Presentation on theme: "Pericarditis, Endocarditis, Myocarditis"— Presentation transcript:
1 Pericarditis, Endocarditis, Myocarditis Victor Politi, M.D., FACPMedical Director, SVCMC, School of Allied Health Professions, Physician Assistant Program
2 The Pericardium Two layers - composed of fibrous tissue inner visceral layer, attached to epicardiumouter parietal layerstabilizes heart in anatomic positionprotects heart - (contact with surrounding structures)
3 The Pericardium Can be a primary site of disease involved in other disease processes that affect the heartaffected 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 lungPathologic process often involves both the pericardium and the myocardium
6 Acute PericarditisPresentation & course may vary depending on the causesyndromes often associated withchest pain (pleuritic/postural)dyspneapericardial 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 dxECGgeneralized ST and T wave changescharacteristic progression (ST elevation, return to baseline, T wave inversion)Echocardiogramoften normal in inflammatory pericarditismay show pericardial effusions
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 ridgePain aggravated by movement or inspiration and by lying supinesitting up and leaning forward reduces the pain
11 Acute Pericarditis - Clinical Features Associated symptoms include;low grade intermittent fever, dyspnea, dysphagiatransient, 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 effusionAs the pericardium stretches,effusions that develop slowly, even large ones, may not produce hemodynamic changesHowever ….those that appear rapidly (even small effusions) can cause tamponade
13 Acute Pericarditis - Clinical Features Tamponadeelevated intrapericardial pressure (>15 mm Hg), that restricts venous return and ventricular filling - resulting in decreased stroke volume /pulse pressure and increased heart rate/venous pressuremost common complaints;dyspnea and decreased exercise tolerancecommon symptoms; weight loss, pedal edema, ascites
15 Acute Pericarditis - Diagnosis ST-segment elevationPericarditis w/o other underlying cardiac disease does not typically produce dysrhythmiasChest x-ray usually normal - but should be done to rule out other diseaseEchocardiography
16 Acute Pericarditis - Diagnosis Other TestsCBC w/diffBUNCreatininestreptococcal serologyappropriate vial serologyother serology (antinuclear and anti-DNA antibodies)thyroid function studiesSed 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, mumpsMost commonly affects males < age 50Diagnosis usually clinicalrising viral titers in paired sera may be obtained for confirmation of diagnosiscardiac enzymes may be slightly elevated - indicating myocarditic component
18 Viral Pericarditis- Treatment Generally symptomatic Txaspirin or NSAIDsCorticosteroids -(unresponsive cases)Symptoms generally subside over several days to weeksMay be recurrences - during first few weeks - monthsRarely, patients suffer from chronic recurrences resulting in constrictive pericarditisMajor early complication - tamponade (< 5% of cases)
19 Bacterial Pericarditis staphylococcus, Strep, pneumoniae, B-hemolytic streptococci, Mycobacterium tuberculosisUsually direct result from pulmonary infectionpatients often present in a critically ill stateBorrelia burgdorferi (Lyme Disease organism) can also cause myopericarditis
20 Tuberculous Pericarditis Rare in developed countries - common elsewhereResults from direct lymphatic or hematogenous spreadcommonly have associated pleural effusions & small to moderate pericardial effusionssubacute presentation/non-specific symptoms (fever, night sweats, fatigue)Diagnosis inferred if acid-fast bacilli found elsewhereUsual therapy - standard antituberculous drugComplication- if therapy unsuccessful- constrictive pericarditis
21 Uremic Pericarditis Complication of renal failure Occurs in untreated uremia and in stable dialysis patientsPresents with or w/o symptoms, typically afebriletamponade is commonusually resolves with institution or more aggressive dialysispericardiectomy may become necessaryindomethacin & systemic glucocorticoids ineffective for uremic pericarditis
22 Neoplastic pericarditis Commonly caused bybreast and renal cell carcinoma, Hodgkin's Disease and lymphomasneoplastic processes involving the pericardium are the most common cause of pericardial tamponade in many countriespresenting symptoms relate to the hemodynamic compromise of the primary disease processMRI/CT
23 Neoplastic pericarditis Prognosis poor - only small minority survive >yearEffusion can be drained, chemotherapeutic agents or tetracycline may prevent recurrencepericardial 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 yearsSymptomatic 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 infarctiontypically presents as pain recurrenceaudible rub, repolarization changesspontaneous resolution usually occurs after a few daysAspirin, NSAID’s -symptomatic relief
26 Dressler’s SyndromeOccurs weeks to several months after MI or open heart surgeryPresentationtypical pain, fever, malaise, leukocytosis, elevated sed ratelarge pericardial/pleural effusions commonTamponade is rare if Dressler’s after MI, but more commonly seen in Dressler’s post-operatively
27 Dressler’s SyndromeNSAID’sCorticosteroidsRecurrences common
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 apexusually - no friction rub
33 DiagnosisECG - may show low voltage QRS complexes and inverted T wavesChest x-ray - 50% of cases show pericardial calcificationDoppler echocardiographyCardiac CT, MRIConsider other diseases - acute pericarditis, myocarditis, exacerbation of chronic ventricular dysfunction, or systemic process (eg sepsis)
34 Treatment General supportive care - initial treatment Symptomatic patients - pericardiectomyGentle diuresisTreatment with appropriate antibiotics if agent is Id’d
35 EndocarditisInfective 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) endocarditisProsthetic valve (early and late) endocarditisEndocarditis 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 organismInfective endocarditis generally occurs as a consequence of nonbacterial thrombotic endocarditis, which results from turbulence or trauma to the endothelial surface of the heart.
42 EndocarditisIncreased mortality rates are associated with increased age, infection involving the aortic valve, development of congestive heart failure, central nervous system (CNS) complications, and underlying diseaseAffects 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 complaintsDyspnea, cough, and chest pain are common complaints of intravenous drug users who have infective endocarditis
44 EndocarditisPrimary cardiac disease may present with signs of congestive heart failure due to valvular insufficiencyHeart murmurs are heard in approximately 85% of patients
45 EndocarditisOne or more classic signs of infective endocarditis are found in as many as 50% of patients. They include the following:Petechiae - Common but nonspecific findingSplinter hemorrhages - Dark red linear lesions in the nailbedsOsler nodes - Tender subcutaneous nodules usually found on the distal pads of the digitsJaneway lesions - Nontender maculae on the palms and solesRoth 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 Endocarditisbaseline studies, such as a complete blood count (CBC), electrolytes, creatinine, BUN, glucose, and coagulation panelBlood 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 EndocarditisEmpiric 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 EndocarditisPatients with a history of IV drug use may be treated with nafcillin and gentamicin to cover for methicillin- sensitive staphylococci.
52 EndocarditisInfection of a prosthetic valve may include methicillin-resistant Staphylococcus aureus; thus, vancomycin and gentamicin may be used, despite the risk of renal insufficiency
53 EndocarditisRifampin 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 Endocarditisprophylaxis against infective endocarditis in patients at higher risk. Patients at higher risk include those with the following conditions:Presence of prosthetic heart valveHistory of endocarditisHistory of rheumatic heart diseaseCongenital heart disease with a high-pressure gradient lesionMitral valve prolapse with a heart murmur
55 Endocarditisprophylaxis 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 packingIncision and drainage of an abscessAnoscopy and Foley catheter placement when a urinary tract infection is present or suspected
58 Myocarditis Inflammation of the myocardium May be the result of systemic disorder or infectious agent ...usually follows an upper resp infectionPericarditis frequently accompanies myocarditisDrug induced, cytotoxic agents,also, cocaine
59 Myocarditis Bacterial cases include; Viral etiologies include; Corynebacterium diphtheriae, Neisseria meningitides, Mycoplasma pneumoniae, and B-hemolytic streptococciViral 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 pericarditispericardial friction rub in cases of concomitant pericarditisIn severe cases - symptoms of progressive heart failure (CHF, pulmonary rales, pedal edema, etc.)
61 DiagnosisNonspecific ECG changes, atrioventricular block, prolonged QRS duration, or ST segment elevation (in cases of accompanying pericarditis)normal chest x-raycardiac enzymes may be elevatedDifferential diagnosis includes cardiac ischemia or infarction, valvular disease and sepsis
62 Treatment Supportive care If bacterial cause suspected, antibiotics are appropriateMyocardial biopsy may reveal inflammatory patternMany cases spontaneously resolve others progress to dilated cardiomyopathy