Clinical Medicine: Carditis Flashcards
What is acute infective endocarditis?
Staph Aureus
develops on normal heart valve endothelium
fatal in <6wks if not treated
What is subacute infective endocarditis?
less virulent, S. viridans, Enterococcus
develops on damaged heart valve endothelium
fatal >6wks if not treated
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
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
What are risk factors for infective endocarditis?
older age
male
IV drug use (right sided)
poor dentition
structural heart disease
implanted device
What bacteria is the most common cause of right sided endocarditis among IV drug users
S. Aureus
HACEK bacteria include the following and are a small cause of infective endocarditis?
Fastidious g- bacilli
Haemophilus
Actinobacillis
Cardiobacterium
Eiknella
Kingella
What is the classical presentation of infective endocarditis?
Fever
Constitutional sx
new cardiac murmur
vascular embolic events
What are the physical exam findings for infective endocarditis
splenomegaly
petechiae
splinter hemorrhages
osler’s nodes
Janeway lesion
Roth spots
What is he Modified Duke Criteria?
Echocardiography
Blood cultures (must draw before starting abx)
What are the cardiac complications of infective endocarditis?
heart failure
abscess
pericarditis
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
What are the renal complications of infective endocarditis?
septic embolization
glomerulonepthritis with renal failure
What is the management for infective endocarditis?
Infectious disease consult and consider Vanc
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
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 (mainly viral-coxaskie B, HHV6, ParvoB19)
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?
new onset or worsening heart failure
cardiac conduction abnormalities
acute myocardial infarction-like syndrome
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
what is constrictive pericarditis?
results from scarred, thickened and frequently calcified pericardium which constricts the heart and impairing cardiac filling and cardiac output
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
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 trap
pain worsens with lying flat, better with sitting up/forward
pericardial friction rub
dyspnea
fever
leukocytosis
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
What are the images/studies ordered for cardiac tamponade?
CXR with water bottle sign
ECG
ECHO
What are the clinical manifestations of constrictive pericarditis?
volume overload
reduced cardiac output
JVD
Pulsus paradoxus
Kussmaul’s sign
Pericardial knock
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
