Cardiovascular Infections

Question 1

What is endocarditis?

Answer 1

Infection of the valves

Question 2

Risk factors for endocarditis

Answer 2

1. Bacteremia (IV drug users, intravenous catheters)

2. Structural heart disease (prosthetic valve, severe stenosis or regurgitation)

Question 3

Endocarditis Pathogen: Subacute infection: days-weeks

Answer 3

Streptococcal spp (streptococcus viridians and streptococcus bovis)

Question 4

Endocarditis Pathogen: Acute infection: hours-days

Answer 4

Staphylococcus auerus

Question 5

Streprococcal Spp

Answer 5

subacute onset of low grade fever, fatigue, murmur due to slow valve destruction

Question 6

Staphylococcus Aureus

Answer 6

acute onset due to high grade fever, shaking, chills, murmur due to rapid valve destruction

Question 7

Endocarditis Presentation

Answer 7

fever/ night sweats

new or worsening murmur

Question 8

Endocarditis to right side valves

Answer 8

lung emboli (presents as pneumonia)

Question 9

Endocarditis to left side valves

Answer 9

embolic stroke, MI, retinal emboli, renal emboli, Janeway lesions, Osler nodes, splinter hemorrhages

Question 10

Janeway lesions

Answer 10

non-painful

Question 11

Osler nodes

Answer 11

painful

Question 12

Best Initial workup for Endocarditis

Answer 12

Blood cultures- necessary to establish diagnosis

Question 13

Tests for diagnosis of Endocarditis

Answer 13

1. Blood cx: Initial test (95% sensitive). Necessary to establish the diagnosis.
2. TTE: Initial imaging test. 60-70% sensitivity for vegetations. Visualization of vegetations is necessary for diagnosis. Negative TTE will require to perform TEE
3. TEE: Useful for establishing diagnosis if initial TTE is negative. 95%-100% sensitive. Maybe initial test for patients with prosthetic valve
4. ECG: Non-specific changes. Do not require for diagnosis

Question 14

What is needed for Dx of Endocarditis?

Answer 14

Positive Blood Cultures + Vegetation on ECHO

Question 15

How to establish Dx of Endocarditis if Blood Cx are negative?

Answer 15

fever(+), risk factors (+) embolic phenomena + vegetation on ECHO

Question 16

Endocarditis Treatment

Answer 16

• Empiric coverage with intravenous Vancomycin (staph spp. including MRSA) + Ampicillin (strep spp.). Gentamycin can be added for synergism
• Change abx based on sensitivity when culture results are available
• X 4-6 weeks IV antibiotics
• Surgery for ruptured valve and embolism (large vegetations)

Question 17

When to give prophylaxis for endocarditis?

Answer 17

significant valvular defect + risk for bacteremia

1. Significant Valvular defect: prosthetic valve, previous endocarditis, unrepaired/partially repaired cyanotic defect (tetralogy of Fallot)
2. Risk of bacteremia: dental work with blood (extraction, root canal, dental cleaning), respiratory tract procedures with blood (biopsy, tonsillectomy)

Question 18

Recommended Prophylaxis for Endocarditis

Answer 18

Amoxicillin / Clindamycin (single dose before procedure)

Question 19

Pericarditis

Answer 19

infection/inflammation of pericardium

Question 20

Causes of pericarditis

Answer 20

idiopathic, infection (viral-coxsackie virus), autoimmune (lupus),
malignancy (Hodgkin’s lymphoma, lung cancer), metabolic causes (uremia), Trauma (chest trauma)

Question 21

Pericarditis: Clinical Presentation

Answer 21

POSITIONAL pain (relieved by sitting forward)
PLEURITIC pain (deep inspiration)
friction rub (disappears with pericardial effusion)

Question 22

Best Initial Dx Test for Pericarditis

Answer 22

ECG- shows diffused ST elevations and PR depressions on multiple leads

Question 23

Pericarditis Tx

Answer 23

• NSAIDS w/ or w/o Colchicine
• Steroids if insufficient response to NSAIDS
• Resolves in 2-6 wks

Question 24

Tests for Pericarditis

Answer 24

1. ECG: Initial test. Done to r/o myocardial ischemia. ECG maybe non-specific in pericarditis or show diffused ST elevations and PR depressions
2. ECHO: TO R/O PERICARDIAL EFFUSION and tamponade. Pericarditis w/o effusion- normal ECHO
3. Inflammatory markers: Non-specific, likely elevated
4. Viral cultures: Rarely change the treatment
5. Chest x-ray: Normal

Question 25

Intensity of the murmurs

Answer 25

* Grade 1- faint (S1 and S2 is louder than a murmur) * Grade 2 - quiet (S1 and S2 = murmur) * Grade 3 – moderately loud (murmur is louder than S1 and S2) * Grade 4 – loud with palpable thrill * Grade 5 – very loud, with thrill. Maybe heard with a stethoscope is partly off the chest * Grade 6- very loud, with thrill. Maybe heard with a stethoscope entirely off the chest

Question 26

Systolic Murmurs

Answer 26

1. Aortic Stenosis - radiates to the neck | 2. Mitral Regurgitation - radiates to axilla

Question 27

Aortic Stenosis

Answer 27

Symptoms: Angina, Syncope, Dyspnea Signs: systolic murmur at 2nd right intercostal space radiating to neck. S4 is common

Question 28

Mitral Regurgitation

Answer 28

Symptoms: dyspnea (CHF) Signs: systolic murmur at apex radiating to axilla

Question 29

Diastolic Murmur

Answer 29

1. Aortic Regurgitation | 2. Mitral Stenosis

Question 30

Aortic Regurgitation

Answer 30

Causes: infarction, ischemia, infection Symptoms: Dyspnea (CHF) Signs: diastolic murmur at sternal border, widened pulse pressure, S3 common

Question 31

Mitral Stenosis

Answer 31

Causes: infection (RHD) Symptoms: dyspnea, palpitations Signs: low pitch diastolic rumble at apex, A-fib Typical in young pt, pregnant pt

Question 32

Hypertrophic Obstructive Cardiomyopathy (HOCM)

Answer 32

- no blood flow during systole between LV and aorta Symptoms: syncope during exercise, sudden death Signs: harsh systolic murmur radiates to carotid, heard best at right/left sternal border. GETS LOUDER WITH STANDING / VALSALVA

Question 33

Innocent Murmurs

Answer 33

- due to increased blood flow - NO STRUCTURAL PATHOLOGY - physical activity, fever, anemia, hyperthyroidism, pregnancy - Grade 1-3, no thrill - always SYSTOLIC - SOFTER with standing and Valsalva - NO RADIATION beyond precordium - always ASYMPTOMATIC - common in children and young adults - OBSERVE AND RE-EVALUATE

Question 34

Pathologic Murmurs

Answer 34

- STRUCTURAL PATHOLOGY - DIASTOLIC, holosystolic or continuous - GRADE >3 - RADIATING beyond precordium - associated with SYMPTOMS - EVALUATE WITH TTE FIRST