Inflammatory Heart Disease
Pericarditis
• inflammation of the pericardium
Causes: may result from bacterial, viral or fungal infection can be assoc. w/ systemic diseases such as autoimmune disorders, rheumatic fever, tuberculosis, cancer, leukemia, kidney failure, HIV infection, AIDS, and hypothyroidism Heart attack (post-MI pericarditis) and myocarditis radiation therapy to the chest and medications that suppress the immune system injury (including surgery) or trauma to the chest, esophagus, or heart.
Pericarditis
PathophysiologyInflammation of the
pericardium
Ventricular filling and emptying
Intrapericardial pressure
Arterial pressure
Compression of the heart
CO Venous pressure
Pericardial effusionFluid accumulation (serous, purulent,
blood) in the pericardial sac
Acute Pericarditis – result to exudate formation (if severe, can lead to cardiac tamponade)
Chronic Pericarditis – result to fibrosing (hardening) of the pericardial sac
- the thick fibrous pericardium tightens around the heart and efficiency as a pump (Constrictive Pericarditis)
Clinical Manifestations Pericardial friction rub Severe precordial chest pain – caused by the inflamed pericardium rubbing against the heart
Usually relieved by sitting up and leaning forward Pleuritis type: a sharp, stabbing pain May radiate to the neck, left shoulder & arm, back or abdomen Often intensify with deep breathing and lying flat, and may
with coughing and swallowing Breathing difficulty when lying down Need to bend over or hold the chest while breathing Dry cough Ankle, feet and leg swelling (occasionally) Anxiety muffled or heart sounds Fatigue if severe- rales, breath sounds Fever
Diagnostic tests Chest x-ray Echocardiogram Chest MRI or CT scan
show enlargement of the heart from fluid collection in the pericardium, and signs of inflammation. They may also show scarring and contracture of the pericardium (constrictive pericarditis)
ECG is abnormal in 90% of pts. w/ acute pericarditis. may mimic the ECG changes of MI. To rule out heart attack, serial
cardiac marker levels (CK -MB and troponin I) may be ordered
Blood culture CBC, may show increased WBC count Pericardiocentesis, with chemical analysis and pericardial fluid culture
Constrictive Pericarditis
a chronic form of pericarditis in w/c the pericardium is rigid, thickened, scarred, and less elastic than normal
The pericardium cannot stretch as the heart beats, which prevents the chambers of the heart from filling w/ blood
CO & blood backs up behind the heart
symptoms of heart failure
The inflamed pericardium may cause pain when it rubs against the heart.
Causes: most common causes are conditions that induce chronic inflammation of the pericardium: tuberculosis, radiation therapy to the chest, and cardiac surgery. may also result from mesothelioma (a tumor) of the pericardium incomplete drainage of abnormal fluid accumulating in the pericardial sac, which can occur in purulent pericarditis or in post-surgery hemopericardium(bleeding w/in the pericardial sac).S/Sx: dyspnea that develops slowly and progressively worsens Fatigue, excessive tiredness - CO Weakness weak heart sounds distended neck veins chronic swelling (edema) of the legs, ankles hepatomegaly, ascites
Interventions identify the cause, if possible analgesics for pain, anti-pyretics, anti-inflammatory drugs(NSAIDS) such as aspirin and ibuprofen, in some cases, corticosteroids may be prescribed Diuretics- to remove excess fluid Pericardiocentesis - using a 2D-echo-guided needle aspiration or surgically in a minor procedure Antibiotics or antifungal agents(can be instilled directly to the sac) Bed rest, proper positioning, low-Na+ diet If the pericarditis is chronic, recurrent, or causes constrictive pericarditis, cutting or removing part of the pericardium may be recommended (Pericardiectomy)
Cardiac Tamponade compression of the heart caused by blood or fluid accumulation in
the space between the myocardium and the pericardium
prevents the ventricles from expanding fully, so they cannot adequately fill or pump blood
CO & signs of CHF
Causes: Pericarditis caused by bacterial or viral infections Heart surgery dissecting aortic aneurysm (thoracic) wounds to the heart end-stage lung cancer acute MI Other potential causes: heart tumors, kidney failure, recent
heart attack, recent open heart surgery, recent invasive heart procedures, radiation therapy to the chest, and SLE
Clinical Manifestations
weak or absent PMI & peripheral pulses distended neck veins muffled or decreased heart sounds BP, narrowing pulse presure pulsus paradoxus (BP falls when pt. inhales deeply) Anxiety, restlessness, tachycardia, dyspnea, RR, palpitations Fainting, light-headedness, pallor or cyanosis Chest pain- sharp, stabbing, worsened by deep breathing or coughing signs of CHF CXR, Echocardiogram – pericardial effusion
Interventions an Emergency condition ! Goal: save the patient's life, improve heart function, relieve symptoms, and treat the tamponade Pericardiocentesis (to drain the fluid around the heart) or by cutting & removing part of the pericardium (pericardiectomy or pericardial window). IV Fluids- to maintain normal blood pressure Dopamine, dobutamine - BP Oxygen therapy - workload on the heart Identify and treat cause of tamponade – give antibiotics or surgical repair of injury.
Myocarditis inflammatory disease of the myocardium that causes infiltration and injury to myocardial tissueCauses: infectious process – viral, bacterial, parasitic infection
- invasion of myocardial tissue by organisms or production of
toxins (Ex. polio, influenza, rubella) autoimmune reaction – rheumatic fever
cardiac damage is char. by thrombus formation, dilation of ventricles, scarring (fibrosis), hypertrophy, disintegration of cardiac muscle cells heart muscles weaken signs of heart failure
S/Sx: fever, tachycardia, abnormal heart beats abnormal heart sounds (murmurs, extra heart sounds) pericardial friction rub chest pain fatigue, shortness of breath, orthopnea fainting – often related to arrhythmias peripheral edema other signs suggestive of infection: rashes, sore throat, itchy eyes, swollen joints
Interventions: bed rest, low Na+ diet - cardiac workload, promote healing Digitalis (digoxin) - myocardial contractility, HR, to prevent heart failure Diuretics – to control pulmonary or systemic congestion Antibiotics, anti-inflammatory drugs, steroids
Bacterial Endocarditis infection of the inner lining of the heart (endocardium)
caused by direct invasion of bacteria or other organisms leading to deformity of the valve leaflets
Causative agents: Streptococcus viridans (found in the mouth) - 50% of cases, Staphylococcus aureus and enterococcus. Less common organisms include pseudomonas, serratia, and candida.
Classification:1. Acute bacterial endocarditis – rapidly progressing infection
– high fever, murmurs, spleenomegaly, emboli formation– follows a rapid course and may severely damage the
endocardium early in the disease2. Subacute bacterial endocarditis – slower progressing infection
– fever, wt. loss, fatigue, joint pains, headache, malaise– has a prolonged course
Predisposing factors: Who are at risk?
congenital heart defects damaged valves by rheumatic fever, atherosclerosis artificial heart valves may occur after cardiac surgery, invasive procedures
(dental procedures, catheterization, prolonged IV therapy) minor surgery, gynecologic examinations, dialysis
may follow after acute infection of the tonsils, gums, teeth, skin, lungs, GIT, GUT
immunocompromised patients drug abusers (injections)
Pathophysiology
Organism travels in the blood stream
forms vegetations (clumps of bacteria,
fibrin, cellular debris, platelets)
growth of vegetation on heart valves
attaches to the endocardial lining of a
normal heart or an area of defect (heart
valves)
Emboli that can lodge to various organs (kidney, coronary artery, spleen,
lungs, brain)
deforms, thicken, stiffen, perforate the valve leaflets
infected clots may break free and travel through the
bloodstream
Dysfunctional heart valves
obstruct blood flow and produce organ damage
Clinical Manifestations Infection – fever, chills, night sweats, malaise, fatigue, anorexia wt. loss, muscle aches, joint pains Cardiac – murmurs (valve dysfunction), tachycardia
- advanced – signs of CHF Peripheral Manifestations:
– Petechiae – small pinpoint hemorrhages in the conjunctiva, mucous membranes, neck, ankles
– Splinter hemorrhages - small, dark lines under the fingernails
– Osler’s nodes (red, painful nodes with a white center on the pads of fingers, toes, palms or soles) – a late sign of infection
– Janeway lesions (flat, painless, red to bluish-red spots on the palms and soles) – an early sign of endocardial infection
– Roth’s spots ( boat shaped retinal hemorrhages near the optic disc seen in fundoscopy
* result from Microemboli
Janeway lesions
enlarged spleen – continuous antigenic process Embolic manifestations
Lung – hemoptypis, chest pain, shortness of breathKidney – hematuria Heart – myocardial infarctionBrain – sudden blindness, paralysis, meningitis, brain
abscess
Complications: CHF - most common, due to damage to the aortic, mitral valve Embolic episodes – ischemia and necrosis of organs arrhythmias – atrial fibrillation Glomerulonephritis Stroke Brain abscess
Clinical Manifestations (cont.)
blood cultures & sensitivity – to identify organism – best test for detection- obtain sample just before & during height of
fever 2D Echo – valvular vegetations CBC – high ESR, high WBC, anemia ECG
Prevention: Prophylactic antibiotics are often given to people with predisposing heart conditions before dental procedures or surgeries involving the respiratory, urinary, or intestinal tract Continued medical follow-up is advised for people with a history of endocarditis proper oral hygiene
Diagnostic tests
1. Identify the infectious organism - serial blood cultures2. Destroy the infectious org., stop the growth of valvular vegetations
IV Antibiotics 4-6 weeks (Penicillin, Aminoglycosides) - to ensure high blood levels of medication- to eradicate the bacteria from the chambers
& valves repeated blood cultures are done to assess effectiveness of
the drug3. Surgical repair of valvular deformities and congenital defects4. Provide nutritional supplementation & bed rest5. Prevent relapse and recurrent fever & infection
- good oral hygiene, avoid invasive procedures as possible prophylactic antibiotic therapy, aseptic technique
Medical Interventions
Nursing Interventions
Provide comfort measures, fever encourage adequate fluids & nutrition CBR if w/ signs of valve dysfunctions (murmurs) assess for signs of heart failure, tachycardia, embolic manifestation provide health teachings: cause of infection, prolonged
use of antibiotic, prophylactic antibiotics, preventing
recurrence of infection (good oral hygiene), monitor signs of
recurrence
Rheumatic Fever
– an acute or chronic systemic inflammatory process, characterized by attacks of high fever, polyarthritis, severe carditis (valvular damage)
Predisposing Factors: – Age - 5-15 years old, can also affect elderly– socioeconomic factors – Poor persons living in crowded,
urban areas (slum areas) are more susceptible due to malnutrition, greater exposure to bacterial infections, less money for medical care and medications
– Genetic
Etiology: Group A Beta Hemolytic Streptococci the body undergoes an allergic response to invading
streptococci the host develops an “autoimmune response” in w/c the
streptococcal antibodies attack host tissue follows after an URTI by group A beta- hemolytic strep. –
after 18 days, only 2-3 percent develops rheumatic fever
Pathophysiology: a diffuse, proliferative & exudative inflammatory process
that affects connective tissues in organs through the body ( heart, joints, nervous system, respiratory system)
produces permanent & severe heart damage – if valves are involved
Rheumatic Heart Disease (RHD)– can develop during 1st – 2nd week– may involve one or all of the layers of the heart– myocarditis – temporary loss of contractile power of the
heart– pericarditis – pericardial friction rub– endocarditis – inflammation, ulceration, erosion of valve
leaflets– Progressive fibrosis (hardening) scarring calcification of
valve leaflets – valve stenosis & insufficiency/regurgitation
Clinical Manifestations
Polyarthritis – joint swelling, tenderness, redness, limited movement & pain ( fingers, knees, ankles)
Carditis – tachycardia, murmurs, muffled heart sounds, pericardial friction rub, precordial pain, cardiomegaly, signs of CHF
fever subcutaneous nodules – small, painless, firm nodules
(knees, knuckles, elbows) erythema marginatum – non-pruritic rash, macules on
the trunk and inner aspect of extremities, macules join together – looks like chicken wire appearance on skin
Chorea (Sydenham’s Chorea, St. Vitus Dance) – nervous disorder, involuntary grimacing and jerky, purposeless movements, late stage of the disease
Abdominal pain – engorgement of liver Minor Manifestation – malaise, weakness, wt. loss ,
anorexia epistaxis, ESR, WBC Evidence of streptococcal infection:
- (+) ASO- antistreptococcal antibodies titer in the blood
- (+) throat culture of Group A streptococcus
a person is diagnosed w/ rheumatic fever if he meets 2 major criteria or 1 major and 2 minor criteria, as well as having evidence of a recent streptococcal infection
Clinical Manifestations (cont.)
ManagementGoals:1.Suppression of acute inflammatory process – steroids, aspirin for fever and joint pain2.Eradication of the streptococcal infection – antibiotics (Penicillin/ Erythromycin)3.Prevention of disease occurrence4.To protect the heart against damaging effects of carditisInterventions:1.bed rest – reduce strain on the heart produced by activity
- minimize metabolic needs during acute, febrile state2. Diet – protein, calorie, Vit., sodium
- adequate nutrition to promote healing- if w/ CHF – restrict fluids
3. Maintain body alignment
Interventions (cont.)
4. Diuretics, digitalis if w/ signs of CHF5. Prevent recurrence – teach pt. on good nutrition, proper hygiene practices, adequate rest, immediate treatment of sore throat
- taking prophylactic doses of Penicillin to prevent recurrence of attacks of RF – 5 years after 1st attack
- take prophylaxis of antibiotics before & after surgery or
dental procedures- Severe RHD – Penicillin IM (Penadur) 1-2 x a month
or oral penicillin for lifetime