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Acute Pericarditis and Pericardial Effusion

Acute Pericarditis and Pericardial Effusion. Meghan York October 15, 2008. Outline. Anatomy of pericardium Overview of pericardial disease Etiology Clinical presentation Ancillary diagnostics 6) Echocardiography in evaluation. Anatomy. Normal amount of pericardial fluid: 15-50 cc

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Acute Pericarditis and Pericardial Effusion

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  1. Acute Pericarditis and Pericardial Effusion Meghan York October 15, 2008

  2. Outline • Anatomy of pericardium • Overview of pericardial disease • Etiology • Clinical presentation • Ancillary diagnostics 6) Echocardiography in evaluation

  3. Anatomy • Normal amount of pericardial fluid: 15-50 cc • Two layers: • Outer layer is the parietal pericardium and consists of layers of fibrous and serous tissue • Inner layer is visceral pericardium and consists of serous tissue only

  4. Pericardium • Fibroelastic sac consisting of 2 layers • Visceral at epicardial side • Parietal at mediastinal side • Pericardial fluid formed from ultrafiltrate of plasma

  5. Diseases of the Pericardium • Acute Fibrinous Pericarditis • Pericardial Effusion • Without cardiac tamponade • Cardiac tamponade • Recurrent Pericarditis • Constrictive Pericarditis

  6. Epidemiology of Acute Pericarditis • 0.1% of hospitalized patients • 5% of patients admitted to Emergency Department for non-acute myocardial infarction chest pain

  7. Major Causes of Pericardial Disease 1)Infection 2)Radiation 3)Neoplasm 4)Cardiac 5)Trauma 6)Autoimmune 7)Drugs 8)Metabolic *viral, autoreactive, and neoplastic most common diagonsis

  8. a) viral -adenovirus -enterovirus -cytomegalovirus -influenza -hepatitis B -herpes simplex -echovirus -mumps b) mycoplasma c)Fungal d)Parasitic e)Bacterial -staph -strep -pneumococcus -haemophilus -neisseria -chlamydia -legionella -tuberculous -lyme disease Etiology of Acute Pericarditis: Infectious

  9. 2) Radiation 3)Neoplasm -metastatic -primary cardiac -paraneoplastic 4)Cardiac -early infarction -Dressler’s -myocarditis -aortic dissection 5)Trauma -blunt -iatrogenic (perforations, post-surg) 6)Autoimmune -rheumatic disease -non-rheumatic -Wegners, sarcoid, IBD Etiology: continued

  10. 7)Drugs -drug induced lupus hydralazine isoniazid procainamide -doxorubicin -phenytoin 8)Metabolic -hypothyroid -uremia -ovarian hyperstimulation Etiology: continued

  11. Lab Testing • Of note, the historic yield of diagnostic evaluation is low, typically only in approximately 16% of patients is etiology determined. • More recently, evaluation of pericardial fluid and tissue with tumor markers, PCR, immunohistochemistry, flourescence-activated cell sorting has shown a trend toward higher yield of diagnosis

  12. Diagnosis: Presence of two of the following necessary • Chest pain • Sudden onset • localized to anterior chest wall • pleuritic • sharp • Positional: may improve if pt leans forward, worse with lying flat • Cardiac auscultation: Pericardial friction rub • Present in up to 85% of pts with pericarditis without effusion • friction of the two inflamed layers of pericardium, typically triphasic rub, heard with diaphragm of stethoscope at left sternal border • Characteristic ECG changes • Pericardial effusion

  13. Pertinent Lab Results • Elevated C reactive protein level (such a strong correlation that normal CRP makes acute pericarditis diagnosis less likely) • Elevated CK, CK-MB, and Troponin (can be normal) • Often elevated Troponin alone • Indicates inflammation of myocardium just beneath the visceral pericardium • Not associated with worse outcomes • Leukocytosis

  14. ECG Findings: 60% of patients • Stage 1: hours to days • Diffuse ST elevation -sensitive v5-v6, I, II • ST depression I/aVR • PR elevation aVR • PR depression diffuse -especially v5-v6 • PR change is marker of atrial injury • Stage 2: • Normalization

  15. Stage 3: Diffuse T wave inversions ST segments isoelectric Stage 4: EKG may normalize T wave inversions may persist indefinitely ECG changes over weeks

  16. STEMI or Pericarditis by ECG • ST elevation in pericarditis • Starts at J point • Rarely exceeds 5mm • Retains normal concavity • Non-localizing • Arrhythmias very unlikely in pericarditis (suggest myocarditis or MI)

  17. Acute Pericarditis • 51yo man with acute onset sharp substernal chest pain two days prior

  18. Pericardial Effusion • Low voltage and Electric Alternans

  19. Echocardiographic Findings • Echo is typically normal in acute pericarditis unless associated with pericardial effusion

  20. ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article • Recommended specific circumstances for use of echocardiography in pericardial disease

  21. Class I Recommendations 1. Patients with suspected pericardial disease, including effusion, constriction, or effusive-constrictive process. 2. Patients with suspected bleeding in the pericardial space, eg, trauma, perforation, etc.

  22. Class I (continued) 3. Follow-up study to evaluate recurrence of effusion or to diagnose early constriction. Repeat studies may be goal directed to answer a specific clinical question 4. Pericardial friction rub developing in acute myocardial infarction accompanied by symptoms such as persistent pain, hypotension, and nausea.

  23. Class IIa 1)Follow-up studies to detect early signs of tamponade in the presence of large or rapidly accumulating effusions. A goal-directed study may be appropriate. 2)Echocardiographic guidance and monitoring of pericardiocentesis.

  24. Class IIb 1) Postsurgical pericardial disease, including postpericardiotomy syndrome, with potential for hemodynamic impairment. 2) In the presence of a strong clinical suspicion and nondiagnostic TTE, TEE assessment of pericardial thickness to support a diagnosis of constrictive pericarditis.

  25. Effusion: 2D Parasternal Long

  26. Pericardial Fat Pad • Often pericardial fat pads can be seen in this view anterior to the RVOT • Fat pads usually not seen elsewhere

  27. Effusion: Parasternal Short Axis

  28. Posterior Effusions • Pericardial effusions can track posteriorly toward sinus • In this case, may only be seen in axial 4 chamber view

  29. Effusion: 2D Apical

  30. Tamponade • Hypotension caused by pericardial fluid under pressure • Diagnostic techniques • 2D looking for RA/RV collapse during diastole • M-mode for RA/RV collapse during diastole • Doppler of Mitral and Tricuspid inflow • Mitral inflow to decrease by 25% with inspiration • Tricuspid inflow increased by 40% with inspiration • IVC diameter fails to increase with inspiration

  31. Tamponade: 2D

  32. Tamponade: M-Mode

  33. Tamponade: DopplerMitral Inflow

  34. Chest X ray • Normal in patients with acute pericarditis unless pericardial effusion is present • Enlarged cardiac silhouette • Requires 200cc of fluid

  35. Fibrinous Pericarditis

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