Other cardiac Flashcards
What does this indicate
Acute, persistent febrile illness (lower grade in elderly, HF, and kidney failure), nonspecific symptoms
Embolization or metastatic infection may cause:
Cough, dyspnea, arthralgia/arthritis, diarrhea, abdominal pain, stroke or cardiac embolism
Peripheral lesions: petechiae on palate or conjunctiva or beneath fingernails, subungual “splinter” hemorrhages
Strokes + major events can occur early on
Right sided often has fever and constitutional symptoms (mostly drug users)
endocarditis
endocarditis prophylaxis
Prophylaxis recommended with predisposing anomalies undergoing dental procedures, operations involving the respiratory tract, or operations of skin or MSK (unrepaired cyanotic congenital disease, incompletely repaired congenital disease, or if repaired with prosthetics)
meds for endocarditis prophylaxis
Amoxicillin
PCN allergy: clindamycin or cephalexin or azithromycin
IV: ampicillin or clindamycin or cefazolin
What are risks for endocarditis?
Rheumatic valve abnormality
Bicuspid aortic valves
Calcific or sclerotic aortic valves
Hypertrophic subaortic stenosis
MVP
Congenital disorders
Tricuspid = PWID 90%
Left-sided = PWID 20%
What does this cause:
Bacterial or fungal infection of surface of the heart, usually in valves
Commonly from dental, upper respiratory, urologic, and lower GI diagnostic + surgical procedures
Intravascular devices
Staph aureus or viridans strep, enterococci
endocarditis
negative culture organisms for endocarditis
HACEK organisms - NEG organisms
Haemophilus aphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella species
What does this indicate:
Changing new onset regurgitant murmur (uncommon)
Osler nodes = painful, violaceous raised lesions of fingers, toes, feet
Janeway lesions = painless erythematous lesions of palms or soles
Roth spots = exudative lesions in retina
Hematuria + proteinuria
Right-sided = emboli to lungs
EKG: conduction abnormalities
endocarditis
What imaging is best for endocarditis?
TEE
with blood cultures to diagnose!
Duke criteria
BE TIMER major minor
Blood culture +
Echo evidence
Temp>38
Immunologic phenomena (skin)
Microbio evidence
Embolic phenomenon
Risk factors
Definitive diagnosis - endocarditis
two major or one major + 3 minor or 5 minor
How do you treat endocarditis
Consult ID – treat empirically while cultures are pending
Cover: staph, strep, and entero →
IV vancomycin + ceftriaxone
When is surgery indicated for endocarditis
if medication management is unsuccessful in preventing heart failure
Almost always required if fungal is present or unresponsive to treatment 7-10 days
If sinus of Valsalva is involved or septal abscess
Recurrent infection
Continuing embolization
Large vegetation
Embolic stroke
T/f: use anticoagulants in endocarditis
false
What does this indicate:
Dyspnea, chest pain, arrhythmias
Suspect in:
<45y w/ new cardiac symptoms w/o cardio risk factors
New cardiac/HF symptoms + Hx of recent viral infection (several days-weeks)
Symptoms of HF w/o clear underlying cause
myocarditis
Hypersensitivity to sulfonamides, PCNs, ASA, radiation, chemo, illicit/toxic substances, phenothiazines, lithium, chloroquine, cocaine
Younger or healthier people w/o heart disease
myocarditis RFs
Inflammatory disease of cardiac muscle from infection + non-infection → acute, subclinical, or chronic
- acute viral infection or post viral response, or bacterial, spirochetes, Rickettsia, fungi, protozoa and helminths
Or autoimmune disease, medication, venom, sarcoidosis, heat stroke, hypothermia, transplant rejection, radiation injury
myocarditis
Diagnosis based on biopsy of tissue
myocarditis -
HF, normal or dilated LV <2 weeks from onset
OR dilated LV 2 weeks-3m after onset of symptoms, new ventricular arrhythmias, or not responding to care
Pericardial friction rub, gallop, depressed LV function, ST changes + positive cardiac markers, wall abnormalities on echo
Microaneurysms, dilated cardiomyopathy
Pulmonary + systemic emboli can occur
EKG: sinus tach, arrhythmia or conduction abnormalities, Q waves or LBBB (poor), ventricular ectopy
CXR: cardiomegaly, pulm HTN
WBC, ESR, CRP, troponin elevated
Echo = exclude other causes
MRI w/ gadolinium to confirm diagnosis
myocarditis
How do you treat myocarditis?
ACEI + BBs if LVEF<40%
NSAIDS for pain
Treat arrhythmias
How do you treat more severe myocarditis?
Specific antimicrobial therapy when infecting agent has been identified
Exercise limited
Severe: cardiac transplant or ventricular assistive devices
refer!
Viral: anterior pleuritic chest pain, worse supine, better upright, w/ radiation to neck, shoulders, back, epigastric
Dyspnea, febrile, pericardial friction rub
Bacterial: more severe + toxic appearing, critically ill
pericarditis
Inflammation of the pericardium – infectious or systemic disease
MCC = viral infections
Autoimmune syndromes, radiation, toxicity, surgery
Dressler syndrome - 2-5 days after MI or heart surgery
pericarditis
Viral diagnosis is usually clinical
Leukocytosis
Cardiac enzymes may be slightly elevated
Echo often normal or only small amounts of fluid, pericardial effusion
Dressler syndrome = ESR elevated
Bacterial WBC count high
CMP to assess kidney function (high = uremic)
EKG: general ST + T wave changes, STE, T wave inversion
CXR: cardiomegaly, lesions + enlarged lymph nodes
pericarditis
Treatment of pericarditis
Restriction of activity until symptoms resolve
Aspirin w/ taper
(ibuprofen can be given instead)
Colchicine to prevent recurrence + continued for 3 months, may be given for longer in refractory/recurrent cases
Dressler syndrome = aspirin + colchicine
Slowly progressing dyspnea, fatigue, weakness, chronic peripheral edema, hepatic congestion, ascites
constrictive pericarditis
Pericardial compression syndrome – restricts diastolic filling + produces chronic elevated venous pressure
constrictive pericarditis
Kussmaul sign → elevated JVP
Cardiac cath + non-invasive tests for diagnosis (differentiate from restrictive cardiomyopathy)
constrictive pericarditis
How do you treat constrictive pericarditis?
Determine underlying etiology and treat accordingly
Aggressive diuresis
Surgical pericardiectomy if unable to control w/ meds
Chest pain or painless -
Dyspnea, cough, pericardial friction rub, tachycardia
Hepatomegaly
Sitting forward helps
Pain radiates to the shoulder, neck, and back
pericardial effusion
Fluid within the sac exceeds small amount normally present
Normal = 15-50mL
Small effusions that occur rapidly → tamponade
Often after illness or injury, cancers
pericardial effusion
EKG: electrical alternans is pathognomonic
Echo: primary method for demonstrating effusion
Cardiac CT + MRI
Pericardiocentesis or biopsy may be indicated
pericardial effusion
How do you treat pericardial effusion?
Small: careful observation of JVP + pulse, serial echos
Large: drainage
(Avoid vasodilators + diuretics to avoid HOTN)
Refer a pericardial effusion if
Any unexplained effusion
Significant in those with HF or pericarditis
HOTN or paradoxical pulse
Any signs of tamponade
Tachycardia, tachypnea, HOTN, narrow pulse pressure, pulsus paradoxus (decreases w/ inspiration)
Beck’s triad = hypotension, JVD, muffled heart sounds
pericardial tamponade
Accumulation of pericardial fluid under pressure, restricting venous return + filling from trauma, aortic dissection and/or rupture OR slow onset from cancer, inflammation, hypothyroidism
pericardial tamponade
Elevated intrapericardial pressure
SV + arterial pulse fall
HR + venous pressure increase
RA+RV can collapse
Decline of >10mmHG in SBP w/ inspiration + lower SV
Raised JVP, muffled heart sounds, decreased EKG voltage
CXR: effusion, cardiomegaly
EKG: reduced voltage
pericardiac tamponade
pericardiac tamponade treatment
Urgent pericardiocentesis or cardiac surgery
diagnostic criteria for pericarditis
- pericardic chest pain
- pericardial rubs
- new widespread STE or PR depression
- pericardial effusion (new or worsening)
additional: inflammatory markers, evidence through imaging technique
