Clinical Medicine 2: Carditis (Selby GOAT) Flashcards by Monika Eszterhazy

What is acute infective endocarditis?

Staph Aureus

develops on normal heart valve endothelium

fatal in <6wks if not treated

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What is subacute infective endocarditis?

less virulent, S. viridans, Enterococcus

develops on damaged heart valve endothelium

fatal >6wks if not treated

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What is non-bacterial thrombotic endocarditis

(Marantic endocarditis)

sterile platelet vegetations on cardiac valves

seen in pt’s with metastatic cancer

found on autopsy

may present with new onset murmur

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What is non-bacterial verrucous endocarditis

(libman-sacks)

sterile platelet vegetations on cardiac valves

typically seen in patients with SLE

may have new onset murmur

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What are risk factors for infective endocarditis?

older age

male

IV drug use (right sided)

poor dentition

structural heart disease

implanted device

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What bacteria is the most common cause of right sided endocarditis among IV drug users

S. Aureus

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Frequency of infective endocarditis by various micro-organisms

Staph A. (31%)

Strep Viridians (17%)

Enterococci (11%)

Strep Bovis (7%) - often with Colon Cancer or IBD

HACEK (2%)

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HACEK bacteria include the following and are a small cause of infective endocarditis?

Fastidious g- bacilli

Haemophilus

Actinobacillis

Cardiobacterium

Eiknella

Kingella

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What is the classical presentation of infective endocarditis?

Fever

Constitutional sx (anorexia, weight, night sweats, etc)

new cardiac murmur

vascular embolic events (ischemic stroke, renal infarction, splenic infarction)

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What are the physical exam findings for infective endocarditis

splenomegaly

petechiae

splinter hemorrhages

osler’s nodes

Janeway lesion

Roth spots

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What is he Modified Duke Criteria?

Echocardiography (TTE, but can get TEE if TTE is negative but suspicion is high)

Blood cultures (must draw before starting abx)

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Dx criterai for IE

2 major clinical (pos blood culture, echo, or new regurg)

1 major and 3 minor

5 minor (predesposition, fever, vascular phenomena, immunologic phenomena, micro evidence)

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What are the cardiac complications of infective endocarditis?

heart failure

abscess

pericarditis

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What are metastatic infections as a result of infective endocarditis?

septic embolization leading to stroke, paralysis, infarct of other organs, PE, etc.

metastatic abscess

meningitis

mycotic aneurysm

osteomyelitis

septic arthritis

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What are the renal complications of infective endocarditis?

septic embolization

glomerulonepthritis with renal failure

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What is the management for infective endocarditis?

Infectious disease consult and consider Vancomycin

may need to remove cardiac devices

consider surg. consult for patients with complications

When is endocarditis prophylaxis used?

Only in high risk patients

Hx of infective endocarditis

hx of prosthetic heart valve replacement

hx of cardiac valve repair with prosthetic material

hx of cardiac transplant with valve regurg.

congenital heart disease

before dental procedures (periapical or gingival procedures)

not indicated for GI/GU precedures unless known infection

What is myocarditis?

inflammatory disease of mycardium diagnosed by bx

What are the main causes of myocarditis?

idiopathic

infectious: viral >> bacterial

coxaskie B, HHV6, ParvoB19

Others:

SLE, Anca vasculitis, gient-cell myocarditis

Cardiac toxins (etoh, cocaine, etc)

Hypersensitivity

Radiation

What is the clinical presentation for myocarditis?

varies, but can lead to sudden cardiac death

recent viral infection weeks prior to developing myocarditis

What are the three patterns of presentation for myocarditis?

Most myocarditis Pts present with the following 3 patterns:

1) new onset or worsening heart failure (SOB, DOE, etc.)
2) cardiac conduction abnormalities (arrhythmias, HB, etc)
3) acute myocardial infarction-like syndrome (EKG abnormalities such as ST, TWI, troponins, etc.)

How is a definitive diagnosis of myocarditis made?

What images are taken?

What labs?

Endomyocardial biopsy

CXR, ECG, Echo, CMR

CBC with diff (leukocytosis), elevated ESR/CRP, elevated cardiac enzymes, elevated BNP

What is the standard treatment for myocarditis?

ACEi or ARB

B-blockers

Diuretics

Aldsoterone receptor blocker

refractory heart failure devices (LVAD, ECMO, transplant)

antiarrhymthmic therapy as needed

heart pacers

Pericarditis can lead to what life-threatening state?

Cardiac tamponade with the accumulation of pericardial fluid that compresses the heart and impairs diastolic filling and decreases cardiac output

more likely to be acute

What is constrictive pericarditis?

results from scarred, thickened and frequently calcified pericardium which constricts the heart and impairing cardiac filling and cardiac output - more likely to be **chronic**

What is the epidemiology of pericarditis?

**rare,** but most common disease of pericardium **iodiopthic or viral**, most cases in developing world are from **TB** diagnosing etiology is not necessary in most patients UNLESS TB!

What are the major causes of pericardial disease?

idiopathic infectious (viral and then bacterial) noninfectious (autoimmune, malignancy, cardiac, trauma, metabolic/uremic, radiation, etc)

What are the clinical manifestations of acute pericarditis?

chest pain radiating to _trapezius ridge_ pain worsens with lying flat, better with sitting up/forward (tripod) pericardial friction rub dyspnea fever leukocytosis

Dx criteria for Acute Pericarditis

2 of the 4 following criteria 1) pericarditic chest pain 2) pericardial rubs 3) new widespread ST elevation or PR depression of ECG 4) pericardial effusion Additional supporting findings include: elevated inflamm markers such as ESR, CRP, and WBC....and evidence of inflammation by imaging

What labs/imaging are ordered for suspected pericarditis?

CBC with diff elevated ESR and CRP Troponin I CXR ECHO ECG changes **most of the time a definitive cause of the acute pericarditis is not given and the course is relatively benign**

What is Beck's Triad for Cardiac Tamponade? What other features may be present

Hypotension Muffled heart sounds JVD may also see: Pericardial friction rubs JV waveforms Pulsus peadoxus ECG changes with electrical alternans and low voltage QRS

Clinical manifestation of Cardiac Tamponade

**_Beck's triad_** ( hyptension, muffled sounds, JVD) Nonspecific findings: angine, dyspnea, fatigue, tachy, etc **_Pericardial friction rub_** **Pulsus paradoxus** **_Absent y descent on JVP_** curve d/2 constricted RV ECG Changes 1 ) alternating amplitude of QRS, or 2) low amplitude QRS

What are the images/studies ordered for cardiac tamponade?

**CXR** with _water bottle_ sign **ECG** (electrical alterans, low amplitude QRS, ST elevation and/or PR depression) **ECHO** (effusion, chamber collapse, dilated IVC)

What are the clinical manifestations of constrictive pericarditis?

volume overload and reduced cardiac output **_JVD with prominent x and y descends_** **Pulsus paradoxus** **Kussmaul sign** (JVP fails to decrease, or may even increase during inspiration) **ECG Changes** (alternating amplitude of QRS) **Pericardial knock** (abrupt cessation of ventricular filling) difficult to distinguish from restrictive cardiomyopathy

What is ordered for constrictive pericarditis?

CXR with pericardial calcifications ECG with no specific changes ECHO CMR and or CT Cardiac cath

What is the treatment for acute pericarditis?

treat underlying cause if possible avoid strenuous exercise untile sx are better NSAIDs (indomethacin), Cochicine, Glucocorticoids

What is the treatment for cardiac tamponade?

therapuetic pericadiocentesis to remove fluid

What is the treatment for constrictive pericarditis?

pericardiectomy

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Clinical Medicine 2: Carditis (Selby GOAT) Flashcards

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