Infective Endocarditis + Pericarditis

Question 1

What is infective endocarditis?

Answer 1

Infection of the endothelium of the heart most commonly affecting the heart valves

Question 2

What are the risk factors for developing infective endocarditis?

Answer 2

IVDU (Intravenous Drug User)
Prosthetic heart valve
Poor oral hygiene
Structural heart disease
CKD (especially dialysis)
Immunocompromised (Cancer, HIV or immunosuppressive medications)
History of infective endocarditis

Question 3

What structural heart disease increase the risk of developing infective endocarditis?

Answer 3

Valvular heart disease
Hypertrophic cardiomyopathy
Prosthetic heart valves
Implantable cardiac devices

Question 4

What are the most common causative organisms for infective endocarditis?

Answer 4

Staphylococcus aureus
Streptococcus (viridans group)
Enterococcus

Rare:
Pseudomonas, HACEK organisms

Question 5

How does a patient with infective endocarditis present?

Answer 5

Fever
Fatigue
Night sweats
Muscle aches
Anorexia
Sepsis

Question 6

What examination findings can be present with infective endocarditis?

Answer 6

New/change of heart murmur
Splinter haemorrhages
Janeaway lesions
Oslers nodes
Roth spots (retina on fundoscopy)
Splenomegaly
Finger clubbing

Question 7

What is the pathophysiology of splinter haemorrhages in infective endocarditis?

Answer 7

Micro septic emboli in the finger nails

Question 8

What is the pathophysiology of Roth spots on fundoscopy?

Answer 8

Haemorrhages on the retina

Question 9

What investigations do you do to investigate infective endocarditis?

Answer 9

Blood cultures

ECHOCARDIOGRAM OR TRANSOESOPHAGEAL ECHOCARDIOGRAM (looking for vegetations)
May require PET CT if prosthetic valve

Question 10

What is the name of the criteria used to diagnose infective endocarditis?

Answer 10

Modified Duke Criteria

Question 11

What do you need to diagnose infective endocarditis according to the modified Duke criteria?

Answer 11

One major + Three minor criteria
Five minor criteria

Question 12

What are the major criteria for diagnosing infective endocarditis?

Answer 12

Persistently positive blood cultures

Specific imaging findings (vegetations on echo)

Question 13

What are the minor criteria for diagnosing infective endocarditis?

Answer 13

Predisposition/risk factors (IVDU or heart valve pathology)
Fever > 38
Vascular phenomena (Janeaway lesions, splenic infarction, intracranial haemorrhage)
Immunological phenomena (Oslers nodes, roth spots, glomerulonephritis)
Microbiological phenomena (positive cultures not qualifying for major criteria)

Question 14

What is the management for infective endocarditis?

Answer 14

Refer cardiology and/or microbiology

IV broad spectrum (AMOXICILLIN + GENTAMICIN) then specific ABX once causative organism is identified

Question 15

How long are antibiotics given to treat infective endocarditis?

Answer 15

4 weeks for normal native heart valve
6 weeks for prosthetic heart valve

Question 16

How long are antibiotics given to treat infective endocarditis?

Answer 16

4 weeks for normal native heart valve
6 weeks for prosthetic heart valve

Question 17

When is surgery appropriate for infective endocarditis?

Answer 17

Heart failure caused by valve pathology caused by the infective endocarditis
Large vegetations or abscesses
Infection not responding to ABX

Question 18

What are some complications of infective endocarditis?

Answer 18

Heart valve damage leading to regurgitation
Heart failure
Infective and non infective emboli (abcesses, strokes and splenic infarction)
Glomerulonephritis

Question 19

Which valve is most commonly affected in infective endocarditis and why?

Answer 19

Tricuspid valve
First valve come into contact if a patietn has an infection from being an IVDU

Question 20

What’s is pericarditis?

Answer 20

Inflammation of the pericardium which is the membrane surrounding the heart

Question 21

What are some causes of pericarditis?

Answer 21

Idiopathic
Infection (TB, HIV, EBV, coxsackievirus and other viruses)
Autoimmune (SLE, Rheumatoid arthritis)
Trauma to pericardium
Uraemia (renal impairment)
Cancer
Meds (methotrexate)

Question 22

What is a pericardial effusion?

Answer 22

The potential space of the pericardium fills with fluid due to the infection or inflammation creating pressure on the heart which can lead to pericardial tamponade

Question 23

What is pericardial tamponade?

Answer 23

Pericardial effusion large enough to raise the Intra-pericardial pressure enough to put pressure on the heart impairing its action in diastole reducing cardiac output

Question 24

Why is pericardial tamponade an emergency?

How is it managed?

Answer 24

Can severely reduce cardiac output

Requires emergency drainage of the pericardial effusion to relieve the pressure

Question 25

What are the 2 key features of a pericarditis presentation?

Answer 25

Chest pain
Low-grade fever

Question 26

What type of chest pain is experienced with pericarditis?

Answer 26

Sharp
Central
Pleuritic
Worse on lying down
Better on sitting forward

Question 27

What sound can be heard on auscultation with pericarditis?

Answer 27

Pericardial rub

Question 28

What investigations would you do for pericarditis?

Answer 28

Bloods (WBC, CRP, ESR)
ECG

Question 29

What ECG changes do you see with pericarditis?

Answer 29

Wide spread / Global ST ELEVATION

PR depression

Question 30

What is the firstline medical management of pericarditis?

Answer 30

NSAIDs (aspirin or ibuprofen)
Colchicine (longer term)

Question 31

What medication can be given second line to treat pericarditis?

Answer 31

Steroids in recurrent cases or associated inflammatory conditions

Question 32

When may pericardiocentesis be necessary when treating pericarditis?

Answer 32

If there’s significant pericardial effusion or tamponade