69. Infective endocardiditis and Valvulopathy Flashcards
What is infective endocarditis?
infection of native or prosthetic heart valve, endocardium or inwelling cardiac device
90 day mortality from IE?
25%
Predictors of poor outcomes of IE
older
comorbidities
staph infection
HF
perivalvular extension
2 Predictors of improved outcomes of IE
strep infection
isolated RS infection
What kind of background physiology does IE require?
predisposing valve dusfunction (occulr degenerative disease, bicuspid valve), endothelial damage ofr prosthetic material to get plt-fibrin thrombus which is then seeded with materials
Higher risk CHD infections for IE?
cyanotic
reapired lesions with prosthetic material, shunt, valve regurg
IVDU with IE - r or L sided lesion mc?
r
When is highest risk for prosthetic valve endocarditis?
6mo post surg
Prosthetic valve - what is highest risk valve/side?
RS - tricuspid
7 high risk populations and predisposing conditions for IE?
prior hx of IE
chd
IVDU
prosthetic heart valve
ICD - PM, defib
hemodialysis
recent hospitalization with central or LT IV access
Implicated sources (other than IVDU) for pt with bacteremia causing IVDU?
poor dentition
dental procedures
cystoscopy
lt lines
MC overall bug causing IE?
staph aureus
Leading etiology of IE in developing countries
streptococcus
GI malignancy IE bug?
strep bovis
PVE and native valve infection - what bug can cause this in elderly and debilitated pt?
enterococcus faecalis
15% of IE caused by HACEK group - what are these?
haemophilius
aggregatibacter actinomycetemcmonitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
what zoonotic etiologies can cause endocarditis?
coxiella burnetii (q fever)
brucella
bartonella
fungal endocarditiis causes in pt with prosthetic valves, IDU, immunocompromised states
candida
aspergillus
Highest risk valve for clinical heart failure when effected by IE?
aortic as can get aortic insufficiency
Complications of infective endocarditis
CV:
conduction blocks in myocardium
ao insufficiency
downstream infarction
mycotic aneurysm
Lungs: if from R side - PE
Cerebral emboli - hemorrhagic transformation common
Infectious:
abscess in myocardium
metastatic abscess
immune complex deposition
vertebral OM
Duke criteria for Dx of IE:
Definite endocarditis:
2 major clinical
1 major and any 3 minor
5 minor clinical
Duke criteria for Dx of IE: Possible endocarditis
one major, and one or two minor clinical
3 minor
Duke criteria for Dx of IE: Major criteria
1). At least two sets of + blood cultures with typical IE (staph, strep viridans including strep bovis, enterococcus, HACEK)
or persistent + culture with organism consistent with IE
or single culture or serology + for coxielli burnetii
- Evidence of endocardial involvement by echo: pendulum like veg on valve endocardium
paravalvular abscess
prosthetic valve dehisc
new valve regurg
Duke criteria for Dx of IE: Minor criteria (6 categories)
- Predisposition: heart cond or IVDU
- fever >38
- vascular phenomena: arterial emboli, pulmonary infarct, mycotic aneurysm, conjuntival hemorrhage, Janeway lesions
- Immunologic: GN, osler nodes, roth spots, RF +
- Micro evidence: + BlCx but doesn’t meet criteria
- echo findings - consistent but no meeting major criteria
Clinical syndromes consistent with IE presentation (6)
- mild and nonsp febrile illness
- ac HF
- focal neuro deficit with septic emboli to cerebral
- ams
- axial spine pain from OM
- pneumonia from septic emboli
Physical exam signs consistent with IE? (8)
CV:
- heart murmur
- splinter hemorrhage
-cardiac device pocket inflamm
Immune/deposition:
-janeway lesion or osler node
roth spot
GN
Anemia
Splenomegaly
Blood cultures - how to draw for IE:
at least 2 sets each containing 10cc of blood from separate site as and if possible separate by 1 hour at least
3 sets of blood cultures required in suspected PVE or cardiac device infection
Dx sens of TTE for IE
> 70%
Summary for indications of surgical tx for IE:
ao in mitra insuff w/ vent failure
valve perforation o rupture
perivalvular ext, abscess, fistula, assoc heart block
prosth valve dehisc
<10mm veg on ant mitral leaflet
recurrent embolization or persistent bacteremia on therapy
**TEE is now recommended after TTE in all cases, though this inva- sive modality will usually be performed after hospital admission. The value of point of care TTE, performed immediately by experienced emergency clinicians in the setting of suspected IE, has been demon- strated in numerous case reports, although its role has yet to be evalu- ated in a large study
Tx IE - general abx
vanco 20-35mg/kg actual BW loading then 15-20mg/kg q8-12h, not over 3g
If HACEK: ceftr 2g/day
get ID involved
usually 3-4 weeks
Prophylaxis for what procedure needed when consider IE?
dental AND cutaneous abscess drainage in following conditions:
prior hx IE
CHD - cyanotic or prior surgery
presence of prosthetic valve
Prophylaxis IE what? abx for high risk conditions
vanco 15mg/kg
Rheumatic fever: what age group is greatest risk?
y4-9
Acute rheumatic fever: what is this?
nonsuppurative complication of streptocooccal pharyngitis from exaggerated immune repsonse to GAS
Acute rheumatic fever: when does this occur after pharyngitis?
1-5 weeks
Acute rheumatic fever:defn of chorea
random rapid purposeless movements of extremities and face
Acute rheumatic fever: dx - what criteria (just name)
Jones
Acute rheumatic fever: Jones criteria major
Carditis (peri, myo, endo)
Polyarthritis of large joints
chorea
erythema marginatum
subcutaneous nodules
Acute rheumatic fever: minor criteria
Arthralgias
fever
incr CRP/ESR
Prolonged PR
Acute rheumatic fever: how to determine evidence of preceding strep infection
+ throat gulcture GAS or + rapidd strep
Elevated or rising anti streptolysin O titre
ARF: tx
penicillin oral: 250mg PO if <28kg, 500mg >/=28kg BID or TID x10d
IM: 600 000 units pen b if <28kg, >/=28kg: 1.2 million as one time dose
Once diagnosed with Acute rheumatic fever, how long to receive prophylactic abx?
penicillin
up to 10y
Most common cause of Mitral stenosis world wide vs developed country
rheumatic heart disease
older - calcification
Normal cross sectional area of MV orifice size?
4-6cm squared
What complications can you get from mitral stenosis?
afib mc
pulmonary htn, RVH, RV failure
Symptoms of early vs late mitral stenosis:
decreased ex tolerance
dyspnea on exertion
vs later:
orthopnea, peripheral edema
embolic events from afib
hemoptysis rupture of bronchial vein
hoarseness due to compression on recurr laryngeal n
Signs of mitral stenosis of PE
loud s1 and opening snap in early diastole, low pitch rumbling descrescendo diastolic murmur best heard at apex
CXR findings mitral stenosis
cephalization pulmonary vascularture or congestion
normal
LA enlargement
ECG findings of mitral stenosis
afib
LAE
RVH
Mitral stenosis diagnostic test?
TTE
Precipitants of worsening mitral stenosis
pregnancy
infection
hyperthyroidism
anemia
Treatment of mitral stenosis:
treat underlying precip
diuresis if overloaded
rate control and anticoag if aib present
surgery: perc and open approach
MC valvular disease world wide?
mitral regurg
Mitral regurg: causes of primary
degenerative disease
rheumatic heart disease
MVP in CTD
acute papillary muscle rupture/trauma
Mitral regurg: causes of secondary
LV enlargement
remodeling due to CAD or another cardiomyopathy
Mitral regurg: acute presnetation
sudden incr afterload with low compliance and incr LAP —> pulmonary vascular congestion
dyspnea
acute pu;monary edema
cardiogenic shock
Mitral regurg: chronic MR presentation
cardiomyopathy
progressive incr LA compliance, near normal LAP
Signs of acute MR:
harsh, high pitched midsystolic murmur loudest at apex
radiation to axilla
possible S3 and short diastolic rumble
Acute MR CXR
unilateral or bilateral pulmonary edema
Acute MR ECG
ischemia/infarction - q wave, t changes, LBBB
Mitral regurg acute: diagnostic test and management?
TTE emergently and RH cardiac cath (esp if papillary m rupture)
meantime: tx pulmonary edema with IV nitrates, diuretics, CPAP/bipap
NE if BP low –> if cont low then dobutamine
bridge to surgery: intraaortic balloon pump
Mitral regurg: chronic tx
ACEI/arb
beta blocker
diuretics
MVP: what is this?
abnormal mitral valve leaflet movement during systole (myxomatous proliferation of middle spongiosa layer of valve leaflet so they abnormally billow)
MVP: underlying disorder
often stand alone but can be:
marfan
ehlers danlos
MVP: complications
progressive MR
afib
heart failure
endocarditis
MVP: sx
asymp
palpitations
cp
dyspnea
lightheaded
fatigue
anxiety
MVP: signs
midsystolic click (chordae tendinae snap over top of prolapsed valve)
can have late to mid systolic murmur as well over LLSB
MVP: test?
echo
MVP: tx
edu
beta blocker for sx such as palpitations/cp/anxiety
avoidance of stim/life style
MC cause aortic stenosis?
calcific degeneration
Ao stenosis: causes
calcific degen
bicuspid ao valve
rheumatic heart disease
Ao stenosis - normal size valve?
3-4cm squared
Ao stenosis - how does this occur?
calcification, inflamm, oxidate stress and remodeling cause narrowing – get incr in LV afterload leading to LV hypertrophy to compensate to maintain CO
incr wall tension to incr risk of ischemia
can then get dysfunction, LAE and afib
can also lead to pHTN and RHFailure when really bad
Ao stenosis severe - definition?
peak velocity >/= 4m/s, mean pressure gradient >/=40mmhg or valve area <1cm squared
Ao stenosis - what sets pt off?
any mismatch between myocardial oxygen sypply and demand
Ao stenosis symptoms?
fatigue
exertional dyspnea
angina
lightheaded/syncope
Ao stenosis classic murmur?
cres-desc systolic murmur at RUSB radiating to carotids
maybe s4 at apex
caroitd pulse: parvus (diminished intensity) and tardus - slow
Ao stenosis ecg
LVH
lae, lad, lbbb, afib
Ao stenosis dx of severity?
echo
Ao stenosis considerations for surgery?
surgical risk
patient frailty and comorbidity
pt preference
high risk = balloon
Ao stenosis tx in Ed if decompensate?
fluid resus
blood transfusion
restore sinus rhymthm
phenylephrine or NE ifneed support
Ao stenosis AVOID what meds?
vasodilator
diuretic
inotropic agents
Aortic regurg: caused by ?
VALVE: disease of aortic leflets or disortion aortic root and ascending aorta:
calcifci degen
congenital bicuspid valve
IE
rheumatic heart disease
NONVALVULAR:
idiopathic, ctd, syphilis, aortic aneurysm, aortic dissection
Aortic regurg: pathophysiology sudden development:
increased LVEDP, reduced CO, then acute pulmonary vascular congestion
Aortic regurg: acute sx
resp distress
cardiogenic shock
Aortic regurg: signs
tachy
hypotensive
hypoxic
pulse pressure normal or wide
short soft diastolic murmur
Aortic regurg: cxr
pulmonary vascular congestion
ECG: Aortic regurg:
typically normal, can have demand ischemia
Aortic regurg: chronic AR pulse pressure?
wide
Aortic regurg: chronic AR - signs?
wide pp
pmi displaced, sustained
high pitched blowing diastolic murmur LLSB
water hammer/corrigan pulse, head bobbing
quinck’es
bruit over fem artery
Aortic regurg: chronic murmur name?
austin flint - soft mid diastolic rumble by regurgitant stream against anterior leaflet of MV
Aortic regurg: chronic cxr findings?
cardiomegaly
pulmonary congestion
Acute Aortic regurg: __ emergency tx
surgical
Aortic regurg: acute - medical stabilization?
SA vasodilators like nitroprusside, nicardipine and diuretics
if by ao dissection, beta blocker use
Prosthetic valve complications - 5
structure failure
valve thrombosis
systemic embolization
hemolysis
endocarditis
When do prosthetic valves tend to fail? (years)
10y - 20-30% fail biopros
Prosthetic valve complication: mech vs biologic which tends to thrombose more?
similar when appropro anticoag
Prosthetic valve thrombosis: signs on exam?
murmur - decr or absent valve click, new regurg murmur, louder than expected stenotic murmur
Prosthetic valve thrombosis tx
fibrinolysis
surg
Prosthetic valve systemic embolization risk?
1%/year
Prosthetic valve embolization risk - highest risk valve?
mitral >2x risk aortic
biopros = mechanical
Prosthetic valve hemolysis: worsening sx
dyspnea
fatigue
jaundice
Prosthetic valve staph PVE tx of IE?
vanco
consider add gent and rifampin
- What is the most common manifestation of acute rheumatic fever (ARF)?
a. Carditis
b. Chorea
c. Erythemamarginatum d. Polyarthritis
D
- A 49-year-old woman presents with progressive dyspnea on exer- tion and orthopnea. Vital signs are temperature 36.7°C (98.1°F; oral), heart rate, 110 beats/min, blood pressure, 135/80 mm Hg, respiratory rate, 22 breaths/min, and oxygen (O2) saturation, 97% on room air. The physical examination is remarkable for clear lung fields and an irregularly irregular rhythm with a 4/6 diastolic mur- mur in the left anterior axillary line. She has no peripheral edema. Which of the following would be appropriate hemodynamic man- agement of her cardiac pathophysiology?
a. Aggressivediuresis
b. β1-Agonist to increase chronotropy c. Betablocker
d. Selective arterial vasodilator
Answer: c. This patient has a picture consistent with atrial fibrilla- tion and mitral stenosis. The apical diastolic murmur and left atrial enlargement, along with progressive dyspnea, all support the diagnosis. Tachycardia is poorly tolerated because of the need for higher left atrial pressures and a longer time during diastole to perfuse across the ste- notic valve. Slow and full are appropriate goals. Diuresis might decrease venous return. Any agent producing tachycardia would decrease dias- tole time and left ventricular preload. An arterial vasodilator would have little effect, given the normal blood pressure and the fact that sys- temic vascular dilation would not be seen at the mitral valve level as long as the aortic valve was competent.
- A 32-year-old woman with a history of injection drug use presents with persistent fevers, night sweats, and shortness of breath. Vital signs are temperature 38.2°C (100.8°F; oral), heart rate, 123 beats/ min, blood pressure, 105/60 mm Hg, respiratory rate, 26 breaths/ min, and oxygen (O2) saturation, 93% on room air. The physical examination is remarkable for scattered rhonchi and a 2/6 systolic murmur in the left lower sternal border. Which of the following is the most appropriate antibiotic to start?
a. Clindamycin b. Vancomycin c. Ceftriaxone d. Cefepime
B
A 62-year-old man with presents 3 days after being admitted for an inferior ST-segment elevation myocardial infarction (STEMI). He underwent a successful percutaneous coronary intervention (PCI) and was just discharged earlier in the day. He developed sudden onset shortness of breath at home, and he arrives in extremis. Vital signs are temperature 37.2°C (98.8°F; oral), heart rate, 112 beats/ min, blood pressure, 85/68 mm Hg, respiratory rate, 24 breaths/ min, and oxygen (O2) saturation, 90% on room air. The physical examination is remarkable for severe respiratory distress, diffuse crackles, and a 2/6 systolic murmur in the left lower sternal border. Which of the following is the most appropriate intervention?
a. Give 2L of crystalloid over an hour.
b. Start dobutamine.
c. Initiation of dialysis for volume overload.
d. Initiate continuous positive airway pressure (CPAP) therapy.
Answer: d. This patient presents with likely acute mitral regurgitation (MR) from a papillary muscle rupture after an myocardial infarction (MI). Giving additional fluid will likely make his pulmonary edema worse. Starting dobutamine without a vasopressor while he is hypoten- sive could make the hypotension worse. When the diagnosis of acute MR is suspected, initial stabilization in the ED includes treatment of pulmonary edema with intravenous nitrates, diuretics, and noninva- sive positive pressure ventilation.
- A 38-year-old man with presents with progressive dyspnea over a day, starting 2 hours before arrival. Vital signs are temperature 38.9°C (102.0°F; oral), heart rate, 115 beats/min, blood pressure, 120/72 mm Hg, respiratory rate, 26 breaths/min, and oxygen (O2) saturation, 92% on room air. The physical examination is remark- able for diffuse crackles and a 2/6 systolic murmur in the left lower sternal border. His echocardiogram demonstrates a large, mass on the mitral valve with severe mitral regurgitation (MR). In addition to managing his pulmonary edema, which of the following is the most appropriate intervention?
a. Administer beta-blockade to reduce the risk of embolization. b. Consult Cardiac Surgery.
c. Start a heparin infusion.
d. Start digoxin for heart rate control.
Answer: b. Patients with suspected infectious endocarditis (IE) and acute heart failure require immediate consultation by a cardiothoracic surgeon. In general, there has been a shift toward earlier surgical treat- ment in IE, with approximately one-half of patients with left-sided infection undergoing surgery during the index admission. If possible, patients with left-sided IE should be managed by a multidisciplinary team at a center capable of cardiothoracic surgery. There is no role for addition of beta-blockade in this patient in heart failure. Heparin and digoxin are not indicated for IE.
Aortic stenosis: do I want them tachy or brady?
bradycardic
Mechanical mitral valves vs bileaflet mechanical aortic valves INR target
2.5-3 vs 2-3
