1. Acute Pericarditis/ ECG conference Jimmy Klemis, MD Jan 8, 2002

2. Pericardium  Visceral / serous –Direct contact with epicardium (ST elev) – single layer mesothelial cells  Parietal / fibrous – mesothelial and fibrous layer

3. Pericardial Anatomy Visceral – transparent Parietal – translucent Transverse sinus – curved probe

4. Etiology – Acute Pericarditis  Infectious – Viral : Coxsackie, Echo, EBV, Influenza, HIV – Bacterial: TB, staph, hemophillus, pneumococcal, salmonella – Fungal/other: histo/blasto/coccidio, rickettsia  Rheumatologic –SLE, Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis, Scleroderma, PAN  Neoplastic –Primary: angiosarcoma, mesothelioma –Metastatic: breast, lung, lymphoma, melanoma, leukemia  Immunologic –Celiac sprue, Inflammatory Bowel Disease  Drug –Hydralizine, Procainamide  Other –MI, Dressler’s, Post Pericardiotomy, Chest Trauma, Aortic dissection – Uremic, Post Radiation – IDIOPATHIC

5. Acute Pericarditis – Clinical  History – preceding viral illness, etc  Symptoms –Chest pain  Signs – Friction Rub  ECG – early: PR / ST changes – late: isoelectric ST/ T inv

6. History  Often preceding viral illness 1-2wk prior  Chest Pain –Sudden, sharp,pleuritic, constant – worse supine/ L lat decub, relief sitting up – radiation: back, trapezius ridge – symptoms usually resolve by 2 weeks, ECG abnormalities may persist for months

7. Auscultory – Rub(s)  Endopericardial (classic) – “triphasic”: atrial sys, ventricular sys, early diastole – may only hear 2 phase (afib or tachycardia) or 1 – loudest LSB, raised extremities/increased venous return  Pleuropericardial – “exopericardial”, extension into adjacent structures – marked resp variation, musical quality  Conus – dilation of pulm conus in hyperactive heart – PE, thyroid storm, acute beriberi  Pneumohydropericardium –air/gas overlying pcard fluid – metallic tinkle (small amt) ; churning/splashing “mill-wheel sound” (lg)

8. ECG  PR depression  ST elevation – concave up, ST/T V6 >.25, no reciprocal  DDx: – Acute MI – Early Repolarization – Myocarditis – Aneurysm – other: Brugada, BBB

9. ECG

10. Acute Pericarditis - Stages  Stage I – first few days  2 weeks – ST elev, PR depression – up to 50% of pt with sxs/rub do NOT have/evolve stage I 1  Stage II – last days  weeks – ST returns to baseline, flat T  Stage III – after 2-3 weeks, lasts several weeks – T wave inversion  Stage IV – lasts up to several months – gradual resolution of T wave changes 1 Spodick DH, Pericardial Disease. Braunwauld 6 th

11. Acute PCARD – Stage I, II 60 y/o man with acute PCARD on presentation and after 1 mo resolution of sxs, * Marriott’s Practical ECG 10 th ed, p 208

12. Acute PCARD – Stage III 19 y/o Female after 1 wk in hospital with Acute Pericarditis

13. DDx: PCARD vs Repol Acute Pericarditis Early Repolarization SexEither Usually Male AgeAny Usually < 40 PR segment dev CommonUncommon T waves nl, blunt tall, peaked J-ST / T ampl V6 > 25% <25% Tallest precordial R Usually V5 Usually V4

14. DDx: PCARD vs MI Pericarditis Angina, ischemia J-ST Diffuse concave elevation w/o reciprocal changes Localized, convex, w/ reciprocal changes in infarct PR depression Frequent Almost never Q waves Not usual, unless with infarct Common with q wave infarct T waves Inverted after J returns to baseline Inverted while ST still elevated ArrhythmiaRareFrequent Conduction disturbances Rarefrequent

15. Cardiac Isoenzymes - ? helpful  2 year study, ER based 1 – 14 pt with 2/3 findings (CP typical for PCARD, rub, and ECG changes c/w PCARD) – 71% had elevated TropI (pk 21) with negative CAD workup  Not reliable to differentiate MI vs PCARD 1 Brandt RR, et al. Am J Card 2001, June 1

16. Treatment  NSAIDS/ASA – ASA 650 q3-4hr – Ibuprofen 300-600 q 6-8 hrs x 1-4days  Avoid Indocin, reduces CBF  Steroids – if no response after 48hr NSAID – use concurrent NSAID  Colchicine –.6 q12 chronic +/- NSAID – useful in recurrent pericarditis – symptom free period 3.1 +/- 3mos vs 43 +/- 35mos (p<.00001) in largest multicenter trial to date 1 in largest multicenter trial to date 1 –Anecdotal evidence of benefit in Acute PCARD, effusion 1 Adler Y, et al. Circulation, 1998 June 2

17. Complications  Pericardial Effusion/Tamponade  Constrictive Pericarditis – can be “transient” – 10% may have transient sxs within 1 st month, resolves by 3 months  Recurrent Pericarditis (20-25%) –Rx – NSAIDS/Colchicine +/- steroids

18. Gross Pathology “Bread & Butter” appearanceFibrinous stranding

19. Acute PCARD – Stage I

20. ECG Quiz Acute Pericarditis, Stage I

21. ECG quiz 2 Acute Ant MI

22. ECG quiz 3 Early Repolarization

23. ECG quiz 4 Early Repolarization

24. ECG Quiz 5 Pericardial dz, diffuse ST elev

25. ECG Quiz 6

26. ECG Quiz 6a Acute antseptal MI

27. ECG Quiz 7 Early Repolarization

28. ECG quiz 8 Incomplete RBBB