Acute PericarditisAcute Pericarditis

Incidence – Post mortem 1-6%, diagnosed Incidence – Post mortem 1-6%, diagnosed in only 0.1% of hospitalized patients. 5% of in only 0.1% of hospitalized patients. 5% of patients seen in emergency rooms with CP patients seen in emergency rooms with CP and no MI.and no MI.

Sequelae – Cardiac tamponadeSequelae – Cardiac tamponade

Recurrent pericarditisRecurrent pericarditis

Pericardial constrictionPericardial constriction

EtiologyEtiology

Viral or idiopathicViral or idiopathic After MIAfter MI Infectious diseasesInfectious diseases With dissecting aortic aneurysmsWith dissecting aortic aneurysms TraumaTrauma MetastasisMetastasis XRTXRT UremiaUremia After cardiac or other thoracic surgeryAfter cardiac or other thoracic surgery Autoimmune diseasesAutoimmune diseases MedicationsMedications

Clinical PresentationClinical Presentation

HistoryHistory Physical Exam- 85% have audible friction rub Physical Exam- 85% have audible friction rub

during the course of their disease ( the rub is high during the course of their disease ( the rub is high pitched scratchy or squeaky sound best heard at pitched scratchy or squeaky sound best heard at the left sternal border at end of expiration with the the left sternal border at end of expiration with the patient leaning forward)patient leaning forward)

The rub has three components- atrial systole, The rub has three components- atrial systole, ventricular systole and rapid ventricular filling ventricular systole and rapid ventricular filling during early diastole.during early diastole.

EvaluationEvaluation

A diagnosis of acute pericarditis should be A diagnosis of acute pericarditis should be reserved for patients with an audible reserved for patients with an audible pericardial friction rub or CP with typical pericardial friction rub or CP with typical EKG findings, most notably ST- segment EKG findings, most notably ST- segment elevation.elevation.

EKG EKG

Stages of pericarditis:Stages of pericarditis:

I- Diffuse ST elevation and PR segment depression I- Diffuse ST elevation and PR segment depression (seen in more than 80%)(seen in more than 80%)

II- Normalization of the ST and PRII- Normalization of the ST and PR

III- Widespread T- wave inversionsIII- Widespread T- wave inversions

IV- Normalization of the T wavesIV- Normalization of the T waves The most reliable distinguishing feature may be The most reliable distinguishing feature may be

the ratio of ST segment elevation (in millimeters) the ratio of ST segment elevation (in millimeters) to T-wave amplitude in lead V6; ratio > 0.24to T-wave amplitude in lead V6; ratio > 0.24

Cardiac TamponadeCardiac TamponadeClinical FindingsClinical Findings

Systemic arterial hypotensionSystemic arterial hypotension TachycardiaTachycardia Elevated JVPElevated JVP Pulsus paradoxus (most sensitive but not Pulsus paradoxus (most sensitive but not

specific)specific) 15% of patients with idiopathic pericarditis or 15% of patients with idiopathic pericarditis or

as many as 60% of those with neoplastic, as many as 60% of those with neoplastic, tuberculous, or purulent pericarditis can tuberculous, or purulent pericarditis can present with Cardiac Tamponade.present with Cardiac Tamponade.

Echo Findings in Pre-Tamponade Echo Findings in Pre-Tamponade PhysiologyPhysiology

Diastolic right ventricular collapseDiastolic right ventricular collapse Right atrial collapse/inversionRight atrial collapse/inversion Exagerated respiratory variation in inflow Exagerated respiratory variation in inflow

velocityvelocity Exagerated respiratory variation in inferior Exagerated respiratory variation in inferior

vena cava flowvena cava flow Dilated IVC in the right settingDilated IVC in the right setting

Echo-Guided PericardiocentesisEcho-Guided Pericardiocentesis

Multiple Echo windows should be used to Multiple Echo windows should be used to determine the distribution of the fluid. Specifically, determine the distribution of the fluid. Specifically, the distribution and depth from the surface of the the distribution and depth from the surface of the chest at which contact with the fluid is anticipated chest at which contact with the fluid is anticipated by the pericardiocentesis needle should be by the pericardiocentesis needle should be determined. If the location of a pericardiocentesis determined. If the location of a pericardiocentesis needle is in question, agitated saline can be needle is in question, agitated saline can be injected to further define the location of the tip.injected to further define the location of the tip.

Differential DiagnosisDifferential Diagnosis

PericarditisPericarditis

Clinical presentation should guide the ordering of Clinical presentation should guide the ordering of additional tests. Routine serologic testing, additional tests. Routine serologic testing, including testing for ANA and RF, reveals a source including testing for ANA and RF, reveals a source for the pericarditis for only 10-15% of patients.for the pericarditis for only 10-15% of patients.

Plasma troponin concentrations are elevated in Plasma troponin concentrations are elevated in 35-50% of patients with pericarditis. The 35-50% of patients with pericarditis. The magnitude of the ST elevation appears to correlate magnitude of the ST elevation appears to correlate with magnitude of troponin elevation. A troponin with magnitude of troponin elevation. A troponin elevation lasting more than 2 weeks, suggests elevation lasting more than 2 weeks, suggests associated myocarditis.associated myocarditis.

Pericardiocentesis and BiopsyPericardiocentesis and Biopsy

In those with pericardial tamponade and in In those with pericardial tamponade and in those with known or suspected purulent or those with known or suspected purulent or neoplastic pericarditis.neoplastic pericarditis.

In a study involving 230 patients with acute In a study involving 230 patients with acute pericarditis in whom the cause was pericarditis in whom the cause was unknown, pericardiocentesis and pericardial unknown, pericardiocentesis and pericardial biopsy provided a diagnosis in only 6% and biopsy provided a diagnosis in only 6% and 5% respectively.5% respectively.

Laboratory EvaluationLaboratory Evaluation

Red and white cell count.Red and white cell count. CytologyCytology TGTG CTXCTX No evidence for PH, glucose, LDH and No evidence for PH, glucose, LDH and

protein measurement.protein measurement. PCR > 30 U/L for adenosine deaminase PCR > 30 U/L for adenosine deaminase

activity may help in identifying MTBactivity may help in identifying MTB

TreatmentTreatment

In observational studies, NSAIDS relieved CP in In observational studies, NSAIDS relieved CP in 85-90% of patients: ASA, Indomethacin or 85-90% of patients: ASA, Indomethacin or Ibuprofen.Ibuprofen.

Indomethacin may impair coronary blood flow in Indomethacin may impair coronary blood flow in CAD. CAD.

In a multicenter trial of 51 patients who had In a multicenter trial of 51 patients who had recurrent pericarditis despite tx with NSAIDS, recurrent pericarditis despite tx with NSAIDS, glucocorticoids, pericardiocentesis or some glucocorticoids, pericardiocentesis or some combination. Only 7 of those treated with combination. Only 7 of those treated with colchicine had a recurrence during 1004 patient-colchicine had a recurrence during 1004 patient-months of follow up.months of follow up.

Sauleda

TreatmentTreatment

Typically CP improves within days of initiating Typically CP improves within days of initiating antinflammatory tx. antinflammatory tx.

• If CP persists after two weeks of tx with an NSAID, If CP persists after two weeks of tx with an NSAID, a different NSAID should be given or colchicine a different NSAID should be given or colchicine should be added to provide combination therapy. should be added to provide combination therapy.

• Glucocorticoids should be considered if CP Glucocorticoids should be considered if CP persists after combination tx. persists after combination tx.

• Lack of response to steroids often reflects the use Lack of response to steroids often reflects the use of an inadequate dose or too rapid tapering. of an inadequate dose or too rapid tapering.

TreatmentTreatment

Several indicators of poor prognosis:Several indicators of poor prognosis: >38*C>38*C Subacute onsetSubacute onset ImmunosuppressedImmunosuppressed After traumaAfter trauma Anticoagulation useAnticoagulation use MyopericarditisMyopericarditis Large effusion or tamponadeLarge effusion or tamponade

TreatmentTreatment

Use of steroids should be reserved for patients Use of steroids should be reserved for patients with CTD, recurrent severe pericarditis that is with CTD, recurrent severe pericarditis that is unresponsive to combination of NSAIDS and unresponsive to combination of NSAIDS and colchicine.colchicine.

Some studies suggest that the early use of these Some studies suggest that the early use of these drugs may increase the risk of recurrence drugs may increase the risk of recurrence (exception colchicine). (exception colchicine).

Observational data suggest that physical invasion Observational data suggest that physical invasion of the pericardium (pericardiotomy or a window) of the pericardium (pericardiotomy or a window) promotes recurrences.promotes recurrences.

Effusive Constrictive PericarditisEffusive Constrictive Pericarditis

Is a clinical hemodynamic syndrome in Is a clinical hemodynamic syndrome in which constriction of the heart by the which constriction of the heart by the visceral pericardium occurs in the visceral pericardium occurs in the presence of tense effusion in a free presence of tense effusion in a free pericardial space.pericardial space.

The hallmark is the persistence of elevated The hallmark is the persistence of elevated right atrial pressure after intrapericardial right atrial pressure after intrapericardial pressure has been reduced to normal levels pressure has been reduced to normal levels by removal of pericardial fluid.by removal of pericardial fluid.