Acute pericarditis, constrictive pericarditis and pericardial effusions Flashcards
causes of pericardial effusions:
idiopathic
viral - coxsackie bacterial, fungal, TB,
uremia- ESRD
hypothyroidism,
collagen vascular disease & autoimmune (SLE)
malignancy- lymphoma
post MI and trauma- Dressler syndrome
what labs to order for work up for chronic pericardial effusion?
CBC, BMP, TSH, dsDNA, complement levels.
if new onset heart failure, history of chest radiation and clear lungs think:
constrictive pericarditis
causes of constrictive pericarditis
idiopathic
viral pericarditis
prior cardiac surgery
radiation therapy
tuberculous pericarditis (in endemic areas)
clinical presentation of constrictive pericarditis
fatigue, dyspnea on exertion
peripheral edema,
ascites
increased JVP
pericardial knock may be heard
pulsus paradoxus
Kussmaul’s sign
EKG findings of constrictive pericarditis
nonspecific, afib with low voltage QRS
Chest imaging may have pericardial thickening or calcification
echocardiogram findings of constrictive pericarditis
see increased pericardial thickness
abnormal septal motion
biatrial enlargement pericardial thickness>4 mm
is suggestive of constrictive pericarditis
Findings of constrictive pericarditis on right heart catherization
prominent x and Y descents, equalization of left and right ventricular end diastolic pressures
right sided heart failure signs and elevated JVP and low voltage QRS on EKG and history of chest radiation, think
constrictive pericarditis
what causes cardiac cirrhosis
long standing right sided heart failure.
When do we get CT or cardiac MRI for evaluation of constrictive pericarditis?
get imaging to assess the extent of pericardial thickening and plan surgical resection in appropriately selected pts.
acute pericarditis stage one will see these findings on EKG
diffuse concave upward ST segment elevation across percordial and limb leads with reciprocal ST depression in aVR and V1.
PR segment is elevated in aVR with depression in other limb leads.
PR segment depressions is
very specific for acute pericarditis
When do we see pathological ! waves
days or weeks after MI.
what is this?
Evolution of acute pericarditis
Stage 1- seen a few hours and see diffuse concave upward ST segment and reciprocal ST depressions in leads aVR and V1 and see PR depressions
Stage 2: normalization of ST and PR segment and seen in first few days
Stage 3: presence of diffuse T wave inversions
Stage 4: normalization of the EKG or the persistence of T wave inversions over the next few weeks.
treatment of acute pericarditis
high dose NSAIDs and colchicine 1.2mg daily in acute pericarditis.
ASA 650-1000 q6-8h
ibuprofen 400-800 mg q8h
indomethacin 50 mg q8h
NSAIDS should be tapered over next few weeks.
Do not give colchicine by itself as it’s not used that way. (also side effect of colchicine is diarrhea and neuropathy)
See pleuritic chest pain which is relieved by leaning forward and see diffuse ST elevation and depression of PR interval in limb and left percordial leads.
features of acute pericarditis
post pericardiotomy syndrome or PCIS) after recent cabg is from
surgical damage to the mesothelial pericardial cells and resultant blood in the pericardial space which creates a autoimmune reponse against the cardiac antigens.
These immune complexes can deposit and cause infalmmation into the lung, pericardium and pleura.
presentation of postpericardiotomy syndrome
acute pericarditis, typical pleuritic chest pain, pericardial friction rub, and EG changes
may have a new or worsening pericardial effusion. EKG may be hard to interpret if they had an abnormal EKG to begin with.
Treatment of post pericardiotomy syndrome (Dressler’s syndrome)
Tx with NSAIDS and steroids can be given in refractory cases
giving colchicine after cardiac surgery may decrease the incidence of PCIS
when does post operative mediastinitis occur after CABG and what are the symptoms of presentation?
occur 1st two weeks after surgery
present with fever, tachycardia, chest pain and signs of sternal wound infection and purulent discharge.
Graft occlusion occurs when
in first 30 days after CABG and typically present with postischemic symptoms.
See significant ECG abnormalities and ventiruclar arrhythmias and hemodynamic instability.
Pt is >4 weeks surgery is less likely.
diagnostic criteria for pericarditis and myopericarditis
what is myopericarditis?
this is acute pericarditis with myocardial inovlement as seen with elevated cardiac enzymes, myocarditis on cardiac MRI or newly depressed LV EF.
Pericarditis and myopericarditis have the same etiologies which is viral or idiopathic.
Treatment of uncomplicated myopericarditis:
normal EF no arrhythmias
- treat same way as pericarditis:
NSAIDS (aspirin, indomethacin, ibuprofen) to control pain and reduce inflammation. IN post MI, aspirin is NSAID of choice as other NSAIDS inhibit formation of scar
Colchicine is recommend WITH NSAIDs to improve symptoms and decrease rate of recurrence.
what should be avoided in pts wo have myopericarditis or pericarditis?
steroids or prednisone as this is associated with a higher rate of recurrence and only indicated in refractory pericarditis despite NSAID therapy.
also need to treat undelrying cause of pericarditis (autoimmune ,connective tissue disorder or ESRD)
recent MI and pleuritic chest pain with radiation to the should and pericardial friction rub
Treatment for this condition?
peri-infarction pericarditis - seen within days of MI and seen in pts who do not get reperfusion. it is generally self limiting and will heal with higher doses of aspirin
Aspirin -650-1000 mg tid and continue plavix
Don’t give NSAIDs or steroids after recent MI because this can cause poor scar healing and scar thinning and lead to infarct expansion and myocardial free wall rupture.
NSAIDs are used in symptomatic relief in Dressler’s syndrome which happens weeks to months after acute MI.
