ECHO - Pericardial disease Flashcards
What is the pericardium?
- doulble-layered membrane with visceral and parietal components
- visceral: serosal monolayer that adheres firmly to the epicardium, reflects over the origin of the great vessels
- parietal: tough, fibrous layer
- pericardial space between the two serosal layers contains up to 50 mL of plasma ultrafiltrate (the pericardial fluid)
When do pericardial pressures rise and restraint becomes clinically important?
pericardial reserve volume is exceeded
What is the pericardial reserve volume?
equal to the difference between the unstressed pericardial volume and the cardiac volume
What are the clinicopathologic processes involving the pericardium?
- acute pericarditis
- and complications of pericardial inflammation (which arise when pericardial fluid accumulates)
- Pericardial scarring and inelasticity / Compressive syndromes
- tamponade, constrictive pericarditis, effusive-constrictive pericarditis
- Tumors
- primary and metastatic (especially)
- Congenital pericardial lesions
Why is Echo evaluation essential in suspected acute pericarditis?
- Helps identify:
- pericardial effusion (one of the diagnostic criteria for pericarditis)
- high-risk patient who warrants hospitalization
- Excludes other etiologies of chest pain
How is size of the pericardium measured on Echo?
- semi-quantitatively described by the end-diastolic distance of the echo-free space between parietal and visceral pericardium
- Small ( < 10 mm) or 50-100 mL
- Moderate ( 10-20 mm) or 100-500 mL
- Large ( > 20 mm) or > 500 mL
Define cardiac tamponade
life-threatening condition caused by fluid accumulation in the pericardial sac
- characterized by:
- elevation and equalizatin of cardiac diastolic and pericardial pressures
- reduced CO
- Pulsus paradoxus
- exaggerated inspiratory decrease in arterial systolic pressure ( > 10 mmHg)
What are the key echocardiographic signs of cardiac tamponade (visually)?
- pericardial effusion
- small cardiac chambers
- plethoric IVC
- supportive signs
- increased pericardial pressure
- right sided chamber collapse
- increased ventricular interdepdendence
- respiratory variation of ventricular dimensions and transvalvular velocities
- increased pericardial pressure
What are the Echocardiographic findings of cardiac tamponade?
What are common etiologies of pericarditis?
- Idiopathic
- Infectious (viral, myocobacterial, fungal, purulent)
- Autoimmune disease (SLE, Rheumatic fever)
- Acute myocardial infarction (acute, delayed)
- Postcardiotomy syndrome (cardiac surgery, trauma)
- Post-radiation therapy
- Drug-induced (Isoniazid, cyclosporin)
- Uremia
- Neoplastic disease
Describe the findings
- PW doppler with respirometer recording of mitral inflow - Cardiac tamponade
- peak velocities are low because of reduced CO
What are characteristic findings in routine evaluation for acute pericarditis?
What are the four EKG stages of acute pericarditis?
- 2 weeks
- widespread STE and PR depression with reciprocal changes in aVR
- 1-3 weeks
- normalization of ST changes
- generalized T wave flattening
- 3- several weeks
- flattened T waves become inverted
- Weeks-months
- EKG returns to normal
****less than 50% of patients progress through all four classical stages and evolution of changes may not follow this typical pattern
What is one treatment tat has been shown to reduce the risk of recurrence of acute pericarditis?
Colchicine
- should be given with NSAIDs
- 0.6mg x 3 months
- < 70 kg –> daily
- > 70 kg –> BID
What is one treatment that has been shown to increase the risk of pericarditis recurrence?
Corticosteroids
- not recommended as first-line therapy (class III, level C per ESC guidelines)
- can be considered if contraindication or failure of aspirin/NSAIDs and colchicine and if infection is excluded or if another indication (class IIa, level C per ESC guidelines)
What trial demonstrated effectiveness of colchicine in acute pericarditis?
ICAP - “Investigation on Colchicine for Acute Pericarditis” (2013)
- Clinical question (n = 280)
- In patients experiencing their first episode of acute pericarditis, does colchicine reduce the rate of incessant or recurrent pericarditis when compared to placebo?
- Bottom line
- In patient experiencing their first episode of acute pericarditis, the addition of colchicine to NSAID or glucocorticoid therapy significantly reduces the rate of incessant or recurrent pericarditis
- Primary outcome:
- reduction of incessant or recurrent pericarditis (16.7% vs. 37.5%)
- higher remission at one week (85.0% vs. 58.3%)
- fewer hospitalizations (5.0% vs. 14.2%)
What is required for a clinical diagnosis of acute pericarditis?
- at least 2 / 4 of the following:
- Chest pain that is worse with inspiration and when supine
- EKG: ST-segment elevation and PR depression
- Pericardial friction rub
- Pericardial effusion (more than trivial)
What are the categories of pericarditis?
- Acute = < 4-6 weeks
- Incessant = > 4-6 weeks
- Chronic = > 3 months
- Recurrent
- freedom of symptoms for 4-6 weeks with recurrence
What is the probability of developing incessant pericarditis or a first recurrence within 18 months?
15-30%
What are the high risk markers of acute pericarditis?
- Fever > 38 C (100.4 F)
- Subacute course (without acute onset of chest pain)
- Hemodynamic compromise
- suggesting cardiac tamponade
- Large pericardial effusion (on Echo)
- Immunosuppression
- Anticoagulation therapy
- Acute trauma
- Elevated troponin (suggesting myopericarditis)
When should treatment be tapered in patients with acute pericarditis?
- resolution of symptoms and
- biomarkers (CRP) negative
***usually over several weeks
To what degree does Colchicine reduce the risk of recurrent pericarditis?
50%
- meta-analysis including 8 randomized trials ~ 1635 patients
What is the major side effect of colchicine therapy?
GI intolerance
- 5-10% of patients
- improved with dose reduction
When should corticosteroids be utilized in patients with acute pericarditis?
- failure of 1st line therapy (NSAIDS, colchicine)
- Alternative indications
- autoimmune disease
- contraindication to NSAIDS or colchicine
- pregnancy, anticoagulant therapy, renal failure
What are the recommendations for activity restriction in acute pericarditis?
- Pericarditis
- Noncompetitive athletes –>
- resolution of symptoms
- normal biomarkers
- Competitive athletes –>
- at least 3 months followed by reevaluation
- resolution of symptoms
- normal biomarkers
- Noncompetitive athletes –>
- Myopericarditis
- at least 6 months followed by reevaluation
- resolution of symptoms
- normal biomarkers
What is the treatment dosing for NSAIDS in acute pericarditis?
- Ibuprofen 600-800mg TID
- Aspirin 650-1000mg TID
- Indomethacin 25-50mg TID
***resolution of symptoms –> taper dose weekly for 2-4 weeks in an attempt to reduce recurrence rate
What patients should receive GI prophylaxis in treatment of acute pericarditis?
- History of PUD
- Age > 65 years
- Concurrent use of:
- ASA
- Anticoagulation
- Corticosteroids
What is the recommended treatment strategy for corticosteroids in acute pericarditis?
Dosing recommendations?
- Treatment failure or recurrence
- Low dose > High dose
- 0.2-0.5 mg/kg/day
- tapered over 3-6 months
What patients require advanced treatments pericarditis?
- Refractory to standard therapy
- Steroid dependent patients
- Colchicine-refractory patients
What are the advanced treatment options for steroid-dependent and colchicine refractory pericarditis?
- Azathioprine
- Human immunoglobulins
- Anakinra
- Pericardectomy
Describe the stages of pericarditis with regards to:
- Imaging
- Treatment
