Pharmaceutical, interventional and surgical treatment options of Acute Coronary Syndrome; Infective Endocarditis

Question 1

What is Infective Endocarditis?

Answer 1

It is an infectious inflammation disease of the endocardium, that affects the heart valves.

It is a condition that results from bacteremia, especially after recent Dental procedures, Surgery, usage of unhygenic needles [drug abuse or otherwise] and distant primary infections causing bacteremia.

Question 2

Two presentations of Infective Endocarditis

Answer 2

Acute and Subacute

Question 3

Difference between Acute IE and Subacute IE

Answer 3

Acute IE is usually caused by Staphylococcus aureus and leads to rapid destruction of the endocardium. It affects normal and healthy valves. It usually develops in the time span of hours to days. It requires immediate management and attention

Subacute IE is usually caused by Streptococcus viridans spp and primarily affects patients with previous heart valve defects, prosthetic heart valves, and structural heart defects. It usually develops in the time span of weeks to months and is not as aggressive as Acute IE

Question 4

FROM JANE accronym

Clinical Features of Infective Endocarditis

Answer 4

• Constituitional symptoms and ‘B’ symptoms [Fever, chills, malaise, weakness, night sweats, weight loss]
• Dyspnea, cough and Pleuritic chest pain [valvulopathy symptoms]
• Arrhythmias

FROM JANE:
- Fever
- Roth spots [white spots on retina]
- Osler nodes [raised nodular lesions on fingers and toes]
- Murmur [new onset, based on affected valve, most likely Mitral or Aortic]
- JAneway lesions [erythematous lesions on palm or sole]
- Nail-bed hemorrhage [aka Splinter hemorrhage from septic emboli occlusion]
- Emboli [septic emboli occluding various vessels]

Question 5

Dx approach to Infective Endocarditis

Answer 5

Dx based on DUKE-ISCVID criteria that gives points on pathology and presence of bacteria in cultures

• Multipe Blood cultures [3 sets of blood drawn from 3 different venupuncture sites] on clinical suspicion of IE
• Use the DUKE-ISCVID criteria to help dx [Definitive IE, Possible IE, Rejected dx are the options based on scores]
• TTE to assess valvulopathy and any other structural heart diseases [however TEE is more sensitive in detecting IE]
• ECG
• Cardiac CTA [to help confirm diagnosis]
• CXR, Abd US, MRI head for septic emboli, abscess formations
• Serology for negative culture IE
• Routine labs

Question 6

Treatment strategies for Infective Endocarditis

Answer 6

Acute IE is a medical emergency due to its aggressive nature. Evaluate and detect symptoms early, follow Sepsis management, Heart Failure management and Bradycardia management protocols

Methicillin-suscpetible staphylococcus: MSSA
- Native valve: Oxacillin/Nafcillin/Cefazolin
- Prosthetic valve: Nafcillin/Oxacillin + Rifampin + Gentamicin

Methicillin-resistance staphylococcus: MRSA
- Native valve: Vancomycin
- Prosthetic valve: Vancomycin + Rifampin + Gentamicin

Viridans Strep group:
- Aqueous crystalline Penicillin G/Ceftriaxone + Gentamicin
- Vancomycin

Enterococcus spp Penicillin sensitive: E.faecalis most common
- Ampicillin/Aqueous Penicillin G + Gentamicin
- Ampicillin + Ceftriaxone

Enterococcus spp Pencillin resistant: E.faecium most common
- Vancomycin + Gentamicin

HACEK group:
- Ceftriaxone first line
- Ampicillin/Ciprofloxacin

HACEK pathogens are fastidious organisms normally part of normal oral and pharyngeal flora. Members include Haemophilus spp, Aggregatibacter actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae