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Yr3 Medicine- Cardiology > Valvular Heart Disease > Flashcards

Valvular Heart Disease Flashcards

1
Q

What do we mean by valvular heart disease?

A

Pathology related to abnormal structure of valves

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2
Q

Why is it important to recognise significant valvular heart disease?

A
  • Pt may benefit from surgery (repair or replacement)
  • Left uncorrected it has negative consequences such as irreversible ventricular dysfunction and/or pulmonary hypertension
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3
Q

Remind yourself how many leaflets each of the valves in the heart have?

A
  • Mitral= 2
  • All others= 3
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4
Q

What do we mean by mixed valve disease?

A

Both stenosis & regurgitation are present; overall efffect depends on severity of each

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5
Q

What are the most common valvular heart diseases?

A
  • Aortic stenosis
  • Aortic regurgitation
  • Mitral regurgitation
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6
Q

Discuss the pathophysiology behind aortic stenosis, include:

  • What happens to LV as a result of AS
  • Why pts develop symptoms such as angina, syncope & SOB
A
  • Narrowing of aortic valve decreased blood flow across the valve; get LV hypertrophy to compensate and maintain SV. Progressive LV hypertrophy leads to smaller, less compliant LV. Therefore, end diastolic pressure is increased.
    • Angina: hypertrophied LV which is also working against high resistance requires more oxygen and high end diastolic pressure reduce coronary artery perfusion.
    • Syncope: stenosis prevents appropriate increase in cardiac output. If pt is exercises, skeletal muscle vasculature will also vasodilate and contribute to reduced cerebral perfusion
    • SOB: cardiac decompensation
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7
Q

State some risk factors for developing aortic stenosis highlighting which is most common

A
  • Age (senile calcification)
  • Bicuspid aortic valve
  • Rheumatic heart disease
  • CKD (abnormal Ca2+ homeostasis- AS often progresses quicker in pts with CKD)

Less important: but anything that increases risk of aortic calcification:

  • Smoking
  • Hypertension
  • Diabetes
  • High cholesterol
  • High CRP
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8
Q

Congenital abnormalities of aortic valve are found in about 1-2% of population; patients with what two conditions have higher incidence of bicuspid aortic valves?

A
  • Turner’s syndrome
  • Coarctation of aorta
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9
Q

What are the three classical features (and hence symptoms) of aortic stenosis?

A

Pts could have severe aortic stenosis and be asymptomatic but the three classical symptoms:

  • Angina (chest pain)
  • Heart failure (decrease exercise tolerance/SOB exertion)
  • Syncope

Pts often initially present with decrease in exercise tolerance or dyspnoea on exertion. Pts may also present with dizziness on standing (again due to reduced cerebral perfusion)

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10
Q

What might you find on clinical examination of someone with aortic stenosis?

A
  • Parvus et tardus (weak and delayed peripheral pulse)
  • Aortic thrill
  • Left ventricular heave
  • Ejection systolic murmur
  • Features of heart failure:
    • Bibasal creptitations
    • Peripheral odeama (RV)
    • Raised JVP (RV)
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11
Q

For the aortic stenosis murmur, state:

  • Where it is heard best
  • How it is best described
  • Where it radiates to
  • What manouevre you can do to hear it best
A
  • Aortic area (2nd ICS on right)
  • Cresendo-decrescendo ejection systolic
  • Radiates to carotids/neck
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12
Q

What is parvus et tardus?

A

Slow rising pulse with narrow pulse pressure.

Feel carotid pulse and it would be delayed and weak

It is uncommon to find it. May be even harder to find in older pts due to their vasculature being less compliant hence you can try to find it in brachial artery

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13
Q

Describe how aortic stenosis murmur changes over time

A
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14
Q

What investigations would you do if you suspect aortic stenosis, include:

  • Bedside
  • Bloods
  • Imaging

*For each, justify why

A

Bedside

  • ​ECG
  • ABG if pt acutely SOB

Bloods

  • FBC (anaemia can precipate a new or exacerbate existing murmurs)
  • TFTs (hyperthyroidism can precipate a new or exacerbate exisiting murmurs)
  • U&ES: CKD? Get idea of renal func
  • Glucose:underlying diabetes
  • Cholesterol: underlying hypelipidaemia

Imaging

  • ECHO (transthoracic=first line)
  • CXR (may see calcification of aorta, features of HF)
  • Consider exercise stress test
  • Consider cardiac catheter if results of ECHO inconclusive
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15
Q

What might you find on ECG of someone with aortic stenosis?

A
  • Left ventricular hypertrophy wtih strain pattern
    • LV hypertrophy:
      • Prominent R wave in V5 & V6
      • Prominent S wave in V1 & V2
      • May see some left axis devation
    • Left ventricular strain:
      • T wave inversion in I & aVL
      • ST depression in V5 & V6
  • P Mitrale (due to dilation left atria)
  • Bundle branch block (left or right)
  • First to third degree heart block
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16
Q

When doing an ECHO to investigate aortic stenosis, what useful information can an ECHO give you?

A
  • Size of orifice
  • Degree of thickening of valve
  • Gradient across valve
  • LV size
  • LV function
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17
Q

We use ECHOs to assess severity of aortic stenosis; what 3 parameters do we measure to assess severity of aortic stenosis?

A
  • Mean gradient (mmHg)
  • Peak gradient (mmHg)
  • AoV “Aortic valve area” (cm2)
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18
Q

Aortic stenosis is assessed based on: mean gradient, peak gradient and aortic valve area. Give a rough approximation of the values of each of these parameters that would make the aortic stenosis:

  • Mild
  • Moderte
  • Severe
A
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19
Q

Discuss the management of aortic stenosis

A

Principles of management:

  • Asymptomatic: usually observe
  • Indications for valve replacement:
    • Symptomatic
    • Asymptomatic severe aortic stenosis (gradient >40mmHg) with features of left systolic dysfunction
    • Asymptomatic severe aortic stenosis with abnormal exercise tests (e.g. drop in BP, ST changes)
    • Asymptomatic severe aortic stenosis at the time of another cardiac surgery (e.g. CABG)

Options for valve replacement:

  • Surgical AVR (young, fit, low/medium risk)
  • TAVR (transcatheter aortic valve replacement if high operative risk)

Balloon valvuloplasty may be used in:

  • Children with no aortic valve calcification
  • Adults with critical aortic stenosis (unstable) who are not fit for valve replacement
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20
Q

State 4 indications for surgery to fix aortic stenosis

A
  • Symptomatic AS (regardless of severity)
  • Asymptomatic severe AS with LV systolic dysfunction
  • Asymptomatic severe AS wtih abnormal exercise tests (e.g. drop in BP, ST changes)
  • Asymptomatic severe AS at the time of another cardiac surgery (e.g. CABG)
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21
Q

What is TAVI?

Who would we consider TAVI in?

A
  • Transcatheter aortic valve implantation (also known as TAVR- transcatheter aortic valve replacement); replace aortic valve by gaining access through femoral artery
  • Used to only be considered in pts who are unsuitable for open heart surgery; HOWEVER, being considered for more pts now
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22
Q

State some potential complications of aortic stenosis

A
  • Left ventricular failure
  • Infective endocarditis
  • Ventricular arrhythmias leading to sudden death
  • Thrombosis if mechanical valve (THIS IS WHY MECHANICAL VALVES NEED LIFE LONG ANTICOAGULATION)
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23
Q

Aortic stenosis can cause acute congestive heart failure; why must you be cautious when it comes to prescribing beta blockers and calcium channel blockers in acute HF caused by aortic stenosis?

A
  • Beta blockers and CCB decrease heart rate and therefore decrease cardiac output
  • Cardiac output already reduced due to aortic stenosis
  • Optimal therapy is to repair valve
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24
Q

Discuss the pathophysiology of aortic regurgitation focusing on:

  • What happens to left ventricle
  • How AR leads to breathlessness
A
  • Aortic regurgitation causes blood to flow back into LV
  • Increase blood in LV
  • LV stretched more causing increase contractility (starlings Law)
  • LV dilation & hypertrophy
  • SV increased (can be doubled, trebled)
  • Increase left ventricular diastolic pressure
  • Pulmonary oedema
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25
Q

State some causes/risk factors for aortic regurgitation

A
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26
Q

Discuss the symptoms of aortic regurgitation

A

Pts can be asymptomatic despite significant regurgitation or they could have any of following:

  • Awareness of heartbeat- particularly when lying on left side
  • Reduced exercise tolerance
  • SOB
  • Paroxysmal nocturnal dyspnoea
  • Orthopnea
  • Angina (severe AR)
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27
Q

What might you find when doing a clinical examination on someone with aortic regurgitation?

A

Murmurs

  • Early diastolic blowing murmur
  • Austin flint murmur

Pulses

  • Collpasing pulse
  • Corrigans sign (marked carotid pulsation in neck)
  • de Musset’s sign (head nodding with pulse)
  • Quincke’s sign (capillary pulsation in nailbed)
  • Duroziez’ sign (compression of femoral artery 2cm prox to stethoscope gives systolic murmur, if 2cm dist gives diastolic murmur)
  • Traube’s sign (pistol shot heard over femoral artery in systole)
  • Muller’s sign (visible pulsation of uvula)

Other Signs

  • Diplaced, hyperdynamic apex beat
  • Bibasal crepitations (pulmonary oedema)
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28
Q

What is an Austin Flint murmur?

A

Mid diastolic murmur, heard best at apex, which is heard due to regurgitation stream hittiing mitral valve and causing fluttering of the valve. This can cause a functional mitral valve stenosis.

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29
Q

Where is the murmur of aortic regugitation heard best?

What manouevre can you do to help you hear the murmur?

A
  • Left sternal border
  • Sit pt forward get them to expire and then hold breath

**NOTE: not in aortic area!!!

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30
Q

What investigations would you do for someone with suspected aortic regurgitation, include:

  • Bedside
  • Bloods
  • Imaging
A

Bedside

  • ECG: look for LV hypertrophy
  • ABG: if pt SOB

Bloods

  • FBC: anaemia can preciptate new/exacerbate existing murmur
  • TFTs: hypthyroidism can precipitate new/exacerbate existing murmur
  • U&Es: assess renal func- important future treatment
  • Glucose: CVD risk factor
  • Cholesterol: CVD risk factor

Imaging

  • ECHO (transthoracic): look at valve and LV
  • CXR: heart failure
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31
Q

What might you see on the ECG of someone with aortic regurgitation?

A
  • Left ventricular hypertrophy wtih strain pattern
    • LV hypertrophy:
      • Prominent R wave in V5 & V6
      • Prominent S wave in V1 & V2
      • May see some left axis devation
    • Left ventricular strain:
      • ST depression & T wave inversion in leads II, III, aVF, V5 and V6
  • Q waves in lateral leads (due to promient septal depolarisation)
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32
Q

What might you see on the ECHO of someone with aortic regurgitation?

A
  • Aortic root dilation & separation of cusps
  • Dilated LV
  • Fluttering of anterior mitral valve leaflet
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33
Q

Discuss the management of chronic aortic regurgitation

A
  • Medical management of heart failure
  • Valve replacement (if indicated- see next FC); options include:
    • ​Open heart surgery
    • May consider TAVI as off label indication
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34
Q

State 3 indications for surgery in pts with chronic AR

A
  • Symptomatic pts with severe AR
  • Asymptomatic severe AR with evidence of early LV systolic dysfunction
  • Asymptomatic severe AR of any severity with aortic root dilation of >5.5cm (or 4.5cm in Marfan’s or bicuspid valve)
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35
Q

State some complications of aortic regurg

A
  • Congestive heart failure
  • Arrhythmias
  • Infective endocarditis
  • Myocardial ischaemia (decreased coronary artery flow reserve [decreased maximum increase in blood flow through coronary arteries])
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36
Q

Discuss the pathophysiology of chronic mitral regurgitation, include:

  • What happens to LA
  • What happens to LV
  • What happens to pressures in LA & LV
A
  • Gradual dilation of LA with little increase in pressure
  • Gradual dilation of LV
  • LV diastolic & LA pressures gradually increase
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37
Q

State some causes/risk factors for mitral regurgitation

A
  • Mitral valve prolapse
  • Rheumatic heat disease
  • IHD
  • Infective endocarditis
  • Ischaemic papillary muscle dysfunction (particularly after inferior MI)
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38
Q

State some symptoms of mitral regurgitation

A

NOTE: Most patients with MR are asymptomatic, and patients suffering from mild to moderate MR may stay largely asymptomatic indefinitely. Symptoms tend to be due to failure of the left ventricle, arrhythmias or pulmonary hypertension. This may present as fatigue, shortness of breath and oedema.

  • Dyspnoea on exertion
  • Reduced exercise tolerance
  • Peripheral oedema
  • Palpitations
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39
Q

What might you find on clinical examination of someone with mitral regurgitation?

A
  • Bibasal crepitations
  • Pleural effusion
  • Displaced hyperdyanmic apex beat
  • Irregularly irregular pulse
  • Thrill (mitral area: 5th ICS mid clavicular line)
  • Pan systolic blowing murmur that radiates to axilla
40
Q

Where is the murmur of mitral regurgitation best heard?

Where does it radiate to?

What manoeuvre can help you to hear the murmur?

A
  • 5th ICS on the left, mid clavicular line
  • Axilla
  • Pt lean forward, expire and hold
41
Q

What investigations would you do if you suspect mitral regurgiation, include:

  • Bedside
  • Bloods
  • Imaging
A

Bedside

  • ECG: changes associated with LA dilation e.g. p mitrale, AF can occur due to LA dilation
  • ABG: if pt SOB

Bloods

  • FBC: anaemia can precipitate new/exacerbate existing murmur
  • TFTs: hyperthyroidism can precipitate new/exacerbate existing murmurs
  • U&Es: renal function indicator
  • Glucose: CVS risk
  • Cholesterol: CVS risk

Imaging

  • ECHO (transthoracic): assess severity of murmur and look for any changes to LA and LV
  • CXR: features of heart failure
42
Q

What might you find on the ECG of someone with mitral regurgitation?

A
  • P mitrale (caused by LA dilation)
  • P pulmonale (caused by RA dilation)
  • Atrial fibrillation (caused by LA dilation)
  • Left ventricular hypertrophy wtih strain pattern
    • LV hypertrophy:
      • Prominent R wave in V5 & V6
      • Prominent S wave in V1 & V2
      • May see some left axis devation
  • Left ventricular strain:
    • ST depression & T wave inversion in leads II, III, aVF, V5 and V6
43
Q

What might you find on ECHO of someone with mitral regurgitation?

A
  • Regurgitation through valve
  • LA dilation
  • LV dilation & hypertrophy
44
Q

Discuss the management of mitral regurgitation

A
  • Medical management of heart failure
  • Acute cases may require nitrates, diuretics, inotropes, intra-aortic balloon pump
  • In acute, severe cases surgery is indicated; surgery can be:
    • Valve repair (lower mortality & higher survival in degenerative regurgitation)
    • Valve replacement with artificial or pig valve
45
Q

State some indications for surgery in someone with mitral regurgitation

A
  • Severe MR and symptomatic
  • Asymptomatic with severe MR and mild-moderate LV dysfunction (EF 30-60% and LVESD 4.5cm-5.5cm)
46
Q

What is mitral valve prolapse?

What might you hear on ausculatation if there is a mitral valve prolpase?

A
  • When leaflets of mitral valve bulge into left atrium during systole. This can cause some blood to flow back into LA. It is very common cause of mitral regurgitation.
  • Mid systolic click followed by mid-late systolic murmur
47
Q

Discuss the pathophysiology of mitral valve stenosis, include:

  • What happens to LA
  • What happens to pulmonary pressure
  • What happens to RV
A
  • Increased LA pressure required to force blood through stenosed valve
  • LA dilation
  • Pulmonary hypertension develops secondary to increased LA pressure
  • RV hypertrophy due to pulmonary hypertension
  • RV failure (cor pulmonale) develops
48
Q

State some causes/risk factors for mitral stenosis highlighting the main one

A
  • Rheumatic fever
  • Congenital
  • Carcinoid syndrome
  • Senile calcification
49
Q

State some symptoms of mitral stenosis

A

Pulmonary hypertension can cause:

  • Dyspnoea
  • Orthopnoea
  • Haemoptysis (uncommon)

Pressure from enlarged LA can cause:

  • Hoarsness of voice (compression recurrent laryngeal nerve)
  • Dysphagia (compression of oesophagus)
  • Bronchial obstruction

Others

  • Fatigue
  • Palpitations
  • Chest pain
50
Q

What might you find on clinical examination of someone with mitral stenosis?

A
  • Malar flush
  • Tapping apex beat (manifestation of S1 as palpable beat)
  • Low volume pulse
  • Irregularly irregular pulse (LA dilation causing AF)
  • Right ventricular heave (pulmonary hypertension)
  • Loud S1
  • Loud P2
  • Low pitched diastolic rumble
51
Q

For the mitral stenosis murmur, state:

  • Where it is heard best
  • Where it radiates to
  • Manoeuvres to help you hear the murmur
A
  • 5th ICS mid clavicular line
  • Axilla
  • Manouevres:
    • Roll to left
    • Expire & hold breath
52
Q

What investigations would you do if you suspect mitral stenosis, include:

  • Bedside
  • Bloods
  • Imaging
A

Bedside

  • ECG: changes associated with LA dilation e.g. p mitrale, AF can occur due to LA dilation
  • ABG: if pt SOB

Bloods

  • FBC: anaemia can precipitate new/exacerbate existing murmur
  • TFTs: hyperthyroidism can precipitate new/exacerbate existing murmurs
  • U&Es: renal function indicator
  • Glucose: CVS risk
  • Cholesterol: CVS risk

Imaging

  • ECHO (transthoracic): assess severity of murmur and look for any changes to LA and LV
  • CXR: features of heart failure
  • ?Dyanmic stress test
  • ?Cardiac catheterisation
53
Q

What might you find on the ECG of someone with mitral stenosis?

A
  • P mitrale (due to LA dilation)
  • AF (due to LA dilation)
  • RVH (due to pulmonary hypertension)
54
Q

What might you find on the ECHO of someone with mitral stenosis?

A
  • LA dilation
  • Stenosis of mitral valve
55
Q

Discuss managment of mitral stenosis

A

General principles:

  • Asymptomatic: observe/monitor with regular ECHOs
  • Symptomatic: intervention/surgery

If in atrial fibrillation:

  • Need anticoagulation (warfarin still recommended but increasing evidence for DOACs emerging)
  • ?rate control?

Options for intervention/surgery:

  • Percutaneous balloon mitral valvotomy
  • Mitral valve commissurotomy
  • Mitral valve replacement
56
Q

You don’t need to know much about tricuspid regurgitation as it isn’t common; but for tricuspid regurgitation state:

  • Causes
  • Symptoms
  • Signs
  • Diagnosis
  • Management
A
  • Causes: RV dilation, rheumatic fever, infective endocarditis, congenital
  • Symptoms: fatgiue, hepatic pain on exertion (due to venous congestion), ascites, oedema
  • Signs: pansystolic murmur heard best at left sternal border in 5th ICS, irregularly irregular pulse as AF can occur, ascites, jaundice
  • Diagnosis: ECHO
  • Management: diuretics, valve repair or replacement
57
Q

You don’t need to know much about tricuspid stenosis as it isn’t common; but for tricuspid stenosis state:

  • Causes
  • Symptoms
  • Signs
  • Diagnosis
  • Management
A
  • Causes: rheumatic fever, congenital, infective endocarditis
  • Symptoms: fatigue, ascites, oedema
  • Signs: early diastolic murmur heard best as left sternal edge 5th ICS on inspiration
  • Diagnosis: ECHO
  • Management: diuretics, valve replacement
58
Q

You don’t need to know much about pulmonary stenosis as it isn’t common; but for pulmonary stenosis state:

  • Causes
  • Symptoms
  • Signs
  • Management
A
  • Causes: congenital e.g. Turners, Fallots tetralogy, rheumatic fever, carcinoid syndrome
  • Symptoms: dyspnoea, fatigue, odema, ascites
  • Signs: RV heave, ejection systolic murmur, thrill, peripheral cyanosis
  • Diagnosis: ECHO
  • Management: valve replacement
59
Q

You don’t need to know much about pulmonary regurgitation as it isn’t common; but for pulmonary regurgitation state:

  • Causes
  • Signs
A
  • Causes: anything that causes pulmonary hypertension
  • Signs: early diastolic decrescendo murmur
60
Q

Mitral & aortic regurgitation can occur acutely. State some causes of:

a. ) Acute mitral regurgitation
b. ) Acute aortic regurgitatoin

A

Acute Mitral Regurgitation

  • Infective endocarditis causing leaflet disruption
  • Myocardial infarction causing papillary muscle dysfunction
  • Trauma (typically blunt e.g. hitting steerin gwheel in RTA)

Acute Aortic Regurgitation

  • Acute rheumatic fever
  • Infective endocarditis
  • Aortic dissection
  • Blunt trauma
61
Q

Discuss the pathophysiology of acute mitral regurgitation

A
  • Volume overload in LA
  • No time for LA to dilate
  • Sudden increase in LA presure
  • Increase pulmonary pressure
  • Acute pulmonary oedema
62
Q

Discuss the management of acute mitral regurgitation

A
  • Emergency surgery
  • Pre-op diuretics
  • Intra-aortic balloon counter pulsation
63
Q

Discuss the pathophysiology of acute aortic regurgitation

A
64
Q

Discuss the management of acute aortic regurgitation

A
  • Inotropes e.g. dopamine
  • Vasodilators e.g. nitroprusside
  • Aortic valve repair
65
Q

What is infective endocarditis?

A
  • Infective endocarditis= infection involving the endocardial surface of the heart, including the valvular structures, chordae tendinae, sites of congenital abnormalities (e.g. septal defects) or the mural endocardium
66
Q

Discuss the pathophysiology of infective endocarditis

A
  • Typically develops on valvular surfaces of heart which have endothelial damage secondary to sustained turbulent flow. Platelets and fibrin adhere to damaged area of endothelium- making area vulnerable to colonisation by blood-borne organisms
  • The avascular tissue and presence of fibrin and platelet deposits help to protect the organism from immun system hence vegetations can form.
  • Vegetations can grow large enough to cause obstruction or embolism.
  • Ajacent tissue is also destroyed and abcesses can form. This can lead to regurgitation or stenosis of valve.
  • Extracardiac manifestations, such as skin lesions & vasculitis, can from due to emboli or immune complexes
67
Q

Discuss the difference between acute and subacute infective endocarditis

A

Acute IE

  • Tends to occur on normal/healthy valves
  • Rapidly progresses
  • Organisms with high virulence causing rapid development of necrotizing & destructive lesions
  • Pts often present with signs & symptoms of peripheral or central emboli and/or features of acute congestive heart failure

Subacute IE

  • Tends to occur on abnormal valves
  • Organisms with low virulence
  • Develops over weeks to months
68
Q

State some risk factors for developing infective endocarditis

A
  • Mitral valve prolapse
  • Prosthetic material (valves & patches NOT STENTS)
  • Rheumatic heart disease
  • Calcified/degenerative aortic stenosis
  • Congenital abnormalities e.g. bicuspid aortic valve, VSD, PDA, coartctation of aorta
  • Post operative
  • IV drug user
69
Q

Which valve is at particular risk of infective endocarditis in IV drug users?

What is the organism that comonly causes infective endocarditis in IV drug users?

A
  • Tricuspid valve
  • Staphylococcus aureus
70
Q

Which valve is most commonly affected by infective endocarditis?

A

Mitral valve

71
Q

State the most common causative organisms of infective endocarditis

Highlight which is most common

A

The infecting organisms is dependent on the origin of infection:

  • Staphylococcus aureus (skin) **NOW THE MOST COMMON CAUSE
  • Coagulase negative staphylococcus (e.g. Staphylococcus epidermis) common 2/12 post prosthetic valve surgery
  • Streptococcus viridans (mouth) **USED TO BE MOST COMMON CAUSE. LINKED TO POOR DENTAL HYGIENE
  • Streptococcus bovis (bovis IE associated large bowel cancer so need colonscopy)
  • Culture negative infective endocarditis (5%)
  • HACEK organisms
72
Q

If a pt who has infective endocarditis is an IV drug user, what is the most likely causative organism?

A

Staphylococcus aureus

73
Q

Infective endocarditis, caused by fungal infection, is common in which groups of people?

A
  • Immunosupressed
  • IV drug use
  • Cardiac surgery
  • Prolonged exposure to antimicrobial drugs
  • IV feeding
74
Q

State some potential causes of culture negative cases of infective endocarditis

A

Culture negative causes

  • prior antibiotic therapy
  • Coxiella burnetii
  • Bartonella
  • Brucella
  • HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
75
Q

Discuss how mortality varies dependent on the causative organism of infective endocarditis

A
  • Staphylococcus aureus: 25-47%
  • Streptococcus viridans: 4-16%
  • Fungal infection: >50%

Mortality is mostly from heart failure, CNS emboli or uncontrolled infection.

76
Q

If a patient has ____ and ______ it is infective endocarditis until proven otherwise

A
  • Fever
  • New murmur
77
Q

State some symptoms of infective endocarditis

A
  • Fever
  • Chills
  • Night sweats
  • Malaise
  • Fatigue
  • Anorexia & weight loss
  • Headache
  • Weakness
  • SOB
78
Q

State what you might find on clinical examination of someone with infective endocarditis

A

Hands

  • Splinter haemorrhages (8%)
  • Janeway’s lesions (5%)
  • Oslers nodes (<5%)
  • Clubbing (10%) *ONLY IN CHRONIC PRESENTATION

Heart

  • New murmur
  • Worsening of existing murmur
  • Signs of cardiac failure

Other

  • Poor dentition
  • Roth’s spots (5%)
  • Splenomegaly
  • Microscopic haematuria (25%)
  • Petechial rash
79
Q

Describe each of the following, include where they are found, what they look like, whether they are tender and what causes them:

  • Janeway lesions
  • Oslers nodes
  • Splinter haemorrhages
  • Roth’s spots
A

Janeway lesions:

  • Palms
  • Erythmatous haemorrhagic or pustular spots
  • Non-tender
  • Microabcesses due to septic emboli

Oslers nodes

  • Fingers/finger pads & toes (ends of fingers)
  • Reddish/brown, slightly raised
  • Tender
  • Immun complex deposition leading to inflammatory response

Splinter Haemorrhages

  • Nailbeds
  • Red, small lines in nails
  • Non-tender
  • Various causes

Roth’s spots

  • Retina
  • Haemorrhages with pale centres
  • N/A
  • ?
80
Q

Discuss what investigations you want for someone with suspected endocarditis, include:

  • Bedside
  • Bloods
  • Imaging

*For each test, try to justify why you are doing it

A

Bedside

  • ECG (IE can cause abcesses, emboli & HF which all have ECG changes)
  • Urine dip (haematuria due to immune complex deposition)
  • MSU for microscopy & culture (check for bacteruria)

Bloods

  • Blood cultures (check bacteria in blood)
  • FBC (WCC, anaemia)
  • U&Es (IE can affect renal func. Also give baseline in case use neprhotoxic antibiotics)
  • CPR/ESR (signs of inflammation/infection)
  • LFTS
  • ?Anti-nuclear antibodies (rheumatological conditions can cause febrile episodes mimicing IE)

Imaging

  • ECHO (check for vegetations, abcess, valvular regurg, dehiscene of prosthesis etc..)
  • CXR (features of heart failure)
  • ?CT cardiac/head (if cerebral infarction or other complications suspected)
81
Q

What are the 2 key diagnostic tests in infective endocarditis?

A
  • Blood cultures
  • ECHO
82
Q

What might you find on the ECG of someone with infective endocarditis?

A
  • Prolonged PR interval (paravalvular abscess can affect AV node)
  • Ischaemic changes (due to coronary emboli)
  • Widened QRS (due to heart failure)
83
Q

Discuss how many blood cultures do you need to do if you suspect infective endocarditis?

A
  • At least 3 (preferably 6) blood cultures should be taken from different sites over several hours
  • If pt is stable you should delay antibiotics until you have obtained all 3 (or 6) samples as once antibiotics have started it becomes difficult to detect the causative organism
84
Q

Give two reasons why patients with proven infective endocarditis might have negative blood cultures

A
  • Recent antibiotics
  • Infection with slow growing or fastidious organism e.g. HACEK organisms, Coxiella Burnetii, brucella spp etc..
85
Q

If the blood cultures come back negative, but you still have high clinical suscpicion of infective endocarditis what can you do?

A

Samples can be taken in special media that allows growth of fastidioius organisms; liase with duty microbiologist for further advice.

86
Q

What might you expect the followiig blood results to show in someone with infective endocarditis:

  • FBC
  • U&Es
  • LFTs
  • CRP/ESR
A
  • FBC: normocytic, normochromic anaemia, raised WCC
  • U&Es: creatnine and urea could be elevated if renal failure present- UNCOMMON
  • LFTs: ?
  • CRP/ESR: elevated in 60% cases
87
Q

Explain why you might find normocytic, normochromic anaemia in someone with infective endocarditis

A
88
Q

Discuss whether you would do a transthoracic or a transoesophageal ECHO for someone with suspected infective endocarditis

A
  • Transthoracic
    • Detect 65% vegetations
    • Less invasive
  • Transoesphageal
    • Detect 95% vegetations
    • Useful for mitral valve and prosthetic valve vegetations
    • More sensitive at detected aortic root septal abcesses and leaflet perforatoins
    • More invasive

General Guidance from BMJ Best Practice

  • Do TTE if:
    • Suspect native valve IE
  • Do TOE if:
    • Suspect prosthetic valve IE
    • Negative TTE but still suspicous
    • Positive TTE but suspect likely complications in surgery (gives better idea of what is going on)
89
Q

In practise we use the Modified Duke’s criteria for the diagnosis of infective endocarditis. Explain the criteria inlcuding:

  • How many major, major & minor or minor criteria required
  • What the major criteria are
  • What the minor criteria are.
A

For diagnosis you need either:

  • 2 major
  • 1 major & 3 minor
  • 5 minor

Major Criteria

  • Positive blood cultures
    • Typical organism from 2 blood cultures
    • Persistent positive cultures >12hrs apart or >3 positive cultures if less specific/typical pathogen
  • Endocardial involvement
    • Positive ECHO findings
    • New valvular regurgitation
    • Dehiscence of prosthesis, abscess, vegetation

Minor Criteria

  • Predisposing valvular or cardiac abnormality
  • IV drug abuser
  • Pyrexia >38oC
  • Embolic phenomenom
  • Vascular phenomenom (e.g. emboli, conjunctival haemorrhage, Janeway’s lesions)
  • Immunological phenomenom (e.g. Osler’s nodes, Roth’s spots)
  • Blood cultures suggestive (i.e. organism grown but not achieving major criteria)
90
Q

How do we treat infective endocarditis? (broadly speaking)

What is it useful for the pt to have to make giving treatment easier?

A
  • Managment includes:
    • Antibiotics over 4-6 weeks
    • Surgery if required
  • Central venous line
91
Q

What antibiotic therapy is recommended as ‘initial blind therapy’ in infective endocarditis? Think about differences for native and prosthetic valve

A

Native: amoxicillin + consider low dose gentamicin (vancomycin if penicillin allergic)

Prosthetic: vancomycin + rifampicin + low dose gentamicin

92
Q

What antibiotic therapy is required for infective endocarditis caused by:

  • Streptococci
  • Staphylococci (native and prosthetic)
  • Enterococci
A

Streptococci

  • Benzylpenicillin IV 4-6 weeks (or vancomycin if pen allergic)
  • Low dose gentamicin (needs review at 2 weeks)

Staphylocci

  • Native valve= flucloxacillin 4-6 weeks (or vancomycin if pen allergic)
  • Prosthetic valve= flucloxacillin + rifampicin + low dose gentamycin (or vancomycin in penicillin allergic)

Enterococci

  • Amoxicillin IV 4-6 weeks (or vancomycin if pen allergic)
  • Low dose gentamycin (needs review at 2 weeks)
93
Q

When treating infective endocarditis it is vital that you monitor response to therapy; discuss 3 ways in which you can monitor the response to therapy and how often you should do each test

A
  • ECHO
    • ​Once weekly
    • Assess vegetation size, look for complications
  • ECG
    • ​At least 2x weekly
    • Detect conduction distrubances which could suggest development of abscesses/desruction etc..
  • Blood tests
    • ​Twice weekly
    • FBC, U&Es, CRP, ESR
94
Q

Surgery may be required as part of treatment for infective endocarditis; state some situations in which surgery may be indicated

A
  • Cardiac failure due to valve compromise
  • Valve dehiscence
  • Uncontrolled infec despite antibiotics
  • Threatened or actual systemic emboli
  • Paravalvular infection e.g. aortic root absess
  • Valve obstruction
  • Relapse after optimal medical therapy
  • Fungal infections
  • Overwhelming sepsis despite antibiotics
  • Sinus of Valsalva aneuryseum
95
Q

Discuss the Levine Scale of murmur intensity

A
  • *1= difficult to hear even by experts*
  • 2= usually audible ot all listeners*
  • 3=easy to hear even by inexperienced listeners*
  • …*
96
Q

Which valve is most commonly affected by infective endocarditis?

A

Mitral valve

97
Q

State some indications for surgery in infective endocarditis

A
  • severe valvular incompetence
  • aortic abscess (often indicated by a lengthening PR interval)
  • infections resistant to antibiotics/fungal infections
  • cardiac failure refractory to standard medical treatment
  • recurrent emboli after antibiotic therapy

Yr3 Medicine- Cardiology (12 decks)

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