Myocarditis & Pericarditis

Question 1

Incidence of myocarditis

Answer 1

• younger patients w/ MALE predominance

Question 2

Diagnosing myocarditis

Answer 2

• ECG, Labs, Echo, Cardiac MRI, Endomyocardial Biopsy

Question 3

Diagnosing myocarditis: ECG

Answer 3

• 47% sensitivity

- abnormal QRS, NW axis deviation, new LBBB higher mortality

Question 4

Diagnosing myocarditis: labs

Answer 4

• cardiac biomarkers: troponin I (89% spec, 34% sens adults; 83% spec, 71% spes in children)
• higher levels of troponin T associated w/ poor prognosis**

Question 5

Diagnosing myocarditis: echo

Answer 5

• most useful at ruling out other causes of HF

Question 6

Diagnosing myocarditis: MRI

Answer 6

• best evaluation: edema, hyperemia, necrosis/fibrosis

- lake louise criteria: when two of the three imaging criteria are positive, 78% diagnostic accuracy

Question 7

Diagnosing myocarditis: MRI

Answer 7

• only two indications
• new onset HF less than 2 wks w/ normal or dilated LV & hemodynamic compromise (Fulminant Myocarditis)
• unexplained HF 2wks-3months associated w/ dilated LV and new arrhythmias (Giant Cell Myocarditis)

Question 8

Cardiac MRI showing myocarditis

Answer 8

• patches of white in myocardium

Question 9

Etiology of pericardial disease

Answer 9

• idiopathic: presumed to be viral or autoimmune

- drugs: includes drug induced lupus (hydrolazine)

Question 10

Clinical presentation of percarditis

Answer 10

• chest pain
• pericardial friction rub
• ECG changes: NEW WIDESPREAD ST or PR DEPRESSION-signifies epicardial inflammation as parietal pericardium is electrically inert
• pericardial effusion

Question 11

Pericardial friction rub sound

Answer 11

• hear sandpaper subbing sound in background of lub dub

Question 12

Four stages in evolution of ECG in acute percarditis

Answer 12

Stage 1: diffuse ST elevation & PR depression (hours to days)
Stage 2: normalization of ST/PR segments (week 1)
Stage 3: diffuse T wave inversions after STs are isoelectric
Stage 4: normalization of ECG or persistent T wave inversions

Question 13

Chronic percarditis

Answer 13

• leads to thickening and tethering of pericardium to epicardial surface
• can progress to constrictive pericarditis, where pericardial sac tightly encases the heart preventing diastolic relaxation (only treatment is surgical percardiectomy)

Question 14

Pericardial effusions

Answer 14

• baseline pericardial fluid estimated at 30-50 mL or clear, serous fluid
• inflammation is most common reason for serous or fibrinous effusions

Question 15

Clinical effects of pericardial effusions & treatment

Answer 15

• slowing building effusions well tolerated
• rapid fluid accumulation can lead to restricted diastolic filling & CARDIAC TAMPONADE (fatal)
• treatment: pericardiocentesis

Question 16

Cardiac tamponade

Answer 16

• increasing pericardial pressure leads to compression of cardiac chambers
• leads to changes in systemic venous return & significant respiratory variation in venous return

Question 17

Cardiac tamponade signs

Answer 17

• classic signs: tachycardia, elevated JVP, pericardial rub, pulsus paradoxus
• beck’s triad: hypotension, jugular venous distention, & distant heart sounds

Question 18

Pathology of myocarditis

Answer 18

• lymphocytic
• eosinophilic: HYPERSENSITIVITY REACTIONS: drugs toxins, helminthic infections
• mixed infiltrate (neutrophil predominant)
• Giant cell (fulminant)

Question 19

Pathology of acute pericarditis

Answer 19

• serous: lymphocytes
• fibrinous & serofibrinous: serous effusion + fibrinous exudate
• suppurative: fibrinopurulent (yellow/green color)
• caseous: granulomatous inflammation (TB)
• hemorrhagic

Question 20

Treatment of myocarditis

Answer 20

• supportive care w/ standard HF drugs, electrical therapy, advance therapies (ECMO, VAD[bridge to transplant), antiviral therapy, immunomodulation, immunosuppression (giant cell myocarditis)

Question 21

Treatment for acute pericarditis

Answer 21

• treat underlying cause if not idiopathic or viral

- 3 mainstays of treatment: NSAIDs, colchicine, certicosteroids

Question 22

NSAID treatment of pericarditis

Answer 22

• ibuprofen or aspirin w/ gastric protection
• ketorolac or indomethacin
• if in setting of MI use ASA
• if no response in 1 WEEK REASSESS UNDERLYING ETIOLOGY

Question 23

Colchicine treatment or pericarditis

Answer 23

• colchicine + ASA better than just ASA
• recommended is 4-6wks of colchicine, esp if don’t respond to 1wk of NSAIDs
• caution with: renal disease, hepatobiliary disease, blood dyscrasias, GI motility disorders

Question 24

Corticosteroids for pericarditis treatment

Answer 24

• only if no benefit from NSAIDs or colchicine or initially if underlying immune mediated disease, CT disease, uremic percarditis
• early use in other cases associate w/ high risk of relapsing

Question 25

Summary of myocarditis

Answer 25

• injury & innate immune response, acquired immune disease, recovery or persistent cardiomyopathy
• diagnosis based on clinical story, exam, labs, echo/MRI
• endomyocardial biopsy: FULMINANT or GIANT CELL or eosinophilic
• treatment: evidence based heart failure therapy

Question 26

Summary of pericarditis

Answer 26

• four major clinical manifestations: chest pain, pericardial effusion, pericardial rub, ECG changes
• treatment: focused on resolving inflammation unless another identified cause

Question 27

Constrictive pericarditis

Answer 27

• occurs with fibrotic adhesion from chronic inflammation

- looks like restrictive cardiomyopathy

Question 28

Pericardial effusions

Answer 28

• rate of accumulation: faster rate poorly tolerated
• amount of fluid: pericardial space can accept a large accumulation if it occurs slowly
• tamponade most feared complication can be FATAL

Question 29

Presentation of myocarditis

Answer 29

• dyspnea, angina w/ spontaneous resolution to cardiogenic shock and sudden cardiac death