Carditis (Cardio 1) Flashcards
(49 cards)
1
Q
Pericarditis
A
- inflammation of the pericardial sac
- most common disorder involving pericardium
- 0.1% of hospitalized pts and 5% of pts in ED w/ non ischemic chest px
- may be first sign of underlying systemic dz
2
Q
Major Causes of Pericardial Dz
A
- 85% idiopathic
- infectious: prodrome of flu-like illness (cocksackie, echovirus, CMV, herpes, HIV, staph, strep, pneumococcus)
- radiation
- neoplasm
- trauma
- metabolic: hypothyroid, uremia
- cardiac: Dressler’s syndrome, myocarditis, dissecting AA
- autoimmune
- drugs: phenytoin, procainamide, INH, penicillins
3
Q
Uremic Pericarditis
A
- occurs in 6-10% of advanced renal failure pts not yet on dialysis
- 13% of dialysis pts due to no/inadequate dialysis
- EKG dos NOT usually show the typical diffuse STE
4
Q
Major Clinical Features of Pericarditis
A
- chest pain: 95%+, sudden onset, sharp, pleuritic, improved by sitting up/leaning forward
- pericardial friction rub: 35-85%, scratchy/squeaky sound heard with diaphragm over LSB when pt holds breath and leans forward
- EKG changes: 60%, widespread STE or PR depression
- pericardial effusion: 60%; inflammatory cells and serum accumulate in pericardial space
5
Q
Pericarditis on EKG
A
- EKG changes signify inflammation of epicardium
- some causes of pericarditis don’t result in inflammation of epicardium so may not change EKG at all
- 4 stages of EKG progression: highly variable, tx can alter the stages
6
Q
Pericarditis Stage 1 EKG Changes
A
-first hours to days
7
Q
Pericarditis Stage 2 EKG Changes
A
- 1-3 weeks
- normalization of ST and PR segments
8
Q
Pericarditis Stage 3 EKG Changes
A
- 3 to several weeks
- diffuse TWI, not seen in some pts
9
Q
Pericarditis Stage 4 EKG Changes
A
- several weeks onward
- normalization of EKG or indefinite persistence of TWI
10
Q
Lab Evaluation - Pericarditis
A
- CBC, inflammatory markers, troponin
- can see general serum markers of inflammation (eg leukocytosis) but does not make a dx
- CXR: typically normal; cardiomegaly not a common finding
- echocardio: often normal
11
Q
Causes of Pericarditis
A
- specific etiology in only 17% patients
- most cases in immunocompetent pts are idiopathic or viral
- course associated with common pericarditis causes is benign
12
Q
Tx of Pericarditis
A
- viral: ibuprofen, colchicine
- post-MI: ASA, colchicine
- refractory or CIs to NSAIDs or ASA: prednisone, colchicine
13
Q
Beck’s Triad of Cardiac Tamponade (3 Ds)
A
- decreased BP
- distended neck veins
- distant or muffled heart sounds
14
Q
Symptoms of Cardiac Tamponade
A
- dyspnea
- tachypnea
- tachycardia
- elevated JVD
- hypotension
- pulsus paradoxicus
- electrical alternans
15
Q
Pulsus Paradoxicus in Cardiac Tamponade
A
- drop in systolic BP during inspiration; weaker peripheral pulses during inspiration
- R side of heart expands, but no room for L heart to expand outward –> exaggerated septal shift = severe drop in stroke volume
16
Q
Electrical Alternans in Cardiac Tamponade
A
- consecutive, normally conducted QRS complexes alternate in height
- heart is essentially wobbling back and forth in pericardial sack
17
Q
Tamponade Tx
A
- pericardial drainage: catheter placed to drain effusion
- pericardiotomy/pericardial window: surgical removal of all or part of pericardium (rare!)
18
Q
Myocarditis
A
inflammation of heart muscle
19
Q
Infectious Causes of Myocarditis
A
- viral: parvo B19, HHV 6, cocksackie, adeno, CMV, EBV, HCV
- bacterial: staph, strep, TB
- spirochetes, mycotic, rickettsial, protozoal, heminthal
- developed countries = viral
- undeveloped = rheumatic fever, chagas dz, advanced HIV
20
Q
Non-Infectious Causes of Myocarditis
A
- cardiotoxins: EtOH, CO, cocaine, catecholamines, heavy metals
- hypersensitivity rxns: abx, clozapine, diuretics, lithium
- systemic disorders: celiac, CVD, Wegener’s, SLE, HE, IBD, Kawasakie dz, sarcoid
- radiation
21
Q
Clinical Presentation of Myocarditis
A
- highly variable; many cases can go undetected
- usually 20-50 yo
- some pts have viral prodrome or rash
- myocardial inflammation may be focal or diffuse
- fatigue
- chest px, heart failure
- cardiogenic shock
- arrhythmias (tachy or brady)
- sudden death
22
Q
Myocarditis Virus-Immune Hypothesis
A
- for acute viral myocarditis, pts NOT predisposed to autoimmunity develop self-limited dz and recover fully
- genetic predisposition to autoimmunity may initiate a chronic autoimmune myocarditis leading to DCM
23
Q
Myocarditis Physical Exam
A
- signs of fluid overload, CHF
- occas S3 and S4 heard
- new murmurs
- friction rub
24
Q
Myocarditis Lab Evaluation
A
-EKG, troponin, NT-pro-BNP, CXR
25
Echocardiogram for Myocarditis
- key method of detecting impaired ventricular function
| - may have focal or global wall motion abnormalities, LV dilation, MR or TR
26
Diagnosing Myocarditis
-gold standard is endomyocardial biopsy, but most pts can be diagnosed based on clinical presentation and non-invasive diagnostic findings
27
Dallas Criteria for Endomyocardial Biopsy
-inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes not typical of ischemic damage
28
Tx of Myocarditis
- treat underlying cause if able: antiviral therapy, immunosuppressive therapy, IVIG
- NO NSAIDs (they can enhance myocarditis and increase mortality)
- restrict activity
- treat for HF if cardiomyopathy has developed
29
Myocarditis in Kids
- 1:100,000 children, bimodal but avg age 9 yo
- more acute presentation than adults
- viral: recent URI or GI illness, prodrome of fever/myalgia/malaise
- usually more acute and fulminant, usually present with signs of heart failure
- viral titers often drawn
- EMB and cardiac MRI commonly used
30
Myocarditis F/U
- many require hospitalization
- post-discharge, routine F/U every 1-3 months
- echocardiogram at 1 and 6 mos then annually
31
Endocarditis
- inflammation of the inner layer of the heart
- can involve septum, chordae tendinae, mural endocardium
- characterized by vegatation: mass of platelets, fibrin, microorganisms, inflamm cells
- 10000 to 15000 new US cases annually
- incidence varies
- survival rate 80% (1/6 doesn't survive to discharge)
32
Endocarditis Pathogenesis (3 steps)
1. formation of small, noninfected thrombus on abnormal endothelial surface
2. 2ary infection with bacteria circulating in bloodstream
3. proliferation of bacteria result in formation of vegetations on endothelial surface
33
Endocarditis Risk Factors
- over age 60: more than 1/2 cases occur in pts >60
- males more common 3:2
- IV drug use
- dental infection
34
Conditions Associated with Endocarditis
- 75% structural heart dz: valvular dz, congenital heart dz, prosthetic heart valve
- hx of infective endocarditis
- presence of intravascular device (PICC, central line)
- chronic hemodialysis
- HIV infection
35
Microbiology of Endocarditis
- strep viridans (65%)
- staph (20%)
- enterococcus (10%)
- gram negative bacteria (HACEK, 5%)
- fungus: in immunocompromised pts
- culture negative endocard (8%)
36
Endocarditis Physical Exam Findings
- new murmur
- new heart failure
- skin findings: petechiae, splinter hemorrhages, Janeway lesions (macular, red non-tender on soles and palms), Osler's nodes (painful, violaceous nodules fingers and toes), Roth spots: exudative hemorrhagic lesion of retina
37
Endocarditis Lab and Imaging Work Up
- blood culture prior to giving abx (90% positive)
- CBC, basic metabolic panel
- inflammatory markers
- EKG and CXR
- echocardiogram
38
Echo in Infectious Endocarditis
- perform as soon as possible in moderate to high suspicion pts
- allows detection and characterization of vegetation on valves or other sites, evaluates valve function, can detect abscesses
- detection of vegetation = positive test, but absence does not rule out endocarditis
39
Culture Negative Endocarditis
- <10% of pts w/ endocard
- cardiac vegetation in the absence of positive blood cultures in pt w/ persistent fever and other infectious signs
- perhaps from previous abx therapy, inadequate microbio techniques
40
Treatment of Native-Valve Infectious Endocarditis
- bactericidal therapy
- empiric therapy after blood cultures drawn should cover staph, strep, enterococci
- duration generally 4-6 wks IV
- follow up blood cultures to ensure effective therapy
41
Tx of Strep Infectious Endocarditis
- strep viridans and bovis account for 40-65% of native valve IE
- most are highly penicillin sensitive
- 4 weeks
42
Tx of Staph Infectious Endocarditis
- MSSA: nafcillin, cefazolin or vancomycin
- MRSA: vancomycin
- 6 weeks
43
Tx of Enterococci Infectious Endocarditis
- narrower spectrum of susceptibility than strep species
- can be resistant to pens cephs
- if susceptible, gentamicin plus one of the following penG/ampicillin/vancomycin
- 4-6 wks
44
Tx of HACEK Infectious Endocarditis
- gram negative bacilli
- 5-10% of all IE cases
- ceftriaxone or ampicillin or ciprofloxacin
- 4 wks
45
Tx of Culture Negative Infectious Endocarditis
- cover both gram + and - organisms
- amp/sulb + gentamicin
- PCN allergy: vanco + genta + cipro
46
Antimicrobial Prophylaxis for Bacterial Endocarditis
- standard in most developed countries
| - no human study has shown that prophylaxis has prevented endocarditis after an invasive procedure
47
High Risk Conditions to Prophylax for Endocarditis
- prosthetic heart valve
- prior history of infectious endocard
- cardiac valvulopathy in transplanted heart
- congenital heart defects
48
Rheumatic Heart Dz
- most severe sequelae of acute rheumatic fever
- usually 10-20 yrs after original illness
- most common cause of acquired valve disease
- mitral stenosis is a classic finding
- no routine abx prophylaxis for RHD unless hx of valve repair
49
Carditis in Acute Rheumatic Fever
- antimicrobial therapy doesn't alter course or severity of cardiac complications
- salicylates 4-6 wks then taper
- steroids reserved for severe carditis
