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Infective & Inflammatory Disorders of the Heart (Myocarditis Focal…

- - - - Criteria for Diagnosis
        need at least two of the following:
        -positive blood cultures
        -presence of new or changed murmur
        -presence of intracardiac mass or vegetation on echocardiogram
    - - Drug Therapy
        -accurate identification of the infecting organism is the key to successful treatment
        -long term tx is necessary to kill dormant bacteria within the valvular vegetations
        -complete elimination can take weeks
        -relapses are common
        -patients are initially hospitalized w/ IV ABX based on blood cultures
        -subsequent blood cultures are later assessed for effectiveness of tx:
        positive cultures indicate inadequate antibiotic, aortic root or myocardial abscess, or the wrong diagnosis
        -fungal endocarditis & prosthetic valve endocarditis:
        respond poorly to ABX tx when used alone
        early valve replacement & prolonged (6 wks or more) ABX tx is recommended tx
        -endocarditis w/ heart failure:
        responds poorly to drug therapy & valve replacement
        often life-threatening
        -fever may persist for several days after starting drug therapy:
        aspirin
        acetaminophen
        ibuprofen
        fluids
        rest (complete bedrest only indicated if those patients w/ continued fever or s/s of heart failure)
- - - - COMPLICATIONS
        pericardial effusion
        -build up of fluid in pericardium
        -distant & muffled heart sounds
        cardiac tamponade
        -develops as the peripheral effusion increases volume
        -compresses heart
        -can occur:
        acutely-rupture of heart, trauma
        subacutely-secondary to renal failure
        -s/s:
        dyspnea (in slow onset)
        sharp chest pain
        confusion (anxious & restless)
        decreased cardiac output
        muffled heart sounds
        narrowed pulse pressure
        tachypnea
        tachycardia
        increased JVD
        (+) pulsus parodoxus (decreased systolic BP during inspiration & needs to be >10 mmHg)
        
        COLLABORATIVE CARE
        pericardiocentesis
        -to relieve cardiac pressure
        -for pts w/ acute pericarditis, purulent pericarditis, suspected neoplasm
        -administer volume expanders & inotropic agents
        -discontinue any anticoagulants
        -guided by echocardiography
        -complications:
        dysrhythmias
        further cardiac tamponade
        pneumomediastinum
        pneumothorax
        myocardial laceration
        coronary artery laceration
        pericardium window
        -to dx or for drainage
        -involves cutting a"window" of the pericardium
        -allows fluid to drain continuously into peritoneum or chest
        
        Drug Therapy
        antibiotics
        -for bacterial pericarditis
        NSAIDS
        -control pain & inflammation
        corticosteroids
        -pericarditis 2ndary to SLE
        -colchicine (Colsalide) can be used for recurrent pericarditis (originally used for gout)
  - - - CLINICAL MANIFESTATIONS
        
        progressive sharp chest pain
        -worst w/ deep inspiration & when lying supine
        -may radiate to neck, arms, or left shoulder
        -referred to the trapezius muscle (shoulder & upper back)
        pericardial friction rub
        -scratching
        -grating
        -high pitched sound
        -best heard at lower left sternal border of chest w/ patient leaning forward & holding their breath
        dyspnea
        fever
        anxiety
        
        DIAGNOSTICS
        ECG
        -diffused ST segment elevation
        -abnormal repolarization
        echocardiography
        -differentiates between pericardial effusion or cardiac tamponade
        Doppler imaging & color M-mode
        -determines diastolic function & dx constrictive pericarditis
        CT & MRI
        -visualization of pericardium & pericardial space
        CXR
        -cardiomegaly in patients w/ large pericardial effusion
        pericardiocentesis
        pericardium biopsy
        
        CBC:
        -elevated WBC
        ESR:
        -elevated
        C-reactive protein levels:
        -elevated
        troponin levels
        -elevated
        
        NURSING MANAGEMENT
        manage patient's pain & anxiety:
        -put pt on bedrest w/ HOB at 45 degrees
        -anti-inflammatory meds to be given w/ food or milk & to avoid alcohol
        -pantoprazole to reduce stomach acid
        -to decrease anxiety, explain procedures & tx to pt
        assess pain to distinguish from MI:
        -left trapezius muscle
        -sharp pleuritic quality that increases w/ inspiration
        -relieved when pt sits up or leans forward
        -worst when lying supine
        monitor pt for s/s of cardiac tamponade:
        -sharp chest pain
        -confusion (anxious & restlessness)
        -decreased cardiac output
        -muffled heart sounds
        -narrowed pulse pressure
        -tachypnea
        -tachycardia
        -increased JVD
        -pulsus parodoxus
        prepare pt for possible pericardiocentesis
- - - - DIAGNOSTICS
        CXR
        -may show normal or enlarged heart
        2D echo
        -thickened pericardium
        CT & MRI
        -provide measurement of pericardial thickness & assessment of diastolic filling patterns
        
        COLLABORATIVE CARE
        pericardiectomy
        -complete resection of the pericardium by a median sternotomy