Inflammatory and infectious conditions

Question 1

List the layers of the heart

Answer 1

Visceral pericardium - epicardium
Myocardium
Endocardium

Question 2

What is the Most common inflammatory heart condition?

Answer 2

Acute pericarditis

Question 3

What is defined as acute inflammation of the pericardium?

Answer 3

Acute pericarditis

Question 4

List a bunch of etiologies of acute pericarditis

Answer 4

-Idiopathic
-Infectious: Viral – coxsackie, influenza, Covid; MTB; Bacterial
-Post MI – Dressler syndrome ** (important)
-Post pericardiotomy – mgt for tamponade
-Chest trauma
-Uremia ** (important)
-Neoplastic disease
-Post XRT
-Collagen vascular disease – RA, lupus, scleroderma

Question 5

Give the OLDCARTS for pericarditis

Answer 5

Onset, duration, timing: acute, persistent, weeks/months
Location: substernal
Character: Sharp & pleuritic substernal CP
Alleviating factors: CP improves with sitting up/leaning forward
Aggravating factors: CP worsens with supine, coughing, deep inspiration
Radiation: back
Associated Symptoms: dyspnea

Question 6

What 2 things may you see on PE with pericarditis?

Answer 6

1) May find tachycardia
2) Pericardial friction rub

Question 7

1) What is seen in 60-90% of patients?
2) What is seen on CXR?
3) What is seen on echocardiogram?

Answer 7

1) EKG findings: Most often diffuse ST segment elevations and/or PR segment depression
2) Normal or enlarged heart
3) Normal +/- Pericardial effusion, pericardial thickening

Question 8

List some DDXs for pericarditis (other chest pain conditions)

Answer 8

-Myocardial infarction
-Aortic dissection
-Cardiac tamponade
-GI – gastritis, PUD
-Myocarditis
-PE
-Tension pneumothorax
-Stress cardiomyopathy (Takotsubo syndrome/broken heart syndrome)

Question 9

List some EKG findings with pericarditis from stages 1-4

Answer 9

1) Widespread ST elevation (<5mm) and PR depression
2) Normalization
3) Widespread T wave inversion
4) Normalization

Question 10

If myocardial involvement suspected in pericarditis, what should you do? Why?

Answer 10

MRI or CT cardiac scan
-Sensitive to assess small effusions, detect pericardial constriction, and determine extent of myocardial involvement

Question 11

_______________________ is recommended for cardiac tamponade or suspected neoplasm or bacterial or MTB pericarditis

Answer 11

Pericardiocentesis with biopsy

Question 12

Pericarditis management: What is the initial Tx for most pts?

Answer 12

ASA or NSAID
+
Colchicine

Question 13

Pericarditis management: What should you do for initial Tx post-MI?

Answer 13

ASA
+
Colchicine

Question 14

Pericarditis management: What should you do for refractory cases or patients with contraindication to NSAID therapy?

Answer 14

Prednisone
+
Colchicine

Question 15

What is the prognosis for Idiopathic or viral pericarditis?

Answer 15

Excellent; even with myocardial extension – 90% have normal EF at 1 year

Question 16

Factors associated with poor prognosis of pericarditis include what?

Answer 16

Subacute course (beyond 6 weeks)
New or worsening pericardial effusion
Constrictive pericarditis
Lack of response after 1 week of therapy

Question 17

What are the recurrence rates for pericarditis? What can influence them?

Answer 17

15-30%; reduced by 50% if early treatment with colchicine is initiated

Question 18

Autoimmune, neoplastic, or metabolic pericarditis (non-infectious) have mortality rates of _______%

Answer 18

20-30%

Question 19

Describe the activity restrictions for pericarditis

Answer 19

Return to all forms of physical activity is recommended after 1-3 months for patients that recovered completely from acute pericarditis
Inflammatory markers, cardiac enzymes, and LV function on TTE must be normalized
Athletes with acute pericarditis – consider EKG and GXT prior to resuming competitive sports

Question 20

Constrictive pericarditis - cardiomyopathy: Describe how it occurs

Answer 20

Pericardial Inflammation
Thickened fibrotic pericardium – restricts diastolic relaxation
Restricted venous return
Restricted diastolic filling
Decreased preload of RV
Decreased RV SV
Decreased RV CO
Clinical symptoms of Right HF

Question 21

Constrictive pericarditis diagnostic studies:
1) What is it difficult to differentiate from?
2) What may CXR show?
3) What does echo show?
4) Is there use for CT or MRI?
5) What is diagnostic?

Answer 21

1) Difficult to DDx from restrictive cardiomyopathy
2) May show normal or enlarged cardiac silhouette
3) Rarely demonstrates thickened pericardium
4) Likely rarely helpful
5) Cardiac catheterization

Question 22

What is the Tx for constrictive pericarditis?

Answer 22

1) Target specific etiology
2) Anti-inflammatories
3) RHF = aggressive diuresis for volume overload
-Pericardiectomy if diuretics not effective

Question 23

Cardiac tamponade:
1) Define this condition
2) What does it cause the heart to do?

Answer 23

1) Pericardial fluid/blood accumulates in pericardial space/sac
2) —Impaired diastolic filling (decreased pre-load): Mechanically compresses the myocardial chambers
—Decreased cardiac output

Question 24

Cardiac tamponade: What are the etiologies?

Answer 24

Acute pericarditis/myocarditis
Free myocardial wall post MI – transmural infarct
Trauma
Malignancy
Aortic dissection
Iatrogenic

Question 25

Give the OLDCARTS for cardiac tamponade

Answer 25

**Onset, duration, timing:** acute to chronic, persistent **Location:** Chest pain **Character:** depending on cause e.g., sharp (inflammatory) **Aggravating:** similar to pericarditis or any activity **Alleviating:** not much **Radiation:** n/a **Associated symptoms:** Dyspnea, anxiety

Question 26

Pulsus paradoxus or paradoxical pulse: Define this condition

Answer 26

An abnormally large decrease in stroke volume, systolic blood pressure and pulse wave amplitude during inspiration. The normal fall in pressure is less than 10 mmHg. When the drop is more than 10 mmHg, it is referred to as pulsus paradoxus.

Question 27

Describe cardiac tamponade diagnostic testing

Answer 27

1) Imaging studies TTE – pericardial effusion, RV diastolic collapse, large cardiac silhouette CXR – enlarged cardiac silhouette 2) EKG: Low voltage and electrical alterans 3) PCI – cardiac cath

Question 28

Aortic tear or dissection & effusions: List 3 risk factors

Answer 28

1) AS 2) Bicuspid aortic valve 3) MVA

Question 29

Describe the pathophysiology from effusion to tamponade

Answer 29

Speed of accumulation affects hemodynamic effects Slow 1000ml less hemodynamic affect (tamponade) Tamponade occurs when intrapericardial cavity pressure > 15 mm Hg Restricts venous return Decreased preload Decreased stroke volume Decreased cardiac output Hypotension Shock

Question 30

Pericardial effusions treatments (referral) include?

Answer 30

1) IVS with normal saline – address low preload (similar to Right ventricle MI) 2) Pericardial centesis 3) Pericardial window

Question 31

Primary cardiac tumors: 1) Are they common? 2) What is the most common type? 3) What is the second most common type?

Answer 31

1) No, rare 2) Atrial myxoma 3) Valvular papillary fibroelastomas and atrial septal lipomas

Question 32

Primary cardiac tumors: Atrial myxomas: 1) What % of this category do these make up? 2) What part does it affect? 3) What are the Sx of the syndrome that accompanies it? 4) What is a DDX? How is it diagnosed?

Answer 32

1) 50% of all tumors 2) Left atrial septum 3) Fever, malaise, weight loss, elevated WBC and ESR, and embolic risk 4) DDx = infective endocarditis; Dx with echocardiogram

Question 33

Primary cardiac tumors: Are they valvular papillary fibroelastomas and atrial septal lipomas benign or cancerous? (don't really need to know)

Answer 33

Benign

Question 34

Give 3 examples of secondary cardiac tumors

Answer 34

1) Malignant melanoma 2) Bronchogenic carcinoma 3) Adenocarcinoma of breast

Question 35

Secondary cardiac tumors: What are the main symptoms?

Answer 35

Often clinically silent but may lead to tamponade and arrhythmias

Question 36

Myocarditis: 1) What is it? 2) What is it often associated with? 3) What age group?

Answer 36

1) Inflammatory disease of myocardium triggered by non-ischemic factors 2) Often associated with pericarditis 3) 3rd leading cause of sudden death among college athletes -Brugada syndrome and HoCM

Question 37

3rd leading cause of sudden death among college athletes is what?

Answer 37

Myocarditis: Brugada syndrome and HoCM

Question 38

Myocarditis: 1) What is the most common etiology? 2) What are some other triggers?

Answer 38

1) Viral: coxsackie and parvovirus B-19 most common 2) Autoimmune, hypersensitivity, & drug or toxin exposure

Question 39

Myocarditis: 1) What is the range of presentation? 2) What may precede cardiac Sx by days to weeks?

Answer 39

1) Asymptomatic to severe 2) Flu like and GI symptom may precede cardiac symptoms by days to weeks – 20-80%

Question 40

Myocarditis: What are the common Sx?

Answer 40

Chest pain – 90% Dyspnea – 20-50% Fever – 65% Arrhythmias – 18% Syncope – 6% Fatigue, anorexia, abdominal pain

Question 41

Myocarditis: 1) How is it often diagnosed? 2) When should you have a high index of suspicion?

Answer 41

1) Often Dx of exclusion: r/o MI, valvular heart disease, HF, arrhythmias 2) -Young patient with evidence of MI or HF in absence of cardiac RF -Cardiovascular symptoms after recent viral infection

Question 42

Myocarditis: Describe management

Answer 42

1) Multispecialty consultation; inpatient management 2) HFrEF: GDMT until resolution of HF symptoms 3) Arrhythmia management: supportive, often resolve as inflammation resolves 4) Treatment of underlying conditions -NOTE: NSAIDS are ineffective for myocarditis and relatively contraindicated in HF

Question 43

Describe the prognosis for myocarditis

Answer 43

Favorable for viral and idiopathic Develop of HFrEF worse prognosis Biopsy proven autoimmune myocarditis have worse prognosis

Question 44

Describe myocarditis in relation to COVID-19

Answer 44

1) 19-28% have cardiac dysfunction 2) Associated with azithromycin use; association with Covid-19 vax is rare 3) ACC recommends consideration of IV corticosteroids, but other sources have alternative recommendations 4) Same follow up care as other viruses

Question 45

Infective endocarditis (IE): 1) What is it? 2) What is a cause of acute IE? 3) What abt subacute IE?

Answer 45

1) Hematologic spread of bacteria; infection of the endocardial surface, typically the valves surface. 2) S. aureus: rapidly progressive, affects healthy valves 3) Viridans Group Streptococcus sps. (normal flora of GI) > Insidious onset, affects damaged valves

Question 46

What may you see on PE with IE?

Answer 46

New heart murmur Splinter hemorrhages, petechiae Janeway lesions Osler nodes Roth spots

Question 47

Define and describe Roth's spots (assoc. with IE)

Answer 47

1) Roth's spots, AKA “Litten” spots or the “Litten” sign, are non-specific red spots with white or pale centers, seen on the retina 2) Traditionally associated with infective endocarditis, but occur in other conditions including hypertension, diabetes, collagen vascular disease, extreme hypoxia

Question 48

What are 3 labs you should get for IE diagnostic testing?

Answer 48

Blood cultures – 3 sets prior to antibiotics is optimal CBC – elevated WBC Elevated serum markers of inflammation

Question 49

IE: Evaluation 1) What is the initial test that's key to diagnosis? 2) What may you see?

Answer 49

1) TTE initially, TEE – more sensitive 2) Vegetations on valves Abscess New dehiscence of prosthetic valve

Question 50

IE: Evaluation 1) What is low-yield? What may you see? 2) What may you see on an EKG?

Answer 50

1) CXR – low yield, septic pulmonary infarcts 2) r/o BBB or AV conduction delay

Question 51

What is used to stratify IE pts into definite IE, probable IE, or no IE?

Answer 51

Modified Duke criteria + clinical picture

Question 52

Modified Duke criteria + clinical picture for IE has limited sensitivity, especially in patients with prosthetic valves and implantable cardiac devices, for what stratification?

Answer 52

No IE

Question 53

What is the origin of the Modified Duke Criteria?

Answer 53

Proposed 1994, modified 2000 Accepted standard for diagnostic classification of IE …. Not by all

Question 53

What are the minor modified Duke's criteria for IE?

Answer 53

Predisposing condition (VHD, prosthetic valve, IV drug use) Fever Vascular phenomena Immunologic disease + blood cultures that don’t meet major criteria + echo that did not meet major criteria

Question 54

Acute Rheumatic HD: How is it diagnosed?

Answer 54

Jones criteria

Question 55

__________ is caused by GABHS, a multi-systemic autoimmune disease process that may affects the heart and valves

Answer 55

RHD