Infective endocarditis

Infective endocarditis (IE) is an infection of the endocardium of the heart

It produces both intra-cardiac effects as well as a whole range of systemic effects, both emboli (sterile or infected) and a variety of immunological mechanisms


Epidemiology

• 1.7-6.2 cases per 100000 patients / year
• Higher in at-risk groups such as IV drug users
• More common in men (3x)
• More common in elderly
• Other diseases such as diabetes, cancer, and alcoholism

Risk factors

• Previous IE with valvular damage
• Invasive vascular procedures
• Recreational drug abuse
• Rheumatic heart disease (fewer than 20% of cases of IE)
• Elderly patients with calcific aortic stenosis
• Congenital heart disease (accounts for 15%) with bicuspid aortic valve being the most common
• Prosthetic valve implants

Pathogenesis

Thrombus acting as a prerequisite for invasion and adhesion

• Acute IE
• Direct infection of the thrombus
• Subacute IE
• Infection not enough for invading thrombus
• Nonbacterial thrombotic endocarditis
• Renal failure, SLE, neoplasia, malnutrition

Common organisms responsible

• Staphylococcus aureus (the one with IV drug abuse and prosthetic valves 30%)
• Streptococcus
• Pseudomonas aeruginosa
• HACEK
• Haemophilus aphrophilus
• Actinobacillus actinomycetemcomitans
• Cardiobacterium hominis
• Eikenella corrodens
• Kingella kingae
• Fungi
• Enterococci

Presentation

• FEVER + MURMUR
• Subtle and non-specific
• Back pain
• Weight loss
• Polymyalgia-like symptoms
• Look for history of invasive procedures
• Look for history of infarcts in other organs such as kidneys and spleens

Examination

• Fever
• Murmurs
• Petechiae
• Splinter or subungual haemorrhages
• Osler's nodes
• Clubbing
• Roth's spots
• Janeway lesions
• Arthritis
• Splenomegaly
• Meningitis

Differential diagnosis

• SLE
• Atrial myxoma
• Lyme disease
• Antiphospholipid syndrome
• Polymyalgia rheumatica
• Reactive arthritis

Investigations

• Blood cultures
• Serological tests
• Imaging studies
• Transthoracic echocardiography (TTE)
• Transoesophageal echocardiography (TEE)

Diagnostic criteria

• The Duke criteria

Management

• Hospitalisation
• Blood cultures
• Temperature records
• Basic haematology and biochemistry investigations
• ECG and CXR
• Comprehensive TTE
• Blood cultures
• Take 3 to 6 cultures at short intervals
• Referral
• When positive to cardiologist
• At outset to microbiologist
• TTE or TEE
• In all patients with prosthetic heart valves
• Serological testing
• Only if still suspected by cultures negative after 7 days

Medical

• Antibiotic therapy 2-6 weeks

Surgical

• Needed in about 50% of patients
• Stable patients - after antibiotic therapy
• Unstable patients - earlier opportunity

Complications

• Valve dysfunction
• Myocardial abscess
• Embolic phenomena
• Heart failure
• Metastatic infection
• Immunological disease and organ dysfunction
• Complications even after bacteriological care
• Conduction defects (patients with IE should have daily ECGs)

Prognosis

• Cure rates 60 to 98%
• Lower by 10% in PVE for all categories

Prevention

• ANTIBIOTIC PROPHYLAXIS

Acute coronary syndrome

Acute coronary syndrome (ACS) is a medical emergency and requires IMMEDIATE HOSPITAL ADMISSION!


Definition

• Classified based on changes on the ECG and serial cardiac troponin levels
• Refers to a range of acute myocardial ischaemic states
• ST elevation
• Non-ST elevation
• Unstable angina (no rise in troponin levels)
• Non-ST elevation MI (rise in troponin levels)
• Troponin I is more SPECIFIC (less false positives)
• Troponin T is more SENSITIVE (less false negatives)

Epidemiology

• 3 in 1000 every year for Non-STEMI
• 114000 in total every year

Risk factors (for atherosclerosis)

Modifiable

• Age
• Male
• FH
• Premature menopause
• Racial - Indian, Pakistan, Bangladesh

Non-modifiable

• Smoking
• Diabetes mellitus (impaired glucose tolerance)
• Hypertension
• Dyslipidaemia (Raised LDL and Lowered HDL)
• Obesity
• Physical inactivity

Presentation

Symptoms of ACS

• Pain in the chest and/or other areas including the arms, back or jaw lasting longer than 15 minutes
• Chest pain with nausea and vomiting, marked sweating and/or breathlessness, or haemodynamic instability
• New-onset chest pain, or abrupt deterioration in stable angina, with recurrent pain occuring frequently with little or no exertion and lasting longer than 15 minutes

• Prolonged (more than 20 minutes) anginal pain at rest
• New-onset angina with limitation on daily activities
• Recent destabilisation of previously stable angina, with moderate or severe limitation of daily activites
• Post-myocardial infarction angina
• Associated with:
• Sweating
• Nausea
• Vomiting
• Dyspnoea
• Fatigue
• Shortness of breath
• Palpitations

Differential diagnoses

• Cardiovascular
• Acute pericarditis
• Myocarditis
• Aortic stenosis
• Aortic dissection
• Pulmonary embolism
• Respiratory
• Pneumonia
• Pneumothorax
• Gastrointestinal
• Oesophageal spasm
• Oesophagitis
• GORD
• Acute gastritis
• Cholecystitis
• Pancreatitis
• Musculoskeletal
• Tietze's

Investigations

• 12-lead ECG
• Cardiac enzymes
• FBC
• Blood glucose
• Echocardiography
• CXR
• Cardiac Magnetic Resonance imaging (CMR)
• Coronary angiography (gold standard)

Management

• Urgent hospital admission
• Resuscitation
• Pain relief - Intravenous opioid (with anti-emetic), GTN
• 300mg Aspirin unless patient is allergic
• Resting 12 lead ECG
• Oxygen sats with pulse oximetry

Drugs

• Anticoagulation
• Aspirin
• Clopidogrel
• Prasugrel + Aspirin
• Ticagrelor + Aspirin (long term)
• Glycoprotein IIb/IIIa inhibitors
• Antithrombin therapy
• Revascularisation
• Coronary angiography with follow on PCI
• Other
• Nitrates
• Beta-blockers
• Calcium antagonists (Calcium channel blockers)
• ACE inhibitors

Further

• Assess LV function
• Cardiac rehabilitation
• LIFESTYLE ADVICE

Prognosis

• In hospital death and re-infarction in 5-10%
• Poor prognosis factors:
• Advanced age
• Severe ECG changes
• Big rise in troponin
• LV dysfunction, cardiogenic shock
• Increased heart rate + arrhythmias
• Renal impairment
• Diabetes mellitus
• Anaemia
• Cerebrovascular disease/ peripheral vascular disease

Prevention

LIFESTYLE ADVICE!!!!!

Angina

Definition

 

Angina is chest pain or discomfort that is caused when the heart muscle does not get enough blood.

 

The question is always whether or not it is ACUTE CORONARY SYNDROME instead.

 

Epidemiology

• Roughly 10% for men and 5% for women over 55 years
• South Asian origin
• Lower socio-economic groups

 

Risk factors

• Family history
• Smoking
• Diabetes mellitus
• Metabolic syndrome
• Hyperlipidaemia
• Hypertension
• Obesity
• Lack of exercise
• Cardiac abnormalities (like hypertrophic obstructive cardiomyopathy)

 

Presentation

 

Note: If chest pain is present at the time of consultation, give some sublingual glyceryl trinitrate (GTN) and if the pain doesn't resolve within a few minutes, treat as ACUTE CORONARY SYNDROME

 

• Anginal pain (Typical = all 3, Atypical = 1 or 2)
• Constricting discomfort in the front of the chest, neck, shoulders, jaws, and arms
• Precipitated by physical exertion
• Relieved by rest or GTN in about 5 minutes

• Consider
• Risk factors as listed above
• History of cardiovascular disease
 

Differential diagnoses

• Acute myocardial infarction
• Prinzmetal's angina
• Acute pericarditis
• Musculoskeletal pain (Tietze's)
• GORD
• Pleuritic chest pain
• Aortic dissection
• Gallstones

 

Investigations

• ECG
• Pathological Q waves
• LBBB
• ST segment or T wave abnormalities
• FBC
• Renal function
• Fasting blood glucose
• Fasting blood cholesterol and triglycerides
• LFTs before statins
• TFTs
• Test troponins or cardiac enzymes
• Echocardiography

 

Management

If there are warning signs suggestive of acute coronary syndrome, referral is necessary

Conservative

• Patient informed of diagnosis and implications
• Exercise more, stop smoking, and generally reduce modifiable risk factors
• Check driving fitness
• If an attack is experienced
• Stop and rest
• Take GTN, again after 5 minutes if still not subsided, and a third time after another 5 minutes
• Call the ambulance if it still hasn't subsided

Medical

• Beta-blocker or calcium-channel blocker as first line
• Switch or combine if there is a problem
• After that, or if there are contraindications:
• Long-acting nitrate
• Ivabradine
• Nicorandil
• Ranolazine
• Other
• Aspirin or clopidogrel
• Statins
• ACE inhibitors (in those with stable angina and diabetes)

Surgical

• Coronary revascularisation

Prognosis

• 1 in 10 will suffer myocardial infarction within a year of diagnosis
• Annual total mortality rate is 5%

 

Radiological findings of Osteoarthritis vs Rheumatoid arthritis

Osteoarthritis (JOBSS)

• Joint space narrowing
• Osteophytes
• Bone cysts
• Subchondral sclerosis
• Subluxation

Rheumatoid arthritis (JOSS)

• Joint space narrowing
• Osteopenia (juxta-articular)
• Bony erosions
• Soft tissue swelling
• Subluxation

CRITOE criteria for determining the age of a child - Elbow X ray

Elbow X rays on children can be used to determine a child's age, based on the ossification of epiphyseal plates.

Acronym letter - Anatomical part - Age

C - Capitulum - 1
R - Radial head - 3
I - Internal epicondyle - 5
T - Trochlea - 7
O - Olecranon - 9
E - External epicondyle - 11

Gastro-oesophageal reflux disease (GORD)

Definition

• Passage of gastric content into the oesophagus due to relaxation of the lower oesophageal sphincter
• Acid or bile causes mucosal irritation

Aetiology

• Ineffective lower oesophageal sphincter
• Hiatus hernia
• Obesity
• Alcohol (increased acid secretion)
• Oesophageal dysmotility
• Pregnancy
• Drugs: nifedipine / isosorbide mononitrate

Clinical features

• Retrosternal burning pain (heartburn)
• Often during the night or when bending over
• Associated bitter taste in the mouth
• Sore throat / dysphonia
• Excessive salivation (water-brash)
• Nocturnal cough or bronchospasm (aspiration)
• Dysphagia (difficulty in swallowing)
• Peptic stricture

Investigations

• Trial of antacid / proton pump inhibitor
• Upper GI endoscopy
• Oesophageal pH studies and manometry

Management

• Lifestyle changes: reduce smoking / alcohol
• Lose weight
• Antacids
• Histamine2-receptor blocker, e.g. ranitidine
• Proton Pump inhibitors, e.g. omeprazole
• (Laparoscopic) Nissen fundoplication

Complications

• Peptic oesophageal strictures
• Barrett's oesophagus
• Oesophageal adenocarcinoma

Hiatus hernia

Definition

• Herniation of the stomach into the thorax
• Sliding: gastro-oesophageal junction above diaphragm
• Rolling: fundus herniates beside the oesophagus
• Disrupts lower oesophageal sphincter leading to gastro-oesophageal reflux

Clinical features

• Usually none
• Heartburn due to reflux

Management

• Treat reflux
• Surgery for large hernias/severe reflux
• Fundoplication
• 360 degrees Nissen
• 270 degrees Toupet
• 180 degrees Dors (done with Heller's myotomy)