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INFLAMMATORY AND NON
INFLAMMATORY DISORDERS
OF THE HEART
Ukwosah .N. David M.D
INFECTIOUS DISEASES OF THE
HEART
• Any of the heart's three layers may be affected by
an infectious process.
• The diseases are named for the layer of the heart
most involved in the infectious process:
• (Myocarditis (inflammation of the myocardium),
Endocarditis(inflammation of the endocardium)
and pericardium(inflammation of the pericardium)
• The usual management for all infectious diseases
prevention. IV antibiotics are usually necessary
once an infection in the heart has developed.
COMMON INFLAMMATORY
DISEASES OF THE HEART
•
•
•
•
Infective Endocarditis
Acute pericarditis
Myocarditis
Rheumatic fever and Herat disease
PERICARDITIS
• inflammation of the pericardium
• Causes:
 may result from bacterial, viral or fungal infection

•
•


•

•
can be assoc. w/ systemic diseases such as autoimmune
disorders, rheumatic fever, tuberculosis, cancer, leukemia,
kidney failure, HIV infection, AIDS, and hypothyroidism
Heart attack (post-MI pericarditis) and myocarditis
radiation therapy to the chest and medications that
suppress the immune system
injury (including surgery) or trauma to the chest,
esophagus, or heart.
Inflammation of the
pericardium
Pericardial effusion
Fluid accumulation (serous, purulent,
blood) in the pericardial sac
 Intrapericardial
pressure
Compression of the heart
 Ventricular filling and
emptying
 Venous pressure
 CO
 Arterial pressure
CLASSIFICATION OF PERICARDITIS
• Acute Pericarditis – result to exudate formation
•
(if severe, can lead to cardiac tamponade)
• Chronic Pericarditis – result to fibrosing (hardening)
•
•
of the pericardial sac
- the thick fibrous pericardium tightens
•
around the heart and  efficiency as a pump
•
(Constrictive Pericarditis)
CLINICAL MANISFESTATION
 Pericardial friction rub
 Severe precordial chest pain – caused by the inflamed pericardium
•
rubbing against the heart
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









Usually relieved by sitting up and leaning forward
Pleuritis type: a sharp, stabbing pain
May radiate to the neck, left shoulder & arm, back or abdomen
Often intensify with deep breathing and lying flat, and may  with coughing and swallowing
Breathing difficulty when lying down
Need to bend over or hold the chest while breathing
Dry cough
Ankle, feet and leg swelling (occasionally)
Anxiety
 muffled or  heart sounds
Fatigue
 if severe- rales,  breath sounds
Fever
DIAGNOSTIC TEST
Chest x-ray
 Echocardiogram
 Chest MRI or CT scan
 show enlargement of the heart from fluid collection in the pericardium, and signs of
inflammation. They may also show scarring and contracture of the pericardium (constrictive
pericarditis)
 ECG is abnormal in 90% of pts. w/ acute pericarditis.
 may mimic the ECG changes of MI. To rule out heart attack, serial cardiac marker levels (CK -MB and
troponin I) may be ordered
 Blood culture
 CBC, may show increased WBC count
 Pericardiocentesis, with chemical analysis and pericardial fluid
•
culture
CONSTRICTIVE PERICARDITIS
 a chronic form of pericarditis in w/c the pericardium is rigid,
•
thickened, scarred, and less elastic than normal
•

• The pericardium cannot stretch as the heart beats, which prevents the
chambers of the heart from filling w/ blood
•


CO & blood backs up behind the heart

symptoms of heart failure
 The inflamed pericardium may cause pain when it rubs against
•
the heart.
CAUSES
most common causes are conditions that induce chronic
•
inflammation of the pericardium: tuberculosis, radiation
•
therapy to the chest, and cardiac surgery.
 may also result from mesothelioma (a tumor) of the pericardium
 incomplete drainage of abnormal fluid accumulating in the
•
pericardial sac, which can occur in purulent pericarditis or in
•
post-surgery hemopericardium(bleeding w/in the pericardial sac).
SIGN AND SYMPTOMS
dyspnea that develops slowly and progressively worsens
 Fatigue, excessive tiredness -  CO
 Weakness




weak heart sounds
distended neck veins
chronic swelling (edema) of the legs, ankles
hepatomegaly, ascites
INTERVENTION
 identify the cause, if possible
 analgesics for pain, anti-pyretics, anti-inflammatory
•
drugs(NSAIDS) such as aspirin and ibuprofen, in some cases,
•
corticosteroids may be prescribed
 Diuretics- to remove excess fluid
 Pericardiocentesis - using a 2D-echo-guided needle aspiration or
•
surgically in a minor procedure
 Antibiotics or antifungal agents(can be instilled directly to the sac)
 Bed rest, proper positioning, low-Na+ diet
 If the pericarditis is chronic, recurrent, or causes constrictive
•
pericarditis, cutting or removing part of the pericardium may be
•
recommended (Pericardiectomy)
CARDIAC TAMPONADE
 compression of the heart caused by blood or fluid accumulation in
•
the space between the myocardium and the pericardium
• 
• prevents the ventricles from expanding fully,
• so they cannot adequately fill or pump blood
• 
•  CO & signs of CHF
 Causes:
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





Pericarditis caused by bacterial or viral infections
Heart surgery
dissecting aortic aneurysm (thoracic)
wounds to the heart
end-stage lung cancer
acute MI
Other potential causes: heart tumors, kidney failure, recent heart attack, recent open heart surgery, recent invasive
heart procedures, radiation therapy to the chest, and SLE
CLINICAL MANIFESTATION
weak or absent PMI & peripheral pulses
 distended neck veins
 muffled or decreased heart sounds
  BP, narrowing pulse presure
 pluses paradoxus (BP falls when pt. inhales deeply)
 Anxiety, restlessness, tachycardia, dyspnea,  RR, palpitations
 Fainting, light-headedness, pallor or cyanosis
 Chest pain- sharp, stabbing, worsened by deep breathing or coughing
 signs of CHF
 CXR, Echocardiogram – pericardial effusion
INTERVENTION
an Emergency condition !
 Goal: save the patient's life, improve heart function, relieve
•
symptoms, and treat the tamponade
 Pericardiocentesis (to drain the fluid around the heart) or by
•
cutting & removing part of the pericardium (pericardiectomy or
•
pericardial window).
 IV Fluids- to maintain normal blood pressure
 Dopamine, dobutamine -  BP
 Oxygen therapy -  workload on the heart
 Identify and treat cause of tamponade – give antibiotics or
•
surgical repair of injury.
MYOCARDITIS
• Myocarditis is an inflammatory disease of the myocardium
• caused by different infectious and noninfectious triggers
CAUSES OF MYOCARDITIS
ACUTE VIRAL
MYOCARDITIS
• Viruses That Have
Been Shown to
Cause Myocarditis
DIAGNOSTICS
• Myocarditis is a challenging diagnosis due to the heterogeneity of clinical
presentationsClinical presentation
• Myocarditis presents in many different ways, ranging from mild
symptoms of chest pain and palpitations associated with transient
ECG changes to life-threatening cardiogenic shock and ventricular
arrhythmia
SIGN AND SYMPTOMS
• Chest pain (often described as "stabbing" in character).
• CHF(leading to edema, breathlessness and hepatic congestion).
• Palpitations (due to arrhythmias).
• Sudden death (in young adults, myocarditis causes up to 20% of all cases of sudden death).
• Fever (especially when infectious)
• Since myocarditis is often due to a viral illness, many patients give a history of symptoms consistent
with a recent viral infection, including fever, diarrhea, joint pains, and easy fatigue ability.
• Myocarditis is often associated with pericarditis, and many patients present with signs and
symptoms that suggest concurrent myocarditis and pericarditis.
DIAGNOSTIC TEST
• ECG- Non-specific T-wave abnormalities
• CK-MB and Troponin may be elevated
• Chest X-Ray- Variable (Normal to Cardiomegaly)
• Echocardiogram
• Cardiovascular Magnetic Resonance
• A safe and sensitive noninvasive diagnostic test to confirm the diagnosis is not
available
• Endomyocardial biopsy- there are risks and not used for every case but is definitive
for myocarditis
ECG IN MYOCARDITIS
ECG changes can be variable and include:
•Sinus tachycardia.
•QRS / QT prolongation.
•Diffuse T wave inversion.
•Ventricular arrhythmias.
•AV conduction defects.
•With inflammation of the adjacent pericardium, ECG features
of pericarditis can also been seen ( =myopericarditis.(
NB. The
most common abnormality seen in myocarditis is sinus tachycardia with nonspecific ST segment and T wave changes
TREATMENT
• Acute myocarditis resolves in about 50% of cases in the first 2–4 weeks,
but about 25% will develop persistent cardiac dysfunction and 12–25%
may acutely deteriorate and either die or progress to end-stage DCM
with a need for heart transplantation.
• The core principles of treatment in myocarditis are optimal care of
arrhythmia and of heart failure
Patients with LV dysfunction or symptomatic HF should follow current HF therapy guidelines,
including diuretics and ACE inhibitors or ARBs
*Beta-blockers can be used cautiously in the acute setting.
*Digoxin should be avoided in patients suffering from acute HF induced by viral myocarditis
INEFFECTIVE ENDOCARDITIS
• Endocarditis is inflammatory process of the
endocardium, especially the valves.
• This disorders carriers high morbidity and
mortality rates, but outcomes can be
improved greatly with early diagnosis and
effective treatment.
ETIOPATHOPHYSILOGY
• Common injecting organisms include
1. Staphylococci (s. aureus, S.faecalis,
S.epidermidis)
2. Streptococci
3. Escherichia coli
4. Gram negative organisms
(klebsiella,pseudomonas,)
5. Fungai (Candida,aspergillus) and HACEK
organisms
CONTI.....
• These organisms enter the body through the
oral cavity after dental procedures, mouth or
tooth abscesses, oral irrigations, or irritations
from dental floss or bridge work.
CONTI...
• the upper respiratory tract is another port of
entry following surgery, intubations, or
infections.
• Direct exposure of the bloodstream to
organisms can occur with prolonged IB
catheters,hemodialysis catheters and IB drug
use.
CONTI..
• procedures involving the gastrointestinal and
geneto urinary tract(barium enemas
sigmoidoscopy,clonoscopy,liver biopsy and
prostatectomy) have been associated with
infective endocarditis
RISK FACTORS
Previous heart damage
Dental procedures which lead into the introduction of bacteria's
Heart surgery
Intubations
Procedures involving gastrointestinal and genitourinary tracts
e.g. barium, enemas, sigmoidoscopy, catheterization and
cystoscopy
• Reproductive conditions like delivery of new babies, abortions
and pelvic inflammatory disease
•
•
•
•
•
PATHOPHYSIOLOGY
• Usually in this case the bacteria's or any other causing
agents enter the blood stream through invasive procedures
like dental procedures, surgery , urinary cauterization.
• Then they accumulate on the valves of the heart or
endocardium
• Finally they form vegetations or clusters
• These vegetation they lead into damage heart valves by
perforating and deforming the valves leaflets
• This at the end leads to tearing which means there is poor
flow of blood and lead into accumulation of blood in
chambers of the heart hence endocarditis
CLINICAL MANIFESTATIONS
• The primary presenting symptoms of infective
endocarditis are fever and a heart murmur.
• Clinical manifestations related to the infection
include
• Fever ,chills, alternating with sweats,
malaise,weakness, anorexia,weigt loss, pallor,
backache and spleeno megaly
CLINICAL MANIFESTATIONS RELATED
TO EMBOLIZATION OCCURS IN ANY
PART OF THE BODY
• Stroke, TIA, aphasia
• Loss of vision form embolization of the brain or
retinal artery
• Roth’s spots
• Myocardial infarction
• Pulmonary embolism
• Splinter haemorrhage
• Clubbing of the fingers
ASSESSMENT AND DIAGNOSTIC
TESTS
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History collection
Physical examination
Based on parenting symptoms
WBC
Eco cardiography
ESR
Blood culture
COMPLICATIONS
• Heart failure
• Cerebral vascular complications
PREVENTION
•
Antibiotics prophylaxis is recommended for moderate and high risk
patients is recommended before and sometimes after the following
procedures
1. Dental procedures
2. Tonsillectomy and adenoidectomy
3. Surgical procedures that mainly intestinal and respiratory
4. Bronchoscopy
5. Fall bladder surgery
6. Urethral catheterization
7. Urinary tract and prostatic surgery
MEDICAL MANAGEMENT
• The objective of management is to eradicate the
infecting organisms through adequate doses of an
appropriate antimicrobial therapy and to treat
complications
CONTI...
• The choice of antibiotics therapy depends on the
types of organisms involved.
• Penicillin and gentamicin commonly used
• Therapy should administer at least 4 to 6 weeks
NURSING ASSESSMENT
• It includes history taking like;
• Subjective data:
• past medical history: patient asked of signs of the disease
and the onset of the disease and review with patient
history of risk factors like cardiac failure, shock
• Medication history: has the pt ever taken any medication,
what happened afterwards
• Family history:asked of any case at home of the similar
conditions
• Social history: social behaviors that can trigger the
problem
• Surgical history: if ever operated on
• Objective data: assess for temperature
elevations, heart mummer, evidence of cough ,
peripheral edema and embolism, auscultate for
heart sound, monitor arterial blood gas, rapid
purse rate, dyspnea, restlessness and
manifestation of heart failure
DIAGNOSES
• Infective breathing pattern related to inflammation of heart
muscle as evidenced by use of accessory muscle, dyspnea.
• Impaired gaseous exchange related to fluid accumulation
in the lungs as evidenced by shortness of breath
• Decreased cardiac output related to valvular dysfunction
as evidenced by poor tissue perfusion
• Imbalanced nutrition less than body requirement related to
anorexia as evidenced by loss of weight.
NURSING MANAGEMENT
• Position the patient at semi fowlers position to help in
infective breathing through providing enough room
for lung expansion as abdominal contents goes
down
• Administer oxygen therapy 4-6 l/min to help pt in
breathing effectively through supplementing oxygen
• Monitor arterial blood gas , carbon dioxide, oxygen
saturation hourly and document to monitor signs of
respiratory acidosis
• Encourage and provide small frequent meals reach
in proteins helping in repairing worn-out tissues
• Monitor vital signs , heart and lung sound, level of
consciousness to evaluate how effectively the
organs like the heart and the lungs are working
• Schedule nursing activities to allow rest
• Encourage and assist pt to cough and deep breath to promote
chest expansion
• provide tepid sponging to reduce raised body temperature by
evaporation and conduction
• Encourage patient on exercises in order to improve patients
mobility through making the body physically fit
• Make yourself available to the patient and nurse with love and
respond well to his/her questions to array pain and anxiety
• Educate the patient on disease process to make pt cope up
with therapy and the condition
BACTERIAL ENDOCARDITIS
infection of the inner lining of the heart (endocardium) caused by direct invasion of
bacteria or other organisms leading to deformity of the valve leaflets
• Causative agents: Streptococcus viridans (found in the mouth) - 50% of cases,
Staphylococcus aureus and enterococcus. Less common organisms include
pseudomonas, serratia, and candida.
• Classification:
• 1. Acute bacterial endocarditis – rapidly progressing infection
• high fever, murmurs, spleenomegaly, emboli formation
• follows a rapid course and may severely damage the endocardium early in the
disease
• 2. Subacute bacterial endocarditis – slower progressing infection
• fever, wt. loss, fatigue, joint pains, headache, malaise
• has a prolonged course
PREDISPOSING FACTORS
Who are at risk:
 congenital heart defects
 damaged valves by rheumatic fever, atherosclerosis
 artificial heart valves
 may occur after cardiac surgery, invasive procedures (dental procedures,
catheterization, prolonged IV therapy) minor surgery, gynecologic examinations,
dialysis
 may follow after acute infection of the tonsils, gums, teeth, skin, lungs, GIT, GUT
 immunocompromised patients
 drug abusers (injections)
Pathophysiology
Organism travels in
the blood stream
attaches to the
endocardial lining of a
normal heart or an
area of defect (heart
valves)
infected clots may break
free and travel through the
bloodstream
Emboli that can lodge to
various organs (kidney,
coronary artery, spleen,
lungs, brain)
obstruct blood flow and
produce organ damage
forms vegetations
(clumps of bacteria,
fibrin, cellular debris,
platelets)
growth of vegetation on
heart valves
deforms, thicken, stiffen,
perforate the valve leaflets
Dysfunctional heart
valves
CLINICAL MANIFESTATION
 Infection – fever, chills, night sweats, malaise, fatigue, anorexia
•
wt. loss, muscle aches, joint pains
 Cardiac – murmurs (valve dysfunction), tachycardia
•
- advanced – signs of CHF
 Peripheral Manifestations:
• Petechiae – small pinpoint hemorrhages in the conjunctiva, mucous membranes, neck, ankles
• Splinter hemorrhages - small, dark lines under the fingernails
• Osler’s nodes (red, painful nodes with a white center on the pads of fingers, toes, palms or
soles) – a late sign of infection
• Janeway lesions (flat, painless, red to bluish-red spots on the palms and soles) – an early sign of
endocardial infection
• Roth’s spots ( boat shaped retinal hemorrhages near the optic disc seen in fundoscopy
•
* result from Microembo
CONTINUATION
 enlarged spleen – continuous antigenic process
 Embolic manifestations
•
Lung – hemoptysis, chest pain, shortness of breath
•
Kidney – hematuria
•
Heart – myocardial infarction
•
Brain – sudden blindness, paralysis, meningitis, brain abscess
• Complications:

CHF - most common, due to damage to the aortic, mitral valve

Embolic episodes – ischemia and necrosis of organs

arrhythmias – atrial fibrillation

Glomerulonephritis

Stroke

Brain abscess
JANEWAY LESION
MEDICAL INTERVENTION
• Identify the infectious organism - serial blood cultures
• 2. Destroy the infectious org., stop the growth of valvular vegetations
 IV Antibiotics 4-6 weeks (Penicillin, Aminoglycosides)
- to ensure high blood levels of medication
- to eradicate the bacteria from the chambers & valves
 repeated blood cultures are done to assess effectiveness of the drug
• 3. Surgical repair of valvular deformities and congenital defects
• 4. Provide nutritional supplementation & bed rest
• 5. Prevent relapse and recurrent fever & infection
- good oral hygiene, avoid invasive procedures as possible prophylactic antibiotic
therapy, aseptic technique
NURSING INTERVENTION
 Provide comfort measures,  fever
 encourage adequate fluids & nutrition
 CBR if w/ signs of valve dysfunctions (murmurs)
 assess for signs of heart failure, tachycardia, embolic
manifestation
 provide health teachings: cause of infection, prolonged use
of antibiotic, prophylactic antibiotics, preventing recurrence
of infection (good oral hygiene), monitor signs of recurrence
RHEUMATIC FEVER
• an acute or chronic systemic inflammatory process, characterized by
attacks of high fever, polyarthritis, severe carditis (valvular damage)
• Predisposing Factors:
• Age - 5-15 years old, can also affect elderly
• socioeconomic factors – Poor persons living in crowded, urban areas (slum
areas) are more susceptible due to malnutrition, greater exposure to bacterial
infections, less money for medical care and medications
• Genetic
• Etiology:
 Group A Beta Hemolytic Streptococci
 the body undergoes an allergic response to invading streptococci
 the host develops an “autoimmune response” in w/c the streptococcal antibodies
attack host tissue
 follows after an URTI by group A beta- hemolytic strep. – after 18 days, only 2-3
percent develops rheumatic fever
• Pathophysiology:
 a diffuse, proliferative & exudative inflammatory process that affects connective
tissues in organs through the body ( heart, joints, nervous system, respiratory system)
 produces permanent & severe heart damage – if valves are involved
RHEUMATIC HEART DISEASE (RHD)
•
•
•
•
•
•
can develop during 1st – 2nd week
may involve one or all of the layers of the heart
myocarditis – temporary loss of contractile power of the heart
pericarditis – pericardial friction rub
endocarditis – inflammation, ulceration, erosion of valve leaflets
Progressive fibrosis (hardening) scarring calcification of valve leaflets – valve
stenosis & insufficiency/regurgitation
CLINICAL MANIFESTATIONS
Polyarthritis – joint swelling, tenderness, redness, limited movement & pain (
fingers, knees, ankles)
Carditis – tachycardia, murmurs, muffled heart sounds, pericardial friction rub,
precordial pain, cardiomegaly, signs of CHF
fever
subcutaneous nodules – small, painless, firm nodules (knees, knuckles, elbows)
erythema marginatum – non-pruritic rash, macules on the trunk and inner aspect
of extremities, macules join together – looks like chicken wire appearance on
skin
Chorea (Sydenham’s Chorea, St. Vitus Dance) – nervous disorder, involuntary
grimacing and jerky, purposeless movements, late stage of the disease
CONTINUATION
Abdominal pain – engorgement of liver
Minor Manifestation – malaise, weakness, wt. loss , anorexia epistaxis,  ESR, 
WBC
Evidence of streptococcal infection:
•
- (+) ASO- antistreptococcal antibodies titer in the blood
•
- (+) throat culture of Group A streptococcus
 a person is diagnosed w/ rheumatic fever if he meets 2 major
•
criteria or 1 major and 2 minor criteria, as well as having evidence
•
of a recent streptococcal infection
MANAGEMENT
• Goals:
1. Suppression of acute inflammatory process – steroids, aspirin for fever and joint pain
2. Eradication of the streptococcal infection – antibiotics (Penicillin/ Erythromycin)
3. Prevention of disease occurrence
4. To protect the heart against damaging effects of carditis
• Interventions:
1. bed rest – reduce strain on the heart produced by activity
•
- minimize metabolic needs during acute, febrile state
•
2. Diet –  protein,  calorie,  Vit.,  sodium
•
- adequate nutrition to promote healing
•
- if w/ CHF – restrict fluids
•
3. Maintain body alignment
• . Diuretics, digitalis if w/ signs of CHF
• . Prevent recurrence – teach pt. on good nutrition, proper hygiene
•
practices, adequate rest, immediate treatment of sore throat
•
- taking prophylactic doses of Penicillin to prevent
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recurrence of attacks of RF – 5 years after 1st attack
•
- take prophylaxis of antibiotics before & after surgery or
•
dental procedures
•
- Severe RHD – Penicillin IM (Penadur) 1-2 x a month or
•
oral penicillin for lifetime