Pericarditis and Endocarditis Flashcards by Courtney Birkett

Janeway lesions

Non-tender erythematous macules on palms and soles
More common in acute IE
Reflect microabscesses with neutrophil infiltration of caps

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When does risk of mortality increase in endocarditis?

The type of microbe, presence of HF, if embolization occurs and if pt is candidate for cardiac surgery

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What is the first diagnostic test for pts suspected of IE?

TTE

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Non-cardiac risk factors of IE

IV drug use, indwelling intravenous catheter, immunosuppression, recent dental or surgery or older

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Rare physical exam findings highly suggestive for endocarditis

Janeway lesions, Osler nodes, Roth spots

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What is myopericarditis?

Acute pericarditis that also has myocardial inflammation (presentation depends on degree of involvement)
Troponin higher but same tx

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Characteristics of the chest pain seen in pericarditis

Most common presentation (especially if infectious cause)
Sudden in onset and over anterior chest
Improved by sitting up and leaning forward (reduce pressure on parietal pericardium)
Worsened by lying flat, deep inspiration, coughing and sneezing

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Main etiology of healthcare associated IE or IE in IV drug users

Staphylococci

*IV drug users more commonly have right sides valvular disease

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Typical work-up for pericarditis

Blood work (especially troponin), chest x-ray, ECG and echo (urgent if pericardial tamponade)

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What is endocarditis?

Infection of one or more heart valves or infection of an intracardiac device
Either native or prosthetic valve IE

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Most notable risk factors for IE

Age >60, male, IV drug use, poor dentition

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What is obtained in the blood work for pericarditis?

Troponin, ESR, CRP and CBC (only for support of diagnosis)

Also blood cultures if fever above 100.4

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Most common reasons for pericarditis in immunocompetent patients

Viral infection (Coxsackievirus or influenza) or idiopathic

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When do you think the cause of pericarditis is not idiopathic or viral?

When the pt does not improve after use of NSAIDs within 1 wk

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Where is the pericardial friction rub best heard?

Over left sternal border, when pt is sitting up and leaning forward (can come and go)

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Empiric therapy for native valve IE

Vanco (covers staph, strep and enterococci)
Usually 4-6 wks
Most pts should be afebrile 3-5 days after start

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Pt with suspected IE without acute sxs

Empiric therapy not always necessary (wait for the blood culture to get most effective antibiotic)

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What tests must also be done to delineate the etiology of pericarditis?

TB test, antinuclear antibody, HIV serology, chest CT scan with contrast, cardiac MRI

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What is pericardial tamponade and what are the sxs?

When the pressure on the heart is too great and the heart can’t pump effectively
Beck’s triad: hypotension, muffled heart sounds and JVD

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What etiologies are associated with higher mortality?

Prosthetic valve IE or IV drug use IE

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What does cardiac tamponade demand?

DRAINAGE (percutaneous or surgical)

Blood cultures and endocarditis

They are almost always positive
Need at least 3 cultures from separate venipuncture sites
30-60 min spacing

General treatment considerations for IE

Need a bactericidal agent- target organism isolated from blood cultures

Why ECG used in pericarditis

Reflect inflammation of epicardium (because pericardium is electrically inert) so therefore the changes are diffuse

Therapy for prosthetic valve IE

More difficult than native valve and may need surgical replacement of prosthesis with abx (ID organism) for a longer time

Common complications of endocarditis

Cardiac- valvular insufficiency, heart failure, percarditis Neurologic- embolic stroke, intracerebral hemorrhage, brain abscess Septic emboli- infarction of kidneys/spleen etc Metastatic infection- vertebral osteomyelitis etc (MSK) Might think of renal damage b/c of abx *think of these as the complaint due to the body system affected by IE

Roth spots

Exudative, edematous hemorrhagic lesions of retina with pale centers (retinal cap rupture)

What is the most common indication for cardiac surgery in pts with IE?

Heart failure

Definition of pericarditis

Inflammation of the pericardial sac that leads to potential for an increased production of pericardial fluid (effusion) and increased pressure on the heart and surrounding vessels

Management for acute pericarditis

NSAIDs and duration is based on persistence of symptoms (usually less than 2 wks) Consider giving proton pump inhibitors also to protect GI tract

Osler nodes

Tender subcutaneous violaceous nodules on pads of fingers and toes (may be on thenar and hypothenar eminences) More common in subacute IE Localized immune-mediated vasculitis

Cardiac risk factors of IE

History of prior IE, presence of prosthetic valve or cardiac device, history of valvular or congenital heart disease

Why is colchicine used in pericarditis?

Can be used as ad adjunct to NSAIDs to reduce sxs and decrease rate of recurrence

4 stages of ECG changes in pericarditis

1 (hours to days): diffuse ST elevation and PR segment depression 2 (1st wk): normalization of ST and PR segments 3: diffuse T wave inversions after normalization of ST and PR 4: normalization of ECG or indefinite persistence of T wave inversions (chronic pericarditis)

3 classic signs that should make us think pericarditis

ECG changes, chest pain and pericardial effusion

What is the most common cause of death in pts with IE?

Heart failure

Most common sxs of endocarditis

Fever (cardiac murmurs are also seen alot)

When is pericarditis more common?

In men and adults over kids

Constrictive pericarditis

Result of scarring and consequent loss of normal elasticity of sac Cardiac filling is impaired Usually idiopathic or viral Chronic (will see pericardial thickening with or without calcification) Can lead to pericardial tamponade Repair by pericardiectomy

When do dental procedures need prophylaxis in endocarditis?

When pts have prosthetic heart valves, prior IE, congenital heart disease or procedures on infected skin of MSK tissue

What might pericarditis be the first manifestation of?

Underlying systemic disease

Acutely ill pts suspected of IE

Empiric abx given directly after BCs drawn

Rules for using glucocorticoids with pericarditis

Considered only if sxs are refractory to NSAIDs and colchicine OR Etiology is connective tissue disease, autoimmune pericarditis or uremic OR Pt has significant contraindications to NSAIDs *they increase risk of recurrence and give unwanted side effects

Culture-negative IE

When pt has negative blood cultures and persistent fever with one more clinical findings consistent with IE

Main etiology of community acquried IE

Staphylococci and streptococci

Recurrent pericarditis

Occurs in 1/3 of pts (weeks to months later) Tx now is NSAIDs and colchicine only (no steroids) Good prognosis

Other etiologies of pericarditis

TB, neoplasm, renal failure, autoimmune/inflammatory disorders, trauma, post MI, drugs, bacterial infection

Cutaneous manifestations of endocarditis

Petechiae or splinter hemorrhages

What do you think of with fever of unknown origin?

Endocarditis!!

Major clinical presentations of pericarditis

``` Chest pain (sharp and pleuritic) Pericardial friction rub ECG changes (widespread ST elevation or PR depression) New pericardial effusion *must have 2 of 4 criteria for diagnosis ```