M. Gorky Donetsk National Medical University Technique Guidelines for the students’ individual preparation for icon

M. Gorky Donetsk National Medical University Technique Guidelines for the students’ individual preparation for




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M.Gorky Donetsk National Medical University


Technique Guidelines

for

the students’ individual preparation for

Practice activities


On the Subject

Valvular Heart Disease”


INTENDED AUDIENCE: 5-year students of International Medical Faculty


Donetsk

2009


Internal Disease: Technique Guidelines for the students’ individual preparation for Practice activities on the Subject “Valvular Heart Disease” intended for 5-year students of International Medical Faculty


Published: 2009, Donetsk, Ukraine, p.27

Edited by: Ass. Prof. Gnylorybov A., DM


The present Technique Guidelines were prepared by the Internal Disease Department N3 to meet requirements of the Quality Control System intended for exercising management of education by targets set by a relevant Syllabus developed. The Guidelines include both key goal and specific objectives set for each single subject and contain exercises and cases that belong to the pre-practice and in-practice levels of study along with the procedure-sequence and breakdown charts, different models and diagnostics algorithms.


The Technique Guidelines can also be helpful for interns and general practitioners.


Reviewed by:

Parkhomenko T., Ass. Prof., Chair of Internal Medicine N2,

Bassiy R., ., Ass. Prof., Chair of Normal Anatomy, Chief of the Method Learning Department of Donetsk National University


Approved by:


I. Importance of the Subject:

Valvular heart disease is the most serious complication of acute rheumatic fever and infectious endocarditis. Rheumatic fever and infectious endocarditis are widespread in all climate and geographical regions of the world. Last decades data convincingly showed the relationship between incidence of these diseases and economic situation of the country and its preferred expansion in poorly advanced and developing countries. Nowadays the disease is characterized by progressing course with often multiple valvular deformities, lung hypertension, early mortality under worsening heart failure. Chronic rheumatic heart disease remains the leading cause of mitral valve stenosis and valve replacement in adults.

All above-stated form the basis for careful studying of the subject, which demands from students deep knowledge of Normal and Pathological Anatomy and Physiology as well as Propedeutical Therapy. Taking into account the wide prevalence of the disease and systemic organs involving, the patients suffering from valvular heart disease may occur in therapeutic, pediatric, cardiologic, cardiosurgic, rheumatologic, nephrologic, neurologic doctor practice.


^ II. Key Objective: to develop skills in differentiation of the most important forms of valvular heart disease and its origin; in setting a treatment tactic.



Specific Goals

to develop skills in:

^ Prior-to-Practice Level of Knowledge and Skills Possessing a knowledge of and skills in:

Determining the main syndromes associated with valvular heart disease.

1. Choosing from patient’s complaints, medical history and physical examination data, which show the cardiovascular and musculoskeletal systems involving.

2. Composing individual scheme for diagnostic search and evaluation the results of investigations in case of valvular heart disease.


2. Determining the necessary list and subsequence of diagnostic procedures:

-physical examination and laboratory analysis: clinical blood test, С-reactive protein, streptococcus antibodies titers and antistreptolysin O (Departments of Propedeutical Therapy, Physiology and Pathophysiology);

-instrumental procedures:

-Chest X-ray (Department of X-ray Diagnostics);

-ECG, EchoCG (Departments of Propedeutical Therapy and X-ray Diagnostics).

3. Differential diagnostics between diseases manifested with joint lesion and heart involving with valvular disorders formation.

3. Finding out the joint syndromes, diagnosing the disease manifested with carditis (Department of Propedeutical Therapy).

4. Substantiation of the treatment and care principles of patient suffered from valvular disorders.

4. Using the medications for etiotropic, pathogenic and symptomatic therapy (Pharmacology Department), аs well as recommendations of the surgical methods of treatment.



The necessary information to possess the prior-to-practice level of knowledge and skills you can find in next literature sources:

  1. Cardiovascular Physiology Concepts. Klaunde R.E. Lippincott, Williams & Wilkins, 2004.

  2. Harrison’s Principles of Internal Medicine: Kaspers et al. (eds). − McGraw-Hill Medical Publishing Division. − 2005.− Part II, P.71-81.

III. Test Questions for Pre-Practice Self-Assessment Purposes.


To assess your Pre-Practice level of knowledge and skills carry out the following tasks. Check your answers with the Key.


Test 1

Patient T., 30 y.o., suffers from rheumatic heart disease. On auscultation of his heart he has loud first sound, mesodiastolic murmur on cardiac apex, opening snap of mitral valve. What valvular disease the patient has?

А) mitral stenosis;

B) mitral insufficiency;

C) tricuspid insufficiency;

D) aortic stenosis

E) aortic insufficiency.


Test 2

Patient Т., 40 y.o., suffers from rheumatism, mitral insufficiency. His doctor for the first time has found ΙΙ sound accent over patient’s lung artery.

What does this auscultative sign mean?

А) pulmonary circulation hypertension;

B) increase of volume of blood circulation;

C) systemic blood pressure increse;

D) myocarditis;

E) infective endocarditis .


Test 3

Patient А., 24 y.o., complains of pain in left half of his chest. On auscultation valvular disease was suspected.

What test is the most informative in this case?

А) ECG;

B) phonography;

C) echocardiogram;

D) angiography;

E) X-ray.


Test 4


Systolic thrill of chest wall was found in patient F., 27 y.o., with aortic stenosis (phenomenon of purr).

Where is the epicenter of this thrill?

А) along left sternal border;

B) on the heart apex;

C) on the fifth point (Botkin-Erb point);

D) in the left intercostal space near sternum;

E) in the right intercostal space near sternum.


Test 5

Mitral stenosis was diagnosed in patient U., 35 y.o. What is the most probable cause of this valve disease?

А) infectious endocarditis;

B) acute rheumatic fever;

C) fibrocalcinosis;

D) syphilis;

E) scleroderma.


Test 6

Patient Р., 24 y.o., with aortic stenosis, presents with fever after tooth extraction. CBC shows leukocytosis with shift to the letf, anemia, ESR increase. On auscultation rough systolic murmur became louder. What is the most reasonable cause of the phenomenon?

А) myocarditis;

B) pericarditis sicca;

C) exudative pericarditis;

D) infective endocarditis.


^ Standard answer to test 1.

Correct answer А) – mitral stenosis. In mitral stenosis the mitral valve at the moment of left ventricle diastole remains opened due to high transmitral gradient and closes with loud clatter sound. Opening snap of mitral valve also appears due to high transmitral pressure gradient. Mesodiastolic murmur appears due while blood flow passing through narrow mitral orifice.


If you have made sure that your pre-practice level of knowledge and skills meets the requirements of the starting level, pass on to mastering the subject material.


^ IV. Subject Material


Theory Topics on the subject:



  1. Methods of clinical, laboratory and instrumental diagnostics of rheumatic heart disease, infectious endocarditis and valvular deformities.

  2. Differential diagnostics of rheumatic heart disease and other diseases manifested with joint lesion and carditis, differential diagnostics of valvular disorders.

  3. Classification of valvular heart disease.

  4. Etiology and pathophysiology of valvular heart disease.

  5. Treatment principles of valvular heart disease.



Recommended literature sources to possess theoretical knowledge on the subject:

  1. Harrison’s Principles of Internal Medicine: Kaspers et al. (eds). − McGraw-Hill Medical Publishing Division. − 2005.− Part VIII, P.1359-1378.

  2. Evidence Based Cardiology; Usuf S. Y., Cairns J., Camm J., Fallen E. L., Gersh B. BMJ Publishing Group, 2002.

  3. Cardiovascular Physiology Concepts. Klabunde R. E. Lippincott, Williams &Wilkins; 2004.

  4. Internal Diseases. An introductory course. Edites by V. Vasilenko and A Grebenev. Moscow, 2006.

  5. Oxford Handbook of Clinical Medicine.Murray Longmore. Ian B. Wilkinson, Supvay Rajagopalan. New York, 2004.

  6. Lectures on Internal Diseases..

  7. Break-Down Chart on the Subject “Rheumatic fever and rheumatic heart disease” (Appendix 1).

  8. Diagnostic Algorithm of syndrome «Cardiac murmur» (Appendix 2).

  9. Diagnostic Algorithm of syndrome «Carditis» (Appendix 3).

  10. Differential diagnostics of joint lesion syndrome caused by rheumatic fever and rheumatoid arthritis (Appendix 4).

  11. Classification of rheumatic heart disease (Appendix 5).

  12. Jones diagnostic criteria for rheumatic fever (Appendix 6).



Target Activity Questions on the Subject


Q1.

The blood test of patient K., 45 years old, suffering from rheumatic heart disease showed following changes: erythrocytes - 4,0х1012 per litter, hemoglobin 140 g/l, leukocytes - 9,0х109/l, , band neuthrophyls-10%, segmented neuthrophyls-60%, lymphocytes –20%, monocytes-10%, erythrocyte sedimentation rate (ESR) – 30mm/h. С-reactive protein - ++.

What activity degree may you suppose in that case?

А) І;

B) ІІ;

C) ІІІ;

D) ІV;

E) V.


Q 2.

After asking of patient’s (patient K., 32 years old) complaints, previous medical history and physical examination cardiologist made a suspicion of chronic rheumatic heart disease, mitral regurgitation.

What instrumental procedure can undoubtedly confirm the presence of certain valvular disorder in the patient’s heart?

А) ECG;

B) auscultation of the heart;

C) Chest X-ray;

D) EchoCG;

E) Holter ECG monitoring.


Q 3.

An EchoCG of 25-year-old patient, suffering from rheumatic heart disease, mitral stenosis, revealed that his mitral orifice square equals 1,2 sm2.

What severity of mitral stenosis is in this case?

А) asymptomatic;

Б) mild;

В) moderate;

Г) severe;

Д) critical.


Q 4.

Patient Т., 22 years old, suffering from rheumatic disease during many years, with complaints of pain in left knee joint was recommended an X-Ray examination of the joint.

What X-ray changes may confirm the rheumatic origin of the joint lesion?

А) subhondral cysts;

B) subhondral osteosclerosis;

C) marginal osteophytes;

D) erosions;

E) X-ray cannot give any information in case of rheumatic arthritis.


Q 5.

During examination of patient M., 24 years old, suffering from rheumatic myocarditis, rheumatic nodules, fever, polyarthritis and prolonged PQ interval on ECG were revealed.

How many major Jones manifestations has the patient?

А) 1;

B) 2;

C) 3;

D) 4;

E) 5.


Q 6.

On heart auscultation of patient К., 32 years old, suffering from rheumatic heart disease, to the right of the second intercostal space can be heard a rude systolic murmur which radiates to the neck vessels.

Which remedy is contraindicated to the patient?

А) Hypothiazid;

B) Captopril;

C) Cordaron;

D) Riboxin;

E) Preductal.


Key Answer to Q 4.


The correct answer is E) – X-ray cannot give any information in case of rheumatic arthritis. Rheumatic joint syndrome manifests with polyarthritis and as a rule takes place only at first attack. At further attacks more often patients suffer from arthralgias (jointaches). According to this there are no specific X-ray symptoms for rheumatic joint syndrome. Listed in test signs such as subhondral cysts, subhondral osteosclerosis, marginal osteophytes are specific for osteoarthritis. Erosions can be found in case of rheumatoid arthritis.


^ Summary of procedures for the practice on the Subject: «valvular disorders»


Making assessment of prior-to-practice level of knowledge and skills. Clinical analysis of patients with the syndromes in question, substantiation of a hypothetical diagnosis, methods and techniques of giving medical service. Carrying out test-questions. Final testing. Summing up the results.

Appendix 1

break-down chart on the subject:

«Valvular heart disease”

^

Rheumatic fever and rheumatic heart disease






Leading symptoms and syndromes





Central nervous system lesion


^


Joint syndrome





Carditis

Skin and subcutaneous fat lesion

Polyarthritis with preffered involving of big joints, «fleeting» pains, good therapeutic effect from Penicillin




Arrhythmias and conductive disorders, valvular deformities






Congestive

heart failure


^ Medical history заболевания




Often antecedent anginas in childhood, scarlet fever, the presence of chronic infective foci in pharynx, chronic tonsillitis


^

Diagnostic procedures



Instrumental Techniques


Laboratory Tests







Clinical blood test (leukocytosis with shift to the left, increased ESR), the precence of С-reactive protein, increased streptoccocal antibody titer (including antistreptolysin O).




ECG: prolonged PQ(PR) interval, tachycardia, bradycardia, extrasystoles, atrial fibrillation.

EchoCG: valvular damage (marginal valve thickness, prolapse, valve regurgitation), pericardial separation.

Chest X-ray: heart configuration changes, cardiomegaly, detecting the pleural exudate, inflammatory foci in lungs







Differential diagnostics by Algorithm: infectious endocarditis, systemic lupus erythematosus, rheumatoid arthritis, systemic sclerodermia, myocarditis



Classification







^

Clinical Anatomy Characters

Course

Нeart failure


Phase




Medical Care





^

Prevention



Pathogenic Treatment




Etiotropic Treament

Symptomatic Treatment

Primary






Non-Steroid Anti- Inflammatory Drugs and Corticosteroids


Penicillin, Erythro-mycin

Eradicating of Strepto-coccus infective foci


Antiarryth-mics,

Digoxin, Diuretics,

ACE inhibitors,

-blockers

Secondary


Long-lasting benzathine benzylpenicillin regimen




Appendix 2


Diagnostic Algorithm on syndrome

«Cardiac murmur»


The list of valvular disorders


  1. Mitral regurgitation (МR)




  1. Аоrtic stenosis (АS)




  1. Tricuspid regurgitation (ТR)




  1. Pulmonary stenosis (PS)




  1. Mitral stenosis (МS)




  1. Аоrtic regurgitation (АR)




  1. Tricuspid stenosis (ТS)




  1. Pulmonary regurgitation (PA)


Diagnostic Algorithm on syndrome

«Cardiac murmur»


Cardiac murmur



Systolic murmur


yes


Apical, muffled S1, the presence of S3


yes



no

MRT


Basal, to the right of sternal border in the second intercostal space, muffled S2 over aorta


yes


AS

no


By xiphoid process, muffled S, the presence of S3


yes


no


TR


Along left sternal border, muffled S2 over pulmonary artery



yes


PS


Diastolic murmur


no


Apical, accentuated S1, opening snap of the mitral valve

yes






MS


no


By the left sternal border in 3-4th intercostal space, decreasing of diastolic blood pressure, increasing of pulse blood pressure


yes


AR





no


By xiphoid process, accentuated S1, opening snap of the tricuspid valve

yes


TS





no


By the left sternal border in 2-4th intercostal space, muffled S2 over

pulmonary artery

yes


PA



^

Appendix 3
Diagnostic Algorithm on syndrome
«Carditis»

The list of the diseases

  1. Infectious endocarditis
  2. Systemic lupus erythematosis
  3. Rheumatoid arthritis
  4. Systemic sclerodermia
  5. Myocarditis

6. Rheumatic Heart Disease



Carditis




Hematologic syndrome: anemia, lack leukocyte or platelet amount, LE-cells, photosensibility

no


^

Vegetations on EchoCG
y
1

yes

no
es
^

Small joints lesion, morning stiffness, Rheumatoid factor

2

Rheumatologist’s

consultation

Cardiologist’s and Cardio-surgeon’s consultations

yes

3

no


Increased streptococcal antibody titers, antistreptolysin O,

polyarthritis,

Sydenham’s chorea, erythema marginatum, subcutaneuos nodules

CREST-syndrome

4

yes

no

no

yes

5

6



Appendix 4


Differential diagnostics on Joint Syndrome of Rheumatic and Rheumatoid Arthritis origin


Morning stiffness

No


No


Yes


Yes


No

Yes


Yes


No


No


Yes

^ Involving of small joints


«Floating” joint pains




^ Good Effect from Penicillin


X ray signs: erosions









^ Rheumatic origin of arthritis


Rheumatoid Arthritis

Appendix 5


Rheumatic Heart Disease Classification

(А.I.Nesterov, 1964)


Phase of the disease

System and organs involving

Course

Heart failure

Cardiac manifes-tations

Noncardiac manifestations

Ι, ΙΙ, ΙΙΙ activity degree


Nonactive

Primary rheumatic carditis without valve damage


Recurrent rheumatic carditis with valve damage

(name valve insufficiency type)


Rheumatic fever without cardiac involving


Rheumatic myocardial sclerosis. Valve insufficiency (name the type)

Polyarthritis, serositis (pleuritis, peritonitis, abdominal syndrome), Sydenham’s chorea, encephalitis, meningocephalitis, cerebral vasculitis, nervous and psychical disorders, vasculitis, nephritis, hepatitis, pneumonia, skin lesion, iridocyclitis, thyreoiditis


Outcomes and residual manifestations of antecedent noncardiac lesions

Acute, subacute, long-lasting, contineously recurrent, latent

After N.D. Strazhesko, V.H.Vasilenko,G.F.Lung

НF0

НF1

НFΙΙА

НFΙΙБ

НFΙΙΙ



Appendix 6


Diagnostic criteria of Rheumatic Fever

(by T.D. Jones)


Major manifestations:


1.Carditis

2.Polyarthritis

3.Chorea

4.Erythema marginatum

5.Subcutaneous rheumatic nodules


Minor manifestations:


1.Fever

2.Arthralgia

3.ESR increasing

4.Presence of С-reactive protein

5.Prolonged PQ(PR) interval on ECG


Guidelines for diagnosis published more than 50 years ago by T. Duckett Jones have been slightly revised by the American Heart Association (AHA). Prior history of a preceding group A streptococcal infection is helpful but not required. In addition, 2 major manifestations or 1 major and 2 minor manifestations must be present.


After having finished the studying of section “Valvular Heart Disease” you’ll have to pass through summary testing. Try to answer these questions as an example.


^ Summary Test Questions


Test 1

Patient K., 50 y.o., suffers from rheumatism, mitral stenosis for a long time. He mentions inspiratory dyspnea, cough with foamy, occasionally blood streaked sputum. On ECG PQ interval is 0.3 s. What medication is contra-indicated to this patient?

А) Furosemid;

B) Aspirin;

C) Penicilline;

D) Anapriline;

E) Diclophenac.


Test 2

Patient W., 20 y.o., complains of dyspnea of mild exertion, asthmatic fit and cough at lying position. On auscultation he has loud first sound over heart apex, opening snap of mitral valve, mesodiastolic murmur, second sound accent over pulmonary artery, tachycardia. He also has bilateral bubbling rales, diminished breath sounds over lower parts of lungs. What are the most effective medications in this case?

А) cardiac glycosides;

B) diuretics;

C) peripheral vasodilator;

D) adrenoblockers without internal simpathomimetic activity;

E) anticoagulants, antiaggregants


Test 3

Patient І., 50 y.o., who suffers from night paroxysmal dyspnea attacks, presents with low first sound on heart apex, pansistolic murmur irradiating to the left axillary area, third sound, second sound accent over pulmonary artery. His pulse is rhythmic, 78 beats per min, BP is 140/85 mm Hg.

What are the most effective medications in this case?

А) ACE inhibitors;

B) cardiac glycoside;

C) diuretics;

D) beta-blockers.


Test 4

Patient R.., 50 у.о., presents with rough systolic murmur in his 2-nd left intercostal space, systolic thrill of his chest, low second sound. Murmur is localized, it does not irradiate upon cervical vessels. ECG shows significant right atrial and ventricular hypertrophy.

These signs are specific for:

А) aortic stenosis;

B) mitral insufficiency;

C) pulmonary artery stenosis;

D) tricuspid insufficiency;

E) aortic insufficiency.


Test 5

Patient K., 29 y.o., with aortic stenosis, on echocardiography presents with aortic valve opening area 1.2 сm2, his maximal pressure gradient between aorta and left ventricle is 40 mm Hg.

What is the degree of this aortic stenosis?

A) preclinical;

B) mild;

C) moderate;

D) severe;

E) terminal.


Test 6

Patient С., 33 y.o., suffers from mitral stenosis for last 5 years. He reports dyspnea for recent weeks. What medication should be prescribed in the first place?

А) cardiac glycosides;

B) diuretics;

C) nitrates;

D) beta-blockers;

E) ACE inhibitors.


Test 7

Patient В., 17 y.o., in autumn after pharyngitis ahd rheumocarditis for the first time in his life. When one should expect clinically significant mitral stenosis formation in case of lack of proper rheumatic fever prophylaxis and treatment?

А) in acute period of rheumocarditis;

B) in 1-2 years;

C) in 10-12 years;

D) in 20-25 years.


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