Infectious diseases of the heart
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Transcript of Infectious diseases of the heart
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3.2 INFECTIOUS DISEASES OF THE HEART
• 3.2.1.ENDOCARDITIS
• 3.2.2. MYOCARDITIS
• 3.2.3. PERICARDITIS
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•Endocardium → Endocarditis•Myocardium → Myocarditis•Pericardium → Pericarditis
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The Layers of the HeartEndocardium – membrane that lines inside the chambers of the heart and forms the surface of the valves.
Myocardium – muscular tissue of the heart
Pericardium – membrane enclosing the heart.
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3.2.1. Endocarditis
• It is an inflammation of the inner layer of the Heart, the ENDOCARDIUM.• It usually involves the HEART VALVES.• Characterized by a lesion called
VEGETATION
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Other structures which may be involved include the:• INTERVENTRICULAR SEPTUM • CHORDAE TENDINAE• MURAL ENDOCARDIUM• INTRACARDIAC DEVICES.
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How does Endocarditis happen?This occurs when bacteria or other germs from another part of your body, such as your mouth, spread through your bloodstream and attach to damaged areas in your heart
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Symptoms:• Fever and chills • A new or changed heart murmur• Fatigue• Aching joints and muscles• Night sweats• SOB
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• Paleness• Persistent cough• Swelling on the
feet, legs and abdomen
• Unexplained weight loss
• Blood in the urine• Tenderness in the
spleen• Osler’s nodes• petechiae
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Risk factors:• Artificial heart valves• Congenital heart defects• History of endocarditis• Damaged heart valves• History of intravenous (IV) illegal drug use
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Complications:
• Stroke • Organ damage• Infections in other parts of the body• Heart failure
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Tests and diagnosis• Blood tests• Transesophageal echocardiogram• Electrocardiogram• Chest X-ray• CT scan or MRI
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Treatment:
• Antibiotics – first line of treatment in Endocarditis
• Surgery – If the infection damages your heart valves
– Sometimes needed to treat Endocarditis caused by a fungal infection.
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Prevention:
Dental health
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Avoid body piercings and tattoos.
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Seek prompt medical attention if you develop any type of skin infection, open cuts or sores that don’t heal properly.
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Preventive antibiotics
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• Artificial or prosthetic heart valve• Previous endocarditis infection• Certain types of congenital heart defects• Heart transplant complicated by heart
valve problems
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Antibiotics are recommended before the ff procedures:a)Dental procedures that cut through the
gum tissue or part of the teethb)Procedures involving the respiratory tract,
infected skin or tissue that connects muscle to bone
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3.2.2. Myocarditis
• Inflammation of the middle layer of the heart wall, the MYOCARDIUM.
• It involves the heart’s MUSCLE CELLS and ELECTRICAL SYSTEM.• May be chronic or acute• It is usually of sudden onset.• Studies suggest that myocarditis is a major cause of sudden (20%),
unexpected death in adults less than 40 years of age
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COMPARISON:
Myocarditis causes the heart muscle to become thick and swollenIf severe, the pumping action of the heart weakens, and the heart won’t be able to supply the rest of the body with enough blood.CLOTS could also form, leading to a stroke or a heart attack.
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An infectio
us organis
m directly invades myocardium
Triggers an
autoimmune ,
cellular or
humoral reaction
Local and
systemic
immunological inflamm
ation ensues
Inflammation leads to
hypertrophy, fibrosis and
inflammatory changes of
the myocardium
and conduction
system
Heart muscle weakens and
contractility is reduce
d
Heart muscl
es dilate
d
Pinpoint
hemorrhages
may develo
p
Pathophysiology of Myocarditis
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EtiologyInfection: • viruses : Cocksackie B, Echovirus, HIV, Adenovirus,
Cytomegalovirus, Epstein-Barr Virus, Varicella Zoster Virus and others
• bacteria: Diptheria (in ¼ of Diptheria cases), in setting of endocarditis
• spirochetes: lyme (Borrelia bergdorferi) • fungi: Candida, Aspergillus, histo, cocci, crypto • parasites: Chagas (Trypanosoma cruzi), toxocara,
trichinosis
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EtiologyDrugs/Toxins • hypersensitivity reactions: sulfa, PCN, NSAIDs, • chemo: doxorubicin • others: cocaine, Li, cyclophosphamide, EtOH Autoimmune diseases:• SLE (Systemic Lupus Erythematosus), sarcoidosis, RA,
dermatomyositis • Other: radiation, Giant-Cell myocarditis
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Clinical ManifestationPatients may be asymptomatic with an infection that resolves on its own. May develop mild to moderate symptoms such as:• Flu-like symptoms and tachycardia (most common)• Dyspnea• Palpitations• discomfort in chest and upper abdomen
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Clinical Manifestation• Pericardial friction rub may be heard if associated with
pericarditis• Cardiomegaly (arrhythmia, edema)• pulsus alternans may be present (alternating strong and weak
pulses)• Murmurs of mitral or tricuspid regurgitation are common, s3
and s4 gallops may also be heard.• CHF symptoms may develop
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Medical Management• Penicillin - for hemolytic streptococci• ACE Inhibitors - relax the blood vessels in the heart and help
blood flow more easily• Beta-blockers are avoided because it decreases the strength
of ventricular contraction (have a negative inotropic effect)• Anticongestive measures such as diuretics, inotropics,
oxygen, digoxin (use cautiously) IVIG (2g/kg over 24 hours) effective in some cases secondary to Kawasaki disease;
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Nursing Management • Monitor for Digitalis toxicity (Dysrhythmia, anorexia, N/V, bradycardia,
headache, malaise)• Apply and instruct patient and family in use of elastic stockings and
active and passive exercises• Instruct patient to increase physical activity slowly and report symptoms
of rapid heart rate upon increasing activity.• Instruct patient to avoid competitive sports and alcohol• Promote bed rest• Continuous cardiac monitoring
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Diagnostic Tests• ECG: Sinus tachycardia, decreased QRS voltage, ST-T wave
abnormalities, arrhythmias• CXR: Enlarged heart; pulmonary edema• 2D Echo: Cardiac chamber enlargement, impaired LV function• Labs: Cardiac troponin levels (Troponin-I and T) and
myocardial enzymes (CK-MB) elevated; confirmed by biopsy
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Prevention:• Avoid people with viral or flu-like illnesses until they’ve
fully recovered.• Follow good hygiene.• Avoid risky behaviors.• Minimize exposure to ticks.• Get your vaccines, especially those that protect against
rubella and influenza – diseases that can cause Myocarditis.
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Key points in Myocarditis• Myocarditis can be caused by viral, bacterial, spirochetal,
fungal, or parasitic infections, drugs/toxins, and autoimmune diseases. • EKG’s in myocarditis can have non-specific ST-T changes,
atrial or ventricular arrhythmias, or ST-elevation diffusely or focally. • Troponin I will be positive in 1/3 of cases of myocarditis. • Treatment is supportive, including exercise avoidance
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3.2.3 Pericarditis• It is the swelling and irritation of the membranous sac
enveloping your heart called the PERICARDIUM. • May be ACUTE or CHRONIC.• Associated with a sharp chest pain (pericardium rub• Usually begins suddenly but doesn’t last long.
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Acute pericard
ial effusion
The pressure
of the pericard
ial cavity
increases
FV (filling
volume) of the
ventricular
diastoledecreas
es
SV (Strok
e volum
e) decrea
ses
BP lowe
rs
Pathophysiology of Pericarditis
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Etiology• Idiopathic/Viral: 75-80% of cases Infection: • viral: coxsackie, echo, adeno, EBV, HIV, hepatitis B • bacterial: Staph, Strep, pneumococcus, H. flu, TB • fungal: histo (most common fungus), aspergillus, cocci • rickettsial, parasitic
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Etiology• Radiation • Malignancy: lung, breast, lymphoma, melanoma, primary
cardiac (rhabdomyosarcoma) • Autoimmune: SLE, RA, systemic sclerosis, vasculitis, Behcet’s,
sarcoid • Drugs/toxins: procainamide, INH, hydralazine (lupus
syndrome), PCN, dilantin • Other: uremia, post-MI, post-CABG, trauma, amyloid
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Clinical Manifestation/Physical Exam• Chest pain is the most common complaint
• sharp, pleuritic, retrosternal, radiating to L shoulder, relieved by sitting up
• can mimic angina/ischemic chest pain
• Can have fever, myalgias, fatigue • Heart failure is rare and indicates myocarditis • Pericardial friction rub can be heard in up to 85% of
patients • scratchy or squeaking sound • classic 3 phase: atrial systole, ventricular systole, ventricular
diastole
• Look for evidence of Tamponade on exam
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Types of acute pericarditis:
• Serous pericarditis• Fibrinous pericarditis• Purulent pericarditis• Hemorrhagic pericarditis
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Serous pericarditis• Usually caused by non-infectious inflammatory diseases such
as RHEUMATOID ARTHRITIS, SYSTEMIC LUPUS ERYTHEMATOSUS, SCRELORDERMA, TUMOR, UREMIA.
• BACTERIAL PLEURITIS may cause sufficient irritation of the pericardium.
• VIRAL INFECTION antedates pericarditis.• Morphology: inflammatory reaction with few neutrophils,
lymphocytes and histiocytes.
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Fibrinous pericarditis• Most common type of pericarditis• It is an exudative inflammation.• The epicardium is infiltrated by the fibrinous exudate.• Common causes include: ACUTE MYOCARDIAL
INFARCTION, POSTINFARCTION (incl. Dressler syndrome), UREMIA, RADIATION and TRAUMA.
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Purulent or suppurative pericarditis• Red, granular surface coated with pus, lots of subsurface
neutrophils, up to 500ml exudate in the pericardium.• Immunosuppression facilitates this condition.• Commonly seen in patients with empyema, mediastinitis,
endocarditis, burn, and post pericardiodectomy.• Diagnosis: ECG, echocardiography, Gallium67 scan with
SPECT, Gallium67 and TC99 scan.
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Hemorrhagic pericarditis• Blood mixed with a fibrinous or suppurative effusion• Most commonly caused by TUBERCULOSIS or DIRECT
NEOPLASTIC INVASION.• Can also occur in severe bacterial infections• Also common after surgery and may cause tamponade• Clinical significance is similar to suppurative pericarditis
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Type of chronic pericarditis:
• Adhesive mediastino pericarditis• Constricitive pericarditis
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Adhesive mediastino pericarditis• Follows suppurative pericarditis, cardiac surgery or
irradiation. • The pericardial potential space is obliterated• Adhesion of the external surface to the surrounding
structures occurs• Clinically, systolic contraction of ribcage and
diaphragm may be observed• ↑ workload may cause massive cardiac hypertrophy
and dilatation
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Constrictive pericarditis
• Usually caused by hemorhhagic, suppurative or caseous pericarditis
• Heart becomes encased in a layer of scar or calcification
• Usually 0.5cm to 1cm thick, resembling a plaster mold
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Clinical Management• Treatment depends on the cause• Analgesics and NSAIDS• Corticosteroid• Antibiotic• Pericariocentesis• Surgical treatment
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Nursing Management• Stress the importance of bed rest,• Assist the patient with bathing if necessary.• Provide a bedside commode because this method puts
less stress on the heart rather than using a bed pan.• Place the patient in upright position to relieve
dyspnea and chest pain.• Provide analgesics to relieve pain and oxygen to
prevent tissue hypoxia.
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Nursing Management• Assess the patient’s cardiovascular status frequently,
watching for signs of cardiac tamponade.• Monitor the patient’s pain level and the effectiveness of
analgesics.• Explain all tests and treatments to the patient.• Before giving antibiotics, obtain a patient history for
allergy.• Tell the patient to resume his daily activities slowly and
to schedule rest periods into his daily routine for a while.
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Diagnostic Tests• Labs/EKG/ECHO • Troponin I positive in up to 49% of patients • EKG shows diffuse ST elevations and PR depression • Look for PR elevation in lead aVR (“knuckle sign”) • Can be followed by diffuse T-wave inversions • No Q waves or reciprocal ST-changes (unlike acute MI) • Echo typically shows small accumulation of fluid w/o tamponade
and nl LV fxn
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Key Points • Acute pericarditis is most commonly
viral/idiopathic but can be caused by infection, radiation, malignancy, autoimmune disease, drugs, and uremia.• Classic presentation is pleuritic chest pain w/
associated friction rub. • EKG shows diffuse ST elevation and PR
depression w/ PR elevation in lead aVR.
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Rosemarie C. ReyesBSN III
NCM 103 – LectureMr. Rafael Salinas
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