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CPR 2 Exam 1 > Clinical Cardiac Part 2 > Flashcards

Clinical Cardiac Part 2 Flashcards

1
Q

What are the classifications of endocarditis?

A

Infective
Non-bacterial thrombotic endocarditis
Non-bacterial verrucous endocarditis

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2
Q

What are the two type of infective endocarditis?

A

Acute

Subacute

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3
Q

What typically causes acute infective endocarditis?

A

Staph aureus

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4
Q

Staph aureus infects what type of heart valves?

A

Normal heart valve endothelium

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5
Q

Is acute infective endocarditis fatal?

A

Yes within 6 weeks without treatment

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6
Q

What typically causes subacute infective endocarditis?

A

Streptococcus viridans

Enterococcus

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7
Q

Where does subacute infective endocarditis infect?

A

Damaged heart valve endothelium

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8
Q

Is subacute infective endocarditis fatal?

A

Yes but takes longer than 6 weeks to die

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9
Q

What is Marantic endocarditis?

A

Sterile platelet vegetations on cardiac valves

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10
Q

In what patient population is Marantic endocarditis typically found?

A

Patients with metastatic malignancy

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11
Q

What is Libman-Sacks endocarditis?

A

Sterile platelet vegetations on cardiac valves

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12
Q

What patient population is Libman-Sack endocarditis found?

A

SLE patients

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13
Q

What endocarditis presents with new cardiac murmur in setting embolic disease?

A

Non-bacterial thrombic/verrucous endocarditis

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14
Q

What are the risk factors for infective endocarditis?

A 
Older age (>60)
Male sex
IV drug use
Poor dentition or dental infection
Structural heart disease
Implantable cardiac device
Hemodialysis
HIV
Hx of infective endocarditis
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15
Q

IV drug use present with what sided endcarditis?

A

Right

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16
Q

What structural heart disease cause an increased risk for infective endocarditis?

A 
Rheumatic heart disease
Mitral valve prolapse
Bicuspid aortic valve
Congenital heart disease
Prosthetic heart valve repalcement
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17
Q

What implantable cardiac devices increase a patient’s risk for infective endocarditis?

A

Pacemaker

Implantable cardioverter defibrillator

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18
Q

What is the pathogenesis of infective endocarditis?

A

Endothelial injury -> bacteremia -> pathogen adheres to valve surface -> proliferation of bacteria -> embolization of vegetation particles -> complications

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19
Q

Does staph aureus need endothelial damage to develop infective endocarditis?

A

No

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20
Q

What are the most common pathogens in infective endocarditis?

A 
Staph aureus
Strep viridans
Enterococci
Strep bovis
HACEK
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21
Q

What is strep bovis associated with?

A

Colon cancer or IBD

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22
Q

What are the HACEK organisms?

A 
Haemophilus
Actinobacillus
Cardiobacterium
Eiknella
Kingella
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23
Q

What are the clinical symptoms associated with infective endocarditis?

A

Fever (of unknown origin)
Constitutional symptoms (anorexia, weight loss, night sweats)
New cardiac murmur (regurgitation)
Vascular embolic events

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24
Q

What are the physical exam findings for infective endocarditis?

A 
Petechiae
Splinter hemorrhages
Osler's nodes
Janeway lesions
Roth spots
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25
Q

What are splinter hemorrhages?

A

Emboli phenomenon

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26
Q

What are osler’s nodes?

A

Red, raised, painful lesions in distal extremities (immunologic phenomenon)

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27
Q

What are Janeway lesions?

A

Red, flat, painless lesions often on palms or fingers as a result of embolic phenomenon

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28
Q

What are Roth spots?

A

Retinal hemorrhages with white centers (immunologic phenomenon)

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29
Q

How do you diagnose infective endocarditis?

A

Modified Duke Criteria

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30
Q

What is the Modified Duke Criteria?

A 
Echocardiography TTE then TEE
Blood cultures (must draw before starting antibiotics)
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31
Q

How are most people diagnosed with infective endocarditis?

A

Clinically

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32
Q

What is one of the major modified duke criteria that isn’t ECHO or blood cultures?

A

New valvular regurgitation

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33
Q

What are cardiac complications with infective endocarditis?

A

Heart failure
Perivalvular abscess (conduction disease like heart block)
Pericarditis

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34
Q

What are metastatic infection complications with infective endocarditis?

A 
Septic embolization (stroke, paralysis, splenic/renal infarction, pulmonary embolism
Metastatic abscess
Meningitis
Mycotic aneurysm
Osteomyelitis
Septic arthritis
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35
Q

What are renal complications with infective endocarditis?

A

Septic embolization

Glomerulonephritis with renal failure

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36
Q

What is the first thing you do after diagnosing infective endocarditis?

A

Obtain an infectious disease consult

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37
Q

What is initial therapy for infectious endocarditis?

A

Vancomycin

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38
Q

From when is the duration of antibiotics calculated in infective endocarditis?

A

From the first day the blood cultures or negative (usually 4-6 weeks)

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39
Q

Do cardiac devices need to be removed in infective endocarditis?

A

Maybe

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40
Q

When do you consider a surgical consult in patients with infective endcarditis?

A

Patients with complications

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41
Q

Which patients received endocarditis prophylaxis?

A

Hx of infective endocarditis
Hx of prosthetic heart valve replacement
Hx of valve repair with prosthetic material
Hx of cardiac transplantation with valvular regurgitation
Congenital heart disease
Dental procedures

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42
Q

Do patients with GI/GU procedures need endocarditis prophylaxis?

A

Not unless there is a known infection

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43
Q

What are examples of congenital heart disease that need endocarditis prophylaxis?

A

Unrepaired cyanotic disease
Repaired cyanotic disease with residual defects
Repaired cyanotic disease with prosthetic material within 6 months

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44
Q

Do patients with respiratory procedures need endocarditis prophylaxis?

A

Yes, those involving incision, biopsy, or respiratory tract

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45
Q

What is typically given as endocarditis prophylaxis?

A

Oral amoxicillian 2g 30-60 minutes before procedure

46
Q

What is myocarditis?

A

Inflammatory disease of the myocardium diagnosed by cardiac biopsy

47
Q

What are the three types of myocarditis?

A

Acute
Subacute
Chronic

48
Q

What are the causes of myocarditis?

A 
Idiopathic (don't know why)
Infectious (Cocksackie B)
Autoimmune (ANCA-vasculitis, giant cell,)
Cardiac toxins
Hypersensitivity reactions
Radiation
49
Q

What is pathogenesis of viral myocarditis?

A

Breakdown of T-cell tolerance to self myocardial antigens -> chronic myocytolysis due to humoral and/or cell-mediated organs-specific autoimmunity -> dilated cardiomyopathy

50
Q

What are the most common viral causes of myocarditis?

A

Cocksackie virus B
HHV 6
Parvovirus

51
Q

What is the clinical presentation ofmyocarditis?

A

Viral prodrome
New onset/worsening heart failure
Cardiac conduction abnormalities
Acute MI like syndrome

52
Q

What is seen in the new onset or worsening heart failure symptoms with myocarditis?

A 
DOE
Orthopnea
PND
LE edema
Weight gain
JVD
S3
53
Q

What is seen with acute MI infarction like syndrome with myocarditis?

A 
Chest pain
DOE
ST segment elevation/depression
Elevated troponins
Pleuritic chest pain
54
Q

How is the definitive diagnosis of myocarditis made?

A

Endomyocardial biopsy

55
Q

What imaging can be ordered when diagnosing myocarditis?

A

CXR (look for pulmonary edema, cardiomegaly)
ECG (look for ischemia, heart block)
ECHO (look for LV or RV dysfunction)
CMR (myocardial edema, myocardial necrosis)

56
Q

What laboratory testing should be order when diagnosing myocarditis?

A 
CBC with diff (leukocytosis)
Elevated ESR
Elevated CRP
Elevated troponin
Elevated BNP
57
Q

Patients with myocarditis that leads to heart failure should be treated with what?

A 
ACEi or ARB
Beta-blockers
Diuretics
Aldosterone-receptor blocker
Refractory heart failure (LV assist device, ECMO, cardiac transplant)
58
Q

What should be given for the bradycardia associated with myocarditis?

A

Transcutaneous pacing

Transvenous pacing

59
Q

What is the pericardium made of?

A 
Fibrous sac (outer)
Serous sac (inner double layered -> parietal layer, visceral layer)
60
Q

What are the four types of pericardial disease?

A

Pericarditis
Pericardial effusion
Cardiac tamponade
Constrictive pericarditis

61
Q

What are the types of pericarditis?

A

Acute
Subacute
Chronic
Recurrent (30%)

62
Q

What is pericarditis?

A

Inflammation of the pericardium

63
Q

What is pericardial effusion?

A

Normally only 15-50mL of serous fluid

64
Q

What is cardiac tamponade?

A

Life threatening accumulation of pericardial fluid that compresses the heart and impairs diastolic filling -> decreased cardiac output

65
Q

What is constrictive pericarditis?

A

Scarred, thickened, calcified pericardium which constricts the heart impairing cardiac filling and cardiac output

66
Q

What is the most common disorder involving the pericardium?

A

Acute pericarditis

67
Q

In the developed world what is the cause of acute pericarditis?

A

Idiopathic

Viral

68
Q

In the developing world what is the cause of acute pericarditis?

A

Tuberculosis

69
Q

What are the major causes of pericardial disease?

A

Idiopathic
Infectious (mainly viral)
Noninfectious

70
Q

What are the noninfectious causes of pericarditis?

A 
Autoimmune disease
Malignancy
Cardiac
Trauma
Metabolic
Radiation exposure
Drugs (rare)
71
Q

Radiation causes what type of pericarditis?

A

Restrictive pericarditis

72
Q

What are the clinical signs of acute pericarditis?

A

Pleuritic chest pain
Pain is worse lying flat or relieved by sitting up and leaning forward
Pericardial friction rub

73
Q

Where does pain often radiated in acute pericarditis?

A

Trapezius ridge or neck

74
Q

What are the diagnostic criteria for acute pericarditis?

A

AT LEAST 2

1) Pericardic chest pain
2) Pericardial rubs
3) New widespread ST-elevation or PR depression
4) Pericardial effusion

75
Q

What should be ordered when acute pericarditis is suspected?

A 
CBC w/ diff
Elevated ESR and CRP
Troponin I (suggest myocardial involvement)
CXR
ECHO
ECG changes
76
Q

What are the ECG changes seen with pericarditis?

A

ST-segment elevation

PR segment depression

77
Q

What can be seen on CXR and ECHO in pericarditis?

A

Pericardial effusion

78
Q

Is it important to find the definitive cause of acute pericarditis?

A

Nope because of the benign course

79
Q

Is pericardiocentesis therapeutic or diagnostic?

A

Both

80
Q

What is Beck’s triad?

A

1) Hypotension
2) Muffled heart sounds
3) JVD

81
Q

What is Beck’s triad symptoms for?

A

Cardiac tamponade

82
Q

What is the tachycardia seen in cardiac tamponade due to?

A

Compensatory mechanism given low stroke volume

83
Q

What is heart with cardiac tamponade?

A

Pericardial friction rub

84
Q

What jugular waveforms are seen with cardiac tamponade?

A

Absent y descent

lack of RV filling because it’s compressed

85
Q

What is pulsus paradoxus?

A

Abnormally large decrease in systolic BP during inspiration > 10 mmHg

86
Q

What is pulsus paradoxus seen with?

A

Cardiac tamponade

87
Q

What ECG changes are seen with cardiac tamponade?

A

Electrical alternans

Low voltage QRS

88
Q

What is electrical alternans?

A

Alternating amplitude of QRS complex in any lead (often precordial leads)

89
Q

What is the a wave on JVW?

A

Right atrial contraction

90
Q

What is the c wave on JVW?

A

Right ventricular contraction causes tricuspid valve to close and bulge in the right atria

91
Q

What is the v wave on JVW?

A

Right atrial filling

92
Q

What is the x descent on JVW?

A

Right atrial relaxation

93
Q

What is the y descent on JVW?

A

Right ventricular filling

94
Q

What is seen on CXR in cardiac tamponade?

A

Water bottle sign (enlarged cardiac silhouette)

95
Q

What is seen on ECG with cardiac tamponade and pericarditis?

A

ST elevation/PR depression
Low voltage QRS
Electrical alteranas

96
Q

What is seen on ECHO with cardiac tamponade?

A

Large pericardial effusion
Cardiac chamber collapse (right chambers)
Dilated IVC

97
Q

What are the most common causes of cardiac tamponade?

A 
Pericarditis
Tuberculosis
Iatrogenic
Trauma
Neoplasm/malignancy
98
Q

What are the clinical manifestations of constrictive pericarditis?

A

Volume over load (peripheral edema, anasarca, hepatomegaly)

Reduced cardiac output (DOE, fatigue, exercise intolerance)

99
Q

What is seen on physical exam with constrictive pericarditis?

A

Jugular venous distension
Pulsus paradoxus
Kussmaul’s sign
Pericardial knock

100
Q

What jugular venous waveform changes are seen with constrictive percarditis?

A

Prominent X descent

Prominent Y descent

101
Q

What is Kussmaul’s sign?

A

JVP fails to decrease with inspiration (or in some cases increases during inspiration)
Fixed diastolic volume right heart

102
Q

What is a pericardial knock?

A

High pitched diastolic sound that results from abrupt cessation in ventricular filling

103
Q

What is constrictive pericarditis difficult to distinguish between?

A

Restrictive cardiomyopathy

104
Q

How do you diagnose constrictive pericarditis?

A

CXR (pericardial calcification)
ECG
ECHO (increased pericardial thickness, dilated IVC, bi-atrial enlargement)
Cardiac MR and CT (pericardial thickening, pericardial calcifications)
Cardiac catheterization

105
Q

What is seen on CXR in constrictive pericarditis?

A

Pericardial calcifications

106
Q

What is cardiac catheterization in the case of constrictive pericarditis reserved for?

A

Patients in which non-invasive tests are non-diagnostic

107
Q

What is seen on cardiac catheterization with constrictive pericarditis?

A

Increased atrial pressures
Equalization of end-diastolic amongst all chambers
Square root sign of ventricular diastolic pressure
Respiratory variation

108
Q

What is the management for acute pericarditis?

A

NSAIDs

Colchine

109
Q

What NSAIDs are given for acute pericarditis?

A

Indomethacin

110
Q

When are glucocorticoids given for acute pericarditis?

A

When the patient can’t take NSAIDs

Associated with recurrent pericarditis

111
Q

What is the management for cardiac tamponade?

A

Therapeutic pericardiocentesis

112
Q

What is the management for constrictive pericarditis?

A

Pericardiectomy

CPR 2 Exam 1 (20 decks)

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