Infective endocarditis and rheumatic heart disease

Question 1

what is infective endocarditis

Answer 1

inflammation of the endocardium, usually involves the valves, characterised by vegetations- platelets, fibrin and micoroganisms

Question 2

clinical history of infective endocarditis

Answer 2

can be acute, fulminant, subacute/chronic. it is a systemic disease so affects multiple organs. - embolic strokes, PE, MI, infarction of kidney, spleen, mesenteric, skin, immune response

Question 3

predisposing conditions of infective endocarditis

Answer 3

prosthetic valves, cardiac devices, IV drug users, congenital heart diseases, rheumatic heart disease, mitral valve prolapse, immunosuppression, prolonged admission to ITU/ hospital

Question 4

clinical presentation of IE

Answer 4

peripheral infarcts, mitral valve vegetation, pace lead with vegetation, aortic valve leaflet with perforation, Roth spots, septic PE, splenic infarcts, pyogenic brain abscess, embolic stroke with hemorrhagic conversion

Question 5

signs and symptoms of IE

Answer 5

fever, chills, poor appetite, weight loss, heart murmur, less frequent- myalgia, abdoo/back pain, confusion, embolic complications

Question 6

vascular and immunological phenomena

Answer 6

oslers nodes, janeway lesions, splinter haemorrhage

Question 7

lab signs of infection for diagnosis

Answer 7

elevated C reactive protein, erythrocyte sedimentation, leucocytosis, anaemia, microscopic haematuria. blood cultures (3 sets, 30 mins apart. essential prior to any antibiotic therapy is started)

Question 8

blood cultures look for what in IE

Answer 8

staph aureus, streptococci, enterococci, coagulase neg staphylococci, HACEK group (haemophilia, aggregatibacter, cardiobacterium, eikenelly, kingella)

Question 9

negative IE blood culture

Answer 9

brucella spp, coxiella brunette, bartonella spp, tropheryma whipplei, mycoplasma spp, legionella spp, fungi(candida, aspergillus) - non infective = systemic lupus or marantic endocarditis

Question 10

imaging for IE

Answer 10

transthoracic echocardiogram, transoesophageal echo, CT/MRI (detection of embolic events), PET (if diagnosis unclear)

Question 11

transthoracic echo is used to find

Answer 11

vegetation, abscess, new dehiscence of prosthetic valve

Question 12

transoesophageal echo used when

Answer 12

if high clinical suspicion without TTE, used alongside TTE to rule out complications or to if there are prosthetic valves or intracardiac devices

Question 13

diagnostic criteria for IE

Answer 13

definitive- 2 major or 1 major and 3 minor

possible- 1 major and 1 minor or 3 minor

Question 14

major criteria for IE

Answer 14

major- blood culture pos for typical microorganisms, echo showing valvular vegetation,

Question 15

minor criteria for IE

Answer 15

minor- predisposing cardiac lesion, IV drug use, temp less than 38, embolic phenomena, immunological phenomena, pos blood culture not as above.

Question 16

prognosis depends on

Answer 16

patient characteristics eg age, comorbidities, diabetes, which infecting organism it is, presence of cardiac or non cardiac complications, echocardiographic findings

Question 17

endocarditis treatment

Answer 17

antibiotics

Question 18

if streptococci what usually prescribed

Answer 18

penicillin with or without vancomycin

Question 19

when surgery needed for IE

Answer 19

heart failure with valvular dysfunction or cardiac complications, uncontrolled infection eg persistent fever and positive blood culture, prevention of embolism if vegetation is persistently large and presented with one or more embolic episodes

Question 20

rheumatic heart disease is

Answer 20

very common in low or middle income countries, develops from strep pharyngitis then to acute rheumatic fever (carditis) then to rheumatic heart disease- progressive valvular disease after years of rheumatic fever

Question 21

clinical features of rheumatic heart disease

Answer 21

dyspnoea, symptoms of heart failure

Question 22

investigations for rheumatic heart disease

Answer 22

ECG- atrial fibrillation, CXR, echocardiography

Question 23

RHD echocardiography

Answer 23

RHD typically affects left sided valves with greater consequence for mitral valve. causes mitral stenosis and or regurgitation. aortic issues less common

Question 24

drug treatment of RHD

Answer 24

after prophylaxis established (penicillins). treat heart problems with diuretics, vasodilators, treatment for AF- beta blockers or anticoagulants (WARFARIN)

Question 25

severity of RHD

Answer 25

can be symptomatic, asymptomatic clinically significant, subclinical- echo positive but clinically silent, advanced

Question 26

subcutaneous treatment for RHD

Answer 26

balloon mitral valvuloplasty. effective if symptomatic mitral stenosis, suitable for younger patients and pregnancy

Question 27

surgical treatment of RHD

Answer 27

valve replacement, repair might not be feasible. can be bioprosthesis or mechanical prosthesis