INFECTIOUS AND INFLAMMATORY CARDIAC CONDITIONS Flashcards
What are the viral etiologies of acute pericarditis ?
Coxackeiviruses A and B, Echovirus, Mumps, adenovirus, EBV, HIV, and Influenza.
What are the bacterial etiologies of acute pericarditis ?
Pneumococcus, streptococcus, staphylococcus, legionella, M. tuberculosis and avium.
What are the fungal etiologies of acute pericarditis ?
Histoplasmosis, coccidioidomycosis, candidiasis, and balastomycosis.
What are the non-infectious etiologies of acute pericarditis ?
ideopathic, neoplasms and metastasis, Mesothelioma, renal failure and MI, hypothyroidism, aortic dissection with hemopericardium, and pneumonia.
What are the auto-immune causes of acute pericarditis ?
SLE, RA, Scleroderma, Mixed arteritis, Polyarteritis nodosa, temporal arteritis, IBD and post MI syndrome.
What are the drugs that can cause acute pericarditis ?
Procainamide, Hydralazine, Isoniazide, Cyclosporin and Phenytoin.
What are the traumatic causes of acute pericarditis ?
Throacic duct injury and mediastinal irradiation.
What is the clinical presentation of acute pericarditis ?
- Sharp retrosternal CP that radiates to trapezius ridge and worse on inspiration and lying flat. Relief when sitting up or leaning forward.
- Pericardial friction rub +/- Fever.
What are the ECG changes in Acute pericarditis ?
- Stage 1:
– Widespread ST elevation with ST
depressions in AVR &/or V1
– PR depressions - Stage 2: (days later)
– Return of ST segments to baseline - Stage 3: (days later)
– T wave inversion - Stage 4: (weeks later)
– Return to baseline
What is the diagnostic criteria for acute pericarditis ?
A Dx of inflammatory pericardial syndrome require 2 of the 4 following criteria:
1) Pericarditic CP
2) Pericardial rubs
3) New widespread STE or PR depression in ECG
4) pericardial effusion.
What are the supporting findings of acute pericarditis ?
- Blood works showing elevated ESR< CRP and WBC
- CT or CMR evidence of pericardial inflammation.
What is the diagnostic criteria for incessant pericarditis ?
Pericarditis lasting for > 4 to 6 weeks, but less than 3 months without remission.
What is recurrent pericarditis ?
Recurrence of pericarditis episode with symptom free intervals of 4 to 6 week or longer.
What is chronic pericarditis ?
Pericarditis lasting for > 3 months.
what is the acute pericarditis risk stratification ?
https://www.escardio.org/static-file/Escardio/Medias/working-groups/myocardial-pericardial/2015.11-Paper-Tab1.2-DiagnosticCriteriaAndDefinition.png?mts=1592522397000.png
What are the factors to consider in treating acute pericarditis ?
- Rule out myocardial infarction
- Anti-Inflammatory.
- Antibiotics (if bacterial cause)
- Discontinue anticoagulant therapy – may lead to haemopericardium
What is the pharmacological management of pericarditis ?
https://www.escardio.org/static-file/Escardio/Medias/working-groups/myocardial-pericardial/2015.11-Paper-Tab2.1-TherapeuticSchemesForAcutePericarditis.png?mts=1592522679000.png
What is the treatment algorithm of acute and recurrent pericarditis ?
https://www.escardio.org/static-file/Escardio/Medias/working-groups/myocardial-pericardial/2015.11-Paper-Tab2.2-TherapeuticSchemesForAcutePericarditis.png?mts=1592522228000.png
What are the causes of pericardial effusion ?
- Infections and cancer
- trauma and autoimmune diseases.
- Iatrogenic: post cardiac surgery pericardial effusion.
- Associated with heart failure, liver cirrhosis, CKD & kidney failure
- ideopathic.
What is the clinical presentation of pericardial effusion ?
- Small or slowly accumulating pericardial effusions may be asymptomatic or cause only mild symptoms.
- DOE and fatigue
- Orthopnea and PND
- Cough and CP
- Sxs of local compression:
– Nausea (diaphragm)
– Dysphagia (oesophagus)
– Hoarseness (recurrent
laryngeal nerve)
– Hiccups (phrenic nerve)
What are the physical examination findings in pericardial effusion ?
- May be normal
- May have friction rub if
pericarditis also present - Large volumes:
– Muffled heart sounds
– Neck vein distension
– Pulsus paradoxus
What are the clinical signs of pericardial effusion ?
*Water bottle sign: Enlargement of the cardiac silhouette on CXR.
* Ewart’s sign: Base of left lung compressed by pericardial fluid
and Causes dullness, increased
fremitus & egophony beneath
angle of left scapula.
What is the gold standard test for pericardial effusion ?
Transthoracic echo (TTE)
What is the definition of small pericardial effusion ?
The presence of a small amount of fluid surrounding the heart, usually <10 mm in end-diastole or < 100 mL in volume.
What is the definition of large pericardial effusion ?
In echocardiography, a large pericardial effusion is typically defined as an effusion > 10 mm in end-diastole or a volume >100 mL.
What is the management of pericardial effusion?
- Treat underlying condition / pericarditis
- Can consider drainage of effusion if unresponsive to initial treatment
- Effusion in the absence of pericarditis or identifiable etiology has no proven treatment strategies
What is the definition of cardiac tamponade ?
The accumulation of fluid in the pericardial space in a quantity sufficient to cause serious obstruction to the inflow of blood to the ventricles.
What is rapid onset cardiac tamponade ?
“Rapid onset cardiac tamponade” refers to a condition in which the sudden accumulation of fluid within the pericardial sac causes compression of the heart chambers and impaired cardiac function. It may only require 200 ML to develop tamponade.
What is slow onset cardiac tamponade ?
Accumulation of pericardial fluid leads to a gradual increase in intrapericardial pressure, which eventually compromises cardiac filling and output. It may require > 2000 mL to develop tamponade.
What is the presentation of cardiac tamponade ?
It may present like heart failure
with Dyspnea, Orthopnea and Hepatic engorgement.
What is the Dx criteria for cardiac tamponade?
*Beck’s triad: Hypotension, Soft or absent heart sounds and JVD.
* Pulsus paradox: > 10 mmHg inspiratory decline in SBP
* ECHO positive for tamponade.
What is the Tx of cardiac tamponade?
pericardiocentesis
What is the pathophysiology of constrictive pericarditis ?
Constrictive pericarditis is a condition characterized by the thickening, fibrosis, and calcification of the pericardium, leading to impaired cardiac filling and hemodynamic compromise.
What are the causes of constrictive pericarditis ?
- It commonly occurs post TB pericarditis.
- It also can occurs following: Post radiation, Trauma, Cardiac surgery, autoimmune diseases, CKD with uremia.
What is the clinical presentation of constrictive pericarditis ?
- Weakness and fatigue due to systolic compromise secondary to diastolic dysfunction.
- fluid overload
- Kussmaul’s Sign
- jaundice and ascites secondary to Congestive hepatomegaly.
What are the work-ups in constrictive pericarditis ?
- ECG: low voltage of QRS, diffuse T
wave flattening or inversion - CXR: usually normal silhouette
- Echo: pericardial thickening
- CT or MRI: pericardial thickening
and calcifications
What is the Tx of constrictive pericarditis ?
- Pericardial resection
- Treat underlying cause if known.
- Anti-inflammatories
What are the infectious etiologies of
myocarditis ?
– Viral – Coxsackievirus, adenovirus and parvovirus B19
– Bacterial – Staph, Strep, Borellia and Rickettsia
– Parasites – Trypanosoma cruzi
what is the pathophysiology of myocarditis ?
Infectious agents or autoantibodies triggers an inflammatory cascade within the myocardium.Immune cells infiltrate the myocardium and release pro-inflammatory cytokines and chemokines leading to myocyte necrosis, apoptosis, heart failure,
arrhythmias and SCD.
What is the symptomatology of myocarditis ?
It has a spectrum of symptoms ranging from none to fatal arrhythmias and fullminent HF. The main presentations are pericardial chest pain, Palpitations, lightheadedness and syncope if arrhythmia.
What are the work-up findings in myocarditis ?
- ECG: may be normal or ST segment elevations or non-specific ST/T wave changes
- Troponin: elevated in advanced disease (necrosis)
*Echo: wall motion abnormalities (necrosis) and Systolic dysfunction. - Biopsy – not routinely done
What is the C-MRI in myocarditis ?
- Cardiac MRI: characteristic pattern of late gadolinium enhancement in the subepicardial and mid-myocardial walls which is a different pattern than ischemia.
What is the treatment of Myocarditis ?
- Treat underlying condition, if known
- Heart failure treatment: ACE or ARB or ARB+neprilysin, beta blocker, aldosterone antagonist
*Diuretics and nitrates for Sx control - Anti-arrhythmics: amiodarone, sotalol etc.
What are the organisms involved in Native Valve Endocarditis?
- Staphylococcus aureus
– Most common in nosocomial
– Most common in IVDU - Viridans Streptococci
– Most common in community
acquired
What are the organisms in Prosthetic Valve Endocarditis?
- Staphylococcus aureus
(frequently MRSA) - Others:
– Fungi
– ‘HACEK’ organisms
– Strep gallolyticus
– Enterococci
What is the clinical presentation of infective endocarditis ?
- Common symptoms: Fever, fatigue, dyspnea, & weight loss.
– Acute
- Usually involves normal valves
- Rapidly progressive symptoms that develop within days to weeks
– Subacute - Only affects abnormal valves
- Indolent course with symptoms gradually worsen over the course of several months.
What are the physical examination findings in infectious endocarditis ?
- new cardiac murmur
- Splinter haemorrhages
- Janeway lesions
- Osler nodes
- Roth spots
- embolic stroke
What are the diagnostic work-ups in infective endocarditis ?
- Blood cultures drawn from 3 separate sites at least 1 hour apart
- Echocardiogram ( TTE/TOE)– looking for vegetations
Modified duke criteria in infective endocarditis ?
https://youtu.be/lYwnAzpkDb4?t=103
What is the management of acute native valve endocarditis ?
Draw blood cultures and then start empiric IV antibiotics for 4-6 weeks:
* Ampicillin-Sulbactam + Gentamycin Or
* Vancomycin + gentamycin + ciprofloxacin
Adjust antibiotics based on results of blood culture results. Continue to check blood cultures every 48 to 72 hours until negative
What is the management of Subacute IE?
Draw BCs, can wait to start antibiotics until culture results available. Continue to check blood cultures every 48 to 72 hours until negative
What is the management of acute Prosthetic valve endocarditis?
Draw blood cultures and then start empiric IV antibiotics for 6 weeks with Vancomycin + gentamycin + rifampin.Adjust antibiotics based on results of blood culture results.Continue to check blood cultures every 48 to 72 hours until negative.
What are the surgical indications for IE ?
– All patients with prosthetic valve endocarditis
– Patients with new valvular incompetence and heart failure.
– Patients with fungal infections, recurrent embolization and treatment failure or persistent vegetations.
What are the preventive measures in IE ?
- Prior to dental and surgical procedures, prevent IE in those at high
risk with prophylactic antibiotics such as those with Previous endocarditis, Prosthetic valves
– Congenital heart disease and Surgically constructed pulmonary shunts
What are the preventive therapy for endocarditis ?
Oral amoxicillin or IV/IM ampicillin one hour before procedure
– PCN allergy: azithromycin, clarithromycin, cephalexin or clindamycin
