Cardio: Infective Endocarditis, Myocardial, Pericardial Disease Flashcards
Define Infective Endocarditis
Infection of the lining of the heart
What is non-infective Endocarditis [2] and what causes it [5]?
Non-Bacterial Thrombotic Endocarditis [1]
The formation of a sterile Fibrin-platelet vegetation due to some disruption of the valve endothelium. [1]
- Turbulent Flow
- Electrodes/Catheters
- Rheumatic Carditis
- Degenerative Disease
- Local inflammation
How do we classify cases of endocarditis [3]
Acute/Subacute/Chronic pattern
Causative organism
If prosthetic is it early or late? (<1yr or >1yr)
How can Infective endocarditis be acquired? [4]
- IVDA
- Community Acquired
- Nosocomial
- Healthcare Related but Non-Nosocomial
How do the IE organisms reach the circulation? [3]
From Extra Cardiac Infection
- Invasive Procedures
- Gingival Disease
- Daily livinig (e.g. brushing teeth & defecating)
What are the risk factors for IE? [7]
Male (though women have worse prognosis) Elderly Recent invasive procedures IVDA Prosthetic Valves Any Heart Defect/Disease Immunocompromised
Name 3 main symptoms and 4 others
FEVER - MALAISE - FATIGUE
also chills - arthralgia - weight loss - headache
What are the clinical signs of IE?
General [6]
Vascular [3]
Immunological [3]
General:
CHF - New Murmur - Splenomegaly - Emboli - Anaemia
Vascular: Janeway Lesions (blood seeped into palms/soles) Splinter Haemorrhages Vasculitic Rash (feet, purple/red spots from burst capillaries)
Immunological:
Roth Spots (Retinal Haemorrhage)
Osler’s Nodes (Red raised painful spots of fingers, palms & soles)
Nephritis
When could the clinical signs be absent from IE? [3]
In the elderly, immunocompromised or post antibiotic treatment
What does the mnemonic FROM JANE stand for?
- Fever
- Roth Spots
- Oslers Nodes
- Malaise
- Janeway Lesions
- Anaemia
- Nephritis & Nail haemorrhages
- Emboli
What investigations are done on a suspected IE case? [7]
FBC(neutrophilia)/CRP/ESR U + Es Blood Cultures Urinalysis ECG CXR ECHO
What are we looking for an ECG? [2]
A conduction delay caused by IE forming an abscess over part of the bundle of his or purkinje fibres. [1]
Wide QRS [1]
What shows up on a CXR in IE? [2]
Heart Failure and Pulmonary Abscesses
Cardiomegaly
What kind of ECHO do we use for Infective Endocarditis?
What do you do if TTE is negative but clinical suspicion is high?
A Trans-Thoracic Echo (TTE) is 1st line, TOE is 2nd line
TOE is used if TTE is -ve but your still suspicious OR if TTE is +ve for a better view of abscess/vegetation/complications
What do we do if both TTE & TOE are -ve but we’re still suspicious of IE? [1]
Repeat them 7-10 days later or earlier if theres a new complication
How many blood cultures do we take for IE? [1]
How would this change if they’re in septic shock? [1]
3 from different sites with 6 hours between them
Or if they’re in septic shock then just 2 from different sites with 1 hour between them.
In a patient with IE, what can cause false negative picture in blood cultures? [3]
- Recent antibiotics
- Fastidious Organisms have different diets so wont grow on blood culture (Nutritionally varied Strep - HACEK gram -ve bacilli - Brucella - Fungi)
- Nor would Intracellular Bacteria (Coxiella Burnetii - Bartonella - Chlamydia)
What are the common complications of IE? [6]
- Heart Failure, Atrioventricular Heart Block
- Fistula Formation
- Leaflet Perforation
- Uncontrolled Infection, Abscess Formation
- Embolism
- Prosthetic valve endocarditis (PVE) & PV dysfunction
What criteria are needed to have a sure diagnosis of IE? [3]
Definite diagnosis with:
2 Major
1M + 3m
5m
of the Modified Duke Criteria
What are the Major Duke criteria? [5]
- IE causing organisms in 2 seperate blood cultures
- IE organisms found in persistant blood cultures
- +ve blood culture for Coxiella Burnetii
- +ve ECHO
- New Murmur
What are the minor Duke Criteria? [5]
- Predisposition (IVDA or Heart Condition)
- Fever
- Vascular Signs
- Immunologic Signs
- Microbiological evidence that doesnt meet the major duke critera (serology or blood culture)
Name 3 top micro-organisms implicated in IE
- Staphylococcus aureus
- Streptococcus viridans
- coagulase-negative Staphylococci such as Staphylococcus epidermidis
How do we empirically treat IE? (ie before the blood cultures come back) [3]
We use 2 IV antibiotics at once, AFTER the bloods are taken. [1]
Standard is Amoxicillin + low dose gentamicin
What do we use to empirically treat IE if the patient is severely septic, allergic to penicillin or infected with MRSA? [2]
Antibiotic if gram-negative suspected?
Vancomycin (replacing the amoxicillin) + low dose gentamicin
Gram negative: Meropenum and vancomycin
Antibiotic regimen
* Native valve endocarditis caused by staphylococci
* Prosthetic valve endocarditis caused by staphylococci
- Flucloxacillin
- Flucloxacillin + rifampicin + low-dose gentamicin
When do we use surgery as well as antibiotics?
The complications are indicators surgery is now necessary
How do we treat fungal IE? [2]
In what patients does Fungal IE occur?
With dual antifungals, often for life. And usually valve replacement too.
In PVE/IVDA/immunocompromised patients.
When is amoxicillin replaced with vancomycin in empirical IE treatment? [3]
If the patient has severe sepsis, is allergic to penicillin or has MRSA
What is the HACEK group of organisms [6]
All gram-negative [1]
Haemophilus influenza Actinobacillus Cardiobacterium Eikenella Kingella
Streptococcus viridans - associated with one risk factor
they are both commonly found in the mouth and in particular dental plaque so endocarditis caused by these organisms is linked with poor dental hygiene or following a dental procedure
Risk factor: coagulase-negative Staphylococci such as Staphylococcus epidermidis
commonly colonize indwelling lines and are the most cause of endocarditis in patients following prosthetic valve surgery, usually the result of perioperative contamination.
Streptococcus bovis - risk factor
associated with colorectal cancer
What is myocarditis [1]
Inflammation of the heart muscle
What causes myocarditis? [5]
Infection (Coxsackie virus, fungal, bacterial or parasitic)
Cocaine
Chemo & other drugs
Autoimmune e.g. rheumatic fever and SLE, sarcoid
Idiopathic 50%
How does myocarditis present? [5]
- Prodrome - days to weeks
- Palpitations caused by sinus, tachy, vent extrasystole, VT, VF
- Chest pain mimics angina
- SOBOE from sudden heart failure
- Syncope
Investigations [3]
Bloods - troponin
ECG - AV block, bundle branch block, Q waves, ST depression, TWI.
ECHO
Encomyocardial biopsy
How do we treat myocarditis? [4]
Mostly its self limiting
Exclude reversible causes like MI
In-patient monitoring
Immunosuppressant drugs - steroids, azathioprine, interferon B
Causative organisms
Virus [7]
Bacterial [9]
Protozoa
Virus:
flu, hepatitis, mumps, rubella, coxsackie, polio, HIV
Bacterial
clostridium, diphtheria, TB, tetanus, meningococci, mycoplasma, brucellosis, psittacosis, spirochetes
Protozoa: Chagas
Drugs that cause myocarditis [4]
Cyclophosphamide, Herceptin
Penicillin, chloramphenicol sulphonamides
Methyldopa, spironolactone
Phenytoin, carbamazepine
Signs on cardiac examination [3]
Tachycardia
Soft 1 murmur
S4 gallop
What are the 3 types of cardiomyopathy?
Restrictive - Stiffening of Myocardium
Hypertrophic - hypertrophy of myocardium
Dilated - Dilation of ventricles
What causes DCM? [4] What is the most common cause
Complication and prognosis?
- Genetics e.g. Muscular Dystrophy
- Doxorubicin/alcohol/chemicals
- Coxsackie B virus
- Idiopathic*
Cx: sudden cardiac death
Pro: 40% mortality in 2y
How does DCM present?
Symptoms [6]
Signs [8]
- Fatigue
- Dyspnoea/Orthopnea/PND
- Peripheral edema
- Cough
- LHF: Weak Pulses, pleural effusion
- RHF: Raised JVP, Ascites, jaundice, hepatomegaly
- Tachycardia, hypotension
- S3 gallop, mitral/tricuspid regurg
- Displaced apex beat
DCM investigations and results
4 first line
2 others
- Bloods: FBC, U&E and creatinine (low Na+ indicates poor prognosis), LFT, BNP confirms HF
- ECG: tachycardia, non-specific T wave changes, poor R wave progression, LVH. LBBB
- Echo: dilated hypokinetic heart with low ejection fraction (may have MR, TR or mural thrombus)
- CXR - Pulm congestion + Cardiomegaly
Cardiac MRI
Endomyocardial biopsy - Visibally stretched fibres
How do we treat DCM? [6]
Bed rest Diuretics, ACEi, BB (reduce strain) Digoxin (increase contractility) Warfarin (reduce thrombus risk) Biventricular pacing, ICD Heart transplant
What causes RCM? [7]
Amyloidosis Sarcoidosis Haemochromatosis Fibrosis - MI, drugs, radiation, idiopathic Genetic mutations causing familial Diabetes Loffler's endocarditis
How does RCM present? [5]
Symptoms are similar to constrictive pericarditis, SOB, fatigue
Right ventricular failure predominates
- Cough, Chest Pain
- Oedema, Ascites, Hepatomegaly
- Raised JVP
- Tachycardia
- Audible S3/4
How do we test for RCM? [6] which one is gold standard
*Right ventricular biopsy: gold standard with +ve Congo red staining, may show sarcoidosis, amyloidosis
Serum Fe (Haemochromatosis)
ECHO - biatrial enlargement and patchy fibrosis from infiltrative disease
MRI (ddx from constrictive pericarditis)
CXR (pulm congestion + normal heart size)
ECG (AF)
Note: normal heart size and normal ejection fraction in ECHO
How do we treat RCM? Treat the cause Rx 3 Devices 1 Definitive treatment 1
Rx
- Warfarin (AF)
- B-blockers - ACEI - Diuretic -> Reduce strain on heart
- Amiodarone (arrhythmia’s)
ICD
Heart Transplant
What is THE cause of HCM? [3]
Pathogenesis [3]
Familial hypertrophic cardiomyopathy
Autosomal dominant
Strong genetic components
Leading cause of sudden cardiac death in the young
Missense mutations [1] of beta-myosin chains [1] which affect sarcomeric proteins [1]
How does HCM present?
Symptoms [7]
Signs [5]
Asymptomatic until the valve is occluded or the heart cant pump enough blood anymore:
- Fatigue
- Chest Pain, angina
- Dyspnoea
- Palpitations
- Tachycardia
- Presyncope
- Exertional Arrythmias
- Notched/bifid Pulse
- Raised JVP
- Audible S4
- Double apex beat
- Systolic ejection murmur worse on valsalva
How do we test for HCM?
6 investigations
ECG ECHO CXR Cardiac catheterisation (MR) Exercise testing with respiratory gas mask (risk stratification) Genetic Testing Biopsy - myocyte dissaray
How do we treat HCM? Rx 4 Lifestyle modification 1 Devices 1 Surgical methods 3
Lifestyle mods: reduce exercise/stress
Rx:
Warfarin + Beta blockers (reduce contractility)
Verapamil
Amiodarone
Devices: Dual chamber pacing (ICD)
Surgical: 1. Septal myomectomy/ablation (reduces outflow gradient) 2. Surgical mitral repair 3. Heart transplant
What should we see on ECG for HCM? [4]
LVH Progressive T wave inversion Deep Q waves (inferior and lateral leads) AF, WPW Ventricular ectopic, VT
What would we see on ECHO for HCM? [4]
- asymmetrical septal hypertrophy
- non-dilated small LV cavity with hyper contractile posterior wall
- mid-systolic closure of aortic valve
- systolic anterior movement of mitral valve
Arrhythmogenic right ventricular dysplasia Ax Pathophys Symptoms [3] Sign
- AD mutation in genes coding for desmosome components
Patho: right ventricular myocardium replaced with fatty and fibro-fatty tissue
Sy: palpitations, syncope, sudden cardiac death
Late sign is RHF
Arrhythmogenic right ventricular dysplasia
Mx
Sequelae
Soltalol Catheter ablation ICD Manage HF Seq: SCD
Cardiac myxoma
Ep
Ax
Pathophys
Ep: F>M
Ax: benign cardiac tumour that is usually sporadic but can be familial (Carney complex)
Px: 75% in left atrium, usually attached to fossa ovalis
Cardiac myxoma
Symptoms [5]
Signs [5]
Mimics [2]
Sy:
- SOB, fatigue, weight loss, palpitations, PUO
Si:
- irregular pulse (AF), finger clubbing, emboli, mid-diastolic murmur and “tumour plop”
mimics IE and mitral stenosis
Cardiac myxoma
Investigations
Management
Ix:
- ECG (AF)
- echo (pedunculated heterogeneous mass attached to fossa ovalis region of interatrial septa)
Mx: surgical excision
What is the difference between acute pericarditis, Constrictive Pericarditis and Cardiac Tamponade?
Acute pericarditis = Inflammation of the pericardium
Constrictive Pericarditis = Fibrosing of the pericardium leading to the heart being encased in a rigid sac
Cardiac Tamponade = Increase in pericardial fluid -> Increase in intrapericardial pressure -> Lower ventricle filling and reduced Cardiac Output
What causes acute pericarditis? [4]
List 2 types of infective causes
List 3 auto-immune causes of pericarditis
MI
Neoplastic
Radiation
Myxoedema
Infective
- Viral
- Bacterial eg TB
Autoimmune
- RA, SLE
- Scleroderma
- Dressler’s syndrome
How does acute pericarditis present? [4]
Central Chest Pain [1] eased by leaning forward [1]
Pericardial Rub
~ Fever
Acute pericarditis investigations [5]
When do we decide to admit?
- ECG - Saddle shaped (concave) ST elevation
- CXR - May show a pericardial effusion (follow with ECHO)
- Bloods - FBC, ESR, U+E, Cardiac enzymes e.g. troponin
- Blood cultures & Viral Serology
the majority of patients can be managed as outpatients
patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient
How do we treat acute pericarditis? [2]
- strenuous physical activity should be avoided until symptom resolution and normalisation of inflammatory markers
- a combination of NSAIDs and colchicine for idiopathic or viral pericarditis
What causes constrictive pericarditis? [3]
Often unkown - TB - Post-pericarditis
How does constrictive pericarditis present?
Symptoms [3]
Signs [3]
Fatigue - Dyspnoea - weakness - Peripheral Oedema (symptoms of RHF) Raised JVP on inspiration (Kussmaul's signs) - Ascites (abdominal swelling) - quiet heart sounds
How do we test for constrictive pericarditis? [4]
ECG - low voltage complexes
CXR = May see small heart and calcification
CT/MRI - IF CXR unclear
ECHO
Cardiac Catheterization
How do we treat constrictive pericarditis? [1]
Surgical Excision
What causes cardiac tamponade? [3]
Any pericarditis
Aortic Dissection
Warfarin
How does cardiac tamponade present?
Symptoms [4]
Signs [3]
Cardiogenic Shock:
- Dizziness
- Weakness/collapse
- Dyspnoea, Cough
- Central Chest Pain
Becks Triad: - muffled Heart Sounds - Raised JVP - drop in BP, increase HR Pulsus paradoxus Kussmaul breathing
How do we diagnose Cardiac Tamponade? [4]
Describe what you might see that would confirm the diagnosis
CXR: Over 250ml will show a big globular heart
ECG: Low voltage QRS complexes, QRS alternans
ECHO: Larger pericardium +/- collapsed ventricles (mainly right heart in diastole)
Aspirate some fluid and send for M,C & S
How do we treat Cardiac Tamponade? [4]
Treat the cause
URGENT drainage of the fluid (pericardiocentesis
Percutaneous balloon pericardiotomy
Pericardial resection
Restrictive cardiomyopathy
- amyloidosis (e.g. secondary to myeloma) - most common cause in UK
- haemochromatosis
- post-radiation fibrosis
- Loffler’s syndrome: endomyocardial fibrosis with a prominent eosinophilic infiltrate
- endocardial fibroelastosis: thick fibroelastic tissue forms in the endocardium; most commonly seen in young children
- sarcoidosis
- scleroderma
What features suggest restrictive cardiomyopathy rather than constrictive pericarditis
- prominent apical pulse
- absence of pericardial calcification on CXR
- the heart may be enlarged
- ECG abnormalities e.g. bundle branch block, Q waves
