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49 Cards in this Set
- Front
- Back
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Compare and contrast the differences between left- and right-sided endocarditis. Which valves are typically affected?
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Left-Sided Endocarditis:
• SYSTEMIC vascular involvement (whole body) • MV most commonly affected • Seen in acquired and congenital valve dz Right-Sided Endocarditis: • PULMONARY vascular involvement • TRICUSPID valve most commonly affected • Seen in IVDU |
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Describe the sx and physical exam findings of pericarditis
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Symptoms:
• Precordial or retrosternal CP, worse w/ inspiration • Sx RELIEVED sitting up and leaning forward • Radiation of pain to the TRAPEZIUS muscle ridge, esp on the left • Dyspnea, low grade fever PE: • Pericardial friction rub is pathognomonic • Friction rub best heard sitting up and leaning forward |
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How likely is it to hear a new heart murmur in IVDU endocarditis?
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Murmur LESS LIKELY to be heard given that the tricuspid valve is difficult to hear
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State the two most common causes of pericarditis
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Most common causes:
• IDIOPATHIC • VIRAL (coxackie, echo, adeno, EBV...) Other causes: Malignancies, metastatic: • Leukemia, lymphoma, lung, breast, melanoma Systemic illnesses: • RA • Rheumatic fever, acute • SLE • Scleroderma • Sarcoidosis Medications • Procainamide • Hydralazine • Anticoagulants Other: • AMI • Dressler's syndrome • Posttraumatic --> Constrictive pericarditis • Uremia • Bacterial pericarditis |
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State the Stage 1 - 4 EKG changes in pericarditis
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Stage 1:
• Diffuse ST segment elevation w/ upward concavity (all leads except aVR, V1) • ST depression in aVR, V1 • PR DEPRESSION (very SPECific) - most prominent in lead II; early sign Stage 2: • Hyperacute T waves Stage 3: • ST becomes isoelectric Stage 4: • T wave inversion |
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The causes of endocarditis vary with the TYPE of valve involved and presence of IVDU. State the causative organisms for:
• Native valve • Prosthetic valve • IVDU |
NATIVE valve:
• VIRIDANS strep (most common, per Sanford) • Non-viridans strep • Staph aureus • Enterococci PROSTHETIC valve: First 60 days post-op: • Staph aureus/ epidermis • Gram-neg and fungi After 60 days post-op: • Same as for native valve IVDA: • Staph aureus • Strep species • G-neg bacilli |
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What are Libman-Sachs vegitations, and with which condition are they associated?
Where are they found? |
NON-INFECTIOUS, autoimmune vegitations found on the MITRAL valve in SLE pts
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What are the empiric abx regimens for native and prosthetic endocarditis?
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Native:
• PCN + • Nafcillin/ oxacillin + • Gent OR • Vanc + gent (in PCN allergic) Prosthetic: • Vanc + • Gent + • Rifampin |
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What are the ophthalmologic, cutaneous, and neurologic findings of endocarditis?
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Ophtho:
• Conjunctival hemorrhages • Roth spots (retinal hemorrhage w/ central clearing) Cutaneous: • Splinter hemorrhages • Osler's nodes -- TENDER erythematous nodules on fingertips • Janeway lesions -- NONTENDER erythematous macules on fingers, palms, soles • Petichiae Neuro: • Focal motor deficits • AMS |
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What are the risk factors for infectious endocarditis?
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• Prosthetic valves
• Congental valve dz (eg, MVP) • Acquired valve dz (eg, RF) • IVDA • Indwelling venous catheters • Extensive BURN injury |
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What are the symptoms of endocarditis?
What about in kids? |
Adults -- non-specific sx:
• Fever/chills/ sweats • Malaise, fatigue • Wt loss • CP • Cough Kids -- most common sxs: • Malaise • Wt loss |
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What are the urinalysis findings in endocarditis?
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Hematuria in > 50% of pts
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What heart conditions warrant abx prophylaxis for infective endocarditis?
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• Prosthetic heart valves
• H/o bacterial endocarditis • UNREPAIRED complex cyanotic congenital heart defects REPAIRED: • heart defects in the FIRST 6 MOS • congenital heart dz w/ residual defects ADJACENT to a prosthetic patch • Cardiac TRANSPLANT pts who develop VALVULOPATHY |
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What is the difference regarding post-MI pericarditis and Dressler's syndrome?
Tx? |
Post-MI pericarditis -- Occurs within 4 days of MI
Dressler's -- 2-3 weeks after MI Tx -- NSAIDS |
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What is the role of steroids in the tx of pericarditis?
What is the rate of relapse upon d/c of steroids? What dx must be excluded before steroids are rx'd? |
Steroids should be RESERVED for pts who fail NSAID tx
25% of pts rx'd w/ steroids will experience relapsing pericarditis when discontinued Steroids should not be used until the presence of bacterial or mycobacterial INFECTION has been excluded |
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What should you suspect with the finding of severe hemolysis in a pt w/ a mechanical prosthetic valve? What other findings will the pt present with?
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Paravalvular leak
Pts present with: • Fatigue • Orthostasis • Jaundice |
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What structural finding is the hallmark of endocarditis?
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Vegetation. Can be on:
• Valve leaflets • Endocardium |
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Which cohort of pts are most at risk for endocarditis?
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• Acquired and congenital valve dz
• Prosthetic valves |
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Which procedures require prophylaxis for bacterial endocarditis in at-risk pts?
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• Dental procedures w/ gingival manipulation
• Rigid bronchoscopy • Abscess I & D Prophylaxis is NO LONGER RQD for GI & GU procedures |
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Describe the murmur of MITRAL regurgitation, acute and chronic
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Acute:
• Holosystolic, late systolic, or crescendo-decrescendo Chronic: • Holosystolic |
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Describe the murmur of MVP and associated provocative maneuvers
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• Late systolic murmur heard best at apex; CLICK
Decreased ventricular volume (VALSALVA) --> • Greater prolapse • INCREASED duration of murmur Increased ventricular volume (SQUAT) --> • DECREASED duration of murmur |
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What are the causes and signs of prosthetic paravalvular leak?
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Immediately post-op -- suture disruption
Delayed -- endocarditis Signs: Sudden onset of: • Pulmonary edema • Severe HEMOLYTIC ANEMIA --> elevated LDH |
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What are the physical exam findings of CHRONIC aortic regurgitation?
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'Duz Austin's Quick Muscle Car Blow?'
• Duroziez's murmur -- singsong murmur over femoral artery • Austin-Flint murmur -- presystolic or mid-diastolic murmur • Quincke's pulse -- prominent nail pulsations • deMusset's sign -- head bobbing w/ each beat • Corrigan's (Water-Hammer) pulse -- rapid upstroke, dramatic collapse • High-pitched decrescendo diastolic BLOWING murmur (sine qua non) |
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What are the primary symptoms of MVP?
What symptoms are NOT seen? |
Most common sxs:
• Chest pain • Palpitations NOT SEEN -- sxs of heart failure |
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What etiology is responsible for > 90% of all cases of isolated mitral stenosis?
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Rheumatic heart dz
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What is the difference in device life expectancy and need for anti-coagulation between mechanical and tissue prosthetic heart valves?
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Mechanical:
• Lifespan: > 20 yrs • Requires lifelong anticoagulation Tissue: • Lifespan: 8 - 10 yrs • Following post-op period, anticoagulation optional |
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What is the etiology of mitral valve prolapse?
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Can be:
Autosomal dominant congenital d/o Connective tissue dz: • Marfan's • Ehrlers-Danlos Skeletal abnormalities: • Severe scoliosis Sporadically in o/w nl people |
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What is the most common cause of aortic stenosis in pts less than, and greater than, 65 yo?
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< 65 yo:
• Congenital bicuspid aortic valve > 65 yo: • Calcific aortic stenosis |
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What is the most common complication of mitral stenosis?
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Afib
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What is the most common valvular heart dz?
What is the male to female ratio? |
Mitral valve prolapse
F:M --> 2:1 |
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What is the natural progression of symptoms with aortic stenosis?
Tx once sxs appear? |
1 Angina
2 Syncope 3 Heart failure • ('Aortic Stenosis -- ASH') Valve REPLACEMENT is the only effective tx once sx appear |
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What is the prevalence of MVP?
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10%
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What is the rate of onset of sxs with mitral stenosis?
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Often 10 - 15 years after the onset of murmur
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Which valve dz tends to produce more complications: Mitral stenosis or regurg?
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Mitral STENOSIS
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Which valvular diseases are caused by Marfan's Dz?
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• MVP
• Mitral regurgitation, CHRONIC • Aortic regurgitation, ACUTE |
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Which valvular dz commonly presents with hemoptysis?
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Mitral stenosis
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Which valvular heart conditions are caused by infective endocarditis?
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• Mitral REGURGITATION, acute
• Aortic REGURGITATION • Tricuspid REGURGITATION • Tricuspid stenosis |
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Which valvular heart disease is caused by acute MI? What is the mechanism?
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Mitral regurgitation, acute
Caused by abrupt rupture of: • Chordae tendineae • Papillary muscle • Valve leaflet |
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Which valvular heart dz has a female to male 2:1 ratio?
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MVP
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Which valvular heart dz is characterized by a malar rash?
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Mitral stenosis
malar rash = 'mitral facies' |
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Which valvular heart dz is characterized by a young female athlete who passes out during practice?
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MVP
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What is the general target BP in the acute tx of hypertensive emergency?
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Reduce MAP by 25% in 30-60 minutes
OR Reduce diastolic pressure to about 110 mmHg. |
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What is the treatment protocol for catecholamine-induced hypertensive emergency?
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Pheo or MAOI -- Drugs of choice:
• Labetolol IV; OR • Phentolamine (alpha-blocker) FOLLOWED by a ß-blocker Acute Clonidine Withdrawal: • Restart clonidine; or • Labetolol; or • Phentolamine --> ß-Bl Acute Cocaine Toxicity: • Benzo; if HTN persists --> • Phentolamine --> ß-Bl • Labetolol is alpha-1 and Beta antagonist and is best choice if using a BB alone. |
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What is the treatment protocol for hypertensive emergency + ischemic CVA?
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Tx of HTN with ischemic stroke can be DETRIMENTAL!
Acute reduction in HTN can reduce perfusion to peripheral watershed areas. BP reduction should only be undertaken in pts with severe HTN (> 220/120) IV Nipride or Labetalol are the drugs of choice |
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State the clinical end-organ presentations seen in hypertensive emergency
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• Hypertensive encephalopathy
• CVA, SAH • Aortic dissection • Acute pulmonary edema • AMI/ Ischemia • Eclampsia • Acute renal insufficiency |
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What drugs are indicated for the tx for malignant HTN and hypertensive encephalopathy?
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Nipride -- drug of choice
Other acceptible agents: • Labetalol IV • Nicardipine IV |
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What is the definition and treatment goal of hypertensive URGENCY?
Management/ meds? |
Defn: DP > 115 w/out evidence of end organ failure. (Others say > 180/120).
Tx goal: GRADUALLY lower BP OVER 24 - 48 hrs Give po HCTZ and d/c to home with good f/u instructions. |
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What is the definition of hypertensive EMERGENCY?
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Severely elevated DP (> 115) w/ evidence of acute end-organ damage
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What condition should be suspected in a pt with aortic regurg and aortic valve endocarditis who suddenly develops complete heart block?
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ABSCESS formation extending into the interventricular septum
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