Inflammatory Heart Disease Pericarditis inflammation of the pericardium

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

Pathophysiology

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 2 D-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,

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 tissue Causes: �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 disease 2. Subacute bacterial endocarditis – slower progressing infection – fever, wt. loss, fatigue, joint pains, headache, malaise

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

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

Janeway lesions

Clinical Manifestations (cont. ) �enlarged spleen – continuous antigenic process �Embolic manifestations Lung – hemoptypis, chest pain, shortness of breath Kidney – hematuria Heart – myocardial infarction Brain – 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

Diagnostic tests �blood cultures & sensitivity – to identify organism – best test for detection - obtain sample just before & during height of fever � 2 D 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

Medical Interventions 1. Identify the infectious organism - serial blood cultures 2. 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 drug 3. Surgical repair of valvular deformities and congenital defects 4. Provide nutritional supplementation & bed rest 5. Prevent relapse and recurrent fever & infection - good oral hygiene, avoid invasive procedures as possible prophylactic antibiotic therapy, aseptic technique

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 1 st – 2 nd 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

Clinical Manifestations (cont. ) �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. )

Management Goals: 2. Suppression of acute inflammatory process – steroids, aspirin for fever and joint pain 3. Eradication of the streptococcal infection – antibiotics (Penicillin/ Erythromycin) 4. Prevention of disease occurrence 5. To protect the heart against damaging effects of carditis