Вы находитесь на странице: 1из 35

MODUL 1

DYSPNOE

PRESENTED BY GROUP:

A2
Scenario 2

A 55 year old woman comes to a hospital


with hardly breathe followed by a feeling of fast heart
beat when doing physical activities. In age 12, she was
suffered from rheuma fever and there is a murmur
sound from her auscultation since. She has got atrium
fibrillation since 2 years ago but it is in control with
digoxin 4 x 0.25mg. Vital sign: heart beat 80/min,
blood pressure 130/80 mm Hg, respiration 16/min.
Weak wet ronchi is heard on both lungs. First heart
sound (S1) is loud and there is a single second heart
sound (S2) with an opening snap (OS).
KEYWORDS

 Hardly breathe and Tachycardia during physical


activities
 Suffer rheuma fever in 12 years old
 History of Atrium fibrillation (in control with
digoxin)
 Murmur sound
 First heart sound and 2nd sound with opening snap
Anatomy & Physiology
The Conduction System of the Heart
(pacemaker → conduction fibres →contractile fibres )
 conduction fibres: larger diameter
 atria – ventricles: separated by
fibrous bundles

2. Internodal pathways

1. Sinoatrial (SA) node

3. Atrioventricular (AV) node 4. AV bundle


(Bundle of His)

6. Purkinje fibres
5. Right and left
bundle branches
LV
RV
coordinated contraction
a. AP is initiated in the SA node

f. rest b. AP are
conducted
throughout
the atria
• very rapid
e. AP • large cells
spread
through c. Conduction
the slows at
ventricles the AV node
(bottom • small cells
to top)
d. AP travel rapidly
through the branch
bundles
Basic Pathway of Blood Flow
CS

SVC Pulmonary
Right Tricuspid Right
Semilunar
Atrium Valve Ventricle
IVC Valve

Systemic Pulmonary
Capillaries Trunk

Aorta Pulmonary
Arteries

Aortic Semilunar Valve


Pulmonary
Left Capillaries
Bicuspid
Ventricle Left Atrium Pulmonary
Valve
Veins
Frequent Cardiacvascular disease
THE DIFFERENTIAL DIAGNOSE
Mitral Mitral Regurgitation Mitral Valve Prolapse
Stenosis
Hardly Yes Yes (fatigue, weakness, Yes
breathe and exertional dyspnea)
tachycardia
during activity

Rheuma fever Yes Yes Yes


Atrium Yes Yes (crhonic) No
fibrilation
Murmur Yes Yes (holosystolicapical Yes
sound murmur)
S1 and s2 Yes (diastolic Yes (systolic murmur)
murmur) Yes (systolic murmur)S2 S2 sound louder
S1 sound sound louder
louder with
OS
Mitral Stenosis: Etiology

 Primarily a result of rheumatic fever


(~ 99% of MV’s @ surgery show rheumatic damage )
 Scarring & fusion of valve apparatus
 Rarely congenital
 Pure or predominant MS occurs in approximately
40% of all patients with rheumatic heart disease
 Two-thirds of all patients with MS are female.
Correlation between Rheumatic Fever &
Mitral Stenosis
Approximately 60% of patients with isolated mitral stenosis
have rheumatic fever; approximately 90% of patients with
multivalvular disease have isolated mitral stenosis. One of the
critical consequences of acute rheumatic fever is pancarditis, which
occurs in 40-50% of patients; pancarditis progresses gradually,
causing chronic abnormalities. The mitral valve is frequently
involved; the free edges of the commissures become fused, giving
the mitral valve a characteristic fish-mouth appearance. Subvalvular
structures, such as the chordae tendineae, gradually thicken and
become calcified, leading to further restriction of leaflet mobility.
The mean latent period between the occurrence of acute rheumatic
fever and mitral stenosis is usually 20 years. Another 7-10 years
pass before patients become significantly disabled.
Rheumatic fever-pathogenesis

Group A streptococcal(GAS) pharyngeal infection Body


produce antibodies against Antibodies react with human
tissues because of the antigenic similarity between streptococcal
components and human connective tissues (molecular
mimicry)[there is certain amino acid sequence that is similar btw
GAS and human tissue] Immunologically mediated
inflamation & damage (autoimmune) to human tissues which
have antigenic similarity with streptococcal components- like heart,
joint, brain connective tissues.
Rheumatic fever-pathogenesis
Normal Mitral Stenosis
Mechanism of Tachycardia

 Typically refers to the cardiac rhythm which produces a


ventricular rate greater than 100 beats per minute;
 Sometimes refers to the cardiac rhythm which produces an
atrial rate greater than 100 beats per minute while the
ventricular rate remains unaffected.
 When the heart beats rapidly preload and after load may be
negatively affected, causing the heart to pump blood less
efficiently. The increased heartbeat leads to increased
myocardial oxygen demand, which accounts for the
shortness of breath felt during an acute coronary event.
Weak wet ronchi

Atrium Fibrilation in mitral valve  blood can


not flow in maximal to the left
ventricle  Increase the pressure of left
Atrium blood flow back to the vena
Pulmonalis(regurgitation)  edema In
lungs weak wet ronchi
The Breathlessness

 During mild Mitral Stenosis usually hard to breath happen

when doing physical activities, fever,pregnancy,etc..

 Increase pulmonary venous P, increase LA, Fluid increase

in intertitium lung reduce pulmonary compliance that


cause increasenwork of breathing
Recognizing Mitral
Stenosis
Palpation:
 Small volume pulse Auscultation:
 Tapping apex-palpable S1  Loud S1- as loud as S2 in
 +/- palpable opening snap
aortic area
(OS)  A2 to OS interval inversely
 RV lift
proportional to severity
 Diastolic rumble: length
 Palpable S2
proportional to severity
ECG:
 In severe MS with low flow-
 LAE, AFIB, RVH, RAD
S1, OS & rumble may be
inaudible
EXAMINATION OF THE HEART
 INSPECTION AND PALPATION
HEART SOUNDS
 AUSCULTATION
 S1 → mitral and tricuspid valve
 S2 → aortic and pulmonal valve

 S3 → the rush of blood during early diastole

 S4 → atrial contraction
Mitral Stenosis: Physical Exam

S1 S2 OS S1
 First heart sound (S1) is accentuated and
snapping
 Opening snap (OS) after aortic valve closure
 Low pitch diastolic rumble at the apex
 Pre-systolic accentuation (esp. if in sinus
rhythm)
Common Murmurs and
Timing (click on murmur to play)

Systolic Murmurs
 Aortic stenosis
 Mitral insufficiency
 Mitral valve prolapse
 Tricuspid insufficiency
Diastolic Murmurs
 Aortic insufficiency
 Mitral stenosis

S1 S2 S1
HEART SOUNDS
 AUSCULTATION
Radio Imaging for Mitral Stenosis

 Electrocardiography
 Chest radiograph
 Echocardiography
 Cardiac catheterization
Treatment and Prevention

Treatment :
 Beta blockers or rate-limiting calcium channel antagonist
(verapamil or diltiazem) to slow ventricular rate in AF
 Diuretics and sodium restriction
 Warfarin for pts with AF and or history of systemic and
pulmonaly emboli
 In umcomplicated MS, percutaneous balloon valvuloplasty is the
produce of choice
 If not feasible, then open surgical valvotomy
Balloon Mitral valvuloplasty
Prevention:

 Follow treatment recommended for conditions that may cause valve disease.
Treat strep infections promptly to prevent rheumatic fever. we should know
the patient’s family history of congenital heart diseases, and heart valve
disease before medical treatment
 Mitral stenosis itself often cannot be prevented, but complications can be
prevented. For example, any dental work, including cleaning, and any
invasive procedure, can introduce bacteria into the bloodstream. These
bacteria can infect a damaged mitral valve. Preventive antibiotics before these
procedures will help to decrease the risk for endocarditis.
 Taking anticoagulation medication as prescribed is very important because
mitral stenosis tends to produce both cerebral and peripheral emboli (blood
clots in the brain and extremities), which can cause severely disabling and/or
life-threatening complications like stroke.
Cardiac Rehabilitation
The program of cardiac rehabilitation:

 Counseling for the patient, helping him or her understand the effects of the
condition and to assist with managing the rehabilitation process.
 Introducing a program of physical exercise.

 Aiding the patient with some lifestyle changes. The program tries to reduce some of
the risk factors that can contribute to heart disease, such as: high blood pressure,
diabetes, high cholesterol, obesity, inactivity, and smoking.

 Offering vocational help to enable the patient to return to work, or find work.
Overall, to help patients lead a normal life once more.

 Telling patients the truth about their health condition, and explaining any
limitations they might have.
 Providing the patient with emotional support.
The goal of cardiac rehabilitation

 decreasing cardiac symptoms and complications.


 encouraging independence through self-
management.
 reducing hospitalizations.
 stabilizing or reversing atherosclerosis (plaque
buildup in the blood vessels).
 improving social, emotional, and vocational status.
Cardiac Rehabilitation
Prognosis

 Depending on severity of symptoms of mitral stenosis


(by the NYHA functional class), the 10-year survival
rate is as follows:
 85% for no symptom (class I)
 34-42% for mild symptoms (early class II)
 40% for moderate-severe symptoms (late class II, class III)
 0% for class IV (Of class IV patients, survival is 42% at 1 year
and 10% at 5 years.)
 The operative mortality rate is 1-2% for mitral
commissurotomy and 2-5% for mitral valve
replacement.
THANK YOU !!!!!!!!!!!!

Вам также может понравиться