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VALVULAR DISEASE

VALVULAR DISEASE. Mark Boyko, CCFP-EM R3. One night at the Foot…. 64yo male found down at home… -HR 111 -BP 109/67 -RR 12 -Temp 38.6 -O2 88% -Glucose 22. At first glance…. Moving both sides of body (barely) Not speaking to you GCS 9. Labs. -Hgb 108 -WBC 14 -Lytes N

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VALVULAR DISEASE

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  1. VALVULAR DISEASE Mark Boyko, CCFP-EM R3

  2. One night at the Foot… 64yo male found down at home… -HR 111 -BP 109/67 -RR 12 -Temp 38.6 -O2 88% -Glucose 22

  3. At first glance… • Moving both sides of body (barely) • Not speaking to you • GCS 9

  4. Labs -Hgb 108 -WBC 14 -Lytes N -EKG pacer spikes

  5. REPORT: Multiple ischemic areas consistent with embolic stroke

  6. DDx Embolic Stroke ? • Valvular disease (infective or sterile) • Prosthetic valves • A fib / Arrythmia • MI / Mural thrombus • Cardiac tumours • Cardiomyopathy (amyloid, sarcoid) • Antiphospholipid Ab, pro-thrombotic states • R-sided emboli with PFO • Carotid plaques

  7. You decide to.. • Treat for aspiration pneumonia secondary to stroke • Intubate for decreased GCS • Off to ICU, neuro consult • Carotid dopplers N • Echo of heart reveals vegetations on mitral valve • Blood Cultures later reveal +Strep Bovis

  8. Question • Due to his blood culture, what further (non-acute) examination does this patient require in the future?

  9. Infective Endocarditis (IE)

  10. Question Which age group is most commonly affected? a) < 30 yrs b) 31-60 yrs c) >60 yrs

  11. Pathophysiology • Turbulent flow is the biggest enemy, it denudes the endothelium over time • IDU’s  there is often talc mixed in with the drug injection, in addition to cocaine-induced ischemia, causing damage to valves • A vegetation begins as platelets and thrombin, and may be sterile at first. But it is a perfect home for a bacteria present in the bloodstream

  12. Transient Bacteremia • A brief period where the bacterial count in the bloodstream is <10 organisms/mL blood. • This should only last 30min or so, and for most people this is not a problem. However, for people with valvular disease, it is.

  13. Acute vs Subacute IE • Historically IE classified as acute (rapid onset, hemodynamic compromise) or subacute, but best viewed as a continuum • Acute is lethal in days if left untreated • For us… • Acute: if they are sick and this is a rapid change • Subacute: grumbling along last few weeks

  14. Question Which microbe causes most cases of IE overall?

  15. Microbiology of IE • Overall, #1 cause is Staph Aureus • However, many causitive agents, the microbiology of IE is best classified by: • Native valve, non-IDU • IDU’s • Prosthetic Valves

  16. GROUP #1 Native Valve, Non IDU #1 Streptococcus Viridans (40%) #2 Staph Aureus (30%) #3 Enterococci (10%) #4 HACEK group *Culture Negative 5% (Coxiella Burnetti, Bartonella)

  17. Question Can you name at least 3 organisms in the HACEK group? …. Alternatively…. Which NHL team first drafted famous Czeck goaltender Dominik Hasek?

  18. HACEK Organisms • Haemophilus aphrophilus • Actinobacillus actinomycetemcomitans • Cardiobacterium hominis • Eikenella corrodens • Kingella kingae

  19. HACEK Organisms • Just remember they are GRAM Negative organisms, difficult to culture • Collectively, cause 5-10% of IE in people that are not IDU’s

  20. GROUP #2 Injection Drug Users (IDU’s) #1 Staph #2 Strep #3 Pseudomonas #4 Serratia #5 Fungal (Candida, Apergillis)

  21. GROUP #3 Prosthetic Valve #1 Staph Epidermidis (50%) #2 Streptococcus

  22. IE Risk Factors • Prior episode IE • Prosthetic Valve (same risk mechanical vs biological) • Recent invasive procedures • Structural Heart Disease (congenital and acquired valvular) • IDU

  23. IDU’s • Right-sided IE • Tricuspid > Pulmonary valve • PE more common • Less likely to have peripheral embolic findings • High recurrance rate

  24. Question • Rank the cardiac valves in order of decreasing incidence of IE

  25. Answer • Aortic • Mitral • Tricuspid • Pulmonary

  26. Valves • LEFT-SIDED valves are more commonly hit! • However, when all cases of right-sided IE are analyzed, the vast majority occur in IDUs

  27. What about Pacemakers? • Rare, but can get IE • Right-sided vegetations (on either valves or pacer leads) • Seen from 0-20 months post insertion • Look for hematomas, cellulitis at site • Be suspicious!

  28. Question • What percent of people with IE will have a murmur at some point during the course of their illness?

  29. Clinical Presentation • Fever 80% • General malaise 40% • Skin manifestations 20-50% • Splenomegaly if present for weeks 20% • Murmur 30-80% (but almost all will have a murmur at some point during their course of illness)

  30. Better way to remember things… • Bacteremia-related symptoms • Fever, chills, SIRS • Cardiac symptoms • Chest pain, SOB, CHF • Embolic Phenomenon • CNS, cardiac, pulmonary, GI, renal, DERM

  31. Question Which of the following lesions are painful? a) Osler’s Nodes b) Janeway Lesions c) Splinter hemorrhages d) Roth spots

  32. Dermatologic Findings in IE • These are immune-complexes (bacteria + Ig + fibrin) that have become lodged in distal arterioles, just under the skin. • Usually only seen in sub-acute IE because it takes time for them to develop.

  33. Osler Nodes (Ouch!)

  34. Janeway Lesions

  35. Splinter Hemorrhages

  36. Roth’s Spots

  37. EKG • Usually normal, but can have new conduction disturbances • BBB • AV dissociation

  38. Diagnosis of IE • DUKE Criteria • Not straight-forward, but sensitivity ~90% • We cannot make the diagnosis of IE in the ER! But you must be suspicious. • Requires blood cultures to come back, echo to be done, and monitoring over course of an admission.

  39. Blood Culture • Key to the diagnosis • Draw 3 samples total, 3 different sites • 2 different sites at time 0 • 3rdseparate site at time 1hr • 90-95% will be positive if truly IE

  40. ECHO • TTE ~60% sensitive for vegetations • TEE ~ 80% sensitive for vegetations • If TTE negative but clinical suspicion remains high, make sure you get a TEE • NPV value for IE with a normal TEE without prosthetic valves ~100% • All patients need one within 12hrs, but if they are acutely decompensating order one STAT.

  41. Question When is the highest risk for IE after prosthetic valve surgery? a) 0-6mos b) 6mos-3yrs c) 3-10yrs d) >10yrs

  42. Question What is Olser’s Triad?

  43. Osler’s Triad • Pneumonia, endocarditis, meningitis • Streptococcus pneumoniae is the culprit • Often associated with alcohol abuse, mortality is extremely high

  44. Empiric Treatment Native Valve • Ceftriaxone 2g IV, plus • Gentamicin 1mg/kg IV q8hrs IDU • Native valve regimen, plus • Vancomycin 15mg/kg IV q12hr Prostethic Valve • IDU regimen, plus • Rifampin 300mg PO TID

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