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Rosens > 69. Infective endocardiditis and Valvulopathy > Flashcards

69. Infective endocardiditis and Valvulopathy Flashcards

1
Q

What is infective endocarditis?

A

infection of native or prosthetic heart valve, endocardium or inwelling cardiac device

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2
Q

90 day mortality from IE?

A

25%

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3
Q

Predictors of poor outcomes of IE

A

older
comorbidities
staph infection
HF
perivalvular extension

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4
Q

2 Predictors of improved outcomes of IE

A

strep infection
isolated RS infection

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5
Q

What kind of background physiology does IE require?

A

predisposing valve dusfunction (occulr degenerative disease, bicuspid valve), endothelial damage ofr prosthetic material to get plt-fibrin thrombus which is then seeded with materials

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6
Q

Higher risk CHD infections for IE?

A

cyanotic
reapired lesions with prosthetic material, shunt, valve regurg

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7
Q

IVDU with IE - r or L sided lesion mc?

A

r

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8
Q

When is highest risk for prosthetic valve endocarditis?

A

6mo post surg

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9
Q

Prosthetic valve - what is highest risk valve/side?

A

RS - tricuspid

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10
Q

7 high risk populations and predisposing conditions for IE?

A

prior hx of IE
chd
IVDU
prosthetic heart valve
ICD - PM, defib
hemodialysis
recent hospitalization with central or LT IV access

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11
Q

Implicated sources (other than IVDU) for pt with bacteremia causing IVDU?

A

poor dentition
dental procedures
cystoscopy
lt lines

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12
Q

MC overall bug causing IE?

A

staph aureus

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13
Q

Leading etiology of IE in developing countries

A

streptococcus

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14
Q

GI malignancy IE bug?

A

strep bovis

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15
Q

PVE and native valve infection - what bug can cause this in elderly and debilitated pt?

A

enterococcus faecalis

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16
Q

15% of IE caused by HACEK group - what are these?

A

haemophilius
aggregatibacter actinomycetemcmonitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae

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17
Q

what zoonotic etiologies can cause endocarditis?

A

coxiella burnetii (q fever)
brucella
bartonella

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18
Q

fungal endocarditiis causes in pt with prosthetic valves, IDU, immunocompromised states

A

candida
aspergillus

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19
Q

Highest risk valve for clinical heart failure when effected by IE?

A

aortic as can get aortic insufficiency

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20
Q

Complications of infective endocarditis

A

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

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21
Q

Duke criteria for Dx of IE:
Definite endocarditis:

A

2 major clinical
1 major and any 3 minor
5 minor clinical

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22
Q

Duke criteria for Dx of IE: Possible endocarditis

A

one major, and one or two minor clinical

3 minor

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23
Q

Duke criteria for Dx of IE: Major criteria

A

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

  1. Evidence of endocardial involvement by echo: pendulum like veg on valve endocardium
    paravalvular abscess
    prosthetic valve dehisc
    new valve regurg
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24
Q

Duke criteria for Dx of IE: Minor criteria (6 categories)

A
  1. Predisposition: heart cond or IVDU
  2. fever >38
  3. vascular phenomena: arterial emboli, pulmonary infarct, mycotic aneurysm, conjuntival hemorrhage, Janeway lesions
  4. Immunologic: GN, osler nodes, roth spots, RF +
  5. Micro evidence: + BlCx but doesn’t meet criteria
  6. echo findings - consistent but no meeting major criteria
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25
Q

Clinical syndromes consistent with IE presentation (6)

A
  1. mild and nonsp febrile illness
  2. ac HF
  3. focal neuro deficit with septic emboli to cerebral
  4. ams
  5. axial spine pain from OM
  6. pneumonia from septic emboli
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26
Q

Physical exam signs consistent with IE? (8)

A

CV:
- heart murmur
- splinter hemorrhage
-cardiac device pocket inflamm

Immune/deposition:
-janeway lesion or osler node
roth spot
GN

Anemia

Splenomegaly

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27
Q

Blood cultures - how to draw for IE:

A

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

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28
Q

Dx sens of TTE for IE

A

> 70%

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29
Q

Summary for indications of surgical tx for IE:

A

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

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30
Q

**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

A
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31
Q

Tx IE - general abx

A

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

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32
Q

Prophylaxis for what procedure needed when consider IE?

A

dental AND cutaneous abscess drainage in following conditions:

prior hx IE
CHD - cyanotic or prior surgery
presence of prosthetic valve

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33
Q

Prophylaxis IE what? abx for high risk conditions

A

vanco 15mg/kg

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34
Q

Rheumatic fever: what age group is greatest risk?

A

y4-9

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35
Q

Acute rheumatic fever: what is this?

A

nonsuppurative complication of streptocooccal pharyngitis from exaggerated immune repsonse to GAS

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36
Q

Acute rheumatic fever: when does this occur after pharyngitis?

A

1-5 weeks

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37
Q

Acute rheumatic fever:defn of chorea

A

random rapid purposeless movements of extremities and face

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38
Q

Acute rheumatic fever: dx - what criteria (just name)

A

Jones

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39
Q

Acute rheumatic fever: Jones criteria major

A

Carditis (peri, myo, endo)
Polyarthritis of large joints
chorea
erythema marginatum
subcutaneous nodules

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40
Q

Acute rheumatic fever: minor criteria

A

Arthralgias
fever
incr CRP/ESR
Prolonged PR

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41
Q

Acute rheumatic fever: how to determine evidence of preceding strep infection

A

+ throat gulcture GAS or + rapidd strep
Elevated or rising anti streptolysin O titre

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42
Q

ARF: tx

A

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

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43
Q

Once diagnosed with Acute rheumatic fever, how long to receive prophylactic abx?

A

penicillin
up to 10y

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44
Q

Most common cause of Mitral stenosis world wide vs developed country

A

rheumatic heart disease

older - calcification

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45
Q

Normal cross sectional area of MV orifice size?

A

4-6cm squared

46
Q

What complications can you get from mitral stenosis?

A

afib mc

pulmonary htn, RVH, RV failure

47
Q

Symptoms of early vs late mitral stenosis:

A

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

48
Q

Signs of mitral stenosis of PE

A

loud s1 and opening snap in early diastole, low pitch rumbling descrescendo diastolic murmur best heard at apex

49
Q

CXR findings mitral stenosis

A

cephalization pulmonary vascularture or congestion

normal

LA enlargement

50
Q

ECG findings of mitral stenosis

A

afib
LAE
RVH

51
Q

Mitral stenosis diagnostic test?

A

TTE

52
Q

Precipitants of worsening mitral stenosis

A

pregnancy
infection
hyperthyroidism
anemia

53
Q

Treatment of mitral stenosis:

A

treat underlying precip
diuresis if overloaded
rate control and anticoag if aib present

surgery: perc and open approach

54
Q

MC valvular disease world wide?

A

mitral regurg

55
Q

Mitral regurg: causes of primary

A

degenerative disease
rheumatic heart disease
MVP in CTD
acute papillary muscle rupture/trauma

56
Q

Mitral regurg: causes of secondary

A

LV enlargement
remodeling due to CAD or another cardiomyopathy

57
Q

Mitral regurg: acute presnetation

A

sudden incr afterload with low compliance and incr LAP —> pulmonary vascular congestion

dyspnea
acute pu;monary edema
cardiogenic shock

58
Q

Mitral regurg: chronic MR presentation

A

cardiomyopathy
progressive incr LA compliance, near normal LAP

59
Q

Signs of acute MR:

A

harsh, high pitched midsystolic murmur loudest at apex
radiation to axilla

possible S3 and short diastolic rumble

60
Q

Acute MR CXR

A

unilateral or bilateral pulmonary edema

61
Q

Acute MR ECG

A

ischemia/infarction - q wave, t changes, LBBB

62
Q

Mitral regurg acute: diagnostic test and management?

A

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

63
Q

Mitral regurg: chronic tx

A

ACEI/arb
beta blocker
diuretics

64
Q

MVP: what is this?

A

abnormal mitral valve leaflet movement during systole (myxomatous proliferation of middle spongiosa layer of valve leaflet so they abnormally billow)

65
Q

MVP: underlying disorder

A

often stand alone but can be:

marfan
ehlers danlos

66
Q

MVP: complications

A

progressive MR
afib
heart failure
endocarditis

67
Q

MVP: sx

A

asymp
palpitations
cp
dyspnea
lightheaded
fatigue
anxiety

68
Q

MVP: signs

A

midsystolic click (chordae tendinae snap over top of prolapsed valve)

can have late to mid systolic murmur as well over LLSB

69
Q

MVP: test?

A

echo

70
Q

MVP: tx

A

edu
beta blocker for sx such as palpitations/cp/anxiety
avoidance of stim/life style

71
Q

MC cause aortic stenosis?

A

calcific degeneration

72
Q

Ao stenosis: causes

A

calcific degen
bicuspid ao valve
rheumatic heart disease

73
Q

Ao stenosis - normal size valve?

A

3-4cm squared

74
Q

Ao stenosis - how does this occur?

A

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

75
Q

Ao stenosis severe - definition?

A

peak velocity >/= 4m/s, mean pressure gradient >/=40mmhg or valve area <1cm squared

76
Q

Ao stenosis - what sets pt off?

A

any mismatch between myocardial oxygen sypply and demand

77
Q

Ao stenosis symptoms?

A

fatigue
exertional dyspnea
angina
lightheaded/syncope

78
Q

Ao stenosis classic murmur?

A

cres-desc systolic murmur at RUSB radiating to carotids

maybe s4 at apex

caroitd pulse: parvus (diminished intensity) and tardus - slow

79
Q

Ao stenosis ecg

A

LVH

lae, lad, lbbb, afib

80
Q

Ao stenosis dx of severity?

A

echo

81
Q

Ao stenosis considerations for surgery?

A

surgical risk
patient frailty and comorbidity
pt preference

high risk = balloon

82
Q

Ao stenosis tx in Ed if decompensate?

A

fluid resus
blood transfusion
restore sinus rhymthm

phenylephrine or NE ifneed support

83
Q

Ao stenosis AVOID what meds?

A

vasodilator
diuretic
inotropic agents

84
Q

Aortic regurg: caused by ?

A

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

85
Q

Aortic regurg: pathophysiology sudden development:

A

increased LVEDP, reduced CO, then acute pulmonary vascular congestion

86
Q

Aortic regurg: acute sx

A

resp distress
cardiogenic shock

87
Q

Aortic regurg: signs

A

tachy
hypotensive
hypoxic
pulse pressure normal or wide

short soft diastolic murmur

88
Q

Aortic regurg: cxr

A

pulmonary vascular congestion

89
Q

ECG: Aortic regurg:

A

typically normal, can have demand ischemia

90
Q

Aortic regurg: chronic AR pulse pressure?

A

wide

91
Q

Aortic regurg: chronic AR - signs?

A

wide pp
pmi displaced, sustained

high pitched blowing diastolic murmur LLSB

water hammer/corrigan pulse, head bobbing
quinck’es
bruit over fem artery

92
Q

Aortic regurg: chronic murmur name?

A

austin flint - soft mid diastolic rumble by regurgitant stream against anterior leaflet of MV

93
Q

Aortic regurg: chronic cxr findings?

A

cardiomegaly
pulmonary congestion

94
Q

Acute Aortic regurg: __ emergency tx

A

surgical

95
Q

Aortic regurg: acute - medical stabilization?

A

SA vasodilators like nitroprusside, nicardipine and diuretics

if by ao dissection, beta blocker use

96
Q

Prosthetic valve complications - 5

A

structure failure
valve thrombosis
systemic embolization
hemolysis
endocarditis

97
Q

When do prosthetic valves tend to fail? (years)

A

10y - 20-30% fail biopros

98
Q

Prosthetic valve complication: mech vs biologic which tends to thrombose more?

A

similar when appropro anticoag

99
Q

Prosthetic valve thrombosis: signs on exam?

A

murmur - decr or absent valve click, new regurg murmur, louder than expected stenotic murmur

100
Q

Prosthetic valve thrombosis tx

A

fibrinolysis
surg

101
Q

Prosthetic valve systemic embolization risk?

A

1%/year

102
Q

Prosthetic valve embolization risk - highest risk valve?

A

mitral >2x risk aortic
biopros = mechanical

103
Q

Prosthetic valve hemolysis: worsening sx

A

dyspnea
fatigue
jaundice

104
Q

Prosthetic valve staph PVE tx of IE?

A

vanco
consider add gent and rifampin

105
Q
  1. What is the most common manifestation of acute rheumatic fever (ARF)?
    a. Carditis
    b. Chorea
    c. Erythemamarginatum d. Polyarthritis
A

D

106
Q
  1. 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
A

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.

107
Q
  1. 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
A

B

108
Q

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.

A

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.

109
Q
  1. 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.
A

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.

110
Q

Aortic stenosis: do I want them tachy or brady?

A

bradycardic

111
Q

Mechanical mitral valves vs bileaflet mechanical aortic valves INR target

A

2.5-3 vs 2-3

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