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CARDIO > old endocarditis, pericardial, myocardial disease > Flashcards

old endocarditis, pericardial, myocardial disease Flashcards

1
Q

what is infective endocarditis?

A

cardiac valves develop vegetations composed of bacteria + platelet-fibrin thrombus

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2
Q

what are the risk factors of infective endocarditis?

A 
1) cardiac disease-> subacute
prosthetic valves
degenerative valvulopathy
VSD, PDA, CoA
rheumatic fever
2) normal valves -> acute
dental caries
post-op wounds
IVDU- tricuspid valve
immunocomp inc DM
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3
Q

what are the causes of culture postiive infective endocarditis?

A 
S. viridian's
S. bovis
s. aureus
s. epidermidis
enterococci 
pseudomonas
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4
Q

what are the causes of culture negative infective endocarditis?

A 
haemophilus
actinobacillus
caardobacterium
eikenella
kingella
coxiella
chlamydia
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5
Q

what are the non-infective causes of infective endocarditis?

A

SLE

marantic

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6
Q

what are the categories of clinical features of infective endocarditis?

A

sepsis
cardiac
embolic phenoomena
immune complex deposition

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7
Q

what are the clinical features of septic infective endocarditis picture?

A 
fever
rigors
night sweats
weight loss
anaemia
splenomegaly
clubbing
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8
Q

what are the clinical features of cardiac infective endocarditis picture?

A

new/changing murmur
- MR 85%, AR 55%
AV block
LVF

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9
Q

what are the clinical features of embolic phenomena infective endocarditis picture?

A

abscesses in brain, heart, kidney, spleen, gut + lung if R sided
janeway lesions

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10
Q

what are the clincal features of immune complex deposition infective endocarditis picture?

A 
micro haematuria due to GN
vasculitis
roth spots
splinter haemorrhages
osler's nodes
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11
Q

what are roth spots

A

boat-shaped retinal haemorrhages with pale centre

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12
Q

what are janeway lesions

A

painlesss palmer macules

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13
Q

what are osler’s nodes

A

painfull purple papules on finger pulps

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14
Q

what criteria is used to diagnose infective endocarditis + when is diagnosis made?

A

duke criteria

2 major OR
1 major + 3 minor OR
All 5 minor

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15
Q

what are the major criteria in duke’s criteria for infective endocarditis?

A

1) positive blood culture- typical organism in 2 separate cultures or persistently + cultures eg 3 >12h apart

2) endocardium involved
so positive echo- vegetation, abscess, valve dehiscence OR new valvular regurgitation

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16
Q

what are the minor criteria in duke’s criteria for infective endocarditis?

A

1) predisposition- cardiac lesion, IVDU
2) fever>38
3) emboli- septic infarcts, splinters, janeway lesions
4) immune phenomenon- GN, osler’s nodes, roth spots, RF
5) positive blood culture not meeting major criteria

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17
Q

what investigations would you do for infective endocarditis?

A

1) bedside- urine dipstick, eCG
2) bloods- FBC, ESR/CRP, blood cultures x3 >12h apart, serology for unusual organisms
3) ECHO

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18
Q

what can bloods show in infective endocarditis?

A

Normochromic normocytic anaemia
elevated ESR + CRP
positive IgG RF (immune phemomenon)

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19
Q

what would urine dipstick show in infective endocarditis?

A

micro haematuria

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20
Q

what could ECG show in infective endocarditis?

A

AV block

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21
Q

what could ECHO show in infective endocarditis?

A

TTE detects vegations >2mm
TOE more senstiive

vegetation
abscess
valve dehiscence

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22
Q

what is the empirical management of infective endocarditis?

A

acute severe- fuclox + gent IV

subacute- benpen + gent IV

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23
Q

what is the management of infective endocarditis with streps?

A

benpen + gent IV

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24
Q

what is the management of infective endocarditis with enterococci?

A

amoxicillin + gent IV

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25
Q

what is the management of infective endocarditis with staphs?

A

fluclox +/- rifampicin IV

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26
Q

what is the management of infective endocarditis with fungi?

A

flucytosine IV + fluconazole PO

ampnotericin if flucytosine resistance or aspergillus.

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27
Q

when would you consider surgical management for infective endocarditis?

A

HF
emboli
valve obstruction
prosthetic valve

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28
Q

would you do prophylaxis for infective endocarditis?

A

abx to prevent IE NOT recommended

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29
Q

what is the mortality for infective endocarditis with staphs, bowel flora and senstive streps?

A

staphs 30%
bowel flora 14%
senstiive streps 6%

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30
Q

what is the cause of rheumatic fever?

A

group A beta-haemolytic strep (pyogenes)

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31
Q

what is the epidemiology for rheumatic fever?

A

5-15yo
rare in west. common in developing world
2% populaton susceptible

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32
Q

what is the pathophysiology of rheumatic fever?

A

antibody cross reactivity following s. pyogenes infection leads to T2 hypersenstivity reaction (molecular mimicry)

  • antibodies vs M protein in cell wall
  • cross react with myosin, muscle glycogen and SM cells
  • pathology: aschoff bodies + anitschkow myocytes
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33
Q

what can be seen on pathology with rheumatic fever?

A

aschoff bodies

anitschkow myocytes

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34
Q

what criteria is used to diagnose rheumatic fever + when is diagnosis made?

A

revised Jones criteria

evidence of GAS infection AND:

  • 2 major OR
  • 1 major + 2 minor
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35
Q

what indicates evidence of GAS infection?

A

positive throat culture
rapid strep Ag test
raised ASOT or DNase B titre
recent scarlet fever

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36
Q

what is the major criteria in revised Jones criteria for rheumatic fever?

A 
pancarditis
arthritis
subcutaneous nodules
erythema marginatum
sydenham's chorea
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37
Q

what is the minor crtieria in revised Jones criteria for rheumatic fever?

A 
fever
raised ESR or CRP
arthralgia of large joints- not arthritis
prolonged PR interval- not carditis
previous rheumatic fever
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38
Q

what is pancarditis?

A

pericarditis- chest pain, friction rub

myocarditis- sinus tachy, AV block, HF, raised CK, T inversion

endocarditis- murmurs- MR, AR, carey Coombs (MDM)

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39
Q

what is meant by subcutaneous nodules in rheumatic fever?

A

small mobile painless nodules on extensor surfaces especially elbows

40
Q

what is meant by erythema marginatum in rheumatic fever?

A

red raised edges with central clearing

on trunk, thighs and arms

41
Q

what is meant by sydenham’s chorea in rheumatic fever?

A

occurs late

grimacing, clumsy, hypotonia (stops in sleep)

42
Q

what investigations would you do in rheumatic fever?

A

1) bloods- strep Ag test or ASOT, FBC, ESR/CRP
2) ECG
3) ECHO

43
Q

what is the management of rheumatic fever?

A

1) bed rest until CRP normal for 2 weeks
2) benpen 0.6-1.2mg IM 10 days
3) anaglesia for carditis/arthritis- aspirin/NSAIDs
4) add oral pred if- CCF, cardiomegaly, 3rd degree block
5) chorea- haldol or diazepam

44
Q

what is the prognosis of rheumatic fever?

A

1) attacks last about 3 months
2) 60% with carditis develop chronic rheumatic heart disease
3) recurrence precipitated by- further strep info, pregnancy, OCP
4) valve disease: regurg-> stenosis M>A>T>P

45
Q

what secondary prophylaxis can you do for rheumatic fever?

A 
prevent recurrence
pen v 250mg/12h PO
- carditis + valve disease until 40yo
- carditis with no valve disease for 10yrs
- no carditis- 5 years
46
Q

what are the causes of acute pericarditis?

A

1) viral- coxsackie, flu, ebv, hiv
2) bacterial- pneumonia, rheumatic fever, TB, staphs
3) fungi
4) MI, Dressler’s
5) drugs- peniciillin, isoniazid, procainamide, hydralazine
6) other- uraemia, RA, SLE, sarcoid, radiotherapy

47
Q

what are the clinical features of acute pericarditis?

A

central/restrosternal chest pain- sharp, pleuritic, worse lying down, relieved sitting forward, radiates to L shoulder

pericardial friction rub
fever
signs of effusion/tamponade

48
Q

what investigations are done for acute pericarditis + what results?

A

ECG- saddle shaped ST elevation +/- PR depression

bloods- FBC, ESR, trop may be raised, cultures, virology

49
Q

what is the management of acute pericarditis?

A

analgesia- ibuprofen 400mg/8h PO
treat cause
consider steroids/immunosuppression

50
Q

what is constrictive percarditis?

A

heart encased in rigid pericardium

51
Q

what are the causes of constrictive percarditis?

A

often unknown

may occur after any percarditis

52
Q

what are the clinical features of constrictive percarditis?

A

1) RHF with raised JVP- prominent x + y descents
2) kussmaul’s sign- raised jvp with inspiration
3) quiet heart sounds
4) S3
5) hepatosplenomegaly
6) ascites, oedema

53
Q

what investigations would you do for constrictive percarditis?

A

CXR- small heart + pericardial calcification
ECHO
cardiac catherisation

54
Q

what is the management of constrictive percarditis?

A

surgical excision

55
Q

what is percardial effusion?

A

abnormal accumulation of fluid in the pericardial cavity. Because of the limited amount of space in the pericardial cavity, fluid accumulation leads to an increased intrapericardial pressure which can negatively affect heart function.

56
Q

what are the causes of percardial effusion?

A

any cause of pericarditis

so viral, bacterial, fungi, MI, drugs etc

57
Q

what are the clinical features of percardial effusion?

A

dyspnoea
raised jvp- prominent x descent

bronchial breathing at left base
- ewart’s sign: large effusion compressing lower left lobe

signs of cardiac tamponade maybe

58
Q

what investigations would you do for percardial effusion?

A

CXR- enlarged, globular heart
ECG- low voltage QRS complex, alternating QRS amplitude (electrical altering)
ECHO- echo-free zone around heart

59
Q

what is the management of percardial effusion?

A

treat cause

pericardiocentesis can be diagnostic or therapeutic- culture ZN stain, cytology

60
Q

what is tamponade?

A

accumuulation of percardial fluids
leading to raised intra-pericardial pressure
leading to poor ventriular filling so low CO

61
Q

what are the causes of tamponade?

A

any cause of pericarditis- viral, bacterial, fungi, drugs

aortic dissection
warfarin
trauma

62
Q

what are the signs of tamponade?

A

beck’s triad- low bp, raised jvp, quiet heart sounds

pulsus paradoxus- pulse fades on inspiration

kussmaul’s sign

63
Q

what investigations would you do for tamponade?

A

ECG- low-voltage QRS +/- electrical altemans
CXR- large globular heart
ECHO- diagnostic, echo free zone around heart

64
Q

what is the management of tamponade?

A

urgent pericardiocentesis- aspirate continuously and watch ECG

treat cause
send fluid for cytology, ZN stain + culture

65
Q

what is acute myocarditis?

A

also known as inflammatory cardiomyopathy, is inflammation of the heart muscle

66
Q

what are the causes of acute myocarditis?

A

idiopathic 50%
viral- coxsackie B, flu, HIV
bacterial- s aureus, syphilis
drugs- cyclophosphamide, herceptin, CBZ, phenytoin

autoimmune- giant cell myocarditis associated with SLE

67
Q

what are the symptoms of acute myocarditis?

A

flu like prodrome- fever, sore throat, myalgia
dypnoea
fatigue
chest pain (may coexist wtih bomholm disease)
arrhythmia -> palps

68
Q

what are the signs of acute myocarditis?

A

soft S1

S4 gallop

69
Q

what investigations would you do for acute myocarditis + results?

A

bloods- postive trop, raised CK

ECG- ST elevation/deprssion, T wave inversion, transient AV block

70
Q

what is the management of acute myocarditis?

A

supportive

treat cause

71
Q

what is hypertrophic obstructive cardiomyopathy?

A

LVOT obstruction from asymmetric septal hypertrophy

AD inheritance but 50% sporadic
beta-myosin heavy chainmutation most common
ask for FH sudden death

72
Q

what are the symptoms of hypertrophic obstructive cardiomyopathy?

A

angina
dyspnoea
palpitations- AF, WPW, VT
exertional syncope or sudden death

73
Q

what are the signs of hypertrophic obstructive cardiomyopathy?

A

jerky pulse
double apex beat
harsh ESM at LLSE with systolic thrill
S4

74
Q

what investigations would you do for hypertrophic obstructive cardiomyopathy?

A

ECG
ECHO- ASH
exercise test +/- holter monitor to quantify risk

75
Q

what is seen on ECG for hypertrophic obstructive cardiomyopathy?

A

LVH/LAD/L strain
ventricular ectopics
VT
VF

76
Q

what is the medical management of hypertrophic obstructive cardiomyopathy?

A

1) negative inotropes 1st beta blocker 2nd verapamil
2) amiodarone- arrhythmias
3) anticoagulate- if AF/emboli

77
Q

what is the non medical management for hypertrophic obstructive cardiomyopathy?

A 
septal myomectomy (surgical or chemical) if severe symptoms 
consider ICD
78
Q

what is cardiac myxoma

A

rare bengin cardiac tumour, F>M 2:1 90% in L atrium- fossa ovalis

may be familial eg carney complex. cardiac + cutneous myxoma, skin pigmentation, endocrinopathy eg cushing’s

79
Q

what are the features of cardiac myxoma?

A 
clubbing 
fever
weigth loss
raised ESR
signs similar to MS (MDM, systemic emboli, AF) but vary with posture
80
Q

how do you diagnose cardiac myxoma?

A

ECHO

81
Q

what is the management of cardiac myxoma?

A

excision

82
Q

what is restricive cardiomyopathy?

A

ventricular walls too rigid to expand as they fill with blood

83
Q

what are teh causes of restricive cardiomyopathy?

A 
miSSHAPEN
sarcoid
systemic sclerosis
haemochromatosis 
amyloidosis
primary- endomyocardial fibrosis
eosinophilia- loffler's eosinophilic endocarditis
neoplasia- carcinoid (-> TR + PS)
84
Q

what are the clinical features of restricive cardiomyopathy?

A

same as constrictive percarditis

RHF with raised JVP -prominent x and y descents

kussmaul's sign- raised jvp on inspiration 
quiet heart sounds 
S3
hepatoslenomegaly 
ascites, oedema
85
Q

how do you diagnose restricive cardiomyopathy?

A

catheterisation

86
Q

what is the treatment of restricive cardiomyopathy?

A

treat cause

87
Q

what are the causes of dilated cardiomyopathy?

A

DILATE

1) dystrophy- muscular, myotonic, glycogen storage disease
2) infection- myocarditis complication
3) late pregnancy- peri, post partum
4) autoimmune- SLE
5) toxins- alcohol, doxorubicin, cyclophosphamide, DXT
6) endocrine- thyrotoxicosis

88
Q

how does dilated cardiomyopathy present?

A

LVF + RVF

arrythmias

89
Q

what are the signs of dilated cardiomyopathy?

A 
very raised JVP 
displaced apex
S3 gallop
low bp 
MR/TR
90
Q

what investigations would you do for dilated cardiomyopathy?

A

CXR
ECG
ECHO
cather + biopsy

91
Q

what would CXR show in dilated cardiomyopathy?

A

cardiomegaly

pulmonary oedema

92
Q

what would ECG show in dilated cardiomyopathy?

A

T inversion

poor progression

93
Q

what would ECHO show in dilated cardiomyopathy?

A

globally dilated
hypokinetic heart
reduced EF

94
Q

what would catheter + biopsy show in dilated cardiomyopathy?

A

myocardial fibre disarray

95
Q

what is the management of dilated cardiomyopathy?

A

bed rest
medical- diuretics, ACEi, digoxin, anticoagulation
non-medical- biventricular pacing, ICD
surgical- heart tx

CARDIO (10 decks)

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