Infectious Diseases of the Heart.

Any of the heart’s layer ay be affected by infectious process Infectious are named for the layer of
the heart most involved in the infectious process; infective endocarditis (endocardium),
myocarditis (myocardium), pericarditis (pericardium).
Rheumatic endocarditis
What is rheumatic fever?
Rheumatic fever is an inflammatory disease that can be triggered by a streptococcal bacterial
infection. It usually starts out as a strep throat infection or scarlet fever that hasn’t been treated
with antibiotics. Rheumatic fever can cause inflammation of connective tissues throughout the
body including the heart, joints, brain or skin.
What is rheumatic heart disease?
Rheumatic heart disease describes a group of short-term (acute) and long-term (chronic) heart
disorders that are caused by rheumatic fever. It usually occurs 10-20 years after the initial illness.
Not everyone with rheumatic fever will go on to develop rheumatic heart disease.
Infective endocarditis
A microbial infection of the endothelial surface of the heart. It usually develops in people
with prosthetic heart valves, cardiac devices or structural cardiac defects.
Pathophysiology
A deformity or injury of the endocardium leads to accumulation of fibrin and platelets
(clot formation) on the endocardium. Infectious organisms, usually staphylococci or streptococci,
invade the clot and endocardial lesion. Other causative microorganism include fungi and
rickettsia. Infection most frequently results on platelets, fibrin, blood cells, and microorganisms
that cluster as vegetation on the endocardium. As the clot in the endocardium continues to
expand, the infecting organism is covered by the new clot and concealed from the body’s normal
defenses. Infection may erode through the endocardium into underlying structures, causing tears
or other deformities of the valve leaflets, dehiscence of prosthetic valves, deformity of chordae
tendineae, or mural abscess.
 Destruction of heart valves
 Embolization of fragments of vegetative growth on the endocardium
Clinical Manifestations
Fever and heart murmur. Fever may be intermittent or absent, especially on patients who are
receiving antibiotics or corticosteroids, in older adults, and those who have a heart failure and
kidney injury. A heart murmur may be absent initially but develops in most all patients. In
addition to fever and heart murmur. Clusters of petechaie may be found in the body. Small,
painful nodules may be present in pads in fingers or toes. Irregular, red or purple, painless flat
macules may be present on palms, finger, hands, soles, and toes. Hemmorhages with pale centers
cause by emboli may be observed in fundi of the eyes. Central nervous system manifestations of
infective endocarditis include headache , temporary or transient cerebral ischemia; and strokes.
Assessment and Diagnostic Findings
A definitive diagnosis is made when a microorganism is found in to separate blood cultures, or in
a vegetation or abscess. In addition, patient’s may be anemic, have positive rheumatoid factor,
and an elevated erythrocyte sedimentation rate or c-reative protein. Echocardiography may assist
in diagnosis by demonstrating a mass o a valve., prosthetic valve, or supporting structures and by
identifying vegetations, abscesses, new prosthetic valve dehiscence, or new regurgitation.
Prevention
Antibiotic prophylaxis is recommended for high risk patient immediately before and sometimes
after dental procedures that involve manipulation of gingival tissue or periapical area of teeth or
perforation of oral mucosa (except routine anesthetic injections through noninfected tissue,
placement of orthodontic brackets, loss of deciduous teeth, bleeding from trauma to lips or oral
mucosa, dental x-rays, adjustment of orthodontic appliances, and placement of removable
prosthodontic or orthodontic appliances). Updated guidelines no longer recommend antibiotic
prophylaxis for patients undergoing nondental procedures. Equally important is ongoing good
oral hygiene. Poor dental hygiene can lead to bacteremia
 avoid using toothpicks or other sharp objects in the oral cavity
 avoid nail biting
 avoid body piercing, branding, tattooing
 minimize outbreaks of acne, psoriasis
Female patients are advised to use intrauterine devices (IUDs).
Minimize the risk of infection, nurse must ensure meticulous hand hygiene, maintenance
procedures. All catheters, tubes, drains, and other devices are removed as soon as they are no
longer needed or no longer function

Medical management
Antibiotic therapy usually is given for 2 to 6 weeks every 4 hours or continuously by IV
infusion. Parenteral therapy is given in doses that produce a high serum concentration for a
significant period to ensure eradication of dormant bacteria within dense vegetations.
But penicillin usually is the medication of choice. In fungal endocarditis, an antifungal agent
such as amphotericin B ( Abelcet, Amphocin ) is the usual treatment.

Surgical management
Surgical intervention may be required if the infection does not respond to medications or the
patients has prosthetic heart valve endocarditis, has a mobile vegetation, has heart failure, has
heart block, or develops complications such as a septal perforation. valve debridement and
closure of an abscess, and closure of a fistula. Aortic or mitral valve debridement, excision, or
replacement is required in patients who:
 develop congestive heart failure despite adequate medical treatment
 have more than one serious systemic embolic episode
 develop a valve obstruction
 Develop a periannular (heart valve), myocardial, or aortic abscess
 have uncontrolled infection, persistent or recurrent infection, or fungal
endocarditis
Nursing management
The nurse monitors the patient’s temperature. The nurse administers antibiotic, antifungal, or
antiviral medication as prescribed or educates the patients to take them as prescribed. Heart
sounds assessed. The nurse monitors for the signs and symptoms of systemic embolization, or,
for patients with right sided heart endocarditis, for signs and symptoms of pulmonary infarction
and in filtrates. In addition, the nurse assessed the signs and symptoms of organ damage such as
strokes (i.e., cerebrovascular disease or brain attack), meningitis, heart failure, myocardial
infarction, glomerulonephritis, and splenomegaly. All invasive lines and wounds must be
assessed daily for redness, tenderness, and warmth, swelling, drainage, or other signs of
infections. The nurse emphasizes the antibiotic prophylaxis. If the patient had undergone surgical
treatment, the nurse provides postoperative care and instructions. The home care nurse
supervises and monitors IV antibiotic therapy delivered in the home setting and educated the
patient and family about prevention and health promotion. The nurse provides the patient and
family with emotional support and facilitates coping strategies during prolonged course of
infection and antibiotic treatment.

Myocarditis
An inflammatory process involving the myocardium, can cause heart dilation, thrombi on the
heart wall mural (mural thrombi). Infiltration of circulation blood cells around the coronary
vessels ad between the muscle fibers, and a degeneration of the muscles fibers themselves.
Pathophysiology
Myocarditis usually results from viral (eg., coxsackievirus A and B, human deficiency virus,
influenza), bacterial rickettsial, fungal, parasitic, metazoal, protozoal (eg., Chagas disease), or
sprochital infection. It also may be immune related, occurring after acute systemic infection such
as rheumatic fever. It may develop in patients receiving immunosuppressive therapy or in those
with infective endocarditis, Crohn’s disease, or systemic lupus erythematosus.
Myocarditis may result from an inflammatory reaction to toxins such as pharmacologic agents
used in the treatment or other diseases. It may begin in one small area of the myocardium and
thenspread throughout the myocardium. The degree of myocardial inflammation and necrosis
determines the degree of interstitial collagen and elastin destruction. The greater the destruction,
the greater is the hemodynamic effect and resulting signs and symptoms.
Clinical Manifestations
Patients may be asymptomatic, with an infection that resolves on its own. However, they may
develop mild-to-moderate symptoms and seek medical attention, often reporting fatigue ad
dyspnea, syncope, palpitations, and occasional discomfort in the chest and upper abdomen.
Sudden cardiac death or quickly develop severe congestive heart failure.
Assessment and diagnostic findings.
MRI is being used more often as a diagnostic tool because of its non- invasive approach. MRI
may be diagnostic and can guide clinicians to sites for endocardial biopsies, which may be
diagnostic for an organism or its genome, an immune process, or radiation reaction causing the
myocarditis. Patients without any abnormal structure (at least initially) may suddenly develop
dysrhythmias or ST-T- wave changes. May disclose cardiac enlargement, faint, heart sounds
(especially S1), pericardial friction rub a gallop rhythm, or a systolic murmur. The WBC count,
C-reactive protein, leukocyte count, and ESR may be elevated.
Prevention
By means of appropriate immunization and early treatment appears to be important in decreasing
the incidence of myocarditis.
Medical management
Patients are given specific treatment for the underlying cause if it is known and are placed on bed
rest to decreased cardiac overload. Bed rest also helps decreased myocardial damage and the
complication of myocarditis. In young patient’s with myocarditis, activities especially athletics,
should be limited for a 6 month period or at least until heart size and function have returned to
normal. Physical activity is increased slowly, and the patient is instructed to report any
symptoms that occur with increasing activity, such as rapidly beating heart. If heart failure or
dysrhythmia develops, management is essentially the same as for all causes of heart failure and
dysrhythmias. NSAID should not be used for pain control; they have been shown to be
ineffective in relieving the inflammatory process in myocarditis.
Nursing Management
Nurses assesses for resolution of tachycardia, fever, and any other clinical manifestation. The
cardiovascular assessment focuses on signs and symptoms of heart failure and dysrhythmias.
Patients with dysrhythmias should have continuous cardiac monitoring with personal and
equipment readily available to treat life threatening dysrhythmias.
Pericarditis
Refers to an inflammation of the pericardium which is the membranous sac enveloping the heart
It may be primary illness, or it may be develop during various medical and surgical disorder.
Pericarditis also may occure 10 days to 2 months after acute myocardial infarction (Dressler
syndrome). Pericarditis may be acute, chronic or reoccurring. It is classified either as adhesive
(constrictive), because the layers of the pericardium become attached to each other and restrict
ventricular feeling or by what accumulates in the pericardial sac.
Pathophysiology
An accumulation of fluid in the pericardial sac (pericardial effusion) and increase pressure on the
heart, leading to cardia tamponade. Frequent or prolong episodes of pericarditis also may lead to
thickening and decreased elasticity of pericardium, or scaring may fuse the visceral and parietal
pericardium. The pericardium may become calcified, further restricting ventricular expansion
during ventricular filling (diastole)
Clinical Manifestation
Pericarditis may be asymptomatic. The most characteristic symptoms of pericarditis is chest
pain. Although pain also may be located beneath the clavicle, in the neck, or in the left trapezius
(scapula) region. Pain or discomfort usually remain fairly constant, but it may worsen with deep
inspiration and when lying down or turning. The characteristic clinical manifestation of
pericarditis is a creaky or scratchy friction rub heard most clearly at the left lower sternal border.
Other signs may include a mild fever, increased WBC count, anemia, and an elevated ESR or C-
reactive protein level. Patient may have a nonproductive cough or hiccup. Dyspnea as well as
respiratory splinting because of pain upon inspiration, and other signs and symptoms of heart
failure may occur as a result of pericardial compression due to constrictive pericarditis or cardiac
tamponade.
Assessment and diagnostic
Diagnosis most often is made on the basis of history, signs, and symptoms. An echocardiogram
may detect inflammation pericardial effusion or tamponade, and heart failure. TEE may be
useful in diagnosis but may be underestimate the extent of pericardial effusion. CT imaging may
be the best diagnostic tool for determining size, shape, and location of the pericardial effusion
and may be used to guide pericardiocentesis. Cardiac MRI may assist with detection of
inflammation and adhesion.
Medical Management
Analgesic medication and NSAIDs such as aspirin or ibuprofen (motrin) may be prescribed for
pain relief during the acute phase. Colchisine (colcryis) or corticosteroids (predisone) May be
prescribed if the pericarditis is severe or if the patient does not respond to NSAIDs. Colchisine
also may be used instead of NSAIDs during the acute phase. Surgical or removal of tough
encasing pericardium (pericardiectomy) may be necessary to release both ventricle from
constrictive and restrictive inflammation and scaring.
Nursing Management
With analgesics, assistance with positioning and, psychological support. The nurse help the
patient with activity restriction until pain and fever subside. As a patient’s condition improves,
the nurse encourages gradual increases of activity the nurse indicated the patient and the family
about a healthy lifestyle to enhance the patient’s immune system. Nursing caring of patient with
pericarditis must be alert to cardiac tamponade.