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Cardiovascular

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Dr. Donald Sefcik

Donald J. Sefcik is the Associate Dean at the Chicago College of Osteopathic Medicine (CCOM), Midwestern University (MWU), in Downers Grove, IL. He is a tenured professor and board certified in both Emergency Medicine and Family Medicine. From June L997 through May 2000, Dr. Sefcik served as Medical Director for the Physician Assistant Program, College of Health Sciences (CHS), at MWU. Dr. Sefcik's lectures are based upon his experiences as a clinician and preceptor, tenure as a medical school faculty member, and his student assessment research.

Dr. Sefcik has practiced with physician assistants since 1988 and been involved in the clinical training of physician assistants since 1990. Prior to joining lVlidwestern Universrty's faculty, Dr. Sefcik was a faculty member in the Pharmacology Department at Butler University and in the Nursing Department at Marian College, both in Indianapolis, Indiana. Dr. Sefcik has a Bachelor of Science in Pharmacy (1981), a Master of Science in Pharmacology (1994), both from Butler University, ffid an MBA (May 2004) from Purdue University.

CME Resources Certification & Recertification Exam Review

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CertiJication & RecertiJication Exam Review CME Resources

2004 Cardiovascular Medicine - I Diagnostic Modalities and Murmurs Donald J. Sefcik, D.O., FACOEP

Learning Objectives
Upon completion of this portion of the review course, the participant should be able to:

Discuss the following common cardiovascular diagnostic tools:

2. 3.

4. 5. 6,

Electrocardiographs(EKC) ExerciseElectrocardiography(StressTests) Echocardiography CardiacCatheterization Ultrafast CT scans Differentiate left-sided and right-sided heart murmurs. Compare and contrast the following systolic and diastolic murmurs: r Aortic stenosis e Aortic regurgitation o Mitral stenosis o Mitral regurgitation (including MVP; Barlow's syndrome) . Right-sided valvular defects Define and describe Rheumatic heart disease. o Discuss Jones criteria. Discuss endocarditis and its classic features. Compare and contrast Roth spots, Osler's nodes and Janeway lesions.

o . . . o

Chest x-rays

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Certification and Recertification Exam Review Cardiology - I

2004

Case

A 64 year-old female presents complaining of crushing chest pain. She also advises you that she is nauseous and is experiencing indigestion. She is notably diaphoretic. Her blood pressure is 124178 mm Hg. Her 12lead EKG reveals regional ST segment elevation, Her rhythm strip is included for your interpretation.

Case 1 .1 Which one of the following myocardial infarctions is most likely?

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A. anterior aspect of the left ventricle B. posterior aspect of the right ventricle
C. D. E.
inferior aspect of the left ventricle lateral aspect of the left ventricle anteriolateral aspect of the left ventricle

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Case 1.2 Which one of the following best describes the rhythm strip?

A. first degree AV block B. second degree AV block, Mobitz type I C. second degree AV block, Mobitz type ll
D. complete heart block E. Wolf-Parkinson-White
syndrome

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Certification and Recertification Exam Review Cardiology - I

2004

Gase 2

A 36 year-old male presents complaining o{lgft-qggq ngrnlgqs for the past several hours. He relates that he is in excellent heailh-?ndmsnTseen a clinician since high school. His examination reveals murmurs, loudest at the aortic listening post, grades lllA/l systolic and llful diastolic.

Case 2.1 Which one of the following would most expeditiously provide support for your initial diagnosis?

A.
B. C. D. E.

echocardiogram fundoscopic examination examination of peripheral pulses complete neurological examination CT scan of his brain

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Case 2.2 { '---._ ff tfre patient \

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began to complain of a headache during your evaluation and then became 'obtunded, which of the following would you suspect as the most likely cause?

infarCtion l- s,rrr.\\ r*tv.{ ( I cw^. ,n :;;Ze- -- c.[*t,'*E;c rX \{10 \ * .Scr*txy rupture of a berry aneurysm Pro r.rulur ;r' ilorcmarked ischemia of the left parietal lobe marked ischemia of the right occipitat loUet) nr + .\e{ie *,9 Yr,Y\ritn r;:r"1rnL West Nile Viral encephalopathy Lni,1 .e.,,r\r:)

* CrJ,^.

".t..Ll- \

betcy clncw\i'*r {f! h^^"lt,^ Va,,^"{

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Certification and Recertification Exam Review CardiologY - I

2004

Case 3 A 62 year-old female presents complaining of palpitations. She has experienced two previous episodes that lasted only a few minutes. This episode has lasted two hours' She is mildly short of breath, mostly because of anxiety. She denies chest pain. Her rhythm strip is included for your interpretation.

Case 3.1 Wnic-f' one of the following therapeutic choices would be LEAST effective at controlling this arrhythmia?

A. quinidine t -*'^ B. lidocaine - c^\ *!f..'\rz C. amiodarone'v*-*..-r,a

D. diltiazem E. digoxin
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Case 3.2 Which one of the following diagnostic tests would be the most likely to provide the definitive diagnosis underlying her arrhythmia?

A.

complete blood count

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B. free serum Ta level C. 24 hour holter monitor D. HDL cholesterol level E. serum potassium level

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Certification and Recerti{ication Exam Review Cardiology - I

2004

Gase 4

A 56 year-old male presents complaining of severe tightness in his chest for 45 minutes. He is a smoker, with longstanding hypertension, diabetes mellitus type 2 and hyperlipidemia. His EKG reveals ST segment elevation (4 mm) and T wave changes.

Case 4.1 Which one of the following, if identified on this patient's EKG, supports the diagnosis of acute myocardial infarction with a positive predictive value of greater than 90%?

LeJ reciprocal sr segment depression D. multifocal premature atrial complexes

A.

R waves greater than 11 mm in height in tead

asymmetric T wave inversion

avf {LV q

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E.

unifocal premature ventricular

complexes

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Case 4.2 lf this patient is not having an acute myocardial infarction, which one of the following is

LEAST likely the correct diagnosis?

@ rate-related event - go e$ w''\ S,\"e(\ B. myocarditis ls{.-Y\.-rr\'r: 1 *r*., c, {\ c. hiperkalemia

.

D' bundle-branch block E. acute pericarditis

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,

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Certification and Recertification Exam Review Cardiology - I

2004

Case 5

A 62 year-old male presents complaining of_sho of breath on exertion for the past several weeks; now he is short of breath at resl congestive

heartfaiIure.HisexaminationlffiS,SinuStachycardia,bilate-rallower

extremity edema (3+/4+), indirect (bedside) evidence of elevated right atrial pressure and a heart gallop.

Case 5.1 Which one of the following is the most specific manifestation supporting a current diagnosis of congestive heart failure in this patient?

A. bibasilar rales B. atrialgallop C. ventricular gallop D. jugular venous distention E. peripheral edema

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Case 5.2 This patient has documented diastolic dysfunction. Aggressive diuresis in this patient might cause hypotension because:

@such patients are preload dependent.

B. most diuretics are negative inotropes. C. most diuretics are positive chronotropes. D, the ensuing vasoconstriction will reduce peripheral resistance. E. the baroreceptor reflexive response will be bradycardia.

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e

rtificatio n and Recertificatio n Exam Review Cardiology - I 2004

Gase 6

A 64 year-old female presents to your practice for her first visit. She had a myocardial infarction two years ago. She currently is asymptomatic, just wants to establish rappotl with a clinician in her new neighborhood. Her blood pressure is 122174 mm Hg and her pulse is 64. Her total cholesterol is 230, with an LDL of 130. Her BMI is 24. She has no other medical problems. She follows a low fat diet and walks briskly in the mall every day.

Case 6.1 Which one of the following is the most appropriate at this time?

A. no intervention is required

@tart

lovastatin C. start cholestyramine D. start metoprolol E. order an echocardiogram

Case 6.2 Six weeks later the patient presents to the Emergency Depadment complaining of 45 minutes of crushing chest pain. She has 4 mm of ST segment elevation in leads ll, lll and aVF. Her blood pressure is 142182 mm Hg and pulse is 72. Based only upon what is known, which of the following should NOT be administered to this patient?

A. aspirin

@diltiazem

C. metoprolol D. oxygen (2 liters) E. a thrombolytic agent

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Certificatio n and Recertifrcation Exam Review Cardiology - I 2004

Case 7 A 68 year-old female presents to your practice complaining of dyspnea on exertion. She advises you that the symptoms began about four weeks ago. She denies chest pain, dizzine_sq qnd orthopnea. During her examination, you auscultate a grade lllA/l electiorGvsto.l*urmur that radiates into her carotids and into her axilla (loudest in the left-lateral decubitus position). \

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Case 7.1 Which one of the following is most likely a cause of the murmur that you hear?

A. aorlic regurgitation -b,tr>t B. mitral regurgitatiop - -slsrui',LC. pulmonic regurgitation rr n D. iricuspid ste-nos-is ) l)'cn'sotlc E. Austin-Flint murmur

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Case 7 .2 Which of the following sets of EKG findings would you expect to find on her EKG?

A. low voltage and sinus tachycardia B. R waves in lead V5 less than 10 mm in height and right axis deviation C. S waves in lead V2 less than 5 mm in height and left axis deviation D. right atrial enlargement and right axis deviation E. P waves in lead ll greater than 3 mm in width and P waves in lead V1 thaHl rn11n clgnth

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Certification and Recertification Exam Review Cardiology - I

2004

Case 8

, SNI_ A patient is noted tofauera'grade lllA/l crescendo-decrescendo systolic murmur that begins well after th{S1 heart sound. The murmur is most notable at the lower left sternal border. The cErotid pulsation rapidly rises.
Case 8.1 Which of the following is the most likely cause of this murmur?

n*-mitral-stenosis - c\ B, mitral regurgitation

ffi E. hypertrophic cardiomyopathy

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Case 9 A 76 year-old male presents after a syncopal episode. He is currently asymptomatic. Historically, he advises you thai he has suffered from exertional dyspnea and anginal chest pain. His blood pressure is

114196.

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Case Which of the following is most likely to be discovered during his examination?

9.1

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llA/l

@pmurmur at lower left sternal border

border

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-E-+ridsystolic click

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e\ee\",c^L
,Selecferl Cardiovas

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I.

cular Diagnostic Tools Chest X-Ray (CXR)

or-c) rw^.y*.J\n

a.

o r b,
r

General usefulness Rapidly assesses cardiac silhouette and occasionally individual chamber changes Heafi:thoracic ratio > 0.5 - cardiomegaly on upright posterior-anterior (pA) film Cardiac silhouette - measured from midline to the right and to the left Transthoracic diameter measured at height of right hemidiaphragm Pulmonary veins - more horizontal

R,bs = fi-d\
lnlsrh$b'a,

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Pulmonary arteries

more vertical

Aortic coarctation

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,

Mlt '/ 6.inn\o''nctfa t .a tc. {'*\/J\d}'-' Pulmonarv edema

Absence of aortic knob Rib notching (secondary to elevated intercostal arterial pressure) h 1U Consider in younger patients refractory to therapy ( <\',c' 5lur Brachial-femoral blood pressure and pulse disparities

I , . \)

"

d.

Alveolar.J:ffi,rN\:c,.3eli/ uF lun5i *.1) ::ffitjl*:];^" ----.us:'\ Trt j^1 ( ..*,,*,\.\^y \ ,,\. \pericardial [q \-*-Y J.

:--t;;i"]i,]ation"ofvascutature ., fer}"s\, cf tjo;\ f:cs-+, . r..i.@ilrct.lQorizontal lines in basal periphery; interstitial fluid)

o "water bottle " heart (not an acute chanee) --;, ^ .-^,f::=),^-^lr]l --,-. nol{lechocardiographyj confirms; quantifies fluid

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II. Patient Conditions

1.

Electrocardiogram

(EKG)
r,

i'ct

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f h ''s

Discussed in Chest Pain and Myacardial Infarction section

2.

Ge Exercise Electrocardiography fStress Tests]

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Li

r,=sivl *15"/"

SpecK{-

a. b.

assesstnent for coronary artery disease (70% sensitive detection; 75Yo specifieity exclusion)

r . .

various protocols
Bruce - degree of eievation and speed changed every 3 minutes Naughton - degree of elevation changes every 2 minutes Echocardiogram (check for wall motion changes - hypokinesis)

c.

o ' .

Interpretation:

How farllong did the patient go ? [< 3 minutes

Symptoms
?
?

high risk]

EKG Changes

**

ST segment changes

horizontal or down-sloping ST segments = very suggestive CAD

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Ar..,-{\"^I Juas n;* Ptffi:*e

d.
Perfusion Scintigraphy Thallium-2}| (apotassiumanalog) - Injected at peak exercise; images ASAP afterwards and at 2 * infarcted "cold" spot; stays cold * Ischemic "cold" spot; reperfuses -

'

6 hours

. .

Usdul: Abnormal resting EKGs (BBB); Equivocal Treadmill

stress tests

More accurate for determining extent and dislribution of ischemia

3. Cardiac Catheterization a.
b. c.
Best test to "get the answer"

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coronary arterial anatomy hernodynamics

Significant narowing - defined as at least 70% luminal narrowing Note: 70% luminal narrowing corresponds to 50Yo reduction in cross-sectional area

Therapeuticstratification . Low risk - Single vessel disease (usually do well with medical therapy) . High risk - Triple vessel disease (with decreased left ventricular function) Left Main Coronary artery disease

4.

Ultrafast CT Scans

a. b. c. d.

identifies coronary arterial "calcifrcation,, Does not visualize (quantify) all "blockage"
Noninvasive Role as a "Screening Test"?

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B, Valvular Heart Disease

w',rr\yl urr cf-

1.

- adequate for - 90 % ofcases) a. assessment of valvular disorders b. assessment of cardiac ejection fractions c. assessment of charnbers/wall motion d. quantifies pericardial effirsions e. Doppler echocardiography measures blood flow velocity f. assessment of ventricular thrombus g. can coupie with Exercise Electocardiography r Transesophageal approach:
Echocardiography (Transthoracic

better views of left atrium; mitrai valve and thoracic (ascending)

aorta

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2.

Cardiac Catheterization

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C.

Anltythmias

1.

Electrocardiogram (EKG)

a. b.

If patient symptomatic at the time:

may provide definitive diagnosis or rule out anhythmia

If

done between symptomatic episodes, may provide ,,clues',:

.Pre.excitationsyndromes(shortPRinterval)A.,v,y\+f4/^\< i. Wolf-Parkinson-White $MpW) - delta wave pre$ent 'i

ii.

Long-Ganong-Levine 0-GL) o-cl.)

- no delta wave -no delta;;*'

Long QT interval interval -ong

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2.

Ambulatory Monitors
a. Holter Monitor

b, Event Recorder

- 24 hours - days - weeks -

months... ...

(T.{.q\an tr x.DJts\

3.

Signal-Averaged EKG
The presence of late potentials is suggestive of a risk for ventricular anhythmias

Monitors high-frequency, low-amplitude signal from terminal portion of QRS complex

4.

Electrophysiologic (EP) Studies

Intracardiac catheters

stimulate and record cardiac events

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Valves

* Afrioventicuiar: fught - TricusPid

Left

Mitral

* Semilunar:

Left - Aortic
Right - Pulmonic

Heart Solutds
Mechanisms:

Valve Vibrations 2. Walis of Chambers

1.

+ S\e.*. \e**"
pte:sur
krt otrP

cauje,
HYP"r{wv c 64t-*( VulOrnC *j' \'dtun

3. Vessels

u'sit-.\' *

Diaphraqm:
S1 (Lubb) - onset of systole

v'r\u:

(AV Valves)

Or,rcdu^J,'*

52 (Dubb) - onset of diastole (SL Valves)

,-+
\t-

solit s2

\-(--A2- Aortic Valve Closwe \ Pz- Pulmonic Valve Closure

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r)
r^ -, ,--l ,. -r.. n [. * Di**obtL hect* Lt)-nvt
f\ \1
Ct.>

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Bell:

**-GALLyEEC\\ f
Enhanced

S3) Vent'icular Gallop (Passive Venticular Filling)

R 5ro"gs oF pe.)pr- ; *w\._ s4-AtrialGallop(ActiveVentricularFilline) P\rrv\"'''t S 3'L'() f;t\r,.\*.-^:#. -tqw,r- J ,lurrr-., Enhancedby, ofiance ts\\d.$ft?I\ Y,]*5 pir-,r*rr) ffi'-F-4'-birn\?teL Act,rcfuJ\r.rtr1 * Venticular Hyperrophy (LVH) Przgr*Jt,
AUSCULTATE: (first with diaphragm' then bell)

Venticte(cnrLj RapidFilling(anemia'thyrotoxicosis)
Dilated

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err

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Aortic area (2nd right ICS, RSB) Pulmonic area (2nd left ICS, LSB) -

C"\

*\

Second pulmonic area (3rd left ICS' LSB)

V."\,t'JO-9

Tricuspid area (4th and 5th left ICS' LSB) Apex or mitral area (5 left ICS in MCL)

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:6
MURMURS
A. What ????
a. Relatively prolonged exta heart sounds b. Heard in Systole or Diastole or Both c. Caused by turbulent blood flow into/through/out ofthe heart d. May be benign or pathologic

B. Descriptions ????
a. Timing & Duration

Early Systolic, Midsystolic (Ejection), Late Systolic Early Diastolic, Middiastolic, Late Diastolic (Presystolic) Holosystolic (Pansystolic) Holodiastolic (Pandiastolic)
Continuous
b, Intensity

Grade I Grade II Grade III Grade IV Grade V Grade VI

c. Location

Barely Audible Quiet, but clearly audible Moderately t( rnt , 6 Loud and Associated witrr Very Loud, Thrill easily pu$E5t/ Audible with Stethoscope not in contact with chest and thrill is visible

Loud

--. ffiiD-

r[ 6t

r '

Auscultatory area - area ofgreatest intensity

C4. Jugular Venous Pulsations

B,f;-

ir.re^W: !\)ne-

Ld(^\'t- '= 'ar-'

('\2'p,

J, *'*\r'icrs' S,

\4

"a" wave = right atial contraction

c" wave = closure tricuspid valve
carotid activity wave = venous filling (volume) of RA

"x" Slope:

RA relaxation during

"y"

RV Systole
(TV is closed)

slope = RA emptying during RV Diastole (TV is open)

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gS'L
SYSTOLE

rcrur.^\^ts
C/rfe_

Left s'*"J
sv"o*e

'-\ J+iAr\hiR rn.;cwvl

ps Ag
tnR

TR

DIASTOLE

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RICUSPID

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VALVE

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Left-Sided Valvular Problems

Aortic Stenosis (AS)

a.

.-,of\
'/
rheumatic fever

origin (bicuspid), calcific changes tn@ b. Causes left ventricular outflow obstruction (during systole)

one(gggenqln
Symptoms: Signs:

/:\

DJpryu, Angina, Syncope, Fatigue, Weakness sro*

ririnJ.-oron*.frr..

Diffuse left ventricular impulse Left venticular hyperlrophy

c.

t*"r **r
'r(
*/'

.t tardus;f,

Systolic murmur (often diamond shaped)

)r

If symptomatic - sugery, generally - therapy of

choice

----*-A
o

i*d\N# r , \\\ C\gurr,icr.t,L b' Crf-SC6,,Jc,

'a\r*
t.i,{
\ c\r,- '$<r pr,.

"'

rtic Re g urg it ati o n (AR)

u. Oft .fu!gg-ut!!g rdgid congenital, infl ammatory/infectious b. Blood retums to left venticle during diastole

Symptoms:
Signs:

Dyspnea on exertion (DOE), Angina, Syncope Palpitations, Orthopnea/PND, Chest Pain

Diastolic murmur (
Often 53; occasioni occasionally 54
c, Ifacute - surgery

If chronic - sugery,

once symptomatic

S1\i
.-.d
)t-v
Mitrat stenosis
b.

b' *'h-

I
\p
(-\ \J

T:1

-(q,

p\'.dt],l"r

B1 fuHrr"a..

N\'=--\ \i

(MS)
(- 3F:lM)

a. Often\rheurnatic in origin\more common in women

.-s\.

'{: }az '..*' :

5fl,^ ,KAtf,'

ElevatidTEft-atriffiGEiil.
Symptoms:

DyspneaiDoE, orthopneai?ND, Pulmonary edema, Angina

He^t'r\"

'*}T-Y--

Signs:

ffi*' Pulmonaryhypertension/edema
atrial

(9 [""*-)

It)!r *uu\> \

arrhythmias

c. Medicai: Atrial fibrillation - anticoagulation and digitalis

Surgical: Valvuloplasty, Commissurotomy,

Replacement

._\. ?' ?-^ J,^,f , {-xr ) tn

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,$"
kArutq

Mitr al Re g ur g itatio n (MR)

a.

Many etiologies:

infective endocarditis, chorda tendinae rupture, papillary muscle infarction...

Chronic: Blsumatic-dsease, congenital, calcification of annulus.... * generally - best tolerated of valwlar iesions

* Commofr-Sp-to T0Tlo of females ?) * Most common cause of MR * Myxomatous changes (may be part of Marfan's syndrome) * Floppy valve - Click * Barlow's syndrome - MVP + Quasicardiologic symptoms
- - 80 % of all patients may be symptomatic - nonspecific chest pain, palpitations, shorfness of breath....

P)I--Z.ZIa '{g^q

b. Syrnptomatology Symptoms

(acute):

Symptoms
Signs Signs

(chronic):

Dyspnea/PND Waxing/Waning Shortness of Breath and Fatigue Pulmonary edema

(acute): (chronic):

LVH, Pulmonary hypertension atrial fibrillation

c. Ifsevere - surgery

O;"r'dk'
f);rpncrr.

un t'{tl

um'

Lesion

Sy

Signs

UUb
Angina
Syncope

Earlv drastollc murmur

D-ggssggrrdo Wide oulse Dressure Boundins pulses

Louddf->
slttlng

Notes

7C

OrthopnealPND

-Siffiff ;i-"r,
54 (occasionally)

L.\r
^,l'\'o

leaning forward full exhalation

LV Heave
AS DOE
Chest Pain (angina)

Late-peaking Systolic murmur(

Pulsus parvus et tardus LV Heave
S4

\-. Loufrr", '}f --s-min-g leaning forward

Syncope

MR

Acute
Dyspnea, pulmonary edema

Holosystolic murmur Wide splits 52

Radiates

Aoex to axilla

Chronic WaxingAVaning dyspnea DOE PND ,l

Atrial fibrillation

(-,,.+ ODenrns snaD-\

Diastolic Rumble

I-nr&+
l9!-1aleral
decubitus

iilaff

l*-=.

r,.r

oosition

C^

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Miscellaneous Murmur Notes

@turmurs
. .

of Childhood

A. Stills Murmur 2-8yearsoid -_.

r r

low pitched; musical quality systolic - grade II - III / VI .r loudest iftuap.fiil;simfr-\ itiori loudest - midway from low left sternal border to apex caused by turbulent flow in left ventricular outflow

B. Venous Hum

---5yearsold gradel-III/VI r continuousavicular

a a

ion; radiates i

neck
ind or head turned
as pass

caused by turbulent flow

jugular veins,

clavicle

2. When to worry about Childhood murmurs

o . . .

Loud and Harsh Holosystolic Diastolic 4(

Suspiciousassociation:

Loud 52
Gallops
Cyanosis

Clicks

Alteration in pulses Failure to thrive

:t

AR..

3. Murmur Characteristtcs
Diagnostic Maneuvers

fn(

a "; $e,^\ Res*u At L

Deep Inspiration * Increases TR

Y Continuous -

Patent Ductus Arteriosus (PDA)

"-$

($ll0

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Rheumatic I{eart Disease

Definition An inflammatory disease, possibly autoimmune, involving the: Heart, joints, skin and CNS
Aschoffbody - focal, interstitial myocardial inflammation Foliows Streptococcal infections Incidence Most common in 5 - 15 year olds
Recurrences are common, if not treated with antibiotics

7 - 35 days (mean

- 18 days)
(- 20 %)

Clinical Presentation

Joints: Cardiac: Skin: Serology:

Arthralgias

-75%-- Migratory LL'lgl*h

Myocarditis, Pericarditis

*MR-60-80 %;Ar-30%
Erythema marginatum < 5

Valvular

0{:8, Av b\ot VS )k tb
BUT, negative in up to
10 %)

7o

Evidence of Streptococcal infection (4SO

Jones Criteria (Must have Two Major or One Major and Two Minor) fplus evidence of Streptococcal infection, recently]

Major
S-gbgg[aneous nodules - 5 - I0 % P-olyarthritis - 75 % E-ryhqma marginatum - < 5 Yo

earditis

--65%
diagnostic Purposeless, rapid, involuntary movements

Chorea-2-3% ** Sydenham's - rare, but very

Emotionally labile

Minor
Fever

Artkalgias

&rrc Acute phase reactants - elevated C t \ R' ' -ig ^t Prolonged PR interval (increase of 0.04 seconds or more, over baseline) Previous rheumatic fever

!, ^

^ , \\

11

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Infective Endocarditis
Definition
usually an infection ofthe valvular endocardium
Valves

r'--:. Q.@t
al:

Aortic >> Tricuspid> Pulmonic

1; MVP =

, - tf

Rh-eumatic Heart Disease

100F

Be suspiciozts of the NEW cardiac murmur; especially in febrile patients

Special PatientsiSpecial Organisms IDU - Staphylococcus aureus ('ricuspid

'

valve) {

tru -"-.

'

r G\ s.tL s{ na#t'

"- '-,

Predisposing Risk

Prosthetic Valves

MVP

Congenital heart malformations -- Dental procedures (transient bacteremia) Rheumatic valvular disease

IDU
Miscellaneous

NOTE - Reduced risk with Secundum Atriol SePtal Defects

Classic

gp5,\ ,.^;" ) \ oodo*ri-f - ,o %) - alsoknown as:Litten's sign

Findine2r'

ophthalmic (retinal) hemorrhages with central white spots

t
t
1

Osler Nodes (- 5 - 25 %) tender lesions, digital pads

Janeway Lesions

(- 2 - 10 %) nontender, nonpalpable, nonblanching - violet colored

Splinter Hemorrhages (- 5 - 15 %) linear streaks subungually Clubbing

(-

10

- 50 %)

Diagnostics
Transthoracic echocardiogam

Transesophageal echocardiogram

45 - 75 % - 90 %

Blood cultures - negative in 5 - 15 % (commonly secondary to antibiotic previously prescribed or HACEK) [Hemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella]

t2