Presentation on theme: "Acute Pericarditis Emory Family Medicine"— Presentation transcript:
1Acute Pericarditis Emory Family Medicine Susan Schayes M.D.Assistant Professor-CTFamily Medicine, Emory University School of MedicineIAFP 2002
2The PericardiumA fibroelastic sac composed of visceral and parietal layersBoth these layers are separated by a pericardial cavity.The cavity normally contains 15 to 50 ml of straw-colored fluid.Visceral layer is in contact with the epicardium (ST elevation)
3The Clinical problemCan be an isolated entity or part of a systemic disease0.1% of all hospitalized patients5% of ER visits for chest pain without an MI
5Other PearlsViral and Autoimmune causes constitute > 50% of cases of acute pericarditisPericardial disease is the most frequent cardiovascular manifestation of AIDSThe typical diffuse ST elevation is not seen in uremic pericarditis,in which there is fibrin deposition in the parietal layer but no epicardial inflammation.
6Clinical Presentation Chest painPericardial friction rubDiffuse ST segment elevation on EKGPericardial effusionPresence of at least two of the above features is necessary to make the diagnosis
7Chest Pain Retrosternal in location Sudden in onset Pleuritic and sharp in natureExacerbated by inspirationWorsens when supine and improves upon sitting upright or leaning forward.Can often radiate to the neck, arms, or left shoulder.Radiation to one or both trapezius muscle ridges, suggests a probable pericarditis (phrenic nerve traverses the pericardium)
8Pericardial Friction Rub Present in 85% of cases of pericarditisHighly specific with a variable sensitivityA high-pitched scratchy or squeaky sound best heard with the diaphragm at the LSB with the patient leaning forward.Corresponds temporally to the movement of heart within the pericardial sac.Has 3 components, which correspond to atrial systole, ventricular systole, and early diastole.Pericardial friction rub is audible throughout the respiratory cycle, whereas the pleural rub disappears when respirations are on hold.
9EKG in PericarditisWidespread upward concave ST-segment elevation and PR-segment depressionIf the ratio of ST-segment elevation to T-wave amplitude in V6 > 0.24, acute pericarditis is almost always present.The EKG changes have 4 phases during the course of illness
11EKG Stages Stage I Stage II Stage III Stage IV first few days 2 weeksST elevation, PR depressionup to 50% of pt with symptoms / rub do NOT have or evolve into stage IStage IIlast days weeksNormalization of ST and PR segmentsST returns to baseline, flat T wavesStage IIIafter 2-3 weeks, lasts several weeksWidespread T wave inversionStage IVlasts up to several monthsgradual resolution of T wave changes
17Pericarditis vs Early Repolarization Acute PericarditisEarly RepolarizationSexEitherUsually MaleAgeAnyUsually < 40PR segment devCommonUncommonT wavesnl, blunttall, peakedJ-ST / T ampl> 25%<25%Tallest precordial RUsually V5Usually V4
18Early RepolarizationJ point and ST segment elevation is most prominent in V4 to V6.The ST segment maintains its normal configuration and is slightly concave
19Pericarditis vs AMI Pericarditis MI ST segment Diffuse,concave elevation in all leads except aVR+ V6 w/o reciprocal changesHeight Not > 5mmLocalized, convex, with reciprocal changes in infarctHeight may be > 5 mmPR depressionFrequentAlmost neverQ wavesNot usual, unless with infarctCommon with q wave infarctT wavesInverted after J returns to baselineT inversions and ST ↑ are not seen simultaneously on the same EKGInverted while ST still elevatedT inversions and ST ↑ can be seen simultaneously on the same EKGArrhythmiasRareConduction disturbancesfrequent
21Laboratory testing Laboratory abnormalities CBC – very high WBC (purulent pericarditis)↑ESRChem-7 (uremic etiology)↑CRPHIV in selected casesANARheumatoid factorBlood cultures if febrileViral cultures and antibody testing not indicated
22Cardiac Isoenzymes - ? helpful MB fraction of CK and Troponin I are modestly elevatedThe rise in TnI is related to the extent of myocardial inflammation.Features associated with a rise in Tn I are younger age,male gender,presence of effusion and a recent infectionEnzyme rise is transient,resolving within the first week, persistent ↑ suggest myopericarditisNot reliable to differentiate MI vs pericarditisTwo studies that included 187 patients with idiopathic pericarditis ,TnI was detectable in 32-49% and in 8-22% it was >1.5 mcg/mlAnother 2 year ER based study-Out of 14 pts with 2/3 findings (typical CP, rub, and ECG changes)71% had elevated Tn I with negative CAD workup
23Other Studies Tuberculin skin testing Echocardiogram Chest X-ray Normal unless there is an effusionPresence of effusion supports the diagnosis, but absence does not exclude it.The ACC/AHA/ASE all recommend to obtain an echo in any suspected pericardial diseaseChest X-rayRecommended in all casesTypically normalEnlarged cardiac silhouette in effusion (with clear lung fields)
24Need for hospitalization Many physicians tend to admit them, but this may not be necessary.Uncomplicated acute pericarditis can undergo initial evaluation in a same day hospital facility or clinic, with an outpatient follow-upFeatures of high risk include:Subacute symptoms (eg, developing over several days or weeks)High fever (>38ºC [100.4ºF]) and leukocytosisEvidence suggesting cardiac tamponadeA large pericardial effusionImmunosuppressed stateA history of oral anticoagulant therapyAcute traumaFailure to respond within seven days to NSAID therapy, a generous allocation of timeElevated cardiac troponin, suggestive of myopericarditis
25Complications Pericardial Effusion/ Tamponade Constrictive Pericarditiscan be “transient” – 10% may have transient within 1st month, resolves by 3 monthsRecurrent Pericarditis (15-32%)Recurrent sx after the initiating event is no longer activeMost likely an autoimmune etiologyRx : NSAIDS/ Colchicine +/- steroids
26Treatment Goals of acute therapy: Relieve PainTreat the inflammationPrevent Cardiac tamponadeMost viral infections are self-limitedTreat the underlying disease processDrain purulent effusionsSymptomatic therapyNone of the treatments unfortunately, have not been proven to prevent the complications.
27NSAIDsMay require weeks to months of treatment with high doses of NSAIDsThe choice is usually empiric, based on the physician’s familiarity with the agent and/or its availability.Rapidly titrate the dose within 1–2 days to achieve maximum symptomatic reliefEvaluate for a response within 1–2 wks,Sx usually subside in a week.If adequate clinical response,continue NSAIDs for 1 wk after complete resolution of Sx and then taper in 2–3 days.
28Preferred in patients with CAD Ibuprofen NSAIDsAspirin2-6 gm daily650mg Q3-4 hrsPreferred in patients with CADIbuprofenmg daily mg q 6-8 hrsabove average response rate and has a very good side effect profileIndomethacinmg dailyTry to avoid, unless absolutely needed as it can ↓ coronary blood flow.Nonsteroidal Anti-inflammatory Drugs in the Treatment of Pericarditis: Clinical ReviewSCHIFFERDECKER, BRANISLAV MD; SPODICK, DAVID H. MD, DScCardiology Review ; Volume 11(4), July/August 2003, pp
29Colchicine A prospective, randomized, open-label design was used. 120 patients with a first episode of acute pericarditis were randomly assigned toconventional treatment with aspirin (group I) orconventional treatment plus colchicine 1.0 to 2.0 mg for the first day and then 0.5 to 1.0 mg/d for 3 months (group II).Colchicine significantly reduced the recurrence rate (10.7% vs 32.3%; P=0.004;) and presence of symptoms at 72 hours (11.7% vs 36.7%; P=0.003).Based upon this, addition of it to the Rx regimen for an initial episode of acute pericarditis is an option for physicians.Colchicine in Addition to Conventional Therapy for Acute PericarditisResults of the COlchicine for acute PEricarditis (COPE) TrialCirculation. 2005;112: /CIRCULATIONAHA eeeeew
30Steroids In patients refractory to NSAIDs and colchicine Steroid therapy with initial episode is more likely associated with recurrent episodes.Evidence available argues against the routine administration of corticosteroids during a first episode of acute pericarditisSpecific conditions that will benefit:Acute pericarditis due to connective tissue diseasesAuto-immune pericarditisUremic pericarditis
31Myocardial Infarction-Associated Pericarditis Early post MI pericarditis is a consequence of transmural infarction.Aspirin is the drug of choice in this setting. (650 mg Q4h)Late MI associated pericarditis (Dressler syndrome), occurs days to months after infarction,Autoimmune in etiology.NSAIDs are the treatment of choice.Colchicine seems to be the most effective if NSAIDs failCorticosteroids seem to provide symptomatic benefit but do not prevent recurrence.Pericardiectomy is only rarely curative
32Summary Etiology of Acute Pericarditis Clinical Presentation and EKG findingsDifferential DiagnosisEvaluationTreatment