Cardiac Arrhythmias Overview
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Questions and Answers

What is the formula to calculate heart rate from QRS complexes?

Count the number of QRS complexes and multiply by 10 to get BPM.

What is a normal duration for a P wave?

  • > 0.20 seconds
  • 0.06-0.12 seconds (correct)
  • 0.06-0.10 seconds
  • 0.12-0.20 seconds

    • What does the PR interval measure?

    The time interval from the onset of atrial contraction to the onset of ventricular contraction.

    What indicates a normal sinus rhythm?

    <p>A regular rhythm of the heart set by the sinoatrial node.</p> Signup and view all the answers

    What is a common cause of sinus bradycardia?

    <p>Medications</p> Signup and view all the answers

    Atrial flutter leads to a 4:1 ratio of F waves to QRS complexes.

    <p>True</p> Signup and view all the answers

    What is the normal duration of the QRS complex?

    <p>&lt; 0.12 seconds</p> Signup and view all the answers

    Which condition is characterized by the absence of ventricular electrical activity?

    <p>Asystole</p> Signup and view all the answers

    What is infective endocarditis commonly associated with?

    <p>Intravenous drug use.</p> Signup and view all the answers

    Pericarditis is always caused by a viral infection.

    <p>False</p> Signup and view all the answers

    What is the hallmark finding in pericarditis?

    <p>Pericardial friction rub.</p> Signup and view all the answers

    What type of sound is heard from friction between the pericardial and epicardial surfaces?

    <p>Scratching, grating, high-pitched sound</p> Signup and view all the answers

    Which of the following are major complications of pericardial effusion? (Select all that apply)

    <p>Phrenic nerve compression</p> Signup and view all the answers

    Pulmonary tissue compression can cause cough, dyspnea, and tachypnea.

    <p>True</p> Signup and view all the answers

    What is Pulsus paradoxus?

    <p>A large decrease in systolic BP during inspiration</p> Signup and view all the answers

    What does an ECG reveal in the presence of pericardial effusion?

    <p>Widened ST segment</p> Signup and view all the answers

    Which of the following can cause myocarditis? (Select all that apply)

    <p>Viruses</p> Signup and view all the answers

    Myocarditis can result in heart dysfunction.

    <p>True</p> Signup and view all the answers

    Which symptoms can occur due to myocarditis? (Select all that apply)

    <p>Progressive heart failure</p> Signup and view all the answers

    What is the most common cause of Rheumatic heart disease?

    <p>Rheumatic fever</p> Signup and view all the answers

    Rheumatic fever occurs as a complication ___ weeks after group A streptococcal pharyngitis.

    <p>2-3</p> Signup and view all the answers

    What is a major criteria for diagnosing Rheumatic fever?

    <p>Arthritis or polyarthritis</p> Signup and view all the answers

    An echocardiogram can show valvular insufficiency in patients with Rheumatic fever.

    <p>True</p> Signup and view all the answers

    What is the treatment for group A streptococcal pharyngitis to prevent Rheumatic fever?

    <p>Intramuscular Benzathine Penicillin G</p> Signup and view all the answers

    Which conditions can cause a prolonged PR interval on an ECG? (Select all that apply)

    <p>Calcium channel blockers</p> Signup and view all the answers

    It is advisable to give digoxin to patients with myocarditis without considering toxicity.

    <p>False</p> Signup and view all the answers

    What is a common symptom associated with atrial fibrillation?

    <p>Uncontrolled and irregular heartbeat</p> Signup and view all the answers

    Which medication is NOT typically used for rate control in atrial fibrillation?

    <p>Aspirin</p> Signup and view all the answers

    What is the primary goal of treatment in a patient with atrial fibrillation?

    <p>To slow ventricular rate to 80-100 BPM</p> Signup and view all the answers

    Which characteristic is associated with atrial flutter?

    <p>Sawtooth-shaped flutter waves</p> Signup and view all the answers

    Which of these is NOT a possible cause of atrial fibrillation?

    <p>Excessive exercise</p> Signup and view all the answers

    What is the effect of atrial fibrillation on cardiac output?

    <p>Decrease due to loss of atrial kick</p> Signup and view all the answers

    Which of the following symptoms might a patient with atrial flutter experience?

    <p>Dizziness and rapid heartbeat</p> Signup and view all the answers

    What is a potential consequence of untreated atrial fibrillation?

    <p>Thrombi formation in the atria</p> Signup and view all the answers

    What does the QT interval represent in an electrocardiogram?

    <p>Time taken for electrical depolarization and repolarization of the ventricles</p> Signup and view all the answers

    Which variation in the T wave may indicate fluid and electrolyte imbalances?

    <p>T wave inversions seen in more than one lead</p> Signup and view all the answers

    What sign could indicate hypokalemia on an EKG strip?

    <p>Presence of a prominent U wave</p> Signup and view all the answers

    What is a potential cause for sinus tachycardia?

    <p>High fever</p> Signup and view all the answers

    What is a characteristic feature of sinus bradycardia?

    <p>Heart rate less than 60 bpm</p> Signup and view all the answers

    Which values indicate a normal PR interval?

    <p>0.12-0.20 seconds</p> Signup and view all the answers

    What can cause interference seen on an EKG strip?

    <p>Patient movement</p> Signup and view all the answers

    What does a regular rhythm on an ECG imply?

    <p>Intervals between QRS complexes are uniform.</p> Signup and view all the answers

    In which condition might you consider using transcutaneous pacing?

    <p>Persistent sinus bradycardia with symptoms</p> Signup and view all the answers

    What does the presence of inverted P waves typically indicate?

    <p>Atrial depolarization issues</p> Signup and view all the answers

    Which condition is generally NOT associated with variations in the QT interval?

    <p>Normal physical activity</p> Signup and view all the answers

    If the QRS interval is greater than 0.12 seconds, what could it imply?

    <p>Possible problem in ventricular conduction</p> Signup and view all the answers

    What does a measurement of less than 0.06 seconds between QRS complexes signify?

    <p>Normal conduction</p> Signup and view all the answers

    Which characteristic of P waves is considered abnormal?

    <p>Irregularity in P wave timing</p> Signup and view all the answers

    Which of the following is a key question to assess the QRS complex?

    <p>Are the QRS complexes consistent in duration?</p> Signup and view all the answers

    What typically happens to the heart rate when counting QRS complexes?

    <p>Multiply the number of QRS complexes by 10</p> Signup and view all the answers

    What distinguishes monomorphic ventricular tachycardia from polymorphic ventricular tachycardia?

    <p>Monomorphic VT has QRS complexes that are identical in shape, size, and direction.</p> Signup and view all the answers

    Which condition is characterized by irregular waveforms of varying shapes and amplitude on an ECG?

    <p>Ventricular fibrillation</p> Signup and view all the answers

    Which clinical signs indicate a patient may be experiencing Torsades de pointes?

    <p>Upward and downward QRS deflections around the baseline</p> Signup and view all the answers

    What is the immediate treatment approach for a patient in ventricular fibrillation?

    <p>Implement CPR with immediate defibrillation</p> Signup and view all the answers

    Asystole is identified by which of the following characteristics?

    <p>Absence of ventricular electrical activity</p> Signup and view all the answers

    Which symptom is not typically associated with ventricular tachycardia?

    <p>Normal pulse rate and rhythm</p> Signup and view all the answers

    What underlying issue can often lead to Torsades de pointes?

    <p>Electrolyte imbalance and prolonged QT interval</p> Signup and view all the answers

    In the context of ventricular fibrillation, what is the primary reason for rapid defibrillation?

    <p>To restore an effective heart rhythm</p> Signup and view all the answers

    Which of the following is a major criterion for diagnosing infective endocarditis?

    <p>Positive blood culture</p> Signup and view all the answers

    What is the typical duration of IV antibiotic treatment for infective endocarditis?

    <p>4-8 weeks</p> Signup and view all the answers

    Which symptom is considered a minor criterion for diagnosing infective endocarditis?

    <p>Predisposing heart condition</p> Signup and view all the answers

    Which diagnostic study is essential for confirming the presence of vegetative growth in infective endocarditis?

    <p>Echocardiogram</p> Signup and view all the answers

    Which of the following observations should be monitored in a patient being treated for infective endocarditis?

    <p>Height and weight changes</p> Signup and view all the answers

    What should be emphasized in patient teaching for someone recovering from infective endocarditis?

    <p>Need to avoid infections and complete antibiotics</p> Signup and view all the answers

    Which of the following complications can arise from infective endocarditis?

    <p>Kidney failure</p> Signup and view all the answers

    Which of the following signs indicates a severe progression of infective endocarditis?

    <p>Roth spots</p> Signup and view all the answers

    Which of the following is a hallmark characteristic of Osler's nodes?

    <p>Tender purple or pink nodules on fingers or toes</p> Signup and view all the answers

    In diagnosing infective endocarditis, which combination of criteria is acceptable?

    <p>Two major criteria and one minor criterion</p> Signup and view all the answers

    What is the preferred initial treatment for infective endocarditis after identifying the organism?

    <p>IV antibiotics for 4-8 weeks</p> Signup and view all the answers

    What symptom might suggest a need for immediate assessment of heart disease in a patient?

    <p>Weight changes and cough</p> Signup and view all the answers

    Which of these is considered a major criterion for diagnosing infective endocarditis?

    <p>New valvular vegetation</p> Signup and view all the answers

    In the context of patient teaching for those with infective endocarditis, which recommendation is crucial?

    <p>Monitor body temperature regularly</p> Signup and view all the answers

    How frequently should follow-up blood cultures be conducted during treatment for infective endocarditis?

    <p>Every 24-48 hours</p> Signup and view all the answers

    What should be done to prevent reinfection in patients at risk after dental procedures?

    <p>Take prescribed antibiotics as directed</p> Signup and view all the answers

    What is the most widely used antibiotic for the treatment of rheumatic fever?

    <p>Benzathine Penicillin G</p> Signup and view all the answers

    What is a potential complication for patients with a history of rheumatic fever?

    <p>Susceptibility to repeated rheumatic fever</p> Signup and view all the answers

    Which of the following symptoms requires patients to seek medical care after developing rheumatic fever?

    <p>Excessive fatigue</p> Signup and view all the answers

    What form of management may be prescribed for joint pain in patients with rheumatic fever?

    <p>Corticosteroids</p> Signup and view all the answers

    What is the target age for prophylactic antibiotic treatment in patients with rheumatic fever without carditis?

    <p>Until age 20</p> Signup and view all the answers

    Which skin condition should a nurse specifically assess in patients with rheumatic fever?

    <p>Erythema marginatum</p> Signup and view all the answers

    What assesses the heart’s electrical activity in patients suspected of having rheumatic fever?

    <p>Electrocardiogram (ECG)</p> Signup and view all the answers

    Which of these findings indicate a problem with atrial depolarization on an ECG?

    <p>Inverted P wave</p> Signup and view all the answers

    What does the U wave, when visible, typically indicate on an EKG strip?

    <p>Hypokalemia</p> Signup and view all the answers

    Which feature is typical of sinus tachycardia?

    <p>High heart rate with potential palpitations</p> Signup and view all the answers

    What is a common cause for sinus bradycardia?

    <p>Hypoglycemia</p> Signup and view all the answers

    If the QRS complex is less than 0.06 seconds in width, what could this indicate?

    <p>Rapid ventricles depolarization</p> Signup and view all the answers

    Which symptom could suggest the need for intervention in a patient with sinus bradycardia?

    <p>Dizziness</p> Signup and view all the answers

    What does the QT interval represent in electrocardiography?

    <p>Time taken for ventricular depolarization and repolarization</p> Signup and view all the answers

    Which factor can introduce artifact into an EKG strip?

    <p>Loose or defective electrodes</p> Signup and view all the answers

    What is the normal duration of a T wave in an EKG?

    <p>0.16 seconds</p> Signup and view all the answers

    What is indicated by a variation in the interval between the QRS (R) waves longer than 0.06 seconds?

    <p>The rhythm is considered irregular.</p> Signup and view all the answers

    What would a PR interval greater than 0.20 seconds suggest about conduction?

    <p>Possible AV node dysfunction.</p> Signup and view all the answers

    Which characteristic of the P wave is essential for normal sinus rhythm identification?

    <p>It should be rounded and upright.</p> Signup and view all the answers

    What possible issue can arise from a wide Q wave observed on an ECG?

    <p>Indication of myocardial infarction.</p> Signup and view all the answers

    How can you determine if the heart rate is accelerated by looking at the number of QRS complexes?

    <p>If there are more than 10 QRS complexes counted in 6 seconds.</p> Signup and view all the answers

    What is the sign of inconsistent appearance among P waves in an ECG strip?

    <p>Possible atrial conduction disturbance.</p> Signup and view all the answers

    What does a normal QRS interval signify about ventricular depolarization?

    <p>It suggests normal ventricular function.</p> Signup and view all the answers

    Which characteristic is a sign of irregular rhythm based on QRS intervals?

    <p>Intervals differ by more than 0.06 seconds.</p> Signup and view all the answers

    What treatment is commonly used for bacterial pericarditis?

    <p>Antibiotics</p> Signup and view all the answers

    Which condition might lead to the use of steroids in treating pericarditis?

    <p>Lupus-related pericarditis</p> Signup and view all the answers

    What is a potential consequence of untreated myocarditis?

    <p>Dilated cardiomyopathy</p> Signup and view all the answers

    Which symptom may appear several days following a viral infection related to myocarditis?

    <p>Chest pain with pericardial friction rub</p> Signup and view all the answers

    What role do diuretics play in the management of myocarditis?

    <p>Reduce fluid volume and preload</p> Signup and view all the answers

    What is the purpose of using anticoagulants in patients with myocarditis?

    <p>To reduce the risk of clot formation</p> Signup and view all the answers

    Which of the following cardiac signs may develop late in the course of myocarditis?

    <p>Peripheral edema</p> Signup and view all the answers

    What type of drugs may be used to reduce afterload and improve cardiac output in myocarditis management?

    <p>IV drugs like nitroprusside</p> Signup and view all the answers

    What is the primary treatment for a patient experiencing asystole?

    <p>Epinephrine administration</p> Signup and view all the answers

    What characterizes pulseless electrical activity (PEA)?

    <p>Organized electrical activity with no mechanical heart function</p> Signup and view all the answers

    Which type of ventricular tachycardia has QRS complexes that show the same shape, size, and direction?

    <p>Monomorphic VT</p> Signup and view all the answers

    Which of the following is NOT a common cause of pulseless electrical activity?

    <p>Atrial fibrillation</p> Signup and view all the answers

    What triggers Torsades de pointes, a type of polymorphic VT?

    <p>Electrolyte imbalance</p> Signup and view all the answers

    Which of the following is a common clinical presentation of ventricular fibrillation?

    <p>Quivering heart muscle with no effective contraction</p> Signup and view all the answers

    Which bacterium is most commonly associated with infective endocarditis?

    <p>Staphylococcus aureus</p> Signup and view all the answers

    In which stage of infective endocarditis do bacteria adhere to the heart valve?

    <p>Adhesion</p> Signup and view all the answers

    What immediate treatment is necessary for a patient in asystole?

    <p>CPR and advanced cardiac life support</p> Signup and view all the answers

    What is a distinguishing feature of ventricular tachycardia in terms of heart rate?

    <p>Rate between 150-250</p> Signup and view all the answers

    What can happen to parts of the vegetation formed in infective endocarditis?

    <p>They can embolize to distant sites</p> Signup and view all the answers

    Which of the following symptoms is NOT associated with ventricular tachycardia?

    <p>Coronary artery occlusion</p> Signup and view all the answers

    What condition can result from damage to the heart due to infective endocarditis?

    <p>Heart failure</p> Signup and view all the answers

    In ventricular tachycardia, how is the QRS complex typically characterized?

    <p>Wide and distorted</p> Signup and view all the answers

    Which risk factor is NOT associated with an increased likelihood of developing infective endocarditis?

    <p>Regular exercise</p> Signup and view all the answers

    What is the key therapeutic approach when a patient with ventricular tachycardia is unstable but has a pulse?

    <p>Cardioversion and drug therapy</p> Signup and view all the answers

    What is the primary treatment for bacterial pericarditis?

    <p>Antibiotics</p> Signup and view all the answers

    Which of the following is a potential complication of myocarditis?

    <p>Dilated cardiomyopathy</p> Signup and view all the answers

    Which medication can reduce the risk of clot formation in myocarditis patients?

    <p>Anticoagulants</p> Signup and view all the answers

    Which symptom might appear earliest after a viral infection in myocarditis?

    <p>Chest pain</p> Signup and view all the answers

    What is a common reason for using steroids in pericarditis treatment?

    <p>For patients with prior steroid use</p> Signup and view all the answers

    Which of the following clinical manifestations is NOT typically associated with myocarditis?

    <p>Pharyngitis</p> Signup and view all the answers

    Which treatment option is used cautiously due to the risk of toxicity in myocarditis?

    <p>Digoxin</p> Signup and view all the answers

    What is a typical change in the ECG for myocarditis due to associated pericardial involvement?

    <p>ST segment changes</p> Signup and view all the answers

    What does a prolonged QRS complex indicate?

    <p>Ventricular conduction delay</p> Signup and view all the answers

    What is the significance of an inverted T wave?

    <p>Indication of myocardial damage</p> Signup and view all the answers

    Which feature is typical of second-degree AV block, type 1?

    <p>Gradually widening PR interval</p> Signup and view all the answers

    In second-degree AV block, type 2, what is a likely consequence?

    <p>Decreased cardiac output</p> Signup and view all the answers

    What is a characteristic finding in third-degree AV block?

    <p>Regular P waves that outnumber QRS complexes</p> Signup and view all the answers

    Which drugs are commonly associated with second-degree AV block?

    <p>Beta blockers and calcium channel blockers</p> Signup and view all the answers

    Which treatment may be necessary for second-degree AV block, type 2?

    <p>Temporary pacing or permanent pacemaker</p> Signup and view all the answers

    What might the presence of low cardiac output indicate in a patient with a heart rhythm disorder?

    <p>Potential for decreased blood flow and symptoms</p> Signup and view all the answers

    Which heart valves are most commonly affected by Rheumatic heart disease?

    <p>Mitral and aortic valves</p> Signup and view all the answers

    What is a major complication that can arise from rheumatic fever?

    <p>Rheumatic infective endocarditis</p> Signup and view all the answers

    What does not contribute to the diagnosis of rheumatic fever?

    <p>Elevated blood pressure</p> Signup and view all the answers

    What is the primary purpose of antibiotic therapy in the context of rheumatic fever?

    <p>To eliminate residual group A streptococci</p> Signup and view all the answers

    What is a common diagnostic finding in patients with rheumatic heart disease?

    <p>Prolonged PR interval on ECG</p> Signup and view all the answers

    Which of the following treatments is most widely used to control fever and joint manifestations in rheumatic fever?

    <p>Salicylates and NSAIDs</p> Signup and view all the answers

    What effect does chronic rheumatic carditis have on the heart valves?

    <p>Causes valve regurgitation and stenosis</p> Signup and view all the answers

    Which layer of the heart is not commonly involved in rheumatic pancarditis?

    <p>Epicardium</p> Signup and view all the answers

    Study Notes

    Cardiac Arrhythmias

    • Heart Rate - normal rhythm of the heart is set by the sinoatrial node, measured by counting the number of QRS complexes and multiplying by 10
      • Sinus bradycardia: slow heart rate (<60 bpm) - common in athletes, sleep, vagal maneuvers
        • Causes: hypoglycemia, hypothermia, hypothyroidism, medications, MI, sick sinus syndrome
        • Symptoms: syncope, dizziness, SOB, cool, clammy skin
        • Treatment: stop, hold, or reduce medications, IV atropine (anticholinergic), transcutaneous pacing, possible permanent pacemaker
      • Sinus tachycardia: fast heart rate (>100 bpm) - may be normal variation
        • Causes: heart disease, hypertension, hyperthyroidism, fever, stress, alcohol, caffeine, nicotine, medications, pain, electrolyte imbalance
        • Symptoms: dizziness, SOB, lightheaded, palpitations, chest pain, syncope
        • Treatment: vagal maneuvers, IV beta blockers, adenosine, calcium channel blockers, synchronized cardioversion
    • Atrial Arrhythmias - When the SA node fails to generate an impulse, atrial tissues or internodal pathways may initiate an impulse
      • Atrial fibrillation: uncoordinated electrical signal circles through atria causing them to quiver, ventricles contract out of rhythm, irregular heartbeat, decreased CO, thrombi may form
        • Causes: heart failure, COPD, pericarditis, heart disease, stress, alcohol, caffeine
        • Symptoms: palpitations, irregular pulse, dizziness, fainting, fatigue, confusion, trouble breathing, chest tightness
        • Treatment: rate control (digoxin, beta blockers, calcium channel blockers), antithrombotic therapy, chemical or electrical cardioversion
      • Atrial Flutter: coordinated rapid beating of the atria, identified by recurring, regular, sawtooth-shaped flutter waves, atria beat faster than the ventricles
        • Causes: heart failure, pulmonary embolism, MI, digoxin toxicity, CAD, valve problems, drugs, hyperthyroidism, cor pulmonale, hypertension
        • Symptoms: palpitations, SOB, anxiety, weakness, angina, syncope
        • Treatment: cardioversion, antiarrhythmics (procainamide, diltiazem, verapamil, digitalis, beta blockers), heparin
    • Ventricular Arrhythmias
      • Premature Ventricular Contractions (PVCs): early occurrence of a QRS complex, wide and distorted, signifies contraction coming from an ectopic focus in the ventricles
        • Causes: caffeine, alcohol, nicotine, epinephrine, isoproterenol, electrolyte imbalances, heart disease, hypoxia, fever, exercise, emotional stress
        • Treatment: assess hemodynamic status, beta blockers, lidocaine, amiodarone
      • Accelerated Idioventricular Rhythm: ventricles try to prevent cardiac standstill, no P wave
        • Causes: drugs, MI, metabolic imbalances, hyperkalemia, cardiomyopathy
        • Symptoms: pale, cool skin, weakness, dizziness, hypotension, mental status changes
        • Treatment: usually tolerated well, atropine if symptomatic, temporary pacing
      • Ventricular Tachycardia (VT): run of 3 or more PVCs, ectopic focus fires repeatedly, ventricle takes control as pacemaker, life threatening dysrhythmia
        • Causes: underlying heart disease, MI, medications that prolong QT interval, electrolyte imbalance, digitalis toxicity, CHF
        • Symptoms: angina, syncope, lightheadedness, dizziness, palpitations, shortness of breath, absent or rapid pulse, loss of consciousness, hypotension
        • Treatment: CPR if no pulse, cardioversion if pulse and unstable, drug therapy (amiodarone, lidocaine, antiarrhythmics), ablation, long-term ICD
      • Ventricular Fibrillation (VF): severe derangement of the heart rhythm, irregular waveforms, ventricle quivering, no effective contraction, lethal dysrhythmia
        • Causes: AMI, untreated VT, electrolyte imbalance, hypothermia, myocardial ischemia drug toxicity, trauma
        • Symptoms: loss of consciousness, absent pulse
        • Treatment: CPR with immediate defibrillation
      • Asystole: absence of ventricular electrical activity, no ventricular contraction, lethal dysrhythmia
        • Causes: advanced heart disease, severe cardiac conduction system problem, end-stage HF
        • Treatment: CPR, epinephrine (no shock needed)
      • Pulseless Electrical Activity (PEA): organized electrical activity on ECG but no mechanical heart activity, patient has no pulse, high mortality rate
        • Causes: hypovolemia, hypoxia, metabolic acidosis, hyperkalemia, hypokalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, thrombosis, tension pneumothorax, and trauma
        • Treatment: CPR, epinephrine, intubation

    Infective Endocarditis

    • Disease of the endocardium and heart valves, associated with poor prognosis and decreased life expectancy
    • Increasing cases linked to IV drug use
      • Subacute form: affects those with preexisting valve disease
      • Acute form: affects those with healthy valves
      • Commonly caused by Staphylococcus aureus and Streptococcus viridans
    • Risk Factors: rheumatic heart disease, congenital heart disease, Marfan's syndrome
      • Occurs in three stages: bacteremia, adhesion, vegetation
        • Vegetation: masses of bacteria, fibrin, and platelets that form on the heart valves or the endocardium
        • Vegetation can break off and leak into the bloodstream (embolization)
          • Left-sided vegetation: brain, kidneys, spleen, extremities
          • Right-sided vegetation: lungs (PE)
    • Clinical Manifestations
      • Chills
      • Roth spots (on the eye)
      • Malaise
      • Fatigue
      • Anorexia
      • Splinter hemorrhages (under fingernails)
      • Petechiae
      • Osler’s nodes (tender purple/pink nodules on fingers and/or toes)
      • Janeway’s lesions (painless, small flat hemorrhages on the palms or soles)
      • Fever
    • Diagnostic Studies
      • 2 to 3 blood cultures in one hour from different sites
      • ESR, C-reactive protein, CBC
      • Echo to show vegetation
    • Diagnosis: 2 major criteria and 1 minor, 1 major and 3 minor, or 5 minor
      • Major criteria: positive blood culture, new valvular vegetation
      • Minor criteria: predisposing heart condition (rheumatic fever) or IV drug use
    • Treatment: IV antibiotics for 4-8 weeks (vancomycin or penicillin), 2 sets of blood cultures done every 24-48 hours, follow-up echo and inflammatory markers, valve replacement if needed
    • Patient Teaching: avoid contact with people with infections, avoid stress and fatigue, rest periods, regular dental visits, complete antibiotic regimen, drug rehab, monitor body temperature, s/s of complications, nature of disease, how to prevent reinfection, good nutrition, prompt treatment of common infections, assess home setting and coping strategies, compression stockings, deep breathing and coughing

    Pericarditis

    • Inflammation of the pericardial sac, often with fluid accumulation

    • Most often idiopathic (unknown cause)

      • Acute pericarditis: rapid development, inflammation and fluid leakage (pericardial effusion)
      • Subacute pericarditis: weeks to months after an event
      • Chronic pericarditis: lasts longer than 6 months

    • Clinical Manifestations

      • Progressive, severe, sharp chest pain, worse with deep respiration and laying flat, relieved by sitting up and leaning forward
      • May radiate to the neck, arms, or left shoulder similar to angina
      • Hallmark finding: pericardial friction rub (scratching, grating, high-pitched sound heard at the lower left sternal border with the patient leaning forward)

    • Complications

      • Pericardial effusion: build-up of fluid in the pericardium
        • Pulmonary tissue compression: cough, dyspnea, tachypnea
        • Phrenic nerve compression: hiccups
        • Laryngeal nerve compression: hoarseness
      • Cardiac tamponade: pericardial effusion volume increases and compresses the heart, speed of fluid accumulation affects severity, can occur acutely (ruptured heart, trauma) or subacutely (renal failure, cancer)

    • Diagnostic Studies

      • ECG: widened ST segment
      • Echo: presence of pericardial effusion and cardiac tamponade
      • Doppler imaging and color mode: constrictive pericarditis
      • CT scan, MRI: visualize the pericardium and pericardial space
      • Laboratory: leukocytosis, increased CRP with ESR, troponin levels may be increased

    • Treatment

      • Antibiotics: bacterial pericarditis
      • NSAIDs: control pain and inflammation
      • Steroids: pericarditis from lupus, previous steroid use, non-response to NSAIDs
      • Pericardiocentesis: pericardial effusion with acute cardiac tamponade, purulent pericarditis, suspected cancer### Myocarditis

    • Focal or diffuse inflammation of the myocardium

    • Causes: viruses, bacteria, fungi, radiation therapy, pharmaceuticals and chemicals

    • As the infection progresses, an autoimmune reaction occurs, causing further destruction of myocytes.

    • Myocarditis leads to heart dysfunction.

    • Can result in dilated cardiomyopathy.

    • Clinical manifestations:

      • May begin without symptoms
      • Progressive heart failure
      • Dysrhythmias
      • Sudden cardiac death
      • Fever, fatigue, malaise, myalgias
      • Pharyngitis
      • Dyspnea
      • Lymphadenopathy
      • Nausea/vomiting
      • Early cardiac signs appear 7-10 days after viral infection, often accompanied by pericarditis: chest pain with a pericardial friction rub and effusion.
      • Late cardiac signs indicate heart failure development: S3 heart sound, crackles, jugular venous distention, syncope, peripheral edema, and angina.
      • ECG changes are often nonspecific but may reflect associated pericardial involvement: ST segment changes.
      • Endomyocardial biopsy may be done to confirm myocarditis.

    • Treatment:

      • Management of symptoms
      • ACE inhibitors and Beta blockers used if the heart is enlarged or to treat heart failure.
      • Diuretics reduce fluid volume and preload.
      • If the patient is not hypotensive, intravenous drugs such as nitroprusside may be used to reduce afterload and improve cardiac output by decreasing resistance.
      • Digoxin improves heart contractility and reduces heart rate. Used cautiously in patients with myocarditis due to increased sensitivity to adverse effects such as dysrhythmias and potential toxicity.
      • Anticoagulants reduce the risk of clot formation from blood stasis in patients with low ejection fraction.
      • Myocarditis predisposes to digoxin toxicity, use cautiously.

    Rheumatic Fever & Rheumatic Heart Disease

    • An acute inflammatory disease that can involve all of the heart layers.
    • Chronic scarring and deformity of the heart valves resulting from Rheumatic fever.
    • Occurs as a complication 2-3 weeks after a group A streptococcal pharyngitis.
    • An abnormal immune response to strep.
    • Affects the heart, skin, joints, and central nervous system.
    • Rheumatic heart disease, caused by Rheumatic fever, mainly affects children and young adults.
    • About 50% of all Rheumatic fever episodes are rheumatic pancarditis: involving all layers of the heart (endocardium, myocardium, and pericardium).
    • Rheumatic infective endocarditis is mainly found in the valves in vegetation forms.
    • Lesions initially create a thickening of the valve leaflets.
    • Valve leaflets may become calcified, resulting in stenosis.
    • Some of the valve leaflets may not close properly, resulting in regurgitation.
    • Mitral and aortic valves are most often affected.
    • Major criteria such as arthritis or polyarthritis are required for diagnosis, minor criteria of fever, monoarthralgia, or evidence of laboratory findings of A streptococci.

    Rheumatic Fever Complications

    • Chronic rheumatic carditis results from changes in valve structure months to years after an episode of Rheumatic fever.
    • Rheumatic infective endocarditis can result in fibrous tissue growth in valve leaflets and chordae tendineae with scarring and contractures.
    • The mitral valve is most often involved.
    • The aortic and tricuspid valves may be affected.

    Rheumatic Fever Diagnostic Studies

    • No single diagnostic test exists for Rheumatic fever.
    • An echocardiogram may show valvular insufficiency and pericardial fluid or thickening.
    • A chest x-ray may show an enlarged heart.
    • The most consistent ECG change is a prolonged PR interval from delayed AV conduction.

    Rheumatic Fever Care/Treatment

    • Antibiotic therapy does not change the course of the acute disease or the development of carditis.
    • Eliminates residual group A streptococci in the tonsils and pharynx and prevents spread through close contact.
    • Salicylates, NSAIDs, and corticosteroids are the 3 inflammatory agents most widely used to control fever and joint manifestations.

    Rheumatic Fever Interprofessional Care

    • Diagnostic Assessment:
      • History and physical assessment
      • Laboratory studies
      • Chest x-ray
      • Echocardiogram
      • ECG
    • Management:
      • Bed rest or limited activity
      • Drug therapy:
        • Antibiotics
        • NSAIDs
        • Salicylates
        • Corticosteroids

    Rheumatic Fever Nursing Management

    • Inspect the skin for subcutaneous nodules and erythema marginatum.
    • Palpate for subcutaneous nodules over all bony surfaces and along extensor tendons of the hands and feet.
    • Erythema marginatum can occur on the trunk and inner aspects of the upper arm and thigh.
    • Assess for these bright pink maculae in good light because the rash is hard to see, especially in patients with dark skin.
    • Early detection and immediate treatment of group A streptococcal pharyngitis can prevent Rheumatic fever.
    • Treatment with an initial dose of intramuscular Benzathine Penicillin G is the most widely used antibiotic to treat.
    • If the patient is allergic to penicillin, a narrow-spectrum cephalosporin (e.g., cephalexin), clindamycin (Cleocin), or azithromycin (Zithromax)
    • Therapy requires strict adherence to the full course of treatment.

    Rheumatic Fever Acute Care

    • Give antibiotics as prescribed to treat the streptococcal infection.
    • Teach the patient that completing the full course of antibiotics is vital to successful treatment.
    • Promote optimal rest.
    • Give salicylates, NSAIDs, and corticosteroids as prescribed for joint pain.
    • Implement measures to manage fever.

    Rheumatic Fever Ambulatory Care

    • The aim of secondary prevention is to stop a recurrence of Rheumatic fever.
    • Prior history makes the patient more susceptible to a second attack after a streptococcal infection.
    • The best prevention is treatment with prophylactic antibiotics.
    • Patients with Rheumatic fever without carditis need prophylaxis until age 20 and for a minimum of 5 years.
    • Patients with rheumatic carditis and residual heart disease (e.g., persistent valve disease) need lifelong prophylaxis.
    • Tell the patient to seek medical care for symptoms, such as excessive fatigue, dizziness, palpitations, unexplained weight gain, or exertional dyspnea.

    ECG Interpretation

    • EKG is a graphic record of the heart’s electrical activity, or conduction of impulses.
    • P wave represents depolarization of the atria, a problem with the P wave indicates swelling of the atria.
    • QRS complex represents depolarization of the ventricles, and atrial repolarization. If the QRS wave is prolonged, this indicates that ventricular conduction delay is occurring.
    • T wave reflects repolarization of the ventricles. Inverted T wave often seen after myocardial damage.

    ECG Wave Intervals

    • P wave: 0.06-0.12 (variation indicates problem in atria)
    • PR interval: 0.12-0.20 (variation indicates problem in AV node, bundle of His, or atria)
    • QRS variation: MI may develop if wide and deep Q wave.
    • QRS interval (beginning to end of QRS complex): represents time taken for depolarization (contraction) of both ventricles (systole) (0.20 seconds), everything else normal. Can be normal for some patients or caused by MI or calcium channel blockers, beta blockers, or digoxin.

    2nd Degree Heart Block

    • The patient may or may not have symptoms, continue to monitor either way to be sure it doesn't progress to a worse block or abnormal rhythm.

    • 2nd degree, type 1:*

    • Electrical signal going from the atria to the ventricles is slowing down until it doesn’t stimulate the ventricles to contract.

    • QRS complex will be missing here and there, from gradually widened PR interval.

    • When QRS is present, it will be normal.

    • Can be caused by MI, calcium channel blockers, beta blockers, digoxin.

    • Treatment: assess for symptoms, if none present continue to monitor. Meds that slow the AV system may be stopped. Be sure patient is not having MI. If symptoms are present, activate rapid response, may need atropine or temporary pacing.

    • 2nd degree, type 2:*

    • Ventricular rate will be slower, due to missed QRS complexes.

    • Can be caused by MI, CAD, or meds such as calcium channel blockers, beta blockers, digoxin that show the AV conduction system.

    • Ventricular rate is lower than previous type, more likely to have symptoms since lower cardiac output.

    • Treatment: temporary pacing, permanent pacemaker.

    3rd Degree Heart Block

    • Electrical signal from the atria doesn’t make it to the ventricles.
    • Regular P waves, making the atrial rhythm regular and its rate normal.
    • QRS complexes will be regular, making the ventricular rhythm regular.
    • Fewer QRS complexes than P waves.
    • Causes: congenital, heart disease, MI, digoxin toxicity, structural damage, heart valve problem.
    • Symptoms will likely be present: low cardiac output, low blood pressure, weak pulse, mental status changes, pale clammy skin.
    • Treatment: activate rapid response, possibly give atropine to help the heart pump effectively.

    Lead Placement

    • Count the number of QRS complexes and multiply by 10 for beats per minute (BPM)
    • Atrial rate = number of P waves
    • Ventricular rate = total QRS x 10

    Rhythm

    • Regular pattern - interval between QRS waves is the same, may vary by less than 0.06 seconds or 1.5 boxes
    • Irregular pattern - interval between QRS waves is not the same, varies by longer than 0.06 seconds or 1.5 boxes

    P Wave

    • Produced when left and right atria depolarize and is the first deviation from the isoelectric line
    • Normal duration is 0.06-0.12 seconds

    PR Interval

    • Measured from the beginning of the P wave to the beginning of the QRS
    • Normal interval is 0.12-0.20 seconds or 3-5 small squares

    QRS Complex

    • Q wave: First negative deflection after the P wave, short and narrow, not present in several leads.
    • R wave: First positive deflection in QRS.
    • S wave: First negative deflection after the R wave.
    • Normal duration < 0.03 seconds
    • QRS interval: Measured from the beginning of the QRS complex to the end, represents ventricular depolarization (contraction), normal duration < 0.12 seconds
    • QT interval: Represents the time taken for ventricular depolarization and repolarization, normal duration 0.34-0.43 seconds

    T wave

    • Represents ventricular repolarization
    • Normal duration 0.16 seconds

    U wave

    • Usually not visible, but if present appears smaller than the T wave, rounded, and upright

    Artifact

    • Non-cardiac waves on EKG strips, often resulting from patient movement, loose electrodes, or faulty EKG equipment

    Normal Sinus Rhythm

    • Normal/regular rhythm of the heart set by the SA node

    Sinus Bradycardia

    • Regular but unusually slow heartbeat (less than 60 BPM)
    • Causes: hypoglycemia, hypothermia, hypothyroidism, medications, MI, sick sinus syndrome
    • S/S: Syncope, dizziness, SOB, cool, clammy skin
    • Treatment: If due to medication adjust dosage, IV atropine for symptomatic patients, may need a permanent pacemaker

    Sinus Tachycardia

    • Fast heartbeat related to rapid firing of the SA node
    • S/S: Dizziness, SOB, lightheadedness, palpitations, chest pain, syncope
    • Treatment: Vagal maneuvers first, then IV beta blockers, adenosine, or calcium channel blockers

    Atrial Fibrillation

    • Uncoordinated electrical signal inside the atria causing quivering, the ventricles don't receive a regular beat, heartbeat becomes uncontrolled and irregular
    • Decreased cardiac output (CO) due to ineffective atrial contractions
    • Thrombi may form in the atria due to blood stasis, which can cause a stroke
    • S/S: Palpitations, irregular pulse, dizziness, fainting, fatigue, confusion, trouble breathing, tightness in chest
    • Treatment: Rate control to slow ventricular rate to 80-100 BPM, antiarrhythmic medications, anticoagulation, cardioversion

    Atrial Flutter

    • Coordinated rapid beating of the atria, identified by regular sawtooth-shaped flutter waves
    • S/S: Palpitations, rapid heartbeat, dizziness

    Ventricular Tachycardia (VT)

    • Life-threatening dysrhythmia
    • Different forms exist, depending on QRS configuration
    • Monomorphic VT - QRS complexes are the same in shape, size, and direction
    • Polymorphic VT - QRS complexes gradually change shape, size, and direction over series of beats
    • Torsades de Pointes (TdP) - polymorphic VT associated with prolonged QT interval
    • Causes: Underlying heart disease, MI, electrolyte imbalances, medication-induced, digitalis toxicity
    • S/S: Angina, syncope, dizziness, palpitations, SOB, absent or rapid pulse, loss of consciousness
    • Treatment: CPR if no pulse, cardioversion and drug therapy (amiodarone, lidocaine, antiarrhythmics), ablation, long term ICD

    Ventricular Fibrillation (VF)

    • Severe derangement of cardiac rhythm, characterized on ECG by irregular waveforms of varying shapes and amplitude
    • The ventricle is quivering with no effective contraction, resulting in no CO
    • Lethal dysrhythmia
    • Causes: AMI, untreated VT, electrolyte imbalance, hypothermia, myocardial ischemia, trauma
    • S/S: Loss of consciousness, absent pulse
    • Treatment: CPR with immediate defibrillation

    Asystole

    • Absence of ventricular electrical activity
    • Lethal dysrhythmia
    • S/S: Unresponsive, pulseless, and apneic
    • Treatment: CPR and advanced cardiac life support (ACLS) interventions

    ### Lead Placement

    • Heart Rate
    • Count the number of QRS complexes and multiply by 10 for the heart's beats per minute (BPM).
    • Atrial Rate: Count the number of P waves
    • Ventricular Rate: Count the number of QRS complexes and multiply by 10.
    • Rhythm
      • Regular: The space between QRS complexes is consistent, varying by less than 0.06 seconds or 1.5 boxes on the ECG strip.
      • Irregular: The space between QRS complexes is inconsistent, varying by more than 0.06 seconds, or 1.5 boxes.
    • P Wave
      • Depolarization of the left and right atria.
      • The first deviation from the isoelectric line.
      • Smooth, round, and upright.
      • Normal duration is 0.06 to 0.12 seconds.
    • PR Interval
      • Measured from the beginning of the P wave to the beginning of the QRS complex, representing the time from atrial contraction to ventricular contraction.
      • Normal range: 0.12 - 0.20 seconds or 3 to 5 small squares.
    • QRS Complex
      • Q Wave: First negative deflection after P wave, short, narrow, and not present in several leads.
      • R Wave: First positive deflection in the QRS complex.
      • S Wave: Negative deflection following the R wave.
      • QRS Interval: Beginning to end of the QRS complex, representing the time for ventricular depolarization (contraction).
        • Normal duration: < 0.12 seconds.
      • QT Interval: Beginning of QRS to end of T wave, representing the time for ventricular depolarization and repolarization.
        • Normal duration: 0.34 - 0.43 seconds.
    • T Wave
      • Represents the time for ventricular repolarization.
      • First positive deflection following the QRS complex.
      • Normal duration: 0.16 seconds.
    • U Wave
      • Often not visible, but follows the T wave if present.
      • Smaller than the T wave, rounded, positive deflection after QRS complex.
      • May suggest hypokalemia.
    • Artifact
      • Interfering ECG waves from outside the heart.
      • Causes include patient movement, loose electrodes, or faulty ECG equipment.
      • Must differentiate from actual cardiac waves.

    Normal Sinus Rhythm (NSR)

    • Normal and regular rhythm of the heart set by the sinoatrial (SA) node (natural pacemaker).

    Sinus Bradycardia

    • Regular but slower heart rhythm (<60 bpm).
    • May be normal for some individuals.
    • Potential causes: hypoglycemia, hypothermia, hypothyroidism, medications, MI, sick sinus syndrome.
    • Symptoms: Dizziness, lightheadedness, shortness of breath, syncope, cool and clammy skin.
    • Treatment: Address underlying causes, medication adjustment, atropine (anticholinergic), transcutaneous pacing, or dopamine, atropine, or epinephrine infusion.

    Sinus Tachycardia

    • Increased heart rate resulting from rapid firing of the SA node.
    • May be normal for some individuals.
    • Potential causes: exercise, stress, anxiety, fever, caffeine, nicotine, stimulants.
    • Symptoms: Palpitations, dizziness, shortness of breath, chest pain, fatigue.
    • Treatment: Addressing underlying causes, rest, relaxation techniques, beta-blockers, or calcium channel blockers.

    Heart Failure

    • A condition where the heart cannot pump enough blood to meet the needs of the body.
    • Symptoms: Shortness of breath, fatigue, swelling in the legs and feet, coughing, weight gain.
    • Treatment: Medications, lifestyle changes, medical devices, surgery.

    Endocarditis

    • Infection of the inner lining of the heart chambers and heart valves.
    • Most commonly caused by bacteria.
    • Symptoms: Fever, fatigue, shortness of breath, heart murmur, swelling in the legs or feet, pain in the joints, skin changes.
    • Treatment: Antibiotics, surgery.

    Pericarditis

    • Inflammation of the pericardium (sac surrounding the heart).
    • Often associated with fluid accumulation.
    • Causes: Infection, autoimmune diseases, heart surgery, cancer.
    • Symptoms: Chest pain, fever, shortness of breath.
    • Treatment: NSAIDs, sometimes steroids, pericardiocentesis (fluid removal).

    Myocarditis

    • Inflammation of the heart muscle (myocardium).
    • Can be caused by viruses, bacteria, fungi, autoimmune diseases, and other factors.
    • Symptoms: Chest pain, shortness of breath, fatigue, fever, heart palpitations, arrhythmias, sudden cardiac death.
    • Treatment: Supportive care, medications, heart transplant if necessary.

    Rheumatic Fever

    • Inflammatory disease that can affect the heart, joints, skin, and brain.
    • Occurs after an infection with Group A Streptococcus (GAS).
    • Symptoms: Fever, joint pain, rash, heart murmur.
    • Treatment: Antibiotics, aspirin or other NSAIDs, corticosteroids.

    Important Points

    • ECG: Electrocardiogram, a graphic record of the heart's electrical activity.
    • P Wave: Wave representing atrial depolarization.
    • QRS Complex: Complex representing ventricular depolarization (contraction).
    • QT Interval: Interval representing the time for ventricular depolarization and repolarization.
    • T Wave: Wave representing ventricular repolarization.
    • U Wave: Wave sometimes present, following the T wave, may indicate hypokalemia.
    • Arrhythmia: Abnormality in the heart's rhythm.
    • Bradycardia: Slow heart rate.
    • Tachycardia: Fast heart rate.
    • Myocardial Infarction (MI): Heart attack.
    • Sick Sinus Syndrome (SSS): Abnormality of the SA node, leading to irregular heart rate.
    • Valve Disease: Dysfunction of heart valves, affecting blood flow.

    Ventricular Tachycardia

    • Rate: 40-100
    • Rhythm: regular
    • No P wave
    • QRS wide and distorted
    • Life-threatening dysrhythmia due to decreased cardiac output and potential for ventricular fibrillation.
    • Occurs when an ectopic focus fires repeatedly and the ventricle takes control as the pacemaker.
    • Types include Monomorphic and Polymorphic VT
      • Monomorphic VT has QRS complexes that are the same in shape, size, and direction.
      • Polymorphic VT occurs when the QRS complexes gradually change back and forth from one shape, size, and direction to another over a series of beats.
    • Torsades de pointes is a polymorphic VT associated with a prolonged QT interval.
    • Causes include underlying heart disease, Myocardial infarction (MI), medications that prolong the QT interval, electrolyte imbalance, digitalis toxicity, and congestive heart failure (CHF).
    • Symptoms include angina, syncope, lightheadedness/dizziness, palpitations, shortness of breath, absent or rapid pulse, loss of consciousness, and hypotension.
    • Treatment includes CPR if no pulse, cardioversion if a pulse and the patient is unstable, and drug therapy (Amiodarone, lidocaine, antiarrhythmics, ablation, long-term implantable cardioverter-defibrillator (ICD)).

    Ventricular Fibrillation

    • Rate: 150-250
    • Rhythm: regular or irregular
    • No P wave
    • QRS wide and distorted
    • Severe derangement of the heart rhythm characterized by irregular waveforms of varying shapes and amplitude on ECG.
    • Represents the firing of multiple ectopic foci in the ventricle.
    • The ventricle quivers with no effective contraction, resulting in no cardiac output.
    • Lethal dysrhythmia requiring immediate defibrillation.
    • Causes include AMI, untreated VT, electrolyte imbalance, hypothermia, myocardial ischemia, drug toxicity, and trauma.
    • Symptoms include loss of consciousness and absent pulse.
    • Treatment includes CPR with immediate defibrillation.

    Asystole

    • Rate: not measurable
    • Rhythm: irregular
    • No P wave, QRS not measurable
    • Absence of ventricular electrical activity.
    • Lethal dysrhythmia requiring immediate treatment.
    • Patients may be unresponsive, pulseless, and apneic.
    • May be caused by advanced heart disease, severe cardiac conduction system problems, or end-stage heart failure.
    • Treatment includes epinephrine, as defibrillation is not needed.

    Pulseless Electrical Activity (PEA)

    • Organized electrical activity is seen on the ECG, but there is no mechanical heart activity, and the patient has no pulse.
    • The most common dysrhythmia seen after defibrillation.
    • Causes include hypovolemia, hypoxia, metabolic acidosis, hyperkalemia, hypokalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade, thrombosis, tension pneumothorax, and trauma.
    • Poor prognosis unless the underlying cause is quickly identified and treated.
    • Treatment includes CPR, drug therapy (epinephrine), intubation, and correcting the underlying cause.

    Infective Endocarditis

    • Disease of the endocardium, the innermost layer of the heart, and the heart valves.
    • Associated with a poor prognosis and a decreased life expectancy.
    • Increase in cases largely linked to increased intravenous (IV) drug use.
    • Types: subacute (preexisting valve disease) and acute (healthy valves).
    • Most commonly caused by Staphylococcus aureus and Streptococcus viridans.

    Risk Factors for Infective Endocarditis

    • Previous history of valve or heart issues such as rheumatic heart disease, congenital heart disease, or Marfan’s syndrome.
    • Open wounds, abscesses, procedures, infected needles, prosthetic valves, and prior history.

    Infective Endocarditis Stages

    • Bacteremia, adhesion, vegetation.
    • Vegetation is masses of bacteria, fibrin, and platelets that form on the heart valves or the endocardium in patients with endocarditis. Parts of the mass can break off and leak into the bloodstream (embolization).
    • Left-sided vegetation can move to the brain, kidneys, spleen, and extremities.
    • Right-sided vegetation can move to the lungs (pulmonary embolism/PE).
    • Heart damage can lead to heart failure (HF), dysrhythmias, kidney problems, night sweats, and shortness of breath.

    Pericarditis

    • Inflammation of the pericardium.
    • May be caused by bacterial infection, viruses, autoimmune diseases, trauma, or medications.
    • Can lead to pericardial effusion (fluid buildup around the heart).
    • If pericardial effusion is significant, it can lead to cardiac tamponade (compression of the heart by fluid).
    • Symptoms can include chest pain, dyspnea, fever, and tachycardia.
    • Treatment may include antibiotics, NSAIDs, corticosteroids, and pericardiocentesis (removal of fluid from the pericardium).

    Myocarditis

    • Focal or diffuse inflammation of the myocardium (heart muscle).
    • Causes include viruses, bacteria, fungi, radiation therapy, and pharmacologic/chemical factors.
    • As the infection progresses, an autoimmune reaction occurs, causing further destruction of myocytes.
    • Leads to heart dysfunction.
    • Dilated cardiomyopathy can occur.

    Clinical Manifestations of Myocarditis

    • May begin without any symptoms.
    • Progressive heart failure (HF).
    • Dysrhythmias.
    • Sudden cardiac death
    • Fever, fatigue, malaise, myalgias.
    • Pharyngitis.
    • Dyspnea.
    • Lymphadenopathy.
    • Nausea/vomiting.
    • Early cardiac signs appear 7-10 days after viral infection due to accompanying pericarditis. Signs include chest pain with a pericardial friction rub and effusion.
    • Late cardiac signs include developing HF with an S3 sound, crackles, JVD, syncope, peripheral edema, and angina.
    • ECG changes are often nonspecific.

    Treatment of Myocarditis

    • Consists of managing symptoms.
    • ACE inhibitors and Beta-blockers are used if the heart is enlarged or to treat HF.
    • Diuretics reduce fluid volume and preload.
    • If the patient is not hypotensive, IV drugs such as nitroprusside may be used to reduce afterload and improve cardiac output by decreasing resistance.
    • Digoxin improves heart contractility and reduces heart rate. Used cautiously in patients with myocarditis because of increased sensitivity to the adverse effects such as dysrhythmias and the potential toxicity.
    • Anticoagulants reduce the risk of clot formation from blood stasis in patients with low ejection fraction.
    • Myocarditis predisposes to digoxin toxicity, use cautiously.

    Rheumatic Fever and Rheumatic Heart Disease

    • Rheumatic fever is an acute inflammatory disease that can involve all of the heart layers.
    • Rheumatic heart disease is chronic scarring and deformity of the heart valves resulting from rheumatic fever.
    • Occurs 2-3 weeks after a group A streptococcal pharyngitis.
    • Abnormal immune response to strep.
    • Affects the heart, skin, joints, and central nervous system (CNS).
    • Rheumatic heart disease mainly affects children and young adults.
    • Approximately 50% of all rheumatic fever (RF) episodes involve all layers of the heart (rheumatic pancarditis).
    • Rheumatic infective endocarditis (IE) is mainly found in the valves in vegetation forms. The lesions initially create thickening of the valve leaflets.
    • Valve leaflets may become calcified, resulting in stenosis.
    • Valve leaflets may not close properly, resulting in regurgitation.
    • Mitral and aortic valves are most commonly affected.
    • Major criteria (such as arthritis or polyarthritis) are needed for diagnosis. Minor criteria include fever, monoarthralgia, or evidence of laboratory findings of group A streptococci.

    Complications of Rheumatic Heart Disease

    • Chronic rheumatic carditis results from changes in valve structure months to years after an episode of RF.
    • Rheumatic IE can lead to fibrous tissue growth in valve leaflets and chordae tendineae with scarring and contractures.
    • Mitral valve is most often involved.
    • The aortic and tricuspid valves may be affected.

    Diagnostic Studies for Rheumatic Fever

    • No single diagnostic test exists for RF.
    • Echocardiogram may show valvular insufficiency and pericardial fluid or thickening.
    • Chest X-ray may show an enlarged heart.
    • The most consistent ECG change is a prolonged PR interval from delayed AV conduction.

    Care and Treatment of Rheumatic Fever

    • Antibiotic therapy does not change the course of the acute disease or the development of carditis.
    • Antibiotics eliminate residual group A streptococci in the tonsils and pharynx and prevent the spread of organisms through close contact.
    • Salicylates (aspirin), NSAIDs, and corticosteroids are the 3 inflammatory agents most widely used to control fever and joint manifestations.

    Electrocardiogram (ECG) Basics

    • QRS complex represents depolarization of the ventricles, and atrial repolarization.
    • Prolonged QRS wave indicates ventricular conduction delay is occurring.
    • T wave reflects repolarization of the ventricles.
    • Inverted T wave often seen after myocardial damage.
    • P wave: 0.06-0.12 sec (variation indicates a problem in the atria).
    • PR interval: 0.12-0.20 sec (variation indicates a problem in the AV node, bundle of His, or atria).
    • QRS variation: MI may develop if a wide and deep Q wave is present.
    • QRS interval (beginning to end of QRS), represents time taken for depolarization (contraction) of both ventricles (systole) (0.20 seconds), everything else is normal.

    Heart Block

    • Can be normal for some patients or caused by MI, or medications such as calcium channel blockers, beta blockers, or digoxin.
    • The patient may or may not have symptoms, continue to monitor either way to be sure it doesn't progress to a worse block or abnormal rhythm.

    1st Degree Heart Block

    • Electrical signal going from the atria to the ventricles is slowing down but still reaching the ventricles.
    • The PR interval will be prolonged.
    • Causes include MI, calcium channel blockers, beta blockers, and digoxin.
    • Treatment: assess for symptoms, if none present, continue to monitor. Medications that slow the AV system may be stopped.

    2nd Degree Heart Block, Type 1 (Mobitz I)

    • Electrical signal going from the atria to the ventricles is slowing down until it doesn’t stimulate the ventricles to contract.
    • QRS complex will be missing here and there, forming a gradually widened PR interval.
    • When a QRS is present, it will be normal.
    • Causes include MI, calcium channel blockers, beta blockers, and digoxin.
    • Treatment: assess for symptoms. If none present, continue to monitor. Medications that slow the AV system may be stopped.
    • If symptoms are present, activate the rapid response team. The patient may require atropine or temporary pacing.

    2nd Degree Heart Block, Type 2 (Mobitz II)

    • Ventricular rate will be slower due to missed QRS complexes.
    • Causes include MI, CAD, or medications such as calcium channel blockers, beta blockers, and digoxin.
    • Ventricular rate is lower than in Type 1, making symptoms more likely due to lower cardiac output.
    • Treatment: temporary pacing, permanent pacemaker.

    3rd Degree Heart Block (Complete Heart Block)

    • Electrical signal originating from the atria doesn’t make it to the ventricles.
    • Regular P waves make the atrial rhythm regular, and its rate normal.
    • QRS complexes will be regular, making the ventricular rhythm regular.
    • Fewer QRS complexes than P waves.
    • Causes include congenital heart disease, MI, digoxin toxicity, structural damage, and heart valve problems.
    • Symptoms are likely: low cardiac output, low blood pressure, weak pulse, mental status changes, pale clammy skin.
    • Treatment: temporary pacing, permanent pacemaker.

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