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PATHOPHYSIOLOGY
It is believed that certain proteins produced by the group A Streptococci are structually similar to
those found in the heart. The immune system reacts to the presence of bacteria by producing specific
substances, called antibodies, to attack them and stop their spread inside the body. But as these antibodies
attack the bacteria, some of them also attack or cross-react with the tissues in the heart, and this often
results in the manifestation of many RHD symptoms.
Classification
RHD
Mitral valve
aortic valve
tricuspid valve
Regurgitation
Regurgitation
Regurgitation
stenosis
A. MITRAL REGURGITATION:
A condition which is characterized by a regurgitation of blood from the left ventricle into the atrium due
to a problem with the mitral valve.
or
Backflow of blood from the left ventricle into the left atrium, owing to imperfect functioning of the
mitral valve.
Hemodynamics
pulmonary circulation and the right heart. Left atrial compliance decreases the afterload on the LV,
whereas LV dilation and hypertrophy increases contractility. These important changes keep the overall
afterload on the left heart normal or unchanged. Although the regurgitant fraction may be high, the larger
stroke volume compensates, maintaining a nearly normal forward cardiac output (see the image below).
Symptoms:
Children with mild to moderate regurgitation usually do not develop any symptoms
and lead a normal life. Children with more severe leakage may experience
symptoms such as:
Shortness of breath
Difficulty breathing, especially during exertion
Fatigue
Rapid breathing
tachypnoea
Poor feeding
Delayed growth and failure to thrive
Excessive sweating
Fast heart rate
Palpitations
congestive Heart failure
Heart sounds: Upon auscultation, the first heart sound is usually slightly diminished,
whereas the second heart sound is usually split. With more severe mitral regurgitation, a
third heart sound and a mid diastolic low frequency murmur may be present, caused by
increased ventricular filling.
Murmur: Patients with mild mitral regurgitation may reveal no signs other than a
characteristic apical systolic murmur. The sound of the typical mitral regurgitation murmur
is characterized as blowing and high pitched, and it is loudest over the apex with radiation
to the left axilla. The murmur is often pansystolic, beginning immediately after the first
heart sound, and may continue beyond the aortic component of the second heart sound,
thus obscuring the murmur.
B. MITRAL STENOSIS
Definition
Mitral valve stenosis results from a pathologic process that narrows the effective mitral valve orifice.
Hemodynamics
Mitral stenosis obstruction to blood flow from LA to LV increase LA pressure hypertrophy of LA
increase pulmonary venous pressure pulmonary congestion dyspnoea
Clinical manifestation
Patients with mitral stenosis may present with exertional dyspnea, fatigue, atrial arrhythmias, embolic
events, angina-like chest pain, hemoptysis, or even right-sided heart failure. Previously asymptomatic or
stable patients may decompensate acutely during exercise, emotional stress
The characteristic findings of MS on auscultation are an accentuated first heart sound, an opening snap,
and a mid-diastolic rumble.
C. AORTIC REGURGITATION
Definition : A condition which is characterized by a backward leak from aorta into the left ventricle
during diastole.
Classification
Mild :difference between systolic pressure in brachial artery and femoral artery is
20 mm of hg
Moderate: pressure difference is 20-40 mm of hg
Severe: pressure difference is 40-60 mm of hg
less than
HEMODYNAMICS
Blood volume in LV increase
blood
increase size of LV
LV pressure
D. TRICUSPID REGURGITATION
Definition: Refers to the failure of the heart's tricuspid valve to close properly
during systole. As a result, with each heart beat some blood passes from the right
ventricle to the right atrium, the opposite of the normal direction.
Hemodynamics
Systolic leak
volume load of RV, RA increase Increase size of RA, RV
diaplace downward and outward
RA, RV
Clinical features
Systolic and diastolic murmur loud during inspiration, pain right hypochondrium,
fatigue, dyspnoea, pulmonary arterial hypertension, enlarged RA and RV displaced
downward, prominent V waves in the jugular venous pulse, systolic pulsation of
liver, systolic murmur in lower left sternal border increasing intensity with inspiraton
DIAGNOSIS Of RHD
History
Physical examination
Vital
Cardiac examination
Laboratory Studies
Throat
signs
culture
Throat culture findings for group A beta hemolytic Streptococcus are usually negative by the time
symptoms of rheumatic fever or rheumatic heart disease appear. Attempts should be made to isolate the
organism before the initiation of antibiotic therapy to help confirm a diagnosis of streptococcal
pharyngitis and to allow typing of the organism if it is isolated successfully.
Rapid antigen detection test
This test allows rapid detection of group A streptococcal antigen and allows the diagnosis of streptococcal
pharyngitis and the initiation of antibiotic therapy. Because the rapid antigen detection test has a
specificity of greater than 95% but a sensitivity of only 60-90%, a throat culture should be obtained in
conjunction with this test.
Antistreptococcal antibodies
The clinical features of rheumatic fever begin at the time antistreptococcal antibody levels are at their
peak. Thus, antistreptococcal antibody testing is useful for confirming previous group A streptococcal
infection. Sensitivity for recent infections can be improved by testing for several antibodies. Antibody
titers should be checked at 2-week intervals in order to detect a rising titer.
Imaging Studies
Chest roentgenography
Cardiomegaly, pulmonary congestion, and other findings consistent with heart failure may be seen on
chest radiography. When the patient has fever and respiratory distress, chest radiography helps
differentiate heart failure from rheumatic pneumonia.
Doppler-echocardiogram
In acute rheumatic heart disease, Doppler-echocardiography identifies and quantitates valve insufficiency
and
ventricular
dysfunction.
Other Tests
On ECG, sinus tachycardia most frequently accompanies acute rheumatic heart disease.
Histologic Findings
Pathologic examination of the insufficient valves may reveal verrucous lesions at the line of closure.
Cardiac catheterization
o Cardiac catheterization is usually performed in infants, children, and older adolescents in
anticipation of balloon aortic valvuloplasty.
o Other indications for catheterization may include the need for accurate hemodynamic
assessment in patients with multiple levels of obstruction, such as mitral stenosis or
subaortic stenosis in combination with aortic valve stenosis.
MEDICAL MANAGEMENT
Medications: Medications do not rectify the valves but treat the complications and reduce the
consequences. Medications cannot make up the mechanical problems due to narrowing of valves
especially in stenotic cases which essentially require surgery. Medications are generally effective in
valvular regurgitation cases.
1. Angiotensin Converting Enzyme (ACE) Inhibitors: These are used to widen blood vessels, lower
blood pressure and decrease the workload on heart (in valvular regurgitation). Eg ramipril, 1.5mg/day
2. Antiarrhythmics: These maintain a regular heartbeat and reduce the rapid heart rhythms. Thus, the
heart beats less frequently but pumps blood more throughout the body . Inj atropine
Age
(years)
2
3
4
5
6-8
9-12
1.5-3.0
2.0-3.0
2.0-4.0
2.5-4.5
2.5-5.0
3.5-5.0
3. Anticoagulants: Valvular problems can lead to blood clots. Anticoagulants help prevent clot
formation inside the heart chambers or on a damaged heart valve. Eg aspirin 3-5 mg/kg/day
4. Antibiotics: Antibiotics are given to the patients suffering from valvular heart disease before any dental
procedure, surgery and IV drug to prevent bacteria from sticking to abnormal heart valves. Amoxicillin 50
mg/kg orally 1 h before procedure. Ampicillin 50 mg/kg I.M./I.V. within 30 min before procedure
5. Beta-blockers: Beta-blockers slow the heart rate so the work of heart is made easier. Eg propanolol 2-4
mg/kg/day in two devided doses orally.
9. Digitalis: Digitalis is prescribed for treatment of arrhythmias, particularly atrial fibrillation. This drug
increases the force of the heart muscles contraction and is helpful if a person has suffered congestive
heart failure. Eg: digoxin 2030 g/kg IV; give 1/2 the initial dose, then 1/3 of dose at 812 h.
10. Diuretics: These drugs help the body rid of excess fluid and salt. Diuretics also reduce swelling and
ease the workload on heart. Eg thiazide 2mg/kg/day BD and Infants under 6 months of age may require
up to 3 mg/kg per day, in 2 divided doses.
Surgical management
Valve repair: This is an open heart surgery in which the surgeon cuts in to repair the damaged
valve. One such surgery is commissurotomy used to rectify mitral stenosis. In this procedure the
narrowed valve leaflets are widened by opening the fused leaflets or commissures with a scalpel.
Commissurotomy or vulvotomy
Diet
The diet should be nutritious and without restrictions except in the patient with congestive heart failure. In
these patients, fluid and sodium intake should be restricted. Potassium supplementation may be necessary
if steroids or diuretics are used.
Activity
Initially, patients should be placed on bed rest followed by a period of indoor activity before being
permitted to return to school. Full activity should not be allowed until the acute phase reactants have
returned to normal levels.
Nursing management
A. Assessment
The objective assessment is to collect data on :
Cardiac function
Nutritional Status
Discomfort level
Sleep disruption
Knowledge of parents and patients (according to the patient's age) of patient understanding.
Assessment :
Hospital chart
Cardiac auscultation, heart sounds with the rhythm of marching weakened diastole
Vital signs
1.
Intervention :
2.
Activity intolerance related to decreased cardiac output, oxygenation supply and demand
imbalance
goal :
Carrying out activities within the limits of his ability (pulse activity can not be greater than
90 X / minute, no chest pain)
Intervention :
Maintain a sleep until the results of laboratory and clinical status improved
In line with the better situation, monitor the gradual increase in the level of activity
Teach the children / parents who do not realize that the movement is connected with the
Korean and temporary.
In case of chorea, protect from accidents, bedrest and provide appropriate sedation
program.