Other heart disease Flashcards
rheumatic heart disease
-systemic immune process that is a sequelae of Group A Beta Hemolytic Streptococcal infection of pharynx
-autoimmune type of reaction that is complication of strep -> NOT AN INFECTION OF VALVE
-Perivascular granulomatous reaction with vasculitis*
-75-80% Mitral valve, 30% Aortic valve, Tricuspid, and Pulmonic 5%.
-2-3 weeks post infection typical
-Become quite uncommon in US, seen in immigrant population
-Peak incidence 5- 15 yo
-Jones Criteria!*
jones criteria
-Must meet either:
-2 major criteria (2M)
-1 major and 2 minor (1M & 2m)
-Subclinical on echocardiogram
-Lower threshold in high-risk populations
MAJOR
-carditis
-erythema marginatum
-chorea
-subcutaneous nodules
-polyarthritis only (monoarthritis or polyarthritis- high risk)
MINOR
-polyarthralgia (monoarthralgia high risk)
-fever
-ESR >60 (30 for high risk) and/or CRP >3
-prolonged PR interval (first degree AV block)
Chronic RHD
-has rigidity and deformity of the valve cusps, fusion of the commissures or shortening and fusion of the chordae tendinea
-subsequent scarring after
-Valvular stenosis or regurgitation results.
-60% of pts with RHD report a history of RHD
rheumatic heart disease tx
-Bedrest until afebrile, normal SED rate, normal heart rate and EKG at baseline.
-Salicylates
-Fever reduction
-Joint pain reduction
-Penicillin
-Benzathine PCN once or Procaine PCN daily for 7 days
-Corticosteroids
-Prednisone daily taper over two weeks
-Joint symptom relief
rheumatic heart disease: prevention/prognosis
-Early treatment of strep throat with PCN.
-Prevent reoccurrence (50%)
-Initial episode can last weeks to months
-Mortality 1-2%
-30% of children affected die within 10 years
-After 10 years, 2/3 will have detectable valvular abnormalities
bacterial endocarditis
-Bacterial or fungal infection of the valvular or endocardial surface of heart
-Bacteria in the blood stream colonize a valve surface
-vegetations (pus, growing clumps of bacteria)
-Clinical presentation depends on organism and valve infected
-Staph Aureus more rapidly progressive and destructive infection -> drugs, IVs -> Leading cause
-Virulent organisms give an acute febrile illness complicated by early embolization
-Subacute picture with viridans strains or strep and enterococci, yeast and fungi
-Underlying valvular disease alters blood flow producing a jet, this disrupts endothelial surface… nidus for attachment!
-> Rheumatic valves, bicuspid aortic valve, sclerotic valves, hypertrophic subaortic stenosis, mitral valve prolapse (with regurgitation), congenital disorders. (Regurgitation valves more likely then stenotic) -> MONITOR
-bacteria can attach to these valves easily -> sepsis
endocarditis organisms
-Acute endocarditis: -> septic type sx
-Streptococcus pneumoniae
-Streptococcus pyogenes
-Neisseria gonorrhea
-Staphylococcus aureus- IV drug usersand large vegetations seen on valves
-Subacute bacterial endocarditisis characterized by slower onset and less severe symptoms:
-Streptococcus bovis (with a GI bacterai)- in the setting ofcolon cancer
-Enterococcus- in the setting ofgastrointestinal/genitourinary procedures
-Streptococcus viridans- often a complication ofdental procedures -> makes dextrans, which binds to fibrin-platelet aggregates on the heart valves
-Staphylococcus epidermidis- often in the setting ofprosthetic valves
-Candida albicans- IV drug users
-non-infectious endocarditis:
-Libman-Sacks endocarditis- (granulomatis) from systemic lupus erythematosus -> mitral or aortic valve involvement
-marantic endocarditis- from metastatic cancer seeding to the valves -> very poor prognosis
bacterial endocarditis: S&S
-Febrile
-Murmur
-Embolization (stroke, systemic, kidney)
-Metastatic infections
-Cough
-Dyspnea
-Arthralgias
-Arthritis
-Diarrhea
-Abdominal or Flank Pain (emboli to kidney)
-Peripheral lesions:
-Petechiae
-Subungual hemorrhages - splinter hemorrhages
-Osler nodes
-Janeway lesions
-Roth Spots- red in eyes
-conjunctival petechiae
duke criteria
-def dx with 2 major, 1 major, with 3 minor , or 5 minor
-possible dx with 1 major with 1 minor or 3 minor
MAJOR
-2 separate blood cultures at diff sites +
-echo evidence- vegetation, abscess
-new valve regurgitation- auscultate
MINOR
-heart condition or IV drug use
-temperature >38c
-vascular- emboli, septic pulmonary infarct, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhage, janeway
-immune process- glomerulonephritis, osler, roth, rheumatoid factor
-microbiological evidence- +blood culture (only 1), serologic evidence of active infection with organisms consistent with infective endocarditis
endocarditis work up
-Most common order:
-Mitral
-Aortic
-Tricuspid
-Pulmonic
-Imaging
-Transesophageal echocardiogram
-Labs
-Blood Cultures:
-3 sets at least 1 hour apart before starting antibiotics
endocarditis: complications
-perivalvular abscess
-Arrhythmias
-aneurysms
-heart failure
-Myocardial infarction
-Stroke
-Embolism to spleen or kidneys
-Septic pulmonary embolism/ lung abscesses
endocarditis work up: prevention
AHA recommends antibiotic prophylaxis with predisposing congenital or valvular anomalies having dental procedures, respiratory operations, operations of infected skin or musculoskeletal tissue
endocarditis tx
-Management approach:
-choice of antibiotics ultimatelydepend on causative agent and susceptibilityas well as the presence of prosthetic material in the heart
-all antibiotics should be given IV
-dual broad spectrum
-Medical:
-Treat infectious cause.
-IV antibiotics, anti-fungal, anticoagulation
-for pts with no prosthetic valve
-empiric antibiotic therapy
-operative:
-surgical valve replacement
indications*
-anyone with prosthetic valve
-heart failure
-patients who are refractory to medical therapy
-abscess formation
-conduction disturbance
myocarditis
-Primary: acute viral infection or post viral immune response (including COVID)
-Secondary: non-viral, medications, chemicals, inflammatory diseases, radiation, cocaine, chemotherapy (HER 2 positive Breast CA regime 28%)
myocarditis: S&S
-Heart failure
-Shock
-Pericardial friction rub
-Dyspnea
-Chest pain
-Tachycardia
-Gallop
-ST changes on EKG- broad inflammation changes
myocarditis: work up
-Echocardiogram- inflammation
-Cardiac MRI to show infiltration
-Endomyocardial bx- finds underlying cause
myocarditis: tx
-Aggressive support for shock
-similar to HF:
-ACE inhibitor
-Beta blocker
-Treat underlying systemic disorder
-Avoid causative agent
takotsubo cardiomyopathy
-broken heart syndrome
-condition is usually the result of severe emotional or physical stress, such as a sudden illness, the loss of a loved one, a serious accident, or a natural disaster such as an earthquake
-condition is also called stress-induced cardiomyopathy, or broken-heart syndrome
-LV becomes shaped like a balloon
-apical dilation and no contraction (akinesis)
-decrease contractility
-can be reversed
acute pericarditis
-Inflammation of the pericardium can cause chest pain, pericardial rub, widespread ST elevations and a pericardial effusion.
-Lasting <2 weeks
-Movement of the heart can cause friction between the 2 pericardial layers,producing a friction rub
-Inflammation may cause a pericardial effusion
-dx- EKG with clinical picture
-Characterized by sharp pain worse supine than upright.
-Relived with sitting and leaning forward
-Kussmaul sign- increase JVD on inspiration
acute pericarditis causes
-serous:
-autoimmune disease
-systemic lupus erythematosus
-rheumatoid arthritis
-uremia
-viral illness- Coxsackievirus
-Lyme’s disease
-complication of myocardial infarction (MI)
-2-5 days after MI (Dressler syndrome*) -> see if its relieved with sitting up
-fibrinous pericarditis
-rheumatic fever
-Invasive cardiac procedures
-hemorrhagic -> effusion
-tuberculosis
-malignancy
-constrictive
-radiation therapy
-viral illness
-tuberculosis
acute pericarditis work up and tx
-clinical picture (auscultate) + (sitting up and laying down) + EKG
-echo
-CT or MRI in neoplasm cases
-tx:
-Restriction of activity
-NSAIDS
-Colchicine
-Dressler’s: ASA and Colchicine
-Uremic - dialysis
pericardial effusion and tamponade
-Pericardial effusion can develop during pericarditis.
-Speed of accumulation determines the importance due to pericardial stretch.
-chronic collection vs acute -> Acute cant stretch as much
-Tamponade occurs when intrapericardial pressure is greater than 15 mm Hg… this causes restriction of venous return and filling. Then cardiac stroke volume and arterial pulse pressure fall! -> Shock and death can then occur!
-RV collapse
-JVD- collapse of IVC and SVC and RV -> back flow
-muffled heart sounds- fluid distorts
pericardial effusion and tamponade causes
-pericarditis
-malignancy
-uremia
-systemic lupus erythematosus
-malignancy
-tuberculosis
-penetrating trauma
-pericardial effusion
-hemorrhageinto pericardial sac
-iatrogenic
pericardial effusion and tamponade PE
-physical exam:
-Beck triad
-muffled heart sounds
-jugular venous distention
-hypotension
-cardiac
-↑ heart rate
-pericardial rub if the patient has an inflammatory pericarditis
-pulsus paradoxus- decrease of blood pressure > 10 mmHg during inhalation
-pulmonary
-shortness of breath
-lung fields are typically clear
-extremities
-cold and clammy
-peripheral cyanosis
pericardial effusion and tamponade work up
-EKG- low voltage (restricted)
-EKG- electrical alternans- one complex is big and one is small -> fluid sac is swinging
-ultrasounds/echo:
-fluid in percardial sac
-collapse of RV
-hemodynamic collapse
pericardial effusion and tamponade tx
-Conservative- 1st line if not getting worse
-close monitoring and volume expansion*
-indication:
-cardiac tamponade without hemodynamic compromise
-modalities:
-serial echocardiographs
-intravenous bolus of fluids
-Procedural
-percutaneous pericardiocentesis*
-indication- first-line treatment
-Operative
-surgical drainage*
-indications:
-patients with coagulopathy or need for biopsy
-purulent pericarditis
-traumatic cardiac tamponade
-*surgical drainage with pericardial window placement
-indication:
-patients with chronic pericardial effusions
-patients who decompensate
-trauma with hole that needs to be repaired
-tube rather than tap
cardiac rehab
-Rehabilitation for pts with concerns for complications of exercise in setting of heart disease or recent cardiac surgery
-One on one supervised exercise regimen for up to 3 months. (2-5 times per week for 12 weeks)
-Cardiac diet counseling
-Cardiovascular risk reduction education
-Benefits
-Quality of life improvement
-Prevent future cardiac events
-Heart healthier lifestyle modifications
-Improved exercise tolerance and strength
-Improved emotional health and improved social engagement
indications for cardiac rehab
-Myocardial Infarction
-Stable angina
-Peripheral artery disease
-Congestive heart failure
-Percutaneous coronary intervention
-CABG
-Valve Replacement / Repair
-Heart transplant / Lung transplant
-Pulmonary HTN
-Only 2/3 are referred who are eligible
-¼ of those attended the service
-Transition to self driven home regimen
things included in cardiac rehab
-Supervised exercise tailored to patient’s fitness level
-Blood pressure, heart rhythm and Oxygen saturation monitored.
-Aerobic exercise 30-45 min
-Walking
-Cycling
-Rowing
-Stair climbing
-Strength training
-Weights
-Resistance bands
-Nutrition counseling
-Emotional counseling
-Social worker
-Peer support
cardiac rehab complications
-Injuries
-Muscle strain
-Sprains
-Cardiovascular complications
-Cardiac Arrest 8.9/1,000,000
-Myocardial ischemia 3.4/1,000,000
-Death 1.3/1,000,000 rate per million patient hours of exercise
questions
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