Carditis Flashcards
what is the most common cause of viral myocarditis
cocksackie B
viral myocarditis can lead go what three ways
- acute myocardial failure
- progression to dilated cardiomyopathy
- resolution
clinical presentation
- S3, S4
- mitral or tricuspid valve regurg
- edema-hepative and peripheral
- congestion-rales
- low CO
myocarditis
what lab values are typically increased in myocarditis
- BNP
- troponin: may be increased
what will echo typically show in myocarditis
- LV dilation
- wall motion abnormalities
- decreased systolic function
What presentations should you consider myocarditis
- unexplained cardiac abnormality such as CHF, shock, or arrhythmia
- 20-50 yo typically
- h/o viral illness
- acute LV dysfunction
- percarditis with biomarker elevation
- acute MI w/o h/o CAD and (-) angiogram
standard treatment of acute myocarditis
- IVIG, steroids, plamapharesis
- supportive care
- oxygen
- inotropes
- diuretics
- afterload reduction
- anticoagulation
hat labs/tests would you order in workup for myocarditis
- CXR
- EKG
- BNP, toponin
- ECHO
- MRI
- possible biopsy
what are the three categories of infective endocarditis
- native valve endocarditis
- prosthetic valve endocarditis
- endocarditis in IV drug users
what organisms cause native valve endocarditis? what valves are commonly affected
- streptococci, enterococci, staphylococci
- normal mouth organisms
- mitral and aortic valves
what organisms cause prosthetic valve endocarditis
- 10-20% of endocarditis
- staph species most common
what organisms cause IV drug abusers endocarditis? What valves are commonly affected
- staph aureus
- Right side valves (tricuspid and pulmonic)
acute bacterial endocarditis is usually caused from which bacteria
- staph aureus
- rapidly destructive
- if untreated, fatal in < 6 weeks
subacute bacterial endocarditis is usually caused from which bacteria
- viridans strep (nl mouth flora)
clinical presentation
- previous normal valve
- large bulky vegetation
- IV drug user -> RF
- rapid onset of fever or sepsis
- splenomegaly and embolic events
acute bacterial endocarditis
clinical presentation
- previous abnormal valve
- small vegetation
- slow onset of symptoms
subacute bacterial endocarditis
60-80% of people who get infective endocarditis have what
- identifiable predisposing cardiac lesion
- rheumatic valve lesion (25%)
- congenital heart disease (10-20%)
- mitral prolapse (10-33%)
>50% of cases with infective endocarditis are people in what age group
> 60 yo
what are some skin signs associated with infective endocarditis
- petechiae
- Osler’s nodes
- Janeway lesions
- splinter hemorrhages (pictured)
ocular signs of endocarditis
- Roth spot (specific)
- scleral hemorrhage
what should your history be geared toward if you suspect infective endocarditis
- prior cardiac lesions
- recent source of bacteremia
what can be found on a echocardiogram that is diagnostic for infective endocarditis
- vegetation
- if echo negative, do transesophageal echo
treatment of IE
- bactericidal Abx
- duration: elimiate microorganisms growing within valvular vegetations
- 4-6 weeks of high dose
- often use indwelling central catheter
indications for surgery in IE
- staph infection -> more aggressive
- IE +
- CHF
- persistent or uncontrolled infection (Sepsis)
- recurrent emboli
- vegetation > 1-2 cm in size
antibiotic prophylaxis recommended in dental procedures or procedures involving respiratory tract or infected skin, tissues just under the skin, or musculoskeletal tissue
- prosthetic cardiac valve
- previous endocarditis
- cardiac transplant recipients
- congenital heart disease
- wait 6 months if repaired
what is given for antibiotic prophylaxis in dental, oral, respiratory, or esophageal procedures (adults)
- amoxicillin 2g p.o. 1 hr before procedure
- allergy?
- azithromycin, cephalexin, or clindamycin
- allergy?
differentiate between fibrous and serous pericardium
- fibrous pericardium
- fibrous sac
- holds heart in position, seperates it from surroundind structures
- serous pericardium
- parietal layer : lines fibrous pericardium
- visceral layer: line epicardium
differentiate between acute, subacute, and chronic pericarditis?
- acute: < 6 weeks duration
- most common
- subacute: 6 wks-6 mon
- chronic: > 6 mon
**may be characterized as serous, fibrinous (pictured), adhesive or constrictive
clinical presentation
- severe, pleuritic, shap chest pain aggravated by breathing, coughing, position change
- pain is relieved by sitting up and leaning forward
- pain is intensified by lying supine
acute pericarditis
what is the most characteristic physical exam finding in acute pericarditis
pericardial friction rub
- high/medium pitch, scratching grating
- loudest during inspiration
what EKG findings are consistent with acute pericarditis
widespread elevation of ST segments
- usually with reciprocal deprssion in aVR and V1
treatment of acute percarditis with viral or idiopathic etiology
- anti-inflammatory meds
- Aspirin 600-900 mg QID
- other NSAID, eg Indomethacin
- may need steroids
- **Avoid anticoagulants
What is constrictive pericarditis
- result of scarring and consequent loss of normal elasticity of pericardial sac
- pericardium becomes inelastic -> inability to adapt to volume changes
- results in ventricular interdependence
what is the big difference between constrictive pericarditis to restrictive cardiomegaly
- constrictive pericarditis: cardiac filling is impaired by extrinsic or external force
- restrictive CM: cardiac filling is impaired by intrinsic force
what happens to blood flow in heart during inspiration in normal pericardium
- during inspiration -> decreased intrathoracic pressure -> inc. venous return to right heart -> increased rt heart size -> increased pericardial size; left heart filling is not impaired
what happens to blood flow in heart during inspiration in constrictive pericardium
- normal inspiratory decrease in intrathoracic pressure is not transmited to heart chamber -> pericardium does not expand to accommodate increase in Rt heart size from venous return
- reduction in LV fillings, septum shifts into LV and further impairs LV filling
- stroke volume and CO are impaired
common causes of constrictive pericarditis
- idiopathic or viral 40-50%
- post-surgery
- post-radiation (hodgkin’s, breast CA)
What are the common signs/symptoms associated with constrictive pericarditis
- fluid overload: peripheral edema to anasarca
- diminished cardiac output in response to exertion/exercise
- fatigue
- DOE
physical exam
- increased JVP (JVD)
- pericardial knock
- pulsus paradoxius
- kussmaul’s sign - increased JVP with inspiration
constrictive pericarditis
CXR findings consistent with constrictive pericarditis
calcifications
treatment of constrictive pericarditis
pericardiectomy
what is pericardial effusion? what appearance will be on CXR and EKG?
- build-up of fluid within pericardial space
- CXR: “water bottle” appearance
- EKG: low voltage of QRS (QRS < 0.5 mV)
- friction rub may disappear and heart sounds may become faint
what is the diagnostic test of choice for pericardial effusion
echocardiogram
acute pericarditis can cause what kind of pericardial effusion
- viral - serous
- bacteria - purulent
renal failure with uremia can cause what kind of pericardial effusion
serous usually
What analysis is done on fluid extracted from pericardial effusion
- gram stain, bacterial and fungal culture
- cytology
- ARB stain and mycobacterial culture and PCR
treatment of pericardial effusion
- if no evidence of hemodynamic compromise -> no immediate intervention
- severe -> percardial fluid drainage
- in reality, since may be related to pericarditis, treat with NSAIDS or steroids and judicious diuresis
what is pericardial tamponade
- when pericardial fluid accumulates in an amount sufficient to cause serious obstruction to inflow of blood into the ventricles
what are the three most common causes of pericardial tamponade
- neoplasia
- idiopathic pericarditis
- uremia - renal failure
what is electrical alternans? It supports what diagnosis
- alternating size of QRS complexes
- a finding in effusion with tamponade
What is Beck’s Triad and what condition does it describe
- distended neck veins (elevated JVD)
- distant heart sounds (muffled)
- hypotension
**pericardial tamponade
what is paradoxical pulse
-
> 10mmHg reduction in systolic BP during inspiration
- may be detected as reduced pulse during inspiration
- LV output is temporarily reduced during inspiration since both ventricles are w/in confines of the reduced pericardial space
treatment of cardiac tamponade
- oxygen, IV fluids, T+C, CXR/ECHO (do not send to radiology)
- DO NOT give pain medications, sedate, or intubate
- ECHO guided pericardiocentesis, only sedate once fluids hooked up and ready to decompress
