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Cardiology 2 > Endocarditis, Pericarditis, Tamponade > Flashcards

Endocarditis, Pericarditis, Tamponade Flashcards

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1
Q

endocarditis

A
  • infection of the hearts endocardial surface (heart valves)
  • native or prosthetic valves
  • could be surgical complication; nosocomial
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2
Q

subacute endocarditis

A
  • may have predisposing conditions
  • indolent nature
  • prolonged course - low grade fever - non-specific symptoms
  • if not treated, fatal by 1 yr
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3
Q

acute endocarditis

A
  • heart may be normal
  • rapidly destructing
  • fulminant - high grade fever - acutely ill
  • if not treated, fatal by 6 weeks
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4
Q

risk factors for endocarditis

A
  • acquired heart defects
  • congenital heart defects
  • IV drug use**
  • age > 60
  • male
  • poor dentition
  • presence of artificial heart valves or devices
  • IV catheters (PICC)
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5
Q

what are the 3 main things that should be on your differential for a symptomatic IVDA?

A
  • discitis
  • epidural abscess
  • endocarditis
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6
Q

what is the pathophysiology of endocarditis?

A
  • turbulent blood flow disrupts the endocardium making it sticky
  • bacteremia delivers the organisms to endocardial surface
  • organisms adhere to endocardial surface
  • eventual invasion of the vascular leaflets
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7
Q

through what every day activities could bacteria enter the blood stream?

A
  • brushing teeth
  • chewing food
  • (esp. if poor dentition)
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8
Q

What other medical conditions could allow bacteria to enter the blood stream?

A
  • skin sore
  • gum dz
  • inflammatory bowel dz
  • dental procedure
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9
Q

which bugs are most common in native valves?

A
  • s. aureus (most common)
  • strep viridans
  • HACEK
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10
Q

which bugs are most common in prosthetic valves?

A
  • early: coagulase negative staph, s. aureus, gram negative bacilli, dupheroids, fungii
  • late: strep, s. aureus, enterococci, coagulase negative staph
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11
Q

what are the HACEK oraganisms?

A
  • Haemophilus, aggregatibacter, cardiobacterium, eikenella, kingella
  • normal part of the human microbiota
  • group of gram-negative bacteria that are an unusual cause of infective endocarditis
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12
Q

common bugs in subacute endocarditis

A
  • strep viridans

- coagulase neg. staph

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13
Q

common bugs in acute endocarditis

A

-s. aureus

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14
Q

common bugs in endocarditis d/t IVDA

A
  • MRSA
  • polymicrobial
  • unusual organisms like pseduomonas, candida, lactobacillus
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15
Q

symptoms of endocaditis

A
  • fever in most cases
  • SOB, fatigue, weight loss, arthralgis/myalgia (sounds a lot like flu)
  • abd pain, N/V, back and chest pain, hematuria/proteinuria, anorexia

-regurg murmur is a finding** not sx

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16
Q

cardiac manifestations of endocarditis

A
  • new regurg murmurs
  • new CHF
  • valve damage
  • myocarditis
  • perivalvular dz
  • pericarditis
  • heart block
  • MI d/t embolic phenomena
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17
Q

non cardiac manifestations of endocarditis

A
  • septic embolization
  • embolic strokes
  • mycotic aneurysms (arising from bacterial infection of arterial wall)
  • brain microabscesses
  • glomerulonephritis
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18
Q

physical signs of endocarditis

A
  • petechae
  • splinter hemorrhages
  • oslers nodes
  • janeway lesions
  • roth spots
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19
Q

petechae

A

-small capillary hemorrhages most commonly on the feet/ankles (never on soles)

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20
Q

how can you tell petechiae from a rash?

A
  • glass test
  • push on the dots to see if they go away
  • petechiae don’t go away
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21
Q

What are the big 3 things that have petechiae?

A
  • endocarditis
  • rocky mountain spotted fever
  • meningococcal meningitis
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22
Q

splinter hemorrhages

A
  • vessel damage from swelling of blood vessels (vasculitis) or tiny clots that damage the small capillaries (microemboli)
  • multiple linear, reddish brown marks along the axis of fingernails and toe nails
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23
Q

oslers nodes

A
  • painful, erythematous nodules
  • located on pulp (bulbs?) of fingers and toes
  • immune-mediated
  • commonly indicative of subacute endocarditis
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24
Q

janeway lesions

A
  • nonpainful, erythematous, blanching macules
  • located on palms and soles
  • d/t microabcessess of dermis w/ marked necrosis and inflammatory infiltrate
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25
roth spots
- exudative, edematous hemorrhagic lesions of the retina w/ pale centers - flame shaped
26
labs to order for endocarditis
- blood cultures | - serology for brucella, bartonella, legionella, c. burnetii
27
timing for blood cultures in endocarditis
- 3 sets of them, 1 hr apart | - ideally before start of abx
28
diagnostic tests for endocarditis
- CXR: look for infiltrates or calcification of valves | - ECG: rarely diagnositc, look for ischemia, conduction delay, arrhythmias
29
echo in endocarditis
1. TTE: first test used if blood cultures are non-diagnostic; only 55-65% sensitive; can't rule out but can confirm 2. TEE: used in high risk pts or high clinical suspicion; 90% sensitive
30
What defines the diasnostic criteria for endocarditis?
Dukes criteria
31
guidelines for a probable diagnosis of endocarditis per Dukes criteria
- 1 major PLUS 1 minor | - 3 minor
32
guidelines for a definite diagnosis of endocarditis per Dukes criteria
- 2 major - 1 major + 3 minor - 5 minor
33
minor factors for endocarditis per Dukes criteria
- predisposing heart condition or IVDA - fever >38C - major arterial emboli - septic pulmonary infarcts - mycotic aneurysm - intracranial or conjunctival hemorrhage - janeway lesions, osler's nodes, roth spots, glomerulonephritis
34
major actors for endocarditis per Dukes criteria
- persistently positive blood culture for typical organisms - ECHO: vegetation, dehiscence, abscess - new valvular regurg murmur - coxiella burnetii infection
35
tx of endocarditis
- high serum concentration IV abx - prolonged tx: 4-6 wks for native valves, 6+ weeks for prosthetic valves - empiric tx w/ vancomycin then tailor to oganism ASAP - if a fungus - surgery required
36
Who are the high risk endocarditis patients that require prophylaxis?
- prosthetic valves - previous endocarditis - some congenital heart dz - valve dz after transplant
37
procedures to consider prophylaxis in endocarditis risk
- dental - respiratory track - infected skin/musculoskeletal tissue - NOT GI/GU procedures
38
endocarditis prophylaxis meds
- give 30-60 mins before procedure - amoxicillin or cephalexin 2g PO - clindamycin 600 mg PO - azithromycin 500 mg PO - claritrhomycin 500 mg PO or IM/IV
39
what is the pericardium
- fibro-elastic sac w/ parietal and visceral layers - pericardial cavity b/w layers - usually contains 15-50ml of straw-colored fluid
40
what is a common sx of pericarditis?
-sharp, stabbing chest pain
41
etiology of pericarditis
- infections: viral, bacterial, fungal - rheumatologic - immunologic - neoplastic - drug
42
infectious causes of pericarditis
- viral: coxsackie, flu, HIV, EBV - bacterial: TB, staph, haemophilus, pneumococcal, salmonella - fungal/other: histoplasma, coccidiomycosis, rickettsia
43
rheumatologic causes of pericarditis
- SLE - sarcoidosis - RA - dermatomyositis - ankylosing spondylitis - scleroderma
44
immunologic causes of pericarditis
- celiac sprue | - IBS
45
neoplastic causes of pericarditis
- angiosarcoma - mesothelioma - metastatic breast, lung, melanoma, leukemia, lymphoma
46
drug causes of pericarditis
- hydralazine | - procainamide
47
other etiologies of pericarditis
- Dressler's - automimmune inflammyory reaction to myocardial neo-antigens - post-pericardiotomy - chest trauma - aortic dissection - uremia - post radiation - idiopathic
48
clinical presentation of pericarditis
- chest pain - pericardial friction run - diffuse ST elevation - pericardial effusion -at least 2 must be present to make diagnosis
49
chest pain in pericarditis
- sudden onset - retrosternal - pleuritis and sharp - can radiate to neck, arms, shoulder - worse w/ inspiration and supine position - **improved w/ sitting upright and leaning forward
50
pericardial friction rub
- high pitched scratchy or squeaky sound - best heard w/ diaphragm at left sternal border w/ pt leaning forward - present in 85% of pericarditis cases - audible throughout respiratory cycle
51
EKG changes in pericarditis
- widespread upward concave ST segment elevation and PR segment depression - can take months for full resolution of ECG changes
52
differential diagnosis for a clinical presentation consistent w/ pericarditis
- MI - myocarditis - PE - pneumothorax - pneumopericardium - costochondritis - from EKG findings: AMI, early repol., myocarditis, hyperkalemia, ventricular aneurysm, normal variant
53
workup for pericarditis
- lab tests - CBC w/ high WBC ct. - increased ESR and CRP - CMP w/ uremia - rheumatoid factor, ANA - blood cultures if febrile - +/- HIV - cardiac enzymes NOT reliable - viral cultures not indicated
54
echo in pericarditis
- normal unless effusion is present - effusion supports diagnosis but absence does not exclude it - recommended in any cases of suspected pericardial dz
55
CXR in pericarditis
- recommended in all cases - typically normal | - enlarged cardiac silhouette in effusion
56
When to hospitalize pericarditis
- subacute sx - high fever and leukocytosis - lg. pericardial effusion - evidence for tamponade - immunosuppression - anticoagulated - acute trauma - failure to respond to NSAIDs
57
goals of treatment of pericarditis
- relieve pain - tx inflammation - prevent cardiac tamponade
58
tx of pericarditis
- tx underlying cause - drain purulent effusions - pericardiectomy if constrictive - NSAIDs - sx usually subside in 1 week - steroids if refractory to NSAIDs - colchicine
59
MI-associated pericarditis
- consequence of transmural infarction - tx of choice: Aspirin - can be late - Dressler syndrome
60
pericardial effusion
- prolonged and sever inflammation leads to fluid accumulation around the heart - can be normal variant - over 150 is when it starts to cause problems
61
physical exam in pericardial effusion
- diminished heart sounds | - may have friction rub if pericarditis
62
EKG in pericardial effusion
- low-voltage QRS | - electrical alternans
63
CXR in pericardial effusion
-enlarged, water bottle shaped heart
64
what confirms the diagnosis of pericardial effusion?
-pericardiocentesis
65
cardiac tamponade
accumulation of fluid that results in an increase in pericardial pressure and impairs ventricular filling and CO (same etiologies as pericardial effusion)
66
Becks triad in cardiac tamponade
- JVD - muffled/distant heart sounds - low BP
67
clinical manifestations of cardiac tamponade
- hypotension - tachycardia - tachypnea - jvd - dyspnea - narrow pulse pressure (<30 mmHg difference b/w systolic and diastolic) - pulsus paradoxus
68
pulsus paradoxus
- abnormally lg decrease in systolic BP and pulse wave amplitude during inspiration - (normally is <10 mmHg)
69
what is diagnostic for cardiac tamponade?
-echo
70
tx of cardiac tamponade
- echo-guided pericardiocentesis - may need to leave drain in place - tx underlying cause

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