2Acute Pericarditis and Pericardial Effusion Meghan YorkSeptember 9, 2009
3Outline Anatomy of pericardium Overview of pericardial disease EtiologyClinical presentationAncillary diagnostics6) Echocardiography in evaluation
4Anatomy Normal amount of pericardial fluid: 15-50 cc Two layers: Outer layer is the parietal pericardium and consists of layers of fibrous and serous tissueInner layer is visceral pericardium and consists of serous tissue only
5Pericardium Fibroelastic sac consisting of 2 layers Visceral at epicardial sideParietal at mediastinal sidePericardial fluid formed from ultrafiltrate of plasma
6Diseases of the Pericardium Acute Fibrinous PericarditisPericardial EffusionCardiac tamponadeRecurrent PericarditisConstrictive Pericarditis
7Epidemiology of Acute Pericarditis 0.1% of hospitalized patients5% of patients admitted to Emergency Department for non-acute myocardial infarction chest pain
8Findings on Echo Pericardial effusion Pericardial thickening If present, possibility of tamponade physiology needs to be consideredPericardial thickeningIncreased echogenicity of pericardial reflection and as multiple parallel reflections posterior to the LV on M-modeIf present, evidence of constrictive physiology should be considered
14Major Causes of Pericardial Disease 1)Infection2)Radiation3)Neoplasm4)Myocardial intrinisic disease5)Trauma6)Autoimmune7)Drugs8)Metabolic*viral, autoreactive/autoimmune, and neoplastic most common diagnosis
15Etiology of Acute Pericarditis: Infectious Viral-adenovirus-enterovirus-cytomegalovirus-influenza-hepatitis B-herpes simplex-echovirus-mumpsMycoplasmaFungalParasiticBacterial-staphylococcus-streptococcus-pneumococcus-haemophilus-neisseria-chlamydia-legionella-tuberculous-lyme disease
17Etiology: continued Drugs -drug induced lupus hydralazine isoniazid procainamide-doxorubicin-phenytoinMetabolic-hypothyroid-uremia-ovarian hyperstimulation
18Lab Testingthe historic yield of diagnostic evaluation is low, typically only in 16% of patients is etiology determined.evaluation of pericardial fluid and tissue with tumor markers, PCR, immunohistochemistry, flourescence-activated cell sorting has shown a trend toward higher yield of diagnosis
19Diagnosis of Pericarditis: Presence of two of the following necessary 1) Chest painSudden onsetlocalized to anterior chest wallpleuriticsharpPositional: may improve if pt leans forward, worse with lying flat2) Cardiac auscultation: Pericardial friction rubPresent in up to 85% of pts with pericarditis without effusionfriction of the two inflamed layers of pericardium, typically triphasic rub, heard with diaphragm of stethoscope at left sternal border3) Characteristic ECG changes4) Pericardial effusion
20Pertinent Lab Results Elevated C reactive protein level strong correlation - normal CRP makes acute pericarditis diagnosis less likelyElevated CK, CK-MB, and TroponinOften elevated Troponin aloneIndicates inflammation of myocardium just beneath the visceral pericardiumNot associated with worse outcomesLeukocytosis
21ECG Findings: 60% of patients Stage 1: hours to daysDiffuse ST elevation -sensitive v5-v6, I, IIST depression I/aVRPR elevation aVRPR depression diffuse-especially v5-v6PR change is marker of atrial injuryStage 2:Normalization
22ECG changes over weeks Stage 3: Stage 4: Diffuse T wave inversions ST segments isoelectricStage 4:EKG may normalizeT wave inversions may persist indefinitely
23STEMI or Pericarditis by ECG ST elevation in pericarditisStarts at J pointRarely exceeds 5mmRetains normal concavityNon-localizingArrhythmias very unlikely in pericarditis (suggest myocarditis or MI)
24Acute Pericarditis51yo man with acute onset sharp substernal chest pain two days prior
25Pericardial EffusionLow voltage and Electric Alternans
26ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article Recommended specific circumstances for use of echocardiography in pericardial disease
27Class I Recommendations 1. Patients with suspected pericardial disease, including effusion, constriction, or effusive-constrictive process.2. Patients with suspected bleeding into the pericardial space (trauma, perforation, dissection)
28Class I (continued)3. Follow-up study to evaluate recurrence of effusion or to diagnose early constriction; repeat studies may be goal directed to answer a specific clinical question4. Pericardial friction rub developing in acute myocardial infarction accompanied by symptoms such as persistent pain, hypotension, and nausea.
29Class IIa1)Follow-up studies to detect early signs of tamponade in the presence of large or rapidly accumulating effusions. A goal-directed study may be appropriate.2)Echocardiographic guidance and monitoring of pericardiocentesis.
30Class IIb1) Postsurgical pericardial disease, including postpericardiotomy syndrome, with potential for hemodynamic impairment.2) In the presence of a strong clinical suspicion and nondiagnostic TTE, TEE assessment of pericardial thickness to support a diagnosis of constrictive pericarditis.
37TamponadePressure in pericardium exceeds pressure in the cardiac chambers, lower chamber atria affected before higher pressure ventriclesCompressive effect is seen best in the phase when the intrachamber pressure is lowest – systole for atria and diastole for ventriclesDiagnostic techniques2D looking for RA/RV collapse during diastoleM-mode for RA/RV collapse during diastoleDoppler of Mitral and Tricuspid inflowMitral inflow to decrease by 25% with inspirationTricuspid inflow increased by 40% with inspirationIVC diameter fails to increase with inspiration