Myopericarditis Flashcards
…… and …… chest pain indicates pericardial involvement
Sharp and pleuritic
If acute pericarditis and pain exacerbated with swallowing, ………….. pericardium may be involved.
Posterior
If acute pericarditis and pain radiates to the neck, ………….. pericardium may be involved. Why?
Inferior.
This region is adjacent to phrenic nerve
Viral pericarditis usually follows an antecedent ………………………….
Upper respiratory infection
What two types of pericarditis can manifest after MI?
Peri-infarction pericarditis (PIP);
Dressler syndrome
When develops PIP?
10-20proc MI patients; between 2 - 4 days after TRASMURAL MI
What type of MI may result in PIP?
Transmural
Why pericarditis manifest after MI?
It is a reaction to necrosis of myocardium in adjacent pericardium.
Inflammation is spread or local in PIP?
Localized - inflammation of the visceral and parietal pericardium overlying the necrotic myocaridial segment.
Treatment of PIP?
Resolves with several days of supportive care, sometimes may need high-dose aspirin.
How may be called Dressler syndrome in other name?
Postcardiac injury syndrome
Pathophysiology of Dressler syndrome?
Autoimmune mediated pericarditis - likely provoked by antigens exposed or created by infarction and necrosis of cardiac muscle.
What may manifest Dressler syndrome?
Week to months
Inflammation in pericardium is spread or local in Dressler syndrome?
Spread (autoimmune origin)
Myocardial ischemia vs pericarditis pain
Pericarditis - sharp and pleuritic, may be exacerbated by swallowing or coughing
Ischemic - constant, substernal and ,,crushing”
Acute pericarditis pleuritic chest pain decreases when …………..
When sitting up
ECG in acute pericarditis?
Diffuse ST elevation
Pericardial effusion ECG?
Decr. QRS voltage +/- electric alterans
Pericarditis may complicate into ………….
Pleural effusion
What type of inflammations cause pericardial effusion?
Fibrinous or serofibrinous pericardial inflammation
What causes dyspnea on exertion in pleural effusion?
Decreased diastolic ventricular filling –> decreased SV
Tachycardia in pleural effusion is to …………….
To compensate for decreased ventricular filling.
Low voltage QRS in pleural effusion is due to ………..
Pericardial fluid accumulation increasing the distance between the heart and the ECG leads
Why diminished heart sounds in pericardial effusion?
Pericardial fluid accumulation increasing the distance between the heart and stethoscope
Why there are electrical alternans on ECG in pericardial effusion?
Swinging motion of the heart
How is called a variation in the QRS axis in pleural effusion?
Beat to beat variation
2 x-ray characteristics of pleural effusion?
Enlarged, globular cardiac silhouette;
Clear lungs
Enlarged cardiac silhouette occur over …….. to …….. (ie ………. course)
Due to progressive pericardial stretching over days to weeks (Subacute course).
What volume of fluid may accumulate in subacute pericardial effusion course?
up to 1-2L
Why there are clear lung in pericardial effusion?
high pericardial pressure affects the low pressure chambers ie right-sided heart chamber more than left –> right sided blood flow obstruction therefore lung are clear. If left-sided obstruction would be more prominent than right-sided - then would be fluid in lungs.
Reason of DCM?
Direct insult to the myocardium –> decreased contractile function of both ventricles.
Why left ventricular structural changes are dangerous for patients with DCM?
Sudden death due to ventricular arrhythmia.
Bet ir trombai jeigu labai issiplete skilveliai? (tsg klausimas buvo apie structural changes)
When patients are considered are idiopathic DCM?
When no apparent cause is identified
Idiopathic DCM –> likely familial (inherited) cause. What structures (2) can be affected by mutations?
Sarcomere (ie contractile apparatus) or nonsarcomere proteins.
What gene is most commonly affected in DCM? What it encodes?
TTN gene. Sarcomere protein titin.
What is the function of titin protein?
It is elastin protein that anchors the beta-myosin heavy chain with Z disc –> contributes to passive myocardial tension
What is the inheritance of TTN gene mutation?
Autosomal dominant
Why there may be delayed or absent clinical manifestation of TTN gene DCM?
TTN gene mutations have incomplete penetrance
Takotsubo cardiomyopathy is characterized by ………………. of the mid and apical and ………………… of basal segments. It lead to ………….. dysfunction.
Hypokinesis;
Hyperkinesis.
LV systolic dysfunction –> reduced EF
What is pathophysiological factor causing takotsubo?
Physical/emotional stress –> catecholamine surge –> microvascular spasm –> ischemia or myocardial stunning or direct myocardial dysfunction
What is seen on echocardiography in takotsubo?
Balloon shape of LV
What population is mostly affected by takotsubo?
Postmenopausal women
Symptoms and diagnostic features of takotsubo?
MI and HF symptoms + ECG show ischemia BUT NO CAD ON ANGIOGRAPHY
Treatment of takotsubo?
The condition usually resolves within several weeks with supportive treatment only.
How IV drugs affect valves and increase the risk of vegetation formation?
Particulate material denudes the surface of the valves –> variegated surface for m/os attachement.
Why right-sided valves are at high risk of damage in IV drugs use?
- Venous infection –> venous blood reaches right-heart.
2. Pulmonary capillaries prevent large particulate matter from reaching the left side of the heart
Tricuspid valve IE in IV drugs users manifestation?
Right sided HF and/or septic pulmonary emboli
Who are seen septic pulmonary emboli on x-ray in IV drugs users?
Multiple pulmonary nodules
Why there are crackles and rhonchi in IV drug users?
Due to septic emboli
What shows echocardiography in IV drug users?
Valvular vegetations which result in regurgitation (due to incomplete valve closure)
Murmur in IV drug users. Location on the chest?
Blowing, holosystoli mumur;
Along left lower sternal border
What intenses and what reduces holosystolic mumur in IV drug users?
Intensified during inspiration;
Reduced with standing
Why septic pulmonary emboli are less common in aortic/mitral valve IE?
Septic thrombi lodge in capillary beds eg cutaneous prior to returning to the right-side of the heart
Conditions that decrease compliance if LV lead to ……………………… (pressure volume)
Increased LVEDP at the same LVED volumes
Why there will be increased pulmonary vasculature pressures in restrictive cardiomyopathy?
Higher LV filling pressures are transmitter back to pulmonary vasculature –> pulmonary edema
What protein plays important role in restrictive cardiomyopathy?
Transthyretin (TTR)
Where is produced transthyretin (TTR)?
In liver as tetramer.
What is a carrier function of transthyretin?
Carries thyroxine and retinol
Why mutations in the transthyretin (TTR) gene may result in restrictive cardiomyopathy?
Mutation –> TTR misfold –> amyloid protein –> infiltration of the myocardium = infiltrative cardiomyopathy
What CT features suggest restrictive pericarditis? (2)
Thickening and calcification of pericardium.
What is normal pericardium thick and what is in constrictive pericarditis?
Normal: 1-2mm
In CP: 4-20mm
What 3 symptoms typically have patients with constrictive pericarditis?
Progressive dyspnea + chronic edema + ascitis
What abnormality is seen in jugular venous pressure tracing in case of constrictive pericarditis?
Rapid y-descent that becomes both deeper and steeper during inspiration
What are the possible causes of constrictive pericarditis?
Radiation therapy to the chest, cardiac surgery, tuberculosis
Cardiac arrhythmia leads to ….. and ….. –> SCD
Markedly decreased CO and impaired coronary artery perfusion
What causes SCD in older adults and younger adults?
Older adults - CAD
Younger adults - undelying structural heart disease - hypertrophic cardiomyopathy is one of the most common precipitating diseases
Histology of hypertrophic cardiomyopathy? (3)
Cardiomyocyte hypertrophy + myofiber disarray + interstitial fibrosis
What causes ventricular arrhythmia in hypertrophic cardiomyopathy?
Structural disarray lead to conduction abnormalities
Patient has pneumonia which complicates into purulent pericarditis. M/o?
Streptococcus pneumoniae
How staph. aureus can reach pericardium and cause purulent pericarditis? (2)
- Portals from skin to bloodstream (eg tunneled dialysis catheter)
- From skin to pericardium eg in chest injury, cardiothoracic surgery
- Hematologic spread of distant infection
Fungal pericarditis m/o?
Candida albicans
What patient population with catheters have increased risk of purulent pericarditis by staph. aureus?
End-stage renal disease patients who have vascular catheters
What 3 patient population have increase risk for candidemia which may complicate into purulent pericarditis due to fungi?
parenteral feeding, prolonged corticosteroid use, immunosuppression due to malignancy
What is an important diagnostic method and features to detect purulent pericarditis?
Pericardiocenthesis: turbid pericardial effusion with high number of leukocytes/frank pus
What are the primary mediators of organized cardiac conduction?
Intercalated discs
2 mechanisms that cause ventricular arrhythmia in hypertrophic cardiomyopathy
Conduction system impairment due to disarray (remodeling);
Myocardial ischemia due to a) increased oxygen demand due to hyperthrophied myocardium + b) microvascular impairement in coronary system and obstructed blood outflow due to septal predominance
How can be reduced sharp and pleuritic pain in acute pericarditis?
By leaning forward –> decreased pressure on parietal pericardium
What is the most specific physical finding in acute pericarditis?
Pericardial friction rub (high pitch, leathery, scratchy)
HCM effect on the coronary capillary network?
Poorly developed in hypertrophied regions + microvascular dysfunction
What is hyperthrophy in athletes heart?
Predominant concentric –> incr. LV cavity size + small degree eccentric –> uniformly increased LV wall thickening
What type of cardiomyopathy and what features manifest due to CAD?
CAD –> Ischemic cardiomyopathy = manifest as dilated cardiomyopathy –> enlarged LV ventricle cavity + thin LV wall –> systolic dysfunction
Anabolic steroid abuse can cause pathologic …………………… LV hypertrophy
Concentric
What type of collagen are in scar post MI?
Type 1
histopathology of acute myocarditis?
Myocyte necrosis/degeneration + inflammatory mononuclear cell infiltrate
Acute myocarditis can lead to what cardiomyopathy?
Dilated cardiomyoapthy
Cardiac adaptation in athlete’s: CO and afterload
Increased CO due to increased load on the heart (MOSTLY)
Slightly increased pressure load (incr. afterload)
How changes right heart in athletes?
The right ventricular cavity slightly increased to support an increase in CO
Athlete’s heart. Effect on coronary arteries and resting heart rate?
Enhanced coronary capillary development;
Decreased resting HR due to improved efficiency of cardiac pumping
Overall result of high-intensity endurance exercises on heart. (4)
Increase in LV mass; enlarged LV cavity size; slightly increased LV wall thickness;
decreased resting heart rate.
What function impairment in dilated cardiomyopathy leads to thrombus formation?
Global hypokinesis of the left ventricle leads to stagnation of blood flow and the possible development of LV mural thrombus and subsequent systemic embolization
Where can radiate pleuritic chest pain?
Radiate to the bilateral scapulae posteriorly.
When does pleuritic chest pain worsen?
When lying flat
Why there is an ST elevation in acute pericarditis?
Due to ventricular myocardium inflammation
In what cardiac cycle stages occurs pleuritic friction rub?
During atrial systole, ventricular systole, and early ventricular diastole
What vital signs alterations are seen in ARF carditis?
Tachycardia, hypotension, tachypnea
What valve is damaged and what murmur occurs in pancarditis due to ARF?
Acute mitral valve regurgitation –> holosystolic murmur.
Anitchkoff cells in myocarditis in ARF are ……………. with ,,………….” chromatin
Macrophages with characteristic ,,caterpillar” chromatin
Aschoff body consist of (3) cells?
Macrophages + lymphocytes + scattered multinucleated giant cells.
Eventually aschoff bodies are replaced by …………… and results in ……………..
Fibrous scar tissue;
Mitral valve stenosis and regurgitation
Dilated cardiomyopathy due to chemotherapeutic agents. Biopsy findings?
Patchy fibrosis with vacuolization and lysis of myocytes.
Who aschoff bodies are called in other way?
Interstitial myocardial granulomas
What amount of blood can drastically increase pressure in pericardial space in cardiac tamponade?
Pericardial space is not compliant, therefore even small amount eg 100-200ml can significantly compress heart
Why there is JVD in cardiac tamponade?
Because right-sided ventricle is low-pressure and is easier to compress –> results in decreased diastolic function –> distended jugular veins
Why there is hypotension in tamponade despite tachycardia?
Due to compressed right ventricle there is decreased diastolic filling –> decreased outflow volume.
Why there is dyspnea and tachypnea in tamponade?
Due to decreased blood outflow there is impaired peripheral perfusion –> unmet oxygen demand –> dyspnea, increased respiratory drive and tachypnea
Which heart side symptoms predominantly occurs in constrictive pericarditis?
Right
What are seen biopsy changes in case of constrictive pericarditis?
Thick, fibrous tissue in pericardial space
What is pericardial knock in constrictive pericarditis?
Early diastolic sound that occurs before S3
What 3 pathophysiological features will be seen in constrictive pericarditis?
Pulsus paradoxus;
Pericardial knock;
Kussmaul sign
2 ways how malignancy can cause pleural effusion?
Direct tumor extension or metastatic spread via blood and lymphatics
How progresses subacute pericardial effusion eg in malignancy?
Pressure is stable in pericardial space + it gives time to stretch for pericardium –> patients have nonspecific symptoms eg dyspnea and chest discomfort. Impaired cardiac function when larger volumes exceed pericardial stretch capability.
What are pericardiocentesis characteristics in malignancy pleural effusion?
Hemorrhage - due to bleeding from irrigated vessels.
Cytology –> atypical malignant cells
Fibrinous pericarditis is the most common type of pericarditis and consists of …………………
Pericardial inflammation with serous fluid and fibrin-containing exudate in the pericardial space.
Why there is friction rub in pericarditis?
Due to fibrin depositions that result in rough visceral and parietal pericardium
Pleural friction rub can be heard during atrial systole, ventricular systole, and early ventricular diastole, therefore is called ………………
triphasic friction rub
When pericardial friction rub can be absent in case of pericarditis?
If significant pleural effusion occurs
What is the most common type of inflammation in case of pericarditis?
Fibrinous
In what cases hemorrhagic pericarditis can occur?
Most commonly in malignancy, but can occur in TB and cardiac surgery, or underlying coagulopathy
Hemorrhagic pericarditis consists of …..
Blood mixed with fibrinous exudate
Fibrinous pericarditis consists of ……
Serous exudate with fibrin
How dilation of the heart helps in pregnancy?
Heart accommodates to increased end-diastolic volume
In what time period manifests peripartum dilatation?
Dilated cardiomyopathy occurs during the last month of pregnancy or within 5 months after delivery.
Pathogenesis of peripartum dilatation. What may predispose?
May be related to impaired function of angiogenic growth factors (eg, vascular endothelial growth factor) during the peripartum period. In addition, certain individuals may have genetic mutations affecting cardiac structural proteins that predispose to the development of peripartum cardiomyopathy.
How is thickened LV wall in cardiac amyloid?
Uniformly
What exacerbates LVOT obstruction?
The systolic anterior motion of the mitral valve toward the interventricular septa this way blocking aortic valve
What murmur occurs due to LVOT obstruction? What causes it?
Harsh crescendo-decrescendo systolic murmur at the apex and left lower sternal border; the murmur is caused by blood flow through the narrowed LVOT
what types of ventricular arrhythmia can occur in HCM? (2)
Ventricular tachycardia or ventricular fibrillation
What m/o causes chagas disease? What is a vertor?
Trypanosoma cruzi; vectos - triatomine (,,kissing”) bug
Endemic regions for trypanosoma cruzi?
Central and South America
Why in chagas disease manifest cardiac damage? (2)
Chronic parasite-induced and immune-mediated myocarditis –> dilated cardiomyopathy
What are the structural changes in the heart due to chagas disease?
Localized apical wall thinning with a large apical aneurysm.
Why aneurysma in chagas disease is dangerous?
Can predispose formation of mural thrombus which may systemically embolize and cause stroke
What rhytmic changes can manifest in chagas disease? why?
Damage to the conduction system can also trigger ventricular arrhythmias (ventricular tachycardia/fibrillation)
What can lead to sudden death in chagas disease?
Ventricular arrhythmias
What can lead to dilation and dysfunction of the esophagus and colon in chagas disease?
Destruction of the myenteris plexus
What is peripheral pulse in case of MI?
Weak or undetectable peripheral pulse
Hereditary hemochromatosis is assoc. with mutation in …………. gene
HFE
What does HFE protein? What disease mutation cause?
Causes hereditary hemochromatosis.
Hfe protein binds to the tranferin receptor and regulates intestinal and hepatic iron uptake
What type of injury causes the accumulation of iron in the heart?
Oxidative damage
What are early and late changes in the heart in hemochromatosis?
Early - diastolic LV dysfunction (restrictive)
Late - dilated cardiomyopathy
What 3 features due to conduction system changes can be seen in hemochromatosis?
Atrial and ventricular arrhythmias;
sudden cardiac death;
Sinus node dysfunction (sick sinus syndrome)
How can be called sinus node dysfunction in hemochromatosis in other name?
Sick sinus syndrome
What leads to progression of dilated cardiomyopathy in hemochromatosis?
progressive ventricular remodeling
Sinus node dysfunction can lead to ……….. or ………
Presyncope or syncope
What is seen in microscopy in cardiac hemochromatosis?
Brown, granular deposits in cardiomyocytes that stain strongly with Prussian blue
What is a treatment of hemochromatosis?
Therapeutic phlebotomy
What is the onset time of acute cardiac transplant rejection?
Within 6 months
How to diagnose acute cardiac transplant rejection?
Endomyocardial biopsy
What mediates acute transplant rejection?
Predominantly - cell mediated;
less commonly - antibody mediated
What are microscopic changes in acute cardiac transplant rejection? (2)
Interstitial lymphocytic infiltrate (primarily T lymphocytes) and damaged myocytes
What is mechanism of immune activation in acute heart transplant rejection?
Host T lymphocytes are sensitized against HLA in cardiac allograft –> inflammation and injury to the transplant organ
What are the symptoms of progressive cardiac transplant rejection?
Systolic dysfunction (eg dyspnea on exertion)
What leads to cardiac allograft vasculopathy?
Concentric intimal thickening of the coronary arteries
Cardiac allograft vasculopathy can lead to …………. (2)
Ischemic damage and long-term graft dysfunction
What induces concentric intimal thickening of the coronary arteries?
Release of cytokines –> smooth muscle cell proliferation in the vessel wall
Patchy necrosis with granulation tissue is indicative of ……….. to the donor heart
ischemic damage
What indicates (microchages) ischemic damage in donor heart?
Patchy necrosis with granulation tissue
When can occur ischemic damage in donor heart? (3)
Resuscitation, transportation from donor to recipient, during initial perfusion after transplantation
What causes hypersensitivity myocarditis?
it is immunologic response to a newly initiated drug
What are the changes in the myocardium in hypersensitivity myocarditis?
Perivascular infiltrate with abundant eosinophils
What mediates chronic rejection of transplant?
Host T lymphocytes as well as antibodies
What is changes in transplanted organ in chronic rejection?
Interstitial fibrosis with scant inflammation
It is believed that an ……………………… to the viral infection allows virus to infect and persist inside cardiomyocytes.
Inadequate immune response
By which 2 mechanisms does viral myocarditis damages myocardium?
Direct cytotoxic effect or a destructive autoimmune reaction
What changes in myocardium in viral myocarditis leads to systolic dysfunction?
Depletion of cardiomyocytes with subsequent fibrosis –> weakened myocardial contractility (systolic dysfunction) + volume overload + ventricular dilation
Regional wall motion abnormality is suggestive of …………….
ischemic heart disease (eg MI)
Where is impaired myocardial function in MI?
Contractile function is impaired in the damaged portion of myocardium,
What are 2 clinical features of hyperthrophic cardiomyopathy?
Clinical features of hypertrophic cardiomyopathy include exercise-induced syncope (due to outflow obstruction) and sudden cardiac death (due to ventricular arrhythmia) in young athletes
How is called systolic ejection murmur in hypertrophic cardiomyopathy?
Harsh crescendo-decrescendo
What maneuvers/conditions decreased LV preload?
Abrupt standing, Valsalva strain phase, dehydration
What maneuvers/conditions decreased LV afterload?
Administration of vasodilators
What 2 changes in LV increase the intensity of hypertrophic cardiomyopathy murmur?
Decreased LV preload and decreased LV afterload
What maneuvers/conditions increase LV preload?
Passive leg raising, squatting
What maneuvers/conditions increase LV afterload?
arterial vasoconstrictors or sustained handgrip
What 2 conditions in LV alleviate hypertrophic cardiomyopathy murmur?
increased LV preload and increased LV afterload
