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Anatomy and PhysiologyAnatomy and Physiology
Parietal layer– Thick, collagenous, stiff– Adventitial attachments to
sternum, diaphragm, mediastinum
Visceral layer– Thin– Closely adherent to
epicardial surface
Pericardial Pericardial Anatomy/PhysiologyAnatomy/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
Case #1Case #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 - HistoryPericarditis - 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
Pericarditis Ischemic pain
Location Precordium, L trapezius ridge
Retrosternal, L shoulder, arm
Quality Pleuritic Pressure, tightness, burning
Duration Hours to days 1-15 minutes
Exacerbation Lying down, chest wall motion
exertion
Relief Leaning forward Rest
Associated SSx SOB, diaphoresis, no N/V
N/V, diaphoresis, SOB Aric™
Pericarditis is…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…DDx to consider…
Pneumonia or pneumonitis with pleurisyPE CostochondritisGERDMI Aortic dissectionPneumothorax
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 ExamPhysical Exam
Looks to be in pain, not toxic lookingVS–HR 110,RR-12(98%),T – 38.7°, 138/75Cardiac: S1+,S2+, (link), JVP 2 ASA, no
peripheral edema, PMI N.Lungs – clear, no c or w, no WOB,
shallow respirationsRest of exam N
What’s that sound?What’s that sound?
Mono-,Bi-,Tri-phasic Rub1. Atrial systolic rub that precedes S1,
2. Ventricular systolic rub between S1 and S2 and coincident with the peak carotid pulse, and
3. Early diastolic rub after S2 (usually the faintest).
Best heard at LLSB, pt sitting forward Intermittent and migratory (unlike murmur) Spec 100%, Sens Poor
LabsLabs
WBC usually elevatedESR usually elevated - do not orderTroponin
– What does it signify if +ve?– Does this change disposition?
aVR PR segment
PR (most specific) ST (diffuse, concave)
What are the other phases?
What phase of ECG changes are these?
ECG Findings of PericarditisECG 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 Stage 1 (hours days) 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)Stage 2 (variable timeline)
ST / PR return to baselineSome T-wave flattening
Stage 3 (Variable timeline)
• T-wave inversion
–Deep, uniform
Stage 4 (Weeks to months)Stage 4 (Weeks to months)
Return to normal– Some patients may have residual T-wave
inversion
But how do we distinguish But how do we distinguish these ST changesthese ST changes from BER from BER??
ST=PR-Jp pt
T=J pt to peak of Twave
Pericarditis versus AMIPericarditis versus AMI
Pericarditis– Concave STE– <5mm– No reciprocal STD– ECG changes usually
over hours to days
AMI– Convex– Variable amt STE– Often see reciprocal – ECG can evolve very
rapidly
What is the significance of this What is the significance of this ECG in the setting of his CXR?ECG in the setting of his CXR?
Criteria for this?
ECG Findings of Pericardial ECG Findings of Pericardial EffusionEffusionWhen 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?Etiology of pericarditis? Idiopathic
Infectious– 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)
Immune-inflammatory– Connective tissue disease (SLE, RA, scleroderma)– Early post-myocardial infarction– Late post-myocardial infarction (Dressler syndrome), late post-cardiotomy/thoracotomy, late post-trauma
Drug induced (e.g., procainamide, hydralazine, isoniazid, cyclosporine) Neoplastic disease
– Secondary: breast and lung carcinoma, lymphomas, leukemias Radiation induced
Trauma– Blunt and penetrating, post-cardiopulmonary resuscitation
Miscellaneous– Chronic renal failure, dialysis related– Hypothyroidism – Amyloidosis – Aortic dissection
Pericarditis - etiologyPericarditis - etiology
INFECTIOUS Viral
– Coxsackie, adeno, Echoviruses, HIV, mumps, EBV, etc.
Bacterial– Pneumococcus, Staphylococcus,
Streptococcus, Mycoplasma, Lyme disease, Hemophilus influenzae, Neisseria meningitidis
Fungal
NON-INFECTIOUS IDIOPATHIC (MC) Traumatic
– Days to mths after Post-MI
– Early – Late: Dressler’s
Auto-immune dz: RA, SLE, vasculitides, sarcoid
Malignant Post-irradiation Drug-induced
Pericarditis
Acute Chronic (>3/12)
Recurrent
Consider broad Ddx Usually inflammatory
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 TxMainstay’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/IdiopathicViral/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 Recurrent Pericarditis or Refractory to initial TxRefractory to initial TxWhat 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 auto-immune process)
What do the (french) What do the (french) cardiologist do…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%, and for >21 days by 14% of cardiologists.
•Arch Mal Coeur Vaiss. 2006 Jan;99(1):61-4.[Acute pericarditis: results of a survey of treatment practices of cardiologists]
Bacterial pericarditisBacterial 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 +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 PericarditisUremic Pericarditis
Usually seen with ARF/CRF prior to dialysis
Correlates with degree of azotemia+/- pericardial rub, usu no ECG changesTx with dialysis
– +/- pericardial drain/pericardectomy if not improving
Auto-Immune DiseaseAuto-Immune Disease
MC with RA, SLE, SclerodermaOnly 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 Pericarditis PrognosisPrognosis
Excellent60% 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 #2Case #2
A 47M presents to the ED feeling pre-syncopal 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 ExamPhysical Exam
What is Beck’s triad?What is the pathophysiology of pulsus
paradoxus?– How do you check for it?
How much pericardial fluid
Management of Management of Tamponade?Tamponade?Temporizing measures?
– Non-invasive?– Invasive?
Definitive tx– Surgical or pericardial drain
Complications of Complications of PericarditisPericarditisPericardial Effusion (unsure of IR, but
likely <5% for moderate – severe)Constrictive PericarditisRecurrence (15-30%)
Disposition of PericarditisDisposition 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)
Epidemiology and EtiologyEpidemiology and Etiology
IR: unknown but 10% of autopsies have evidence (??how many had clinical Sx), 50% of HIV patients have evidence
EtiologyEtiology
INFECTIOUS*– Viruses (MC):
enteroviruses (MC in Western world), Chagas (MC worldwide) also adeno, influeza, para-influenza, EBV, mumps,
– Bacteria: strep, chlamydia, – Others: mycobacterium,
*Pathophys is felt to be molecular mimicry
NON- INFECTIOUS– Medications (i.e.
adriamycin)– Toxins (i.e. cocaine)– Rheumatologic
HistoryHistory
– 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 ExamPhysical Exam
VS: ↑HR, ↑RR, +/- BP– Resp: crackles, – Cardiac: EHS - S3, +/- rub, JVP ↑– Extremities: pedal edema
ECGECG
Extremely non-specific– Can be normal– Non-specific ST changes, I-V blocks– Pericarditis changes– Ischemic changes
LabsLabs
Elevated cardiac enzymes – Trop better than CK-MB early on
Evidence of MODS– Liver, kidneys, lactic acidosis, resp failure
ImagingImaging
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
Tx – in the EDTx – 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 EDTx – out of the ED
Balloon pump, ventricular assist device, bypass as a bridge to transplantation
IVIGCardiac Transplantation
Myocarditis ComplicationsMyocarditis Complications
Dysrhythmias (including VT/VF)Mechanical (DCM, aneurysm)Cardiogenic shockDeathThromboembolic (from akinesis)
PrognosisPrognosis
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