CVS Disorder part II Infectious Diseases of The Heart (1).pdf

4/5/2023 By: Yonatan Solomon (Ass. Professor) DDU Nursing 1

Introduction
• Any of the heart’s three layers may be affected by an infectious process.
• Infections are named for the layer of the heart most involved in the infectious
process: infective endocarditis (endocardium), myocarditis (myocardium), and
pericarditis (pericardium).
• Ideal management for all infectious diseases is prevention.
• IV antibiotics usually are necessary once an infection has developed in the heart.

Rheumatic Heart disease
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 Rheumatic fever is an inflammatory disease that occurs following a
Streptococcus pyogenes infection, such as streptococcal pharyngitis.
 The resulting damage to the heart from RF is called Rheumatic Heart Disease,
a chronic condition characterized by scaring and deformity of the heart valves.
 Rheumatic fever causes chronic progressive damage to the heart and its valves
 Believed to be caused by antibody cross-reactivity that can involve the heart.
 The illness typically develops two to three weeks after a streptococcal infection
By: Yonatan Solomon (Ass. Professor) DDU Nursing

4/5/2023 4
 Prompt treatment of strep throat with antibiotics can prevent the
development of rheumatic fever.
 The Streptococcus is spread by direct contact with oral or respiratory
secretions
Cont...

Malnutrition
Overcrowding
Low socio- economic status
Familial tendency
Skin (subcutaneous) nodules
Lungs ( fibrous pleurisy)
Joints (polyarthritis)
Risk factors

Pathophysiology
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 It is not infectious in the sense that these tissues are not invaded and
directly damaged by destructive organisms; rather, they represent a
sensitivity phenomenon or reaction occurring in response to hemolytic
streptococci.
 Leukocytes accumulate in the affected tissues and form nodules, which
eventually are replaced by scar tissue.
 Rheumatic myocarditis develops, which temporarily weakens the
contractile power of the heart.

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 Acute rheumatic fever is a sequel of a previous group A streptococcal
infection, usually of the upper respiratory tract
 The pericardium also is affected, and rheumatic pericarditis occurs during
the acute illness.
 These myocardial and pericardial complications usually occur without
serious sequelae.
 Rheumatic endocarditis, however, results in permanent and often crippling
side effects.
Cont...

Clinical Manifestations
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The presence of 2 major criteria or one major and 2 minor criteria plus
evidence of a preceding group A streptococcal infection.
Major criteria:
Carditis [Most serious manifestation which affect any cardiac tissue] results in signs:
 Murmurs of mitral or aortic regurgitation, or mitral stenosis;
 Cardiac enlargement and HF; SOB, chest pain, murmur,
 Pericarditis, Rhythm disturbances, Pericardial friction rubs
 Cardiac failure, High pulse rate

Major criteria
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 Mono- or polyarthritis causes swelling, heat, redness, tenderness, and
limitation of motion.
 Chorea (Sydenham’s chorea) involves involuntary movements, especially
of the face and limbs, muscle weakness, and disturbances of speech and gait.
 Erythema marginatum lesions are bright pink, non-pruritic, map like
macular lesions that occur mainly on the trunk and proximal extremities.
 Subcutaneous nodules are firm, small, hard, painless swellings located over
extensor surfaces of the joints.

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Erythema marginatum lesions Subcutaneous nodules

Minor criteria
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Clinical findings:
Fever
Arthralgia
Laboratory findings: elevated ESR, elevated WBC,CRP
Prolonged PR interval

Arthritis
 Most common feature: present in 80% of patients
 Painful, migratory, short duration, excellent response for salicylates
 Usually >5 joints affected and large joints preferred
o Knees
o Ankles
o Wrists
o Elbows
o Shoulders
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Diagnosis
 History
 Physical Exam
 Lab tests
 ECG
 Chest X-ray
 Synovial fluid analysis
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Jones Criteria for the diagnosis of ARF
Two major or
One major and two minor
Major criteria
Carditis
Polyarthritis
Chorea
Erythematic mariginatum
Subcutaneous nodules
Minor criteria
Fever
Previous occurrence of RF or RHD
Arthralgia
Prolonged PR interval
Lab findings
14
4/5/2023 By: Yonatan Solomon (Ass. Professor) DDU Nursing

Management
4/5/2023 15
The primary goals of managing a patient with ARF are
☞ To control and eradicate the infecting organism
☞ Prevent cardiac complications; and
☞ Relieve joint pain, fever, and other symptoms with antibiotics,
optimal rest, antipyretics, NSAIDS, ASA and corticosteroids.

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☞ Treat group A streptococcal infection regardless of organism detection.
 Ampicillin 500 mg PO QID or Amoxicillin 500 mg PO TID for 10 days or
 Benzathin penicillin 1.2 million IU IM single dose or
 Erythromycin 500 mg PO QID for 10 days ( for penicillin allergic patient).
☞ Administer 2ndry prophylaxis: is indicated for all patients with RF
 Taking benzathin penicillin is the first choice for better compliance and longer
prevention.
 Benzathin penicillin 1.2 million IU IM every 4 weeks , but if the there is high risk
of recurrence, it can be given every 3weeks
Cont...

Infective Endocarditis
 It is a microbial infection of the valves and endothelial surface of the
heart
Causes
Bacteria
Streptococci (60%)
Staphylococci (20%)
Rickettsia
Fungi
Chlamydia
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Risks/incidence
☞ More common in older people
☞ IV/injection drug users, immunosuppressive drugs
☞ The combination of invasive procedure, bacteremia, and cardiac defect
☞ Those with prosthetic (artificial) heart valves, previous endocarditis,
congenital malformations
☞ Pts with RHD or mitral valve prolapsed (insufficiency).

Pathophysiology
 Bacteria or other infectious microorganism can enter the bloodstream
during certain procedures
 Bacteria can grow and form infected clots that break off and travel to
the brain, lungs, kidneys, or spleen.
 Direct invasion of the endocardium by microbes.
 Causes deformity of the valve leaflets, and sometimes affect other
cardiac structures.

Fever
Chills, anorexia, weight loss
Arthralgia, myalgia, back pain, weakness, malaise, fatigue
Clubbing of fingers
Splinter hemorrhages occur in nail beds
Petechiae in conjunctiva & mucus membranes
Cardiomegaly & heart failure
Cerebral ischemia, stroke, headache
Embolization to brain, kidneys, liver, limb & spleen
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20

Clinical Manifestations …
Abnormal urine color, Blood in the urine
Excessive sweating (Night sweats)
Shortness of breath with activity
Swelling of feet, legs, abdomen
Bleeding in the retina (Roth's spots)

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Petechiae
1. Nonspecific
2. Often located on extremities or mucous membranes

4/5/2023
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Splinter Hemorrhages
1. Linear reddish-brown lesions found under the nail bed
2. Usually do NOT extend the entire length of the nail

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Osler’s Nodes
1. More specific
2. Painful and erythematous nodules
3. Located on pulp of fingers and toes
4. More common in subacute IE

4/5/2023
25
Janeway Lesions
1. More specific
2. Non-painful Erythematous, blanching macules
3. Located on palms and soles

Diagnosis
History
Physical examination
Blood culture (positive in 90-95% of patients)
ESR
Chest X-ray
ECG
Echocardiography
Increased WBCs
U/A
4/5/2023
26

Prevention
Antibiotics prophylaxis before and after dental, oral, respiratory, urinary or
esophageal procedures
Continued medical follow-up
Medical Mgt
 Appropriate parenteral antibiotics for 2-6 wks
E.g.. vancomycin and ceftriaxone, penicillin, aminoglycoside
 Antifungal agents like amphotericin- if fungal endocarditis
 Antipyretics: PCM
Surgical Mgt
 Surgical valve repair or replacement for sever valve case
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27

Potential Complications
Blood clots or emboli to brain, kidneys, lungs, etc
Brain abscess, Stroke
Congestive heart failure
Glomerulonephritis
Neurological changes
Dysrhythemias
Severe valve damage

Heart Failure
 Heart failure (HF) is a clinical syndrome resulting from structural or functional
cardiac disorders that impair the ability of the ventricles to fill or eject blood.
 In the past, HF was often referred to as congestive heart failure (CHF), because
many patients experience pulmonary or peripheral congestion with edema.
 Currently, HF is recognized as a clinical syndrome characterized by signs and
symptoms of fluid overload or inadequate tissue perfusion.

Cont…
 Fluid overload and decreased tissue perfusion result when the heart cannot
generate cardiac output (CO) sufficient to meet the body’s demands for
oxygen and nutrients.
 The term heart failure indicates myocardial disease in which impaired
contraction of the heart (systolic dysfunction) or filling of the heart
(diastolic dysfunction) may cause pulmonary or systemic congestion.

Classification of HF
Systolic Vs Diastolic dysfunction
Systolic Dysfunction: alteration in ventricular contraction also called
systolic heart failure, which is characterized by a weakened heart muscle the
ventricle is unable to contract forcefully enough during systole. Reduced
ejection fraction (EF) is a hallmark of systolic HF.
Diastolic dysfunction: the left ventricle is unable to relax adequately during
diastole which is characterized by a stiff and noncompliant heart muscle,
making it difficult for the ventricle to fill.
4/5/2023
32

Cont…
Based on the side of the heart involved
 Left Heart Failure
 Right Heart Failure

Left-sided heart failure (LSHF)
This type of heart failure occurs as a result of ineffective left ventricular contractile
function.
As the pumping ability of the left ventricle fails, cardiac output falls.
Blood is no longer effectively pumped out into the body; it backs up into the left
atrium and then into the lungs, causing pulmonary congestion, dyspnea, and activity
intolerance.
If the condition persists, pulmonary edema and right-sided heart failure may result.
Common causes include left ventricular infarction, hypertension, and aortic and
mitral valve stenosis.

Right-sided Heart Failure (RSHF)
Right-sided heart failure results from ineffective right ventricular contractile function.
Consequently, blood is not pumped effectively through the right ventricle to the lungs,
causing blood to back up into the right atrium and into the peripheral circulation.
The patient gains weight and develops peripheral edema and engorgement of the kidney and
other organs.
It may be due to an acute right ventricular infarction or a pulmonary embolus.
However, the most common cause is profound backward flow due to left-sided heart failure.

Etiology/Underlying Cause
4/5/2023 37
Most often caused by coronary artery disease, cardiomyopathy,
hypertension, diabetes mellitus or valvular disorders.
Atherosclerosis of the coronary arteries is the primary cause of HF, and
Coronary artery disease is found in more than 60% of the patients with HF.

Precipitating cause
4/5/2023 38
H- Hypertension (systemic)
E- Endocarditis (infections)
A- Anemia
R- Rheumatic fever
T- Thyrotoxicosis
F- Fever (infections)
A-Arrhythmia
I- infarction (myocardial)
L- Lung infection
E- Embolism (pulmonary)
S- Stress (emotional, physical, environment, dietary,
fluid excess)

Cont…
Compensatory mechanisms for CO:
Increased HR
Improved SV (stroke Volume)
Arterial vasoconstriction
Sodium & water retention
Myocardial hypertrophy

Pathophysiology of LSHF
☞ LV dysfunction, causes blood to back up in the left atrium and pulmonary veins
☞ The increased left ventricular end-diastolic blood volume increases the left ventricular
end-diastolic pressure
☞ Decreases blood flow from the left atrium into the left ventricle during diastole
☞ The blood volume and pressure in the left atrium increases,
☞ Decreases blood flow from the pulmonary vessels
☞ Pulmonary venous blood volume and pressure rise, forcing fluid from the pulmonary
capillaries into the pulmonary tissues and alveoli,
☞ Impairment of gas ex-change.
☞ Backward failure

Pathophysiology of RSHF
RV failure

Inability of RV to empty
completely

Increased volume &
pressure in the systemic
veins

Systemic venous congestion
Systemic Congestion
 Peripheral edema
 Hepatomegally
 Spleenomegally
 Congestion of the GI tract
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Left sided HF
Decreased CO
 Fatigue
 Decreased activity tolerance
 Oliguria during the day
 Nocturia
 Angina
 Confusion, restlessness
 Apical impulse displacement
 Tachycardia, palpitation
 Dizziness
 Pallor
 Cyanosis
 Weak peripheral pulse
 Cool extremities at rest
43
Pulmonary congestion
 Cough -hacking, worsen at night
 Dyspnea, orthopnea, PND
 Crackles/ rales or wheezes in lungs
 Tachypnea
 Dullness
 Murmurs
 S3/S4

Clinical Manifestation RSHF
Systemic Congestion
 Jugular vein distension (JVD)
 Hepatomegally & Spleenomegally
 Anorexia, nausea
 Dependent edema -legs & sacrum
 Ascites
 Nocturia
 Weight gain
 Change in PB
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Diagnosis
History
Physical Examination
Lab tests
ECG
Chest X-ray
Echocardiogram
Pulseoximetry
B-type natriuretic peptide(BNP)
Cardiac catheterization
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Medical Management
Objectives
To eliminate or reduce etiologic or contributing factors
To reduce the workload on the heart by reducing after load & preload
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Pharmacologic Therapy
I. ACE - inhibitors (ACE-Is)
 Promotes vasodilatation & diuresis
 Include:
o Captopril
o Enalapril
o Lisinopril
II. Angiotensin II receptor blockers (ARBs): Losartan
 Decreases BP & systemic vascular resistance
III.Hydralazine
 Decreases systemic vascular resistance
IV.Beta blockers e.g. propranolol
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Cont…
IV.Digitalis e.g. digoxin
 Increases the force of myocardial contraction & slow conduction through the
AV node
V. Diuretics
 Thiazides e.g. chlorothiazide, hydrochlorothiazide
 Loop diuretics e.g. furosemide (lasix)
 Potassium sparing e.g. spironolactone
 Combination agents e.g. spironolactone + hydrochlorothiazide
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IV.Other medications
 Anticoagulants
 Antianginal medications
 Avoid NSAID-b/c they increase vascular resistance and decrease renal perfusion
V. Nutritional therapy
 Low sodium diet (< 2g -3g /day)
 Avoid excessive fluid intake
 Tell the patient’s family which foods are high in sodium
Cont…

DACA of Ethiopia
Digoxin 0.125-0.375 mg po daily
Plus
Furosemide , 40-240 mg, po divided in to 2-3 doses daily
Plus
Potassium chloride, 600 mg po once or twice daily
And/or
Enalopril 5-40 mg po once or divided in to two dose daily
And/or
Spironolactone 25-100mg po once daily or divided into two
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50

Monitoring and managing potential complications
Hypokalemia
Hyperkalemia
Hypotension
Renal dysfunction
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Acute complications of heart failure include:
• Pulmonary Edema
• Acute Renal Failure
• Arrhythmias

53
Hypertension

Blood pressure
 In normal circulation, pressure is exerted by the flow of blood
through the heart and blood vessels.
 High blood pressure can result from a change in cardiac output,
peripheral resistance, or both.
 High BP can be viewed in three ways: as a sign, a risk factor for
atherosclerotic CVD, or a disease

55
Hypertension
☞ Hypertension-is defined as: systolic BP (SBP) > 140 mmHg and
diastolic BP (DBP) > 90mmHg; based on the average of two or more
correct BP measurements taken during two or more contacts with
the health care provider.

New BP categories are:
1) normal (<120 systolic and <80 mm Hg diastolic),
2) elevated (120–129 systolic and <80 mm Hg diastolic),
3) stage 1 hypertension (130–139 systolic or 80–89 mm Hg diastolic) and
4) stage 2 hypertension (≥140 systolic or ≥90 mm Hg diastolic).
BP categories

 These categories should not be based on BP readings at a single point in time but
rather should be confirmed by two or more readings (averaged) made on at least
two separate occasions.
 Individuals are classified according to their highest systolic or diastolic BP
category.
 Out of office BP readings (home or ambulatory BP monitoring) should also be
obtained for comparison with office BP readings.
 The BP category of pre-hypertension is no longer used.
Cont…

58
Etiology of Hypertension
Can be primary (essential) or secondary hypertension
I.Primary (Essential) hypertension
Accounts for 90-95% of all cases
Has no known causes
Onset usually between the age of 30 & 50yrs
Associated risk factors include:
 Advanced age
 Family history
 Obesity
 High sodium intake
 Cigarette smoking
 Sedentary lifestyle
 Excessive alcohol in take
 Diabetes
 Stress and increased serum lipid level

II. Secondary hypertension
 Has specific cause
 Accounts for <5% of cases
 Identifiable causes include:
 Coarctation or congenital abnormalities of aorta
 Renal disease
 Renovascular HTN
 Pheochromocytoma
 Cushing’s syndrome
 Brain tumors
 Pregnancy
 Medications: Estrogen, Glucocorticoids,
Sympathomimetics (e.g. dopamine, dobutamine)
59

Clinical manifestations
 HTN is often called “silent killer”
 With severe hypertension symptoms developed secondary to effect on
blood vessels in various organs and tissues or to increased work load
of the heart
60

Cont…
 Headache; Most common symptom and occurs in occipital region
 Nocturia
 Increased BUN & creatinine
 Speech & vision alternation
 Dizziness
 Weakness
 Faintness (sudden fall)
 Sudden hemiplegia
 Occasionally, retinal changes; Hemorrhages, Exudates, small infarction
 Stroke or TIA
 Blurring of vision
 Epistaxis
61

Hypertensive crises
 Present as hypertensive urgency or hypertensive emergency
 Systolic reading of 180 mm Hg or higher OR diastolic reading of 110
mm HG or higher, on two separate occasions at minutes interval
 Needs immediate emergency medical treatment

Hypertensive Urgency
 There is no associated organ damage.
 Patients may or may not experience one or more of these symptoms:
 Severe headache, Shortness of breath, Nose bleeds, and Severe anxiety.
 Treatment requires readjustment and/or additional dosing of oral
medications, without hospitalization

Hypertensive emergency
 Is hypertension with acute impairment of one or more organ systems that can
result in irreversible organ damage.
 It generally occurs at blood pressure levels exceeding 180 systolic OR 120
diastolic, but can occur at even lower levels in patients whose blood pressure had
not been previously high.
 Manifestations
 Retinal hemorrhage or an exudate , Papilloedema
 Headache, vomiting, and/or subarachnoid or cerebral hemorrhage
 Hematuria, proteinuria and acute renal failure

Diagnosis
History
Physical Examination
Measuring blood pressure (at least 1week apart)
Ophthalmologic examination
Lab tests
ECG
Echocardiography & chest X-ray
65

Medical Management
Goals
Preventing death and complications
Achieving and maintaining the arterial BP at:
 140/90 mmHg or lower
 <130/80 mmHg for people with DM & chronic kidney diseases
The managements of hypertension include:
Lifestyle modifications
Pharmacologic therapy
66

Cont…
 Indications of Life style modification: person with either border line or
sustained HTN
 Lifestyle modifications
 Weight reduction
 Moderation of alcohol intake
 Regular physical activity
 Reduction of sodium intake
 Smoking cessation
67

Indications of drug therapy:
 BP remaining > 140/90mmHg after 3-6 months of life style changes
 Presence of target organ damage
 Presence of other complications or risk factors
Cont…

Drugs used for the treatment of HTN include:
Vasodilating drugs
hydralazine
β-adrenergic blocking drugs
Atenolol
Metoprolol
Propranolol
Antiadrenergic drugs (centrally acting)
Methyldopa
69
Alpha (α)-adrenergic blocking drugs
Doxazosin
Prazosin
Calcium channel blockers
Nifidipine
Verapamil
Diltiazem

Angiotensin-converting enzyme (ACE) inhibitors
Captopril
Enalapril
Lisinopril
Angiotensin II receptor antagonists
Losartan
Valsartan
Irbesartan
Diuretics
Furosemide (Lasix)
Hydrochlorothiazide
70
Cont…

DACA of Ethiopia
Any one of the following classes of drugs could be used as first step
agents:
☞Diuretics
☞Beta Blockers
☞Calcium antagonists
☞ACE-Is
71

First line drugs for non-emergency conditions
Hydrochlorothiazide, 12.5-50 mg/day PO And/or
Nifedipine 10-40 mg, PO TID And/or
Propranolol 40-160 mg PO divided in to 2-4 doses
Alternative
Enalopril, 2.5-40 mg PO, once or divided in to two doses daily And/or
Methyldopa, 250-2000 mg PO in divided doses.
72

Drugs used to treat hypertensive crisis include:
 Nitroprusside, nifedipine, propranolol, captopril, hydralyzine
1. Treatment of Hypertensive Emergency
 Hydralazine, 5 mg IV every 15-min
 Depending on the underlying condition/TOD, furosemide, 40 mg IV can be
used.
2. Treatment of Hypertensive Urgency
 Nifedipine, 20-120 mg p.o in divided doses per day. OR
 Captopril, 25-50 mg p.o three times daily

Prevention
British Hypertension Society suggestions:
Dietary changes - - DASH diet
Weight reduction
Regular aerobic exercise (e.g., walking)
Reducing dietary sugar intake
Reducing sodium (salt)
Discontinuing tobacco use and alcohol consumption
Reducing stress
74

75
DASH Eating Plan
Low in saturated fat, cholesterol
Eating fruits, vegetables, and low fat diary products
Reduced red meat, sweets, and sugar containing beverages
Rich in magnesium, potassium, protein, and fiber
Low sodium intake
o Can reduce BP in 2 weeks

Potential Complications
 Left ventricular hypertrophy
 Myocardial infarction
 HF
 Cerebrovascular accident (stroke or brain attacks)
 Renal insufficiency & failure
 Retinal hemorrhage
76

DISEASES OF THE VEINS

Varicose vein (varicosities)
 Enlarged, weakened, twisted and dilated veins that have permanently
lost ability to carry blood from the legs back up to the heart against the
force of gravity.
 Most commonly occurs in lower extremities
 Veins in which the one-way valves aren't working well.
 They don't close properly, causing some of the blood to pool in the legs

Causes/risk factors
☞ Heredity
☞ Sex –women more at risk
☞ Pregnancy
☞ Obesity, aging
☞ Hormone-containing medications
☞ Standing for long periods
☞ Traumatic injury to the leg
☞ abdominal straining, and crossing legs
☞ Post phlebitic obstruction
☞ Venous and arteriovenous malformations

Pathophysiology
 Varicose veins may be considered primary (without involvement of
deep veins) or secondary (resulting from obstruction of deep veins).
 A reﬂux of venous blood in the veins results in venous stasis.
 If only the superﬁcial veins are affected, the person may have no
symptoms but may be troubled by the appearance of the dilated veins.

Tired, Feeling of heaviness, aching, swollen legs
Nighttime leg cramps and leg restlessness
Visible, enlarged veins
Mild swelling of ankles especially in evening
Skin at the ankle discolored
Skin ulcers near the ankle
Increased susceptibility to injury and infection

Cont…
Appearance of spider veins (telangiectasia) in the affected leg.
Redness, dryness, and itchiness of areas of skin (stasis dermatitis or venous eczema)
Cramps when making a sudden move as standing up.
Minor injuries to the area may bleed more and/or take long time to heal.
Lipodermatosclerosis (skin above the ankle may shrink )

Varicose vein

Varicose vein and spider vein pictures

Diagnosis
History
Physical Examination
Venography (with x-ray)
Venous Duplex Ultrasound Clot

Medical management
Conservative treatment
Wearing compression stockings
Alleviate swelling & pain
Help heal any skin inflammation or ulcerations
Sclerotherapy
Compression Stockings
Sclerotherapy
Micro-Surgery
Phlebectomy (to remove the affected veins)
Ligation and stripping

Prevention
☞Exercise - e.g. Swimming
☞Controlling weight and diet
☞Don't wear tight clothes around waist, legs or groin
☞Avoid long periods of sitting or standing
☞ Don't sit with legs crossed

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