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Cardiovascular Block: Week 2 > Myocarditis and Pericarditis > Flashcards

Myocarditis and Pericarditis Flashcards

1
Q

What is myocarditis?

A

Myocarditis is an inflammatory disease of the myocardium resulting from infectious and non-infectious causes.

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2
Q

What may myocarditis be accompanied by?

A

Pericarditis

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3
Q

What is the most common cause of myocarditis?

A

Viral

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4
Q

What are the three phases of the pathogenesis of myocarditis?

A
  1. Acute Phase
  2. Subacute Phase
  3. Chronic Phase
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5
Q

What occurs in the acute phase of myocarditis?

A

VIRUS REPLICATION
(lasts a few days)
Viral entry into myocytes - necrosis - exposure to the immune system

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6
Q

What occurs in the subacute phase of myocarditis?

A

IMMUNE RESPONSE

Immune activation leads to impairment of cardiac muscle with effect on ventricular function.

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7
Q

What occurs in the chronic phase of myocarditis?

A

DILATED CARDIOMYOPATHY

Viral genome +/- fibrosis, dilation, contractile dysfunction

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8
Q

How is diagnosis of myocarditis made?

A

CANNOT BE MADE ON CLINICAL BASIS ALONE

Combination of clinical evaluation and established histological, immunological and immuno-histochemical criteria

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9
Q

How is definitive diagnosis of myocarditis made?

A

ENDOMYOCARDIAL BIOPSY

Dallas Criteria used in evaluating lymphocyte infiltration and myonecrosis.

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10
Q

Which biomarkers are used in the diagnosis of myocarditis?

A

Biomarkers are not specific but can be used to help confirm diagnosis.

  • troponin is more frequently evaluated than creatine kinase
  • leukocytes and CRP may be elevated
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11
Q

What is important about the diagnosis of infective causes of myocarditis?

A

May be difficult to pick up - there is often a delay in presentation.
- Appropriate viral serology or PCR indicated

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12
Q

What are the clinical features of myocarditis?

A

Ranges from asymptomatic to symptoms resembling a myocardial infarction to cardiogenic shock

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13
Q

What are some of the signs and symptoms of myocarditis?

A
  • chest pain
  • arrhythmias
  • acute / chronic cardiac failure can occur
  • pericardial rub
  • Diagnosis can be made on clinical basis alone
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14
Q

What will be seen on ECG in myocarditis?

A
  • can have non-specific changes

- changes may mimic other conditions e.g. MI

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15
Q

What is the use of Echocardiogram

A

Aids in determining chamber size, wall thickness and systolic and diastolic function.

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16
Q

What is the use of a cardiac MRI in myocarditis?

A

This is more utilized now:

  • detects areas of inflammation
  • helps suggest viral etiology (different viruses affect different parts of the heart)
  • helps to differentiate between MI and myocarditis
  • can help determine if myocarditis is chronic or acute
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17
Q

How is myocarditis treated?

A
  1. Treat the cause (if found)
  2. Limit physical activity
  3. Mainly supportive management in stable patients
  4. Treat the complications
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18
Q

What are the 3 most common complications of myocarditis?

A
  1. Dilated cardiomyopathy (most common)
  2. Arrhythmias
  3. CCF
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19
Q

Outcomes of myocarditis:

A

Most cases resolve without sequelae, however dilated cardiomyopathy is a common complication when patients are followed-up.

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20
Q

What makes up the pericardium?

A

2 layers - composed of fibrous tissue

  1. Inner visceral layer attached to epicardium
  2. Outer parietal layer
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21
Q

What are the 4 functions of the pericardium?

A
  1. Limits the hearts motion (stabilizes the heart within the thoracic cavity)
  2. Protects the heart from mechanical trauma and infection
  3. Pericardial fluid acts as a lubricant and decreases the friction of cardiac surfaces
  4. Prevention of excessive dilation of the heart, especially during a sudden rise in intra-cardiac volume
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22
Q

What are the three ways in which pericarditis may present?

A
  1. As a primary site of disease
  2. Involved in other disease processes that affect the heart (e.g. autoimmune conditions)
  3. Affected by other diseases or adjacent tissues (e.g. from lung: TB / invasive malignancy)
23
Q

What are the three primary presentations of pericarditis?

A
  1. Acute pericarditis
  2. Pericardial effusion - cardiac tamponade
  3. Constrictive pericarditis
24
Q

How does pericarditis present as acute pericarditis?

A

Inflamed pericardial layers

25
Q

How does pericarditis present as pericardial effusion (potentially progressing to cardiac tamponade)?

A

Accumulation of pericardial fluid exerts pressure on cardiac chambers

26
Q

How does pericarditis present as constrictive pericarditis?

A

Thickened +/- calcified pericardium restricts cardiac filling

27
Q

What are the 3 steps in the pathogenesis of pericarditis?

A
  1. Vasodilation
    - transudation of fluid
  2. Increased vascular permeability
    - leakage of protein
  3. Leukocyte exudation
    - neutrophils and mononuclear cells
28
Q

What does the inflammatory response depend on (in pericarditis)?

A

Depends on the underlying cause and severity of inflammation.

29
Q

What types of inflammatory response are seen in pericarditis?

A
  1. Serous pericarditis (often viral)
  2. Serofibrinous pericarditis (often viral)
  3. Suppurative (purulent) pericarditis (often bacterial)
  4. Haemorrhagic pericarditis (often malignancy)
  5. Chylous (lymph pericarditis) = obstruction to lymphatics
30
Q

What are some of the causes of pericarditis?

A
  1. Infectious
  2. Autoimmune disorders
  3. Neoplasms
  4. Radiation pericarditis
  5. Renal failure (uremia)
  6. Traumatic cardiac injury
  7. Idiopathic
31
Q

What is the most common cause of pericarditis?

A

Infectious, specifically VIRAL!

32
Q

What viruses cause pericarditis?

A
  • Coxsackie A & B
  • Influenza
  • Adenovirus
  • HIV
    etc.
33
Q

What are the clinical features of pericarditis?

A
  • Chest pain (sharp-dull ache; tends to refer to the left shoulder or arm)
  • Low grade fever
  • Dyspnoea
  • Palpitations may also occur
  • Pericardial friction rub
34
Q

How is pericarditis diagnosed?

A

Pericarditis is a CLINICAL DIAGNOSIS!

35
Q

What other investigations may support the diagnosis of pericarditis?

A
  1. Echocardiogram: pleural effusion (NB: absence does not rule out pericarditis)
  2. Blood tests: PPD, RF, ANA
  3. Viral serology or PCR
  4. Look for malignancy
36
Q

What is the definition of a pericardial effusion?

A

Abnormal accumulation of fluid n the pericardial cavity increasing intrapericardial pressure & negatively impacting on heart function.

37
Q

What can cause a pericardial effusion?

A
  1. Inflammation from infection
  2. Trauma causing bleeding in the pericardial space
  3. Other non-infectious conditions:
    - increase in pulmonary hydrostatic pressure e.g. congestive heart failure
    - increase in capillary permeability e.g. hypothyroidism
    - decrease in plasma oncotic pressure e.g. cirrhosis
  4. Decreased drainage of pericardial fluid due to obstruction of thoracic duct as a result of malignancy or damage during surgery.
38
Q

What types of pericardial effusions may be seen?

A
  • serous
  • serofibrinous
  • suppurative
  • chylous
  • hemorrhagic
    (depending on etiology)
39
Q

What type of effusions are usually seen due to viral causes?

A

Usually serous or serofibrinous

40
Q

What type of effusions are usually seen due to malignant causes?

A

Usually hemorrhagic

41
Q

How should a pericarditis be treated?

A
  • Bed rest and pain relief (analgesics and anti-inflammatory agents: NSAIDs)
  • Steroids for recurring pericarditis
  • Treat the causative agent
  • Drainage for purulent pericarditis
  • Treat any underlying issue
42
Q

What are some of the complications that can occur due to pericarditis?

A
  1. Pericardial effusion - cardiac tamponade

2. Constrictive pericarditis - CCF

43
Q

What are the clinical features of a pericardial effusion?

A
  1. Pericardium relatively stiff
  2. Symptoms of cardiac compression
  3. Similar to pericarditis
44
Q

What are the symptoms of cardiac compression dependent on?

A
  1. Volume of fluid
  2. Rate of fluid accumulation
  3. Compliance characteristics of the pericardium
45
Q

What do small pericardial effusions not produce?

A

Small effusions do not produce hemodynamic abnormalities

46
Q

What do large pericardial effusions cause?

A

Large effusions, in addition to hemodynamic compromise, may lead to compression of adjoining structures and produce symptoms of:

  • Dysphagia (compression of oesophagus)
  • Hoarseness (recurrent laryngeal nerve compression)
  • Hiccups (diaphragmatic stimulation)
  • Dyspnoea (pleural inflammation / effusion)
47
Q

What are the clinical features (signs) of pericardial effusion?

A
  1. Pulsus paradoxus
  2. Muffled heart sounds
  3. Pericardial friction rub
  4. Ewart’s sign
  5. Beck’s triad
48
Q

What is Ewart’s sign?

A

Compression of the lung in the left infrascapular region (atelectasis, detected as dullness to percussion)

49
Q

What is Beck’s triad?

A

(Cardiac tamponade):

  1. Hypotension
  2. Muffled heart sounds
  3. Jugular venous distention
50
Q

How is pericardial effusion treated?

A
  1. Pericardiocentesis done = sent for MC+S & cytology
    - low diagnostic yield
    - done therapeutically
51
Q

How is constrictive pericarditis treated?

A

Surgery (no other alternative)

52
Q

What is constrictive pericarditis?

A

= late complication of pericardial disease

  • fibrous scar formation
  • fusion of pericardial layers
  • calcification further stiffens pericardium
53
Q

What are some of the etiologies of constrictive pericarditis?

A
  • any cause of pericarditis
  • idiopathic
  • post-surgery
  • TB
  • radiation
  • neoplasms

Cardiovascular Block: Week 2 (4 decks)

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