Other Cardiac problems

Question 1

Acute + subacute bacterial endocarditis
- what is the difference? RF? causes?

Answer 1

Acute IE = occurs on “normal” valves and may present with acute heart failure. Develops suddenly and can become life-threatning within days.

Subacute IE = on abnormal valves

Rf
- IVDU, poor dental hygiene, cardiac surgery
- Acute: skin breaches, renal failure, IMC, DM
- Subacute: valve disease, tricuspid valves in IVDU, patent ductus arteriosus, VSD, prosthetic valves

Causes
- Bacterial: Bactermia, Staph.aureus (most common), Steph.viridans, Pseudo.aeruginosa
- HACEK organisms
- Fungi
- Enterococci

Question 2

IE: Clinical features

Answer 2

FEVER + NEW MURMUR = ENDOCARDITIS unless proven otherwise

(1.) Septic signs: fever, night sweats, malaise, wt loss

(2.) New murmur - aortic regurg usually

(3.) Petechiae = tiny purple or red spots in eye, limbs, chest, oral cavity

(4.) Splinter haemorrhages

(5.) Osler’s nodes = tender red or purple spots

(6.) Roth’s spots = retinal haemorrhages with pale centres.

(7.) Janeway’s lesions = irregular painless erythematous on palms or soles

Question 3

Dx for IE, what makes up the major and minor criteria

Answer 3

Modified Duke’s Criteria

Dx:
- Definite IE = 2 major OR 1 major w/3 minors OR all 5 minors
- Possible IE = 1 major w/1 minor OR 3 minor

Major criteria
(1.) Positive blood cultures
(2.) Evidence of endocarditis
- ECHO (vegetation, abscess etc)
- CT (abnormal activity prosthetic valve)

Minor criteria
(1.) Predisposing factors (e.g. cardiac lesions, IVDU)
(2.) Fever
(3.) Vascular phenomena (emboli, janeway’s etc)
(4.) Immune phenomena (glomerulonephritis, Osler’s etc).
(5.) Ambiguous blood cultures

Question 4

IE: Ix + Mx

Answer 4

Ix
(1.) Blood cultures
(2.) Blood: FBC, UE, CRP, rheumatoid factor
(3.) Urinalysis
(4.) ECG
(5.) CXR
(6.) TTE ECHO: within 24hrs, visualise vegetation, ix of choice
(7.) CT

Mx
(1.) Admission to hospital, liaise with micro + cardio

(2.) Empirical IV Abx
- native: amoxicillin + gentamicin
- prosthetic: vancomycin + gentamicin + rifampicin

(3.) Treat complications: emboli, arrhythmia, HF

(4.) Cardiac surgery, when to operate:
- To remove infectious device
- Infection cannot be cured with abx
- Aortic root abscess, severe valve damage
- Remove large vegetations before they embolise

(5.) Consider IE prophylaxis in high-risk pts (prosthetic valves, previous IE, complex congenital disease)

Question 5

Acute pericarditis - what is it, complications, RF, causes, syx, dx

Answer 5

Inflamed pericardium +/- pericardial effusion.
Complications: Pericardial effusion + Constrictive pericarditis whic can lead to hf.

RF = 20-50y, male, MI, cardiac surgery, recent infection (seasonal viral trend)

Causes
(1.) Idiopathic
(2.) Infection: viral, bacterial, fungal
(3.) Traumatic/ Iatrogenic
(4.) Other: AI, drugs, metabolic e.g. uraemia, hypothyroidism, mets (lung, breast, lymphoma), dressler’s syndrome

Clinical features
(1.) Sharp + stabbing sternal CP
- radiates to neck, left shoulder, arm.
- worse on deep breathing, lying on left.
- better when sitting up or lean forward.
(2.) Fever
(3.) Breathless if tamponade
(4.) O/e: pericardial rub, sinus tachy, pulsus paradoxus

Dx - 2 from:
1. CP
2. Friction Rub
3. ECG: saddle shaped, concave ST elevation
4. Pericardial Effusion on CXR or ECHO

Question 6

Acute pericarditis ix mx

Answer 6

Ix
(1.) ECG: Diffuse ST elevation, Elevated J point (scoped elevated ST segment), PR depression

(2.) Blood: FBC, UE, ESR, troponin. Consider ANA

(3.) CXR: Often normal. May show flask shaped heart i.e. effusion

(4.) TTE: detect any fluid has built up between the layers of pericardium

Mx
(1.) NSAIDs (+PPI) + Colchicine
(2.) Steroids if fails
(3.) Abx if bacterial infection
(4.) Surgical
- Pericardiocentesis drains excess fluid if severe effusion
- Pericardiectomy removal of pericardium in constrictive pericarditis

Question 7

Cardiac tamponade - what is it, dx, ix, mx

Answer 7

Medical emergency as can lead to cardiac arrest. Effusion is large enough to prevent heart chambers from filling and pumping blood normally.

Dx: Beck’ triad: Hypotension, elevated JVP, quiet HS
- Dyspnoea
- Hypotension
- Pulsus paradoxus
- Raised JVP
- Muffled S1 + S2

Investigations
- ECG: tachycardia, low QRS, electrical alteration (QRS has diff heights)
- ECHO (dx): swinging heart, excess fluid
- Cardiac Catherization = pressure is equal in all four chambers

Management
- Seek expert help
- Urgent drainage (pericardiocentesis)
- Send fluid for culture, TB culture, cytology

Question 8

Pericardial effusion: chronic?, causes, syx, ix, mx

Answer 8

Accumulation of fluid in pericardial sac.
- Chronic = slow accumulation allows adaption of pericardium. This compliance reduces the effect on diastolic filling of the chambers. As a result, this rarely causes tamponade h/e it is until the ‘limit of pericardial stretch’ is reached.

Causes
- Pericarditis
- Myocardial rupture via surgery, trauma, post MI (Dressler’s syndrome)
- Aortic dissection
- Malignancy

Clinical features
- Signs of underlying causes
- Dyspnoea
- CP
- Muffled heart sounds
- Look for signs of cardiac tamponade (Beck’s triad)

Dx
- CXR: heart may appear boot-shaped or water bottle.
- ECG
- ECHO: quantifies effusion size + if there is cardiac tamponade.

Mx
1. Treat the cause
2. Pericardiocentesis
- diagnostic = suspected bacterial pericarditis
- therapeutic = cardiac tamponade