Infective Endocarditis

 

Any new onset murmur with fever is infective endocarditis until proven otherwise

 

Infective endocarditis is an infection of the endocardial surface of the heart. The intracardiac effects of this infection include severe valvular insufficiency, which may lead to intractable congestive heart failure and myocardial abscesses

In 75% of cases of IVDA no underlying valvular abnormalities are noted, and 50% of these infections involve the tricuspid valve. Primary cause is:

    • S aureus (aka “Acute bacterial endocarditis”)
    • Overall most common cause is IVDA 
    • More than half the cases are not associated with underlying valvular disease.
    • Prosthetic valves

In non IV drug abusers the mitral is most commonly attacked valve and the primary etiology is:

  • Streptococcus viridans (aka “subacute bacterial endocarditis”)
    • This organism accounts for approximately 50-60% of cases of subacute disease.
    • Most clinical signs and symptoms are mediated immunologically
  • Roth’s spots are noted in the retina
  • Janeway lesions usually arise from infected microemboli
  • Osler Nodes: small tender subcutaneous nodules on digits

DX:

  • Echocardiography has become the indirect diagnostic method of choice
  • Transesophageal echocardiography was developed to overcome the problems in visualizing prosthetic valve thrombi and right-sided events.
  • Procedure of choice if the suspicion is high

 

TX: IV PCN and ceftriaxone

  • Adult antimicrobial IE preventive regimens for dental, oral, respiratory tract, infected soft tissue, or esophageal procedures recommended from oral-dental sources are as follows:
  • Administer amoxicillin at 2 g orally 1 hour before the procedure and 1gm 2hours after the procedure others Ampicliin, cephalexin, clindamycin, ceftriaxone
  • Prophylactic PCN with oral surgeries and Invasive manipulation of the respiratory tract for example tonsillectomies, rigid bronchoscopy. Gastrointestinal surgery, biliary tract surgery, sclerotherapy of esophageal varices, dilatation of esophageal strictures, and ECP
  • Established GU infection
  • Generally, hysterectomies, vaginal delivery, cesarean delivery, urethral catheterizations, dilation and curettage, therapeutic abortions, sterilization procedures, insertion or removal of intrauterine devices, cardiac catheterizations, angioplasties, or endoscopies with or without biopsies do not require prophylaxis.

 

Rheumatic Heart Disease

 

·         Chronic rheumatic heart disease remains the leading cause of mitral valve stenosis and valve replacement in adults in the United States

·         1st Mitral valve, 2nd Aortic Valve, 3rd Tricuspid Valve

·         Rheumatic fever develops in children and adolescents following pharyngitis with group A beta-hemolytic Streptococcus

·         The presence of the M protein is the most important virulence factor for group A streptococcal infection in humans and anti–M antibodies against the streptococcal infection may cross react with heart tissue.

 

·         The major diagnostic criteria include carditis, polyarthritis, chorea, subcutaneous nodules, and erythema marginatum.

·         The minor diagnostic criteria include fever, arthralgia, prolonged PR interval on the electrocardiogram, elevated acute phase reactants (increased erythrocyte sedimentation rate [ESR]), presence of C-reactive protein, and leukocytosis.

·         ASO Titer test

·         Patients with rheumatic heart disease also may develop atrial flutter, multifocal atrial tachycardia, or atrial fibrillation from chronic mitral valve disease and atrial dilation

·          

·         The murmurs of acute rheumatic fever are typically from valve insufficiency The mitral insufficiency is related to dysfunction of the valve, chordae, and papillary muscles.

·         Other SXS include CHF, Pericarditis

 

Aortic Stenosis

 

  • Males>females
  • congenital bicuspid valve, rheumatic fever
  • degenerative calcific changes of the valve
  • most common acquired valve stenosis
  • right 2nd ICS radiates to carotids and down to border of apex
  • SXS: syncope, dyspnea, angina on exertion
  • Visual disturbances
  • Gradual decrease in physical activity with insidious progression of fatigue and dyspnea on exertion
  • Angina pectoris (30-40%)
  • Patients may have a higher incidence of nitroglycerin-induced syncope than the general population.
  • Always consider AS as a possible etiology for a patient in the ED with particular hemodynamic sensitivity to nitrates.
     Syncope during exertion:
  • Proposed mechanisms include arrhythmias and left ventricular failure with an abrupt decline in cardiac output
  • Systolic ejection murmur with radiation to the neck
  • Heard best 2nd ICS right side
  • LVH after long standing disease and left ventricular lift

 

  • CXR will show LVH and on EKG there is LVH

 

  • Need Coumadin to prevent emboli

 

  • Echocardiogram is the diagnostic test of choice

 

Aortic Insufficiency (Regurgitation)

  • Primary causes are idiopathic(80%) and hypertension, rheumatic fever, and bacterial endocarditis, SLE, RA, Marfan ‘s
  • ??SSRIs??
  • SXS: fatigue, weakness, exertional dyspnea, syncope, CP with exertion
  • Wide arterial pulse pressure causing “Water hammer pulse”
  • High pitched decrescendo diastolic murmur heard along the left sternal border  2nd to 3rd ICS
  • Diastolic blowing murmur
  • Austin Flint murmur is a mid-diastolic c/w aortic regurgitation
  • patient is seated and leans forward with breath held in expiration
  • Remember blood flow is going back into the heart and left ventricle being removed from the peripheral arterial system

 

  • Echocardiogram is the diagnostic test of choice

 

 

 

Mitral Stenosis

 

  • Most common valvular disorder caused by rheumatic fever
  • SLE, RA
  • After the initial episode of RF, a latency period of 20-40 years occurs until the onset of symptoms
  • Pathophysiology: type 5 streptococcal M protein, which cross-reacts with myocardial tissue. Pathologic examination of the mitral valve at this time reveals proliferation of fibroblasts and macrophages.
  • Atrial fibrillation in 80% of these patients (new onset)
  • SXS: typical “diastolic opening snap” accentuated S1
  • Characteristic diastolic low-pitched, rumbling murmur sudden squatting all are useful in accentuating the murmur
  • Orthopnea, DOE, PND EKG=LAH
  • Systemic embolism
  • Infective endocarditis
  • Heard best at the apex

 

  • Echocardiogram is the diagnostic test of choice

 

 

Mitral Regurgitation (Insufficiency)

 

  • Most common cause is mitral valve prolapse (MVP) has become the being responsible for 45% of cases of mitral regurgitation
  • Causes: spontaneous chordae tendineae rupture secondary to myocardial infarction the left anterior descending artery being the cause of the acute MI=acute cardiogenic shock
  • spontaneous chordae tendineae or papillary muscle rupture secondary to myocardial infarction
  • Acute mitral regurgitation
  • When associated with coronary artery disease and acute myocardial infarction typically, inferior myocardial infarction, which may lead to papillary muscle dysfunction
  • Rheumatic heart disease
  • The murmur often is harsh. It may be heard over the back of the neck, vertebra, and/or sacrum and may radiate to the axilla, back, and left sternal border.
  • Loud pansystolic murmur at the apex radiating to the axilla and base
  • SXS: fatigue, exertional dyspnea, orthopnea
  • S3 gallop secondary to LVH

 

 

 

 

 

Mitral Valve Prolapse

  • Clinical syndrome which is usually benign
  • Females>males
  • Age 14-30 and thin  ??Marfan’s??
  • SXS: palpitations lightheaded syncope
  • Mid or late systolic click crescendo-decrescendo
  • murmur heard best at the apex
  • Apical midsystolic nonejection click and late systolic murmur are the hallmarks, but either may occur alone.
  • Sometimes see inverted T waves in II, III, aVF
  • Squatting, however, may also be associated with an increase in peripheral vascular resistance, which, in turn, increases the tension on the mitral valve apparatus, preferentially directing blood flow into the left atrium, rather than to the peripheral circulation. The late systolic click and murmur then become accentuated in the squatting position
  • Echocardiogram is the diagnostic test of choice
  • Tx with beta blocker such as Atenolol

 

Tricuspid Regurgitation

  • Caused by pulmonary HTN from COPD
  • Ebstein anomaly is the most common congenital form
  • In young adults Rheumatic disease is the most common cause of pure tricuspid regurgitation due to deformation of the leaflets.
  • In the adult carcinoid, bacterial endocarditis, and CHF, Marfan’s, RA
  • Medication phentermine and fenfluramine (phen-fen) or dexfenfluramine
  • SXS= right sided heart failure, ascites, leg edema, JVD
  • A high-pitched pansystolic murmur (4th ICS in the parasternal region)
  • Increase with inspiration and decrease with exspiration
  • reduced in intensity and duration in the standing position and during a Valsalva maneuver.
  • DX; Echocardiogram

 

Pulmonary Stenosis

Most common cause is congenital

Rheumatic heart disease, carcinoid

SXS: syncope, SOB, RVH leads to RAD

S2  is widely split. The width of the split increases with worsening stenosis.

 Systolic ejection murmur best heard at the left upper sternal border with radiation into infraclavicular regions, axillae, or back.

DX: Echocardiogram

 

 

 

Commotio cordis (which is Latin for "disturbance of the heart") is, in essence, a concussion of the heart. Initially described as early as 1857, it is defined as an instantaneous cardiac arrest produced by a witnessed, nonpenetrating blow to the chest, in the absence of preexisting heart disease or identifiable morphologic injury to the sternum, ribs, chest wall, or heart.

 

EKG Pic