Phase 2 Jamie McConnell & Rolla Ibrahim

Phase 2

Jamie McConnell & Rolla Ibrahim

Arrhythmias, Valvular Disease, and Shock

The Peer Teaching Society is not liable for false or misleading information…

• The ECG• Common/important arrhythmias• Rheumatic Fever• Mitral Valve Disease• Aortic Valve Disease• Shock

– Focusing on Cause, clinical presentation, diagnosis, treatment

• Problem in developing countries• Peak age 5-15 years• Pathology

– Group A, Beta-Hemolytic Strep Strep. Pyogenes– Initially pharyngeal infection– 2% Rheumatic heart disease– Antigenic mimicry

Rheumatic Fever

Revised Jones Criteria• Evidence of Strep infection

– Positive throat culture– Rising or elevated strep

antibody titres– Rapid strep. Antigen test– Recent sarlet fever

• Major Criteria• Mnemonic: JONES• Joints – arthritis• Obviously Cardiac• Nodules – Subcutaneous

nodules• Erythema marginatum• Sydenham’s Chorea

Diagnosis

• Minor Criteria • Mnemonic: criTERIA• Temperature fever• ESR/CRP raised• Raised (prolonged) PR interval• Itself. Previous hx of RF• Arthralgia

…Diagnosis

• Bedrest until CRP normal – usually 3 months• Benzylpenicillin or penicillin for 10 days

– Allergy erythromycin • Carditis/arthritis Analgesia

– NSAID– Severe - Prednisolone

• Chorea haloperidol or diazepam

Management

• 60% Chronic RF disease• Acute attacks 3 months• Recurrence with:

– Pregnancy– The Pill– Strep infection

• Cardiac sequelae– Usually mixed mitral

valve disease– 70% mitral– 40% aoritic– 10% Tricuspid

Prognosis

• Mostly left sided• Murmurs• Innocent murmurs

– Soft, Short, Systolic• Diagnosis: ECHO!• Surgical

– Valve repair – Valvotomy fused cups of

stenosis separated– Valve repalcement

• Homographft – degenerate• Mechanical - anticoagulants

Valvular heart disease

• Stenosis– Valve fails to open fully AND cause impediment to forward flow

• Regurgitation (insufficiency)– Failure to fully close valve at appropriate time, resulting in

backwards flow of blood.• Mixed

– If valve calcified – fixed and tough. Mitral for example:– Diastole – should open fully, but doesn’t open stenosis– Systole – should close but leaves don’t fully come together

regurgitation

Valvular heart disease

• 2 leaves – anterior posterior

• Total surface area: 5cm2

• Symptoms at 1cm2

• Gradual onset

Mitral Stenosis

• Rheumatic heart disease– RF attack valve heals fibrosis distortion and

calcification• Congenital• Age – not as common• Carcinoid syndrome (TS>MS)

– 5HT, histamines, bradykinin– GIT (appendix) liver venous right heart lungs left

heart– Fibroblasts

• Prosthetic valve

MS: Causes

• MS raised intra-artrial pressure LA hypertrophy • With time, LA dilatation

– Atrial Fibrillation because of prolonged time for impulse to reach the bundle of His

• LV becomes under filled• Blood flow stasis in atria THROMBI

– CNS– Kidney– Spleen– Bone– Lung

MS: Pathophysiology

• Lung• Pulmonary-venous congestion• Increase hydrostatic pressure • Pul. Interstitial oedema• Pul. Alveolar oedema• Reactive pulmonary arteriolo-constriction to prevent oedema right ventricular pressure increases

• La Place’s law – increase in radius, decrease pressure• Hypertrophy

Continue Pathophysiology

Left heart features• Exertional dyspnea• Orthopnea• PND• Cough with pink frothy

sputum• Hemoptysis • Recurrent bronchitis

Right heart features• Graham Steel murmur

– Early diastolic murmur– Late

• Rising JVP• Malar flush• Hepatomegaly and ascites• Generalized oedema

Clinical features

• Small volume pulse– Due to decreased volume in left atria

• Apex Beat– Tapping – MS. Lightly taps chest wall– Heaving – AS. Hypertrophy of ventricle. Hits wall strong

and sustained– Thrusting – AR. Short because the ventricle empties

quickly• Ascultation

– Loud S1– Opening snap– Soft rumbling murmur

• Palpitations (AF)• Systemic emboli• Generalized – fatigue

…Continue Features

• ECHO! Diagnostic– Shows structural and

functional changes• Chest X-ray

– Mitral valve calcification – LA enlargement double

shaddow wave– Pulmonary oedema

• ECG• Cardiac catheterization.

Indications:– Angina– Signs of other valve disease– Sever pulmonary hypertension– Calcified mitral valve– Previous valvotomy

Investigations

Medical• Antibiotics – chest infection

and endocarditis• AF – rate control and

warfarin• Digoxin – to suppress AV

node• Diuretics – pulmonery

oedema

Surgical • Trans-septal balloon

valvotomy– Only if not heavily calcified

• Closed valvotomy – open chest, closed heart

• Open valvotomy – open chest, open heart– Only if heavily calcified

• Valve replacemet

Management

Mitral Regurgitation

• Valve itself– Mitral valve prolapse–

most common– Annular calcification– Degenerative valve

• Ventricle– LV dilatation functional

regurg– Ruptured Chordae

tendinae– Pupillary muscle

dysfunction– Cardiomyopathy

• Infective – – RF, endocarditis

• Connective tissue disorders– Marfans, Ehlers Danlos,

SLE• Congenital• Appetite suppressants

fenfluramine, phentermine

MR Causes

• Chronic– Little change in left atrial pressure– Volume overload in ventricle– LV dilatation

• Acute– Slight raise in LA pressure– Pulmonary oedema– Pansystolic murmur

MR: Pathophysiology

• Signs of Pulmonary oedema• Palpitations – hyperdynamic

heart• AF• Congestive Heart Failure• Chronic

– Fatigue– Progressive exertional

dyspnoea– Signs of right heart failure

e.g. peripheral oedema

• Apex beat– Laterally displacd because of LV

distension– Thrusting - forceful

• Ascultation– Quiet S1 – Pansystolic murmur– Systolic thrill– S3

• Thromboembolism less common than MS. But infective endocarditis is more common

MR: Features

• ECHO! Diagnostic– Trans-oesophageal to asses repair– Doppler to assess size

• Chest Xray– Left ventricular hypertrophy

• ECG– AF– Bifid P-waves– Left ventricular hypertrophy

• Cardiac catheterization – not unless indicated

MR: Investigations

• Asymptomatic– Echo every 1-5yrs

• AF rate control• Anticoagulate if:

– AF– Hx of embolism– Prosthetic valve– Additional MS – mixed valvular disease

• Diuretics may help symptom control• Surgery

– If more than mild symptoms– LV involvement

Management

• Mainly in young women• Most common valvular

abnormality• Occurs in one (posterior) leaf

or more• Prolapse back into atrium

during systole• Mitral valve apparatus

– Ventricular muscle– Papillary muscle– Chordae tendinae– Mitral valve leaf– Annulus

Mitral Valve Prolapse

• MCC: myxomatous degeneration mitral valve– Basically, weakness of MV connective tissue

• Enlarged leaflet or annulus• Inappropriately long cordae tendane• Papilary muscle dysfunction• Congenital

– Marfan’, ASD– HOCM enlarged LV, extra pressure on MV

• RF or IHD• Hyperthyroidism

MP: Cause

• Usually Asymptomatic• Atypical chest pain

– Most common presentation. Abnormal ventricular contraction• Palpitations• Auscultation

– Mid-systolic click– Late diastolic murmur not always present. Worse prognosis

• Increased risk of thrombo-embolism and infective endocarditis• Suddden tachy arrhythmia SUDDAN CARDIAC DEATH!

MP: Features

• ECHO!• ECG

– May show inferior T-wave inversion

MP: Investigations

• Antibiotic prophylaxis• Beta blockers

– Chest pain– Palpitations

• AF – Anticoagulation

• Sugery

MP: Management

• 3 leaves• Elderly Degenerative and calcification

– MCC– Inflammation fibrosis

• Middle age congenital bicuspid valve calcification• Rheumatic heart disease

Aortic Stenosis

• Stenosis pressure overload• Left ventricular hypertrophy• Increased myocardial oxygen demand• Ischaemia

– Angina– Arrhythmia– LV failure

AS: Pathology

• Asymptomatic until 1/3rd normal size• *Angina• *Exertional syncope• *Symptoms of CHF• Ventricular arrythmia SUDDEN DEATH• Ascultation

– Ejection click– Ejection systolic murmur– S2 splitting - rare

• Apex beat– Heaving

• Carotids– Slow rising pulse

AS: Features

• ECHO! Diagnostic• Chest X-ray

– Normal size heart– Post-stenotic dilatation– Valvular calcification

• ECG– LV hypertrophy

• Cardiac catheterization

AS: Investigation

• 75% OF PATIENTS WILL DIE IN 3 YEARS IF VALVE NOT REPLACED• Aortic valve replacement indicated

– Symptomatic patients– Asymptomatic with:

• Small surface area• High pressure on echo

• Balloon aortic valvotomy – Childhoo or adolescence

AS: Management

• Acute RF– Myocarditis stretch annulus

• Infective endocarditis• Dissection of aorta• Rupture of sinus of Valsalva Aneurysm

– Dilated pockets at root of aorta

• Failure of prosthetic heart valve

AR: Cause - Acute

• Chronic rheumatic heart disease• Syphilis

– Destruction of vasa vasorum• Arthritides

– Reiter’s syndrome– Ankylosing spondylitis– Rheumatic arthritis

• Severe hypertension• Marfans

– Fibrilin• Osteogenesis imperfecta

– Collagen I• Appetite suppressant

AR: Causes - Chronic

• Column of blood falls back into ventricle• Ventricle overfilled Volume overload

– Frank Sterling law• Systole hyperdynamic• LV

– Volume overload hypertrophy dilated– Pressure overload hypertrophy

• Heart sounds– Systole – ejection systolic murmur– Diastole – Silent S2– Diastole – Early diastolic murmur– Austin flint murmur

AR: Pathophysiology

• Asymptomatic for years• Palpitation hypertrophic heart• Chest pain – acute hypertrophic heart• Exertional dyspnea, Orthopnea, PND• Apex beat Thrusting• Pressure

– Very high systole, normal/low diastole• Pulse• Collapsing/water hammer pulse• Ascultation

– Ejection systolic murmur– Silent S2– Early diastolic murmur– Austin Flint murmur

AR: Clinical Features

• ECHO! Diagnostic• ECG

– Left ventricular hypertrophy• Chest X-ray

– Cardiomegaly– Pulmonary oedema– Dilated ascending aorta

• Cardiac catheterization

AR: Investigations

• Look for underlying cause and treat it• Surgery as soon as symptoms appear.

– Increasing symptoms– Enlarged heart on CXR/Echo– Infective endocarditis– ECG deterioration

– Goal– replace valve before LV dysfunction• ACEi

– Venodilate reduce preload (venous return is less)– Arteriodialate reduce afterload

• Antibiotic prophylaxis

AR: Management

• Sepsis Severe Sepsis Septic Shock• When you see a patient in sepsis, GOAL intervene before septic shock!• Shock

– Circulatory failure resulting in inadequate organ perfusion– Usually Systolic <90mmHg– Anerobic function and lactate

• SIRS – Systemic inflammatory response syndrome. 2 of following– Temperature >36, <38– HR above 90bpm– WCC Above 12 or below 4– RR >20bpm OR decreased PaCO2 <4.3

• Sepsis– SIRS + Evidence of infection

Pump failure• Cardiogenic shock• Secondary

– Pulmonary embolism– Tension pneumothorax– Cardiac tamponade

Peripheral circulation failure• Hypovolaemia

– Bleeding– Fluid loss– Heat exhaustion

• Anaphylaxis• Sepsis• Neurogenic• Endocrine failure

– Addison’s, Hypothyroidism

• Iatrogenic– Anaesthetics,

antihypertensivesThe Peer Teaching Society is not liable for false or misleading information…

SHOCK: Causes

• Sympathoadrenaline– Reflex to hypotension– Catecholamine release

• Vasoconstriction, increase myocardial contractility, increase HR• Goal: restore BP and CO

– Renin-angiotensin system• Vasoconstriction • Salt & water retension

• Neuroendocrine response– Release ACTH, vasopressin, and endogenous opiods

• Microcirculation changes

SHOCK: Pathophysiology

• All about patient history• Pallor• Increase pulse

– Trying to keep organs purfused

• Decreased capillary return• Oliguria

SHOCK: Clinical features

• ABC– Airway– Breathing

• High-flow oxygen

– Circulation• Lay patient flat or head down. • IV access• Crystalloid FAST to raise BP

• Investigations• Septic shock

– Blood cultures before antibiotics

SHOCK: Management

Phase 2 Jamie McConnell & Rolla Ibrahim

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