Acute Acute Pericarditis and Pericarditis and

Pericardial Pericardial EffusionEffusionMeghan YorkMeghan York

September 9, 2009September 9, 2009

OutlineOutline

1)1) Anatomy of pericardiumAnatomy of pericardium

2)2) Overview of pericardial diseaseOverview of pericardial disease

3)3) EtiologyEtiology

4)4) Clinical presentationClinical presentation

5)5) Ancillary diagnosticsAncillary diagnostics

6)6) Echocardiography in evaluation Echocardiography in evaluation

AnatomyAnatomy Normal amount of Normal amount of

pericardial fluid: 15-pericardial fluid: 15-50 cc50 cc

Two layers:Two layers: Outer layer is the Outer layer is the

parietal pericardium parietal pericardium and consists of layers and consists of layers of fibrous and serous of fibrous and serous tissuetissue

Inner layer is visceral Inner layer is visceral pericardium and pericardium and consists of serous consists of serous tissue onlytissue only

PericardiumPericardium Fibroelastic sac Fibroelastic sac

consisting of 2 consisting of 2 layerslayers Visceral at Visceral at

epicardial sideepicardial side Parietal at Parietal at

mediastinal mediastinal sideside

Pericardial fluid Pericardial fluid formed from formed from ultrafiltrate of ultrafiltrate of plasmaplasma

Diseases of the Diseases of the PericardiumPericardium

Acute Fibrinous PericarditisAcute Fibrinous Pericarditis Pericardial EffusionPericardial Effusion

Cardiac tamponadeCardiac tamponade Recurrent PericarditisRecurrent Pericarditis Constrictive PericarditisConstrictive Pericarditis

Epidemiology of Acute Epidemiology of Acute PericarditisPericarditis

0.1% of hospitalized patients0.1% of hospitalized patients

5% of patients admitted to 5% of patients admitted to Emergency Department for non-Emergency Department for non-acute myocardial infarction chest acute myocardial infarction chest painpain

Findings on EchoFindings on Echo

Pericardial effusionPericardial effusion If present, possibility of tamponade If present, possibility of tamponade

physiology needs to be consideredphysiology needs to be considered Pericardial thickeningPericardial thickening

Increased echogenicity of pericardial Increased echogenicity of pericardial reflection and as multiple parallel reflection and as multiple parallel reflections posterior to the LV on M-modereflections posterior to the LV on M-mode

If present, evidence of constrictive If present, evidence of constrictive physiology should be consideredphysiology should be considered

Tamponade: 2DTamponade: 2D

Pericardial thickening on Pericardial thickening on EchoEcho

Findings on CTFindings on CT

Chest X rayChest X ray Normal in Normal in

patients with patients with acute pericarditis acute pericarditis unless pericardial unless pericardial effusion is effusion is presentpresent

Enlarged cardiac Enlarged cardiac silhouettesilhouette

Requires 200cc of Requires 200cc of fluidfluid

Chest X RayChest X Ray

Major Causes of Pericardial Major Causes of Pericardial DiseaseDisease

1)Infection1)Infection2)Radiation2)Radiation3)Neoplasm3)Neoplasm4)Myocardial intrinisic disease4)Myocardial intrinisic disease5)Trauma5)Trauma6)Autoimmune6)Autoimmune7)Drugs7)Drugs8)Metabolic8)Metabolic

*viral, autoreactive/autoimmune, and *viral, autoreactive/autoimmune, and neoplastic most common diagnosisneoplastic most common diagnosis

Etiology of Acute Etiology of Acute Pericarditis: InfectiousPericarditis: Infectious

Viral Viral -adenovirus-adenovirus-enterovirus-enterovirus--

cytomegaloviruscytomegalovirus-influenza-influenza-hepatitis B-hepatitis B-herpes simplex-herpes simplex-echovirus-echovirus-mumps-mumps

MycoplasmaMycoplasma

FungalFungal

ParasiticParasitic

BacterialBacterial-staphylococcus-staphylococcus-streptococcus-streptococcus-pneumococcus-pneumococcus-haemophilus-haemophilus-neisseria-neisseria-chlamydia-chlamydia-legionella-legionella-tuberculous-tuberculous-lyme disease-lyme disease

Etiology: continuedEtiology: continuedRadiationRadiation

NeoplasmNeoplasm-metastatic-metastatic-primary cardiac-primary cardiac-paraneoplastic-paraneoplastic

CardiacCardiac-early infarction-early infarction-Dressler’s-Dressler’s-myocarditis-myocarditis-aortic dissection-aortic dissection

TraumaTrauma-blunt-blunt-iatrogenic (perforations, -iatrogenic (perforations, post-surg)post-surg)

AutoimmuneAutoimmune-rheumatic disease-rheumatic disease-non-rheumatic-non-rheumatic

-Wegners, sarcoid, IBD-Wegners, sarcoid, IBD

Etiology: continuedEtiology: continued

DrugsDrugs

-drug induced -drug induced lupuslupus

hydralazinehydralazine

isoniazidisoniazid

procainamideprocainamide

-doxorubicin-doxorubicin

-phenytoin-phenytoin

MetabolicMetabolic

-hypothyroid-hypothyroid

-uremia-uremia

-ovarian -ovarian hyperstimulationhyperstimulation

Lab TestingLab Testing

the historic yield of diagnostic the historic yield of diagnostic evaluation is low, typically only in 16% evaluation is low, typically only in 16% of patients is etiology determined.of patients is etiology determined.

evaluation of pericardial fluid and evaluation of pericardial fluid and tissue with tumor markers, PCR, tissue with tumor markers, PCR, immunohistochemistry, flourescence-immunohistochemistry, flourescence-activated cell sorting has shown a activated cell sorting has shown a trend toward higher yield of diagnosistrend toward higher yield of diagnosis

Diagnosis of Pericarditis: Diagnosis of Pericarditis: Presence of two of the following Presence of two of the following

necessarynecessary1) Chest pain1) Chest pain Sudden onsetSudden onset localized to anterior chest walllocalized to anterior chest wall pleuriticpleuritic sharpsharp Positional: may improve if pt leans Positional: may improve if pt leans

forward, worse with lying flatforward, worse with lying flat2) Cardiac auscultation: Pericardial friction rub2) Cardiac auscultation: Pericardial friction rub

Present in up to 85% of pts with Present in up to 85% of pts with pericarditis without effusionpericarditis without effusion

friction of the two inflamed layers of friction of the two inflamed layers of pericardium, typically triphasic rub, pericardium, typically triphasic rub, heard with diaphragm of stethoscope at heard with diaphragm of stethoscope at left sternal borderleft sternal border

3) Characteristic ECG changes3) Characteristic ECG changes4) Pericardial effusion4) Pericardial effusion

Pertinent Lab ResultsPertinent Lab Results Elevated C reactive protein levelElevated C reactive protein level

strong correlation - normal CRP makes strong correlation - normal CRP makes acute pericarditis diagnosis less likelyacute pericarditis diagnosis less likely

Elevated CK, CK-MB, and TroponinElevated CK, CK-MB, and Troponin Often elevated Troponin aloneOften elevated Troponin alone Indicates inflammation of myocardium Indicates inflammation of myocardium

just beneath the visceral pericardiumjust beneath the visceral pericardium Not associated with worse outcomesNot associated with worse outcomes

LeukocytosisLeukocytosis

ECG Findings: 60% of ECG Findings: 60% of patientspatients

Stage 1: hours to daysStage 1: hours to days Diffuse ST elevation Diffuse ST elevation

-sensitive v5-v6, -sensitive v5-v6, I, III, II

ST depression I/aVRST depression I/aVR PR elevation aVRPR elevation aVR PR depression diffuse PR depression diffuse

-especially v5-v6-especially v5-v6 PR change is marker PR change is marker

of atrial injuryof atrial injury Stage 2:Stage 2:

NormalizationNormalization

ECG changes over weeksECG changes over weeks

Stage 3:Stage 3: Diffuse T wave Diffuse T wave

inversionsinversions ST segments ST segments

isoelectricisoelectric

Stage 4:Stage 4: EKG may EKG may

normalizenormalize T wave inversions T wave inversions

may persist may persist indefinitelyindefinitely

STEMI or Pericarditis by STEMI or Pericarditis by ECGECG

ST elevation in ST elevation in pericarditispericarditis Starts at J pointStarts at J point Rarely exceeds 5mmRarely exceeds 5mm Retains normal Retains normal

concavityconcavity Non-localizingNon-localizing

Arrhythmias very Arrhythmias very unlikely in unlikely in pericarditis (suggest pericarditis (suggest myocarditis or MI)myocarditis or MI)

Acute PericarditisAcute Pericarditis

51yo man with acute onset sharp 51yo man with acute onset sharp substernal chest pain two days priorsubsternal chest pain two days prior

Pericardial EffusionPericardial Effusion

Low voltage and Electric AlternansLow voltage and Electric Alternans

ACC/AHA/ASE 2003 ACC/AHA/ASE 2003 guideline update for the guideline update for the

clinical application of clinical application of echocardiography: echocardiography: summary article summary article

Recommended specific Recommended specific circumstances for use of circumstances for use of echocardiography in pericardial echocardiography in pericardial diseasedisease

Class I RecommendationsClass I Recommendations

1. Patients with suspected 1. Patients with suspected pericardial disease, including pericardial disease, including effusion, constriction, or effusion, constriction, or effusive-constrictive process.effusive-constrictive process.

2. Patients with suspected 2. Patients with suspected bleeding into the pericardial bleeding into the pericardial space (trauma, perforation, space (trauma, perforation, dissection)dissection)

Class I (continued)Class I (continued)

3. Follow-up study to evaluate 3. Follow-up study to evaluate recurrence of effusion or to diagnose recurrence of effusion or to diagnose early constriction; repeat studies early constriction; repeat studies may be goal directed to answer a may be goal directed to answer a specific clinical questionspecific clinical question

4. Pericardial friction rub developing 4. Pericardial friction rub developing in acute myocardial infarction in acute myocardial infarction accompanied by symptoms such as accompanied by symptoms such as persistent pain, hypotension, and persistent pain, hypotension, and nauseanausea..

Class IIaClass IIa

1)Follow-up studies to detect early 1)Follow-up studies to detect early signs of tamponade in the signs of tamponade in the presence of large or rapidly presence of large or rapidly accumulating effusions. A goal-accumulating effusions. A goal-directed study may be appropriate.directed study may be appropriate.

2)Echocardiographic guidance and 2)Echocardiographic guidance and monitoring of pericardiocentesis.monitoring of pericardiocentesis.

Class IIbClass IIb

1) Postsurgical pericardial disease, 1) Postsurgical pericardial disease, including postpericardiotomy including postpericardiotomy syndrome, with potential for syndrome, with potential for hemodynamic impairment.hemodynamic impairment.

2) In the presence of a strong 2) In the presence of a strong clinical suspicion and clinical suspicion and nondiagnostic TTE, TEE nondiagnostic TTE, TEE assessment of pericardial assessment of pericardial thickness to support a diagnosis of thickness to support a diagnosis of constrictive pericarditis.constrictive pericarditis.

Effusion: 2D Parasternal Effusion: 2D Parasternal LongLong

Pericardial Fat PadPericardial Fat Pad

Often pericardial fat pads can be Often pericardial fat pads can be seen in this view anterior to the seen in this view anterior to the RVOTRVOT

Fat pads usually not seen Fat pads usually not seen elsewhereelsewhere

Effusion: Parasternal Effusion: Parasternal Short AxisShort Axis

Posterior EffusionsPosterior Effusions

Pericardial effusions can track Pericardial effusions can track posteriorly toward sinusposteriorly toward sinus

In this case, may only be seen in In this case, may only be seen in axial 4 chamber viewaxial 4 chamber view

Effusion: 2D ApicalEffusion: 2D Apical

TamponadeTamponade Pressure in pericardium exceeds pressure Pressure in pericardium exceeds pressure

in the cardiac chambers, lower chamber in the cardiac chambers, lower chamber atria affected before higher pressure atria affected before higher pressure ventriclesventricles

Compressive effect is seen best in the phase Compressive effect is seen best in the phase when the intrachamber pressure is lowest – when the intrachamber pressure is lowest – systole for atria and diastole for ventriclessystole for atria and diastole for ventricles

Diagnostic techniquesDiagnostic techniques 2D looking for RA/RV collapse during diastole2D looking for RA/RV collapse during diastole M-mode for RA/RV collapse during diastoleM-mode for RA/RV collapse during diastole Doppler of Mitral and Tricuspid inflowDoppler of Mitral and Tricuspid inflow

Mitral inflow to decrease by 25% with inspirationMitral inflow to decrease by 25% with inspiration Tricuspid inflow increased by 40% with inspirationTricuspid inflow increased by 40% with inspiration

IVC diameter fails to increase with inspirationIVC diameter fails to increase with inspiration

Tamponade: 2DTamponade: 2D

Tamponade: M-ModeTamponade: M-Mode

Tamponade: DopplerTamponade: DopplerMitral InflowMitral Inflow

Fibrinous PericarditisFibrinous Pericarditis