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Inflammatory Heart
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.
Pericarditis
Pathophysiology
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
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 Manifestations
 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 tests
 Chest x-ray
 Echocardiogram
 Chest MRI or CT scan
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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
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The pericardium cannot stretch as the heart beats, which prevents
the chambers of the heart from filling w/ blood
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 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).
S/Sx:
 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
Interventions
 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
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prevents the ventricles from expanding fully,
so they cannot adequately fill or pump blood
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 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 Manifestations
 weak or absent PMI & peripheral pulses
 distended neck veins
 muffled or decreased heart sounds
  BP, narrowing pulse presure
 pulsus 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
Interventions
 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
 inflammatory disease of the myocardium that causes infiltration
and injury to myocardial tissue
Causes:
 infectious process – viral, bacterial, parasitic infection
- invasion of myocardial tissue by organisms or production of
toxins (Ex. polio, influenza, rubella)
 autoimmune reaction – rheumatic fever
 cardiac damage is char. by thrombus formation, dilation of
ventricles, scarring (fibrosis), hypertrophy, disintegration of
cardiac muscle cells heart muscles weaken  signs of heart failure
S/Sx:
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fever, tachycardia, abnormal heart beats
abnormal heart sounds (murmurs, extra heart sounds)
pericardial friction rub
chest pain
fatigue, shortness of breath, orthopnea
fainting – often related to arrhythmias
peripheral edema
other signs suggestive of infection: rashes, sore throat, itchy
eyes, swollen joints
Interventions:
 bed rest, low Na+ diet -  cardiac workload, promote healing
 Digitalis (digoxin) -  myocardial contractility,  HR, to
prevent heart failure
 Diuretics – to control pulmonary or systemic congestion
 Antibiotics, anti-inflammatory drugs, steroids
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)
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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 Manifestations
 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 Microemboli
Janeway lesions
Clinical Manifestations (cont.)
 enlarged spleen – continuous antigenic process
 Embolic manifestations
Lung – hemoptypis, 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
Diagnostic tests
 blood cultures & sensitivity – to identify organism
– best test for detection
- obtain sample just before & during height of
fever
 2D Echo – valvular vegetations
 CBC – high ESR, high WBC, anemia
 ECG
Prevention:
 Prophylactic antibiotics are often given to people with predisposing
heart conditions before dental procedures or surgeries involving
the respiratory, urinary, or intestinal tract
 Continued medical follow-up is advised for people with a history of
endocarditis
 proper oral hygiene
Medical Interventions
1. 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 Interventions
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
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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)
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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
Clinical Manifestations (cont.)
 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
Interventions (cont.)
4. Diuretics, digitalis if w/ signs of CHF
5. Prevent recurrence – teach pt. on good nutrition, proper hygiene
practices, adequate rest, immediate treatment of sore throat
- taking prophylactic doses of Penicillin to prevent
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