Clin Med: Cardio III Flashcards
List causes of pericarditis.
- Infectious
- Systemic dz
- Radiation
- Drug toxicity
- other than viral most are idiopathic
What is the pericardium
a fibrous covering of the heart & great vessels (like aorta)
Describe infectious pericarditis.
- most common is viral
- TB rare in developing countries
- bacterial rare, usually from extension of pulm infx
What are the common viruses that cause pericarditis?(8)
- Coxsackie
- Echovirus
- Influenza
- Epstein-Barr
- Varicella
- Hepatitis
- Mumps
- HIV
What is pulmonary bacteria that causes pericarditis?
strep pneumo
Describe systemic dz causing pericarditis.
autoimmune syndromes, neoplasms
Pericarditis account for how many hospital admissions?
0.2%
Pericarditis account for about what number of pts w/ non-ischemic chest pain in the ED?
5%
Pericarditis: Pathophys
inflammation of pericardium causes chest pain–> movement of heart w/n inflamed pericardium may produce friction
What is pericardial friction rub?
the friction b/t 2 inflamed pericardial layers
(scratchy or squeaky sound; walking on snow)
heard best at Left lower sternal border, louder w/ inspiration, have patient lean forward
Pericarditis: Hx
- pleuritic chest pain
- may report prodrome
- abrupt onset of severe, sharp, inspiratory chest pain on the left side or substernal (pleuritic chest pain)
- chest pain happen days after resp or GI infx
Pericarditis pain may (location):
–> radiate to neck, L. shoulder, & arm
–>radiate to trapezius muscle ridge
be reduced w/ sitting & leaning fwd
–>be aggravated by lying supine or w/ inspiration
Pericarditis: Physical
- assess for signs of cardiac tamponade**
- tachycardia, tachypnea
- Fever
- Pericardial friction rub
Pericarditis: Dx
- usually SL
- leukocytosis
- EKG
- CXR
- Echo
- ESR/CRP elevated
- Look for underlying causes
Pericarditis: Describe EKG
Generalized ST-T wave changes, diffuse ST elevations, followed by return to baseline, then T wave inversions
Pericarditis: Describe CXR
Cardiac enlargement if pericardial effusion
Pericarditis: Describe Echo
can demonstrate pericardial effusion, tamponade
Acute pericarditis: Tx
Aspirin OR Ibuprofen + Colchicine
Recurrent pericarditis: Tx
Aspirin OR Ibuprofen
Describe pericardial Effusion
- Buildup of extra fluid in the space around the heart
- Can occur w/ any form of pericarditis
- Can lead to cardiac tamponade
Describe cardiac tamponade
heart isn’t pumping good bc of fluid accumulation in the pericardial sac
Causes of cardiac tamponade…
- idiopathic pericarditis
- Pericarditis 2ndary to neoplastic dz
- Aortic dissection
- Trauma
- Anticoagulation
3 classic features of cardiac tamponade (Beck’s Triad):
- Hypotension
- Soft or absent heart sounds
- JVD
Other S/S of cardiac tamponade
- Tachypnea
- Chest discomfort
- Lower extremity edema
Cardiac tamponade: Dx (& what will it show)
- CXR: enlarged “globular” heart
- EKG: low voltage (amplitude)
- Echo
Cardiac tamponade: Tx
- treat underlying cause
- Pericardiocentesis
Myocarditis leads to…
decr ability for heart to pump
Myocarditis can be…
infectious or non-infectious
Myocarditis: S/S
- May present several days - weeks after acute febrile illness
- May present w/ S/S of HF
- Tachypnea, chest pain, arrhythmias
Most common cause of myocarditis?
viral
–> parvovirus B19 (5ths dz (erythema Infectiosum))
Myocarditis: Dx & what it will show
- Usually- WBC, ESR, CRP, troponin, BNP elevated
- CXR- may show cardiomegaly, pulmonary edema
- Echo- may show HF
(peripheral edema, dyspnea)
**MRI may show areas of myocardial inflammation
**Myocardial biopsy can make a definitive diagnosis
What is the common workup for myocarditis?
- BNP (HF)
- CBC
- CMP
- CXR
- EKG
- Lipase
- Troponin
Myocarditis: Tx
Antimicrobials/immunosuppressives
- Limit exercise
What is bacterial endocarditis?
infx of the endocardial surface of the heart, most often the heart valves, particularly prosthetic heart valves
They majority of cases of bacterial endocarditis are caused by…
staph or strep (80%)
What is the mortality prediction of bacterial endocarditis in IV drug users
33%
Community Acquired Native valve endocarditis bacteria
- Strep & 2. Staph
Health Acquired: Native valve endocarditis bacteria
- Staph
Prosthetic valve endocarditis bacteria
Staph
IVDA Right-sided bacteria
Staph
IVDA Left-sided bacteria
Enterococci
Bacterial endocarditis: RFs
- prosthetic valves, cardiac devices, & a hx of endocarditis
- IV drug use
- Prolonged bacteremia
- Congenital heart disease
- Poor dental hygiene
- HIV
- Long term hemodialysis
Bacterial Endocarditis risk requires:
- structural heart abnormality to causes turbulent blood flow this forms fibrin deposits
+
Introduction of microbes into bloodstream that get stuck on fibrin
Vegetation is
fibrin + bacteria
What is the HACEK group?
members of fastidious gram (-) bacteria associated w/ infective endocarditis in associated w/ dental procedures (oropharynx/mouth)
List eh HACEK bacteria
- Haemophilus
- Aggregatibacter
- Cardiobacterium
- Eikenella
- Kingella
Infective Endocarditis: Hx
- fever, anorexia, malaise, weight loss
- ask about dental procedures, heart dz, fake valve, pacemaker, rheumatic heart dz, HIV/ RFs, IVDA
Describe the Modified Duke Criteria for dx infective endocarditis
- pathologic criteria
- 2 major + 1 minor OR
- 1 major + 3 minor OR
- 5 minor criteria
Describe pathologic criteria for infective endocarditis
Microorganisms in a vegetation or implant
Describe major criteria for infective endocarditis
- (+) blood culture of typical organism (2 cultures), or (+) PCR
- Evidence of endocardial involvement
Describe minor criteria for infective endocarditis
- Predisposing heart condition or IV drug use
- Fever
- Vascular phenomenon
- Immunologic phenomenon
- Microbiologic (1 (+) blood culture)
Infective endocarditis: PE
Fever
- New or worsening heart murmur
- Splenomegaly
- Roth Spots
- Splinter hemorrhages
- Janeway lesions
- Osler nodes
What are Roth spots?
exudative, edematous lesions of the retina
What are Splinter hemorrhages?
non-blanching, linear, reddish-brown lesions under nails
What are Janeway lesions?
macular, blanching, painless, purple lesions on palms and soles
What are Osler nodes?
painful, purple nodules in pulp of fingers and toes
List and describe complications of infective endocarditis
- cardiac complications (50%)
- Neurologic complications (40%)
- Septic emboli (25%)
- Metastatic infection
- Systemic immune reactions
Infective Endocarditis: Cardiac complications
Valve regurgitation, heart failure, and conduction abnormalities.
Infective Endocarditis: neurologic complications
Embolic stroke, intracerebral hemorrhage, brain abscess
Infective Endocarditis: septic emboli
Infarction of kidneys, spleen, and other organs.
Infective Endocarditis: Metastatic infx
vertebral osteomyelitis, septic arthritis, splenic or psoas abscess
Infective Endocarditis: Systemic immune rxns
glomerulonephritis
Infective endocarditis: Dx
- Modified Duke Criteria
- Blood cultures
- ESR (elevated)
- CBC (elevated WBC)
- EKG (may show AV block that can progress from 1st degree to 3rd degree)
- Echo (TTE vs TEE)
- Brain CT if neuro deficits
Infective endocarditis: Tx
- Guided by blood cultures
- Consult infectious disease
- Pts w/ acute symptoms should be treated empirically w/ Vancomycin
–> 6wks of IV abx (can go home w/ pick line)
Long term tx required
Infective Endocarditis: prophylaxis required for pts with?
- A prior history of IE
- Prosthetic heart valves
- Cardiac valve repair
- Unrepaired cyanotic congenital heart dz
Procedures that can cause infective endocarditis
- Dental work
- Invasive resp procedures
- Skin/soft tissue infx over infxd skin
- Cardiac surgery w/ prosthetic material
+/- GI/GU procedures (depends on organization)
Prophylactic abx to prevent infective endocarditis
MOST PATIENTS WILL GET PCN
Oral Amoxicillin
if not oral–> Ampicillin OR Cefazolin or ceftriaxone
allergic to PCN–> Cephalexin OR Clindamycin OR Azithro or clarithro
allergic to PCN & unable to take oral med–> Cefazoline or ceftriaxone OR Clindamycin OR Vanc
Describe acute infective endocarditis?
develops suddenly & may become life threatening within days.
Describe subacute infective endocarditis?
develops gradually & subtly over a period of wks - several months but also can be life threatening.
Describe noninfective Endocarditis
Blood clots that do not contain microorganisms form on heart valves & adjacent endocardium.
Noninfective endocarditis can lead to infx endocarditis bc microorganisms can attach to & grow w/n the fibrous blood clots.
What is rheumatic fever?
A systemic immune process that is secondary of a B-hemolytic streptococcal infx of the pharynx (strep throat)
Rheumatic fever can affect the…
heart, joints, skin, & brain
Rheumatic fever: prevalence
- rare before 4yo or after 40yo
Rheumatic heart dz: prevalence
- Ages: 25 - 40
Rheumatic Heart Dz: Pathophys
- Immune response against M PRO from strep bacteria
- Those antibodies are thought to cross-react w/ PROs on our own cells.
- Once bound to cardiac tissue, the antibodies activate more immune cells, which causes acytokine-mediated inflammatory response & tissue destruction.
When does rheumatic fever occur?
2-3 weeks after untreated strep infx
Rheumatic Fever: Hx-S/S
- fever
- carditis
- arthritis
- chorea (involty movements)
- subcutaneous nodules
- erythema marginatum
Rheumatic Heart Dz: Hx-S/S
10 -20 years after rheumatic fever
- palpitations
- Fatigue
- Dyspnea
- Chest pain
- Syncope
- Edema
What is needed to make a dx of rheumatic fever?
2 major criteria
OR
1 major & 2 minor criteria
Rheumatic fever: Major Dx Criteria
- Joints (arthritis)
- O (carditis)
- N (nodules)
- E (erythema migrans)
- S (Sydenham chorea)
Rheumatic fever: Minor Dx Criteria
- Fever
- Polyarthralgia
- Prolonged PR interval
- Elevated ESR or CRP
- (+) throat culture, rapid strep test, or elevated (& rising) strep antibody titer
Rheumatic Fever: PE
- Arthritis
- Carditis
- Subcutaneous Nodules
- Erythema migrans
- Sydenham chorea
Describe rheumatic fever: arthritis
swelling & inflammation of the joints, migratory polyarthritis affecting large joints including knees, elbows, ankles, & wrists
Describe rheumatic fever: carditis
endocarditis
Describe rheumatic fever: subcutaneous nodules
on joints including knees, elbows, or wrists.
Small, firm, & painless
Describe rheumatic fever: erythema migrans
nonpruritic, pink, ring-link rash on trunk & proximal extremities,
usually excluding face
rash may be induced by heat & blanches w/ pressure
individual lesions may appear, disappear, & reappear w/n hrs
Describe rheumatic fever: Sydenham chorea
uncontrolled jerky movement
Rheumatic heart dz: PE
- MV most commonly affected
–> mitral regurg
–> mitral stenosis - Aortic valve 2nd most common
–> aortic regurg
Rheumatic Heart Dz: Dx
Echo
Rheumatic Fever: Tx
symptomatic relief of arthritis, carditis w/ NSAIDs for 1-2 weeks (or until joint symptoms go away)
- Eradication of GABHS–>PCN
- Prophy against future GAS infx–> PCN
Rheumatic Heart Dz: Tx
- prophy to prevent recurrent acute rheumatic fever episodes
- treat valvular conditions
Valvular disorder: pathophys
each heart valve is dz–> abnormal valve movement & blood flow–> abnormal heart sounds/murmurs
Which side of the heart is most effected by valve disorders and why?
- left side of heart
- due to incr pressure of systemic circulation
Valvular dz to which valve is rare?
pulmonic valve
(usually related to congenital defects)
What is stenosis?
narrowing of the valve
What is regurgitation?
- allows blood to flow the wrong way. Can occur w/ prolapse
- AKA insufficiency
Write out murmur cheat sheet
DONE
Describe mitral stenosis?
Mid diastolic murmur w/ mitral valve opening snap, best heard over apex
Mitral stenosis is presumed to be caused by…
rheumatic heart dz (rare in US)
Mitral stenosis: S/S
- worse w/ exertion
- lead to HF
Mitral stenosis: Dx
TTE
Mitral stenosis: Tx
depends on severity (always tx HF)
- close monitoring
- balloon valvuloplasty
- MV replacement
Describe mitral regurg
pan systolic murmur, radiates to axilla
Mitral regurg is caused by…
- MI
- endocarditis
- CT dz
Mitral regurg affects what % of the US population.
6-8% over 65yo
Mitral regurg: S/S
leads to HF
Mitral regurg: Dx
TTE
Mitral regurg: Tx
depends on severity (tx HF)
- monitoring
- valve repair
- valve replacement
Describe aortic stenosis?
crescendo-decrescendo murmur head at right sternal border, 2nd ICS, radiates to carotids during systole
Aortic Stenosis occurs due to…
calcification
Aortic Stenosis affects what % of the US
1% usually older age
Aortic Stenosis: S/S
- angina
- syncope
- dyspnea
- fatigue
Aortic Stenosis: Dx
Echo
Aortic Stenosis: Tx
- Mild symptoms–> periodic monitoring
- Mod/severe–> valve replacement
Describe aortic regurg.
early diastolic decrescendo murmur
Aortic regurg common cause…
HTN
Aortic regurg affects what % of the population >65 yo
1%
Aortic regurg: S/S
HF & dyspnea
Aortic Regurg: Dx
echo
Aortic regurg: Tx
valve replacement if very symptomatic
Describe tricuspid stenosis
late diastolic murmur
Prevalence of tricuspid stenosis
very rare
Tricuspid Stenosis is caused by…
- rheumatologic dz
- endocarditis/IV drug uses
Tricuspid stenosis: S/S
- right sided HF w/ hepatomegaly
- ascites
- dependent edema
Tricuspid stenosis: Dx
Echo
Tricuspid stenosis: Tx
- valve replacement if symptomatic
- for mild- diuretics, for moderate/severe- repair or replacement
Describe tricuspid regurg
pansystolic murmur
Describe prevalence of tricuspid regurg?
- mild is common
- severe is rare
Tricuspid regurg is caused by…
- infective endocarditis
- trauma
Tricuspid regurg: S/S
- right sided HF w/ hepatomegaly
- ascites
- dependent edema
Tricuspid regurg: Dx
Echo
Tricuspid regurg: Tx
- mild–> diuretics
- mod/severe–> repair or replacement
Name the two types of prosthetic valves
- Bioprosthetic
- Mechanical
Advantages for bioprosthetic valve
- no lifelong anticoag needed
- lower risk of bleeding
- can be used in pts who can’t tolerate anticoag (pregnancy)
- good for older pts, cancer pts, & pts in renal failure on dialysis
Disadvantages for bioprosthetic valve
- less durable & higher re-operation rates
Advantages for mechanical valve
- more durable & less re-operation rate
- good hemodynamic properties
- good for younger pts
- good in pts w/ other mechanical valves
Disadvantages for mechanical valve
- incr risk of thrombosis
- lifelong need for anticoag
- incr risk of bleeding
Anticoag: mechanical vavles
- lifelong anticoag w/ Coumadin
- target INR 2.5 - 3.0
Anticoag: bioprosthetic valves
- anticoag 3 months
- Coumadin or DOAC
All patients will a valvular disorder must take…
lifelong ASA (aspirin) as an antiplatelet therapy
