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106 Cards in this Set
- Front
- Back
- 3rd side (hint)
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Describe the 2 methods of classification of endocarditis.
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Classic is acute and subacute
Newer: Native valve Addict Prosthetic valve Culture negative |
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What are the usual organisms associated with acute and subacute endocarditis?
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Sub-acute: Strep, Enterococcus, Staph epidermidis
Acute: Staph aurens & Gram negative |
subacute 3
acute 2 |
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What is the most common organism associated with endocarditis? % of time?
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60-80% Strep usually viridans
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What should you do if a pt has Strep bovis endocarditis?
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Colonoscopy often associated with a GI malignancy
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What cardiac conditions are at high risk and require prophylaxis?
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1. All prosthetic valves
2. previous bacterial endocarditis 3. complex cyanotic congenital heart disease that is unreparied, has residual defects or is within 6 months of repair 4. surgical pulmonary shunts 5 cardiac transplant with valve lesions |
5
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When is prophylaxis recommended for dental procedures?
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Situations were there will be bleeding:
Tooth extractions Root cannal Initial placement of endodontic bands dental implants |
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When is prophylaxis usally not needed for dental procedures?
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Where there will be no bleeding. If bleeding does occur give antibiotics within 2 hours.
restorative procedure (fillings) endodontic treatements after intial placement |
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What respiratory tract procedures need prophylaxis?
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Tonsillectomy
Rigid bronchoscopy surgery invoving the respiratory mucosa |
3
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What respiratory tract procedures do not need prophlaxis?
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Flexible bronchoscopy in mod risk pts optional in high risk
endotracheal intubation PE tubes |
3
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What type of endocarditis is associated with older men undergoing a prostate procedure?
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Enterococcal endocarditis
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With endocarditis associated with addicts what are the most common sites of infection?
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Right sided endocarditis Tricuspid and pulmonary valve and often septic pulmonary emboli. Look for RV enlargement on CXR
Staph Aurens, Strep epidermis and gram negative |
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A pt presents with a black toe and toe pain> What diagnosis should you consider?
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endocarditis presenting with embolic events. Rember the heart is the most common source of atheroemboli.
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What is the time cutoff for replacement of prosthetic valve if the pt gets endocarditis?
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If endocariditis occurs within 2 months of operation give one round of antibiotics if it fails to clear replace. Replace if any evidence of valve ring infection or myocardial penetration.
If > 2months may have better success with medical treatment. |
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Pt with a surgical pulmonary shunt do they need prophylaxis with an endoscopy with bx or TEE?
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no it is optional in high risk pts not recommended in moderate risk pts
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Vaginal delivery in a pt with a prosthetic valve does she need prophylaxis?
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Does not need can be optional
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Describe the prohylaxis regimen in dental, oral, or esphogeal procedures. Standard, Unable to take PO, allergic to PCN
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Standard: 2g Amoxicllin 1 hr before
Unable to take PO: 2g Ampicillin IV 30 min before Allergic to PCN: Clindamycin 600mg 1 hr before; Cephelaxin (Keflex)2g PO 1 hr before; zithromax 500mg 1 hr before IV doses 30 min before PO 1 hr before |
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What is the endocarditis prophylaxis regimen for a high risk pt undergoing a GU/GI (not endoscopy) proc.?
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No prophylaxis (New 2007 AHA guidelines)
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What is the prophylaxis regimen in high risk pt undergoing GU/GI allegic to PCN?
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None
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What is the prophylaxis regimen in moderrate risk pt undergoing GU/GI?
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None
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How do you make a diagnosis of Rheumatic Fever?
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JONES criteria
http://en.wikipedia.org/wiki/Rheumatic_fever (C.A.N.C.ER) carditis, arthritis, nodules, chorea, erthema marginatum Minor Previous RF, arthralgias, fever, acute phase reactants (high sed rate or CRP), prolonged P-R interval. 2 maj or 1 MAJ + 2 minor and evidence of preceding Group A strep > 250 Todd ASO titer |
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Pt has mitral and tricuspid stenosis. What is the most likely cause?
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Rheumatic fever
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At what age do bicuspid aortic valves start getting calcified?
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bicuspid 40-70
tricuspid valve >75 years old |
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What is the most common congential valve disorder?
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Bicuspid aortic valve. (1-2%)
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What is the classic triad of sx for aortic stenosis AS ?
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LV failure
syncope with exercise angina |
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What are the PE findings in AS?
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Pulses tardes
Sustained PMI Late peaking diamond shaped SEM at RUSB S4 gallop may have absent second HS or ejection click right after S1 as valve opens M increaces with squatting (increases cardiac volumes) |
pulse
PMI Murmur Manuevers Extra sounds |
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What is the equation for Peak Gradient across a valve? How do you intepret the values
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Gradient = 4(velcoity)squared
nml <30 moderate 30-70 sever >70 (< 0.7 cm3 valve opening) |
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Pt with AS elects medical treatment only what is the prognosis?
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Depends on clnical presentation
Angina = 5yrs Syncope = 3yrs HF = 2 yrs |
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What is the prognosis for AS that is surgically corrected?
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10 yr survival > 60%
medical management 10yr survival =10% |
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What is the restenosis rate for balloon valvuloplasty in aortic stenosis?
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50%
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What should the INR be for prosthetic Aoritc valve? Mitral valve?
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INR Aortic 2.0-3.0
Mitral slightly higher 2.5 to 3.5 |
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If an elderly pt falls and is found to have a severly fracted femur and AS which is fixed first?
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The AS
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List the etiologies of Chronic Aortic Regurgitation?
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1. Congenital (bicuspid valve)
2. Rheumatic Fever 3. Endocarditis 4. Dilation of the aortic roots as seen in Marfan syndrome 5. VSD 6. Giant cell arteritis 7. Relapsing polycondritis 8. Syphilis 9. Ankylosing spondolytis |
7-9
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What is the typical murmur of chronic aortic regurgitation?
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Decrescendo early diastolic high pitched blowing murmur. As flow regurgitates back from the aorta against the anbnormally open aortic valve. Hence diastolic.
May have Austin Flint: Loudest at LSB = Leaflet Loudest at RSB = aortic root Best heard in expiration leaning forward |
How many types of murmurs?
Best position? |
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What is the difference in character between the murmur of AR vs Mitral Stenosis?
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AR is high pitched due to high flow. Occasionally there will be a low pitched rumble (Austin Flint) caused by the regurgitant stream hitting the anterior mitral leaflet.
MS is a low pitched rumble due to low flow. |
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Describe the pulse in Aortic Regurgitation?
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Wide & bounding Corrigan's pulse or water-hammer pulse
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What are the CXR findings in AR?
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Enlarged left ventricle & possible dilation of the ascending aorta.
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What maneuvers make the murmur associated with AR louder?
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Squat, Leg raise, expiration & leaning forward.
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What are 4 peripheral signs of infective endocarditis?
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1. Splinter hemorrhages
2. Osler's nodes -painful, palpable lesions 3. Janeway lesions - pink palmar macules 4. Roth spots flame shaped retinal hemorrhages with a cotton wool center. |
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Pt has a 15-20 mmHg difference in bp between arms. What is the significance of this?
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Possible leaking aortic aneursym
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What is the significance of a delay between the radial and femoral pulse?
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Possible silent aortic coarctation.
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What is a cardiac thrill at the upper RU parasternal area possibly indicate? A thrill at the apex? LUSB
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Grade 5 murmur
Aortic stenosis RUSB Mitral stenosis apex Pulmonary HTN LUSB |
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What test should be done to detect LV dysfunction in AR?
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Exercise MUGA EF normally rises by 10% with exercise. An abnml response to exercise suggests LV decompensation.
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What is the usual treatment for chronic AR? Drugs, tests, dimensions?
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Without LV dysfunction can use diuretics and ACE inhibitors. If pt is symptomatic at rest or when serial echos show LV end systolic dimension >55m or EF <55% replace valve.
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Describe the PMI in AS vs AR?
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Aortic stenosis = pressure overload PMI is non-displaced & sustained
Aortic regurgitation = volume overload PMI is displaced & thrusting |
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What are the CXR finding in AR? AS?
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AR = LVE, prominent aorta
AS = nml unless there is a calcified aortic valve. |
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Describe the clinical presenation with acute AR
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Low cardiac output, cool clamy skin, pulmonary edema, low BP, no bounding pulse, pressure, diastolic murmur is short becasue ventricular pressure rises quickly above low BP. Nearly all require emergent valve replacement.
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Describe the murmur found in mitral stenosis. S1/S2 & manuevers
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Opening snap followed by a diastolic rumble. May have accentuated murmur just before S2 due to atrial contraction. best heard at apex. Increased by squat and expiration.
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What are common ECG findings in mitral stenosis
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tall peaked p waves in II & V1
atrial fib RAD (I neg aVF pos) RV hypertrophy (lg R wave V1 with ST depression and flipped T wave V1) |
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describe the JVP in mitral stenosis.
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Prominent a wave with pulmonary HTN only seen if pt in sinus rhythm.
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What are the casues of Mitral stenosis?
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Rheumaic fever
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What does a malar flush possibly indicate?
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Pulmonary HTN
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Young immingrant female pt presents with pulmonary edema and atrial fib. What is a possible diagnosis
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pregnacy exacerbating unknown mitral stenosis. Pt previous with reheumatic fever.
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When do pts with mitral stenosis need valve replacement? Valve area? What are the treatment options?
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valve area <1.3 to 1.5
balloon valvuloplasty may delay replacement by 10 yrs Treat with anticoagulation. (Heparin during pregnancy) |
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What is the most common clinical presentation of Mitral stenosis?
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Exertional dyspnea: flow through the valve is dependent on the length of diastole, exercise and other casues of tachycardia shorten diastole .
Other sx can include a malar flush from pulm htn, |
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What are the causes of chronic Mitral regurgitation?
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1. MVP,
2. annulus dilation from LV dilation 3. prior episode of endocarditis 4. prior damage from ischemia |
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Desecribe the murmur in chronic mitral regurgitation?
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Leads to volume overload of LV. systolic murmur at apex radiating to axilla, constant intensity blowing pansystolic murmur. Decrescendo in acute MR
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Describe the second heart sound in MR
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Widely or persistently split because LV volume going out 2 exits mitral and aortic causes the aoritc valve to close early.
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How should a pt with MR be evaluated?
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If symptomatic replace valve. Like AR do exercise MUGA to detect subclinical LV dysfunction, treat sx with diuretics and ACE inhibitors.
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Describe the PMI, pulse character, & pulse pressure in MR
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Displaced and hyperdynamic PMI, nml pulse> Widely split S2 aortic valve closes earlier than usual. A2 then P2 P2 nml A2 ealier. Chronic constant intensity pansystolic murmut becasue left atrium has enlarged and is lower pressure than the nml atrium seen in acute MR. Acute MR decreshendo murmur
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What is the prevelence of MVP?
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7% overall 10-12% in the teenaged population. W>M Older men more likely to have rupture. Assoc. low body wt, pectus excavatum, low BP. Most is a nml varient caused by a lax chordae tendinae casuing a billowing of the valve leaflet.
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When is MVP significant?
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MVP with murmur or myxomatous leaflets have an increased reisk of emboli events, infective endocarditis & sudden death.
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Pts with MVP without a murmur or myxomatous leaflets are at slightly increased risk of what?
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cerebral embolic events at a very low rate. 1/11K per yr.
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What are the ascultory findings in MVP?
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Midsystolic click followed by a murmur. Valsalva or standing may move the click & murmur earlier in systole.This differentiates it from AS or pulmonic stenosis which is fixed.
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Is there an increased incidence of dyspnea, panic attacks, chest pain wit MVP.
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No
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What are the cardiac causes & %s of cerebral embolic events?
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1. Atrial fibrillation 45%
2. Acute MI 15% 3. Ventricular aneursym 10% 4. Mechanical valve 10% 5. Valvular heart dz including MVP, patent foramen ovale, other 10% |
5 maj causes
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What conditions that are potential casues of cerebral emboli require anticoagulation or anti-platelet therapy?
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A fib, mechanical valves, cardiomyopathy, Rheumatic Heart dz require anticoagulation if possible
Native valve endocarditis, calcified AS and MVP conly require anti-platelt if at all. |
4 require
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Pt presents with acute onset of pulmonary edema. PE shows a decreshendo systolic ejection murmur at apex? What is the dx and possible casues?
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Acute mitral regurgitation
Endocarditis MI with rupture of choriae tendini or rupture chordea in severe MVP |
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Differentiate the murmur of acute vs chronic Mitral regurgitation?
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Chronic MR pansystolic ejection murmur at apex.
Acute MR decreshendo SEM at apex. Left atrium is dilated and low pressure in chronic wheras in acute the regurgitant stream is ejecting into a higher pressure atrium. |
Left atrium is dilated and low pressure in chronic wheras in acute the regurgitant stream is ejecting into a higher pressure atrium.
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Describe how chronic & acute MR preesnt?
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Chronic MR the left atrium is large and attenuates the MR jet.
Acute MR small atrium with large left sided v waves. |
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What are the causes of Tricuspid Stenosis?
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1. Rheumatic Fever
2. Congential 3. Carcinoid syndrome |
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Describe the murmur and JVP seen in Tricuspid Stenosis
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Diastolic murmur best heard at Left Sternal Border and increases with inspiration. JVP has giant a waves caused by the atrial contraction against a stenotic valve.
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What are the causes of Tricuspid Stenosis?
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1. Rheumatic Fever
2. Congential 3. Carcinoid syndrome (more commonly causes pulmonic stenosis) |
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Describe the bedside findings in Tricuspid Stenosis?
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Diastolic murmur best heard a Left Sternal Border increases with inspiration like all right sided murmurs. Giant a waves secondary to atrium contrating against a stenotic outflow valve teht tricuspid.
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What are the EKG & CXR findings in TS?
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Tall P waves in II & V1 which is evidence of atial hypertorphy. CXR shows enlarged right atrium.
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What cardiac valve is most commonly involved in infective endocarditis seen in drug users? What is the most common organism in this situation?
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Tricuspid,
Staph Aurens |
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What are the causes of Tricuspid Regurgitation?
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Actually casued by functional dilation of the RV seen in end stage RV failure
Specific casuses are submassive pulmoniy emobus Other causes of Pulm HTN Rheumatic heart disease Carcinoid Endocarditis |
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What are the bedside findings in TR? murm, physical exam, JVP
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Holsystolic murmur along LLSB , increases with inspiration, can have a parasternal heave, liver pulsations, JVP with large v that are a result of blood shooting up the jugular as the RV contracts.
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JVP findings
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How can MR and tricuspid regurgitation be distinguished?
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Both have a holosystolic murmur. TR best heard at LLSB which increases with inspiration.
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What is the usual treatment of TR?
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Most common valvular disorder of the right heart. secondary to RV dilation. Treat underlying disease. The valve rarely needs to be removed and is never replaced.
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What are the causes of Pulmonic Stenosis?
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Virtually always congenital and typically does not progress. Other causes are RHF, carcinoid, Noonan's
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What are the bedside findings in pulmonic stenosis? mumrur, sounds, JVP, S1, S2
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No murmur, ejection click, prominent a waves from atrial contaction against a incompletly emptied right ventricle. Persistently wide S2 because of delayed functioning of the RV.
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Pt with congential pulmonic stenosis about to undergo a GU procedure. What is the endocarditis prophylaxis needed?
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None PS and ostium secundum do not need.
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What is Ebstein Anomoly? Associated with what?
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The tricuspid is situated anbnmly low in the RV. TR is common. Assoc. with PSVT and WPW, ASD, patent foramen ovale. Results in RV failure and cardiomegaly.
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When should a porcine valve replacement be considered?
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>65 yo
Cannot tolerate anticoagulation Women of child bearing age to preclude anticoagulation during pregnancy |
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What is the general indication for valve replacement?
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Symptoms at rest
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When in baloon valvuloplasty the procedure of choice?
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Pulmonic stenosis
often used on MS almost never on AS |
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Pt has a mitral valve prosthesis. What is the procedure of choice for following?
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Transesophageal echo
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What is one way of determining the severity of MR?
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The degree of severity of mitral regurgitation can be quantified by the percentage of the left ventricular stroke volume that regurgitates into the left atrium (the regurgitant fraction).
Degree of mitral regurgitation Regurgitant fraction Regurgitant Orifice area Mild mitral regurgitation < 20 percent Moderate mitral regurgitation 20 - 40 percent Moderate to severe mitral regurgitation 40 - 60 percent Severe mitral regurgitation > 60 percent > 0.3 cm2 |
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Nemonic for systolic mururms
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Valsalva
(↓ cardiac filing) Standing (↓ cardiac filing) Leg Raise /Squat/ lying down (↑ cardiac filing) Handgrip (↑ SVR) HCM ↑ ↑ ↓ ↓ MVP ↑ ↑ ↓ ↑ AS ↓ ↓ ↑ ↓ MR ↓ − ↑ ↑ VSD ↓ − ↑ ↑ |
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Describe the JVP seen in TR?
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x decent lost becasue it is overcome by reguritant wave of blood shooting out the RV with systolic emptying leading to a systolic aV wave steep y decent
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What causes prominent a waves?
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Tricuspid stenosis
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What are the types of bacteria associated with drug abuse & prosthetic valve endocarditis?
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Staph aurens (coagulase +)
Staph epidermidis(coagulase -) Gram negative |
3 types of bacteria
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What constitutes a high risk pt for endocarditis and needs prophylaxis?
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Prosthetic valves
Previous episode of endocarditis Congenital heart dx (CHD) -unreparied cyanotic -repaired CHD within months - repaired CHD with residual defects Cardiac transplat pt with valve lesions |
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What is the effect of vasodilators in AS?
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Increases gradient and should not be used.
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When should valve replacement occur in a pt with AR?
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Symptomatic at rest
LVES dimension > 55m LVED dimension >75mm or EF <50% |
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How should mild AR pts be treated?
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Diuretics and ACE inhibitors
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What is a common triad seen on a CXR in a pt with MS?
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1. Pulm artery enlarged vasculatrure
2. Straightening of the L heart border indicating RAE 3. Nml sized LV |
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Pregnant pt with MS now with A fib. How do you treat?
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If unstable DC cardioversion
Can use procanimide, verapamil, & digoxin. Use heparin not coumadin |
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Compare the murmur of MR vs AR
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MR LV pushes jet of blood back into a low presure dilated LA. Therefore murmur is pansystolic constant intensity.
In AR jet of blood occurs as it goes above diastolic BP high pitched blowing |
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Describe S2 in MR
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widely split due to early aortic closure. Split does not occur on exhalation.
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How is mild MR treated?
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Diuretics
Afterload reduction (ACE) to enhance ejection through aoritc valve instead of back flow through Mitral valve |
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What is a common sound in AS associated with bicuspid vs senile AS?
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ejection click like a guitar string being plucked. May also be heard in pulmonic stenosis
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Why should a cath be done in pts with AS?
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High rate of CAD
33% ages 40-59 66% ages > 60 |
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What is the role for vasoldilators in the treatment of AS?
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Should not be used as they increase the gradient
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What is a common echo finding in acute aortic regurgitation?
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Fluttering anterior mitral valve from the regurgitatant stream
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What heart defects are common with maternal rubella infection?
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Supravalvular Aortic stenosis
Pulmonic stenosis |
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