INFECTIVE / INFLAMMATORY CONDITIONS OF THE HEART
Infective/inflammatory conditions of the heart may be caused by any of the following:
 Bacteria
 Viruses
 Autoimmune conditions (especially Rheumatic Fever, Rheumatoid Arthritis,
SLE)
 Drug reactions
 In the immunosuppressed may also be caused by fungus (especially Candida)
In all cases RMT should be aware of medication being used by the client because the
treatment may have to be adapted if the person is taking anti-inflammatories.
ENDOCARDITIS
Endocarditis is inflammation and/or infection of the endocardium. The endocardial lining
of the heart is a continuation of the intimal layer of the blood vessels and also lines the
heart valves. Endocarditis is a relatively uncommon, but not rare condition.
Infective endocarditis occurs when microorganisms adhere to the endocardial surface of
the heart. It is most commonly bacterial in origin but may also be fungal or viral or
secondary to autoimmune disease. Irregular surfaces such as heart valves are most
commonly affected. Areas of congenital, septal and mural defects are also susceptible
areas.
Normally, the smooth inner lining of the heart is inherently resistant to foreign organisms
adhering to it. When an infecting agent is able to attach to the endocardium and ‘set up
shop’, the person’s blood stream provides an ideal environment for proliferation.
Bacterial endocarditis is often caused when bacteria are introduced to the bloodstream
during dental surgery or other medical procedures. Anyone with underlying abnormalities
of the heart may, therefore, be predisposed. In these instances, prophylactic doses of
antibiotics are often given before ‘risky’ procedures.
Endocarditis may be classified as ‘acute’ or ‘subacute’ based on how long the infection
has been present before it is recognized and treated, or by the nature of the infecting
organism (ie. bacterial, fungal, viral).
Acute disease is more severe, associated with fever, systemic toxicity, and death from
sepsis in several days to weeks.
Subacute disease usually occurs in patients with prior valve disease. It is less severe,
associated with low grade fever, vague systemic complaints and various embolic
phenomena.
The endocardium usually repairs well, but there is a risk of valvular damage since the
fine tissues of the valve cusps are extensions of the endocardium. Other complications of
endocarditis include:

Vegetations
o Lesions; clusters of the infecting organism or localizations of autoimmune
activity
o often develop on/inside the cusp (i.e. pockets) of the valves
o they can be either stable or unstable
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vegetations of autoimmune disease are more like erosions of tissue
and tend to be quite stable
vegetations of bacterial or fungal origin are susceptible to breaking
away from the wall/valve under the hemodynamic pressure of the
heart. They can create dangerous emboli. This type of unstable
vegetation is referred to as friable.
Signs and Symptoms of Endocarditis:
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May have general symptoms of fever, chills, fatigue, weight loss, muscle ache,
and sweating
Acute valve damage may lead to acute s/s of CHF (pulmonary edema and SOB)
The infection may spread, especially to the kidneys, leading to hematuria
Constant deep achy chest pain that doesn’t change with rest or activity
Treatment:

Medical treatment is to treat the cause (infection or autoimmune disease).
Infections are usually treated with long-term antibiotics (often four-six weeks, or
more). If valve damage has occurred, surgical repair or valve replacement may be
required.
Complications:
1. Thrombosis, Embolism (thrombus, vegetations, or septic material [may also
spread the infection])
2. Permanent valve damage (heart murmur, and possibly a need for repair or
replacement surgery in extreme cases)
3. CCHF secondary to the valve problems
RMT Concerns:
1. avoid treatment while the condition is active and the risk of embolism is high
(consultation with M.D will be necessary)
2. with a previous history of endocarditis, the RMT should establish whether
there is a present risk of embolism
3. client may be taking anticoagulants i.e. increase bleeding/bruising
4. assess for CCHF status and adapt treatment accordingly
MYOCARDITIS
Myocarditis is an inflammatory condition of heart muscle that can result from a variety of
causes. Most cases are viral in nature, but toxins, drug reactions, and autoimmune
reactions are also common causes. Myocarditis also commonly occurs post myocardial
infarction. It is a rare but serious condition that affects men and women at any age.
The most common causes are: viral infection, post myocardial infarction, autoimmune
disease and drug reactions
Acute myocarditis is a rare inflammatory disease, which may lead to the sudden onset of
cardiac failure and death. Myocarditis can cause considerable morbidity and mortality
and may lead to dilated congestive cardiomyopathy. The clinical diagnosis of myocarditis
is difficult and many times is arrived at only after more common problems including
asthma, recurrent vomiting, and chronic viral illness such as mononucleosis are excluded.
Viral myocarditis is preceded many times by a flu-like illness or gastroenteritis. When
patients present with the classical findings of congestive heart failure (i.e. tachypnea abnormal rapid respiration or tachycardia - abnormal rapid heartbeat), the diagnosis is
more apparent.
Signs and Symptoms:
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Viral infections are often asymptomatic (and may remain undiagnosed)
May present as a constant deep pain similar to endocarditis, or with fatigue, SOB,
fever, and arthralgia.
If the condition persists, CHF may develop
Sudden, acute myocarditis may also appear in the form of heart failure or sudden
cardiac death
May disguise itself as ischemic, valvular, or hypertensive heart disease.
Medical Treatment:
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No medical treatment is necessary with viral infection. Viral causes are generally
self limiting. Management is through rest and avoidance of physical exertion (to
avoid additional stress to the heart)
Fever, chest pain, CHF, arrhythmias, or syncope may develop, requiring medical
management
If bacterial infection is the cause (rare), antibiotics are introduced
Autoimmune causes are usually the most difficult to treat
RMT Concerns:
o Not considered dangerous for massage in the ‘active’ phases
o Awareness of CHF concerns if cardiomyopathy/CHF develop
PERICARDITIS
Pericarditis is inflammation or irritation or the pericardium; the outer, protective covering
of the heart. The pericardium helps anchor the heart in place, preventing excessive
movement of the heart in the chest cavity with changes in body position, helps to protect
the heart from infections and invading tumors, and may help keep the heart from
enlarging.
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There are many possible causes of pericarditis: trauma or infection from heart
surgery, post MI pericardial irritation (esp. if there is a slow bleed through a mural
defect [blood is corrosive]), autoimmune disease (rheumatoid arthritis or lupus),
cancer (an adjacent lung cancer may irritate or metastatic disease can directly
invade the pericardium), kidney failure (irritation due to toxicity of the blood),
drug reactions, radiation therapy (due to burn injury).

The pericardial space is lubricated by lymph and usually contains 10 to 30 cc of
fluid. This fluid provides protection to the heart, and decreases friction with
movement/beating of the heart. An increase in pericardial fluid is called an
effusion. In patients with a small effusion, a pericardial ‘rub’ may be heard. It is a
scratching, grating sound best heard along the left sternal border, with the patient
in the sitting position. In the presence of a large pericardial effusion, the heart
sounds may be diminished or absent. The reduction of cardiac filling from a large
effusion may lead to cardiac tamponade (increased fluid and resultant pressure
fully restrict heart filling and pumping, leading to cardiac arrest and death).
Certain infections may lead to bacteremia which can spread to the pericardium.
Patients then usually present with fever and irritability. Tachycardia, tachypnea, and
chest pain with respiration or cough are common.
Signs and Symptoms:
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Systemic symptoms or the original cause may be present (fever etc with infective
causes)
Constant, extreme chest pain - considered to be the most painful heart
condition
Pain is generally felt below the sternum and/or below the ribs in the left side of
the chest and occasionally into the upper back or neck.
Pain is exacerbated by deep breathing and excessive movements
Lying may exacerbate, sitting up and forward may relieve symptoms
tachycardia and tachypnea are also common
Medical Treatment:
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Is related to the cause
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Complications
o Risk of pericardial effusion leading to cardiac tamponade
o Exudate developed in the pericardium can result in adhering between the
visceral and parietal layers. Friction during heart beating can cause pain
and usually results in reinforcement of the continuously micro damaged
adhesion.
o Fibrosis in the walls of the pericardial sac can result in thickened nonelastic regions which can cause friction and affect the beat.
Concerns for RMT:
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The condition is not worsened by massage. RMT needs to be aware of overall
health concerns in the person whose pericarditis is secondary to another condition.
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Hx of pericarditis should be followed up for CHF status and intrapericardial;
friction problems especially if the heart rate is increased.
Valvular Heart Disease
Definitions:
Valvular regurgitation is the inability of the valve to close properly, resulting in
backflow called a heart murmur.
Valvular stenosis is the inability of the valve to open properly, resulting in a reduced
volume of blood exiting the chamber and considerable pressure in the exit chamber.
Valvular incompetence is a non-specific term which just means that the valve is not
functioning properly.
Most Common Causes:
1. Hypertension/CCHF
2. Complication of MI
3. Rheumatic Fever
 An autoimmune reaction secondary to infection by streptococcus bacteria.
 After a period of some weeks, antibodies which have developed to fight the
infection appear to sense a chemical similarity between the bacteria and heart
tissue. The valves are often particularly aggressively attacked.
4. Endocarditis
5. Congenital Abnormality
Concerns for the RMT
Mention of heart murmur or any of the causes of valvular disorder on the case hx should
lead to the RMT establishing CCHF status. Some heart murmurs are not clinically
significant. Adult onset heart murmurs typically indicate some degree of heart failure.
Hearts with clinically significant valve problems typically do not adapt easily to
increased CO. Watch for signs of dyspnea (i.e. difficult or painful breathing) and
increased SNS activity. Watch for increases in BP post treatment.