Myopericardial Disease Flashcards
How is pericarditis diagnosed?
Have 2/4 criteria:
- Classic chest pain (>85-90% of cases): sharp pleuritic, improved by sitting up and leaning forward and worse with laying back
- Pericardial friction rub (rare)
- Characteristic EKG findings (diffuse ST elevation, PR depression)
- New or worsening pericardial effusion
Most common cause of pericarditis? Other causes?
80% are idiopathic
Other causes:
- viral, bacterial, fungal, parasitic
- Medications (hydralazine, procainamide, INH)
- Autoimmune diseases
- Post-MI (Dressler syndrome)
- Uremia
- Post-traumatic
3 main medicines that cause pericarditis
Procainamide
Hydralazine
Isoniazid
Describe the progression of EKG changes in patients with pericarditis
Stage 1: first hours to days:
- Diffuse ST elevation and PR depressions
Stage 2: ST and PR segments normalize and T waves flatten
Stage 3: Diffuse T wave inversions
Stage 4: Returns to normal (sometimes T wave inversions are permanent)
What are high risk features of pericarditis that would suggest that you may need to admit them?
Hypotension
Fever
A subacute course (symptoms over several days without clear acute onset)
Evidence of a large pericardial effusion or cardiac tamponade
Failure to respond to NSAIDs after 7 days
Pericarditis due to underlying causative process (SLE, uremia, etc) —> admit
Treatment of pericarditis
NSAIDs:
Ibuprofen (600-1600mg daily) or IV Ketoralac (now replace indomethacin)
If concomitant CAD: Aspirin (750-1600 mg daily) is preferred
Colchicine combined with NSAIDS:
- Best for preventing recurrence of NON-bacterial pericarditis
- Must be continued for at least 3 months after the first occurrence to effectively prevent recurrence at 18 months
Talk about the use of steroids for treating pericarditis
Not recommended for ED use - associated with an increased risk of recurrence
Only for patients who do not tolerate NSAIDs or have contraindications to their use. ONLY used after the failure of first-line therapy
Rarely used for refractory or intractable pain
Final option for treatment of pericarditis after failure of all medical therapies?
Pericardectomy at an experienced surgical center
In what percentage of patients does acute pericarditis recur after the first time?
20-30%
Up to 50% of patients with recurrent pericarditis may experience more recurrences
How long should patients wait before returning to competitive sports with acute pericarditis?
until symptoms have resolved and diagnostic tests have normalized. Minimum of 3 months is recommended.
Describe the clinical presentation of Myocarditis (wide range). What are some clues that should increase your suspicion?
Prodrome of a viral illness: fever, rash, sore throat, malaise, arthralgias, non-specific GI and respiratory symptoms.
Complaining of chest pain and/or SOB, arrhythmias, syncope, near-syncope
Increase your suspicion:
- UNEXPLAINED tachycardia or Tachycardia out of proportion to fever.
- New or unexplained cardiomegaly/heart failure.
- Profound troponin elevation.
Define Fulminant myocarditis
Distinct symptom onset within <2 weeks
Signs of severe heart failure, electrical instability, hypotension, or cardiogenic shock
Requires inotropes or mechanical circulatory support
Define Acute NON-fulminant myocarditis
Onset is less distinct than fulminant
HF is less severe if present
No hypotension (or less common)
No vasopressor support necessary
Most common EKG finding in myocarditis
Sinus Tachhycarida
Other possible findings:
- SVT
- ST elevations and depressions
- T-wave inversions
- AV block (more common in chronic disease associated myocarditis like Lyme Disease)
Mainstay of treatment for myocarditis?
Heart Failure treatment
Critically ill/fulminant myocarditis? —> IV fluids, inotropes and vasopressors. Cardiology consult.
