Pericardite acuta

Question 1

General findings

La pericardite acuta è la prima causa di tamponamento cardiaco.

Answer 1

Pericarditis is inflammation of the pericardium that may be acute or chronic. Acute pericarditis is most commonly caused by viral infection; however, a number of conditions can cause an inflammatory response in the pericardium. Acute inflammation typically manifests with fever, pleuritic chest pain, and a pericardial friction rub on auscultation. The diagnosis is established based on clinical findings, although 👓 diffuse ST segment elevations on ECG and imaging may support the diagnosis. Acute pericarditis is usually self-limited, lasting days to weeks, and is therefore managed symptomatically. If pericarditis lasts longer than three months, it is described as chronic pericarditis. Chronic pericarditis may either be constrictive or effusive-constrictive. Constrictive pericarditis is characterized by thickening and rigidity of the pericardium, resulting in both backward and forward failure. Patients typically present with fatigue, jugular vein distention, peripheral edema, and a 👓 characteristic pericardial knock on auscultation, which is caused by a sudden stop in ventricular diastolic filling. Effusive-constrictive pericarditis is characterized by a thickened pericardium with an effusion; this can lead to cardiac tamponade. It may manifest with symptoms similar to constrictive pericarditis, symptoms of pericardial effusion, or cardiac tamponade. In both constrictive and effusive-constrictive pericarditis, imaging is used to confirm the diagnosis. Management consists of treatment of heart failure (e.g., diuretics) and pericardiectomy.

Question 2

definizione

Answer 2

Acute pericarditis: inflammation of the pericardium that either occurs as an isolated process or with concurrent myocarditis (myopericarditis).

Essendo una infiammazione, la febbre è un elemento caratteristico!!! Ricorda un po il discorso delle tiroiditi acute o la de Quervain, cioè il trattamento è innanzitutto sintomatico-antiinfiammatorio!

Question 3

Eziologia

Answer 3

-Idiopathic (soprattuto per quanto riguarda la forma cronico-costrittiva)

• Infectious :
  
  1. Most commonly viral (e.g., 👓coxsackie B virus) [5]
  2. Bacterial (e.g., Staphylococcus spp., Streptococcus spp., or M. tuberculosis)
• Fungal
• Toxoplasmosis (responsabile anche di miocarditi)

-Myocardial infarction
1.Postinfarction fibrinous pericarditis: within 1–3 days
as an immediate reaction (PMN)
2.Dressler syndrome: weeks to months following an
acute myocardial infarction, con versamento
pleurico sinistro

Postoperative (postpericardiotomy syndrome): blunt or sharp trauma to the pericardium
🧨Uremia (e.g., due to acute or chronic renal failure)
Radiation
Neoplasm (e.g., Hodgkin lymphoma)

Autoimmune connective tissue diseases (e.g., rheumatoid arthritis, systemic lupus, scleroderma)

Question 4

Clininca

Lo sfregamento pericardico è udibile lungo il margine sternale sinistro im espirazione

✔Ewart sign: ottusità fonetica sub scapolare a causa di atelettasia da versamento pericardico severo!💥

Tosse non produttiva!👓

Answer 4

Chest pain

-Pleuritic chest pain
-Acute, sharp retrosternal pain caused by inflammation of the parietal pleura
-Typically aggravated by coughing, swallowing, or deep inspiration
🧨Other causes of pleuritic chest pain include pulmonary embolism, myocardial infarction, and pneumothorax.

Improves on sitting and leaning forward!!

Can radiate to the neck and shoulders (most commonly to the left side)

-Pericardial friction rub: high-pitched scratching on auscultation (sfregamento prericardico)
1.Indicates friction between the visceral and parietal pericardial tissue
2.Best heard over the left sternal border during expiration while the patient is sitting up and leaning forward
3.Occurs in atrial and ventricular systole, as well as early diastole
Present in 85% of patients with acute pericarditis!!

Pericardial effusion
Faint heart sounds
Ewart sign🧨
Low-grade intermittent fever, tachypnea, dyspnea, nonproductive cough.

L’intensità dell’impulso apicale è diminuita, cosa che non accade nella miocardiopatia restrittiva

Question 5

Diagnosi

Gli indici di danno miocardico sono elevati!!!!!

Answer 5

At least two of the following four criteria must be present for a diagnosis of acute pericarditis:

• Characteristic chest pain
• Pericardial friction rub
• Typical ECG changes (see below)
• New or worsening pericardial effusion

ECG

Not all patients go through all stages and manifestations may vary. In particular, 👓 pericarditis due to uremia may not involve characteristic ECG changes.

Stage 1: diffuse ST elevations, ST depression in aVR and V1, PR segment depression🧨 (segno di irritazione atriale)
Stage 2: ST segment normalizes in ∼ 1 week.
Stage 3: inverted T waves (con normalizzazione ST, cosa che non accade in IMA in quanto le alterazioni sono contemporanee). Le onde T invertite sono un riscontro anche della pericardite costrittiva.
Stage 4: ECG returns to normal baseline (as prior to onset of pericarditis) after weeks to months.

Question 6

Imaging (🧨attenzione, la diagnosi di pericardite acuta non necessita di imaging! ok?). Infatti serve solamente per individuare eventuale versamento pericardico, che cambierebbe la gestione! Infatti basta registrare uno sfregamento pericardico con il classico dolore acuto retrosternale e la diagnosi è fatta.

Answer 6

The goal of imaging is to identify any new pericardial effusion and rule out alternative etiologies.

-Echocardiography
Indications: considered first-line to evaluate for pericardial disease
Findings: pericardial effusion may be present, often normal

-Cardiac MRI
Indications: Consider if diagnosis is uncertain; preferred imaging modality to assess pericardium. [4]
Findings
Thickened pericardium, pericardial enhancement, pericardial effusion
May show associated myocarditis!!!!! (il gold standar per la miocardite sarebbe la biopsia ma il miglior esame rimane MRI!!!)👓

Question 7

Additional diagnostic evaluation

Answer 7

Pericardiocentesis with pericardial fluid analysis
Indications: large effusion, tamponade, suspected malignant or purulent pericarditis 👓

Senza clinica evidente non si fa la pericardiocentesi

Question 8

Trattamento (la forma acuta è autolimitante, per cui il trattamento è solo sintomatico)

Answer 8

Acute pericarditis is often self-limited but NSAIDs can alleviate symptoms and prevent a recurrence. Consider anti-inflammatory therapy also for chronic pericarditis (transient constrictive pericarditis may respond).

• NSAID therapy
• Aspirin
• Ibuprofen
• Indomethacin

👓Consider colchicine in combination with NSAIDs or as a monotherapy.  
Consider prednisone  only in severe cases or in pericarditis caused by uremia, connective tissue disease, or autoreactivity.
Gastroprotective therapy (e.g., omeprazole ) in patients at risk for GI bleeding 

• Antibiotics for bacterial causes
• Antitubercular therapy
• Immunosuppressants in autoimmune disease
• Dialysis (in the case of uremia)

Restricted physical activity in acute pericarditis