Chapter 37 Inflammatory & Structural Heart Disorders

Question 1

IE – What are the risk factors?

Answer 1

Causitive organisms
Bacterial most common:
1.	Streptococcus viridans
2.	Staphylococcus aureus
Viruses
Fungi

Risk factors:
Cardiac, noncardiac, procedural
Principal risk factors
1.	Age- 50% of older people have it
2.	IV drug abuse (IVDA)
3.	Prosthetic valves
4.	Use of intravascular devices (CVC) resulting in nosocomial infections ex: MRSA
5.	Renal dialysis

Question 2

IE- Clinical Manisfestations

Answer 2

Acute: nonspecific, low-grade fever occurs in 90% of pts, chills, weakness, malaise, fatigue, anorexia
Subacute: arthralgias, myalgias, back pain, abdo discomfort, weight loss, headache, clubbing of fingers d/t hypoxia
Vascular manifestations: splinter hemorrhages in nail beds, petechiae, osler’s nodes on fingers or toes, janeway’s lesions on palms or soles, roth’s spots
Other: mumur in most pts, heart failure, manifestations secondary to embolism- spleen, kidneys, limbs, brain, lungs
IE aortic valve (80%) mitral valve (50%)  HF

Question 3

IE- Diagnosis

Answer 3

Must have 2 of the following:
1. positive blood culture- 2 blood cultures drawn 30 mins apart from diff sites
2. new or changed heart murmur
3. intracardiac mass/vegetation on echo
Ask pt if they have had any dental, urologic, sx, or OBGYN including normal or abnormal obstetric delivery

Question 4

IE- Treatment

Answer 4

Prophylactic antibiotic tx for select pts having:
1. certain dental procedures
2. respiratory tract incisions
3. tonsillectomy and adenoidectomy
4. GI wound infection
5. UTI
Also: Accurate identification of organism to treat it appropriately, IV antibiotics (long term)- relapses are common, repeat blood cultures, valve replacement if needed, antipyretics- fever can persist a few days after tx has started, fluids, rest. Prosthetic valve endocarditis or fungal respond poorly to antibiotics and recommend early valve replacement

Question 5

IE- Complications

Answer 5

Possible embolism d/t vegetation that can break off and spread infection and possibly stroke, heart failure

Question 6

What are the symptoms of decreased cardiac output?

Answer 6

Fluid deficit leads to decreased CO- decreased BP, increased HR

Question 7

Pericarditis – What are the risk factors?

Answer 7

Risk factors:
Infectious- viral, non-infectious- acute pericarditis within 48-72 after MI, and autoimmune- Dressler syndrome within 4-6wks after MI

Question 8

Pericarditis Diagnosis

Answer 8

Diagnositc Studies:
 ECG – diffuse ST segment elevations (must differentiate from MI)
 Echocardiography to look for complications
 High WBC, CRP, ESR
 May send pericardial fluid or tissue for analysis
labs= troponin possibly w/ concurrent ST elevation, CRP, and ESR
Echo is most helpful dx study
WBCs are increased b/c of inflammation

Question 9

Pericarditis Symptoms

Answer 9

Have dyspnea b/c of rapid, shallow breathing to avoid chest pain, Need to distinguish this pain from angina

Pericardial friction rub (can be intermittent), timed with the pulse, may have fever, progressive, severe chest pain:

1. sharp, pleuritic, can radiate
2. worse with deep inspiration and lying supine
3. relieved by sitting and leaning forward (tripod position)
4. may refer to shoulder, neck, and upper back

Question 10

Pericarditis Complications

Answer 10

Complications:
Pericardial effusion
Buildup of fluid in the pericardium
Can compress nearby structures causing cough, dyspnea, tachypnea, hiccups, hoarseness
S/S include distant, muffled heart sounds with normal BP
Pericardial effusion – only takes a small amount of fluid (20-50 mL) to cause symptoms if the fluid accumulates quickly, can be an emergency!
Hiccups – from phrenic nerve compression
Hoarseness – from laryngeal nerve compression
Cardiac tamponade
Happens as the pericardial effusion worsens and compresses the heart
S/S include chest pain, confusion, restlessness, muffled heart sounds, narrowed pulse pressure, tachypnea, tachycardia, marked JVD, pulsus paradoxus
Pulsus paradoxus – gap in Korotkoff sounds > 10 mm on inspiration and expiration

Question 11

Pericarditis Treatment

Answer 11

 Antibiotics, if bacterial
 NSAIDs (i.e ., ASA, ibuprofen) for pain and inflammation
 Corticosteroids if not responding to NSAIDs
 Position upright leaning forward
 Pericardiocentesis
 No opioids, NSAIDs only

Question 12

Chronic Constrictive Pericarditis:

Answer 12

Caused by scarring and loss of elasticity of the pericardial sac after acute pericarditis
 S/S include JVD, dyspnea, peripheral edema, fatigue, no pulsus paradoxus
 Heart sounds – pericardial knock (Pericardial Knock)

 Diagnosis
 ECG changes are non-specific
 CXR - enlarged heart
 Confirmed by color M-mode echo – wall thickening without pericardial effusion
 Treatment
 Pericardial window or pericardiectomy, may take time to show improvement
 Can try a pericardial window first
 Pericardiectomy – complete removal of the pericardium (requires sternotomy & CPB)

Question 13

Rheumatic Fever risk factors

Answer 13

 Risks: Inflammatory disease that occurs after Group A strep infection, can affect heart, joints, skin, and brain
 Rarely see in the US anymore, more common in age 5-15, after age 35 we don’t see it (scarlet fever is a type of strep infection that can lead to RF)