Rheumatic Heart Disease L Li Rheumatic verb a diffise inflammatory. disease characterized: by a delyed response to an inction by group A beta-bomolytic streptococci (GAS) in the tonsiopharyngeal area, aflécting the bear, joints, central nervous sysiem, skin and subcutaneous tissues, [tis thought thet 40-60% of patients with ARF wil go on to developing RHD. DEEL LON © Ricumatic heat disease is ehionic condition tesiiking fom’ sheuimatie fever which imolves all the ers of the heart (ie. pancanitis) and is charncterved by scarring and deformity. of the beart valves. @The commonest valves. acting are tke mitral and ost, in thot onler. Heweyer all four valves can be afected, INCIDENCE matic fever principally a disease of chikthood, with a median’ age of 10 yeas. aithough it ako occurs in aduks (20% of cases). #Rhcuniatic fever occurs in equal numbers. in’ males and females, bit the prognosis is worse for femaks than tor mks. # The disease is scen mpre commonly’ in poor socio-economic strata of the socity living in damp and overcrowded place. © Common in the developing couniries tke: Inf, Pakisian, © The incidence of RF in Developing countries is 27-100/1 kee /yr (G.S-Sainani 2006) The incidence of rheummic fever (RE) varies. ftom 0.2 (0 0.75/1000/ year in schoo} chiklren 5--15 years ofage (2001 Govt. Census) (Ani Grover,Padamavati § etal, [Link] INJ 2002), ETIOLOGY coup A betashetmalytic streptococcus Rheumatic fever RISK FACTORS * Poor socio-eeanomic status: People who are poor axl belongs 10 low sovio-eeonomic conditions are prone to get Rheumatic heart disease. Qver-croyuting: Pcopk who are living im a shim or damp area are more prone to get Rheumatic heart disease, Age: Itappears most commonly in chiklren between the age of Sto 15 years. Climate and season: Itoccurs more in the miny season and in the cold climate, + Upper respiratory trict infection: Rheuitatic fever is ah ouleome of upper respiratory tract infection wih group A’beta- hemolytic streptococci. * Previous history of Rieumatic fever: The client with previous bisory of Rheumatic, fever aredt high risk io develop Rheumatic heart disease. * Genetic predisposition: Rheumatic beart disease: shows tamilier_tenfency. PATHOPHYSIOLOGY Causative agent (Group A Beta-hemolytic streptococci)Untreated Strep throat 4 Rheumatic fever All byers of the heart and the mitral valve become inflamed gu Vegetation forms 4 Valvular regurgitations and stenosis 4 ‘Heart failure CLINICAL MANIFESTATIONS Major manifestations © Cards « Polyanthritis: © Chorea © Erythema marginatum * Subcutaneous nodules « Arthritis Minor manifestations + Fever associated with weakness, maktise, weight loss and anorexia «© Arthralgia Laboratory findings: * Positive throat culture for group A beta- hemolytic streptococci Elevated acute phase reactants: a) Erythrocyte sedimentation rate b) C-reactive protein ) Leukocytosis * Prolonged P-R interval DIAGNOSTIC EVALUATIONS A diagnosis of rheumatic heart disease is mde aller confirming antecedent rheumatic fever, The modified Jones criteria (revised in 1992) provide guidelines for the diagnosis. of rheumatic fever: JONES CRITERIA #2 major or #1 major and 2 minorJones" criteria for the diagnosis of Rheumatic fever jor manifestations © Canditis « Polyanttis: © Chorea Erythema marginal yum: Subcutaneous nodules nor _rmanifestations Previous rheumatic fever or rheumatic heart disease, Arthralgia @ Fever associated with weakness, makiie, weight loss and anorexia Jabormory findings, * Elevated ESR, C-reactive protein and Leukocytosis BCG and echocardiogram to confirm rhythm problems and structural changes (prolonged P-R interval). © Chest X-ray shows enlarged heart. Exalenes of Group A strentocoecal infection © Positive throat culture for strep A © Ekvated or ring antistreptococcal antibody titer © Recem scarkt fever IMAGING STUDIES Chest roenigenography: © Cardiomegaly, puknonary congestion, and other findings consistent with heart failure may be seen on chest radiography. Dopplerechocardiogram @ In acute rheumatic heart discase, Doppker- echocardiography ientifies and quantiates valve insufficiency and ventricular dysfimetion. In chronic rheumatic heart disease, echocardiography rmy ‘be used to track the progression of ake stenosk and may help determine the time ior Surgical intervention. HEART CATHETE! THO) © Inacute rheumatic heart disease, this procedure is not indicated. © With chronic disease, heart catheterization has been performed to evaluate mitral and aortic valve disease and to balloon. stenotic mitral valves. ON ECG @ Sins tachycardia most ffequently accompariies acute theumitic heart disease. Akernatively, some children develop situs bradycardia from increased vagal tone: Patients with rheumatic heart disease abo may develop airitl titer, mmuifocal atria! tachycardia, or atrial fibrillation fiom chronic mitral valve disease and atrial dilation.Sinus "Tachyeardia Atrial fibriliation Atrial Mutter - . Multifocal atrial tachycardia sees HISTOLOGIC FINDINGS Pathologic examination of the msufficient valves may reveal verrucous desions at the line of closure. + Aschof? bodies (perivascular foci of eosinophilic collagen surounded by Iymphocytes, plasma cells, and macrophages) are found in the pericardium, perivascular regions of the myocardium, ard endocardium, © Anischkow cells are plump macrophages within Aschotf bodies. In the pericardium, fibrinous and serofbrinous exudates may produce an appearance of "bread and butter” pericartits. MEDICAL MANAGEMENT Eradicate infection Preventive and prophylictic therapy i indicated after rheumatic fever and acute theumatic heatt disease to prevent further damage to valves. © Primary prophylaxis (initial course of antibiotics administered to eradicate the streptococcal infection) also serves as the first course of secondary prophylaxis (prevention of recurrent rheumatic fever and theumatic heart disease). * An injection of 0.6-1.2 million units of benzathine penicillin G intramuscularly every 4 Weeks & the recommended regimen for secontary prophylaxis. for niost US patients, Administer the same dosage every 3 weeks in areas where rheumatic fever is endemic, in patients with residual carditis, and in high-risk patients, © Contimse antibiotic prophylixis indefinitely for patients at high risk (eg health) care workers, teachers, day care workers) for recurrent GABHS infeetion. Patients with rheumatic fever with carditis and yale disease should receive antibiotics for at least 10 years or unt) age 40 years, Patients with rheumatic heart disease and vale damage require a single dose ofantibioties Thou before surgical and dental procedures to help prevent bacterial endocarditis. © Patients who had rheumatic fever without valve damage do not need endocarditis prophylaxis. © Do not use penicillin, ampicillin, or amoxicillin for endocarditis prophylaxis. in patients already receiving penicillin for secondary rheumatic fever prophylixis (relative resistance of PO streptocecci to penicillin. and amnopeni© Alternate drugs recommended by the American Heart Assoviation’ for these patients incite PO clindamycin (20 mykg. in clikdren, 600mg in adults) and PO azthromyein or chrihromycin (15 mgkg in chikdren, 500mg br adh), Maximize cardiac output * Conicasterokis are wed to-treat carditis, especially if heart filure & evident, @Ifheart ihme develops, treatment, incliding ACE inhibitors, beta blockers and diuretics, 's effective. Promote comfort Cent ‘with arthriic manifestations obtain relief with salicylates, = Bey ie uly proscnie o rele cate et aleve of keaton to ‘subsided. SURGICAL MANAGEMEN’ © When heart filure persists or worsens afier agetessive medical therapy for acuce rheumatic heart disease, surgery 10 decrease valve insufficiency may be life-saving. Forty percent of patients with acute rheumatic heart disease Subsequently develop mitral stenosis. as aduhs, * Cummisurotomy can be done to widen the valve. ‘Jn patients with critical stenosis, tritral yaluilotomy, percutaneous ballon vilvulophisty, or mitral valve replacement inay be indicated. # Due to high nates of recurrent symptoms afler annuloplasty or other repair procedures, valve rephicement appears to be the preferred surgical option NURSING MANAGEMENT Nursing diagnosis Pain rekited to inflanithatory response in the joints. Objectives The cient verbalizes inoreased comiomt as evidenced by reports of reduced discomfort, expression, of joint, pain reduction, relaxed hody posture and a calm ficial expression. Interve ntions # Assess the level of'pain, diration, intensity and fiequieocy of pain. © Compe bed rest-and provide comfpriable position, @ Provide diversional therapy and psychological suppott @ Administer analgesics as needed. Nursing diagnosis Decreased cardinc ouiput relied to valve dysfimction or Hi Objectives Clem increases cardiac output as evidenced by remubir cate rhythm, heart mite, blood pressure, respiration and: urine output within norival limit. Interventions © Assess the syimptoms. of heart Grilure and decreased candiae output inching diminished quality of peripheral pulses, cool skin and extremities, increased respization, increased heart rate, neck vein distention and presence of edema, «Assess for heart sounds. © Monitor iitake and output Provide bed rest + Administration ‘of cardiac stycosides: as presenbed.:Nursing diagnosis Knowledge deficit related to disease condition and long term treatment. Objective Paticmt gains adequate knowledge as evidenced by exphining disease condition, recognizing need for medication, understanding treatment. Intervention # Assess the clients level of knowkdge, « Assess the client's. ability to Jeam. # Exphiin about disease condition and about prophylactic treatment of antbio # Clarify the clients doubt clearly. Nursing diagnosis ‘Amsety rebated to disease coitition and heart failore Objectives Clionts shows inaximum reduction of amety. Interventions @ Assess the chents eye! of amviety. @ Clarify the doubts of the clients by using non medical terms and calm, sow specch. * Exphin all activities, procedures and issues that involves. the ehent. @ Exphin about the disease conditions and prophykictic treatment. # Provide anxiolytics as prescribed.