Diseases of the peri/myocardium Flashcards
Discuss clinical signs of pericarditis
Discuss clinical criteria for pericarditis (two or more of the following)
1) chest pain - typically sharp and pleuritic improved by sitting up and leaning forward
2) ECG changes new widespread ST eleavtion and PR depression
3) Pericardial friction rub
4) pericardial effusion
History
Chest pain – sharp in nature, pleurtic relieved sitting up worse on lying supine, deep breathing or swallowing, Retrosternal pain radiating through to the trapezius
Signs
Pericardial rub
ECG changes
Discuss Aetiology of pericarditis
INfection
- vrial (coxsackie, echovirus, adenovirus, EBV, CMV, varicella)
- bacterail (TB, staph, strep, haemophilus, chlamydia, legionella, salmonella, mycoplasm)
- fungal (histoplasma, aspergillus, coccidiodes, candida)
- parasite
- rickettsia
Post injury
- penetrating
- blunt
- surgery
- MI
- Radiation
- Medications
Systemic disease
- uremia
- metastatic cancer
- rheumatoid arthritis
- SLE
- sarcoidosis
- scleroderma
- dermatomyositis
- amyloidosis
Primary tumours
aortic dissection
Cardiac
- Early and late (dresslers) post MI syndrome
- myocarditis
Discuss IX for pericarditis
ECG
- first stage occurs in the hours to days of illness and includes diffuse ST elevation and reciprical ST depression
- PR depression and reciprical PR elevation
- Next stage ST segment and PR changes resolves and deep symmetrical t-wave appear
- Resolution is the last stage however t-waves can persist
ECG vs STEMI
- nil particular distribution
- Concave rather then convex
- nil q-wave
- not progressive
- simultaneous t-wave inversion are not seen
ECHO - normal does not exclude pericarditis
- pericardial effusion
- thickened pericardium
- tamponade
- cysts
- tumours
- absence of pericardium
BLoods
- TNI –> myocarditis
- WBC
- ESR
Discuss MX and disposition percarditis
NSAIDS – if chosen NSAID is not useful in the 1st week a second calls should be used – ibuprofen has best symptom profile – 600-800 mg TDS
Colchicine – treatment of choice for recurrence
-recurrent pericarditis is often due to an immune or rheumatoological etiology - 0.5-0.6mg BD >70 or OD<70kg
Most HD stable patient can be managed as in OPD setting unless significant pericardial effusion or diagnostic uncertainty. Features of acute pericarditis associated with higher risk who may need hospitalisation include
- fever >38
- Subacute course
- evidence of tamponade
- large pericardial effusion
- immunosuppression
- history of therapy with warfarin or NOAC
- active trauma
- failure to improve following 7 days of NSAIDs and colchicine
- elevated TNI
Discuss uremic pericardial disease
Seen in patient with CKD on HD – can occur with PD but less common –is associated with occult infection and should prompt investigation for the same
Clinical features are typical – ECG however is usually NAD as litte epicardial inflammation occurs.
CXR showing cardiac enlargement wihtout signs of overload or CCF should prompt thoughts of uremic pericarditis
US definitive
Uremic pericarditis treatment is with intensive dialysis- NSAIDS are ineffective and often contrindicated. Systemic steroids can be used for those few who do not respond to dialysis
Discuss post MI pericarditis
Aproximately 20% of patients with transmural MI experience a different quality of chest pain 2-4 days after infarct. There is often fever and a transietn pericardial friction rub.
Early post mi pericarditis is often short lived and treated with aspirin ECG changes are masked by the MI
In contrast to early post MI pericarditis dressler reported a syndroe of fever pleurtisis, leukocytosis, friction rub and CXR evidence of new pericardail or pleural effusion. Frequent relapses are associated with this. May be immunological aetiology.
Treated with NSAIDs
Anticoagulants should be discontinued to reduce the risk of haemorrhage
Discuss Post injury pericarditis
Defined as pericardits after MI cardiac surgery or trauma. Incidence ranges from 5-30% after thoracic surgery or trauma. Can aslo occur in chest truama that does not involve the heart of the pericadium.
Symptoms are reasonably classical.
Interval between onset of pericarditis ranges from 4-12 days post injury,
During hospitalisation purulent pericarditis should be considered as a possible source of febrile illness in a trauma patient with multisystem organ failure
Discuss Neoplastic pericardial disease
Malignant pericardail tumors typically manifest late. Malignant involvement of the pericardium is observed in up to 31% of cancer autopsies
Most common associated cancers are
1) lung (30%)
2) breast 23%
3) lymphoma 17%
4) leukaemia
Prinary cardiac neoplasms initially cause symptoms consistent with pericarditis
Malignant pericardial disease is difficult to diagnosises with asymptomatic patient or nonspecific symptoms such as SOB cough palpitaiton and illdefined chest pain
CT, MRI and US are diagnsotic
Pericardail fluid cytology is recommended if the underlying malignancy is undiagnosedn
Treatmnet may include
pericardiocentesis, local instillation of sclerosing or chemotherapeutic agemt systemic chemo, caridac radiation and pericardial window
Discuss pericardial disease and connective tissue disorders
Occurs in approximatly 1/3 of patient with rehumatoid arthirits, usually within 3 years of diagnosis but is rarely clinically significant. These patient can develop effusions, constrictive pericarditis
Discuss cardiac tamponade
Ten percent of all patient with cancer develop caridac tamponande.
tamponade is the result of compression of the myocardium by the contents of the pericardium. Usually is caused by fluid but can be cuased by blood, pus or air.
Cardiac tamponade occurs in a physiological continuum reflecting the amount of fluid, the rate of accumulation and the natuer of the heart. THe most important factor in the development of tamponade is the rate of fluid accumulation.
There are three factors involved in the development of cardiac tamponade
1) fluid filling the recesses of the parietal pericardium
2) accumulation of fluid faster than the parietal pericardiumis able ot stretch
3) fluid accumulation that exceeds the bodies ability to increase blood volume to support right ventricle filling pressures
The result is increased pericardial pressure whcih decrases ventircle compliance and decreases flow of blood into the heart. THe heart increases rate to compensate for poor SV until late in clinical course
Discuss clinical features and diagnositic testing of tamponande
Symptoms are often non specifc and include chest pain, cough or dyspnoea any of which may be progressive or severe
Becks triad - muffled heart sounds, distended neck veins and hypotension
CXR- cardiomegaly if more than 250 mls accumulation
ECG: small amplitude with electrical alternans
US- large effusion and right chamber collapse in diastoly, -Systolic right atrial collapse
Discuss management of cardiac tamponade
Initial treatment is IV fluids to increase right sided filling pressure to overcome pericardial constriction
Pericardiocentesis or window is the treatment of choice.
If recurrent a drainage catheter may be left in the pericardial space, Pericardioectomy may be ultimately necessary
Discuss purulent pericarditis
Life threatening process most commonly seen in a hospitalized patient with systemic illnesses who develop sepsis. Can occur in any age group and can be cuased by any type of infectious agent. Strep and staph are most common
Can occur by many mechanisms
1) spread from adjecent infection such as pneumonia or empyema
2) Haemategnous spread from a distal site
3) direct inoculation of bacteria (trauma or procedure)
4) Spread from intraarticular source
Features include
tachycardia, dyspnoea, hepatomegaly, elevated central venous pressure, chest pain, friction rub and leukocytosis
Pericardiectomy is the treatment of choice. Indwelling catheters coupled with lavage antibiotics and fibrinolytics may avoid the need for surgery.
Required admit for IVABs or antifungals and monitoring. Fibrinolytics may reduce the rate of contrictive pericarditis when surgery is not an option.
Discuss pneumopericardium
Can be caused by formation fo a fistula between the pericardail and pleural spaces, bronchial tree or upper GIT.
It may result from broncial carcinoma or gas forming purelent pericaritis.
Spontaneous
Hamman’s sign and mediastinal cruncha re the terms used for a loud curnching sound associated with pneumopericardium or pneumomediastinum
Stable patient with spont can be observed
Discuss constrictive pericarditis
May be a late consequence of acute pericarditis of virtually any aetiology. Occurs as a result from fibrous reaction of the pericardium. The key feature is impaired diastolic filling from external cardiac compression caused by a the thickened pericardium.
Clinical features are identical to CHF
ECHO
