Traumatic, Inflammatory, Infectious Heart Disease PDF

Endocarditis What ​ Inflammation of inner lining of the heart and the valves ○​ Infective: inflammation or infection affecting heart valves ​ MOST COMMON (M>W)...

Endocarditis What ​ Inflammation of inner lining of the heart and the valves ○​ Infective: inflammation or infection affecting heart valves ​ MOST COMMON (M>W) ○​ non infective: formation of sterile platelet and fibrin thrombi ​ RARE- found on autopsy Cause ​ Infective: staph, strep viridans (s/p dental), strep pneumo, HACEK, fungi (candida/asp) ○​ Damage to endothelium causes platelets/fibrin deposits which adhere bacteria that invade to cause inflammation and destroy valves ​ Non infective: Rheumatic endocarditis- impacts MV > AV ○​ Endothelial injury to leaflets, platelet activation/deposition, thrombus Classifying endocarditis: ​ Acute infectious (sudden *staph) vs Subacute infections (gradual onset *s viridans) ​ Native valve (community, IV drug use, staph/strep) vs Prosthetic valve ​ Left sided vs right sided (IV tri drugs) Note: vegetations are masses that form due to infection/inflammation s/p damage and can cause emboli- both d/t fibin/plt Signs/Sx Sx: more common to IE than NIE ​ Fever ?, night sweats, fatigue, loss of appetite, weight loss, myalgias/arthralgias FROM JANE PE: ​ New or changing murmur (MR, TR, AR), tachy, arrhythmia (d/t spread of infection disrupt conduction) ​ Splinter hemorrhages (microthrombi) ​ Osler nodes (red nodes on fingers/toes) ​ Janeway lesions (small, painless, erythematous lesions on palms and soles) ​ Roth spots Diagnosis ​ Echo: TTE vs TEE ○​ TTE initial ○​ TEE if TTE is negative and still suspicious ​ Labs: ○​ inflammatory markers: ESR and CRP elevated ○​ CBC: leukocytosis, normocytic anemia ​ Blood culture: 3 samples from different sites obtained prior to starting abx (- dont r/o endo) ​ ECG: usually normal- baseline tracing and could ID heart block or bundle branch block ​ CXR: R/O other causes of sx- but in endocarditis: septic emboli or pulm edema, cardiomegaly ​ CT: metastatic infection ​ MRI: if concerned for cerebral embolic events NIE: antinuclear antibodies, lupus anticoags, antiphospholipid antibodies Duke criteria: 2 major, 1 major + 3 minor, 5 minor Treatment Infective ​ Patients get admitted and start empiric abx and Consult ID, cardiology, CT surgery ○​ Native valve: Vanco + gent or ceftriaxone | Niaficilin + gent ○​ Prosthetic valve: Vanco + gent + rifampin ​ Meds for 4-6 weeks ​ Blood cultures repeated q24 hrs ​ Continuous PE ​ Discharge once hemodynamically stable, negative blood culture, sx was consulted ○​ Discuss outpt IV therapy Noninfective ​ tx underlying condition + anticoags Surgical management ​ Valve repair for: HF, persistent infection, embolic events, conduction abnormalities ​ Pacemaker needed if: sepsis, pocket infection, persistent infection, staph bacterimia Need abx b4 dental work Prophylaxis for valves, congenital defects/disease of heart (amox, ceph, clinda) risks Noninfective: ​ trauma, circulating immune complexes, cytokines, antigen-antibody relations ​ Hypercoagulable state ​ Thrombus Infective: heart disease (rheumatic, congenital), 60>, IV drug user, immunocomp, prior hx, poor dentition Complications Cardiac: perivalvular, valve insufficiency, valve rupture, HF, pericarditis Renal: glomerulonephritis, antibiotic induced nephrotoxicity Metastatic infections and death  Pericarditis What ​ Inflammation of the pericardium, double layer sac surrounding the heart ​ Classification: based on duration ○​ Acute 6mo (constrictive, adhesive) ​ Common to young men Cause ​ Idiopathic: ○​ CP 1-2 weeks after infection ​ Viral infection: coxsackievirus B (see above) ​ Bacterial infection: TB, rheumatic fever ○​ + culture or bx reveals caseating granuloma ​ Cardiovascular: Dressler syndrome (post MI) ○​ 1-4 weeks after operation/injury ​ Cancers or meds ​ Fungal is rare Signs/Sx Acute Pain: severe, sharp, pleuritic, steady pain that can radiate to neck, shoulder, arm, trapezius ​ Worsens when lying supine + coughing ​ Improves when leaning forward PE: ​ Neck vein distention, pericardial friction rub (heard w/expiration and leaning forward) Chronic pain: less severe, could be absent if slowly developing ​ May have dyspnea (SOB) PE: ​ May have neck vein distention ​ X ray: large cardiac silhouette Diagnosis ​ EKG: ○​ Acute: Diffuse ST segment elevation w/ upward concavity and w/o T wave inversions ○​ PR depressions ○​ Chronic: electrical alternans (QRS amplitude alternate) with a large effusion ○​ EKG findings happen in both due to inflammation of atria disrupt conduction ​ Echo: ○​ Isolated: normal ○​ Acute and chronic: Pleural effusion (fluid in between layers of pericardium) ​ Blood: may show nonspecific- inc ESR, CRP, leukocytosis Treatment Viral or idiopathic ​ O2 and analgesia (can be tx on outpt basis with NSAIDS or high dose ASA x 7-14 days) ​ KNOW: NSAID and colchicine 7-14 days + gastric protection ○​ Colchicine enhances response and decreases recurrence rate ​ If no improvement w/ above- use STEROIDS When to admit: fever, tamponade/effusion, immunosuppressed, ↑ troponin: intense dialysis, abx, tb tx Complications Cardiac tamponade, pericardial effusion, constrictive pericarditis Constrictive pericarditis: thickened/scarred pericardial sac that lies around heart and prevents proper diastolic filling ​ Cant fill properly so more venous pressure leading to decreased SV ​ Slow onset: dyspnea, fatigue, orthopnea, cough, weight gain, right sided HF, JVD/edema, pericardial knock (high pitched 3rd sound) ​ CXR: pericardial calcification ​ ECHO: pericardial thickening ​ EKG: low voltage QRS, afib ​ TX: surgery- resection of pericardial is only definitive tx and use diuretics before sx 6 Ps: pleuritic, persistent, positional, cP, pericardial friction rub, PR depressions  Pericardial effusion and cardiac tamponade What ​ PE: Accumulation of fluid in pericardial space ○​ 2/2 pericarditis, uremia, cardiac trauma ​ CT: rapid accumulation of pericardial fluid/pericardial effusion to impaired cardiac filling and cause hemodynamic compromise ○​ Occurs in pericardial sac ○​ Common to boys/men Cause ​ Viral- most common (coxsackie, influenza,HIV, EBV, CMV) ​ Bacteria (staph, strep, neisseria, legionella) ​ Fungal ​ Malignancy ​ Trauma, post procedure ​ Autoimmune (SLE, RA) ​ Meds (hydralazine, minoxidil, anticoags) Whats happening: normal fluid exists- but when there is too much, it ↑ pressure and compresses heart ​ ↓ diastolic filling, SV, CO ​ ↑ HR to maintain CO Rapid filling of fluid= tamponade Signs/Sx With tamponade ​ Dyspnea, cough, CP, lightheaded, syncope, palpitations, hoarseness, fatigue Triad CT: JVD, W/O tamponade muffled sounds, ​ Usually no sx- but if sx usually related to underlying cause (infection, autoimmune etc) hypoTN, pulse weak PE: ​ Vitals: hypotn, tachy ​ Cards: pericardial friction rub, muffled heart sounds, JVD, hepatojugular reflux, weak peripheral pulse, pulsus p ​ Resp: dullness to percussion/diminished breath sounds Diagnosis ​ EKG: sinus tachy, low voltage QRS, diffuse ST elevation w/PR depression, electrical alternans (qrs alt height) ​ CXR: enlarged cardiac silhouette when >250mL fluid ​ TEE: diagnostic test of choice ○​ Pericardial effusion: echolucent space in pericardial sac ○​ CT: R atrial free wall collapse during Systole and RV wall collapse during Diastole. IVC dilated ​ Pericardial fluid analysis/bx but not common ​ Labs: CBC, BUN/Cr, ESR, CRP, ANA, TSH, quantiFERON, HIV Treatment PE ​ Depends on stability and underlying cause- tx pericarditis like above ​ Small effusions are self resolving ​ Drain for large (pericardiocentesis) CT ​ Admin O2, IV fluids, pericardiocentesis Surgery: bx, pericardiotomy or window  Myocarditis What ​ Inflammatory disease of the myocardium ○​ Affects young men and young adults more Cause ​ Idiopathic ​ Infections: virus (coxsackie B), bacterial, protozoal, fungal ​ Immune mediated disorder: rheum fever, SLE, allergic reactions, sarcoid/scleroderma ​ Genetics ​ Env: black widow venom ​ Drugs: cocaine, amphetamines, ethanol Whats happening: inflammation causes heart to enlarge and dilate the chambers- this injures myocytes ​ Viral toxicity or bacterial invasion or autoantibodies etc ​ Essentially lead to inflammation/injury, tissue dies ​ Severe can lead to fibrosis and chamber remodeling- DCM Issues lead to HF, arrhythmias, pericarditis Signs/Sx ​ Classify based on sx onset/progression: subclinical, acute, chronic ​ Sx: fever, CP, orthopnea, loss of appetite, fatigue, abdominal pain, decreased exercise PE: heart failure signs ​ Tachy, arrhythmias, peripheral edema, hepatomegaly, JVD, murmurs (MR/TR), S3/S4 gallops, pericardial rub Diagnosis ​ EKG: nonspecific ST changes, arrhythmias, conduction delays ​ CXR: cardiomegaly ○​ HF indications (pulm venous congestion, pleural effusion) ​ Echo: Can be normal in early or mild disease ○​ LV dilation, Ventricular systolic dysfunction, MR/TR, pericardial effusion, intracardiac thrombi ​ Labs: ESR, CRP, troponin + CK MB, natriuretic peptide, rheumatologic screening ​ Cardiac MRI: shows enhancement of myocardial wall ​ Endomyocardial bx: gold standard (rare tho) ○​ Cellular infiltrates: lymphocytic, eosinophilic, neutrophilic, mononuclear Treatment ​ Supportive mainstay- tx HF, arrhythmias, fix any underlying cause ​ Meds: diuretics, ACEI, BB, Angiotensin 2 blockers ​ Intense HF: balloon pump, LVAD, transplant ​ Tx arrhythmias; cardioversion, meds, pacing ​ Anticoags?? AVOID: NSAIDS, alcohol, exercise