phase 2 jamie mcconnell & rolla ibrahim
DESCRIPTION
Arrhythmias, Valvular Disease, and Shock. Phase 2 Jamie McConnell & Rolla Ibrahim. The Peer Teaching Society is not liable for false or misleading information…. Aims. The ECG Common/important arrhythmias Rheumatic Fever Mitral Valve Disease Aortic Valve Disease Shock - PowerPoint PPT PresentationTRANSCRIPT
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Phase 2
Jamie McConnell & Rolla Ibrahim
Arrhythmias, Valvular Disease, and Shock
The Peer Teaching Society is not liable for false or misleading information…
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• The ECG• Common/important arrhythmias• Rheumatic Fever• Mitral Valve Disease• Aortic Valve Disease• Shock
– Focusing on Cause, clinical presentation, diagnosis, treatment
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Aims
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• 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
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Rheumatic Fever
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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
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Diagnosis
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• Minor Criteria • Mnemonic: criTERIA• Temperature fever• ESR/CRP raised• Raised (prolonged) PR interval• Itself. Previous hx of RF• Arthralgia
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…Diagnosis
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• 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
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Management
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• 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
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Prognosis
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• 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
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Valvular heart disease
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• 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
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Valvular heart disease
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• 2 leaves – anterior posterior
• Total surface area: 5cm2
• Symptoms at 1cm2
• Gradual onset
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Mitral Stenosis
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• 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
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MS: Causes
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• 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
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MS: Pathophysiology
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• 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
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Continue Pathophysiology
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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
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Clinical features
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• 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
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…Continue Features
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• 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
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Investigations
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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
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Management
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Mitral Regurgitation
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• 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
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MR Causes
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• Chronic– Little change in left atrial pressure– Volume overload in ventricle– LV dilatation
• Acute– Slight raise in LA pressure– Pulmonary oedema– Pansystolic murmur
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MR: Pathophysiology
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• 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
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MR: Features
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• 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
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MR: Investigations
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• 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
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Management
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• 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
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Mitral Valve Prolapse
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• 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
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MP: Cause
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• 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!
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MP: Features
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• ECHO!• ECG
– May show inferior T-wave inversion
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MP: Investigations
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• Antibiotic prophylaxis• Beta blockers
– Chest pain– Palpitations
• AF – Anticoagulation
• Sugery
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MP: Management
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• 3 leaves• Elderly Degenerative and calcification
– MCC– Inflammation fibrosis
• Middle age congenital bicuspid valve calcification• Rheumatic heart disease
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Aortic Stenosis
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• Stenosis pressure overload• Left ventricular hypertrophy• Increased myocardial oxygen demand• Ischaemia
– Angina– Arrhythmia– LV failure
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AS: Pathology
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• 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
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AS: Features
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• ECHO! Diagnostic• Chest X-ray
– Normal size heart– Post-stenotic dilatation– Valvular calcification
• ECG– LV hypertrophy
• Cardiac catheterization
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AS: Investigation
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• 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
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AS: Management
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• 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
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AR: Cause - Acute
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• 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
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AR: Causes - Chronic
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• 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
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AR: Pathophysiology
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• 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
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AR: Clinical Features
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• ECHO! Diagnostic• ECG
– Left ventricular hypertrophy• Chest X-ray
– Cardiomegaly– Pulmonary oedema– Dilated ascending aorta
• Cardiac catheterization
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AR: Investigations
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• 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
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AR: Management
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• 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
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SHOCK
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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
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• 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
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SHOCK: Pathophysiology
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• All about patient history• Pallor• Increase pulse
– Trying to keep organs purfused
• Decreased capillary return• Oliguria
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SHOCK: Clinical features
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• 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
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SHOCK: Management