acute pericarditis and pericardial effusion meghan york october 15, 2008

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Page 1: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008
Page 2: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Acute Acute Pericarditis and Pericarditis and

Pericardial Pericardial EffusionEffusionMeghan YorkMeghan York

October 15, 2008October 15, 2008

Page 3: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

OutlineOutline

1)1) Anatomy of pericardiumAnatomy of pericardium

2)2) Overview of pericardial diseaseOverview of pericardial disease

3)3) EtiologyEtiology

4)4) Clinical presentationClinical presentation

5)5) Ancillary diagnosticsAncillary diagnostics

6)6) Echocardiography in evaluation Echocardiography in evaluation

Page 4: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

AnatomyAnatomy Normal amount of Normal amount of

pericardial fluid: 15-pericardial fluid: 15-50 cc50 cc

Two layers:Two layers: Outer layer is the Outer layer is the

parietal pericardium parietal pericardium and consists of layers and consists of layers of fibrous and serous of fibrous and serous tissuetissue

Inner layer is visceral Inner layer is visceral pericardium and pericardium and consists of serous consists of serous tissue onlytissue only

Page 5: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

PericardiumPericardium Fibroelastic sac Fibroelastic sac

consisting of 2 consisting of 2 layerslayers Visceral at Visceral at

epicardial sideepicardial side Parietal at Parietal at

mediastinal mediastinal sideside

Pericardial fluid Pericardial fluid formed from formed from ultrafiltrate of ultrafiltrate of plasmaplasma

Page 6: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Diseases of the Diseases of the PericardiumPericardium

Acute Fibrinous PericarditisAcute Fibrinous Pericarditis Pericardial EffusionPericardial Effusion

Without cardiac tamponadeWithout cardiac tamponade Cardiac tamponadeCardiac tamponade

Recurrent PericarditisRecurrent Pericarditis Constrictive PericarditisConstrictive Pericarditis

Page 7: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Epidemiology of Acute Epidemiology of Acute PericarditisPericarditis

0.1% of hospitalized patients0.1% of hospitalized patients 5% of patients admitted to 5% of patients admitted to

Emergency Department for non-Emergency Department for non-acute myocardial infarction chest acute myocardial infarction chest painpain

Page 8: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Major Causes of Pericardial Major Causes of Pericardial DiseaseDisease

1)Infection1)Infection2)Radiation2)Radiation3)Neoplasm3)Neoplasm4)Cardiac4)Cardiac5)Trauma5)Trauma6)Autoimmune6)Autoimmune7)Drugs7)Drugs8)Metabolic8)Metabolic

*viral, autoreactive, and neoplastic most *viral, autoreactive, and neoplastic most common diagonsiscommon diagonsis

Page 9: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Etiology of Acute Etiology of Acute Pericarditis: InfectiousPericarditis: Infectious

a) viral a) viral -adenovirus-adenovirus-enterovirus-enterovirus--

cytomegaloviruscytomegalovirus-influenza-influenza-hepatitis B-hepatitis B-herpes simplex-herpes simplex-echovirus-echovirus-mumps-mumps

b) mycoplasmab) mycoplasma

c)Fungalc)Fungal

d)Parasiticd)Parasitic

e)Bacteriale)Bacterial-staph-staph-strep-strep-pneumococcus-pneumococcus-haemophilus-haemophilus-neisseria-neisseria-chlamydia-chlamydia-legionella-legionella-tuberculous-tuberculous-lyme disease-lyme disease

Page 10: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Etiology: continuedEtiology: continued2) Radiation2) Radiation

3)Neoplasm3)Neoplasm-metastatic-metastatic-primary cardiac-primary cardiac-paraneoplastic-paraneoplastic

4)Cardiac4)Cardiac-early infarction-early infarction-Dressler’s-Dressler’s-myocarditis-myocarditis-aortic dissection-aortic dissection

5)Trauma5)Trauma-blunt-blunt-iatrogenic (perforations, -iatrogenic (perforations, post-surg)post-surg)

6)Autoimmune6)Autoimmune-rheumatic disease-rheumatic disease-non-rheumatic-non-rheumatic

-Wegners, sarcoid, IBD-Wegners, sarcoid, IBD

Page 11: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Etiology: continuedEtiology: continued

7)Drugs7)Drugs

-drug induced -drug induced lupuslupus

hydralazinehydralazine

isoniazidisoniazid

procainamideprocainamide

-doxorubicin-doxorubicin

-phenytoin-phenytoin

8)Metabolic8)Metabolic

-hypothyroid-hypothyroid

-uremia-uremia

-ovarian -ovarian hyperstimulationhyperstimulation

Page 12: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Lab TestingLab Testing Of note, the historic yield of diagnostic Of note, the historic yield of diagnostic

evaluation is low, typically only in evaluation is low, typically only in approximately 16% of patients is etiology approximately 16% of patients is etiology determined.determined.

More recently, evaluation of pericardial More recently, evaluation of pericardial fluid and tissue with tumor markers, fluid and tissue with tumor markers, PCR, immunohistochemistry, PCR, immunohistochemistry, flourescence-activated cell sorting has flourescence-activated cell sorting has shown a trend toward higher yield of shown a trend toward higher yield of diagnosisdiagnosis

Page 13: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Diagnosis: Presence of two of the Diagnosis: Presence of two of the following necessaryfollowing necessary

Chest painChest pain Sudden onsetSudden onset localized to anterior chest walllocalized to anterior chest wall pleuriticpleuritic sharpsharp Positional: may improve if pt leans Positional: may improve if pt leans

forward, worse with lying flatforward, worse with lying flat Cardiac auscultation: Pericardial friction rubCardiac auscultation: Pericardial friction rub

Present in up to 85% of pts with Present in up to 85% of pts with pericarditis without effusionpericarditis without effusion

friction of the two inflamed layers of friction of the two inflamed layers of pericardium, typically triphasic rub, pericardium, typically triphasic rub, heard with diaphragm of stethoscope at heard with diaphragm of stethoscope at left sternal borderleft sternal border

Characteristic ECG changesCharacteristic ECG changes Pericardial effusionPericardial effusion

Page 14: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Pertinent Lab ResultsPertinent Lab Results Elevated C reactive protein level (such Elevated C reactive protein level (such

a strong correlation that normal CRP a strong correlation that normal CRP makes acute pericarditis diagnosis less makes acute pericarditis diagnosis less likely)likely)

Elevated CK, CK-MB, and Troponin (can Elevated CK, CK-MB, and Troponin (can be normal)be normal) Often elevated Troponin aloneOften elevated Troponin alone Indicates inflammation of Indicates inflammation of

myocardium just beneath the visceral myocardium just beneath the visceral pericardiumpericardium

Not associated with worse outcomesNot associated with worse outcomes

LeukocytosisLeukocytosis

Page 15: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

ECG Findings: 60% of ECG Findings: 60% of patientspatients

Stage 1: hours to daysStage 1: hours to days Diffuse ST elevation Diffuse ST elevation

-sensitive v5-v6, -sensitive v5-v6, I, III, II

ST depression I/aVRST depression I/aVR PR elevation aVRPR elevation aVR PR depression diffuse PR depression diffuse

-especially v5-v6-especially v5-v6 PR change is marker PR change is marker

of atrial injuryof atrial injury Stage 2:Stage 2:

NormalizationNormalization

Page 16: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

ECG changes over weeksECG changes over weeks

Stage 3:Stage 3: Diffuse T wave Diffuse T wave

inversionsinversions ST segments ST segments

isoelectricisoelectric

Stage 4:Stage 4: EKG may EKG may

normalizenormalize T wave inversions T wave inversions

may persist may persist indefinitelyindefinitely

Page 17: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

STEMI or Pericarditis by STEMI or Pericarditis by ECGECG

ST elevation in ST elevation in pericarditispericarditis Starts at J pointStarts at J point Rarely exceeds 5mmRarely exceeds 5mm Retains normal Retains normal

concavityconcavity Non-localizingNon-localizing

Arrhythmias very Arrhythmias very unlikely in unlikely in pericarditis (suggest pericarditis (suggest myocarditis or MI)myocarditis or MI)

Page 18: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Acute PericarditisAcute Pericarditis

51yo man with acute onset sharp 51yo man with acute onset sharp substernal chest pain two days priorsubsternal chest pain two days prior

Page 19: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Pericardial EffusionPericardial Effusion

Low voltage and Electric AlternansLow voltage and Electric Alternans

Page 20: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Echocardiographic Echocardiographic FindingsFindings

Echo is typically normal in Echo is typically normal in acute pericarditis unless acute pericarditis unless associated with pericardial associated with pericardial effusioneffusion

Page 21: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

ACC/AHA/ASE 2003 ACC/AHA/ASE 2003 guideline update for the guideline update for the

clinical application of clinical application of echocardiography: echocardiography: summary article summary article

Recommended specific Recommended specific circumstances for use of circumstances for use of echocardiography in pericardial echocardiography in pericardial diseasedisease

Page 22: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Class I RecommendationsClass I Recommendations

1. Patients with suspected 1. Patients with suspected pericardial disease, including pericardial disease, including effusion, constriction, or effusion, constriction, or effusive-constrictive process.effusive-constrictive process.

2. Patients with suspected 2. Patients with suspected bleeding in the pericardial space, bleeding in the pericardial space, eg, trauma, perforation, etc.eg, trauma, perforation, etc.

Page 23: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Class I (continued)Class I (continued)

3. Follow-up study to evaluate 3. Follow-up study to evaluate recurrence of effusion or to diagnose recurrence of effusion or to diagnose early constriction. Repeat studies early constriction. Repeat studies may be goal directed to answer a may be goal directed to answer a specific clinical questionspecific clinical question

4. Pericardial friction rub developing 4. Pericardial friction rub developing in acute myocardial infarction in acute myocardial infarction accompanied by symptoms such as accompanied by symptoms such as persistent pain, hypotension, and persistent pain, hypotension, and nauseanausea..

Page 24: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Class IIaClass IIa

1)Follow-up studies to detect early 1)Follow-up studies to detect early signs of tamponade in the presence signs of tamponade in the presence of large or rapidly accumulating of large or rapidly accumulating effusions. A goal-directed study effusions. A goal-directed study may be appropriate.may be appropriate.

2)Echocardiographic guidance and 2)Echocardiographic guidance and monitoring of pericardiocentesis.monitoring of pericardiocentesis.

Page 25: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Class IIbClass IIb

1) Postsurgical pericardial disease, 1) Postsurgical pericardial disease, including postpericardiotomy including postpericardiotomy syndrome, with potential for syndrome, with potential for hemodynamic impairment.hemodynamic impairment.

2) In the presence of a strong 2) In the presence of a strong clinical suspicion and clinical suspicion and nondiagnostic TTE, TEE nondiagnostic TTE, TEE assessment of pericardial assessment of pericardial thickness to support a diagnosis of thickness to support a diagnosis of constrictive pericarditis.constrictive pericarditis.

Page 26: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Effusion: 2D Parasternal Effusion: 2D Parasternal LongLong

Page 27: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Pericardial Fat PadPericardial Fat Pad

Often pericardial fat pads can be Often pericardial fat pads can be seen in this view anterior to the seen in this view anterior to the RVOTRVOT

Fat pads usually not seen Fat pads usually not seen elsewhereelsewhere

Page 28: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Effusion: Parasternal Effusion: Parasternal Short AxisShort Axis

Page 29: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Posterior EffusionsPosterior Effusions

Pericardial effusions can track Pericardial effusions can track posteriorly toward sinusposteriorly toward sinus

In this case, may only be seen in In this case, may only be seen in axial 4 chamber viewaxial 4 chamber view

Page 30: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008
Page 31: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Effusion: 2D ApicalEffusion: 2D Apical

Page 32: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

TamponadeTamponade Hypotension caused by pericardial fluid Hypotension caused by pericardial fluid

under pressure under pressure Diagnostic techniquesDiagnostic techniques

2D looking for RA/RV collapse during diastole2D looking for RA/RV collapse during diastole M-mode for RA/RV collapse during diastoleM-mode for RA/RV collapse during diastole Doppler of Mitral and Tricuspid inflowDoppler of Mitral and Tricuspid inflow

Mitral inflow to decrease by 25% with inspirationMitral inflow to decrease by 25% with inspiration Tricuspid inflow increased by 40% with inspirationTricuspid inflow increased by 40% with inspiration

IVC diameter fails to increase with inspirationIVC diameter fails to increase with inspiration

Page 33: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Tamponade: 2DTamponade: 2D

Page 34: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Tamponade: M-ModeTamponade: M-Mode

Page 35: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Tamponade: DopplerTamponade: DopplerMitral InflowMitral Inflow

Page 36: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Chest X rayChest X ray Normal in Normal in

patients with patients with acute pericarditis acute pericarditis unless pericardial unless pericardial effusion is effusion is presentpresent

Enlarged cardiac Enlarged cardiac silhouettesilhouette

Requires 200cc of Requires 200cc of fluidfluid

Page 37: Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

Fibrinous PericarditisFibrinous Pericarditis