acquired heart disease

Engidaw Ambelu

1. Acquired Heart Disease For Anesthesia II Abinet Mariyo

2. Outline Definition Etiology Pathogenesis Diagnosis and c/f Treatment 5/4/2018 Acquired HD Mario's 2

3. Infective Endocarditis Is an acute and sub acute inflammation of the endocardium caused by bacteria, virus or fungi. 5/4/2018 Acquired HD Mario's 3

4. Etiology Viridans type streptococci ( after dental procd .) Staphylococcus aureus ( no underlying heart defect) Group D enterococci ( lower GI or GU manipulation) Others pseudomonas aeruginosa in IVDA 5/4/2018 Acquired HD Mario's 4

5. Epidemiology Males are commonly affected IE is often a complication of congenital or Rheumatic Heart Disease Can occur in children with out any abnormal valves or cardiac malformation In developed countries CHD is commonest predisposing factor 5/4/2018 Acquired HD Mario's 5

6. Pathogenesis Patients with CHD where there is a turbulent blood flow, if there is high pressure gradient across the defect, turbulent flow Traumatizes the Endothelium, creates a substrate for deposition of fibrin and platelets Formation of non bacterial thrombotic embolus which is initiating lesion for IE Transient bacteremia there will be colonization of NBTE by bacteria and Bacterial proliferation occurs 5/4/2018 Acquired HD Mario's 6

7. Risk factor Intravenous Drug use Prosthetic heart valves Structural Heart Disease(CHD/RHD) Central venous catheter Dental, Intestinal or Urinary tract procedure In 30% a predisposing factor is identified 5/4/2018 Acquired HD Mario's 7

8. Clinical Manifestation Onset may be acute and severe with HGIF and prostration Prolonged fever without other manifestations Common Symptoms are Myalgia, arthralgia, headache, nausea and vomiting 5/4/2018 Acquired HD Mario's 8

9. Physical Examination New/ changing heart murmur Splenomegaly Signs of Heart Failure clubbing Classic skin findings develop late in the course of the disease Osler Nodes ( tender pea sized intradermal nodules in the pads of fingers) Janeway Leshions (painless small hemorrhagic lesions on palms and soles) Splinter Hemorrhages This lesions may represent vasculitis prodiced by Ag-Ab Complex 5/4/2018 Acquired HD Mario's 9

10. Osler Node 5/4/2018 Acquired HD Mario's 10

11. Janeway leshion 5/4/2018 Acquired HD Mario's 11

12. Splinter hge 5/4/2018 Acquired HD Mario's 12

13. Petechie 5/4/2018 Acquired HD Mario's 13

14. Dx Dukes Criteria Major Positive Blood cultures( 2 separate culture for usual pathogen, 2 or more for less typical pathogens) Evidence of endocarditis on Echocardiography Intracardiac mass on a valve or other site Regurgitant flow near a prosthesis Abscess Partial dehiscence of a prosthetic valves New valve regurgitant flow 5/4/2018 Acquired HD Mario's 14

15. Minor Predisposing condition Fever Embolic vascular signs Immune complex phenomena( glomerulonephritis, arthritis, RF, Osler nodes, Roth spots) A single positive blood culture or serologic evidence of infection Echocardiographic signs not meeting the major criteria 5/4/2018 Acquired HD Mario's 15

16. Other minor criteria's Clubbing, splenomegaly, splinter hemorrhages, and petechiae, elevated ESR, elevated CRP, microscopic hematuria 5/4/2018 Acquired HD Mario's 16

17. 2 Major 1 Major + 3 minor 5 minor Suggest definite IE 5/4/2018 Acquired HD Mario's 17

18. Complications Cardiac: Heart failure Myocardial Abscess Toxic myocarditis Systemic emboli Embolic stroke Cerebral abscess Mycotic aneurism and Hemorrhage 5/4/2018 Acquired HD Mario's 18

19. LAB Blood Culture ESR CRP CBC( anemia, leukocytosis) RF U/A ( hematuria) CXR Echocardiography 5/4/2018 Acquired HD Mario's 19

20. Treatment Antibiotics Vancomycin and Gentamycin until culture result arrives( 4-6 wks ) If Heart Failure- Diuretics Surgical intervention Recurrent emboli Increasing size of vegetation while receiving Rx Failure to sterilize blood after adequate antibiotics Severe Aortic/ Mitral valve involvement with intractable HF 5/4/2018 Acquired HD Mario's 20

21. Prevention Improving dental hygiene Careful asepsis during cardiac surgery Antimicrobial prophylaxis before dental and other surgical procedures 5/4/2018 Acquired HD Mario's 21

22. Acute Rheumatic Fever Is a non suppurative sequelae of GAS( S.pyogenes ) infection. 2/3 of patients with Acute rheumatic fever have hx of URTI several weeks before 5/4/2018 Acquired HD Mario's 22

23. 5/4/2018 Acquired HD Mario's 23

24. Epidemiology World wide rheumatic heart disease remains the most common form of Acquired heart disease in all age groups Historically, ARF was associated with poverty and overcrowding The incidence of both initial attacks and recurrences of acute rheumatic fever peaks in children 5-15 yr of age, the age of greatest risk for GAS pharyngitis 5/4/2018 Acquired HD Mario's 24

25. Pathogenesis Several theories of pathogenesis have been proposed, notably the cytotoxicity theory and immunologic theories. Cytotoxicity GAS toxin is involved in the pathogenesis of ARF and RHD GAS produces streptolysin O enzyme which is cytotoxic to mammalian cardiac cells Unable to explain the latent period.(2-4wk) 5/4/2018 Acquired HD Mario's 25

26. 2. Immunologic theory The Antigenicity of several GAS antigens and the immunologic cross reactivity with cardiac antigens ( molecular mimicry) 5/4/2018 Acquired HD Mario's 26

27. Diagnosis and clinical manifestation Because no clinical or lab finding is pathognomonic for ARF, JONEs criteria was introduced There are 5 Major and 4 minor criteria's and a requirement of recent GAS infection 5/4/2018 Acquired HD Mario's 27

28. 5/4/2018 Acquired HD Mario's 28

29. Evidence of Recent infection Acute rheumatic fever typically develops 2-4 wk after an acute episode of GAS pharyngitis at a time when clinical findings of pharyngitis are no longer present and when only 10-20% of patients still harbor GAS in the throat. One-third of patients with acute rheumatic fever have no history of an antecedent pharyngitis. Therefore, evidence of an antecedent GAS infection is usually based on elevated or rising serum antistreptococcal antibody titers ASO9 anti streptolycin O Anti–DNase B, Antihyaluronidase The diagnosis of acute rheumatic fever should not be made in those patients with elevated or increasing streptococcal antibody titers who do not fulfill the Jones criteria 5/4/2018 Acquired HD Mario's 29

30. There are 3 circumstances in which the diagnosis of acute rheumatic fever can be made without strict adherence to the Jones criteria: when chorea occurs as the only major manifestation of acute rheumatic fever. when indolent carditis is the only manifestation in patients who first come to medical attention only months after the apparent onset of acute rheumatic fever, in a limited number of patients with recurrences of acute rheumatic fever in particularly high-risk populations 5/4/2018 Acquired HD Mario's 30

31. Migratory Polyarthritis Occurs in ~ 70% Involves Larger joints(knee, ankle, elbow, wrist) Joint become Hot,red tendr and swollen Migratory in nature Response to salicylates Is non deforming Earliest manifestation of ARF Monoarthritis and poly arthralgia: taken as Major in high risk populations 5/4/2018 Acquired HD Mario's 31

32. Carditis ~50-60% The most serious manifestation of ARF Endocarditis is a universal finding, Mostly Isolated Mitral valve or Combined Mitral and Aortic valve involved Isolated aortic of right sided valvular involvement is quite uncommon Valvular insufficiency is characteristic of acute and convalescent stages of ARF Stenotic lesions (AS, MS) occur years after acute illness Tachycardia, Murmur, cardiomegaly, HF 5/4/2018 Acquired HD Mario's 32

33. Sydenham Chorea 10-15% Usually occur as an isolated frequently subtle mov’t disorder Emotional liability, incoordination, poor school performance, uncontrollable mov’ts and facial grimacing Exacerbated by stress and disappear with sleep Occasionally unilateral The latent period from acute GAS infection to chorea is usually substantially longer than for arthritis or carditis and can be months. 5/4/2018 Acquired HD Mario's 33

34. Clinical maneuvers to elicit features of chorea include: milkmaid’s grip (irregular contractions and relaxations of the muscles of the fingers while squeezing the examiner’s fingers), spooning and pronation of the hands when the patient’s arms are extended. wormian darting movements of the tongue upon protrusion, examination of handwriting to evaluate fine motor movements. 5/4/2018 Acquired HD Mario's 34

35. Erythema Marginatum Rare ~1% erythematous, serpiginous, macular lesions with pale centers that are not pruritic It occurs primarily on the trunk and extremities, but not on the face, and it can be accentuated by warming the skin. 5/4/2018 Acquired HD Mario's 35

36. Subcutaneous Nodules Rare <1% nodules approximately 1 cm in diameter along the extensor surfaces of tendons near bony prominences There is a correlation between the presence of these nodules and significant rheumatic heart disease. 5/4/2018 Acquired HD Mario's 36

37. Minor criteria's (5) Low risk population Polyarthralgia( if arthritis is not used as major criteria ) Fever >= 38.5 Elevated ESR >=60mm/ hr Elevated CRP >=3.0mg/dl High risk Monoarthralgia Fever >= 38 Elevated ESR >= 30mm/ hr Elevated CRP >= 3mg/dl 5/4/2018 Acquired HD Mario's 37 Prolonged PR interval (unless carditis is a major criterion)

38. Treatment Antibiotics: regardless of throat culture result Amoxicillin PO for 10 days Single IM benzathine penicillin Anti-inflammatory Therapy: Asprin corticosteroids 5/4/2018 Acquired HD Mario's 38

39. Prevention Prevention of both initial and recurrent episodes of acute rheumatic fever depends on controlling GAS infections of the upper respiratory tract. Primary Prevention: Prevention of initial attacks, depends on identification and eradication of GAS causing acute pharyngitis. Secondary Prevention : Individuals who have already suffered an attack of acute rheumatic fever Are particularly susceptible to recurrences of rheumatic fever with any subsequent GAS upper respiratory tract infection. Therefore, these patients should receive continuous antibiotic prophylaxis to prevent recurrences 5/4/2018 Acquired HD Mario's 39

40. 5/4/2018 Acquired HD Mario's 40

41. 5/4/2018 Acquired HD Mario's 41

42. 5/4/2018 Acquired HD Mario's 42 THANK YOU