Transcript Pericardial disease

Pericardial Diseases
Several Slides courtesy of Alena Goldman, M.D.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Pericardium
Fibroelastic sack made up
of visceral and parietal
layers separated by a
potential space,
pericardial cavity
► Forms a sac enclosing the
origin of the aorta,
pulmonary artery,
Pulmonary veins, venae
cavae
►
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Categories
►
3 major categories of pericardial diseases (co-existing,
overlaping with one another):
 Pericarditis (inflammation of the pericardium)
 Pericardial effusion (fluid around the heart causing clinical
presentation from asymptomatic to causing tamponade)
 Constrictive pericarditis (inelastic sac that impairs filling)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Etiology of pericardial Diseases
IX.
Idiopathic pericarditis
Infectious (viral, bacterial, Mycoplasma, fungal, parasitic)
Vasculitis/connective tissue disease (lupus, RA, scleroderma, MCTD,
Wegener’s, PAN, sarcoid, IBD, Whipple’s, GCA, Behcet’s)
Hypersensitivity/immunopathies
Diseases of contiguous structures (post-infarction/early, Dressler’s,
myocarditis, dissecting aortic aneurism)
Disorders of metabolism (hypothyroidism, uremia, ovarian
hyperstimulation syndrome)
Trauma (blunt, penetrating, iatrogenic)
Neoplasms (mets, primary, paraneoplastic)
Other (congenital)
2008
Zoll Firm Lecture Series
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Acute Pericarditis: Clinical Presentation
►
Symptoms
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Signs
 Left precordial chest pain
(pleuritic, worsens with
recumbency; relieved with
leaning forward, sudden onset)
 Fever
 Malaise, myalgias
 Symptoms of systemic illness,
depending on the etiology
 Pericardial friction rub (easier
to hear in an absence of an
effusion):
► Three phases: correspond
to
movement of the heart during
atrial systole ventricular
systole, and in the rapid filling
phase of early ventricular
diastole
 serum biomarkers for
myocardial injury: related to
the extent of myocardial
inflammation
 Elevated WBC, CRP
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
ECG Changes
ECG Changes
Low Voltage
If there is an effusion
Injury of
Superficial Myocardium
By pressure of fluid or fibrin
Electrical Alternans
(“Cardiac Nystagmus” by Littman)
ST Segment Deviation
PR Segment Changes
Superficial Myocarditis
2008
Zoll Firm Lecture Series
TWI
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
EKG changes
► Stage I- diffuse PR depression, ST elevation
except in avR and v1 (the typical pericarditis
EKG).
► Stage II- (several days later) PR and ST segments
normalized, T wave becomes flat.
► Stage III- diffuse T wave inversion
► Stage IV- resolution (several days to weeks)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Typical ECG (stage I)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Echocardiography
Acute pericarditis is a clinical diagnosis.
► Echocardiogram is often normal in patients with
acute syndrome unless it is associated with a
pericardial effusion
► Finding of a pericardial effusion in a patient with
known or suspected pericarditis supports the
diagnosis, the absence of a pericardial effusion or
other echocardiographic abnormalities does not
exclude it
► Do not need to order it unless you suspect
substantial pericardial effusion.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
2D Echo
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Identifying the Cause
► In Western countries, most cases of acute
pericarditis in immunocompetent patients that
are not associated with apparent medical or
surgical conditions are due to viral infection
(entero-, echo-, adenoviruses; CMV, EBV, HSV,
influenza, parvo, HCV, HIV) or are idiopathic
► A full diagnostic evaluation is not appropriate in
all patients
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
2008
Zoll Firm Lecture Series
Maisch, B., Heart 2003; 89
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Management
For symptom relieve:
• NSAIDs- indomethacin 25-50mg PO TID or
ibuprofen 600-800mg PO TID for 3 weeks
 Cholchicine- 1mg/d for 3 weeks
 Steroids- less preferred, patient’s symptoms often
rebound when steroids are withdrawn. If neededprednisone 40-60mg PO qd x 3wks
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Complications
► Recurrent in 20-30% of the cases.
► Infrequently, can progress to tamponade or
constriction.
► None of the medical therapy has been
vigorously proven to prevent complications.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Pericardial effusion
► Can be asymptomatic or present as life-threatening
cardiogenic shock (tamponade). Can also present in
between the above two polar opposites.
► Symptoms occur when increase in pericardial fluid
raises the intrapericardial pressure and impairs
diastolic filling.
► The presenting syndrome depends on the:
 Volume (bigger worse)
 rate of accumulation (faster worse)
 Characteristic (thicker worse)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Cardiac Tamponade
► Tamponade is at one extreme of the of the syndrome
and is characterized by:
 Progressive increase in intrapericardial pressure first
becoming equal to the RV then later the LV filling pressures
(equalization of diastolic pressure)
 Continual elevation of intracardiac filling pressure.
 Impairment of diastolic filling
 Lack of filling leads to fall in cardiac output.
 At first, the body compensates through tachycardia and
vasoconstriction. As the syndrome progresses, this
mechanism becomes inadeqaute and shock ensues.
 Needs to be treated by urgent pericardiocentisis.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Relationship Between Intracardiac Filling Pressures and Intrapericardial Pressure and Cardiac
Output in Cardiac Tamponade
Slide 2
Roy, C. L. et al. JAMA 2007;297:1810-1818.
2008
Copyright restrictions may apply.
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Clinical presentation
► Signs:
► Symptoms
 Mostly relates to low
cardiac output and high
filling pressure.
 Mental status changes
 Dypsnea
2008
Zoll Firm Lecture Series

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


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Low BP
Tachycardia
Tachypnea
Diminished heart sounds
Low urine output
Pulsis paradoxusinspiratory decline in SBP
>10mmHg.
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Measurement and Mechanism of Pulsus Paradoxus
Roy, C. L. et al. JAMA 2007;297:1810-1818.
2008
Copyright restrictions may apply.
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Echocardiography in cardiac tamponade
► Visualizes the effusion
► Impairment of diastolic filling causes the cardiac
chambers to be “squashed”
 1st RA collapse (lowest pressure chamber, more sensitive,
less specific)
 2nd RV collapse (fairly specific)
 False negative in the presence of substantial pulmonary
hypertension.
► variation in mitral and tricuspid
inflow.
► Ultimately, cardiac tamponade is a clinical diagnosis
though echocardiogram is very useful in this setting
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Echocardiogram of a 62-Year-Old Woman With Advanced Lung Cancer and Malignant Pericardial
Effusion Causing Cardiac Tamponade
Roy, C. L. et al. JAMA 2007;297:1810-1818.
2008
Copyright restrictions may apply.
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Diastolic RA collapse
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Constrictive Pericarditis
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►
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Typically, long delay between onset of constriction and
pericardial inflammation
Common etiologies includes radiation, TB…etc. Although
many pericardial diseases can lead to constriction.
Presents with R>L sided failure symptoms
 Insidious symptoms at first, followed by dypsnea with exertion,
orthopnea, edema…etc.
►
Diagnosed by a combination of
► Echocardiography (pericardium,
filling patterns, interventricular
dependence…etc)
► chest CT/MRI (better at defining pericardium)
► RHC (gold standard for hemodynamic assessment)
►
2008
Pericardiectomy is the only therapy for a permanent
constriction
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Constrictive Pericarditis Pathophysiology
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2008
Fibrosed or calcified pericardium restricts
diastolic filling of all 4 chambers
constriction leads to elevated and equilibrium
of the diastolic pressures
In early diastole filling is unimpaired =>
abnormally rapid filling
filling is abruptly halted when cardiac volume
meets the limits determined by the stiff
pericardium
Virtually all filling occurs during early diastole
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
CXR
dense
circumferential
calcification of
pericardium
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Chest CT
demonstrating extent
and severity of
pericardial
calcification
Circulation. 2005;112:e137-e139
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.