Pericarditis & Myo

    .

    Pericarditis

    Introduction/Causes

    • Inflammation of the pericardium
    • ESC Guidelines 2015 are the only ones that offer guidance.
    • Large effusions are present in 3% of cases.  (>20mm in width)
    • Acute pericarditis can be three categories:
      • Dry
      • Fibrinous
      • Effusive
    • Chronic pericarditis (>3mo) can be:
      • Effusive
      • Adhesive
      • Constrictive

     

     

    • Causes:
      • 80-90% Idiopathic (presumed Viral) - In Developed Countries
      • Ischemic: Myocardial Infarction (Early: 2-4d post-MI, Late: Dressler's Syndrome)
      • Other Causes:
        • Connective Tissue Disease
        • Cancer
        • Uremia
        • TB, toxoplasma, Medications
      • Familial:
        • TRAPS (tumor necrosis factor receptor–associated periodic syndrome)
        • Familial Mediterranean fever 
      • NOTE: Patients with large effusions >2cm, or constrictive pericarditis, often have non-idopathic pathology.

     

    Symptoms/Physical

    • Symptoms:
      • **CHEST PAIN** --> Pleuritic, relieved by sitting forward, worse laying down, radiates to trapezius ridge (pathognomonic).
      • Prodromal viral illness
      • General: prodrome of fever <39, malaise, myalgia common.
      • Retrosternal pleuritic chest pain.
        • Pain worse supine, better leaning forward.
      • Two or three component friction rub is present.

     

    • Physical Exam
      • Pericardial Friction Rub
        • Transient, mono-, bi-, or triphasic.
      • Determine If Effusion Present:
        • Beck's Triad:
          • JVP Elevation
          • Muffled heart sounds
          • Hypotension 
        • Paradoxial pulse
      • Pleural Effusion may be present.
      • Clinical diagnosis (ECG may not have findings)

     

    Diagnosis/Workup

    • Diagnosis of Acute Pericarditis Criteria:

      • Must have 2/4 OF:

                 1.  Typical Pericardial Chest Pain (Most suspected pericarditis)

                      Typical: Pleuritic, relieved by sitting forward, radiates to trapezius ridge (pathognomonic)

                 2.  Pericardial Friction Rub

                 3.  ECG changes (New widespread ST elevation or PR depression)

                 4.  Pericardial Effusion (new or worsening)

       

      Supporting findings:

      - Inflammatory markers (ESR, CRP, WBC)

      - Pericardial inflammation by imaging)

    • Incessant Pericarditis - Lasting >4-6w but <3mo without remission
    • Recurrent - Must have symptom-free interval of 4-6w or longer
    • Chronic - Pericarditis lasting >3mo

     

    • All presumed pericarditis require workup:  (to exclude causes)
      • Lab Tests (CBC+diff, CRP, Creatinine, LFTs, Troponin, CK-MB)
        • WBC > 13000 suggests a specific cause (i.e. bacterial)
        • Anemia = chronic = cancer or connective tissue disease.
        • CRP = elevated in 75%, normalizes in 1-2w.
      • Chest Xray
      • Echocardiogram (determine if effusion present)
    • ECG
      • Classic:
        • Diffuse ST segment elevation  (non-coronary distribution)
        • PR depression (more specific)
      • However, often variable: sometimes ST elevation is only in few leads (hard to distinguish from STEMI).
      • Sometimes PR depression is the only sign.
      • Effusion findings: electrical alternans.

    pericarditisECGsmall.png

    • CXR
      • Look for effusions (bottle-shaped heart)
    • CT + MRI:
      • Can see patterns:
        • Pericardial thickening
        • Enhanced Gadolinium uptake
    • Biopsy --> gold standard for dx, but rarely needed.

     

    Acute Treatment

    • Drain effusion if indicated.  Indications:
      • Clinical tamponade
      • High suspicion of purulent or neoplastic pericarditis
      • Large symptomatic effusions despite medical management x1 week.
    • Choices:
      • NSAIDs + colchicine are 1st line (70-90% resolve completely.
      • Steroids should be AVOIDED: high risk of recurrence
      • NSAIDs
        • ALL MUST get PPI gastric protection
        • Ibuprophen (600-800mg q6-8h) x 1-2w
          • Favoured in North America
          • Monitor days-weeks until effusion disappears.
          • + GI protection.
          • Duration uncertain (expert opinion 1-2w), dictated by response.
        • Indomethacin 25-50mg q8h
          • (regarded by many older cardiologists)
        • ASA (2-4g daily in divided doses)
          • Indicated especially for ischemic pericarditis
          • Favoured in Europe
      • Colchicine (0.5mg BID)
        • 1st Line --> indicated even for first-time episodes to reduce risk of recurrence.
        • Initially supported by European Society of Cardiology (ESC) in 2004, later RCT trial ICAP strongly supported this practice. 
        • Colchicine 0.5mg BID x3mo if > 70kg
          • Once Daily if ≤ 70kg 
          • DO NOT LOAD --> to avoid risk of GI S/E
        • Often used as first line for recurrent or first line acute pericarditis.
        • Add to NSAID or monotherapy:
          • ICAP Trial: Shown to shorten symptoms, reduces likelihood of recurrent pericarditis. (38% recurrence --> down to 17% w/ colchicine).
      • Prednisone
        • ONLY in connective tissue disease, autoreactive or uremic pericarditis, 
          OR:
        • 3rd line, if non-responsive to other therapies. (i.e. at least 2 trials of NSAID + colchicine)
          • ESC guidelines support steroids if no response to NSAID + colchicine
          • If using steroids, continue NSAID (if can tolerate)
          • 3rd line because increases risk of recurrence of pericarditis.
          • Use medium doses (0.2-0.5mg/kg/day of prednisone) (high doses worsen risk of recurrence) for several weeks then gradual taper q1-2w over 2-4mo if symptoms improve.  Can continue NSAID/colchicine after stopping steroids. 
      • Other immunosuppression: Azathioprine, Cyclophosphamide
        • Usually last line (if not benefited by colchicine/NSAIDs, and cannot tolerate steroids)
    • NOTE: Almost all the studies came out of Italy.
    • NOTE: Constrictive pericarditis - very rare complication.  Requires pericardiectomy. 

     

    Recurrent Pericarditis

    • High recurrence in women, and failure to respond to initial therapy.
      • Consider TRAPS (autoimmune)
    • NSAID/ASA + colchicine (1-2mg on first day, then 0.5-1mg daily x6mo)
    • If many recurrences and poor response, consider prednisone
    • Some evidence for: Anti-TNF agents, azathioprine, anakinra, interleukin-1B antagonist (each has a small trial)
    • Pericardiectomy tried, but more evidence showed poor response (small amount of pericardium remains?)
    • Reassure patients that in absence of underlying cause, serious complications are very rare. 

     

    Constrictive Pericarditis

    • Rare, but disabling.  Impaired filling due to restricted ventricular diastolic expansion because of a stiff pericardium.
    • Clinical Presentation:
      • Dyspnea, Fatigue, Peripheral Edema
      • Atrial Fibrillation (20%)
      • Exam:
        • JVP elevated, Kussmaul sign (JVP engorgement with inspiration).
        • Pericardial knock
        • Hepatomegaly, ascites.  
        • (Usually pulmonary congestion is absent)
    • Causes:
      • Any condition causing pericarditis
      • Most common:
        • Viruses, cardiac surgery, mediastinal irradiation, connective tissue disease.
        • Trauma, malignancy, pericardiotomy.
    • Effusive-Constrictive Pericarditis:
      • Hybrid condition of both tamponade and constriction.
      • Unmasked when the effusion is drained and R-sided pressure remain high.
    • Diagnosis:
      • Must distinguish from restrictive cardiomyopathy.
      • TTE (Primary)
        • Can also use TEE, CMR, CT, catheterization.
        • Saline bolus during a R-heart cath can unmask hemodynamic characteristics of constriction.
    • Management:
      • Loop diuretics (furosemide).  --> reduce dyspnea and edema.
        • CAUTION!  Often require high filling pressure to maintain CO, can cause hypotension.
      • Rate control AFib
        • CAUTION! avoid bradycardia.
      • If Stable:
        • 2-3mo trial of anti-inflammatory therapy.
        • If associated with TB --> treat for TB --> resolves in 6mo.
      • Surgical pericardiectomy:
        • Indications:
          • Chronic constrictive pericarditis  + NYHA Class II or III HF.
          • For NYHA Class IV --> surgical benefit margin (operative mortality 6-19%).
        • May take several months to improve symptoms.

     

    Cardiac Tamponade

    • Typically a triad of: (Beck's Triad)
      • 1.  Distended Jugular Veins
      • 2.  Muffled heart sounds
      • 3.  Low BP
    • Echocardiography --> tamponade?:
      • Look for Tamponade features:
      • Diastolic inversion of the right-sided chambers (RV/ RA)
      • Respiratory variation in the mitral inflow pattern
      • Aventricular septal shift and plethora of the inferior vena cava also may be present
    • Management:
      • If echocardiographic evidence of tamponade (see above) --> must evacuate. 
      • Pericardiocentesis is standard
      • If unresponsive to pericardiocentesis --> pericardial window (through VATS or open procedure in OR)

     

    Constrictive vs. Restrictive vs. Tamponade

     

    Condition History ECG Physical Exam CXR ECHO

    Constrictive

    Pericarditis

    TB, Cardiac Surgery,

    Radiation,

    CTD, Trauma,

    Prior Pericarditis

    Nonspecific

    Pulsus Par. - may have

    JVP (prominent x/y descents,

            Kussmauls)

    Heart Sounds (pericardial

                              Knock)

    Pericardial

    Calcification

    Pericardial Thickening

    Pericardial Effusion

        (Sometimes)

    Ventricular septal flattening

    with inspiration

    Restrictive CM

    Amyoid, Sarcoid,

    Hemochromatosis, etc..

    - R or L Atrial

    Enlargement

    - AV Delay, BBB

    Pulsus Par. - RARE

    JVP - Prominent x/y

              descents

            - Kussmaul's

    Heart Sounds - S4

    Murmurs - MR, TR

    ----

    - Atrial Enlargement

    - Mod/Severe Diastolic

      Dysfunction

    Cardiac

    Tamponade

    Prior effusion,

    cardiac surgery,

    malignancy (i.e. breast Ca),

    recent MI

    Low Voltage,

    Electrical Alternans

    Pulsus Par. - Frequent

    JVP - Abscent/diminished

              y-descent

    Heart Sounds - muffled

    Murmurs - NONE

    Cardiomegaly

    Globular Heart

    - Pericardial Effusion

    - RV collapse during

      systole

     

    Hemodynamics

     

    Constrictive

    Pericarditis

    Restrictive

    CM

    Cardiac Tamponade

    Equalization of diastolic pressures YES

    L-side is higher

    (LV more restricted)

    YES
    Dip & Plateau (Square Root Sign)

    YES

    (restricts at end)

    YES

    (Restricts at end)

    NO

    (restricts entire cycle)

    Respiratory Variation in LV/RV

      Pressures

    Discordant peak

    RV and LV pressures

    (outline restricts/pulsus)

    Concordant peak 

    RV and LV pressures

    (septum restricts too!)

    Variable,

    likely discordant

    (Outline restricts/pulsus)

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