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PENDAHULUAN Demam reumatik dan

Penyakit Jantung Reumatik

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. Epidemiologi Demam reumatik biasanya terjadi pada anak usia sekolah yang sering mengalami infeksi tenggorokan yang disebabkan oleh Streptokokus. Puncak insiden demam rematik terdapat pada kelompok usia 5-15 tahun, penyakit ini jarang dijumpai pada anak dibawah usia 4 tahun dan penduduk di atas 50 tahun. http://www.infopenyakit.com/2008/08/penyakitjantung-rematik-pjr.html

Etiologi

Demam reumatik, seperti halnya dengan penyakit lain merupakan akibat interaksi individu, penyebab penyakit dan faktor lingkungan. Penyakit ini berhubungan sangat erat dengan infeksi saluran napas bagian atas oleh streptococcus hemolytikus tipe A. Kira kira 3% penderita saluran napas oleh kuman tersebut akan mengalami komplikasi demam reumatik atau penyakit jantung reumatik. Infeksi oleh kuman Streptococcus Beta Hemolyticus group A yang menyebabkan seseorang mengalami demam rematik diawali

dengan 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 daundaun katup mengalami perlengketan sehingga menyempit, atau menebal dan mengkerut sehingga kalau menutup tidak sempurna lagi dan terjadi kebocoran.

Patofisiologis 1. Streptokokus grup A akan menyebabkan infeksi faring, 2. Antigen Streptokokus akan menyebabkan pembentukan antibodi pada pejamu yang hiperimun, 3. Antibodi akan bereaksi dengan antigen streptokokus, dan dengan jaringan pejamu yang secara antigenik sama seperti streptokokus (dengan kata lain: antibodi tidak dapat membedakan antara antigen streptokokus dengan antigen jaringan jantung), 4. Autoantibodi tersebut bereaksi dengan jaringan pejamu sehingga mengakibatkan kerusakan jaringan. Patogenesis Skema pathogenesis demam reumatik merupakan reaksi berantai sebagai berikut Faringitis Streptokokus hemolitikus grup A Membentuk Antibody dalam serum terhadap komponen komponen struktur streptokokus Antibody bereaksi dengan komponen komponen protein miokard / valvula / perikard Radang miokard ( miokarditis)

Radang valvula (valvulitis) Radang perikard (perikarditis) Karena reaksi antigen antibody ini mengenai komponen protein dari organ- organ dalam tubuh, maka gejala gejala yang terjadi merupakan kumpulan gejala atau sindrom, oleh karena itu untuk mendiagnosa demam reumatik biasa dipakai kriteria jones.

Patologi anatomi Jantung Baik pericardium, miokardium, dan endokardium dapat terkena. Miokarditis dapat ringan berupa infiltrasi sel sel radang, tetapi dapat erat sehingga terjadi dilatasi jantung yang dapat berakibat fatal. Bila perdangan berlanjut, timbulah badan aschoff yang kelak dapat meninggalkan jaringan parut diantara otot jantung. Perikarditis dapat mengenai lapisan visceral maupun parietal pericardium dengan eksudasi fibrinosa. Jumlah efusi perikard dapat bervariasi tetapi biasanya tidak banyak, bisa keruh tetapi tidak pernah purulen. Bila berlangsung lama dapat berakibat terjadinya adhesi pericardium visceral dan parietal. Endokarditis, merupakan kelainan terpenting, terutama peradangan pada katub- katub jantung. Semua katup dapat terkena, tetapi katup jantung kiri (mitral dan aorta) paling sering menderita, sedangkan katup jantung tricuspid dan pulmonal jarang sekali terkena. Mula mula terjadi edema dan reaksi selular akut yang mengenai katup dan korda tendine. Kemudian terjadi vegetasi mirip veruka ditepi daun daun katup. Secara mikroskopis vegetasi berisi masa hialin. Bila menyembuh akan terjadi penebalan dan kerusakan daun katup yang dapat menetap dan mengakibatkan kebocoran katup. Perubahan perubahan pada katup ini dapat terus berlanjut meskipun stadium akut sudah berlalu. Stenosis katup hamper selalu mengenai katup mitral, dapat terjadi berbulan buolan bahakan bertahuntahun setelah stadium akut.

Gambar 2. Infeksi bakteri demam reuma pada katup jantung

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: Manifestasi kardiak dari demam reumatik Gejala Dini rasa lelah, pucat, tidak bergairah dan anak tampak sakit. Karditis merupakan gejala mayor terpenting, karena hanya karditislah yang dapat meninggalkan gejala sisa. Periode laten manifestasi karditis dan artritis adalah 3 minggu. Stenosis mitralis Bunyi Jantung I sangat mengeras, bising mid-diastolik bernada rendah, & terdengar paling baik di apeks. Insufisiensi mitralis Bunyi jantung I normal/melemah, bising pansistolik apikal, menjalar ke aksila, dan mengeras bila dimiringkan ke kiri.

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 anak-anak. 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 ragu-ragu. Pada saat puncak gejalanya tulisannya tidak dapat dibaca sama sekali. Erithema marginatum merupakan ruam (kemerahan) yang khas untuk demam reumatik dan jarang ditemukan pada penyakit lain. Karena kekhasannya tanda ini dimasukkan dalam manifestasi minor. Keadaan ini paling sering ditemukan pada batang tubuh dan tungkai yang jauh dari badan, tidak melibatkan muka. Ruam makin tampak jelas bila ditutup dengan handuk basah hangat atau mandi air hangat, sementara pada penderita berkulit hitam sukar ditemukan. Nodul subkutan. Frekuensi manifestasi ini menurun sejak beberapa dekade terakhir, dan kini hanya ditemukan pada penderita penyakit jantung reumatik khronik. Nodulus ini biasanya terletak pada permukaan ekstensor sendi, terutama 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.

Pemeriksaan Laboratorium

Biakan usapan tenggorok Mengukur kadar antibody terhadap streptokokus ( ASO) Pemeriksaan reaksi fase akut (CRP dan LED)

Pemeriksaan Penunjang lain Foto Rontgen Thorak EKG

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

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 involvement. A heart murmur is a common finding. This occurs in as many as 40% of patients and may include leaky valves, most commonly mitral regurgitation but also mitral and aortic insufficiency. In addition, the heart muscle and surrounding sac are affected as well. Patients develop unusually faster heart rates and may end up, although rarely, with congestive heart failure and accumulation of excessive amounts of fluid around the heart. Heart involvement is the major cause of long-term medical problems. Younger children tend to develop carditis (heart involvement) first. Patients with carditis are at a greater risk of developing recurrent rheumatic fever and also sustaining further heart damage. A significant percentage of patients with heart involvement end up with rheumatic heart disease (chronic heart involvement). Mitral stenosis is rare in the United States Migratory poly-arthritis. This condition occurs in 75% of patients and many times may be the initial clinical manifestations, especially in the older patients. It usually involves the large joints such as the knees, ankles, elbows and wrists. The term migratory means that it may start in only one knee and then gradually move to the contra-lateral knee joint. Joints become swollen, red and very tender. Joint motion is restricted and patients may have difficulty walking. Subcutaneous nodules: They are firm, painless nodules on the extensor surface of the wrist, elbows and knees. They are found in only 10% of patients. Erythema Marginatum: This skin rash occurs in over 5% of patients. The rash is serpiginous and may be long lasting or evanescent (tend to disappear and reappear). Sydenham Chorea: It consists of rapid purposeless movements of the face and upper extremities. It is also called St.Vitus Dance. Chorea movements are usually present when the patient is awake. Besides chorea there may be other clinical manifestations of brain involvement. Some children may develop mood swings and cry for no reason.

Table #2 Minor Jones Criteria Fever Previous history of rheumatic fever Arthralgia or joint pain (without arthritis) Prolongation of PR interval in the electrocardiogram (approximately 25% of all cases). Abnormal blood test results

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.
Copyright 2008-09 Children's Heart Specialists mykentuckyheart.com/.../RheumaticFever.htm

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 14 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. Erythema marginatum: consists of non-pruritic macules or patches with central pallor and a well defined irregular margin on the trunk and the proximal parts of the limbs. Erythema marginatum occurs in 10 % of the cases of acute rheumatic fever.

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.

Figure 21.3: Clinical features of rheumatic fever 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.

The minor criteria include:


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

Tricuspid Valve Disease


(Tricuspid Regurgitation; Tricuspid Stenosis)
by Michelle Badash, MS Definition | Causes | Risk Factors | Symptoms | Diagnosis | Treatment | Prevention En Espaol (Spanish Version)

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. The two main types of tricuspid valve disease are:

Tricuspid stenosisnarrowing of the tricuspid valve

Tricuspid regurgitationbackflow of blood into the atrium from the ventricle due to improper closing of the tricuspid valve flaps

Anatomy of the Heart

2009 Nucleus Medical Art, Inc.

Causes
Rheumatic fever is the most common cause of tricuspid valve disease world-wide. Other causes include:

Congenital heart problems Heart attack or coronary heart disease Congestive heart failure Endocarditis (an infection of heart valves) Trauma to the heart Tumors (rare)

Risk Factors
A risk factor is something that increases your chance of getting a disease or condition.

History of rheumatic fever Sex: female (for tricuspid stenosis)

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

Tests may include:


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:

Drugs to control heart arrhythmias Diuretics

Vasodilators, which dilate blood vessels

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:

Harrison's Principles of Internal Medicine . 15th ed. McGraw-Hill Professional Publishing; 2001.

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

2009 Nucleus Medical Art, Inc.

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:

Difficulty breathing, especially during exercise and when lying flat Awakening short of breath in the middle of the night Fatigue Chest pain, such as squeezing, pressure, or tightness (rare) Sensation of rapid or irregular heartbeat (palpitations) Cough with exertion Coughing up blood Swelling of the legs or feet Frequent respiratory infections Dizziness, fainting

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:

Abnormal chest sounds, such as a heart murmur or snap Distention of the jugular vein in the neck Signs of fluid in the lungs

Tests may include:


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:

Mitral valvulotomyA surgical cut or enlargement is made in the stenotic mitral valve to relieve the obstruction. Balloon valvuloplastyA balloon device is inserted into the blocked mitral valve to open or enlarge the valve. This may provide temporary relief of symptoms. However, the valve may become blocked again. Mitral valve replacementThis is the surgical replacement of a defective heart valve. This surgery is usually delayed until symptoms are severe or the patient can no longer be helped by other procedures.

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:

Get regular medical care, including checkups and periodic electrocardiograms. Take antibiotics before any dental cleaning, dental work, or other invasive procedures. This will help prevent infection 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. Avoid caffeine, alcohol, and drugs (like decongestants) that speed up your heart rate; these will only worsen your symptoms. Maintain a healthy weight. Follow your doctors recommendations for exercise. Ask your doctor about cutting back on salt; this may help decrease the pressure in your heart and improve your symptoms. Monitor your blood pressure, and inform your healthcare provider if you seem to be developing high blood pressure, which can worsen your symptoms.

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/