Professional Documents
Culture Documents
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 β 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:
• 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.
• Manifestasi kardiak lain adalah gagal jantung kongestif dan perikarditis.
• 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 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 tertahan-
tahan 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.
• 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
Penyakit Jantung Rematik (PJR)
Penyakit Jantung Rematik (PJR) atau dalam bahasa medisnya Rheumatic Heart Disease
(RHD) adalah suatu kondisi dimana terjadi kerusakan pada katup jantung yang bisa
berupa penyempitan atau kebocoran, terutama katup mitral (stenosis katup mitral)
sebagai akibat adanya gejala sisa dari Demam Rematik (DR).
Demam rematik merupakan suatu penyakit sistemik yang dapat bersifat akut, subakut,
kronik, atau fulminan, dan dapat terjadi setelah infeksi Streptococcus beta hemolyticus
group A pada saluran pernafasan bagian atas. Demam reumatik akut ditandai oleh demam
berkepanjangan, jantung berdebar keras, kadang cepat lelah. 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.
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.
Tanda dan Gejala Penyakit Jantung Rematik
Penderita umumnya megalami sesak nafas yang disebabkan jantungnya sudah mengalami
gangguan, nyeri sendi yang berpindah- pindah, bercak kemerahan di kulit yang berbatas,
gerakan tangan yang tak beraturan dan tak terkendali (korea), atau benjolan kecil-kecil
dibawah kulit. Selain itu tanda yang juga turut menyertainya adalah nyeri perut,
kehilangan berat badan, cepat lelah dan tentu saja demam.
Penderita dianjurkan untuk tirah baring dirumah sakit, selain itu Tim Medis akan terpikir
tentang penanganan kemungkinan terjadinya komplikasi seperti gagal jantung,
endokarditis bakteri atau trombo-emboli. Pasien akan diberikan diet bergizi tinggi yang
mengandung cukup vitamin.
Penderita Penyakit Jantung Rematik (PJR) tanpa gejala tidak memerlukan terapi.
Penderita dengan gejala gagal jantung yang ringan memerlukan terapi medik untuk
mengatasi keluhannya. Penderita yang simtomatis memerlukan terapi surgikal atau
intervensi invasif. Tetapi terapi surgikal dan intervensi ini masih terbatas tersedia serta
memerlukan biaya yang relatif mahal dan memerlukan follow up jangka panjang.
Ada beberapa faktor yang dapat mendukung seseorang terserang kuman tersebut,
diantaranya faktor lingkungan seperti kondisi kehidupan yang jelek, kondisi tinggal yang
berdesakan dan akses kesehatan yang kurang merupakan determinan yang signifikan
dalam distribusi penyakit ini. Variasi cuaca juga mempunyai peran yang besar dalam
terjadinya infeksi streptokokkus untuk terjadi DR.
Seseorang yang terinfeksi kuman Streptococcus beta hemolyticus dan mengalami demam
rematik, harus diberikan therapy yang maksimal dengan antibiotiknya. Hal ini untuk
menghindarkan kemungkinan serangan kedua kalinya atau bahkan menyebabkan
Penyakit Jantung Rematik.
http://www.infopenyakit.com/2008/08/penyakit-jantung-rematik-pjr.html
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?
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
• 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:
Medical Treatment:
RHEUMATIC FEVER
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
Clinical Manifestations:
• 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.
• 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.
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.
• 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.
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.
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
by Michelle Badash, MS
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.
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:
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.
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
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 echocardiogram—uses 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 monitor—a 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 drugs—Mitral 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
If you are diagnosed with mitral stenosis, follow your doctor's instructions.
Prevention
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/