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Cardiology 2 > Endocarditis, Pericarditis, Tamponade > Flashcards

Endocarditis, Pericarditis, Tamponade Flashcards

1
Q

endocarditis

A
  • infection of the hearts endocardial surface (heart valves)
  • native or prosthetic valves
  • could be surgical complication; nosocomial
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2
Q

subacute endocarditis

A
  • may have predisposing conditions
  • indolent nature
  • prolonged course - low grade fever - non-specific symptoms
  • if not treated, fatal by 1 yr
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3
Q

acute endocarditis

A
  • heart may be normal
  • rapidly destructing
  • fulminant - high grade fever - acutely ill
  • if not treated, fatal by 6 weeks
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4
Q

risk factors for endocarditis

A
  • acquired heart defects
  • congenital heart defects
  • IV drug use**
  • age > 60
  • male
  • poor dentition
  • presence of artificial heart valves or devices
  • IV catheters (PICC)
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5
Q

what are the 3 main things that should be on your differential for a symptomatic IVDA?

A
  • discitis
  • epidural abscess
  • endocarditis
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6
Q

what is the pathophysiology of endocarditis?

A
  • turbulent blood flow disrupts the endocardium making it sticky
  • bacteremia delivers the organisms to endocardial surface
  • organisms adhere to endocardial surface
  • eventual invasion of the vascular leaflets
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7
Q

through what every day activities could bacteria enter the blood stream?

A
  • brushing teeth
  • chewing food
  • (esp. if poor dentition)
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8
Q

What other medical conditions could allow bacteria to enter the blood stream?

A
  • skin sore
  • gum dz
  • inflammatory bowel dz
  • dental procedure
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9
Q

which bugs are most common in native valves?

A
  • s. aureus (most common)
  • strep viridans
  • HACEK
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10
Q

which bugs are most common in prosthetic valves?

A
  • early: coagulase negative staph, s. aureus, gram negative bacilli, dupheroids, fungii
  • late: strep, s. aureus, enterococci, coagulase negative staph
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11
Q

what are the HACEK oraganisms?

A
  • Haemophilus, aggregatibacter, cardiobacterium, eikenella, kingella
  • normal part of the human microbiota
  • group of gram-negative bacteria that are an unusual cause of infective endocarditis
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12
Q

common bugs in subacute endocarditis

A
  • strep viridans

- coagulase neg. staph

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13
Q

common bugs in acute endocarditis

A

-s. aureus

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14
Q

common bugs in endocarditis d/t IVDA

A
  • MRSA
  • polymicrobial
  • unusual organisms like pseduomonas, candida, lactobacillus
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15
Q

symptoms of endocaditis

A
  • fever in most cases
  • SOB, fatigue, weight loss, arthralgis/myalgia (sounds a lot like flu)
  • abd pain, N/V, back and chest pain, hematuria/proteinuria, anorexia

-regurg murmur is a finding** not sx

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16
Q

cardiac manifestations of endocarditis

A
  • new regurg murmurs
  • new CHF
  • valve damage
  • myocarditis
  • perivalvular dz
  • pericarditis
  • heart block
  • MI d/t embolic phenomena
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17
Q

non cardiac manifestations of endocarditis

A
  • septic embolization
  • embolic strokes
  • mycotic aneurysms (arising from bacterial infection of arterial wall)
  • brain microabscesses
  • glomerulonephritis
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18
Q

physical signs of endocarditis

A
  • petechae
  • splinter hemorrhages
  • oslers nodes
  • janeway lesions
  • roth spots
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19
Q

petechae

A

-small capillary hemorrhages most commonly on the feet/ankles (never on soles)

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20
Q

how can you tell petechiae from a rash?

A
  • glass test
  • push on the dots to see if they go away
  • petechiae don’t go away
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21
Q

What are the big 3 things that have petechiae?

A
  • endocarditis
  • rocky mountain spotted fever
  • meningococcal meningitis
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22
Q

splinter hemorrhages

A
  • vessel damage from swelling of blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli)
  • multiple linear, reddish brown marks along the axis of fingernails and toe nails
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23
Q

oslers nodes

A
  • painful, erythematous nodules
  • located on pulp (bulbs?) of fingers and toes
  • immune-mediated
  • commonly indicative of subacute endocarditis
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24
Q

janeway lesions

A
  • nonpainful, erythematous, blanching macules
  • located on palms and soles
  • d/t microabcessess of dermis w/ marked necrosis and inflammatory infiltrate
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25
Q

roth spots

A
  • exudative, edematous hemorrhagic lesions of the retina w/ pale centers
  • flame shaped
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26
Q

labs to order for endocarditis

A
  • blood cultures

- serology for brucella, bartonella, legionella, c. burnetii

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27
Q

timing for blood cultures in endocarditis

A
  • 3 sets of them, 1 hr apart

- ideally before start of abx

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28
Q

diagnostic tests for endocarditis

A
  • CXR: look for infiltrates or calcification of valves

- ECG: rarely diagnositc, look for ischemia, conduction delay, arrhythmias

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29
Q

echo in endocarditis

A
  1. TTE: first test used if blood cultures are non-diagnostic; only 55-65% sensitive; can’t rule out but can confirm
  2. TEE: used in high risk pts or high clinical suspicion; 90% sensitive
30
Q

What defines the diasnostic criteria for endocarditis?

A

Dukes criteria

31
Q

guidelines for a probable diagnosis of endocarditis per Dukes criteria

A
  • 1 major PLUS 1 minor

- 3 minor

32
Q

guidelines for a definite diagnosis of endocarditis per Dukes criteria

A
  • 2 major
  • 1 major + 3 minor
  • 5 minor
33
Q

minor factors for endocarditis per Dukes criteria

A
  • predisposing heart condition or IVDA
  • fever >38C
  • major arterial emboli
  • septic pulmonary infarcts
  • mycotic aneurysm
  • intracranial or conjunctival hemorrhage
  • janeway lesions, osler’s nodes, roth spots, glomerulonephritis
34
Q

major actors for endocarditis per Dukes criteria

A
  • persistently positive blood culture for typical organisms
  • ECHO: vegetation, dehiscence, abscess
  • new valvular regurg murmur
  • coxiella burnetii infection
35
Q

tx of endocarditis

A
  • high serum concentration IV abx
  • prolonged tx: 4-6 wks for native valves, 6+ weeks for prosthetic valves
  • empiric tx w/ vancomycin then tailor to oganism ASAP
  • if a fungus - surgery required
36
Q

Who are the high risk endocarditis patients that require prophylaxis?

A
  • prosthetic valves
  • previous endocarditis
  • some congenital heart dz
  • valve dz after transplant
37
Q

procedures to consider prophylaxis in endocarditis risk

A
  • dental
  • respiratory track
  • infected skin/musculoskeletal tissue
  • NOT GI/GU procedures
38
Q

endocarditis prophylaxis meds

A
  • give 30-60 mins before procedure
  • amoxicillin or cephalexin 2g PO
  • clindamycin 600 mg PO
  • azithromycin 500 mg PO
  • claritrhomycin 500 mg PO or IM/IV
39
Q

what is the pericardium

A
  • fibro-elastic sac w/ parietal and visceral layers
  • pericardial cavity b/w layers
  • usually contains 15-50ml of straw-colored fluid
40
Q

what is a common sx of pericarditis?

A

-sharp, stabbing chest pain

41
Q

etiology of pericarditis

A
  • infections: viral, bacterial, fungal
  • rheumatologic
  • immunologic
  • neoplastic
  • drug
42
Q

infectious causes of pericarditis

A
  • viral: coxsackie, flu, HIV, EBV
  • bacterial: TB, staph, haemophilus, pneumococcal, salmonella
  • fungal/other: histoplasma, coccidiomycosis, rickettsia
43
Q

rheumatologic causes of pericarditis

A
  • SLE
  • sarcoidosis
  • RA
  • dermatomyositis
  • ankylosing spondylitis
  • scleroderma
44
Q

immunologic causes of pericarditis

A
  • celiac sprue

- IBS

45
Q

neoplastic causes of pericarditis

A
  • angiosarcoma
  • mesothelioma
  • metastatic breast, lung, melanoma, leukemia, lymphoma
46
Q

drug causes of pericarditis

A
  • hydralazine

- procainamide

47
Q

other etiologies of pericarditis

A
  • Dressler’s - automimmune inflammyory reaction to myocardial neo-antigens
  • post-pericardiotomy
  • chest trauma
  • aortic dissection
  • uremia
  • post radiation
  • idiopathic
48
Q

clinical presentation of pericarditis

A
  • chest pain
  • pericardial friction run
  • diffuse ST elevation
  • pericardial effusion

-at least 2 must be present to make diagnosis

49
Q

chest pain in pericarditis

A
  • sudden onset
  • retrosternal
  • pleuritis and sharp
  • can radiate to neck, arms, shoulder
  • worse w/ inspiration and supine position
  • **improved w/ sitting upright and leaning forward
50
Q

pericardial friction rub

A
  • high pitched scratchy or squeaky sound
  • best heard w/ diaphragm at left sternal border w/ pt leaning forward
  • present in 85% of pericarditis cases
  • audible throughout respiratory cycle
51
Q

EKG changes in pericarditis

A
  • widespread upward concave ST segment elevation and PR segment depression
  • can take months for full resolution of ECG changes
52
Q

differential diagnosis for a clinical presentation consistent w/ pericarditis

A
  • MI
  • myocarditis
  • PE
  • pneumothorax
  • pneumopericardium
  • costochondritis
  • from EKG findings: AMI, early repol., myocarditis, hyperkalemia, ventricular aneurysm, normal variant
53
Q

workup for pericarditis

A
  • lab tests
  • CBC w/ high WBC ct.
  • increased ESR and CRP
  • CMP w/ uremia
  • rheumatoid factor, ANA
  • blood cultures if febrile
  • +/- HIV
  • cardiac enzymes NOT reliable
  • viral cultures not indicated
54
Q

echo in pericarditis

A
  • normal unless effusion is present
  • effusion supports diagnosis but absence does not exclude it
  • recommended in any cases of suspected pericardial dz
55
Q

CXR in pericarditis

A
  • recommended in all cases - typically normal

- enlarged cardiac silhouette in effusion

56
Q

When to hospitalize pericarditis

A
  • subacute sx
  • high fever and leukocytosis
  • lg. pericardial effusion
  • evidence for tamponade
  • immunosuppression
  • anticoagulated
  • acute trauma
  • failure to respond to NSAIDs
57
Q

goals of treatment of pericarditis

A
  • relieve pain
  • tx inflammation
  • prevent cardiac tamponade
58
Q

tx of pericarditis

A
  • tx underlying cause
  • drain purulent effusions
  • pericardiectomy if constrictive
  • NSAIDs
  • sx usually subside in 1 week
  • steroids if refractory to NSAIDs
  • colchicine
59
Q

MI-associated pericarditis

A
  • consequence of transmural infarction
  • tx of choice: Aspirin
  • can be late - Dressler syndrome
60
Q

pericardial effusion

A
  • prolonged and sever inflammation leads to fluid accumulation around the heart
  • can be normal variant - over 150 is when it starts to cause problems
61
Q

physical exam in pericardial effusion

A
  • diminished heart sounds

- may have friction rub if pericarditis

62
Q

EKG in pericardial effusion

A
  • low-voltage QRS

- electrical alternans

63
Q

CXR in pericardial effusion

A

-enlarged, water bottle shaped heart

64
Q

what confirms the diagnosis of pericardial effusion?

A

-pericardiocentesis

65
Q

cardiac tamponade

A

accumulation of fluid that results in an increase in pericardial pressure and impairs ventricular filling and CO (same etiologies as pericardial effusion)

66
Q

Becks triad in cardiac tamponade

A
  • JVD
  • muffled/distant heart sounds
  • low BP
67
Q

clinical manifestations of cardiac tamponade

A
  • hypotension
  • tachycardia
  • tachypnea
  • jvd
  • dyspnea
  • narrow pulse pressure (<30 mmHg difference b/w systolic and diastolic)
  • pulsus paradoxus
68
Q

pulsus paradoxus

A
  • abnormally lg decrease in systolic BP and pulse wave amplitude during inspiration
  • (normally is <10 mmHg)
69
Q

what is diagnostic for cardiac tamponade?

A

-echo

70
Q

tx of cardiac tamponade

A
  • echo-guided pericardiocentesis
  • may need to leave drain in place
  • tx underlying cause

Cardiology 2 (13 decks)

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