Final: IE, Murmurs Flashcards
infectious endocarditis
- microbial infection w/in endothelium of heart veg
- vegetation forms on endothelial structures
- 50% are > 50 yrs old (2men:1women)
- acute: death days-6wks: staph aureus
- subacute: death 6 wks-3 months: & chronic: death > 3 months
- viridan’s streptococci
*risk factors of infectious endocarditis
- IV drug use
- structural cardiac abnormalities
- implantable devices
- cardiac/vascular prostheses
- immunosuppression
- IE hx
IE clinical presentation
- fever
- (absent in elderly, immune comp, CHF, renal failure, tx’ed with previous antibiotics)
- chills, weight loss
- conduction disturbances, heart block, pericarditis, fistulas, fibrosis leaflets
- murmurs
- CHF (poor prognosis)
- emboli
- neurologic or opthalmologic → Roth spots
- PE - IVDU or indwelling central line
- splenic septic emboli
- petechiae
- janeway lesions - macules palms, soles from septic embolization
- osler nodes - painful nodules finger, toe pads
- renal failure
- arthralgias/myalgias
- proximal joints/lower extremities, monocular unilateral
infectious endocarditis diagnostics
- gold standard to dx: THREE sets of blood cultures (from 3 diff sites before antib started)
- 2nd set 1 hr after 1st
- CBC
- CRP/ESR
- EKG
- continuous monitoring for perivalvular abscess
- TransthoracicEcho (TTE)
- TransesophagealEcho (TEE)
- cardiac CT if echo not clear
Infectious endocarditis management/treatment
- transfer to ED if have fever and sus IE! consult specialist
- infectious dz consult: IV antibiotics (IV!! only)
- improve in 1 week - recheck cx’s (should be - )
- if fungal org → antifungals + valve replacement surgery
**infectious endocarditis prophylaxis for dental, oral, respiratory procedures and WHAT ANTIB?
- antibiotics prior to procedure (dental or other surgical procedures)
- cardiac transplant and valvulopathy
- Prosthetic valve
- prosthetic material in valve repair w/in first 6 months of surgery
- hx of infectious endocarditis
-
amoxicillin oral 2g once 30-60 mins before procedure
- or clindamycin oral 600 mg if PCN allergy
if suspect IE…
refer to ED!!! ideally with cardiac surgery availability
where is aortic area?
Right upper sternal border or 2nd ICS
**where is pulmonic area?
Left upper sternal border or 2nd intercostal space
where is the tricuspid area?
left lower sternal border
where is the mitral area?
apex
Grade III murmur
moderately loud
Grade IV murmur
loud, palpable thrill
grade V murmur
very loud with thrill, heard when stethoscope partly off chest
early systolic murmur
- least common
- high pitched, sharp
- pathologic
- mitral or tricuspid regurgitation
*midsystolic murmur
- most common
- crescendo-decrescendo that build in intensity as velocity increases then decreases well before S2
- heard in aortic or PS
- valsalva maneuver increases murmur in hypertrophic cardiomyopathy
late systolic murmur
- start mid or late systole
- continue to s2 in crescendo pattern
- in MVP or tricuspid valve prolapse
pansystolic
- result from blood flow transferring from high pressure chamber to low pressure
- mitral regurgitation or tricuspid valve or VSD
what does diastolic murmurs indicate
pathologic and heart disease bc of regurgitation or stenosis
*Stills murmur
- benign innocent murmur
- classic vibratory/musical parasternal precordial murmur
- mid systolic
- mid left sternal border and apex
- common in healthy infants, children 3-6 yrs or 8-12 yrs
- asymptomatic, no abnormal findings
****when to refer with murmurs?
pathologic murmurs:
- diastolic, holosystolic murmur
- grade 3 and up systolic murmurs
- murmur with extra heart sounds (S3, S4, or click)
- murmur that increases in intensity when pt stands
murmur diagnostics
- EKG
- chest xray
- ECHO
- stress test if asx severe VHD
Stages of valvular heart disease
- Stage A: has risk factors
- Stage B: with progressive VHD (mild-mod, asx)
- Stage C: Asx with severe VHD
- C1 - asx w/ severe VHD with L or R ventricle compensating
- C2 - asx w/ severe VHD with decompensation of L or R ventricle
- Stage D: have sx’s
*valvular heart disease complications
- heart failure
- volume overload → leads to changes in heart muscle wall
- reduced functional status
- L ventricular pump failure
- Death - from dysrhythmias
NP role in VHD
- history - know risk factors in PMH
- PE - recognize early heart sound changes
- aus / inspect chest wall, palp pulse, PMI
- diagnosis - if SOB, fatigue, edema, new murmur
- get diagnostics and refer
- refer to Level 2 primary valve center - surgery (w/w/o CABG) or Level 1 for transcatheter valve replacement
- get diagnostics and refer
Systolic murmurs
MR. Peyton Manning AS MVP
- Mitral regurgitation
- physiological murmur
- aortic stenosis
- mitral valve prolapse
diastolic murmurs
ARMS
- aortic regurgitation
- Mitral Stenosis
steps to find a murmur
- systolic or diastolic? if carotid pulsing same time as chest = systolic murmur
- MR PEYTON MANNING AS MVP or ARMS
- Location: All Pt’s E. Take Meds
*aortic stenosis
- MR PEYTON MANNING AS MVP - systolic
- most common
- rheumatic fever
- mid systolic, harsh murmur
- crescendo-decrescendo
- often with mitral regurgitation
- audible S4
***which murmur is louder when squatting?
and is quiet during valsalva/standing
-
aortic stenosis
- squatting = increases preload
- valsava SHRINKS the ventricles so less blood to pump thru AS = decrease murmur
aortic stenosis best heard where?
- Right sternal border/2nd intercostal space
- can radiate down L sternal border to apex or up to carotid arteries
*aortic stenosis symptoms
triad:
- angina/chest pain
- syncope - dizziness & exertional, exercise intolerance
- congestive heart failure (dyspnea)
symptomatic: can be asx until 5-6 decade then rapid deterioration. early recognization of ANY sx and refer asap!
*aortic stenosis diagnostics
- transthoracic 2D ECHO - show thick, calcified immobile AS leaflets
- echo shows cardiomegaly (LATE)
- EKG - normal with LVH, 1st deg AV block, BBB,
- Chest Xray - rounding of L ventricle
Aortic stenosis treatment
- if asx → monitor
- mod-severe: NO competitive sports, tx risk factors (HTN, HLD w/ ACE)
- Stage B or greater: surgery (AVR or TAVR to replace valves or brio prosthetic)
hypertrophic cardiomyopathy
- peaks mid systole
- best heard over L sternal border
-
murmur decreased with squatting
- increases with standing/valsava
- increased murmur with valsalva
- S4 present
- opposite of AS murmur
*aortic regurgitation
- ARMS - diastolic murmur
- loud blowing HIGH pitched
- best heard Left lower sternal border, leaning forward post exhale
- mid systolic ejection murmur in beginning then progresses to diastolic murmur
*when is aortic regurgitation heard loudest?
leaning forward post exhale
aortic regurgitation sx’s
-
asx for 10-15 yrs then acute palpitations, exercise tolerance/SOB at rest
- late:: CHF
- “head pounding”
- angina
- orthopnea/dyspnea
- fatigue
- paroxysmal nocturnal dyspnea
aortic regurgitation treatment
- asx - annual f/u
- surgical interventions Stage C or D - goal to intervene before EF < 50%
- treat HTN (CCB/ACE), afib, bradcycardia
- refer for post heart Cath
*mitral stenosis
- ARMS - diastolic
- low pitch, rumbling
- opening snap
mitral stenosis best heard where and loudest where?
- louder in LEFT lateral recumbent position
- best heard at apex
*mitral stenosis symptoms and PE
- most common: dyspnea
- EKG: atrial fibrillation
- loud S1, apical towards axilla
- CXR - left atrium enlarged
- hemoptysis
- R ventricular hypertrophy
mitral stenosis functional classes 1-4
- 1: asx
- 2: dyspnea great than ordinary exertion
- 3: dyspnea less than ordinary exertion
- 4: dyspnea minimal exertion, orthopnea, paroxysmal nocturnal dyspnea, PE
mitral regurgitation most caused by
mitral valve prolapse
*mitral regurgitation best heard where? what does it sound like?
- at apex, radiates to axilla
- PMI displaced downward & to left
- holosystolic/pansystolic, harsh/blowing systolic murmur
mitral regurgitation sx’s
asx for decades then
- fatigue, exertional dyspnea, orthopnea
- atrial fibrillation
- Cxray: L atria/ventricle enlarged
- palpitations, tachycardia
- late: R sided HF, PE, LV dysfunction, CHF
*mitral regurgitation treatment
- asx = monitoring at heart valve clinic
-
treat underlying causes/sequelae to prevent Left Ventricular dysfunction
- give BB, ACE/ARB, spironolactone
- give anticoagulant/warfarin for A Fib to prevent stroke/MI
- consider surgery if asx but LV growing on echo w/o dysfunction
mitral valve prolapse risk factors
- causes mitral regurgitation!
- usually benign and asx
- marfans syndrome, osteogenesis imperfecta, Ehlers danos syndrome
*mitral valve prolapse heard best where and sounds like?
- mid-late systolic click (occasional honking)
- high pitched murmur
- heard best with diaphragm on apex/Left lower sternal border
MVP sx’s
- syncope
- palpitations
- chest pain
- afib
- SVT, PVCs - with exercise
- EKG normal
MVP diagnostics
echo - leaflets blowing 2 mm into atria
*MVP treatment
- monitor with ECHO q 3-5 yrs if asymptomatic
- treat underlying SVT with beta blockers (metoprolol)
- anticoagulants with atrial fibrillation
aortic stenosis etiologies
- Ages 15-65
- usually congenital, rheumatic fever is 2nd most common cause, calcified
- If rheumatic fever is the cause than usually the mitral valve is involved too
- asx til 5-6th decade then rapid deterioration at onset of sx
*pulmonary stenosis best heard?
- 2nd/3rd intercostal spaces
- radiates down L sternal border to apex, possible base
- valsalva increases the murmur
- mid systolic, harsh medium pitched w/ crescendo - descrendo pattern
*pulmonary regurgitation heard best?
- diastolic soft, high pitched descrendo murmur
- heard best at 3rd/4th left intercostal space
- increases when pt sitting, leaning forward
*tricuspid stenosis
- less common than mitral stenosis
- diastolic, soft, short in duration
- heard best 4th or 5th left ICS
tricuspid stenosis sx’s
- fatigue, lethargy (low CO)
- hepatomegaly
- ascites, edema
- fluttering feeling of discomfort in neck
- fluttering
- tx: surgical repair
tricuspid regurgitation
- most commonly d/t R ventricular dilation
- often asx,
- exertion dyspnea
7 S’s of Innocent Murmurs [normal PE/neg ROS]
- does murmur change with child position or respiration?
- short duration (not holosystolic)
- single
- not with gallop or click
- small/not radiating
- low amplitude
- musical/sweet sound
- systolic
**red flags for murmurs!! REFER!!!!
- holosystolic
- diastolic
- grade 3 >
- harsh
- angina
- a/s with congenital defects (marinas, downs)
- a/s with additional sounds
- increased intensity with standing/valsalva, decreased with squatting (hypertrophic cardiomyopathy)
- any child less than 1 yrs old
*Left to Right shunt defects ACYANOTIC
- Ventricular septal defect (VSD)
- Patent ductus arteriosus (PDA)
- Atrial septal defect (ASD)
- Atrioventricular defect (AVSD)
what is the most common congenital heart defect?
ventricular septal defect (VSD)
ventricular septal defect sx’s
- not heard til 2-8 wks old
- loud murmur
- harsh, high pitched grade 2-4-6 holosystolic murmur at Left lower sternal border
- thrill along left sternal border
- s/sx CHF
- S3 or S4
VSD Diagnostic
- chest x ray (shows enlargement with Ig shunts)
- EKG - normal , maybe LVH
- ECHO
VSD treatment
- small VSD, no CHF monitor q 6 months
- larger defects with sx/s CHF:
- lanoxin (Digoxin), diuretics, ACE-i, BB
- monitor nutrition, weight gain
- family teaching about s/sx CHF
- surgery/percutaneous device if no improvement
- SBE prophylaxis necessary for 6 months after surgery
*patent ductus arteriosus
- should close by 1-3 days post birth
- aorta-pulmonary artery shunting
- L→ R shunt
**tricuspid atresia
- NO tricuspid valve
- blind pouch at tricuspid valve
- shunts blood from patent foramen ovale (PFO) & ventricular septal defect (VSD)
- causes cyanosis, tachycardia, dyspnea
- clubbing
- tx: IV prostaglandins to keep ductus arterosus, digoxin, diuretics
- need surgery in stages
**right to left shunt defects (CYANOTIC)
blood skipping the lungs
- tetralogy of fallot
- transportation of great arteries
