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CPR II Exam 1 > DSA: Clinical Approach to Endocarditis, Myocarditis, and Pericarditis (Selby) > Flashcards

DSA: Clinical Approach to Endocarditis, Myocarditis, and Pericarditis (Selby) Flashcards

1
Q

What is the difference in development of Acute vs Subacute Infective Endocarditis?

A

Acute: typically from STAPH AUREUS infection

  • develops on normal heart valve endothelium
  • fatal in < 6 wks if untreated

Subacute: STREP VIRIDANS or enterococcus

  • develops on damaged heart valve endothelium
  • fatal in > 6 wks if untreated
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2
Q

What are Marantic Endocarditis and Libman-Sacks Endocarditis?

A

ME: non-bacterial thrombotic endocarditis

  • sterile platelet vegetation
  • seen in pts. w/metastatic malignancy (autopsy)

LSE: non-bacterial verrucous endocarditis

  • sterile platelet vegetation
  • seen in pts. with Systemic Lupus Erythematous

pts. present with new cardiac murmur in setting of embolic disease

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3
Q

What are 6 risk factors of Infective Endocarditis? (A/M/IV/D/SHD/ID)

A
  1. older Age (> 60 yo)
  2. Male sex
  3. IV drug use (RIGHT-SIDED; S. Aureus)
  4. poor Dentition or dental infection
  5. Structural Heart Disease
  6. Implanted cardiac device (pacemaker or ICD)
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4
Q

Infective Endocarditis Causes

What is Streptococcus Bovis associated with and what are the 5 HACEK organisms?

A

SB: can cause infective endocarditis
- associated with colon cancer or IBD

HACEK
- fastidious gram - bacilli (no blood culture growth)

haemophilus, actinobacillus, cardiobacterium, eiknella, kingella

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5
Q

What are the 4 classical presentations of Infective Endocarditis?

What are 4 common physical exam findings? (SH/ON/JL/RS)

A

CP: fever > 38.0 C, constitutional symptoms, new cardiac murmur (regurgitation), vascular embolic events

PE:

  • Splinter Hemorrhage (embolic event of nail)
  • Osler’s Nodes (raised, red, painful lesions on ext.)
  • Janeway Lesions (red, flat, painless; palms/fingers)
  • Roth Spots (retinal hemorrhage w/white center)
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6
Q

What is used to diagnose Infective Endocarditis?

A

Modified Duke Criteria

  • Echocardiography (TTE first, TEE if TTE negative)
  • Blood Culture (draw before starting Abx)

Pathologic Criteria: lesions and microorganism culture
Clinical Criteria: 2 major or 1 major/3 minor, or 5 minor
- positive blood culture, persistent (+)
- ECHO (+) or new valvular regurgitation

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7
Q

How is Infective Endocarditis treated?

A
  • infectious disease consult –> use VANCOMYCIN
    • Abx should cover MSSA/MRSA, Strep, Entero
  • possibly remove cardiac devices
  • possible surgical consult for pts. with complications
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8
Q

What are 6 reasons for Endocarditis Prophylaxis? (IE/HVR/CVR/T/CHD/DP)

A

history of: infective endocarditis, prosthetic heart valve replacement, cardiac valve repair w/prosthetic material, cardiac Transplant w/valvular regurg.

  • congenital heart disease and dental procedures

prophylaxis NOT required for GI/GU procedures unless there is KNOWN infection

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9
Q

What is Myocarditis and what are its two main causes?

What does viral myocarditis lead to in pts. with a genetic predisposition to autoimmunity?

A
  • inflammatory disease of myocardium diagnosed by cardiac biopsy
    causes: idiopathic and infections (Viral = COXSACKIE B VIRUS; Parvovirus B19, HHV-6)
  • virus can initiate a chronic autoimmune myocarditis leading to DILATED CARDIOMYOPATHY (T-Cell self-tolerance breakdown)
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10
Q

How does Myocarditis typically present? (3 patterns)

How can Myocarditis be diagnosed?

A

P: new onset/worsening heart failure, cardiac conduction abnormalities, acute MI-like syndrome
- usually viral infection symptoms a few wks prior

D: definitive diagnosis via endomyocardial biopsy (EMB) –> will biopsy alter patient management?

  • can image w/Chest X-Ray, ECG, ECHO, CMR
  • CMR = Cardiovascular Magnetic Resonance
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11
Q

What 5 drugs are used to treat and manage pts. with viral myocarditis? (A/A/B/D/A)

How can bradycardia in these pts. be treated?

A

Drugs: ACE inhibitors, angiotensin II receptor blockers, B-blockers, diuretics, aldosterone-receptor blockers

  • treat Bradycardia with transcutaneous pacing or transvenous pacing
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12
Q

What is the difference between Cardiac Tamponade and Constrictive Pericarditis?

A

CT: life-threatening accumulation of pericardial fluid that compresses the heart, impairing diastolic filling and dec. cardiac output

CP: from scarred, thickened, frequently calcified pericardium which constricts the heart, impairing cardiac filling and cardiac output

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13
Q

What is the difference in cause of acute pericarditis between the developed and developing world?

A

Developed World: either idiopathic or viral

Developing World: tuberculosis

do no need to determine the exact etiology in most patients

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14
Q

What is the classical presentation of Acute Pericarditis?

What does the pain feel like and where does it radiate to?

A
  • sudden onset chest pain that is PLEURITIC (exacerbated by inspiration) and radiates to trapezius ridge or neck
  • pain is worse when lying flat and relieved by sitting up or leaning forward
  • pericardial friction rub can be heard on auscultation
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15
Q

What are the four criteria that can help diagnose inflammatory pericardial syndrome? (CP/R/ECG/PE)

A
  1. pericarditic chest pain
  2. pericardial rubs
  3. new widespread ST-elevation or PR depression on ECG
  4. pericardial effusion (new or worsening)
  • get CBC w/diff, check for elevated ESR/CRP and troponin
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16
Q

What is the classical presentation of Cardiac Tamponade? (BT/PFR/JVW/PP)

What is Pulsus paradoxus?

A

CP:

  • Beck’s Triad: hypotension/muffled heart sounds/JVD
  • pericardial friction rub
  • jugular venous waveforms (absent y descent)
  • pulsus paradoxus

Pulsus Paradoxus: abnormally large dec. in systolic BP during inspiration (> 10 mmHg)

17
Q

What ECG changes are associated with Cardiac Tamponade?

A
  • electrical alternans = alternating amplitude of QRS complex in any lead (reduced amplitude then higher amplitude)
  • low voltage (amplitude) QRS complexes
18
Q

How do Chest X-Rays, ECG, and ECHO help diagnose Cardiac Tamponade?

A

CXR: enlarged cardiac silhouette (water-bottle sign)

ECG: electrical alternans, low voltage QRS, ST elevation/PR segment depression

ECHO: large pericardial effusion, cardiac chamber collapse (diastolic right atrial collapse)

19
Q

What are the two manifestations of Constrictive Pericarditis?

What are 4 physical exam findings of disease? (JVD/PP/KS/PK)

A
  1. symptoms of volume overload
    • right heart failure w/preserved right/left vent. function
  2. symptoms of reduced cardiac output

PE:

  • Jugular Venous Distension (prominent X/Y descent)
  • Pulsus Paradoxus
  • Kussmaul’s Sign - JVP fails to dec. w/inspiration
  • Pericardial Knock -high pitched diastolic sound
20
Q

How do Chest X-Rays, ECHO, and CMR help diagnose Constrictive Pericarditis?

A

CXR: pericardial calcifications present

ECHO: inc. pericardial thickness, dilated IVC, bi-atrial enlargement

CMR: pericardial thickening or calcifications

21
Q

What is the treatment for Acute Pericarditis, Cardiac Tamponade, and Restrictive Pericarditis?

A

AP: NSAIDs (Indomethacin) and Colchicine
- treat underlying etiology, avoid strenuous exercise

CT: therapeutic pericardiocentesis

RP: pericardiectomy (definitive therapy)

CPR II Exam 1 (15 decks)

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