Pericarditis Pericarditis &&

MyocarditisMyocarditis

April 6th, 2006Shawn Dowling

ObjectivesObjectivesReview

– Dx– Tx

– ECG’s changes

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

Innervation/SensationInnervation/Sensation

Case #1Case #1You’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 painLocation Precordium, L

trapezius ridgeRetrosternal, 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 ExamLooks 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 Rub

1. 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

InvestigationsInvestigationsWhat are you going to order?

– Labs?– Imaging?– CV investigations?

LabsLabsWBC usually elevatedESR usually elevated - do not orderTroponin

– What does it signify if +ve?– Does this change disposition?

ImagingImagingCXRCT scanMRI

Not our domain

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 ptT=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

His CXR

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 - etiologyINFECTIOUS 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 recurrence2)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-immunedisease

Mainstay’s of TxMainstay’s of TxDrugs

– 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]

Pericarditis to watch out Pericarditis to watch out for…for…

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 PericarditisUsually seen with ARF/CRF prior to

dialysisCorrelates with degree of azotemia+/- pericardial rub, usu no ECG changesTx with dialysis

– +/- pericardial drain/pericardectomy if not improving

Auto-Immune DiseaseAuto-Immune DiseaseMC 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 PrognosisPrognosisExcellent60% 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 #2A 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 ExamWhat is Beck’s triad?What is the pathophysiology of pulsus

paradoxus?– How do you check for it?

How much pericardial fluid

Beck’sTriad

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)

Case #3Case #3Myocarditis

MyocarditisMyocarditisEpi, etiologyDx (hx, p/e, labs, imaging)Tx (general and disease specific)Px

Epidemiology and EtiologyEpidemiology and EtiologyIR: 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 ExamVS: ↑HR, ↑RR, +/- BP

– Resp: crackles, – Cardiac: EHS - S3, +/- rub, JVP ↑– Extremities: pedal edema

ECGECGExtremely non-specific

– Can be normal– Non-specific ST changes, I-V blocks– Pericarditis changes– Ischemic changes

LabsLabsElevated cardiac enzymes

– Trop better than CK-MB early onEvidence of MODS

– Liver, kidneys, lactic acidosis, resp failure

ImagingImagingCXR

– 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

ImagingImagingECHO

EF– Pericardial effusion– Wall motion abnormalities (focal or segmental)

Tx – in the EDTx – in the EDABC’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 ComplicationsDysrhythmias (including VT/VF)Mechanical (DCM, aneurysm)Cardiogenic shockDeathThromboembolic (from akinesis)

PrognosisPrognosisDifficult 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

DispositionDispositionAll should be admitted

– Most are likely to go to CCU

SummarySummary

ReferencesReferences Adler Y, Finkelstein Y, Guindo J, et al: Colchicine treatment for recurrent pericarditis: A

decade of experience. Circulation 97:2183, 1998.