Clinical Cardiac Part 2 Flashcards
What are the classifications of endocarditis?
Infective
Non-bacterial thrombotic endocarditis
Non-bacterial verrucous endocarditis
What are the two type of infective endocarditis?
Acute
Subacute
What typically causes acute infective endocarditis?
Staph aureus
Staph aureus infects what type of heart valves?
Normal heart valve endothelium
Is acute infective endocarditis fatal?
Yes within 6 weeks without treatment
What typically causes subacute infective endocarditis?
Streptococcus viridans
Enterococcus
Where does subacute infective endocarditis infect?
Damaged heart valve endothelium
Is subacute infective endocarditis fatal?
Yes but takes longer than 6 weeks to die
What is Marantic endocarditis?
Sterile platelet vegetations on cardiac valves
In what patient population is Marantic endocarditis typically found?
Patients with metastatic malignancy
What is Libman-Sacks endocarditis?
Sterile platelet vegetations on cardiac valves
What patient population is Libman-Sack endocarditis found?
SLE patients
What endocarditis presents with new cardiac murmur in setting embolic disease?
Non-bacterial thrombic/verrucous endocarditis
What are the risk factors for infective endocarditis?
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
IV drug use present with what sided endcarditis?
Right
What structural heart disease cause an increased risk for infective endocarditis?
Rheumatic heart disease Mitral valve prolapse Bicuspid aortic valve Congenital heart disease Prosthetic heart valve repalcement
What implantable cardiac devices increase a patient’s risk for infective endocarditis?
Pacemaker
Implantable cardioverter defibrillator
What is the pathogenesis of infective endocarditis?
Endothelial injury -> bacteremia -> pathogen adheres to valve surface -> proliferation of bacteria -> embolization of vegetation particles -> complications
Does staph aureus need endothelial damage to develop infective endocarditis?
No
What are the most common pathogens in infective endocarditis?
Staph aureus Strep viridans Enterococci Strep bovis HACEK
What is strep bovis associated with?
Colon cancer or IBD
What are the HACEK organisms?
Haemophilus Actinobacillus Cardiobacterium Eiknella Kingella
What are the clinical symptoms associated with infective endocarditis?
Fever (of unknown origin)
Constitutional symptoms (anorexia, weight loss, night sweats)
New cardiac murmur (regurgitation)
Vascular embolic events
What are the physical exam findings for infective endocarditis?
Petechiae Splinter hemorrhages Osler's nodes Janeway lesions Roth spots
What are splinter hemorrhages?
Emboli phenomenon
What are osler’s nodes?
Red, raised, painful lesions in distal extremities (immunologic phenomenon)
What are Janeway lesions?
Red, flat, painless lesions often on palms or fingers as a result of embolic phenomenon
What are Roth spots?
Retinal hemorrhages with white centers (immunologic phenomenon)
How do you diagnose infective endocarditis?
Modified Duke Criteria
What is the Modified Duke Criteria?
Echocardiography TTE then TEE Blood cultures (must draw before starting antibiotics)
How are most people diagnosed with infective endocarditis?
Clinically
What is one of the major modified duke criteria that isn’t ECHO or blood cultures?
New valvular regurgitation
What are cardiac complications with infective endocarditis?
Heart failure
Perivalvular abscess (conduction disease like heart block)
Pericarditis
What are metastatic infection complications with infective endocarditis?
Septic embolization (stroke, paralysis, splenic/renal infarction, pulmonary embolism Metastatic abscess Meningitis Mycotic aneurysm Osteomyelitis Septic arthritis
What are renal complications with infective endocarditis?
Septic embolization
Glomerulonephritis with renal failure
What is the first thing you do after diagnosing infective endocarditis?
Obtain an infectious disease consult
What is initial therapy for infectious endocarditis?
Vancomycin
From when is the duration of antibiotics calculated in infective endocarditis?
From the first day the blood cultures or negative (usually 4-6 weeks)
Do cardiac devices need to be removed in infective endocarditis?
Maybe
When do you consider a surgical consult in patients with infective endcarditis?
Patients with complications
Which patients received endocarditis prophylaxis?
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
Do patients with GI/GU procedures need endocarditis prophylaxis?
Not unless there is a known infection
What are examples of congenital heart disease that need endocarditis prophylaxis?
Unrepaired cyanotic disease
Repaired cyanotic disease with residual defects
Repaired cyanotic disease with prosthetic material within 6 months
Do patients with respiratory procedures need endocarditis prophylaxis?
Yes, those involving incision, biopsy, or respiratory tract
What is typically given as endocarditis prophylaxis?
Oral amoxicillian 2g 30-60 minutes before procedure
What is myocarditis?
Inflammatory disease of the myocardium diagnosed by cardiac biopsy
What are the three types of myocarditis?
Acute
Subacute
Chronic
What are the causes of myocarditis?
Idiopathic (don't know why) Infectious (Cocksackie B) Autoimmune (ANCA-vasculitis, giant cell,) Cardiac toxins Hypersensitivity reactions Radiation
What is pathogenesis of viral myocarditis?
Breakdown of T-cell tolerance to self myocardial antigens -> chronic myocytolysis due to humoral and/or cell-mediated organs-specific autoimmunity -> dilated cardiomyopathy
What are the most common viral causes of myocarditis?
Cocksackie virus B
HHV 6
Parvovirus
What is the clinical presentation ofmyocarditis?
Viral prodrome
New onset/worsening heart failure
Cardiac conduction abnormalities
Acute MI like syndrome
What is seen in the new onset or worsening heart failure symptoms with myocarditis?
DOE Orthopnea PND LE edema Weight gain JVD S3
What is seen with acute MI infarction like syndrome with myocarditis?
Chest pain DOE ST segment elevation/depression Elevated troponins Pleuritic chest pain
How is the definitive diagnosis of myocarditis made?
Endomyocardial biopsy
What imaging can be ordered when diagnosing myocarditis?
CXR (look for pulmonary edema, cardiomegaly)
ECG (look for ischemia, heart block)
ECHO (look for LV or RV dysfunction)
CMR (myocardial edema, myocardial necrosis)
What laboratory testing should be order when diagnosing myocarditis?
CBC with diff (leukocytosis) Elevated ESR Elevated CRP Elevated troponin Elevated BNP
Patients with myocarditis that leads to heart failure should be treated with what?
ACEi or ARB Beta-blockers Diuretics Aldosterone-receptor blocker Refractory heart failure (LV assist device, ECMO, cardiac transplant)
What should be given for the bradycardia associated with myocarditis?
Transcutaneous pacing
Transvenous pacing
What is the pericardium made of?
Fibrous sac (outer) Serous sac (inner double layered -> parietal layer, visceral layer)
What are the four types of pericardial disease?
Pericarditis
Pericardial effusion
Cardiac tamponade
Constrictive pericarditis
What are the types of pericarditis?
Acute
Subacute
Chronic
Recurrent (30%)
What is pericarditis?
Inflammation of the pericardium
What is pericardial effusion?
Normally only 15-50mL of serous fluid
What is cardiac tamponade?
Life threatening accumulation of pericardial fluid that compresses the heart and impairs diastolic filling -> decreased cardiac output
What is constrictive pericarditis?
Scarred, thickened, calcified pericardium which constricts the heart impairing cardiac filling and cardiac output
What is the most common disorder involving the pericardium?
Acute pericarditis
In the developed world what is the cause of acute pericarditis?
Idiopathic
Viral
In the developing world what is the cause of acute pericarditis?
Tuberculosis
What are the major causes of pericardial disease?
Idiopathic
Infectious (mainly viral)
Noninfectious
What are the noninfectious causes of pericarditis?
Autoimmune disease Malignancy Cardiac Trauma Metabolic Radiation exposure Drugs (rare)
Radiation causes what type of pericarditis?
Restrictive pericarditis
What are the clinical signs of acute pericarditis?
Pleuritic chest pain
Pain is worse lying flat or relieved by sitting up and leaning forward
Pericardial friction rub
Where does pain often radiated in acute pericarditis?
Trapezius ridge or neck
What are the diagnostic criteria for acute pericarditis?
AT LEAST 2
1) Pericardic chest pain
2) Pericardial rubs
3) New widespread ST-elevation or PR depression
4) Pericardial effusion
What should be ordered when acute pericarditis is suspected?
CBC w/ diff Elevated ESR and CRP Troponin I (suggest myocardial involvement) CXR ECHO ECG changes
What are the ECG changes seen with pericarditis?
ST-segment elevation
PR segment depression
What can be seen on CXR and ECHO in pericarditis?
Pericardial effusion
Is it important to find the definitive cause of acute pericarditis?
Nope because of the benign course
Is pericardiocentesis therapeutic or diagnostic?
Both
What is Beck’s triad?
1) Hypotension
2) Muffled heart sounds
3) JVD
What is Beck’s triad symptoms for?
Cardiac tamponade
What is the tachycardia seen in cardiac tamponade due to?
Compensatory mechanism given low stroke volume
What is heart with cardiac tamponade?
Pericardial friction rub
What jugular waveforms are seen with cardiac tamponade?
Absent y descent
lack of RV filling because it’s compressed
What is pulsus paradoxus?
Abnormally large decrease in systolic BP during inspiration > 10 mmHg
What is pulsus paradoxus seen with?
Cardiac tamponade
What ECG changes are seen with cardiac tamponade?
Electrical alternans
Low voltage QRS
What is electrical alternans?
Alternating amplitude of QRS complex in any lead (often precordial leads)
What is the a wave on JVW?
Right atrial contraction
What is the c wave on JVW?
Right ventricular contraction causes tricuspid valve to close and bulge in the right atria
What is the v wave on JVW?
Right atrial filling
What is the x descent on JVW?
Right atrial relaxation
What is the y descent on JVW?
Right ventricular filling
What is seen on CXR in cardiac tamponade?
Water bottle sign (enlarged cardiac silhouette)
What is seen on ECG with cardiac tamponade and pericarditis?
ST elevation/PR depression
Low voltage QRS
Electrical alteranas
What is seen on ECHO with cardiac tamponade?
Large pericardial effusion
Cardiac chamber collapse (right chambers)
Dilated IVC
What are the most common causes of cardiac tamponade?
Pericarditis Tuberculosis Iatrogenic Trauma Neoplasm/malignancy
What are the clinical manifestations of constrictive pericarditis?
Volume over load (peripheral edema, anasarca, hepatomegaly)
Reduced cardiac output (DOE, fatigue, exercise intolerance)
What is seen on physical exam with constrictive pericarditis?
Jugular venous distension
Pulsus paradoxus
Kussmaul’s sign
Pericardial knock
What jugular venous waveform changes are seen with constrictive percarditis?
Prominent X descent
Prominent Y descent
What is Kussmaul’s sign?
JVP fails to decrease with inspiration (or in some cases increases during inspiration)
Fixed diastolic volume right heart
What is a pericardial knock?
High pitched diastolic sound that results from abrupt cessation in ventricular filling
What is constrictive pericarditis difficult to distinguish between?
Restrictive cardiomyopathy
How do you diagnose constrictive pericarditis?
CXR (pericardial calcification)
ECG
ECHO (increased pericardial thickness, dilated IVC, bi-atrial enlargement)
Cardiac MR and CT (pericardial thickening, pericardial calcifications)
Cardiac catheterization
What is seen on CXR in constrictive pericarditis?
Pericardial calcifications
What is cardiac catheterization in the case of constrictive pericarditis reserved for?
Patients in which non-invasive tests are non-diagnostic
What is seen on cardiac catheterization with constrictive pericarditis?
Increased atrial pressures
Equalization of end-diastolic amongst all chambers
Square root sign of ventricular diastolic pressure
Respiratory variation
What is the management for acute pericarditis?
NSAIDs
Colchine
What NSAIDs are given for acute pericarditis?
Indomethacin
When are glucocorticoids given for acute pericarditis?
When the patient can’t take NSAIDs
Associated with recurrent pericarditis
What is the management for cardiac tamponade?
Therapeutic pericardiocentesis
What is the management for constrictive pericarditis?
Pericardiectomy
