Myocarditis, Pericarditis and Endocarditis Flashcards
What is Pericarditis?
Inflammation of the pericardial sac which can be caused by fibrin deposits on the pericardium (constrictive) or cause by effusions into the pericardial sac (restrictive)
The most common cause of pericarditis include……:
MI, viral infection, autoimmune disease, renal failure, trauma, idiopathic in nature, TB, septicemia, endocarditis, collagen diseases, and neoplastic
Idiopathic in nature —>likely viruses and Dx with recent virus -most common form
What are the most common symptoms of Percarditis?
- Non-radiating, sharp, knifelike chest pain over the area of PMI (Apex ).
- Decrease pain or changes in the characteristics of a pain when sitting up or leaning forward. (Mohammad’s sign
- Pain increase with deep inspiration, coughing, swallowing, or a recumbent position (Laying supine).
- SOB secondary to pain with inspiration.
- Fever possibly
- Physical examination is a pericardial friction rub heard at the left lower sternal border or a pleural fiction rub.
Pericarditis work up includes ….
- EKG-which could show diffuse concave ST elevation with T-wave inversion’s and PR interval depression.
- Chest x-ray which could show increased in cardiac silhouette with a “water bottle heart.”
- Echocardiogram may be normal or detect a pericardial effusion, left ventricular and right ventricular dysfunction may lead to a diagnosis of myocarditis.
- Cardiac enzymes are typically normal.
What is the Evidence-based management for Percarditis?
NSAIDS for 7 to 14 days then taper.
For recurrent or cannot tolerate NSAIDS —> can add colchicine 1-2 mg dose as a one time, then 0.5 to 1 mg twice a day x 3 months. Colchine added to NSAIDs is thought to reduce the incidence of recurrance.
Steroids are reserved for systemic rheumatoid disease, an autoimmune disorders, uremia, pregnancy and for patients where NSAIDS are contraindicated since systemic steroids may increase the risk of pericarditis reoccurrence.
Avoidance of anticoagulation.
If pericardial effusion continues and is recurrent, consider a pericardial window.
Monitor for tamponade. (hypotension, JVD, muffled or distant heart sounds, pulses paradoxus).
What is Endocarditis ?
Endocarditis is an infection of the endocardium resulting from the entrance of bacteria into the vascular system.
Disorders of the cardiac valve lead to bacterial adhesions and the propagation of infectious vegetations on the valve leaflets.
Valvular disease such as stenosis and regurgitation can lead to turbulent blood flow across the valves which promotes the adherents of bacteria.
Mitral valve mostly affected follwed by aortic
The most common cause of endocarditis…….
The most common cause of endocarditis includes any situation in which bacteria can enter the bloodstream.
Bacteria enter through penetration of the skin or mucous membrane and adhere to a valve leaflet and produce vegetation.
Common causes of endocarditis include the following IV drug use, dental procedures, surgical procedures.
risk facotrs include overthe age of 60 and male
What are the most common organisms that cause Endocarditis?
The most common organisms are Staphylococcus Aureus
Group A and B hemolytic Streptococcus
Streptococcus pneumoniae.
Common causes of endocarditis include IV drug use, dental procedures, ans/or surgical procedures.
Endocarditis can be Acute or sub acute in presentation. What are the symptoms?
Acute Endocarditis symptoms are associated with sepsis.
Subacute symptoms include fatigue, subjective fever, anemia, emboli, , and a history of skin- layer penetration.
Physical examination findings may include the following:
* Roth spots (retinal hemorrhages with pale centers caused by emboli on nerve fibers)
* new onset or changing cardiac murmur (mostly regurgitation in nature)
* janeway lesions (nontender hemorrhagic plaques on palms of hands and soles of feet)
* oshlar’s nodes (tender nodules on finger pad and digits)
* petechiae
* purpura
* pallor
* Splinter hemorrhages (linear, subungual (under tongue) splinter appearing)
* Splenomegaly (up to 50% of patients).
Work up for Endocarditis?
Immunocomprimised patitent?
Work up includes blood cultures, Laboratory test, echocardiogram, and EKG.
In immunocompromised patients consider fungal infection.
What is the treatment for Endocarditis ?
When is surgical intervention considered?
Evidence based treatment start with systemic antibiotics with broad coverage and narrow down based on culture results.
Typical duration is 4 to 6 weeks.
Surgical intervention is aimed at decrease in the reoccurrence of infection and improving structural integrity.
Surgical treatment considered
1. severe valvular dysfunction with refractory heart failure symptoms
2. uncontrolled infection
3. organisms based conditions (S. Aureus, fungal, and drug -resistant organisms) , systemic embolization, prosthetic valve ( with valve dysfunction).
Suggested treatment includes
1. Native valve with acute endocarditis -vancomycin can consider adding gentamicin but is not routinely recommended.
2. Native valve with subacute endocarditis - Rocephin, consider adding gentamicin if the likely causes is enterococcus or if the patient is an older female or the condition is OB/GYN in nature.
3. Prosthetic valve-vancomycin gentamicin and cefepime <60 days after valve replacement. Vancomycin and gentamicin >60 days to one year after valve replacement. Vancomycin gentamicin rocephin if greater than one year after valve replacement.
What is Myocarditis?
Inflammation of the heart muscles.
Myocarditis can result in dilation of the heart, development of thrombi on the heart walls (mural thrombus) , infiltration of blood cells around coronary vessels and between muscle fibers causing further degeneration of muscle tissue. The heart becomes enlarged, weak, and the ability to pump blood is impaired, leading to congestive heart failure.
What is a trigger for Myocarditis?
It is usually triggered by a viral infection, but it can also be caused by bacteria, fungi or parasites or an allergic response to medications (chemotherapy drugs and some antibiotics ). It can also be a complication of endocarditis.
What are the symptoms of Myocarditis?
Symptoms depend upon the extent of damage but may include fatigue dyspnea pressure and discomfort in the chest or epigastric area and palpitations.
What is the work up for Myocarditis?
Work up includes EKG, Xray, ECHO, Cardiac Cath or biopsy (only 65% confirmation as not all heart muscle affected) , cultures, and PCR.
