rheumatic heart disease in the elderly
Introduction
Introduction to elderly rheumatic heart disease Rheumatic fever is an autoimmune connective tissue disease associated with group A beta-hemolytic streptococcus infection, mainly involving the heart and joints, followed by the skin, serosa and blood vessels. It has a recurrent tendency and often leaves the heart valve. Damage causes rheumatic heart disease (senilerheumatic heart disease). The most common clinical mitral and aortic valve disease, elderly patients with rheumatic heart disease mostly continue to grow into old age, a very small number of cases in later years, the patient can live to the elderly may be due to the original heart The degree of invasion is lighter, the number of recurrent episodes of rheumatic fever is less, or the age of onset is later. In recent years, due to the significant improvement in the diagnosis techniques and treatments of valvular diseases, the functional status of heart valves can be quantitatively evaluated through many non-invasive methods. With the development of modern fine biological valves and mechanical valves, patients with rheumatic valvular heart disease survive. The rate is increasing. basic knowledge The proportion of illness: 0.005% Susceptible people: the elderly Mode of infection: non-infectious Complications: congestive heart failure, arrhythmia, cerebral embolism, infective endocarditis, cerebral infarction, myocardial infarction, pulmonary edema, aortic regurgitation, thrombosis
Cause
The cause of rheumatic heart disease in the elderly
(1) Causes of the disease
It is currently recognized that acute rheumatic fever is an allergic or allergic disease caused by infection of group A beta-hemolytic streptococcus. The outermost layer of streptococcus is the capsule, the middle is the cell wall, the inner layer is the cell membrane and the cytoplasm, and the cell wall is from From the inside to the outside, it is composed of protein, polysaccharide and mucopeptide. The protein layer is a specific protein, which can be divided into M, T, R, S and other antigen components. The M protein molecule and the muscle protein tropomyosin have common antigenicity. It has been confirmed that the trypsin-degraded fragment of M protein has cross-antigenicity with myocardial fiber membrane; the polysaccharide on cell wall and the glycoprotein of heart valve have cross-antigenicity, and intravenous injection of mucopeptide can also cause rheumatoid-like nodular heart damage. The lipoprotein on the cell membrane also has complex antigenicity, and it also has cross-antigenicity with heart valves, muscle fiber membranes and vascular smooth muscles. When streptococcus infection, if the body's immune function is normal, then the body mistakenly thinks that streptococci are The autoantigen does not produce a normal immune response to remove it. Once the immune function of the body is abnormal, the antigen on the surface of the streptococcus entering the body can be The immune response produces antibodies that react not only with streptococcal-associated antigens, but also with those myocardium and heart valves that have cross-antigens with streptococcus, causing tissue damage, repeated chains. Cocci infection can continuously stimulate the body to produce antibodies, causing repeated damage to the heart valve and hardening to form valvular disease.
(two) pathogenesis
The damage to the heart after the patient is infected with streptococcus is mainly manifested in two aspects:
1 rheumatic carditis caused by acute phase: acute rheumatic fever can cause almost heart damage, involving the pericardium, myocardial and endocardial formation of complete heart disease, pericardial cell-like inflammatory exudation, or myocardial production Acute edema and endocarditis.
2 valvular heart disease caused by recurrent episodes: visible fibrous scars in the myocardium, left atrial endocardial fibrosis, blood vessel formation on the valve leaflets, etc., the valve can be congested, swollen, scar formation and sacral papillary muscle adhesion, Hardening, calcification and contracture, leading to stenosis or regurgitation of the valve, mitral valve disease is more common than aortic valve, mitral and aortic valve lesions can exist at the same time, the type of lesion in the mitral valve is mostly narrow, and the main The arterial flap is mainly closed, and the tricuspid and pulmonary valve lesions caused by simple rheumatism are clinically rare in the elderly. Even if there are many mitral and aortic valve lesions, this chapter mainly describes the second chapter. Mitral and aortic valve lesions.
Mitral valve disease
The mitral valve maintains a tightly closed state when the left ventricle contracts. It is accomplished by the mitral valve itself and the various components of its surrounding anatomy. These are collectively referred to as the mitral valve device and consist of six components: the left atrium. , mitral valve leaflets, mitral annulus fibrosus, chordae, papillary muscles and left ventricular wall.
The early stage of rheumatic mitral stenosis is mainly caused by edema at the valve junction and its basal edema, inflammation and neoplasms. In the late stage of healing, due to fibrin deposition and fibrosis, adhesions between the anterior and posterior lobes are gradually formed. , fusion, valve thickening, hardening and chordae shortening and adhesion to each other, limiting valve function and opening, leading to stenosis of the valve, calcification of the annulus can be seen in elderly patients with mitral stenosis, characterized by annulus fibers Thickening, lipid deposition calcification is an age-related degeneration, the most obvious part of the calcification of the annulus is the posterior lobular ventricular surface. When the calcium deposition gradually increases, the posterior leaf can be pushed forward and fixed, due to Many elderly mitral stenosis have no clinical evidence of rheumatic activity and are too long to be associated with rheumatic fever at a young age. Therefore, it is believed that the development of mitral stenosis in the elderly may be due to acute valvular healing. The presence of turbulence occurs when blood flows through it, and sustained mechanical shock causes progressive non-specific valvular injury, formation of scars or adhesions, depending on the lesion Degrees can be divided into four types: type membrane, the membrane thickening, funnel and funnel-shaped diaphragm according to the degree of stenosis and compensation state can be divided into three:
1 left atrial compensation period: most of the stenosis is mild, due to the obstruction of the left atrial ventricle in the diastolic period, the left atrial is modernized to expand and hypertrophy to enhance the contractile force, so that the active blood output during diastole is increased, at this time the heart function can still Complete compensation.
2 left atrial decompensation period: as the lesions aggravate and the disease progresses, the left atrial compensatory enlargement, hypertrophy and enhanced contractility are difficult to overcome the hemodynamic disorder caused by the stenosis of the valve, left atrial pressure may occur Pulmonary venous pressure and pulmonary capillary pressure increase, on the one hand, can lead to decreased lung compliance, respiratory function disorders lead to hypoxemia, on the other hand, pulmonary capillary pressure rises, causing plasma and even blood cells to leak out of the capillaries Into the alveoli caused acute pulmonary edema, the signs of left atrial failure.
3 right ventricular failure period: long-term pulmonary congestion after lung compliance decreased, reflex caused pulmonary arteriospasm contraction, eventually leading to pulmonary hypertension, increased right heart and rear load to thicken right ventricular wall, right heart cavity enlargement, causing right heart Depletion, at this time, the blood flow through the lungs is reduced, so that pulmonary congestion and left atrial failure are alleviated, but in patients with atrial fibrillation with rapid ventricular rate and diastolic shortening, pulmonary edema is still prone to occur when pulmonary capillary pressure is elevated.
Mitral regurgitation is mainly due to recurrent episodes of rheumatic fever leading to thickening of the valve, scar formation and valve leaf contracture, as well as chordae tendine adhesion, rupture and papillary muscle scar formation and shortening, which restricts valve movement to affect its closure, usually without valve Calcium deposits or only mild calcareous deposits, blood flow from the left ventricle to the left atrium during the entire systolic phase, resulting in increased left atrial pressure and volume, this reflux can continue until the left ventricular pressure drops to Below left atrial pressure, long-term reflux can enlarge the left atrium, acute pulmonary edema, followed by pulmonary hypertension and right ventricular overload caused by right ventricular hypertrophy, right heart failure, and left ventricular volume load during diastole Increased can produce eccentric left ventricular enlargement and hypertrophy, although the left ventricular ejection resistance is reduced, the ejection fraction is normal or increased, but the left ventricular circumferential diameter shortening rate is reduced compared with normal people, the left ventricular end-systolic volume index is increased, Rheumatic mitral regurgitation has a gradual development trend, the reasons:
1 rheumatoid lesions sustainable activities;
2 The scarring process can last for several years;
3Edwards proposes that when the mitral regurgitation causes left atrial enlargement, the latter causes the posterior lobe of the mitral valve to shift, resulting in a counter-flow increase to form a vicious circle.
2. Aortic valve disease
Aortic valve disease accounts for 20% to 35% of senile rheumatic heart disease, but most of them have mitral valve disease. It is considered that simple aortic stenosis is not caused by rheumatic fever, and many are caused by calcification. Aortic valve stenosis generally develops slowly, and left ventricular contractility is very strong, so the heart has sufficient time to maintain relatively good cardiac function through compensatory mechanism. In severe stenosis, left ventricular systolic load increases, and wall fibers increase. Thick elongation, resulting in left ventricular centripetal hypertrophy, so that contraction force is enhanced, systolic blood pressure is increased, left ventricular-aortic pressure difference is increased to maintain normal cardiac output, but long-term left ventricular load increase causes left ventricular hypertrophy The following adverse effects:
1 myocardial hardening, diastolic dysfunction, diastolic compliance decreased, leading to left ventricular diastolic dysfunction, left ventricular end-diastolic pressure, so that the front load is extremely sensitive, that is, mild preload can lead to pulmonary venous hypertension, and even Pulmonary congestion and pulmonary edema occur.
2 Cardiac hypertrophy and the number of capillaries does not increase, so that the diffusion radius of oxygen is increased, the myocardial relative blood supply is insufficient, the left ventricular ejection resistance is increased, and the myocardial contractility is enhanced to increase myocardial oxygen consumption.
3 left ventricular end-diastolic pressure increased, hypertrophic myocardium squeezed small coronary veins in the wall, thereby increasing coronary perfusion resistance and reducing diastolic coronary flow; while the reduction of aortic mean pressure made coronary perfusion insufficient, further aggravating myocardial Ischemia, long-term blood supply can produce fibrosis of the left ventricle myocardium, especially the subendocardial fibrosis is the most extensive, so that myocardial contractility is reduced, compliance is further reduced, heart failure is gradually developed, and even angina and myocardial infarction are induced. People are often accompanied by coronary artery disease, which makes the condition worse and the prognosis worse.
Aortic regurgitation is mainly due to shortening of the valve leaflets after rheumatic aortic valve disease, deformation, the magnitude of the reverse flow is related to the size of the reflux valve mouth, but also with left ventricular compliance, peripheral vascular resistance, heart rate The speed and the pressure difference between the aorta and the left ventricle are related. Because there is a significant pressure difference between the aorta and the left ventricle during diastole, even if the reflux diameter is small, significant blood reflux can occur, and a large amount of blood flows back into the left. The left ventricular volume load in the diastolic period is increased, the left ventricular myocardium is passively stretched, and the left ventricular cavity is gradually enlarged, which can develop into a giant left ventricle. When the left ventricular end diastolic pressure is increased to a certain extent, especially left Poor systolic dysfunction, can cause left ventricular end-diastolic volume and pressure rise sharply, left atrial pressure and pulmonary venous pressure, eventually leading to left heart failure and pulmonary edema, while the reduction of aortic diastolic blood pressure can affect coronary blood supply, so that Myocardial ischemia further reduces myocardial contractility, aggravates cardiac insufficiency, and the pressure rise occurs earlier in the left ventricular systole, the blood ejection period is shorter, and the blood reaches the peripheral small artery. Born in early systole, when a large amount of blood into the arteries of insufficient filling in early systole, peripheral artery can significantly impact the flu.
Prevention
Elderly rheumatic heart disease prevention
Elderly patients undergoing open heart surgery are at great risk and must be cautious, but severe mitral stenosis, rapid decline in cardiac function, or atrial fibrillation and embolic embolization may be used for border separation, left atrial thrombectomy and valve replacement. Surgery should not be limited by age, but should be determined according to the patient's general condition. For the elderly, the surgical indications and contraindications should be mastered, the surgical tolerance of the patients before surgery, the functional status of each major organ, the operation mode and timing. The choice, the critical conditions that may occur during the operation, postoperative complications and prevention measures should be considered comprehensively and comprehensively.
Complication
Elderly rheumatic heart disease complications Complications Congestive heart failure arrhythmia cerebral embolism Infective endocarditis Cerebral infarction Myocardial infarction Pulmonary edema Aortic valve regurgitation thrombosis
Congestive heart failure
It is the most common complication and cause of death in elderly patients with rheumatic heart disease. It occurs in more than 50% of patients. As the age increases, the myocardial compliance of the elderly decreases and the output per heart is low. Human blood volume is more than young people, resulting in increased pre-cardiac load; poor coronary reserve capacity and other basic factors, so it is prone to heart failure, mostly due to lung infection, physical activity, excessive transfusion, sodium intake Excessive, improper treatment of digitalis and some drugs that inhibit myocardial contractility are induced by factors such as -blockers and antiarrhythmic drugs. After mitral stenosis enters the left atrial decompensation period, there are many lungs. Congestion causes difficulty in breathing. Long-term ventricular tachycardia can cause pulmonary edema. Long-term pulmonary hypertension can cause right ventricular dilatation and hypertrophy. In addition, rheumatic myocardial damage can cause right heart failure and death. Simple mitral regurgitation is not easy. Heart failure, aortic stenosis can have a long period of asymptomatic period, but when the symptoms of heart failure, the average life expectancy is only 2 to 3 years, aortic regurgitation Can be asymptomatic for a long time, but if there is left ventricular hypertrophy, pulse pressure increases, heart failure can occur within a few years and die.
2. Arrhythmia
Premature contraction, atrial fibrillation and paroxysmal tachycardia can occur, of which the most common atrial fibrillation is the late manifestation of mitral stenosis, mainly seen in patients with obvious left atrial enlargement, the vast majority of elderly mitral valve Stenosis patients with atrial fibrillation, mitral regurgitation also 30% with atrial fibrillation, aortic valve disease with atrial fibrillation and mitral valve disease at the same time, initially paroxysmal, later turned into persistence, often first Multiple atrial premature contractions, paroxysmal atrial fibrillation or atrial flutter, later become chronic atrial fibrillation, atrial fibrillation such as ventricular tachycardia can aggravate heart failure, in addition to atrial fibrillation easy to cause left atrial and left atrial appendage thrombosis Forming, shedding can cause embolism.
3. Embolization
In patients with moderate mitral stenosis, the left atrium and left atrial appendage are dilated and congested, which is prone to thrombosis. If accompanied by atrial fibrillation, it is more likely to promote thrombosis. Thrombosis can cause cerebral arteries, coronary arteries, mesenteric arteries, kidneys and limbs. Embolism in arteries, etc., causing corresponding clinical manifestations such as cerebral infarction, myocardial infarction, ischemic enteritis, hematuria and renal hypertension and limb gangrene, etc., 5% to 10% of cases of arterial embolism can occur, of which more than 60% For cerebral embolism, venous thrombosis can occur in elderly people who have been bedridden for a long time. Patients with atrial fibrillation can also form thrombus in the right atrium. Once they fall off, they can cause pulmonary infarction. Some patients with obvious calcification may also undergo embolization after valve separation. Therefore, the presence of valvular calcium may also be one of the causes of embolism.
4. Infective endocarditis
More common in patients with mitral regurgitation and aortic regurgitation, simple mitral stenosis occurs less, especially in patients with severe stenosis, thickening and atrial fibrillation are more rare, may be due to atrial fibrillation, heart failure or two When the cusp stenosis is severe, the blood flow velocity is slowed down or the pressure gradient is small, and turbulence and jet flow are not easy to occur, which is not conducive to the formation of neoplasms, resulting in less infective endocarditis, but in recent years, catheterization and interventional examination And treatment, as well as valvular surgery, the chance of infection has increased, so preoperative prophylactic antibiotics are necessary.
5. Pulmonary infection
Long-term pulmonary congestion reduces lung compliance, bronchial mucosal swelling and ciliated epithelial dysfunction, pulmonary interstitial exudate often becomes a good medium, coupled with low resistance in the elderly, it is prone to repeated lung infections, Infection can also induce and aggravate cardiac insufficiency.
Symptom
Elderly rheumatic heart disease symptoms common symptoms loss of appetite fatigue valve thickening dyspnea weakness arrhythmia labor dyspnea sound hoarseness palpitations dysphagia
Elderly rheumatic heart disease can have no or few clinical symptoms, but also can have progressive heart damage, but also due to rheumatism, hypertension, coronary heart disease and infection and other factors can make the symptoms worse, when the elderly have rheumatism activities can be expressed as Carditis - tachycardia, new murmurs, changes in ECG and increased erythrocyte sedimentation rate, but also arthritis, but ring erythema, chorea and subcutaneous nodules are rare in elderly patients.
Mitral stenosis
Symptoms of mitral stenosis in the elderly are similar to those of other age groups, mainly related to the severity of stenosis, the rate of progression of the lesion, the difference in living conditions and compensatory mechanisms, and can be asymptomatic or only fatigued in the left atrial compensatory period, coughing Entering the left atrial decompensation period may have labor dyspnea, even sitting breathing, coughing, hemoptysis or coughing pink foam sputum, left atrial enlargement can oppress the left recurrent laryngeal nerve and esophagus causing hoarseness and difficulty in swallowing, housing There may be palpitations during tremor; chest pain may occur when pulmonary arterial pressure is further increased or combined with rheumatic coronary arteritis and coronary embolism. When the right ventricle is involved and dysfunction, due to gastrointestinal congestion and dysfunction, loss of appetite may occur. Hepatic congestion and dysfunction cause pain in the liver area, abdominal distension, and lower extremity edema.
The apical period diastolic murmur is the most important and most common sign of mitral stenosis. It is often confined to the apical region. The low-pitched, rumbling-like murmurs in the middle and late diastolic are not necessarily proportional to the degree of stenosis. Elderly patients lack this murmur, which may be due to: 1 elderly due to fibrosis or calcification of the mitral valve, loss of flexibility, and early diastolic opening sound and typical rumbling-like diastolic murmurs are reduced or disappeared, 2 valves Severe stenosis, thickening and adhesion of the valve, reduced mobility, slowing blood flow through the mitral valve and reducing blood volume, resulting in extremely low noise, 3 pulmonary hypertension, right ventricle significantly enlarged, extremely clockwise index, left The left posterior shift of the chamber affects the conduction of mitral valve murmur. 4 When the aortic valve disease is combined with the increase of left ventricular diastolic pressure, the left atrial left ventricular pressure difference is reduced, and the apical diastolic murmur is weakened or Disappeared, 5 elderly people often have emphysema to affect the transmission of murmur, or the squeaky sound of lung disease caused by chronic bronchitis concealed diastolic murmur, 6 elderly people are prone to heart function Incomplete or combined atrial fibrillation, severe arrhythmia, etc. can significantly reduce the original murmur, etc., other signs have apical area first heart sound hyperthyroidism, mitral valve open slap sound, pulmonary heart valve area second heart sound hyperactive split, generally in Young patients have lower pulse pressures, and older people may lack this sign due to peripheral atherosclerosis.
Echocardiography can show the EF slope and CE amplitude of the anterior mitral regurgitation, the Q-wave of the mitral anterior flap and the anterior lobe of the mitral valve are prolonged, and the posterior lobe and the anterior lobe are in the same direction. Ultrasound showed thickening of the leaflets, enhanced echo, no separation of the tip of the anterior and posterior lobes during diastole, limited open activity, significantly reduced valve area, etc. Check left atrium, right ventricular enlargement, pulmonary artery segment prominent, heart shadow is pear-shaped change, left main bronchus changes due to enlargement of left atrium, lung congestion, pulmonary portal vein blood redistribution and increased pulmonary vascular shadow The lower part is reduced, and some patients may have Kerley A and B lines.
2. Mitral regurgitation
Mild mitral regurgitation in the elderly is often asymptomatic. Some patients can be asymptomatic for life, and develop rapidly until the left heart failure occurs due to incomplete ablation. The main symptoms include shortness of breath and difficulty breathing after exhaustion, and even sitting breathing; Decreased aortic ejection caused by mitral regurgitation can cause fatigue and weakness; left ventricular diastolic overload and increased left ventricular stroke can cause palpitations; some patients with left atrial enlargement can cause right chest pain and swallow discomfort.
The systolic murmur in the apical region is the most important sign. The murmur is mostly systolic. It is a high-profile blast, multi-directional subgingival and left scapular sacral conduction. When the valve leaf junction or posterior lobes are involved, the noise can be transmitted to The left sternal border, the third intercostal space and the second auscultation area of the aortic valve, a few are rough noises. When the chordae or papillary muscles are involved, there may be music-like murmurs. The loudness of the murmur depends on the degree of valve damage, the return flow and the atrioventricular compartment. The pressure difference between the other signs, the first heart sound is weakened, the second heart sound in the pulmonary valve area is hyperthyroidism, and the pathological third heart sound is present. The apical area may have ascending pulsation and full systolic tremor.
Two-dimensional ultrasound can show the thickening of two leaflets. The systolic mitral valve can not be completely closed or has multiple echoes. Color Doppler can be seen in the left atrium and the systolic phase is abnormally reversed from the mitral valve. Turbulent signal, ECG has left atrial enlargement and left ventricular hypertrophy, strain performance, fluoroscopy with left ventricular pulsation enhancement, systolic and diastolic internal diameter increased, left atrium, left ventricular enlargement, left atrial enlargement in right ventricular heart There is a double shadow in the shadow, and the right ventricular enlargement and pulmonary congestion in the late stage.
3. Aortic stenosis
Aortic stenosis generally progresses slowly, plus left atrial and left ventricular compensatory function, so elderly with mild stenosis can be asymptomatic, angina can be severe when the condition is severe, and its incidence increases with age and stenosis. The severity increases and increases. Its nature is more difficult to distinguish from angina pectoris of coronary heart disease, but it can occur when tired or at rest. It is not necessarily related to physical activity. The reason is due to increased oxygen consumption of cardiac hypertrophy, left ventricle. Wall systolic tension is too high and aortic valve pressure is reduced due to coronary perfusion. Some elderly people may have sudden syncope and sudden death. The reason may be that most of the elderly have atherosclerosis, and the cerebral artery and coronary artery itself have Different degrees of hardening and stenosis, plus labor to dilate the surrounding blood vessels, and the cardiac output can not be increased correspondingly, causing cardiac circulatory dysfunction or myocardial ischemia induced severe arrhythmia, leading to a sharp disorder of hemodynamics, other symptoms have cardiac insufficiency Labor difficulties caused by dyspnea, palpitations, etc.
The typical aortic stenosis noise is the third intercostal space on the right side of the sternum and the third edge of the sternum. The most common between the four intercostals is the jetting and roughness. The loudness is above 3 to 4, and more often accompanied by tremor. Neck conduction, in general, the more obvious the stenosis, the higher the intensity of the murmur, the longer the duration, the majority of the rhomboid murmur, that is, the peak intensity in the mid-systolic murmur, and finally the second heart sound aortic valve component before the elderly The systolic murmur is often high-profile and can be most loud in the apical region. The reason is that the elderly emphysema weakens the heart-bottom murmur intensity and the valve stiffness, and there is no adhesion. The vibration can be transmitted to the ventricular cavity and reach the apical region. Severe aortic stenosis can cause abnormal second division of heart sound due to significant left ventricular ejection time. The third heart sound often reflects left ventricular dysfunction. Generally, peripheral systolic pressure and pulse pressure difference decrease, but the elderly Often accompanied by aortic atherosclerosis or arteriosclerotic hypertension, despite the moderate aortic stenosis, pulse pressure can still be normal, there may be increased systolic blood pressure.
On the echocardiogram, the aortic opening amplitude and velocity are reduced, the ratio of the valve opening diameter to the aortic inner diameter is reduced, the valve can be enhanced by thickening or calcification, the density is increased, and the Doppler examination can be performed at the aortic valve. A systolic turbulence or jet signal was detected at the top of the aorta, and the aortic root was stenotic and swelled due to rapid septic jetting. The electrocardiogram showed left axis deviation and left ventricular hypertrophy. The left ventricle was displayed on the X-ray. Increase, due to aortic stenosis mainly caused by increased left ventricular afterload, often with centripetal hypertrophy and ventricular cavity often no significant increase, so the left ventricular shadow is mostly mildly enlarged, late stage may have pulmonary congestion and right heart enlargement Signs.
4. Aortic valve insufficiency
Mild to moderate aortic regurgitation in the elderly may have no obvious symptoms, such as increased blood output and increased cardiac contractility. Patients may have palpitations or chest discomfort. About half of the patients may have angina as the disease progresses. Due to the coronary artery lesions in the elderly, and the reduction of aortic diastolic pressure at this time, coronary perfusion is further affected; and the left ventricle is in a state of capacity overload for a long time, the myocardial contractility is enhanced and the myocardial oxygen consumption is increased, and the blood supply is not completed. Due to the proportion, repeated episodes of angina pectoris in the elderly suggest a poor prognosis. In the event of left ventricular dysfunction, the condition often deteriorates rapidly, and there is nocturnal paroxysmal dyspnea, coughing pink foam, etc., and a small number of patients may have sudden fatal arrhythmia. And drowning.
The main sign of aortic regurgitation is early gas-like or high-profile air-like murmur in the diastolic, third in the left sternal border, the most common between the four intercostals, often to the apex, due to aortic regurgitation impact mitral valve In the anterior lobe, it can cause relative mitral stenosis, while early murmur in the apex region is heard, ie, Austin-Flint murmur, moderate aortic regurgitation, left ventricular cardiac output increased and blood flow velocity increased. It can produce relative aortic stenosis and cause systolic rhomboid murmur in the aortic valve area. Peripheral vascular signs are unique signs of aortic regurgitation, including increased pulse pressure difference, water pulse, and gunshot sound. When the femoral artery is gently compressed with a stethoscope, systolic and diastolic double murmurs (Duroziez sign), capillary pulsation signs and nod signs can be heard.
Ultrasound can be seen under the aortic valve opening amplitude and speed increase, but the closure delay, systolic blood flow velocity increased, the valve leaf can have a fine flutter, the diastolic right coronary valve and the non-crown valve can not be closed into a line and double line, Color Doppler flow imaging was performed in the left ventricular outflow tract and/or left ventricle. Abnormal color reflux blood flow originating from the aortic valve orifice was detected during diastole, and left ventricle was seen by fluoroscopy. The amplitude of the aorta increased significantly, the left ventricle extended to the left and the boots were extended, the aorta was often widened, and the electrocardiogram showed left axis deviation of the electric axis and left ventricular hypertrophy. In severe cases, the aortic valve disease involved the atrioventricular junction. Caused the extension of the PR interval.
5. Combined valvular disease
Rheumatic valvular heart disease, if there are two or more valves at the same time damaged, called combined valvular disease, is not uncommon in the elderly with valvular disease, the most common is mitral stenosis combined with aortic regurgitation Clinically, combined valvular lesions have the symptoms and signs caused by each valve. They are generally prominent with more severely damaged valves and interact with each other. When the mitral stenosis is combined with aortic regurgitation, the mitral valve can be dilated. The murmur was relieved, and the peripheral vascular sign of aortic regurgitation was not significant. Its effect on cardiac function was generally more severe than that of single valvular disease.
Examine
Elderly people with rheumatic heart disease
ESR increased or normal, anti-streptolysin "O" (ASO): >500U rheumatoid factor positive or negative, C-reactive protein positive.
Electrocardiogram
PR prolongation, there may be ST-T changes, QT normal or arrhythmia.
2. Echocardiography
Visible abnormal changes.
Diagnosis
Diagnostic identification of elderly patients with rheumatic heart disease
Diagnostic criteria
The performance of rheumatic heart disease in the elderly is often atypical, and the elderly often have multiple lesions, such as coronary heart disease, pulmonary heart disease, hypertensive heart disease, etc., the symptoms and signs of rheumatic heart disease are covered; many The elderly have a slow development of rheumatic heart disease, relatively mild disease, no history of acute rheumatic fever or rheumatism, so they are often missed. Although the current inspection methods are progressing, it is not uncommon to find misdiagnosis and missed diagnosis through clinical and autopsy. As long as careful medical history and physical examination, combined with laboratory examination and ultrasound, X-ray and cardiac catheterization performance, pay attention to identify some non-rheumatic causes of valvular disease, generally can make a correct diagnosis.
Differential diagnosis
Mitral stenosis
In patients with mitral stenosis who can live to the elderly, the valve infarction is relatively light, often due to atrial fibrillation, heart failure or embolism, so attention should be paid to the occurrence of atrial fibrillation and transient ischemic attack in the elderly. Auscultation in the cusp area, the occurrence of hemoptysis should be differentiated from tuberculosis and bronchiectasis, and diastolic murmurs in the apical region may occur in the following cases:
1 Chronic pulmonary heart disease due to right ventricular hypertrophy, enlargement, cardiac cavity transposition, sometimes in the apical area can be heard in the apical region of the relative tricuspid stenosis caused by diastolic murmur.
2 severe anemia, due to the acceleration of blood circulation can cause relative stenosis of the mitral valve, diastolic murmur.
3 rheumatic valvular heart disease and spastic mitral valve disease of systemic lupus erythematosus.
4 constrictive pericarditis, etc., the rhythm of rheumatic valvular heart disease is more enhanced after heart failure control, and the noise caused by pulmonary heart disease and mitral valve inflammation is more weakened or disappeared after heart failure control, according to the original disease Clinical manifestations can be identified with this disease.
2. Mitral regurgitation
If mitral stenosis and aortic valve disease are combined at the same time, it is generally considered to be rheumatic lesions. The following conditions should be considered for non-rheumatic mitral regurgitation in the elderly:
1 mitral valve prolapse: the elderly are often secondary to coronary heart disease, myocardial infarction due to papillary muscle ischemic necrosis or chordae tendon rupture caused by the loss of traction of the leaflets to the atrium, but also due to valvular calcification and cardiomyopathy Caused by M-mode echocardiography, the characteristic mitral valve has a hammock-like change in the middle and late stages.
2 papillary muscle dysfunction: any cause of papillary muscle contraction or spatial position changes and necrosis, can lead to mitral regurgitation, which may be due to papillary muscle ischemia, left ventricular dilatation, papillary muscle non-ischemic atrophy , dilated and hypertrophic cardiomyopathy and endocardial diseases, etc., the common cause of coronary heart disease in the elderly, there are three types: papillary muscle ischemia or necrosis and its dysfunction, ventricular axonal formation causes ventricular contraction During the period of opposite movement, the corresponding part of the papillary muscle pulls the mitral valve, the papillary muscle fracture causes the mitral valve to lose traction in the ventricular systole and turn to the left atrium, according to its corresponding clinical manifestations and ultrasound characteristics can be identified.
3. Aortic stenosis
Older aortic stenosis is often associated with arteriosclerosis and calcification of the valve leaf. The systolic murmur of senile calcific aortic stenosis is often at the apex of the heart, rather than at the base of the heart, and is transmitted to the lower axilla rather than to the neck. With coronary artery disease and atrioventricular conduction disorder, the valve has obvious calcium deposition under ultrasound, while adhesion and leaflet deformation are less common.
4. Aortic valve insufficiency
Older people with hypertension and aortic atherosclerosis can cause relative aortic regurgitation due to annulus dilatation. These patients often have a history of hypertension, obesity, and hyperlipidemia, and their murmurs are second ribs on the right side of the sternum. More obvious, more along the right edge of the sternum, no other valvular lesions, aortic widening under the X-ray, prolonged flexion, calcification shadow in the bow and descending, etc. Cause aortic regurgitation and heart failure, when patients with chest pain or back pain first heard aortic valve diastolic murmur, should pay attention to the possibility of aortic dissection aneurysm, timely ultrasound and X-ray examination to identify .
