Cardiac infections Flashcards
What is endocarditis
infection of the endocardium
*generally regarding valve leaflets
What is the median age of diagnosis for endocarditis
58
Which gender is more commonly effected by endocarditis
men
How many people who have endocarditis also have underlying cardiac conditions
50-60%
What are the major complications of endocarditis
stroke
valve surgery
What is the pathophysiology of endocarditis
bacteremia and damage in the endothelium allow for bacterial vegetations
What are the causes of endocarditis
Sepsis
IVDU
Atherosclerosis
systemic disease
mechanical valve
rheumatic/congenital valve disease
Which patient population is at high risk for endocarditis
IVDU
HD
DM
HIV
immunosuppression
dental procedures
valvular heart disease
endaovascular hardware
Which side does endocarditis generally occur
typically left side of heart
***IVDU gets right side endocarditis
Why is the left side of the heart more prone to endocarditis
more pressure
more O2
Valvular disorders more common
What are the common organisms associated with endocarditis
Staph (usually acute endocarditis)
Strep
Enterococci
What symptoms do patients with endocarditis generally have
Fever
New / changing murmur
acute HF from regurge
What are ‘classic’ manifestations of endocarditis
Oslers nodes
Janeway lesion
splinter hemorrhage
Petechiae
Clubbing
Roth spots
What are Oslers nodes
painful red lesions on hands and feet
What are Janeway lesions
Non-tender, flat, small red lesions on hands and feet
What are splinter hemorrhages
capillary hemorrhages under fingernails
What are Roth spots
retinal hemorrhages with pale center
How do you workup endocarditis
blood cultures
echo
What is the number 1 cause of endocarditis
Staph aureus
how do you draw blood cultures for endocarditis
2-3 sets from 2 DIFFERENT locations
**4-6 bottles
SHOULD be collected BEFORE empiric abx
How do you treat endocarditis
Early infectious disease consult
Empiric abx (broad spectrum)
treat for 2-6 weeks
How to choose which abx to give for endocarditis
the valve type
most likely organism
local resistance pattern
What is the Duke criteria
Criteria used to diagnose endocarditis
2 major
1 major + 1 minor
5 minor
What are the major criteria in the duke criteria
positive blood cultures
evidence of endocardial involvement by echo
What are the minor criteria of endocarditis
Fever
predisposition
micro evidence
vascular phenomena
echo findings that don’t meet major criteria
What are the main antibiotics for endocarditis
Penicillin or subtype of pCN
Cefazolin / ceftriaxone
*occasionally need to add Gentamicin / vancomycin
If antibiotics don’t work, how do you treat endocarditis
Surgical consult
How can you prevent endocarditis
Prophylaxis prior to:
-significant dental work
-invasive respiratory procedures
-procedures w/ skin or MSK
What is the preferred prevention regimen for endocarditis
Amoxicillin 2g PO 1 hr before procedure
Ampicillin / ceftriaxone 2g IV
*If PCN allergy: Cephalexin, clindamycin, azithromycin
What is the peak age for rheumatic fever
5-15 years old
Which areas of the world are at higher risk for rheumatic fever
Developing countries
What is rheumatic fever a sequelae of
strep pharyngitis
-> beta hemolytic strep
*symtoms develop 2-3 weeks post pharyngitis
what is Jones criteria
The diagnostic criteria for rheumatic fever
What does JONES criteria stand for
Joints
Heart
Nodules
Erythema marginatum
Sydenham chorea
Why do we treat strep throat
To avoid rheumatic fever and the cardiac damage that can occur
What is Erythema marginatum
Rapidly enlarging ring or crescent shaped macule w/ central clearing
What do the subcutaneous nodules associated with rheumatic fever look like
Small, firm, non-tender nodules that adhere to underlying structures
Which valve is most commonly effected by rheumatic fever
Mitral
What kind of valvular damage can result from rheumatic fever
Stenosis
regurge
or both
How do you treat rheumatic heart disease
best treatment is prevention
*acute rheumatic fever (NSAIDs, PCN, +/- prednisone)
How do you prevent recurrent episodes of rheumatic fever
PCN prophylaxis (IM every 4 weeks)
When is the highest risk period for rheumatic heart disease
Within 5 years post initial ARF episodes
What is myocarditis
inflammation of the myocardium
Which patient population is at highest risk for myocarditis
Kids
pregnant females
immunosuppressed
What agents cause infectious myocarditis
Viral is most common
- occasionally a post viral immune response
How will myocarditis present
Flu like illness that persists for 7-14 days
-dyspnea
-chest pain
-arrythmias
-tachycardia
-hypotension
What is a major complication of myocarditis in kids
sudden cardiac arrest
What might be seen on exam with myocarditis
S3
S4 Rales
Tachycardia
What is the gold standard for dx of myocarditis
cardiac muscle bx
How is nuclear imaging useful with myocarditis dx
it can give the degree of damage
How do you acutely treat myocarditis
IV / O2
Tx of arrythmias
Tx of HF
How do you treat subacute myocarditis
avoid NSAIDs
Avoid cardiotoxic agents
if severe - > refer to cardiology
if mild -> recover over several months
What is pericarditis
inflammation of the pericardium
If pericarditis is infectious, what is the common cause
viral
If pericarditis is non-infectious, what is the common cause
autoimmune
What is Dressler’s syndrome
Post - MI pericarditis
What is the classic presentation of pericarditis
Fever
Sharp, retrosternal chest pain
Pleuritic chest pain
Pericardial rub on auscultation
Kussmauls sing
What is kussmauls sign
Elevated JVP with inspiration
When are symptoms of pericarditis worse
When laying down
With inspiration
What are classic EKG findings with pericarditis
Diffuse ST elevations in limb / precordial leads
Diffuse PR depression in limb / precordial leads
Reciprocal ST depression and PR elevation in aVR +/- VI
How do you treat pericarditis
Treat underlying cause
Activity restriction until asymptomatic or until CRP normalizes
What is the first line medication treatment of pericarditis
High dose NSAID (or ASA) AND Colchicine
*prednisone is second line
What is pericardial effusion
Build up of fluid in the pericardial space (between pericardium and heart)
When does pericardial effusion turn into pericardial tamponade
pressure gets above 15mmHg
-causes restriction of venous return and ventricular filling
What else besides effusion can cause tamponade
hemorrhage
What is the number one cause of pericardial effusion
Viral
*often secondary to viral pericarditis
How does pericardial effusion present
acute effusion (lower volumes)
Chronic (higher volumes)
-dyspnea /cough/ edema/ fatigue / tachycardia
What will be seen on physical exam with pericardial effusion
Pericardial friction rub
What will be seen on physical exam with cardiac tamponade
Becks triad
pulses paradoxus
tachycardia / tachypnea
cool / clammy extremities
What is Becks triad
Hypotension
JVD
Muffled heart sounds
What is pathognomonic for pericardial effusion / tamponade
electrical alternans
*alternating height of QRS (heart swinging in pericardial sac)
How do you workup pericardial effusion and tamponade
Echo (best for dx)
pericardiocentesis (diagnostic and therapeutic)
If effusion is persistent/ recurrent/ very large how do you treat the patient
pericardial window
