1B valvular disease

Question 1

What is infective endocarditis?

Answer 1

An infection of the endocardium or vascular endothelium of the heart

Question 2

Where does infective endocarditis typically effect?

Answer 2

Heart valves

Question 3

What is the most common pathogen causing infective endocarditis?

Answer 3

Streptococci (20-40 % of cases) are the most common infection.

Question 4

Explain the pathology of infective endocarditis

Answer 4

It is usually the result of bacteria entering the blood stream and forming ”a vegetation” (a bacterial infection surrounded by a layer of platelets and fibrin) in the endocardium.

Question 5

How do you diagnose infective endocarditis?

Answer 5

Duke criteria

Question 6

What are features of heart decomposition?

Answer 6

Answer:
- Cardiac decompensation
- Vascular and embolic phenomena
(stroke, Janeway lesions, splinter/ conjunctival haemorrhages)
- Immunological phenomena
(Osler’s nodes, Roth spots)

Question 7

What are symptoms of cardiac decomposition?

Answer 7

• Symptoms include shortness of breath, frequent coughing, swelling of the legs and abdomen, fatigue
• Clinical signs include raised JVP, lung crackles and oedema

Question 8

What part of the heart does infective endocarditis affect?

Answer 8

Infective endocarditis affects the endocardium, especially the valves of the heart
Aortic valve is affected most frequently (aortic > mitral > right-sided valves)

Question 9

How is infective endocarditis managed?

Answer 9

• Medical heart failure therapy - ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists
• Diuretics for fluid overload
• Anticoagulation for atrial fibrillation
• Cardiac devices – cardiac resynchronisation therapy and/or implantable cardioverter defibrillator
• Transplant

Question 10

What is the difference between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction?

Answer 10

HF with preserved ejection fraction: EF greater than 50%. Presence of diastolic or right heart dysfunction. Diastolic dysfunction leads to an increased reservoir of blood in the pulmonary veins, leading to increased pulmonary hypertension and pulmonary oedema.

HF with reduced ejection fraction: EF less than 50%. Impaired left ventricular systolic function leading to pulmonary oedema secondary to impaired systolic function and flow of blood via the aorta. This leads to the backflow of blood into the pulmonary veins and lungs (leading to pulmonary oedema).

Question 11

What are the clinical signs and symptoms of heart failure and how does it differ between left and right heart failure?

Answer 11

Right heart failure – peripheral oedema e.g. leg swelling, raised jugular venous pressure
Left heart failure – pulmonary oedema

Question 12

What medications are used to treat heart failure?

Answer 12

Heart failure with preserved ejection fraction: Diuretics and SGLT2 inhibitors.

Heart failure with reduced ejection fraction: ACE inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) – e.g. preformulated in Entresto. Beta blockers. Mineralcorticoid receptor antagonists, SGLT2 inihbitors, diuretics.

Question 13

How is HF monitored?

Answer 13

Clinical signs and symptoms of fluid overload: E.g. shortness of breath, leg swelling, orthopnoea (needing an extra pillow at night), reduced exercise tolerance due to shortness of breath.

Observations: Low oxygen saturation

Biomarkers: NT-proBNP

Imaging: Echocardiogram