Infective Endocarditis, Pericarditis, Myocarditis, Rheumatic Fever

infective endocarditis what is it

heart valve or tissue is infected by bacteria or fungus

platelet fibrin deposition on abnormal valves at sites of endothelial injury and inflammation, microorganisms adhere to the deposits

• s aureus (hospital/healthcare/community acquired)

• viridans group streptococci

native valve endocarditis

happens on valve you were born with

prosthetic valve endocarditis

happens on valve that was surgically placed

infective endocarditis risk factors

IV drug use (IVDU)

male

age > 60

poor dentition or dental infection

comorbid conditions

infective endocarditis symptoms

fever (immunocompromised or elderly may not have)

murmur new or changing

petechiae on conjunctiva, palate, buccal mucosa, extremities

splinter hemorrhages

osler nodes

janeway lesions

roth spots

chills, myalgias, weight loss, anorexia, malaise

embolization, valvular or cardiac damage, immunologic response

• cough, dyspnea, athralgias, GI, pain: back flank abdomen, stroke, ischemic limb

infective endocarditis dx

blood cultures 2 sets 30-60 mins apart before abx

separate venipuncture sites, 3 sites preferred

CBC - anemia or leukocytosis

elevated ESR, C reactive protein

proteinuria or microscopic hematuria

CXR

EKG

ECHO, TTE then TEE

empiric IV abx if pt is ill for infective endocarditis

vancomycin + ceftriaxone

prosthetic valve endocarditis treatment

vancomycin + gentamicin + rifampin

duration of abx treatment for infective endocarditis

4-6 weeks

surgical eval for all prosthetic valve endocarditis

treatment failures, resistant organisms, large vegetations, valvular incompetence and HF, fungal infections, recurrent

what is avoided in natal valve endocarditis

anticoagulation

prevention of infective endocarditis

good oral hygiene

amoxicillin 2g 30-60 min prior to dental procedure

PCN allergic: cephalexin 2g, azithromycin 500mg, clarithromycin 500mg, doxycycline 100mg

DUKE ISCVID criteria

pathologic criteria, needs:

• two major criteria

• one major criterion and 3 minor criteria

• five minor criteria

major DUKE criteria

microorganisms that commonly cause IE isolated from 2 or more separate CBC sets

abnormal metabolic activity involving a native or prosthetic valve

evidence of IE by direct inspection during heart surgery

minor DUKE criteria

previous history of IE

endovascular intracardiac implantable device (CIED)

positive culture for an organism consistent from IE from body site other than cardiac tissue

abnormal activity within 3 mo implantation of prosthetic valve

linear reddish lesions on nail bed

splinter hemorrhages

papulopustules on pulp of finger

osler nodes

macular, erythematous lesions on palms and soles

janeway lesions

pain in pulp of big toe and multiple painless flat Janeway lesions over sole, white centered retinal hemorrhage

roth spots

infective endocarditis complications

early embolization

acute valve regurgitation

myocardial abscess formation

infective endocarditis prophylaxis

dental procedures

placement of prosthetic valves

LVAD or artificial heart

prior hx of IE

what is pericarditis

inflammation of pericardial sac

idiopathic or viral

infection - bacterial, fungal, TB

post viral

autoimmune, neoplasm, radiation, drugs and toxins, post cardiac injury

viral pericarditis sx

viral: preceded by respiratory or GI sx

infectious: fever, leukocytosis

chest pain

• abrupt, sharp, stabbing, pleuritic (exacerbated by cough or deep breath), improves when pt sits up or leans forward

pericardial friction rub

pericarditis dx

ECG: diffuse ST elevation, PR depression

CXR: normal or cardiomegaly, 200mL of fluid before cardiac silhouette enlarges

ESR/CRP: elevated

Tropnonin may be elevated

Pericardiocentesis

Pericardial biopsy

when do you do pericardiocentesis

small or moderate effusions do not require drainage unless sample needed for diagnostic purposes

diagnostic in malignancy or bacterial etiology

when do you do pericardial biopsy

recurrent pericarditis, tamponade, or conj with pericardiocentesis

tissues sent for cytology, gram stain, cultures

pericarditis tx

ibuprofen 600-800 mg TID or indomethacin 25-50mg TID (3/day)

ASA 650-1000mg TID (acute MI or pts who require antiplatelet therapy)

colchicine 0.5-0.6mg BID for 3 mo (reduces sx and recurrent)

avoid strenuous activity for 1 mo until biomarkers normalize

hospital admission for pericarditis if

fever and leukocytosis

large pericardial effusion

acute trauma

elevated troponin

hx of therapy w oral anticoags

failure to respond within 7 days to NSAID tx

what not to use to treat pericarditis

glucocorticoids, increase in recurrent episodes

• only use when NSAIDs are contra or have failed = pregnancy, renal failure

can be used in pts with connective tissue disease

complications of pericarditis

tamponade, recurrent pericarditis, restrictive pericarditis

how many patients following previous attack of acute pericarditis get recurrent pericarditis

1/3

etiology of recurrent pericarditis

autoimmune, happens 4-6 weeks after initial episode

recurrent pericarditis tx

glucocorticoids, IL 1 inhibitors, pericardiectomy

what is constrictive pericarditis

result of scarring and consequent loss of normal elasticity of pericardial sac

• inelastic thickened pericardium restricts cardiac filling

• follows pericarditis

connective tissue disorders, malignancy, postinfectious (TB)

constrictive pericarditis sx

edema

DOE, fatigue (diminished CO)

elevated JVP on exam (Kussmaul sign)

pulsus paradoxus

pericardial knock

ascites, cachexia

constrictive pericarditis dx

CXR: pericardial calcification

ECG: afib

Echo is critical for dx

pericardial thickness

CT or cardiac MRI

cardiac cath

constrictive pericarditis tx

new pts: trial NSAIDs + colchicine for 2-3 mo

no response:

• glucocorticoid + colchicine

• immunotherapy (IL1 inhibitor)

• pericardiectomy

what is myocarditis

inflammatory disease, viral infection

inflammatory cardiomyopathy = myocarditis + cardiac dysfunction

myocarditis and covid 10

small risk of myocarditis after infection or vaccination

risk of myocarditis greater with disease than with vaccination for most pts

myocarditis sx

subclinical disease

fatigue

chest pain

heart failure

cardiogenic shock: arrhythmias

sudden cardiac death

myocarditis dx

CXR

ECG

troponin may be elevated

BNP elevated

Echo

Cardiac MRI

endomyocardial biopsy = definitive dx

myocarditis tx

admit pt

standard therapy for acute and chronic HF (ARNI/ACE/ARBs/SGLT2 inhibs/ etc)

tx of arrhythmias

LVAD or cardiac transplantation

what to avoid for myocarditis

NSAIDs

alcohol

exercise for 3-6 mo

what would you see on a CXR for myocarditis

cardiomegaly

pulmonary congestion

pleural effusions

what would you see on an ECG for myocarditis

NSST changes

ectopic beats

arrhythmias

heart block

ST elevation

Q waves

LBBB

what would you see on an echo for myocarditis

systolic dysfunction

LV dilation

wall motion abnormalities

acute rheumatic disease jones criteria

two major

one major two minor

major jones criteria

migratory arthritis

carditis and valvullitis

CNS involvement

erythema marginatum

subq nodules

minor jones criteria

arthralgia

fever

elevated ESR and CRP

prolonged PR interval

acute rheumatic fever sx

fever

arthritis

• joints, leg joints, migrates from joint to joint

carditis

• pancarditis, damage to cardiac valves may result in cardiac decompensation

sydenham chorea

• nonrhythmic involuntary movements, muscular weakness

erythema marginatum

• evanescent, pink or faintly red, non-pruritic rash involving trunk and limbs, may appear and disappear within hours

• hot baths make them more evidence

subcutaneous nodules

• firm, painless, elbow, over bony prominence or near tendons

acute rheumatic fever dx

establish group A strep

assess cardiac fx

acute rheumatic fever antibiotic therapy

IM penicillin preferred

throat cultures for household contacts

NSAIDs for arthritis and fever

treatment of carditis = valve replacement, conventional therapy for HF

acute rheumatic fever prevention

tx of group A strep

penicillin G IM every 4 wks

oral PCN for pts with severe valvular disease, HF, or LV dysfunction

general info on rheumatic heart disease

disease of poverty and lack of access to healthcare, follows episodes of ARF

chronic valve disease, mostly mitral but also aortic valve and tricuspid valve

mitral regurg to mitral stenosis

rheumatic heart disease sx

mitral regurg

aortic regurg

LV dilation and HF

rheumatic heart disease dx

portable echocardiography

screen in ages 5-19 in high prevalence areas

rheumatic heart disease tx

abx prophylaxis for years

penicillin G benzathine admin IM every 21-28 days

watchful waiting of valvular disease

• valve repair, replacement, valvuloplasty if needed