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Stage 3 > Cardiology infections > Flashcards

Cardiology infections Flashcards

1
Q

What is myocarditis?

A

An inflammatory disease of the myocardium

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2
Q

What is myopericarditis?

A

When myocarditis is concurrent with inflammation of the pericardium

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3
Q

How does myocarditis typically present?

A

Range of signs and symptoms is broad, reflecting the variability in extent of myocardial involvement
1) Cardiac-type chest pain
2) Fatigue
3) Palpitations/tachycardia
4) Symptoms of heart failure
5) Difficulty breathing
6) Can sometimes present with sudden unexplained cardiac death

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4
Q

What are examination findings in myocarditis?

A

Examination findings are non-specific
1) Signs of heart failure may be evident along with S3 and S4 gallops
2) If pericarditis is associated, auscultation can reveal a pericardial friction rub

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5
Q

What does an ECG show in myocarditis?

A

Abnormal heart rhythms
1) Non specific ST segment and T wave changes - may be regional, depending on the degree and location of myocardial involvement
2) Along with ectopic beats and arrhythmias if present, and low voltage complexes
3) Sinus tachycardia

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6
Q

What blood test would you do for myocarditis and what would it show

A

Troponin - can be markedly elevated

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7
Q

What can echo show in myocarditis?

A

Ventricular dysfunction if present - in the form of diastolic dysfunction or regional wall motion abnormalities

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8
Q

Which imaging can help help to confirm the diagnosis of myocarditis and how?

A

Cardiac MRI by showing the presence and extent of inflammation

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9
Q

What is the gold standard diagnostic tool for myocarditis?

A

Endomyocardial biopsy via cardiac catheterisation - but associated with own risks as it is an invasive test

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10
Q

How is myocarditis managed?

A

1) Address the underlying cause alongside supportive management
2) ITU support may be required as patients may require vasopressors
3) Corticosteroids - sometimes considered in a select group of patients with viral myocarditis
4) After recovery, patients should be advised to limit activity for a few months

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11
Q

What is the most common viral cause of myocarditis?

A

Coxsackievirus B

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12
Q

What is an example of another causative organism of myocarditis?

A

Poxvirus (less common than coxsackievirus B)

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13
Q

What are rare causative organisms of myocarditis?

A

Influenza, parvovirus B19, herpesvirus (basically not the answer in an MCQ)

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14
Q

What factors are associated with infective endocarditis?

A

1) Age > 60
2) Male
3) IV drug use - right sided valve disease e.g. tricuspid endocarditis
4) Poor dentition and dental infections

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15
Q

Which is the infective organism for infective endocarditis associated with IV drug use?

A

Staph aureus

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16
Q

What are the four most common organisms involved in infective endocarditis in order?

A

1) Staph aureus
2) Strep viridans
3) Enterococci
4) Staph epidermidis (coagulase negative staph)

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17
Q

Which infective organism often causes infective endocarditis in patients with colonic lesions e.g. IBD or carcinoma?

A

Strep bovis

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18
Q

What are the two ways infective endocarditis present?

A

1) Acutely and progress rapidly with symptoms of heart failure (on normal valves)
2) Subacutely/chronically with nonspecific symptoms

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19
Q

What is the most common symptom of infective endocarditis?

A

Fever

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20
Q

What are symptoms of infective endocarditis?

A

1) Fever
2) Anorexia
3) Weight loss
4) Headache
5) Myalgia/arthralgia
6) Night sweats
7) Abdominal pain
8) Cough
9) Pleuritic pain

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21
Q

What presentation should always raise the suspicion of infective endocarditis?

A

Fever + new murmur

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22
Q

What are signs of infective endocarditis?

A

1) Murmur
2) Janeway lesions (non tender macules on palms and soles)
3) Osler nodes (tender subcutaneous nodules on the finger pads and toes)
4) Roth spots (exudative haemorrhagic retinal lesions with pale centres)
5) Microscopic haematuria and glomerulonephritis
6) Splinter haemorrhages
7) PR prolongation or complete AV block - signs of aortic root abscess

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23
Q

What is a red flag sign in infective endocarditis and why?

A

PR prolongation or complete AV block on ECG - signs of aortic root abscess

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24
Q

What are complications of infective endocarditis which can also be the initial presenting complaint?

A

1) Acute valvular insufficiency causing HF
2) Neurologic complications e.g. stroke, abscess, haemorrhage (mycotic abscess)
3) Embolic complications causing infarction of kidneys, spleen or lung
4) Infection e.g. osteomyelitis, septic arthritis

25
Q

What initial investigations would you do for infective endocarditis?

A

1) ECG
2) CXR
3) Blood tests - FBC, U&E, LFT, CRP
4) Blood cultures

26
Q

How should blood cultures be taken in infective endocarditis?

A

At least 3 sets of blood cultures should be taken at different times from various sites

27
Q

What is the first line imaging investigation in infective endocarditis?

A

Transthoracic echocardiogram

28
Q

What is the most sensitive diagnostic test in infective endocarditis?

A

Transoesophageal echocardiogram

29
Q

Which criteria can be used for infective endocarditis diagnosis?

A

Dukes criteria

30
Q

What are the major Dukes criteria?

A

1) Blood culture positive for IE
2) Imaging positive for IE

31
Q

What are the minor Dukes criteria?

A

1) Predisposition to IE
2) Fever > 38
3) Vascular phenomena e.g. arterial emboli, haemorrhages, Janeway lesions
4) Immunological phenomena e.g. GN, Osler’s nodes, Rf
5) Microbiological evidence e.g. blood culture not meeting major criteria

32
Q

How do you define definite infective endocarditis using the Dukes criteria?

A

Two major criteria OR one major + three minor criteria OR all five minor criteria

33
Q

What is the mainstay of treatment for infective endocarditis?

A

Long term IV antibiotics (6 weeks minimum) - initially broad spectrum but can be rationalised to more specific ones when organism + sensitivities are known

34
Q

What are indications for surgical repair in infective endocarditis?

A

1) Haemodynamic instability
2) Severe HF
3) Severe sepsis despite abx
4) Aortic root abscess (and secondary to that PR interval prolongation)
5) Valvular obstruction
6) Infected prosthetic valve
7) Persistent bacteraemia/ongoing fever > 5 days from initiation of therapy
8) Repeated emboli

35
Q

Is antibiotic prophylaxis recommended against infective endocarditis e.g. to at risk patients undergoing interventional procedures like dentistry?

A

No

36
Q

Which antibiotic is first line for treating MRSA?

A

Vancomycin

37
Q

What is acute pericarditis?

A

Inflammation of the pericardium (fibroelastic sac surrounding the heart) - inflammation can also extend to the myocardium, in which case the condition is referred to as perimyocarditis or myopericarditis depending on which is predominant.

38
Q

What are the most common viral causes of pericarditis?

A

1) Coxsackie
2) Echovirus
3) CMV
4) Herpesvirus
5) HIV

39
Q

What are the most common bacterial cause of pericarditis?

A

1) Staphylococcus
2) Pneumococcus
3) Streptococcus (rheumatic carditis)
4) Haemophilus influenzae
5) Mycoplasma tuberculosis

40
Q

What are malignant causes of pericarditis?

A

1) Lung cancer
2) Breast cancer
3) Hodgkin lymphoma

41
Q

What are cardiac causes of pericarditis?

A

1) Heart failure
2) Post-cardiac injury syndrome (Dressler’s syndrome) incl. post-trauma

42
Q

How does radiation cause pericarditis?

A

Often secondary to therapy for other malignancies

43
Q

What drugs can cause pericarditis?

A

1) Anthracycline chemotherapy (Doxorubicin)
2) Hydralazine
3) Isoniazid
4) Methyldopa
5) Phenytoin
6) Pencillins - hypersensitivity

44
Q

What are rheumatological causes of pericarditis?

A

1) SLE
2) Rheumatoid arthritis
3) Sarcoidosis
4) Vasculitides - Takayasu’s, Behcet’s

45
Q

What are other causes of pericarditis?

A

1) Renal failure (uraemia)
2) Hypothyroidism
3) IBD
4) Ovarian hyperstimulation

46
Q

How does pericarditis present?

A

1) Chest pain - usually pleuritic and worse on lying flat
2) Fever
3) Pericardial friction rub

47
Q

Which investigations do you do in pericarditis?

A

1) ECG
2) Troponin - raised

48
Q

What ECG changes are seen in acute pericarditis?

A

1) Widespread saddle-shaped ST elevation
2) PR depression

49
Q

How can ECG changes in pericarditis evolve over weeks?

A

1) 1-3 weeks - normalisation of ST changes, T wave flattening
2) 3-8 weeks - flattened T waves become inverted
3) > 8 weeks - ECG returns to normal

50
Q

How do you diagnose pericarditis?

A

1) Clinical
2) ECG
3) Troponin - tends not to peak like MIs but instead stays constantly elevated in the acute phase
4) Echo
5) Angiogram - shows normal coronary arteries (excludes MI)

51
Q

How do you manage idiopathic or viral pericarditis?

A

1) Exercise restriction + NSAIDs ± colchicine (use in caution in patients with renal/hepatic impairment)
2) Corticosteroids - for pts unable tolerative or refractory to NSAIDs and in non-viral pericarditis (due to the risk of reactivation) and once infection has been ruled out

52
Q

When can you use corticosteroids as second line management in pericarditis when patients are unable to tolerate or refractory to NSAIDs?

A

1) Non-viral pericarditis
2) When infection has been ruled out

53
Q

How is bacterial pericarditis managed?

A

1) IV abx
2) Pericardiocentesis - if purulent exudate is present
2) Pericardectomy - if adhesions or recurrent tamponade occurs

54
Q

What are potential complications of pericarditis?

A

Rare
1) Cardiac tamponade + pericardial effusion - requires pericardiocentesis
2) Long term - pts can occasionally develop constrictive pericarditis

55
Q

What is constrictive pericarditis?

A

1) The result of scarring and loss of elasticity of the pericardial sac
2) The upper limit of cardiac volume is constrained by the rigid pericardium, which prevents normal cardiac filling
3) As a result of the restriction on ventricular volume, stroke volume and cardiac output are limited

56
Q

What causes constrictive pericarditis?

A

1) Idiopathic
2) Can occur after any pericardial disease process e.g. previous acute pericarditis

57
Q

How does constrictive pericarditis present?

A

1) Symptoms of fluid overload
2) Poor exercise tolerance/exertional dyspnoea
3) On examination:
- Raised JVP
- Kussmaul’s sign (paradoxical rise in JVP with inspiration),
Pulsus paradoxus (drop in cardiac output on inspiration)
Heart sounds may also be quiet (if pericardial effusion also present)
Third heart sound (S3) may be present (due to rapid early diastolic ventricular filling).

58
Q

What would you see on examination in constrictive pericarditis?

A

1) Raised JVP
2) Kussmaul’s sign (paradoxical rise in JVP with inspiration)
3) Pulsus paradoxus (drop in cardiac output on inspiration)
4) Heart sounds may also be quiet (if pericardial effusion also present)
5) Third heart sound (S3) may be present (due to rapid early diastolic ventricular filling)

Stage 3 (61 decks)

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