acute pericarditis and pericardial effusion meghan york october 15, 2008
TRANSCRIPT
Acute Acute Pericarditis and Pericarditis and
Pericardial Pericardial EffusionEffusionMeghan YorkMeghan York
October 15, 2008October 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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)
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
Pericardial EffusionPericardial Effusion
Low voltage and Electric AlternansLow voltage and Electric Alternans
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
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
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.
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..
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.
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.
Effusion: 2D Parasternal Effusion: 2D Parasternal LongLong
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
Effusion: Parasternal Effusion: Parasternal Short AxisShort Axis
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
Effusion: 2D ApicalEffusion: 2D Apical
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
Tamponade: 2DTamponade: 2D
Tamponade: M-ModeTamponade: M-Mode
Tamponade: DopplerTamponade: DopplerMitral InflowMitral Inflow
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
Fibrinous PericarditisFibrinous Pericarditis