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Clin Med II > L8: Pericarditis/Endocarditis > Flashcards

L8: Pericarditis/Endocarditis Flashcards

1
Q

What is pericarditis?

A
  • Inflammation of the pericardial sac

- Leads to potential for an increased production of pericardial fluid (pericardial effusion)

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2
Q

How much fluid does the pericardial sac usually contain?

A

15-50 mL of an ultrafiltrate of plasma

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3
Q

An increase in pericardial fluid in a closed pericardial sac can lead to:

A

increased pressure on the ear and surrounding vessels = BAD

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4
Q

_____ is the most common disorder of the pericardium.

A

Pericarditis

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5
Q

Pericarditis is most common in: (population)

A

Adult men

No difference b/w etiology, clinical course, and prognosis between elderly and younger patients

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6
Q

How important is it to discover the etiology of pericarditis?

A
  • Low yield info
  • Looking for etiology usually unnecessary
  • Usually viral or idiopathic but WE DON’T KNOW
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7
Q

What are the most common viruses that cause pericarditis?

A

Coxsackie and influenza

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8
Q

Pericarditis is an _____ process.

A

isolated, self-limiting

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9
Q

Pericarditis might be the first manifestation of an ____.

A

Underling, systemic disease

*in this case you would want to search for etiology

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10
Q

True or false: Pericarditis is only acute.

A

False - may become chronic

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11
Q

What are the main 4 clinical manifestations of pericarditis? How many do they need to have for dx?

A
  • Chest pain (sharp and pleuritic)**
  • Pericardial friction rub (scratchy or squeaking heart sound)
  • EKG changes (new widespread ST elevation or PR depression)
  • New pericardial effusion

*Must have 2/4 for dx!

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12
Q

95% of people with pericarditis have the primary complaint of:

A

chest pain

*especially if cause is infectious!

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13
Q

Describe the chest pain associated with pericarditis. (5)

A
  • Sudden onset
  • Over anterior chest
  • Sharp and pleuritic (unlike ischemic pain)
  • Improved by sitting up and leaning forward
  • Worsened by lying flat, deep inspiration, coughing, or sneezing
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14
Q

Pericardial friction rub is highly SPECIFIC for ______.

A

Acute pericarditis

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15
Q

Why does pericardial friction occur?

A

Friction between the 2 layers due to inflammation

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16
Q

How can you hear pericardial friction best?

A
  • Left sternal border
  • Scratchy or squeaking quality
  • Heard best when pt is sitting up and leaning forward

*vary in intensity; can come and go

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17
Q

Describe the use of an EKG in regards to dxing pericarditis?

A
  • EKG can show changes with inflammation of the epicardium (changes seen on EKG are diffuse)
  • Some cases do not have significant inflammation, therefore WILL NOT ALTER THE EKG
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18
Q

What is the first diagnostic test you should use to assess for pericardial effusion?

A

Echocardiogram

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19
Q

Why does pericardial effusion occur with pericarditis?

A
  • Pericardial sac = potential space
  • As inflammation increases, amount of fluid increases
  • Amount of effusion varies greatly
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20
Q

Pericardial tamponade (from pericarditis) may lead to:

A

Beck’s triad

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21
Q

What is Beck’s triad?

A
  1. Hypotension (can’t pump blood out)
  2. Muffled heart sounds (can’t hear past the fluid)
  3. JVD (blood backs up)
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22
Q

How do we typically diagnose pericarditis? What is a characteristic physical exam finding for pericarditis that would confirm diagnosis?

A
  • Usually just clinical based on CHARACTERISTIC CHEST PAIN

- Pericardial friction rub = clinically confirms dx

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23
Q

Aside from clinical hx, what else can we use to dx pericarditis?

A
  • Blood work
  • CXR
  • EKG
  • Echocardiogram (urgently if sign of pericardial tamponade)
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24
Q

Specifically what blood work would we order for pericarditis? How is this blood work applicable?

A

Order: troponin level, ESR, CRP, and CBC (can consider blood cultures if high fever)
-Abnormalities support the dx but are NOT SENSITIVE OR SPECIFIC FOR PERICARDITIS

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25
Q

What 5 labs/studies can we order to determine the specific etiology of pericarditis?

A
  • TB test
  • Antinuclear test
  • HIV serology
  • Chest CT scan with contrast
  • Cardiac MRI
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26
Q

What might a CXR show in a patient with pericarditis?

A
  • Typically normal

- Pts may have enlarged cardiac silhouette with significant pericardial effusion

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27
Q

How would you manage pericarditis with an identifiable cause (like bacterial infection)?

A

Manage the underlying disordedr

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28
Q

How would you manage pericarditis (in general)? (5)

A
  • AVOID STRENUOUS PHYSICAL ACTIVITY! May trigger worsening
  • Rest
  • Most pts safely treated as outpatient
  • High risk pts (fever, cardiac tamponade, immunosuppressed, etc.) should be admitted to hospital
  • NSAIDs (FIRST LINE!)
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29
Q

Duration of tx of pericarditis is based on _____.

A

Persistence of symptoms

usually lasts 2 weeks or less

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30
Q

There is a theoretical concern that antiplatelet activity of an NSAID might promote the development of _____.

A

hemorrhagic pericardial effusion

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31
Q

What is important to remember when treating a patient w/ pericarditis with NSAIDs?

A
  • Treat w/ NSAIDs for SHORTEST interval possible
  • Consider giving GI protection (like proton pump inhibitor) for pts with hx of peptic ulcer, >65, concurrent aspirin, steroid, or anticoagulant use
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32
Q

If a patient fails to clinically improve with first line tx NSAIDs within ONE week, consider that cause of pericarditis is ____.

A

NOT idiopathic or viral! Important to search for etiology at this point

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33
Q

What other medication can be used in adjunct to NSAID therapy?

A

Colchicine

  • Reduces sxs
  • Decreases rate of recurrent pericarditis
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34
Q

When should glucocorticoid tx be used in the management of pericarditis?

A

Considered ONLY if acute pericarditis results in sxs that are refractory to NSAIDs + cholchicine

OR

pericarditis due to a connective tissue disease, pregnancy, autoimmune peri., or uremic. peri.

OR

Significant contraindications for NSAID therapy

***steroids increase risk for recurrent pericarditis and have unwanted side effects

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35
Q

What are 4 possible complications of pericarditis?

A
  • Pericardial tamponade
  • Recurrent pericarditis
  • Constrictive pericarditis
  • Myopericarditis
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36
Q

Moderate-large pericardial effusion + hemodynamically unstable may cause

A

cardiac tamponade

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37
Q

Cardiac tamponade demands _____ for tx.

A

drainage

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38
Q

What are the 2 specific treatments for pericardial tamponade?

A
  • Pericardiocentesis (percutaneous)

- Pericardiectomy or pericardial window (surgical)

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39
Q

How do you perform a pericardiocentesis?

A
  • Needle used to remove fluid around heart
  • Use US for guidance
  • Catheter can be left to drain any reaccumulation of fluid
40
Q

What is a pericardial window?

A

Surgically removing a small part of pericardial sac

-Allows for continual drainage

41
Q

What is recurrent pericarditis? How often does it occur?

A
  • Reappearance of signs and sxs after tx of original episode

- Occurs in 1/3 of pts (weeks to months later)

42
Q

How would you treat recurrent pericarditis? What should you avoid?

A
  • Tx with NSAIDs and colchicine
  • NO glucocorticoids! Can cause further recurrences!

*Prognosis generally excellent

43
Q

What is constrictive pericarditis? What is the etiology

A

Scarring and consequent loss of normal elasticity of the pericardial sac = impaired cardiac filling

Etiology usually idiopathic or viral

44
Q

Is constrictive pericarditis acute or chronic?

A

Typically chronic

45
Q

What are common findings seen on imaging studies associated with constrictive pericarditis?

A

Pericardial thickening with or without calcification

46
Q

Constrictive pericarditis can lead to _____.

A

Pericardial tamponade

47
Q

What is the tx for constrictive pericarditis?

A
  • If they have pericardial tamponade = pericardiocentesis

- Definitive repair: pericardiectomy

48
Q

What is myopericarditis?

A

Acute pericarditis that also demonstrates myocardial inflammation

49
Q

What is the clinical presentation of myopericarditis?

A
  • Reflects degree of myo pericardial involvement
  • Presentation and diagnostic work up similar to pericarditis (troponin might be elevated)
  • Tx similar
  • Prognosis good
50
Q

What is endocarditis (IE)?

A

Infection of the endocardial surface of the heart = IE

  • Can be infection of one or more valves or intracardiac device (native valve IE, prosthetic valve IE, IV drug abuse IE, nosocomial IE)
  • Can be acute or subacute
51
Q

Describe acute endocarditis.

A
  • Usually involves normal heart valves

- Rapidly destructive and deadly

52
Q

Describe subacute andocarditis

A
  • Often affects damaged heart valves
  • Indolent (ongoing) in nature
  • Delay in tx may NOT be fatal unless
  • Usually have a very long-standing fever!
53
Q

What is the pathophysiology of endocarditis?

A
  • Turbulent blood flow disrupts endocardium and makes it “sticky”
  • Normal circulatory BF delivers organism to endocardial surface
  • Organism adheres to surface
  • Invades the valvular leaflets and causes destruction of the valve
54
Q

What are the cardiac risk factors of endocarditis?

A
  • Prior IE
  • Prosthetic valve or cardiac device
  • Hx of valvular or congenital heart disease
55
Q

What are the non-cardiac risk factors for endocarditis?

A
  • IV drug use
  • indwelling IV catheter
  • Immunosuppression
  • Recent dental/surgical procedure
  • Advanced age
56
Q

What are the most notable risk factors for IE?

A
  • males 60 years or older
  • Injection drug use
  • Poor dentition/infection
57
Q

The most common cause of healthcare-associated IE and IV drug users IE is _____.

A

staphylococci

58
Q

The most common cause of community-acquired IE is ____.

A

both staphylococci and streptococci (roughly equal in CIE)

staph aureus, viridans strep

59
Q

What is the most common symptom of endocarditis?

A

Fever!

60
Q

What are the sxs of endocarditis?

A
  • can be highly variable
  • Fever!!!
  • Cardiac murmurs!!!
  • Malaise, H/A, myalgia, abdominal pain, cough, etc.
  • Cutaneous manifestations

(Subacute/chronic will have fever and nonspecific sxs)

61
Q

What are the cutaneous manifestations of endocarditis?

A
  • Petechiae

- Splinter hemorrhages (reddish-brown lesions under nail bed)

62
Q

What are 3 rare PE findings for endocarditis?

A
  • Janeway lesions
  • Osler nodes
  • Roth spots

*Can be very characteristic if you find it though!

63
Q

What are Janeway lesions?

A

NONTENDER erythematous macules on the palms and soles

64
Q

What are Osler nodes?

A

TENDER subcutaneous violaceous nodules

65
Q

What are Roth spots?

A

Exudative, edematous hemorrhagic lesions of the retina with pale centers

  • Rare
  • Most likely from retinal capillary rupture
66
Q

Janeway lesions are more common in _____ endocarditis.

A

Acute (rather than subacute)

microabscesses

67
Q

Osler nodes are more common in _____ endocarditis.

A

Subacute

localized immune mediated vasculitis

68
Q

It is possible for a patient to come in with a presenting complaint centered on a _____ affected by IE rather than the heart.

A

body system

69
Q

What are 4 complications of endocarditis?

A
  • Cardiac
  • Neurologic
  • Septic emboli
  • Metastatic infection
70
Q

How do we diagnose endocarditis?

A
  • Clinical manifestations
  • Blood cultures
  • Echocardiogram
  • **Modified Duke criteria
71
Q

_____ should be considered in the differential in all patients with a fever of unknown origin.

A

Endocarditis

72
Q

Add endocarditis to your differential in a patient with:

A

fever and risk factors (cardiac or non-cardiac)

73
Q

When trying to diagnose endocarditis, you should have at least ____ sets of blood cultures from _____.

A

3 sets from separate venipuncture sites

*Blood work = HIGH diagnostic yield!

74
Q

If a patient has negative blood cultures but persistent fever and clinical findings associated with endocarditis, you should be suspicious of:

A

Culture-negative IE

75
Q

What is the first diagnostic test for patients with suspected IE?

A

Transthoracic echocardiography

76
Q

Does a TTE or TEE have higher sensitivity for endocarditis?

A

TEE (but more invasive)

Best to get one for cardiac complications

77
Q

What can cause false negatives on the echo?

A

Small vegetations and/or vegetations that have embolized

78
Q

How do you treat endocarditis?

A
  • BacterioCIDAL abx targeted to organism isolated from blood cultures
  • Consult cardiac surgeon for all cases w observed or expected complications
  • Surveillance with blood cultures
79
Q

Empiric abx therapy is not always necessary in a patient _____ of suspected endocarditis.

A

without acute symptoms

80
Q

How do you treat an acutely ill patient with endocarditis?

A

Empiric abx DIRECTLY after BCx are drawn!

81
Q

In general, empiric therapy for IE covers: (bacteria)

A

staphylocci, streptococci, and enterococci

82
Q

What is the DOC for Native valve IE?

A

Vancomycin

83
Q

What is the duration of therapy for a pt with native valve IE?

A

Usually 4-6 weeks but duration can vary (usually pt becomes afebrile 3-5 days after tx with abx)

84
Q

What is the treatment for prosthetic valve IE?

A
  • More difficult to treat!
  • May require surgical replacement of prostheses + abx therapy
  • Must ID causative organism
  • Abx continued for longer period of time than native IE
  • May need to use multiple abx therapy
85
Q

What are 4 etiologies for potential complications from endocarditis?

A
  • Embolic (40% of cases)
  • Local spread of infection
  • Metastatic spread of infection
  • Formation of immune complexes
86
Q

What are 5 body systems that can have complications from endocarditis?

A
  • Cardiac
  • Neurological
  • Renal
  • MSK
  • Systemic
  • Complications may overlap
87
Q

______ is the most common indication for cardiac surgery in patients with IE.

A 
Heart failure
(potential complication of endocarditis)
88
Q

_____ is the most common cause of death in patients with IE.

A

Heart failure (NOT so much the untreated infection!)

89
Q

What are some cardiac complications that can occur from endocarditis?

A
  • HEART FAILURE!*
  • Perivalvular abscess
  • Severe valvular dysfunction
  • Pericarditis
90
Q

What are some neurologic complications that can occur from endocarditis?

A
  • Stroke
  • Brain abscess
  • Meningitis
91
Q

What are some renal complications that can occur from endocarditis?

A
  • Renal infarction
  • Abscess
  • Glomerulonephritis
  • Secondary complication of abx causing renal damage
92
Q

What are some MSK complications that can occur from endocarditis?

A
  • Vertebral osteomyelitis

- Septic arthritis from immune complexes

93
Q

A patient with endocarditis will have increased risk for mortality if they have (4):

A
  • Certain microbes
  • Heart failure
  • Embolization
  • Are not a candidate for cardiac surgery
94
Q

Which 2 types of IE are more commonly associated with higher mortality?

A

Prosthetic valve IE

IV drug use IE

95
Q

What are 6 poor prognostic factors for pts with endocarditis (aka who does worse)?

A
  • Female gender
  • Infection with S. Aureus
  • Large vegetations
  • Aortic valve infection
  • Older age
  • Comorbid conditions
96
Q

What 4 kinds of surgeries require dental prophylaxis?

A
  • Prosthetic heart valves
  • Prior IE
  • Congenital heart disease
  • Procedures on infected skin or MSK tissue
  • Meant to prevent endocarditis
  • GI/GU procedures do not require abx prophylaxis anymore!

Clin Med II (9 decks)

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