old endocarditis, pericardial, myocardial disease Flashcards
1
Q
what is infective endocarditis?
A
cardiac valves develop vegetations composed of bacteria + platelet-fibrin thrombus
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
3
Q
what are the causes of culture postiive infective endocarditis?
A
S. viridian's S. bovis s. aureus s. epidermidis enterococci pseudomonas
4
Q
what are the causes of culture negative infective endocarditis?
A
haemophilus actinobacillus caardobacterium eikenella kingella coxiella chlamydia
5
Q
what are the non-infective causes of infective endocarditis?
A
SLE
marantic
6
Q
what are the categories of clinical features of infective endocarditis?
A
sepsis
cardiac
embolic phenoomena
immune complex deposition
7
Q
what are the clinical features of septic infective endocarditis picture?
A
fever rigors night sweats weight loss anaemia splenomegaly clubbing
8
Q
what are the clinical features of cardiac infective endocarditis picture?
A
new/changing murmur
- MR 85%, AR 55%
AV block
LVF
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
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
11
Q
what are roth spots
A
boat-shaped retinal haemorrhages with pale centre
12
Q
what are janeway lesions
A
painlesss palmer macules
13
Q
what are osler’s nodes
A
painfull purple papules on finger pulps
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
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
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
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
18
Q
what can bloods show in infective endocarditis?
A
Normochromic normocytic anaemia
elevated ESR + CRP
positive IgG RF (immune phemomenon)
19
Q
what would urine dipstick show in infective endocarditis?
A
micro haematuria
20
Q
what could ECG show in infective endocarditis?
A
AV block
21
Q
what could ECHO show in infective endocarditis?
A
TTE detects vegations >2mm
TOE more senstiive
vegetation
abscess
valve dehiscence
22
Q
what is the empirical management of infective endocarditis?
A
acute severe- fuclox + gent IV
subacute- benpen + gent IV
23
Q
what is the management of infective endocarditis with streps?
A
benpen + gent IV
24
Q
what is the management of infective endocarditis with enterococci?
A
amoxicillin + gent IV
25
what is the management of infective endocarditis with staphs?
fluclox +/- rifampicin IV
26
what is the management of infective endocarditis with fungi?
flucytosine IV + fluconazole PO
ampnotericin if flucytosine resistance or aspergillus.
27
when would you consider surgical management for infective endocarditis?
HF
emboli
valve obstruction
prosthetic valve
28
would you do prophylaxis for infective endocarditis?
abx to prevent IE NOT recommended
29
what is the mortality for infective endocarditis with staphs, bowel flora and senstive streps?
staphs 30%
bowel flora 14%
senstiive streps 6%
30
what is the cause of rheumatic fever?
group A beta-haemolytic strep (pyogenes)
31
what is the epidemiology for rheumatic fever?
5-15yo
rare in west. common in developing world
2% populaton susceptible
32
what is the pathophysiology of rheumatic fever?
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
33
what can be seen on pathology with rheumatic fever?
aschoff bodies
| anitschkow myocytes
34
what criteria is used to diagnose rheumatic fever + when is diagnosis made?
revised Jones criteria
evidence of GAS infection AND:
- 2 major OR
- 1 major + 2 minor
35
what indicates evidence of GAS infection?
positive throat culture
rapid strep Ag test
raised ASOT or DNase B titre
recent scarlet fever
36
what is the major criteria in revised Jones criteria for rheumatic fever?
```
pancarditis
arthritis
subcutaneous nodules
erythema marginatum
sydenham's chorea
```
37
what is the minor crtieria in revised Jones criteria for rheumatic fever?
```
fever
raised ESR or CRP
arthralgia of large joints- not arthritis
prolonged PR interval- not carditis
previous rheumatic fever
```
38
what is pancarditis?
pericarditis- chest pain, friction rub
myocarditis- sinus tachy, AV block, HF, raised CK, T inversion
endocarditis- murmurs- MR, AR, carey Coombs (MDM)
39
what is meant by subcutaneous nodules in rheumatic fever?
small mobile painless nodules on extensor surfaces especially elbows
40
what is meant by erythema marginatum in rheumatic fever?
red raised edges with central clearing
on trunk, thighs and arms
41
what is meant by sydenham's chorea in rheumatic fever?
occurs late
| grimacing, clumsy, hypotonia (stops in sleep)
42
what investigations would you do in rheumatic fever?
1) bloods- strep Ag test or ASOT, FBC, ESR/CRP
2) ECG
3) ECHO
43
what is the management of rheumatic fever?
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
what is the prognosis of rheumatic fever?
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
what secondary prophylaxis can you do for rheumatic fever?
```
prevent recurrence
pen v 250mg/12h PO
- carditis + valve disease until 40yo
- carditis with no valve disease for 10yrs
- no carditis- 5 years
```
46
what are the causes of acute pericarditis?
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
what are the clinical features of acute pericarditis?
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
what investigations are done for acute pericarditis + what results?
ECG- saddle shaped ST elevation +/- PR depression
bloods- FBC, ESR, trop may be raised, cultures, virology
49
what is the management of acute pericarditis?
analgesia- ibuprofen 400mg/8h PO
treat cause
consider steroids/immunosuppression
50
what is constrictive percarditis?
heart encased in rigid pericardium
51
what are the causes of constrictive percarditis?
often unknown
| may occur after any percarditis
52
what are the clinical features of constrictive percarditis?
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
what investigations would you do for constrictive percarditis?
CXR- small heart + pericardial calcification
ECHO
cardiac catherisation
54
what is the management of constrictive percarditis?
surgical excision
55
what is percardial effusion?
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
what are the causes of percardial effusion?
any cause of pericarditis
| so viral, bacterial, fungi, MI, drugs etc
57
what are the clinical features of percardial effusion?
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
what investigations would you do for percardial effusion?
CXR- enlarged, globular heart
ECG- low voltage QRS complex, alternating QRS amplitude (electrical altering)
ECHO- echo-free zone around heart
59
what is the management of percardial effusion?
treat cause
| pericardiocentesis can be diagnostic or therapeutic- culture ZN stain, cytology
60
what is tamponade?
accumuulation of percardial fluids
leading to raised intra-pericardial pressure
leading to poor ventriular filling so low CO
61
what are the causes of tamponade?
any cause of pericarditis- viral, bacterial, fungi, drugs
aortic dissection
warfarin
trauma
62
what are the signs of tamponade?
beck's triad- low bp, raised jvp, quiet heart sounds
pulsus paradoxus- pulse fades on inspiration
kussmaul's sign
63
what investigations would you do for tamponade?
ECG- low-voltage QRS +/- electrical altemans
CXR- large globular heart
ECHO- diagnostic, echo free zone around heart
64
what is the management of tamponade?
urgent pericardiocentesis- aspirate continuously and watch ECG
treat cause
send fluid for cytology, ZN stain + culture
65
what is acute myocarditis?
also known as inflammatory cardiomyopathy, is inflammation of the heart muscle
66
what are the causes of acute myocarditis?
idiopathic 50%
viral- coxsackie B, flu, HIV
bacterial- s aureus, syphilis
drugs- cyclophosphamide, herceptin, CBZ, phenytoin
autoimmune- giant cell myocarditis associated with SLE
67
what are the symptoms of acute myocarditis?
flu like prodrome- fever, sore throat, myalgia
dypnoea
fatigue
chest pain (may coexist wtih bomholm disease)
arrhythmia -> palps
68
what are the signs of acute myocarditis?
soft S1
| S4 gallop
69
what investigations would you do for acute myocarditis + results?
bloods- postive trop, raised CK
ECG- ST elevation/deprssion, T wave inversion, transient AV block
70
what is the management of acute myocarditis?
supportive
| treat cause
71
what is hypertrophic obstructive cardiomyopathy?
LVOT obstruction from asymmetric septal hypertrophy
AD inheritance but 50% sporadic
beta-myosin heavy chainmutation most common
ask for FH sudden death
72
what are the symptoms of hypertrophic obstructive cardiomyopathy?
angina
dyspnoea
palpitations- AF, WPW, VT
exertional syncope or sudden death
73
what are the signs of hypertrophic obstructive cardiomyopathy?
jerky pulse
double apex beat
harsh ESM at LLSE with systolic thrill
S4
74
what investigations would you do for hypertrophic obstructive cardiomyopathy?
ECG
ECHO- ASH
exercise test +/- holter monitor to quantify risk
75
what is seen on ECG for hypertrophic obstructive cardiomyopathy?
LVH/LAD/L strain
ventricular ectopics
VT
VF
76
what is the medical management of hypertrophic obstructive cardiomyopathy?
1) negative inotropes 1st beta blocker 2nd verapamil
2) amiodarone- arrhythmias
3) anticoagulate- if AF/emboli
77
what is the non medical management for hypertrophic obstructive cardiomyopathy?
```
septal myomectomy (surgical or chemical) if severe symptoms
consider ICD
```
78
what is cardiac myxoma
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
what are the features of cardiac myxoma?
```
clubbing
fever
weigth loss
raised ESR
signs similar to MS (MDM, systemic emboli, AF) but vary with posture
```
80
how do you diagnose cardiac myxoma?
ECHO
81
what is the management of cardiac myxoma?
excision
82
what is restricive cardiomyopathy?
ventricular walls too rigid to expand as they fill with blood
83
what are teh causes of restricive cardiomyopathy?
```
miSSHAPEN
sarcoid
systemic sclerosis
haemochromatosis
amyloidosis
primary- endomyocardial fibrosis
eosinophilia- loffler's eosinophilic endocarditis
neoplasia- carcinoid (-> TR + PS)
```
84
what are the clinical features of restricive cardiomyopathy?
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
how do you diagnose restricive cardiomyopathy?
catheterisation
86
what is the treatment of restricive cardiomyopathy?
treat cause
87
what are the causes of dilated cardiomyopathy?
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
how does dilated cardiomyopathy present?
LVF + RVF
| arrythmias
89
what are the signs of dilated cardiomyopathy?
```
very raised JVP
displaced apex
S3 gallop
low bp
MR/TR
```
90
what investigations would you do for dilated cardiomyopathy?
CXR
ECG
ECHO
cather + biopsy
91
what would CXR show in dilated cardiomyopathy?
cardiomegaly
| pulmonary oedema
92
what would ECG show in dilated cardiomyopathy?
T inversion
| poor progression
93
what would ECHO show in dilated cardiomyopathy?
globally dilated
hypokinetic heart
reduced EF
94
what would catheter + biopsy show in dilated cardiomyopathy?
myocardial fibre disarray
95
what is the management of dilated cardiomyopathy?
bed rest
medical- diuretics, ACEi, digoxin, anticoagulation
non-medical- biventricular pacing, ICD
surgical- heart tx
