SM 149a - Endocarditis and Pericardial Disease Flashcards
What is Nonbacterial Thrombotic Endocarditis (NBTE)?
Endocarditis caused by deposition of small masses of fibrin, platelets, and other blood components on the leaflets of cardiac valves
What are the 3 layers of the semi-lunar valve leaflets?
Fibrosa (Vessel side)
Spongiosa (middle)
Ventricularis (Ventricle side)
What are the criteria for diagnosing rheumatic fever?
2 major or 1 major and 2 minor manifestations
- Major = JONES
- Joints (polyarticular arthritis)
- <3 Carditis
- Nodules (Aschoff)
- Erythema Marginatum
- Syndenhem’s Chorea
Describe the pathophysiology of the chronic inflammation associated with Rheumatic Fever?
Chronic inflammation causes…
- Scarring of the heart valves
- The valves become fibrotic
- Almost always mitral, sometimes aortic is involved too
- Commisures fuse
- Chordae tendineae shorten and thicken
-
Valvular stenosis and insufficiency
- Heart failure
- Distorted valves
- Potential for infective endocarditis
What factors predispose a person to infective endocarditis?
-
Abnormal valves
- Prosthetic
- Damaged by rheumatic fever or other causes
-
Turbulent flow
- VSD, other defect
-
Bacteremia
- IV drug use
- Gingivitis
- Indwelling catheter
Which bacteria most commony causes acute bacterial endocarditis?
Staph. aureus
Rheumatic fever only occurs following ____________________ infection
Rheumatic fever only occurs following pharyngeal Group A Strep infection
______ bacterial endocarditis typically only occurs in people with abnormal heart valves (prosthetic valve, valvular disease)
Subacute bacterial endocarditis typically only occurs in people with abnormal heart valves (prosthetic valve, valvular disease)
Which bacteria most commonly causes subacute bacterial endocarditis?
Strep. viridans
What is an Aschoff nodule?
If present, it would raise suspicion for which condition?
A nodule made from Anitschkow cells. Aschoff nodules are pathopneumonic for heart disease
(Anitschkow cells have a round or oval nucleolus with chromatin condensed at the nuclear periphery and along the center; they look like owl eyes)
What factors predispose a person to Nonbacterial Thrombotic Endocarditis (NBTE)?
- Malignancy (tumor)
- Chronic disease
- Hypercoagulable state
- Scarred or prosthetic valve
- Rarely - valves are usually previously normal
What kind of endocarditis is associated with systemic lupus erythematosus?
Libman-Sacks Endocarditis
How does inflammation change the appearance of the pericardium?
Normally, the pericardium is transparent and glistening
When inflamed, with will become dull and opaque, with a “sandy” appearance due to pericardial scarring and fibrosis
Describe the clinical manifestation of infective endocarditis
- Prolonged fever
- Due to infection
- Heart murmur that changes
- Due to vegetations
- Emboli (possible)
- Immune complex disease (possible)
- Valve rupture (possible)
List 4 common types of endocarditis
- Infective endocarditis
- Nonbacterial Thrombotic Endocarditis
- Rheumatic Endocarditis
- Libman-Sacks Endocarditis
What causes constrictive pericarditis?
Constrictive pericarditis is post-inflammatory. It develops after subacute pericarditis with effusion.
It evolves over weeks
Describe the clinical manifestation of Nonbacterial Thrombotic Endocarditis (NBTE)
Asymptomatic unless embolization occurs
Can embolize to the heart, kidney, speen, and brain
(Vegetations do not affect valve function)
Describe the progression of bacterial endocarditis
Presentations can be acute (progresses quickly) or subacute
-
Vegetations form on heart valves
- Thrombotic material + microorganisms +
granulation tissue
- Thrombotic material + microorganisms +
- Vegetations can cause partial destruction of the valve
- Vegetations can break off
- Distant ischemic events
- V. complicated becase they are infectious
- Can cause septic infarct, infected aneurysms
What is a jet lesion?
What causes the development of one?
Jet lesions = turbulent backflow that rubs against the endocardium
They can cause thickening and fibrosis of the endocardium, predisposing the individual to endocarditis (bacteria can seed)
Develops in aortic regurgitation
Describe the pathologies associated with aging heart valves
- Valves thicken and become less pliable
- Increased collagen content
- Calcification
- Fibrosis of the annulus
- Damage to the endothelial surface due to pressure, flow
- Seeding of bacteria
A rapidly develping pericardial effusion will cause cardiac tamponade at about _______cc’s,
while a slowly developing pericardial effusion will not cause cardiac tamponade until there are _____cc’s.
A rapidly develping pericardial effusion will cause cardiac tamponade at about 400 cc’s,
while a slowly developing pericardial effusion will not cause cardiac tamponade until there are 1000 cc’s (1 L).
Describe the vegetations associated with Nonbacterial Thrombotic Endocarditis (NBTE)
- Can be small or large
- Usually form on Aortic and Mitral valves, at the line of closure
- Composed of thrombotic material (sterile)
- No effect on valve function
- Cause symptoms when they embolize and cause infarcts in other organs
How can rheumatic and non-rheumatic valve disease be distinguished?
- Rheumatic
- Commisures fuse
- Non-Rheumatic
- Commisures become calcified
What mitral valve deformity is associated with rheumatic fever?
Fish-mouth deformity
Associated with mitral stenosis caused by rheumatic fever
In patients with mitral regurgitation, what pathology (if present) is most likely to lead to sudden cardiac death?
Mitral valve prolapse (often a result of fibrosis)
Note: MI causes fibrosis
What complications can arise from infective endocarditis?
- Septicemia
- Emboli
- Heart, Kidney, Spleen, Brain
- Immune Complex Disease
- Kidney
- Hematuria, renal failure
- Subcutaneous
- Splinter hemorrhage, Osler’s nodes
- Retina
- Roth spots
- Kidney
- Valve Rupture
What is “bread and butter” pericarditis?
What might cause it?
Fibrinous pericarditis associated with rheumatic fever
Describe the complications associated with acute rheumatic fever
- CNS involvement
- Sydenham’s chorea
- Polyarticular Arthritis
- Skin changes
- Pancarditis
- Endocarditis + myocarditis + pericarditis
- Valve involvement
- Death
- Rare, but usually due to myocarditis that disrupts the conduction system
