L8: Pericarditis/Endocarditis Flashcards
What is pericarditis?
- Inflammation of the pericardial sac
- Leads to potential for an increased production of pericardial fluid (pericardial effusion)
How much fluid does the pericardial sac usually contain?
15-50 mL of an ultrafiltrate of plasma
An increase in pericardial fluid in a closed pericardial sac can lead to:
increased pressure on the ear and surrounding vessels = BAD
_____ is the most common disorder of the pericardium.
Pericarditis
Pericarditis is most common in: (population)
Adult men
No difference b/w etiology, clinical course, and prognosis between elderly and younger patients
How important is it to discover the etiology of pericarditis?
- Low yield info
- Looking for etiology usually unnecessary
- Usually viral or idiopathic but WE DON’T KNOW
What are the most common viruses that cause pericarditis?
Coxsackie and influenza
Pericarditis is an _____ process.
isolated, self-limiting
Pericarditis might be the first manifestation of an ____.
Underling, systemic disease
*in this case you would want to search for etiology
True or false: Pericarditis is only acute.
False - may become chronic
What are the main 4 clinical manifestations of pericarditis? How many do they need to have for dx?
- 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!
95% of people with pericarditis have the primary complaint of:
chest pain
*especially if cause is infectious!
Describe the chest pain associated with pericarditis. (5)
- 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
Pericardial friction rub is highly SPECIFIC for ______.
Acute pericarditis
Why does pericardial friction occur?
Friction between the 2 layers due to inflammation
How can you hear pericardial friction best?
- Left sternal border
- Scratchy or squeaking quality
- Heard best when pt is sitting up and leaning forward
*vary in intensity; can come and go
Describe the use of an EKG in regards to dxing pericarditis?
- 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
What is the first diagnostic test you should use to assess for pericardial effusion?
Echocardiogram
Why does pericardial effusion occur with pericarditis?
- Pericardial sac = potential space
- As inflammation increases, amount of fluid increases
- Amount of effusion varies greatly
Pericardial tamponade (from pericarditis) may lead to:
Beck’s triad
What is Beck’s triad?
- Hypotension (can’t pump blood out)
- Muffled heart sounds (can’t hear past the fluid)
- JVD (blood backs up)
How do we typically diagnose pericarditis? What is a characteristic physical exam finding for pericarditis that would confirm diagnosis?
- Usually just clinical based on CHARACTERISTIC CHEST PAIN
- Pericardial friction rub = clinically confirms dx
Aside from clinical hx, what else can we use to dx pericarditis?
- Blood work
- CXR
- EKG
- Echocardiogram (urgently if sign of pericardial tamponade)
Specifically what blood work would we order for pericarditis? How is this blood work applicable?
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
What 5 labs/studies can we order to determine the specific etiology of pericarditis?
- TB test
- Antinuclear test
- HIV serology
- Chest CT scan with contrast
- Cardiac MRI
What might a CXR show in a patient with pericarditis?
- Typically normal
- Pts may have enlarged cardiac silhouette with significant pericardial effusion
How would you manage pericarditis with an identifiable cause (like bacterial infection)?
Manage the underlying disordedr
How would you manage pericarditis (in general)? (5)
- 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!)
Duration of tx of pericarditis is based on _____.
Persistence of symptoms
usually lasts 2 weeks or less
There is a theoretical concern that antiplatelet activity of an NSAID might promote the development of _____.
hemorrhagic pericardial effusion
What is important to remember when treating a patient w/ pericarditis with NSAIDs?
- 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
If a patient fails to clinically improve with first line tx NSAIDs within ONE week, consider that cause of pericarditis is ____.
NOT idiopathic or viral! Important to search for etiology at this point
What other medication can be used in adjunct to NSAID therapy?
Colchicine
- Reduces sxs
- Decreases rate of recurrent pericarditis
When should glucocorticoid tx be used in the management of pericarditis?
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
What are 4 possible complications of pericarditis?
- Pericardial tamponade
- Recurrent pericarditis
- Constrictive pericarditis
- Myopericarditis
Moderate-large pericardial effusion + hemodynamically unstable may cause
cardiac tamponade
Cardiac tamponade demands _____ for tx.
drainage
What are the 2 specific treatments for pericardial tamponade?
- Pericardiocentesis (percutaneous)
- Pericardiectomy or pericardial window (surgical)
How do you perform a pericardiocentesis?
- Needle used to remove fluid around heart
- Use US for guidance
- Catheter can be left to drain any reaccumulation of fluid
What is a pericardial window?
Surgically removing a small part of pericardial sac
-Allows for continual drainage
What is recurrent pericarditis? How often does it occur?
- Reappearance of signs and sxs after tx of original episode
- Occurs in 1/3 of pts (weeks to months later)
How would you treat recurrent pericarditis? What should you avoid?
- Tx with NSAIDs and colchicine
- NO glucocorticoids! Can cause further recurrences!
*Prognosis generally excellent
What is constrictive pericarditis? What is the etiology
Scarring and consequent loss of normal elasticity of the pericardial sac = impaired cardiac filling
Etiology usually idiopathic or viral
Is constrictive pericarditis acute or chronic?
Typically chronic
What are common findings seen on imaging studies associated with constrictive pericarditis?
Pericardial thickening with or without calcification
Constrictive pericarditis can lead to _____.
Pericardial tamponade
What is the tx for constrictive pericarditis?
- If they have pericardial tamponade = pericardiocentesis
- Definitive repair: pericardiectomy
What is myopericarditis?
Acute pericarditis that also demonstrates myocardial inflammation
What is the clinical presentation of myopericarditis?
- Reflects degree of myo pericardial involvement
- Presentation and diagnostic work up similar to pericarditis (troponin might be elevated)
- Tx similar
- Prognosis good
What is endocarditis (IE)?
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
Describe acute endocarditis.
- Usually involves normal heart valves
- Rapidly destructive and deadly
Describe subacute andocarditis
- Often affects damaged heart valves
- Indolent (ongoing) in nature
- Delay in tx may NOT be fatal unless
- Usually have a very long-standing fever!
What is the pathophysiology of endocarditis?
- 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
What are the cardiac risk factors of endocarditis?
- Prior IE
- Prosthetic valve or cardiac device
- Hx of valvular or congenital heart disease
What are the non-cardiac risk factors for endocarditis?
- IV drug use
- indwelling IV catheter
- Immunosuppression
- Recent dental/surgical procedure
- Advanced age
What are the most notable risk factors for IE?
- males 60 years or older
- Injection drug use
- Poor dentition/infection
The most common cause of healthcare-associated IE and IV drug users IE is _____.
staphylococci
The most common cause of community-acquired IE is ____.
both staphylococci and streptococci (roughly equal in CIE)
staph aureus, viridans strep
What is the most common symptom of endocarditis?
Fever!
What are the sxs of endocarditis?
- 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)
What are the cutaneous manifestations of endocarditis?
- Petechiae
- Splinter hemorrhages (reddish-brown lesions under nail bed)
What are 3 rare PE findings for endocarditis?
- Janeway lesions
- Osler nodes
- Roth spots
*Can be very characteristic if you find it though!
What are Janeway lesions?
NONTENDER erythematous macules on the palms and soles
What are Osler nodes?
TENDER subcutaneous violaceous nodules
What are Roth spots?
Exudative, edematous hemorrhagic lesions of the retina with pale centers
- Rare
- Most likely from retinal capillary rupture
Janeway lesions are more common in _____ endocarditis.
Acute (rather than subacute)
microabscesses
Osler nodes are more common in _____ endocarditis.
Subacute
localized immune mediated vasculitis
It is possible for a patient to come in with a presenting complaint centered on a _____ affected by IE rather than the heart.
body system
What are 4 complications of endocarditis?
- Cardiac
- Neurologic
- Septic emboli
- Metastatic infection
How do we diagnose endocarditis?
- Clinical manifestations
- Blood cultures
- Echocardiogram
- **Modified Duke criteria
_____ should be considered in the differential in all patients with a fever of unknown origin.
Endocarditis
Add endocarditis to your differential in a patient with:
fever and risk factors (cardiac or non-cardiac)
When trying to diagnose endocarditis, you should have at least ____ sets of blood cultures from _____.
3 sets from separate venipuncture sites
*Blood work = HIGH diagnostic yield!
If a patient has negative blood cultures but persistent fever and clinical findings associated with endocarditis, you should be suspicious of:
Culture-negative IE
What is the first diagnostic test for patients with suspected IE?
Transthoracic echocardiography
Does a TTE or TEE have higher sensitivity for endocarditis?
TEE (but more invasive)
Best to get one for cardiac complications
What can cause false negatives on the echo?
Small vegetations and/or vegetations that have embolized
How do you treat endocarditis?
- BacterioCIDAL abx targeted to organism isolated from blood cultures
- Consult cardiac surgeon for all cases w observed or expected complications
- Surveillance with blood cultures
Empiric abx therapy is not always necessary in a patient _____ of suspected endocarditis.
without acute symptoms
How do you treat an acutely ill patient with endocarditis?
Empiric abx DIRECTLY after BCx are drawn!
In general, empiric therapy for IE covers: (bacteria)
staphylocci, streptococci, and enterococci
What is the DOC for Native valve IE?
Vancomycin
What is the duration of therapy for a pt with native valve IE?
Usually 4-6 weeks but duration can vary (usually pt becomes afebrile 3-5 days after tx with abx)
What is the treatment for prosthetic valve IE?
- 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
What are 4 etiologies for potential complications from endocarditis?
- Embolic (40% of cases)
- Local spread of infection
- Metastatic spread of infection
- Formation of immune complexes
What are 5 body systems that can have complications from endocarditis?
- Cardiac
- Neurological
- Renal
- MSK
- Systemic
- Complications may overlap
______ is the most common indication for cardiac surgery in patients with IE.
Heart failure (potential complication of endocarditis)
_____ is the most common cause of death in patients with IE.
Heart failure (NOT so much the untreated infection!)
What are some cardiac complications that can occur from endocarditis?
- HEART FAILURE!*
- Perivalvular abscess
- Severe valvular dysfunction
- Pericarditis
What are some neurologic complications that can occur from endocarditis?
- Stroke
- Brain abscess
- Meningitis
What are some renal complications that can occur from endocarditis?
- Renal infarction
- Abscess
- Glomerulonephritis
- Secondary complication of abx causing renal damage
What are some MSK complications that can occur from endocarditis?
- Vertebral osteomyelitis
- Septic arthritis from immune complexes
A patient with endocarditis will have increased risk for mortality if they have (4):
- Certain microbes
- Heart failure
- Embolization
- Are not a candidate for cardiac surgery
Which 2 types of IE are more commonly associated with higher mortality?
Prosthetic valve IE
IV drug use IE
What are 6 poor prognostic factors for pts with endocarditis (aka who does worse)?
- Female gender
- Infection with S. Aureus
- Large vegetations
- Aortic valve infection
- Older age
- Comorbid conditions
What 4 kinds of surgeries require dental prophylaxis?
- 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!
