Pericardial disease and Myocarditis

Question 1

Myocarditis

Answer 1

inflammation of the myocardium leading to myocyte injury
● Acute or Chronic
● Occur alone or in setting of systemic process

Question 2

Etiology of Myocarditis

Answer 2

can be infectious, immune-mediated, environmental, drugs/medications, and some causes may be related to genetic predisposition.

Question 3

Acute Myocarditis clinical presentation

Answer 3

● Symptoms: Chest pain, dyspnea, arrhythmia, cardiac dysfunction (HF)
● Physical Exam may look similar to heart failure
● Diagnostics: Abnormal EKG, elevated biomarkers, echo with contractile
dysfunction, cardiomegaly

Question 4

Diagnosis of Myocarditis

Answer 4

clinical; pathology on biopsy or autopsy

Question 5

Management of myocarditis

Answer 5

supportive; aimed at prevention or treating complications

Question 6

A major cause of sudden cardiac death in those under 40 YOA and may account
for some cases of idiopathic dilated cardiomyopathy.

Answer 6

Acute Myocarditis

Question 7

The most frequent causes of myocarditis are ____

Answer 7

viral infections, cardiotoxins/chemotherapy agents, recreational drugs, and immune system activation
50% of cases are IDIOPATHIC

Question 8

Infectious causes of Myocarditis

Answer 8

● Viral (MCC of lymphocytic myocarditis in North America and
Europe)
● Bacterial
● Fungal
● Protozoal (MCC in Africa, Asia and South America): Chagas
disease caused by Trypanosoma cruzi

Question 9

Drugs/Medications causing myocarditis

Answer 9

Cocaine/amphetamines
EtOH
Doxorubicin
Antibiotics: PCN,
cephalosporins, sulfonomides
Immune therapies and novel
cancer therapies

Question 10

Acute Myocarditis: Pathophysiology

Answer 10

○ Inflammation due to multiple etiologies
results in myocyte damage à necrosis
○ Prolonged damage à fibrosis à chamber
remodeling à dilated cardiomyopathy
○ Results in heart failure, cardiac arrhythmia
and or extension to the pericardium causing
pericarditis.

Question 11

Progression of Acute Myocarditis presentation

Answer 11

subclinical à acute à chronic
○ Classically presents several days to a few weeks after the onset of an
acute febrile illness or respiratory tract infection.

Question 12

Some possible signs and symptoms of Acute Myocarditis include:

Answer 12

■ Dyspnea (72%)
■ Chest pain (32%)
■ Tachycardia and fever
■ Murmurs: MR, TR
■ Peripheral edema
■ Arrhythmias (18%)
■ Cardiogenic shock
■ Faint S3 and/or S4 gallops
■ Pericardial friction rub
■ JVD

Question 13

EKG findings of Acute Myocarditis

Answer 13

commonly shows nonspecific ST changes, arrhythmia.
○ QRS and PR prolonged, PR segment depression (pericarditis)
■ Pathologic Q waves and LBBBs are a poor prognostic sign

Question 14

Chest X-ray findings of Acute Myocarditis

Answer 14

findings are also nonspecific, but may show cardiomegaly
(frequent, not always).
■ If present with CHF, CXR may show signs of pulmonary edema

Question 15

Labs for Acute Myocarditis

Answer 15

■ WBC, ESR, CRP, Troponin, CK, CMP, hepatic panel, ABG, BNP
■ Blood cultures, lactate
■ +/_ rheumatology labs

Question 16

Cardiac MRI findings of Acute Myocarditis

Answer 16

Cardiac MRI with gadolinium contrast may show enhancement in spotty
areas of injury throughout the myocardium

Question 17

Gold Standard diagnostic test for Acute Myocarditis

Answer 17

Endomyocardial Biopsy is considered Gold
Standard diagnostic but is rarely needed

Question 18

Treatment/Management of Acute Myocarditis

Answer 18

○ Supportive care is the first-line of therapy for patients with myocarditis.
○ Restrict physical activity to decrease cardiac work.
■ Some bed rest is advisable if febrile or obvious viremia
○ Arrhythmia management
○ HF management : ACEi/ARB, diuretics, salt restriction, etc.
■ May need ICD, inotrope assistance, LVAD, etc. in severe cases
○ Cardiac transplantation may be needed for some

Question 19

Acute Pericarditis

Answer 19

● Acute Pericarditis is the acute inflammation of the pericardial sac.
● Like Myocarditis, it is most commonly thought of as a viral infectious process, but there are several other known causes as well

Question 20

Acute Pericarditis etiology

Answer 20

○ Viral infections are the most common cause and are probably responsible for most cases classified as idiopathic too.
■ Most common: Coxsackieviruses and Echoviruses
○ Bacterial causes are rare and usually result from direct expansion from bacterial pneumonia or Lyme disease.
○ Tuberculosis is a rare cause in developed countries but remains common in the developing world.
○ Uremic pericarditis is a common complication of CKD (uncertain pathogenesis) and occurs in both untreated and stable CKD patients
○ Post-MI pericarditis may occur days to weeks after an MI due to an inflammatory reaction to transmural myocardial necrosis.
○ Connective tissue diseases, such as rheumatoid arthritis and lupus, are
also known causes of pericarditis (like myocarditis).

Question 21

Pathophysiology of Acute Pericarditis

Answer 21

○ Whatever the cause, the pericardial
tissue becomes acutely inflamed.
○ The inflammatory process can interrupt
the normal development of pericardial
fluid that is normally lubricating

Question 22

Signs and Symptoms of Acute Pericarditis

Answer 22

○ The most common presenting
symptom is chest pain.
■ It is usually pleuritic and postural
■ Anterior chest pain that is
classically worse when lying supine
and relieved by sitting upright
■ Dyspnea, JVD, weakness, fatigue
○ A Pericardial Friction Rub is characteristic
○ A pericardial effusion may or may not be present as well.

Question 23

Diagnosis of Acute Pericarditis

Answer 23

○ The diagnosis of viral pericarditis is usually clinical, although it’s
important to confidently rule out ischemic causes for the pain
○ EKG - generalized or diffuse ST and T wave changes
○ CBC often reveals leukocytosis, but not always.
○ ESR and/or CRP are often elevated, especially in Dressler Syndrome.
○ Chest X-ray is commonly normal
○ Echocardiogram reveals a pericardial effusion (usually mild/small) in
about 60% of patients and may show evidence of pericardial inflammation.
○ CT or MRI can be used in select patients and may reveal pericardial inflammation or extracardiac disease.

Question 24

Acute Pericarditis treatment

Answer 24

○ Current guidelines recommend the use of either Aspirin or Ibuprofen.
■ Aspirin 750-1000 mg every 8 hours for 1-2 weeks, then taper down
by decreasing dose by 250-500 mg every 1-2 weeks, OR
■ Ibuprofen 600 mg every 8 hours for 1-2 weeks, then taper down by
decreasing dose by 200-400 mg every 1-2 weeks
■ Always include gastroprotection measures!
■ Adjuvant Colchicine and should be continued for 3 months
■ Alternatively: short term steroids
○ Restriction of activity for acute pericarditis.

Question 25

Constrictive Pericarditis

Answer 25

● Severe, chronic, or recurrent pericardial inflammation can lead to a
thickened, fibrotic, adherent pericardium over time.
○ This can restrict diastolic filling and can produce chronically elevated
venous pressures.

Question 26

Diagnosis of Constrictive Pericarditis

Answer 26

● Establishing the diagnosis is often difficult, as there is no one test that is the
gold standard.
○ May include CXR, Echo, Cardiac CT or MRI… none are specific.
○ If anything, Cardiac Catheterization is the most helpful.

Question 27

Constrictive Pericarditis presentation

Answer 27

● Patients developing Constrictive Pericarditis have slowly progressive
dyspnea, fatigue, and weakness. Chronic edema, hepatic congestion,
elevated JVP, and even ascites are usually present eventually.

Question 28

Constrictive Pericarditis treatment

Answer 28

● Initial treatment is aimed at the specific etiology if possible.
● Mainstay of treatment is diuretics to avoid volume overload.
○ Pericardiectomy is an option for severe cases (high mortality rate though)

Question 29

A classic physical exam sign for Constrictive Pericarditis

Answer 29

Kussmaul Sign
○ This is a paradoxical rise in JVP
on inspiration, or rather the
failure of JVP to fall with
inspiration
○ Most commonly seen with
Constrictive Pericarditis and
Restrictive Cardiomyopathy

Question 30

Pericardial Effusion & Tamponade

Answer 30

Effusion development in the pericardial sac can
occur during acute pericardial inflammation.
○ Can occur with any of the known causes of
pericarditis

Question 31

Pathophysiology of Pericardial Effusion & Tamponade

Answer 31

○ The speed of accumulation determines the
physiologic importance of the effusion
○ Because of pericardial stretch, effusions larger
than 1000 mL that develop slowly may
produce no hemodynamic effects
○ On the other hand, effusions that develop quickly are more likely to
cause tamponade, even if much smaller than 1000 mL
○ Cardiac Tamponade restricts venous return and ventricular filling,
resulting in decreased stroke volume, cardiac output, and BP

Question 32

Signs and Symptoms of Pericardial Effusion & Tamponade

Answer 32

○ Patients may report chest pain if the effusion is associated with an acute
inflammatory process
○ The effusion may be painless, however, in patients with effusions due to
neoplastic or uremic syndromes
○ A pericardial friction rub may be present, even in large effusions.
○ If cardiac tamponade has developed, the patient will display
tachycardia, hypotension, raised JVP, muffled heart sounds, & dyspnea.
■ Beck’s Triad - Three classic signs of cardiac tamponade
● Hypotension, JVD, and muffled heart sounds

Question 33

Beck’s Triad

Answer 33

Three classic signs of cardiac tamponade
● Hypotension, JVD, and muffled heart sounds

Question 34

Pulsus Paradoxus with Cardiac Tamponade

Answer 34

A decline of greater than 10 mmHg in SBP during inspiration.

Question 35

Pericardial Effusion & Tamponade Diagnosis

Answer 35

○ Echocardiogram is the primary method for demonstrating pericardial effusion and is highly sensitive.
○ Cardiac CT and MRI are also highly sensitive for demonstrating pericardial fluid, pericardial thickening, and extracardiac lesions.
○ Chest X-ray may suggest a chronic effusion by showing an enlarged cardiac silhouette.
○ The same imaging study is most commonly normal in acute effusions, however, even
if tamponade is present

Question 36

Electrical Alternans with Pericardial Effusion

Answer 36

○ Although not always present, the EKG finding of Electrical Alternans is
pathognomonic and is believed to be due to the heart swinging back
and forth within a large effusion.
○ This results in a changing depolarization axis from beat to beat, so the
QRS amplitude will change from beat to beat

Question 37

Pericardial Effusion & Tamponade Treatment

Answer 37

○ Small effusions can be followed clinically by careful observation of the JVP and looking for changes in the paradoxical pulse
○ If no immediate intervention is planned, serial echocardiograms would
be indicated, but no clear guidelines about frequency.
○ When Cardiac Tamponade is present,
urgent Pericardiocentesis or open cardiac
surgery are required
○ Treat the underlying condition whenever possible.
○ Vasodilators and diuretics should be avoided, as these can dramatically
decrease preload, which can result in enlarging effusion

Question 38

Pericardiocentesis

Answer 38

○ This procedure allows for the aspiration of fluid from the pericardial
space and can be life-saving for patients with Cardiac Tamponade