Cardiovascular Infections Flashcards
What is endocarditis?
Infection of the valves
Risk factors for endocarditis
- Bacteremia (IV drug users, intravenous catheters)
2. Structural heart disease (prosthetic valve, severe stenosis or regurgitation)
Endocarditis Pathogen: Subacute infection: days-weeks
Streptococcal spp (streptococcus viridians and streptococcus bovis)
Endocarditis Pathogen: Acute infection: hours-days
Staphylococcus auerus
Streprococcal Spp
subacute onset of low grade fever, fatigue, murmur due to slow valve destruction
Staphylococcus Aureus
acute onset due to high grade fever, shaking, chills, murmur due to rapid valve destruction
Endocarditis Presentation
fever/ night sweats
new or worsening murmur
Endocarditis to right side valves
lung emboli (presents as pneumonia)
Endocarditis to left side valves
embolic stroke, MI, retinal emboli, renal emboli, Janeway lesions, Osler nodes, splinter hemorrhages
Janeway lesions
non-painful
Osler nodes
painful
Best Initial workup for Endocarditis
Blood cultures- necessary to establish diagnosis
Tests for diagnosis of Endocarditis
- Blood cx: Initial test (95% sensitive). Necessary to establish the diagnosis.
- TTE: Initial imaging test. 60-70% sensitivity for vegetations. Visualization of vegetations is necessary for diagnosis. Negative TTE will require to perform TEE
- TEE: Useful for establishing diagnosis if initial TTE is negative. 95%-100% sensitive. Maybe initial test for patients with prosthetic valve
- ECG: Non-specific changes. Do not require for diagnosis
What is needed for Dx of Endocarditis?
Positive Blood Cultures + Vegetation on ECHO
How to establish Dx of Endocarditis if Blood Cx are negative?
fever(+), risk factors (+) embolic phenomena + vegetation on ECHO
Endocarditis Treatment
- Empiric coverage with intravenous Vancomycin (staph spp. including MRSA) + Ampicillin (strep spp.). Gentamycin can be added for synergism
- Change abx based on sensitivity when culture results are available
- X 4-6 weeks IV antibiotics
- Surgery for ruptured valve and embolism (large vegetations)
When to give prophylaxis for endocarditis?
significant valvular defect + risk for bacteremia
- Significant Valvular defect: prosthetic valve, previous endocarditis, unrepaired/partially repaired cyanotic defect (tetralogy of Fallot)
- Risk of bacteremia: dental work with blood (extraction, root canal, dental cleaning), respiratory tract procedures with blood (biopsy, tonsillectomy)
Recommended Prophylaxis for Endocarditis
Amoxicillin / Clindamycin (single dose before procedure)
Pericarditis
infection/inflammation of pericardium
Causes of pericarditis
idiopathic, infection (viral-coxsackie virus), autoimmune (lupus),
malignancy (Hodgkin’s lymphoma, lung cancer), metabolic causes (uremia), Trauma (chest trauma)
Pericarditis: Clinical Presentation
POSITIONAL pain (relieved by sitting forward) PLEURITIC pain (deep inspiration) friction rub (disappears with pericardial effusion)
Best Initial Dx Test for Pericarditis
ECG- shows diffused ST elevations and PR depressions on multiple leads
Pericarditis Tx
- NSAIDS w/ or w/o Colchicine
- Steroids if insufficient response to NSAIDS
- Resolves in 2-6 wks
Tests for Pericarditis
- ECG: Initial test. Done to r/o myocardial ischemia. ECG maybe non-specific in pericarditis or show diffused ST elevations and PR depressions
- ECHO: TO R/O PERICARDIAL EFFUSION and tamponade. Pericarditis w/o effusion- normal ECHO
- Inflammatory markers: Non-specific, likely elevated
- Viral cultures: Rarely change the treatment
- Chest x-ray: Normal
Intensity of the murmurs
- Grade 1- faint (S1 and S2 is louder than a murmur)
- Grade 2 - quiet (S1 and S2 = murmur)
- Grade 3 – moderately loud (murmur is louder than S1 and S2)
- Grade 4 – loud with palpable thrill
- Grade 5 – very loud, with thrill. Maybe heard with a stethoscope is partly off the chest
- Grade 6- very loud, with thrill. Maybe heard with a stethoscope entirely off the chest
Systolic Murmurs
- Aortic Stenosis - radiates to the neck
2. Mitral Regurgitation - radiates to axilla
Aortic Stenosis
Symptoms: Angina, Syncope, Dyspnea
Signs: systolic murmur at 2nd right intercostal space radiating to neck. S4 is common
Mitral Regurgitation
Symptoms: dyspnea (CHF)
Signs: systolic murmur at apex radiating to axilla
Diastolic Murmur
- Aortic Regurgitation
2. Mitral Stenosis
Aortic Regurgitation
Causes: infarction, ischemia, infection
Symptoms: Dyspnea (CHF)
Signs: diastolic murmur at sternal border, widened pulse pressure, S3 common
Mitral Stenosis
Causes: infection (RHD)
Symptoms: dyspnea, palpitations
Signs: low pitch diastolic rumble at apex, A-fib
Typical in young pt, pregnant pt
Hypertrophic Obstructive Cardiomyopathy (HOCM)
- no blood flow during systole between LV and aorta
Symptoms: syncope during exercise, sudden death
Signs: harsh systolic murmur radiates to carotid, heard best at right/left sternal border. GETS LOUDER WITH STANDING / VALSALVA
Innocent Murmurs
- due to increased blood flow
- NO STRUCTURAL PATHOLOGY
- physical activity, fever, anemia, hyperthyroidism, pregnancy
- Grade 1-3, no thrill
- always SYSTOLIC
- SOFTER with standing and Valsalva
- NO RADIATION beyond precordium
- always ASYMPTOMATIC
- common in children and young adults
- OBSERVE AND RE-EVALUATE
Pathologic Murmurs
- STRUCTURAL PATHOLOGY
- DIASTOLIC, holosystolic or continuous
- GRADE >3
- RADIATING beyond precordium
- associated with SYMPTOMS
- EVALUATE WITH TTE FIRST
