pericarditis Flashcards
what is the definition of pericarditis?
Acute pericarditis: inflammation of the pericardium that either occurs as an isolated process or with concurrent myocarditis (myopericarditis). [1]
Perimyocarditis: condition predominantly affecting the myocardium with pericardial involvement
Transient constrictive pericarditis: constrictive pericarditis that lasts < 3 months
Chronic pericarditis: inflammation of the pericardium that lasts > 3 months [2][3]
Constrictive pericarditis is characterized by compromised cardiac function caused by a thickened, rigid, and fibrous pericardium secondary to acute pericarditis.
Effusive-constrictive pericarditis: Pericardial effusion occurs in addition to a thickened pericardium, which can lead to tamponade. [4
what is the etiology of pericarditis?
Idiopathic
Infectious
Most commonly viral (e.g., coxsackie B virus) [5]
Bacterial (e.g., Staphylococcus spp., Streptococcus spp., or M. tuberculosis)
Fungal
Toxoplasmosis
Myocardial infarction
Postinfarction fibrinous pericarditis: within 1–3 days as an immediate reaction
Dressler syndrome: weeks to months following an acute myocardial infarction
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)
what is the clinical features of acute pericarditis?
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
Indicates friction between the visceral and parietal pericardial tissue [7]
Best heard over the left sternal border during expiration while the patient is sitting up and leaning forward [8]
Occurs in atrial and ventricular systole, as well as early diastole [9]
Present in 85% of patients with acute pericarditis. [10]
Pericardial effusion
- Faint heart sounds
- Ewart sign(A clinical finding of dullness at the base of the left lung, with increased vocal fremitus and bronchial breathing. Secondary to compression of the lung parenchyma by a large pericardial effusion.)
Low-grade intermittent fever, tachypnea, dyspnea, nonproductive cough
what is the clinical features of chronic pericarditis?
Constrictive pericarditis [5][6]
Symptoms of fluid overload (i.e., backward failure)
Jugular vein distention, ↑ jugular venous pressure
Kussmaul sign
Hepatic vein congestion: hepatomegaly, painful liver capsule distention, hepatojugular reflux
Peripheral edema or anasarca, ascites with abdominal discomfort
Symptoms of reduced cardiac output (i.e., forward failure)
Fatigue, dyspnea on exertion
Tachycardia
Pericardial knock: sudden cessation of ventricular filling during early diastole that is heard best at the left sternal border
Pulsus paradoxus: ↓ blood pressure amplitude by at least 10 mm Hg during deep inspiration
Effusive-constrictive pericarditis [4]
Effusive-constrictive pericarditis is characterized by symptoms of chronic constrictive pericarditis, pericardial effusion, or a mixture of both.
what is the diagnosis of acute pericarditis?
Diagnostic criteria for acute pericarditis [4]
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. [11]
Stage 1: diffuse ST elevations, ST depression in aVR and V1, PR segment depression
Stage 2: ST segment normalizes in ∼ 1 week.
Stage 3: inverted T waves
Stage 4: ECG returns to normal baseline (as prior to onset of pericarditis) after weeks to months.
In contrast to myocardial infarction, pericarditis is characterized by a diffuse distribution of ST elevations in ECG
Imaging [4][5]
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 [4][5]
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 [12]
May show associated myocarditis [12]
CT scan with IV contrast
Indications: Consider if the diagnosis is uncertain.
Findings: thickened pericardial layers, pericardial effusion
Chest x-ray: usually normal; may show an enlarged cardiac silhouette
Laboratory studies
Elevation of inflammatory markers may support the diagnosis of pericarditis but are not considered to be a part of the diagnostic criteria. [4]
CBC: leukocytosis
↑ Troponin I
↑ ESR
↑ CRP
↑ Creatinine kinase
Additional diagnostic evaluation
Pericardiocentesis with pericardial fluid analysis [10]
Indications: large effusion, tamponade, suspected malignant or purulent pericarditis [5]
Investigations depend on suspected etiology.
Gram stain
Bacterial culture
Acid-fast bacilli and culture
Polymerase chain reaction
Cytology
Additional workup based on suspected etiology
Uremic pericarditis: BUN, creatinine, electrolytes
Bacterial pericarditis: blood cultures (2 sets)
Tuberculous pericarditis: interferon-γ release assay, HIV test
Autoimmune pericarditis: ANA, rheumatoid factor
what is the diagnosis of chronic pericarditis?
The diagnostic approach and findings for chronic pericarditis are similar to acute pericarditis but ECG, echocardiography, and imaging findings may vary.
Constrictive pericarditis
The diagnosis of constrictive pericarditis is based on characteristic imaging findings (most commonly echocardiography but MRI and CT may be used).
Echocardiography
↑ Pericardial thickness
Abnormal ventricular filling with sudden halt during early diastole
Variation in ventricular filling with inspiration
Across the tricuspid valve: The velocity of blood flow increases.
Across the mitral valve: The velocity of blood flow decreases.
Moderate biatrial enlargement [15]
Excludes right ventricular hypertrophy and cardiomyopathy
Imaging
CT and cardiac MRI
Pericardial thickening > 2 mm
Calcifications
Normal cardiac silhouette
Chest x-ray (PA and lateral views) [14]
Heart size: normal or slightly increased
Pericardial calcifications
Clear lung fields
Constrictive pericarditisConstrictive pericarditis
Cardiac catheterization
Indications: if noninvasive methods have failed to provide a definitive diagnosis [4]
Findings [16]
Similar pressures in the left and right atria and right ventricle at the end of diastole (e.g., “equalization of pressures”)
Normal pulmonary artery systolic pressure < 40 mm Hg
Mean right arterial pressure > 15 mm Hg
Square root sign [4]
Also known as dip-and-plateau waveform
Sudden dip in the right and left ventricular pressure in early diastole followed by a plateau during the last stage of diastole
ECG
No conclusive findings: generalized flat/inverted T waves, low QRS voltage
Atrial fibrillation can occur in severe disease. [17]
Effusive-constrictive pericarditis
The diagnostic findings of effusive-constrictive pericarditis are similar to those of pericardial effusion, with the exception that in addition to pericardial effusion, pericardial thickening may also be seen. Elevation of right atrial pressures despite pericardiocentesis is strongly suggestive of effusive-constrictive
what is the treatment for pericarditis?
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). [10]
NSAID therapy
Aspirin
Ibuprofen
Indomethacin
Consider colchicine in combination with NSAIDs or as a monotherapy. [4]
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
Additional considerations
Treat any known underlying causes.
Antibiotics for bacterial causes
Antitubercular therapy
Immunosuppressants in autoimmune disease
Dialysis (in the case of uremia)
Restricted physical activity in acute pericarditis [4][22]
Nonathletes: until symptoms have resolved and CRP has normalized
Athletes: until symptoms have resolved, CRP has normalized, and ECG and echocardiogram findings have normalized
Surgical therapy
Pericardiocentesis: indicated for cardiac tamponade, large pericardial effusion, acute management of effusive-constrictive pericarditis [4]
Pericardiectomy: complete removal of the pericardium
what is the etiology of myocarditis?
Most commonly implicated: coxsackie B1-B5 (picornavirus), parvovirus B19, human herpesvirus 6 (HHV-6), adenovirus, HCV, HIV
Other viruses: EBV, CMV, echovirus, H1N1 influenza A
Bacterial
Group A β-hemolytic Streptococcus (acute rheumatic fever)
Corynebacterium diphtheriae (diphtheria)
Borrelia burgdorferi (borreliosis)
Mycobacterium (tuberculosis)
Mycoplasma pneumoniae
Fungal (Candida, Aspergillus)
Parasitic
Protozoan: Toxoplasma gondii, Trypanosoma cruzi (Chagas disease, common in South America)
Helminthic: Trichinella, Echinococcus
Connective tissue diseases (e.g., systemic lupus erythematosus, sarcoidosis, dermatomyositis, polymyositis)
Vasculitis syndromes (e.g., Kawasaki disease)
Toxic myocarditis
Toxins (e.g., carbon monoxide poisoning, black widow venom)
Medication (e.g., sulfonamides), chemotherapy (e.g., anthracycline, doxorubicin)
Alcohol, cocaine
Radiation therapy
what are the clinical features of myocarditis?
Often asymptomatic, but may range from acute, fulminant cases to chronically active or persistent myocarditis
Preceding (1–2 weeks) flulike symptoms (fever, arthralgia, myalgia, upper respiratory tract infections): indicate possible viral cause
Fatigue, weakness, dyspnea, nausea, vomiting [4]
Cardiac arrhythmias: sinus tachycardia (often dissonantly high in relation to patient’s body temperature), ventricular extrasystoles with palpitations or syncope, heart block with bradyarrhythmia
Chest pain: indicates pericardial involvement (perimyocarditis)
Acute decompensated congestive heart failure with dilated cardiomyopathy (see “Symptoms of left heart failure” and “Symptoms of right heart failure”)
Cardiogenic shock in fulminant cases
Auscultation findings
Brief systolic murmurs
Heart failure: S3 and S4 gallops
Pericarditis: pericardial friction rub
In infants and young children: poor feeding, irritability, respiratory distress, and failure to thrive
The clinical manifestation of myocarditis is heterogeneous and nonspecific, ranging from asymptomatic courses to fulminant cardiac decompensation.
what is the diagnosis of myocarditis?
Although ECG abnormalities due to myocardial inflammation are very nonspecific and may only manifest temporarily, myocarditis should be suspected if the following findings are observed:
Sinus tachycardia
Arrhythmias: atrial or ventricular ectopic beats, complex ventricular arrhythmia, atrial tachycardia
Repolarization abnormalities
Nonspecific T-wave and ST-segment changes [1]
Possible ST-segment elevations may mimic myocardial infarction [1]
Heart block: right bundle branch block, complete heart block, AV block
Rule out myocardial infarction: loss of R wave and pathological Q wave specific to myocardial infarction, not found in myocarditis
Pericardial effusion: low voltage (low R-wave with poor progression)
Laboratory findings ↑ Cardiac enzymes (CK, CK-MB, troponin T) ↑ ESR (and CRP) Leukocytosis ↑ BNP Virus serology
Imaging
Chest x-ray and CT: cardiac enlargement, pulmonary congestion, pleural effusions
Echocardiography
Findings often unremarkable
Ventricles: dilation, diffuse hypokinesia, reduced ejection fraction, impaired contractility, regional wall motion abnormalities
Pericardial effusion: localized or circumferential fluid surrounding the ventricles
Exclusion of other possible etiologies of heart failure (e.g., heart defects)
Myocardial biopsy
Via cardiac catheterization of the left heart and MRI-supported biopsy
Indications
New onset heart failure, severe arrhythmias, resistance to treatment
Only performed if previous diagnostics are inconclusive and a definitive diagnosis of myocarditis might influence treatment
Results
Possible detection of viral DNA/RNA
Immunohistochemical detection of inflammation: Focal necrosis with lymphocytic infiltration most often has a viral etiology
what is the treatment of myocarditis?
Supportive therapy
Inpatient surveillance (cardiac monitoring, oxygen administration, management of fluid status)
Rest; avoid physical activity
Analgesic drugs if required
Causative treatment
Antibiotic therapy for bacterial myocarditis
Antimycotic therapy (fluconazole, amphotericin B) for fungal infections
Treatment of complications
Congestive heart failure: (e.g., management of fluid accumulation with diuretics, beta blockers , ACE inhibitors)
Treatment of cardiac arrhythmias (e.g., amiodarone)
Heart transplantation
what are the complications of myocarditis?
Progression to dilated cardiomyopathy (∼ 15% of cases)
Heart failure or sudden cardiac death: probably due to ventricular tachycardia or fibrillation (common in adults < 40 years old)
Acute and/or persistent arrhythmias
Atrioventricular block
Intracardiac thrombi formation, which can result in systemic embolization
Concurrent pericarditis (perimyocarditis) that may lead to cardiac tamponade (associated with large pericardial effusions)
