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Cardiology IIa

Second Semester

Infective Endocarditis Nidus Rheumatic valve dz, aortic valve sclerosis, aortic/mitral regurge, MVP, congenital heart defects, prosthetic heart valves, IV Drug Users & Patients with indwelling catherters
Subacute endocarditis organism Strept Viridans
Acute (IV User) Endocarditis Organism Staph Aureus
Prosthetic Valve Endocarditis Organism Staph Epidermidis
Fungal Endocarditis caused by... Indwelling Catherters
Endocarditis Pathology Cardiovascular structural abnormality causes a pressure gradient which generates turbulent flow, which causes damage to the low pressure side of the valve. Platlet forms at site of injury. Bacteremia sticks to the sticky platelet & multiplies.
Factors that increase endocarditis risk... Frequent bacteremia. Ability of organism to adhere to the platlet. Organisms ability to resist host defenses.
Classic Triad (Endocarditis) Fever, New murmur or exacerbation of a pre-existing murmur, positive blood cultures.
Presentation of SBE (Subacute bacterial endocarditis) Subtle, low grade fever, constitual symptoms (malaise, anoexia, weight loss, arthralgias, myalgias), Mimics URI, Normal WBC
Presentation of ABE (Acute bacterial endocarditis) Explosive, sudden illness with high fever/rigors, disseminated metastatic infections/infarctions (multiple organ systems), Leukocytosis
Physical Findings of Endocarditis Roth spots (retinal halo), Petechiae, pallor, splenomegaly, subungual (splinter) hemorrhages, Osler nodes (painful, raised lesions), Janeway Lesions (painless/ flat erythematous lesions), CHF, Arrhythmia, Septic pulmonary emboli, neurologic complications
Anticoagulants & Endocarditis... NO - increases the number/amount of bleeding
IV users endocarditis - which valve is usually effected Tricuspid Valve
Prosthetic Valve Endocarditis effects... Both the leaflets AND perivalvular structures (blood goes through sewing ring)
Endocarditis Diagnosis Procedure Dukes Criteria: 2 major criteria OR 1 major/3 minor criteria OR 5 minor criteria
Dukes Major Criteria 2 Positive blood cultures of the organism. Evidence of endocardial involvement (vegetation, myocardial abscess, dehiscence of prosthetic valve)
Dukes Minor Criteria Presence of predisposing condition. Fever greater than 38 C or 104 F. Embolic dz. Immunologic phenomena. Positive blood culture.
Culture method for SBE & ABE SBE - 3 sets of blood cultures obtained several hours apart.ABE - All 3 blood cultures drawn simultaneously (seperate venous sites)
Initial Dx study for endocarditis Transthoracic 2D echo - misses 50% of vegitation - however visualizes complications well
2nd Dx Study for endocarditis Transesophogeal Echo (TEE) - better for prosthetic valves. 90% sensitive. ONLY DO IF IT WILL CHANGE YOUR TREATMENT METHOD
Endocarditis Tx. IV (PICC Line) Bactericidal Abx at high dosages for 4-6 weeks. ABE must be started immediately. SBE can be started 2-3 days following Dx.
Fungal Endocarditis Tx. Amphotericin is the only Abx. fungus responds to however, bad SE. Surgical Valve Replacement - fungus does not respond well to antimicrobial therapy.
Indications that Endocarditis needs Surgical Tx. Progressive/refractory CHF. Persistently positive blood cultures after several days of Abx. Recurrent major emboli. Myocardial abscess associated with conduction abnormalities. Fungal endocarditis. Prosthetic valves tend not to respond to Tx as well.
Endocarditis Prophylaxis Recommended for... Prosthetic cardiac valves, previous bacterial endocarditis, cyanotic congenital heart dz, surgically constructed systemic-pulmonary shunts, cardiac transplant.
Cardiomyopathy heart is abnormally enlarged, thickened, and/or stiff. Heart can not pump blood as well as it should.
Types of Cardiomyopathy Dilated (Primary systolic Dysfunction), Hypertrophic (Systolic/diastolic dysfunction), Restrictive (Primarily diastolic dysfunction)
Dilated Cardiomyopathy Systolic contractile dysfunction - ventricular enlargement (decrease in EF = ^ stasis of blood/thrombi)
Hypertrophic Cardiomyopathy Both systolic and/or diastolic dysfunction
Restrictive Cardiomyopathy Diastolic Dysfunction
Cardiomyopathy Causes Majority are idiopathic. Toxins. Metabolic. Infectious. Inflammatory. Neuromuscular. Inherited.
Toxin causes of Cardiomyopathy ETOH, adriamycin, cocaine, mercury, cobalt & lead
Metabolic causes of Cardiomyopathy Thiamine Deficiency (beri-beri), acrmegaly, thyrotoxicosis, pheochromocytoma
Infectious causes of Cardiomyopathy Viral (coxsackie, CMV, HIV), Rickettsia, Diphtheria, Mycobacteria, Fungal & parasites (Toxoplasma, trichinosis, Chagas)
Inflammatory causes of Cardiomyopathy Scleroderma, SLE, Sarcoidosis, Peripartum (pregnancy)
Neuromuscular causes of Cardiomyopathy Duchenne's muscular dystrophy
Cardiomyopathy DX CXR (cardiomegaly, pulmonary vascular congestion & pleural effusions). 2D Echocardiograph (systolic/diastolic function, EF, valvular function & pericardial dz)
When is Endomyocardial Biopsy for Cardiomyopathy necessary? Differentiating restrictive Cardiomyopathy from constrictive pericarditis. Amyloidosis, carcinoid, sarcoidosis & hemochromatosis. Myocarditis. Toxicity. Cardiac transplant rejection. Endocardial fibroelastosis & endomyocardial fibrosis. Cardiac tumors.
Acute Exacerbation Tx for Cardiomyopathy Diuretics (IV Lasix) & Nitrates (less preload)
Chronic Management for Cardiomyopathy ACE-Inhibitors/ARB's or Hydralazine & nitrate(afterload reducer). Beta blockers (Carvedilol or metoptolol). Digoxin (+ inotrope & - chronotrope) - especially with associated atrial tachycardia.
Amiodarone Ventricular Tachycardia associated with Cardiomyopathy
K+ levels >4.0meq/L
Mg2+ levels >2.0meq/L
Diuretics decrease the ion levels of... K+ & Mg2+
Patients with sustained VT or EF < 35% with Cardiomyopathy should be Tx with... AICD/PCD (Defibrillator)
Anticoagulation Tx & Cardiomyopathy Yes - if no CIs. Especially if EF < 20-30%
Surgical intervention & Cardiomyopathy Ventricular assist devices (temporary), biventricular pacemaker (wide QRS complex), transplant (when all else fails)
Created by: 147401391
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