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Rosens > 68. Myocarditis and pericarditis > Flashcards

68. Myocarditis and pericarditis Flashcards

1
Q

Dilated cardiomyopathy: what two things is this characterized by?

A

ventricular dilation and decr contractility

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2
Q

Dilated cardiomyopathy: 1/3 cases are ?

A

herediatry - mutation of genes

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3
Q

Dilated cardiomyopathy: major sx

A

dyspnea - exertion or supine

other:
cp
peripheral edema
dysrhythmias
syncope sudden death

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4
Q

Dilated cardiomyopathy: EF <?% required?

A

45

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5
Q

Dilated cardiomyopathy: possible ECG findings

A

poor R wave progression
IV conduction delay
LBBB
LVH with or without repol changes
ectopy common

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6
Q

Dilated cardiomyopathy: mc nongenetic cause?

A

ischemic cardiomyopathy by CAD

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7
Q

Dilated cardiomyopathy: List 10 causes

A
  1. CAD -> ischemic
  2. etoh
  3. cocaine
  4. meth
  5. chemo with antrhacycline
  6. hemochromatosis
    7.pseudoephedrine
  7. ephedra
  8. phenothiazines
  9. Li
  10. anabolic steroid
  11. clozapine
  12. hydroxychloroquine
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8
Q

Dilated cardiomyopathy: medical tx generally

A
  1. diuretics
    - furos 1-2x pt baseline dose or 10mg if naiive
  2. vasodilators
    -NTG 5mcg/min and titrate up
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9
Q

Dilated cardiomyopathy: LT management meds by cardio?

A

acei/arb (mortality benefit)
sglt2i also helpful mortality
spirono
diuretic? sx only

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10
Q

Dilated cardiomyopathy: when to get an ICD?

A

ef <35%

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11
Q

Dilated cardiomyopathy: when to be adm to hospital

A
  1. new rhythm not adq controlled with meds
  2. deterioration of function by sx or dx data
  3. sign pulmonary fluid overload that cannot be reversed
  4. first dx (ish indication)
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12
Q

Hypertrophic cardiomyopathy: what is this?

A

AD sarcomere mutation causing LVH and scar formation, leading to dysrh and heart failure

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13
Q

Hypertrophic cardiomyopathy: pathophys

A

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

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14
Q

When are most HCM patient’s diagnosed?

A

30-40y

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15
Q

HCM - diastolic dysfunction symptoms common. Examples?

A

exertional dyspnea
orthopnea
peripheral edema

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16
Q

Signs of HCM on exam:

A

displaced left pmi
harsh midsystolic grade 3-4 murmur loudest apex and LLSB
valsalva incr murmur

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17
Q

HCM: ECG

A

90% abnormal:

afib
LVH
st segment alteration
twi
LAE
abnormal q wave
dimished or absent R wave in lateral leads

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18
Q

Meds in HCM for exercise related sx

A

metop or ccb if intolerant (dilt)

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19
Q

Meds in HCM for afib (acute)

A

cardioversion and rate control - dilt consider or emsmolol

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20
Q

Meds in HCM for afib (chronic)

A

amiodarone
doac

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21
Q

Persistent hypotension in a HCM pt - what med to use?

what to avoid?

A

phenylephrine

dobutamine

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22
Q

Risk calculation for ICD in HCM pt includes what factors?

A

pt age
family hx of first degree relative with Sudden cardiac death age <40y or confirmed HCM, presence of vent tachy, and unexplained syncope

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23
Q

What pt with HCM should be hospitalized? (ie what presentations?)

A

angina
syncope
near syncope
dysrth
abrupt HD changes

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24
Q

Restrictive cardiomyopathy: how does this occur?

A

gradual and proressive limit of vent filling secondary to myocardial infiltration - stiffness of. ventricles with normal diastolic vol and ventricular wall thickness

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25
Q

Restrict cardiomyopathy causes:

A

amyloidosis (mc)

sarcoid
hemochromatosis
scleroderma
neoplastic cardiac infiltration
glycogen storage disorder
fabry disease
gaucher disease
mutation of myocardial m proteins

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26
Q

Restrictive cardiomyopathy: when to hospitalize?

A

sob
hypotension

both not responsive to ED tx

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27
Q

Restrictive cardiomyopathy: 2 signs of poor px?

A

tricuspid regurg
small LVEDV

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28
Q

Peripartum cardiomyopathy: RF

A

African ancestry
preeclampsia
advanced mat age
tocolytic use
twins
obesity
cocaine use

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29
Q

Peripartum cardiomyopathy: presents iwth symptoms like what other cardiomyopathy?

A

very similar to dilated cardiomyopathy

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30
Q

Peripartum cardiomyopathy: ecg

A

lvh
nonsp st-t wave chagnes

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31
Q

DDX Peripartum cardiomyopathy:

A

preeclampsia
MI
coronary dissection
PE
pneumonia
primary rhythm disturbance

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32
Q

Peripartum cardiomyopathy: labs/imaging

A

trop
chem10
ecg
BNP
cxr
if high wells consider CTA (but also is it valid in this population???)
pulse ox and monitor
fetal monitor

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33
Q

Peripartum cardiomyopathy: management acute

A

furosemide if preload concern but is category c drug to worry about

afterload: hydralazine 5-10mg IV

get cardio and obs involved

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34
Q

Peripartum cardiomyopathy: factors related to good px/higher recovery of LV function:

A

small LV diastolic dimension
EF >35% at time dx
absence trop elevation
abscence of LV thrombus

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35
Q

Takutsubo cardiomyopathy: pathophys?

A

elevated catecholamines from physical/emotional stress can cause cardiac myocyte dysfunction (microvascular spasm), causing regional cardiac stunning

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36
Q

RF Takutsubo cardiomyopathy:

A

smoking
etoh abuse
anxiety
hyperlipidemia

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37
Q

Takutsubo cardiomyopathy: risk in gender, age

A

wo
>60y

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38
Q

Takutsubo cardiomyopathy: causes - Vascular:

A

inferior vena cava clot
MI
pneumopericardium
SAH
TIA

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39
Q

Takutsubo cardiomyopathy: causes - Infectious/inflammatory

A

anaphylaxis
anesthetisa
asthma
diarrhea/emesis
emotional stress
Pancreatitis
Scorpion evnenomation
sepsis
sexual IC
stress test

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40
Q

Takutsubo cardiomyopathy: causes - neoplasm/heme

A

chemo
TTP

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41
Q

Takutsubo cardiomyopathy: causes - endocrine

A

addison disease
hypoglycemia
pheo
thyrotoxicosis

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42
Q

Takutsubo cardiomyopathy: causes - iatrogenic/trauma

A

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

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43
Q

Takutsubo cardiomyopathy: ECG

A

looks like ACS
sinus tach
STE or dep
prolonged QT

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44
Q

Takutsubo cardiomyopathy: trops?

A

mild elevation

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45
Q

Takutsubo cardiomyopathy: BNP?

A

up to 6x normal
may be test that best correlates with TS - CXR unremarkable so differentiate from edema

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46
Q

Takutsubo cardiomyopathy: tx

A

cath as looks like MI

if hypotensive - phenylephrine
can anticoagulate sign hypokinesis

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47
Q

Arrhythmogenic RV Cardiomyopathy: what is this?

A

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

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48
Q

Arrhythmogenic RV Cardiomyopathy: mc sx

A

vent dysh
sudden death

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49
Q

ddx Arrhythmogenic RV Cardiomyopathy:

A

toxins : coke, meth
genetic

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50
Q

Arrhythmogenic RV Cardiomyopathy: work up

A

ecg
chem 10
tsh
family hx

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51
Q

Arrhythmogenic RV Cardiomyopathy: ECG findings

A

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

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52
Q

Arrhythmogenic RV Cardiomyopathy: meds to definitie tx

A

antidys (amio +/- beta blocker-sotalol), heart failure med, cath ablation and possibly heart transplant

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53
Q

Channelopathies: name 3 common

A

brugada
short qt
long qt

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54
Q

Brugada ecg changes

A

st segment e leads v1-3
incr pr or QRS intervals

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55
Q

Myocarditis: what is this?

A

mononuclear cell infiltrates in myocardial cells, may be caused by viral illness

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56
Q

Name 10 infectious causes of myocardiits

A

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

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57
Q

3 stages of Myocarditis: names

A
  1. acute with cytotoxicity and focal necrosis
  2. subacute - incr humoral factors to autoimm injury
  3. chronic: diffuse myocardial fibrosis, cardiac dyfunction that can lead to DCM
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58
Q

Myocarditis: clinical features

A

sx flu like - mc child = dyspnea
adult - dyspnea, cp, dysrh

can also just be toxic or tachy

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59
Q

Myocarditis: ECG changes

A

sinus tach
wide qrs
low voltage
prolonged qt
avb
ami pattern

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60
Q

Myocarditis: labs helpful?

A

not really as a trop can be negative
wbc, esr, crp nil

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61
Q

Myocarditis: formal dx best?

A

immunohistochemical bx

vs mri can be helpful - gad enhancement septal, mid wall or patchy can have incr risk sudden eath/ischemia

62
Q

Myocarditis: symptomatic acute tx

A

diuretic
+/- vasodilator: NTG if HF sx
if deteriorate enough: dobutamine or VAD

63
Q

Complications of Myocarditis:

A

vent dysrh
LV aneurysm
HF
dilated cardiomyopathy

64
Q

Chagas disease: caused by what bug?

A

trypanosoma cruzi by insect

65
Q

Chagas - acute infection

A

nonsp viral
later crdaic ph - conduction abnorm, then dilated cardiomyopathy

66
Q

Cardiac sx of chagas disease

A

angina cp
dysrh
embolic episodes
heart failure
conduction abnormalities
multifocal ventricular premature contractions
syncope/pre

67
Q

ECG Chagas disease findings

A

st segment elevation
twi
incr PR or QRS interval
ventricular tachycardia *hallmark of disease

68
Q

How to dx chagas disease

A

serum testing for aprasite
anti IgG for T cruzi

69
Q

Tx of Chagas disease

A

benznidazole age 2-12, nifurtimox age 12+

Amio to tx ventricular tachycardia

70
Q

Why can cocaine cause cardiotoxicity?

A

direct negative inotropic effect

71
Q

What heart problems can cocaine cause?

A

ischemic
myocarditis
dilated cardiomyopathy

72
Q

Cardiac causes of sudden death

A

channelopathies
myocarditis
congenital abnormalities
HCM
anomalous coronary artery circulation

73
Q

MC sx pre sudden cardiac death in people <20 vs > ?

A

<20 - dizzy
>20 cp

74
Q

What is pericarditis?

A

inflamm of pericardium caused by granulocytic and lymphocytic infiltration

75
Q

5 categories of etiology of pericarditis

A

Infectious
Postinjury/trauma
Systemic disease
Primary tumors
Ao dissection

76
Q

4 infectious causes of pericarditis

A

bact
fungal
parasite
viral

77
Q

6 postinjury causes of pericarditis

A

blunt trauma
med
MI
penetrating tauma
rads
surgery

78
Q

7 systemic diseases that can cause of pericarditis

A

amyloid
metastatic tumor
RA
sarcoid
scleroderm
SLE
uremia

79
Q

Functions of a normal pericardium

A

maintains position
lubricates surface
prevents spread infection or overdilation
augments atrial filling
maintains normal pressure-vol relationship of cardiac chambers

80
Q

Clinical sx of pericarditis:

A

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

81
Q

pericarditis: PE

A

pericardial friction rub at LLSB

82
Q

DDX pericarditis:

A

MI
inflamm/infectious disease of chest
PE (rare but possible)

83
Q

Diagnosis pericarditis: based off of what 4 features

A

cp
pericardial rub
ste
new pericardial effusion

84
Q

pericarditis: ECG stage I

A

diffuse STE, reciprocal STEdep

most also have PR segment depression

85
Q

pericarditis: ecg stage II

A

st and PR segments normalize

86
Q

pericarditis: ecg stage III

A

twi

87
Q

pericarditis: ecg stage IV

A

reverts to normal but twi can be permanent

88
Q

Is ventricular dysrhthymia common in pericarditis?

A

no

89
Q

Tx of nonsp pericarditis

A

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

90
Q

Second line tx for pericarditis if RF too strong for renal disease, etc?

A

predn 0.2-0.5mg/kg.d x5d

91
Q

Indications for hospitalization in pt with pericarditis

A

HD abnormalities
Dx uncertainty with ACS plausible
temp >38
large effusion
failure first round tx

92
Q

When are you more likely to have a recurrent pericarditis?

A

features:
- failure of initial nsaid
-fever
-pericardial effusion
-subsacute course (most recover 1 week)

93
Q

2 mc causes of uremic pericarditis?

A

reanl failure
dialysis

94
Q

Uremic pericarditis feared complication

A

tamponade

95
Q

Uremic pericarditis tx

A

intensive dialysis –> if no response consider predn
NSAID
+/- drainage

96
Q

Post MI Pericarditis: when after MI?

A

2-4d

97
Q

Post MI Pericarditis: early (2-4d post): tx with?

A

aspirin

98
Q

Post MI Pericarditis: poor px?

A

yes, may mean more myocardium damaged in mi than thought

99
Q

Dressler syndrome/late Post MI Pericarditis: syndrome/dx?

A

delayed fever
pleuritis
wbc incr
frcition rub
cxr new effusion

100
Q

Dressler syndrome/late Post MI Pericarditis: cause?

A

thought to be immunologic

101
Q

Dressler syndrome/late Post MI Pericarditis: mc timing of presentation

A

2-8 weeks post infarct

102
Q

Dressler syndrome/late Post MI Pericarditis: after MI, but when can this also occur?

A

post PE
after peritoneal hemorrhage

103
Q

Dressler syndrome/late Post MI Pericarditis: tx

A

maybe stop antoac to reduce risk hemorrhage
nsaid per same dose idiopathic pericarditis tx

104
Q

Postinjury pericarditis: definition?

A

after MI, cardiac surgery or trauma (includes overlap dressler)

105
Q

Postinjury pericarditis: days to onset after injury?

A

4-12d

106
Q

Postinjury pericarditis: tx?

A

same as idiopathic

107
Q

Can radiation case pericarditis?

A

yes

108
Q

Which cancers mc see radiation pericarditis? (2)

A

lymphoma
br cancer

109
Q

RA - pericarditis can occur in 1/3 of pt within _ years of dx

A

3

110
Q

Name 5 immunologic diseases that can cause pericarditis

A

sle
behcet
sjogren
gca
ank spond
systemic sclerosis
polyarteritis

111
Q

Name 5 bacteria that can cause pericarditis

A

ricketssi (mediterranean spotted fever)
mycoplasma pnemoniae
nocardia
chlampydia tachomatis
H actinomyco

also TB

112
Q

Name a virus that can cause pericarditis?

A

ebv

113
Q

Name a fungi that can cause pericariditis

A

coccidiodomycosis

114
Q

Pericardial effusion - name 6 different categories of causes

A

idiopathic
viral
malignancy
uremia
trauma
rads

115
Q

What amount of fluid is necessary for pericardial effusion on cxr?

A

200-250ml

116
Q

Small effusion tx percardial effusion in general

A

nsaid and close follow up with ultrasound

117
Q

Purulent pericarditis: what is this?

A

staph or strep (commonly) infection in typically hopistlalized pt that can cause sepsis

118
Q

RF for candida pericarditis

A

immmunocomp post cardiac surgery

119
Q

4 ways purulent pericarditis can occur:

A

spread adj infection
hematogenous spread
direct inoculation trauma/procedure
intracardiac source

120
Q

Purulent pericarditis: traditional tx of choice

A

pericardiectomy after pericardiocentesis for dx/tx if tamponade

also do abx/antifungal

121
Q

Purulent pericarditis: if surgical tx not needed, consider what therapy?

A

fibrinolytic

122
Q

What is a late consequence of any etiology of acute pericarditis?

A

constrictive pericarditis

123
Q

constrictive pericarditis: what is this?

A

thickened pericardium causing impaired diastolic filling (cp, RHF sx)

124
Q

constrictive pericarditis tx

A

pericardiectomy

125
Q

Cardiac tamponade: what is this?

A

compression of myocardium by contents of pericardium

126
Q

Cardiac tamponade: most important factor in development

A

rate of fluid accumulation

also depends on amount of fluid
underlying cond of heart

127
Q

When to suspect cardiac tamponade (ie what conditions have a higher incidence of leading to this)

A

penetrating chest wound
malignancy (32%)
infection (16%)
idiopathic
iatrogenic
post MI
uremic

128
Q

What 4 cancers often cause cardiac tamponade?

A

lung
breast
lymphoma
GI

129
Q

Cardiac tamponde - what bugs often cause infection?

A

staph
strep
tb
hiv

130
Q

Classic Beck’s triad for cardiac tamponade

A

hypotension
muffled heart sounds
distended neck veins

131
Q

ECG for cardiac tamponade

A

electrical alternans
decreased voltage
tachycardia

132
Q

Management of medical cause of cardiac tamponade

A

IV fluid to incr RS filling pressure to overcome constriction
pericardiocentesis consideration

133
Q

Management of penetrating trauma cause of pericardial tamponade

A

pericardial window

134
Q

Pneumopericardium - what is this?

A

fistulae between pericardial and pleural space, bronchial tree or UGI tract

135
Q

Pneumopericardium - causes?

A

bronchial carcinoma
infection with gas producing organisms
idiopathic/spontaneous

136
Q

RF spontaneous Pneumopericardium -

A

asthma
labor
barotrauma from PPV
valsalva
weight lifting
rec drug inhalation

137
Q

Pneumopericardium - classic PE signs

A

heart sounds “metallic”
splashing sound - Hamman sign/mediastinal crunch

138
Q

Pneumopericardium - often presents like what other disease?

A

tamponade

139
Q

Tension Pneumopericardium - treated with?

A

emergency pericardiocentesis

140
Q
  1. 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
A

b

141
Q
  1. 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
A

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.

142
Q
  1. 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
A

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.

143
Q
  1. 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
A

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.

144
Q

Cause peripartum cardiomyopathy ?

A

immune response from fetal cells

145
Q

Peripartum cardiomyopathy: if cardiomegaly persists past 6mo risk ? at 6y

A

50%

146
Q

4 names for takutsubo cardiomyopathy

A

octopus trap
broken heart syndrome
apical ballooning syndrome
takutsubo cardiom

147
Q

Old vs new hypokinesis of heart - how to tell?

A

thickness of wall uniform across hypo and contracting part = new

if old typically thicker

148
Q

VT - how to tell outflow tract - what ecg feature?

A

RV focus - LBBB
LV focus - RBBB

149
Q

What happens to cause pulsus paradoxis in cardiac tamponade?

A

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

150
Q

RV diastolic collapse signs from tamponade on ultrasound

A

trampolining of RV
M mode inversion of RV in diastole

151
Q

RA diastolic collapse signs from tamponade on ultrasound

A

precedes rV collapse
persisting >1/3 atrial diastolic sn and sp for tamponade

152
Q

Signs of cardiac tamponade on u/s

A

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

Rosens (48 decks)

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