Infective Endocarditis and Rheumatic Heart Disease Flashcards Preview

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Flashcards in Infective Endocarditis and Rheumatic Heart Disease Deck (65)
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1

What is infective endocarditis?

Infection of the endocardium (inner layer of the heart)

2

What structures might be infected by infective endocarditis?

Heart valves
Interventricular septum
Chordae tendinae
Intra-cardiac devices

3

What is the change in the incidence and mortality of infective endocarditis in the last 30 years?

No change in either

4

What is the general prognosis and mortality of infective endocarditis?

Poor prognosis
High mortality

5

What factors affect the prognosis and morality from infective endocarditis?

Underlying cardiac disease
Micro-organism involved
Presence of complications
Patient characteristics

6

What professions are involved in the collaborative approach to treating infective endocarditis?

Primary care physicians
Acute medicine
Cardiologists
Surgeons
Microbiologists
Infectious disease
Neurologist
Neurosurgeon
Radiologist
Pathologist

7

What is the incidence of infective endocarditis?

3-10 episodes per 100,000 person years in general population
14.5 episodes per 100,000 person years in 70-80 year olds

8

What is the difference in incidence of infective endocarditis between males and females?

Males : females
2:1

9

Is the prognosis worse in males or females?

Females

10

What percentage of people infected with infective endocarditis will not have an underlying structural heart disease?

Around 25%

11

What are the potential epidemiologies of infective endocarditis?

Older patients with degenerative AS
Rheumatic heart disease
Health care associated
Invasive procedures
Intra-cardiac devices
Prosthetic valves
Mitral valve prolapse
Bicuspid aortic valve
Congenital heart disease
IV drug abuse
Immunocompromise

12

What are the potential pathophysiologies of infective endocarditis?

Adherence and invasion of non-bacterial thrombotic endocarditis
Mechanical disruption of valve endothelium

13

What are the possible causes of mechanical disruption of the valve endothelium?

Turbulent blood flow
Electrodes
Catheters
Inflammation
Degenerative changes

14

What percentage of people with infective endocarditis will have a physically normal endothelium?

25%

15

When might bacteraemia be present in infective endocarditis?

Extra-cardiac infections
Invasive procedures e.g. oral, abdominal, genitourinary, intravascular catheters
Gingival disease

16

How is infective endocarditis classified?

Acute, subacute or chronic
Early (< 1 year after surgery) or late (> 1 year after surgery)
Side of infection
Infected devices

17

What is right sided infective endocarditis associated with?

IV drug abusers

18

What are the presenting features of nosocomial/idiopathic infective endocarditis?

Signs and symptoms > 48 hours after hospitalisation

19

What are the presenting features of non-nosocomial infective endocarditis?

Signs and symptoms < 48 hours after hospitalisation plus healthcare contact

20

What factors might be associated with infective endocarditis?

Home-based nursing, IV therapy or haemodialysis < 30 days before onset
Acute care facility < 90 days before onset
Resident in nursing home or long-term care facility
IVDA

21

What features might suggest infective endocarditis?

Variable presentation
High index of suspicion
Bacteraemic episode
Non-specific symptoms e.g. fever, fatigue, malaise

22

What are the possible signs of infective endocarditis?

Congestive cardiac failure
Vascular or immunological phenomena
Immune complex deposition
Embolic phenomena
Focal neurological signs
Peripheral embolus or abscess (30%)
Pulmonary embolus or abscess

23

What are the signs of immune complex deposition?

Vasculitic rash - diffuse, non-blanching, petechial, purpuric
Roth spots - retinal haemorrhages, white/pale centre, coagulated fibrosis
Osler's nodes - deep red spots, painful, raised, on finger plumps, palms and soles
Janeway lesions - flat, macular, echymotic, on palms and soles, non-tender
Nephritis

24

What should prompt a high index of suspicion?

Fever
New murmur
Pyrexia of unknown origin when other diagnoses have been ruled out
Known IE causative organism isolated in culture
Prosthetic material
Previous IE
Congenital heart disease
New conduction disorder
Immunocompromised
IVDA

25

When might signs of infective endocarditis be absent?

Elderly
After antibiotic treatment
Immunocompromised
IE involving less virulent or atypical organism

26

What should be done in the investigation of suspected infective endocarditis?

Markers of infection/inflammation
FBC
CRP
ESR
U&Es
Blood culture prior to starting antibiotics
Urinalysis
ECG
CXR
Echocardiogram

27

What blood cultures should be taken in the investigation of infective endocarditis?

3 sets from different sites with > 6 hours in between

In severe sepsis or septic shock then take 2 sets of bloods from different sites within 1 hour

28

What is the standard echocardiography protocol in infective endocarditis?

Transthoracic 1st line imaging
If good quality TTE normal with low clinical suspicion then no TOE needed
If TTE normal with high clinical suspicion then TOE Needed
If TTE or TOE is normal but suspicion of IE remains high, repeat at 7-10 days
If TTE positive then do TOE for complications, abscesses and measuring size of vegetation

29

When should TTE and TOE be repeated?

New complication
New murmur
Persisting fever
Embolism
Heart failure
Abscess
Atrioventricular block

30

In uncomplicated IE, when is an echo repeated?

To assess ongoing treatment for 'silent' complications and vegetation size
To assess treatment success on completion - view valve morphology and cardiac function