Question

A 38-year-old man comes to the emergency department due to a day of progressive shortness of breath. Over the past week, he has also had fever and malaise. The patient uses intravenous heroin daily. Temperature is 39.6 C (103.3 F), blood pressure is 100/56 mm Hg, pulse is 102/min and regular, and respirations are 20/min. Oxygen saturation is 93% on room air. The patient is in moderate respiratory distress. Bibasilar crackles are heard on lung auscultation. Cardiac examination reveals a 3/6 holosystolic murmur that radiates to the left axilla. There is 1+ bilateral pedal edema. Laboratory evaluation shows a hematocrit of 33% and a leukocyte count of 19,000/mm³ with a left shift. ECG reveals sinus tachycardia. Chest x-ray reveals pulmonary edema and no cardiomegaly. Echocardiography demonstrates a 1-cm vegetation on the mitral valve and severe mitral regurgitation. Blood cultures are drawn, and empiric broad-spectrum antibiotics are initiated. Oxygen is also administered via nasal canula. What is the most appropriate next step in management?

A. Intravenous heparin infusion

B. Intravenous metoprolol

C. No additional intervention

D. Radionucleotide bone scan

E. Surgical consultation

Correct Answer: E. Surgical Intervention

(Pss btw..….Flashcards for this question at the bottom of the Email )

IV Drug Use (Daily Heroin Use)
⬇️
🧠 Risk for Endocarditis (Bacterial introduction into bloodstream)
⬇️
Bacteremia ⬆ (seeding of heart valves, commonly Staphylococcus aureus)
⬇️
Vegetation Formation on Mitral Valve (Platelets, fibrin, and bacteria adhere to endothelium)

⬇️

• Valve damage → Mitral Regurgitation (MR)

• Embolization Risk ⬆

Mitral Regurgitation
⬇️
🧠 Backflow of Blood from LV → LA during Systole
⬇️
⬆ Left Atrial Pressure
⬇️
⬆ Pulmonary Venous Pressure
⬇️
Pulmonary Edema (Bibasilar crackles, dyspnea, hypoxemia [SpO₂ 93%])
⬇️
Acute Heart Failure Symptoms

• Respiratory distress

• Tachypnea

• Bilateral pedal edema

Septicemia from IE
⬇️
Systemic Inflammatory Response (Fever: 39.6°C, Leukocytosis: 19,000/mm³, Left Shift)
⬇️
Further Cardiac Stress ⬆

🧠 Key Diagnostic Features from Scenario

• Echocardiography: 1-cm vegetation, severe MR

• Chest X-Ray: Pulmonary edema, no cardiomegaly (suggests acute MR)

• Vitals: Hypotension (BP 100/56), tachycardia (HR 102), respiratory distress

  ⬇️

The guidelines for infective endocarditis recommend early surgical intervention for severe valvular dysfunction with heart failure symptoms (e.g., acute pulmonary edema).

Antibiotics alone will not resolve the valvular damage or the resultant hemodynamic instability.

Explanation of Other Answers

A. Intravenous Heparin Infusion

Anticoagulation contraindicated in infective endocarditis (risk of embolization or mycotic aneurysm rupture).

B. Intravenous Metoprolol

Beta-blockers can worsen cardiac output in acute heart failure and are not appropriate in the setting of acute MR.

C: No Additional Intervention

The patient is decompensating due to acute severe MR and requires surgical intervention for definitive management.

D: Radionucleotide Bone Scan

Although bone scans can detect metastatic infection, this is not a priority in the setting of acute heart failure and respiratory distress.

E: Surgical Consultation

Acute severe MR due to IE with heart failure is an indication for urgent surgery to prevent hemodynamic collapse and embolic complications.

Flashcards

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