Pericarditis Flashcards by Hannah Nolan

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

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Supportive findings of pericarditis

Elevation of CRP/ESR/WCC
Evidence of pericardial inflammation on CT/CMR

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What is recurrent pericarditis

Documented first episode + symptoms free 4-6 weeks
Normally within 18-24 months
15-30% recurrence rate

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What is incessant pericarditis

> 4-6 weeks of symptoms
<3 months without remission
Chronic >3 months

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Vrial causes of pericarditis

Viral - enteroviruses - coxsackie, e-coli
Herpes - EBV, CMV, HHV-6

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Bacterial course of pericarditis

Common - Mycobacterium tuberculosis
Many other rare causes

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Fungal causes of pericarditis

Histoplasma more likely immunocompetent
Aspergillus, blastomyces spp, candida - more likely in immunocompromised

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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

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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

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Metabolic causes of pericarditis

Uraemia
Myxoedema
Anorexia nervosa

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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

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Drugs causing lupus like syndrome pericarditis

Procainamide
Hydralazine
Methyldopa
Isoniazid
Phenytoin

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Antineoplastic drugs pericarditis

CM -> percardiopathy
Doxorubicin
Daunorubicin

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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

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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

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Minor pericarditis prognosis

Myopericarditis
Immunosupresson
Trauma
Oral anticoagulatn therapy

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When admit to hospital w pericarditis

Underlying aetiology or at least one predictor of poor prognosis or major or minor risk factors

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How manage pericarditis outside of hospital

Outpatient empiric anti inflammatories and short term follow up after 1 weeks assess response

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Investigations with pericarditis

12 lead ECG
TTE
CXR
Infalm marer - CRP, ESR
MI markers - CK, troponin
ECHO
CMR

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First line treatment pericarditis

Aspirin/NSAIDs + PPI
Colichine as adjunct

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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