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