Cardiology #2 (Endocarditis, Pericarditis)

Question 1

What is the MC valve affected with endocarditis?

Answer 1

Mitral

Question 2

However, if the patient has a history of IVDU, the MC valve affected is

Answer 2

Tricuspid

Question 3

Risk factors for endocarditis

Answer 3

• Increased age
• IVDU
• rheumatic heart disease
• immunosuppression
• prosthetic heart valves
• Congenital heart disease

Question 4

What is acute bacterial endocarditis and what is the main cause?

Answer 4

• Infection of normal valves with a virulent organism

- Staph Aureus

Question 5

What is subacute bacterial endocarditis and what is the main cause?

Answer 5

• Infection of abnormal valves with less virulent organism

- Strep Viridans

Question 6

IV-drug related endocarditis is MC due to which organism?

Answer 6

Staph Aureus (especially MRSA)

Question 7

If the patient has prosthetic valve endocarditis, and the infection occurs early (within 60 days of the operation), what is the MC organism involved?

Answer 7

Staph Epidermis

Question 8

Which organism of endocarditis is associated with poor dentition or dental procedures?

Answer 8

Strep Viridans

Question 9

What organisms should be suspected with endocarditis in patients with endocarditis and negative blood cultures?

Answer 9

HACEK organisms

Haemophilus aphrophils
Actinobacillus
Cardiobacteirum hominis
Eikenella corodens
Kingella kingae

Question 10

What organism with endocarditis is associated with men > 50 years old with recent history of GI or GU procedure?

Answer 10

Enterococcus

Question 11

In patients with colon cancer or ulcerative colitis, this organism is more prominent with endocarditis

Answer 11

Strep Bovis

Question 12

Symptoms of endocarditis (7)

Answer 12

• Generalized constitutional symptoms (persistent fever MC)
• New onset murmur or worsening of existing murmur
• Osler nodes: painful or tender raised violaceous nodules on pads of digits and palms
• Janeway lesions: painless macules on palms and soles
• Splinter hemorrhages: linear brown lesions under nail beds
• Roth spots: retinal hemorrhages with central clearing
• Splenomegaly, glomerulonephritis

Question 13

Diagnostic studies for endocarditis

Answer 13

• Blood cultures (before ABX initiation): 3 sets at least 1 hour apart
• ECG: at regular intervals (patient prone to arrhythmias)
• Echocardiogram: TEE much more sensitive than TTE
• Labs: Increased ESR/RF

Question 14

What are the 2 MAJOR Duke criteria for endocarditis?

Answer 14

• Sustained Bacteremia: 2 + blood cultures by organism known to cause endocarditis
• Endocardial Involvement: either + endocardiogram (vegetation, abscess, etc.) OR new valvular regurgitation (aortic or mitral regurgitation)

Question 15

What are the MINOR Duke Criteria for endocarditis. There are 4 different ones.

Answer 15

1) Predisposing condition: abnormal valves, IVDA, indwelling catheters
2) Fever
3) Vascular phenomena: Janeway lesions, pulmonary emboli
4) Immunologic phenomena: Osler nodes, Roth spots, + RF, worsening/existing murmur

Question 16

To diagnose as endocarditis, how many MAJOR and MINOR criteria need to be met?

Answer 16

2 MAJOR
OR
1 MAJOR + 3 MINOR 
OR 
5 MINOR

Question 17

If the endocarditis is associated with a native valve, what is the treatment of choice?

Answer 17

• Anti-Staph PCN (Nafcillin, Oxacillin) + either Ceftriaxone or Gentamicin
• Vancomycin if PCN allergy or MRSA suspected

Question 18

If prosthetic valve is involved with endocarditis, what is the treatment?

Answer 18

-Vancomycin + Gentamicin + Rifampin

Question 19

If the endocarditis is fungal in nature, what is the treatment?

Answer 19

Amphotericin B (treat 6-8 weeks)

Question 20

What is the duration of therapy usually in a patient with endocarditis?

Answer 20

Usually 4-6 weeks (with aminoglycosides such as Gentamicin used for only the first 2 weeks)

Question 21

What cardiac conditions are indications for prophylaxis regarding endocarditis?

Answer 21

• Prosthetic heart valves
• Heart repairs (not including stents)
• Prior history of endocarditis
• Congenital heart disease
• Transplanted heart

Question 22

What is the prophylaxis needed for endocarditis?

Answer 22

• Amoxicillin 2g 30-60 minutes prior to procedure

- Clindamycin 600 mg if PCN allergic

Question 23

What is Libman-Sacks Endocarditis and what is it associated with?

Answer 23

Nonbacterial thrombotic endocarditis is a noninfectious endocarditis due to sterile platelet thrombi deposition in affected valve (MC in mitral and aortic valves)

-SLE (Lupus)

Question 24

What are the 2 MCC of pericarditis

Answer 24

Idiopathic and viral (Coxsackievirus and Echovirus)

Question 25

Other causes of pericarditis

Answer 25

• Dressler Syndrome
• Autoimmune
• Radiation
• Medications

Question 26

What is Dressler Syndrome?

Answer 26

-Post MI Pericarditis + Pleural effusion + Fever

Question 27

Symptoms of pericarditis

Answer 27

• Chest pain: sudden onset of Pleuritic (sharp, worse with inspiration), Persistent, Postural (worse when supine and improved with sitting forward). Pain may radiate to shoulder, back, neck, arm, or epigastric area.
• Pericardial friction rub: best heard at end expiration while upright and leaning forward.

Question 28

What is seen on an ECG for pericarditis?

Answer 28

-Diagnostic of choice: diffuse ST elevations in precordial leads with associated PR depression in those leads

However, in aVR, it is opposite. ST depression and PR elevation

Question 29

What is the management of a patient with pericarditis?

Answer 29

• NSAIDs or Aspirin (1st line) x 7-14 days

- Colchicine is 2nd line

Question 30

For Dressler syndrome, what is the treatment?

Answer 30

Aspirin or Colchicine (avoid NSAIDs because they interfere with myocardial scar formation)