Cardiovascular

Endocarditis

• Typical symptoms include fever, chills, malaise and a new heart murmur.
• Subungual hemorrhages (splinter hemorrhages on the nail bed) can occur.
• Petechiae may appear on the palate.
• Osler nodes, which are painful, violet-colored nodes, can develop on the fingers or feet.
• Janeway lesions, nontender red spots, may appear on the palms and soles.
• Roth spots or retinal hemorrhages can be detected during a fundoscopic exam.
• Referral to the emergency department is advised.

Endocarditis Prophylaxis

• Antibiotic prophylaxis is recommended for high-risk conditions such as a previous history of bacterial endocarditis, prosthetic heart valve, congenital heart disease, or cardiac transplant with abnormal valvular function.
• Invasive procedures that may require antibiotic prophylaxis include dental procedures that traumatize the oral mucosa, gingiva, or the periapical area of the teeth, invasive procedures on the respiratory tract, and if an existing infection is present before cystoscopy.
• Antibiotic prophylaxis is no longer given for mitral valve prolapse (MVP) or GI/GU procedures.

Standard Antibiotic Regimen for Endocarditis Prophylaxis

• Adults: Amoxicillin 2 g PO x 1 dose one hour before the procedure.
• Children: Amoxicillin 50 mg/kg PO x 1 dose one hour before the procedure.
• For penicillin allergies: clindamycin, azithromycin, clarithromycin (Biaxin) or cephalexin (Keflex).

Deep Vein Thrombosis (DVT)

• Acute blood clot formation inside the deep lower extremity or pelvic veins.

Risk Factors for Deep Vein Thrombosis

• Stasis from prolonged travel, car rides, immobilization, or bed rest.
• Trauma to vessel walls causing vascular injury or venous incompetence.
• Congestive heart failure in the presence of chronic inflammatory state, lifestyle.
• Increased coagulation related to inherited disorders like Factor C deficiency or Leiden.
• External factors such as oral contraceptive use, pregnancy, long bone fractures, trauma, recent surgery, or malignancy.
• Obesity, orthopedic surgery, immobility, trauma, pregnancy, oral contraceptive use, malignancy, coagulation deficits, venous catheters, high altitude elevations, polycythemia vera, rheumatoid disease, and lupus are also risk factors.

Prevention of Deep Vein Thrombosis

• Limit periods of immobility.
• Prophylactic anticoagulation for associated risk factors is recommended.
• Avoidance of estrogen-containing oral contraceptives or low use low dose should be considered.
• Postsurgical mechanical leg compression can be beneficial.

DVT Presentation and Assessment

• Gradual onset of swelling on the lower leg following prolonged sitting or travel for more than 3 hours.
• Complaint of a painful and swollen lower extremity that is red and warm.
• Positive Homan's sign, indicated by lower leg pain on dorsiflexion of the foot.
• Ultrasound of the extremity is crucial.
• Hospital admission for heparin IV then warfarin (Coumadin) PO is usually required with monitoring of CBC, platelets, PT/PTT/INR, D-dimer, chest x-ray, and EKG.
• Treatment for a single-episode DVT typically lasts for 3 months; longer if recurrent.

Pulmonary Embolus and DVT

• Pulmonary Embolus is the same manifestation as DVT with the same treatment, requiring emergent referral. The mortality rate exceeds 20%.
• Classic symptoms include abrupt onset of chest pain, sudden onset of dyspnea, dizziness, syncope, and cough.
• Other signs include hemoptysis, tachycardia, tachypnea, accentuated S2, pleural friction rub, rales, and pleuritic chest pain.
• Pulmonary CT is highly sensitive, and ECG may show right heart strain.

Coumadin

• Maintenance therapy is usually started in the hospital, overlapping with heparin or Lovenox initially.
• Adjust dose to maintain an INR of 2 to 3.
• Coumadin is teratogenic and should not be used in pregnant patients but is safe when breastfeeding.
• Vitamin K is used to reverse Coumadin's effects.

Superficial Thrombophlebitis

• Acute inflammation and clot formation of a superficial vein due to local trauma.
• Risk factors include intravenous drug use, secondary bacterial infection, IV therapy, and trauma.
• Assessment findings consist of an isolated indurated cord-like vein, warmth, redness, and tenderness along the vein, but no significant swelling of the extremity.
• Treatment: bed rest with elevated extremity, NSAIDs, antibiotic if secondary to bacterial infection (think S. aureus).
• Refer to ED for hospitalization if sepsis is suspected.

Syncope

• Temporary loss of consciousness, accompanied by fainting and loss of muscle tone.

Important Details for Syncope

• A detailed history is needed to assess symptoms before and after the event.
• Position changes, prolonged standing, exposure to a warm environment, and the last time eating can all be factors.
• Lightheadedness, diaphoresis, nausea, and visual changes before the event.
• Length of loss of consciousness, seizure activity, height of fall, and any injuries.
• Confusion or drowsiness after the event.
• Associated cardiac or neuro symptoms: chest pain, diaphoresis, palpitations, headache, diplopia, aphasia, unilateral motor weakness, paresthesia.
• Incontinence of bladder or bowel should be noted.
• Medications like vasodilators, beta-blockers, diuretics, and anticholinergics can be factors.
• Recent drug or medication use should be reviewed.
• Past medical history: cardiac, neurologic, seizures, and family history.
• Interview family member or witness if possible.

Physical Exam for Syncope

• Vital signs should be taken, including orthostatic hypotension.
• Cardiovascular assessment: arrhythmia, murmurs, displaced PMI, bruits, and differences in BP between arms, including orthostatic pressures.
• Neurologic exam for focal deficits.

Syncope and Presyncope Etiology

• Cardiac-related syncope has a high mortality rate.
• Most commonly, syncope is vasovagal or cardioneurogenic.
• A common cardiac cause is arrhythmia: sick-sinus syndrome, supraventricular tachycardia, ventricular tachycardia, heart blocks, and bradycardia.

Sick-Sinus Syndrome

• Inability of the heart's natural pacemaker (sinus node) to create a heart rate that's appropriate for the body's needs, causing irregular heart rhythms (arrhythmias).
• This syndrome has multiple manifestations on the electrocardiogram, including sinus bradycardia, sinus arrest, sinoatrial block, and alternating patterns of bradycardia and tachycardia (bradycardia-tachycardia syndrome).

Tachycardia

• A very fast heart rate of more than 100 beats per minute. If in the ventricles, it’s ventricular tachycardia. If it begins above the ventricles, it's supraventricular tachycardia.
• Supraventricular tachycardia (SVT) is a broad term for tachyarrhythmias that originate above the ventricular electrical conduction system (Purkinje fibers).
• Classic Paroxysmal SVT has a narrow QRS complex and a very regular rhythm with inverted P waves sometimes seen after the QRS complex. These are called retrograde p waves.

Heart Block

• It is an abnormal heart rhythm where the heart beats too slowly because electrical signals being partially or totally blocked between the upper (atria) and lower chambers (ventricles).

Bradycardia

• Bradycardia is a slower than normal heart rate. The hearts of adults at rest usually beat between 60 and 100 times a minute. Less than 60 bpm is considered bradycardia.

Aortic Aneurysms and Myocardial Infarctions

• Severe, sharp, excruciating pain located in the abdomen, flank, and/or back. It may be described as gnawing, deep, tearing pain.
• Other symptoms: distended abdomen, pulsating and abnormal vital signs (hypotension).
• Risk factors: Smokers and HTN at higher risk.

Acute Myocardial Infarction (MI) Presentation

• Also known as an ST elevation myocardial infarction (STEMI) and acute coronary syndrome (ACS).

Classic Presentation of Acute Myocardial Infarction

• Gradual onset of intense, steady chest discomfort or pain described as squeezing, tightness, crushing, heavy pressure, like an elephant sitting on the chest.
• Pain or discomfort may radiate to the left side of the neck, jaw, and/or left arm.
• Pain or discomfort continues at rest.
• Diaphoresis with cool, clammy skin.

Atypical Presentation of Acute Myocardial Infarction

• Women and elderly are more likely to present with nonspecific symptoms of MI -Shortness of breath or dyspnea -Weakness, fatigue
  • Nausea and vomiting
  • Syncope
  • Epigastric pain, may be related to heartburn
• Present with back pain instead of anterior chest pain

Kawasaki Disease

• Also known as Kawasaki Syndrome and Mucocutaneous Lymph Node Syndrome.
• It is the leading cause of acquired heart disease in children.
• Acute, febrile immune-mediated disease of young children characterized by vasculitis that leads to coronary artery aneurysms by causing inflammation of the blood vessels, particularly the coronary arteries.
• The average age of those affected is 2 and 75% are younger than 5. Boys are 1.5 times more likely than girls to get KD. 25% are older children, adolescents.

Kawasaki Disease Diagnosis

• Diagnosed when a patient runs a fever of 101°F – 104°F and above for five days or longer in addition to four of the following five symptoms:

  -A rash over the torso, especially in the groin area.

  • Swollen, red hands and feet. Light peeling of the skin on the fingers and toes occurs in the second and third weeks of the illness. -Bloodshot eyes.
  • Swollen lymph glands in the neck. One lymph node measuring more than 1.5 centimeters. -Redness and swelling of the mouth, lips, throat and tongue. “Strawberry” tongue – the tongue is bumpy and red with enlarged taste buds.

Kawasaki Disease Treatment

• It is treated in the hospital with intravenous immunoglobulin and aspirin.
• Aspirin in moderate doses is used in the acute phase to help control fever, afterward it is given in lower doses to help prevent blood clots. Aspirin is stopped after 4 to 6 weeks if the child has normal coronary dimensions.
• COVID-19 in children: New syndrome named multisystem inflammatory syndrome (MIS-C). Symptoms include fever, significant abdominal pain, and some features of Kawasaki disease (red eyes, red tongue, swollen hands/feet, rash).

Kawasaki Follow Up

• Most cases resolve in 4 to 8 weeks but may have serious sequelae aortic dissection ・coronary aneurysms ・blood clots ・dysrhythmias heart valve problems from scarring ・myocarditis
• Need follow up with pediatric cardiologist for several years because effects may not be apparent for years.