68. Myocarditis and pericarditis Flashcards
Dilated cardiomyopathy: what two things is this characterized by?
ventricular dilation and decr contractility
Dilated cardiomyopathy: 1/3 cases are ?
herediatry - mutation of genes
Dilated cardiomyopathy: major sx
dyspnea - exertion or supine
other:
cp
peripheral edema
dysrhythmias
syncope sudden death
Dilated cardiomyopathy: EF <?% required?
45
Dilated cardiomyopathy: possible ECG findings
poor R wave progression
IV conduction delay
LBBB
LVH with or without repol changes
ectopy common
Dilated cardiomyopathy: mc nongenetic cause?
ischemic cardiomyopathy by CAD
Dilated cardiomyopathy: List 10 causes
- CAD -> ischemic
- etoh
- cocaine
- meth
- chemo with antrhacycline
- hemochromatosis
7.pseudoephedrine - ephedra
- phenothiazines
- Li
- anabolic steroid
- clozapine
- hydroxychloroquine
Dilated cardiomyopathy: medical tx generally
- diuretics
- furos 1-2x pt baseline dose or 10mg if naiive - vasodilators
-NTG 5mcg/min and titrate up
Dilated cardiomyopathy: LT management meds by cardio?
acei/arb (mortality benefit)
sglt2i also helpful mortality
spirono
diuretic? sx only
Dilated cardiomyopathy: when to get an ICD?
ef <35%
Dilated cardiomyopathy: when to be adm to hospital
- new rhythm not adq controlled with meds
- deterioration of function by sx or dx data
- sign pulmonary fluid overload that cannot be reversed
- first dx (ish indication)
Hypertrophic cardiomyopathy: what is this?
AD sarcomere mutation causing LVH and scar formation, leading to dysrh and heart failure
Hypertrophic cardiomyopathy: pathophys
Mutation in beta myosin heavy chain and myosin pro C often leading to affect to actin-myosin bridge, storke power and sn ATP/Ca
Therefore, compensation by m hypertrophy and fibroses
When are most HCM patient’s diagnosed?
30-40y
HCM - diastolic dysfunction symptoms common. Examples?
exertional dyspnea
orthopnea
peripheral edema
Signs of HCM on exam:
displaced left pmi
harsh midsystolic grade 3-4 murmur loudest apex and LLSB
valsalva incr murmur
HCM: ECG
90% abnormal:
afib
LVH
st segment alteration
twi
LAE
abnormal q wave
dimished or absent R wave in lateral leads
Meds in HCM for exercise related sx
metop or ccb if intolerant (dilt)
Meds in HCM for afib (acute)
cardioversion and rate control - dilt consider or emsmolol
Meds in HCM for afib (chronic)
amiodarone
doac
Persistent hypotension in a HCM pt - what med to use?
what to avoid?
phenylephrine
dobutamine
Risk calculation for ICD in HCM pt includes what factors?
pt age
family hx of first degree relative with Sudden cardiac death age <40y or confirmed HCM, presence of vent tachy, and unexplained syncope
What pt with HCM should be hospitalized? (ie what presentations?)
angina
syncope
near syncope
dysrth
abrupt HD changes
Restrictive cardiomyopathy: how does this occur?
gradual and proressive limit of vent filling secondary to myocardial infiltration - stiffness of. ventricles with normal diastolic vol and ventricular wall thickness
Restrict cardiomyopathy causes:
amyloidosis (mc)
sarcoid
hemochromatosis
scleroderma
neoplastic cardiac infiltration
glycogen storage disorder
fabry disease
gaucher disease
mutation of myocardial m proteins
Restrictive cardiomyopathy: when to hospitalize?
sob
hypotension
both not responsive to ED tx
Restrictive cardiomyopathy: 2 signs of poor px?
tricuspid regurg
small LVEDV
Peripartum cardiomyopathy: RF
African ancestry
preeclampsia
advanced mat age
tocolytic use
twins
obesity
cocaine use
Peripartum cardiomyopathy: presents iwth symptoms like what other cardiomyopathy?
very similar to dilated cardiomyopathy
Peripartum cardiomyopathy: ecg
lvh
nonsp st-t wave chagnes
DDX Peripartum cardiomyopathy:
preeclampsia
MI
coronary dissection
PE
pneumonia
primary rhythm disturbance
Peripartum cardiomyopathy: labs/imaging
trop
chem10
ecg
BNP
cxr
if high wells consider CTA (but also is it valid in this population???)
pulse ox and monitor
fetal monitor
Peripartum cardiomyopathy: management acute
furosemide if preload concern but is category c drug to worry about
afterload: hydralazine 5-10mg IV
get cardio and obs involved
Peripartum cardiomyopathy: factors related to good px/higher recovery of LV function:
small LV diastolic dimension
EF >35% at time dx
absence trop elevation
abscence of LV thrombus
Takutsubo cardiomyopathy: pathophys?
elevated catecholamines from physical/emotional stress can cause cardiac myocyte dysfunction (microvascular spasm), causing regional cardiac stunning
RF Takutsubo cardiomyopathy:
smoking
etoh abuse
anxiety
hyperlipidemia
Takutsubo cardiomyopathy: risk in gender, age
wo
>60y
Takutsubo cardiomyopathy: causes - Vascular:
inferior vena cava clot
MI
pneumopericardium
SAH
TIA
Takutsubo cardiomyopathy: causes - Infectious/inflammatory
anaphylaxis
anesthetisa
asthma
diarrhea/emesis
emotional stress
Pancreatitis
Scorpion evnenomation
sepsis
sexual IC
stress test
Takutsubo cardiomyopathy: causes - neoplasm/heme
chemo
TTP
Takutsubo cardiomyopathy: causes - endocrine
addison disease
hypoglycemia
pheo
thyrotoxicosis
Takutsubo cardiomyopathy: causes - iatrogenic/trauma
anesthesia
closed head injury
diving
foley cath insertion
hanging
lightneing strike
polytrauma
near drowning
pneumopericardium
pregnancy
scorpion envenomation
stress testing
SAH
surgery/med procedure
TCA OD
Takutsubo cardiomyopathy: ECG
looks like ACS
sinus tach
STE or dep
prolonged QT
Takutsubo cardiomyopathy: trops?
mild elevation
Takutsubo cardiomyopathy: BNP?
up to 6x normal
may be test that best correlates with TS - CXR unremarkable so differentiate from edema
Takutsubo cardiomyopathy: tx
cath as looks like MI
if hypotensive - phenylephrine
can anticoagulate sign hypokinesis
Arrhythmogenic RV Cardiomyopathy: what is this?
desmosome pro provide electromech conections betwenmyocyte for signal cascade and ion channels - these are replaced by fibrofatty tissue casuing myocardial atrophy
mc in RV so gets arrh
Arrhythmogenic RV Cardiomyopathy: mc sx
vent dysh
sudden death
ddx Arrhythmogenic RV Cardiomyopathy:
toxins : coke, meth
genetic
Arrhythmogenic RV Cardiomyopathy: work up
ecg
chem 10
tsh
family hx
Arrhythmogenic RV Cardiomyopathy: ECG findings
LBBB
tachydysrh
twi v1-v3
episolon wave (Like second R prime after normal QRS - slowing through RV)
prolonged S wave upstroke Vq-V3
RVOT tachycardia
Arrhythmogenic RV Cardiomyopathy: meds to definitie tx
antidys (amio +/- beta blocker-sotalol), heart failure med, cath ablation and possibly heart transplant
Channelopathies: name 3 common
brugada
short qt
long qt
Brugada ecg changes
st segment e leads v1-3
incr pr or QRS intervals
Myocarditis: what is this?
mononuclear cell infiltrates in myocardial cells, may be caused by viral illness
Name 10 infectious causes of myocardiits
adenovirus
chagas
chlamydia
coxsackie b
cmv
ebv
Hep A, B, C
HH6
Influ A or B
Legionella
Mono
Mumps
Mycoplasma
Parvo 19
Parainfluenza
RAbies
Rubella
Covid
Strep
Toxoplasma
varicella
3 stages of Myocarditis: names
- acute with cytotoxicity and focal necrosis
- subacute - incr humoral factors to autoimm injury
- chronic: diffuse myocardial fibrosis, cardiac dyfunction that can lead to DCM
Myocarditis: clinical features
sx flu like - mc child = dyspnea
adult - dyspnea, cp, dysrh
can also just be toxic or tachy
Myocarditis: ECG changes
sinus tach
wide qrs
low voltage
prolonged qt
avb
ami pattern
Myocarditis: labs helpful?
not really as a trop can be negative
wbc, esr, crp nil
Myocarditis: formal dx best?
immunohistochemical bx
vs mri can be helpful - gad enhancement septal, mid wall or patchy can have incr risk sudden eath/ischemia
Myocarditis: symptomatic acute tx
diuretic
+/- vasodilator: NTG if HF sx
if deteriorate enough: dobutamine or VAD
Complications of Myocarditis:
vent dysrh
LV aneurysm
HF
dilated cardiomyopathy
Chagas disease: caused by what bug?
trypanosoma cruzi by insect
Chagas - acute infection
nonsp viral
later crdaic ph - conduction abnorm, then dilated cardiomyopathy
Cardiac sx of chagas disease
angina cp
dysrh
embolic episodes
heart failure
conduction abnormalities
multifocal ventricular premature contractions
syncope/pre
ECG Chagas disease findings
st segment elevation
twi
incr PR or QRS interval
ventricular tachycardia *hallmark of disease
How to dx chagas disease
serum testing for aprasite
anti IgG for T cruzi
Tx of Chagas disease
benznidazole age 2-12, nifurtimox age 12+
Amio to tx ventricular tachycardia
Why can cocaine cause cardiotoxicity?
direct negative inotropic effect
What heart problems can cocaine cause?
ischemic
myocarditis
dilated cardiomyopathy
Cardiac causes of sudden death
channelopathies
myocarditis
congenital abnormalities
HCM
anomalous coronary artery circulation
MC sx pre sudden cardiac death in people <20 vs > ?
<20 - dizzy
>20 cp
What is pericarditis?
inflamm of pericardium caused by granulocytic and lymphocytic infiltration
5 categories of etiology of pericarditis
Infectious
Postinjury/trauma
Systemic disease
Primary tumors
Ao dissection
4 infectious causes of pericarditis
bact
fungal
parasite
viral
6 postinjury causes of pericarditis
blunt trauma
med
MI
penetrating tauma
rads
surgery
7 systemic diseases that can cause of pericarditis
amyloid
metastatic tumor
RA
sarcoid
scleroderm
SLE
uremia
Functions of a normal pericardium
maintains position
lubricates surface
prevents spread infection or overdilation
augments atrial filling
maintains normal pressure-vol relationship of cardiac chambers
Clinical sx of pericarditis:
cp - sharp pleuritic waxes and wanes, varies with pos (better fwd, worse lying down/deep inspire/swallow), retrosternal in nature - can radiate to back
fever m
myalgias
pericarditis: PE
pericardial friction rub at LLSB
DDX pericarditis:
MI
inflamm/infectious disease of chest
PE (rare but possible)
Diagnosis pericarditis: based off of what 4 features
cp
pericardial rub
ste
new pericardial effusion
pericarditis: ECG stage I
diffuse STE, reciprocal STEdep
most also have PR segment depression
pericarditis: ecg stage II
st and PR segments normalize
pericarditis: ecg stage III
twi
pericarditis: ecg stage IV
reverts to normal but twi can be permanent
Is ventricular dysrhthymia common in pericarditis?
no
Tx of nonsp pericarditis
ibuprofen 600mg QID or indometh 25mg TID x10d
if not effective trial naproxen x7d
+
colchicine 0m5mg QD if weight </=70 o.6mg BID if weight >70kg 3-6mo
Second line tx for pericarditis if RF too strong for renal disease, etc?
predn 0.2-0.5mg/kg.d x5d
Indications for hospitalization in pt with pericarditis
HD abnormalities
Dx uncertainty with ACS plausible
temp >38
large effusion
failure first round tx
When are you more likely to have a recurrent pericarditis?
features:
- failure of initial nsaid
-fever
-pericardial effusion
-subsacute course (most recover 1 week)
2 mc causes of uremic pericarditis?
reanl failure
dialysis
Uremic pericarditis feared complication
tamponade
Uremic pericarditis tx
intensive dialysis –> if no response consider predn
NSAID
+/- drainage
Post MI Pericarditis: when after MI?
2-4d
Post MI Pericarditis: early (2-4d post): tx with?
aspirin
Post MI Pericarditis: poor px?
yes, may mean more myocardium damaged in mi than thought
Dressler syndrome/late Post MI Pericarditis: syndrome/dx?
delayed fever
pleuritis
wbc incr
frcition rub
cxr new effusion
Dressler syndrome/late Post MI Pericarditis: cause?
thought to be immunologic
Dressler syndrome/late Post MI Pericarditis: mc timing of presentation
2-8 weeks post infarct
Dressler syndrome/late Post MI Pericarditis: after MI, but when can this also occur?
post PE
after peritoneal hemorrhage
Dressler syndrome/late Post MI Pericarditis: tx
maybe stop antoac to reduce risk hemorrhage
nsaid per same dose idiopathic pericarditis tx
Postinjury pericarditis: definition?
after MI, cardiac surgery or trauma (includes overlap dressler)
Postinjury pericarditis: days to onset after injury?
4-12d
Postinjury pericarditis: tx?
same as idiopathic
Can radiation case pericarditis?
yes
Which cancers mc see radiation pericarditis? (2)
lymphoma
br cancer
RA - pericarditis can occur in 1/3 of pt within _ years of dx
3
Name 5 immunologic diseases that can cause pericarditis
sle
behcet
sjogren
gca
ank spond
systemic sclerosis
polyarteritis
Name 5 bacteria that can cause pericarditis
ricketssi (mediterranean spotted fever)
mycoplasma pnemoniae
nocardia
chlampydia tachomatis
H actinomyco
also TB
Name a virus that can cause pericarditis?
ebv
Name a fungi that can cause pericariditis
coccidiodomycosis
Pericardial effusion - name 6 different categories of causes
idiopathic
viral
malignancy
uremia
trauma
rads
What amount of fluid is necessary for pericardial effusion on cxr?
200-250ml
Small effusion tx percardial effusion in general
nsaid and close follow up with ultrasound
Purulent pericarditis: what is this?
staph or strep (commonly) infection in typically hopistlalized pt that can cause sepsis
RF for candida pericarditis
immmunocomp post cardiac surgery
4 ways purulent pericarditis can occur:
spread adj infection
hematogenous spread
direct inoculation trauma/procedure
intracardiac source
Purulent pericarditis: traditional tx of choice
pericardiectomy after pericardiocentesis for dx/tx if tamponade
also do abx/antifungal
Purulent pericarditis: if surgical tx not needed, consider what therapy?
fibrinolytic
What is a late consequence of any etiology of acute pericarditis?
constrictive pericarditis
constrictive pericarditis: what is this?
thickened pericardium causing impaired diastolic filling (cp, RHF sx)
constrictive pericarditis tx
pericardiectomy
Cardiac tamponade: what is this?
compression of myocardium by contents of pericardium
Cardiac tamponade: most important factor in development
rate of fluid accumulation
also depends on amount of fluid
underlying cond of heart
When to suspect cardiac tamponade (ie what conditions have a higher incidence of leading to this)
penetrating chest wound
malignancy (32%)
infection (16%)
idiopathic
iatrogenic
post MI
uremic
What 4 cancers often cause cardiac tamponade?
lung
breast
lymphoma
GI
Cardiac tamponde - what bugs often cause infection?
staph
strep
tb
hiv
Classic Beck’s triad for cardiac tamponade
hypotension
muffled heart sounds
distended neck veins
ECG for cardiac tamponade
electrical alternans
decreased voltage
tachycardia
Management of medical cause of cardiac tamponade
IV fluid to incr RS filling pressure to overcome constriction
pericardiocentesis consideration
Management of penetrating trauma cause of pericardial tamponade
pericardial window
Pneumopericardium - what is this?
fistulae between pericardial and pleural space, bronchial tree or UGI tract
Pneumopericardium - causes?
bronchial carcinoma
infection with gas producing organisms
idiopathic/spontaneous
RF spontaneous Pneumopericardium -
asthma
labor
barotrauma from PPV
valsalva
weight lifting
rec drug inhalation
Pneumopericardium - classic PE signs
heart sounds “metallic”
splashing sound - Hamman sign/mediastinal crunch
Pneumopericardium - often presents like what other disease?
tamponade
Tension Pneumopericardium - treated with?
emergency pericardiocentesis
- A 33-year-old man presents with a 4-hour history of left anterior chest pain associated with mild shortness of breath. He is other- wise healthy except for chronic tobacco use. Vital signs are: blood pressure, 142/92 mm Hg; heart rate, 120 beats per minute; respira- tory rate, 24 breaths per minute; temperature, 100.4°F (38.0°C) oral; and oxygen saturation, 97%. Physical examination is remarkable for tachycardia and a friction rub. The patient’s electrocardiogram (ECG) is classic stage I for this disease. Which of the following would be the most appropriate therapy?
a. Cardiaccatheterization
b. Ibuprofen 600 mg QID and colchicine
c. Nitroglycerin, aspirin 324 mg oral, cardiology consultation d. Oxygen, serial troponin levels
b
- A 15-year-old female presents during summer break with fever, cough, and chest pain. She has no history of illnesses or medication use. No street drug use. Her vital signs are BP 110/70, T 38.4, P 122, RR 16, SaO2 96% on RA. ECG shows sinus tachycardia with normal intervals and low voltage. You order a troponin test and it is slightly above the normal range. Which other test result would you expect? a. Cardiomegaly on chest x-ray
b. Elevated C-reactive protein
c. Elevated sodium and creatinine
d. Regional wall motion abnormalities on POCUS
Answer: d. Patients with myocarditis show regional wall motion abnormalities and global hypokinesis on POCUS. Even though there is inflammation, WBC and CRP are neither sensitive nor specific for myocarditis. Electrolyte and renal abnormalities should not occur. Car- diomegaly is a late finding if it occurs at all.
- A 55-year-old woman presents with progressive dyspnea, chest pain, and cough over 5 days. She has a past history of renal fail- ure and is on dialysis, last 2 days ago. She does not smoke. Vital signs are: temperature, 100.2°F (37.9°C) oral; heart rate, 120 beats per minute; respiratory rate, 26 breaths per minute; blood pressure, 100/60 mm Hg; and oxygen saturation, 96% on room air. Physical examination is remarkable for 3-cm jugular venous distention at 45 degrees, clear lung fields on auscultation, tachycardia without a friction rub, trace pretibial edema, and weak peripheral pulses that disappear during expiration. Chest radiograph shows an enlarged cardiac silhouette and clear lung fields. What would be the most appropriate initial intervention?
a. Endotracheal intubation with rapid sequence induction b. Enoxaparin 1 mg/kg subcutaneous
c. Computed tomography (CT) scan of the chest
d. Isotonic fluid bolus and point of care cardiac ultrasound
Answer: d. This patient is presenting with cardiac tamponade, presum- ably secondary to an uremic pericardial effusion. Pulmonary embolus is a consideration but less likely, given the picture of normal oxygen saturation and an enlarged heart. The initial intervention should be fluid loading to maintain preload and cardiac output, followed by ultrasound confirmation and likely pericardiocentesis. Fluid loading in renal failure may easily result in pulmonary edema, so expeditious relief of tamponade is indicated. It is too early for intubation because the patient is oxygenating adequately.
- A 44-year-old man complains of swollen legs. He just finished two courses of prednisone for wheezing related to asthma. The first course was prescribed 6 weeks ago in the emergency department (ED), where he was diagnosed with new onset asthma and normal chest radiograph. The second course was prescribed by his family physician 2 weeks ago. The patient denies fever and chest pain and is still mildly short of breath, which is worse at night or with exer- tion. Examination shows bibasilar rales in his lungs, normal heart sounds, and 1+ edema in both legs up to his knees. What is his diagnosis?
a. Asthmaexacerbation
b. Idiopathic dilated cardiomyopathy (DCM) c. Prednisone-inducededema
d. Prednisone-induced liver failure
Answer: b. The patient is unlikely to have a new diagnosis of asthma. He most likely had a viral process leading to reactive airway disease ini- tially and viral myocarditis later. He unfortunately now has a DCM and symptoms of heart failure. Treatment is supportive. Prednisone-related end-organ damage usually does not occur this quickly.
Cause peripartum cardiomyopathy ?
immune response from fetal cells
Peripartum cardiomyopathy: if cardiomegaly persists past 6mo risk ? at 6y
50%
4 names for takutsubo cardiomyopathy
octopus trap
broken heart syndrome
apical ballooning syndrome
takutsubo cardiom
Old vs new hypokinesis of heart - how to tell?
thickness of wall uniform across hypo and contracting part = new
if old typically thicker
VT - how to tell outflow tract - what ecg feature?
RV focus - LBBB
LV focus - RBBB
What happens to cause pulsus paradoxis in cardiac tamponade?
IV septum normally stays bowed toward RV but as heart can no longer expand, moves towards LV and get exaggerated blood pressure drop on inspiration
RV diastolic collapse signs from tamponade on ultrasound
trampolining of RV
M mode inversion of RV in diastole
RA diastolic collapse signs from tamponade on ultrasound
precedes rV collapse
persisting >1/3 atrial diastolic sn and sp for tamponade
Signs of cardiac tamponade on u/s
RA and RV diastolic collpase
swinging septu
A4C view: MV/TV inflow velocity - must be NSR (N TV = 35% resp change and MV 15% vs tamponade 40% and 25% change)
heptic vein change: exagg forward flow in inspiration
IVC distension
Swinging heart
