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dan
PENYAKIT JANTUNG
REMATIK
Abdullah Afif Siregar
Departemen Kardiologi dan Kedokteran
Vaskuler
Fakultas Kedokteran USU
Medan
Pathophysiology:
Rheumatic fever develops in children and adolescents following
pharyngitis with group A beta-hemolytic Streptococcus (ie,
Streptococcus pyogenes).
The organisms attach to the epithelial cells of the upper
respiratory tract and produce a battery of enzymes allowing them
to damage and invade human tissues.
After an incubation period of 2-4 days, the invading organisms
elicit an acute inflammatory response with 3-5 days of sore throat,
Etiopathogenesis :
The pathogenic mechanisms involved in the development of RF remain
Etiopathogenesis :
DIAGNOSIS :
Carditis (40% )
Carditis (40% )
Polyarthritis (75%)
Arthritis is the most common manifestation,
present in 60-80% of patients.
It usually affects the peripheral large joints;
small joints and axial skeleton are rarely
involved.
Knees, ankles, elbows and wrists are the
most
frequently affected. The joints are red, warm
and swollen.
Arthritis is characteristically asymmetrical,
migratory, and very painful, although some
patients may present mild joint complaints. It
usually resolves spontaneously at the most in
2 or 3 weeks.
Arthritis in ARF has an excellent response to
salicylates
Sydenham
Chorea :
Sydenhams chorea is
characterized by involuntary
movements, specially of the
face and limbs, muscle
weakness, disturbances of
speech and gait.
Children usually exhibit
concomitant psychologic
dysfunction, especially
obsessive-compulsive
disorder, increased emotional
lability, hyperactivity,
irritablility and age-regressed
behavior.
It is usually a delayed
manifestation, and is often
the sole manifestation of ARF.
Erythema marginatum :
This is an evanescent, erythematous, non-pruritic
rash with pale centers and rounded or serpiginous
margins. Lesions occur mainly on the trunk and
proximal extremities and may be induced by
application of heat
Diagnosis
:
Infective endocarditis
Reactive arthritis
Drug reactions
Septicaemia
Leukaemia
Gonoccocal arthritis
Tuberculosis
Lyme disease
Serum sickness
Treatment :
Medical therapy involves the following 5 areas:
1. Treat group A streptococcal infection regardless of organism
detection.
2. Steroids and salicylates are useful in the control of pain and
inflammation. The nonsteroidal anti-inflammatory drug (NSAID)
naproxen has also been studied. It is effective and may be easier
to use than aspirin.
3. Heart failure may require digitalis.
4. Administer prophylaxis to patients who have developed ARF.
Patients with ARF should receive prophylaxis against future
GABHS infections. Available regimens include benzathine
penicillin G 1.2 million U IM every month, penicillin V 200,000 U
or 250 mg PO bid, or erythromycin 250 mg PO bid. Most
authorities suggest that prophylaxis be given for 5 years. For
those who have rheumatic carditis, some authorities suggest lifelong prophylaxis.
5. Haloperidol may be helpful in controlling chorea.
Drug Name
Penicillin G benzathine
(Bicillin LA)
Penicillin G procaine
(Crysticillin, Wycillin)
Penicillin VK (Beepen-VK,
Betapen-VK, Robicillin VK,
Veetids)
Description
Long-acting parenteral
penicillin (IM only) indicated
in the treatment of
moderately severe
infections caused by
penicillin G-sensitive
microorganisms.
Some prefer 10-d therapy.
Administer by deep IM
injection only into the upper
outer quadrant of the
buttock.
Adult Dose
Pediatric Dose
Contraindicatio
ns
Documented
hypersensitivity
Documented
hypersensitivity
Documented hypersensitivity
Interactions
Pregnancy
administered concurrently
Drug Name
Description
DOC for patients allergic to penicillin; inhibits RNAdependent protein synthesis, possibly by stimulating the
dissociation of peptidyl t-RNA from ribosomes, which
inhibits bacterial growth.
In children, age, weight, and the severity of infection
determine the proper dosage. When bid dosing is
desired, one-half the daily dose may be administered
q12h. For more severe infections, the dose may be
doubled.
Adult Dose
Pediatric
Dose
Contraindica
tions
Interactions
Pregnancy
Precautions
Description
Adult Dose
60-80 mg/d PO
Pediatric Dose
2 mg/kg/d PO
Contraindicatio
ns
Interactions
Pregnancy
Precautions
Anti inflammatory.
Drug Name
Description
Adult Dose
Pediatric Dose
Contraindications
Interactions
Pregnancy
Precautions
Haloperidol (Haldol)
Description
Adult Dose
0.5-2 mg PO bid/tid
Pediatric Dose
Contraindicatio
ns
Interactions
Pregnancy
Precautions
Digoxin (Lanoxin)
Description
Cardiac glycoside with direct inotropic effects and indirect effects on the cardiovascular
system.
Effects on the myocardium involve a direct action on cardiac muscle that increases
myocardial systolic contractions and indirect actions that result in increased carotid sinus
nerve activity and enhanced sympathetic withdrawal for any given increase in mean
arterial pressure.
Adult Dose
0.125-0.375 mg PO qd
Pediatric Dose
Digitalizing dose:
2-5 years: 30-40 mcg/kg PO
5-10 years: 20-35 mcg/kg PO
>10 years: 10-15 mcg/kg PO
Maintenance dose: 25-35% of PO loading dose
Contraindicatio
ns
Interactions
Pregnancy
Agent
Therapeutic Scheme
Benzathine
penicillin G
Penicillin V
Sulfadiazine
Bed Rest
1-2 wk
Carditis
minimal
2-3 wk
Carditis
moderate
4-6 wk
Carditis
severe
2-4 mo
Indoor ambulation
1-2 wk
2-3 wk
4-6 wk
2-3 mo
Outdor activity
(school)
1-2 wk
2-3 wk
4-6 wk
2-3 mo
Full activity
1-2 wk
2-3 wk
4-6 wk
2-3 mo
Prednisone
Aspirin
0
0
0
0
2-4 wk
2-4 wk
2-6 wk
2-6 wk
Complications
Carditis
Mitral stenosis
Congestive heart failure (CHF)
Prognosis
Sequelae are limited to the heart and are
dependent upon the severity of the carditis
during the acute attack.
.
Rheumatic Heart
Disease
Frequency:
In the US:
Prevalence of rheumatic heart disease in the United States now is less than
0.05 per 1000 population
Internationally:
The incidence of rheumatic fever and rheumatic heart disease has not
decreased in developing countries. Retrospective studies reveal developing
countries to have the highest figures for cardiac involvement and recurrence
rates of rheumatic fever. Estimations worldwide are that 5-30 million children
and young adults have chronic rheumatic heart disease, and 90,000 patients
die from this disease each year. There were no data available in Indonesia
Mortality/Morbidity:
Rheumatic heart disease is the major cause of morbidity from
rheumatic fever and the major cause of mitral insufficiency and
stenosis in the Indonesia and the world.
Variables that correlate with severity of valve disease include the
number of previous attacks of rheumatic fever, the length of time
between the onset of disease and start of therapy, and sex. (The
disease is more severe in females than in males.) Insufficiency from
acute rheumatic valve disease resolves in 60-80% of patients who
adhere to antibiotic prophylaxis.
Race:
The race (when controlled for socioeconomic variables) has not been
documented to influence disease incidence.
Sex:
Rheumatic fever occurs in equal numbers in males and females, but
the prognosis is worse for females than for males.
Age:
Rheumatic fever is principally a disease of childhood,
with a median age of 10 years, although it also occurs in
adults (20% of cases).
Socio-economic factors :
It is well known that socioeconomic and environmental
factors play an indirect, but important, role in the magnitude
and severity of RF and RHD. Such factor as a shortage of
resources for providing quality health care, inadequate
expertise of health-care providers, and a low level of
awareness of the disease in the community can all impact
the expression of the disease in populations. Crowding
adversely affects rheumatic fever incidence
TREATMEN
T
1.
2.
3.
4.
Medical Care:
Medical therapy is directed toward eliminating
the group A strepto coccal pharyngitis
Treatment of the acute inflammatory
manifestations of acute rheumatic fever consists
of administering salicylates and steroids.
If moderate-to-severe carditis is indicated by
cardiomegaly, congestive heart failure, or thirddegree heart block, oral prednisone should be
added to salicylate therapy.
Preventive and prophylactic therapy is indicated
after rheumatic fever and rheumatic heart
disease to prevent further damage to valves.
TREATMEN
T
Surgical Care:
When heart failure persists or worsens after
aggressive medical therapy for acute rheumatic
heart disease, surgery to decrease valve
insufficiency may be life-saving.
Forty percent of patients with acute rheumatic fever
subsequently develop mitral stenosis as adults.
In patients with critical stenosis, mitral valvulotomy,
percutaneous balloon valvuloplasty, or mitral valve
replacement may be indicated.
Due to high rates of recurrent symptoms after
annuloplasty or other repair procedures, valve
replacement appears to be the preferred surgical
option.
Thank You