Myocarditis & Pericarditis

1. Myocarditis & Pericarditis Resident Rounds March 6, 2003 Aric Storck

2. Case 1 • 57 year old man • previously healthy • No cardiac risk factors • One week history of • General malaise, fever/chills, myalgias, coryza • Yesterday • Gradual onset of 6/10 pleuritic chest pain • Worst lying down • Better sitting forward • Not exacerbated by exertion • Slightly SOB

3. Physical exam • HR 105 RR 20 BP 130/80 T 38.2 • H&N – some palpable lymph nodes • CVS – sounds like velcro • Chest – Normal • Abdo - Normal

4. Could this be a heart attack?Should I call the cath lab? What’s going on?

5. Pericardial Disease

6. Chest Pain - Ischemic vs Pericarditis

7. Ischemic vs Pericarditis

8. Pericardial Disease • Pericarditis • Non-specific inflammation of pericardium • Rarely emergent • Pericardial effusion • Accumulation of fluid in pericardial space • Serous, purulent, fibrinous, hemorrhagic • Cardiac tamponade • Impairment of ventricular filling due to fluid in pericardial space • Emergent

9. Pericardial physiology • Parietal layer • Thick, collagenous, stiff • Adventitial attachments to sternum, diaphragm, mediastinum • Visceral layer • Thin • Closely adherent to epicardial surface

10. Pericardial fluid • Potential space between layers • Normally 15-60 cc fluid • Functions • Reduces friction • Prevention of infection • Augmentation of atrial filling • Maintains normal pressure-volume relationship of chambers • No physiological consequence to absent pericardium

11. Pericardial innervation • Parasympathetic • Vagus • Left-recurrent laryngeal nerve • Sympathetic • Stellate • First thoracic ganglia • Little somatic sensory innvervation • Thus visceral nature of chest pain

12. Pericarditis - etiology • Viral • Bacterial • Traumatic • Malignant • Post-irradiation • Post-MI • Drug-induced • Collagen vascular disease

13. Viral Pericarditis • Most common cause • Enteroviruses • Coxsackie A & B • Echovirus • HIV • Mechanism of injury • Direct viral cytotoxicity • Indirect auto-antibody mediated effects

14. Viral Pericarditis - SSx • Syndrome may be immediate or develop 2-4 weeks post viral illness • Chest pain • Pericardial friction rub • Heard with diaphragm over LLSB, leaning forward, breath held • Scratchy • Triphasic (presystolic, systolic, diastolic) • Fever • Tachycardia • Tachypnea,dyspnea • diaphoresis

15. Bacterial Pericarditis • Common in less developed countries • More commonly associated with tamonade • Higher mortality than viral • Streptococcus, staphylococcus, gram negs, anaerobes • TB • Lyme disease

16. Concomitant pneumonia / empyema • Often not diagnosed until tamponade • Definitive Dx requires pericardiocentesis • Treatment Abx • ICU admission indicated

17. Uremic Pericarditis • ESRD / Underdialysis • Bloody pericardial effusions • ECG often normal (little epicardial involvement) • Cardiac tamponade common • Often loculated - therapeutic pericardiocentesis difficult • Treatment • ICU admission • NSAIDS (caution b/c bleeding diathesis of uremia)

18. Post-MI Pericarditis • May occur within days of MI • Direct extension of myocardial inflammation • Presents as “different” chest pain • Must distinguish from reinfarction • Incidence 7-16% • Tx: NSAIDs • Dressler’s syndrome • Thought to be autoimmune • Weeks to months • Fever, chest pain, leukocytosis, pleuritis, pericardial/pleural effusions • Tx: NSAIDs, steroids for resistant cases

19. Collagen Vascular Disease Pericarditis • Common in many CVDs • RA • Incidence 30-50% - many clinically silent • SLE • 50% incidence • Dx: CP, R CHF, echo • ECG/CXR often normal • Tx: steroids • Commonly progress to constrictive pericarditis

20. Malignant pericarditis • Primary tumours rare • Metastatic disease common • Incidence 10% in cancer patients • Lung, breast, lymphoma, leukemia, MM • Children – Hodgkin’s, leukemia, lymphosarcoma • Progress to tamponade in 50-85% • Dx: pericardiocentesis / cytology • Tx: symptomatic

21. Post-Irradiation Pericarditis • Early (days – months) • Dose related pericardial effusion • Must distinguish from malignant effusion • SSx: • SOBOE • can mimic infectious pericarditis (fever, CP, friction rub) • Tx: • Often resolves spontaneously • NSAIDs, steroids, pericardiocentesis • Late (years) • Constrictive pericarditis • Tx: • Often requires pericardiectomy

22. SLE-like syndrome Procainamide Hydralazine Isoniazid Methyldopa Reserpine Hypersensitivity reaction Penicillin Cromolyn sodium Methysergide constrictive pericarditis / generalized mediastinal fibrosis Doxorubicin Chemotherapy Pericarditis / cardiomyopathy Drug-induced pericarditis

23. Back to our caseYou order an ECG on your patient

24. His ECG • STE – I, II, aVF, V2-V6 • Reciprocal STD – aVR • PR depression

25. Pericarditis – ECG 4 Stages • Evolution over 3-4 weeks • Only 50% have all 4 phases

26. Stage 1 • Hours to days • Diffuse ST elevation • ventricular subepicardial injury • I, II, III, aVL, aVF, V2 to V6 • Concave upwards • No distinct J-point • No T-wave inversions • Reciprocal ST depression • aVR, V1 • Diffuse PR depression • atrial injury

27. Stage 2 • Variable timeline • ECG transiently normal • ST / PR return to baseline • Some T-wave flattening

28. Stage 3 • Variable timeline • T-wave inversion • Deep, uniform

29. Stage 4 • Weeks to months • Return to normal • Some patients will have residual T-wave inversion

30. ECG – ECG vs Pericarditis

31. What if your patient was an 18 year old male athlete with burning chest discomfort after one too many seven-layer burritos?

32. His ECG

33. BER vs Pericarditis

34. Pericarditis – Ancillary tests • Most useful for ruling out other diagnoses • Troponin / CK-MB • Normal to mildly elevated (damage of subepicardial myocardium) • ESR – elevated or normal • WBC – elevated or normal

35. Echocardiogram • Gold standard for pericarditis with effusion • Can also evaluate • Pericardial thickness • Tamponade • Tumours / cysts • Constrictive pericarditis

36. Trans-thoracic echocardiogram • Large pericardial effusion • RV compressed

37. You suspect a viral pericarditis. How are you going to treat it?

38. Viral Pericarditis - treatment • All need to be followed to monitor for effusion • Effusion suspected if: • Dyspnea, fatigue, findings of tamponade • Must distinguish between purulent & viral • May need diagnostic pericardiocentesis • NSAIDS – good relief of pain & fever • Colchicine – 1-2mg po od • Steroids – only if NSAID resistant • Admit if: cannot rule out MI, pain control

39. Pericardial Effusion • Collection of fluid in indistensible pericardium • Secondary to pericarditis • infectious, uremic, malignant, post irradiation • Secondary to hemorrhage / trauma • aortic dissection, penetrating trauma • Symptoms related to size and acuity of collection • 80-100cc required before decompensation begins (15-60cc fluid normal) • Chronic effusions rarely progress to tamponade

40. Pericardial tamponade • Physiologic decompensation due to pericardial effusion • Acute surgical tamponade • Penetrating injury • aortic dissection • Iatrogenic (central line insertion) • Medical tamponade • Due to pericardial effusions due to pericarditis • Low-pressure tamponade • Due to severe dehydration • LV pressure lowered to equilibrate with RV pressure

41. Pericardial tamponade • Early • <200cc,  CVP, tachycardia • Moderate • ~200cc,  CVP, tachycardia,  cardiac output,  BP • Severe • >200cc,  CVP (unless hypovolemic),  BP,   cardiac output, +/- bradycardia

42. Traumatic Tamponade • 2% of penetrating thoracic trauma • 80-90% of stab wounds to heart • 20% of GSW to heart • Large instruments cause exsanguination • Foreign bodies, rib fractures • Iatrogenic – cardiac catheterization, pacemaker insertion, pericardiocentesis, cardiac surgery

43. Clinical features • Beck’s triad: • hypotension • distended neck veins (>15mm H20 with hypotension is diagnostic) • muffled heart sounds (unlikely to be heard in trauma room) • pulsus paradoxus – difficult to measure during resuscitation • no response to vigorous fluid resuscitation

44. Diagnosis • Echocardiography • available at some centres, but difficult to perform during resuscitation • TTE better than TEE • 98.1% sensitive, 99.9% specific • Also useful for evaluation of valves and wall motion

45. Diagnosis • Ultrasound • Features include • fluid in pericardial sac • dilated IVC • Compression of RA • Collapse of RV during diastole

46. Diagnosis • ECG • Generalized low voltage • R-wave height <1cm in all leads • Electrical alternans • specific but not sensitive • more likely seen in chronic than acute effusions • Morphology/amplitude of P, QRS, ST-T wave alternate every beat in any single lead • Likely due to inability of heart to return to a single position following each beat because of pericardial fluid

48. Diagnosis • CXR • May show enlarged cardiac shadow if lots of fluid (>200-250cc) • Generally not useful for acute early tamponade as only a small amount of fluid is required to create significant hemodynamic compromise

49. Large Pericardial Effusion • Loss of customary heart borders • “water-bottle” heart

50. Management • Prehospital care • Same as any trauma patient • Consider tension pneumothorax and needle thoracostomy