'e y the in/ecte' host cross-react cross-react ith host connecti&e connecti&e tissue tissue =ie. car'iac! *ul$onary! syno&ial! *eritoneal> anti+ens an' lea' to en'-or+an 'a$a+e y an i$$unolo+ic $echanis$. is eli elie& e&e' e' to e caus cause' e' y anti antio o'y 'y cross crosso "t reacti&ity. his his cros crosss-re reac acti ti&i &ity ty is a T*pe *pe #*persensitivit* reaction an' is ter$e' $olecular $olecular $i$icry. Hsually! Hsually! sel/-reacti&e sel/-reacti&e ) cells re$ain aner+ic in the *eri*hery ithout cell co-sti$ula co-sti$ulation. tion. Durin+ Durin+ a Stre*toco Stre*tococcus ccus in/ection in/ection!! $ature anti+en *resentin+ cells such as $acro*ha+es *resent the acterial anti+en to CDI cells hich 'ierentiate into hel*er 2 cells. (el*er 2 cells suse?uently acti&ate the ) cells to eco$e *las$a cells an' in'uce the *ro'uction o/ antio'ies a+ainst the cell all o/ Stre*tococcus. (oe&er the antio'ies $ay also react a+ainst the $yocar'iu$ an' ! so$eti$es acute +lo$erulone*hritis =AK> o "/ the *atient co$*lains to you o/ tonsillitis! as yoursel/ hether it is a &iral in/ection or not o Chec /or *resence o/ e3u'ates o
Ko e3u'ate 'oes not $ean no ris /or #% E3u'ate E3u'ate ill usually usually a**ear a/ter se&eral se&eral 'ays so ree3a$ine the *atient "/ still still no e3u'a e3u'ate! te! usual usually ly &iral &iral in/e in/ecti ction on.. "/ ith ith e3u'ate! consi'er ris /or #%. %eatur eatures es su++e su++esti sti&e &e o/ viral etiolo+y: etiolo+y: con cou+h 'iarrhea
Sin in/ection only lea's to AK ut ne&er #% ersistence ersistence o/ &irulent strain AS or+anis$ Antio'y res*onse A+e: usually at a+es -1 ecause o/ e3*osure to school +roun's ene eneti tic c or /a$i /a$ili lial al ten' ten'en ency cy:: s*ec s*eci6 i6c c ) cell cell alloanti+en =D81> , (LA i'enti6e' =not yet *ro&en> Socio-econo$ic status o&erty!! o&ercro o&ercro'e' 'e' housin+! housin+! re'uce' re'uce' access access to o o&erty health care still the $ost co$$on ris /actor o
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U-CM 2617 8: O9"! alan+ Pa*antay
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