1. Pericarditis, Endocarditis, Myocarditis
Victor Politi, M.D., FACP
Medical Director, SVCMC, School of Allied Health Professions, Physician Assistant Program

2. The Pericardium Two layers - composed of fibrous tissue
inner visceral layer, attached to epicardium
outer parietal layer
stabilizes heart in anatomic position
protects heart - (contact with surrounding structures)

3. The Pericardium Can be a primary site of disease
involved in other disease processes that affect the heart
affected by other diseases of adjacent tissue

4. The pericardium can permit moderate changes in cardiac size, however, it cannot stretch rapidly enough to accommodate rapid dilation of the heart or accumulation of fluid w/o increasing intrapericardial/intracardiac pressure

5. Acute Pericarditis Acute inflammation of the pericardium Origin
infectious,systemic diseases,malignancy, radiation,drug toxicity,hemopericardium,other inflammatory processes in the myocardium or lung
Pathologic process often involves both the pericardium and the myocardium

6. Acute Pericarditis
Presentation & course may vary depending on the cause
syndromes often associated with
chest pain (pleuritic/postural)
dyspnea
pericardial friction rub (with or w/o evidence of fluid accumulation or constriction)
Fever & leukocytosis

7. Acute Pericarditis Chest x-ray ECG Echocardiogram
may show cardiac enlargement or pleural dx
ECG
generalized ST and T wave changes
characteristic progression (ST elevation, return to baseline, T wave inversion)
Echocardiogram
often normal in inflammatory pericarditis
may show pericardial effusions

8. Acute Pericarditis- Causes
viral infection
most common coxsackievirus, & echovirus
also- HIV,influenza,Epstein-Bar, varicella, hepatitis, mumps
bacterial infection
staphylococcus, Strep pneumoniae, B-hemolytic streptococci, Mycobacterium tuberculosis, lyme dz
Fungal infection
Malignancy

9. Acute Pericarditis - Causes
Drugs
procainamide,hydralazine,minoxidil
radiation
connective tissue disease(lupus,rheum)
uremia
myxedema
post-MI (Dressler’s syndrome)
Idiopathic

10. Acute Pericarditis - Clinical Features
Sudden or gradual onset of sharp or stabbing chest pain that radiates to the back, neck, left shoulder, arm, or trapezial ridge
Pain aggravated by movement or inspiration and by lying supine
sitting up and leaning forward reduces the pain

11. Acute Pericarditis - Clinical Features
Associated symptoms include;
low grade intermittent fever, dyspnea, dysphagia
transient, intermittent friction rub heard best at the lower left sternal border or apex is the most common physical finding

12. Acute Pericarditis - Clinical Features
Pericardial effusion
As the pericardium stretches,
effusions that develop slowly, even large ones, may not produce hemodynamic changes
However ….
those that appear rapidly (even small effusions) can cause tamponade

13. Acute Pericarditis - Clinical Features
Tamponade
elevated intrapericardial pressure (>15 mm Hg), that restricts venous return and ventricular filling - resulting in decreased stroke volume /pulse pressure and increased heart rate/venous pressure
most common complaints;dyspnea and decreased exercise tolerance
common symptoms; weight loss, pedal edema, ascites

14. Acute Pericarditis - Clinical Features
Tamponade
Physical Findings; tachycardia, low systolic BP, narrow pulse pressure, pulsus paradoxus, neck vein distention, distant heart sounds, RUQ pain

15. Acute Pericarditis - Diagnosis
ST-segment elevation
Pericarditis w/o other underlying cardiac disease does not typically produce dysrhythmias
Chest x-ray usually normal - but should be done to rule out other disease
Echocardiography

16. Acute Pericarditis - Diagnosis
Other Tests
CBC w/diff
BUN
Creatinine
streptococcal serology
appropriate vial serology
other serology (antinuclear and anti-DNA antibodies)
thyroid function studies
Sed rate, creatinine kinase levels w/isoenzymes

17. Viral Pericarditis Most commonly caused by coxsackievirus, & echovirus
Can also be caused by HIV, influenza, Epstein-Bar, varicella, hepatitis, mumps
Most commonly affects males < age 50
Diagnosis usually clinical
rising viral titers in paired sera may be obtained for confirmation of diagnosis
cardiac enzymes may be slightly elevated - indicating myocarditic component

18. Viral Pericarditis- Treatment
Generally symptomatic Tx
aspirin or NSAIDs
Corticosteroids -(unresponsive cases)
Symptoms generally subside over several days to weeks
May be recurrences - during first few weeks - months
Rarely, patients suffer from chronic recurrences resulting in constrictive pericarditis
Major early complication - tamponade (< 5% of cases)

19. Bacterial Pericarditis
staphylococcus, Strep, pneumoniae, B-hemolytic streptococci, Mycobacterium tuberculosis
Usually direct result from pulmonary infection
patients often present in a critically ill state
Borrelia burgdorferi (Lyme Disease organism) can also cause myopericarditis

20. Tuberculous Pericarditis
Rare in developed countries - common elsewhere
Results from direct lymphatic or hematogenous spread
commonly have associated pleural effusions & small to moderate pericardial effusions
subacute presentation/non-specific symptoms (fever, night sweats, fatigue)
Diagnosis inferred if acid-fast bacilli found elsewhere
Usual therapy - standard antituberculous drug
Complication- if therapy unsuccessful- constrictive pericarditis

21. Uremic Pericarditis Complication of renal failure
Occurs in untreated uremia and in stable dialysis patients
Presents with or w/o symptoms, typically afebrile
tamponade is common
usually resolves with institution or more aggressive dialysis
pericardiectomy may become necessary
indomethacin & systemic glucocorticoids ineffective for uremic pericarditis

22. Neoplastic pericarditis
Commonly caused by
breast and renal cell carcinoma, Hodgkin's Disease and lymphomas
neoplastic processes involving the pericardium are the most common cause of pericardial tamponade in many countries
presenting symptoms relate to the hemodynamic compromise of the primary disease process
MRI/CT

23. Neoplastic pericarditis
Prognosis poor - only small minority survive >year
Effusion can be drained, chemotherapeutic agents or tetracycline may prevent recurrence
pericardial windows rarely effective, partial pericardiectomy from a subxiphoid incision may be successful

24. Radiation Pericarditis
Usually occurs within the first year after exposure but can be delayed for many years
Symptomatic therapy - initial approach but recurrent effusions and constriction require surgery

25. Post MI or Postcardiotomy Pericarditis
An inflammatory reaction to transmural myocardial necrosis that usually occurs 2-5 days after infarction
typically presents as pain recurrence
audible rub, repolarization changes
spontaneous resolution usually occurs after a few days
Aspirin, NSAID’s -symptomatic relief

26. Dressler’s Syndrome
Occurs weeks to several months after MI or open heart surgery
Presentation
typical pain, fever, malaise, leukocytosis, elevated sed rate
large pericardial/pleural effusions common
Tamponade is rare if Dressler’s after MI, but more commonly seen in Dressler’s post-operatively

27. Dressler’s Syndrome
NSAID’s
Corticosteroids
Recurrences common

28. Constrictive Pericarditis

29. Constriction occurs when fibrous thickening and loss of elasticity of the pericardium results in interference of diastolic filling usually following inflammation

30. Cardiac trauma, open heart surgery, intrapericardial hemorrhage, fungal or bacterial pericarditis, and uremic pericarditis are the most common causes of constrictive pericarditis (in the past, tuberculosis was also included)

31. Constrictive Pericarditis - symptoms
Symptoms develop gradually and mimic those of restrictive cardiomyopathy (CHF, exercise dyspnea, decreased exercise tolerance)
chest pain, orthopnea, and paroxysmal nocturnal dyspnea are uncommon

32. Physical Exam Pedal edema hepatomegaly ascites JVD
Kussmaul’s sign(^jvp w/insp)
pericardial knock (early diastolic sound) heard at the apex
usually - no friction rub

33. Diagnosis
ECG - may show low voltage QRS complexes and inverted T waves
Chest x-ray - 50% of cases show pericardial calcification
Doppler echocardiography
Cardiac CT, MRI
Consider other diseases - acute pericarditis, myocarditis, exacerbation of chronic ventricular dysfunction, or systemic process (eg sepsis)

34. Treatment General supportive care - initial treatment
Symptomatic patients - pericardiectomy
Gentle diuresis
Treatment with appropriate antibiotics if agent is Id’d

35. Endocarditis
Infective endocarditis is defined as an infection of the endocardial surface of the heart, which may include one or more heart valves, the mural endocardium, or a septal defect

36. Endocarditis can be broken down into the following categories:
Native valve (acute and subacute) endocarditis
Prosthetic valve (early and late) endocarditis
Endocarditis related to intravenous drug use

37. Native valve endocarditis (acute and subacute)
Native valve acute endocarditis usually has an aggressive course. Virulent organisms, such as Staphylococcus aureus and group B streptococci, are typically the causative agents of this type of endocarditis.

38. Subacute endocarditis usually has a more indolent course than the acute form. Alpha-hemolytic streptococci or enterococci, usually in the setting of underlying structural valve disease, typically are the causative agents of this type of endocarditis.

39. Prosthetic valve endocarditis (early and late)
Early prosthetic valve endocarditis occurs within 60 days of valve implantation. Staphylococci, gram- negative bacilli, and Candida species are the common infecting organisms.

40. Prosthetic valve endocarditis (early and late)
Late prosthetic valve endocarditis occurs 60 days or more after valve implantation. Staphylococcus epidermidis, alpha-hemolytic streptococci, and enterococci are the common causative organisms.

41. Endocarditis related to intravenous drug use
Endocarditis in intravenous drug abusers commonly involves the tricuspid valve. S aureus is the most common causative organism
Infective endocarditis generally occurs as a consequence of nonbacterial thrombotic endocarditis, which results from turbulence or trauma to the endothelial surface of the heart.

42. Endocarditis
Increased mortality rates are associated with increased age, infection involving the aortic valve, development of congestive heart failure, central nervous system (CNS) complications, and underlying disease
Affects men more than women (2:1 ratio)
Affects all age groups - however, 50% of cases in adults over age 50

43. Endocarditis Most common symptoms - fever (90% of cases) and chills
Anorexia, weight loss, malaise, headache, myalgias, night sweats, shortness of breath, cough, or joint pains are common complaints
Dyspnea, cough, and chest pain are common complaints of intravenous drug users who have infective endocarditis

44. Endocarditis
Primary cardiac disease may present with signs of congestive heart failure due to valvular insufficiency
Heart murmurs are heard in approximately 85% of patients

45. Endocarditis
One or more classic signs of infective endocarditis are found in as many as 50% of patients. They include the following:
Petechiae - Common but nonspecific finding
Splinter hemorrhages - Dark red linear lesions in the nailbeds
Osler nodes - Tender subcutaneous nodules usually found on the distal pads of the digits
Janeway lesions - Nontender maculae on the palms and soles
Roth spots - Retinal hemorrhages with small, clear centers; rare and observed in only 5% of patients.

46. splinter hemorrhages and purpuric papules on the foot of a 10 year old boy with acute bacterial endocarditis

47. Splinter hemorrhages(Panel A) are normally seen under the fingernails
Splinter hemorrhages(Panel A) are normally seen under the fingernails. They are usually linear and red for the first two to three days and brownish thereafter. Panel B shows conjunctival petechiae. Osler's nodes (Panel C)are tender, subcutaneous nodules, often in the pulp of the digits or the thenar eminence. Janeway's lesions (Panel D) are nontender, erythematous, hemorrhagic, or pustular lesions, often on the palms or soles

48. Endocarditis
baseline studies, such as a complete blood count (CBC), electrolytes, creatinine, BUN, glucose, and coagulation panel
Blood cultures: Two sets of cultures have >90% sensitivity when bacteremia is present. Three sets of cultures improve sensitivity and may be useful when antibiotics have been administered previously

49. Endocarditis Echocardiogram
Transthoracic echocardiography has a sensitivity of approximately 60%. Transesophageal echocardiography has a sensitivity of more than 90% for valvular lesions

50. Endocarditis
Empiric antibiotic therapy is chosen based on the most likely infecting organisms. Native valve disease usually is treated with penicillin G and gentamicin for synergistic treatment of streptococci

51. Endocarditis
Patients with a history of IV drug use may be treated with nafcillin and gentamicin to cover for methicillin- sensitive staphylococci.

52. Endocarditis
Infection of a prosthetic valve may include methicillin-resistant Staphylococcus aureus; thus, vancomycin and gentamicin may be used, despite the risk of renal insufficiency

53. Endocarditis
Rifampin also may be helpful in patients with prosthetic valves or other foreign bodies; however, it should be used in addition to vancomycin or gentamicin.

54. Endocarditis
prophylaxis against infective endocarditis in patients at higher risk. Patients at higher risk include those with the following conditions:
Presence of prosthetic heart valve
History of endocarditis
History of rheumatic heart disease
Congenital heart disease with a high-pressure gradient lesion
Mitral valve prolapse with a heart murmur

55. Endocarditis
prophylaxis in patients before they undergo procedures that may cause transient bacteremia, such as the following:
Ear, nose, and throat (ENT) procedures associated with bleeding, including dental manipulations and nasal packing
Incision and drainage of an abscess
Anoscopy and Foley catheter placement when a urinary tract infection is present or suspected

56. Myocarditis

58. Myocarditis Inflammation of the myocardium
May be the result of systemic disorder or infectious agent ...usually follows an upper resp infection
Pericarditis frequently accompanies myocarditis
Drug induced, cytotoxic agents,also, cocaine

59. Myocarditis Bacterial cases include; Viral etiologies include;
Corynebacterium diphtheriae, Neisseria meningitides, Mycoplasma pneumoniae, and B-hemolytic streptococci
Viral etiologies include;
coxsackie B, echovirus, influenza, parainfluenza, Epstein-Barr, and HIV

60. Myocarditis -clinical features
Systemic signs/symptoms (fever, tachycardia, myalgias, headache, and rigors)
chest pain due to coexisting pericarditis
pericardial friction rub in cases of concomitant pericarditis
In severe cases - symptoms of progressive heart failure (CHF, pulmonary rales, pedal edema, etc.)

61. Diagnosis
Nonspecific ECG changes, atrioventricular block, prolonged QRS duration, or ST segment elevation (in cases of accompanying pericarditis)
normal chest x-ray
cardiac enzymes may be elevated
Differential diagnosis includes cardiac ischemia or infarction, valvular disease and sepsis

62. Treatment Supportive care
If bacterial cause suspected, antibiotics are appropriate
Myocardial biopsy may reveal inflammatory pattern
Many cases spontaneously resolve others progress to dilated cardiomyopathy

63. Questions ?