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Year 3: Cardiology > Cardiology: TR & Infective Endocarditis > Flashcards

Cardiology: TR & Infective Endocarditis Flashcards

1
Q

Define what is meant by infective endocarditis

A

Infection of the endocardial surface of the heart, particularly implicating the heart valves or an intracardiac device

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2
Q

What are the three major types or categories of IE? [3]

A

Native valve endocarditis (NVE):
- normal valves without previous intervention
- May be acute or subacute.

Prosthetic valve endocarditis (PVE):
- may occur early (< 1 year) or late (> 1 year) following surgical intervention.
- Account for 10-20% of cases.

Intravenous drug abuse (IVDA) endocarditis:
- classically affects the tricuspid valve (50%). Staphylococcus aureus most common microorganism.

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3
Q

Which valve is most commonly effected by IVDA endocarditis? [1]

A

Tricuspid valve

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4
Q

TOM TIP: In exams, classically infective endocarditis occurs after what type of procedure? [1]

A

Classically, a dental procedure is associated with a brief bacteraemia that our immune system is able to control.

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5
Q

Describe the pathophysiology of IE [6]

A

IE is characterised by the formation of vegetations on cardiac valves.

IE occurs when bacteria enter the bloodstream and deposit onto the endocardial surface of the heart.

Once deposited on the endocardial surface, the organisms adhere and eventually lead to invasion and destruction of the valve leaflets. The key pathological process in IE is formation of infected vegetations.

On the endocardial surface, a small nidus of adherent platelet-fibrin complex becomes infected by deposited bacteria.

This complex forms a vegetation, which is essentially a collection of fibrin, platelets, white blood cells, red blood cell debris and clusters of bacteria.

The vegetation may increase in size and damage the endocardial tissue including valves.

The vegetation can cause local destruction of valves, which leads to regurgitant murmurs and eventually congestive cardiac failure

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6
Q

Which of the following is most commonly effected by IE?

Mitral
Aortic
Combined mitral and aortic
Tricuspid
Pulmonary

A

Mitral - most common
Aortic
Combined mitral and aortic
Tricuspid
Pulmonary - least common

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7
Q

Describe the different presentations of IE [3]

A

Acute
Subacute
Chronic

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8
Q

What are the risk factors for IE?

A
  • Intravenous drug use
  • Structural heart pathology
  • Chronic kidney disease (particularly on dialysis)
  • Immunocompromised (e.g., cancer, HIV or immunosuppressive medications)
  • History of infective endocarditis
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9
Q

Which structural pathologies increase the likelihood of IE? [5]

A
  • Valvular heart disease
  • Congenital heart disease
  • Hypertrophic cardiomyopathy
  • Prosthetic heart valves
  • Implantable cardiac devices (e.g., pacemakers)
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10
Q

What is the most common infective agent causing IE? [1]

A

Staphylococcal aureus

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11
Q

Asides from Staph. aureus, name a common cause of IE [1]

A

Enterococcus faecalis

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12
Q

Describe the symptoms of IE [7]

A
  • Fever (90%)
  • Malaise, lethargy
  • Anorexia
  • Weight loss
  • Abdominal pain: splenic abscess
  • Haematuria: renal embolic phenomenon
  • Cardiac symptoms: shortness of breath, chest pain, palpitations
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13
Q

Name this sign of IE [1]

Is it tender or non-tender? [1]

Is it more likely in acute or subacute?

A

Oslers Nodes

Tender

Subacute > acute.

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14
Q

Name and describe this sign of IE [1]

Is it more likely in acute or subacute?

A

Roth spots: exudative, oedematous hemorrhagic lesions of the retina with pale centre (immune complex deposition)

Subacute > acute.

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15
Q

Name and describe this sign [1]

Is it tender? [1]

Is it found in subacute or acute? [1]

A

Janeway lesions:
- Acute > subacute.
- Tender

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16
Q

Name this sign of IE [1]

A

Conjunctival petechiae in infective endocarditis

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17
Q

Describe the cardiac murmurs found in IE [2]

A

Cardiac murmur (85%): pansystolic murmur of mitral regurgitation
or
early diastolic murmur of aortic regurgitation

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18
Q

What would you expect to hear upon ascultating someone with IE? [2]

A

Murmur
Bibasal crackles

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19
Q

Around 25% of patients with IE have evidence of [] at the time of diagnosis.

A

Around 25% of patients with IE have evidence of embolic phenomenon at the time of diagnosis.

Peripheral stigmata of IE are increasingly less common due to earlier recognition and diagnosis.

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20
Q

Which neurological emboli can IE cause? [4]

A

cerebral abscess
intracerebral haemorrhage
embolic stroke
seizures

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21
Q

Describe the investigations used to investigate IE

A

Blood cultures BEFORE Abx:
- Three blood culture samples are recommended, usually separated by at least 6 hours and taken from different sites.

Transoesophageal echocardiography (TOE)
- Vegetations (an abnormal mass or collection) may be seen on the valves

Special imaging investigations may be used in patients with prosthetic heart valves:
- 18F-FDG PET/CT
- SPECT-CT

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22
Q

Why might you perform thorax and abdominal imaging for IE patients? [2]

A

Thorax and abdominal imaging: CT or US may be needed to look for pulmonary or splenic abscesses

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23
Q

What is the name for the criteria used for IE? [1]

Describe how a diagnosis is made from Dukes criteria [1]

A

Modified Duke criteria

A diagnosis requires either:
* One major plus three minor criteria
* Five minor criteria

24
Q

What are the major criteria in Dukes classification of IE? [2]

What are the minor criteria in Dukes classification of IE? [5]

A

Major criteria:
* Persistently positive blood cultures (typical bacteria on multiple cultures)
* Specific imaging findings (e.g., a vegetation seen on the echocardiogram)

Minor criteria are:
* Predisposition (e.g., IV drug use or heart valve pathology)
* Fever above 38°C
* Vascular phenomena (e.g., splenic infarction, intracranial haemorrhage and Janeway lesions)
* Immunological phenomena (e.g., Osler’s nodes, Roth spots and glomerulonephritis)
* Microbiological phenomena (e.g., positive cultures not qualifying as a major criterion)

25
Q

Which Abx are the mainstay treatment for IE? [1]

A

Intravenous broad-spectrum antibiotics (e.g., amoxicillin and optional gentamicin) are the mainstay of treatment

The choice of antibiotic may be more specific once the causative organism is identified on cultures.

26
Q

Describe the treatment regime for Staphylococcus aureus IE:

Methicillin-sensitive staphylococcus aureus (MSSA)? [1]

Methicillin-resistance staphylococcus aureus (MRSA)? or penicillin allergy? [1]

A

Methicillin-sensitive staphylococcus aureus (MSSA):
* flucloxacillin 12 g/day in 4-6 doses. Duration 4-6 weeks.

Methicillin-resistance staphylococcus aureus (MRSA) or penicillin allergy:
* vancomycin 30-60 mg/kg/day in 2-3 doses. Duration 4-6 weeks.

27
Q

How do you alter Staph. aureus treatment of IE if a patient has a prosethetic valve? [3]

A

NOTE: in the presence of a prosthetic valve, rifampicin and gentamicin should be added to both regimens and the duration should be ≥6 weeks.

28
Q

Describe the treatment regimes for IE, typically used for oral Streptococci and Streptococcus bovis:

Standard four-week regimen [1]

Standard two-week regimen [1]

Penicillin allergic [1]

A

The regimen depends on how resistant the organism is to penicillin. If no resistance, the usual antibiotics may include:

  • Standard four-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone
  • Standard two-week regimen: penicillin G, OR amoxicillin, OR ceftriaxone combined with gentamicin.
  • Penicillin allergic: vancomycin for four weeks
29
Q

Describe the tx regime if orgnaism not yet known:

Native valve or late prosthetic valve? [3]
Early prosthetic valve endocarditis? [2]

A

Native valve endocarditis or late prothetic valve endocarditis:
- Ampicillin & flucloxacillin
& gentamicin

OR
- vancomycin & gentamicin.

Early prosthetic valve endocarditis:
- vancomycin & gentamicin & rifampicin.

30
Q

IE management:

Antibiotics are typically continued for at least:

[] weeks for with native heart valves
[] weeks for patients with prosthetic heart valves

A

Antibiotics are typically continued for at least:

4 weeks for with native heart valves
6 weeks for patients with prosthetic heart valves

31
Q

When might surgery be indicated in IE? [3]

A
  • Heart failure relating to valve pathology
  • Large vegetations or abscesses: prevention of embolism
  • Infections not responding to antibiotics
32
Q

Infective endocarditis has a high mortality rate
What are four key complications that patients are at risk of? [4]

A
  • Heart valve damage, causing regurgitation
  • Heart failure
  • Infective and non-infective emboli (causing abscesses, strokes and splenic infarction)
  • Glomerulonephritis, causing renal impairment
33
Q

Describe the surgical management of IE [1]

A

The two main aims of surgery are removal of infected tissue and reconstruction of cardiac anatomy (i.e. valve repair or replacement).

34
Q

Antibiotic prophylaxis may be used in sub-group of high-risk patients (if benefit is felt to outweigh risk). This group is defined as any patient with: [3]

A
  • Prosthetic heart valves or material used for cardiac valve repair
  • Previous IE
  • Congenital heart disease (any cyanotic heart disease, those with a lifelong shunt or valvular regurgitation)
35
Q

With respect to infective endocarditis, Staphylococcus aureus is associated with which one of the following?

A

patients with no past medical history

36
Q

Staphylococcus aureus is most likely to cause IE in which three populations? [3]

A
  • patients with no past medical history
  • IVDUs who present acutely
  • prosthetic valves after two months
37
Q

Which of the following is the most cause of endocarditis in patients following prosthetic valve surgery?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is the most cause of endocarditis in patients following prosthetic valve surgery?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

38
Q

Which of the following is the most cause of endocarditis in patients with colorectal cancer?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is the most cause of endocarditis in patients with colorectal cancer?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

39
Q

Which of the following is associated most with poor dental hygiene / following a dental procedure?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with poor dental hygiene / following a dental procedure?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

40
Q

Which of the following is associated most with patients with no prior past medical history?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with patients with no prior past medical history?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

41
Q

Which of the following is associated most with IVDU who present acutely?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with IVDU who present acutely?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

42
Q

Which of the following is associated most with IE in the first 2 months following prosthetic valve surgery

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Which of the following is associated most with IE in the first 2 months following prosthetic valve surgery

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

43
Q

Which of the following is associated most with IE on prosethetic valves after two months?

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

A

Staphylococcus epidermidis
Streptococcus viridans
Staphylococcus aureus
Streptococcus bovis
Streptococcus sanguinis

44
Q

Gentamicin has a risk of causing what as a side effect? [1]

A

AKI

45
Q

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

A

Is the most appropriate first-line anti-anginal for stable angina in a patient with known heart failure, if there are no contraindications?

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

46
Q

Patients may develop tolerance to this medication necessitating a change in dosing regime

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

A

Patients may develop tolerance to this medication necessitating a change in dosing regime

A. Verapamil
B. Amlodipine
C. Nifedipine
D. Bisoprolol
E. Nicorandil
F. Isosorbide mononitrate

47
Q

Infective endocarditis:

Acute endocarditis is most commonly caused by []
Subacute cases are most commonly caused by [] .

A

Acute endocarditis is most commonly caused by Staphylococcus
Subacute cases are most commonly caused by Streptococcus species.

48
Q

Native valve endocarditis (NVE): amoxicillin + gentamicin
NVE with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA): vancomycin + gentamicin
NVE with severe sepsis and risk factors gram negative infection: vancomycin + meropenem
Prosthetic valve endocarditis: vancomycin, gentamicin + rifampacin

A

Native valve endocarditis (NVE): amoxicillin + gentamicin
NVE with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA): vancomycin + gentamicin
NVE with severe sepsis and risk factors gram negative infection: vancomycin + meropenem
Prosthetic valve endocarditis: vancomycin, gentamicin + rifampacin

49
Q

amoxicillin + gentamicin is the treatment for:

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

Native valve endocarditis

50
Q

vancomycin + meropenem is the treatment for:

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

vancomycin + meropenem is the treatment for:

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

51
Q

vancomycin, gentamicin + rifampacin is the treatment for

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

Prosthetic valve endocarditis

52
Q

vancomycin + gentamicin is the treatment for

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

A

vancomycin + gentamicin is the treatment for

native valve endocarditis with severe sepsis, penicillin allergy or suspected methicillin-resistent staphylococcus aureus (MRSA)
Native valve endocarditis
Prosthetic valve endocarditis
NVE with severe sepsis and risk factors gram negative infection

53
Q

Which of the following would you use to treat native valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat native valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

54
Q

Which of the following would you use to treat MRSA +ve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat MRSA +ve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

55
Q

Which of the following would you use to treat NVE with severe sepsis and risk factors gram negative infection?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat NVE with severe sepsis and risk factors gram negative infection?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

56
Q

Which of the following would you use to treat prosethetic valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

A

Which of the following would you use to treat prosethetic valve endocarditis?

vancomycin + gentamicin
vancomycin + meropenem
vancomycin, gentamicin + rifampacin
amoxicillin + gentamicin

Year 3: Cardiology (26 decks)

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