RHEUMATIC HEART DISEASE

Introduction

Rheumatic (roo-MAT-ik) heart disease was formerly one of the most

serious forms of heart disease of childhood and adolescence. Rheumatic heart
disease involves damage to the entire heart and its membranes.Rheumatic heart
disease is a complication of rheumatic fever and usually occurs after attacks of
rheumatic fever. The incidence of rheumatic heart disease has been greatly
reduced by widespread use of antibiotics effective against the streptococcal
bacterium that causes rheumatic fever.

Sign and Symptoms

Some of the most common symptoms of rheumatic heart disease are

breathlessness, fatigue, palpitations, chest pain, and fainting attacks.

Diagnosis

The first step in diagnosing rheumatic heart disease is establishing that

your child recently had a strep infection. The doctor may order a throat culture,
a blood test, or both to check for the presence of strep antibodies. However, it is
likely that signs of the strep infection may be gone by the time you take your
child to the doctor. In that case, the doctor will need you to try to remember if
your child recently had a sore throat or other symptoms of a strep infection.

The doctor will do a physical examination and check your child for signs
of rheumatic fever, including joint pain and inflammation. The doctor also will
listen to your child's heart to check for abnormal rhythms or murmurs that may
signify that the heart has been strained.
 In addition, there are a couple of tests that may be used to check the heart
and assess damage, including:

Chest X-ray to check the size of the heart and to see if there is excess
fluid in the heart or lungs

Echocardiogram, a non-invasive test that uses sound waves to create a moving

image of the heart and to measure its size and shape

Rheumatic Heart Disease

Definition:- Rheumatic heart disease is a chronic condition characterized by scaring and

fibrosis of valves and layers of the heart secondary to rheumatic fever

Pathogenesis:-

Autoimmune mechanism has been proposed

Attack of group A beta hemolytic streptococci

Pharyngitis

Antibodies directed against the M proteins of certain strains of streptococci cross-react with
tissue glycoprotein in the heart, joints and other tissues.

(Heart)

Edema of connective tissues and increased acid mucopolysaccharide in the ground substance.

Accumulation of ground substance.

 Separation of collagen fibers.

Collagen fibers become fragmented and disintegrated.

Proliferation of cells (lymphocytes, plasma cells, a few neutrophils, cardiac histocytes

(anitschkow cells) at the margin of the lesion

Aschoff nodules (12 to 16 weeks)

Anitschkow cells nodule becomes spindle shaped with diminished cytoplasm.

AFTER YEARS

Aschoff body becomes less cellular and collagenous tissue is increased

Fibro collagenous scar

Formation of chronic sequelae (endocardium , myocardium, pericardium)

Rheumatic pancardiditis

1. Rheumatic endocarditis

(a).Rheumatic valvulitis

(b).Rheumatic mural endocarditis

2. Rheumatic myocarditis

3. Rheumatic pericarditis
 1(a).Rheumatic Valvulitis

Grossly Microscopically

Acute
1.Thickening and loss of translucency
of the valve leaflets
2.Gray brown, watery vegetations
Chronic
1.Permanent deformity of on one or
more valves (mitral or aortic)
2.Fish mouth or button hole
3.Thickening, shortening and fusion of
chordae tendinae
Acute
1.Edema
2.Cellular infiltration
3.Vegetations of fibrin
Chronic
1.Thicken by fibrous tissue with
hyalinization (Calcification rarely)
2.Thickened blood vessels with
narrowed lumina

1(b).Rheumatic mural endocarditis

Grossly Microscopically
MacCallums patch:- MacCallums patch:-
Lesions of endocardial surface in the a. Edema
posterior wall of the left atrium just above b. Fibrinoid changes in collagen
posterior leaflet of the mitral valve c. Cellular infiltrate of lymphocytes
d. Plasma cells
e. Macrophages
f. Anitschkow cells*

2. Rheumatic Myocarditis

Grossly Microscopically
Acute Acute
Left ventricular myocardium soft and Aschoff nodules are scattered (inter
flabby venticular septum, left ventricle and left
atrium)
Intermediate stage Intermediate stage
Interstitial tissue of the myocardium shows In Aschoff:- Granuloma with central
small foci of necrosis fibrinoid necrosis and surrounded by
palisade of anitschkow cells
Late stage Late stage
Foci of aschoff bodies are visible Aschoffs bodies are replaced by small
fibrous scars

3. Rheumatic Pericarditis

Grossly Microscopically
Chronic chronic
a). Deposition of fibrous exudates (Loss of a). Fibrosis aschoff bodies on the surfaces
normal shiny pericardial surface)
b). Accumulation of fibrous exudates in the
pericardial sac b). Infiltrated sub serosal connective tissue
(Bread and butter appearance)
c). Chronic adhesive pericarditis

c). Adhesions between visceral and parietal

surfaces

Extracardiac Lesions

Polyarthritis
Subcutaneous nodules
Erythema marginatum
Rheumatic arteritis
Chorea minor
Rheumatic pneumonitis pleuritis

ANTOBODIES AGAINST

Beta-Haemolytic streptococci group A

Anti-streptolysin O (ASO)
Anti-streptokinase
Anti-streptohyaluronidase
Anti DNA ase B

Diagnosing criteria

Diagnosed by Jones Criteria:

Either two of the major manifestations or one major and two minor manifestations.

JONES CRITERIA

MAJOR CRITERIA MINOR CRITEIA

1.Carditis 1.Fever
2.Poly arthritis 2.Arthralgia
 3.Chorea:- a neurologic disorder with 3.Previous History of RF
involuntary purposeless rapid movements. 4.Increased
4.Erythema Marginatum a. E.S.R
5.Subcutaneous Nodules b. C-Reactive Protein
c. Leucocytosis
5.Prolonged PR interval

Complications

Severe mitral stenosis progresses to left atrial

hypertrophy and dilatation,

Mural thrombosis,

Pulmonary congestion,

Pulmonary vascular sclerosis and then right

ventricular hypertrophy.

The left ventricle is normal is isolated pure

mitral stenosis.

Other complications of chronic RHD include

heart failure,

Arrhythmias particularly AF in case of M.S,

Thrombo embolic complications and infective

endocarditis.

The long term prognosis is highly variable

Rx- Surgical replacement of diseased valves

with prosthetic device

*anitschkow cell: are the cardiac histocytes present in small numbers in the normal heart. The
nuclei are vesicular and contain prominent central chromatin mass which in longitudinal
section appears serrated or caterpillar like and in cross section it look like an owls eye

**Aschoff bodies: are spheroidal or fusiform distinct microscopic structures occurring in the
intestitium of the heart in RHD.(it contains almost four anitschkow cells )

Medical Management

Medical therapy is directed toward eliminating the group A streptococcal

pharyngitis (if still present), suppressing inflammation from the autoimmune
response, and providing supportive treatment for congestive heart failure. But
the specific treatment for rheumatic heart disease will be determined by your
physician based on:

* Your overall health and medical history

* Extent of the disease

* Your tolerance for specific medications, procedures, or therapies

* Expectations for the course of the disease

* Your opinion or preference

Since rheumatic fever is the cause of rheumatic heart disease, the best
treatment is to prevent rheumatic fever from occurring. Oral penicillin V
remains the drug of choice for treatment of group A streptococcal pharyngitis.
When oral penicillin is not feasible or dependable, a single dose of
intramuscular benzathine penicillin G is therapeutic. For patients who are
allergic to penicillin, administer erythromycin or a first-generation
cephalosporin.Other options include clarithromycin for 10 days, azithromycin
for 5 days, or a narrow-spectrum (first-generation) cephalosporin for 10 days.
To reduce inflammation, aspirin, steroids, or non-steroidal medications may be
given. Surgery may be necessary to repair or replace the damaged valve

Nursing Management

*Monitor blood pressure, pulse apical and peripheral pulse

*Monitor cardiac rhythm and the frequency

*Sleeping position 450 semifowler

*Instruct the client to do stress management techniques (quiet environment,

meditation)

*Aids client activity as indicated when the client is able

BACTERIAL INFECTIVE ENDOCARDITIS

Infective endocarditis is a form of endocarditis, or inflammation of the

inner tissue of the heart, such as its valves, caused by infectious agents. The
agents are usually bacterial, but other organisms can also be responsible.

The valves of the heart do not receive any dedicated blood supply. As a
result, defensive immune mechanisms (such as white blood cells) cannot
directly reach the valves via the bloodstream. If an organism (such as bacteria)
attaches to a valve surface and forms a vegetation, the host immune response is
blunted. The lack of blood supply to the valves also has implications on
treatment, since drugs also have difficulty reaching the infected valve.

Normally, blood flows smoothly through these valves. If they have been
damaged - from rheumatic fever, for example - the risk of bacterial attachment
is increased
Sign and Symptoms

Fever, i.e. fever of unknown origin occurs in 97% of people; malaise and
endurance fatigue in 90% of people.

A new or changing heart murmur, weight loss, and coughing occurs in

35% of people

Vascular phenomena: septic embolism (causing thromboembolic

problems such as stroke in the parietal lobe of the brain or gangrene of
fingers), Janeway lesions (painless hemorrhagic cutaneous lesions on the palms
and soles), intracranial hemorrhage, conjunctivalhemorrhage, splinter
hemorrhages, Renal Infarcts, and Infarct Spleen.

Immunologic phenomena: Glomerulonephritis which allows for blood

and albumin to enter the urine,[1] Osler's nodes (painful subcutaneouslesions in
the distal fingers), Roth's spots on the retina, positive serum rheumatoid factor

Other signs may include; night sweats, rigors, anemia, splenomegaly,

clubbing

Diagnosis

Blood Tests - Blood cultures are the most important blood tests used to
diagnose IE. Blood is drawn several times over a 24-hour period. It's put in
special culture bottles that allow bacteria to grow.

Echocardiography - Echocardiography (echo) is a painless test that uses

sound waves to create pictures of your heart. Two types of echo are useful in
diagnosing IE.
 Transthoracic (tranz-thor-AS-ik) echo. For this painless test, gel is
applied to the skin on your chest. A device called a transducer is moved around
on the outside of your chest.

This device sends sound waves called ultrasound through your chest. As
the ultrasound waves bounce off your heart, a computer converts them into
pictures on a screen.

Your doctor uses the pictures to look for vegetations, areas of infected
tissue (such as an abscess), and signs of heart damage.

Because the sound waves have to pass through skin, muscle, tissue, bone,
and lungs, the pictures may not have enough detail. Thus, your doctor may
recommend transesophageal (tranz-ih-sof-uh-JEE-ul) echo (TEE).

Transesophageal echo. For TEE, a much smaller transducer is attached to

the end of a long, narrow, flexible tube. The tube is passed down your throat.
Before the procedure, you're given medicine to help you relax, and your throat
is sprayed with numbing medicine.

The doctor then passes the transducer down your esophagus (the passage
from your mouth to your stomach). Because this passage is right behind the
heart, the transducer can get detailed pictures of the heart's structures.

EKG - An EKG is a simple, painless test that detects your heart's

electrical activity. The test shows how fast your heart is beating, whether your
heart rhythm is steady or irregular, and the strength and timing of electrical
signals as they pass through your heart.

An EKG typically isn't used to diagnose IE. However, it may be done to

see whether IE is affecting your heart's electrical activity.
 For this test, soft, sticky patches called electrodes are attached to your
chest, arms, and legs. You lie still while the electrodes detect your heart's
electrical signals. A machine records these signals on graph paper or shows
them on a computer screen. The entire test usually takes about 10 minute

Medical Management

High dose antibiotics are administered by the intravenous route to

maximize diffusion of antibiotic molecules into vegetation(s) from the blood
filling the chambers of the heart. Antibiotics are continued for a long time,
typically two to six weeks.

High dose IV crystalline penicillin every 4hrs for 2 weeks is

recommended and still remains the drug of choice.

2 week treatment regimen of benzyl penicillin IV

Nursing Management

During the acute phase of the disease, provide adequate rest by assisting
the patient with daily hygiene. Provide a bedside commode to reduce the
physiological stress that occurs with the use of a bedpan. Space all nursing care
activities and diagnostic tests to provide the patient with adequate rest. During
the first few days of hospital admission, encourage the family to limit visitation.

Emphasize patient education. Individualize a standardized plan of care,

and adapt it to meet the patient's needs. Areas for discussion include the cause
of the disease and its course, medication regimens, technique for administering
IV antibiotics, and practices that help avoid and identify future infections.

If the patient is to continue parenteral antibiotic therapy at home, make

sure that, before he or she is discharged from the hospital, the patient has all the
appropriate equipment and supplies that will be needed. Make a referral to a
home health nurse as needed, and provide the patient and family with a list of
information that describes when to notify the primary healthcare provider about
complications.

CARDIAC CATHETERIZATION

Cardiac catheterization involves passing a thin flexible tube (catheter)

into the right or left side of the heart, usually from the groin or the arm.

How the Test is Performed

You will be given a mild sedative before the test to help you relax. An
intravenous (IV) line is inserted into one of the blood vessels in your arm, neck,
or groin after the site has been cleansed and numbed with a local numbing
medicine (anesthetic).

A catheter is then inserted through the IV and into your blood vessel. The
catheter is carefully threaded into the heart using an x-ray machine that
produces real-time pictures (fluoroscopy). Once the catheter is in place, your
doctor may:

Collect blood samples from the heart

Measure pressure and blood flow in the heart's chambers and in the large
arteries around the heart

Measure the oxygen in different parts of your heart

Examine the arteries of the heart with an x-ray technique called

fluoroscopy (which gives immediate, "real-time" pictures of the x-ray
images on a screen and provides a permanent record of the procedure)
 Perform a biopsy on the heart muscle

How to Prepare for the Test

If possible, you will be asked not to eat or drink for 6 - 8 hours before the test.
The test takes place in a hospital and you will be asked to wear a hospital gown.
Sometimes, you will need to spend the night before the test in the hospital.
Otherwise, you will be admitted as an outpatient or an inpatient the morning of
the procedure.

Tell your doctor if you:

Are allergic to seafood

Have had a bad reaction to contrast material or iodine in the past

Are taking Viagra

Might be pregnant

How the Test Will Feel

The study is done by trained cardiologists with the assistance of trained

technicians and nurses.

You will be awake and able to follow instructions during the test. You
will usually get a mild sedative 30 minutes before the test to help you relax. The
test may last 30 - 60 minutes.

You may feel some discomfort at the site where the catheter is placed.
Local anesthesia will be used to numb the site, so the only sensation should be
one of pressure at the site. You may experience some discomfort from having to
remain still for a long time.

After the test, the catheter is removed. You might feel a firm pressure,
used to prevent bleeding at the insertion site. If the catheter is placed in your
groin, you will usually be asked to lie flat on your back for a few hours after the
test to avoid bleeding. This may cause some mild back discomfort.

Why the Test is Performed

In general, this procedure is done to get information about the heart or its
blood vessels or to provide treatment in certain types of heart conditions. It may
also be used to determine the need for heart surgery.

Your doctor may perform cardiac catheterization to:

Diagnose or evaluate coronary artery disease

Diagnose or evaluate congenital heart defects

Diagnose or evaluate problems with the heart valves

Diagnose causes of heart failure or cardiomyopathy

The following may also be performed using cardiac catheterization:

Repair of certain types of heart defects

Repair of a stuck (stenotic) heart valve

Opening of blocked arteries or grafts in the heart

The procedure can identify heart defects or disease, such as:

Coronary artery disease

 Valve problems

Ventricular aneurysms

Heart enlargement

The procedure also may be performed for the following:

Primary pulmonary hypertension

Heart valve defects, such as pulmonary valve stenosis, mitral valve

regurgitation, aortic stenosis, and others

Pulmonary embolism

Birth defects, such as Tetralogy of Fallot, transposition of the great

vessels, ventricular septal defect,coarctation of the aorta, and others

Cardiac amyloidosis

Risks

Cardiac catheterization carries a slightly higher risk than other heart tests,
but is very safe when performed by an experienced team.

Generally, the risks include the following:

Cardiac arrhythmias ,Cardiac tamponade

Heart attack

Bleeding

Low blood pressure

 Reaction to the contrast medium

Trauma to the artery caused by hematoma

Possible complications of any type of catheterization include the following:

A risk of bleeding, infection, and pain at the IV site

A very small risk that the soft plastic catheters could damage the blood
vessels

Blood clots could form on the catheters and later block blood vessels
elsewhere in the body.

The contrast material could damage the kidneys (particularly in patients

with diabetes).

SUMMARY
Today we have discussed about rheumatic heart disease, its etiology, pathophysiology,
sign and symptoms, nursing and medical management etc.

CONCLUSION
Rheumatic heart disease is a chronic condition characterized by scaring and fibrosis of
valves and layers of the heart secondary to rheumatic fever.

BIBLIOGRAPHY
1. www.wikipedia.com
2. www.google.com
SEMINAR
ON
RHEUMATIC
HEART DISEASE
SUBMITTED TO : SUBMITTED BY :

MR. EKE LAMA TAMANG Ms. Kusum,

TUTOR M.Sc. Nursing 2nd Year

JAMIA HAMDARD