ENDOCARDITIS
MYOCARDITIS
PERICARDITIS
Nursebob
Endocarditis.
Define.
Infective endocarditis.
Inflammation of the innermost layer of the heart.
Can involve:
Valves.
Chordea tendineae
Cardiac septum
The lining of the chambers.
Causes.
Bacterial infection with Streptococcus or
Staphylococcus.
Other possible organisms
Gram negative bacteria
Pseudomonus.
Candida albicans.
Mortality about 25%.
Increases with:
Prosthetic heart valve.
Heart failure.
Abscess formation.
Stroke.
Causes of Infection of the Endocardium.
Valvular damage.
Prosthetic valve.
Damage to cardiac structures.
Damage to the walls of the endocardium.
Symptoms of endocarditis.
General.
Fever.,
Chills, night sweats, fatigue,
anorexia, weight loss, and pain in
the muscles, joints, and back.
Petechiae - palpebral conjunctivae (insides of the eyelids), neck,
anterior chest, abdomen, or oral mucosa.
Janeway lesions - (nontender maculae) on the patient's palms and soles.
Osler's nodes - tender, erythematous, raised nodules on the fingers and
toe pads.
Splinterhemorrhages under the fingernails.
Fundoscopic exam:
Roth's spots - retinal hemorrhages with pale centers known.
Development of a new cardiac murmur.
Beth Israel criteria
Persistent bacteremia (positive blood cultures, found in 91% of
patients),
New regurgitant murmurs
Vascular complications.
Duke criteria - These criteria add echocardiographic changes.
Echocardiographic findings.
evidence of vegetation
thrombus on valves
other endocardiac structures
abscesses
disruption of a prosthetic valve.
Transthoracic echocardiography (TTE)
Accurate for identifying vegetations
accuracy can be reduced in obesity, chronic obstructive pulmonary
disease, or chest-wall deformities.
Transesophageal echocardiography (TEE)
More accurate than TTE.
Allows closer visualization of common sites for vegetations and other
abnormalities.
Better visualization of prosthetic heart valves.
Other signs and symptoms.
Increased sedimentation rate.
Anemia
Leukocytosis
Microscopic hematuria.
Hyperglobulinemia
Positive rheumatoid factor.
Proteinuria.
Treating endocarditis
Support cardiac function.
Eradicating the infection
Preventing complications
Embolization.
Systemic embolization occurs in up to 50% of patients.
Emboli may go to brain, lungs, coronary arteries, spleen, bowel,and
extremities.
Embolic events are most common in the first 2 weeks.
Anticoagulation isn't recommended for patients with endocarditis.
Because of the risk of intracerebral
hemorrhage.
Anticoagulation should be continued on it
before developing endocarditis.
Must have frequent neurologic monitoring.
Heart failure
Related to valvular problems.
More common with aortic valve infections than with infections of the
mitral or tricuspid valve.
Valvular dysfunction can progress in spite of antibiotic therapy
May need valve replacement
High Risk Patients.
Presence of prosthetic heart valves.
Require antibiotic prophylaxis before certain invasive procedures,
including dental extractions.
Medical-alert bracelet
MYOCARDITIS
Inflammation of the myocardium, the heart's muscular layer.
Usually mild it can be fatal.
Can lead to coronary artery thrombus, coronary ischemia, dilated
cardiomyopathy, cardiac arrhythmias,
and sudden death.
Should be considered if myocardial infarction (MI) has been ruled out
in a patient with dyspnea and chest discomfort, especially if he has a
history of recent viral illness.
Causes
Caused by the coxsackievirus type B
Inflammation and fibrosis
Reduce blood flow, causing necrotic areas of the
myocardium
Necrosis maybe patchy or global.
Virus or another underlying cause
Leukocytes, lymphocytes, and macrophages infiltrate the myocardium -
interstitial fibrosis in the myocardium.
Contractility decreases
Reduction in cardiac output (CO).
May cause left
ventricular failure.
Dilated
cardiomyopathy.
Diagnosing Myocarditis
Up to 6 weeks before the patient has signs and symptoms
of myocarditis
Upper respiratory symptoms: fever, chills, and
sore throat.
Abdominal pain
and nausea, vomiting, diarrhea, arthralgia, and myalgia.
Overt Symptoms.
Chest pain.
Heart failure with
dyspnea.
Diagnostic tests.
Chest X-ray
Enlarged heart with
evidence of heart
failure
Prominent blood vessels or
fluid within the lungs.
ECG
Arrhythmias.
ST-segment and T-wave
abnormalities.
Decreased QRS amplitude
suggest myocarditis.
May notice a heart block.
ECG usually returns to
normal within 2 months.
Echocardiogram.
Rule out pericardial effusion.
Hypocontractility
Chamber hypertrophy.
Valvular dysfunction and
pericardial effusions.
Endomyocardial biopsy.
Done via through cardiac
catheterization.
Confirm myocarditis.
Only accurate
only about 65%
of the time.
Lab
Increase in creatine kinase
(CK)
Increase in sedementation
rate
Increase in white
blood cells (leukocytosis).
Treating myocarditis
Most are mild and
self-limiting.
Treatment is supportive.
Recognizing
and treating cardiac arrhythmias.
Preserving myocardial function.
Preventing heart failure
Oxygen
Limiting myocardial oxygen demand
Treat the heart failure.
ACE inhibitors
Diuretics
Sodium restriction.
Anticoagulation to reduce the risk
of thrombosis and pulmonary embolism.
Myocarditis appears to make patients sensitive to
digoxin.
Intravenous immunoglobulin may be given to improve
the immune system
and limit the disease
PERICARDITIS
Remember.
Pericardium is a double-walled fibroserous sac that
surrounds and
supports the heart.
Normally, 15 to 50 mi of fluid separates the two
layers.
Pericarditis.
Pericardium becomes inflamed.
Pericardial Effusion - Excess
fluid
may accumulate in this space eht pericardial sac.
Can Progress to chronic constrictive pericarditis
Cardiac tamponade - fluid compresses the heart and
obstructs blood flow into the ventricles.
Usually occurs with a rapid accumulation of
a small amount of fluid.
Slow the body has time to
compensate for the change and the patient may experience few or no
symptoms.
Causes.
Idiopathic pericarditis
50% are idiopathic.
Other causes.
Infection
Viruses (most common known cause
of pericarditis)
Adenoviruses
Echoviruses
Coxsackie
viruses
Tuberculosis
Bacteria
Pneumococcus.
Streptococcus
Fungi
Candida
Cardiac complications
Acute myocardial infarction
Postpericardiotomy syndrome
Autoimmune or hypersensitivity
reactions
Rheumatic fever
Rheumatoid
arthritis
Systemic lupus
erythematosus
Drugs
Hydralazine
Procainamide
Iminoxidil
Isoniazid
Other causes
Neoplasms
Trauma
Symptoms of Pericarditis.
Chest pain.
Most common symptom.
Sharp and constant, retrosternal.
Leaning forward while sitting may alleviate
pain, this is considered a hallmark sign of pericarditis.
Lying
down can worsen the pain from pericarditis, radiate to the neck,
and back; radiating to the left side.
May have
malaise, tachypnea, and tachycardia.
Pericardial rub, although this is present in about
50% of cases.
Cardiac tamponade
Falling
pressure.
Rising venous pressure
Faint heart sounds.
Low-voltage QRS
ECGs
ST segment
elevation
Reciprocal depression in lead AVR and
sometimes lead V1
ST segments return to normal
and T waves invert after several days.
Pericardial effusion.
Premature atrial beats and atrial fibrillation
on EGG.
Echocardiogram is the preferred imaging method for diagnosing
pericardial effusion or tamponade.
Chest X-ray may be
ordered to rule out pulmonary pathology.
Water bottle shape) if more
than 250 mi of pericardial fluid is present.
Labs
Cardiac enzyme levels
(including troponin) to rule out MI
Complete blood cell count
Blood
culture
C-reactive protein
Sedimentation rate.
Treatment.
Pericardiocentesis.
Large effusions or Cardiac tamponade.
Reduce pressure around the heart.
Pain control.
Nonsteroidal anti-inflammatory drugs
(NSAIDs).
Manage pain and reduce
inflammation.
Pericardiectomy.
If pericarditis recurs frequently.