19 ) Pericarditis. Myocarditisst Flashcards
etiology of myocarditis ?
Viral coxsackie parvovirus adenovirus human herpes virus 6
Bacterial
Group A β-hemolytic Streptococcus (acute rheumatic fever)
Corynebacterium diphtheriae (diphtheria)
Fungal
Candida, Aspergillus
Parasitic
Protozoan: Toxoplasma gondii, Trypanosoma cruzi (Chagas disease, common in South America)
systemic disease
systemic lupus erythematosus, sarcoidosis,
Vasculitis: Kawasaki disease
Medication =sulfonamides
chemotherapy =doxorubicin
Alcohol,
cocaine
Radiation therapy
Clinical features of myocarditis ?
Often asymptomatic,
but may range from acute, chronically active or persistent myocarditis
The clinical manifestation of myocarditis is heterogeneous and nonspecific,
Preceding (1–2 weeks) flulike symptoms = fever,
arthralgia,
myalgia,
upper respiratory tract infections: indicate possible viral cause
sinus tachycardia =often dissonantly high in relation to patient’s body temperature
ventricular extrasystoles with palpitations or syncope,
heart block with bradyarrhythmia
Chest pain: indicates pericardial involvement (perimyocarditis)
Acute decompensated congestive heart failure with dilated cardiomyopathy = Symptoms of left heart failure and Symptoms of right heart failure
Cardiogenic shock in fulminant cases
hypotension
what are the Auscultation findings of myocarditis ?
Brief systolic murmurs
muffled heart sounds
Heart failure: S3 and S4 gallops
Perimyocardits: pericardial friction rub
how do we diagnose myocarditis through ecg ?
ecg
ECG abnormalities d very nonspecific and may only manifest temporarily
Sinus tachycardia
Arrhythmias: atrial or ventricular ectopic beats, complex ventricular arrhythmia,
Ventricular and supraventricular arrhythmias
Repolarization abnormalities
Nonspecific T-wave and ST-segment changes - concave ST segment elevation.
Heart block: right bundle branch block, complete heart block, AV block
Rule out myocardial infarction: loss of R wave and pathological Q wave specific to myocardial infarction, not found in myocarditis
Pericardial effusion: low voltage (low R-wave with poor progression)
what are the other methods to diagnose myocarditis?
ecg
echo = often unremarkable
dilation, diffuse hypokinesia, reduced ejection fraction
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lab
increase in cardiac enzymes : CK , CK-MB , TROPONIN T increase in ESR leukocytosis high bnp virus serology
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myocardial biopsy
Immunohistochemical detection of inflammation: Focal necrosis with lymphocytic infiltration most often has a viral etiology
what is the treatment for myocarditis ?
supportive
Restrain from aerobic physical efforts for months, unsalty diet
limit fluid intake
NSAIDS - increase the mortality
causative treatment
Antibiotic therapy for bacterial myocarditis
Antimycotic therapy (fluconazole, amphotericin B)
antiviral therapy
immune suppressors only used in patient who re not successful after 6-12 months of dilative cardiomyopathy - prednisolone and azathioprine
Antimycotic therapy (fluconazole, amphotericin B) for fungal infections
Treatment of complications
Congestive heart failure: management of fluid accumulation with diuretics, beta blockers , ACE inhibitors
in LV dilation : treatment of CHF with ACEI , ARB , BB , SPIRO
Treatment of cardiac arrhythmias : amiodarone , ICD
Heart transplantation
what are the complications of myocarditis ?
Progression to dilated cardiomyopathy - viral
Heart failure or sudden cardiac death: probably due to ventricular tachycardia or fibrillation (common in adults < 40 years old)
Acute or persistent arrhythmias
Atrioventricular block
Concurrent pericarditis (perimyocarditis) that may lead to cardiac tamponade (associated with large pericardial effusions)
what is the normal amount of pericardial fluid ?
normally 10-50ml lubiricating the two serous layers- visceral and parietal
where is pericardial fluid secreted from ?
from the visceral pericardium
what is the function of the pericardial fluid ?
reduces the rubbing between the heart and surrounding mediastinal structures
barrier for dissemination of infectious and neoplastic diseases
modulating of the intrapericardial and intracardiac pressures
what are the different types of pericarditis ?
Acute pericarditis: can be concurrent myocarditis
Perimyocarditis:
Transient constrictive pericarditis: lasts < 3 months
Chronic pericarditis: inflammation of the pericardium that lasts > 3 months :
> Constrictive pericarditis : compromised cardiac function caused by a thickened, rigid, and fibrous pericardium secondary to acute pericarditis.
> Effusive-constrictive pericarditis: Pericardial effusion occurs in addition to a thickened pericardium, which can lead to tamponade.
what is the etiology of pericarditis ?
Infectious
Most commonly viral
coxsackie B virus , B1
4, Echo 8, mumps
Bacterial
Staphylococcus spp., Streptococcus spp.,
M. tuberculosis
Fungal
Candida
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tumor
Metastatic
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Myocardial infarction
> Postinfarction fibrinous pericarditis: within 1–3 days as an immediate reaction
> Dressler syndrome: weeks to months following an acute myocardial infarction
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Postoperative
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Uremia
due to acute or chronic renal failure
Hypothyroidism
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Radiation
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Neoplasm
Hodgkin lymphoma
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Autoimmune connective tissue diseases
rheumatoid arthritis,
systemic lupus,
scleroderma
what are the clinical features of acute pericarditis ?
Chest pain
Pleuritic chest pain
Acute, sharp retrosternal pain (caused by inflammation of the parietal pleura)
Irradiation to the back, neck, arms, or scapullae (when diaphragm is involved)
Typically aggravated by coughing, swallowing, or deep inspiration
Improves on sitting and leaning forward
Low-grade intermittent fever,
tachypnea, dyspnea,
nonproductive cough
what are the physical findings of acute pericarditis?
Pericardial friction rub: high-pitched scratching on auscultation
Indicates friction between the visceral and parietal pericardial tissue
Best heard over the left sternal border during expiration while the patient is sitting up and leaning forward
Pericardial effusion
Faint heart sounds
s3 gallop when myocarditis present
Other causes of pleuritic chest pain include
pulmonary embolism, myocardial infarction, and pneumothorax
what are the clinical features of Chronic pericarditis
Constrictive pericarditis?
Constrictive pericarditis :
Jugular vein distention, ↑
Kussmaul sign
Hepatic vein congestion: hepatomegaly, painful liver
hepatojugular reflux
Peripheral edema
ascites
Symptoms of reduced cardiac output
Fatigue,
dyspnea on exertion
what are the physical findings of chronic constrictive pericarditis
Pericardial knock: sudden cessation of ventricular filling during early diastole that is heard best at the left sternal border
Pulsus paradoxus: ↓ blood pressure amplitude by at least 10 mm Hg during deep inspiration
what are the clinical features of chronic Effusive-constrictive pericarditis
symptoms of chronic constrictive pericarditis, pericardial effusion, or a mixture of both.
Smaller or slow-growing effusions: Patients may be asymptomatic.
Large effusions or rapidly growing effusions:
dullness at the left base of the lung
symptoms of cardiac tamponade such
Beck triad - hypotension , muffled heart sounds , distended neck veins
also
pluses parodoxicus - drop in blood pressure more than 10mmhg during inspiration , the pulse may go during inspiration
dysphagia
dysphonia
what is the diagnostic criteria for acute pericarditis ?
At least two of the following four criteria must be present for a diagnosis of acute pericarditis: Characteristic chest pain Pericardial friction rub Typical ECG changes New or worsening pericardial effusion
for acute peridicarditis diagnosis what are the typical ECG changes for the diagnostic criteria to be met ?
Not all patients go through all stages and manifestations may vary. In particular, pericarditis due to uremia may not involve characteristic ECG changes.
Stage 1: concave diffuse ST elevations (unlike myocardial infraction) , ST depression in aVR and V1, diffuse PR segment depression
Stage 2: ST segment normalizes in ∼ 1 week , but pr remains
t waves flatten
Stage 3: inverted T waves
Stage 4: ECG returns to normal baseline after weeks to months.
what are the other diagnostics used for acute pericarditis ?
echocardiography
pericardial effusion present but often normal
cardiac MRI
if diagnosis uncertain - but preferred modality to assess pericardium
finding - thickened pericardium , pericardial enhancement , pericardial effusion
CT contrast with IV
if diagnosis is uncertain
thickened pericardial layers and effusion in findings
chest x rya
enlarged cardiac silhouette
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lab
leukocytosis
troponin 1 mild (ugh in with yocardits)
ESR high
CRP
for ureic pericarditis - BUN , creation , electrolyte
bacterial pericarditis - 2 blood cultures
tuberculous pericarditis - interferon y release assay and HIV testing
autoimmune pericarditis - ANA and rheumatoid factor testing
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what is the diagnosis of chronic constrictive pericarditis
echo
pericardial thickening
abnormal ventricular filling - sudden halt during diastole
variation in ventricular filling in with inspiration - increase in velocity of blood flow through mitral and tricuspid valve
moderate biatrial enlargmnet
CT and cardiac mri
pericardial thickening of more than 2mm
calcifications
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cardiac catheterisations
only if noninvasive methods have failed to come up with diagnosis
similar pressure n the left , right atria and right ventricle
mean right arterial pressure more than 15mmhg
square root sign - sudden dip in right and left ventricular pressure in early diastole followed by plateau in the last stages of diastole
dip in ventricular pressure indicates rapid early diastolic filling of the ventricles, while the plateau represents the lack of additional filling due to the restriction imposed by the fibrotic pericardium. pressure tracking looks like a square root
how can we diagnose effusive constrictive pericarditis?
Ewart sign: percutory dullness at the base of the lung base with increased vocal fremitus and bronchial breathing due the compression of lung parenchyma by the pericardial effusion
significant pericardial effusion
Apical impulse is difficult to locate or nonpalpable
Echocardiography, CT, and/or cardiac MRI: pericardial effusion ; pericardial thickening may also be present
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ECG: Low ECG voltage and
-in large effusions and cardiac tamponade
electrical alternans
QRS complexes that alternate between beat in height due to the swinging motion of the heart when surrounded by large amounts of pericardial fluid
PEA
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Chest x-ray
PA: may show a globular-shaped heart and sharp cardiophrenic angles
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pericardiocentesis - pericardial fluid evaluation
indicated when there is large effusions and tamponade , suspected malignancy or purulent pericarditis
do gram staining
bacterial culture
PCR
how do we classify pericardial effusion volume ?
minimal - less than 5mm pericardial separation
50-100ml effusion volume
small
5-10mm seperation
which is 100-250ml
moderate
10-20mm seperation
250-500ml volume
large
more than 20mm separation
more than 500ml
what are the early and late findings which support cardiac tamponade ?
early signs :
collapse of right atrium during systole
collapse of right ventricle during early diastole
later - collapse of left atrium
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swinging motion of the heart :
inspiration : decrease in LV filling
exhalation : increase in LV filling and decrease in RV filling
what is the treatment for pericarditis ?
Acute pericarditis is often self-limited use nsaids
NSAIDS - aspirin / ibuprofen
in combo with colchine
prednisone only in severe cases OR PERICARDITIS CAUSED BY UREMIA OR AUTOREACTIVITY
antibiotics for bacterial
dialysis in case of uremia
restricted physical activity
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chronic
Pericardiectomy remains the only definitive treatment for constrictive pericarditis.
effusive - ericardiocentrisis with pericardioecetomy
what drugs should be avoided in constrictive pericarditis ?
beta blockers and calcium channel blockers
