IE , Cardiomyopathy Flashcards
(11 cards)
Mention the types of cardiomyopathies
1)Dilated cardiomyopathy.
2)Hypertrophic cardiomyopathy. (septal, concentric, apical)
3)Restrictive cardiomyopathy.
4)Obstructive cardiomyopathy.
5)Arrhythmogenic cardiomyopathy.
Regarding dilated cardiomyopathy explain the following :
Causes
Clinical pic
Sex predilection
Invest
Mx
○Clinical picture:
Men more affect than female twice.
1) patient features of HF with S3 Gallop rhythm.
2) arrhythmia with thromboembolism.
3) Dilatation lead to functional Mitral or tricuspid regurgitation.
4) sporadic Chest pain .
5) Sudden death.
-All these features may occur at any stage of the disease.
○Causes:
1)Idiopathic. 2)chronic alcoholism. 3)Viral myocarditis.
4)inherited. 5) Others: DM, Sarcoidosis, connective tissue diseases.
○Investigations:
▪︎Chest X ray: flask shaped heart
▪︎ECG: Nonspecific changes
▪︎Echo: dilatation of ventricles
▪︎Cardiac biopsy: fibrosis and leukocyte infiltration.
▪︎Cardiac catheterization:
-L. V dilatation and dysfunction.
-Low cardiac output.
○Management;
1)Prolonged bed rest with avoidance of alcohol.
2)Control of heart failure (Drugs or even cardiac transplantation may be indicated)
3)Management of arrhythmias pharmacologically by Beta blockers or by ICD.
4)Prophylactic anticoagulant because Thromboembolic event are common.
Regarding HCM :
Causes
Clincal pic
Inves
Management
○Causes:
1)inherited. 2)chronic AHT. 3)some cases are sporadic.
Investigation:
1)Chest X ray: NOT greatly enlarged.
2)ECG:
-features of LVF
-Large Abnormal Q wave
-T wave inversion
-LAD
-Bundle branch block.
3) Echo:
-Left ventricle hypertrophy with small left ventricle cavity.
-Left ventricle diastolic dysfunction.
-Dilated left atrium.
-Systolic anterior motion of Mitral valve.
4) Cardiac catheterization:
-Diastolic dysfunction.
-Left ventricle outflow obstruction.
○Clinical picture:
1) Dyspnea on effort due to pulmonary congestion.
2) angina due to compression on the coronary arteries and increase oxygen requirement,
chest pain NOT response to nitroglycerin
3) Syncope on effort due to decrease Cardiac output during exertion.
4)palpitation due to arrhythmias.
5) Sudden death typically during vigorous activity ,most common in young athletics.
6) congestion cardiac failure.
▪︎Signs:
On palpitation:
1) jerk carotid pulse with sharp up stroke due to rapid ejection and sudden outflow
obstruction.
2) displaced apical beat forceful and diffuse
3) double apical pulsation (palpable S4 due to Left atrial hypertrophy).
4) palpable left ventricle hypertrophy.
5) prominent a wave (due to forceful atrial contraction)
On examination:
1)Normal S1, S2 with S4.
2) mid-systolic murmur best heart between apex with left sternal border radiated to axilla
with best of the heart not into neck vessels, increase
by Valsalva maneuver, standing up, Inotropic and vasodilators and decrease by squinting
caused by asymmetrical septal hypertrophy.
3) Pan systolic murmur at apex caused by mitral regurgitation.
4)Reversed splitting of S2 (delayed closure of Aortic valve)
Regarding restrictive cardiomyopathy:
Causes
Clinical picture
Inves
Mx
○Causes:
1)Amyloidosis. 2)Sarcoidosis. 3)Heamatochromatosis.
4)Irradiation. 5)Idiopathic. 6)Familial.
○Investigations:
▪︎Chest X ray: Cardiomegaly (moderate)
▪︎ECG: Low voltage, Conduction abnormalities.
▪︎Echo:
-Symmetrical myocardial thickening
-Normal systolic function
-Impaired ventricular filling .
4) Cardiac catheterization.
1)Symptoms:
-Dyspnea and fatigue (decrease Cardiac output)
-Palpitation (A.F)
-Hepatic congestion and enlargement lead to abdominal discomfort and ascites signs of right
heart failure.
2)Signs:
They’re similar to those of constructive pericarditis.
-Rapid low volume pulse and pulsus paradoxus.
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-Friedreich’s sign: increase JVP with diastolic Collapse.
-Kussmaul sign: increase JVP with inspiration.
-Cardiomegaly with S3 and S4
-Hepatomegaly, ascites, peripheral edema.
○Management:
-Symptomatic patient, but usually poor prognosis, need for cardiac transplantation.
Mention the risk factors for sudden death in HOCM
1)History of cardiac arrest or sustained ventricular tachycardia.
2)Recurrent syncope.
3)Family history.
4)Exercise induced hypotension.
5)Marked increase in left ventricular wall thickness.
Mention the risk factors for sudden death in HOCM
1)History of cardiac arrest or sustained ventricular tachycardia.
2)Recurrent syncope.
3)Family history.
4)Exercise induced hypotension.
5)Marked increase in left ventricular wall thickness.
What are the most common organisms associated with IE ?
▪︎Streptococcus viridance:
Present at oral cavity enter to circulation through dental extraction.
▪︎Streptococcus faecalis: which present in colon and enter the circulation via colon operation.
▪︎Staphylococcus aureus: which is normal flora of skin via vascular access .
N.B: The HACEK organisms are a group of fastidious Gram-negative bacteria that are an unusual cause of infective endocarditis about 3-4% of cases.
☆HACEK:
Haemophilus, Aggregatibacter (previously Actinobacillus), Cardiobacterium, Eikenella, Kingella.
fungi (candida, Aspergillus): those patients are immunocompromised .
Q fever endocarditis due to coxiella burnetii .
-Streptococcus gallolyticus (previously known as strep. bovis),
should undergo colonoscopy.
What are the S&S of IE
-On extremities:
Osler’s nodes on finger in skin which is tender.
Janeway lesion on palm and sole in Subcutaneous tissue and NOT tender.
Ischemia and loss of pulses, systemic embolism lead to nail fold infract.
Digital clubbing and splinter hemorrhage.
-On Systemic manifestations:
Fever .
Roths spot on retina
How to diagnose IE ?
By Modified Duke Criteria:
-Definitive diagnosis if:
2 major, OR 1 major + 3 minor, OR 5 minor
-Possible diagnosis if:
1 major + 1 minor, OR 3 minor
-Rejected:
Does not meet criteria for definite
Major Criteria:
- Positive blood culture
- Typical organism from two cultures
- Persistent positive ≥2 blood cultures taken >12 hrs apart
- All of 3 or a majority of ≥4 separate cultures of blood (with first and last samples drawn ≥1 hr apart)
- Endocardial involvement
- Positive echocardiographic findings of vegetations
- New valvular regurgitation
Minor Criteria:
- Predisposing valvular or cardiac abnormality
- Intravenous drug misuse
- Pyrexia ≥38°C
- Embolic phenomenon
- Vasculitis phenomenon
- Blood cultures suggestive: organism grown but not achieving major criteria
- Suggestive echocardiographic findings
Mention the indications for cardiac surgery in IE
- Heart failure due to valve damage
- Failure of antibiotic therapy (persistent/uncontrolled infection)
- Large vegetations on left-sided heart valves with echo appearance suggesting high risk of emboli
- Previous evidence of systemic emboli
- Abscess formation
How to manage different types of IE ?
1) Subacute:
Amoxicillin 2g ×6 times I.V (with or without Gentamycin 1mg/kg/BD I.V)
-Native valve: duration 4 weeks.
-Prosthetic valves: 6 weeks.
2) Acute (staph. aureus):
▪︎Methicillin sensitive:
Flucloxacillin 2g ,4-6 times/day
-Native valve: 4 weeks
-Prosthetic valve: 6 weeks +Gentamycin +Rifampicin 300-600mg BD orally.
▪︎Methicillin resistance:
Vancomycin 1g BD I.V
-Native valve : 4 weeks +Gentamycin
-Prosthetic valve: 6 weeks +Rifampicin 300-600mg BD orally.
3) Streptococcus viridans Or bovis:
-Penicillin G after test dose I.V 12-20 million Unit, Or
- Benzylpencillin I.V 1.2g 6 times daily Or
☆- Ceftriaxone 2g I.V or I.M single dose +Gentamycin Or
☆- Vancomycin 30mg/kg/BD
4) Pseudomonas: piperacillin +Vancomycin
5) Fungal: Amphotericin B.
6) HACEK group:
Ceftriaxone 2g/day I.V for 4weeks
Ampicillin /sulbactam 3g I.V for 4weeks
○Surgery
