Cardiology #5 Endocarditis, Pericarditis, Effusion, Tamponade, AAA Flashcards
What is endocarditis, what is the MC valve affected (in general), and what is the MC valve affected in IVUD?
Infection of the valves due to bacteria
-Mitral MC in general
-Tricuspid MC in IVDU
What is the pathophysiology of endocarditis?
Thrombus forms on valve –> damaged endothelium attracts platelets and bacteria –> vegetative growth develops
Risk Factors for endocarditis
-Age
-Rheumatic Heart Disease
-IVDU
-Prosthetic valves
-Immunosuppression
MCC acute endocarditis
-What kinds of valves does it affect
-Is it common in IVDU?
Staph Aureus
-Affects normal valves
-Common in IVDU (MRSA)
MCC subacute endocarditis
-What kinds of valves does it affect
-What else is it associated with?
Strep Viridans
Affects damaged/abnormal valves
-Part of oral flora (poor dentition and dental procedures)
On the other hand, what bacteria affects prosthetic valves (within 60 days of surgery)?
Staph Epidermidis (Coag-Negative)
Regarding the post-op period, what bacteria should you be concerned with in the following time periods?
-First 2 months
-After the first 2 months
-Staph Epidermidis
-Staph Aureus after two months
In men with recent GI or GU procedures, what bacteria should you be worried about with endocarditis?
Enteroccocus
If negative blood cultures, what organisms should you look for in endocarditis?
HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
Symptoms of endocarditis
-Persistent fever (MC)
-New onset murmur or worsening murmur
-Osler nodes: painful on pads of digits/palms
-Janeway lesions: painless macules on soles and palms
-Splinter hemorrhages: linear red lesions under nail bed
-Roth Spots: retinal hemorrhages with central clearing
-Splenomegaly
-Glomerulonephritis
What diagnostics should be obtained for endocarditis?
-Blood cultures: 3 sets at least 1 hour apart
-ECG at regular intervals
-Echo: TEE more sensitive than TTE
-Labs: Leukocytosis, High ESR/RF
Explain the Duke Criteria including 1) what is needed to make the diagnosis of Endocarditis, 2) what the major and minor criteria are
Need (2 major OR 3 minor + 1 major OR 5 minor)
MAJOR:
-2 positive blood cultures of typical organisms
-Either: + echo (vegetation, abscess) OR new valvular regurgitation
MINOR:
-Fever
-Vascular Issue: Janeway lesion, pulmonary emboli
-Immunologic Issue: Osler, Roth, + RF, acute glomerulonephritis
-Worsening of existing murmur
-+ blood culture in organism not known to cause endocarditis
-Predisposition (abnormal valve, IVDU, etc.)
How long does the treatment for endocarditis usually continue?
4-6 weeks
Management for the following cases of Endocarditis:
-Native Valve
-Prosthetic Valve
-Fungal Cause
-Native Valve
–Nafcillin/Oxacillin + Ceftriaxone/Gentamicin
—Vancomycin if PCN allergic
-Prosthetic Valve
–Vanco + Gentamicin + Rifampin
-Fungal (Candida, Aspergillus)
–Amphotericin B (6-8 weeks)
What kinds of things do patients with a history of endocarditis need prophylaxis for in the future?
What is given for prophylaxis?
Cardiac Conditions: Prosthetic valves, heart repairs (not stents), prior history of endocarditis, congenital heart disease
Procedures: dental, respiratory, involving skin/MSK (abscesses, I&D)
Amoxicillin 2g 30-60 min before procedure
–Clindamycin 600mg or Azithromycin 500mg if PCN allergic
What is Libman-Sacks Endocarditis?
What is it usually seen with?
Nonbacterial thrombotic endocarditis
Malignancy, Lupus (SLE)**, Rheumatic Fever
Management for Libman-Sacks Endocarditis?
Treat the SLE for the symptoms to resolve
Acute pericarditis, inflammation of the pericardium, has two common causes…name them.
Also name the other causes, such as what is Dressler Syndrome?
Idiopathic and Viral (Coxsackievirus and Echovirus)
-Others: Radiation, Meds (Hydralazine, Procainamide), Malignancy (lung, breast)
-Dressler Syndrome: post MI pericarditis + fever + pleural effusion
Again, Dressler syndrome has three components. What are they?
Post MI pericarditis + fever + pleural effusion
Symptoms of pericarditis (think of P’s).
Chest pain: sudden pleuritic (worse with inspiration), persistent, postural (worse with supine), pleuritic friction rub (end of expiration, upright, leaning forward). Pain may radiate to shoulder, back, or neck.
In which position can you most likely hear a pericardial friction rub (be specific)?
Upright, leaning forward, end of expiration
What is seen on ECG in a patient with pericarditis?
-Diffuse ST elevations in precordial leads with PR depressions in those leads (V1-V6)
-In aVR, though, ST depressions and PR elevations
Management for pericarditis
Management for Dressler Syndrome (specifically)
-NSAIDs or Aspirin
-Colchicine (2nd line)
Dressler: Aspirin or Colchicine, NO NSAIDS (may impair healing process and cause ventricular rupture)
Pericardial effusion, a complication of pericarditis, is fluid in the pericardial space. What are the symptoms of this condition?
-Decreased (muffled) heart sounds
-Chest pain
-Dyspnea
-Fatigue
What is the diagnostic of choice for a pericardial effusion?
What is seen on an ECG? CXR?
Echo is DOC
-ECG: Low QRS voltage, tachycardia, electrical alternans (alternating amplitudes of QRS -tall-short-tall)
-CXR: water bottle heart
Treatment for pericardial effusion
-Treat underlying cause
-Large effusions need pericardiocentesis
On that same note, what is a cardiac tamponade?
What are some etiologies of this condition?
Pericardial effusion putting pressure on heart, impeding filling, leading to decreased CO and shock
Etiologies: acute pericarditis, trauma, malignancy
Symptoms of a cardiac tamponade (triad and a specific other finding)
Beck’s Triad: muffled heart sounds + increased JVP + hypotension
Pulsus Paradoxus: > 10mmHg decrease in SBP with inspiration
Diagnostics for cardiac tamponade
-Echo: effusion + diastolic collapse of chambers
-ECG: signs of pericardial effusion (low voltage QRS, electrical alternans)
-CXR: enlarged cardiac silhouette
Management for a cardiac tamponade
-Pericardiocentesis (immediately)
What is constrictive pericarditis?
What is the MCC in the US? The world?
Loss of pericardial elasticity (fibrosis) leading to restricted ventricular diastolic filling
US: Any cause of pericarditis
World: TB
Symptoms of constrictive pericarditis
-Dyspnea (MC)
-Right Heart Failure Signs: Increased JVD, Peripheral Edema, Kussmaul’s Sign (increase in JVP with inspiration)
-Pericardial Knock: high pitched diastolic sound (like S3) = sudden cessation of ventricular filling
What is seen on an echo with constrictive pericarditis?
Pericardial thickening and/or calcification. Square root sign = early diastolic dip followed by diastasis.
Management for constrictive pericarditis
-Diuretics
-Pericardiectomy (definitive)
Abdominal Aortic Aneurysm is focal aortic dilation > 1.5cm. Where is the MC site for this condition?
What are some risk factors for AAA?
Infrarenal MC site
RF: Smoking!!!!, Male, Age >60, Caucasian
Symptoms of an AAA
How about symptoms if ruptured?
Most asymptomatic; however, can have abdominal/flank pain, abdominal bruit, pulsatile abdominal mass
Ruptured: same as above, hypotension, syncope, flank ecchymosis
Regarding diagnostics for AAA, what are the best options if…
-Stable
-Unstable
-Best test to monitor progression if asymptomatic
-Stable: CT with IV contrast
-Unstable: Bedside US
-Abdominal US if asymptomatic to monitor progression
Explain the screening for abdominal aortic aneurysms
-One time abdominal US in men 65-75 who ever smoked
Explain the treatment and monitoring for AAA based on size
- 5.5 or more OR > 0.5cm expansion in 6 months = immediate surgery
->4.5: vascular surgeon referral
-4-4.5: US Q6 months
3-4cm: US Q12 months
An aortic dissection, which is a tear through the innermost layer (the intima), has two types. Which type is the MC and associated with the highest mortality?
What are some risk factor associated with this condition?
-Ascending (MC) = highest mortality
RF: Hypertension**, Pregnancy, Men, Collagen disorders (Marfan, Ehler Danlos), Turner’s
Symptoms of aortic dissection
Where is the pain in both types of this condition (it changes based on location).
-Sudden onset severe, ripping, knife-like chest pain radiating between scapulae
-Unequal BP in both arms = decreased peripheral pulses, > 20mmHg difference between arms
-Ascending: anterior CP
-Descending: interscapular pain
Diagnostics for aortic dissection
-CT angiogram (GOLD), TEE
-CXR: Widened mediastinum
Management for both types of aortic dissection
-Surgical: Proximal/Ascending (Stanford A)
-Medical: Distal/Descending (Stanford B)
–Labetolol with Sodium Nitroprusside (for HTN)
–Systolic BP rapidly lowered!
