Acute Inflammatory Disease (Myocarditis, Endocarditis, Pericarditis)

Definition/Etiology:

• Pericarditis, endocarditis and Myocarditis are all conditions in which some part of the heart is inflamed.
  • Endocarditis (Yolk) is specifically inflammation of the endocardium (inner layer of heart), including the valves of the heart.
    • Cause: Usually Bacterial
      • IV Drug Use
      • Valve Replacement
      • Dental Procedures/Tooth abscess
  • Myocarditis (White) is specifically inflammation of the heart muscle itself.
    • Cause: Usually Viral
      • Covid-19
      • Coxsackie B Virus
  • Pericarditis (Shell) is only when the outer membrane of the heart is inflamed → fluid → pressure →↓CO
    • Several Causes
      • Idiopathic – Usually Inflammatory
      • Coxsackie B Virus

Pathophysiology:

• Endocarditis
  • Affects the “egg yolk” portion of the heart
  • Microbial Infection
    • Strep (found in mouth)
    • Staph (found on skin)
  • Non-infective
    • Inflammation/Clotting disorders
    • Auto-immune Diseases (Lupus)
    • ALWAYS vegetation on valves
  • Heart valves = Mitral/Aortic most effected
  • Result = CVA
• Myocarditis
  • Inflammation of the muscular middle layer of heart (egg whites)
  • Damages heart muscles = poor contraction
  • Result = Heart Failure and/or sudden cardiac death
• Pericarditis
  • Affects the outer layer, or the egg shell of the heart.
  • Pouch that heart sits inside of with 50 ml of fluid.
  • Fluid moves from cells to pouch = increased fluid effusion
  • Effusion grows = heart cannot fully relax
    • Result = Cardiac Tamponade
      • Beck’s triad of hypotension, jugular venous distension, and muffled heart sounds

Noticing: Assessment & Recognizing Cues:

• Cardiac Inflammation General Assessment
  • Heart and Lungs sounds
    • Friction Rubs
    • S3
    • Heart Failure symptoms
    • SOB/Cough
  • Vitals
    • Tachycardia
    • Fever/Chills
    • Pain (Chest pain)
    • ↓02 Sat
• Endocarditis Cues
  • Heart Murmur
    • Mitral/Aortic
  • Inflammation → Clotting
    • Sign of Embolism
    • Osler/Janeway
    • Roth Spots (Retinal hemorrhages)
• Myocarditis Cues
  • Arrhythmias
    • Inflammation effects pacemaker cells
  • Heart Failure symptoms
    • Feet & Ankles
    • S3/S4
• Pericarditis Cues
  • Chest Pain
    • Worse with cough, swallowing & deep breaths
    • Improves with leaning forward
  • Pericardial friction rub
    • High pitched
    • Muffled Heart sounds

Interpreting: Analyzing & Planning:

• General Interpreting: Labs
  • CBC/Diff
  • Blood Cultures X2
  • ↑BNP
  • ↑ Troponins
  • ↑ ESR & ↑ CRP
• General Interpreting: Diagnostics
  • ECG: Electricity
    • could be ventricular or supraventricular arrhythmias (in other words, not one “cardinal” rhythm
  • Echocardiogram: Plumbing
  • Chest X-Ray/CT Chest
• Endocarditis
  • TEE: the initial test of choice for all patients with suspected IE. It should ideally be performed within 12 hours of presentation and repeated after completing treatment
• Myocarditis
  • Endomyocardial Biopsy: Looks for dead tissue & exact pathogen
• Pericarditis
  • ECGS
    • Diffuse ST elevations
    • ALTERNANS

Responding: Patient Interventions & Taking Action:

• General
  • IV Patent
  • Vitals
  • Full Cardiopulmonary assessment
  • Continuous bedside heart monitor
• Pharmacological Interventions
  • Iv Abx (if bacterial)
  • Anticoagulants
  • Anti-Inflammatory Medications (NSAIDS)
  • + inotropes
  • Diuretics
  • Colchicine
  • Corticosteroids
• Nonpharmacological
  • Positioning
    • Lean Forward
• Adjunct Medical Therapy
  • Endocarditis
    • DUKE criteria -Physician Calculation
    • Consult Infectious Disease
    • Long-term infusion therapy
  • Myocarditis
    • Treat Symptoms of Heart Failure
    • Transplant Consult
  • Pericarditis
    • Pericardiocentesis
    • Partial Pericardiectomy (Window)

Reflecting: Evaluating Patient Outcomes:

• Flush IV
• Chest Pain = Resolves
• Monitor = Free of arrhythmias
• Vitals = Stable
• Heart Sounds
  • S3/S4 → WNL
  • New Murmur = Resolves
  • Rub → Resolves
• Lung Sounds
  • Clear
• Labs Return to baseline/improve
• Inflammation → Clotting
  • Resolves lesions
• EKG/ECHO = Electricity & Plumbing Improves