Cardiology #5 Endocarditis, Pericarditis, Effusion, Tamponade, AAA

Question 1

What is endocarditis, what is the MC valve affected (in general), and what is the MC valve affected in IVUD?

Answer 1

Infection of the valves due to bacteria

-Mitral MC in general
-Tricuspid MC in IVDU

Question 2

What is the pathophysiology of endocarditis?

Answer 2

Thrombus forms on valve –> damaged endothelium attracts platelets and bacteria –> vegetative growth develops

Question 3

Risk Factors for endocarditis

Answer 3

-Age
-Rheumatic Heart Disease
-IVDU
-Prosthetic valves
-Immunosuppression

Question 4

MCC acute endocarditis

-What kinds of valves does it affect
-Is it common in IVDU?

Answer 4

Staph Aureus

-Affects normal valves
-Common in IVDU (MRSA)

Question 5

MCC subacute endocarditis

-What kinds of valves does it affect
-What else is it associated with?

Answer 5

Strep Viridans

Affects damaged/abnormal valves
-Part of oral flora (poor dentition and dental procedures)

Question 6

On the other hand, what bacteria affects prosthetic valves (within 60 days of surgery)?

Answer 6

Staph Epidermidis (Coag-Negative)

Question 7

Regarding the post-op period, what bacteria should you be concerned with in the following time periods?

-First 2 months
-After the first 2 months

Answer 7

-Staph Epidermidis
-Staph Aureus after two months

Question 8

In men with recent GI or GU procedures, what bacteria should you be worried about with endocarditis?

Answer 8

Enteroccocus

Question 9

If negative blood cultures, what organisms should you look for in endocarditis?

Answer 9

HACEK organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)

Question 10

Symptoms of endocarditis

Answer 10

-Persistent fever (MC)
-New onset murmur or worsening murmur
-Osler nodes: painful on pads of digits/palms
-Janeway lesions: painless macules on soles and palms
-Splinter hemorrhages: linear red lesions under nail bed
-Roth Spots: retinal hemorrhages with central clearing
-Splenomegaly
-Glomerulonephritis

Question 11

What diagnostics should be obtained for endocarditis?

Answer 11

-Blood cultures: 3 sets at least 1 hour apart
-ECG at regular intervals
-Echo: TEE more sensitive than TTE
-Labs: Leukocytosis, High ESR/RF

Question 12

Explain the Duke Criteria including 1) what is needed to make the diagnosis of Endocarditis, 2) what the major and minor criteria are

Answer 12

Need (2 major OR 3 minor + 1 major OR 5 minor)

MAJOR:
-2 positive blood cultures of typical organisms
-Either: + echo (vegetation, abscess) OR new valvular regurgitation

MINOR:
-Fever
-Vascular Issue: Janeway lesion, pulmonary emboli
-Immunologic Issue: Osler, Roth, + RF, acute glomerulonephritis
-Worsening of existing murmur
-+ blood culture in organism not known to cause endocarditis
-Predisposition (abnormal valve, IVDU, etc.)

Question 13

How long does the treatment for endocarditis usually continue?

Answer 13

4-6 weeks

Question 14

Management for the following cases of Endocarditis:

-Native Valve
-Prosthetic Valve
-Fungal Cause

Answer 14

-Native Valve
–Nafcillin/Oxacillin + Ceftriaxone/Gentamicin
—Vancomycin if PCN allergic

-Prosthetic Valve
–Vanco + Gentamicin + Rifampin

-Fungal (Candida, Aspergillus)
–Amphotericin B (6-8 weeks)

Question 15

What kinds of things do patients with a history of endocarditis need prophylaxis for in the future?

What is given for prophylaxis?

Answer 15

Cardiac Conditions: Prosthetic valves, heart repairs (not stents), prior history of endocarditis, congenital heart disease

Procedures: dental, respiratory, involving skin/MSK (abscesses, I&D)

Amoxicillin 2g 30-60 min before procedure
–Clindamycin 600mg or Azithromycin 500mg if PCN allergic

Question 16

What is Libman-Sacks Endocarditis?

What is it usually seen with?

Answer 16

Nonbacterial thrombotic endocarditis

Malignancy, Lupus (SLE)**, Rheumatic Fever

Question 17

Management for Libman-Sacks Endocarditis?

Answer 17

Treat the SLE for the symptoms to resolve

Question 18

Acute pericarditis, inflammation of the pericardium, has two common causes…name them.

Also name the other causes, such as what is Dressler Syndrome?

Answer 18

Idiopathic and Viral (Coxsackievirus and Echovirus)

-Others: Radiation, Meds (Hydralazine, Procainamide), Malignancy (lung, breast)

-Dressler Syndrome: post MI pericarditis + fever + pleural effusion

Question 19

Again, Dressler syndrome has three components. What are they?

Answer 19

Post MI pericarditis + fever + pleural effusion

Question 20

Symptoms of pericarditis (think of P’s).

Answer 20

Chest pain: sudden pleuritic (worse with inspiration), persistent, postural (worse with supine), pleuritic friction rub (end of expiration, upright, leaning forward). Pain may radiate to shoulder, back, or neck.

Question 21

In which position can you most likely hear a pericardial friction rub (be specific)?

Answer 21

Upright, leaning forward, end of expiration

Question 22

What is seen on ECG in a patient with pericarditis?

Answer 22

-Diffuse ST elevations in precordial leads with PR depressions in those leads (V1-V6)

-In aVR, though, ST depressions and PR elevations

Question 23

Management for pericarditis

Management for Dressler Syndrome (specifically)

Answer 23

-NSAIDs or Aspirin
-Colchicine (2nd line)

Dressler: Aspirin or Colchicine, NO NSAIDS (may impair healing process and cause ventricular rupture)

Question 24

Pericardial effusion, a complication of pericarditis, is fluid in the pericardial space. What are the symptoms of this condition?

Answer 24

-Decreased (muffled) heart sounds
-Chest pain
-Dyspnea
-Fatigue

Question 25

What is the diagnostic of choice for a pericardial effusion? What is seen on an ECG? CXR?

Answer 25

Echo is DOC -ECG: Low QRS voltage, tachycardia, electrical alternans (alternating amplitudes of QRS -tall-short-tall) -CXR: water bottle heart

Question 26

Treatment for pericardial effusion

Answer 26

-Treat underlying cause -Large effusions need pericardiocentesis

Question 27

On that same note, what is a cardiac tamponade? What are some etiologies of this condition?

Answer 27

Pericardial effusion putting pressure on heart, impeding filling, leading to decreased CO and shock Etiologies: acute pericarditis, trauma, malignancy

Question 28

Symptoms of a cardiac tamponade (triad and a specific other finding)

Answer 28

Beck's Triad: muffled heart sounds + increased JVP + hypotension Pulsus Paradoxus: > 10mmHg decrease in SBP with inspiration

Question 29

Diagnostics for cardiac tamponade

Answer 29

-Echo: effusion + diastolic collapse of chambers -ECG: signs of pericardial effusion (low voltage QRS, electrical alternans) -CXR: enlarged cardiac silhouette

Question 30

Management for a cardiac tamponade

Answer 30

-Pericardiocentesis (immediately)

Question 31

What is constrictive pericarditis? What is the MCC in the US? The world?

Answer 31

Loss of pericardial elasticity (fibrosis) leading to restricted ventricular diastolic filling US: Any cause of pericarditis World: TB

Question 32

Symptoms of constrictive pericarditis

Answer 32

-Dyspnea (MC) -Right Heart Failure Signs: Increased JVD, Peripheral Edema, Kussmaul's Sign (increase in JVP with inspiration) -Pericardial Knock: high pitched diastolic sound (like S3) = sudden cessation of ventricular filling

Question 33

What is seen on an echo with constrictive pericarditis?

Answer 33

Pericardial thickening and/or calcification. Square root sign = early diastolic dip followed by diastasis.

Question 34

Management for constrictive pericarditis

Answer 34

-Diuretics -Pericardiectomy (definitive)

Question 35

Abdominal Aortic Aneurysm is focal aortic dilation > 1.5cm. Where is the MC site for this condition? What are some risk factors for AAA?

Answer 35

Infrarenal MC site RF: Smoking!!!!, Male, Age >60, Caucasian

Question 36

Symptoms of an AAA How about symptoms if ruptured?

Answer 36

Most asymptomatic; however, can have abdominal/flank pain, abdominal bruit, pulsatile abdominal mass Ruptured: same as above, hypotension, syncope, flank ecchymosis

Question 37

Regarding diagnostics for AAA, what are the best options if... -Stable -Unstable -Best test to monitor progression if asymptomatic

Answer 37

-Stable: CT with IV contrast -Unstable: Bedside US -Abdominal US if asymptomatic to monitor progression

Question 38

Explain the screening for abdominal aortic aneurysms

Answer 38

-One time abdominal US in men 65-75 who ever smoked

Question 39

Explain the treatment and monitoring for AAA based on size

Answer 39

- 5.5 or more OR > 0.5cm expansion in 6 months = immediate surgery ->4.5: vascular surgeon referral -4-4.5: US Q6 months 3-4cm: US Q12 months

Question 40

An aortic dissection, which is a tear through the innermost layer (the intima), has two types. Which type is the MC and associated with the highest mortality? What are some risk factor associated with this condition?

Answer 40

-Ascending (MC) = highest mortality RF: Hypertension****, Pregnancy, Men, Collagen disorders (Marfan, Ehler Danlos), Turner's

Question 41

Symptoms of aortic dissection Where is the pain in both types of this condition (it changes based on location).

Answer 41

-Sudden onset severe, ripping, knife-like chest pain radiating between scapulae -Unequal BP in both arms = decreased peripheral pulses, > 20mmHg difference between arms -Ascending: anterior CP -Descending: interscapular pain

Question 42

Diagnostics for aortic dissection

Answer 42

-CT angiogram (GOLD), TEE -CXR: Widened mediastinum

Question 43

Management for both types of aortic dissection

Answer 43

-Surgical: Proximal/Ascending (Stanford A) -Medical: Distal/Descending (Stanford B) --Labetolol with Sodium Nitroprusside (for HTN) --Systolic BP rapidly lowered!