Acute pericarditis ecg conference
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Acute Pericarditis/ ECG conference. Jimmy Klemis, MD Jan 8, 2002. Pericardium. Visceral / serous Direct contact with epicardium (ST elev) single layer mesothelial cells Parietal / fibrous mesothelial and fibrous layer. Pericardial Anatomy. Visceral – transparent

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Acute Pericarditis/ ECG conference

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Acute pericarditis ecg conference

Acute Pericarditis/ECG conference

Jimmy Klemis, MD

Jan 8, 2002


Pericardium

Pericardium

  • Visceral / serous

    • Direct contact with epicardium (ST elev)

    • single layer mesothelial cells

  • Parietal / fibrous

    • mesothelial and fibrous layer


Pericardial anatomy

Pericardial Anatomy

Visceral – transparent

Parietal – translucent

Transverse sinus – curved probe


Etiology acute pericarditis

Etiology – Acute Pericarditis

  • Infectious

    • Viral : Coxsackie, Echo, EBV, Influenza, HIV

    • Bacterial: TB, staph, hemophillus, pneumococcal, salmonella

    • Fungal/other: histo/blasto/coccidio, rickettsia

  • Rheumatologic

    • SLE, Sarcoid, RA, Dermatomyositis, Ankylosing Spondylitis, Scleroderma, PAN

  • Neoplastic

    • Primary: angiosarcoma, mesothelioma

    • Metastatic: breast, lung, lymphoma, melanoma, leukemia

  • Immunologic

    • Celiac sprue, Inflammatory Bowel Disease

  • Drug

    • Hydralizine, Procainamide

  • Other

    • MI, Dressler’s, Post Pericardiotomy, Chest Trauma, Aortic dissection

    • Uremic, Post Radiation

    • IDIOPATHIC


Acute pericarditis clinical

Acute Pericarditis – Clinical

  • History

    • preceding viral illness, etc

  • Symptoms

    • Chest pain

  • Signs

    • Friction Rub

  • ECG

    • early: PR / ST changes

    • late: isoelectric ST/ T inv


History

History

  • Often preceding viral illness 1-2wk prior

  • Chest Pain

    • Sudden, sharp,pleuritic, constant

    • worse supine/ L lat decub, relief sitting up

    • radiation: back, trapezius ridge

    • symptoms usually resolve by 2 weeks, ECG abnormalities may persist for months


Auscultory rub s

Auscultory – Rub(s)

  • Endopericardial (classic)

    • “triphasic”: atrial sys, ventricular sys, early diastole

    • may only hear 2 phase (afib or tachycardia) or 1

    • loudest LSB, raised extremities/increased venous return

  • Pleuropericardial

    • “exopericardial”, extension into adjacent structures

    • marked resp variation, musical quality

  • Conus

    • dilation of pulm conus in hyperactive heart

    • PE, thyroid storm, acute beriberi

  • Pneumohydropericardium

    • air/gas overlying pcard fluid

    • metallic tinkle (small amt) ; churning/splashing “mill-wheel sound” (lg)


Acute pericarditis ecg conference

ECG

  • PR depression

  • ST elevation

    • concave up, ST/T V6 >.25, no reciprocal

  • DDx:

    • Acute MI

    • Early Repolarization

    • Myocarditis

    • Aneurysm

    • other: Brugada, BBB


Acute pericarditis ecg conference

ECG


Acute pericarditis stages

Acute Pericarditis - Stages

  • Stage I

    • first few days  2 weeks

    • ST elev, PR depression

    • up to 50% of pt with sxs/rub do NOT have/evolve stage I1

  • Stage II

    • last days  weeks

    • ST returns to baseline, flat T

  • Stage III

    • after 2-3 weeks, lasts several weeks

    • T wave inversion

  • Stage IV

    • lasts up to several months

    • gradual resolution of T wave changes

1 Spodick DH, Pericardial Disease. Braunwauld 6th


Acute pcard stage i ii

Acute PCARD – Stage I, II

60 y/o man with acute PCARD on presentation and after 1 mo resolution of sxs,

* Marriott’s Practical ECG 10th ed, p 208


Acute pcard stage iii

Acute PCARD – Stage III

19 y/o Female after 1 wk in hospital with Acute Pericarditis


Ddx pcard vs repol

DDx: PCARD vs Repol


Ddx pcard vs mi

DDx: PCARD vs MI


Cardiac isoenzymes helpful

Cardiac Isoenzymes - ? helpful

  • 2 year study, ER based1

    • 14 pt with 2/3 findings (CP typical for PCARD, rub, and ECG changes c/w PCARD)

    • 71% had elevated TropI (pk 21) with negative CAD workup

  • Not reliable to differentiate MI vs PCARD

1Brandt RR, et al. Am J Card 2001, June 1


Treatment

Treatment

  • NSAIDS/ASA

    • ASA 650 q3-4hr

    • Ibuprofen 300-600 q 6-8 hrs x 1-4days

      • Avoid Indocin, reduces CBF

  • Steroids

    • if no response after 48hr NSAID

    • use concurrent NSAID

  • Colchicine

    • .6 q12 chronic +/- NSAID

    • useful in recurrent pericarditis

    • symptom free period 3.1 +/- 3mos vs 43 +/- 35mos (p<.00001)

      in largest multicenter trial to date1

    • Anecdotal evidence of benefit in Acute PCARD, effusion

1Adler Y, et al. Circulation, 1998 June 2


Complications

Complications

  • Pericardial Effusion/Tamponade

  • Constrictive Pericarditis

    • can be “transient” – 10% may have transient sxs within 1st month, resolves by 3 months

  • Recurrent Pericarditis (20-25%)

    • Rx – NSAIDS/Colchicine +/- steroids


Gross pathology

Gross Pathology

“Bread & Butter” appearance

Fibrinous stranding


Acute pcard stage i

Acute PCARD – Stage I


Ecg quiz

ECG Quiz

Acute Pericarditis, Stage I


Ecg quiz 2

ECG quiz 2

Acute Ant MI


Ecg quiz 3

ECG quiz 3

Early Repolarization


Ecg quiz 4

ECG quiz 4

Early Repolarization


Ecg quiz 5

ECG Quiz 5

Pericardial dz, diffuse ST elev


Ecg quiz 6

ECG Quiz 6


Ecg quiz 6a

ECG Quiz 6a

Acute antseptal MI


Ecg quiz 7

ECG Quiz 7

Early Repolarization


Ecg quiz 8

ECG quiz 8

Incomplete RBBB


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