IN observance of the 13th Annual Association of Consultant Physicians of Jamaica (ACPJ ) Symposium, slated for next Sunday under the theme ‘Updates in Infectious Diseases: The Bugs are back, or did they really leave?’, today’s focus will be on infections and the heart.

The heart structures may become infected with bacteria or viruses leading to some relatively common conditions. In Jamaica, we still see a relatively high number of cases of new Acute Rheumatic Fever, while it is almost non-existent in developed countries. Other heart infections that are seen here include:

1. Pericarditis: Infection of the exterior lining of the heart.

2. Myocarditis: Infection of the heart muscle.

3. Infective endocarditis: Infection of the interior heart structures – most commonly the heart valves.

ACUTE RHEUMATIC FEVER

Being a common problem in the developing world (including Jamaica), this deserves its own review, but I will just summarise the key points here. Acute Rheumatic fever (ARF) is usually triggered by a throat infection, with streptococcus (commonly called strep throat). ARF is not a true infection of the heart, as the heart structures are not directly infected with the bacteria. The commonly held teaching is that the infection with the bacteria, sets up an immune reaction. This can be looked at as a case of mistaken identity, where the heart structures resemble the “bad elements” of the strep bacteria, and are attacked by our body’s defence system – the immune system.

What may start off as a sore throat will lead to joint aches, even arthritis, fever, and, in the worst cases, heart failure. ARF mainly affects children and new episodes are rare in adults. In the majority of cases, the ARF settles with treatment and does not leave any permanent damage to the heart. In a smaller percentage of cases, permanent damage to the heart may ensue – leading to Rheumatic Heart Disease (RHD), which is a lifelong problem requiring regular cardiologist visits and care to prevent repeat episodes of ARF.

PERICARDITIS

This is inflammation of the exterior lining of the heart and may be caused by virus, bacteria or the immune system.

WHY WOULD WE SUSPECT YOU HAVE PERICARDITIS?

We may suspect this if you have chest pain, which is sharp in nature and worse when you lay down, and worse with breathing. You may or may not notice a fever, or other symptoms commonly attributed to the flu.

HOW DO WE CONFIRM THE DIAGNOSIS?

The diagnosis is usually made based on your symptoms and confirmed by ECG changes, which are typical. In some cases, if the inflammation leads to fluid build-up around the heart, we may need to draw the fluid and test it. This only becomes necessary in a very small number of cases, where the fluid build-up is sudden and severe, and causes severe symptoms.

HOW DO WE TREAT PERICARDITIS?

In most cases, if caused by a virus, it settles with rest, painkillers (such as aspirin or other anti-inflammatory medicines). If caused by bacteria, it will require antibiotics.

MYOCARDITIS

This is inflammation of the heart muscle itself, most commonly caused by viruses.

WHY WOULD WE SUSPECT MYOCARDITIS?

Myocarditis may cause the heart to become weak leading to shortness of breath and feeling easily tired. In the most severe cases, it may lead to heart failure and cause your body to retain fluid – this shows up with leg swelling, swelling of the belly, and really severe shortness of breath making it difficult for you to lie flat to sleep.

TREATING MYOCARDITIS

The treatment for myocarditis is usually supportive. And because it is not usually bacterial, antibiotics are not useful. Rest is recommended and treatment of heart failure symptoms where present.

INFECTIVE ENDOCARDITIS

Infective endocarditis is inflammation of the interior lining of the heart, most commonly the heart valves. It is usually caused by bacteria, but may be caused by the body’s own immune system in rare instances. In most cases, people with normal heart structure do not develop infective endocarditis. People who have damaged heart valves, or who are born with holes in the heart are at the highest risk.

WHY WOULD WE SUSPECT INFECTIVE ENDOCARDITIS?

We would suspect infective endocarditis if you have a fever that is not settling, with no other apparent cause, as well as other signs we may detect when we examine you, such as a new heart murmur. We will then test your blood for bacteria, perform ECGs and other tests to confirm the diagnosis.

HOW DO WE TREAT INFECTIVE ENDOCARDITIS

Since this is usually caused by bacteria, once we test your blood and identify the type of bacteria, we can treat with antibiotics that have been proven to kill these bacteria. The course of treatment is usually long – four to six weeks – and requires hospitalisation.

PREVENTING INFECTIVE ENDOCARDITIS

For people who have damaged valves or were born with heart defects, such as hole in the heart, we usually recommend that you see your cardiologist before doing any surgeries or dental procedures, like extraction, that may put you at risk. We assess your risk and prescribe antibiotics before the procedure to prevent infection of your heart valves during or after your procedure.

Dr Claudine Lewis is an adult cardiologist and medical director at Heart Smart Centre in Montego Bay. She is also a cardiologist at the Cornwall Regional Hospital and an associate lecturer with the University of the West Indies. Questions may be sent to questions@heartsmartcentre.com and for additional information call 684-9989 or visit the website www.heartsmartcentre.com