Endocarditis, Myocarditis, and Pericarditis

Question 1

how can endocarditis be classified?

Answer 1

infective, non-bacterial thrombotic, non-bacterial verrucous

Question 2

what is the typical cause of acute infective endocarditis?

Answer 2

s. aureus (highly virulent)

Question 3

what is the typical cause of subacute infective endocarditis?

Answer 3

less virulent bacteria like strep viridans or enterococcus

Question 4

where does acute infective endocarditis occur?

Answer 4

develops on normal heart valve endothelium

Question 5

where does subacute infective endocarditis occur?

Answer 5

on damaged heart valve endothelium

Question 6

what is another name for non-infective thrombotic endocarditis?

Answer 6

marantic endocarditis

Question 7

when is marantic endocarditis usually seen?

Answer 7

in patients with metastatic malignancy; at autopsy

Question 8

what is another name for non-bacterial verrucous endocarditis?

Answer 8

Libman-Sacks endocarditis

Question 9

when is Libman-Sack endocarditis typically seen?

Answer 9

in patients with SLE

Question 10

how do patients with non-bacterial endocarditis typically present?

Answer 10

with a new cardiac murmur in setting of embolic disease

Question 11

IV drug users are at risk for what type of endocarditis?

Answer 11

infective, right-sided endocarditis

Question 12

what is the classic presentation of infective endocarditis?

Answer 12

fever, constitutional symptoms such as: anorexia, weight loss, night sweats; new cardiac murmur (typically regurgitation), vascular embolic events

Question 13

what physical exam findings would you expect to see in a patient with infective endocarditis?

Answer 13

splenomegaly, petechiae, splinter hemorrhages, osler’s nodes, janeway lesion, roth spots

Question 14

if you get a patient with infective endocarditis, how would you go about diagnosing them?

Answer 14

by using the modified duke criteria

Question 15

what goes into the modified duke criteria?

Answer 15

echocardiography and blood cultures

Question 16

what are the cardiac complications associated with infective endocarditis?

Answer 16

heart failure, perivalvular abscess, pericarditis

Question 17

what are the general complications that infective endocarditis can lead to?

Answer 17

cardiac complications, metastatic infection, or renal complications

Question 18

how do you treat and manage a patient with infective endocarditis?

Answer 18

empiric abx–> vancomycin; duration of antibiotics is calculated from the first day the blood cultures are negative so obtain blood cultures every 1-2 days until negative; typical IV abx duration is 4-6 weeks depending on type of infection

Question 19

who is considered to be a high risk patient for endocarditis?

Answer 19

those with hx of infective endocarditis, hx of prosthetic heart valve replacement, hx of cardiac valve repair with prosthetic material, hx of cardiac transplantation with valvular regurgitation, and those with congenital heart dx; those with dental procedures

Question 20

what are 3 examples of viruses that cause viral myocarditis?

Answer 20

coxsackie B virus, HPV 6, parvovirus

Question 21

what are the clinical manifestations of myocarditis?

Answer 21

variable: subclinical disease to sudden cardiac death

Question 22

most myocarditis patients present with one of 3 patterns, what are they?

Answer 22

new onset or worsening heart failure, cardiac conduction abnormalities, and acute MI like syndrome

Question 23

how is definitive diagnosis of myocarditis made?

Answer 23

endomyocardial biopsy

Question 24

how should you treat viral myocarditis?

Answer 24

ACEi/ARB, beta blockers, diuretics, aldosterone receptor blocker

Question 25

how is the pericardium composed?

Answer 25

fibrous sac and a serous sac, which is further broken down into a parietal layer and a visceral layer

Question 26

what are the two most common causes of acute pericarditis?

Answer 26

idiopathic or viral (developed world); undeveloped world: tuberculosis

Question 27

how does acute pericarditis present?

Answer 27

many patients will report a viral prodromal illness that precedes the development of pericarditis; CP-pain is worse lying flat and relieved by sitting forward

Question 28

what EKG changes would you expect to see in a patient with acute pericarditis?

Answer 28

new widespread ST-segment elevation and/or PR segment depression

Question 29

what is the classic presentation of cardiac tamponade?

Answer 29

Beck’s triad: hypotension, muffled heart sounds, JVD; pericardial friction rub, jugular venous waveforms; pulsus paradoxus

Question 30

what are the jugular venous waveforms seen in cardiac tamponade?

Answer 30

absent y descent because of lack of right ventricular filling (ventricle is compressed) by fluid

Question 31

what is pulsus paradoxus seen in cardiac tamponade?

Answer 31

abnormally large decrease in systolic blood pressure during inspiration

Question 32

what EKG changes would you expect to see in cardiac tamponade?

Answer 32

electrical alterans and low voltage QRS complexes

Question 33

what is electrical alterans?

Answer 33

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

Question 34

how do you make the diagnosis of cardiac tamponade?

Answer 34

CXR: shows enlarged cardiac silhoutte; ecg; ECHO: large pericardial effusion present