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Pericarditis & Myocarditis April 6th, 2006 Shawn Dowling Objectives Review – Dx – Tx – ECG’s changes Anatomy and Physiology Parietal layer – Thick, collagenous, stiff – Adventitial attachments to sternum, diaphragm, mediastinum Visceral layer – Thin – Closely adherent to epicardial surface Pericardial Anatomy/Physiology Pericardial space – Normally 15-60 cc fluid Functions – Reduces friction – Prevention of infection – Augmentation of atrial filling & maintains normal pressure-volume relationship of chambers But…No physiological consequence to absent pericardium Innervation/Sensation Case #1 You’re working in the ED and have a patient that is sent in from their family doc with a diagnosis of perdicarditis (based on the history). He’s a 26 yo M. – Describe the classic symptoms of Pericarditis. Pericarditis - History Hx: – Sudden onset severe CP, x 24H – Pleuritic, worsened w/lying flat – Rads to back area – No SOB, not exertional, no PND ROS: – fevers, recent URTI Sx, PMHx: – Otherwise healthy Meds: – Tylenol for the pain – not really working Quality Pericarditis Precordium, L trapezius ridge Pleuritic Duration Hours to days Exacerbation Lying down, chest exertion wall motion Leaning forward Rest Location Relief Associated SSx SOB, diaphoresis, no N/V Ischemic pain Retrosternal, L shoulder, arm Pressure, tightness, burning 1-15 minutes N/V, diaphoresis, SOB Aric™ Pericarditis is… – An inflammation of the pericardium – IR 2-6%, adults>children, Male>female, – # of disease processes/agents responsible – Classic Dx is pleuritic CP, pericardial rub & ECG Can have ischemic quality and positional component For research purposes usually 2 of 3 – Usually benign condition, but there are a few complications – But, you need to consider a few very important Dx before diagnosing pericarditis DDx to consider… Pneumonia or pneumonitis with pleurisy PE Costochondritis GERD MI Aortic dissection Pneumothorax You’re about to examine the patient when the your staff asks you – What physical examine finding is most helpful in making the diagnosis of pericarditis? – Does your inability to illicit this p/e finding rule out the disease? Physical Exam Looks to be in pain, not toxic looking VS–HR 110,RR-12(98%),T – 38.7°, 138/75 Cardiac: S1+,S2+, (link), JVP 2 ASA, no peripheral edema, PMI N. Lungs – clear, no c or w, no WOB, shallow respirations Rest of exam N What’s that sound? Mono-,Bi-,Tri-phasic Rub 1. 2. 3. Atrial systolic rub that precedes S1, Ventricular systolic rub between S1 and S2 and coincident with the peak carotid pulse, and Early diastolic rub after S2 (usually the faintest). Best heard at LLSB, pt sitting forward Intermittent and migratory (unlike murmur) Spec 100%, Sens Poor Investigations What are you going to order? – Labs? – Imaging? – CV investigations? Labs WBC usually elevated ESR usually elevated - do not order Troponin – What does it signify if +ve? – Does this change disposition? Imaging CXR CT scan Not our domain MRI What phase of ECG changes are these? aVR PR segment PR (most specific) What are the other phases? ST (diffuse, concave) ECG Findings of Pericarditis What are the 4 phases of pericarditis? – Which findings are most specific? The staging is not very helpful – but popular question to be asked Stage 1 (hours days) Hours to days (often only ECG findings since we Tx and pt may not progress to next stage) Diffuse ST elevation – ventricular subepicardial injury – I, II, III, aVL, aVF, V2 to V6 Concave upwards No distinct J-point No T-wave inversions PR Elevation – aVR Diffuse PR depression – atrial injury Stage 2 (variable timeline) ST / PR return to baseline Some T-wave flattening Stage 3 (Variable timeline) • T-wave inversion –Deep, uniform Stage 4 (Weeks to months) Return to normal – Some patients may have residual T-wave inversion But how do we distinguish these ST changes from BER? ST=PR-Jp pt T=J pt to peak of Twave Pericarditis versus AMI Pericarditis AMI – Concave STE – Convex – <5mm – Variable amt STE – No reciprocal STD – Often see reciprocal – ECG changes usually – ECG can evolve very over hours to days rapidly His CXR What is the significance of this ECG in the setting of his CXR? Criteria for this? ECG Findings of Pericardial Effusion When should a pericardiocentesis be done – – – – Diagnostically – i.e. concerned about CA, TB, Purulent Pericarditis Unresponsive to treatment Severe symptoms: SOBtamponade Pericardectomy/window: Consider for traumatic hemopericardium and purulent pericarditis Etiology of pericarditis? Idiopathic Infectious – – – Immune-inflammatory – – – Secondary: breast and lung carcinoma, lymphomas, leukemias Radiation induced Trauma – Connective tissue disease (SLE, RA, scleroderma) Early post-myocardial infarction Late post-myocardial infarction (Dressler syndrome), late post-cardiotomy/thoracotomy, late posttrauma Drug induced (e.g., procainamide, hydralazine, isoniazid, cyclosporine) Neoplastic disease – Viral: enterovirus (MC), CMV, hepatitis B, infectious mononucleosis, HIV/AIDs) Bacterial (Pneumococcus, Staphylococcus, Streptococcus, Mycoplasma, Lyme disease, Hemophilus influenzae, Neisseria meningitidis) Mycobacteria (Mycobacterium tuberculosis, Mycobacterium avium-intracellulare) Blunt and penetrating, post-cardiopulmonary resuscitation Miscellaneous – – – – Chronic renal failure, dialysis related Hypothyroidism Amyloidosis Aortic dissection Pericarditis - etiology INFECTIOUS Viral – Coxsackie, adeno, Echoviruses, HIV, mumps, EBV, etc. – Days to mths after Pneumococcus, Staphylococcus, Streptococcus, Mycoplasma, Lyme disease, Hemophilus influenzae, Neisseria meningitidis Fungal Post-MI – Early – Late: Dressler’s Bacterial – NON-INFECTIOUS IDIOPATHIC (MC) Traumatic Auto-immune dz: RA, SLE, vasculitides, sarcoid Malignant Post-irradiation Drug-induced Pericarditis Acute Consider broad Ddx Chronic (>3/12) Usually inflammatory Recurrent Reasons to investigate further: 1)prolonged latent period before recurrence 2)presence of anti-heart antibodies (one way to have ER nurses hate ya – order anti-sarcollemmal/antifibirllary antibodies and keep pt in ED until results come back) 3)Rapid response to steroids in setting of auto-immune disease Mainstay’s of Tx Drugs – NSAID’s (level B, Class 1) Mainstay of treatment for idiopathic/viral cause Advil 600-800mg TID or ASA 650 QID Indocid – avoid since some evidence of coronary flow Duration: recommend x 2wks and discontinue once asymptomatic – Steroids – traditionally recommended, but some evidence that ↑ with stopping steroids Viral/Idiopathic MC cause of pericarditis – Tx: symptomatic treatment with ibuprofen 600mg PO TID until ASx or 2 wks, whichever comes first – ECHO? if considerably symptomatic ?pericardial effusion If being admitted – Trop? If concerned about ischemia If concerned about Myocarditis At your discretion (cardiologist here recommend trop in all cases of pericarditis to ensure no myocarditis) Recurrent Pericarditis or Refractory to initial Tx What other options do you have? – 1st line for recurrent Colchicine (Adler) 2mg PO 1st day, then 0.5 BID until ASx Prednisone (especially when underlying autoimmune process) What do the (french) cardiologist do… • Survey of French cardiologist in 2005 • initial investigations ECG in 100% of cases, ECHO in 95%, b.w. in 93% of cases. • Hospitalisation was advised by only 24% of cardiologists. • Aspirin was prescribed as first choice treatment in 92.5% of cases. • Duration of treatment recommendations varied widely, from <5 days by 2.5%, between 5 and 10 days by 25.5%, 11 and 15 days by 23.0%, 16 to 21 days by 35.3%, days by 14% of cardiologists. •Arch Mal Coeurand Vaiss.for 2006>21 Jan;99(1):61-4. [Acute pericarditis: results of a survey of treatment practices of cardiologists] Pericarditis to watch out for… Bacterial pericarditis – Rare, but universally fatal if not Tx(abx, +/- surgery), otherwise MR 40% (tamponade, sepsis) – Hx/exam/labs: ↑ fever, short duration (2 to 3/7), ↑HR, dyspnea, ↑CVP, CP, friction rub, and ↑WBC – Source: 1) spread from an adjacent infection (i.e.pneumonia) 2) hematogenous spread from a distant site (MC), 3) direct inoculation of bacteria (trauma or procedure), 4) spread from an intracardiac source – RF: immunocompromised, chronic dz (i.e.EtOH, rheumatoid), CV surgery, chest trauma – Tx: as per mgnt of sick/septic pts, CCU/ICU Vanco + cipro (Sanford Guide) Pericardial tap (urgent) +/-pericardectomy Pericarditis and HIV + Can be infectious, non-infective (i.e Rx) and neoplastic (Kaposi’s, lymphoma) – Tx Sx – ECHO to assess for these causes +/-pericardiocentesis depending on ECHO findings – Steroids contra-indicated unless TB pericarditis Uremic Pericarditis Usually seen with ARF/CRF prior to dialysis Correlates with degree of azotemia +/- pericardial rub, usu no ECG changes Tx with dialysis – +/- pericardial drain/pericardectomy if not improving Auto-Immune Disease MC with RA, SLE, Scleroderma Only Tx if Sx (I.e. don’t Tx if only have mild ECG/ECHO findings) Tx – Optimize auto-immune disease Tx – NSAID’s Consider steroids for RA Pericarditis Prognosis Excellent 60% of patients have complete recovery within 1 week, 78% have complete recovery within 3 weeks. Only 3% have a prolonged course with symptoms for more than 3 weeks before complete resolution Case #2 A 47M presents to the ED feeling presyncopal and extremely SOB. It’s 3:00am. – Recently Dx with pericarditis and had been doing okay until the past 24 hrs – Patient appears moribund – VS: sBP 75, sats 85%, obvious resp distress Cardiac: unable to hear his HS, JVP at his jaw – What do you think is going on? Physical Exam What is Beck’s triad? What is the pathophysiology of pulsus paradoxus? – How do you check for it? How much pericardial fluid Beck’s Triad Management of Tamponade? Temporizing measures? – Non-invasive? – Invasive? Definitive tx – Surgical or pericardial drain Complications of Pericarditis Pericardial Effusion (unsure of IR, but likely <5% for moderate – severe) Constrictive Pericarditis Recurrence (15-30%) Disposition of Pericarditis Most can be sent home – Clear d/c instructions: return if Sx not improving within next few days, SOB, feeling generally unwell Admission – Intractable pain – Peri-myocarditis: ↑trop – risk of arrhythmia – Moderate-severe effusion or Tamponade – To r/o other Dx (ischemia, PE) Case #3 Myocarditis Myocarditis Epi, etiology Dx (hx, p/e, labs, imaging) Tx (general and disease specific) Px Epidemiology and Etiology IR: unknown but 10% of autopsies have evidence (??how many had clinical Sx), 50% of HIV patients have evidence Etiology INFECTIOUS* NON- INFECTIOUS – Viruses (MC): – Medications (i.e. enteroviruses (MC in Western world), Chagas (MC worldwide) also adeno, influeza, parainfluenza, EBV, mumps, – Bacteria: strep, chlamydia, – Others: mycobacterium, adriamycin) – Toxins (i.e. cocaine) – Rheumatologic *Pathophys is felt to be molecular mimicry History – Viral prodrome described in 50-90% – Fever 60% – Chest pain (40%) Can be pericardial- suggests peri-myocarditis Ischemic Quality – Resp Sx/CHF Sx Dyspnea, PND, orthopnea, Pedal edema, – Dysrhythmia Sx Palpitations, pre-syncope, syncope, Physical Exam VS: ↑HR, ↑RR, +/- BP – Resp: crackles, – Cardiac: EHS - S3, +/- rub, JVP ↑ – Extremities: pedal edema ECG Extremely non-specific – Can be normal – Non-specific ST changes, I-V blocks – Pericarditis changes – Ischemic changes Labs Elevated cardiac enzymes – Trop better than CK-MB early on Evidence of MODS – Liver, kidneys, lactic acidosis, resp failure Imaging CXR – Findings usually consistent with pulm edema but… – Are dependent on what stage of myocarditis: Initially may be normal Intermediate – pulm edema with normal heart size Late/Fulminant – pulm edema + cardiogemaly Imaging ECHO – EF – Pericardial effusion – Wall motion abnormalities (focal or segmental) Tx – in the ED ABC’s – May BiPAP to try and avoid intubation – Fluids/Pressors/Inotropes if in cardiogenic shock – Manage CHF as per usual – Manage any arrhythmias as per usual Tx – out of the ED Balloon pump, ventricular assist device, bypass as a bridge to transplantation IVIG Cardiac Transplantation Myocarditis Complications Dysrhythmias (including VT/VF) Mechanical (DCM, aneurysm) Cardiogenic shock Death Thromboembolic (from akinesis) Prognosis Difficult to say based on ED presentation – Of those who present with shock & rhythm disturbances MR 15-20% @ 1 yr, 50% at 4 yrs Those who are transplanted have particular bad outcomes and high-graft rejection rates Disposition All should be admitted – Most are likely to go to CCU Summary References Adler Y, Finkelstein Y, Guindo J, et al: Colchicine treatment for recurrent pericarditis: A decade of experience. Circulation 97:2183, 1998.