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CR - Valvular Heart disease (i) (Aortic regurg (acute causes (endocarditis…
CR - Valvular Heart disease (i)
Classifications
valve involved
mitral
tricuspid
aortic
pul
nature of lesion
stenosis
regurg
congenital vs acquired
congenital malformation/dysplasia
bicuspid aortic valve
accelerated degeneration/calcification (presentation @ 30-40 y/o)
common
tetralogy of Fallot
VSD
pul valve stenosis
misplaced aorta
RVH
Ebstein's anomaly of tricuspid valve
septal + post cusps displaced towards apex of right ventricle
acquired
rheumatic heart disease
acute valvulitis + pancarditis
rheumatic fever occurs 2-6wks after S Pyogenes pharyngitis/Scarlet fever
leads to long term sequelae in some patients (valvular heart disease yrs later)
aortic regurg
mitral stenosis
due to cross-reactive Igs
can affect heart, skin, joints, brain
prevalent in developing countries - sharply declined in Europe + N America
Dx = Duckett-Jones criteria
evidence of previous strep upper airway infection with 2 major / 1 major + 2 minor criteria
major
polyarthritis
common (in 80%)
painful
short duration
migratory (usually>5 joints affected, usually large)
carditis
most serious - may lead to death
usually valvular lesion in mitral/aortic
isolated pericarditis / myocarditis rarely seen
sydenham's chorea
fast involuntary movements
muscular hypotonicity
emotional lability
usually late manifestation, months after infection
erythema marginatum
in 7%
highly specific but not pathognomonic
round/ irregularly shaped cut lesions with a pale centre + pink/red border often on trunk/abdo
subcut nodules
firm
non-tender
isolated/in clusters
most common on extensor surfaces of joints
last only a few days
in 9-20%
minor
fever
arthralgia
high CRP/ESR
prolonged PR interval
degenerative valve disease
most common
age-related
increased prevalence in last few decades due to increased life expectancy
myxomatous change (connective tissue disorder characterised by thickening + elongation of mitral cusps + chordae tendonae, + dilation of mitral annulus)
radiation
rheumatological disorders (e.g. SLE)
Aortic regurg
chronic causes
aortic root dilatation
congenital bicuspid valve
rheumatic heart disease
acute causes
endocarditis
aortic dissection
ruptured cusp
traumatic injury (holes in cusps)
failed repair
prevalance increases with age
more common than aortic stenosis
symptoms
palpitations
atypical chest pain
LHF (dyspnoea, orthopnoea, PND)
signs
wide PP
Watson's water hammer pulse (aka Corrigan's/collapsing pulse)
inferolat displacement of apex beat
soft S1 (variable S2/S3)
murmur
dias
loudest when leaning forward on expiration in left lower sternal border
decreases with Valsalva maneuvre (forced attempted expiration against a closed airway)
investigations
ECG
cardiac MRI
TOE (if not transthoracic)
cardiac catherisation
CXR