Pericarditis and Endocarditis Flashcards
Janeway lesions
Non-tender erythematous macules on palms and soles
More common in acute IE
Reflect microabscesses with neutrophil infiltration of caps
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
What is the first diagnostic test for pts suspected of IE?
TTE
Non-cardiac risk factors of IE
IV drug use, indwelling intravenous catheter, immunosuppression, recent dental or surgery or older
Rare physical exam findings highly suggestive for endocarditis
Janeway lesions, Osler nodes, Roth spots
What is myopericarditis?
Acute pericarditis that also has myocardial inflammation (presentation depends on degree of involvement)
Troponin higher but same tx
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
Main etiology of healthcare associated IE or IE in IV drug users
Staphylococci
*IV drug users more commonly have right sides valvular disease
Typical work-up for pericarditis
Blood work (especially troponin), chest x-ray, ECG and echo (urgent if pericardial tamponade)
What is endocarditis?
Infection of one or more heart valves or infection of an intracardiac device
Either native or prosthetic valve IE
Most notable risk factors for IE
Age >60, male, IV drug use, poor dentition
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
Most common reasons for pericarditis in immunocompetent patients
Viral infection (Coxsackievirus or influenza) or idiopathic
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
Where is the pericardial friction rub best heard?
Over left sternal border, when pt is sitting up and leaning forward (can come and go)
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
Pt with suspected IE without acute sxs
Empiric therapy not always necessary (wait for the blood culture to get most effective antibiotic)
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
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
What etiologies are associated with higher mortality?
Prosthetic valve IE or IV drug use IE
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
