Endocarditis, Pericarditis, Tamponade Flashcards
endocarditis
- infection of the hearts endocardial surface (heart valves)
- native or prosthetic valves
- could be surgical complication; nosocomial
subacute endocarditis
- may have predisposing conditions
- indolent nature
- prolonged course - low grade fever - non-specific symptoms
- if not treated, fatal by 1 yr
acute endocarditis
- heart may be normal
- rapidly destructing
- fulminant - high grade fever - acutely ill
- if not treated, fatal by 6 weeks
risk factors for endocarditis
- acquired heart defects
- congenital heart defects
- IV drug use**
- age > 60
- male
- poor dentition
- presence of artificial heart valves or devices
- IV catheters (PICC)
what are the 3 main things that should be on your differential for a symptomatic IVDA?
- discitis
- epidural abscess
- endocarditis
what is the pathophysiology of endocarditis?
- 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
through what every day activities could bacteria enter the blood stream?
- brushing teeth
- chewing food
- (esp. if poor dentition)
What other medical conditions could allow bacteria to enter the blood stream?
- skin sore
- gum dz
- inflammatory bowel dz
- dental procedure
which bugs are most common in native valves?
- s. aureus (most common)
- strep viridans
- HACEK
which bugs are most common in prosthetic valves?
- early: coagulase negative staph, s. aureus, gram negative bacilli, dupheroids, fungii
- late: strep, s. aureus, enterococci, coagulase negative staph
what are the HACEK oraganisms?
- Haemophilus, aggregatibacter, cardiobacterium, eikenella, kingella
- normal part of the human microbiota
- group of gram-negative bacteria that are an unusual cause of infective endocarditis
common bugs in subacute endocarditis
- strep viridans
- coagulase neg. staph
common bugs in acute endocarditis
-s. aureus
common bugs in endocarditis d/t IVDA
- MRSA
- polymicrobial
- unusual organisms like pseduomonas, candida, lactobacillus
symptoms of endocaditis
- 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
cardiac manifestations of endocarditis
- new regurg murmurs
- new CHF
- valve damage
- myocarditis
- perivalvular dz
- pericarditis
- heart block
- MI d/t embolic phenomena
non cardiac manifestations of endocarditis
- septic embolization
- embolic strokes
- mycotic aneurysms (arising from bacterial infection of arterial wall)
- brain microabscesses
- glomerulonephritis
physical signs of endocarditis
- petechae
- splinter hemorrhages
- oslers nodes
- janeway lesions
- roth spots
petechae
-small capillary hemorrhages most commonly on the feet/ankles (never on soles)
how can you tell petechiae from a rash?
- glass test
- push on the dots to see if they go away
- petechiae don’t go away
What are the big 3 things that have petechiae?
- endocarditis
- rocky mountain spotted fever
- meningococcal meningitis
splinter hemorrhages
- 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
oslers nodes
- painful, erythematous nodules
- located on pulp (bulbs?) of fingers and toes
- immune-mediated
- commonly indicative of subacute endocarditis
janeway lesions
- nonpainful, erythematous, blanching macules
- located on palms and soles
- d/t microabcessess of dermis w/ marked necrosis and inflammatory infiltrate
roth spots
- exudative, edematous hemorrhagic lesions of the retina w/ pale centers
- flame shaped
labs to order for endocarditis
- blood cultures
- serology for brucella, bartonella, legionella, c. burnetii
timing for blood cultures in endocarditis
- 3 sets of them, 1 hr apart
- ideally before start of abx
diagnostic tests for endocarditis
- CXR: look for infiltrates or calcification of valves
- ECG: rarely diagnositc, look for ischemia, conduction delay, arrhythmias
echo in endocarditis
- TTE: first test used if blood cultures are non-diagnostic; only 55-65% sensitive; can’t rule out but can confirm
- TEE: used in high risk pts or high clinical suspicion; 90% sensitive
What defines the diasnostic criteria for endocarditis?
Dukes criteria
guidelines for a probable diagnosis of endocarditis per Dukes criteria
- 1 major PLUS 1 minor
- 3 minor
guidelines for a definite diagnosis of endocarditis per Dukes criteria
- 2 major
- 1 major + 3 minor
- 5 minor
minor factors for endocarditis per Dukes criteria
- 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
major actors for endocarditis per Dukes criteria
- persistently positive blood culture for typical organisms
- ECHO: vegetation, dehiscence, abscess
- new valvular regurg murmur
- coxiella burnetii infection
tx of endocarditis
- 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
Who are the high risk endocarditis patients that require prophylaxis?
- prosthetic valves
- previous endocarditis
- some congenital heart dz
- valve dz after transplant
procedures to consider prophylaxis in endocarditis risk
- dental
- respiratory track
- infected skin/musculoskeletal tissue
- NOT GI/GU procedures
endocarditis prophylaxis meds
- 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
what is the pericardium
- fibro-elastic sac w/ parietal and visceral layers
- pericardial cavity b/w layers
- usually contains 15-50ml of straw-colored fluid
what is a common sx of pericarditis?
-sharp, stabbing chest pain
etiology of pericarditis
- infections: viral, bacterial, fungal
- rheumatologic
- immunologic
- neoplastic
- drug
infectious causes of pericarditis
- viral: coxsackie, flu, HIV, EBV
- bacterial: TB, staph, haemophilus, pneumococcal, salmonella
- fungal/other: histoplasma, coccidiomycosis, rickettsia
rheumatologic causes of pericarditis
- SLE
- sarcoidosis
- RA
- dermatomyositis
- ankylosing spondylitis
- scleroderma
immunologic causes of pericarditis
- celiac sprue
- IBS
neoplastic causes of pericarditis
- angiosarcoma
- mesothelioma
- metastatic breast, lung, melanoma, leukemia, lymphoma
drug causes of pericarditis
- hydralazine
- procainamide
other etiologies of pericarditis
- Dressler’s - automimmune inflammyory reaction to myocardial neo-antigens
- post-pericardiotomy
- chest trauma
- aortic dissection
- uremia
- post radiation
- idiopathic
clinical presentation of pericarditis
- chest pain
- pericardial friction run
- diffuse ST elevation
- pericardial effusion
-at least 2 must be present to make diagnosis
chest pain in pericarditis
- 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
pericardial friction rub
- 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
EKG changes in pericarditis
- widespread upward concave ST segment elevation and PR segment depression
- can take months for full resolution of ECG changes
differential diagnosis for a clinical presentation consistent w/ pericarditis
- MI
- myocarditis
- PE
- pneumothorax
- pneumopericardium
- costochondritis
- from EKG findings: AMI, early repol., myocarditis, hyperkalemia, ventricular aneurysm, normal variant
workup for pericarditis
- 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
echo in pericarditis
- normal unless effusion is present
- effusion supports diagnosis but absence does not exclude it
- recommended in any cases of suspected pericardial dz
CXR in pericarditis
- recommended in all cases - typically normal
- enlarged cardiac silhouette in effusion
When to hospitalize pericarditis
- subacute sx
- high fever and leukocytosis
- lg. pericardial effusion
- evidence for tamponade
- immunosuppression
- anticoagulated
- acute trauma
- failure to respond to NSAIDs
goals of treatment of pericarditis
- relieve pain
- tx inflammation
- prevent cardiac tamponade
tx of pericarditis
- tx underlying cause
- drain purulent effusions
- pericardiectomy if constrictive
- NSAIDs
- sx usually subside in 1 week
- steroids if refractory to NSAIDs
- colchicine
MI-associated pericarditis
- consequence of transmural infarction
- tx of choice: Aspirin
- can be late - Dressler syndrome
pericardial effusion
- prolonged and sever inflammation leads to fluid accumulation around the heart
- can be normal variant - over 150 is when it starts to cause problems
physical exam in pericardial effusion
- diminished heart sounds
- may have friction rub if pericarditis
EKG in pericardial effusion
- low-voltage QRS
- electrical alternans
CXR in pericardial effusion
-enlarged, water bottle shaped heart
what confirms the diagnosis of pericardial effusion?
-pericardiocentesis
cardiac tamponade
accumulation of fluid that results in an increase in pericardial pressure and impairs ventricular filling and CO (same etiologies as pericardial effusion)
Becks triad in cardiac tamponade
- JVD
- muffled/distant heart sounds
- low BP
clinical manifestations of cardiac tamponade
- hypotension
- tachycardia
- tachypnea
- jvd
- dyspnea
- narrow pulse pressure (<30 mmHg difference b/w systolic and diastolic)
- pulsus paradoxus
pulsus paradoxus
- abnormally lg decrease in systolic BP and pulse wave amplitude during inspiration
- (normally is <10 mmHg)
what is diagnostic for cardiac tamponade?
-echo
tx of cardiac tamponade
- echo-guided pericardiocentesis
- may need to leave drain in place
- tx underlying cause
