cardiomyopathies and myocarditis + endocarditis

Question 1

50% AD
disordered LV hypertrophy (not parallel like LVH in chronic HTN)
hypertrophied IV septum too close to anterior mitral valve leaflet → outflow obstruction (blood can’t get out of ventricle) → ↓ SOB + syncope

Answer 1

hypertrophic cardiomyopathy

Question 2

ENLARGED + DIFFUSE apical impulse (normal: nickel-sized)
S4 heart sound (thick/non-compliant LV - can’t fill ventricle)
systolic murmur (subaortic stenosis - obstructed proximal to valve - LOUDER valsalva - vs aortic stenosis)

Answer 2

hypertrophic cardiomyopathy

Question 3

systolic murmur LOUDER with valsava (usually makes murmurs quieter) + SOFTER with squatting

Answer 3

hypertrophic cardiomyopathy

↑ intrathoracic pressure →↓ preload (filling of heart) → IV septum is closer to lateral wall of ventricle → worsening of LV outflow tract obstruction

squatting →↑ afterload (more blood in LV) → IV septum moves away from lateral wall → less obstruction

Question 4

most common cause of death among young healthy athletes in US

Answer 4

hypertrophic cardiomyopathy

exercise: volume depleted →↓ preload → outflow obstruction → die

Question 5

treatment of hypertrophic cardiomyopathy

Answer 5

slow heart → prolong diastole →↑ filling of heart + ↓ O2 demand
ß blocker
non-dihydropyridine CCB: verapamil
restrict physical exertion
avoid volume depletion

Question 6

deposition in myocardium thickens myocardium → disrupts diastolic function
S4 heart sound

Answer 6

restrictive cardiomyopathy

Question 7

due to mycoidies → eosinophilia

Answer 7

loffler eosinophilic pneumonitis

Question 8

causes of restrictive cardiomyopathy

Answer 8

LEASH - to restrict a dog
Loffler syndrome: fibrosis of endocaridum + EOSINOPHILS infiltrate
Endocardial fibroelastosis: thick fibroelastic tissue in endocardium of young children
Amyloidosis
Sarcoidosis: granulomas
Hemochromatosis: iron in myocardium (more commonly causes DILATED CM)
–radiation for lung/breast cancer: causes fibrosis in myocardium

Question 9

most common type of cardiomyopathy (90%)

Answer 9

dilated cardiomyopathy

Question 10

causes of dilated cardiomyopathy

Answer 10

CHF from chronic myocardial ischemia
hemochromatosis (most commonly dilated, can be restrictive too)
chemo drugs: doxorubicin, daunorubicin
chronic cocaine and alcohol use (alcohol alone is toxic to myocardium)
wet beriberi (caused by thiamine deficiency due to chronic alcoholism)
chagas disease (protozoa: trypanosoma cruzi)
coxsackie B virus (myocarditis → dilated DM)

Question 11

adding myocytes/sarcomeres in series (not parallel) → dilated → systolic dysfunction (unable to contract)

Answer 11

dilated cardiomyopathy

Question 12

S4 heart sound suggests

Answer 12

stiffened LV:
hypertrophic cardiomyopathy
restrictive cardiomyopathy

Question 13

S3 heart sound suggests

Answer 13

systolic dysfunction of ventricle

Question 14

LATERAL apical impulse (not at mid-clavicular line)

S3 heart sound

Answer 14

dilated cardiomyopathy

Question 15

beriberi is caused by

Answer 15

ber1ber1: thiamine B1 deficiency
chronic alcohol use → thiamine deficiency (vitamin B1)
dry: causes wernicki-korsakaff syndrome
wet: dilated CM + congestive heart failure → peripheral edema (wet)

Question 16

dilated CM
megacolon
megaesophagus

Answer 16

chagas disease: protozoa trypanosoma cruzi

Question 17

generalized inflammation of myocardium (not due to ischemia)

Answer 17

myocarditis

Question 18

most common cause of myocarditis in US

Answer 18

Coxsackie B virus

other viruses can cause it too

Question 19

diffuse interstitial infiltrate of lymphocytes with myocyte necrosis (inflammation causes necrosis)

Answer 19

myocarditis

Question 20

inflammation of endocardium:
involves VALVES, may involve septum, chordae tendinae
vegetations (mass of platelets + fibrin) on valve leaflets → fibrosis or calcification of vegetations

Answer 20

infective (bacterial) endocarditis

Question 21

sterile (noninfective) endocarditis:

inflammation of endocardium (not infection)

Answer 21

libman-sacks endocarditis: caused by SLE (SLE causes LSE - BOTH sides of valve)
marantic endocarditis: vegetations due to
metastatic cancer cells or platelet-fibrin aggregates due to
hypercoaguable state

Question 22

FEVER (most common), chills, weakness, anorexia
NEW REGURGITATION heart murmur or heart failure: MITRAL valve most common (L sided endocarditis), TRICUSPID most common in IVDU → septic pulmonary infarcts (chest pain, SOB, tachycardia)
signs of bacterial emobli from vegetations of L heart:
splinter hemorrhage in fingernails
Osler nodes: PAINFUL red nodules on finger + toe pads
Janeway lesions: PAINLESS erythematous macules on palms + soles
Roth spots (Rare): Retinal hemorrhage with clear central white areas
brain infarct → focal neuro deficits (stroke)
renal infarct → hematuria
splenic infarct → ab or referred shoulder pain
systemic immune reaction: glomerulonephritis, arthritis

Answer 22

infective endocarditis

Question 23

Retinal hemorrhage with clear central white areas

Answer 23

Roth spots (Rare):

Question 24

PAINLESS erythematous macules on palms + soles

Answer 24

Janeway lesions

Question 25

PAINFUL red nodules on finger + toe pads

Answer 25

Osler nodes

Question 26

diagnosis of infective endocarditis

Answer 26

multiple blood cultures BEFORE starting antibiotics

echocardiogram(TEE): vegetations on valves

Question 27

organisms that cause infective endocarditis

Answer 27

s. aureus: 30% of endocarditis cases
viridans streptococci (strep mutans): 20-30%
enterococci: 10%
s. epidermidis (coagulase neg staph): 5-10%

Question 28

ACUTE endocarditis: sick quickly in DAYS

large vegetations on previously NORMAL valves

Answer 28

s. aureus endocarditis

Question 29

SUBACUTE endocarditis: gradual onset (WKS-MO)
smaller vegetations on valves that were already ABNORMAL (bicuspid aortic valve, prosthetic, hx of damage from rheumatic heart disease)
DENTAL procedures if gingival manipulation (give prophylactic ab if abnormal valves)

Answer 29

viridans streptococci endocarditis

Question 30

some strains are developing resistance to VANCOMYCIN (VRE)

Answer 30

enterococcus endocarditis

Question 31

IVDU (bacteria on skin)

Answer 31

staph epidermidis endocarditis

Question 32

types of endocarditis in IVDU

Answer 32

most common overall: s. aureus and viridans strep
s. epidermidis
pseudomonas
fungal (candida)

Question 33

endocarditis associated with colon cancer

Answer 33

strep bovis endocarditis

Question 34

if blood culture is + for strep bovis

Answer 34

need to get colonoscopy to screen for colon cancer

Question 35

signs + symptoms of infective endocarditis
echo: + for vegetations
blood culture: -

Answer 35

culture-negative endocarditis

Question 36

causes of culture-negative endocarditis

Answer 36

all INTRACELLULAR bacteria:
coxiella burnetti (causes Q fever)
bartonella spp (incl. henslae - Cat scratch fever)
brucella spp. (unpastuerized milk)
HACEK: 
Haemophilus
Actinobacillus
Cordiobacterium
Eikenella
Kingella

Question 37

complications of infective endocarditis

Answer 37

embolic complications: stroke, renal infarct, splenic infarct
glomerulonephritis
damage to infected valve → valve regurgitation or stenosis
ruptured chordae tendineae (connect papillary muscles to mitral + tricuspid)→ acute onset of mitral or tricuspid regurg
suppurative pericarditis: infection now outside heart

Question 38

vegetations on both sides of valve

Answer 38

Libman-Sacks endocarditis (due to SLE)

Question 39

preferred empiric treatment of infective endocarditis

Answer 39

empiric IV vancomycin pending culture results (vanco covers staph (incl. MRSA) + strep) → once culture back, switch to ab susceptible to organism