Infective endocarditis and Rheumatic Heart Disease Flashcards
What can be the causes of infective endocarditis?
Infection, ususally a systemic infection that has been able tp form vegetation’s on the heart valves.
Most commonly Staph. Aureus, Streptococcus Viridans and STreptococcus gallolyticus, enterococci, coagulase -ive staphlococci or HACEK group (Haemophillus, Aggregatibacter, Cardiobacterum, Eikenelly, Kingella).
What are the predisposing factors of infective endocarditis?
Pre dispoising factors include:
- Prosthetic Heart Valves
- Cardiac devices (Pacemakers/defibs)
- IV Drug Users
- Congenital Heart Disease
- Rheumatic Heart Disease
- Mitral Valve Prolapse
- Susceptible to infection/immunosuppressed
- Prolonged admission to ITU/Hosp
Which are the most common organisms involved in infective endocarditis?
Staphlycoccus Aureus, Streptococcus Viridans/Streptococcus Gallolyticus, Enterococcus, coagulase Negative Staphlycocci, HACEK group (Haemophillus, Aggregatibacter , Cardiobacterium, Eikenelly, Kingella)
What are the most common signs and symptoms of infective endocarditis?
Most common:
Fever (inc. Rigors/Chills, Poor ppetite, weight loss)
New Heart Murmor
May have:
Myalgia, back pain/abdo pain, confusion
Roth Spots, Janeway Lesions, Osler Nodes, Splinter Hemorrhages
May present as other conditions eg Stroke, Emboli in other organs casing infarction (including MI, PE, Kidney/spleen/mesentric/skin infaction)
What investigations are used in infective endocarditis?
- Echo - can be externally(transthoracic) or internally taken from eophagus (Transoesophageal)
- PET may be used, but susally not the first line, mainly used when the blood culture has come back negative but there is still suspicion, also uswd to detect perhipheral embolic events. Can also do Leucocytes labelled SPECT/CT
- CT/MRI used to see if there have been any embolic events
How is Modified Duke’s criteria used?
Groups into Major and minor symptoms:
Major:
- ECHO (PET or CT - (imaging) in newer version (ESC 2015)) showing vegitations on valve leaflets
- One of the main bugs has come back in a positive blood culture
Minor:
- Fever (38’C+)
- IV Drug user
- Predisposing cardiac lesion
- Embolic phenomena
- Immunological Phenomena (eg glomerulonephritis)
- +ive bloods but not typical organisms
Definite IE = 2 major OR 1 major +3 minor OR 5 minor
POssible IE = 1 major + 1 minor OR 3 minor
How is endocarditis managed and when would cardiac surgery be considered?
Antibiotics, usually a combination is used. 4-6 weeks if no prosthetic valves, longer if prosthetic valves (6 weeks +, may require hospital stay).
Depends on the bacteria found in the blood culture :
Streptococci - penecillin +/- vancomycin
Staphylococci - flucoxacillin +/- vancomycin
Before the blood culture could use empirical treatment:
-Ampicillin + Flucloxacillin + genamicin OR Vancomycin + Gentamicin (if penicillin allergy)
SURGERY:
- ongoing heart failure dispite antibiotics
- uncontrolled infection
- Prevention of embolism: v big vegetation (over 1cm), or 1+ embolic episodes
What is the incidence of Rheumatic Heart disease worldwide?
38-40 million cases/year, 300 000 annual deaths
What is the prevelence of Rheumatic Heart Disease worldwide?
Non endemic countries = 3.4/100 000
Endemic countries = >1000/100 000
Highest prevalence in Ociana, South Asia and Africa
What are the long term effects of Rheumatic Heart Disease?
Valvular diseases, esp. Mitral stenosis +/- regurgitation, aortic stenosis or regurgitation (less common)
What symptoms and investigations would be considered for Rheumatic Heart Disease?
Symptoms = dyspoea + symptoms of heart failure
ECG - no specific findings, but may have left heart enlargement, AF
CXR - May have Left heart enlargement and pulmonary venous congestiobn
How is Rheumatic Heart Disease managed?
Diuretics,
Vasodilators (ACEi/ABR)
If AF then treatment (Betablockers/digocin), anticoagulation (MUST be WARFRIN , can’t use DOACs)
What is the endocardium?
The inside lining of the heart
How does ednocarditis ususally present?
\usually with barteraimia or Septicemia
Often with other sypmtoms eg stroke/PE/MI/infaction of kidney/spleen etc
Fever (chills/rigors, poor appitite, weight loss)
New Heart murmur
Myalgia, abdo/back pain, confusion
What is involved in a vegitation?
Bacteria and platelets and fibrin
What is an osler node?
Red/purple painful lump with a paler center - found fingers and toes
What are janeway lesions?
They are like splinter haemorrages in the skin, non-tender erythematous lesions on palms or soles
What are RothSports
White centered retinal hemorrhage
Suspicion of Endocarditis, what must do?
BLOODS BEFORE ANTIBIOTICS - MUST KNOW WHAT THE BACTERIA IS !!!
Take at least 3 different blood cultures at lease 30 minutes apart
If Blood Culture is negatice, then what could this mean?
Either taken after antibiotics or could be one of these other bugs, needs more testing but can be done after antibiotic therapy has begun via PCR (or if negative Antinuclear antibodies and antiphospholipid syndrome should be ocnsidered):
- Brucella spp
- Coxiella Burnetti
- Bartonella spp
- Tropheryma whipplei
- Mycoplasma spp
- Legionella spp
- Fungi (candida and Aspergillus)
Non infective:
- SLE: Libman-Sacks endocarditis
- Marantic endocarditis
IV drug abuse, often present with what most commonly?
Staph. Aureus
Is PET currently used when?
Often used if clinical suspicial but the bacteria blood comes back negative
Definite VS Possible IE?
Definite = 2 maj OR 1 maj + 3 minor OR (new guidelines) 5 minor
POssible= 3 minor/ 1 maj + 1 minor
What can influence the prognosis?
Age, other conditions (inc. comorbidities, prosthetic valves, diabetes)
Worse for Staph Aureus/Fungi/Non-HACEK Gram -ive
Complications eg Heart Failure/Stroke/Shock/Renal failure
Other heart/heart valve isssues
What antibiotic treatment is given in IE?
Streptococci - penecillin +/- vancomycin
Staphylococci - flucoxacillin +/- vancomycin
Before the blood culture could use empirical treatment:
-Ampicillin + Flucloxacillin + genamicin OR Vancomycin + Gentamicin (if penicillin allergy)
When is surgery considered in IE?
- ongoing heart failure dispite antibiotics eg hole in vlave/calvular dysfunction/cardiac complications
- uncontrolled infection
- Prevention of embolism: v big vegetation (over 1cm), or 1+ embolic episodes
What causes Rheumatic Heart disease? why more in non-developed countries
Agressive Group A beta-haemolytic Strep Infection (STrep Pharyngitis) 5-15 yo.
Develops Acute Rheumatic fever in 2-3 weeks (carditis +painful joints. (frequently missed/not picked up on)
Years later progreses to vavular rheumativ heart disease.
What is rheumatic fever?
2-3 weeks after infection, is inflamation of the heart (carditis, may have pericarditis and valvulitis too) and may also have painful joints
Post Rheumatic fever what is standard of care for prophylaxis of rheumatic heart disease?
4 weekly intramuscular BPG (benzathine penicillin G)
Which valves are more effective, what is most common to form in rhv
Left hand side of the heart (Aortic and mitral), Mitral stenosis (+/- regrgitation) most common
WHy do RHF patients often present with AF?
Because causes dilitation of atria
WHen is Balloon Mitral valvuloplasty used?
Mainly in younger patients with symptomatic mitral stenosis, esp in pregnant women as anticoagulation with warfrin is much harder.
If Valvulorplasty not possible then ehat?
Sometimes valve replacements, but often valve replacements aren’t possible as all the valves likely to be affected
