Definisi
Penyakit jantung reumatik adalah sebuah kondisi dimana terjadi kerusakan permanen dari
katup-katup jantung yang disebabkan oleh demam reumatik. Penyakit jantung reumatik
(PJR) merupakan komplikasi yang membahayakan dari demam reumatik. Katup-katup
jantung tersebut rusak karena proses perjalanan penyakit yang dimulai dengan infeksi
tenggorokan yang disebabkan oleh bakteri Streptococcus hemoliticus tipe A (contoh:
Streptococcus pyogenes), yang bisa menyebabkan demam reumatik. Kurang lebih 39 %
pasien dengan demam reumatik akut bisa terjadi kelainan pada jantung mulai dari
insufisiensi katup, gagal jantung, perikarditis bahkan kematian. Dengan penyakit jantung
reumatik yang kronik, pada pasien bisa terjadi stenosis katup dengan derajat regurgitasi
yang berbeda-beda, dilatasi atrium, aritmia dan disfungsi ventrikel. Penyakit jantung
reumatik masih menjadi penyebab stenosis katup mitral dan penggantian katup pada
orang
dewasa
di
Amerika
Serikat.
Gejala Klinis
Demam reumatik merupakan kumpulan sejumlah gejala dan tanda klinik. Demam
reumatik merupakan penyakit pada banyak sistem, mengenai terutama jantung, sendi,
otak dan jaringan kulit. Tanda dan gejala akut demam reumatik bervariasi tergantung
organ yang terlibat dan derajat keterlibatannya. Biasanya gejala-gejala ini berlangsung
satu sampai enam minggu setelah infeksi oleh Streptococcus. Gejala klinis pada penyakit
jantung reumatik bisa berupa gejala kardiak (jantung) dan non kardiak (jantung).
Gejalanya antara lain:
q Manifestasi kardiak dari demam reumatik
Pankarditis (radang pada jantung) adalah komplikasi paling serius dan kedua
paling umum dari demam reumatik (sekitar 50 %). Pada kasus-kasus yang lebih
lanjut, pasien dapat mengeluh sesak nafas, dada terasa tidak nyaman, nyeri dada,
edema (bengkak), batuk.
Gagal jantung
q Gejala umum non kardiak dan manifestasi lain dari demam rematik akut antara lain:
Poliartritis (radang sendi dibeberapa bagian tubuh) adalah gejala umum dan
merupakan manifestasi awal dari demam reumatik (70 75 %). Umumnya artritis
dimulai pada sendi-sendi besar di ekstremitas bawah (lutut dan engkel) lalu
bermigrasi ke sendi-sendi besar lain di ekstremitas atas atau bawah (siku dan
pergelangan tangan). Sendi yang terkena akan terasa sakit, bengkak, terasa
hangat, kemerahan dan gerakan terbatas. Gejala artritis mencapai puncaknya pada
waktu 12 24 jam dan bertahan dalam waktu 2 6 hari (jarang terjadi lebih dari 3
minggu) dan berespon sangat baik dengan pemberian aspirin. Poliartritis lebih
umum dijumpai pada remaja dan orang dewasa muda dibandingkan pada anakanak.
Khorea Sydenham, khorea minor atau St. Vance, dance mengenai hampir 15%
penderita demam reumatik. Manifestasi ini mencerminkan keterlibatan sistem
syaraf sentral pada proses radang. Hubungan khorea Sydenham sampai demam
reumatik tetap merupakan tanda tanya untuk beberapa waktu lamanya. Periode
laten antara mulainya infeksi streptokokus dan mulainya gejala-gejala khorea
lebih lama daripada periode laten yang diperlukan untuk arthritis maupun karditis.
Periode laten khorea ini sekitar 3 bulan atau lebih, sedangkan periode laten untuk
arthritis dan karditis hanya 3 minggu. Penderita dengan khorea ini datang dengan
gerakan-gerakan yang tidak terkoordinasi dan tidak bertujuan dan emosi labil.
Manifestasi ini lebih nyata bila penderita bangun dan dalam keadaan stres.
Penderita tampak selalu gugup dan seringkali menyeringai. Bicaranya tertahantahan dan meledak-ledak. Koordinasi otot-otot halus sukar. Tulisan tangannya
jelek dan ditandai oleh coretan ke atas yang tidak mantap dengan garis yang raguragu. Pada saat puncak gejalanya tulisannya tidak dapat dibaca sama sekali.
ruas jari, lutut, dan persendian kaki. Kadang-kadang nodulus ini ditemukan pada
kulit kepala dan di atas kolumna vertebralis.
Manifestasi lain dari demam reumatik antara lain nyeri perut, epistaksis
(mimisan), demam dengan suhu di atas 39 C dengan pola yang tidak
karakteristik, pneumonia reumatik yang gejalanya mirip dengan pneumonia
karena infeksi.
q Anemia
Tatalaksana
Tatalaksana bergantung dari tipe dan beratnya penyakit jantung rheuma. Pada
kebanyakan kasus, obat pengencer darah (aspirin) diberikan untuk mencegah
penumpukan. Dokter biasanya juga memberikan beta blocker dan calcium channel
blocker untuk menurunkan kerja jantung. Dan digitalis untuk meningkatkan efisiensi
kerja jantung.
Karena demam rheuma merupakan penyebab dari penyakit jantung rheuma, pengobatan
yang terbaik adalah untuk mencegah relaps dari demam rheuma. Antibiotik seperti
penisilin dan lainnya biasanya dapat mengobati infeksi dari bakteri streptococcus. Dan
menghentikan demam rheuma bermanifestasi. Apabila anda mempunyai riwayat terkena
demam rheuma biasanya kan diberikan terapi antibiotik dalam jangka waktu yang
panjang untuk mencegah demam rheuma timbul kembali dan mengurangi risiko terkena
penyakit jantung rheuma. Untuk mengurangi gejala peradangan dapat diberikan aspirin,
kortikosteroid atau NSAID(obat anti inflamasi non-steroid).
Terapi pembedahan dapat dilakukan untuk memperbaiki dan mengganti katup jantung
yang rusak.
www.uqu1.com/vb/showthread.php?t=4374
Seseorang yang mengalami demam rematik apabila tidak ditangani secara adekuat, Maka
sangat mungkin sekali mengalami serangan penyakit jantung rematik. Infeksi oleh kuman
Streptococcus Beta Hemolyticus group A yang menyebabkan seseorang mengalami
demam rematik dimana diawali terjadinya peradangan pada saluran tenggorokan,
dikarenakan penatalaksanaan dan pengobatannya yang kurah terarah menyebabkan
racun/toxin dari kuman ini menyebar melalui sirkulasi darah dan mengakibatkan
peradangan katup jantung. Akibatnya daun-daun katup mengalami perlengketan sehingga
menyempit, atau menebal dan mengkerut sehingga kalau menutup tidak sempurna lagi
dan terjadi kebocoran.
Rheumatic Fever
Background: Rheumatic fever is an inflammatory disease that occurs
in a very small percentage of children or adolescents with
history of untreated strep throat infection. Symptoms of
rheumatic fever generally appear a few weeks after the throat
infection with group A beta-hemolytic streptococcus. There
seems to be a genetic susceptibility to development of the
disease, which is a body reaction to the streptococcus. There is
no cure for rheumatic fever. It may be prevented by prompt and
complete treatment of a strep throat infection with antibiotics.
The disease may involve the
heart, joints, central nervous
system (brain), skin and
subcutaneous tissue.
Rheumatic fever usually
occurs during the school-age
years when strep throat
infections are most prevalent.
The incidence is low in most
parts of the United States.
The prevalence is higher in
the colder months when strep
throat is most likely to occur.
Ninety percent of cases of
rheumatic fever resolve in 3
months or less.
How it is diagnosed?
In 1944, the Jones criteria were formulated to make it easier to
identify the disease. There are major and minor modified Jones
criteria. In addition to evidence of a previous streptococcal
infection, the diagnosis requires two major Jones criteria or
one major plus two minor Jones criteria.
Table #1
Major Criteria:
Heart
Table #2
Minor Jones Criteria
Fever
Previous
Cardiovascular Tests:
In addition to blood testing, electrocardiogram, chest x-ray and
echocardiogram.
Medical Treatment:
Patients with rheumatic fever need to be treated with antibiotics
regardless of a negative throat culture. High doses of aspirin or
Naproxen are useful in controlling pain and inflammation. Steroids
are rarely used except for extremely sick children, mainly patients in
heart failure. Patients that develop heart failure will require heart
medications and diuretics. Secondary prophylaxis to prevent future
strep infections is used in patients who develop acute rheumatic
fever. The duration of prophylaxis depends on the risks of exposure
to strep infections and if the patient had previous attacks of
rheumatic fever. Penicillin is the drug of choice. Prophylaxis is
usually given for at least five years (or to age 21) in those patients
without heart involvement. Prophylaxis is given for a longer period of
time if there has been heart involvement or chronic heart damage
(rheumatic heart disease may require life-long prophylaxis). Most
patients do not require SBE prophylaxis under the new guidelines
from the American Heart Association. A decision on whether or not
to do this should be made after consultation with the family and Dr.
Villafae. Chorea movements may be controlled with medication as
well.
RHEUMATIC FEVER
Rheumatic fever is a generalized inflammatory connective tissue disease characterized by
fever, joint pains, and heart disease with less frequent involvement of the skin, nervous
system and the subcutaneous tissues. Rheumatic fever has a tendency to recur and is due
to an immune reaction following Group A beta haemolytic streptococcal throat infection.
Epidemiology
Rheumatic fever is common among the children of the poor, where there is overcrowding
and delay in the treatment of throat infections. Rheumatic fever is extremely rare under 2
years of age. Most cases of rheumatic fever occur in children aged 5-15 years.
Cause
Acute rheumatic fever is related to a previous Group A beta haemolytic streptococcal
throat infection. The interval between the throat infection and the attack of acute
rheumatic fever varies from 4- 6 weeks.
Clinical Manifestations:
The clinical manifestations of rheumatic fever include:
fever
polyarthralgia (discomfort in the joints without objective evidence of pain,
redness or swelling)
migratory polyarthritis: this asymmetrical and involves the large joints (knees,
ankles, elbow and the wrist). The affected joints are painful, red, hot, and swollen
for about 24 hours. After the recovery of one group of joints, the attack moves on
to other groups of joints. This movement of the attack from one group of joints to
the other explains the description of the arthritis as migratory. The polyarthritis
lasts 1-4 weeks and subsides without leaving any residual damage in the affected
joints.
Carditis: the most serious manifestation of rheumatic fever, involves all the
layers of the heart wall simultaneously The inflammation of the pericardium
(outer coating of the heart) is called pericarditis. The inflammation of the
myocardium (heart muscle) is called myocarditis. The inflammation of the
endocardium (internal lining of the heart wall) is called endocarditis. The
involvement of the heart is revealed by the occurrence of new mitral and aortic
murmurs and cardiomegaly. Very severe rheumatic heart disease may lead to heart
failure. The heart lesions may remain and worsen with every recurrence of the
acute rheumatic fever.
Subcutaneous nodules: are several tender swellings 0.5-2cm in diameter. These
nodules are found on the extensor surfaces of the bone prominences of the knees,
elbows, shoulders, scapulae, the occiput and the spinal processes. The
subcutaneous nodules occur in less than 15% of the cases and are indicators of a
severe disease.
Sydenham chorea: is characterized by jerky, involuntary and irregular
movements of the limbs and face, emotional instability, inattentiveness,
clumpsiness and crying out loudly. The movements are usually bilateral but may
also be unilateral. The chorea is worsened by stress and disappears when the child
is asleep. Sydenham chorea is rare and affects girls more commonly than boys.
After several weeks or months, spontaneous remission occurs.
The laboratory findings include acute phase reactants (leukocytosis, raised erythrocyte
sedimentation rate, and elevated C-reactive protein), evidence of a preceding
streptococcal infection (elevated or rising antistreptolysin titre, isolation of streptococci
from throat swab culture, and positive streptozyme test) and prolonged PR interval in the
Electrocardiogram (ECG).
In children aged < 2 years the clinical course of the disease tends to be mild and the
correct diagnosis may often be missed in this age group.
Diagnosis.
No single clinical feature or laboratory test can establish the diagnosis of rheumatic fever.
The diagnosis of rheumatic fever is made using some selected clinical features, the major
and minor criteria published by Jones.
The five major criteria are:
migratory polyarthritis;
carditis;
Sydenham chorea;
Subcutaneous nodules; and
erythema marginatum.
fever
Polyarthralgia in the absence of polyarthritis as a major criterion;
prolonged PR interval on the electrocardiogram
Acute phase reactants (leukocytosis, raised erythrocyte sedimentation rate, and
elevated C-reactive protein),
evidence of a preceding streptococcal infection (elevated or rising antistreptolysin
titre, isolation of streptococci from throat swab culture, and positive streptozyme
test)
Activity
6
Write down the usage of the above criteria for making diagnosis of acute rheumatic fever:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
The diagnosis of rheumatic fever is based on the presence of two major criteria or one
major criterion and two minor criteria, together with evidence of a preceding
streptococcal infection
Investigations:
The investigations done on suspecting acute rheumatic fever are throat swab for culture,
Antistreptolysin O titre (ASOT), and blood for acute phase reactants
Complications.
The development of rheumatic valvular heart disease is the major complication of acute
rheumatic fever.
Treatment:
After taking the throat swab, the first intramuscular dose of benzyl penicillin is given.
The intramuscular injections or oral penicillin are then continued for 10 days.
Children with painful joints and carditis often lie still. As they recover, they are not
allowed to walk until the joint involvement has subsided, heart size diminished and rapid
pulse diminished. Thereafter, the children are progressively allowed more activity. If
there has been heart failure, the convalescence may be more prolonged and activity is
restricted until the evidence of rheumatic activity has been absent for 2 weeks.
Anti-inflammatory treatment.
The anti-inflammatory treatment is effected with salicylates 100mg/kg/24 hours divided
in 4 doses for 3-5 days followed by 75mg/kg/24 hours divided in 4 doses for 4-6 weeks.
Patients with carditis or congestive cardiac failure are also given predisone, 2mg/kg/24
hours divided in 4 doses for 2-3 weeks. Thereafter, predisone is tapered over a period of 2
weeks by giving 5mg/24 hours every 2-3 days. While predisone is being withdrawn,
salicylates are given. Mild rebounds after the discontinuation of the anti-inflammatory
drugs are left alone. Those with severe rebounds are given salicylates or steroids once
more.
Congestive cardiac failure is treated with digoxin, diuretics, fluid and salt restriction and
oxygen. The slow digitilization dose of digoxin is 0.04 -0.06 mg/kg in 4 doses. The
maintence digoxin dosage is 0.01 mg/kg in two divided doses. Furosemide 2 mg/kg
intravenously per dose is given when there is pulmonary oedema.
Prevention of rheumatic fever.
a)Primary prevention.
Primary prevention means treatment of the streptococcal upper respiratory infection with
antibiotics to prevent the first attack of rheumatic fever. Antibiotic therapy started up to
the 9th day of the onset of symptoms of the upper respiratory infection can prevent
rheumatic fever.
b)Secondary prevention.
Secondary prevention means prevention of infection of upper respiratory tract with group
A beta haemolytic streptococci in persons who have had an attack of rheumatic fever. The
preferred method of secondary prevention is regular monthly intramuscular injections of
benzathine penicillin G, 1.200,000 units. Patients with rheumatic carditis need a lifelong
secondary prophylaxis. The individuals with no carditis continue with secondary
prophylaxis until early twenties provided that at least 5 years will have passed since the
last attack of rheumatic fever. Before dental or surgical procedures, patients with
rheumatic carditis also need additional antibiotics to prevent infective endocarditis. The
secondary prophylaxis of rheumatic fever is not enough for preventing infective
endocarditis. The additional antibiotics (gentamycin, amoxycillin, cephalexin,
azithromycin or erythromycin) are given within half an hour before the procedure. I hope
you now understand how to diagnose and treat rheumatic fever. Remember that it can be
prevented by treating a sore throat early with antibiotics. So advice parents not to ignore a
child with a sore throat but to bring them for treatment as early as possible.
Before you proceed to read the next section, do the following activity.
www.wikieducator.org/Lesson_21:_Other_Conditions
Definition
Tricuspid valve disease refers to damage to the tricuspid heart valve. This valve is located
between the atrium (upper chamber) and the ventricle (lower pumping chamber) of the
right side of the heart. The tricuspid valve has three cusps, or flaps, that control the
direction and flow of blood.
Causes
Rheumatic fever is the most common cause of tricuspid valve disease world-wide. Other
causes include:
Risk Factors
A risk factor is something that increases your chance of getting a disease or condition.
Symptoms
In many cases, there are no symptoms. However, if symptoms do occur, they may
include:
Difficulty breathing
Fatigue
Sensation of rapid or irregular heartbeat (palpitations)
Swelling in the legs or abdomen
Diagnosis
The doctor will ask about your symptoms and medical history, and perform a physical
exam. The doctor may be alerted to tricuspid valve disease by the following:
Heart murmur
Irregular pulse or heartbeat
Abnormal pulse in the jugular vein of the neck
Swelling in the legs
Chest x-ray a test that uses radiation to take pictures of structures inside the
chest
Electrocardiogram (ECG, EKG)a test that records the heart's activity by
measuring electrical currents through the heart muscle
Echocardiogram a test that uses high-frequency sound waves (ultrasound) to
examine the size, shape, and motion of the heart
Cardiac catheterization an x-ray of the heart's circulation that is done after
injection of a contrast dye
Treatment
If you have mild tricuspid valve disease, your condition will need to be monitored, but
may not need immediate treatment. When symptoms become more severe, treatments
may include:
Medications
Drugs may be prescribed to treat specific symptoms associated with tricuspid valve
disease. These medications include:
Surgery
If tricuspid valve disease is causing severe problems, surgery to repair or replace the
defective valve may be required.
Prevention
Tricuspid valve disease cannot be prevented. But, there are several things you can do to
try to avoid some of the complications:
If you have an abnormal valve, take antibiotics before any dental cleaning, dental
work, or other invasive procedures. This will help prevent infection of the heart
valve.
Treat strep throat infections promptly to avoid rheumatic fever, which can cause
scarring of the heart valve.
If your valve problem was caused by rheumatic fever, talk to your doctor about
antibiotic treatment to prevent future episodes of rheumatic fever.
RESOURCES:
American Heart Association
http://www.americanheart.org
National Heart, Lung, and Blood Institute
http://www.nhlbi.nih.gov
CANADIAN RESOURCES:
Canadian Cardiovascular Society
http://www.ccs.ca/home/index_e.aspx
Canadian Family Physician
http://www.cfpc.ca/cfp/
REFERENCES:
Definition
Mitral stenosis is a narrowing of the mitral valve in the heart. This valve is located
between the atrium (upper chamber) and the ventricle (lower pumping chamber) of the
left side of the heart. Blood must flow from the atrium, through the mitral valve, and into
the ventricle before being pumped out into the rest of the body. Mitral stenosis results in
inadequate blood flow between the two left chambers, and therefore too little blood and
oxygen being pumped throughout the body.
Mitral Valve Stenosis
Causes
The most common cause of mitral stenosis is rheumatic fever, which scars the mitral
valve. A less common cause is a congenital defect, usually part of a complex of multiple
heart defects present at birth. Very rare causes include blood clots, tumors, or other
growths that block blood flow through the mitral valve.
Risk Factors
A risk factor is something that increases your chance of getting a disease or condition.
The main risk factor for mitral stenosis is rheumatic fever. Other risk factors include:
Sex: female
Age: 30 to 50
Symptoms
Symptoms may include:
Diagnosis
The doctor will ask about your symptoms and medical history, and perform a physical
exam. The doctor may be alerted to mitral stenosis by the following:
Chest x-ray a test that uses radiation to take pictures of structures inside the
chest
Electrocardiogram (ECG, EKG)a test that records the heart's activity by
measuring electrical currents through the heart muscle
Echocardiogram a test that uses high-frequency sound waves (ultrasound) to
examine the size, shape, and motion of the heart; in this test, the sound waves are
passed through a transducer that is placed onto your chest.
Transesophageal echocardiogramuses the same ultrasound techniques to create
an image of your heart, but gives a more detailed image. In this test, the
transducer is passed down your esophagus (the tube in your throat that runs from
your mouth into your stomach), to allow a better examination of the mitral valve.
Cardiac catheterization an x-ray of the heart's circulation that is done after
injection of a contrast dye
Holter monitora portable EKG device that you wear for 24 or more hours, to
detect heart rhythm abnormalities that often accompany mitral stenosis
Treatment
If you have mitral stenosis, you will need antibiotics when you have certain infections
(eg, beta-strep infections, usually of the throat) or are having procedures (such as dental
work) that may put you at risk for heart infections. This will help prevent further damage
to your heart.
If you have mild mitral stenosis, your condition will need to be monitored, but may not
need immediate treatment for symptoms associated with mitral stenosis. When symptoms
become more severe, you may need to limit exertion and avoid high-salt foods. In
addition, treatments may include:
Medications
Drugs may be prescribed to treat specific symptoms associated with mitral stenosis.
These medications include:
Drugs that lower the heart rate and improve the heart's function (beta-blockers
and calcium channel blockers)
Water pills (diuretics)
Blood-thinning drugsMitral stenosis can lead to blood clots that can go to the
brain, causing strokes, or to the limbs, causing severe problems.
Drugs to control heart arrhythmias
Surgery
Common types of heart valve surgery include:
If you are diagnosed with mitral stenosis, follow your doctor's instructions.
Prevention
Most cases of mitral stenosis can be prevented by preventing rheumatic fever:
Treat strep throat infections promptly to avoid rheumatic fever, which can cause
scarring of the heart valve; always finish all of the antibiotics prescribed, even if
you feel better before taking all of the doses.
In addition, there are several things you can do to try to avoid some of the complications
of mitral stenosis:
RESOURCES:
American Heart Association
http://www.americanheart.org
National Heart, Lung, and Blood Institute
http://www.nhlbi.nih.gov/index.htm
CANADIAN RESOURCES:
Canadian Cardiovascular Society
http://www.ccs.ca/home/index_e.aspx
Canadian Family Physician
http://www.cfpc.ca/cfp/