Pericarditis Flashcards
What are the normal functions of the pericardium?
- double-layer sac
- exerts restraining force to prevent dilation of cardiac chambers during exercise and with hypervolemia
- restricts anatomic position of the heart
- decreases spread of infections from lungs/pleural cavities to heart
What is pericarditis?
Inflammation of pericardial sac
What are the possible causes of pericarditis?
- Idiopathic
- Infectious
- Systemic diseases
- Neoplasms
- Drug toxicity
- Myocardial injury
- Pericardial injury
What etiology of pericarditis is a large portion of cases and likely viral, but undiagnosed?
Idiopathic
What is the most common cause of infectious pericarditis?
Viral
Which organisms are responsible for viral pericarditis?
- Coxsackievirus
- echovirus
- influenza
- varicella
- hepatitis
- HIV
- measles
- mumps
- CMV
- RSV
What is the epidemiology of viral pericarditis?
seasonal peaks, more common in males
This etiology of infectious pericarditis is rare and if occurs is likely an extension of pulmonary infections
Bacterial
This etiology of infectious pericarditis is rare in developed countries
TB
What systemic diseases can cause pericarditis?
- Hypothyroidism
- Inflammatory diseases (SLE, RA, Scleroderma, Sarcoidosis, IBD, polymyositis)
- CKD
What type of pericarditis results from CKD?
- uremic pericarditis
5-10% of pericarditis is due to ___what___. What type?
cancers
Lung CA and Breast CA = over half
Also, renal cell CA, leukemias, lymphomas, and malignant melanomas
How does cancer enter the pericardium?
via blood, lymph, or direct penetration
What medications can cause drug-induced pericarditis?
- Penicillin and cromolyn sodium
- Anthracycline chemo agents (doxyrubicin and cyclophophamide)
- Procainamide, hydralazine, methyldopa, isoniazid
- phenytoin
Why can penicillin and cromolyn sodium cause drug-induced pericarditis?
induce hypersenstivity reaction
Why can anthracycline chemo agents cause drug-induced pericarditis?
- have direct cardiac toxicity
Why can procainamide, hydralazine, methyldopa, isoniazid cause drug-induced pericarditis?
Develop drug-induced lupus syndrome, leading to pericarditis
What can cause pericardial injury leading to pericarditis?
- Invasive cardiac procedures
- Post-pericardiotomy
- Trauma
- Radiation
What type of invasive cardiac procedures can cause pericarditis?
- Pacemakers
- ICDs
- PCI
- Ablations
What post-pericardiotomy procedures can cause pericarditis? Why?
- CABG, valve replacements
- Exaggerated immune response to injury
Who might be at higher risk for radiation induced pericarditis?
- Those receiving high doses in areas surrounding heart
What can cause myocardial injury leading to pericarditis?
- MI
- Cardiotomy
- Trauma
What sort of MI may cause pericarditis? How soon after MI can this occur?
- Transmural MI; large MI
- 2-5 days
What is Dressler Syndrome?
- pericarditis 2 weeks after MI due to delayed autoimmune/inflammatory response
What are the 4 diagnostic features of pericarditis?
- Chest pain
- Pericardial friction rub
- EKG
- Pericardial effusion
What is the cardinal symptom of pericarditis?
Chest pain
Why might patients have chest pain due to pericarditis?
Due to heart rubbing against pericardium
What are characteristics of chest pain with pericarditis?
- Precordial or retrosternal with referral to trapezius ridge, neck, left shoulder, or arm
- Pleuritic quality, but can be sharp, dull, aching, burning, and/or pressing
- Worse when lying flat, during swallowing or coughing, with body motion
- Varying intensity
- May be relieved by sitting and leaning forward; not affected by eating or exertion
In addition to chest pain, what is the clinical presentation of pericarditis?
- Dyspnea, especially if effusion
- Fever common
- Pericardial friction rub
- Other exam findings vary on cause as well as complications
What is the diagnostic evaluation of pericarditis?
- Typically clinical
- Labs directed at suspected cause:
- Viral titers/panel
- Cardiac enzymes: may be elevated if myocardium involved
- Echocardiogram: OBTAIN ON ALL SUSPECTED PERICARDITIS PTS–> most likely normal, unless significant effusion
- CBC: elevated WBC
- BMP, thyroid function tests
- ESR, CRP
- EKG
What patterns will be present on EKG?
- diffuse ST segment elevation progressing to T wave inversions
- PR segment may be depressed
Inflammation of both ventricles (ST-T) changes and atria (PR changes)
What does the ST elevation in pericarditis look like?
- Diffuse, in anterior and inferior precordial leads with reciprocal ST depression in aVR upward concavity morphology
- Less prominent than in STEMI
What does PR depression in pericarditis look like?
- Diffuse
- Anterior and inferior precordial leads with reciprocal PR elevation in aVR in discordance with ST segment
What are characteristics of the T wave inversion in pericarditis?
- Only seen on occasions
- Less prominent than in STEMI
In stage I of pericarditis, what changes are seen on EKG?
- ST segment elevation
- PR segment depression
- Reciprocal PR segment elevation and ST depression in aVR and occassionally V1
In stage II of pericarditis, what changes are seen on the EKG?
- Normalization of the ST and PR segments
In stage III of pericarditis, what changes are seen on the EKG?
- Widespread T wave inversions
In stage IV of pericarditis, what changes are seen on the EKG?
- Normalization of the T waves
How is pericarditis diagnosed?
- Chest x ray- typically normal, unless underlying malignancy or lung process identified or large effusion
- CT or MRI may be necessary if malignancy is suspected
What are the essentials of diagnosis of pericarditis?
- Anterior pleuritic chest pain that is worse supine than upright
- Pericardial rub
- Fever common
- ESR or inflammatory CRP usually elevated
- ECG with diffuse ST segment elevation and associated PR depression
What are the goals of management of pericarditis?
- Determine inpatient or outpatient treatment
- Treat symptoms/resolve the inflammation
- Prevent recurrence
- Address underlying cause if possible
How is the pain and inflammation managed in pericarditis?
- NSAIDs are first-line
- Ibuprofen for 1 to 2 minutes, then taper over next 2 weeks
- ASA in post-MI cases
What factors should be indication to consider inpatient management?
- Fever >100.4
- Subacute onset
- Immunosuppression
- Trauma
- Oral anticoagulation therapy
- ASA or NSAID treatment failure
- Myocarditis
- Large pericardial effusion or tamponade
How is recurrence of pericarditis prevented?
- Colchicine is adjuvant therapy
- Corticosteroids only if underlying disease process needs them or severe, refractory cases or if patients can’t tolerate NSAIDs or colchicine, prednisone
How would you treat pericarditis if TB is the underlying cause?
Standard anti-TB drug regimen = treatment of choice
How would you treat pericarditis if due to uremia with ESRD?
- Dialysis
- Chronic pericarditis with production of effusions common
- NSAIDs help with pain and fever, but not process itself
What is the pathophysiology of pericardial effusion/tamponade?
- If the pericardial effusion gets big it puts pressure on the heart
- Fluid and immune cells move into pericardial tissues and the layer becomes thicker
What is the etiology of pericardial effusion?
- same as pericarditis
- aortic dissection/rupture can also lead to pericardial effusion or tamponade
What is tamponade?
- State of increased pressure
- Characterized by elevated intrapericardial pressure, leading to decreased venous return and ventricular filling –> reduced CO
What is the clinical presentation of pericardial effusion/tamponade?
- If small, likely no symptoms or only symptoms of pericarditis
- depends on size of effusion
- if large, fatigue and shortness of breath
- if hemodynamically significant (tamponade) - signs of cardiogenic shock
What is Beck’s triad?
Clinical presentation of tamponade
* Distant/muffled heart sounds
* Hypotension
* Distended jugular veins
What are specific signs that can clue you into cardiac tamponade?
- Kussmaul’s sign
- Pulsus paradoxus
What is Kussmaul’s sign?
increase in JVP on inspiration instead of normal decrease
What is pulsus parodoxus
Inspiratory systolic fall in arterial pressure >12 mmHg during normal breathing - 70-80% of patients
What are signs of cardiac tamponade?
- Tachypnea/dyspnea
- Tachycardia/cardiac arrhythmias (PACs, PVCs)
- Hypotension
- Signs of shock
- Palpitations
- Low-grade fever
- Pericardial friction rub
- Narrow pulse pressure
- Dry cough/hiccups
- Edema
- Cyanosis
- Varying degrees of consciousness
- Hepatomegaly and ascites
What are symptoms of pericaridal effusion/cardiac tamponade?
- air hunger
- anorexia
- fatigue
- dysphagia
- palpitations
What is pathognomonic of cardiac tamponade?
Electrical alternans
How do you diagnose pericardial effusion/cardiac tamponade?
- ECG
- CXR
- Echo
- CT scan
- MRI
Characterized by alternating levels of ECG voltage of the p wave, QRS complex, and T waves, results from swinging of heart in large effusion
Electrical alternans
How will a effusion/cardiac tamponade present on CXR?
- Uncomplicated pericarditis and small effusions may be normal
- Flask shaped, enlarged cardiac silhouette may be first indication of large effusion or cardiac tamponade
What is the initial test of choice for detecting pericardial effusions?
Transthoracic echo
When checking for tamponade on an echo, what 3 things do we look for?
- RV collapse
- LV collapse
- Dilated IVC w/out inspiratory collapse
What are advantages of a CT for pericardial effusion/tamponade?
- Can see anatomic details of entire pericardium
- Capacity to detect pericardial calcifications
What are considerations for MRI in pericardial effusion/tamponade?
- Anatomic details of pericardium and heart without ionizing radiation or contrast
- Sensitive for detecting pericardial effusion and loculated pericardial effusion and thickening
- Limited use in patients with arrhythmias
How is pericardial effusion/cardiac tamponade managed?
- Small effusions, serial echocardiograms
- Large effusions or evidence of hemodynamic compromise, hospital admission
- Pericardiocentesis
- Pericardial diodesis
- Pericardiotomy
- Pericardial window
- Pericardiectomy
What are indications for hospital admission in pericardial effusion/tamponade?
- large effusion
- hemodynamic compromise
- fever >100.4 and leukocytosis
- immunosuppressed state
- history of therapy with V-K antagonists
- acute trauma
- failure to respond within seven days to NSAID therapy
- Elevated cardiac troponin, which suggests myopericarditis
Procedure where fluid is removed from the pericardium
Pericardiocentesis
When would you perform a pericardiocentesis?
- Effusions >250 mL
- Effusions when size increases despite intensive dialysis for 10-14 days
- Effusions with evidence of tamponade
What are complications of pericardiocentesis?
Fatal cardiac laceration
What can be analyzed on pericardial fluid analysis?
- RBCs, total protein, LDH, adenosine deaminase activity, gram stain, scid fast, fungal staining, cultures, cytology
- investigate for tuberculous bacilli and perform cytologic study
What is the appearance of the fluid in purulent or suppurative pericarditis?
thin to creamy pus
What is the appearance of effusions in uremic pericarditis?
bloody
adhesions present between membranes that are thickened
what is the appearance of the pericardial fluid in hypothyroidism?
clear with high protein and cholesterol level and few cells
installation of chemical or other agents into the pericardial space
pericardial diodesis
What is the function of pericardial diodesis?
- Used in recurrent pericardial effusions
- Cause sclerosis of the pericardium
Incision into the pericardium
Pericardiotomy
When would a pericardiotomy be performed?
for large effusions that don’t resolve
lower risk of complications that pericardiectomy and effective
surgical procedure to create a fistula from the pericardial space to the pleural cavity, allowing the effusion to drain out of the pericardial space into the chest cavity
can be performed with a balloon catheter
pericardial window
removal of the pericardium
most effective surgical procedure for managing large effusions
pericardiectomy
when is pericardiectomy considered?
requires thoracotomy and general anesthesia so only if pericardiotomy can’t be performed or is unsuccessful
what is the pathophysiology of constrictive pericarditis?
- Inflammation of pericardium –> thickened fibrotic, adherent pericardium
- restricts diastolic filling –> right heart failure
what are the most common causes of constrictive pericarditis?
- TB in developing countries
- Radiation, cardiac surgeries, viral pericarditis MC in developed
What is the clinical presentation of constrictive pericarditis?
- Progressive dyspnea
- Fatigue
- Weakness
- Signs of right heart failure- edema, ascites, hepatic congestion
- elevated JVP-Kussmaul sign
- atrial fibrillation
how is restrictive pericarditis diagnosed?
- Echo- shows thickened pericardium, RV/LV filling changes, especially with inspiration
- Chest xray- heart may be normal size or enlarged
- Cardiac CT or MRI- may show pericardial thickening
- Cardiac catheterization- confirmatory
What is the benefit of cardiac catheterization in restrictive pericarditis?
- Allows for simulataneous measurement of intracardiac pressures in the RV and LV, during inspiration and expiration
How is restrictive pericarditis managed?
- Diuresis with loop diuretics, aldosterone antagonists
- Surgical pericardiectomy for patients unresponsive to diuretics
