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cardiology > 19 ) Pericarditis. Myocarditisst > Flashcards

19 ) Pericarditis. Myocarditisst Flashcards

1
Q

etiology of myocarditis ?

A 
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

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2
Q

Clinical features of myocarditis ?

A

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

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3
Q

what are the Auscultation findings of myocarditis ?

A

Brief systolic murmurs

muffled heart sounds

Heart failure: S3 and S4 gallops

Perimyocardits: pericardial friction rub

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4
Q

how do we diagnose myocarditis through ecg ?

A

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)

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5
Q

what are the other methods to diagnose myocarditis?

A

ecg

echo = often unremarkable
dilation, diffuse hypokinesia, reduced ejection fraction

=========

lab

increase in cardiac enzymes : CK , CK-MB , TROPONIN T  
increase in ESR 
leukocytosis 
high bnp 
virus serology

=======

myocardial biopsy

Immunohistochemical detection of inflammation: Focal necrosis with lymphocytic infiltration most often has a viral etiology

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6
Q

what is the treatment for myocarditis ?

A

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

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7
Q

what are the complications of myocarditis ?

A

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)

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8
Q

what is the normal amount of pericardial fluid ?

A

normally 10-50ml lubiricating the two serous layers- visceral and parietal

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9
Q

where is pericardial fluid secreted from ?

A

from the visceral pericardium

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10
Q

what is the function of the pericardial fluid ?

A

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

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11
Q

what are the different types of pericarditis ?

A

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.

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12
Q

what is the etiology of pericarditis ?

A

Infectious

Most commonly viral

coxsackie B virus , B1
4, Echo 8, mumps

Bacterial
Staphylococcus spp., Streptococcus spp.,
M. tuberculosis

Fungal
Candida

=======

tumor
Metastatic

===================
Myocardial infarction

> Postinfarction fibrinous pericarditis: within 1–3 days as an immediate reaction

> Dressler syndrome: weeks to months following an acute myocardial infarction

==============

Postoperative

===========

Uremia
due to acute or chronic renal failure

Hypothyroidism

===========

Radiation

===============
Neoplasm
Hodgkin lymphoma

========

Autoimmune connective tissue diseases
rheumatoid arthritis,
systemic lupus,
scleroderma

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13
Q

what are the clinical features of acute pericarditis ?

A

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

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14
Q

what are the physical findings of acute pericarditis?

A

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

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15
Q

Other causes of pleuritic chest pain include

A

pulmonary embolism, myocardial infarction, and pneumothorax

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16
Q

what are the clinical features of Chronic pericarditis

Constrictive pericarditis?

A

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

17
Q

what are the physical findings of chronic constrictive pericarditis

A

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

18
Q

what are the clinical features of chronic Effusive-constrictive pericarditis

A

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

19
Q

what is the diagnostic criteria for acute pericarditis ?

A 
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
20
Q

for acute peridicarditis diagnosis what are the typical ECG changes for the diagnostic criteria to be met ?

A

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.

21
Q

what are the other diagnostics used for acute pericarditis ?

A

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

===========
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

=============

22
Q

what is the diagnosis of chronic constrictive pericarditis

A

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

===========

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

23
Q

how can we diagnose effusive constrictive pericarditis?

A

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

==========

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

=============
Chest x-ray
PA: may show a globular-shaped heart and sharp cardiophrenic angles

=====
pericardiocentesis - pericardial fluid evaluation

indicated when there is large effusions and tamponade , suspected malignancy or purulent pericarditis

do gram staining
bacterial culture
PCR

24
Q

how do we classify pericardial effusion volume ?

A

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

25
Q

what are the early and late findings which support cardiac tamponade ?

A

early signs :
collapse of right atrium during systole
collapse of right ventricle during early diastole

later - collapse of left atrium

=======
swinging motion of the heart :

inspiration : decrease in LV filling
exhalation : increase in LV filling and decrease in RV filling

26
Q

what is the treatment for pericarditis ?

A

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

==========

chronic

Pericardiectomy remains the only definitive treatment for constrictive pericarditis.

effusive - ericardiocentrisis with pericardioecetomy

27
Q

what drugs should be avoided in constrictive pericarditis ?

A

beta blockers and calcium channel blockers

cardiology (32 decks)

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