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Fall 2014 - CM Cardio > Carditis (Cardio 1) > Flashcards

Carditis (Cardio 1) Flashcards

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
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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
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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
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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
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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
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6
Q

Pericarditis Stage 1 EKG Changes

A

-first hours to days

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7
Q

Pericarditis Stage 2 EKG Changes

A
  • 1-3 weeks

- normalization of ST and PR segments

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8
Q

Pericarditis Stage 3 EKG Changes

A
  • 3 to several weeks

- diffuse TWI, not seen in some pts

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9
Q

Pericarditis Stage 4 EKG Changes

A
  • several weeks onward

- normalization of EKG or indefinite persistence of TWI

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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
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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
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12
Q

Tx of Pericarditis

A
  1. viral: ibuprofen, colchicine
  2. post-MI: ASA, colchicine
  3. refractory or CIs to NSAIDs or ASA: prednisone, colchicine
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13
Q

Beck’s Triad of Cardiac Tamponade (3 Ds)

A
  • decreased BP
  • distended neck veins
  • distant or muffled heart sounds
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14
Q

Symptoms of Cardiac Tamponade

A
  • dyspnea
  • tachypnea
  • tachycardia
  • elevated JVD
  • hypotension
  • pulsus paradoxicus
  • electrical alternans
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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
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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
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17
Q

Tamponade Tx

A
  • pericardial drainage: catheter placed to drain effusion

- pericardiotomy/pericardial window: surgical removal of all or part of pericardium (rare!)

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18
Q

Myocarditis

A

inflammation of heart muscle

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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
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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
Q

Echocardiogram for Myocarditis

A
  • key method of detecting impaired ventricular function

- may have focal or global wall motion abnormalities, LV dilation, MR or TR

26
Q

Diagnosing Myocarditis

A

-gold standard is endomyocardial biopsy, but most pts can be diagnosed based on clinical presentation and non-invasive diagnostic findings

27
Q

Dallas Criteria for Endomyocardial Biopsy

A

-inflammatory infiltrate of the myocardium with necrosis and/or degeneration of adjacent myocytes not typical of ischemic damage

28
Q

Tx of Myocarditis

A
  • 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
Q

Myocarditis in Kids

A
  • 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
Q

Myocarditis F/U

A
  • many require hospitalization
  • post-discharge, routine F/U every 1-3 months
  • echocardiogram at 1 and 6 mos then annually
31
Q

Endocarditis

A
  • 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
Q

Endocarditis Pathogenesis (3 steps)

A
  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
Q

Endocarditis Risk Factors

A
  • over age 60: more than 1/2 cases occur in pts >60
  • males more common 3:2
  • IV drug use
  • dental infection
34
Q

Conditions Associated with Endocarditis

A
  • 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
Q

Microbiology of Endocarditis

A
  • strep viridans (65%)
  • staph (20%)
  • enterococcus (10%)
  • gram negative bacteria (HACEK, 5%)
  • fungus: in immunocompromised pts
  • culture negative endocard (8%)
36
Q

Endocarditis Physical Exam Findings

A
  • 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
Q

Endocarditis Lab and Imaging Work Up

A
  • blood culture prior to giving abx (90% positive)
  • CBC, basic metabolic panel
  • inflammatory markers
  • EKG and CXR
  • echocardiogram
38
Q

Echo in Infectious Endocarditis

A
  • 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
Q

Culture Negative Endocarditis

A
  • <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
Q

Treatment of Native-Valve Infectious Endocarditis

A
  • 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
Q

Tx of Strep Infectious Endocarditis

A
  • strep viridans and bovis account for 40-65% of native valve IE
  • most are highly penicillin sensitive
  • 4 weeks
42
Q

Tx of Staph Infectious Endocarditis

A
  • MSSA: nafcillin, cefazolin or vancomycin
  • MRSA: vancomycin
  • 6 weeks
43
Q

Tx of Enterococci Infectious Endocarditis

A
  • 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
Q

Tx of HACEK Infectious Endocarditis

A
  • gram negative bacilli
  • 5-10% of all IE cases
  • ceftriaxone or ampicillin or ciprofloxacin
  • 4 wks
45
Q

Tx of Culture Negative Infectious Endocarditis

A
  • cover both gram + and - organisms
  • amp/sulb + gentamicin
  • PCN allergy: vanco + genta + cipro
46
Q

Antimicrobial Prophylaxis for Bacterial Endocarditis

A
  • standard in most developed countries

- no human study has shown that prophylaxis has prevented endocarditis after an invasive procedure

47
Q

High Risk Conditions to Prophylax for Endocarditis

A
  • prosthetic heart valve
  • prior history of infectious endocard
  • cardiac valvulopathy in transplanted heart
  • congenital heart defects
48
Q

Rheumatic Heart Dz

A
  • 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
Q

Carditis in Acute Rheumatic Fever

A
  • antimicrobial therapy doesn’t alter course or severity of cardiac complications
  • salicylates 4-6 wks then taper
  • steroids reserved for severe carditis

Fall 2014 - CM Cardio (5 decks)

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