1. ACQUIRED CARDIAC DISEASE Rheumatic Fever Arterial Ischemic Stroke Arrhythmia

2. Pathophysiology of Rheumatic Fever  Also known as Kawasaki disease (KD)  Leading cause of acquired heart disease in children  An acute, febrile, multisystem disease is usually manifested by a self-limited generalized vasculitis of unknown etiology. (Ferri: Ferri's Clinical Advisor 2011)

3. Risk Factors for Cardiac Disease  Tobacco use  High blood cholesterol  Obesity  Poor physical activity  Diabetes

4. Demographics of Patient with Rheumatic Fever  Children <5 years old; peak age 18-24 months  Asian descent have highest incidence, followed by African Americans, Puerto Ricans, Mexican Americans and American Indians  Evidence of coronary artery disease

5. Signs and Symptoms of Rheumatic Fever  Fever (greater than 102.2 F) for more than 5 days and 4 out of the 5 below features: o bilateral, painless bulbar conjuctival injection without exudate o oral mucosal changes: erythema and fissured lips, strawberry tongue o polymorphous exanthema (in truncal region) o extremity changes: acute erythema and edema of hands and feet; membranous desquamation of fingertips o cervical lymphadenopathy <1.5 cm in diameter; unilaterally and anterior

6. Additional S&S of Rheumatic Fever  Cervical lymphadenopathy  Exanthema and extremity changes  Aneurysms of peripheral arteries (axilla)  Beaus’s lines (transverse grooves of the nails)  Diarrhea  Dyspnea  Arthralgia  Myalgia

7. Treatment for Rheumatic Fever  Reduce inflammation in systemic and coronary arteries to prevent arterial thrombosis (aspirin)  Prevent myocardial ischemia or infarction  Oxygen therapy  Salt restriction in pts with congestive heart failure  Emollient creams for peeling skin  Angioplasty and coronary bypass graft surgery for chronic conditions

8. Arterial Ischemic Stroke (AIS) Risk factors  Antiphospholipid antibodies  Increased Lipoprotein  DNA factor V Leiden mutation  Factor II genotype  congenital heart malformation  sickle cell disease and hypoxemia  meningitis  Cardiac procedures such as surgery, biopsy, interventions  Immobilization  Anemia  lipid metabolism disorders  Prothrombotic abnormalities such as anticardiolipin antibody, lupus anticoagulant, deficiencies in protein C and S and antithrombin

9. Signs and Symptoms of AIS  Fever  Seizures/symptomatic epilepsy  Cognitive impairments  Hemiparesis  Large middle cerebral or cerebellar infarcts

10. Treatment for AIS  Anti-thromotic therapies  Low molecular weight heparins (first choice) indications include arterial dissectino, coagulation disorders, embolisms from heart, progressive neurologic deficits  Heparin therapy  Aspirin- to reduce reoccurrence  Warfarin- for congenital or acquired heart disease, sever hypercoagulable states, arterial dissection, recurrent AIS while on aspirin  Thrombolytic agents  Neuroprotective agents  Immunosuppressive therapy  Stabilizing systemic factors and managing the causes

11. Arrhythmia Pathophysiology  IVNC- Isolated Ventricular Non-Compaction  Tachycardia  Abnormal heart rhythms  Can quickly progress to cardiac arrest and brain death

12. Demographics of Patient with Arrhythmia  Children or adults  Appear healthy  44.8% are men with an average age of 66.8 years

13. Signs and symptoms of Arrhythmia  Symptoms are not obvious until disease is advanced  Heart palpitations  Dysarthria  Hemiparesis  Recent onset of nausea, vomiting and malaise  Tachycardia  Reduced systolic function  Anger and hostility common in men

14. Treatment for Arrhythmias  Anticoagulants decreases risk for a recurrent stroke by 50%

15. References  Ferri, Fred, M.D., F.A.C.P. (2011). Ferri’s Clinical Advisor, 1 st ed. Philadelphia, PA.  Barreirinho, S. MD, et al (2003) Inherited and Acquired Risk Factors and Their Combined Effects in Pediatric Stroke. Pediatric Neurology; 28, 3.  Vatthyam, R. K., Bates, J. R., & Waller, B. F. (2009). Acute cardiac and neurologic decompensation in a high school athlete. J Am Soc Echocardiogr, 22(12), 1420 e1421-1423. doi: 10.1016/j.echo.2009.06.010  Kumar, A.S et al (1995). Results of Mitral Valve Reconstruction in Children with Rheumatic Heart Disease. The Society of Thoracic Surgeons, 60: 1044- 7.