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Phase 2 Jamie McConnell & Rolla Ibrahim

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

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Phase 2 Jamie McConnell & Rolla Ibrahim

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  1. Arrhythmias, Valvular Disease, and Shock Phase 2 Jamie McConnell & Rolla Ibrahim The Peer Teaching Society is not liable for false or misleading information…

  2. Aims • The ECG • Common/important arrhythmias • Rheumatic Fever • Mitral Valve Disease • Aortic Valve Disease • Shock • Focusing on Cause, clinical presentation, diagnosis, treatment The Peer Teaching Society is not liable for false or misleading information…

  3. Rheumatic Fever • 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 The Peer Teaching Society is not liable for false or misleading information…

  4. Diagnosis Revised Jones Criteria Major Criteria Mnemonic: JONES Joints – arthritis Obviously Cardiac Nodules – Subcutaneous nodules Erythemamarginatum Sydenham’s Chorea • Evidence of Strep infection • Positive throat culture • Rising or elevated strep antibody titres • Rapid strep. Antigen test • Recent sarlet fever The Peer Teaching Society is not liable for false or misleading information…

  5. …Diagnosis • Minor Criteria • Mnemonic: criTERIA • Temperature  fever • ESR/CRP raised • Raised (prolonged) PR interval • Itself. Previous hx of RF • Arthralgia The Peer Teaching Society is not liable for false or misleading information…

  6. Management • 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 The Peer Teaching Society is not liable for false or misleading information…

  7. Prognosis • 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 The Peer Teaching Society is not liable for false or misleading information…

  8. Valvular heart disease • 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 The Peer Teaching Society is not liable for false or misleading information…

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

  10. Mitral Stenosis • 2 leaves – anterior posterior • Total surface area: 5cm2 • Symptoms at 1cm2 • Gradual onset The Peer Teaching Society is not liable for false or misleading information…

  11. MS: Causes • 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 The Peer Teaching Society is not liable for false or misleading information…

  12. MS: Pathophysiology • 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 The Peer Teaching Society is not liable for false or misleading information…

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

  14. Clinical features Left heart features Right heart features Graham Steel murmur Early diastolic murmur Late Rising JVP Malar flush Hepatomegaly and ascites Generalized oedema • Exertionaldyspnea • Orthopnea • PND • Cough with pink frothy sputum • Hemoptysis • Recurrent bronchitis The Peer Teaching Society is not liable for false or misleading information…

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

  16. Investigations • 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 The Peer Teaching Society is not liable for false or misleading information…

  17. Management Medical 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 • Antibiotics – chest infection and endocarditis • AF – rate control and warfarin • Digoxin – to suppress AV node • Diuretics – pulmoneryoedema The Peer Teaching Society is not liable for false or misleading information…

  18. Mitral Regurgitation The Peer Teaching Society is not liable for false or misleading information…

  19. MR Causes • Valve itself • Mitral valve prolapse– most common • Annular calcification • Degenerative valve • Ventricle • LV dilatation  functional regurg • Ruptured Chordaetendinae • Pupillary muscle dysfunction • Cardiomyopathy • Infective – • RF, endocarditis • Connective tissue disorders • Marfans, Ehlers Danlos, SLE • Congenital • Appetite suppressants fenfluramine, phentermine The Peer Teaching Society is not liable for false or misleading information…

  20. MR: Pathophysiology • Chronic • Little change in left atrial pressure • Volume overload in ventricle • LV dilatation • Acute • Slight raise in LA pressure • Pulmonary oedema • Pansystolic murmur The Peer Teaching Society is not liable for false or misleading information…

  21. MR: Features • Signs of Pulmonary oedema • Palpitations – hyperdynamicheart • AF • Congestive Heart Failure • Chronic • Fatigue • Progressive exertionaldyspnoea • 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 The Peer Teaching Society is not liable for false or misleading information…

  22. MR: Investigations • 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 The Peer Teaching Society is not liable for false or misleading information…

  23. Management • 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 The Peer Teaching Society is not liable for false or misleading information…

  24. Mitral Valve Prolapse • 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 • Chordaetendinae • Mitral valve leaf • Annulus The Peer Teaching Society is not liable for false or misleading information…

  25. MP: Cause • MCC: myxomatous degeneration mitral valve • Basically, weakness of MV connective tissue • Enlarged leaflet or annulus • Inappropriately long cordaetendane • Papilary muscle dysfunction • Congenital • Marfan’, ASD • HOCM  enlarged LV, extra pressure on MV • RF or IHD • Hyperthyroidism The Peer Teaching Society is not liable for false or misleading information…

  26. MP: Features • 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 • Sudddentachy arrhythmia  SUDDAN CARDIAC DEATH! The Peer Teaching Society is not liable for false or misleading information…

  27. MP: Investigations • ECHO! • ECG • May show inferior T-wave inversion The Peer Teaching Society is not liable for false or misleading information…

  28. MP: Management • Antibiotic prophylaxis • Beta blockers • Chest pain • Palpitations • AF • Anticoagulation • Sugery The Peer Teaching Society is not liable for false or misleading information…

  29. Aortic Stenosis • 3 leaves • Elderly  Degenerative and calcification • MCC • Inflammation fibrosis • Middle age  congenital bicuspid valve calcification • Rheumatic heart disease The Peer Teaching Society is not liable for false or misleading information…

  30. AS: Pathology • Stenosis pressure overload • Left ventricular hypertrophy • Increased myocardial oxygen demand • Ischaemia • Angina • Arrhythmia • LV failure The Peer Teaching Society is not liable for false or misleading information…

  31. AS: Features • 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 The Peer Teaching Society is not liable for false or misleading information…

  32. AS: Investigation • ECHO! Diagnostic • Chest X-ray • Normal size heart • Post-stenotic dilatation • Valvular calcification • ECG • LV hypertrophy • Cardiac catheterization The Peer Teaching Society is not liable for false or misleading information…

  33. AS: Management • 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 The Peer Teaching Society is not liable for false or misleading information…

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

  35. AR: Cause - Acute • 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 The Peer Teaching Society is not liable for false or misleading information…

  36. AR: Causes - Chronic • Chronic rheumatic heart disease • Syphilis • Destruction of vasavasorum • Arthritides • Reiter’s syndrome • Ankylosingspondylitis • Rheumatic arthritis • Severe hypertension • Marfans • Fibrilin • Osteogenesisimperfecta • Collagen I • Appetite suppressant The Peer Teaching Society is not liable for false or misleading information…

  37. AR: Pathophysiology • 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 The Peer Teaching Society is not liable for false or misleading information…

  38. AR: Clinical Features • Asymptomatic for years • Palpitation  hypertrophic heart • Chest pain – acute  hypertrophic heart • Exertionaldyspnea, 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 The Peer Teaching Society is not liable for false or misleading information…

  39. AR: Investigations • ECHO! Diagnostic • ECG • Left ventricular hypertrophy • Chest X-ray • Cardiomegaly • Pulmonary oedema • Dilated ascending aorta • Cardiac catheterization The Peer Teaching Society is not liable for false or misleading information…

  40. AR: Management • 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 The Peer Teaching Society is not liable for false or misleading information…

  41. SHOCK • 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 The Peer Teaching Society is not liable for false or misleading information…

  42. SHOCK: Causes Pump failure Peripheral circulation failure Hypovolaemia Bleeding Fluid loss Heat exhaustion Anaphylaxis Sepsis Neurogenic Endocrine failure Addison’s, Hypothyroidism Iatrogenic Anaesthetics, antihypertensives • Cardiogenic shock • Secondary • Pulmonary embolism • Tension pneumothorax • Cardiac tamponade The Peer Teaching Society is not liable for false or misleading information…

  43. SHOCK: Pathophysiology • 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 The Peer Teaching Society is not liable for false or misleading information…

  44. SHOCK: Clinical features • All about patient history • Pallor • Increase pulse • Trying to keep organs purfused • Decreased capillary return • Oliguria The Peer Teaching Society is not liable for false or misleading information…

  45. SHOCK: Management • 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 The Peer Teaching Society is not liable for false or misleading information…

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