Pericarditis Flashcards
Diagnosis of pericardial disease
Over or equal to 2 of following 4
Pericardial chest pain
Pericardial rubs
New widespread ST elecation or PR depression ECG
Pericardial effusion - new or worsening
Supportive findings of pericarditis
- Elevation of CRP/ESR/WCC
- Evidence of pericardial inflammation on CT/CMR
What is recurrent pericarditis
Documented first episode + symptoms free 4-6 weeks
Normally within 18-24 months
15-30% recurrence rate
What is incessant pericarditis
> 4-6 weeks of symptoms
<3 months without remission
Chronic >3 months
Vrial causes of pericarditis
Viral - enteroviruses - coxsackie, e-coli
Herpes - EBV, CMV, HHV-6
Bacterial course of pericarditis
Common - Mycobacterium tuberculosis
Many other rare causes
Fungal causes of pericarditis
Histoplasma more likely immunocompetent
Aspergillus, blastomyces spp, candida - more likely in immunocompromised
Non infective causes of pericarditis
Autoimmune - common
Neoplastic
Primary tumours eg pericardial mesothlioma (rare)
Secondary metastatc tumours (lung, breast, lymphoma)
Metabolic
Trauma and iatrogenic
Drug related
other - amyloidosis, aortic dissection, pulmonary and arterial HPTN, chronic HF
Congenital partial and complete absence of pericardium
AI causes of pericarditis
- Erythematosus
- Sjrogen syndrome
- Rheumatoid arthritis
- scleroderma
- Vasculitdes ie Eosinophilic granulomatosis w polyangitis or allergic granulomatosis (churg-strauss sydnrome)
- Horton disease
- Takayusus disease
- Behcet syndrome
- Sarcodiosis
- Familial
Metabolic causes of pericarditis
- Uraemia
- Myxoedema
- Anorexia nervosa
Trauma and iatrogenic causes of pericarditis
Early onset
Direct injusry - oesophageal perforation, penetrating thoracc injury
Indirect injury - eg radiation
Delayed onset - pericardial injury eg post MI syndrome, postpericardiotomy, PCI, pacemaker lead insertion, readio ablation
Drugs causing lupus like syndrome pericarditis
- Procainamide
- Hydralazine
- Methyldopa
- Isoniazid
- Phenytoin
Antineoplastic drugs pericarditis
CM -> percardiopathy
Doxorubicin
Daunorubicin
Drugs causing pericarditis
Amiodraone
Methydergide
Mesalazine
Clozapine
Monoxidil
Dantrolene
Practolol
Phenylbutazone
THiazides
Streptomycin
Thiouracils
Streptokinae
P-aminosalicyclic acid
Sulfa drugs
Cyclosporinne
Bromocriptine
Several vaccines
GM-CSF
Anti TNF agents
Major predictors of poor prognosis in pericarditis
Fever >38 degrees
Subacute onset
Large pericardial effusion
Cardiac tamponade
Lack of resposne to aspirin or NSAIDs after at least one week of tehrapy
Minor pericarditis prognosis
Myopericarditis
Immunosupresson
Trauma
Oral anticoagulatn therapy
When admit to hospital w pericarditis
Underlying aetiology or at least one predictor of poor prognosis or major or minor risk factors
How manage pericarditis outside of hospital
Outpatient empiric anti inflammatories and short term follow up after 1 weeks assess response
Investigations with pericarditis
12 lead ECG
TTE
CXR
Infalm marer - CRP, ESR
MI markers - CK, troponin
ECHO
CMR
First line treatment pericarditis
Aspirin/NSAIDs + PPI
Colichine as adjunct
ECG changes pericarditis
ST elevation, PR depression in II, aVF
PR elevation in aVR
Colichine MOA pericarditis
- Improves response to above
- Prevents recurrenes
- halves recurrence rate
2nd line treatment pericarditis
Low dose corticosteroids
Maanagemnet of recurrent pericaridtis
1 - Aspirin or NSAID eg ibuprogen, indomethacin + colichine + exercise restriction
Decrease dose 250-500mg every 1-2 weeks
2 - low dose CCS
3 - IV immunoglobulin or anakinra or azathioprine
4 - pericardectomy
Complications of percarditis
Cardiac tamponade
Constricitve pericarditis
More likely in bacterial
What is cardiac tamponade
Life threatening slow or rapid compression of the heart due to pericardial accumulation of fluid, pus, blood, clots or gas
Classification of cardiac tamponade
Acute or subacute or chronic >3 months
Size - mild <10mm, large >20mm
Circumferential or loculated
What amount of pericardial fluid can cause tamponade
300-600ml
Causes of cardiac tamponade
- Pericarditis
- TB
- Iatrogenic
- Trauma
- Neoplasm/malignancy
Uncommon causes
- Collagen vascular diseases
- SLE
- Rheumatoid arthritis
- Scleroderma
- Radiation induced
- post MI
- Uraemia
- Aortic dissection
- Bacterial infection
- Pneumopericardium
Characteristics of cardiac tamponade
- Elevated intra cardiac pressures
- Progressive limitation of ventricular diastolic filling
- Reduced in CO
Signs and symptoms of pericarditis
- Dyspnoea + chest discomfort
- Agitation + restlessness
- Palpitation
- Drowsiness or stupor
- Decrease urine output
- Weakness
- Anorexia
- Weight loss with chronic effusion
Becks triad
Hypotension
Increasing JVP
Small, quiet heart
Physical findings cardiac tamponade
Raised Central venous pressure
Tachypnoea
Tachycardia
Diminished heart sounds through fluid
Pericardial friction rub
Pulsus paradoxus
What is pulsis paradox
inspiratory decline in systolic BP >10mmhg
-Increase venous return during inspiration
Features of pericarditis on ECHO
- Chamber collapse
- Doppler signs increased ventricular interdependence
- Inferior vena cava plethora
Right atrial chamber collapse - inversion
- R atrial chamber begins late diastole
- Sensitive but not specific
- Early diastole, goes for longer the worse the haemodynamics are
Features of pericarditis on ECHO
Chamber collapse
Atria compressed in systole
IVC plethora - Dilated IVC >2.1cm with<50% resp change (elevated intrapericacrdial pressure)
What are benefits of needle paricardiocentesis
- Allows rapid drainage
- Less invasive
- Minimal preparation
Complications of needle paracentesis
Laceratons of heart, coronaries or lungs
Incomplete drainage or recurrence
Not recommended for small effusions<1cm, loculation, adhesions or fibrinous standing
Treatment for cardiac tamponade
Needle paracentesis
Surgical drainage
Percutaneous balloon pericardiotomy
+ and negatives of surgical drainage for cardiac tamponade
More complete drainage
Less likely recurrence
Access for tissue biospy
Drain loculated effusions
Complciations - more pain, longer recovery, more morbidity
When do Percutaneous balloon pericardiotomy
- Large effusions esp malignant
- Limited complication
- Recurrence rare
Medical therapy in cardiac tamponade
If hypotensive
For volume expansion, inotropic supprt
Avoidance of diuretics or vasodilators
How to score for cardiac tamponade
Step 1 - score aetiology
2 - score clinical presentation
3 - score imagine
Cumulative score
What score in aetiology of cardiac tamponade
Malignant disease - 2
TB - 2
Recent radiotherapy
Recent viral infection
Recurrent PE, previous pericardiocentesis
Chronic terminal renal failure
IMMUNODEFICIENCY or immunosupression
Hypo or hyperthyroidism or systemic AI disease = -1
Clinical presenation scoring cardiac tamponade
Dyspnoea
Orthopneoa
Hypotnesion
Progressiec sinus tachycardua
Oliguria
Pulsus paradoxus >10 mmHg
Friction rub
Rapid worsenging symptoms
Slow evolution of disease = -1
Imaging scoring for cardiac tamponade
Cardiomegaly ECHO
ECG changes
PE
IVC > 2.1cm
RV collapse
L atrial collapse
Swinging heart
Urgent surgical management for cardiac tamponade causes
Type A aortic dissecction
Ventricular free wall rupture after acute MI
Severe recent chest trauma
Iatrogenic haemopericardium when bleeding cannot be controlled percutaneoisly
Score for urgent pericardiocentesis vs postponing
> 6
