Pericardium & Pericarditis

32 year old woman with no pmh presents to ER with 6 hours of sharp chest pain. Chest pain is worse with lying down and better with sitting upright. ECG is obtained. What is the MOST likely diagnosis? A. Acute MI B. Acute pericarditis C. Pulmonary embolism D. Pneumothorax

*B. Acute Pericarditis* EKG shows ST segment elevation.

A 19 year old woman presents with chest pain. One week ago, she had a self limiting cold. Chest pain is central in location with radiation to trapezius ridge. Pain is worse lying down and improves with sitting upright. Physical exam reveals HR of 106 bpm, BP of 120/70 mmHg, no pulsus paradoxus, flat JVP, and a loud 3 component friction rub. What exam would offer the most information regarding the presumed diagnosis of acute pericarditis? A. Arterial blood gas B. Cardiac enzymes C. Electrocardiogram D. Transthoracic echocardiogram

*C. Electrocardiogram*

A 19 year old woman presents with chest pain. One week ago, she had a self limiting cold. Chest pain is central in location with radiation to trapezius ridge. Pain is worse lying down and improves with sitting upright. Which of the following physical finding/lab test is most specific in making a diagnosis of acute pericarditis? A. Elevated ESR B. Leukocytosis C. Low grade fever D. Pericardial friction rub E. Tachycardia

*D. Pericardial Friction Rub*

Acute Pericarditis - Routine Diagnostic Tests

*EKG (diagnostic)* CBC + Diff Blood cultures - looks for infection. Viral titers (acute and convalescent) - looks for viral infection. PPD skin test - looks for TB infection. Antinuclear Ab, rheumatoid factor, complement levels - looks for autoimmune issues. Serum creatinine In Select Cases: Cardiac enzymes Echocardiogram

Restrictive Cardiomyopathy vs Constrictive Pericarditis

*Have the same general appearance but restrictive diseases do NOT have a thickened pericardium*. The pericardium is fine but here is another issue that is causing "restriction" of the heart (sarcoidosis, amyloidosis, hemochromatosis)

Acute Pericarditis - Etiology

*Idiopathic (most common, responds to NSAIDs)* Acute MI Infection (viral, bacterial, TB) Chest wall trauma Invasive tumor Irradiation Symptom of Uremia Cardiac surgery Medications Autoimmune or inflammatory diseases

What is acute pericarditis?

*Inflammation of hte pericardium* with/without a resultant pericardial effusion.

Fibrinous/Serofibrinous Pericarditis - Overview

*Most common form of acute pericarditis* Caused by: - MI - Post-MI Dressler syndrome - Uremia - Radiation - Rheumatic fever - SLE - Trauma

Acute Pericarditis - Physical Exam Findings

*Pericardial Friction Rub* - harsh, scratchy sound - localized, transient, and not affected by maneuvers. - may have 1, 2, or 3 components that correspond to LV movement (1. early rapid filling of the ventricle, 2. atrial contraction, 3. ventricular contraction)

How can you diagnose pulses paradoxus?

1. BP cuff inflated until no sounds appreciated (above systolic arterial pressure) 2. BP cuff pressure lowered until heart sounds heard during expiration 3. BP cuff pressure lowered until heart sounds heard in both expiration and inspiration If difference >10 mmHg patient has pulsus paradoxus

A 19 year old woman presents with chest pain. One week ago, she had a self limiting cold. Chest pain is central in location with radiation to trapezius ridge. Pain is worse lying down and improves with sitting upright. physical exam reveals HR of 106 bpm, BP of 120/70 mmHg, no pulsus paradoxus, flat JVP, and a loud 3 component friction rub. You diagnose her with pericarditis after obtaining an EKG. What is the initial best choice of treatment? A. Prednisone B. NSAIDS like ibuprofen C. Antibiotics D. No treatment is usually needed

A - prednisone is a great antiinflammatory medication but patient can get really bad pericarditis again when stopped. *B. CORRECT* NSAIDs are the treatment of choice for idiopathic acute pericarditis. C. Antibiotics are only indicated if it is caused by suppurative pericarditis. D. NO! Acute pericarditis is a very painful condition so you must give patients symptom relief.

What are some diseases of the pericardium?

Acute Pericarditis Cardiac Tamponade Constrictive Pericarditis

Types of Chronic/Healed Pericarditis

Adhesive Pericarditis - delicate fibrous adhesions obliterate pericardial sac but usually have no effect on cardiac function. Adhesive Mediastinopericarditis - pericardial sac is obliterated with adherence to surrounding structures. Adhesions pull on surrounding structures which strains cardiac function and may lead to hypertrophy and dilation. Constrictive Pericarditis - heart is encased in dense fibrous/ fibrocalcific scar, which limits diastolic expansion

How fast does cardiac tamponade develop?

Anywhere from minutes to days to months. Depends on the nature/cause of the effusion. Acute Causes = aortic dissection, MVA Chronic Causes = renal failure, hypothyroid

Chest MRI - Constrictive Pericarditis

Arrows show thickened pericardium around right ventricle (RV) and left ventricle (LV).

Hemorrhagic Pericarditis

Blood mixed with fibrinous or suppurative effusion. Causes acute pericarditis. Most common cause = malignancy (usually direct invasion) Other Causes = Bacterial infection TB Bleeding diathesis Post-surgical Cytology will show malignant cells

55 year old man with history of Hodgkin's Lymphoma s/p radiation to his chest 20 years ago now presents with 3-4 months of shortness of breath, fatigue and lower extremity swelling. On exam BP is 100/50, JVP is 9 cm and increases with inspiration. CT scan of his chest shows thickened and calcified pericardium. What is the most likely diagnosis? A. Restrictive cardiomyopathy B. Dilated cardiomyopathy C. Constrictive pericarditis D. Relapse of Hodgkins lymphoma

C. Constrictive Pericarditis - malignancy is a common cause of constrictive mericarditis in the US and a thickened/calcified pericardium is diagnostic of constrictive pericarditis.

48 year old woman with history of breast cancer s/p chemotherapy and radiation presents with 3 days of worsening shortness of breath and fatigue. On exam, HR is 120, BP is 80/50. JVP is elevated to 12cm and she is diaphoretic. Lungs are clear to exam and heart sounds are distant. You correctly diagnose her with cardiac tamponade after obtaining an echocardiogram. What is the best way to treat her underlying emergency? A. Chemotherapy B. Thrombolytics C. Diuretics D. Pericardiocentesis

C. DO NOT GIVE diuretics! Decreases filling of heart further and patient can crash. *D. CORRECT. Pericardiocentesis* - gets the effusion out of the pericardial sac which relieves the pressure on the heart.

What is cardiac tamponade?

Cardiac tamponade occurs when there is pericardial fluid accumulation that increases intrapericardial pressure and "squeezes" the heart. This limits filling of the heart resulting in a decreased stroke volume and a low output state.

Constrictive Pericarditis - Overview/ Etiologies

Characterized by a thickened fibrotic pericardium which restricts diastolic filling of the heart. - Acute Viral Pericarditis ("resolved") - *Tuberculosis (most common cause outside US)* - Remote bacterial, fungal, parasitic pericarditis - Inflammatory & autoimmune (RA, SLE, scleroderma) - Chronic renal failure (pt on hemodialysis) - Irradiation - *Malignancy* (w/ pericardial involvement) - *Previous cardiac surgery* - *Hemopericardium* (trauma, anticoagulants, etc) - Idiopathic Malignancy, Previous cardiac surgery, and hemopericardium ar emost common in US. Picture shows heart and great vessels with gray-white tumor in pericardial space and invasion of the IV septum.

A 19 year old woman presents with chest pain. One week ago, she had a self limiting cold. Chest pain is central in location with radiation to trapezius ridge. Pain is worse lying down and improves with sitting upright. physical exam reveals HR of 106 bpm, BP of 120/70 mmHg, no pulsus paradoxus, flat JVP, and a loud 3 component friction rub. You diagnose her with pericarditis after obtaining an EKG and treat with NSAIDs. One week later she presents to ER with worsening shortness of breath and diaphoresis. On exam, HR is 130, BP is 80/50. JVP is elevated to 12cm and she is diaphoretic. Lungs are clear to exam and heart sounds are distant. What is the most likely diagnosis? A. Acute myocardia infarction B. Pulmonary embolism C. Congestive heart failure D. Cardiac Tamponade

D. Cardiac Tamponade - she has formed a pericardial effusion from her acute episode that is now "squishing" her heart.

Cardiac Tamponade - Signs

Decreased BP Narrowed pulse pressure (nl = 40. pericarditis <40) Tachycardia Tachypnea Elevated JVP Pulsus paradoxus (SBP drop >10 mmHg upon inspiration) *Faint heart sounds* *Clear lung fields*

Constrictive Pericarditis - Diastolic Pressures

Diastolic pressures are elevated and equalized due to the inability to fill the heart enough.

Acute Pericarditis - EKG Findings

Diffuse ST segment elevation and PR segment depression.

How do you diagnose Cardiac Tamponade?

Echocardiogram! CXR shows large heart with clear lung fields. EKG shows low voltage/electrical alternans due to the heart swinging away from the chest wall with every beat.

Constrictive Pericarditis - Clinical Findings

Elevated JVD Kussmauls sign - paradoxical increase in JVP on inspiration. Diastolic pericardial "knock" Ascites Pulsatile hepatomegaly Peripheral edema

Suppurative Pericarditis - Morphology

Exudate = may be thin and cloudy, or resemble frank pus Serosal Surface = red, granular, & coated with exudate Microscopic = Acute inflammation Healed = Organization and scarring

Fibrinous/Serofibrinous Pericarditis - Morphology

Fibrinous = Dry, rough, finely granular pericardial surface *Serofibrinous (most common)* = Yellow or brown turbid fluid containing leukocytes, RBCs, & fibrin. Fibrin may lyse or organize. Serous (uncommon) = Noninfectious inflammatory diseases (autoimmune), uremia, primary viral pericarditis

Types of Acute Pericarditis

Fibrous/Serofibrous Pericarditis (most common) Suppurative Pericarditis (rare) Hemorrhagic Pericarditis - usually due to malignant tumor invasion. Caseous Pericarditis - caused by TB infection unless proven otherwise.

EKG of Acute Pericarditis

HR = ~100 Rhythm = pretty normal, sinus Diffuse ST segment elevation and PR segment depression.

Acute Pericarditis - Treatment

Hospitalization for high risk features - Large effusion - myopericarditis - immunosuppression - recent trauma - NSAID failure - anticoagulant therapy First Line Therapy - NSAID (High dose; ibuprofen, naproxen, etc.) - Colchicine - Aspirin (high doses)

Cardiac Tamponade - Treatment

Intravenous Saline Pericardiocentesis

What is pulsus paradoxus?

Normally, systolic BP decreases slightly upon inspiration (no more than 10 mmHg) since a large amount of blood is being brought into the venous system and then the right atrium. In pulses paradoxus there is an increased drop in Systolic BP of >10 mmHg upon inspiration.

How can you tell the difference between ischemic pain (as with an MI) versus acute pericarditis pain?

Pericarditis - pain radiates from retrosternal to trapezius ridge. NTG = nitroglycerin.

Acute Pericarditis - Symptoms

Pleuritic Chest Pain - worsens while laying down and with inspiration. Dyspnea/cough Pain may be localized to epigastrium and mimic acute abdomen. *Sharp retrosternal pain that radiates to the trapezius ridge.*

Suppurative Pericarditis - Overview

Rare Caused by direct invasion by microorganisms.

Acute Pericarditis - Complications

Recurrent Pericarditis Cardiac Tamponade - from effusion in pericardial sac that squiches heart. Constrictive pericarditis

Echocardiogram of Cardiac Tamponade (1)

Shows a large Pericardial Effusion (PE) Compressing the RV (right panel) During Diastole

Echocardiogram of Cardiac Tamponade

Shows a large pericardial effusion (PE) compressing the right atrium (RA) and right ventricle (RV)

CXR - Constrictive Pericarditis

Shows calcification/thickening of pericardium.

CXR - Constrictive Pericarditis (1)

Shows calcification/thickening of pericardium.

Chest CT - Constrictive Pericarditis

Shows dilated SVC due to decreased filling/CO and increased blood build up. Shows thickened/calcified pericardium behind sternum.

CXR of Cardiac Tamponade

Shows large heart with clear lung fields.

Constrictive Pericarditis - Symptoms

Symptoms of Right heart failure since RV and RA are getting "squished": - Abdominal girth increase/ascites - RUQ pain - nausea, anorexia - pedal edema Symptoms of low output state due to inability to fill completely: - fatigue - exercise intolerance

Caseous Pericarditis

TB until proven otherwise, usually direct spread. Rarely fungal in origin. Causes acute pericarditis. May cause chronic fibrocalcific constrictive pericarditis Morphology = necrotic degeneration of bodily tissue into a soft, cheeselike substance. Macroscopicially = caseous necrosis have a "cheesy-milky" appearance.

What is the pericardium?

The pericardium is a membrane of fibrous tissue that surrounds the heart and the base of the great vessels.