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Clin Med II - Exam 3 > Infective Endocarditis > Flashcards

Infective Endocarditis Flashcards

1
Q

infective endocarditis - etiology and info

A

heart valve/ tissue infected by “vegetation” - bacteria/ fungus
10-15,000 new cases per year, more in elderly >50% of new
can be acute or chronic, native or prostatic valve (PVE)
risks - male, age >60, poor dentition, IVDU
platelet-fibrin deposition occurs on endothelial injury and inflammation, during bacteria, microorganisms deposit here
minority- bacteremia w/ intact valvular endothelium
comorbidities - Hx of IE, PVE, Structural heart disease - rheumatic, degenerative, congenital, IV device, HIV
normally: mitral> aortic > tricuspid > pulmonary
IVDU: tricuspid > mitral = aortic > pulmonary

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2
Q

IE Signs and Symptoms

A

Fever, chills, sweats, fatigue, anorexia, weight loss, malaise, dyspnea, cough, hemoptysis, CP, myalgia, arthralgia, stroke, headache, confusion, N&V, abdominal pain, back pain
heart murmur, neuro abnormalities, emobli, splenomegaly, clubbing, anemia, hematuria
* petechiae, splinter hemorrhages, osler nodes, janeway lesions, roth spots, fever

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3
Q

IE organisms

A

staph and strep
Staph - healthcare associated IE
strep - community-acquired IE
IVUD - s. aureus

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4
Q

IE Dx

A

labs - CBC: anemia or leukocytosis, elevates ESR, elevated C-reactive protein, rheumatoid factor in > 50%, proteinuria and microscopic hematuria in some patient
modified duke criteria
hallmark - bacteremia - obtain 3 blood cultures, 1 hr apart from 3 separate sites BEFORE starting antibiotics
imaging - visualize via TTE or TEE if necessary

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5
Q

IE tx

A

empiric IV antibiotics pending culture
Vancmycin (NVE)
Vanconycin + gentamicin + cefapime for PVE
tx based on organism found, follow cultures until -
tx: 4 weeks (NVE) or 6 weeks (PVE)
high mortality rate - up to 25%
surgery - refer all PVE, Rx failures, new valve incompetence or HF, fungal, recurrent embolization

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6
Q

IE Prevention

A

good oral hygiene
high-risk valvular conditions should have antibiotic prophylaxis for high-risk procedures
procedures - dental, respiratory with biopsy, GI, GU, skin, muscles with active infections, placement of prosthetic valves or IV materials
conditions - PVE, Hx of IE, unrepaired or prosteticaly repair for 6 mos post-op cyanotic congenital heart disease, congenital disease with residual defect at site of prosthetic, cardiac vavulopathy in transplanted heart
amoxicillin 2 grams orally 30-60 min before procedure, PCN allergic - cephalexin, azithromycin, clarithryomycin, clindamycin or known organism, tx appropriately
NO stenosis, regurg conditions, acyanotic VSD, ASD, HCN, bicuspid aortic valve or mitral prolapse

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7
Q

Cardiomyopathies

A

dilated - dilated ventricle and systolic dysfcn
hypertrophic - SCD, genetic
restrictive - stiffened heart walls

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8
Q

Dilated Cardiomyopathy

A

dilation or impaired contraction of LV or both ventricles
systolic dysfunction w/ or w/o HF
10,000 deaths and 45,000 hospitalizations
etiology - idiopathic, genetic, myocarditis (viral), peripartum, tachycardia-mediated, infectious - viral, HIV, Lyme, Chagas, toxic - alcohol, cocaine, chemotherapy, metabolic - thrombotoxicosis, pheochromocytoma
S/S - HF, ventricular arrhythmias, SCD
dx: echo, MUGA, Cardiac MRI
tx: avoid cause, HF tx, ICD
prognosis - 5 year mortality rate - 50%

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9
Q

Hypertrophic cardiomyopathy

A

genetic mutations of cardiac sarcomere
LVH disease - LVOT narrowed by asymmetric septal hypertrophy or systolic anterior motion of mitral valve
diastolic dysfcn
symptoms - asymptomatic, dyspnea, CP, syncope, palpitations, SCD
signs - systolic murmur @ L sternal border, S4, bisferiens carotid pulse
most common cause of SCD in athletes

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10
Q

HCM Dx

A

EKG - LVH, inferolateral Q waves, p wave abnormalities, l axis deviation, deep inverted T waves
echo - LV wall thickness > 15 mm, LVOT gradient, SAM
Cardiac MR- more info
after dx - test ambulatory EKG for arrhythmias, careful exercise stress test, genetic testing

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11
Q

HCM Tx

A 
beta blockers 1st line
verapamil second line
add disopyramide if still symptomatic
ICD
specialist could do alcohol septal ablation, surgical myectomy
screen 1st degree relatives - especially teens annually - hx, PE, echo, EKG
maintain NSR when possible
avoid vasodilators, dig, diuretics
tx as symptomatic or hgh risk
know recommendations for activity
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12
Q

HCM high risks

A

prior arrest, spontaneous sustained or NS VT, Fx of SCD, syncope, Abnormal BP response to exercise, massive LVH

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13
Q

Restrictive cardiomyopathy

A

impaired diastolic filling with preserved contractile function - no hypertrophy
systolic fcn normal until late in disease, less common in US
etiology - amyloidosis (most common), sarcoidosis, hemochromatosis, scleroderma, chemotherapy, radiation therapy, idiopathic, familial, endomyocardial fibrosis (Africa)
S&S - dyspnea, peripheral edema, palpitations, fatigue, exercise intolerance, elevated JVP, kussmaul’s sign, S3, pleural effusions, hepatospenomegaly, ascites

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14
Q

RCM Dx

A

EKG - nonspecific abnormalities
elevated BNP
CXR - cardiomegaly (atrial), pulmonary venous congestion, pleural effusion
echo - diastolic dysfcn, biatrial enlargement, normal EF and wall thickness
cardiac MR, cardiac cath, endomyocardial biopsy

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15
Q

RCM Tx

A

tx underlying disease
diuretic to relieve congestion
control HR to increase filing time - BBs, CCB
cardiac transplantation

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16
Q

Heart failure

A

23 million ppl
20% of elderly hospitilazations
1/2 millions new cases annually
inability of heart to provide sufficient forward output to meet perfusion and oxygenation requirements of the tissues while maintaining normal filling pressures
anything that impair ventricular filling or ejection
decreased output - initiates compensation which long term exacerbates the problem
increased filling pressures - backs up circulation into pulmonary and systemic venous circulation
can be systolic of diastolic

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17
Q

systole

A

cardiac contraction

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18
Q

diastole

A

ventricular filling

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19
Q

cardiac output

A

volume of blood being pumped by the ventricles per min.

= SV*HR

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20
Q

stroke volume

A

volume of blood pumped from ventricle by 1 beat
= ESV-EDV
determined by contractility, preload, afterload

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21
Q

contractility

A

myocardium ability to contract

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22
Q

preload

A

stretch of ventricular muscle fibers at end of diastole

reflected by EDV and EDP

23
Q

afterload

A

ventricular resistance against contraction

24
Q

ejection fraction

A

percent of blood leaving LV each time it contracts, normally 50-55% +

25
Q

Hear failure adaptations

A 
neurohumoral
SNA
renin-angiotensin-aldosterone
neuroendocrine activation causes vasopressin release
ANP release
endothelin release
26
Q

systolic HF

A

HF w/ decreased LVEF and systolic dysfcn
systolic dyfcn - decrease in myocardial contractility
HFrEF
etiology - CHD, HTN, idopathic cardiomyopathy - DCM, valve disease, DCM from toxic, infection, peripartum

27
Q

diastolic HF

A

normal LVEF and diastolic dysfcn - abnormal LV filling and elevated filling pressures
HFpEF
etiology - HTN, LVH causes, HCM, CHD, DM, RCM

28
Q

left sided HF

A

systolic or diastolic dysfunction of the left ventricle
symptoms of low CO and elevated pulmonary venous pressure
dyspnea

29
Q

right sided HF

A

usually caused by LV failure
symptoms of fluid overload predominate
isolate RV failure- RV infarct, pulmonary HTN - COPD, PE, pulmonary fibrosis, connective tissue disorders

30
Q

HF stages

A

A- high risk, no symptoms or structural disease
B- structural disease w/o symptoms
C- structural disease w/ prior or current symptoms
D - refractory HF requiring specialized interventions

31
Q

HF S&S

A

symptoms - dysnpnea - on exertion, orthopnea, PND or at rest, cough, nocturia, fatigue/weakness, exercise intolerance, weight gain or loss, edema, anorexia, nasuea, ab pain/ distention
signs - sinus tach, narrow PP, hypotension, pulsus alternanas, diaphoresis, cyanosis, elevated JVP, inspiratory crackles, dullness to percussion, positive HJR, hepatomegaly, axcites, pitting edema

32
Q

HF Dx

A

PE - parasternal lift, displaced, enlarge, sustained PMI, diminished S1, S3 gallop, S4 - diastolic, murmur
Labs - BMP - glucose, renal, electrolytes, sodium - hyponatremia indicates severe HF, CMP - anemia, infection, liver and thryoid function tests, BNP
EKG: arrhythmias, ischemia, LVH
CXR: cardiomegaly, cephalization of pulmonary vessles, Kerley B-lines, pleural effusions
Echo- atrial and ventricular size, LVEF, diastolic fcn of LV, valvular disease, wall motion abnormalities
Stress test- only compesation, CHD, exercise capacity, Vo2 max
Cath - left for CHD

33
Q

Brain natruiretic peptide

A

natriuretic hormone released from ventricles
indicates HF
used to distinguish HF from other forms of dyspnea and to evaluate tx response
also elevated w/ renal failure, sepsis, AFib

34
Q

HF management

A

correct reversible causes - revascularize, address valve issues, control HTN, correct systemic factors - thyroid, infection, DM, OSA
discontinue alcohol, drugs
stop smoking, restriction alcohol consumption
sodium restriction - 2 g/ day, fluid restriction - 1.5 - 2 L
weight reduction
exercise
daily weight to catch decompensation
pneumococcal and influenza vaccination

35
Q

HF Rx

A

loop diuretics - ? mortality benefits, improve symptoms
ACEI - mortality reduction, all pts with reduced EF
ARBs - pts that cannot tolerate/ use ACEIs
BBs - mortality, hospitalization, symptom, LVEF benefit
spironololactone - diuretic, mortality benefit
digitalis - positive inotrope, symptom and hospitalization relieft but no mortality benefit
vasoldilators - hydralazine + nitrates - used in blacks/ cannot tolerate ACEIs, ARBs
CCBs - can accelerate HF progression, use amlodipine if you must
no routine anticoagulation
ICD or pacing in some patients
cardiac transplantation in some pts as available

36
Q

Loop Diuretics

A

furosemide, bumetanide, torsemide
decrease Na reabsorption so urinary loss of Na and H20
causes negative fluid balance
improve symptoms but no mortality benefit proven
adverse rcns - intravascular volume depletion, renal insufficiency, hypotension, hpokalemia

37
Q

thiazide diuretics

A

HCTZ/ Chlorthalidone - mild fluid retention, BP control, less potent, can add triamterene to reduce K secretion
Metolazone - add-on to loop diuretics in refractory HF, monitor electrolytes and renal fcn closely

38
Q

ACEIs

A

prils
MOA - inhibit antiotensin II formation, decrease preload and afterload, decrease SNA, increase bradykinin - vasoldilation, improve endolthelial function
improve symptoms, less hospitalizations, LVEF same or better, significatn reduction in mortality
all pts with decreased EF unless contraindicated
adverse reactions - hypotension, cough, angioedema, dizziness, renal insufficiency, hyperkalemia (check BMP)
titrate to max dose

39
Q

ARBS

A
  • sartans
    MOA - block angiotensin II binding to receptor, no increase in bradykinin (no cough)
    HF pts - can’t tolerate or use ACEIs
    mortality benefit and decrease in hospitilazations
40
Q

Beta blockers

A

carvedilol, metroprolsuccinate, bisoprolol
reduce SNA
mortality benefit, decr. hospital visits, symptom relieft, LVEF improvement possible
EF < 40%
contraindications - decompensated HF, symptomatic hypotension, bradycardia, AV block, asthma
SE - hypotension, bradycardia, fatigue, impotence, weight gain, worsening of HF, increased airway resistance, worsening of glycemic control, increased incidence of new-onset DM, mask hypoglycemic symptoms, WITHDRAWL

41
Q

Spironolactone

A 
potassium-sparing diuretic
aldosterone antagonists
mortality benefit
monit for hyperkalemia w/ ACEIs
SE- gynecomastia
42
Q

Digitalis

A

positive inotrope - increases contractility
symptomatic relief for pts who remain symptomatic after ACE/ BB/ Diuretic/aldosterone agonist OR AFib rate control
lots of drug interactions, risk of toxicity/arrhythmias, renally cleared - check Dig level in 1-2 weeks, monitor renal fcn
Patient’s HF symptoms worsen when they come off med
decreased hospital visits but no mortality benefit

43
Q

vasodilator

A

hydralazine plus nitrates
reduce cardiac preload, afterload via vasodilation
evidence of benefit for blacks - symptom, mortality
use for patients intolerant of ACEIs and ARBs

44
Q

CCBs

A

accelerate HF progression

- use amlodipine if you must - safer, only for co-morbid conditions

45
Q

Dobutamine

A

positive inotrope, improves symptoms, IV
increases mortality
used for inpatient severe decompensated HF, severe hemodynamic compromise, cardiogenic shock, bridge therapy to LVAD/ transplant or palliative

46
Q

Milrinone

A

positive inotrope and vasodilator
improves symptoms, reduces hospital stay, improves quality of life
increases mortality
used for inpatient severe decompensated HF, severe hemodynamic compromise, cardiogenic shock, bridge therapy to LVAD/ transplant or palliative

47
Q

Nesiritide

A

recombinant BNP - vasodilates, improves CO, less dyspnea
hypotension side effect
no decrease in death, hospital visits, expensive, not recommended

48
Q

Anticoagulation

A

systolic HF increases the risk of thromboemblic events
routine anticoagulation only warranted for recent AWMI, Afib, prior thromboembolic event, mobile LV thrombi
why? rate of emboli = rate of major bleeding from anticoag

49
Q

ICD

A

implantable cardioverter defibrillator
maximize med therapy first
- LVEF < 35 and NYHA II of III

50
Q

Biventricular pacing

A

reduction in mortality and hospitalizations
NYHA II-IV, EF < 35, QRS > 120
put in ICD in same device

51
Q

Cardiac Trasnplantation

A

popular option
median survival rate after = 11 years
limited by donor heart numbers
LVAD can be used as a bridge

52
Q

HF and Arrhythmias

A

high incidence of arrhythmias
BBs first line
amiodarone preferred but does not improve outcomes
VT/NSVT - poorer prognosis
most other arrhythmics contraindicated due to proarrhythmic risk and effects on cardiac fcn

53
Q

Diastolic HF

A 
control sytolic and diastolic HTN
maintain SR, control ventricular rate
revascularization for CHD
tx edema and pulmonary congestion w/ diuretics
high morbidity and mortality

Clin Med II - Exam 3 (3 decks)

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