Acute Pericarditis

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Acute Pericarditis

• Incidence Post mortem 1-6, diagnosed in only
  0.1 of hospitalized patients. 5 of patients
  seen in emergency rooms with CP and no MI.
• Sequelae Cardiac tamponade
• Recurrent pericarditis
• Pericardial constriction

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Etiology

• Viral or idiopathic
• After MI
• Infectious diseases
• With dissecting aortic aneurysms
• Trauma
• Metastasis
• XRT
• Uremia
• After cardiac or other thoracic surgery
• Autoimmune diseases
• Medications

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Clinical Presentation

• History
• Physical Exam- 85 have audible friction rub
  during the course of their disease ( the rub is
  high pitched scratchy or squeaky sound best heard
  at the left sternal border at end of expiration
  with the patient leaning forward)
• The rub has three components- atrial systole,
  ventricular systole and rapid ventricular filling
  during early diastole.

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Evaluation

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

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EKG

• Stages of pericarditis
• I- Diffuse ST elevation and PR segment
  depression (seen in more than 80)
• II- Normalization of the ST and PR
• III- Widespread T- wave inversions
• IV- Normalization of the T waves
• The most reliable distinguishing feature may be
  the ratio of ST segment elevation (in
  millimeters) to T-wave amplitude in lead V6
  ratio gt 0.24

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Cardiac TamponadeClinical Findings

• Systemic arterial hypotension
• Tachycardia
• Elevated JVP
• Pulsus paradoxus (most sensitive but not
  specific)
• 15 of patients with idiopathic pericarditis or
  as many as 60 of those with neoplastic,
  tuberculous, or purulent pericarditis can present
  with Cardiac Tamponade.

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Echo Findings in Pre-Tamponade Physiology

• Diastolic right ventricular collapse
• Right atrial collapse/inversion
• Exagerated respiratory variation in inflow
  velocity
• Exagerated respiratory variation in inferior vena
  cava flow
• Dilated IVC in the right setting

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Echo-Guided Pericardiocentesis

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

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Differential Diagnosis
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Pericarditis

• Clinical presentation should guide the ordering
  of additional tests. Routine serologic testing,
  including testing for ANA and RF, reveals a
  source for the pericarditis for only 10-15 of
  patients.
• Plasma troponin concentrations are elevated in
  35-50 of patients with pericarditis. The
  magnitude of the ST elevation appears to
  correlate with magnitude of troponin elevation. A
  troponin elevation lasting more than 2 weeks,
  suggests associated myocarditis.

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Pericardiocentesis and Biopsy

• In those with pericardial tamponade and in those
  with known or suspected purulent or neoplastic
  pericarditis.
• In a study involving 230 patients with acute
  pericarditis in whom the cause was unknown,
  pericardiocentesis and pericardial biopsy
  provided a diagnosis in only 6 and 5
  respectively.

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Laboratory Evaluation

• Red and white cell count.
• Cytology
• TG
• CTX
• No evidence for PH, glucose, LDH and protein
  measurement.
• PCR gt 30 U/L for adenosine deaminase activity may
  help in identifying MTB

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Treatment

• In observational studies, NSAIDS relieved CP in
  85-90 of patients ASA, Indomethacin or
  Ibuprofen.
• Indomethacin may impair coronary blood flow in
  CAD.
• In a multicenter trial of 51 patients who had
  recurrent pericarditis despite tx with NSAIDS,
  glucocorticoids, pericardiocentesis or some
  combination. Only 7 of those treated with
  colchicine had a recurrence during 1004
  patient-months of follow up.

Sauleda
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Treatment

• Typically CP improves within days of initiating
  antinflammatory tx.
• If CP persists after two weeks of tx with an
  NSAID, a different NSAID should be given or
  colchicine should be added to provide combination
  therapy.
• Glucocorticoids should be considered if CP
  persists after combination tx.
• Lack of response to steroids often reflects the
  use of an inadequate dose or too rapid tapering.

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Treatment

• Several indicators of poor prognosis
• gt38C
• Subacute onset
• Immunosuppressed
• After trauma
• Anticoagulation use
• Myopericarditis
• Large effusion or tamponade

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Treatment

• Use of steroids should be reserved for patients
  with CTD, recurrent severe pericarditis that is
  unresponsive to combination of NSAIDS and
  colchicine.
• Some studies suggest that the early use of these
  drugs may increase the risk of recurrence
  (exception colchicine).
• Observational data suggest that physical invasion
  of the pericardium (pericardiotomy or a window)
  promotes recurrences.

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Effusive Constrictive Pericarditis

• Is a clinical hemodynamic syndrome in which
  constriction of the heart by the visceral
  pericardium occurs in the presence of tense
  effusion in a free pericardial space.
• The hallmark is the persistence of elevated right
  atrial pressure after intrapericardial pressure
  has been reduced to normal levels by removal of
  pericardial fluid.

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