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CARDIOVASCU LAR DISORDERS Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

MAIN OBJECTIVE

• To promote health, prevent illnesses diagnose and manage patients suffering from common cardiovascular disorders. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Specific Objectives

• Define concepts in cardiovascular system • Recognize individuals with disorders of the cardiovascular system • Describe common disorders of the cardiovascular system • Demonstrate ability to care for individuals with common disorders of the cardiovascular system Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

COURSE OUTLINE • Congestive cardiac failure (CCF) • Arteriosclerosis • Atherosclerosis • Intermittent claudication • Myocardial infarction • Rheumatic disease • Sub-acute bacterial endocarditis • Acute bacterial myocarditis • Hypertension • • Deep venous thrombosis Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

INTRODUCTION

• Heart diseases are major cause of death but not all kinds are fatal. • There are many causes as covered under various conditions. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

DIAGNOSTIC TESTS

• Electrocardiogram G) • X-ray • Angiogram • Heart catheterization • Central venous pressure • Radio-Isotopes • • Phonocardiography Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

CONGESTIVE CARDIAC FAIRULE

• is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Pathophysiology • amount of blood pumped by the heart is insufficient to meet the body needs. • The right fails to function properly, the right becomes engorged leading to congestion in the venous system. • The pressure in the superior and inferior venacava rises. The veins in the neck are distended, the liver becomes engorged and the legs become oedematous. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

SPECIFIC SYMPTOMS

• Left sided failure;-Cardinal sign- dyspnoea • Right sided failure;-CS-oedema • Pulmonary oedema;-occurs as a result of accumulation of fluid within the lung tissue due to the left sided failure, presents with;- severe dyspnoea, coughing up bloody stained sputum. • Acute pulmonary oedema can be fatal within a short period of time and presents with;- Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• Sudden onset of breathlessness • Signs of suffocation • Cyanosis • Cold hands • Distended neck veins tachycardia • Incessant coughing • Increasing mucoid sputum • Noisy respirations i.e. crackles Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• TachycardSiaYMPTOMS • Palpitations • Arrhythmia • Dyspnoea • Ascites • Cyanosis • Distended jugular vein • Pitting oedema • Chest pain • Coughing /haemoptsis • Nausea and vomiting • Oliguria Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

GENERAL MANAGEMENT

AIM • To relieve symptoms and reduce venous return to the heart Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• . • • Oxygen administration • Sedation • Rest • Diet • Skin care • Medication ;- digitalis e.g. digoxin •Diuretics;-furesimide •Analgesics;-morphine • Rehabilitation Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• Adequate exercise • A • Tobacco smoking • Stress • Treatment of URTI Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

HOSPITAL MANAGEMENT On admission • Bed rest • Prop-up • Oxygen administration if dyspnoeic or cyanosed • Total nursing care • Vital observations;- 1 hourly later 4 hourly • Medication;- Digitalis(digoxin) Diuretics Analgesics Potassium chloride • Daily weighing • Diet – light, low salt, easily digestible. • Pressure area care Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

- advice on;- • Rest • Low salt, high potassium diet • Compliance to drugs • Follow up • Effects in pregnancy in women Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

DISEASES OF THE ARTERIES

ATHEROSCLEROSIS AND ARTERIOSCLEROSIS ATHEROSCLEROSIS • Is a disease of the arteries in which fatty plagues develop on their inner walls, eventually obstructing blood flow and interfering with absorption of nutrients. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

ARTERIOSCLEROSIS • Literally means hardening of arteries with loss of elasticity within the middle layer of the small arteries, causing impaired blood supply to the organs and severe elevation of blood pressure. • It is associated with some degree of athroma and old age. • Although the processes of atherosclerosis and arteriosclerosis differ, rarely does one occur without the other Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Pathophysiology • It’s a disease of artery in which fatty plaques develop in the internal layer of medium and large artery eventually obstructing blood flow. The deposits interfere with absorption of nutrients by the endothelial cells that compose the lining and protrude into the lumen obstructing blood flow. • There is accumulation of smooth muscle cells, fat plaques with lipids, fatty acids, cholesterol calcium crystal, carbohydrates, blood components and fibrous tissue. • Secondary changes can occur as a result of arterial dilatation and Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Atherosclerosis Modifiable • Nicotine use (i.e., tobacco smoking, chewing) • Diet (contributing to hyperlipidemin) • Hypertension • Diabetes (which speeds the atherosclerotic process by thickening the basement membranes of both large and small vessels) • Stress • Sedentary lifestyle Non modifiable • Age • Gender Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Effects of atherosclerotic plaques • Narrowing the arterial lumen to cause ischaemia • Sudden occluding of the lumen by thrombosis causing infarction • Providing a site for thrombosis then embolism • Forming an aneurism then rupturing • Effects occur most frequently in the heart, the brain, the kidneys,

intestines. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Prevention

• Reduce fat ingestion • Reduce cholesterol intake • Quit smoking • Exercises • Medication to reduce lipid levels;- atorvastatin, nicotinic acid Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Intermittent Claudication • A muscular, cramp-type pain in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest is experienced by patients with peripheral arterial insufficiency. • The pain result from built up of metabolic waste within the muscle tissue. • There is local irritation by this toxic waste causing ischemic pain. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Mechanism Of Intermittent Claudication

Activity/exercise ?Increased tissue oxygen demand ?impaired oxygen supply due to obstruction ?shift to anaerobic metabolism ? build up of metabolic waste ? local irritation of peripheral nerve endings ? pain in extremity ?rest ? decreased tissue oxygen demand ? return to aerobic metabolism ? elimination of metabolic waste ? relief of pain. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Diagnosis

• Peripheral pulses;- e.g. poplitial pulse, dorsalis pedis pulse • Doppler ultrasound Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

General management

• Give bed rest • Provide warmth to cold extremities • Elevate the feet • Moderate regular exercises for the limbs • Skin care • Low fat diet • Stop smoking Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Medication • Vasodilators;- nifedipine • Nicotinic acid;- antilipemic to decrease serum lipids • Antiplatelets;- aspirin • Thrombolitics;- heparin Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Surgical intervention

Peripheral Arterial Bypass • Synthetic graft is anstomosed to a patent arterial source both proximal and distal to the lesion. Complications;- • Infection • Graft failure • Amputation Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Percutaneous Transluminal Angioplasty (PTA) • This use of a small catheter with an inflatable balloon is passed though the vessel to compress the lesion and widen the lumen followed by anticoagulation therapy. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Nursing Care

• Surgical cleaning of wounds • Antibiotics;- prophylaxis/treatment. • Vital observations • Pain management • Psychological support • Support lifestyle changes to Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

The Patient Who Has Peripheral Arterial Insufficiency Nursing Process Nursing Diagnosis • Ineffective peripheral tissue perfusion related to compromised circulation • Chronic pain related to impaired ability of peripheral vessels to supply tissues with oxygen • Risk for impaired skin integrity related to compromised circulation • Deficient knowledge regarding self- care activities Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• On discharge give education on;- aetiology prevention signs and symptoms follow-up Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

CORONARY HEART DISEASE

• D imparment due to an imbalance between coronary blood flow and myocardial oxygen requirement caused by changes in the coronary circulation

• Myocardial ischemia (angina pectoris ) • Myocardial infarction (myocardial cell death) Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Causes

Organic disease ;condition is associated changes in structure;- Arthrosclerosis. Thrombosis. Ateriosclerosis. Functional changes ; where no physical changes can be found – coronary artery spasm Forms. • Acute-cardiac arrest • Chronic • Silent myocardial infarction (people just die) Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• CHD causes occlusion of blood flow either partial leading to ischemia or complete leading to infarction • Ischemia is reversible if myocardial blood flow is not increased or myocardial o ischemia progresses to infarction Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Risk factors • cigarette smoking and second-hand smoke • Diabetes • high blood cholesterol, especially a high level of LDL, the carrier for cholesterol • high blood levels of triglycerides • high blood pressure • increasing age • lack of exercise • male gender • overweight or obesity • Genetic factors that affect heart disease risk are beyond a person's control. These include a strong family history of the following: coronary heart disease, heart attack, high cholesterol Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Angina pectoris

• This is a clinical syndrome produced by a reduction in the blood supply in the muscle of the heart caused by narrowing or partial occlusion of the coronary arteries

• When a muscle has to work with deficient oxygen a severe cramping pain occurs. This pain is due oxygen deficiency and is common to all the muscles (intermittent claudication). Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Sign and symptoms.

• Severe cramping pain which radiates down the left and arm neck and sometime upper abdomen. It may be trigered by bending or climbing stairs especially during cold weather the pain disappears after rest. • Tightness in the chest. • Profuse perspiration(diaphoresis.) pallor and flashing of the face. • dyspnoea Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Causes.

1.Arteriosclerosis of coronary artery i.e. become to narrow to provide blood supply to the myocardium 2.Hypertension leading to enlargement of the heart (cardiomegally.) and greater oxygen requirement. 3.Aortic Aneurisms or stenosis 4.Severe anemia Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Management • Avoidance of sudden physical exertion, emotional upsets. DRUGS. • • Beta blockers; e.g. propranolol • Sedatives; diazepam. Diet. • Low calorie diet for the obese to reduce the weight and strain the heart • Treatment of hypertension Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Surgical management

• angioplasty, a procedure in which a tube with a balloon is inserted to reopen the artery. • atherectomy, which involves removing plaques that cause narrowing of a blood vessel • laser surgery, which uses light waves to dissolve plaques • placement of a stent, a rigid tube, into the artery at the reopened area to keep it from narrowing again Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Myocardial infarction

• This is an area of necrotic tissues of the myocardium resulting from obstructed blood supply from the coronary artery to the area. • Can occur in any chamber but mostly occur in LV coz its oxygen need is great Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Clinical features • The most common symptom is chest pain, or angina. Angina is described as a feeling of crushing, pressure, fullness, heaviness, or aching in the centre of the chest which may radiate to the neck, the jaw, and down the left arm. Angina is often associated with other symptoms, including: • excessive sweating, nausea, shortness of breath weakness . • The type of angina known as stable angina is brought on by exertion and relieved by rest or nitroglycerin. The type of angina known as unstable angina is more frequent and more severe. It can occur even when the person is resting. Unstable angina is a medical emergency. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Diagnosis

• History taking • • Serum enzymes(transaminases)- changes Indicating muscle necrosis • ECG • Angiography Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Management • First aid(pre-hospital care) • Any person presenting with spontaneous angina

should be managed of acute MI • Aim;- relief pain Restoration of myocardial flow through;- CPR Oxygen Prevention of shock and complications Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Management in the hospital

• Total bed rest • Oxygen via mask • Cardiac monitoring( ECG) • Vital signs • Iv access for emergency drug administration • Pain management;- morphine or pethidine Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Medical management

• Vasodilators;- nitroglycerine to reduce artery spasms • Anticoagulant therapy;- heparin, aspirin • Antiarrythmias;- lidocaine • Thrombolytics;- streptokinase, Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Surgical interventions

• Percutaneous coronary intervention

• Coronary artery bypass grafting Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Hypertension

• Hypertension (HTN) or pressure is a chronic medical condition in which the systemic arterial blood pressure is elevated. • a systolic blood pressure greater than 140 mm Hg and a diastolic pressure greater than 90 mm Hg over a sustained period, based on the average of two or more blood pressure measurements taken in two or more contacts with the health care provider after an initial screening. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Types

primary (essential) or secondary. About 90–9 primary hypertension which refers to high blood pressure for which no medical cause can be found. The remaining 5–10% of cases Secondary hypertension are caused by other conditions that affect the kidneys, arteries, heart, or endocrine system Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Classification

• hypertension stage I;- 140- -99 • hypertension stage II>160/>100 • Hypertension stage III >180/>110 • isolated systolic hypertension Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Pathophysiology

• The precise cause for most cases of hypertension cannot be

occur, there must be a change in one or more factors affecting peripheral resistance or cardiac output. • Hypertension may be caused by one or more of the following: Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• Increased sympathetic nervous system activity related to dysfunction of the autonomic nervous system • Increased renal reabsorption of sodium, chloride, and water related to a genetic variation in the pathways by which the kidneys handle sodium • Increased activity of the renin-angiotensin- aldosterone system, resulting in expansion of extracellular fluid volume and increased systemic vascular resistance • Decreased vasodilation of the arterioles related to dysfunction of the vascular endothelium • Resistance to insulin action, which may be a common factor linking hypertension, type 2 diabetes mellitus, hypertriglyceridemia, obesity, and glucose intolerance Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Risk factors

• With diabetes. About 3 in 10 people with Type 1 diabetes and more than half of people with Type 2 diabetes eventually develop high blood pressure. • From African-Caribbean origin. • From the Indian sub-continent. • With a family history of high blood pressure. • With certain lifestyle factors. That is, those who: are overweight, eat a lot of salt, don't eat many fruit and vegetables, don't take enough exercise, drink a lot of coffee (or other caffeine-rich drinks), or drink a lot of alcohol Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Signs and symptoms

• Mild to headaches moderate – Vomiting – Asymptomatic – Convulsions – Headache – Papilloedema – Dizziness – Visual – Tinnitus disturbances – Epitaxis – CVA – Breathlessness – Paralysis – Angina • Severe – Severe Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Diagnosis

• Done through diastolic pressure;- mild 90-104mmHg moderate 105-114mmHg

severe above 115mmHg (3 readings not necessary) Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Lifestyle Modifications for Hypertension

• Lose weight if overweight. • Limit alcohol intake. • Increase aerobic physical activity (30 to 45 minutes most days of the week). • Reduce sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride). • Maintain adequate intake of dietary potassium (approximately 90 mmol per day). • Maintain adequate intake of dietary calcium and magnesium for general health. • Stop smoking and reduce intake of dietary saturated fat and cholesterol for overall cardiovascular health Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Medical management

• A • Alpha blockers (e.g., prazosin) • Angiotensin II receptor antagonists (e.g., losartan) • Beta blockers (e.g., propranolol) • Calcium channel blockers (e.g., verapamil) • Diuretics (e.g. hydrochlorothiazide) • Direct renin inhibitors (e.g., aliskiren) Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Discussion

• Nursing care Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Infective Endocarditis • Infection of the endocardium, (commonly, streptococci and staphylococci) or fungi. • It causes fever, heart murmurs, petechiae, anemia, embolic phenomena, and endocardial vegetations.(Usually a sterile fibrin- platelet vegetation formed when damaged endothelial cells release tissue factor) • Vegetations may result in valvular incompetence or obstruction, myocardial abscess, or mycotic aneurysm Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Etiology

• The normal heart is relatively resistant to infection • 2 factors are generally required for endocarditis: – a predisposing abnormality of the endocardium. – microorganisms in the bloodstream (bacteremia). Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• Endocardial factors: – Congenital heart defects,eg , ventricular-septal defects, and patent ductus arteriosus – Rheumatic valvular disease, bicuspid or calcific aortic valves, mitral valve prolapse, and – Hypertrophic cardiomyopathy. – Prosthetic valves are a particular risk. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• Microorganisms that infect the endocardium may originate from distant infected sites (e.g., cutaneous abscess, inflamed or infected gums, UTI) or have obvious portals of entry such as a central venous catheter or a drug injection

material (eg, prosthetic device) is at risk of bacterial colonization, thus becoming a source of bacteremia and hence endocarditis. • Endocarditis also may result from asymptomatic bacteremia, such as typically occurs during invasive dental, medical, or surgical procedures. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Classification

• Subacute bacterial endocarditis (SBE)

• Acute bacterial endocarditis (ABE)

• Prosthetic valvular endocarditis Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Subacute bacterial

usually develops insidiously and progresses slowly. Often, no source of infection or portal of entry is evident. SBE is caused most commonly by streptococci. SBE often develops on abnormal valves after asymptomatic bacteremia due to periodontal, GI, or GU infections. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Acute bacterial endocarditis (ABE)

• usually develops abruptly and progresses rapidly (i.e., over days). • A source of infection or portal of entry is often evident. When bacteria are virulent or bacterial exposure is massive, ABE can affect normal valves. It is usually caused by S. aureus, group A hemolytic streptococci, pneumococci, or gonococci Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Prosthetic valvular endocarditis (PVE) • Develops after . It is more common after aortic than after and affects mechanical and bioprosthetic valves equally. • Caused mainly by contamination during surgery with antimicrobial- resistant bacteria (eg, s. Epidermidis, diphtheroids, coliform bacilli, candida sp, aspergillus sp). Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

are nonspecific. Initially, symptoms are vague: low-grade fever (< 39° C), night sweats, fatigability, malaise, and weight loss. Chills and arthralgias may occur. Symptoms and signs of valvular insufficiency may be a first clue. Physical examination may be normal or include pallor, fever, murmurs, and tachycardia. Roth's spots, petechiae, Osler's nodes, Janeway lesions Signs of embolism depending on the organ affected;- brain- CVA, kidneys- pain in flanks In ABE and PVE the symptoms are more rapid and septic shock may result. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Diagnosis

• Blood cultures • Echocardiography • Clinical criteria Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Treatment

• IV antibiotics (based on the organism and its susceptibility)- penicillin is the drug of choice and vancomycin if the patient is sensitive to penicillins. • Sometimes valve debridement, repair, or replacement Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Bacterial myocarditis

• May be acute or chronic • May occur at any age • May be assymptomatic and recover simultaniously or diffuse leading to cardiac failure • Other causes;- viruses, protozoa, mycotic, chemical poisons, idiopathic Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• Follows a streptococcal infection • Can lead to;- – Alteration of heart fibres – Necrosis of heart tissue – Scar formation (fibrosis) – Hypertrophy from cardiac overload and decreased muscle fiber capacity – Permanent damage of the muscle leading to CCF Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Signs and symptoms

Non specific;- Dyspnoea, Palpitations,Fever Muscle fiber degeneration causes – Right and left sided heart failure – Cardiomegally – Distended neck veins – Tachycardia – Arrythmias – murmurs Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Management

• Antibiotics • Bed rest • Total nursing care • O • Digitalis • For arrythmias;- procainamide, lidocaine Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Prognosis

• Majority of patients recover spontaneously with the exption of rheumatic fever, Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

PERICARDITIS

• Inflammation of the , the membranous sac enveloping the heart. • Pericarditis can lead to an accumulation of fluid in the pericardial sac () and increased pressure on the heart, leading to Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• some of the causes underlying or associated with pericarditis: • Idiopathic or nonspecific causes • Infection • Disorders of connective tissue: systemic lupus erythematos • Disorders of adjacent structures: myocardial infarction, pleural and pulmonary disease (pneumonia) • Neoplastic disease: caused by metastasis from lung cancer or breast cancer, leukemia • Trauma: chest injury, , , pacemaker implantation • Renal failure and uremia • Tuberculosis Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Clinical Manifestations

• Chest pain • Friction rub • D heart failure may occur as the result of pericardial restriction. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Diagnosis

• History • Physical exam • ECG • Echocardiogram Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Management

• Bed rest • • Corticosteroids (e.g., prednisone • • Pericardial window • Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• Inflammatory disease that occurs

infection, (such as strep throat or scarlet fever) caused by antibody cross-reactivity that can involve the heart, joints, skin, and brain. The illness typically develops two to three weeks after a streptococcal infection. • Acute rheumatic fever commonly appears in children between the

of first-time attacks occurring in adults. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Diagnosis

• The diagnosis of rheumatic fever can be made when two of the major criteria, or one major criterion plus two minor criteria, are present along with evidence of streptococcal infection. • Chorea and carditis are indicative of rheumatic fever. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Major criteria • Migratory polyarthritis: a temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards. • Carditis: inflammation of the heart muscle which can manifest as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur. • Subcutaneous nodules: painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees. • Erythema marginatum: a long lasting rash that begins on the trunk or arms as macules and spreads outward to form a snake like ring while clearing in the middle. This rash never starts on the face and it is made worse with heat. • Sydenham's chorea (St. Vitus' dance): a characteristic series of rapid movements without purpose of the face and arms. This can occur very late in the disease. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Minor criteria

• Fever • Arthralgia: Joint pain without swelling • Raised Erythrocyte sedimentation rate. • Leukocytosis • ECG showing features of heart block, such as a prolonged PR interval • Supporting evidence of Streptococcal infection: elevated or rising Antistreptolysin O titre. • Previous episode of rheumatic fever or inactive heart disease Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Treatment

• Anti-inflammatory medications such as aspirin or corticosteroids. Aspirin is the drug of choice and should be given at high doses of 100 mg/kg/day. One should watch for side effects like gastritis and salicylate poisoning. In children and teenagers, the use of aspirin and aspirin-containing products can be associated with Reye's syndrome, a serious and potentially deadly condition. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• penicillin must be given for a period of five years in patients having one attack of rheumatic fever. If there is evidence of carditis, the length of Penidure therapy may be up to 40 years. Another important cornerstone in treating rheumatic fever includes the continual use of low-dose antibiotics (such as penicillin, sulfadiazine, or erythromycin) to prevent recurrence. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Chronic rheumatic valvular disease

• This follows acute stage and may be for many years before effects are noticed • Chronic inflammation causes;- – Thickening – Distortion – Loss of elasticity and function of the valve Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

• There are 2 main effects: 1.Valves adhere to each other causing stenosis and obstruction of blood flow 2.Loss of elasticity and distortion leading to valve incompetence All the heart valves may be affected but the most common damaged are;- the mitral valve;-mitral stenosis, mitral incompetence aortic valve;- aortic stenosis, aortic incompetence They may cause few symptoms till the heart fails. Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Signs and symptoms

• Murmurs • Severe dyspnoea • Heart enlargement Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Management

• Patient is advised to avoid undue exertion which might strain the heart precipitating heart failure. • Surgical – Mitral valvotomy – Mitral valvectomy Please purchase PDFcamp Printer on http://www.verypdf.com/ to remove this watermark.

Complications

• Cardiac failure • Embolism