#1---"admitted into the hospital with a blood pressure of 190/110"

A sign that your hypertension may be caused by renal artery re-stenosis is hypertension that used to be well controlled but is now difficult to manage. Balloon angioplasty used by itself has a high re-stenosis rate. Occlusion is a common disorder affecting the renal arteries due to embolism from mural thrombi (atrial arrhythmias, etc.)


#2---"swollen feet and difficulty breathing, extreme nausea, a feeling that my heart was stopping for a few seconds, then tachycardia."

When a patient has pulmonary hypertension and moderate-to-severe tricuspid regurgitation their symptoms include neck vein pulsations, swelling of the abdomen, swelling of the feet and ankles, fatigue, tiredness, weakness, decreased urine output, and generalized swelling.

Hypertension and valvular heart disease can cause CHF and pulmonary edema. The following symptoms are usually predictive of CHF: peripheral edema, tachycardia, tachypnea (rapid respiratory rate), using accessory muscles of respiration, hypertension, pulsus alternans (alternating weak and strong pulse indicative of depressed left ventricle function, diaphoretic or cold, gray, and cyanotic skin, jugular venous distention, wheezing, aortic or mitral valvular abnormalities (e.g. an S3 or S4 heart sound), and lower extremity edema ("swollen feet").

Your heartbeat begins when your natural pacemaker cells in the sinoatrial node in the upper part of your heart sends an electrical impulse to the atria which spreads to both of your ventricles. In cardiac arrhythmias the pacemaker cells do not function properly which makes the heart beat too fast, too slow, unevenly (sometimes too slow and then sometimes too fast), or completely skip a beat. When your heart skips a beat then this causes the heart to pump blood less effectively and makes you feel dizzy or short of breath. Most cardiac arrhythmias are temporary and benign. Most temporary and benign arrhythmias are those where your heart skips a beat or has an extra beat. The occasional skip or extra beat is caused by emotions, exercise, or, sometimes by cardiac conduction or valve abnormalities. When the heart valve is damaged the path of the electrical signals may disrupt the heartbeat. Sometimes the AV node or bundle of His fails to properly conduct the pacemaker signal to the rest of the heart which is called heart block. In a complete block the ventricles will generate their own ineffectual contractions and the patient will eventually lose consciousness. In other situations the ventricles erratically spontaneously contract (premature ventricular contractions/PVC's) which can lead to death although occasional PVC's are not usually deadly. Some of the usual symptoms of cardiac arrhythmias are fatigue, weakness, lightheadedness, faintness, dizziness, palpitations, chest pain, difficulty breathing, and dyspnea during minimal exertion.

#3---"what is the process of Rheumatic fever if developed as an adult. . . . .If I actually did have rheumatic fever, is it possible to have developed this as an adult without being aware of it or is this a disease simply for children from 5 18 years of age."

Anybody can develop rheumatic fever following pharyngitis with group A beta-hemolytic Streptococcus pyogenes. It attaches to the epithelial cells of the upper respiratory tract and produces enzymes which damage tissues. After an incubation period of 2 to 4 days, the S. pyogenes elicit an inflammatory response with sore throat, fever, malaise, headache, and an elevated leukocyte count. Signs and symptoms of rheumatic fever might (but not always) include a combination of painful swollen joints, chest pain, fatigue and shortness of breath. Symptoms can persist for months and reoccur at a later time if strep throat reoccurs. Patients who have more rheumatic involvement of their heart will have a less acute onset of symptoms compared to those that have mostly joint complaints.

Penicillin V is the drug of choice for treatment of group A streptococcal pharyngitis. Preventive and prophylactic therapy is indicated after rheumatic fever and rheumatic heart disease to prevent further damage to valves. The initial course of antibiotics given to eradicate the streptococcal infection also serves as the first course of prophylaxis. An injection of 0.6 to 1.2 million units of benzathine penicillin G IM every 4 weeks is the recommended regimen for secondary prevention for most patients in the United States. Valvular insufficiency from acute rheumatic valve disease resolves in 60 to 80% of patients who adhere to antibiotic prophylaxis.

Rheumatic heart disease is responsible for 99% of mitral valve stenosis in adults in the United States and associated atrial fibrillation or left atrial thrombus formation from chronic mitral valve involvement and atrial enlargement. Rheumatic heart disease is the major cause of morbidity from rheumatic fever and the major cause of mitral insufficiency and stenosis in the United States and the world. The disease is more severe in females than in males.


#4---If I do have rheumatic cardiac disease now, is the reason for the past 6-7 years . . . .fatigue, headaches, nausea and simply a feeling of malase. . . . .no fever. . . . Am I misunderstanding or is it true that once one has this condition, it will continually surface at different intervals no matter how many years have passed since the original infection occurred?

Given your information, I suspect that the cause of your mitral valve stenosis (scarred calcification of the leaflets of your mitral valve) and atrial fibrillation are due to untreated rheumatic fever. This occurs in some people of your age group who were never treated as youngsters with penicillin for sore throats and fevers. Prophylaxis for a patient who has had rheumatic fever should be continued indefinitely because recurrent group A streptococcal infection and rheumatic fever are possible at any age. The American Heart Association recommends that rheumatic fever patients without carditis receive prophylactic antibiotics for 5 years; however, there are physicians who will treat a patient prophylactically indefinitely. Speak to your cardiologist about prophylactic antibiotic treatment.

Because the most common cause of mitral stenosis is rheumatic heart disease, secondary prophylaxis for rheumatic fever is recommended for all patients who do not have another obvious etiology for their valvular disease. Benzathine penicillin G is the treatment of choice; intramuscular administration is preferred over oral because its compliance rates are higher. Patients with a history of rheumatic heart disease should be maintained on antibiotic prophylaxis for at least 5 years after their most recent attack of rheumatic fever. Patients who are at increased risk for exposure to group A streptococci e. g. healthcare and childcare workers are candidates for longer periods of antibiotic prophylaxis.

Most people with rheumatic fever will have one or more of their heart's valves scarred and it sometimes won't be noticed for 20 or more years later. Permanent heart damage due to rheumatic fever is known as rheumatic heart disease. The inflammation can cause so much damage to the heart muscle that it could lead to congestive heart failure. A scarred heart valve prevents adequate blood flow and allows backward flow of blood. Surgery is usually necessary to repair or replace the damaged valve. In general, the incidence of residual rheumatic heart disease at 10 years is 34% in patients without recurrences but 60% in patients with recurrent rheumatic fever. Disappearance of the murmur, when it occurs, happens within 5 years in 50% of patients although valve abnormalities have been known to resolve 10 years after an episode of rheumatic fever.

Approximately 70,000 heart valve replacement procedures are performed annually in the United States for mitral valve stenosis resulting from rheumatic fever, mitral regurgitation from "floppy" valves, and calcified aortic stenosis.

There are no tests that can definitively diagnose rheumatic fever. Antibodies to extracellular streptococcal antigens rise during the first month after infection and then plateau for 3 to 6 months before returning to normal after 6 to 12 months. Evidence of a strep throat infection by a throat swab culture and the presence of either two of the major criteria or the presence of one major plus two minor criteria is usually necessary for a physician to make a diagnosis of rheumatic fever. Major criteria include inflammation of your heart indicated by weakness and shortness of breath or chest pain, arthritis affecting your ankles, wrists, knees, and/or elbows which can move from joint to joint, jerky involuntary movements of your arms, legs, and face and/or deterioration in handwriting and, rarely, lumps or a pink skin patch/es. Minor criteria are joint pain, fever, previous rheumatic fever or rheumatic heart disease, arrhythmia, elevated C-reactive protein (pro-inflammatory cytokines are an underlying cause of systemic inflammation that is indicated by excess C-reactive protein (CRP) in the blood), and new heart murmurs. Patients with elevated basal levels of CRP are at an increased risk for hypertension and cardiovascular disease. Elevated erythrocyte sedimentation rate (ESR) can be used to monitor inflammatory disease. Although it is a screening test (cannot be used to diagnose a specific disorder), it is useful in detecting rheumatologic disorders. A prolonged PR interval in first degree heart block (a delay in the conduction pathway from the sino-atrial node to the ventricles) is a symptom in some patients with rheumatic fever. This is why you have the skipped heart beat with the rapid tachycardia following. The tachycardia is your heart attempting to perfuse your body with blood in spite of your Sino Atrial Node unable to elicit conduction due to your damaged valve resulting in skipping a beat.

Edited by morekare on April 28 2006 at 4:38 AM

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