3.2.1.

ENDOCARDITI
S
3.2.2.
3.2
INFECTIOUS MYOCARDITIS
DISEASES OF 3.2.3.
THE HEART
PERICARDITIS

 Endocardium Endocarditis
Myocardium Myocarditis
Pericardium Pericarditis

The Layers of the Heart

Endocardium membrane that lines
inside the chambers of the heart and
forms the surface of the valves.
Myocardium muscular tissue of the
heart
Pericardium membrane enclosing
the heart.

3.2.1. Endocarditis
It is an inflammation of the inner layer of
the Heart, the ENDOCARDIUM.
It usually involves the HEART VALVES.
Characterized by a lesion called
VEGETATION

Other structures which may be

involved include the:

INTERVENTRICULAR SEPTUM
CHORDAE TENDINAE
MURAL ENDOCARDIUM
INTRACARDIAC DEVICES.

How does Endocarditis

happen?
This occurs when bacteria or other
germs from another part of your body,
such as your mouth, spread through
your bloodstream and attach to
damaged areas in your heart

Symptoms:

Fever and chills

A new or changed heart murmur
Fatigue
Aching joints and muscles
Night sweats
SOB

 Paleness
Persistent cough
Swelling on the
feet, legs and
abdomen
Unexplained
weight loss

Blood in the urine

Tenderness in the
spleen
Oslers nodes
petechiae

Risk factors:

Artificial heart valves

Congenital heart defects
History of endocarditis
Damaged heart valves
History of intravenous (IV) illegal drug use

Complications:
Stroke
Organ damage
Infections in other parts of the body
Heart failure

Tests and diagnosis

Blood tests
Transesophageal echocardiogram
Electrocardiogram
Chest X-ray
CT scan or MRI

Treatment:
Antibiotics first line of treatment in
Endocarditis

Surgery If the infection damages your heart

valves
Sometimes needed to treat Endocarditis
caused by a fungal infection.

Prevention:
Dental health

Avoid
body
piercings
and
tattoos.

Seek prompt
medical
attention if
you develop
any type of
skin infection,
open cuts or
sores that
dont heal
properly.

Preventive
antibiotics

 Artificial or prosthetic heart valve

Previous endocarditis infection
Certain types of congenital heart defects
Heart transplant complicated by heart
valve problems

Antibiotics are recommended

before the ff procedures:
a)Dental procedures that cut through the
gum tissue or part of the teeth
b)Procedures involving the respiratory tract,
infected skin or tissue that connects
muscle to bone

3.2.2. Myocarditis
Inflammation of the middle layer of the heart wall, the

MYOCARDIUM.
It involves the hearts MUSCLE CELLS and ELECTRICAL
SYSTEM.
May be chronic or acute
It is usually of sudden onset.
Studies suggest that myocarditis is a major cause of sudden (20%),
unexpected death in adults less than 40 years of age

COMPARISON:
Myocarditis causes the heart
muscle to become thick and
swollen
If severe, the pumping action of
the heart weakens, and the
heart wont be able to supply
the rest of the body with
enough blood.
CLOTS could also form, leading
to a stroke or a heart attack.

Pathophysiology of
Myocarditis
An
infectio
us
organis
m
directly
invades
myocar
dium

Triggers
an
autoimm
une ,
cellular
or
humoral
reaction

Local
and
systemic
immunol
ogical
inflamm
ation
ensues

Inflammation
leads to
hypertrophy,
fibrosis and
inflammatory
changes of
the
myocardium
and
conduction
system

Heart
muscle
weaken
s and
contrac
tility is
reduce
d

Heart
muscl
es
dilate
d

Pinpoi
nt
hemorr
hages
may
develo
p

Etiology
Infection:
viruses : Cocksackie B, Echovirus, HIV, Adenovirus,
Cytomegalovirus, Epstein-Barr Virus, Varicella Zoster
Virus and others
bacteria: Diptheria (in of Diptheria cases), in setting of
endocarditis
spirochetes: lyme (Borrelia bergdorferi)
fungi: Candida, Aspergillus, histo, cocci, crypto
parasites: Chagas (Trypanosoma cruzi), toxocara,
trichinosis

Etiology
Drugs/Toxins
hypersensitivity reactions: sulfa, PCN, NSAIDs,
chemo: doxorubicin
others: cocaine, Li, cyclophosphamide, EtOH
Autoimmune diseases:
SLE (Systemic Lupus Erythematosus), sarcoidosis, RA,
dermatomyositis
Other: radiation, Giant-Cell myocarditis

Clinical Manifestation
Patients may be asymptomatic with an infection
thatresolves on its own. May develop mild to
moderate symptoms such as:
Flu-like symptoms and tachycardia (most common)
Dyspnea
Palpitations
discomfort in chest and upper abdomen

Clinical Manifestation
Pericardial friction rub may be heard if associated with

pericarditis
Cardiomegaly (arrhythmia, edema)
pulsus alternans may be present (alternating strong and
weak pulses)
Murmurs of mitral or tricuspid regurgitation are common,
s3 and s4 gallops may also be heard.
CHF symptoms may develop

Medical Management
Penicillin - for hemolytic streptococci
ACE Inhibitors - relax the blood vessels in the heart and
help blood flow more easily
Beta-blockers are avoided because it decreases the strength
of ventricular contraction (have a negative inotropic effect)
Anticongestive measures such as diuretics, inotropics,
oxygen, digoxin (use cautiously) IVIG (2g/kg over 24 hours)
effective in some cases secondary to Kawasaki disease;

Nursing Management
Monitor for Digitalis toxicity (Dysrhythmia, anorexia, N/V,

bradycardia, headache, malaise)

Apply and instruct patient and family in use of elastic stockings and
active and passive exercises
Instruct patient to increase physical activity slowly and report
symptoms of rapid heart rate upon increasing activity.
Instruct patient to avoid competitive sports and alcohol
Promote bed rest
Continuous cardiac monitoring

Diagnostic Tests
ECG: Sinus tachycardia, decreased QRS voltage, ST-T wave
abnormalities, arrhythmias
CXR: Enlarged heart; pulmonary edema
2D Echo: Cardiac chamber enlargement, impaired LV
function
Labs: Cardiac troponin levels (Troponin-I and T) and
myocardial enzymes
(CK-MB) elevated; confirmed by biopsy

Prevention:
Avoid people with viral or flu-like illnesses until theyve

fully recovered.
Follow good hygiene.
Avoid risky behaviors.
Minimize exposure to ticks.
Get your vaccines, especially those that protect against
rubella and influenza diseases that can cause
Myocarditis.

Key points in Myocarditis

Myocarditis can be caused by viral, bacterial, spirochetal,
fungal, or parasitic infections, drugs/toxins, and
autoimmune diseases.
EKGs in myocarditis can have non-specific ST-T changes,
atrial or ventricular arrhythmias, or ST-elevation diffusely
or focally.
Troponin I will be positive in 1/3 of cases of myocarditis.
Treatment is supportive, including exercise avoidance

3.2.3 Pericarditis
It is the swelling and irritation of the membranous sac
enveloping your heart called the PERICARDIUM.
May be ACUTE or CHRONIC.
Associated with a sharp chest pain (pericardium rub
Usually begins suddenly but doesnt last long.

Pathophysiology of
Pericarditis
Acute
pericard
ial
effusion

The
pressure
of the
pericard
ial cavity
increase
s

FV
(filling
volume)
of the
ventricul
ar
diastole
decrease
s

SV
(Stroke
volume
)
decrea
ses

BP
lowe
rs

Etiology
Idiopathic/Viral: 75-80% of cases
Infection:
viral: coxsackie, echo, adeno, EBV, HIV, hepatitis B
bacterial: Staph, Strep, pneumococcus, H. flu, TB
fungal: histo (most common fungus), aspergillus, cocci
rickettsial, parasitic

Etiology
Radiation
Malignancy: lung, breast, lymphoma, melanoma, primary
cardiac (rhabdomyosarcoma)
Autoimmune: SLE, RA, systemic sclerosis, vasculitis,
Behcets, sarcoid
Drugs/toxins: procainamide, INH, hydralazine (lupus
syndrome), PCN, dilantin
Other: uremia, post-MI, post-CABG, trauma, amyloid

Clinical
Manifestation/Physical
Exam
Chest pain is the most common complaint
sharp, pleuritic, retrosternal, radiating to L shoulder, relieved by
sitting up
can mimic angina/ischemic chest pain

Can have fever, myalgias, fatigue

Heart failure is rare and indicates myocarditis
Pericardial friction rub can be heard in up to 85% of
patients
scratchy or squeaking sound
classic 3 phase: atrial systole, ventricular systole, ventricular
diastole

Look for evidence of Tamponade on exam

Types of acute pericarditis:

Serous pericarditis
Fibrinous pericarditis
Purulent pericarditis
Hemorrhagic pericarditis

Serous pericarditis
Usually caused by non-infectious inflammatory diseases
such as RHEUMATOID ARTHRITIS, SYSTEMIC LUPUS
ERYTHEMATOSUS, SCRELORDERMA, TUMOR, UREMIA.
BACTERIAL PLEURITIS may cause sufficient irritation of
the pericardium.
VIRAL INFECTION antedates pericarditis.
Morphology: inflammatory reaction with few neutrophils,
lymphocytes and histiocytes.

Fibrinous pericarditis

Most common type of pericarditis

It is an exudative inflammation.
The epicardium is infiltrated by the fibrinous exudate.
Common causes include: ACUTE MYOCARDIAL
INFARCTION, POSTINFARCTION (incl. Dressler
syndrome), UREMIA, RADIATION and TRAUMA.

Purulent or suppurative
pericarditis
Red, granular surface coated with pus, lots of subsurface
neutrophils, up to 500ml exudate in the pericardium.
Immunosuppression facilitates this condition.
Commonly seen in patients with empyema, mediastinitis,
endocarditis, burn, and post pericardiodectomy.
Diagnosis: ECG, echocardiography, Gallium67 scan with
SPECT, Gallium67 and TC99 scan.

Hemorrhagic pericarditis
Blood mixed with a fibrinous or suppurative effusion
Most commonly caused by TUBERCULOSIS or DIRECT
NEOPLASTIC INVASION.
Can also occur in severe bacterial infections
Also common after surgery and may cause tamponade
Clinical significance is similar to suppurative pericarditis

Type of chronic pericarditis:

Adhesive mediastino pericarditis
Constricitive pericarditis

Adhesive mediastino
pericarditis
Follows suppurative pericarditis, cardiac surgery or

irradiation.
The pericardial potential space is obliterated
Adhesion of the external surface to the surrounding
structures occurs
Clinically, systolic contraction of ribcage and
diaphragm may be observed
workload may cause massive cardiac hypertrophy
and dilatation

Constrictive pericarditis

Usually caused by
hemorhhagic, suppurative
or caseous pericarditis
Heart becomes encased in a
layer of scar or calcification
Usually 0.5cm to 1cm thick,
resembling a plaster mold

Clinical Management

Treatment depends on the cause

Analgesics and NSAIDS
Corticosteroid
Antibiotic
Pericariocentesis
Surgical treatment

Nursing Management
Stress the importance of bed rest,
Assist the patient with bathing if necessary.
Provide a bedside commode because this method puts
less stress on the heart rather than using a bed pan.
Place the patient in upright position to relieve
dyspnea and chest pain.
Provide analgesics to relieve pain and oxygen to
prevent tissue hypoxia.

Nursing Management
Assess the patients cardiovascular status frequently,

watching for signs of cardiac tamponade.

Monitor the patients pain level and the effectiveness of
analgesics.
Explain all tests and treatments to the patient.
Before giving antibiotics, obtain a patient history for
allergy.
Tell the patient to resume his daily activities slowly and
to schedule rest periods into his daily routine for a
while.

Diagnostic Tests

Labs/EKG/ECHO
Troponin I positive in up to 49% of patients
EKG shows diffuse ST elevations and PR depression
Look for PR elevation in lead aVR (knuckle sign)
Can be followed by diffuse T-wave inversions
No Q waves or reciprocal ST-changes (unlike acute MI)
Echo typically shows small accumulation of fluid w/o
tamponade and nl LV fxn

Key Points
Acute pericarditis is most commonly
viral/idiopathic but can be caused by infection,
radiation, malignancy, autoimmune disease,
drugs, and uremia.
Classic presentation is pleuritic chest pain w/
associated friction rub.
EKG shows diffuse ST elevation and PR
depression w/ PR elevation in lead aVR.

Rosemarie C. Reyes
BSN III
NCM 103 Lecture
Mr. Rafael Salinas