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JC WCS > Cardiology JC005: Fever And A Heart Murmur > Flashcards

Cardiology JC005: Fever And A Heart Murmur Flashcards

1
Q

Common valvular disease

A
  1. Valvular stenosis
    - valve cannot open properly
    - hypertrophy of ***proximal chamber —> dilatation when chamber fails
  2. Valvular regurgitation
    - dilatation of chamber on ***either side of valve

Diseases:
1. Mitral stenosis
2. Mitral regurgitation
3. Mitral valve prolapse
4. Aortic stenosis
5. Aortic regurgitation
6. Tricuspid regurgitation

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2
Q

Symptoms of valvular heart disease

A
  1. LH failure
    - progressive exertional dyspnea
  2. RH failure
    - ankle edema
    - hepatic pain (∵ hepatic congestion)
  3. Chest pain
    - myocardial ischaemia
  4. Palpitations
    - AF (common)
  5. Fatiguability
    - low CO
  6. Complications
    - thromboembolism
    - infective endocarditis
    - problems during pregnancy
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3
Q

***Investigations of valvular heart disease

A
  1. ***ECG
    - chamber enlargement
    - AF
  2. CXR
    - dilated heart
  3. ***Echocardiogram
    - Valvular architecture
    - Chamber size
    - Chamber function
    - Doppler: Valvular gradient / regurgitant volume
    - Low dose dobutamine (β1 selective: ↑ CO): assess ischaemia, contractile reserve
  4. Exercise testing
    - functional capacity
  5. Cardiac catheterisation
    - Associated coronary artery disease
    - **Pressure gradient
    - **    Inject contrast to assess regurgitant lesions
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4
Q

Chronic Rheumatic Heart Disease

A

Rheumatic: diseases affecting CT

MS > MR + MS > MR

Common valvular involvement:
1. Mitral
2. Aortic + Mitral
3. Aortic
4. Tricuspid

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5
Q
  1. Mitral stenosis
A
  • 95% Rheumatic
  • 5% Congenital (rare)
  • Normal: 2 cm^2
  • Stenosis: <1 cm^2

***Haemodynamics:
LV inflow obstruction
—> ↑ LA pressure
—> ↑ Pulmonary venous pressure
—> ↑ Thickness of pulmonary vascular bed
—> Pulmonary arterial hypertension (2nd stenosis)
—> RH failure

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6
Q

Symptoms of MS

A
  1. Respiratory symptoms
    - ***SOB on exertion
    - Paroxysmal Nocturnal Dyspnea (PND)
  2. Chronic RV failure
    - Congestive cardiac failure
  3. AF
    - **∵ ↑ LA size
    - 50-75% of MS
    - important cause of **    Cardiac decompensation
    —> Normal LA contributes 20% of LV filling, become more important in MS
    —> ↑ Ventricular rate —> ***↓ Diastolic LV filling —> ↓ SV + CO
  4. Systemic embolisation
    - LA enlarged —> Stasis of blood
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7
Q

Signs of MS

A
  1. Malar flush
    - MS —> pulmonary hypertension —> CO2 retention —> Vasodilatory effects
  2. Pulse volume
    - small, irregular if AF
  3. JVP
    - loss of A wave (in AF)
    - ↑ JVP (in RH failure)
  4. Precordium
    - Tapping apex
    - Parasternal heath
    - Loud S1
    - Opening snap (OS)
    - Mid diastolic rumble (at apex)
    —> enhanced by exercise / lying on left side
  5. Signs of complications
    - Pulmonary edema
    - Embolisation: peripheral vessels, stroke
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8
Q

Investigations of MS

A
  1. CXR
    - **↑ LA (straight L heart border)
    - **    Pulmonary edema —> Kerley’s A + B lines
    (A: thickened interlobular septa that contain lymphatic connections between perivenous and bronchoarterial lymphatics deep within the lung parenchyma
    B: thickened subpleural interlobular septa and usually seen at lung bases)
  2. ECG
    - **Bifid P wave (P mitrale) if sinus rhythm —> Left atrial enlargement
    - **    AF
    - ***RVH
  3. Echocardiogram
    - Thickened + Doming
    - Parallel diastolic movement of MV
    - Size of MV opening (significant MS < 1.5 cm^2)
  4. Cardiac catheterisation
    - assess associated coronary artery disease
    - assess RH pressure
    - unnecessary if pure MS
  5. Clinical severity
    - symptoms
    - signs:
    —> Pulmonary HT
    —> Duration of murmur
    —> Interval between S2 and OS
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9
Q

Treatment of MS

A

Medical:
1. ***Diuretics

  1. Digoxin (if AF) / Ca blockers / β-blockers
    - ***Rate control drugs
  2. ***Anticoagulation (Valvular AF)
    - Warfarin
    - history of embolisation
    - paroxysmal / sustained AF

Surgical:
1. ***Valvuloplasty
- Percutaneous balloon dilatation
- if valve not calcified and no significant MR

  1. Valvotomy (closed / open)
  2. MV replacement (MVR)
    - mechanical / bioprosthetic valve
    - if valve calcified / badly destroyed
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10
Q

Causes of Acute decompensation of MS

A
  1. ***AF
  2. Chest infection
  3. ***Pregnancy (↑ intravascular volume by 30%)
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11
Q
  1. Mitral regurgitation
A

Incomplete closure of Mitral valve during systolic phase

Etiology:
1. ***Rheumatic (50% associated with MS)

  1. ***Mitral valvular prolapse (MVP)
  2. ***Rupture chordae tendinae
    - degenerative / collagen disease e.g. Marfan, Ehler Danlos
    - infective e.g. IE
    - active rheumatic heart disease
  3. Papillary muscle dysfunction
    - ∵ ischaemia / MI
  4. ***LV dilatation (functional MR)
    - ∵ enlarged MV ring

Haemodynamics:
1. ***Volume overload of LV —> LV enlargement + failure
2. ↑ LA pressure only in systole —> ∴ pulmonary hypertension usually a late feature

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12
Q

Symptoms of MR

A
  1. Exercise limitation
  2. ***Heart failure
  3. Acute rupture of chordae
    - Acute LV failure (∵ LV no time adapt to ↑ volume)
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13
Q

Signs of MR

A

Precordium
- LV dilatation (displaced apex)
- S1 not increase
- S2 obscured by murmur
- S3 usual
- Pansystolic
- Heard at apex —> Radiate to axilla

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14
Q

Investigations

A
  1. CXR
    - ~ MS + ***LV enlargement
  2. Echocardiogram
    - define cause of MR
    - Doppler: blood flow
  3. Cardiac catheterisation
    - assess MR severity
    - assess associated CAD
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15
Q

Treatment of MR

A

MV repair / replacement

Indication:
- Symptomatic
- Asymptomatic: ↑ Heart size, ↓ LV ejection fraction (LVF)
- Functional MR
- Poor LV
- Refractory HF

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16
Q
  1. Mitral valvular prolapse
A

Systolic prolapse of MV into LA
- Isolated
- Associated with **Secundum ASD, **PDA, **Turner’s syndrome, **Wolff-Parkinson-White syndrome

Clinical features:
1. Asymptomatic
2. Atypical chest pain
3. Palpitation
4. Mid systolic click + Late systolic murmur (accentuated by Standing: ↓ Venous return —> ↓ LV volume —> ↑ Laxity of chordae —> ↑ MVP —> ↑ Duration of murmur)

Complications:
1. Progressive severe MR may require MV replacement
2. Emboli
3. AF

17
Q
  1. Aortic stenosis
A

Etiology:
- Rheumatic (often associated with MS)
- Non-rheumatic
—> ***Calcific AS
—> Congenital: Valvular (Bicuspid —> easier to get stenosis), Subvalvular, Supravalvular

Severe AS:
- ***AV area <1 cm^2
- Mean pressure gradient >50 mmHg (lower in HF)

According to age:
- <60: Rheumatic, Congenital (Bicuspid, Unicuspid)
- 60-75: Calcified bicuspid valve (male usually)
- >75: Degenerative calcification (female usually)

Haemodynamics:
1. Gradient developed across AV obstructing aortic outflow during systole
—> Compensatory LV hypertrophy (no dilatation until HF)

  1. Inadequate ↑ in CO during exercise
    —> symptoms of HF
18
Q

Clinical features of AS

A
  1. Exertional dyspnea
  2. Angina pectoris
    - inadequate blood supply to an already enlarged myocardium
  3. Congestive cardiac failure
  4. Syncope / Sudden death
    - when AS become symptomatic —> mortality 50% in 3 years
19
Q

Signs of AS

A
  1. Slow rising pulse
  2. Heaving apex (LV hypertrophy)
  3. ↓ A2 (if calcified + severely stenotic)
  4. Thrill + Ejection systolic murmur at Aortic area —> Radiate to Carotid artery
20
Q

Treatment of AS

A

Aortic valvular replacement
- for symptomatic
- may reverse LV impairment

21
Q
  1. Aortic regurgitation
A

Incomplete closure of AV during Diastolic phase

Etiology:
1. Rheumatic

  1. Non-rheumatic (Degenerative)
  2. Infective endocarditis (diseased valve / normal valve in drug addict)
  3. Syphilis (Dilatation of aortic valvular ring)
  4. Congenital
    - Marfan
    - Congenital bicuspid valve
  5. Seronegative rheumatoid syndrome
    - Ankylosing spondylitis
    - Reiter’s syndrome
    - Psoriatic arthropathy
  6. Traumatic
    - Aortic dissection
    - Rupture sinus of valsalva (into LV / RV)
    - External trauma

Haemodynamic:
Regurgitation volume
—> ↑ LV end-diastolic volume (with normal LVEDP)
—> ↑ SV in compensated case by LV dilatation
—> Deterioration of LV function
—> ↑ LVEDP + ↓ SV
—> SOB + HF + Early MV closure (∵ ↑ LVEDP) (causing impedance to LV filling)

Symptoms:
- ~ AS

22
Q

Signs of AR

A
  1. Collapsing pulse (***Pulse pressure >50 mmHg)
    - ↑ Systolic pressure ∵ ↑ SV
    - ↓ Diastolic pressure ∵ Blood leave aorta and regurgitate back to heart quickly
  2. Displaced apex (LV dilatation)
  3. Early blowing diastolic murmur following S2 (left lower sternal border)

Eponyms (Classical signs):
1. Austin-Flint murmur (Diastolic murmur across MV)
2. Duroziez sign (to and fro murmur over femoral arteries)
3. Quincke’s pulse (capillary pulsation in finger tips / mucous membranes)
4. Tranle’s sign (pistol shot murmur)
5. De Musset’s head bobbing sign
6. Corrigan’s pulse (rapid upstroke + collapse of carotid artery)

23
Q
  1. Tricuspid regurgitation
A

Etiology:
- **Functional RH failure secondary to LH disease e.g. DCMP, valvular heart disease
- **Rheumatic
- ***Infective endocarditis
- Infiltrative

S/S:
1. RH failure
2. Systolic S wave (Giant V wave in JVP)
3. RV heave
4. Pansystolic murmur (over LSB, ↑ with inspiration)
5. Pulsatile liver, Ascites
6. Cardiac cirrhosis

Treatment:
1. Bed rest
2. **Diuretics +/- Spironolactone
3. **Valvuloplasty

24
Q

Infective endocarditis

A
  • Only type of valvular infection / Cardiac infective disease
  • caused by Microbial infection of Endocardial lining of heart (or blood vessels)
  • **Abnormal valve + **Turbulence —> ***Bacterial adherence / infection
  • insidious

Predisposing CVS etiologies
1. **Valvular (MR > MS, AR > AS, prosthetic, normal in IVDA)
2. **Shunts (Congenital, Post-surgical e.g. VSD, PDA, AV fistula)

25
Q

***Clinical features of IE

A

History + Examination + Investigations

  1. Systemic infections
    - Fever, Chills, Rigors (highly variable)
    - Pallor, Weight loss, Splenomegaly
    - Anaemia, Leukocytosis, ↑ ESR, ↑ CRP, ***+ve blood culture
  2. Manifestations of IV lesions
    - Heart: **Chest pain, Heart failure
    - Embolism: **    Stroke, Cold limbs
    - Changing murmurs (progressively severe), Signs of HF, Petechiae, **Roth spots, **Osler’s nodes, **Janeway lesions, **Splinter haemorrhage
    - RBC urine, CXR, ***Echocardiogram (detect vegetations), Arteriography, Liver-spleen scan
  3. Manifestations of Immunological reactions
    - Arthralgia, Myalgia, Tenosynovitis, **Glomerulonephritis
    - **    Arthritis, Uraemia, Vascular phenomena, Finger clubbing
    - Proteinuria, Polyclonal Ig casts, **↑ RF, **↓ Complements, ***Immune complex
26
Q

Janeway lesions vs Osler’s nodes

A

Janeway lesions (Immunological reaction)
- Macular non-painful
- Erythematous
- Palms + Soles

Osler’s nodes (Peripheral emboli)
- Tender papulopustules
- Pulp of finger

27
Q

***Diagnosis of IE

A
  1. Clinical features
  2. Blood cultures
    - **3 venous cultures (different sites + separate **>=30 mins)
  3. Other investigations
    - ***Transthoracic Echocardiogram (for vegetation)
    - Transesophageal echocardiogram (better delineation of vegetation)
  4. ***Modified Duke criteria
28
Q

***Modified Duke criteria

A

Pathologic criteria:
1. Microorganisms demonstrated in a vegetation
2. Pathologic lesions = confirmed by histology

Clinical criteria:
Definite:
- 2 major
or
- 1 major + 3 minor
or
- 5 minor

Major:
1. **Blood culture showing persistent bacteraemia of typical organisms (>2/3)
2. **Evidence of endocardial involvement: **moving masses, abscess, **new MR, prosthetic valve dehiscence

Minor:
1. Predisposing lesions / main-lining addicts
2. Fever >38oC
3. Embolic phenomenon
4. IC disease (GN, Osler’s nodes, Roth’s spots, RF)
5. Atypical organisms in blood culture
6. Other Echo features of endocarditis

29
Q

Organisms: Native valves

A
  1. Streptococcus (2nd Commonest)—> Penicillin
    - **Viridans (e.g. Sanguis, Mutans): **oropharynx, >50% IE
    - Bovis: **GI, elderly, underlying CA colon / polyp
    - **    Group A (Pyogenes): beta-haemolytic, attacks normal valves
    - ***Group B (Agalactiae): friable vegetation
  2. Enterococci (Faecalis, Faecium)
    - GI, urethra
    - resistant to penicillin (cephalosporin resistant) —> need Aminoglycoside
    - post GI / GU manipulation
  3. ***Staphylococcus (Aureus, Epidermidis) (Commonest)
    - skin
    - variable sensitivity
    - fulminant valve destruction, prosthetic valve, mainlining addicts
  4. HACEK (Haemophilus, Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens, Kingella)
    - oropharynx
    - variable sensitivity
    - large vegetation (difficult to isolate)
30
Q

Streptococci

A

Classifications:
- Bio-assay (Beta-haemolysis)
- Serology (Lancefield grouping)

Lancefield Group A: Pyogenes
- **Rheumatic fever
- SBE (subacute bacterial endocarditis)
- **Scarlet fever
- **Toxic shock syndrome
- **Pharyngitis
- Cellulitis
- ***GN (strains: M type 1, 2, 4 etc.)

Lancefield Group B: Agalactiae
- **Neonatal sepsis
- **UTI
- SBE (subacute bacterial endocarditis)

31
Q

Culture-negative endocarditis

A
  1. Inadequate technique
  2. Prior antibiotics
  3. ***Fastidious organisms
    - Mycoplasma
    - HACEK
    - Abiotrophia
    - Bartonella
  4. ***Fungal (mainlining addicts, immunocompromised)
    - lethal
32
Q

***Treatment of IE

A

Initiate (according to likely organisms) while pending for cultures

Principles:
1. Eradicate source of infection (e.g. dental extraction)
2. **Bactericidal agents (∵ host defence is reduced)
3. **IV treatment + **High dose antibiotics
4. **Adequate treatment duration
5. Surgery + complications management

Clinical assessment of progress:
1. Physical signs
2. Body weight
3. Urine testing
4. Renal function
5. Blood counts
- ESR may take weeks to ↓
6. Drug level
7. ***Echocardiogram (for vegetation size)
8. Fever may take 1-2 weeks to ↓

Medical:
- High dose, IV, Prolonged
- Streptococcus: **Penicillin G 12-18 megaunits + **Gentamicin 1mg/kg q8h for 2 weeks
- Penicillin resistant / allergic: **Vancomycin 15mg/kg q12h for 4-6 weeks
- MRSA: **Vancomycin

Surgical:
- Native valve endocarditis:
—> Haemodynamic instability e.g. HF
—> Large emboli / embolic events

  • Prosthetic valve endocarditis: Surgery required
    —> Early (< 3 months): intraoperative contamination (usually Staphylococcus)
    —> Late (> 3 months): foreign bodies, early surgery required
  • Fungal endocarditis
    —> ∵ anti-fungal not effective
33
Q

Summary of IE

A
  1. Variable clinical presentation
    - acute to low grade fever
  2. Broad spectrum of complications
    - cardiac + neurologic complications
  3. Diagnosis should be suspected in patients with fever in setting of relevant cardiac / non-cardiac risk
  4. 3 sets of blood culture
  5. Echocardiogram important
34
Q

Antibiotic prophylaxis for IE

A
  1. IE more likely result from frequent exposure to random bacteraemia with daily activities than bacteraemia caused by dental, GI tract, GU tract procedure
  2. Prophylaxis only prevent an exceedingly small number of IE cases
  3. Risk of antibiotic-associated adverse events > benefits
  4. Maintenance of optimal oral health and hygiene can reduce incidence of bacteraemia from daily activities —> more important than prophylactic antibiotics

Reasonable situations:
***High risk patients
- Dental procedures involving Gingival tissues / Periapical region of teeth / Perforation of oral mucosa
- Procedures on respiratory tract / infected skin, skin structures, MSS tissue

***GU / GI tract procedures: NOT recommended

35
Q

High risk patients

A
  1. Prosthetic cardiac valve / Prosthetic material used for cardiac valve repair
  2. Previous IE
  3. Congenital heart disease (CHD)
    - **Unrepaired cyanotic CHD
    - Completely repaired CHD with **    prosthetic material / device by surgery / catheter
    —> first 6 months after procedure
    - Repaired CHD with ***residual defects at site / adjacent to site of prosthetic patch / device (which inhibit endothelialisation)
  4. Cardiac transplantation recipients who develop cardiac valvulopathy (∵ on ***immunosuppressant)
36
Q

Regimens for prophylaxis

A
  1. Penicillin
    - Amoxicillin
    - Ampicillin
    - Ceftriaxone
  2. Clindamycin
  3. Macrolide
    - Azithromycin
    - Clarithromycin

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