Clinical Cardiac Part 2 Flashcards
(112 cards)
1
Q
What are the classifications of endocarditis?
A
Infective
Non-bacterial thrombotic endocarditis
Non-bacterial verrucous endocarditis
2
Q
What are the two type of infective endocarditis?
A
Acute
Subacute
3
Q
What typically causes acute infective endocarditis?
A
Staph aureus
4
Q
Staph aureus infects what type of heart valves?
A
Normal heart valve endothelium
5
Q
Is acute infective endocarditis fatal?
A
Yes within 6 weeks without treatment
6
Q
What typically causes subacute infective endocarditis?
A
Streptococcus viridans
Enterococcus
7
Q
Where does subacute infective endocarditis infect?
A
Damaged heart valve endothelium
8
Q
Is subacute infective endocarditis fatal?
A
Yes but takes longer than 6 weeks to die
9
Q
What is Marantic endocarditis?
A
Sterile platelet vegetations on cardiac valves
10
Q
In what patient population is Marantic endocarditis typically found?
A
Patients with metastatic malignancy
11
Q
What is Libman-Sacks endocarditis?
A
Sterile platelet vegetations on cardiac valves
12
Q
What patient population is Libman-Sack endocarditis found?
A
SLE patients
13
Q
What endocarditis presents with new cardiac murmur in setting embolic disease?
A
Non-bacterial thrombic/verrucous endocarditis
14
Q
What are the risk factors for infective endocarditis?
A
Older age (>60) Male sex IV drug use Poor dentition or dental infection Structural heart disease Implantable cardiac device Hemodialysis HIV Hx of infective endocarditis
15
Q
IV drug use present with what sided endcarditis?
A
Right
16
Q
What structural heart disease cause an increased risk for infective endocarditis?
A
Rheumatic heart disease Mitral valve prolapse Bicuspid aortic valve Congenital heart disease Prosthetic heart valve repalcement
17
Q
What implantable cardiac devices increase a patient’s risk for infective endocarditis?
A
Pacemaker
Implantable cardioverter defibrillator
18
Q
What is the pathogenesis of infective endocarditis?
A
Endothelial injury -> bacteremia -> pathogen adheres to valve surface -> proliferation of bacteria -> embolization of vegetation particles -> complications
19
Q
Does staph aureus need endothelial damage to develop infective endocarditis?
A
No
20
Q
What are the most common pathogens in infective endocarditis?
A
Staph aureus Strep viridans Enterococci Strep bovis HACEK
21
Q
What is strep bovis associated with?
A
Colon cancer or IBD
22
Q
What are the HACEK organisms?
A
Haemophilus Actinobacillus Cardiobacterium Eiknella Kingella
23
Q
What are the clinical symptoms associated with infective endocarditis?
A
Fever (of unknown origin)
Constitutional symptoms (anorexia, weight loss, night sweats)
New cardiac murmur (regurgitation)
Vascular embolic events
24
Q
What are the physical exam findings for infective endocarditis?
A
Petechiae Splinter hemorrhages Osler's nodes Janeway lesions Roth spots
25
What are splinter hemorrhages?
Emboli phenomenon
26
What are osler's nodes?
Red, raised, painful lesions in distal extremities (immunologic phenomenon)
27
What are Janeway lesions?
Red, flat, painless lesions often on palms or fingers as a result of embolic phenomenon
28
What are Roth spots?
Retinal hemorrhages with white centers (immunologic phenomenon)
29
How do you diagnose infective endocarditis?
Modified Duke Criteria
30
What is the Modified Duke Criteria?
```
Echocardiography TTE then TEE
Blood cultures (must draw before starting antibiotics)
```
31
How are most people diagnosed with infective endocarditis?
Clinically
32
What is one of the major modified duke criteria that isn't ECHO or blood cultures?
New valvular regurgitation
33
What are cardiac complications with infective endocarditis?
Heart failure
Perivalvular abscess (conduction disease like heart block)
Pericarditis
34
What are metastatic infection complications with infective endocarditis?
```
Septic embolization (stroke, paralysis, splenic/renal infarction, pulmonary embolism
Metastatic abscess
Meningitis
Mycotic aneurysm
Osteomyelitis
Septic arthritis
```
35
What are renal complications with infective endocarditis?
Septic embolization
| Glomerulonephritis with renal failure
36
What is the first thing you do after diagnosing infective endocarditis?
Obtain an infectious disease consult
37
What is initial therapy for infectious endocarditis?
Vancomycin
38
From when is the duration of antibiotics calculated in infective endocarditis?
From the first day the blood cultures or negative (usually 4-6 weeks)
39
Do cardiac devices need to be removed in infective endocarditis?
Maybe
40
When do you consider a surgical consult in patients with infective endcarditis?
Patients with complications
41
Which patients received endocarditis prophylaxis?
Hx of infective endocarditis
Hx of prosthetic heart valve replacement
Hx of valve repair with prosthetic material
Hx of cardiac transplantation with valvular regurgitation
Congenital heart disease
Dental procedures
42
Do patients with GI/GU procedures need endocarditis prophylaxis?
Not unless there is a known infection
43
What are examples of congenital heart disease that need endocarditis prophylaxis?
Unrepaired cyanotic disease
Repaired cyanotic disease with residual defects
Repaired cyanotic disease with prosthetic material within 6 months
44
Do patients with respiratory procedures need endocarditis prophylaxis?
Yes, those involving incision, biopsy, or respiratory tract
45
What is typically given as endocarditis prophylaxis?
Oral amoxicillian 2g 30-60 minutes before procedure
46
What is myocarditis?
Inflammatory disease of the myocardium diagnosed by cardiac biopsy
47
What are the three types of myocarditis?
Acute
Subacute
Chronic
48
What are the causes of myocarditis?
```
Idiopathic (don't know why)
Infectious (Cocksackie B)
Autoimmune (ANCA-vasculitis, giant cell,)
Cardiac toxins
Hypersensitivity reactions
Radiation
```
49
What is pathogenesis of viral myocarditis?
Breakdown of T-cell tolerance to self myocardial antigens -> chronic myocytolysis due to humoral and/or cell-mediated organs-specific autoimmunity -> dilated cardiomyopathy
50
What are the most common viral causes of myocarditis?
Cocksackie virus B
HHV 6
Parvovirus
51
What is the clinical presentation ofmyocarditis?
Viral prodrome
New onset/worsening heart failure
Cardiac conduction abnormalities
Acute MI like syndrome
52
What is seen in the new onset or worsening heart failure symptoms with myocarditis?
```
DOE
Orthopnea
PND
LE edema
Weight gain
JVD
S3
```
53
What is seen with acute MI infarction like syndrome with myocarditis?
```
Chest pain
DOE
ST segment elevation/depression
Elevated troponins
Pleuritic chest pain
```
54
How is the definitive diagnosis of myocarditis made?
Endomyocardial biopsy
55
What imaging can be ordered when diagnosing myocarditis?
CXR (look for pulmonary edema, cardiomegaly)
ECG (look for ischemia, heart block)
ECHO (look for LV or RV dysfunction)
CMR (myocardial edema, myocardial necrosis)
56
What laboratory testing should be order when diagnosing myocarditis?
```
CBC with diff (leukocytosis)
Elevated ESR
Elevated CRP
Elevated troponin
Elevated BNP
```
57
Patients with myocarditis that leads to heart failure should be treated with what?
```
ACEi or ARB
Beta-blockers
Diuretics
Aldosterone-receptor blocker
Refractory heart failure (LV assist device, ECMO, cardiac transplant)
```
58
What should be given for the bradycardia associated with myocarditis?
Transcutaneous pacing
| Transvenous pacing
59
What is the pericardium made of?
```
Fibrous sac (outer)
Serous sac (inner double layered -> parietal layer, visceral layer)
```
60
What are the four types of pericardial disease?
Pericarditis
Pericardial effusion
Cardiac tamponade
Constrictive pericarditis
61
What are the types of pericarditis?
Acute
Subacute
Chronic
Recurrent (30%)
62
What is pericarditis?
Inflammation of the pericardium
63
What is pericardial effusion?
Normally only 15-50mL of serous fluid
64
What is cardiac tamponade?
Life threatening accumulation of pericardial fluid that compresses the heart and impairs diastolic filling -> decreased cardiac output
65
What is constrictive pericarditis?
Scarred, thickened, calcified pericardium which constricts the heart impairing cardiac filling and cardiac output
66
What is the most common disorder involving the pericardium?
Acute pericarditis
67
In the developed world what is the cause of acute pericarditis?
Idiopathic
| Viral
68
In the developing world what is the cause of acute pericarditis?
Tuberculosis
69
What are the major causes of pericardial disease?
Idiopathic
Infectious (mainly viral)
Noninfectious
70
What are the noninfectious causes of pericarditis?
```
Autoimmune disease
Malignancy
Cardiac
Trauma
Metabolic
Radiation exposure
Drugs (rare)
```
71
Radiation causes what type of pericarditis?
Restrictive pericarditis
72
What are the clinical signs of acute pericarditis?
Pleuritic chest pain
Pain is worse lying flat or relieved by sitting up and leaning forward
Pericardial friction rub
73
Where does pain often radiated in acute pericarditis?
Trapezius ridge or neck
74
What are the diagnostic criteria for acute pericarditis?
AT LEAST 2
1) Pericardic chest pain
2) Pericardial rubs
3) New widespread ST-elevation or PR depression
4) Pericardial effusion
75
What should be ordered when acute pericarditis is suspected?
```
CBC w/ diff
Elevated ESR and CRP
Troponin I (suggest myocardial involvement)
CXR
ECHO
ECG changes
```
76
What are the ECG changes seen with pericarditis?
ST-segment elevation
| PR segment depression
77
What can be seen on CXR and ECHO in pericarditis?
Pericardial effusion
78
Is it important to find the definitive cause of acute pericarditis?
Nope because of the benign course
79
Is pericardiocentesis therapeutic or diagnostic?
Both
80
What is Beck's triad?
1) Hypotension
2) Muffled heart sounds
3) JVD
81
What is Beck's triad symptoms for?
Cardiac tamponade
82
What is the tachycardia seen in cardiac tamponade due to?
Compensatory mechanism given low stroke volume
83
What is heart with cardiac tamponade?
Pericardial friction rub
84
What jugular waveforms are seen with cardiac tamponade?
Absent y descent
| lack of RV filling because it's compressed
85
What is pulsus paradoxus?
Abnormally large decrease in systolic BP during inspiration > 10 mmHg
86
What is pulsus paradoxus seen with?
Cardiac tamponade
87
What ECG changes are seen with cardiac tamponade?
Electrical alternans
| Low voltage QRS
88
What is electrical alternans?
Alternating amplitude of QRS complex in any lead (often precordial leads)
89
What is the a wave on JVW?
Right atrial contraction
90
What is the c wave on JVW?
Right ventricular contraction causes tricuspid valve to close and bulge in the right atria
91
What is the v wave on JVW?
Right atrial filling
92
What is the x descent on JVW?
Right atrial relaxation
93
What is the y descent on JVW?
Right ventricular filling
94
What is seen on CXR in cardiac tamponade?
Water bottle sign (enlarged cardiac silhouette)
95
What is seen on ECG with cardiac tamponade and pericarditis?
ST elevation/PR depression
Low voltage QRS
Electrical alteranas
96
What is seen on ECHO with cardiac tamponade?
Large pericardial effusion
Cardiac chamber collapse (right chambers)
Dilated IVC
97
What are the most common causes of cardiac tamponade?
```
Pericarditis
Tuberculosis
Iatrogenic
Trauma
Neoplasm/malignancy
```
98
What are the clinical manifestations of constrictive pericarditis?
Volume over load (peripheral edema, anasarca, hepatomegaly)
| Reduced cardiac output (DOE, fatigue, exercise intolerance)
99
What is seen on physical exam with constrictive pericarditis?
Jugular venous distension
Pulsus paradoxus
Kussmaul's sign
Pericardial knock
100
What jugular venous waveform changes are seen with constrictive percarditis?
Prominent X descent
| Prominent Y descent
101
What is Kussmaul's sign?
JVP fails to decrease with inspiration (or in some cases increases during inspiration)
Fixed diastolic volume right heart
102
What is a pericardial knock?
High pitched diastolic sound that results from abrupt cessation in ventricular filling
103
What is constrictive pericarditis difficult to distinguish between?
Restrictive cardiomyopathy
104
How do you diagnose constrictive pericarditis?
CXR (pericardial calcification)
ECG
ECHO (increased pericardial thickness, dilated IVC, bi-atrial enlargement)
Cardiac MR and CT (pericardial thickening, pericardial calcifications)
Cardiac catheterization
105
What is seen on CXR in constrictive pericarditis?
Pericardial calcifications
106
What is cardiac catheterization in the case of constrictive pericarditis reserved for?
Patients in which non-invasive tests are non-diagnostic
107
What is seen on cardiac catheterization with constrictive pericarditis?
Increased atrial pressures
Equalization of end-diastolic amongst all chambers
Square root sign of ventricular diastolic pressure
Respiratory variation
108
What is the management for acute pericarditis?
NSAIDs
| Colchine
109
What NSAIDs are given for acute pericarditis?
Indomethacin
110
When are glucocorticoids given for acute pericarditis?
When the patient can't take NSAIDs
| Associated with recurrent pericarditis
111
What is the management for cardiac tamponade?
Therapeutic pericardiocentesis
112
What is the management for constrictive pericarditis?
Pericardiectomy
