Myocarditis & Pericarditis Flashcards
Incidence of myocarditis
- younger patients w/ MALE predominance
Diagnosing myocarditis
- ECG, Labs, Echo, Cardiac MRI, Endomyocardial Biopsy
Diagnosing myocarditis: ECG
- 47% sensitivity
- abnormal QRS, NW axis deviation, new LBBB higher mortality
Diagnosing myocarditis: labs
- cardiac biomarkers: troponin I (89% spec, 34% sens adults; 83% spec, 71% spes in children)
- higher levels of troponin T associated w/ poor prognosis**
Diagnosing myocarditis: echo
- most useful at ruling out other causes of HF
Diagnosing myocarditis: MRI
- best evaluation: edema, hyperemia, necrosis/fibrosis
- lake louise criteria: when two of the three imaging criteria are positive, 78% diagnostic accuracy
Diagnosing myocarditis: MRI
- 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)
Cardiac MRI showing myocarditis
- patches of white in myocardium
Etiology of pericardial disease
- idiopathic: presumed to be viral or autoimmune
- drugs: includes drug induced lupus (hydrolazine)
Clinical presentation of percarditis
- chest pain
- pericardial friction rub
- ECG changes: NEW WIDESPREAD ST or PR DEPRESSION-signifies epicardial inflammation as parietal pericardium is electrically inert
- pericardial effusion
Pericardial friction rub sound
- hear sandpaper subbing sound in background of lub dub
Four stages in evolution of ECG in acute percarditis
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
Chronic percarditis
- 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)
Pericardial effusions
- baseline pericardial fluid estimated at 30-50 mL or clear, serous fluid
- inflammation is most common reason for serous or fibrinous effusions
Clinical effects of pericardial effusions & treatment
- slowing building effusions well tolerated
- rapid fluid accumulation can lead to restricted diastolic filling & CARDIAC TAMPONADE (fatal)
- treatment: pericardiocentesis
Cardiac tamponade
- increasing pericardial pressure leads to compression of cardiac chambers
- leads to changes in systemic venous return & significant respiratory variation in venous return
Cardiac tamponade signs
- classic signs: tachycardia, elevated JVP, pericardial rub, pulsus paradoxus
- beck’s triad: hypotension, jugular venous distention, & distant heart sounds
Pathology of myocarditis
- lymphocytic
- eosinophilic: HYPERSENSITIVITY REACTIONS: drugs toxins, helminthic infections
- mixed infiltrate (neutrophil predominant)
- Giant cell (fulminant)
Pathology of acute pericarditis
- serous: lymphocytes
- fibrinous & serofibrinous: serous effusion + fibrinous exudate
- suppurative: fibrinopurulent (yellow/green color)
- caseous: granulomatous inflammation (TB)
- hemorrhagic
Treatment of myocarditis
- supportive care w/ standard HF drugs, electrical therapy, advance therapies (ECMO, VAD[bridge to transplant), antiviral therapy, immunomodulation, immunosuppression (giant cell myocarditis)
Treatment for acute pericarditis
- treat underlying cause if not idiopathic or viral
- 3 mainstays of treatment: NSAIDs, colchicine, certicosteroids
NSAID treatment of pericarditis
- 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
Colchicine treatment or pericarditis
- 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
Corticosteroids for pericarditis treatment
- 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
Summary of myocarditis
- 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
Summary of pericarditis
- four major clinical manifestations: chest pain, pericardial effusion, pericardial rub, ECG changes
- treatment: focused on resolving inflammation unless another identified cause
Constrictive pericarditis
- occurs with fibrotic adhesion from chronic inflammation
- looks like restrictive cardiomyopathy
Pericardial effusions
- 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
Presentation of myocarditis
- dyspnea, angina w/ spontaneous resolution to cardiogenic shock and sudden cardiac death
