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Flashcards in Carditis Deck (53):

what is the most common cause of viral myocarditis 

cocksackie B 


viral myocarditis can lead go what three ways 

  1. acute myocardial failure
  2. progression to dilated cardiomyopathy
  3. resolution


clinical presentation

  • S3, S4
  • mitral or tricuspid valve regurg
  • edema-hepative and peripheral
  • congestion-rales
  • low CO



what lab values are typically increased in myocarditis

  • BNP
  • troponin: may be increased 


what will echo typically show in myocarditis

  • LV dilation
  • wall motion abnormalities
  • decreased systolic function 


What presentations should you consider myocarditis

  1. unexplained cardiac abnormality such as CHF, shock, or arrhythmia
    • 20-50 yo typically
    • h/o viral illness
  2. acute LV dysfunction
  3. percarditis with biomarker elevation
  4. acute MI w/o h/o CAD and (-) angiogram


standard treatment of acute myocarditis 

  • IVIG, steroids, plamapharesis
  • supportive care
    • oxygen
    • inotropes
    • diuretics
    • afterload reduction
    • anticoagulation 


hat labs/tests would you order in workup for myocarditis

  • CXR
  • EKG
  • BNP, toponin
  • ECHO
  • MRI
  • possible biopsy 


what are the three categories of infective endocarditis 

  1. native valve endocarditis
  2. prosthetic valve endocarditis
  3. endocarditis in IV drug users 


what organisms cause native valve endocarditis? what valves are commonly affected

  • streptococci, enterococci, staphylococci
  • normal mouth organisms
  • mitral and aortic valves 


what organisms cause prosthetic valve endocarditis

  • 10-20% of endocarditis
  • staph species most common 


what organisms cause IV drug abusers endocarditis? What valves are commonly affected

  • staph aureus
  • Right side valves (tricuspid and pulmonic) 


acute bacterial endocarditis is usually caused from which bacteria 

  • staph aureus
  • rapidly destructive
  • if untreated, fatal in < 6 weeks


subacute bacterial endocarditis is usually caused from which bacteria 

  • viridans strep (nl mouth flora) 


clinical presentation

  • previous normal valve
  • large bulky vegetation
  • IV drug user -> RF
  • rapid onset of fever or sepsis
  • splenomegaly and embolic events

acute bacterial endocarditis 


clinical presentation

  • previous abnormal valve
  • small vegetation
  • slow onset of symptoms 

subacute bacterial endocarditis 


60-80% of people who get infective endocarditis have what

  • identifiable predisposing cardiac lesion
    • rheumatic valve lesion (25%)
    • congenital heart disease (10-20%)
    • mitral prolapse (10-33%) 


>50% of cases with infective endocarditis are people in what age group 

> 60 yo


what are some skin signs associated with infective endocarditis 

  • petechiae
  • Osler's nodes
  • Janeway lesions
  • splinter hemorrhages (pictured)  


ocular signs of endocarditis 

  • Roth spot (specific)
  • scleral hemorrhage 


what should your history be geared toward if you suspect infective endocarditis 

  • prior cardiac lesions
  • recent source of bacteremia 


what can be found on a echocardiogram that is diagnostic for infective endocarditis 

  • vegetation
    • if echo negative, do transesophageal echo 


treatment of IE

  • bactericidal Abx 
    • duration: elimiate microorganisms growing within valvular vegetations 
  • 4-6 weeks of high dose 
  • often use indwelling central catheter 


indications for surgery in IE

  • staph infection -> more aggressive
  • IE +
    • CHF
    • persistent or uncontrolled infection (Sepsis)
    • recurrent emboli 
    • vegetation > 1-2 cm in size 


antibiotic prophylaxis recommended in dental procedures or procedures involving respiratory tract or infected skin, tissues just under the skin, or musculoskeletal tissue  

  • prosthetic cardiac valve
  • previous endocarditis
  • cardiac transplant recipients
  • congenital heart disease 
    • wait 6 months if repaired 


what is given for antibiotic prophylaxis in dental, oral, respiratory, or esophageal procedures (adults)

  • amoxicillin 2g p.o. 1 hr before procedure
    • allergy?
      • azithromycin, cephalexin, or clindamycin 


differentiate between fibrous and serous pericardium 

  • fibrous pericardium
    • fibrous sac
    • holds heart in position, seperates it from surroundind structures
  • serous pericardium
    • parietal layer : lines fibrous pericardium
    • visceral layer: line epicardium


differentiate between acute, subacute, and chronic pericarditis?

  1. acute: < 6 weeks duration
    • most common
  2. subacute: 6 wks-6 mon
  3. chronic: > 6 mon

**may be characterized as serous, fibrinous (pictured), adhesive or constrictive 


clinical presentation

  • severe, pleuritic, shap chest pain aggravated by breathing, coughing, position change
  • pain is relieved by sitting up and leaning forward
  • pain is intensified by lying supine

acute pericarditis 


what is the most characteristic physical exam finding in acute pericarditis 

pericardial friction rub

  • high/medium pitch, scratching grating
  • loudest during inspiration


what EKG findings are consistent with acute pericarditis

widespread elevation of ST segments 

  • usually with reciprocal deprssion in aVR and V1


treatment of acute percarditis with viral or idiopathic etiology

  • anti-inflammatory meds
    • Aspirin 600-900 mg QID
    • other NSAID, eg Indomethacin 
    • may need steroids 
  • **Avoid anticoagulants 


What is constrictive pericarditis 

  • result of scarring and consequent loss of normal elasticity of pericardial sac
  • pericardium becomes inelastic -> inability to adapt to volume changes
  • results in ventricular interdependence


what is the big difference between constrictive pericarditis to restrictive cardiomegaly

  • constrictive pericarditis: cardiac filling is impaired by extrinsic or external force
  • restrictive CM: cardiac filling is impaired by intrinsic force 


what happens to blood flow in heart during inspiration in normal pericardium 

  • during inspiration -> decreased intrathoracic pressure -> inc. venous return to right heart -> increased rt heart size -> increased pericardial size; left heart filling is not impaired 


what happens to blood flow in heart during inspiration in constrictive pericardium 

  • normal inspiratory decrease in intrathoracic pressure is not transmited to heart chamber -> pericardium does not expand to accommodate increase in Rt heart size from venous return
  • reduction in LV fillings, septum shifts into LV and further impairs LV filling
  • stroke volume and CO are impaired 


common causes of constrictive pericarditis 

  1. idiopathic or viral 40-50%
  2. post-surgery
  3. post-radiation (hodgkin's, breast CA)


What are the common signs/symptoms associated with constrictive pericarditis 

  1. fluid overload: peripheral edema to anasarca
  2. diminished cardiac output in response to exertion/exercise
    1. fatigue
    2. DOE


physical exam

  • increased JVP (JVD)
  • pericardial knock
  • pulsus paradoxius
  • kussmaul's sign - increased JVP with inspiration 

constrictive pericarditis 


CXR findings consistent with constrictive pericarditis 



treatment of constrictive pericarditis 



what is pericardial effusion? what appearance will be on CXR and EKG?

  • build-up of fluid within pericardial space
  • CXR: "water bottle" appearance
  • EKG: low voltage of QRS (QRS < 0.5 mV)
  • friction rub may disappear and heart sounds may become faint


what is the diagnostic test of choice for pericardial effusion



acute pericarditis can cause what kind of pericardial effusion

  • viral - serous
  • bacteria - purulent 


renal failure with uremia can cause what kind of pericardial effusion

serous usually 


What analysis is done on fluid extracted from pericardial effusion 

  • gram stain, bacterial and fungal culture
  • cytology
  • ARB stain and mycobacterial culture and PCR


treatment of pericardial effusion

  1. if no evidence of hemodynamic compromise -> no immediate intervention
  2. severe -> percardial fluid drainage
  3. in reality, since may be related to pericarditis, treat with NSAIDS or steroids and judicious diuresis 


what is pericardial tamponade

  • when pericardial fluid accumulates in an amount sufficient to cause serious obstruction to inflow of blood into the ventricles


what are the three most common causes of pericardial tamponade

  • neoplasia
  • idiopathic pericarditis
  • uremia - renal failure 


what is electrical alternans? It supports what diagnosis 

  • alternating size of QRS complexes
  • a finding in effusion with tamponade 


What is Beck's Triad and what condition does it describe 

  1. distended neck veins (elevated JVD)
  2. distant heart sounds (muffled)
  3. hypotension 

**pericardial tamponade 


what is paradoxical pulse 

  • > 10mmHg reduction in systolic BP during inspiration
    • may be detected as reduced pulse during inspiration 
  • LV output is temporarily reduced during inspiration since both ventricles are w/in confines of the reduced pericardial space 


treatment of cardiac tamponade 

  • oxygen, IV fluids, T+C, CXR/ECHO (do not send to radiology)
  • DO NOT give pain medications, sedate, or intubate
  • ECHO guided pericardiocentesis, only sedate once fluids hooked up and ready to decompress