Rheumatic Fever, Rheumatic Heart Disease & Valvular Heart Disease
Carditis
most important sign Murmur(s) mitral & aortic cardiac enlargement and HF pericarditis: muffled heart sounds, CP, pericardial friction rub or signs of effusion
Aortic Valve Regurgitation
*Primary disease of - AV leaflets, aortic root or both AR -> backward flow of blood from ascending aorta into LV during diastole -> volume overload. LV -> dilated & hypertrophied -> decreased myocardial contractility, increased blood volume in LA & pulmonary capillary bed -> pulmonary hypertension & RVF.
Diagnostic studies for RhF
*No single diagnostic test exists for RF. -Echo - can show valve insufficiency & pericardial fluid/thickening -CXR - enlarged heart if HF present. -EKG changes - delayed AV conduction - prolonged PR interval.
Minimally invasive valvuloplasty
- involves a mini-sternotomy or parasternal approach; can include robotic & thoracoscopic surgical systems. Benefits - compares well to open procedure, shorter LOSs, decreased - pain, blood transfusions, & risks for infection
Sapien Transcatheter Heart Valve
(THV) -Approved for select AS patients. -Catheter inserted through femoral artery & moved to heart. It is released & expanded with a balloon in the location of the AV. -Limited to those who qualify for surgery, but who are at high risk for complications.
Aschoff's bodies
(nodules) - inflammatory reaction -> fibrous scar tissue in myocardium -> rheumatic pericarditis. -Pericardial layers become thick& covered in fibrinous exudate -> pericardial effusion. -When healed, fibrosis & adhesions develop that can partially/completely destroy pericardial sac
Mitral commissurotomy
(valvulotomy) -Procedure of choice for pure mitral stenosis. *Closed procedure -Less precise; has been replaced by open procedure. -In closed, surgeon inserts a transventricular dilator through apex of LV into opening of the MV. *Open procedure -Allows for direct vision, requires use of cardiopulmonary bypass. -Surgeon removes thrombi from atrium & makes a commissure incision; the chordae are separated by splitting the papillary muscle & debriding the calcified valve.
S/S MV Stenosis
*Primary symptom - exertional dyspnea *Heart sounds - low-pitched diastolic murmur & loud S1 *Other s/s - -Hoarseness - atrial enlargement pressing on laryngeal nerve -Hemoptysis - pulmonary hypertension -Chest pain - decreased CO -Seizures/stroke - emboli -Fatigue & palpitations - atrial fib
Annuloplasty
- involves reconstruction of the annulus with/without the aid of prosthetic rings.
Manifestations of AVS
- Classic triad of angina, syncope, & DOE due to LVF; HF, systolic murmur, prominent S4. -Use NTG cautiously since significant hypotension can occur. Chest pain can actually worsen due to decreased preload & b/p
Chronic MVR
- LA enlargement, LV dilation & hypertrophy -> decreased CO. *Manifests as LVF - weakness, fatigue, exertional dyspnea, S3; loud, holosystolic murmur
Etiology of MV Regurgitation
- MI, chronic rheumatic heart disease, MVP, ischemic papillary muscle dysfunction & infective endocarditis. -MI with LVF increases risk for rupture of chordae tendineae & acute MVR =Blood flows back into LA from LV because of incomplete closure during systole -> increased workload on both LA/LV.
Subcutaneous nodules
- associated with severe carditis Firm, small, hard, painless swellings over extensor surfaces of joints; knees, wrists & elbows
Erythema marginatum lesions
- less common sign of RF Bright pink, nonpruritic, maplike macular lesions occurring mainly on trunk & proximal extremities
Rheumatic endocarditis
- found mainly in valves, noted by swelling & erosion of leaflets. -Thickened valve leaflets, fusion of commissures & chordae tendineae, & fibrosis of papillary muscle -> stenosis & possibly regurge if leaflets do not close completely. -Mitral & aortic valves MC affected.
Genetic link MVP
- increased familial incidence; connective tissue defect, such as Marfan's. -Marfans is connective tissue defect that affects the CV system, most have MVP
Acute MVR
- increased pressure on pulmonary capillary bed -> pulmonary edema. Poorly tolerated, new systolic murmur, pulmonary edema -> cardiogenic shock. *Manifestations - thready peripheral pulses, & cool, clammy extremities
Manifestations MVP
- most patients are asymptomatic. -Palpitations (PVCs, PSVT, & VT), lightheadedness & dyspnea, CP that isn't relieved by Nitrates, better results with BBs; activity intolerance, syncope & holosystolic murmur. -Echo to confirm MVP
Teaching plan for MVP
- take meds as prescribed, eat a healthy diet, avoid caffeine, avoid OTC diet or cold medicines containing caffeine & ephedrine, adopt exercise program, educate on potential s/s & complications.
Mitral Valve Regurgitation
-A defect in; the leaflets, annulus, chordae tendineae, papillary muscles & LA/LV can -> mitral valve regurge.
Manifestations of AVR
-Acute - abrupt onset of profound dyspnea, CP LVF & cardiogenic shock -Chronic - fatigue, DOE, orthopnea, PND, water-hammer pulse (strong, quick beat that collapses suddenly), diminished or absent S1, S2, or S4; soft, high-pitched diastolic murmur
Acute vs Chronic AVR
-Acute AR - trauma, IE or aortic dissection -Chronic AR - result of RHD or congenital bicuspid aortic valve, syphilis or chronic rheumatic conditions, such as ankylosing spondylitis or reactive arthritis
Rheumatic Fever
-Acute inflammatory disease of heart, can involve all 3 layers of heart; endocardium, myocardium & pericardium. -Complication occurs as a delayed result of a group A streptococcal pharyngitis. -Affects - heart, skin, joints, & CNS -Declined in developed countries; continues to be found commonly in developing countries.
Surgical Therapy
-Decision for surgery is based upon patient's clinical state of functional disability per NY Heart Association classification system. *Valve repair versus valve replacement -Depends upon valves involved, the pathology/severity of disease & patient's clinical condition. *Valve repair -Usually surgical procedure of choice. -Lower operative mortality rate than valve replacement. -Often used in mitral or tricuspid valve disease.
Nursing Diagnoses for Valvular disease
-Decreased CO RT incompetent valve -Excess fluid volume RT fluid retention secondary to pump failure DT incompetent valve -Activity intolerance RT imbalance in oxygen supply & demand
Nursing Diagnoses for RhF
-Decreased CO RT valve incompetence or failure of heart muscle to pump adequately -Activity intolerance RT joint pain/swelling/tenderness -Ineffective self-health management RT lack of knowledge/resources/finances
Mitral Valve Prolapse
-Defect in MV leaflets, papillary muscle or chordae -> leaflets prolapsing/buckling back into LA during systole. -MC form of valve disease in U.S. -Often benign, but serious complications can occur - MR, IE, SCD, HF & cerebral ischemia.
Acute Intervention/Ambulatory/Home Care
-Heart failure MC reason for seeking health care. -Perform ongoing cardiac assessments to monitor effectiveness of treatments & medications, including prophylactic antibiotic treatment if valve disease caused by RF. -If patient is no longer able to maintain homeostasis with medical management, may need surgical intervention. -Patient education regarding available & appropriate options for surgery. -Anticoagulant therapy for those patients on Coumadin/Warfarin. -Educate - when to seek medical care, s/s of infection & bleeding, HF, any planned invasive or dental procedures patient must notify MD.
Mono or poly arthritis
-MC finding in RF -Synovial membranes of joints - swelling, heat, redness, tenderness & decreased ROM
Mitral Valve Stenosis
-Most cases of adult MV stenosis due to rheumatic heart disease. -Rheumatic endocarditis -> scarring of leaflets & chordae tendineae, contractures & adhesions develop between commissures -Fish mouth appearance -Block blood flow & create pressure differences between LA & LV during diastole -> increased pulmonary vascular pressure -Increased risk for Atfib
Goals for RhF
-Normal or baseline heart function -Resumption of normal daily activities -Ability to self-manage health -Prevention of complications
Percutaneous transluminal balloon valvuloplasty
-Performed in cardiac cath lab. -Used for patients with MV, TV & PV stenosis. -A balloon-tipped catheter is threaded from femoral artery/vein to stenotic valve. Balloon is inflated to open fused commissures. -Indicated for older adults & those who are poor surgical candidates.
Health Promotion
-Speedy diagnosis & treatment of patients with RF, to prevent rheumatic heart/valve disease. -Patient education of disease process, s/s of disease, and treatment measures.
Complications of RF
-chronic rheumatic heart disease; -scarring & contractures of valve leaflets & chordae tendineae; -MV most commonly affected.
Valvuloplasty
-involves repair of valve by suturing torn leaflets, chordae tendineae or papillary muscles. Used to treat mitral or tricuspid regurge.
Aortic valve stenosis
AVS -> obstruction of blood flow from LV to aorta during systole -> LVH & increased myocardial oxygen consumption. As disease progresses & compensatory mechanisms fail -> reduced CO -> decreased tissue perfusion, pulmonary hypertension & HF.
Drug therapy
Antibiotics - Penicillin V or Amoxicillin x 10 days; if allergic to PCN then cephalexin, clindamycin, or azithromycin can be used. Eliminates residual group A strep, but doesn't change the course of the acute disease or prevent development of carditis Salicylates & NSAIDs - fever & joint pain/swelling Corticosteroids - severe carditis
Biological Valves
Biological (tissue) - bovine, porcine & human hearts -Asymmetric in shape. -Produce a more natural pattern of blood flow. -Less durable & tend to cause early calcification, tissue degeneration & stiffening of leaflets.
Rheumatic heart disease: Clinical manifestations: Major Criteria
Carditis - Cardiac enlargement & HF Pericarditis - Mono or polyarthritis - Sydenham's chorea - Erythema marginatum lesions - Subcutaneous nodules -
Pancarditis
Carditis - 40% of RF cases, known as rheumatic pancarditis (all layers of heart involved).
POTENTIAL COMPLICATION of RhF
Chronic Rheumatic Carditis due to changes in valve structure from scarring & contractures
Aortic valve stenosis: Congenital
Congenital AVS - found in childhood, adolescence or young adult; Older adults typically a result of RF or degeneration with age.
DX studies for Valvular diseases
Diagnosis -Patient's history & PE -CT of chest with contrast - gold standard to evaluate aortic disorders -Echo - valve structure, function & heart chamber size. -TEE & doppler color-flow imaging - help to diagnosis & monitor progression. -CXR - reveals heart size, altered pulmonary circulation & valve calcification. -EKG - HR, rhythm, & any ischemia or ventricular hypertrophy. -Cardiac cath - measures pressure changes in cardiac chambers, records pressure differences across valves & measures size of valve openings.
Ambulatory & Home Care for RhF
Educate patient about disease process, possible sequelae & need for continuous antibiotic prophylaxis Prior history of RF increases patient's risk of reinfection. Patients with RF without carditis require prophylaxis until age 20 for minimum of 5 years Patients with rheumatic carditis & residual heart disease need long-term or even life-long prophylaxis. Report to MD s/s of - excessive fatigue, dizziness, palpitations, unexplained weight gain or DOE.
Health Promotion for RhF
Educating the community to seek prompt treatment for suspected strep throat. Early detection & immediate treatment of group A streptococcal pharyngitis. RHD is a preventable cardiovascular disease.
Tricuspid Valve issues
Incompetent tricuspid valve leads to regurgitation of the blood into the R atria R atria stretches, loses contractility, blood pools (clots?), and becomes irritated and leads to A fib complicating the stasis even more Tricuspic Stenosis- increases resistance to moving blood into the R ventricle, so RA gets bigger, irritable and increased risk for A fib Both lead to decreased perfusion issues
Rheumatic heart disease: Clinical manifestations: Minor criteria
Lab results - elevated ESR, WBC & CRP Fever & polyarthralgia EKG - prolonged PR interval Evidence of infection Preceding group A streptococcal infection
Prosthetic valves
Mechanical - made from artificial materials -More durable, last longer. -Increased risk of thromboembolism. -Requires long-term anticoagulation therapy. -Main complication - bleeding from anticoagulation therapy.
Valve replacement
Performed for mitral, aortic, tricuspid & occasionally pulmonary valve disease. Desirable valves - non-thrombogenic & durable & create minimal stenosis. *mechanical or biologic *Choice of valve type depends upon; -Can patient take anticoagulant? -Age? -Child-bearing status? -Physical activity?
Aortic valve stenosis: Rheumatic valve disease
Rheumatic valve disease -> fusion of commissures & secondary calcification -> valve leaflets stiffen & retract -> stenosis. 0If AVS occurs DT RHD, MV disease accompanies it.
stenosis vs regurgitations
Stenosis - forward blood flow is impaired -> increased pressure differences between chambers. Regurgitation - incomplete closure of valve -> backflow of blood
Tx of Valvular Heart Disease
Treatment depends upon valve involved & severity of disease. *Focus is prevention of; -Exacerbation of CHF, acute pulmonary edema, thromboembolism & recurrent endocarditis *Conservative therapy -HF treatment - vasodilators, + inotropes, B-adrenergic blockers, diuretics & low Na+ diet. -Anticoagulant therapy - prevent/treats systemic or pulmonary emboli. -Atrial dysrhythmias are common; treated with CCB, BBs, antidysrhythmics or cardioversion.
Tricuspid & Pulmonic Valve Disease
Uncommon occurrence. Stenosis occurs more often than regurge. Tricuspid stenosis Occurs almost exclusively in patients who have RF or who are IV drug abusers. Results in RA enlargement & elevated systemic venous pressures. Pulmonic stenosis Almost always congenital Results in RV hypertrophy & hypertension
Rheumatic heart disease
chronic condition resulting from RF - characterized by scarring/deformity of heart valves -mitral valve most commonly affected
Mitral valve regurgitation issues
leads to higher preload b/c the blood isn't getting to the LV, lower EF, LA enlargement, LA irritability etc. Not at increased risk for Afib, but increased rsik for Vfib: because there is less blood perfusing the myocardium and the blood may be less oxygenated b/c pulmonary congestion
Sydenham's chorea
major CNS sign of RF Delayed sign occurring months after initial infection Characterized by involuntary movements of face & limbs, muscle weakness & disturbances of speech & gait.
