Pericarditis Flashcards
Periicarditis?
Acute pericarditis is an inflammation to the pericardium.
Causes of peri?
1- idopathic.
2- infection
Auatoamuune disease
Cardia surgery
Clinical presentation of peri?
AP is diagnosed when at least two of the following criteria are met:
1. Characteristic Chest pain
2. Characteristic ECG changes
3. Pericardial Friction rub
4. New or worsening pericardial effusion
What is Characteristic chest pain in peri?
Sharp.
Persistent not related to exertion.
Pleuritic, increases with respiration.
Positional relieved when the patient leans forward and made
worse in the supine position. Often radiates to the trapezius ridge.
and may be associated with a low grade fever or other
symptoms of viral infection.
Friction rub is diastolic and systolic
Physical exam and echo, ecg, chest x ray and blood test?
Physical : pericaridal rub
Ecg: diffuse st elevation and pr segemnt changes.
Echo : percardial effusion
Chest x ray: : cradiomegaly
Blood test: white blood cells! Esr , crp
Dullness over left posterior lung field due to
compressive atelectasis from pericardial
effusion
Ewart’s sign ( in pericarditis)
ECG changes in peri?
Diffuse ST-segment elevation (concave upward)
• PR-segment depression in lead II and PR elevation in
aVR early in the course of pericarditis in >60% of cases, with
Diagnosis for peri?
1- Troponin may be very mildly elevated in 25% of patients usually associated with normal CKMB. When
troponin values are higher and without wall motion abnormalities, the diagnosis of myopericarditis.
2-CXR may reveal pleural disease, cardiomegaly, or even the classic “water bottle” heart when a large
effusion is present, although it is most often normal in AP
2-Echo is essential to detect pericardial effusion and tamponade, Pericardial effusion is reported in about
50-60% of cases of pericarditis, and it is usually mild (<10 mm)
In dfficult cases?
difficult cases, CT can show the inflamed pericardium as contrast enhanced
When you will say the patient has?
Recurrent pericarditis: in cases of New symptoms after a remission with a symptom-free interval of >4-6 weeks
Incessant pericarditis: In cases of prolonged symptoms without remission.
Chronic pericarditis: for patients with continued symptoms >3 months
Which drug reduces the incidence of post pericardioctomy syndrome?
Colchicine
Whencwe admit patient to hopital ( high risk)
• High fever (>38°C),
• Subacute onset
, • Large pericardial effusion,
• Tamponade,
• The use of anticoagulants( to avoid hemoragic peri)
, • Trauma, • Evidence of myocarditis • Immuno-suppression • Lack of response to anti-inflammatory therapy
Treatment of peri?
1-NSAID ( high dose iburprofen or asa or indomethacin) for 2 to 4-week and taper after resolution of symptoms and CRP normalization, along with
Colchicine for 3 months.
Aspirin is favored in post–myocardial infarction pericarditis.
Which of the following agents may contribute to an increased risk of recurrent pericarditis?
Corticostirod
When we use cortcistirod in acute pri?
Contraindications to NSAID therapy,
Failure of NSAID therapy,
Recurrences not responding to NSAID therapy,
Systemic inflammatory disease on steroids
Pregnancy,
Renal failure,
Concomitant anticoagulant therapies
therapeutic options to be considered after failure of triple anti-inflammatory therapy include?
1- Azathioprine,
2-IVIG,
3-and biological agents (the most common in clinical practice is Anakinra)
How much do you know about Kineret (Anakinra)?
Anakinra, an Interleukin-1 antagonist, Derived from E coli, is especially indicated in patients with recurrent pericarditis:
Steroid dependence and not able to withdraw steroids,
Colchicine resistance (unable to control the disease with colchicine),
Evidence of systemic inflammation (e.g., fever, CRP elevation)
Steps of treatmnt in peri?
Aspirin or NSAID plus colchicine first,
Then if the patient is still not responding or has additional recurrences, change to
a corticosteroid plus colchicine.
If additional therapy is necessary, triple therapy may be considered with aspirin or
an NSAID plus corticosteroid plus colchicine
In patients on steroids, it is critical to use low to moderate doses (e.g.,
prednisone 0.2-0.5 mg/day or equivalent) for 4 weeks,
Then slow tapering after symptom resolution and normalization of CRP
What are the causes of peri effusion?
Likely to progress to cardiac tamponade:
Neoplastic diseases
Infections (i.e. viral: EBV, CMV enteroviruses, HIV, bacterial, especially tuberculosis)
Iatrogenic hemopericardium Post-traumatic pericardial effusion
Post-cardiotomy syndrome
Hemopericardium in aortic dissection and rupture of the heart after acute myocardial
infarction.
Renal failure
Rarely progressing to cardiac tamponade
Systemic autoimmune disease
Hypo- or hyperthyroidism
Early and late pericarditis (Dressler’s syndrome) in acute myocardial infarction
Others: Chylopericardium
What is dressler syndrome?
Peri due to late post MI
Which causes that never progressive to cardiac temponade?
Pericardial transudates caused by heart failure or
pulmonary hypertension
Pericardial transudates in the last trimester of normal
pregnancy
What is temponade?
Tamponade is a life-threatening cause of cardiogenic shock that may
develop acutely or chronically
Why The rate of pericardial fluid accumulation is critical for the clinical
presentation
If pericardial fluid is quickly accumulating, even less than 250 ml,
may cause acute cardiac tamponade “surgical tamponade” within
few minutes.
Conversely, a slowly accumulating pericardial fluid may allow the
collection of 1000-1500 ml within days or weeks before
development of cardiac tamponade “medical tamponade
What are the symptoms of cardiac temponade?
Signs and Symptoms
• tachycardia, hypotension, increased JVP
• tachypnea, dyspnea, shock, mufed heart sounds
• pulsus paradoxus (inspiratory fall in sBP >10 mmHg during quiet breathing)
• JVP “x” descent only, blunted “y” descent
• hepatic congestion/peripheral edema
How to treat cardiac temonade?
pericardiocentesis recommended
What to find in echo for cardaic temopnade?
pericardial efusion (size, location, hemodynamic impact),
swinging of the heart,
What is the beck’s triad?
Found in temponade which are
1- high JVP.
2- hypotensiom.
3- muffled heart sound ( distent heart sound)
Investigation pf cardiac temponade?
Ecg: swinging heart
Cxr: icreass cardia silhoutette
Echo:collapse of RA/ RV
How to great peri effusion?
• Patients diagnosed with a large pericardial effusion and minimal or no evidence of hemodynamic
compromise may be treated conservatively with:
• Careful hemodynamic monitoring, • fluid resuscitation in an effort • serial echo, • avoidance of diuretics and vasodilators, • and therapy aimed at the underlying cause of the pericardial effusion. • Mechanical ventilation should be avoided whenever possible.
What is Constrictive Pericarditis?
loss of pericardial elasticity caused by granulation tissue formation; leads to restricted ventricular
flling
Signs and symptoms of cp?
• dyspnea, fatigue, palpitations
• abdominal pain
• may mimic CHF (especially right-sided HF)
■ venous congestion, ascites, hepatosplenomegaly, edema, pleural efusions
• increased JVP, Kussmaul’s sign (paradoxical increase in JVP with inspiration), Friedreich’s sign
(prominent “y” descent)
Invitsagtiom of choice in cp?
Echo: pericardial thickening, calcifcation ± characteristic echo-Doppler fndings (Note:
CMR is discouraged if patient is hemodynamically impaired)
How to treat cp?
surgery (pericardiectomy): mainstay treatment for chronic, permanent constrictive pericarditis •
medical therapy: can be used in 3 situations
1. for specifc pathologies/etiologies (e.g. TB) 2. for transient constriction that is temporarily caused by pericarditis, or new constriction
diagnosis with evidence of infammation of the pericardium (use anti-infammatories) 3. supportive when high/prohibitive surgical risk (goal is to relieve congestive symptoms diuretics,
salt restriction)
